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3<title>Proposals for the #Enzian addendum and update: an international expert survey for item generation - Facts, Views and Vision in ObGyn</title>
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.swiper-slide{transform-style:preserve-3d}.swiper-css-mode>.swiper-wrapper{overflow:auto;scrollbar-width:none;-ms-overflow-style:none}.swiper-css-mode>.swiper-wrapper::-webkit-scrollbar{display:none}.swiper-css-mode>.swiper-wrapper>.swiper-slide{scroll-snap-align:start start}.swiper-css-mode.swiper-horizontal>.swiper-wrapper{scroll-snap-type:x mandatory}.swiper-css-mode.swiper-vertical>.swiper-wrapper{scroll-snap-type:y mandatory}.swiper-css-mode.swiper-free-mode>.swiper-wrapper{scroll-snap-type:none}.swiper-css-mode.swiper-free-mode>.swiper-wrapper>.swiper-slide{scroll-snap-align:none}.swiper-css-mode.swiper-centered>.swiper-wrapper:before{content:"";flex-shrink:0;order:9999}.swiper-css-mode.swiper-centered>.swiper-wrapper>.swiper-slide{scroll-snap-align:center 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9<style>:root{--swiper-navigation-size:44px}.swiper-button-next,.swiper-button-prev{align-items:center;color:var(--swiper-navigation-color,var(--swiper-theme-color));cursor:pointer;display:flex;height:var(--swiper-navigation-size);justify-content:center;margin-top:calc(0px - var(--swiper-navigation-size)/2);position:absolute;top:var(--swiper-navigation-top-offset,50%);width:calc(var(--swiper-navigation-size)/44*27);z-index:10}.swiper-button-next.swiper-button-disabled,.swiper-button-prev.swiper-button-disabled{cursor:auto;opacity:.35;pointer-events:none}.swiper-button-next.swiper-button-hidden,.swiper-button-prev.swiper-button-hidden{cursor:auto;opacity:0;pointer-events:none}.swiper-navigation-disabled .swiper-button-next,.swiper-navigation-disabled .swiper-button-prev{display:none!important}.swiper-button-next svg,.swiper-button-prev svg{height:100%;-o-object-fit:contain;object-fit:contain;transform-origin:center;width:100%}.swiper-rtl .swiper-button-next svg,.swiper-rtl .swiper-button-prev svg{transform:rotate(180deg)}.swiper-button-prev,.swiper-rtl .swiper-button-next{left:var(--swiper-navigation-sides-offset,10px
9);right:auto}.swiper-button-lock{display:none}.swiper-button-next:after,.swiper-button-prev:after{font-family:swiper-icons;font-size:var(--swiper-navigation-size);font-variant:normal;letter-spacing:0;line-height:1;text-transform:none!important}.swiper-button-prev:after,.swiper-rtl .swiper-button-next:after{content:"prev"}.swiper-button-next,.swiper-rtl .swiper-button-prev{left:auto;right:var(--swiper-navigation-sides-offset,10px)}.swiper-button-next:after,.swiper-rtl .swiper-button-prev:after{content:"next"}</style>
10<style>.swiper-pagination{position:absolute;text-align:center;transform:translateZ(0);transition:opacity .3s;z-index:10}.swiper-pagination.swiper-pagination-hidden{opacity:0}.swiper-pagination-disabled>.swiper-pagination,.swiper-pagination.swiper-pagination-disabled{display:none!important}.swiper-horizontal>.swiper-pagination-bullets,.swiper-pagination-bullets.swiper-pagination-horizontal,.swiper-pagination-custom,.swiper-pagination-fraction{bottom:var(--swiper-pagination-bottom,8px);left:0;top:var(--swiper-pagination-top,auto);width:100%}.swiper-pagination-bullets-dynamic{font-size:0;overflow:hidden}.swiper-pagination-bullets-dynamic .swiper-pagination-bullet{position:relative;transform:scale(.33)}.swiper-pagination-bullets-dynamic .swiper-pagination-bullet-active,.swiper-pagination-bullets-dynamic .swiper-pagination-bullet-active-main{transform:scale(1)}.swiper-pagination-bullets-dynamic .swiper-pagination-bullet-active-prev{transform:scale(.66)}.swiper-pagination-bullets-dynamic .swiper-pagination-bullet-active-prev-prev{transform:scale(.33)}.swiper-pagination-bullets-dynamic .swiper-pagination-bullet-active-next{transform:scale(.66)}.swiper-pagination-bullets-dynamic .swiper-pagination-bullet-active-next-next{transform:scale(.33)}.swiper-pagination-bullet{background:var(--swiper-pagination-bullet-inactive-color,#000);border-radius:var(--swiper-pagination-bullet-border-radius,50%);display:inline-block;height:var(--swiper-pagination-bullet-height,var(--swiper-pagination-bullet-size,8px));opacity:var(--swiper-pagination-bullet-inactive-opacity,.2);width:var(--swiper-pagination-bullet-width,var(--swiper-pagination-bullet-size,8px))}button.swiper-pagination-bullet{-webkit-appearance:none;-moz-appearance:none;appearance:none;border:none;box-shadow:none;margin:0;padding:0}.swiper-pagination-clickable .swiper-pagination-bullet{cursor:pointer}.swiper-pagination-bullet:only-child{display:none!important}.swiper-pagination-bullet-active{background:var(--swiper-pagination-color,var(--swiper-theme-color));opacity:var(--swiper-pagination-bullet-opacity,1)}.swiper-pagination-vertical.swiper-pagination-bullets,.swiper-vertical>.swiper-pagination-bullets{left:var(--swiper-pagination-left,auto);right:var(--swiper-pagination-right,8px);top:50%;transform:translate3d(0,-50%,0)}.swiper-pagination-vertical.swiper-pagination-bullets .swiper-pagination-bullet,.swiper-vertical>.swiper-pagination-bullets .swiper-pagination-bullet{display:block;margin:var(--swiper-pagination-bullet-vertical-gap,6px) 0}.swiper-pagination-vertical.swiper-pagination-bullets.swiper-pagination-bullets-dynamic,.swiper-vertical>.swiper-pagination-bullets.swiper-pagination-bullets-dynamic{top:50%;transform:translateY(-50%);width:8px}.swiper-pagination-vertical.swiper-pagination-bullets.swiper-pagination-bullets-dynamic .swiper-pagination-bullet,.swiper-vertical>.swiper-pagination-bullets.swiper-pagination-bullets-dynamic .swiper-pagination-bullet{display:inline-block;transition:transform .2s,top .2s}.swiper-horizontal>.swiper-pagination-bullets .swiper-pagination-bullet,.swiper-pagination-horizontal.swiper-pagination-bullets .swiper-pagination-bullet{margin:0 var(--swiper-pagination-bullet-horizontal-gap,4px)}.swiper-horizontal>.swiper-pagination-bullets.swiper-pagination-bullets-dynamic,.swiper-pagination-horizontal.swiper-pagination-bullets.swiper-pagination-bullets-dynamic{left:50%;transform:translate(-50%);white-space:nowrap}.swiper-horizontal>.swiper-pagination-bullets.swiper-pagination-bullets-dynamic .swiper-pagination-bullet,.swiper-pagination-horizontal.swiper-pagination-bullets.swiper-pagination-bullets-dynamic .swiper-pagination-bullet{transition:transform .2s,left .2s}.swiper-horizontal.swiper-rtl>.swiper-pagination-bullets-dynamic .swiper-pagination-bullet{transition:transform .2s,right .2s}.swiper-pagination-fraction{color:var(--swiper-pagination-fraction-color,inherit)}.swiper-pagination-progressbar{background:var(--swiper-pagination-progressbar-bg-color,rgba(0,0,0,.25));position:absolute}.swiper-pagination-progressbar .swiper-pagination-progressbar-fill{background:var(--swiper-pagination-color,var(--swiper-theme-color));
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7910.52054/FVVO.2026.359</a></span></div></div><div class="block md:flex items-center md:flex-wrap gap-5 mt-6 px-1 text-gray-100"><!--[--><div class="block md:flex items-center md:flex-nowrap md:mb-0 mb-4"><a tabindex="0" role="link" class="relative focus:outline-none"><!--[--><div class="flex items-center flex-nowrap"><span class="iconify i-fa6-brands:orcid lg:text-xl md:text-lg" aria-hidden="true" style=""></span><span class="text-cyan-300 text-sm ms-2 text-nowrap">Milena Petrovic <sup></sup><sup>1</sup></span><span class="ms-1"><span class="iconify i-material-symbols-light:mail-outline-rounded text-xl" aria-hidden="true" style=""></span></span></div><!--]--><!----></a></div><div class="block md:flex items-center md:flex-nowrap md:mb-0 mb-4"><a tabindex="0" role="link" class="relative focus:outline-none"><!--[--><div class="flex items-center flex-nowrap"><span class="iconify i-fa6-brands:orcid lg:text-xl md:text-lg" aria-hidden="true" style=""></span><span class="text-sm ms-2 text-nowrap">Jörg Keckstein <sup></sup><sup>2</sup></span><!----></div><!--]--><!----></a></div><div class="block md:flex items-center md:flex-nowrap md:mb-0 mb-4"><a tabindex="0" role="link" class="relative focus:outline-none"><!--[--><div class="flex items-center flex-nowrap"><span class="iconify i-fa6-brands:orcid lg:text-xl md:text-lg" aria-hidden="true" style=""></span><span class="text-sm ms-2 text-nowrap">Mohamed Mabrouk <sup></sup><sup>1</sup></span><!----></div><!--]--><!----></a></div><div class="block md:flex items-center md:flex-nowrap md:mb-0 mb-4"><a tabindex="0" role="link" class="relative focus:outline-none"><!--[--><div class="flex items-center flex-nowrap"><span class="iconify i-fa6-brands:orcid lg:text-xl md:text-lg" aria-hidden="true" style=""></span><span class="text-sm ms-2 text-nowrap">Ertan Saridogan <sup></sup><sup>1</sup></span><!----></div><!--]--><!----></a></div><div class="block md:flex items-center md:flex-nowrap md:mb-0 mb-4"><a tabindex="0" role="link" class="relative focus:outline-none"><!--[--><div class="flex items-center flex-nowrap"><!----><span class="text-sm ms-2 text-nowrap">Mario Malzoni <sup></sup><sup>3</sup></span><!----></div><!--]--><!----></a></div><div class="block md:flex items-center md:flex-nowrap md:mb-0 mb-4"><a tabindex="0" role="link" class="relative focus:outline-none"><!--[--><div class="flex items-center flex-nowrap"><!----><span class="text-sm ms-2 text-nowrap">Gernot Hudelist <sup></sup><sup>4,5</sup></span><!----></div><!--]--><!----></a></div><!--]--></div><div class="block md:flex items-end justify-between"><div class="mt-6"><div class="block md:flex items-center text-xs gap-4"><button class="opacity-75 flex items-center"><span class="iconify i-material-symbols:arrow-right-rounded text-xl rotate-0 transition-all duration-300 ease-in-out" aria-hidden="true" style=""></span> Author Information</button><button class="opacity-75 flex items-center"><span class="iconify i-material-symbols:arrow-right-rounded text-xl" aria-hidden="true" style=""></span> Copyright &amp; Licence Information</button><button class="opacity-75 flex items-center"><span class="iconify i-material-symbols:arrow-right-rounded text-xl" aria-hidden="true" style=""></span> Galenos &amp; Facts Views Vis ObGyn Disclaimer</button></div><div class="text-sm overflow-hidden transition-all duration-300 ease-in-out px-6" style="height:0px;opacity:0;transform:translateY(-6px);"><div class="py-3 opacity-85"><!--[--><div><div class="mb-1"><span class="font-semibold me-1">1.</span> UCLH Endometriosis Centre,  University College London Hospital, London, United Kingdom</div></div><div><div class="mb-1"><span class="font-semibold me-1">2.</span> Endometriosis Clinic Dres. Keckstein,  Villach, Austria</div></div><div><div class="mb-1"><span class="font-semibold me-1">3.</span> Malzoni Research Hospital,  Center for Advanced Pelvic Surgery, Endometriosis National Center, MACC Cancer Center, Avellino, Italy</div></div><div><div class="mb-1"><span class="font-semibold me-1">4.</span> Center for Endometriosis and Minimally Invasive Surgery,  Hospital of St. John of God, Wien, Austria</div></div><div><div class="mb-1"><span class="font-semibold me-1">5.</span> Department of Gynaecology,  Jagiellonian University of Krakow, Krakow, Poland</div></div><!--]--></div></div><div class="text-sm overflow-hidden transition-all duration-300 ease-in-out -translate-y-6 opacity-0 max-h-0 px-6"><div class="py-3 opacity-85">No information available.</div></div><div class="text-sm overflow-hidden transition-all duration-300 ease-in-out -translate-y-6 opacity-0 max-h-0 px-6"><div class="py-3 opacity-85">No information available</div></div><div class="text-xs font-normal opacity-75 mt-6"><div class="flex"><span class="iconify i-fa6-solid:calendar-days me-1" aria-hidden="true" style=""></span><div class="me-5">Received Date: <span class="font-semibold">23.01.2026</span></div><div class="me-5">Accepted Date: <span class="font-semibold">15.06.2026</span></div><div class="me-5">Online Date: <span class="font-semibold">15.09.2026</span></div><div class="me-5">Publish Date: <span class="font-semibold">15.09.2026</span></div><div class="me-5">E-Pub Date: <span class="font-semibold">31.07.2026</span></div></div></div></div><div class="flex items-end gap-1 mt-4 md:mt-0"><span></span><a href="/pdf/58770459-5a06-4076-a747-5b73e24cd7c0/articles/FVVO.2026.359/171-177.pdf" rel="noopener noreferrer" target="_blank"><div class="text-center text-gray-300 px-3 py-2 rounded bg-black bg-opacity-10 border-0 border-b-0 border-gray-200 min-w-16 hover:bg-opacity-50 hover:text-white cursor-pointer"><span class="iconify i-material-symbols:cloud-download-rounded text-xl mb-2" aria-hidden="true" style=""></span><div class="text-xs" style="">PDF</div></div></a><div class="text-center text-gray-300 px-3 py-2 rounded bg-black bg-opacity-10 border-0 border-b-0 border-gray-200 min-w-16 hover:bg-opacity-50 hover:text-white cursor-pointer"><span class="iconify i-bi:chat-left-quote text-xl mb-2" aria-hidden="true" style=""></span><div class="text-xs" style="">Cite</div></div><div class="text-center text-gray-300 px-3 py-2 rounded bg-black bg-opacity-10 border-0 border-b-0 border-gray-200 min-w-16 hover:bg-opacity-50 hover:text-white cursor-pointer"><span class="iconify i-material-symbols-light:share text-xl mb-2" aria-hidden="true" style=""></span><div class="text-xs" style="">Share</div></div><a href="https://www.galenos.com.tr/form-permission" rel="noopener noreferrer" target="_blank"><div class="text-center text-gray-300 px-3 py-2 rounded bg-black bg-opacity-10 border-0 border-b-0 border-gray-200 min-w-16 hover:bg-opacity-50 hover:text-white cursor-pointer"><span class="iconify i-material-symbols:lock-open-right text-xl mb-2" aria-hidden="true" style=""></span><div class="text-xs" style="">Request</div></div></a></div></div><!--]--></div></div><div><div class="container mx-auto max-w-screen-xl p-4 min-h-screen" id="content"><div class="flex gap-4"><div class="hidden lg:block"><div class="sticky max-w-48 top-0 px-3"><div class="pt-5 pt-32 overflow-hidden transition-all min-h-screen"><div><!--[--><a class="flex relative cursor-pointer text-gray-600 text-sm font-semibold mb-5"><div class="-mt-0.5 ms-6">ABSTRACT</div><div class="absolute left-0 w-4 h-4 border-4 rounded-full border-gray-400"></div></a><a class="flex relative cursor-pointer text-gray-600 text-sm font-semibold mb-5"><div class="-mt-0.5 ms-6">Introduction</div><div class="absolute left-0 w-4 h-4 border-4 rounded-full border-gray-400"></div></a><a class="flex relative cursor-pointer text-gray-600 text-sm font-semibold mb-5"><div class="-mt-0.5 ms-6">Methods</div><div class="absolute left-0 w-4 h-4 border-4 rounded-full border-gray-400"></div></a><a class="flex relative cursor-pointer text-gray-600 text-sm font-semibold mb-5"><div class="-mt-0.5 ms-6">Results</div><div class="absolute left-0 w-4 h-4 border-4 rounded-full border-gray-400"></div></a><a class="flex relative cursor-pointer text-gray-600 text-sm font-semibold mb-5"><div class="-mt-0.5 ms-6">Discussion</div><div class="absolute left-0 w-4 h-4 border-4 rounded-full border-gray-400"></div></a><a class="flex relative cursor-pointer text-gray-600 text-sm font-semibold mb-5"><div class="-mt-0.5 ms-6">References</div><div class="absolute left-0 w-4 h-4 border-4 rounded-full border-gray-400"></div></a>
