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I'm sorry. So, hello, everyone, welcome to our T talk and talk webinar today. Uh We have wonderful guests. And uh first, I'd like to uh welcome and say hello to our president of European Network of trainees in subjects and gynecology, Sophia from Greece. Hello, Sophia. Hello, good afternoon, Miba. So nice to have you here. Thank you for joining. Thank you very much then, thanks and foremost, I would like to thank you for the kind invitation. I would like to congratulation, the Turkey's uh Chinese Society for this great interesting webinar uh that is all endorsed by the independent of trainees because it's all your work. And thank you very much for that for doing that for the Turkish colleagues. And I'm very fascinated to attend it and to know more about the ultrasound diagnosis in uh endometriosis. Thank you very much for your support and, and your endorsement. And um I'd like to also introduce our wonderful uh colleague and speaker today, Allen Constantin. Um He's going to talk to us about ultrasound diagnosis on endometriosis and correlations to the surgical findings. He is working in the University of Ireland in the Departments of Obstetrics Gynecology and reproductive medicine. He is also one of the yo young core team members of European Endometriosis League and we have been working together for a couple of years now. And thank you so much Ellen for accepting our invitation and joining us today. Thank you very much for the, for the invitation and I congratulate you for the initiative. I think training for the trainees is extremely important. And uh yeah, as most of us know, endometriosis is quite a neglected topic. And uh I can remember when I was studying for my um specialty exam from a total of 700 pages. Endometriosis was covered over two pages. So yeah, in the name of the patients, I think that's, that's unfair. And uh I think we have a long way to go in terms of uh of training and awareness. Yes. Thank you for mu very much for uh increasing that awareness for us trainees and young OBGYN S and this uh video will be recorded and will be online. So as you know, a lot of the trainees are on night shifts and working very hard. So I have the chances to watch online and if you are um OK, we can start with your webinar stent and uh we can let me get my screen. That's fine. This one for everybody. Yeah, it looks great. OK. It's quite a long presentation with a lot of videos I think uh we um as doctors love videos and especially for trainees. This is um extremely important. So I'll be talking about the ultrasound diagnosis of endometriosis and correlations to the surgical findings. And I think we can start by saying that we have an unacceptable delay um when it comes to diagnosis and therapy of endometriosis. So the delay is between four and 11 years in most of the countries. And I think we need to change the narrative regarding uh the diagnosis of endometriosis. And uh we'll see what we can do tonight in terms of diagnosis. That's important because we know that endometriosis patients are uh suffering um due to pain, infertility and the quality of life. And this is causing a significant impair uh in terms of wellbeing, physical, social, emotional and me. But which are the challenges uh of endometriosis diagnosis. We can, we can classify the diagnosis of endometriosis in forming pillars, analysis uh history, taking the examination, clinical exam, the imaging, uh and last but not least uh laparoscopy. So we'll take them one by one and we'll start with the patient history. So, uh diagnosing uh and shows this patient, it's important to focus on family history of end thats menstrual cycle past surgeries, uh gp childish infertility, any past treatments for heos or medical treatment partners. When it comes to infertility, we should ask about symptoms about pelvic pain. So we have the four main d the dysmenorrhea, deep dyspareunia, dyschesia dysuria, but not just these four main symptoms. We also need to ask about any catamenial symptoms or cyclical pain. Um So whenever we're suspecting lung endometriosis, we should ask about cyclic hemoptysis, uh catamenial hemothorax or hemithorax, uh skin and other systems. Um Other symptoms and signs include pain in population or heavy menstrual bleeding. Whenever the patients are suffering because of adenomyosis, pain after intercourse or any noncyclic pelvic pain, premenstrual spotting, fatigue, any catamenial symptoms, constipation, diarrhea, bloating, the end of belly nausea, all these symptoms should uh should rise our suspicion of endometriosis. Now, working with questionnaires uh can make our life easier and we can save a lot of time when it comes to writing the findings. And we know that uh this aspect is taking a lot of time um uh when, when you're working as doctors and this is something that it's increasing. So you can either use questionnaires that you design yourself or you can use standardized validated questionnaires like the E HP five or 30 or sf 36 depending on what you're looking for. But this is something that saves a lot of time and helps us especially with the follow up of this patient. Now, the second pillar was the clinical exam and uh for that, we have the inspection and palpation. Um The recommendation would be to use a Cipro specula because that helps us to evaluate the posterior vaginal four it easier. Um We should perform a bimanual examination, vaginal palpation plus minus regular vaginal palpation, depending on the vaginal palpation and last but not least, we, we should also look for abdominal scars because endometriosis is something that we can also find in the liver, for example of the C section scars. So I was saying that the separate specula will help us to better evaluate the posterior vaginal for and lesions. As these ones are quite often just the tip of the iceberg. Um The physical examination which includes also evaluating the umbilicus, uh looking for a primary or um secondary uh umbilical endometriosis or C section, uh scar endometriosis. Um But just the, the history taking and the clinical exam are not going to help us to uh know before the surgery that we're going to expect something like this, like a frozen p pelvis with endometriosis cyst, the ovaries stuck to the uterus, the bowel stuck to the pelvic sidewall. So these are, these are surprises that we'd like to avoid. These. These are findings that we'd like to know before we start the surgery. And why is it, uh why is it difficult because as you can see in this uh uh video recording of the surgery endometriosis um uh has this iceberg phenomenon. So