Diagnostic Accuracy of MRI Using the #Enzian Classification in Endometriosis: A Single-Center Retrospective Cohort Study

Objectives: The aim of this study was to evaluate the diagnostic accuracy of pelvic magnetic resonance imaging (MRI) interpreted using the #Enzian classification system by comparing MRI findings with laparoscopic outcomes in women suspected of having endometriosis. Design: Retrospective observational study. Participants and Setting: Twenty-four women aged 19 to 49 who underwent laparoscopic surgery for endometriosis at Galilee Medical Center from 2016 to 2023 had preoperative pelvic MRI available. Methods: MRI and laparoscopic findings were classified using the #Enzian classification across 64 anatomical compartments. Diagnostic accuracy was evaluated for lesion location and size. Associations between MRI accuracy and patient characteristics were analyzed using appropriate statistical tests. Results: MRI accurately identified the lesion location in 31.3% of compartments and lesion size in 20.3%. The highest accuracy was found in the tubo-ovarian region (60%), rectovaginal septum (42.9%), and ovaries (41.7%), while the lowest accuracy was observed in the parametrium (7.1%), rectum, extragenital sites, bladder and ureter (0%). Higher age, parity, and gastrointestinal symptoms were significantly associated with improved MRI accuracy (0.05). Limitations: The small sample size, retrospective design, and MRI scans from various centers with differing imaging quality and radiologist expertise may restrict generalizability. Conclusions: MRI utilizing the #Enzian classification provides a structured method for evaluating deep infiltrating endometriosis; however, it demonstrates limited accuracy for superficial or parametrial disease. While it is useful for surgical planning, MRI cannot substitute for laparoscopy, which remains crucial for a thorough evaluation and treatment of endometriosis.