79<!--]--></div></div></div></div><div class="flex-1 text-gray-600 article border border-gray-200 px-6 py-8 my-4 max-w-full overflow-hidden"><div class="mb-10 section" id="abstract"><!--[--><!--[--><h1>ABSTRACT</h1><span></span><!--]--><!--[--><p class="font-semibold mt-4">Background</p><span></span><!--]--><!--[--><p class="">Accurate and standardised characterisation of endometriosis extent is essential for patient counselling regarding pain and fertility outcomes, surgical planning, multidisciplinary communication, and clinical research. The Enzian classification has been applied in Central Europe for over two decades, while the updated #Enzian classification, published in 2021, has subsequently gained broader international acceptance.</p><span></span><!--]--><!--[--><p class="font-semibold mt-4">Objectives</p><span></span><!--]--><!--[--><p class="">To evaluate international expert perspectives and generate potential items informing updates to selected compartments of the #Enzian classification.</p><span></span><!--]--><!--[--><p class="font-semibold mt-4">Methods</p><span></span><!--]--><!--[--><p class="">Twenty-six internationally recognised experts in endometriosis surgery, imaging, and reproductive medicine were invited to participate in a structured survey. The electronic questionnaire comprised 29 single-choice and open-ended items addressing five #Enzian compartments: T (tuboovarian condition), B (sacrouterine ligaments, cardinal ligaments, pelvic sidewall), C (rectum), FB (bladder), and FA (adenomyosis). Responses were collected anonymously, analysed descriptively, and thematically grouped. Consensus thresholds followed established criteria.</p><span></span><!--]--><!--[--><p class="font-semibold mt-4">Main Outcome Measures</p><span></span><!--]--><!--[--><p class="">Expert perspectives regarding the need for revision of selected #Enzian compartments and proposed modifications.</p><span></span><!--]--><!--[--><p class="font-semibold mt-4">Results</p><span></span><!--]--><!--[--><p class="">Twenty-three experts responded (88.5%). Strong agreement for revision was observed for compartments B, C, and FB (&gt;80%). Moderate agreement (&gt;60%) supported updates to compartments T and FA. Specific suggested refinements included adding the suffix d within compartment T to reflect tubal dilatation (73.9% in favour) and the suffix P within compartment B to denote pelvic sidewall/parametrial involvement (78.3% in favour). For colorectal disease (compartment C), respondents supported reporting lesion–anal verge distance and multifocality. A graded FA1–FA3 system for adenomyosis was favoured (73.9%). Opinions regarding descriptors of bladder endometriosis were heterogeneous.</p><span></span><!--]--><!--[--><p class="font-semibold mt-4">Conclusions</p><span></span><!--]--><!--[--><p class="">Experts identified clear priorities for refining the #Enzian classification, particularly regarding parametrial involvement, colorectal deep endometriosis and adenomyosis extent. These findings could provide a structured framework to inform subsequent Delphi consensus rounds.</p><span></span><!--]--><!--[--><p class="font-semibold mt-4">What is New?</p><span></span><!--]--><!--[--><p class="">The study identifies international expert-agreed priorities for refinement of selected #Enzian classification compartments.</p><span></span><!--]--><!--]--><div class="flex items-baseline gap-2 mt-4 keywords"><div class="font-semibold">Keywords:</div><div class=""><span>Adenomyosis, colorectal, Delphi consensus, endometriosis, fertility, reproductive medicine</span></div></div></div><!--[--><div class="mb-10 section" id="introduction"><!--[--><!--[--><h1>Introduction</h1><span></span><!--]--><!--[--><p class="">Endometriosis is a chronic, oestrogen-dependent condition characterised by heterogeneous phenotypes, including superficial peritoneal implants, ovarian endometrioma, deep endometriosis (DE) affecting various anatomical locations and adenomyosis.<sup><a class="xref" data-type="ref" data-target="1">1</a></sup> Accurate and standardised description of disease extent is essential for patient counselling regarding pain and fertility outcomes, surgical planning, multidisciplinary communication and clinical research. Traditional staging systems, including the revised American Society for Reproductive Medicine (ASRM) score, have limited ability to describe deep and extragenital disease in anatomical detail, while the American Association of Gynaecological Laparoscopists (AAGL) score reflects surgical complexity rather than providing comprehensive non-invasive anatomical mapping system.<sup><a class="xref" data-type="ref" data-target="2-4">2-4</a></sup> These limitations prompted the development of anatomically oriented classification systems, including the Enzian classification, used in central European countries over two decades and accepted worldwide since its updated #Enzian version published in 2021.<sup><a class="xref" data-type="ref" data-target="5">5</a></sup></p><span></span><!--]--><!--[--><p class="">The #Enzian classification was designed as a comprehensive non-invasive and surgical description system encompassing peritoneal, ovarian, deep and extragenital endometriosis as well as selected adhesions, structured by anatomical compartments, it can be applied using transvaginal ultrasound (TVS), magnetic resonance imaging (MRI), surg
79ical assessment, thereby bridging pre-operative evaluation and intra-operative findings. Several studies have demonstrated high accuracy of the classification when combined with TVS<sup><a class="xref" data-type="ref" data-target="6-8">6-8</a></sup> whose use is supported by a recent consensus statement on imaging and classification of DE.<sup><a class="xref" data-type="ref" data-target="9">9</a></sup> Diagnostic accuracy and inter-observer agreement for ultrasound<sup><a class="xref" data-type="ref" data-target="10">10</a></sup> and MRI-based #Enzian have been reported as promising, particularly for selected compartments.<sup><a class="xref" data-type="ref" data-target="11">11</a></sup></p><span></span><!--]--><!--[--><p class="">Despite these advances, several limitations of the current #Enzian system have been highlighted. Narrative reviews and comparative studies underline its complexity,<sup><a class="xref" data-type="ref" data-target="12">12</a></sup> variable performance of specific compartments,<sup><a class="xref" data-type="ref" data-target="9">9</a></sup> and limited descriptors for certain clinically relevant features, such as correlation with pain,<sup><a class="xref" data-type="ref" data-target="13">13</a>, <a class="xref" data-type="ref" data-target="14">14</a></sup> fertility outcomes, distal tubal pathology, and parametrial and pelvic sidewall involvement. The absence of standardised non-invasive infertility assessment frameworks underscores the need for more comprehensive, reproducible tools such as #Enzian to bridge this critical diagnostic deficit.<em> </em>Recent proposals to convert #Enzian into a four-stage system further illustrate the current drive toward harmonisation with other classification schemes.<sup><a class="xref" data-type="ref" data-target="15">15</a></sup></p><span></span><!--]--><!--[--><p class="">Artificial intelligence (AI) applications in MRI and ultrasound rely heavily on detailed anatomical inputs, with deep learning models achieving substantial improvements in lesion detection and segmentation. Comprehensive and granular datasets may become increasingly relevant for effective AI integration in endometriosis imaging.<sup><a class="xref" data-type="ref" data-target="16">16</a></sup> Against this background, we conducted an international survey among experts in endometriosis surgery, imaging and medically assisted reproduction to evaluate the perceived need for targeted refinement of selected #Enzian compartments and to identify priorities for a future revision of the classification.</p><span></span><!--]--><!--]--><!----></div><div class="mb-10 section" id="methods"><!--[--><!--[--><h1>Methods</h1><span></span><!--]--><!--[--><p class="">This study represents&nbsp;a<em> </em>preliminary, item-generating international expert survey designed to inform subsequent Delphi rounds evaluating potential updates to the #Enzian classification. The survey was created to explore expert views on the established current version of the #Enzian classification of endometriosis.<sup><a class="xref" data-type="ref" data-target="5">5</a></sup> Twenty-six experts were purposively selected based on academic contribution and recognised clinical expertise in endometriosis, imaging and fertility. The original #Enzian development team was included to preserve continuity. Invitations were distributed by e-mail, and participation was voluntary and anonymous, with no personal identifiers. A structured electronic questionnaire comprising 29 items (single-choice and open-ended) was developed. The instrument targeted five compartments of the #Enzian system, as agreed during the initial in-person core expert group meeting in May 2025: B (sacrouterine ligaments, cardinal ligaments, pelvic sidewall)-questions 1-6; T (tuboovarian condition)-questions 7-12; C (bowel)-questions 13-19; FB (bladder)-questions 20-24 and FA (adenomyosis)-questions 25-29.</p><span></span><!--]--><!--[--><p class="">All questions addressed both, the perceived need for revision and agreement with proposed modifications (e.g., suffixes, numeric indices, anatomical distances). The questionnaire was distributed electronically using the blind carbon copy function. A 30-day response window was provided, with an estimated completion time of five minutes. The questionnaire is available on <a target="_blank" rel="noopener noreferrer nofollow" href="https://www.surveymonkey.com/r/V7QCTRV">https://www.surveymonkey.com/r/V7QCTRV</a>.</p><span></span><!--]--><!--[--><p class="">Quantitative (single choice) responses were tabulated and analysed descriptively. Free-text answers were standardised and thematically grouped. Consensus thresholds were applied in line with previously published works<sup><a class="xref" data-type="ref" data-target="9">9</a></sup> as follows: experts provided binary responses (agree/disagree); grades of agreement were defined as strong agreement (more than 80% agree), moderate agreement (more than 60% agree), equipoise (40%-60% agree), or disagreement (less than 40% agree). The summary of this survey and their levels of agreement are presented in this work. The study fulfilled criteria for minimal-risk survey research, and although formal ethical approval was not required, compliance with local survey research standards was ensured.</p><span></span><!--]--><!--]--><!----></div><div class="mb-10 section" id="results"><!--[--><!--[--><h1>Results</h1><span></span><!--]--><!--[--><p class="">Of 26 invited experts, 23 completed the survey with a response rate of 88.5%. Respondents represented geographically diverse regions: Australia (1), Austria (2), Belgium (1), Brazil (1), Canada (1), France (1), Germany (5), Hungary (2), Italy (6), Poland (1), Portugal (1), Switzerland (2), and the United Kingdom (2).</p><span></span><!--]--><!--[--><p class="">Most experts endorsed revising the #Enzian classification according to the following compartments: T (tubo-ovarian condition), B (sacrouterine ligaments, cardinal ligaments, pelvic sidewall), 