basically, when we do the laparoscopy, we'll be able to um surf just uh just the peritoneum and see anything that's uh that's above the peritoneum. So, the challenge with endometriosis is to diagnose the uh retroperitoneal disease, the deep endometriosis and the laparoscopy will not, uh will not help us to identify all these lesions. And uh sometimes these lesions might infiltrate the bowel or the posterior vaginal pharynx or the ureter or the bladder. And uh we need to prepare for that. So to prepare for that, we need to know before the surgery what we're dealing with. And we need to uncover the this iceberg of uh of ignorance. And uh in order to diagnose deep endometriosis that might uh infiltrate the bowel of the bladder, the rectal vaginal uh space or the pelvic nerves, we need imaging because imaging allows us to evaluate um not only the retroperitoneum but also evaluate the, the, the adhesions and the mobility of different organs. And for that, we have the ultrasound and the MRI. These are the two most important tools that we have when we uh when we get to uh diagnose endometriosis. Now, the transvaginal ultrasound has lots of advantages. It's a tool in the hand of the gynecologist. So for most of us, whenever we start our, our training, we're going to do a transvaginal scan. Maybe in our first or second week, it's also faster than MRI. It's cheaper, it has less contraindications, it's a repeatable uh diagnostic tool. It's a dynamic examination um and it doesn't require any preparation. Um Now, I think most of us are, are uh familiar with the EF I score. Then it shows fertility um uh index which allows us um based on the surgical findings and the historical factors to uh predict which are the chances that the patient is going to become pregnant. Um Now, Carla Toti from Belgium published a very nice paper where she um managed to demonstrate that um preoperative ultrasound can estimate the endometriosis fertility index. So, based on the ultrasound findings, we can tell our patients which are the chances that they're, they're going to become pregnant after the surgery. Um Another challenge is that we only see what we look for, but we only look for what we know. And, uh, most of us start our training learning that doing a transvaginal ultrasound. Uh, there are a couple of organs. So we see an uterus, some ovaries, uh, bladder and, uh, that's it. But if we know that there's more than these organs, then we'll be able to look for that. And this is important because the best surgery is the first surgery. So we don't, we want to avoid unnecessary repetitive surgery. So we don't want to go for a laparoscopy to excite endometriosis and then have a surprise. Oh, this is the frozen pelvis, the bowel is infiltrated or the bladder and the patient didn't sign the informed consent for that. So by doing the pre op ultrasound, we get a mapping of the disease and we, we, we're going to prepare for that. Um, and this, this thing from Benjamin Franklin by failing to prepare, you are preparing to fail. So we need to, to, to prepare because we don't want to fail. So how do we prepare? Now? We have two main um papers um from 2016, 2015, we have the idea consensus in the Musa consensus. And the idea consensus paper tells us how we should define the lesions, how we should measure the lesions, which terms should we uh use. And the MUSA basically is doing the same thing. But for adenomyosis and for myomas, these are free papers. So I encourage you to go and uh and uh read them and take your time for that because this is a good start to, to understand how we should diagnose endometriosis per ultrasound. But it's important that we also speak the same language, not only when we scan for endometriosis, but also when you classify. So I'm not speaking uh Turkish. But if some of you are going to see a patient and uh classified endometriosis in Turkey with the hashtag and um then I will be able to read the code and understand, OK. These are the type of lesions that um this patient was diagnosed with and the same goes for patients in, in China or India or Australia or other countries that don't speak the same language that I'm speaking. But using the hashtag nse A code, we can communicate with each other and we can offer a better care to our patients. Now, we have multiple studies. We have this uh study from digit, which is a retrospective study and study from Iana Montanata, which is a prospective study. Both of them showed uh very good uh correlations of the preop ultrasound uh hashtag ancient findings and uh intraop uh surgical findings. And we can see that um you're having good sensitivity, good specificity and overall a good accuracy for these type of lesions. Now, the idea consensus paper is recommending four steps and we'll take them one by one. and uh uh to understand better what which, which are the main touch points uh that we're getting when, when we doing the transvaginal ultrasound. So the first step is to evaluate the uterus and evaluating the uterus. We need to look for adenomyosis. And for that, we have direct and indirect signs recommended by the MUSA paper as the symmetry of the uterine wall hyper lesions, uh irregular or interrupted junctional zone, um globular uterus, the but the um subendometrial lines. So all these are information you you'll find in the, in the Mussa paper. So, diagnosis of adenomyosis has also a very good sensitivity specificity uh when we do that with the transvaginal ultrasound. And here are a couple of examples of some uteri uh where you can, we can see where you can see multiple ultrasound signs according to the MUSA criteria. Um In this case, like the asymmetry, the, the defense shaping or in this case, we again, you're seeing that the anterior rectal or anterior uterine wall is much thicker than the posterior wall. You can see a lot of hyperechoic lesions in the anterior uterine wall. Um There's another example where you also get to, to see some uh cystic uh lesions. Um This is a picture from, from a surgery from the osada technique where um a patient failed to become pregnant after more than five IVF S. So, uh we recommended her on uh cytoreduction surgery where we excised the adenomyosis from the, from the, from the uterus wall. This is a uh ultimate ratio, um a recommendation. So this is a surgery that we shouldn't perform. Uh very often. It's like the last resort for patients who don't manage to become pregnant in any other ways. Um Then the next step would be to evaluate the, the ovaries and the tubes. So, dealing with the ovaries in most cases will be seeing the typical aspect of the endometriomas