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Review
. 2016 Feb 26;2(2):CD009591.
doi: 10.1002/14651858.CD009591.pub2.

Imaging modalities for the non-invasive diagnosis of endometriosis

Vicki Nisenblat  1 , Patrick M M Bossuyt, Cindy Farquhar, Neil Johnson, M Louise Hull
Affiliations
Review

Imaging modalities for the non-invasive diagnosis of endometriosis

Vicki Nisenblat et al. Cochrane Database Syst Rev. .

Abstract

Background: About 10% of women of reproductive age suffer from endometriosis. Endometriosis is a costly chronic disease that causes pelvic pain and subfertility. Laparoscopy, the gold standard diagnostic test for endometriosis, is expensive and carries surgical risks. Currently, no non-invasive tests that can be used to accurately diagnose endometriosis are available in clinical practice. This is the first review of diagnostic test accuracy of imaging tests for endometriosis that uses Cochrane methods to provide an update on the rapidly expanding literature in this field.

Objectives: • To provide estimates of the diagnostic accuracy of imaging modalities for the diagnosis of pelvic endometriosis, ovarian endometriosis and deeply infiltrating endometriosis (DIE) versus surgical diagnosis as a reference standard.• To describe performance of imaging tests for mapping of deep endometriotic lesions in the pelvis at specific anatomical sites.Imaging tests were evaluated as replacement tests for diagnostic surgery and as triage tests that would assist decision making regarding diagnostic surgery for endometriosis.

Search methods: We searched the following databases to 20 April 2015: MEDLINE, CENTRAL, EMBASE, CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, MEDION, DARE, and PubMed. Searches were not restricted to a particular study design or language nor to specific publication dates. The search strategy incorporated words in the title, abstracts, text words across the record and medical subject headings (MeSH).

Selection criteria: We considered published peer-reviewed cross-sectional studies and randomised controlled trials of any size that included prospectively recruited women of reproductive age suspected of having one or more of the following target conditions: endometrioma, pelvic endometriosis, DIE or endometriotic lesions at specific intrapelvic anatomical locations. We included studies that compared the diagnostic test accuracy of one or more imaging modalities versus findings of surgical visualisation of endometriotic lesions.

Data collection and analysis: Two review authors independently collected and performed a quality assessment of data from each study. For each imaging test, data were classified as positive or negative for surgical detection of endometriosis, and sensitivity and specificity estimates were calculated. If two or more tests were evaluated in the same cohort, each was considered as a separate data set. We used the bivariate model to obtain pooled estimates of sensitivity and specificity when sufficient data sets were available. Predetermined criteria for a clinically useful imaging test to replace diagnostic surgery included sensitivity ≥ 94% and specificity ≥ 79%. Criteria for triage tests were set at sensitivity ≥ 95% and specificity ≥ 50%, ruling out the diagnosis with a negative result (SnNout test - if sensitivity is high, a negative test rules out pathology) or at sensitivity ≥ 50% with specificity ≥ 95%, ruling in the diagnosis with a positive result (SpPin test - if specificity is high, a positive test rules in pathology).

Main results: We included 49 studies involving 4807 women: 13 studies evaluated pelvic endometriosis, 10 endometriomas and 15 DIE, and 33 studies addressed endometriosis at specific anatomical sites. Most studies were of poor methodological quality. The most studied modalities were transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI), with outcome measures commonly demonstrating diversity in diagnostic estimates; however, sources of heterogeneity could not be reliably determined. No imaging test met the criteria for a replacement or triage test for detecting pelvic endometriosis, albeit TVUS approached the criteria for a SpPin triage test. For endometrioma, TVUS (eight studies, 765 participants; sensitivity 0.93 (95% confidence interval (CI) 0.87, 0.99), specificity 0.96 (95% CI 0.92, 0.99)) qualified as a SpPin triage test and approached the criteria for a replacement and SnNout triage test, whereas MRI (three studies, 179 participants; sensitivity 0.95 (95% CI 0.90, 1.00), specificity 0.91 (95% CI 0.86, 0.97)) met the criteria for a replacement and SnNout triage test and approached the criteria for a SpPin test. For DIE, TVUS (nine studies, 12 data sets, 934 participants; sensitivity 0.79 (95% CI 0.69, 0.89) and specificity 0.94 (95% CI 0.88, 1.00)) approached the criteria for a SpPin triage test, and MRI (six studies, seven data sets, 266 participants; sensitivity 0.94 (95% CI 0.90, 0.97), specificity 0.77 (95% CI 0.44, 1.00)) approached the criteria for a replacement and SnNout triage test. Other imaging tests assessed in small individual studies could not be statistically evaluated.TVUS met the criteria for a SpPin triage test in mapping DIE to uterosacral ligaments, rectovaginal septum, vaginal wall, pouch of Douglas (POD) and rectosigmoid. MRI met the criteria for a SpPin triage test for POD and vaginal and rectosigmoid endometriosis. Transrectal ultrasonography (TRUS) might qualify as a SpPin triage test for rectosigmoid involvement but could not be adequately assessed for other anatomical sites because heterogeneous data were scant. Multi-detector computerised tomography enema (MDCT-e) displayed the highest diagnostic performance for rectosigmoid and other bowel endometriosis and met the criteria for both SpPin and SnNout triage tests, but studies were too few to provide meaningful results.Diagnostic accuracies were higher for TVUS with bowel preparation (TVUS-BP) and rectal water contrast (RWC-TVS) and for 3.0TMRI than for conventional methods, although the paucity of studies precluded statistical evaluation.