79C (rectum), FB (bladder) and FA (adenomyosis) (<a class="xref" data-target="table-1" data-type="table">Table 1</a>). Strong agreement (&gt;80%) was achieved for revising topics concerning compartments (81.6%), C (82.6%), and FB (82.6%). Moderate agreement (&gt;60%) was reached for compartments T and FA (73.9 % each).</p><span></span><!--]--><!--[--><p class="">Participants reached moderate agreement that the current description of compartment T does not provide sufficient information regarding the presence or absence of tubal dilatation, a feature that may suggest impaired tubal function. Within this exploratory item, 73.9% supported adding the suffix&nbsp;d<em> </em>to better describe this possible pathology within compartment T. The proposed suffix was not intended to grade the severity of dilatation or to define management decisions, but rather to improve structured documentation of potentially fertility-relevant pathology. Opinions diverged on a further subclassification describing tubal content (hydrosalpinx vs. hematosalpinx) with only 21.7% supporting its inclusion, whereas 56.5% considered it an unnecessary level of detail and a further 21.7% did not support the item on the basis on their prior response (disagreement with suggested suffix d addition), indicating an overall lack of agreement.</p><span></span><!--]--><!--[--><p class="">There was moderate agreement (78.3%) to support the addition of a suffix&nbsp;<em>p</em> within compartment B&nbsp;to denote pelvic sidewall and/or lateral parametrial involvement. In this exploratory survey, lateral parametrial involvement was used to describe disease extending laterally towards the pelvic sidewall, including clinically relevant proximity to or involvement of ureteric or nerve structures. Experts emphasised the surgical relevance of the lateral disease extension, with 78.3% reporting that such involvement always (47.8%) or often (30.4%) influences their operative strategy, and a further 21.8% indicating that it occasionally does so.</p><span></span><!--]--><!--[--><p class="">Regarding the compartment C (rectum), moderate agreement was reached for documenting distance from the anal verge to the lowermost rectal DE lesion (73.9%) and necessity to record the number of rectal nodules (78.3%), in addition to existing lesion size descriptors used. Respondents also noted that these variables better support surgical planning, particularly for the low rectal lesions: 69.6% survey participants reported lesion proximity to the anal verge as being a frequent determinant in operative decision-making, and 65.2% supported the suffix “L” use within compartment C for lesions &lt;5 cm from the anal verge.</p><span></span><!--]--><!--[--><p class="">Experts reached moderate agreement (73.9%) regarding exploration of a graded FA1–FA3 system to better characterise according to the estimated proportion myometrial involvement. This proposal should be interpreted as an item for further evaluation rather than a validated quantitative grading system. Although strong agreement (82.6%) was observed regarding the need for revising FB descriptors for bladder endometriosis, no single descriptor achieved agreement: 34.8% favoured maximum lesion diameter, 34.8% supported recording the distance between the lesion and the ureteral orifice irrespective of lesion size, 13.0% were uncertain, and 17.4% proposed alternative approaches in<em> </em>free-text comments, including ureteral involvement or trigonal extension descriptions.</p><span></span><!--]--><!--[--><p class="">Thematic analysis of free-text responses identified several recurring suggestions, summarised in <a class="xref" data-target="table-2" data-type="table">Table 2</a>. Key issues included the need for a more detailed description of compartment B, clinically relevant descriptors of possible tubal pathology within compartment T, inclusion of lesion-to-anal-verge distance and multifocality for colorectal disease within compartment C, and clearer differentiation between focal and diffuse adenomyosis in alignment with MUSA criteria.<a class="xref" data-target="17" data-type="ref"><sup>17</sup></a> Views and opinions on bladder endometriosis (FB) classification remained heterogeneous, with many experts preferring simplicity and descriptive annotations rather than additional coding.</p><span></span><!--]--><!--]--><!----></div><div class="mb-10 section" id="discussion"><!--[--><!--[--><h1>Discussion</h1><span></span><!--]--><!--[--><p class="font-semibold mt-4"><em>Main findings</em></p><span></span><!--]--><!--[--><p class="">The present work reports the results of an international expert survey conducted as a preliminary item generation step to inform future Delphi-based refinement of the current #Enzian classification. The findings suggest that several clinically relevant anatomical features may currently be insufficiently represented, particularly within compartments B, C and FB. This likely reflects increasing recognition of the importance of parametrial extension, colorectal multifocality, and bladder-related descriptors in contemporary endometriosis imaging and surgical practice. Nevertheless, variability regarding the preferred implementation of these descriptors highlights the complexity of balancing anatomical details with practical usability within an integrated classification system. Expert support for including lesion–to-anal-verge distance and multifocality in colorectal DE further suggests that lesion size descriptors alone may not adequately reflect the complexity and surgical relevance of rectosigmoid disease. This may be particularly relevant since the surgical literature shows that these variables indeed correlate with operative complexity, choice of technique, and postoperative morbidity.<a class="xref" data-target="18" data-type="ref"><sup>18</sup></a><sup>, </sup><a class="xref" data-target="19" data-type="ref"><sup>19</sup></a>
79 Furthermore, these descriptors may support not only operative planning but also patient counselling and informed consent, particularly in cases of low rectal disease where surgical morbidity may substantially differ. Recent prospective data have additionally demonstrated promising diagnostic accuracy of structured ultrasound assessment for rectosigmoid DE using the IDEA protocol and #Enzian classification framework, supporting the feasibility of more anatomically detailed preoperative reporting.<a class="xref" data-target="20" data-type="ref"><sup>20</sup></a></p><span></span><!--]--><!--[--><p class="">The strong interest in refining parametrial and pelvic sidewall descriptors also reflects increasing awareness of the importance of these anatomical regions in both imaging and surgical management of DE. Recently published methodological consensus papers have further standardised ultrasound assessment of the pelvic sidewall and parametrium, potentially facilitating broader implementation and reproducibility of these evaluations in clinical practice.<a class="xref" data-target="21" data-type="ref"><sup>21</sup></a><sup>, </sup><a class="xref" data-target="22" data-type="ref"><sup>22</sup></a></p><span></span><!--]--><!--[--><p class="">Moderate agreement regarding modifications to the compartment T reflects growing recognition of the importance of documenting tubal pathology, including tubal dilatation, which may impact reproductive outcomes. The proposed suffix d was intended as an exploratory descriptor to better integrate documentation of fertility-relevant parameters into the #Enzian classification rather than to directly determine management strategies. Importantly, no agreement was achieved regarding subclassification of hydrosalpinx vs. hematosalpinx, suggesting that experts favoured simplified descriptors at this preliminary stage. Although not formally evaluated within this survey, additional imaging markers such as “kissing ovaries” may also warrant consideration within subsequent Delphi rounds due to their recognised association with posterior compartment disease.<a class="xref" data-target="23" data-type="ref"><sup>23</sup></a> Proposed refinements to compartment FB underscore the heterogeneity of bladder endometriosis and the absence of universally accepted descriptors reflecting lesion complexity and surgical relevance. However, no clear agreement emerged regarding whether lesion size and/or proximity to the ureteral orifice should be prioritised within future #Enzian classification descriptors. Interest in exploring a graded FA1–FA3 scheme for adenomyosis may reflect increasing recognition of the need for more structured adenomyosis phenotyping within endometriosis classification systems. Importantly, this proposal should not be interpreted as a validated quantitative grading system, as objective volumetric assessment of adenomyosis remains challenging in both imaging and surgical practice. Furthermore, differentiation between focal and diffuse adenomyosis based on direct and indirect MUSA criteria remains complex and requires further validation for their extent within the classification.</p><span></span><!--]--><!--[--><p class="">Persistent challenges regarding symptom-disease correlation in endometriosis<a class="xref" data-target="24" data-type="ref"><sup>24</sup></a> further support the need for more structured and anatomically detailed classification systems. Limited standardised phenotyping may reduce the ability to analyse symptom patterns, reproductive outcomes and disease severity prospectively. However, recent prospective imaging research, particularly the work of Exacoustos and colleagues,&nbsp; demonstrates that when standardised and anatomically detailed descriptors are applied, such as RADAR graphical mapping in conjunction with the #Enzian classification, clinically meaningful correlations with symptoms may indeed be achieved.<a class="xref" data-target="10" data-type="ref"><sup>10</sup></a> These findings highlight the need for consistent, prospective data acquisition across all clinical pathways, including assisted reproductive techniques, as robust symptom–disease analyses fundamentally rely on high diagnostic quality. In parallel, contemporary AI applications increasingly rely on high-quality structured anatomical datasets, further emphasising the potential future relevance of refined and reproducible classification.<a class="xref" data-target="16" data-type="ref"><sup>16</sup></a> Nevertheless, implementation of such approaches remains highly depen
79dent on expert imaging assessment, particularly in TVS, and standardised methodology which remains inconsistently implemented across clinical settings.<a class="xref" data-target="25" data-type="ref"><sup>25</sup></a></p><span></span><!--]--><!--[--><p class="">Overall, the thematic convergence observed across expert responses indicates that future alterations of the #Enzian classification should prioritise (i) improved delineation of parametrial and pelvic sidewall disease, (ii) more comprehensive characterisation of colorectal involvement, (iii) standardised descriptors for tubal pathology, and (iv) integration of contemporary sonographic criteria for describing the extent of adenomyosis.</p><span></span><!--]--><!--[--><p class="">Importantly, the absence of universal agreement across several proposed items likely reflects complexity and heterogeneity of endometriosis, differences in surgical approaches, imaging modality expertise and clinical priorities among international experts. Rather than weakening the findings, this observation reinforces the rationale for a structured Delphi process with aim to refine, prioritise and harmonise expert perspectives into even more widely applicable and acceptable classification system.</p><span></span><!--]--><!--[--><p class="font-semibold mt-4"><em>Strengths and Limitations</em></p><span></span><!--]--><!--[--><p class="">The strength of the present work is that it includes the opinion of twenty-three purposively selected experts, including original #Enzian developers reflecting a high external validity within the expert community. Several limitations should be acknowledged. Only selected #Enzian compartments were evaluated, while other potentially relevant domains (e.g. A, O, and F categories outside FB/FA) were beyond the scope of this preliminary survey. Additionally, binary response formats may oversimplify complex anatomical and clinical considerations, making qualitative free-text responses potentially crucial to contextual interpretation. Finally, only moderate agreement was reached on several topics which can be seen as<em> </em>promising but requires refinement and further consensus testing.</p><span></span><!--]--><!--[--><p class="font-semibold mt-4"><em>Clinical implications</em></p><span></span><!--]--><!--[--><p class="">In summary, this work constitutes a structured item-generation phase designed to inform subsequent Delphi consensus processes and to support the further evolution of the #Enzian classification. The proposed exploratory items aim to enhance its clinical relevance, surgical utility, and compatibility with contemporary imaging and emerging AI-based applications.</p><span></span><!--]--><!--[--><p class="font-semibold mt-4"><em>Unanswered questions and future research</em></p><span></span><!--]--><!--[--><p class="">At this stage, no definitive classification changes are proposed, and further Delphi rounds are necessary to refine, prioritise, and validate the suggested modifications.</p><span></span><!--]--><!--]--><!----></div><!--]--><!----><!--[--><div class="py-2"><!----><div class=""><!--[--><div><strong>Acknowledgments</strong></div><div>The authors would like to thank all participating experts for their time, expertise, and valuable contributions to this study.</div><!--]--></div></div><div class="py-2"><!----><div class=""><!--[--><div><strong>Contributors:</strong> Concept: M.P., J.K., M.M., E.S., M.Ma., G.H., Design: J.K., M.M., E.S., M.Ma., G.H., Data Collection or Processing: M.P., J.K., M.M., G.H., Analysis or Interpretation: M.P., J.K., M.M., E.S., M.Ma., G.H., Literature Search: M.P., J.K., M.M., G.H., Writing: M.P., J.K., M.M., E.S., M.Ma., G.H.</div><!--]--></div></div><div class="py-2"><!----><div class=""><!--[--><div><strong>Funding: </strong>The authors declared that this study received no financial support.</div><!--]--></div></div><div class="py-2"><!----><div class=""><!