as a ground glass aspect. We should however, evaluate this. Um this cyst according to the aorta criteria, not to miss any, any malignant findings. Um maybe an important takeaway message for everybody is that isolated ovarian endometrioma are a myth. So whenever you hear any colleagues saying uh yeah, I'll do the surgery tomorrow. It's just an endometriosis cyst. This is a myth and uh we have multiple papers like this one demonstrating that uh it's never just an endometriosis cyst. You, you will definitely find um other lesions in terms of adhesions or deep endometriosis. So, the, the endometrioma is a sign of complex surgery and uh extended endometriosis. Then the second step would be the soft markers. Remember that we have two hands. So we may palpate the pelvis, um using one hand on the, on the abdomen and the other other hand, holding the um ultrasound probe and we can basically revert the uterus, push the ovary toward the probe. And here are a couple of examples where you can see that the, the right ovary um slides very well towards the pelvic side, well to the, to the uterus. So in this case, we're not having any ultrasound signs of adhesions of this ovary. We have just a hemorrhagic cyst over there, but no signs of adhesions on the right side. On the other hand, here, you can see um we're having an endometriosis cyst which is not attached to the uh uterine sidewall, but which is attached to the pelvic side wall into the inter sacral ligament. This is another example of uh of uh of the right ovary, which is tuck to the uterus site. Well, but it's free um uh free uh to the to the pelvic cycle. So this is one of the main advantages of, of ultrasound. It's a dynamic examination compared to the MRI. So it's quite easy for us to evaluate any signs of adhesions and mobility of the organs and the same goes for the sliding signs. So, using the ultrasound probe. In the other hand, uh palpating the the abdomen, we can evaluate and see if uh we're having any a lesions of the posterior uterine wall or the anterior uterine wall. So this is a simple sign uh which provides us a lot of information because in this way, we can confirm or we can exclude a frozen pelvis, which means complex signature. Now let's move to the anterior and posterior compartment and see what is important for the for the surgeon because these are basically the compartments and the type of deep endometriosis that are going to make the surgery more complicated. And we'll start with the bladder endometriosis. But it's important for the for the surgeon, but it's important for us before going into the or so, it's important to know what's the size of this leg lesion. Where is this lesion localized? How many lesions do we have? And what's the distance to the Trigon? And what's the distance to the uh osteo? Because these are two aspects that might make the surgery more complex or might be uh might give us a hint that maybe we shouldn't do any surgery as well, especially when these lesions are close to the tri. And why is this important? Because dealing with bladder endometriosis, we might need to involve a urologist. We might need to do a cystoscopy before the surgery depending how close that lesion is uh to the to the ureter, we might decide to do a to place a stent uh in the ureter. Uh we might consider doing the surgery as a conventional laparoscopy or robotic surgery. We should consider urethral reimplantation. Um So these are two nice pictures from the idea consensus paper which is recommending that we scan the bladder with a small amount of urine inside because this is going to reduce the false negative findings. So basically, if you have, we don't have enough urine in the bladder, we cannot evaluate the bladder wall and we might get some folding, which might make us think there might be endometriosis over there. Um And we shouldn't do it when the bladder is full because it's difficult to evaluate the whole uh the whole bladder do. And it's difficult to evaluate the posterior compartment because the full bladder is going to push the uterus uh uh backwards. The bladder is the most forgiving organ. I think all of us know that. So cutting the bladder um is no problem. As long as we realize that during the surgery, we suture the bladder and we leave um bladder catheter for 6 to 7 days. So this is an example of a of a, a huge bladder endometriosis nodule about 3.5 centimeter. So in this case, the lesion was quite big, was quite close to the to the osteo ureteral. Now, in this case, we decided to do this with robot, we placed for the surgery, um DJ stents on both sides you can see that uh we're not dealing just with the bladder endometriosis. There's also some Aden component uh which is important to excise and not leave it over there because it might infiltrate against the bladder. Um So here you can see that in the first place. Uh we were excising about 80% of the lesion. And then there was still some of this adenoma component. Here, you can see the distance to the, to the ureter. You can see the DJ stents in, in place. Um And this, this is the moment where the urologist was, was called in. Uh he showed him the findings and he said, ok, no problem will be suturing that like we always did. And after that, we checked for, for any leak, but it's not just the size of the lesion, it's also the number of the lesions that are important. So, in this case, you see that before the surgery, we, we saw that we're going to deal with two bladder endometriosis nodule, putting the Doppler, you saw that both lesions are far away from the, from the ureter. So in this case, it wasn't a difficult surgery, we had to excise two lesions, suture, the bladder, uh leave a, leave a bladder catheter for for seven days and uh everything would be would be fine. Let's move further to the ureter and menstrualis. What is important for the surgeon again, the size of the lesion? What's the length of the stenosis where the lesion is causing the stenosis of the ureter. And what's the distance to the bladder? Why is this important? Because in this way, we can decide if we're going to um involve uh, a urologist, we're going to do a renal scintigraphy in order to check the renal function if we have to place before the surgery and the, uh, uh urethral stent, we're going to repeat the renal scintigraphy after we put the D stent after 6 to 8 weeks, are we going to do the surgery with conventional laparoscopy or do we have to do with the robot? Um So, so these are, these are cases that we need to discuss in a multidisciplinary team with the urologist. Now, we know that ETS is classified in extrinsic