The ‘sliding sign’ in conjunction with sonovaginography: is this the optimal approach for the diagnosis of Pouch of Douglas obliteration and posterior compartment deep infiltrating endometriosis?

Abstract

Introduction: Endometriosis is a chronic peritoneal disease that may progress as a deep infiltrating lesion involving the posterior compartment of the pelvis. Efforts to improve pre‐operative knowledge of the location and extent of these lesions have resulted in the development of Transvaginal ultrasound (TVS) as the first‐line imaging modality for extra‐ovarian endometriosis. However, various techniques of TVS have been described in the literature for this purpose. Methods: In this review we will detail the evolution of TVS as the primary imaging modality in the pre‐operative diagnosis of posterior compartment deep infiltrating endometriosis (DIE). We will also discuss the potential of an emerging new real‐time diagnostic ultrasound‐based technique known as the ‘sliding sign’ in combination with office gel sonovaginography for the pre‐operative diagnosis of Pouch of Douglas obliteration and posterior compartment DIE. Conclusion: Implementation of the new real‐time dynamic, reproducible and simple ‘sliding sign’ in conjunction with SVG has the potential to challenge the current concept that traditional laparoscopy is the ‘gold standard’ modality for the diagnosis of women with posterior compartment DIE.

Performance of ultrasound‐based endometriosis staging system (UBESS) for predicting level of complexity of laparoscopic surgery for endometriosis

“…Preoperative recognition of these phenotypes of endometriosis would facilitate triage of these women to centers of excellence for higher-stage endometriosis, consistent with the recommendation of the WES 3,7,21 . Integrating the use of TVS to identify women with bowel DIE and POD obliteration into the clinical work-up of women in whom surgery for endometriosis is planned would improve patient counseling, enhance theater-list management and potentially reduce women's exposure to multiple laparoscopies, with the attendant operative risks and healthcare costs 7,32,33 .…”

Interpreting the real-time dynamic ‘sliding sign’ and predicting pouch of Douglas obliteration: an interobserver, intraobserver, diagnostic-accuracy and learning-curve study

“…Preoperative diagnosis of POD obliteration could be useful as a triage tool for referring women to centers of excellence for optimal management of severe endometriosis. Recently, Reid et al .…”

“…POD obliteration has also been associated with bowel DIE 12 ; Khong et al 13 demonstrated that women with POD obliteration had a three-fold higher risk of having coexisting bowel DIE requiring bowel surgery than did those without POD obliteration. Thus, symptomatic women presenting with both POD obliteration and bowel DIE should have endoscopic surgery performed by an appropriately trained laparoscopic surgeon working within a multidisciplinary team environment that includes a colorectal surgeon 14,15 .…”

Gel Sonovaginography

“…As done above, gel sonovaginography has not been used so far to assess cases of local cervical and vaginal disorders other than for posterior compartment deep infiltrating endometriosis in a few recently published studies. 13,14 Limitations of this study were that it was done by a single operator in a single center. Also, the number of cases was limited.…”

“…Gel sonovaginography is well tolerated in an outpatient setting, requires a single operator, and can be performed at a single visit as an extension of regular transvaginal sonography. As done above, gel sonovaginography has not been used so far to assess cases of local cervical and vaginal disorders other than for posterior compartment deep infiltrating endometriosis in a few recently published studies 13 , 14 …”