--[--><div><strong>Competing interests:</strong> Mohamed Mabrouk, MD, serves as Associate Editor for Facts, Views and Vision in ObGyn. Ertan Saridogan, MD, serves as Associate Editor for Facts, Views and Vision in ObGyn. They had no involvement in the peer-review of this article and had no access to information regarding its peer-review. Jörg Keckstein, MD, is a member of the ESGE Editorial Board of the Facts, Views and Vision in ObGyn. He had no involvement in the peer-review of this article and had no access to information regarding its peer-review. The other authors declared that there is no conflict of interest.</div><!--]--></div></div><div class="py-2"><!----><div class=""><!--[--><div><strong>Ethical approval:</strong> The study fulfilled criteria for minimal-risk research. Formal ethical approval was not required, and the study was conducted in accordance with local survey research standards.</div><!--]--></div></div><div class="py-2"><!----><div class=""><!--[--><div><strong>Informed consent:</strong> Completion of the survey was taken as implied informed consent.</div><!--]--></div></div><div class="py-2"><!----><div class=""><!--[--><div><strong>Data sharing:</strong> The data supporting the findings of this study are available from the corresponding author upon reasonable request.</div><!--]--></div></div><div class="py-2"><!----><div class=""><!--[--><div><strong>Transparency:</strong> The authors confirm that this manuscript is an honest, accurate, and transparent account of the study being reported, and that no important aspects of the study have been omitted.</div><!--]--></div></div><!--]--><div id="references" class="section mt-6"><h1 class="mb-3">References</h1><div class="flex flex-col gap-4"><!--[--><div><div class="flex items-baseline ref-list border-b border-gray-100 pb-3"><div class="flex items-start gap-3"><span id="refnum" class="refnum font-semibold text-gray-700">1</span><div class="flex-1"><div class="break-words text-gray-800 leading-relaxed" style="overflow-wrap:anywhere;">Giudice LC, Liu B, Irwin JC. 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Hum Reprod. 2025;40:1643-50.</div><div class="flex flex-wrap gap-4 mt-1 text-xs text-gray-500"><!----><!----><!----></div></div></div></div></div><div><div class="flex items-baseline ref-list border-b border-gray-100 pb-3"><div class="flex items-start gap-3"><span id="refnum" class="refnum font-semibold text-gray-700">15</span><div class="flex-1"><div class="break-words text-gray-800 leading-relaxed" style="overflow-wrap:anywhere;">Fadinger N, Oppelt P, Trautner PS, Szilagyi I, Raidl S, Enzelsberger SH. Transforming the #Enzian classification into a four-stage system: a feasibility study by comparison with the 2021 AAGL endometriosis classification. 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Ultrasound Obstet Gynecol. 2024;64:275-80.</div><div class="flex flex-wrap gap-4 mt-1 text-xs text-gray-500"><!----><!----><!----></div></div></div></div></div><div><div class="flex items-baseline ref-list border-b border-gray-100 pb-3"><div class="flex items-start gap-3"><span id="refnum" class="refnum font-semibold text-gray-700">23</span><div class="flex-1"><div class="break-words text-gray-800 leading-relaxed" style="overflow-wrap:anywhere;">Guerriero S, Ajossa S, Pascual MA, Rodriguez I, Piras A, Perniciano M, et al. Ultrasonographic soft markers for detection of rectosigmoid deep endometriosis. 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Eur J Obstet Gynecol Reprod Biol X. 2025;28:100438.</div><div class="flex flex-wrap gap-4 mt-1 text-xs text-gray-500"><!----><!----><!----></div></div></div></div></div><!--]--></div></div><!----><!----></div></div></div></div><span></span><!--]--><!--]--><div class="footer"><div class="top"><div class="container"><div class="flex items-center justify-between py-4 px-2"><div class="py-6"><div><img onerror="this.setAttribute(&#39;data-error&#39;, 1)" alt="Footer Logo" data-nuxt-img srcset="https://d2v96fxpocvxx.cloudfront.net/58770459-5a06-4076-a747-5b73e24cd7c0/footer-logo.png?v=58770459-5a06-4076-a747-5b73e24cd7c0 1x, https://d2v96fxpocvxx.cloudfront.net/58770459-5a06-4076-a747-5b73e24cd7c0/footer-logo.png?v=58770459-5a06-4076-a747-5b73e24cd7c0 2x" class="max-h-20 max-w-96" src="https://d2v96fxpocvxx.cloudfront.net/58770459-5a06-4076-a747-5b73e24cd7c0/footer-logo.png?v=58770459-5a06-4076-a747-5b73e24cd7c0"></div></div><div class=""><div class="hidden sm:ml-6 md:ml-3 md:block"><ul><!--[--><li class="relative group"><a href="/about" class="relative"><span>About Us</span><!----></a><!----><!----></li><li class="relative group">
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79<script type="application/json" data-nuxt-data="nuxt-app" data-ssr="true" id="__NUXT_DATA__">[["ShallowReactive",1],{"data":2,"state":633,"once":639,"_errors":640,"serverRendered":37,"path":643,"pinia":644},["ShallowReactive",3],{"article":4},{"articleId":5,"issueId":6,"doi":7,"pmId":8,"articleType":9,"title":10,"slug":11,"keywords":12,"affiliations":19,"pdfUrl":25,"version":26,"startPage":27,"endPage":28,"acceptedDate":29,"receivedDate":30,"onlineDate":31,"publishDate":31,"epubDate":32,"authors":33,"fullTextLang":67,"hasAbstract":37,"createdAt":68,"abstract":69,"fullText":106,"references":180,"fnItems":577,"files":608,"xrefs":609,"tables":610,"issue":620},"FVVO.2026.359","2026-018-003","10.52054/FVVO.2026.359","42533569","Original Article","Proposals for the #Enzian addendum and update: an international expert survey for item generation","proposals-for-the-enzian-addendum-and-update-an-international-expert-survey-for-item-generation",[13,14,15,16,17,18],"Adenomyosis","colorectal","Delphi consensus","endometriosis","fertility","reproductive medicine",[20,21,22,23,24],"UCLH Endometriosis Centre,  University College London Hospital, London, United Kingdom","Endometriosis Clinic Dres. Keckstein,  Villach, Austria","Malzoni Research Hospital,  Center for Advanced Pelvic Surgery, Endometriosis National Center, MACC Cancer Center, Avellino, Italy","Center for Endometriosis and Minimally Invasive Surgery,  Hospital of St. John of God, Wien, Austria","Department of Gynaecology,  Jagiellonian University of Krakow, Krakow, Poland","171-177.pdf",6,171,177,"15.06.2026","23.01.2026","15.09.2026","31.07.2026",[34,43,49,53,57,61],{"email":35,"orcid":36,"isCorrespondingAuthor":37,"phone":38,"full_name":39,"affiliationIndexes":40,"correspondence":42,"affiliation":20},"[email protected], [email protected] ","0000-0002-8833-8924",true,"","Milena Petrovic",[41],1,"Milena Petrovic, UCLH Endometriosis Centre, University College London Hospital, London, United Kingdom",{"full_name":44,"email":38,"orcid":45,"correspondence":38,"isCorrespondingAuthor":46,"phone":38,"affiliationIndexes":47,"affiliation":21},"Jörg Keckstein","0000-0002-3943-3300",false,[48],2,{"email":38,"full_name":50,"phone":38,"orcid":51,"correspondence":38,"affiliationIndexes":52,"isCorrespondingAuthor":46,"affiliation":20},"Mohamed Mabrouk","0000-0002-9762-6979",[41],{"isCorrespondingAuthor":46,"full_name":54,"affiliationIndexes":55,"correspondence":38,"email":38,"orcid":56,"phone":38,"affiliation":20},"Ertan Saridogan",[41],"0000-0001-9736-4107",{"affiliationIndexes":58,"correspondence":38,"phone":38,"isCorrespondingAuthor":46,"full_name":60,"email":38,"affiliation":22},[59],3,"Mario Malzoni",{"correspondence":38,"email":38,"affiliationIndexes":62,"isCorrespondingAuthor":46,"phone":38,"full_name":65,"affiliation":66},[63,64],4,5,"Gernot Hudelist","Center for Endometriosis and Minimally Invasive Surgery,  Hospital of St. John of God, Wien, Austria, Department of Gynaecology,  Jagiellonian University of Krakow, Krakow, Poland","en",1785479760169,{"articleId":5,"type":70,"lang":67,"index":71,"subType":70,"contents":72,"boxed":46},"abstract",0,[73,76,79,82,84,86,88,90,92,94,96,98,100,102,104],{"content":74,"type":75},"ABSTRACT","sectiontitle",{"type":77,"content":78},"subtitle","Background",{"type":80,"content":81},"content","Accurate and standardised characterisation of endometriosis extent is essential for patient counselling regarding pain and fertility outcomes, surgical planning, multidisciplinary communication, and clinical research. The Enzian classification has been applied in Central Europe for over two decades, while the updated #Enzian classification, published in 2021, has subsequently gained broader international acceptance.",{"type":77,"content":83},"Objectives",{"type":80,"content":85},"To evaluate international expert perspectives and generate potential items informing updates to selected compartments of the #Enzian classification.",{"type":77,"content":87},"Methods",{"content":89,"type":80},"Twenty-six internationally recognised experts in endometriosis surgery, imaging, and reproductive medicine were invited to participate in a structured survey. The electronic questionnaire comprised 29 single-choice and open-ended items addressing five #Enzian compartments: T (tuboovarian condition), B (sacrouterine ligaments, cardinal ligaments, pelvic sidewall), 
79C (rectum), FB (bladder), and FA (adenomyosis). Responses were collected anonymously, analysed descriptively, and thematically grouped. Consensus thresholds followed established criteria.",{"type":77,"content":91},"Main Outcome Measures",{"type":80,"content":93},"Expert perspectives regarding the need for revision of selected #Enzian compartments and proposed modifications.",{"content":95,"type":77},"Results",{"type":80,"content":97},"Twenty-three experts responded (88.5%). Strong agreement for revision was observed for compartments B, C, and FB (&gt;80%). Moderate agreement (&gt;60%) supported updates to compartments T and FA. Specific suggested refinements included adding the suffix d within compartment T to reflect tubal dilatation (73.9% in favour) and the suffix P within compartment B to denote pelvic sidewall/parametrial involvement (78.3% in favour). For colorectal disease (compartment C), respondents supported reporting lesion–anal verge distance and multifocality. A graded FA1–FA3 system for adenomyosis was favoured (73.9%). Opinions regarding descriptors of bladder endometriosis were heterogeneous.",{"type":77,"content":99},"Conclusions",{"content":101,"type":80},"Experts identified clear priorities for refining the #Enzian classification, particularly regarding parametrial involvement, colorectal deep endometriosis and adenomyosis extent. These findings could provide a structured framework to inform subsequent Delphi consensus rounds.",{"type":77,"content":103},"What is New?",{"type":80,"content":105},"The study identifies international expert-agreed priorities for refinement of selected #Enzian classification compartments.",[107,121,131,149],{"articleId":5,"type":108,"lang":67,"index":71,"subType":109,"contents":110,"boxed":46},"fullText","introduction",[111,113,115,117,119],{"type":75,"content":112},"Introduction",{"content":114,"type":80},"Endometriosis is a chronic, oestrogen-dependent condition characterised by heterogeneous phenotypes, including superficial peritoneal implants, ovarian endometrioma, deep endometriosis (DE) affecting various anatomical locations and adenomyosis.\u003Csup>\u003Ca class=\"xref\" data-type=\"ref\" data-target=\"1\">1\u003C/a>\u003C/sup> Accurate and standardised description of disease extent is essential for patient counselling regarding pain and fertility outcomes, surgical planning, multidisciplinary communication and clinical research. Traditional staging systems, including the revised American Society for Reproductive Medicine (ASRM) score, have limited ability to describe deep and extragenital disease in anatomical detail, while the American Association of Gynaecological Laparoscopists (AAGL) score reflects surgical complexity rather than providing comprehensive non-invasive anatomical mapping system.\u003Csup>\u003Ca class=\"xref\" data-type=\"ref\" data-target=\"2-4\">2-4\u003C/a>\u003C/sup> These limitations prompted the development of anatomically oriented classification systems, including the Enzian classification, used in central European countries over two decades and accepted worldwide since its updated #Enzian version published in 2021.\u003Csup>\u003Ca class=\"xref\" data-type=\"ref\" data-target=\"5\">5\u003C/a>\u003C/sup>",{"content":116,"type":80},"The #Enzian classification was designed as a comprehensive non-invasive and surgical description system encompassing peritoneal, ovarian, deep and extragenital endometriosis as well as selected adhesions, structured by anatomical compartments, it can be applied using transvaginal ultrasound (TVS), magnetic resonance imaging (MRI), surgical assessment, thereby bridging pre-operative evaluation and intra-operative findings. Several studies have demonstrated high accuracy of the classification when combined with TVS\u003Csup>\u003Ca class=\"xref\" data-type=\"ref\" data-target=\"6-8\">6-8\u003C/a>\u003C/sup> whose use is supported by a recent consensus statement on imaging and classification of DE.\u003Csup>\u003Ca class=\"xref\" data-type=\"ref\" data-target=\"9\">9\u003C/a>\u003C/sup> Diagnostic accuracy and inter-observer agreement for ultrasound\u003Csup>\u003Ca class=\"xref\" data-type=\"ref\" data-target=\"10\">10\u003C/a>\u003C/sup> and MRI-based #Enzian have been reported as promising, particularly for selected compartments.\u003Csup>\u003Ca class=\"xref\" data-type=\"ref\" data-target=\"11\">11\u003C/a>\u003C/sup>",{"content":118,"type":80},"Despite these advances, several limitations of the current #Enzian system have been highlighted. Narrative reviews and comparative studies underline its complexity,\u003Csup>\u003Ca class=\"xref\" data-type=\"ref\" data-target=\"12\">12\u003C/a>\u003C/sup> variable performance of specific compartments,\u003Csup>\u003Ca class=\"xref\" data-type=\"ref\" data-target=\"9\">9\u003C/a>\u003C/sup> and limited descriptors for certain clinically relevant features, such as correlation with pain,\u003Csup>\u003Ca class=\"xref\" data-type=\"ref\" data-target=\"13\">13\u003C/a>, \u003Ca class=\"xref\" data-type=\"ref\" data-target=\"14\">14\u003C/a>\u003C/sup>