or intrinsic. Most of the cases is just extrinsic endometriosis, which means that the adventis that's overlying the, the ureter is causing an external com compression. So, in cases like this, we're getting away just with the, with the urethrolysis. But whenever we're dealing with intrinsic, which means that the spate layer of the ureter is involved, then in this case, we're dealing with a complex surgery, we have to excise a segment and perform with anastomosis or uh go for a ureteral reimplantation. In most cases, the left ureter uh is involved more frequent than the right one and the distal third of the ureter is more affected than, than the rest. So what can the ultrasound, do so with the transvaginal ultrasound, we can um evaluate the ureter, the intramural part. We can follow the ureter all the way cranially uh up to the crossing with the uterine artery and then cranial to the uterine artery. And here a couple of examples of hydroureter. So, according to the hash s classification, we're talking about the hydroureter whenever the diameter of the ureter is above six millimeters. And this is a sign of stenosis. So the T VS helps us to identify the lesion that is causing the stenosis of the, of the ureter. And in this way, we can plan the surgery. So in this case, we knew what we're dealing with. We placed a stent, we checked the renal function, we involved the urologist. We knew that this is going to be a complex surgery or we'll be deciding during the surgery if we are going to um uh do a partial resection of the ureter with anastomosis or we have to uh to reimplant. And in this case, we decided not to reimplant the ureter, but we performed um partial resection of the ureter with an end to end anastomosis. Um There is another example with a massive hydroureter in this case due to the length of the, of the stenosis and the distance to the bladder. Um we decided to perform a uh ureteral reimplantation. And here we can see the steps of the urethrolysis here, we can see that we're dealing with the intrinsic um endometriosis. So that's the stenosis of the ureter. So that's why we decided that, that it's better to, to go for a reimplantation. Um Each patient with endometriosis and not just deep endometriosis. So, whenever you have the suspicion of endometriosis, please perform a kidney ultrasound. It's fast. It doesn't take more than 30 seconds, but it provides us extremely important information because uh hydronephrosis is an indirect sign of the arterial stenosis. And here on the right side, you can see the result of uh um kidney uh syn gray and you can see that the renal function on the left side was just 4.2%. So, in this case, we're not uh thinking about uh what type of surgery we are going to do. We reimplant the ureter or do a end to end anastomosis. No, in this case, it was unfortunately too late for the patient and we had to do a nephrectomy and uh ureterectomy. So kidney ultrasound again, doesn't take more than 30 seconds, but it's going to exclude any severe disease um in the premium involving the urethra. Um Of course, it's not always able to see endometriosis of the ureter. And here you can see one of the cases where when we did the transvaginal ultrasound, we, we didn't see the lesion causing the, the hydroureter, but we did the kidney ultrasound which showed us uh that there is hydronephrosis. Um And then we decided to go for an MRI. And here you can see this was a lesion which was quite cranial uh at the level of the mesorectum and the inter sacral ligament which was causing the stenosis. So the upper the lesion uh is found the more difficult it is for the transvaginal ultrasound to, to identify lesions like this once sometimes. However, we're not getting any um any hydronephrosis and we don't see anything on the T VS. So this is the patient that was referred to me uh with the suspicion of urethro endometriosis. I did ATV S scan, I only found she had a lesion on the UACR ligament and I followed the, the ureter up to the crossing with the eternal artery and then further above, I didn't see any hydroureter. I didn't see any lesion close to the ureter. So I guess, ok, maybe, maybe in the colleagues who did the first surgery, um maybe they, they misunderstood. So this is the lesion that I saw in ultrasound, which was the lesion found on the transvaal on the uter sacral ligament. But as I started to, to dissect the ovary from the left ovarian fossa, I saw this lesion and again, in the first place, I thought maybe this is just a superficial lesion. But uh as soon as I started to perform the urethrolysis, I found this was uh this was uh a serious lesion that is uh that is affecting the, the ureter, but it's not causing any, any, any hydroureter. So, um yeah, this is a difficult situation where you, you can, where you have basically two options, you say, OK, I'll stop and then I'll do everything in a second session, discuss the options with the patient. Um However, in this case, we decided to do a, a deep shaving of lesion and we tried to, to excise as much as possible um of these endometriosis lesions from the, from the ureter. Of course, after that, we called the urologist to evaluate the ureter. He said everything is fine, but we decided to be on the, on the safe side and we placed um a digest stent for six weeks. Um Let's move now to the posterior compartment and see what is it that we can find uh when we're looking for deep endometriosis at this level. So we'll start with the vaginal endometriosis. What is important for the surgeon again, the size of the lesion. And we need to know if the rectum is infiltrated. It is important because we need to know if you're going to have to involve a general surgeon. Do we need any complex vaginal reconstruction when we have to do um an extended partial lumpectomy? Do we need any prophylactic uh preparation for bowel surgery whenever this uh this is uncertain. So earlier, we saw this picture and we, I was saying that some that in most cases lesions like this, when I infiltrating the poster vaginal forni are just the tip of the iceberg and the ultrasound is going to help us to, to dive deep and understand what is it below? Is the bowel infiltrated or it is a, a good example of uh of a of a massive um endometriosis lesion infiltrating the posterior of for um this was this is actually uh was actually a colleague of us uh medical student back then. Um And you can see in all these cases, the bowel is not infiltrated here. You can see that this lesion is also infiltrating the rectovaginal septum. You can see those spikes over there, but there is no rectum infiltrated. So this