Authors' conclusions: None of the evaluated imaging modalities were able to detect overall pelvic endometriosis with enough accuracy that they would be suggested to replace surgery. Specifically for endometrioma, TVUS qualified as a SpPin triage test. MRI displayed sufficient accuracy to suggest utility as a replacement test, but the data were too scant to permit meaningful conclusions. TVUS could be used clinically to identify additional anatomical sites of DIE compared with MRI, thus facilitating preoperative planning. Rectosigmoid endometriosis was the only site that could be accurately mapped by using TVUS, TRUS, MRI or MDCT-e. Studies evaluating recent advances in imaging modalities such as TVUS-BP, RWC-TVS, 3.0TMRI and MDCT-e were observed to have high diagnostic accuracies but were too few to allow prudent evaluation of their diagnostic role. In view of the low quality of most of the included studies, the findings of this review should be interpreted with caution. Future well-designed diagnostic studies undertaken to compare imaging tests for diagnostic test accuracy and costs are recommended.

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Conflict of interest statement

All review authors have declared no conflicts of interest.

Figures

1
1
Sequential approach to non‐invasive testing of endometriosis.
2
2
Flow of studies identified in literature search for systematic review on imaging modalities for a non‐invasive diagnosis of endometriosis.
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3
Risk of bias and applicability concerns graph: review authors' judgements about each domain presented as percentages across included studies.
4
4
Risk of bias and applicability concerns summary: review authors' judgements about each domain for each included study.
5
5
Forest plot of TVUS for detection of pelvic endometriosis. Plot shows study‐specific estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. Studies are ordered according to the year of publication. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional TVUS are presented as 'modified method'.
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6
Summary ROC plot of TVUS for detection of pelvic endometriosis. Each point represents the pair of sensitivity and specificity from a study. The size of each point is proportional to the study sample size. The solid black circle represents the pooled sensitivity and specificity, which is surrounded by a 95% confidence region (dashed line).
7
7
Forest plot of MRI for detection of pelvic endometriosis. Plot shows study‐specific estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. Studies are ordered according to year of publication. Tests on the same population (different MRI methods) are presented separately as MRI* and MRI**. FN: false negative; FP: false positive; TN: true negative; TP: true positive.
8
8
Summary ROC plot of MRI for detection of pelvic endometriosis. Each point represents the pair of sensitivity and specificity from a study. The size of each point is proportional to the study sample size. Tests on the same population (different MRI methods) are presented separately as MRI* and MRI**. The solid black circle represents the pooled sensitivity and specificity, which is surrounded by a 95% confidence region (dashed line).
9
9
Forest plot demonstrating the direct comparison between MRI methods for pelvic endometriosis. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive.
10
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Forest plot demonstrating the direct comparison between MRI methods for pelvic endometriosis. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive.
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Forest plot demonstrating the direct comparison between MRI methods for pelvic endometriosis. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive.
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Forest plot of US methods (TVUS, TRUS) for detection of ovarian endometriosis. Plot shows study‐specific estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. Studies are presented for TVUS and TRUS and are ordered according to year of publication. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional TVUS are presented as 'modified method'.
13
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Summary ROC plot of US methods (TVUS, TRUS) for detection of ovarian endometriosis. Each point represents the pair of sensitivity and specificity from a study. The size of each point is proportional to the study sample size. The solid black circle represents the pooled sensitivity and specificity, which is surrounded by a 95% confidence region (dashed line) (for TVUS).
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Forest plot of MRI for detection of ovarian endometriosis. Plot shows study‐specific estimates of sensitivity and specificity (squares) with 95% CI (black line). Studies are ordered by year of publication. FN: false negative; FP: false positive; TN: true negative; TP: true positive.
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15
Forest plot demonstrating the direct comparison between TVUS and TRUS for ovarian endometriosis. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
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16
Forest plot demonstrating the direct comparison between TRUS and MRI for ovarian endometriosis. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
17
17
Forest plot demonstrating the direct comparison between TVUS and MRI for ovarian endometriosis. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