79 fertility outcomes, distal tubal pathology, and parametrial and pelvic sidewall involvement. The absence of standardised non-invasive infertility assessment frameworks underscores the need for more comprehensive, reproducible tools such as #Enzian to bridge this critical diagnostic deficit.\u003Cem> \u003C/em>Recent proposals to convert #Enzian into a four-stage system further illustrate the current drive toward harmonisation with other classification schemes.\u003Csup>\u003Ca class=\"xref\" data-type=\"ref\" data-target=\"15\">15\u003C/a>\u003C/sup>",{"type":80,"content":120},"Artificial intelligence (AI) applications in MRI and ultrasound rely heavily on detailed anatomical inputs, with deep learning models achieving substantial improvements in lesion detection and segmentation. Comprehensive and granular datasets may become increasingly relevant for effective AI integration in endometriosis imaging.\u003Csup>\u003Ca class=\"xref\" data-type=\"ref\" data-target=\"16\">16\u003C/a>\u003C/sup> Against this background, we conducted an international survey among experts in endometriosis surgery, imaging and medically assisted reproduction to evaluate the perceived need for targeted refinement of selected #Enzian compartments and to identify priorities for a future revision of the classification.",{"articleId":5,"type":108,"lang":67,"index":41,"subType":122,"contents":123,"boxed":46},"methods",[124,125,127,129],{"content":87,"type":75},{"content":126,"type":80},"This study represents&nbsp;a\u003Cem> \u003C/em>preliminary, item-generating international expert survey designed to inform subsequent Delphi rounds evaluating potential updates to the #Enzian classification. The survey was created to explore expert views on the established current version of the #Enzian classification of endometriosis.\u003Csup>\u003Ca class=\"xref\" data-type=\"ref\" data-target=\"5\">5\u003C/a>\u003C/sup> Twenty-six experts were purposively selected based on academic contribution and recognised clinical expertise in endometriosis, imaging and fertility. The original #Enzian development team was included to preserve continuity. Invitations were distributed by e-mail, and participation was voluntary and anonymous, with no personal identifiers. A structured electronic questionnaire comprising 29 items (single-choice and open-ended) was developed. The instrument targeted five compartments of the #Enzian system, as agreed during the initial in-person core expert group meeting in May 2025: B (sacrouterine ligaments, cardinal ligaments, pelvic sidewall)-questions 1-6; T (tuboovarian condition)-questions 7-12; C (bowel)-questions 13-19; FB (bladder)-questions 20-24 and FA (adenomyosis)-questions 25-29.",{"content":128,"type":80},"All questions addressed both, the perceived need for revision and agreement with proposed modifications (e.g., suffixes, numeric indices, anatomical distances). The questionnaire was distributed electronically using the blind carbon copy function. A 30-day response window was provided, with an estimated completion time of five minutes. The questionnaire is available on \u003Ca target=\"_blank\" rel=\"noopener noreferrer nofollow\" href=\"https://www.surveymonkey.com/r/V7QCTRV\">https://www.surveymonkey.com/r/V7QCTRV\u003C/a>.",{"type":80,"content":130},"Quantitative (single choice) responses were tabulated and analysed descriptively. Free-text answers were standardised and thematically grouped. Consensus thresholds were applied in line with previously published works\u003Csup>\u003Ca class=\"xref\" data-type=\"ref\" data-target=\"9\">9\u003C/a>\u003C/sup> as follows: experts provided binary responses (agree/disagree); grades of agreement were defined as strong agreement (more than 80% agree), moderate agreement (more than 60% agree), equipoise (40%-60% agree), or disagreement (less than 40% agree). The summary of this survey and their levels of agreement are presented in this work. The study fulfilled criteria for minimal-risk survey research, and although formal ethical approval was not required, compliance with local survey research standards was ensured.",{"articleId":5,"type":108,"lang":67,"index":48,"
79subType":132,"contents":133,"boxed":46},"results",[134,135,137,139,141,143,145,147],{"type":75,"content":95},{"type":80,"content":136},"Of 26 invited experts, 23 completed the survey with a response rate of 88.5%. Respondents represented geographically diverse regions: Australia (1), Austria (2), Belgium (1), Brazil (1), Canada (1), France (1), Germany (5), Hungary (2), Italy (6), Poland (1), Portugal (1), Switzerland (2), and the United Kingdom (2).",{"content":138,"type":80},"Most experts endorsed revising the #Enzian classification according to the following compartments: T (tubo-ovarian condition), B (sacrouterine ligaments, cardinal ligaments, pelvic sidewall), C (rectum), FB (bladder) and FA (adenomyosis) (\u003Ca class=\"xref\" data-target=\"table-1\" data-type=\"table\">Table 1\u003C/a>). Strong agreement (&gt;80%) was achieved for revising topics concerning compartments (81.6%), C (82.6%), and FB (82.6%). Moderate agreement (&gt;60%) was reached for compartments T and FA (73.9 % each).",{"content":140,"type":80},"Participants reached moderate agreement that the current description of compartment T does not provide sufficient information regarding the presence or absence of tubal dilatation, a feature that may suggest impaired tubal function. Within this exploratory item, 73.9% supported adding the suffix&nbsp;d\u003Cem> \u003C/em>to better describe this possible pathology within compartment T. The proposed suffix was not intended to grade the severity of dilatation or to define management decisions, but rather to improve structured documentation of potentially fertility-relevant pathology. Opinions diverged on a further subclassification describing tubal content (hydrosalpinx vs. hematosalpinx) with only 21.7% supporting its inclusion, whereas 56.5% considered it an unnecessary level of detail and a further 21.7% did not support the item on the basis on their prior response (disagreement with suggested suffix d addition), indicating an overall lack of agreement.",{"content":142,"type":80},"There was moderate agreement (78.3%) to support the addition of a suffix&nbsp;\u003Cem>p\u003C/em> within compartment B&nbsp;to denote pelvic sidewall and/or lateral parametrial involvement. In this exploratory survey, lateral parametrial involvement was used to describe disease extending laterally towards the pelvic sidewall, including clinically relevant proximity to or involvement of ureteric or nerve structures. Experts emphasised the surgical relevance of the lateral disease extension, with 78.3% reporting that such involvement always (47.8%) or often (30.4%) influences their operative strategy, and a further 21.8% indicating that it occasionally does so.",{"content":144,"type":80},"Regarding the compartment C (rectum), moderate agreement was reached for documenting distance from the anal verge to the lowermost rectal DE lesion (73.9%) and necessity to record the number of rectal nodules (78.3%), in addition to existing lesion size descriptors used. Respondents also noted that these variables better support surgical planning, particularly for the low rectal lesions: 69.6% survey participants reported lesion proximity to the anal verge as being a frequent determinant in operative decision-making, and 65.2% supported the suffix “L” use within compartment C for lesions &lt;5 cm from the anal verge.",{"content":146,"type":80},"Experts reached moderate agreement (73.9%) regarding exploration of a graded FA1–FA3 system to better characterise according to the estimated proportion myometrial involvement. This proposal should be interpreted as an item for further evaluation rather than a validated quantitative grading system. Although strong agreement (82.6%) was observed regarding the need for revising FB descriptors for bladder endometriosis, no single descriptor achieved agreement: 34.8% favoured maximum lesion diameter, 34.8% supported recording the distance between the lesion and the ureteral orifice irrespective of lesion size, 13.0% were uncertain, and 17.4% proposed alternative approaches in\u003Cem> \u003C/em>free-text comments, including ureteral involvement or trigonal extension descriptions.",{"type":80,"content":148},"Thematic analysis of free-text responses identified several recurring suggestions, summarised in \u003Ca class=\"xref\" data-target=\"table-2\" data-type=\"table\">Table 2\u003C/a>. Key issues included the need for a more detailed description of compartment B, clinically relevant descriptors of possible tubal pathology within compartment T, inclusion of lesion-to-anal-verge distance and multifocality for colorectal disease within compartment C, and clearer differentiation between focal and diffuse adenomyosis in alignment with MUSA criteria.\u003Ca class=\"xref\" data-target=\"17\" data-type=\"ref\">\u003Csup>17\u003C/sup>
79\u003C/a> Views and opinions on bladder endometriosis (FB) classification remained heterogeneous, with many experts preferring simplicity and descriptive annotations rather than additional coding.",{"articleId":5,"type":108,"lang":67,"index":59,"subType":150,"contents":151,"boxed":46},"discussion",[152,154,156,158,160,162,164,166,168,170,172,174,176,178],{"content":153,"type":75},"Discussion",{"type":77,"content":155},"\u003Cem>Main findings\u003C/em>",{"content":157,"type":80},"The present work reports the results of an international expert survey conducted as a preliminary item generation step to inform future Delphi-based refinement of the current #Enzian classification. The findings suggest that several clinically relevant anatomical features may currently be insufficiently represented, particularly within compartments B, C and FB. This likely reflects increasing recognition of the importance of parametrial extension, colorectal multifocality, and bladder-related descriptors in contemporary endometriosis imaging and surgical practice. Nevertheless, variability regarding the preferred implementation of these descriptors highlights the complexity of balancing anatomical details with practical usability within an integrated classification system. Expert support for including lesion–to-anal-verge distance and multifocality in colorectal DE further suggests that lesion size descriptors alone may not adequately reflect the complexity and surgical relevance of rectosigmoid disease. This may be particularly relevant since the surgical literature shows that these variables indeed correlate with operative complexity, choice of technique, and postoperative morbidity.\u003Ca class=\"xref\" data-target=\"18\" data-type=\"ref\">\u003Csup>18\u003C/sup>\u003C/a>\u003Csup>, \u003C/sup>\u003Ca class=\"xref\" data-target=\"19\" data-type=\"ref\">\u003Csup>19\u003C/sup>\u003C/a> Furthermore, these descriptors may support not only operative planning but also patient counselling and informed consent, particularly in cases of low rectal disease where surgical morbidity may substantially differ. Recent prospective data have additionally demonstrated promising diagnostic accuracy of structured ultrasound assessment for rectosigmoid DE using the IDEA protocol and #Enzian classification framework, supporting the feasibility of more anatomically detailed preoperative reporting.\u003Ca class=\"xref\" data-target=\"20\" data-type=\"ref\">\u003Csup>20\u003C/sup>\u003C/a>",{"content":159,"type":80},"The strong interest in refining parametrial and pelvic sidewall descriptors also reflects increasing awareness of the importance of these anatomical regions in both imaging and surgical management of DE. Recently published methodological consensus papers have further standardised ultrasound assessment of the pelvic sidewall and parametrium, potentially facilitating broader implementation and reproducibility of these evaluations in clinical practice.\u003Ca class=\"xref\" data-target=\"21\" data-type=\"ref\">\u003Csup>21\u003C/sup>\u003C/a>\u003Csup>, \u003C/sup>\u003Ca class=\"xref\" data-target=\"22\" data-type=\"ref\">\u003Csup>22\u003C/sup>\u003C/a>",{"type":80,"content":161},"Moderate agreement regarding modifications to the compartment T reflects growing recognition of the importance of documenting tubal pathology, including tubal dilatation, which may impact reproductive outcomes. The proposed suffix d was intended as an exploratory descriptor to better integrate documentation of fertility-relevant parameters into the #Enzian classification rather than to directly determine management strategies. Importantly, no agreement was achieved regarding subclassification of hydrosalpinx vs. hematosalpinx, suggesting that experts favoured simplified descriptors at this preliminary stage. Although not formally evaluated within this survey, additional imaging markers such as “kissing ovaries” may also warrant consideration within subsequent Delphi rounds due to their recognised association with posterior compartment disease.\u003Ca class=\"xref\" data-target=\"23\" data-type=\"ref\">\u003Csup>23\u003C/sup>