is important because in cases like this, you know that you can do the surgery by yourself, you don't need to involve a general surgeon. You know that you're going to deal with a partial lumpectomy. Uh you excise, uh a part of the post vaginal fornix and then sutured sometimes. However, the bowel is infiltrated. What is important for us? Again, the size of the lesion? What's the distance from the anal bridge to the lesion? Why is this important? Because the lower the lesion is the more uh risky the surgery can get in terms of an anastomotic. Is there any stenosis of the bowel? Do you have to have any concomitant infiltration of the vagina? Again, this is a risk factor for an anastomotic leak. And are we dealing with a single or multiple condition? So, this is important again to involve a ball surgeon to perform a bowel prep, uh to give antibiotic to the pa patient. Decide, decide on the surgical technique. Are we dealing with multiple anastomosis? Should we consider a protective urostomy or not? Now? Bone and necrosis is something that we are finding uh quite often and we'll be finding this more often as we're going to improve our di uh diagnosis still in terms of um transvaginal ultrasound or MRI. So we're talking about bone and meris whenever the mus colitis property of the bone is infiltrated. Now, the good news is that in almost 84 85% of the cases, the bone and metros is located at the level of the rectosigmoid. So, appendix cecum or um small bowel is something that um that it's, that is quite rare. Usually these are findings that we're going to uh we're going to find whenever we do a laparoscopy because the tvs and the MRI don't have a very good accuracy uh to, to diagnose this. Um So this is why this is one of the biggest challenges from a surgical perspective. So earlier, I was saying that with the T VS, we can measure the distance uh to the anal verge. Um And another important aspect is that we should always um uh measure these lesions on the media sagittal. So the, the distance to the end of the bridge is important because the T VS can predict the height of the final surgical anastomosis. So basically anything that's below 656 centimeters is going to be an ultralow anastomosis which comes with higher risks for an anastomotic leak. The TS can also diagnose the diabola like nodules. What are these? It's a rectovaginal nodules infiltrating the posterior vaginal for neck. So there you can see the tip of the iceberg and in this case, you see by doing the T VS, we can see that not only the vagina but also the anterior rectal. And here you can see a very nice indian re side. This is another example. So massive infiltration of the rectum. Then you can see a small continuum between the bowel and the vagina. And you can see that the vagina is also um infiltrated. The T VS can help us also to diagnose multifocal lesions. So here you can see the first lesion and that you scan the bowel further above, you can find a second lesion. How good are we in diagnosis these multifocal lesions? It's a question that we can uh answer it at the moment. We are still looking for studies for that. And you can see a nice example again of multifocal lesion. So you can see one lesion seen in the ultrasound before the surgery here in the middle, you can see the healthy part of the bowel connecting um the the the two parts of the ball which are infiltrated. Um So this is also this is also a challenge because sometimes you see just the lesions that's localized caudal. And when you do the laparoscopy, you get a surprise to find the second or the third or fourth lesions. What can we do in terms of surgical techniques? We have um a conservative treatment uh by doing a shaving um or a disc excision, by excising the lesion and suturing that or by using a circular stapler to do a disc excision or whenever the lesions are too big or you're having a multifocal lesions, we have to perform a segmental colorectal resection. But how do we diagnose endometriosis when you're doing the laparoscopy? Um We, we do that by visualizing these lesions, we resp them, we pull them, we palpate them. And this is something that is offering us a haptic feedback. Now, how reliable is the haptic feedback? That's a, that's a, that's a good question. Um And this is a challenge, especially if we're going to do robotics, we don't have any heptic feedback. And then um uh the other challenge is that uh we cannot rely very much on what we're seeing on what we're palpating. Um Because after all, we're having an instrument that we're using to, to, to palpate the ball. So you saw in the ultrasound earlier that uh in the pre op ultrasound that we saw, we saw one lesion, uh two lesions. And here during the surgery, we were finding at least three lesions and again, this is robotic surgery and we cannot rely too much on the haptic feedback. So here I was sitting at a console and I was asking my assistant, please grab the bottle and tell me, is there anything that you can palpate? So again, it's not me myself. Uh I'm palpating the bowel. I have to rely on my assistant. How reliable is that? Of course, it depends from system to system and one solution for that would be to perform an intraop uh uh intraabdominal ultrasound. So here you can see that basically through the laparoscopic port, we're placing the probe on the bowel. And you can see in real time um the anterior wall, the posterior wall and uh a thickening of the of the bowel is going to indicate us. OK. Here is the deep endometriosis bowel localized. However, this is a technology that not all the gyne departments uh have it. In this case, I was, I was asking the general surgeons to, to, to give, give us the the probe to check this. This is something they're using for uh hepatic metastasis. Same example here, you can see that I'm I'm uh rolling the, the bowel uh to understand better uh how big is the lesion. But again, it's what I'm seeing. What I'm palpating is just an estimation. But by doing the um intraop intraabdominal ultrasound, you can measure in real time, how big is the lesion and depending on the size you can decide if you want to do a disc excision or you have to do a segmental resection. Um This is another example of, uh, of robotic surgery, bowel, endometriosis. This was a huge nodule almost four centimeters where we decided to do a deep shaving. And here you can see with the, with the thread, uh, we were marking the lesion and then basically, we put a circular stapler inside the, uh, rectum and then we closed that slowly and the unhealthy part of the bowel was basically pushed inside the mouth of the, of the record. Um