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Forest plot of TVUS for detection of DIE/Posterior DIE. Plot shows study‐specific estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. Studies are ordered according to year of publication for DIE and Posterior DIE, respectively. Tests on the same population (different TVUS methods) are presented separately as TVUS*. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional TVUS are presented as 'modified method'.
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Summary ROC plot of TVUS for detection of DIE/Posterior DIE. Each point represents the pair of sensitivity and specificity from a study. The size of each point is proportional to the study sample size. Tests on the same population (different TVUS methods) are presented separately as TVUS*. The solid black circle represents the pooled sensitivity and specificity, which is surrounded by a 95% confidence region (dashed line).
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Forest plot of MRI for detection of DIE/Posterior DIE. Plot shows study‐specific estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. Studies are ordered according to year of publication. Tests on the same population (different MRI methods) are presented separately as MRI*. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional MRI are presented as 'modified method'.
21
21
Summary ROC plot of MRI for detection of DIE/Posterior DIE. Each point represents the pair of sensitivity and specificity from a study. The size of each point is proportional to the study sample size. Tests on the same population (different MRI methods) are presented separately as MRI*. The solid black circle represents the pooled sensitivity and specificity, which is surrounded by a 95% confidence region (dashed line).
22
22
Forest plot demonstrating the direct comparison between TVUS and DCBE for DIE/Posterior DIE. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
23
23
Forest plot demonstrating the direct comparison between TVUS methods for DIE/Posterior DIE. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
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24
Forest plot demonstrating the direct comparison between MRI methods for DIE/Posterior DIE. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
25
25
Forest plot demonstrating the direct comparison between 3D‐TVUS and MRI for DIE/Posterior DIE. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
26
26
Forest plot of all imaging tests for diagnosis of USL involvement by endometriosis. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. Studies are ordered according to year of publication for each test. Tests on the same population (different MRI methods) are presented separately as MRI*. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
27
27
Summary ROC plot of TVUS for detection of USL involvement by endometriosis. Each point represents the pair of sensitivity and specificity from a study. The size of each point is proportional to the study sample size. The solid black circle represents the pooled sensitivity and specificity, which is surrounded by a 95% confidence region (dashed line).
28
28
Summary ROC plot of MRI for detection of USL involvement by endometriosis. Each point represents the pair of sensitivity and specificity from a study. The size of each point is proportional to the study sample size. Tests on the same population (different MRI methods) are presented separately as MRI*. The solid black circle represents the pooled sensitivity and specificity, which is surrounded by a 95% confidence region (dashed line).
29
29
Forest plot demonstrating the direct comparison between TVUS and TRUS for USL involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
30
30
Forest plot demonstrating the direct comparison between MRI and TRUS for USL involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
31
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Forest plot demonstrating the direct comparison between MRI and TVUS for USL involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
32
32
Forest plot demonstrating the direct comparison between 2D‐MRI and 3D‐MRI for USL involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
33
33
Forest plot of all imaging tests for diagnosis of RVS involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. Studies are ordered according to the year of publication for each test. Tests on the same population (different TVUS methods) are presented separately as TVUS*. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
34
34
Summary ROC plot of TVUS for detection of RVS involvement. Each point represents the pair of sensitivity and specificity from a study. The size of each point is proportional to the study sample size. Tests on the same population (different TVUS methods) are presented separately as TVUS*. The solid black circle represents the pooled sensitivity and specificity, which is surrounded by a 95% confidence region (dashed line).
35
35
Forest plot demonstrating the direct comparison between TVUS and RWC‐TVS for RVS involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
36
36
Forest plot demonstrating the direct comparison between TVUS and TRUS for RVS involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
37
37
Forest plot demonstrating the direct comparison between MRI and TRUS for RVS involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
38
38
Forest plot demonstrating the direct comparison between MRI and TVUS for RVS involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
39
39
