{'fraction_non_alphanumeric': 0.02395926924228811, 'fraction_numerical': 0.013477088948787063, 'mean_word_length': 5.374045801526718, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 1, 'zh_pornsignals.json': 0}}
The Sonographic Diagnosis of Deep Endometriosis

J Ultrasound Med 2009; 28:408–411 To the Editor: The study entitled “Sonorecto vaginography: A New Sonographic Technique for Imaging of the Posterior Compartment of the Pelvis” by Bignardi and Condous1 describes the use of an imaging method for the diagnosis of endometriosis in the retrocervical area, rectovaginal septum, rectal wall, and pouch of Douglas. In our opinion, deep endometriosis involving the posterior compartment of the pelvis is a very relevant problem, and various studies with sonography are being described to allow the surgeon to perform the best surgical procedure inasmuch as sometimes laparoscopy lets us see only the tip of the iceberg.2–6 However, in these studies,2–6 the imaging methods are realized before the surgical procedure, which allows the surgeon to evaluate the pelvis properly, to discuss the procedure with the patient, and to define the best surgical approach. Another aspect to be pointed out is that nowadays, the specificity and sensitivity of sonography are high, as reported in these various studies. In an analysis of 104 cases,3 transvaginal sonography with bowel preparation (a simple enema 1 hour before the examination) was found to have sensitivity rates of 98% and 95% for rectosigmoid and retrocervical endometriosis, respectively. Also, the upper vagina and the pouch of Douglas can be evaluated using a less complex technique than that proposed by Bignardi and Condous1 (Figure 1). The modified tendernessguided approach consisted of transvaginal sonography combined with the introduction of 12 mL of ultrasound transmission gel (instead of the usual 4 mL) in the probe cover to create a standoff to visualize the near-field area4,6 (Figure 1). The posterior fornix was evaluated accurately with an up-and-down sliding movement of the probe. In addition, when the patient indicated that tenderness was evoked by the probe’s pressure, the sliding movement was stopped, and particular attention was paid to the painful site for detection of endometriotic lesions.4,6 Using this approach, sensitivity of 90% was obtained.4 We consider preoperative diagnosis extremely important nowadays as well as the fact that gynecologic and radiologic centers develop specific protocols to stage the disease properly but also conduct specific operator training based on the following: (1) knowledge of protocols that are simple and efficient, such as tenderness-guided sonography and bowel preparation before the examination; (2) evaluation of specific sites of the pelvis, such as, retrocervical areas; and (3) recognition of sonographic patterns associated with endometriotic lesions. Various published studies in this field show that with simple protocols, it is feasible to achieve the diagnosis of this disease, which is very helpful to the surgeon for planning the best surgical strategy.2–6 To conclude, we believe that the technique proposed by Bignardi and Condous1 is invasive and very complex to perform and does not allow the surgeon to plan the surgery in advance, to discuss the surgical procedure with the patient (because it is performed with anesthesia), and to build a multidisciplinary team before the procedure. On the contrary, we suggest the development of centers of excellence to treat endometriosis and Letters to the Editor