The Diagnostic Accuracy of Magnetic Resonance Imaging Versus Transvaginal Ultrasound in Deep Infiltrating Endometriosis and Their Impact on Surgical Decision-Making: A Systematic Review.

Objectives: This study aimed to systematically compare the diagnostic accuracy of magnetic resonance imaging (MRI) and transvaginal ultrasound (TVUS) for deep infiltrating endometriosis (DIE) and to evaluate their impact on surgical decision-making. Methods: We carried out a systematic review of studies (2015-2025) comparing MRI and TVUS for DIE in the same patients, with surgical/histological confirmation used as the reference standard. The primary outcomes were sensitivity and specificity by lesion site; the secondary outcomes included the reported impact on surgical decision-making and treatment planning. Results: Nine studies met the inclusion criteria. For rectosigmoid lesions, the sensitivity was 79-94% for TVUS and 86-94% for MRI, with a high specificity for both (84-95%). TVUS demonstrated strong diagnostic accuracy for posterior compartment disease, but its sensitivity was notably lower for uterosacral ligament and bladder lesions (25-83%). MRI showed higher sensitivity for anterior and multi-compartmental lesions (75-94%), reflecting its superior anatomical coverage. Imaging informed surgical planning, ensuring the inclusion of subspecialists such as colorectal or urological surgeons. It also guided the extent of resection and need for radical versus conservative procedures. Conclusions: TVUS and MRI are complementary imaging modalities in the diagnosis and staging of DIE. TVUS offers high specificity and remains particularly effective for posterior compartment disease, whereas MRI provides broader anatomical coverage and higher sensitivity for anterior and multi-compartmental involvement. Importantly, integrating imaging into preoperative planning improves multidisciplinary coordination, optimises preparedness, and guides resection. This is the first review to systematically compare MRI and TVUS for DIE with an emphasis on lesion-level accuracy and the impact on surgical decision-making.