79\u003C/a> Proposed refinements to compartment FB underscore the heterogeneity of bladder endometriosis and the absence of universally accepted descriptors reflecting lesion complexity and surgical relevance. However, no clear agreement emerged regarding whether lesion size and/or proximity to the ureteral orifice should be prioritised within future #Enzian classification descriptors. Interest in exploring a graded FA1–FA3 scheme for adenomyosis may reflect increasing recognition of the need for more structured adenomyosis phenotyping within endometriosis classification systems. Importantly, this proposal should not be interpreted as a validated quantitative grading system, as objective volumetric assessment of adenomyosis remains challenging in both imaging and surgical practice. Furthermore, differentiation between focal and diffuse adenomyosis based on direct and indirect MUSA criteria remains complex and requires further validation for their extent within the classification.",{"type":80,"content":163},"Persistent challenges regarding symptom-disease correlation in endometriosis\u003Ca class=\"xref\" data-target=\"24\" data-type=\"ref\">\u003Csup>24\u003C/sup>\u003C/a> further support the need for more structured and anatomically detailed classification systems. Limited standardised phenotyping may reduce the ability to analyse symptom patterns, reproductive outcomes and disease severity prospectively. However, recent prospective imaging research, particularly the work of Exacoustos and colleagues,&nbsp; demonstrates that when standardised and anatomically detailed descriptors are applied, such as RADAR graphical mapping in conjunction with the #Enzian classification, clinically meaningful correlations with symptoms may indeed be achieved.\u003Ca class=\"xref\" data-target=\"10\" data-type=\"ref\">\u003Csup>10\u003C/sup>\u003C/a> These findings highlight the need for consistent, prospective data acquisition across all clinical pathways, including assisted reproductive techniques, as robust symptom–disease analyses fundamentally rely on high diagnostic quality. In parallel, contemporary AI applications increasingly rely on high-quality structured anatomical datasets, further emphasising the potential future relevance of refined and reproducible classification.\u003Ca class=\"xref\" data-target=\"16\" data-type=\"ref\">\u003Csup>16\u003C/sup>\u003C/a> Nevertheless, implementation of such approaches remains highly dependent on expert imaging assessment, particularly in TVS, and standardised methodology which remains inconsistently implemented across clinical settings.\u003Ca class=\"xref\" data-target=\"25\" data-type=\"ref\">\u003Csup>25\u003C/sup>\u003C/a>",{"type":80,"content":165},"Overall, the thematic convergence observed across expert responses indicates that future alterations of the #Enzian classification should prioritise (i) improved delineation of parametrial and pelvic sidewall disease, (ii) more comprehensive characterisation of colorectal involvement, (iii) standardised descriptors for tubal pathology, and (iv) integration of contemporary sonographic criteria for describing the extent of adenomyosis.",{"type":80,"content":167},"Importantly, the absence of universal agreement across several proposed items likely reflects complexity and heterogeneity of endometriosis, differences in surgical approaches, imaging modality expertise and clinical priorities among international experts. Rather than weakening the findings, this observation reinforces the rationale for a structured Delphi process with aim to refine, prioritise and harmonise expert perspectives into even more widely applicable and acceptable classification system.",{"type":77,"content":169},"\u003Cem>Strengths and Limitations\u003C/em>",{"content":171,"type":80},"The strength of the present work is that it includes the opinion of twenty-three purposively selected experts, including original #Enzian developers reflecting a high external validity within the expert community. Several limitations should be acknowledged. Only selected #Enzian compartments were evaluated, while other potentially relevant domains (e.g. A, O, and F categories outside FB/FA) were beyond the scope of this preliminary survey. Additionally, binary response formats may oversimplify complex anatomical and clinical considerations, making qualitative free-text responses potentially crucial to contextual interpretation. Finally, only moderate agreement was reached on several topics which can be seen as\u003Cem> \u003C/em>promising but requires refinement and further consensus testing.",{"content":173,"type":77},"\u003Cem>
79Clinical implications\u003C/em>",{"type":80,"content":175},"In summary, this work constitutes a structured item-generation phase designed to inform subsequent Delphi consensus processes and to support the further evolution of the #Enzian classification. The proposed exploratory items aim to enhance its clinical relevance, surgical utility, and compatibility with contemporary imaging and emerging AI-based applications.",{"content":177,"type":77},"\u003Cem>Unanswered questions and future research\u003C/em>",{"type":80,"content":179},"At this stage, no definitive classification changes are proposed, and further Delphi rounds are necessary to refine, prioritise, and validate the suggested modifications.",[181,227,245,253,269,284,297,313,321,329,340,348,356,363,370,382,394,401,436,473,486,520,527,541,570],{"originalText":182,"pubmed":183,"pmId":187,"year":222,"additionalInfo":38,"authors":223,"volume":211,"isPubmedChecked":37,"index":71,"isParsed":37,"isCrossrefChecked":46,"doi":203,"pages":224,"text":182,"containerTitle":225,"title":221,"type":226,"issue":188},"Giudice LC, Liu B, Irwin JC. Endometriosis and adenomyosis unveiled through single-cell glasses. Am J Obstet Gynecol. 2025;232:S105-23.",{"pages":184,"nlmuniqueid":185,"pubdate":186,"uid":187,"issue":188,"articleids":189,"publishername":38,"pubtype":208,"epubdate":38,"volume":211,"authors":212,"fulljournalname":220,"title":221},"S105-S123","0370476","2025 Apr","40253075","4S",[190,192,196,199,202,205],{"value":187,"idtypen":41,"idtype":191},"pubmed",{"idtypen":193,"idtype":194,"value":195},8,"mid","NIHMS2086294",{"idtype":197,"idtypen":193,"value":198},"pmc","PMC12282335",{"value":200,"idtypen":64,"idtype":201},"pmc-id: PMC12282335;manuscript-id: NIHMS2086294;","pmcid",{"idtypen":59,"value":203,"idtype":204},"10.1016/j.ajog.2024.08.043","doi",{"idtype":206,"value":207,"idtypen":63},"pii","S0002-9378(24)00898-6",[209,210],"Journal Article","Review","232",[213,216,218],{"clusterid":38,"name":214,"authtype":215},"Giudice LC","Author",{"clusterid":38,"name":217,"authtype":215},"Liu B",{"name":219,"clusterid":38,"authtype":215},"Irwin JC","American journal of obstetrics and gynecology","Endometriosis and adenomyosis unveiled through single-cell glasses.","2025","Giudice LC, Liu B, Irwin JC","S105-23","Am J Obstet Gynecol","journal",{"additionalInfo":228,"index":41,"volume":229,"year":230,"pages":231,"containerTitle":232,"issue":233,"text":234,"isPubmedChecked":37,"type":226,"crossref":235,"doi":241,"authors":243,"isParsed":37,"title":244,"isCrossrefChecked":37,"originalText":234},"e1.","28","2021","1941-50","J Minim Invasive Gynecol","11","Abrao MS, Andres MP, Miller CE, Gingold JA, Rius M, Neto JS, et al. AAGL 2021 endometriosis classification: an anatomy-based surgical complexity score. J Minim Invasive Gynecol. 2021;28:1941-50.e1.",{"publisher":236,"volume":229,"page":237,"title":238,"issue":233,"type":240,"DOI":241,"containerTitle":242},"Elsevier BV","1941-1950.e1",[239],"AAGL 2021 Endometriosis Classification: An Anatomy-based Surgical Complexity Score","journal-article","10.1016/j.jmig.2021.09.709","Journal of Minimally Invasive Gynecology","Abrao MS, Andres MP, Miller CE, Gingold JA, Rius M, Neto JS, et al","AAGL 2021 endometriosis classification: an anatomy-based surgical complexity score.",{"volume":246,"year":247,"containerTitle":248,"index":48,"additionalInfo":38,"title":249,"pages":250,"isCrossrefChecked":37,"type":226,"isParsed":37,"isPubmedChecked":37,"text":251,"originalText":251,"authors":252},"37","2022","Hum Reprod","Comparison of #Enzian classification and revised American Society for Reproductive Medicine stages for the description of disease extent in women with deep endometriosis.","2359-65","Montanari E, Bokor A, Szabó G, Kondo W, Trippia CH, Malzoni M, et al. Comparison of #Enzian classification and revised American Society for Reproductive Medicine stages for the description of disease extent in women with deep endometriosis. Hum Reprod. 2022;37:2359-65.","Montanari E, Bokor A, Szabó G, Kondo W, Trippia CH, Malzoni M, et al",{"index":59,"title":254,"pages":255,"doi":256,"crossref":257,"isPubmedChecked":37,"containerTitle":265,"originalText":266,"publicationFormat":38,"isParsed":37,"text":267,"publisherType":38,"year":230,"additionalInfo":38,"type":226,"isCrossrefChecked":37,"issue":262,"authors":268,"volume":258},"What to choose and why to use - a critical review on the clinical relevance of rASRM, EFI and Enzian classifications of endometriosis.","331-8","10.52054/fvvo.13.4.041",{"volume":258,"type":240,"title":259,"page":261,"DOI":256,"issue":262,"containerTitle":263,"publisher":264},"13",[260],"What to choose and why to use – a critical review on the clinical relevance of rASRM, EFI and Enzian classifications of endometriosis","331-338","4","Facts, Views and Vision in ObGyn","Galenos Yayinevi","Facts Views Vis Obgyn","Hudelist G, Valentin L, Saridogan E, Condous G, Malzoni M, Roman H, et al. What to choose and why to use - a critical review on the clinical relevance of rASRM, EFI and Enzian classifications of endometriosis. Facts Views Vis Obgyn. 2021;13(4):331-8.","Hudelist G, Valentin L, Saridogan E, Condous G, Malzoni M, Roman H, et al. What to choose and why to use - a critical review on the clinical relevance of rASRM, EFI and Enzian classifications of endometriosis. Facts Views Vis Obgyn. 2021;13:331-8.","Hudelist G, Valentin L, Saridogan E, Condous G, Malzoni M, Roman H, et al",{"type":226,"index":63,"containerTitle":270,"originalText":271,"isParsed":37,"isPubmedChecked":37,"pages":272,"title":273,"crossref":274,"text":271,"issue":280,"authors":283,"additionalInfo":38,"volume":279,"doi":282,"isCrossrefChecked":37,"year":230},"Acta Obstet Gynecol Scand","Keckstein J, Saridogan E, Ulrich UA, Sillem M, Oppelt P, Schweppe KW, et al. The #Enzian classification: a comprehensive non-invasive and surgical description system for endometriosis. Acta Obstet Gynecol Scand. 2021;100:1165-75.","1165-75","The #Enzian classification: a comprehensive non-invasive and surgical description system for endometriosis.",{"publisher":275,"title":276,"containerTitle":278,"volume":279,"issue":280,"page":281,"type":240,"DOI":282},"Wiley",[277],"The #Enzian classification: A comprehensive non‐invasive and surgical description system for endometriosis","Acta Obstetricia et Gynecologica Scandinavica","100","7","1165-1175","10.1111/aogs.14099","Keckstein J, Saridogan E, Ulrich UA, Sillem M, Oppelt P, Schweppe KW, et al",{"isPubmedChecked":37,"crossref":285,"isParsed":37,"additionalInfo":38,"volume":289,"type":226,"originalText":293,"title":294,"containerTitle":295,"authors":252,"pages":296,"doi":291,"year":247,"text":293,"issue":286,"index":64,"isCrossrefChecked":37},{"issue":286,"publisher":275,"title":287,"volume":289,"containerTitle":290,"DOI":291,"type":240,"page":292},"3",[288],"Accuracy of sonography for non‐invasive detection of ovarian and deep endometriosis using #Enzian classification: prospective multicenter diagnostic accuracy study","59","Ultrasound in Obstetrics &amp; Gynecology","10.1002/uog.24833","385-391","Montanari E, Bokor A, Szabó G, Kondo W, Trippia CH, Malzoni M, et al. Accuracy of sonography for non-invasive detection of ovarian and deep endometriosis using #Enzian classification: prospective multicenter diagnostic accuracy study. Ultrasound Obstet Gynecol. 2022;59:385-91.","Accuracy of sonography for non-invasive detection of ovarian and deep endometriosis using #Enzian classification: prospective multicenter diagnostic accuracy study.","Ultrasound Obstet Gynecol","385-91",{"isParsed":37,"originalText":298,"year":299,"crossref":300,"additionalInfo":38,"isCrossrefChecked":37,"index":2