Whenever the lesions are too big or you have multiple lesions, then in this case, we have to remove a segment. This is quite a standardized procedures, uh procedure from our colleagues from uh about surgery. In this case, uh This was uh uh a technique uh called the nose technique where basically we avoid the mini part to me to bring the anvil and take out the lesions. So basically, we, we do a tullar resection, then we open the, the rectum, we excise the lesion and then through the rectum, we'll, we'll bringing in the Advil and uh we're taking out the lesions and then we per perform the surgery in a, in a standard uh manner uh by doing um side to end or an end to end anastomosis. Um depending on the, on the height of the lesion and the level of the expected anastomosis. Um sometimes we might get surprises. And this is an, an example of uh of a of a patient where in ultrasound, we saw just one lesion. And when we did the laparoscopy, we realized we were palpating at least seven deep endometriosis lesions. So in this case, we had to excise uh quite a long segment of the, of the bowel. And then we sent you to pathology. And uh we were amazed uh that the pathologist found 48 endometriosis lesions in this 31 centimeter segment of bowel. So, as I was saying, uh the transvaginal ultrasound is an excellent tool, but uh sometimes we might get surprises and we might find additional lesions further cranial or involving other um segments of the bowel. How about peritoneal endometriosis? This is also a challenge because they're so superficial, so small lesions that we don't manage to diagnose them when we do ultrasound. However, there are lesions uh that we might pick up when we do the transvaginal ultrasound which are localized at the level of uh of the pouch of dolus. And here you can see those uh hypoechoic lesions at the level of the peritoneum at the level of the pouch of tacs. However, we're getting uh an accuracy of only 64 68% conclusions. Um take away messages. Well, sophisticated ultrasound should be the primary imaging modality. We should perform this according to the idea consensus. Remember that the surgical intervention to confirm the diagnosis alone is not recommended anymore. And for that, we have the, the new guidelines, a pre op imaging procedure with T VS and or MRI is strongly recommended. The ultrasound examination however, does not allow the definitive exclusion of endometriosis. You've seen that the peritoneal lesions, for example, um are not that easy to, to pick up the combination of TBS, kidney ultrasound and clinical exam are sufficient in, in most, in most cases, remember that the kidney ultrasound is mandatory for marima. We should use the aorta criteria not to miss any malignancy. We should use the idea terminology. Whenever we have to document this Rh adenomyosis, we have the well-defined musa criteria. Remember that MRI is not superior to differentiate the skilled ultrasonography. So whenever you compare expert MRI with expert ultrasound, you cannot uh we don't have data showing that MRI is superior in terms of colorectal mes. For example, the TP is better than the MRI has in classification. Um uh should be used to, to, to uh to um document endometriosis findings. As I was saying, it's easier for all of us to, to communicate with each other. It's easier to, to follow the code instead of uh reading uh um multiple multiple phrases um describing the lesion, the major advantage of noninvasive imaging and classification of uh endometriosis. Um It's a differentiated planning or possible avoidance of surgical interventions. As I was saying by doing the sophisticated T vs um social media preop mapping, we can avoid unnecessary laparoscopies. Um We need to, to know to adapt to the imaging, diagnostic to the clinical context. So it's not just TBS or MRI. We should also think about the Mr Andy whenever we suspect small bowel endometriosis or ask for an MRI dit or thoracic MRI. Whenever we suspect some extragenital disease which might be localized at this level, we need to build a, an MDTA multidisciplinary team um because complex cases are not that rare and last, but not least we should also create so P or standard operating procedure in order to, to smooth the blood flow in the hospitals. Um Thank you very much. I hope I didn't talk too much. And um I'm more than happy to invite you next year in uh in Bucharest from the sixth to the eighth of June. We'll be organizing the segment European Metro Congress. Thank you very much. Thank you very much Allen for your excellent presentation. And uh it was, it was really nice to see how the ultrasound images that you, you've seen as endometriosis and how you see them on the surgery. And um well, for you as an expert, it is uh it is nice to hear, but I think we'll have uh some questions from trainees and young OBGYN S to how to uh be an expert. But I just want to ask about you. When did you start learning endometriosis and treating endometriosis? Oh, that's a good question. Let me, let me think about it. So I moved to Germany in 2016 and 2018, I started to work with Roti Beg. So that makes five years. So basically five years ago, I started to, let's say five years ago, I did my first sub total hysterectomy and I think uh four years ago or 4.5, I started with uh with ultrasound. OK, perfect. So, so in four or five years, we can we train we have if we have? That's good. That's, that's, that's a good question. I uh so I think it's not just uh the time, I think it's also important to have a good volume to have exposure to these cases. I think it's important to scan these patients to yourself and then also be in the or so, even if you're not doing the surgery yourself, if there's a colleague doing that, I think it's important to, to be in the or to understand uh there are any lesions that I did not pick up? Are there any lesions that I classified as endometriosis? And there wasn't um Yeah, I saw an ultrasound, some additions between the ovary and the uterus and maybe it wasn't confirmed. So basically the way A I is working with di learn knee is the same thing we have to do as gynecologist. Uh It's also a trial and error and we need to understand which were our mistakes. What was it that we did not pick up. And what was it that we thought there is something and it wasn't because otherwise just spending your time in front of the ultrasound machine and not following up for these patients, you're not going to, to improve uh your skills. So I think this is uh this is an important aspect to, to acquire these uh skills. And then of course, you need uh you need um the cases because