Search Results (159)

Endometriosis is a chronic, debilitating condition affecting approximately 10–15% of reproductive-aged women and it is often associated with significant diagnostic delays due to its heterogeneity and unreliable non-invasive tests. Artificial intelligence (AI) offers innovative methods for improving endometriosis diagnosis, prognosis and research via advanced pattern recognition and data analysis capabilities. The integration of AI in diagnostic workflow has the potential to improve efficiency, accuracy, and patient outcomes. This review summarises current developments of AI—including machine learning, deep learning, and natural language processing—in the diagnostic workflow of endometriosis. It analyses different fields of diagnostics ranging from AI-assisted imaging in detection of pouch of Douglas to multi-omics biomarkers assisting the clinical decision process. AI can enhance accuracy, reducing diagnostic delays and supporting personalised treatment planning. However, there are multiple limitations, such as small datasets, overfitting, and lack of external validation and variability. Further research and evaluation are required before it can be implemented into healthcare systems. AI holds promise as a non-invasive, scalable adjunct to current diagnostics, potentially reducing the economic and personal burden endometriosis carries. Full article

Background/Objectives: This study evaluates the 1-year follow-up outcomes after minimally invasive nerve-sparing surgery for the complete excision of deep endometriosis (DE), with a specific focus on deep dyspareunia. Cases with undesirable outcomes were explored in detail to better understand the evolution of this cornerstone endometriosis-related symptom. This approach supports personalized medicine initiatives by seeking to stratify patients into likely surgical responders and non-responders. Methods: This is an interdisciplinary retrospective observational study assessing 195 consecutive cases. Inclusion criteria comprised women with an established diagnosis of DE who had been sexually active in the 6 months prior to surgery. Because pregnancy and postpartum can interfere with the longitudinal assessment of deep dyspareunia, women in these phases during follow-up were excluded. Additionally, individuals who had not been sexually active in the preceding 6 months for reasons unrelated to deep dyspareunia were excluded. Deep dyspareunia was measured using an 11-point (0–10) self-reported Numerical Rating Scale (NRS). Hierarchical clusters were established based on preoperative scores: NONE (NRS = 0), MILD (1 ≤ NRS ≤ 3), MODERATE (4 ≤ NRS ≤ 6), and SEVERE (NRS ≥ 7). Results: In the SEVERE cluster, 82.2% (95% CI: 72.4–92.0) of women improved by ≥3 points. In the NONE cluster, 70.1% (95% CI: 60.3–79.2) remained asymptomatic. Although improvements in deep dyspareunia were statistically significant across the total sample, individual trajectories were not uniform; the response was considered undesirable in 34 cases (17.4%; 95% CI: 12.1–22.8). The frequency of preoperatively asymptomatic women (NRS = 0) developing De Novo deep dyspareunia (NRS ≥ 3) at the 1-year follow-up was estimated at 14.9% (95% CI: 8.0–22.7). These results highlight the marked phenotypic and clinical heterogeneity in patient trajectories and the inherent unpredictability of adverse responses. Conclusions: Postoperative pain outcomes likely result from a complex interplay among surgical, myofascial, neurological, psychological, inflammatory, and hormonal factors. While surgery remains an effective and safe approach for treating pain, our findings underscore that even preoperatively asymptomatic patients should receive targeted counseling regarding the unexpected risk of developing postoperative deep dyspareunia. Full article

