uog journal club: uterine sliding sign in die

UOG Journal Club: June 2013Prediction of pouch of Douglas obliteration in women with suspected endometriosis using a new real-time dynamic transvaginal ultrasound

technique: the sliding signS. Reid, C. Lu, I. Casikar, G. Reid, J. Abbott, G. Cario, D. Chou, D. Kowalski, M.

Cooper, G. CondousVolume 41, Issue 6, Date: June 2013, pages 685–691

Uterine sliding sign: a simple sonographic predictor for presence of deep infiltrating endometriosis of the rectum

G. Hudelist, N. Fritzer, S. Staettner, A. Tammaa, A. Tinelli, R. Sparic, J. Keckstein

Volume 41, Issue 6, Date: June 2013, pages 692–695

Journal Club slides prepared by Dr Tommaso Bignardi(UOG Editor for Trainees)

UOG Journal Club: June 2013

Prediction of pouch of Douglas obliteration in women with suspected endometriosis using a new real-time dynamic transvaginal ultrasound

technique: the sliding sign

S. Reid, C. Lu, I. Casikar, G. Reid, J. Abbott, G. Cario, D. Chou, D. Kowalski, M. Cooper, G. Condous


To evaluate whether real-time dynamic transvaginal sonography (TVS) can predict pouch of Douglas (POD)

obliteration.

Prediction of pouch of Douglas obliteration in women with suspected endometriosis using a new real-time dynamic transvaginal ultrasound technique: the sliding sign

Reid et al., UOG 2013

Objective

Patients and Methods

• Multicenter prospective observational study

• 100 consecutive women with symptoms suggestive of endometriosis scheduled for laparoscopy

Presence of sliding was evaluated at TVS in two locations: over the posterior cervix/posterior vaginal wall and at the upper uterus/fundus

Final diagnosis of endometriosis was based on surgical resection with histological confirmation



Predicted POD obliteration

(sliding sign negative)

True POD obliteration

Yes No

Yes 25 2 PPV = 92.6%

No 5 68 NPV = 93.2%

Sensitivity = 83.3% Specificity = 97.1% (P = 1.8E−16)

True pouch of Douglas (POD) obliteration vs predicted POD obliteration

PPV, positive predictive value; NPV, negative predictive value



Results

DIE nodule location Sensitivity Specificity PPV NPV

Rectosigmoid/ anterior rectum nodule

17/20 (85.0) 73/80 (91.3) 17/24 (70.8) 73/76 (96.1)

Uterosacral ligament nodule

4/10 (40.0) 86/90 (95.6) 4/8 (50.0) 86/92 (93.5)

Rectovaginal septum/vaginal nodule*

2/8 (25.0) 92/92 (100.0) 2/2 (100.0) 92/98 (93.9)

Results

Data are given as n/n (%). *7/8 (87.5%) of the nodules invading the rectovaginal septum/vagina were contiguous with an anterior rectal nodule. NPV, negative predictive value; PPV, positive predictive value



Prediction of deep infiltrating endometriosis (DIE) location

Comparison of DIE location according to pouch of Douglas (POD) obliteration transvaginal sonography

Data are given as n (%) *More than one DIE nodule was visualized in some patients†Sliding sign negative. ‡Sliding sign positive.



DIE nodule location* POD obliteration†

(n=27)

POD non-obliteration‡

(n = 73)

Anterior rectum 10 (37%) 0 (0%)

Rectosigmoid 11 (41%) 3 (4%)

Uterosacral ligament 5 (19%) 3 (4%)

Rectovaginal septum/vagina 0 (0%) 2 (35)

DIE absent 1 (4%) 66 (90%)

Results

• The sliding sign may give important additional information for planning laparoscopic surgery

• High NPV of this simple technique means that one can confidently expect the POD to be non-obliterated when the sliding sign is positive

Discussion



• Surgical exploration with histological confirmation in all women included in the study

Strengths of the study

Weaknesses• Surgeons who performed the surgeries were not blinded to the preoperative TVS results

• A large proportion of women had a previous history of endometriosis confirmed at laparoscopy