796,"issue":307,"type":226,"isPubmedChecked":37,"authors":309,"pages":310,"doi":301,"containerTitle":311,"text":298,"title":312,"volume":308},"Di Giovanni A, Montanari E, Hudelist G, Malzoni M, Keckstein J. Comparison between sonography-based and surgical evaluation of endometriotic lesions using the #Enzian classification - a retrospective data analysis. Ultraschall Med. 2023;44:290-8.","2023",{"DOI":301,"containerTitle":302,"title":303,"type":240,"publisher":305,"page":306,"issue":307,"volume":308},"10.1055/a-1713-3573","Ultraschall in der Medizin - European Journal of Ultrasound",[304],"Comparison Between Sonography-Based and Surgical Evaluation of Endometriotic Lesions Using the #Enzian Classification – A Retrospective Data Analysis","Georg Thieme Verlag KG","290-298","03","44","Di Giovanni A, Montanari E, Hudelist G, Malzoni M, Keckstein J","290-8","Ultraschall Med","Comparison between sonography-based and surgical evaluation of endometriotic lesions using the #Enzian classification - a retrospective data analysis.",{"year":299,"isParsed":37,"authors":314,"isCrossrefChecked":37,"additionalInfo":38,"volume":315,"pages":316,"containerTitle":317,"type":226,"isPubmedChecked":37,"index":318,"text":319,"originalText":319,"title":320},"Bindra V, Madhavi N, Mohanty GS, Nivya K, Balakrishna N","307","179-86","Arch Gynecol Obstet",7,"Bindra V, Madhavi N, Mohanty GS, Nivya K, Balakrishna N. Pre-operative mapping and structured reporting of pelvic endometriotic lesions on dynamic ultrasound and its correlation on laparoscopy using the #ENZIAN classification. Arch Gynecol Obstet. 2023;307:179-86.","Pre-operative mapping and structured reporting of pelvic endometriotic lesions on dynamic ultrasound and its correlation on laparoscopy using the #ENZIAN classification.",{"text":322,"isParsed":37,"volume":323,"year":324,"pages":325,"containerTitle":326,"additionalInfo":38,"isPubmedChecked":37,"authors":327,"originalText":322,"index":193,"type":226,"title":328,"isCrossrefChecked":37},"Condous G, Gerges B, Thomassin-Naggara I, Becker C, Tomassetti C, Krentel H, et al. Non-invasive imaging techniques for diagnosis of pelvic deep endometriosis and endometriosis classification systems: an International Consensus Statement. Facts Views Vis ObGyn. 2024;16:127-44.","16","2024","127-44","Facts Views Vis ObGyn","Condous G, Gerges B, Thomassin-Naggara I, Becker C, Tomassetti C, Krentel H, et al","Non-invasive imaging techniques for diagnosis of pelvic deep endometriosis and endometriosis classification systems: an International Consensus Statement.",{"isCrossrefChecked":37,"volume":323,"pages":330,"type":226,"title":331,"authors":332,"isPubmedChecked":37,"isParsed":37,"year":324,"additionalInfo":38,"index":333,"crossref":334,"issue":335,"text":339,"doi":338,"originalText":339,"containerTitle":265},"47-58","Reproducibility of #Enzian classification by transvaginal ultrasound and its correlation with symptoms.","Russo C, Lazzeri L, Siciliano T, Selntigia A, Farsetti D, Chiaramonte C, et al",9,{"volume":323,"containerTitle":263,"issue":335,"title":336,"publisher":264,"DOI":338,"type":240,"page":330},"1",[337],"Reproducibility of #Enzian classification by transvaginal ultrasound and its correlation with symptoms","10.52054/fvvo.16.1.008","Russo C, Lazzeri L, Siciliano T, Selntigia A, Farsetti D, Chiaramonte C, et al. Reproducibility of #Enzian classification by transvaginal ultrasound and its correlation with symptoms. Facts Views Vis Obgyn. 2024;16:47-58.",{"isPubmedChecked":37,"isCrossrefChecked":37,"type":226,"originalText":341,"additionalInfo":38,"authors":342,"year":299,"volume":343,"containerTitle":344,"pages":345,"title":346,"text":341,"isParsed":37,"index":347},"Harth S, Kaya HE, Zeppernick F, Meinhold-Heerlein I, Keckstein J, Yildiz SM, et al. Application of the #Enzian classification for endometriosis on MRI: prospective evaluation of inter- and intraobserver agreement. Front Med (Lausanne). 2023;10:1303593.","Harth S, Kaya HE, Zeppernick F, Meinhold-Heerlein I, Keckstein J, Yildiz SM, et al","10","Front Med (Lausanne)","1303593","Application of the #Enzian classification for endometriosis on MRI: prospective evaluation of inter- and intraobserver agreement.",10,{"authors":349,"originalText":350,"year":230,"additionalInfo":38,"volume":258,"text":350,"containerTitle":351,"pages":352,"title":353,"isPubmedChecked":37,"isCrossrefChecked":37,"index":354,"organization":355,"isParsed":37,"type":226},"International Working Group of AAGL, ESGE, ESHRE and WES","International Working Group of AAGL, ESGE, ESHRE and WES; Vermeulen N, Abrao MS, Einarsson JI, Horne AW, Johnson NP, Lee TTM, et al. Endometriosis classification, staging and reporting systems: a review on the road to a universally accepted endometriosis classification. Facts Views Vis Obgyn. 2021;13:305-30."," ","305-30","Facts Views Vis Obgyn.",11,"Vermeulen N, Abrao MS, Einarsson JI, Horne AW, Johnson NP, Lee TTM, et al. Endometriosis classification, staging and reporting systems: a review on the road to a universally accepted endometriosis classification",{"pages":357,"title":358,"isPubmedChecked":37,"year":247,"index":359,"isParsed":37,"type":226,"isCrossrefChecked":37,"volume":360,"additionalInfo":38,"authors":361,"containerTitle":265,"text":362,"originalText":362},"245-53","Preoperative pain measurements in correlation to deep endometriosis classification with Enzian.",12,"14","Metzemaekers J, Blikkendaal MD, V Nieuwenhuizen KE, Bronsgeest K, Rhemrev JPT, Smeets MJGH, et al","Metzemaekers J, Blikkendaal MD, V Nieuwenhuizen KE, Bronsgeest K, Rhemrev JPT, Smeets MJGH, et al. Preoperative pain measurements in correlation to deep endometriosis classification with Enzian. Facts Views Vis Obgyn. 2022;14:245-53.",{"additionalInfo":38,"isPubmedChecked":37,"isParsed":37,"title":364,"type":226,"originalText":365,"index":366,"isCrossrefChecked":37,"containerTitle":248,"year":222,"text":365,"volume":367,"authors":368,"pages":369},"Evaluation of the association between self-reported pre-operative symptoms with surgically diagnosed endometriosis using the #ENZIAN classification in a multi-centre cohort.","Reiser E, Göbel G, Perricos-Hess A, Buchweitz O, Jaekel M, Westphal E, et al. Evaluation of the association between self-reported pre-operative symptoms with surgically diagnosed endometriosis using the #ENZIAN classification in a multi-centre cohort. Hum Reprod. 2025;40:1643-50.",13,"40","Reiser E, Göbel G, Perricos-Hess A, Buchweitz O, Jaekel M, Westphal E, et al","1643-50",{"isPubmedChecked":37,"containerTitle":232,"index":371,"pages":372,"title":373,"text":374,"doi":375,"originalText":374,"issue":280,"authors":376,"volume":377,"year":222,"crossref":378,"additionalInfo":38,"isCrossrefChecked":37,"isParsed":37,"type":226},14,"639-45","Transforming the #Enzian classification into a four-stage system: a feasibility study by comparison with the 2021 AAGL endometriosis classification.","Fadinger N, Oppelt P, Trautner PS, Szilagyi I, Raidl S, Enzelsberger SH. Transforming the #Enzian classification into a four-stage system: a feasibility study by comparison with the 2021 AAGL endometriosis classification. J Minim Invasive Gynecol. 2025;32:639-45.","10.1016/j.jmig.2025.01.017","Fadinger N, Oppelt P, Trautner PS, Szilagyi I, Raidl S, Enzelsberger SH","32",{"volume":377,"issue":280,"containerTitle":242,"page":379,"title":380,"DOI":375,"publisher":236,"type":240},"639-645",[381],"Transforming the #Enzian Classification Into a Four-Stage System: A Feasibility Study by Comparison With the 2021 AAGL Endometriosis Classification",{"volume":383,"containerTitle":295,"doi":384,"isParsed":37,"additionalInfo":38,"text":385,"index":386,"issue":286,"type":226,"authors":387,"title":388,"pages":389,"crossref":390,"isPubmedChecked":37,"year":222,"originalText":385,"isCrossrefChecked":37},"65","10.1002/uog.29178","Deslandes A, Avery JC, Chen HT, Leonardi M, Knox S, Lo G, et al. Intra- and interobserver agreement of proposed objective transvaginal ultrasound image-quality scoring system for use in artificial intelligence algorithm development. Ultrasound Obstet Gynecol. 2025;65:364-71.",15,"Deslandes A, Avery JC, Chen HT, Leonardi M, Knox S, Lo G, et al","Intra- and interobserver agreement of proposed objective transvaginal ultrasound image-quality scoring system for use in artificial intelligence algorithm development.","364-71",{"page":391,"title":392,"
79issue":286,"containerTitle":290,"publisher":275,"DOI":384,"volume":383,"type":240},"364-371",[393],"Intra‐ and interobserver agreement of proposed objective transvaginal ultrasound image‐quality scoring system for use in artificial intelligence algorithm development",{"index":395,"isParsed":37,"volume":396,"originalText":397,"pages":398,"title":399,"isPubmedChecked":37,"isCrossrefChecked":37,"containerTitle":295,"type":226,"additionalInfo":38,"text":397,"authors":400,"year":247},16,"60","Harmsen MJ, Van den Bosch T, de Leeuw RA, Dueholm M, Exacoustos C, Valentin L, et al. Consensus on revised definitions of Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis: results of modified Delphi procedure. Ultrasound Obstet Gynecol. 2022;60:118-31.","118-31","Consensus on revised definitions of Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis: results of modified Delphi procedure.","Harmsen MJ, Van den Bosch T, de Leeuw RA, Dueholm M, Exacoustos C, Valentin L, et al",{"containerTitle":402,"isPubmedChecked":37,"isParsed":37,"pages":403,"pubmed":404,"doi":412,"originalText":432,"additionalInfo":38,"authors":433,"year":434,"text":432,"type":226,"index":435,"volume":415,"title":406,"pmId":410,"isCrossrefChecked":46,"issue":286},"Hum Reprod Update","329-39",{"pages":403,"nlmuniqueid":405,"title":406,"pubdate":407,"articleids":408,"volume":415,"epubdate":416,"authors":417,"publishername":38,"pubtype":430,"fulljournalname":431,"uid":410,"issue":286},"9507614","Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before management.","2015 May-Jun",[409,411,413],{"value":410,"idtype":191,"idtypen":41},"25618908",{"idtypen":59,"value":412,"idtype":204},"10.1093/humupd/dmv003",{"value":414,"idtypen":63,"idtype":206},"dmv003","21","2015 Jan 24",[418,420,422,424,426,428],{"name":419,"authtype":215,"clusterid":38},"Abrão MS",{"authtype":215,"clusterid":38,"name":421},"Petraglia F",{"authtype":215,"name":423,"clusterid":38},"Falcone T",{"clusterid":38,"name":425,"authtype":215},"Keckstein J",{"name":427,"authtype":215,"clusterid":38},"Osuga Y",{"name":429,"authtype":215,"clusterid":38},"Chapron C",[209,210],"Human reproduction update","Abrão MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C. Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before management. Hum Reprod Update. 2015;21:329-39.","Abrão MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C","2015",17,{"index":437,"issue":335,"pubmed":438,"originalText":470,"isCrossrefChecked":46,"volume":469,"additionalInfo":38,"isParsed":37,"containerTitle":270,"title":471,"isPubmedChecked":37,"pmId":459,"pages":442,"type":226,"doi":467,"text":470,"authors":472,"year":222},18,{"nlmuniqueid":439,"issue":335,"pubtype":440,"pages":442,"epubdate":443,"publishername":38,"pubdate":444,"authors":445,"title":458,"uid":459,"articleids":460,"fulljournalname":468,"volume":469},"0370343",[209,441],"Multicenter Study","95-101","2024 Nov 29","2025 Jan",[446,448,450,452,454,456],{"authtype":215,"clusterid":38,"name":447},"Hudelist G",{"clusterid":38,"authtype":215,"name":449},"Darici Kurt E",{"clusterid":38,"name":451,"authtype":215},"Szabó G",{"authtype":215,"name":453,"clusterid":38},"Miklos D",{"name":455,"authtype":215,"clusterid":38},"Hudelist T",{"authtype":215,"clusterid":38,"name":457},"Bokor A","Surgical outcomes of women undergoing radical resection of deep endometriosis of the sacral plexus: A prospective cohort study.","39611222",[461,462,464,466],{"idtype":191,"idtypen":41,"value":459},{"value":463,"idtypen":193,"idtype":197},"PMC11683532",{"idtype":201,"idtypen":64,"value":465},"pmc-id: PMC11683532;",{"idtype":204,"value":467,"idtypen":59},"10.1111/aogs.15015","Acta obstetricia et gynecologica Scandinavica","104","Hudelist G, Darici Kurt E, Szabó G, Miklos D, Hudelist T, Bokor A. Surgical outcomes of women undergoing radical resection of deep endometriosis of the sacral plexus: a prospective cohort study. Acta Obstet Gynecol Scand. 2025;104:95-101.","Surgical outcomes of women undergoing radical resection of deep endometriosis of the sacral plexus: a prospective cohort study.","Hudelist G, Darici Kurt E, Szabó G, Miklos D, Hudelist T, Bokor A",{"isParsed":37,"containerTitle":311,"index":474,"type":226,"isCrossrefChecked":37,"volume":475,"issue":476,"authors":477,"doi":478,"additionalInfo":38,"title":479,"crossref":480,"pages":484,"text":485,"isPubmedChecked":37,"originalText":485,"year":324},19,"45","01","Szabó G, Hudelist G, Madár I, Rigó JJ, Dobó N, Fintha A, et al","10.1055/a-2034-2022","Diagnostic accuracy of the IDEA protocol for non invasive diagnosis of rectosigmoid DE - a prospective cohort study.",{"title":481,"page":483,"type":240,"issue":476,"volume":475,"DOI":478,"containerTitle":302,"publisher":305},[482],"Diagnostic accuracy of the IDEA protocol for non invasive diagnosis of rectosigmoid DE – a prospective cohort study","61-68","61-8","Szabó G, Hudelist G, Madár I, Rigó JJ, Dobó N, Fintha A, et al. Diagnostic accuracy of the IDEA protocol for non invasive diagnosis of rectosigmoid DE - a prospective cohort study. Ultraschall Med. 2024;45:61-8.",{"authors":487,"doi":488,"index":489,"pmId":490,"title":491,"isPubmedChecked":37,"text":492,"additionalInfo":38,"pubmed":493,"containerTitle":295,"type":226,"issue":335,"isParsed":37,"pages":516,"year":222,"volume":383,"originalText":492,"isCrossrefChecked":46},"Fischerova D, Culcasi C, Gatti E, Ng Z, Burgetova A, Szabó G","10.1002/uog.29122",20,"39499650","Ultrasound assessment of the pelvic sidewall: methodological consensus opinion.","Fischerova D, Culcasi C, Gatti E, Ng Z, Burgetova A, Szabó G. Ultrasound assessment of the pelvic sidewall: methodological consensus opinion. Ultrasound Obstet Gynecol. 2025;65:94-105.",{"volume":383,"pubdate":444,"issue":335,"fulljournalname":494,"epubdate":495,"title":491,"authors":496,"uid":490,"articleids":508,"nlmuniqueid":515,"publishername":38,"pages":516,"pubtype":517},"Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology","2024 Nov 5",[497,499,501,503,505,507],{"clusterid":38,"authtype":215,"name":498},"Fischerova D",{"authtype":215,"clusterid":38,"name":500},"Culcasi C",{"authtype":215,"clusterid":38,"name":502},"Gatti E",{"name":504,"authtype":215,"clusterid":38},"Ng Z",{"clusterid":38,"name":506,"authtype":215},"Burgetova A",{"clusterid":38,"authtype":215,"name":451},[509,510,512,514],{"idtypen":41,"idtype":191,"value":490},{"idtype":197,"idtypen":193,"value":511},"PMC11693842",{"value":513,"idtypen":64,"idtype":201},"pmc-id: PMC11693842;",{"idtypen":59,"idtype":204,"value":488}
