Piketty 2009.

Study characteristics
Patient sampling	Primary objectives: to compare results of transvaginal ultrasonography (TVUS) with those of transrectal ultrasonography (TRUS), which is the investigation of choice for the diagnosis of rectal wall infiltration, and to clarify whether TVUS is limited Study population: patients suffering from pelvic pain (alone or associated with infertility) who underwent complete surgical exeresis of deeply infiltrating endometriosis (DIE), which was suspected in all cases preoperatively (questioning, clinical examination, imaging) Selection criteria: not specified Study design: prospective, observational; non‐consecutive enrolment
Patient characteristics and setting	Clinical presentation: dysmenorrhoea, deep dyspareunia, non‐cyclical chronic pelvic pain, gastrointestinal symptoms, lower urinary tract symptoms; previous hormonal treatment for endometriosis 134/134, previous surgery for endometriosis 88/134 Age: mean 32.1 ± 5.0 years, range 22 to 47 years Number enrolled: 134 women Number available for analysis: 134 women Setting: University Hospital, Université Paris Descartes Place of study: Paris, France Period of study: January 2005 to July 2007 Language: English
Index tests	Index test:TVUS; TRUS Description of positive case definition by index test as reported:TVUS ‐ DIE defined as presence of hypoechoic and irregular nodes in assessed pelvic structures; intestinal DIE (ileum ‐ rectum) defined as previously published (referenced to Bazot et al., 2007) and described; TRUS ‐ DIE showed up as hypoechoic peridigestive nodules of rounded or roughly triangular shape (ileum ‐ rectum); diagnosis of bowel infiltration in accordance with previously published (referenced to Chapron et al., 1998) and described Examiners:TVUS ‐ single experienced radiologist; TRUS ‐ single examiner, level of expertise not reported; both examiners informed that DIE was suspected but blinded to the results of clinical findings and previous imaging examinations Interobserver variability: not provided
Target condition and reference standard(s)	Target condition: bowel (ileum ‐ rectum) endometriosis Prevalence of target condition in the sample: DIE 134/134 (100%), bowel endometriosis 75/134 (56%) Reference standard: laparoscopy, laparotomy (numbers for each procedure not specified) + histopathology Description of positive case definition by reference test as reported: diagnosis based on histological assessment ‐ criteria not specified; surgical procedure not described Examiners: numbers or level of expertise of surgeons or pathologists not reported; unclear whether blinding to the results of index tests
Flow and timing	Time interval between index test and reference standard: < 12 months (communication with study authors) Withdrawals: no withdrawals reported for TRUS, 1 (1%) unexplained withdrawal in TVUS group
Comparative
Key conclusions by the authors	TVUS and TRUS have similar degrees of accuracy for predicting intestinal involvement. TVUS must be the first‐line imaging process performed for patients presenting with clinically suspected DIE. The question for the coming years is to define whether it is necessary for TRUS to be carried out systematically in cases of clinically suspected DIE
Conflict of interests	Not reported
Notes	Reported accuracy estimates for TVUS and TRUS for diagnosis of bowel DIE confirmed as accurate Other sites of DIE assessed, but data are sufficient for calculation of accuracy estimates for these areas ‐ not presented in this review
Methodological quality
Item	Authors' judgement	Risk of bias	Applicability concerns
DOMAIN 1: Patient Selection
Was a consecutive or random sample of patients enrolled?	No
Did the study avoid inappropriate exclusions?	No
Was a 'two‐gate' design avoided?	Yes
		High	Low
DOMAIN 2: Index Test Any test
Were the index test results interpreted without knowledge of the results of the reference standard?	Yes
Did the study provide a clear pre‐specified definition of what was considered to be a “positive” result of index test?	Yes
Was the index test performed by a single operator or interpreted by consensus in a joint session?	Yes
Were the same clinical data available when the index test results were interpreted as would be available when the test is used in practice?	Yes
		Low	Low
DOMAIN 3: Reference Standard
Is the reference standards likely to correctly classify the target condition?	Yes
Were the reference standard results interpreted without knowledge of the results of the index tests?	Unclear
		Unclear	Low
DOMAIN 4: Flow and Timing
Was there an appropriate interval between index test and reference standard?	Yes
Did all patients receive the same reference standard?	Yes
Were all patients included in the analysis?	Yes
		Low