Endometriosis (EMs) is an estrogen-dependent inflammatory disease characterized by the presence of endometrial-like tissue outside the uterine cavity, yet its precise pathogenesis remains incompletely elucidated. TICAM1, a key adaptor protein in the Toll-like receptor (TLR) signaling pathway, is known to be involved in inflammatory responses; however, its specific role in EMs has not been defined. This study integrated evidence from clinical tissue samples of patients with ovarian endometriomas, in vitro studies, and in vivo models to explore the role of TICAM1 in EMs. TICAM1 expression was significantly upregulated in both eutopic and ectopic endometrium, with the highest levels observed in ectopic lesions, where it was primarily localized to stromal and glandular epithelial cells. Functional experiments showed that TICAM1 overexpression promoted the proliferation, migration, and invasion of human endometrial stromal cells (hESCs), while TICAM1 knockdown suppressed these activities. Concurrently, TLR3 and TLR4 were also upregulated in EMs tissues, and their activation increased TICAM1 expression. Knockdown of TICAM1 attenuated the enhanced cellular activities induced by TLR3/TLR4 activation. Mechanistically, IRF3 and IFN-β levels were elevated in both EMs tissues and TICAM1-overexpressing hESCs, while TICAM1 knockdown inhibited TLR3/TLR4-induced IRF3 phosphorylation and subsequent IFN-β production. These findings were further corroborated in a mouse model of EMs. Together, our findings suggest that TICAM1 may enhance the proliferation, migration, and invasion of hESCs by mediating TLR3/TLR4 signaling and promoting IRF3 phosphorylation and subsequent IFN-β production, thereby potentially contributing to EMs progression. Therefore, targeting TICAM1 may represent a potential therapeutic direction for ovarian endometrioma-associated EMs, while its relevance to superficial peritoneal and deep infiltrating EMs requires further investigation. Full article

Adenomyosis is a benign gynecologic condition characterized by ectopic endometrial glands and stroma present within the myometrium. Background/Objectives: The gold standard in diagnosis is the histology of hysterectomy specimens. Due to the heterogeneity of this disease, there is a lack of valid classification. The most important symptoms are chronic pelvic pain and abnormal uterine bleeding, followed by infertility. Noninvasive diagnostic tools have been sought, with ultrasound being a valuable option. The objective of our study was to evaluate the correlation of transvaginal ultrasound, used in addition to three-dimensional ultrasonography and Doppler, with the histology of adenomyosis. Methods: An observational retrospective study was conducted between January 2015 and November 2018 on 160 women with adenomyosis managed by hysterectomy. All patients underwent transvaginal sonography combined with 3D and Doppler sonography. Results: Comparing the location of adenomyosis in the myometrium observed using ultrasound with histological findings, a statistically significant correlation was observed (p = 0.0001). Symptoms were associated with the location of the lesions, heavy period in internal adenomyosis (p ≤ 0.001), and infertility (p = 0.001), while pelvic pain was observed in external adenomyosis (p = 0.03). Deep endometriosis was associated with external adenomyosis (p = 0.001). An ill-defined junctional zone was observed via Doppler investigation in internal adenomyosis (p = 0.0001), also correlated with the symptoms. Histology confirmed all cases of adenomyosis, with statistically significant similarities regarding pattern, location, and depth (p < 0.001). Conclusions: The increasing use of 3D and Doppler evaluations enhances TVUS importance, and 3D TVUS offers high diagnostic capacity for adenomyosis, in accordance with histological findings. This procedure facilitates the adoption of therapeutic modalities other than surgery with uterus preservation. Full article

Background/Objectives: Abdominal wall and extrapelvic endometriosis are uncommon entities that may mimic other surgical conditions and delay diagnosis. This study evaluated their clinicopathological, diagnostic, and surgical features in a single-center case series. Methods: This retrospective study included 29 patients with histopathologically confirmed abdominal wall or extrapelvic endometriosis treated at a tertiary referral center between 2009 and 2025. Demographic and clinical characteristics, surgical history, CA-125 levels, imaging findings, lesion size, and surgical features were analyzed. Abdominal wall cases were further evaluated based on the presence of muscle or fascial invasion. Results: Abdominal wall lesions comprised 93.1% of cases, while extrapelvic lesions (6.9%) were all vaginal. Most cases had a history of cesarean section; however, one patient had no prior abdominal surgery, consistent with spontaneous disease, with concomitant endometrioma and deep infiltrating endometriosis. Muscle or fascial invasion was observed in 63.0% of cases. Both CA-125 levels (p = 0.005) and CA-125 positivity (≥35 U/mL) (p = 0.029) were significantly higher in patients with invasion. Cyclic symptoms were present in 89.7% of patients, and mesh repair was required in two cases with large lesions. Conclusions: Abdominal wall endometriosis should be suspected in patients with cyclic pain or swelling at surgical sites, particularly after cesarean delivery, although it may occur without prior surgery. Deep muscle and fascial invasion may be associated with elevated CA-125 levels and increased CA-125 positivity, sometimes requiring wider excision and mesh repair. These findings may support earlier diagnosis and surgical planning. Full article

