Diagnostic performance of MRI and transvaginal ultrasound for urinary tract endometriosis: a systematic review and meta-analysis

Objective To compare the diagnostic accuracy of transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) for detecting urinary tract endometriosis (UTE), including ureteral and bladder involvement. Methods A systematic review and meta-analysis were conducted according to PRISMA 2020 guidelines. PubMed, Embase, and Scopus were searched from inception to December 2025 for diagnostic accuracy studies evaluating TVUS and/or MRI for UTE. Surgical findings, with or without histopathological confirmation, were used as the reference standard. Studies reporting sufficient data to construct 2 × 2 contingency tables were included. Pooled sensitivity and specificity with 95% confidence intervals (CI) were calculated using a bivariate random-effects model, with separate analyses for ureteral and bladder endometriosis. Results Thirty-six studies met the inclusion criteria. For ureteral endometriosis, TVUS demonstrated a pooled sensitivity of 0.89 (95% CI 0.65–0.97) and specificity of 1.00 (95% CI 0.97–1.00), while MRI showed a pooled sensitivity of 0.96 (95% CI 0.50–1.00) and specificity of 1.00 (95% CI 0.96–1.00). For bladder endometriosis, TVUS yielded a pooled sensitivity of 0.70 (95% CI 0.55–0.81) and specificity of 1.00 (95% CI 0.99–1.00), whereas MRI demonstrated a pooled sensitivity of 0.77 (95% CI 0.58–0.89) and specificity of 0.99 (95% CI 0.98–1.00). Substantial heterogeneity was observed, particularly for sensitivity estimates. Conclusion TVUS and MRI show excellent specificity for diagnosing urinary tract endometriosis. MRI provides slightly higher sensitivity for ureteral disease, while both modalities demonstrate moderate sensitivity for bladder involvement. A complementary, site-specific imaging approach is, therefore, supported, with cautious interpretation of negative findings.