• All TVS performed by an experienced sonologist



Conclusions

• TVS with the sliding sign technique may be useful in the identification of women at increased risk for bowel endometriosis

• Preoperative use of the sliding sign may ensure appropriate referral of women to an advanced laparoscopic surgeon if appropriate



UOG Journal Club: June 2013


G. Hudelist, N. Fritzer, S. Staettner, A. Tammaa, A. Tinelli, R. Sparic, J. Keckstein


• Several imaging techniques based on transvaginal sonography (TVS) or magnetic resonance imaging have been used to investigate deep infiltrating endometriosis (DIE) prior to laparoscopy.

• In women with DIE, obliteration of the pouch of Douglas may predict difficult surgery.

• There are limited data on the use of preoperative TVS as a simple test to predict obliteration of the pouch of Douglas in women with suspected endometriosis.

Background

To evaluate if uterine sliding sign on transvaginal sonography (TVS) can predict deep infiltrating endometriosis (DIE) of the

rectum.


Hudelist et al., UOG 2013

Objective

• The transducer is introduced in the posterior vaginal fornix, then withdrawn to assess the movement of the rectum against the posterior vaginal fornix and the posterior uterine wall, in a midsagittal plane

• Examiner’s left hand is placed on the patient’s abdomen to apply pressure on the uterus

Sliding sign positive: sliding of the rectum against the posterior uterine wall

Sliding sign negative: immobility of the rectum against the uterus



Assessment of the uterine sliding sign

Patients and Methods

• 117 consecutive women with symptoms suggestive of endometriosis who underwent laparoscopic surgery

• Presence of positive or negative uterine sliding was evaluated at TVS by one examiner prior to surgery

Final diagnosis of endometriosis was based on surgical resection with histological confirmation

Sensitivity, specificity, PPV and NPV, respectively, test accuracy and LR+ and LR–, were calculated for the presence or absence of uterine sliding in relation to the presence of DIE affecting the rectosigmoid



Site of disease n/total (%)Primary locations

Pelvic peritoneum 62/117 (53)

Ovaries 13/117 (11)

DIE of the rectum 34/117 (29)

Other locations

Uterosacral ligaments 34/117 (29)

Pouch of Douglas 20/117 (17)

Vagina 15/117 (13)

Rectovaginal space 21/117 (18)

Urinary bladder 10/117 (9)

Results: surgical findings



n/total (%) or ratio 95% CI

Prevalence of rectal/sigmoidal endometriosis

34/117 (29)

Negative sliding sign 32/117 (27)

Sensitivity 29/34 (85) 73–97

Specificity 80/83 (96) 92–100

PPV 29/32 (91) 81–100

NPV 80/85 (94) 89–99

Accuracy 109/117 (93)

LR + 23.6 7.7–72.3

LR – 0.15 0.07–0.34

LR+, positive likelihood ratio; LR–, negative likelihood ratio; NPV, negative predictive value; PPV, positive predictive value.

Results: diagnostic performance of a negative uterine sliding sign



• A negative uterine sliding sign could be an easy method for prediction of DIE involving the rectum

• This sign could be a valuable ‘red flag’ sign for triaging women to specialized clinics for detailed investigation

Discussion



• Surgical exploration with histological confirmation in all women included in the study

Strengths of the study

Weaknesses

• TVS was performed by a highly experienced sonographer in a tertiary referral center, this may not reflect a primary care setting

• No data on intra/inter-observer reproducibility



Discussion points

Uterine sliding sign: a simple sonographic predictor for presence of deep infiltrating

endometriosis of the rectumHudelist et al., UOG 2013

Prediction of pouch of Douglas obliteration in women with suspected endometriosis using a new real-time

dynamic transvaginal ultrasound technique: the sliding sign


• Do we need a simple test for diagnosing deep infiltrating endometriosis in the primary care setting?

• What are the surgical implications of a positive sliding test?

• Is the ‘sliding sign’ also a reliable method in less experienced hands?

• Should evaluation of the posterior pelvis always be included in the routine transvaginal scan?

uog journal club: uterine sliding sign in die

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