if you're dealing just with 1020 cases per year, that's uh it's going to take you uh a longer time to, to, as I was saying, to acquire and improve and develop these skills. Thank you so much. So, uh let's ask the audience and our team if they have any questions. Yeah, I have a question. Uh Thank you very much for explaining this e with us and sharing your good information. I'm wondering um do you think pelvic floor ultrasound uh is useful in the diagnosis of deep endometriosis? And do you use any daily routine pelvic floor? And the ultrasound? Uh This is, this is something that is not recommended by the idea consensus paper. Uh However, let's not forget that the idea consensus paper was published 2016. So that's seven years ago. So we definitely need an update. And in the last seven years, the the medical indus industry has developed a lot. Um And last week, for example, we had the Endometriosis Congress of the German speaking, con uh speaking countries and that was uh I was checking the, the new technology that g is having on the, on the new vs and they were, they were, they were demonstrating the capabilities of the pelvic floor. Uh um I think it was 2.0 with 3d and so on. Um So I think this is uh we can classify this as enhanced uh um ultrasound techniques. Um I don't know if this, this is going to become routine for diagnosis and the meris. But for sure, in, in, in selected cases, this uh this is something that might help and I would speculate that this might be helpful whenever we have to deal uh with uh with the bladder endometriosis infiltrating the trigone. So basically the lesions that we might found find closer to the to the ait test. Um me myself, I don't have any experience with this. Uh I would like to, I would love to try that. Um And as I was saying, given the, the advances of this technology, I'm sure that new papers are going to come out and uh help us identify the the proper indications for this. Thank you. And I'm also wondering um how long do you continue the medical treatment uh of the patients after endometrial surgery? We don't have any data or any indications that will tell us for how long um we have, but we have the data, for example, from, from, from Italy we know that patients who are um doing um are getting uh AC O CS. So combined oral contraceptive after uh endometriosis surgery, um they have a lower risk to, to get endometriosis cyst compared to those who are not getting uh this. Um, on the other hand, should we recommend uh medical treatment to all these patients? Again, we have the new paper from, from uh Ro Joos from uh from London saying that only one third of the patients are going to get more lesions that those lesions are going to increase in size. So, yeah, that's also an ethical question. Should we, should we recommend this medical therapy to all these patients? Uh This study was however, for deep endometriosis, most of these patients are also having adenomyosis. Um If you're asking me from, from my uh for my uh clinical practice, I'm I'm recommending all my patients after the surgery to have a hormonal treatment. So, basically, and uh um hormonal induced amenorrhea. So my recommendation is to take some contraceptives, which one doesn't matter as long as they're not bleeding, as long as they don't have any side effects from this uh hormonal treatment and undefined. I'm I'm not telling them for how long I'm telling them. Yeah. Keep taking them whenever you decide to become pregnant. You can, you can uh you can stop them. Thank you, Sophia. Do you have a question for us? Hello. Congratulations for this very, very well structured. Uh presentation, I think that if you covered all the things and you have been showing directly with all this. Thank you very much for this hard work for all of us. Just to comment about the, the nutritional do because something a thing that now rising in the what you will comment about theno in this. Thank you for the question. It's a very good question. So well, it depends if these patients had intercourse and of course, you can do the transvaginal ultrasound. Um If you, if, if we're dealing with a VGO DTA patient, then an option would be a transrectal ultrasound. So basically the same transvaginal ultrasound probe placed uh inside the, inside the rectum. And then we can evaluate and look for adenomyosis or any signs of deep endometriosis. It's as good as the transvaginal ultrasound. However, it's an invasive procedure and then the alternative uh would be uh would be MRI this is actually practicing Italian colleagues that they do use it the transrectal route for the Virgo. So for the younger patients about the soft marks that you have shown us so clearly in your presentation. But for us as younger as juniors as we don't have the experience ultrasound in this specific disease, how is to recognize these soft markers or this like for example, the per canal disease that you show on this soft, I would, I would, I would say that soft markers are easier to uh to diagnose than deep endometriosis. And hm, as, as I've seen my, my uh my residents who are working with me or who have been working with me, they're picking this up quite fast. So I moved to, to, to this university clinic uh three weeks ago and uh there's a colleague of mine, I don't know if he's attending uh this webinar. And uh for example, today he was doing the T VS scan and I think we spent maybe just two days and I was, I was truly impressed by, by his skills. So soft markers are quite easy because as I was saying, we're having two hands. So if you're having one hand on the probe, the other hand of the patient, and you just push toward the ovaries, push toward the uterus, you're going to see how the organs slide towards each other. So whenever you, you you're having adhesions, you'll see that they're moving together in, in, in, in, in the same direction. If you don't have any adhesions, one is going to move the other is going to stay or they're going to get away from each other. So this is something uh which is not difficult to pick up. And this was published in multiple studies especially for the sliding sign. Um Then regarding the peritoneal disease. Yeah, this is, this is difficult. And uh we, we we managed to to pick up these lesions whenever they localized to the level of the pouch of dark list and we managed to pick them up when the patient has uh has some free fluid over there. Um There's also a nice paper from the, from Matthew Leonardi and from George condos, uh the so pod technique where you can take a catheter, place it inside the uterus um and put some fluid hoping that at least one of