Photoacoustic imaging (PAI) is an emerging hybrid biomedical imaging modality that combines the high molecular contrast of optical excitation with the deep tissue penetration of ultrasound detection. This review presents recent advances in PAI-based techniques for the detection and characterization of gynecological diseases in women, with particular focus on endometriosis and uterine-related disorders. We summarize the application of PAI across preclinical and translational studies, highlighting progress in photoacoustic microscopy, spectroscopic photoacoustic imaging, and endoscopic and probe-based implementations for non-invasive, high-resolution tissue evaluation. The role of functional and contrast-enhanced PAI approaches is discussed, emphasizing their ability to enhance diagnostic sensitivity, enable longitudinal monitoring, and provide detailed information on vascular, biochemical, and structural tissue characteristics. Furthermore, the expanding applications of PAI in assessing uterine, cervical, and ovarian pathologies, including tumor detection and tissue remodeling, are reviewed. Finally, current challenges, limitations, and future directions toward clinical translation are addressed. Collectively, this review underscores the potential of photoacoustic imaging as a powerful, non-invasive platform for early diagnosis, disease monitoring, and improved management of women’s health conditions. Full article

Endometriosis is a chronic estrogen-dependent disorder affecting approximately 10% of women of reproductive age. Increasing epidemiological and molecular evidence indicates that it may represent a precursor condition for a subset of ovarian malignancies collectively defined as endometriosis-associated ovarian cancer (EAOC), predominantly endometrioid and clear cell carcinomas. Malignant transformation is driven by the interplay between chronic inflammation, oxidative stress, and local hyperestrogenism within the endometriotic microenvironment. Recurrent hemorrhage and persistent immune activation further promote genomic instability and clonal expansion. Shared somatic mutations have been identified in both atypical endometriosis and adjacent carcinomas, supporting a model of stepwise tumorigenesis. Dysregulation of signaling pathways and epigenetic mechanisms, including microRNA alterations, further contribute to tumor development. Although the absolute risk of malignant transformation remains low, women with ovarian endometriosis and deep infiltrating disease show an increased risk of ovarian cancer. EAOC is frequently diagnosed at earlier stages and generally demonstrates a more favorable prognosis than high-grade serous carcinoma, although clear cell histotypes may exhibit chemoresistance and distinct molecular vulnerabilities. This review summarizes current evidence on the pathogenesis, molecular mechanisms, and clinical implications of EAOC, highlighting future strategies for risk stratification and personalized surveillance. Full article

Background: Current endometriosis classification systems have important limitations in accurately describing total disease burden and predicting clinical outcomes. Existing staging frameworks often fail to integrate adenomyosis and do not adequately distinguish between genital and extragenital disease involvement. The aim of this article was to introduce the AGCES (American & Global College of Endometriosis Specialists) classification system, a novel framework designed to provide a more comprehensive and clinically meaningful approach to staging endometriosis. Methods: The AGCES classification system was developed through an expert consensus process involving scientific members of the American & Global College of Endometriosis Specialists (AGCES), informed by extensive surgical experience on thousands of endometriosis surgeries, synthesis of published evidence on disease pathophysiology and anatomical distribution, and systematic analysis of the limitations of existing classification systems (rASRM, ENZIAN, AAGL, EFI). Results: The framework integrates adenomyosis as a component of endometriosis staging and separates genital and extragenital disease into independent staging categories. Disease burden is reported using three parallel components representing adenomyosis (A), genital endometriosis (G), and extragenital endometriosis (E). A standardized operative reporting template and digital implementation through web-based applications were also developed to support clinical use. Conclusions: The AGCES classification system introduces a novel approach to endometriosis staging by integrating adenomyosis and separating genital and extragenital disease components. This framework provides a more complete assessment of disease burden and has the potential to improve clinical documentation, surgical planning, and research standardization in endometriosis care. Full article

