Expert sonographers and surgeons are needed to manage deep infiltrating endometriosis.

We read with interest the article by Menakaya et al.1 on the importance of accurate sonographic detection of deep infiltrating endometriosis (DIE). They reported for the study group all details related to location, dimension and overall features of DIE that are useful for both diagnosis and prediction of surgical difficulty. They proposed a novel scoring system, ultrasound-based endometriosis staging system (UBESS), which could be useful in both counseling patients and providing surgeons with more information preoperatively in order to reduce the number and severity of surgical complications. To our surprise, we discovered that our paper2, published in 2014, which is highly relevant to Menakaya’s study, was not mentioned in the Discussion or as a reference. In our prospective study we described ESUS (Endometriosis Surgical-Ultrasonographic System), which is similar to UBESS, however, in our opinion, we followed a more appropriate methodology. In fact, only one examiner performed all the sonographic examinations and only two highly expert surgeons carried out the surgical procedures. This is a crucial point considering the importance of operator dependence for both diagnosis and surgical therapy. We also reflect on the recommendations of the Royal College of Obstetricians and Gynaecologists, and believe that endometrioma removal and endometriotic adhesiolysis are not to be considered as easy surgical procedures; to determine the true accuracy of the sonographic evaluation, pelvic adhesiolysis, for removal of all adhesions, and thorough inspection of the retroperitoneum, so as not to miss any deep lesion, should be performed, however these surgical procedures are not possible for a low-skilled laparoscopic surgeon. We firmly believe that preoperative sonographic mapping should be considered mandatory in cases of suspected DIE. Correct counseling is fundamental for the patient but also necessary for the surgical team, which may need to be multidisciplinary with expert general surgeons and/or urologists. We wish to underline that the only substantial drawback of transvaginal ultrasound is the operator dependency. To better define the utility of a sonographic, surgically driven scoring system, validation by a limited number of expert operators should be considered.