Forest plot of all imaging tests for diagnosis of vaginal wall involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. Studies are ordered according to year of publication for each test. Tests on the same population (different MRI methods) are presented separately as MRI*. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
40
40
Summary ROC plot of TVUS for detection of vaginal wall involvement. Each point represents the pair of sensitivity and specificity from a study. The size of each point is proportional to the study sample size. The solid black circle represents the pooled sensitivity and specificity, which is surrounded by a 95% confidence region (dashed line).
41
41
Summary ROC plot of MRI for detection of vaginal wall involvement. Each point represents the pair of sensitivity and specificity from a study. The size of each point is proportional to the study sample size. Tests on the same population (different MRI methods) are presented separately as MRI*. The solid black circle represents the mean sensitivity and specificity, which is surrounded by a 95% confidence region (dashed line).
42
42
Forest plot demonstrating the direct comparison between TVUS and TRUS for vaginal wall involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
43
43
Forest plot demonstrating the direct comparison between TRUS and MRI for vaginal wall involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
44
44
Forest plot demonstrating the direct comparison between TVUS and MRI for vaginal wall involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
45
45
Forest plot demonstrating the direct comparison between 2D‐MRI and 3D‐MRI for vaginal wall involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
46
46
Forest plot of all imaging tests for diagnosis of POD obliteration by endometriosis. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. Studies are ordered according to year of publication for each test. Tests on the same population (different MRI methods) are presented separately as MRI*. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
47
47
Summary ROC plot of TVUS for detection of POD obliteration by endometriosis. Each point represents the pair of sensitivity and specificity from a study. The size of each point is proportional to the study sample size. The solid black circle represents the pooled sensitivity and specificity, which is surrounded by a 95% confidence region (dashed line).
48
48
Summary ROC plot of MRI for detection of POD obliteration by endometriosis. Each point represents the pair of sensitivity and specificity from a study. The size of each point is proportional to the study sample size. Tests on the same population (different MRI methods) are presented separately as MRI*. The solid black circle represents the pooled sensitivity and specificity, which is surrounded by a 95% confidence region (dashed line).
49
49
Forest plot demonstrating the direct comparison between 2D‐MRI and 3D‐MRI for POD obliteration by endometriosis. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
50
50
Summary ROC plot of TVUS and MRI for detection of anterior DIE. Each point represents the pair of sensitivity and specificity from a study. The size of each point is proportional to the study sample size, and the shape designates different imaging modalities. The solid black circle represents the pooled sensitivity and specificity for TVUS, and the bars correspond to 95% CIs of each individual study.
51
51
Forest plot of all imaging tests for diagnosis of rectosigmoid involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. Studies are ordered according to year of publication for each test. Tests on the same population (different TVUS and MRI methods) are presented separately as TVUS* and MRI*. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
52
52
Summary ROC plot of TVUS for detection of rectosigmoid involvement. Each point represents the pair of sensitivity and specificity from a study. The size of each point is proportional to the study sample size. Tests on the same population (different TVUS methods) are presented separately as TVUS*. The solid black circle represents the pooled sensitivity and specificity, which is surrounded by a 95% confidence region (dashed line).
53
53
Summary ROC plot of TRUS for detection of rectosigmoid involvement. Each point represents the pair of sensitivity and specificity from a study. The size of each point is proportional to the study sample size. The solid black circle represents the pooled sensitivity and specificity, which is surrounded by a 95% confidence region (dashed line).
54
54
Summary ROC plot of MRI for detection of rectosigmoid involvement. Each point represents the pair of sensitivity and specificity from a study. The size of each point is proportional to the study sample size. Tests on the same population (different MRI methods) are presented separately as MRI*. The solid black circle represents the pooled sensitivity and specificity, which is surrounded by a 95% confidence region (dashed line).
55
55
Summary ROC plot of MDCT‐e for detection of rectosigmoid involvement. Each point represents the pair of sensitivity and specificity from a study. The size of each point is proportional to the study sample size and the shape designates consecutive or non‐consecutive enrolment. The solid black circle represents the pooled sensitivity and specificity, and the bars correspond to 95% CIs of each individual study.
56
56
Summary ROC plot of DCBE for detection of rectosigmoid involvement. Each point represents the pair of sensitivity and specificity from a study. The size of each point is proportional to the study sample size. The solid black circle represents the pooled sensitivity and specificity, and the bars correspond to 95% CIs of each individual study.