Background: Bowel surgery is a key component of advanced deep endometriosis management, with anastomotic leakage representing the most serious postoperative complication. This study aimed to identify risk factors for dehiscence after lower colorectal anastomosis and to determine effective preventive measures. Methods: This retrospective/prospective study included 425 consecutive patients aged 37.7 ± 6.0 years with laparoscopical bowel resection due to multiorgan complex deep endometriosis. All bowel surgeries were performed with use of indocyanine green (ICG). Many technical aspects of surgery and preventive procedures were analyzed which could impact leakage risk of surgery. Results: Endometriotic nodules were resected with segmental bowel resection (n = 294; 69.8%), discoid bowel resection (n = 84; 20.0%), and shaving procedure (n = 43; 10.2%). A total of 12 dehiscence events occurred (2.8%), including intraperitoneal leakage (n = 1; 0.2%), rectovaginal fistula (RVF) (n = 10; 2.3%), and rectoureteral fistula (n = 1; 0.2%); no rectovesical fistulas were observed. RVF developed only following segmental resections. Protective measures used during lower bowel procedures included fibrin glue (n = 375; 88.2%), omental flaps (n = 86; 20.2%), reinforcing sutures (n = 33; 7.8%), protective stomas (n = 25; 5.9%), and ghost stomas (n = 14; 3.3%). Among patients who developed RVFs, 90% had no protective stoma, and these cases were predominantly associated with low (from 6 to <8 cm; n = 4/77; 5.2%) and very low (from 5 to <6 cm; n = 4/10; 40%) anastomoses. In very low anastomoses (n = 4), 1 RVF occurred despite a protective stoma but there existed other strong risk factors, such as levator ani infiltration and vagina opening, whereas 3 others RVF developed in patients without a protective stoma. Notably, in ultra-low anastomoses (<5 cm), protective stomas prevented the anastomosis in 100%, and no fistula was observed (n = 3). The following factors were associated with the increased rate of RVF: segmental resection (p = 0.0355), low and very low anastomosis (p = 0.0010), lateral infiltration of the levator (p < 0.0001), concomitant hysterectomy or vaginal opening (p = 0.051), and prolonged operative time (p = 0.0010), Clostridioides difficile infection (p = 0.0001). Conclusions: RVFs occurred mainly after segmental resection (no other type of bowel resection), with very low anastomosis (5–6 cm from anal verge), in patients with levator ani infiltration and concomitant vaginal or uterine surgery; in such situations, discoid resection is the safer option. Despite the complexity of procedures, preventive strategies maintained a low overall RVF rate; no RVFs occurred in ultra low anastomoses (<5), indicating effective prevention with protective stomas. Full article

Background/Objectives: Deep endometriosis is a chronic inflammatory disease that significantly affects fertility. The objective was to evaluate the magnitude of the effect of minimally invasive nerve-sparing complete excision of endometriosis on natural conception rate in women with documented infertility. Methods: This pre-planned interdisciplinary retrospective observational study included 45 patients who wished to conceive naturally (spontaneous pregnancy) and were followed for 12 months after surgery. Results: The spontaneous conception rate was 33.3% (95% CI: 20.0–46.7) and the mean time to conception was 6.7 months. Age, body mass index, and history of infertility showed no significant differences between the success and failure spontaneous pregnancy groups, but annual income was positively associated with reproductive success (p = 0.022). None of the procedures needed to be converted to open surgery, required colostomy/ileostomy, blood transfusion or abdominal drains. No cases of urinary retention were observed across different levels of nerve preservation. In addition, the absence of serious surgical complications (Clavien–Dindo III/IV) supports the safety of this intervention for infertile patients. Conclusions: The absence of serious surgical complications in this cohort supports the concept that minimally invasive nerve-sparing complete excision of endometriosis is a safe intervention when performed by an experienced team. The results underscore the importance of exploring socioeconomic-related factors through an individualized assessment of patients who wish to conceive naturally after minimally invasive nerve-sparing surgery. Future studies focusing on personalized management of endometriosis should attempt to identify socioeconomic-related covariates that influence natural conception. Full article