the fallopian tubes is not, uh is not closed and you get the fluid inside the pouch of Douglas, which is going to c to create like an acoustic fenster and get some distance between the posterior vaginal or and the, the rectum. And in this way, you might pick up this small 2345 millimeter lesions localized on the peritoneum. Um However, as I was saying, the sensitivity specificity are not that great for, for, for peritoneal lesions. And I think that um laparoscopy is the gold standard for diagnosing peritoneal disease. Thank you very much for this clear verification. Uh You show your expectation. Thank you very much for sharing your T andrick with us. Thank you very much a stone. Mhm Yeah, that was that was quite exciting to know too, Adam. Do you have a question? Uh Firstly, thank you for the wonderful presentation. A. Uh I believe, I believe there is a learning curve for us training to use ultrasound in diagnosis uh as a trainee who is interested in endometriosis and to learn endometriosis ultrasound. Uh where and how uh can we be trained. Yeah, I II was sure somebody's going to, to ask this before starting this webinar. And this is actually a question that I, that I thought I was getting uh whenever I'm uh at any conference. Um So I think, I think it's important to find uh a mentor, an, an expert, somebody who's doing, who's doing this, somebody who's also having some caseload um where, where you get to deal with this uh with this disease. So, um yeah, maybe one important thing would be finding a mentor, an expert, somebody you can learn from um second homework. So all these papers that I was having in my presentation, I think are extremely important. Um Three of course, workshops, webinars, master classes, Congresses are extremely important. Um And also I would say fellowships. So going and spending 1234 weeks in a center with a lot of cases and hopefully you can, you can do some hands on. This is something that is going to help you, especially to do the fine tuning. Um For me, it was like this, I if you allow me to share my my personal experience. So basically, I started to read the, the idea and the Musa papers and I started the ultrasound, I think it was like January, we were having the cases. And so basically the patients I was scanning, I was then seeing in the or and that was assisting professor. So um that's how the the deep learning algorithm starts. So I knew what I saw when I did, did the ultrasound and I went into the or, and I understood, OK, this is the lesion that I missed. I need to look specifically in that direction or uh some adhesions or anything else. So I was doing this for six months and then I went to, to Italy and I spent uh one week with uh Catarina Atos um where II was doing enzyme. It was still possible back then. And, uh I was seeing like 1516, 17 patients per day and she was close to me and I was basically having the my hand on the ultrasound probe and she was, you know, doing the fine tuning, explaining a book here, go close to a scan like this and so on. Um, so this, this was, let's say my learning curve and then of course you do the fine tuning yourself as you see in more cases, more complex disease, uh and doing the surgeries yourself, then you, you, you understand what is it, uh, what is it that, that you should scan look for? What's, what makes the, the surgery more complex? What is an easy surgery? And these are also things that are going to help you when you plan the surgery? Am I going to call the urologist? Am I going to call general surgeon? Does this patient need a bowel prep? This lesion is quite close to the bowel, maybe we need to do something on the bowel as well. Let's do a prophylactic bowel preparation and let her sign for that as well. Um, then, you know, planning the surgery, how many of these surgeries can I do for per day? One? Too complex and an easy one. Just too complex. So, this, it's, it's, it's a process which, uh, which, uh, which takes time, um, at the moment we don't have any um curriculum, you know, that uh that tells us you need to follow these steps to become an expert in ultrasound or in uh in surgery. We have papers from experts recommending this uh this and this and that. Um So the maximum I can do is share with you my uh my, my, my, my personal journey to say. So, uh what about the el training program? Do you think that would be helpful for them? Yeah, el training program is uh let's say part of the, of the fourth step where, where you go somewhere and you spend two weeks uh with an expert and uh depending on the center you, you get to do some hands on. So the, the colleagues I had when, until one month ago, when I used to be in Hamburg whenever they came in, II tried to offer them as much hands on and experience as possible. So they were, they were assisting in the or the surgeries I was performing and whenever the patient was fine with that. They also got, got to do the transvaginal ultrasound and I was trying to teach them and showing them the, the important uh things. Uh So, yeah, the A L trainee program, it's a good opportunity for um spending some time in the, in the SA center and get to do some hands on, as I was saying, depending on the centers and ava availability. Yes, thank you. As I said, I think mentorship is always so important, isn't it? In, in every case, do we have any other questions where um we can wrap up if we do we have any questions that we did not answer? No? OK, perfect. Well, we're just in time and once again, um Thank you Allen for your excellent uh presentation and sharing uh your knowledge and your personal experiences with us. And as Sophia said, tips and tricks, I'm very sure that this is going to be very helpful for trainees and young Ob GN. And thank you Sophia for uh being here and supporting us and to the webinar. No, thank you because it was a great l over 20 for all of us. Thank you very much, Doctor. Thank you very much governor in the community. Thank you for that. I thank you all once again. And uh uh yeah, again, congratulations for this uh initiative. Uh I think such a, such a society is extremely important for the, for the trainees. Uh because sometimes we uh get neglected, especially when we start. We are totally confused and we don't know where to start, what's important, what is going to happen. So, um yeah, II encourage all the all the trainees to to be part of uh N talk and national N Talks. Um And yeah, keep up the good work. And uh if somebody has any, any questions needs any recommendations, mentorship, I'm more than happy to, to help. Thank you so much. Good evening, everyone take care. Bye bye bye.