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So this is a 37-year-old with infertility.

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We're going to start with our sagittal, go compartment by compartment.

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Alright. And so in this case,

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I actually do see something going on in the anterior compartment.

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So if we look at our bladder here,

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there's this mass along the posterior bladder wall.

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I've lost the normal fat plane between the uterus and the bladder.

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So my vesicouterine space is involved.

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I'm also seeing, in the middle compartment,

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a kind of similar signal intensity nodule here involving the posterior serosa

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of the cervix and also the posterior vaginal fornix here.

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And as I continue to scroll through, I don't really see a whole ton going on

0:45

with either ovary or in the posterior compartment.

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So now let's look at the axial T2s.

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We'll get a better look at that.

0:55

Alright, so bilateral ovaries here,

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tons of follicles, but nothing that looks T2 dark.

1:03

Okay, we have this little

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T2 hypointense, but also with T2 hyperintense cystic spaces

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nodule involving the posterior vaginal fornix.

1:15

And then in the axial plane, this is the bladder lesion.

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It's a little bit easier to see on the sagittal.

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So I'm actually going to pull up my T1 pre

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and the sagittal plane, not the axial plane,

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because I'd like to focus on the anterior compartment with this case.

1:30

So our T2 hypointense, but with tiny cystic spaces mass

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along the posterior bladder wall, also has areas of T1 hyperintensity.

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So this is an example of a deep infiltrating endometriotic implant

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involving the posterior bladder wall and obliterating the vesicouterine space,

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that is of both chronic stromal fibrotic and active glandular morphology.

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And then if we look at the similar finding

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involving the posterior vaginal fornix, it looks the same.

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So T2 hypointense, but with T2 hyperintense cystic spaces

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and little areas of T1 signal hyperintensity.

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So another mixed chronic stromal fibrotic

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and active glandular implant along the posterior vagina there.

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So just some kind of teaching points to make.

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The urothelial system is involved in a minority of endometriosis cases.

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It's only like 1% to 3% of women with endometriosis.

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The most common place you're going to see

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it is along the posterior bladder wall right here.

2:41

Vesicouterine space obliteration is just as important in surgical planning as

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rectouterine space obliteration, which we've seen a couple of times.

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Again, surgeons can't get there

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if the space, the intraperitoneal space, is scarred down.

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And then this area, the posterior vaginal

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fornix is the most common area of vaginal involvement.

3:04

Can we get the next question, please?

3:08

So which of the spaces listed here is extraperitoneal?

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The Rectouterine space,

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the Vesicouterine space, the Rectovaginal space,

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or the Pouch of Douglass?

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And think also, in your head, why does that matter.

3:21

Great. So most of you got it correct.

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The rectovaginal space is extraperitoneal.

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All of the others are intraperitoneal.

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And the reason it matters is because when

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there is endometriosis involving that space, the surgeons have to do

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a deeper pelvic dissection than they normally would.

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Normally, if they don't expect

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that there is extra peritoneal disease, they'll dissect out the endometriosis

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in the peritoneal cavity and they won't violate the peritoneal lining.

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But if they know, based on the MRI,

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that there is extraperitoneal disease, so either in our prevesical space,

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in our vesicovaginal space or in our rectovaginal space,

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then they'll actually go through the trouble

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of doing that deeper dissection,

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so that they can fully resect the patient's disease.