Objective: To analyze multiple aspects of advanced bladder endometriosis surgery, based on the experience of an endometriosis reference center. Methods: This retrospective/prospective study included 80 consecutive patients with deep bladder endometriosis treated with laparoscopic surgery. Results: In 96.3% of cases, bladder endometriosis coexisted with other organ involvement: bowel (87.5%), uterus (61.3%), and ureters (37.5%); isolated bladder lesions occurred in 3.7%. Full-thickness bladder infiltration occurred in 36.4% of patients, and 71.8% had a history of surgery. The most frequent preoperative symptoms related to multiorgan involvement were dysmenorrhea (88.7%), dyschezia (75.0%), and dyspareunia (55.7%). Dysuria (55.7%), pollakiuria (17.9%), and urinary urgency (9.0%) were also reported. Shaving was performed in 45.0% of cases, resection in 40.0%, skinning in 15.0%, with two rare cases requiring bladder augmentation with bowel insert. Of all multiorgan surgeries (96.3% of cases), the most complex 30% were performed by a bi-disciplinary team of gynecologists and urologists. Postoperative complications occurred in 8 patients (10%) and were significantly associated with larger lesions, full-thickness infiltration, trigonum involvement, multiple organs opened, and prior surgery. Conclusions: Laparoscopic management of bladder endometriosis is feasible and effective, even in complex cases. Postoperative complications were linked to disease complexity but remained low, likely due to protective techniques used by the reference team. Optimal outcomes for the most difficult cases are more likely when procedures are performed by a bi-disciplinary team involving both oncological gynecologists specialized in deep endometriosis surgery and urologists. Given the heterogeneous clinical profiles of bladder endometriosis, treatment should be carried out in specialized centers where individualized surgical strategies can be implemented. Full article

Background: Endometriosis is a chronic, estrogen-dependent disorder that may extend beyond the pelvis to involve the gastrointestinal tract, most commonly the rectosigmoid and, less frequently, the small bowel. Although often asymptomatic, such lesions may rarely manifest as acute bowel obstruction. Case: We report a 42-year-old woman who presented with small bowel ileus caused by deep-infiltrating endometriosis (DIE). Imaging revealed a right ovarian endometrioma with severe adhesions resulting in a distal ileal transition point. After partial decompression with conservative treatment, laparoscopic adhesiolysis with right salpingo-oophorectomy and left salpingectomy was undertaken. Intraoperative findings revealed dense adnexal–ileal adhesions without transmural involvement. Postoperative hormonal suppression was instituted. Conclusions: This rare case demonstrates small bowel obstruction caused by DIE adhesions without intestinal invasion. Preoperative imaging facilitated a minimally invasive approach, while combined surgical and hormonal therapy was associated with reduced recurrence risk. These findings expand the recognized spectrum of endometriosis-related intestinal complications and support tailored management strategies. Full article

