When Imaging Misses Disease, Surgery Tells the Full Story
In this case study, Dr. Karli Goldstein examines the role of endometriosis mapping and whether it is truly groundbreaking or, in some cases, overinterpreted.
Advanced imaging has become an increasingly discussed tool in endometriosis care. Mapping technology is often promoted as a way to identify deep disease before surgery and assist with operative planning. While imaging can provide helpful information, this case highlights an important truth: it does not always tell the full story.
In this patient, the scan identified certain findings. However, it failed to detect widespread disease that was later discovered in the operating room during meticulous surgical evaluation.
If you have been told your imaging is normal but your symptoms persist, this discussion is especially important.
What You Will Learn
- What endometriosis mapping is designed to detect and where its limitations lie
- How imaging findings compared to what was ultimately discovered during surgery
- Which areas of disease were missed on imaging, including uterosacral ligament disease, rectal involvement, bladder endometriosis, and appendiceal endometriosis
- Why identifying 50 to 60 percent of lesions still leaves significant disease undetected
- Why imaging should be viewed as a roadmap rather than a definitive diagnosis
What the Imaging Showed Versus What Surgery Revealed
In this case, imaging labeled several critical areas as normal, including the uterosacral ligaments and the vesicouterine compartment. Rectal disease was not clearly identified. Appendiceal endometriosis was not detected.
During surgery, those same areas were found to contain significant endometriosis.
Overall, imaging identified approximately 50 to 60 percent of the lesions present. While that percentage may sound reassuring, it also means that nearly half of the disease remained hidden until direct surgical visualization.
For patients with complex or deep infiltrating disease, this distinction can significantly affect surgical planning, symptom resolution, and long term outcomes.
This Case Is Especially Relevant for Patients Who Are
- Experiencing persistent pelvic pain despite normal or inconclusive imaging
- Considering excision surgery for suspected or confirmed endometriosis
- Trying to understand how imaging fits into comprehensive, expert-level endometriosis care
The Takeaway
Imaging can be a helpful and informative tool. It can assist in surgical preparation and raise suspicion for deeper disease. However, it does not replace a thorough patient history, careful clinical evaluation, and a surgical team prepared to evaluate and treat all potential areas of endometriosis.
This case is a powerful reminder that clear imaging does not always mean a clear pelvis.
If you are navigating ongoing pain or considering excision surgery, individualized evaluation remains essential.