79,"9108340","94-105",[209,518,519],"Research Support, Non-U.S. Gov't","Consensus Statement",{"index":521,"isPubmedChecked":37,"isParsed":37,"volume":522,"pages":523,"containerTitle":295,"title":524,"additionalInfo":38,"type":226,"originalText":525,"year":324,"isCrossrefChecked":37,"authors":526,"text":525},21,"64","275-80","Addendum to consensus opinion from International Deep Endometriosis Analysis (IDEA) group: sonographic evaluation of the parametrium.","Guerriero S, Condous G, Rolla M, Hudelist G, Ferrero S, Alcazar JL, et al. Addendum to consensus opinion from International Deep Endometriosis Analysis (IDEA) group: sonographic evaluation of the parametrium. Ultrasound Obstet Gynecol. 2024;64:275-80.","Guerriero S, Condous G, Rolla M, Hudelist G, Ferrero S, Alcazar JL, et al",{"index":528,"issue":529,"pages":530,"crossref":531,"isParsed":37,"year":537,"containerTitle":295,"isPubmedChecked":37,"type":226,"authors":538,"originalText":539,"doi":536,"isCrossrefChecked":37,"additionalInfo":38,"volume":533,"text":539,"title":540},22,"2","269-73",{"containerTitle":290,"page":532,"volume":533,"issue":529,"title":534,"DOI":536,"type":240,"publisher":275},"269-273","55",[535],"Ultrasonographic soft markers for detection of rectosigmoid deep endometriosis","10.1002/uog.20289","2020","Guerriero S, Ajossa S, Pascual MA, Rodriguez I, Piras A, Perniciano M, et al","Guerriero S, Ajossa S, Pascual MA, Rodriguez I, Piras A, Perniciano M, et al. Ultrasonographic soft markers for detection of rectosigmoid deep endometriosis. Ultrasound Obstet Gynecol. 2020;55:269-73.","Ultrasonographic soft markers for detection of rectosigmoid deep endometriosis.",{"additionalInfo":38,"isCrossrefChecked":46,"containerTitle":270,"isParsed":37,"doi":542,"issue":543,"pages":544,"volume":469,"text":545,"type":226,"title":546,"index":547,"originalText":545,"pubmed":548,"year":222,"isPubmedChecked":37,"pmId":549,"authors":569},"10.1111/aogs.70014","9","1599-602","Hudelist G, Darici Kurt E, Jurkovic D, Tellum T. Endometriosis-the scapegoat for pelvic pain? Acta Obstet Gynecol Scand. 2025;104:1599-602.","Endometriosis-the scapegoat for pelvic pain?",23,{"publishername":38,"volume":469,"uid":549,"pubdate":550,"title":551,"pages":552,"fulljournalname":468,"nlmuniqueid":439,"issue":543,"authors":553,"pubtype":560,"epubdate":561,"articleids":562},"40714888","2025 Sep","Endometriosis-The scapegoat for pelvic pain?","1599-1602",[554,555,556,558],{"name":447,"clusterid":38,"authtype":215},{"clusterid":38,"authtype":215,"name":449},{"clusterid":38,"name":557,"authtype":215},"Jurkovic D",{"clusterid":38,"name":559,"authtype":215},"Tellum T",[209,210],"2025 Jul 27",[563,564,566,568],{"idtypen":41,"value":549,"idtype":191},{"idtype":197,"value":565,"idtypen":193},"PMC12393978",{"idtypen":64,"value":567,"idtype":201},"pmc-id: PMC12393978;",{"idtypen":59,"value":542,"idtype":204},"Hudelist G, Darici Kurt E, Jurkovic D, Tellum T",{"type":226,"isCrossrefChecked":37,"year":222,"volume":229,"pages":571,"isPubmedChecked":37,"isParsed":37,"title":572,"containerTitle":573,"text":574,"authors":575,"index":576,"originalText":574,"additionalInfo":38},"100438","Expert transvaginal ultrasound is determinant for diagnosing pelvic conditions after recurrent implantation failure in IVF.","Eur J Obstet Gynecol Reprod Biol X","Selntigia A, Russo C, Farsetti D, Monaco G, Nocita E, Valeriani S, et al. Expert transvaginal ultrasound is determinant for diagnosing pelvic conditions after recurrent implantation failure in IVF. Eur J Obstet Gynecol Reprod Biol X. 2025;28:100438.","Selntigia A, Russo C, Farsetti D, Monaco G, Nocita E, Valeriani S, et al",24,[578,583,588,592,595,598,602,605],{"type":38,"tag":579,"title":38,"contents":580,"index":71},"ack",[581,582],"\u003Cstrong>Acknowledgments\u003C/strong>","The authors would like to thank all participating experts for their time, expertise, and valuable contributions to this study.",{"index":41,"contents":584,"title":38,"type":586,"tag":587},[585],"\u003Cstrong>Contributors:\u003C/strong> Concept: M.P., J.K., M.M., E.S., M.Ma., G.H., Design: J.K., M.M., E.S., M.Ma., G.H., Data Collection or Processing: M.P., J.K., M.M., G.H., Analysis or Interpretation: M.P., J.K., M.M., E.S., M.Ma., G.H., Literature Search: M.P., J.K., M.M., G.H., Writing: M.P., J.K., M.M., E.S., M.Ma., G.H.","authorship-contributions","fn",{"index":48,"title":38,"type":589,"contents":590,"tag":587},"funding",[591],"\u003Cstrong>Funding: \u003C/strong>The authors declared that this study received no financial support.",{"contents":593,"index":59,"tag":587,"title":38},[594],"\u003Cstrong>Competing interests:\u003C/strong> Mohamed Mabrouk, MD, serves as Associate Editor for Facts, Views and Vision in ObGyn. Ertan Saridogan, MD, serves as Associate Editor for Facts, Views and Vision in ObGyn. They had no involvement in the peer-review of this article and had no access to information regarding its peer-review. Jörg Keckstein, MD, is a member of the ESGE Editorial Board of the Facts, Views and Vision in ObGyn. He had no involvement in the peer-review of this article and had no access to information regarding its peer-review. The other authors declared that there is no conflict of interest.",{"contents":596,"tag":587,"index":63,"title":38},[597],"\u003Cstrong>Ethical approval:\u003C/strong> The study fulfilled criteria for minimal-risk research. Formal ethical approval was not required, and the study was conducted in accordance with local survey research standards.",{"tag":587,"type":599,"title":38,"contents":600,"index":64},"consent",[601],"\u003Cstrong>Informed consent:\u003C/strong> Completion of the survey was taken as implied informed consent.",{"index":2
796,"contents":603,"tag":587,"title":38},[604],"\u003Cstrong>Data sharing:\u003C/strong> The data supporting the findings of this study are available from the corresponding author upon reasonable request.",{"index":318,"title":38,"tag":587,"contents":606},[607],"\u003Cstrong>Transparency:\u003C/strong> The authors confirm that this manuscript is an honest, accurate, and transparent account of the study being reported, and that no important aspects of the study have been omitted.",[],[],[611,616],{"lang":67,"id":612,"title":613,"description":614,"content":615,"isSupplement":46},"table-1","\u003Cp>Table 1. Consensus rates for revising the #Enzian classification according to respective compartments.\u003C/p>","\u003Cp>Thresholds: &gt;80% agreed: strong agreement, 60-80% agreed: moderate agreement, 40%-60% agreed: equipoise, &lt;40% agreed: disagreement.\u003C/p>","\u003Ctable style=\"min-width: 75px\">\u003Ccolgroup>\u003Ccol style=\"min-width: 25px\">\u003Ccol style=\"min-width: 25px\">\u003Ccol style=\"min-width: 25px\">\u003C/colgroup>\u003Ctbody>\u003Ctr>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>Compartment\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>Percent in favour\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>Level of agreement\u003C/span>\u003C/p>\u003C/td>\u003C/tr>\u003Ctr>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>B (Parametrium)\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>81.6%\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>Strong agreement\u003C/span>\u003C/p>\u003C/td>\u003C/tr>\u003Ctr>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>C (Bowel)\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>82.6%\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>Strong agreement\u003C/span>\u003C/p>\u003C/td>\u003C/tr>\u003Ctr>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>FB (Bladder)\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>82.6%\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>Strong agreement\u003C/span>\u003C/p>\u003C/td>\u003C/tr>\u003Ctr>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>T (Fallopian tubes)\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>73.9%\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>Moderate agreement\u003C/span>\u003C/p>\u003C/td>\u003C/tr>\u003Ctr>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>FA (Adenomyosis)\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>73.9%\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>Moderate agreement\u003C/span>\u003C/p>\u003C/td>\u003C/tr>\u003C/tbody>\u003C/table>",{"lang":67,"id":617,"title":618,"description":38,"content":619,"isSupplement":46},"table-2","\u003Cp>Table 2. Thematic synthesis of open-ended responses across compartments.\u003C/p>","\u003Ctable style=\"min-width: 75px\">\u003Ccolgroup>\u003Ccol style=\"min-width: 25px\">\u003Ccol style=\"min-width: 25px\">\u003Ccol style=\"min-width: 25px\">\u003C/colgroup>\u003Ctbody>\u003Ctr>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>Compartment\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>Key themes\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>Illustrative comments (paraphrased)\u003C/span>\u003C/p>\u003C/td>\u003C/tr>\u003Ctr>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>T (Fallopian tubes)\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>Tubal dilatation; patency and adhesion quality\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>“Hydrosalpinx vs hematosalpinx distinction is not necessary.”\u003C/span>\u003C/p>\u003C/td>\u003C/tr>\u003Ctr>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>B (Parametrium)\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>Need for lateral clarity; suffix&nbsp;p; ureter/nerve involvement\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>“Add suffix&nbsp;p&nbsp;
79for lateral sidewall involvement.”\u003C/span>\u003C/p>\u003C/td>\u003C/tr>\u003Ctr>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>C (Bowel)\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>Distance from anal verge; multifocality; number of nodules\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>“Record in cm and add ‘mf’ for multifocality.”\u003C/span>\u003C/p>\u003C/td>\u003C/tr>\u003Ctr>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>FB (Bladder)\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>Heterogeneous views; importance of trigone/ureter proximity; prefer simplicity\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>“Describe trigonal involvement narratively.”\u003C/span>\u003C/p>\u003C/td>\u003C/tr>\u003Ctr>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>FA (Adenomyosis)\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>Distinguish focal vs diffuse; consider % myometrial involvement\u003C/span>\u003C/p>\u003C/td>\u003Ctd colspan=\"1\" rowspan=\"1\">\u003Cp>\u003Cspan>“Add suffix ‘f’ or ‘d’ for focal/diffuse.”\u003C/span>\u003C/p>\u003C/td>\u003C/tr>\u003C/tbody>\u003C/table>",{"journalId":621,"volume":437,"issueNumber":59,"issueType":622,"year":623,"month":333,"isPublished":37,"createdAt":624,"id":6,"coverImage":625,"coverPdf":626,"pdf":629,"updatedAt":632},"58770459-5a06-4076-a747-5b73e24cd7c0","issue",2026,1789136285874,"2026-018-003.jpg",{"tr":627,"en":628},"2026-018-003-cover-tr.pdf","2026-018-003-cover.pdf",{"en":630,"tr":631},"2026-018-003.pdf","2026-018-003-tr.pdf",1789538013828,["Reactive",634],{"$snuxt-i18n-meta":635,"$scitePanel":46,"$spageMeta":636,"$smobileMenu":46,"$sshareModal":46},{},{"title":263,"description":637,"keywords":638},"The Facts, Views and Vision in ObGyn is an open access, scientific, double-blind peer-reviewed journal in the field of obstetricians, gynaecologists, reproductive physicians, ethicists, basic scientists and others who treat and investigate women’s health issues. It is the official publication of the European Society for Gynaecological Surgery and is published quarterly.","health,  science,  medicine,  academic journal,  gynecology",["Set"],["ShallowReactive",641],{"article":642},null,"/articles/proposals-for-the-enzian-addendum-and-update-an-international-expert-survey-for-item-generation/doi/FVVO.2026.359",["Reactive",645],{"config":646,"menu":687,"articleStore":741},{"isFetched":37,"domain":647,"journalId":621,"languages":648,"langContents":649,"defaultLanguage":67,"showSearch":37,"googleAnalyticsIds":652,"gtmTags":654,"theme":656,"colors":657,"mainMenuConfig":668,"footerConfig":671,"topBarConfig":673,"sidebarConfig":676,"homeConfig":680,"socialMedia":-1,"journalSystemUrl":681,"isOldWeb":46,"hideIssueMonth":46,"cdnUrl":621,"title":263,"description":637,"keywords":651,"currentLanguage":67,"showGalenosLogo":682,"onlyHealthcareProfessionals":46,"journalTitle":263,"currentIssueId":6,"issn":683,"eIssn":684,"doi":685,"abbreviation":326,"journalIndexes":686},"fvvo.eu",[67],{"en":650},{"title":263,"keywords":651,"description":637},"health, science, medicine, academic journal, gynecology",[653],"G-FM33KS0CQ1",[655],"GTM-PMQM9Q75","v1",{"primary-200":658,"primary-100":659,"primary-50":660,"primary-900":661,"primary-800":662,"primary-700":663,"primary-600":664,"primary-500":665,"primary-400":666,"primary-300":667},"200 201 211","229 230 234","245 245 247","35 46 92","45 60 119","40 54 106","43 57 113","91 99 139","121 126 156","165 168 186",{"colorTheme":669,"background":670},"dark","colored",{"colorTheme":669,"menuConfig":672,"showLogo":37,"background":670,"showMenu":37},{"colorTheme":669,"background":670},{"colorTheme":674,"menuConfig":675,"showLogo":37,"background":670,"showMenu":37},"light",{"colorTheme":669,"background":670},{"colorTheme":674,"position":677,"authorReviewerType":678,"background":679},"right","big","transparent",{"showTabs":37},"https://fvvo.manuscriptmanager.net/",{"header":37,"footer":37},"2032-0418","2684-4230","10.52054/FVVO",[],{"mainMenu":688,"footerMenu":731,"topBarMenu":736},[689,692,713,716,728],{"title":690,"url":691},"About Us","/about",{"title":693,"submenu":694},"Journal Policies",[695,698,701,704,707,710],{"title":696,"url":697},"Free-of-Charge Publication","/free-of-charge-publication",{"title":699,"url":700},"Copyright & Open Access Policy","/copyright-and-open-access-policy",{"title":702,"url":703},"Digital Archiving & Preservation Policy","/digital-archiving-and-preservation-policy",{"title":705,"url":706}
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