Endometriosis is a chronic gynecological condition characterized by endometrium-like tissue outside the uterus. In clinical practice, diagnosis and anatomical mapping rely heavily on imaging, yet performance remains operator- and modality-dependent. Artificial intelligence (AI) has been increasingly applied to endometriosis imaging. We conducted a PRISMA-ScR-guided scoping review of primary machine learning and deep learning studies using endometriosis-related imaging. Five databases (MEDLINE, Embase, Scopus, IEEE Xplore, and Google Scholar) were searched from 2015 to 2025. Of 413 records, 32 studies met inclusion and most were single-center, retrospective investigations in reproductive-age cohorts. Ultrasound predominated (50%), followed by laparoscopic imaging (25%) and MRI (22%); ovarian endometrioma and deep infiltrating endometriosis were the most commonly modeled phenotypes. Classification was the dominant AI task (78%), typically using convolutional neural networks (often ResNet-based), whereas segmentation (31%) and object detection (3%) were less explored. Nearly all studies relied on internal validation (97%), most frequently simple hold-out splits with heterogeneous, accuracy-focused performance reporting. The minimal AI-method quality appraisal identified frequent methodological gaps across key domains, including limited reporting of patient-level separation, leakage safeguards, calibration, and data and code availability. Overall, AI-enabled endometriosis imaging is rapidly evolving but remains early-stage; multi-center and prospective validation, standardized reporting, and clinically actionable detection–segmentation pipelines are needed before routine clinical integration. Full article

Background: Deep infiltrating endometriosis (DIE) and, in particular, bowel endometriosis stand out for their complexity. While surgery for bowel endometriosis has proven to be effective, there is a lack of standardization concerning the technique used and the reported outcomes. Objectives: The objective is to perform a review aiming to summarize the state of the art of bowel endometriosis and to point out the gaps to be addressed by future research. We also propose a novel classification of surgical procedures to fill these gaps and improve management. Methods: A literature search was performed on PubMed from inception to October 2025. Results: The following three major procedures for the excision of bowel endometriosis have been proposed: the nodule shaving, the discoid excision, and the segmental intestinal resection. One further technique, NOSE (natural orifice specimen extraction), can be applied for the removal of the specimen in cases of discoid or segmental resection. To reduce surgical morbidity, current data support the choice of most conservative surgical options, namely nodule dissection and discoid resection, as well as the use of nerve-sparing techniques in case of segmental resection. Nonetheless, there is little evidence concerning the indication and the most appropriate technique to be used, including their relative risks and benefits in terms of pain control, urinary and gastrointestinal function, risk of future relapse, and fertility outcomes. Conclusions: Significant barriers in comparing surgical outcomes due to unclear definitions, lack of standardization, and incomplete reporting are some of the most relevant issues frequently encountered. To fill these gaps, we propose a new classification system for bowel surgery that describes the dimension and the number of the lesions, as well as the type of surgical technique used, supplemented by the information if vaginal opening was necessary for complete lesion resection. This proposition aims to open a discussion on this topic and boost focused research to evaluate the utility of a new classification in clinical practice. Full article

Endometriosis (EM) is a chronic inflammatory disease characterized by the growth of endometrial-like tissue outside the uterus, yet its molecular mechanisms remain poorly understood. This study investigated the expression of mucins (MUC1, MUC2, MUC5AC, MUC6, MUC16) and their O-glycans in endometriotic lesions, given their roles in epithelial protection, adhesion, and immune modulation. Using immunohistochemistry, Western blotting, lectin profiling, histochemical staining, and transcriptomic analysis, we compared mucin levels and glycosylation patterns in eutopic and ectopic tissues from women with and without endometriosis and measured mucin-derived tumor markers in serum (CA 125/MUC16 and CA 15-3/MUC1) and peritoneal fluid (CA 125/MUC16). The results showed significant upregulation of all mucins in EM biopsies, with increased MUC1 transcript levels, while MUC6 and MUC16 protein levels did not always align with transcripts. Yet, tumor markers CA 125 and CA 15-3 showed no significant differences between groups. Looking at mucin distribution in biopsies of peritoneal (pEM), deep infiltrating and ovarian EM, MUC1 was significantly overexpressed in lesions of all EM forms, while MUC5AC was significantly elevated in pEM. Lectin analysis revealed specific glycan changes, including elevated core-1 O-glycans and α(1-2)-linked fucosylation, while sialylation remained unchanged. These findings demonstrate consistent mucin dysregulation and glycan alterations, implicating their roles in epithelial adhesion, immune evasion, and lesion persistence. Mucin biology thus emerges as a promising target for diagnostic and therapeutic strategies in endometriosis. Full article