57
57
Forest plot demonstrating the direct comparison between TVUS and 3D‐TVUS for rectosigmoid involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
58
58
Forest plot demonstrating the direct comparison between TVUS and MRI for rectosigmoid involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
59
59
Forest plot demonstrating the direct comparison between TVUS and TRUS for rectosigmoid involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
60
60
Forest plot demonstrating the direct comparison between TRUS and MRI for rectosigmoid involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
61
61
Forest plot demonstrating the direct comparison between RWC‐TVS and TRUS for rectosigmoid involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
62
62
Forest plot demonstrating the direct comparison between TVUS and DCBE for rectosigmoid involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
63
63
Forest plot demonstrating the direct comparison between TRUS and DCBE for rectosigmoid involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
64
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Forest plot demonstrating the direct comparison between RWC‐TVS and MDCT‐e for rectosigmoid involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
65
65
Forest plot demonstrating the direct comparison between MDCT‐e and MRI for rectosigmoid involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
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Forest plot demonstrating the direct comparison between 2D‐MRI and 3D‐MRI for rectosigmoid involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
67
67
Forest plot of all imaging tests for diagnosis of bowel [ileum ‐ rectum] involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. Studies are ordered according to year of publication for each test. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
68
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Summary ROC plot of US methods (TVUS, TRUS) for detection of bowel [ileum ‐ rectum] involvement. Each point represents the pair of sensitivity and specificity from a study. The size of each point is proportional to the study sample size. The solid black circle represents the pooled sensitivity and specificity (for TVUS), and the bars correspond to 95% CIs of each individual study.
69
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Summary ROC plot of MDCT‐e for detection of bowel [ileum ‐ rectum] involvement. Each point represents the pair of sensitivity and specificity from a study. The size of each point is proportional to the study sample size. The solid black circle represents the pooled sensitivity and specificity, and the bars correspond to 95% CIs of each individual study.
70
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Forest plot demonstrating the direct comparison between TVUS and TRUS for bowel [ileum ‐ rectum] involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
71
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Forest plot demonstrating the direct comparison between RWC‐TVS and MDCT‐e for bowel [ileum ‐ rectum] involvement. Plot shows study‐specific paired estimates of sensitivity and specificity (squares) with 95% CI (black line) and country in which the study was conducted. FN: false negative; FP: false positive; TN: true negative; TP: true positive. Modifications to the conventional technique are presented as 'modified method'.
1
1. Test
TVUS pelvic.
2
2. Test
TVUS ovarian.
3
3. Test
TVUS DIE.
4
4. Test
TVUS posterior DIE.
5
5. Test
TVUS* posterior DIE.
6
6. Test
TVUS USL.
7
7. Test
TVUS RVS.
8
8. Test
TVUS* RVS.
9
9. Test
TVUS vaginal.
10
10. Test
TVUS POD.
11
11. Test
TVUS anterior DIE.
12
12. Test
TVUS rectosigmoid.
13
13. Test
TVUS* rectosigmoid.
14
14. Test
TVUS bowel [ileum ‐ rectum].
15
15. Test
TRUS ovarian.
16
16. Test
TRUS USL.
17
17. Test
TRUS RVS.
18
18. Test
TRUS vaginal.
19
19. Test
TRUS rectosigmoid.
20
20. Test
TRUS bowel [ileum ‐ rectum].
21
21. Test
MRI pelvic.
22
22. Test
MRI* pelvic.
23
23. Test
MRI** pelvic.
24
24. Test
MRI ovarian.
25
25. Test
MRI DIE.
26
26. Test
MRI posterior DIE.
27
27. Test
MRI* posterior DIE.
28
28. Test
MRI USL.
29
29. Test
MRI* USL.
30
30. Test
MRI RVS.
31
31. Test
MRI vaginal.
32
32. Test
MRI* vaginal.
33
33. Test
MRI POD.
34
34. Test
MRI* POD.
35
35. Test
MRI anterior DIE.
36
36. Test
MRI rectosigmoid.
37
37. Test
MRI* rectosigmoid.
38
38. Test
MDCT‐e rectosigmoid.
39
39. Test
MDCT‐e bowel [ileum ‐ rectum].
40
40. Test
18FDG PET–CT pelvic.
41
41. Test
DCBE DIE.
42
42. Test
DCBE rectosigmoid.
43
43. Test
MRI pelvic1.
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References

References to studies included in this review

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References to studies excluded from this review

Abrao 2004 {published data only}
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References to ongoing studies

NCT01939535 {unpublished data only}
    1. Ongoing trial NCT01939535. Preoperative Staging of Endometriosis With MRI (IDEAL). Registered June 27, 2013.
NCT02233621 {unpublished data only}
    1. Ongoing trial NCT02233621. Assessment of Performance of [18F]‐FES for Endometriosis Diagnosis (ENDOTEP) [Evaluation Des Performances de la Tomographie Par Emission de Positons Avec la 16α‐[18F]Fluoro‐17β‐estradiol ([18F]‐FES) Pour le Diagnostic de l'Endometriose]. Registered June 2012.
NTR3738 {unpublished data only}
    1. Ongoing trial NTR3738. Magnetic Resonance Imaging to Diagnose Endometriosis Using Ablavar® as Contrast Agent: A Feasibility Study. Registered 5‐Dec‐2012.

Additional references

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