Abstract
<jats:title>Abstract</jats:title> <jats:sec> <jats:title>Introduction</jats:title> <jats:p>Endometriomas are common in endometriosis and may coexist with deep pelvic disease. This study aimed to assess the association between endometrioma size and other endometriosis localizations using the #ENZIAN classification.</jats:p> </jats:sec> <jats:sec> <jats:title>Study design</jats:title> <jats:p>This multicenter study included women who underwent laparoscopic surgery for endometriomas between 2021 and 2024, with available surgical reports defining the #ENZIAN classification. Endometriomas were categorized as O1/2 (< 7 cm) or O3 (≥ 7 cm). Other endometriosis localizations were compared between the study groups.</jats:p> </jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>A total of 269 women underwent surgery for endometriosis involving endometriomas. Of these, 42 had #ENZIAN O3 endometriomas, with a significantly higher rate of unilateral cysts compared to women with #ENZIAN O1/2 (92.8% vs. 68.2%, p = 0.0011). After excluding bilateral cases, 194 women with unilateral endometriomas were analyzed: 39 with #ENZIAN O3 and 155 with #ENZIAN O1/2. Women with O3 lesions were significantly younger (31.5 ± 5.9 vs. 34.5 ± 6.6 years; p = 0.011). The rate of adenomyosis (#ENZIAN F-A) was significantly lower in the O3 group (41% vs. 69%, p = 0.0012), as was rectal involvement (#ENZIAN C; 7.7% vs. 23.8%, p = 0.025). The prevalence of severe pelvic wall disease (T/B ≥ 2) did not differ significantly between groups.</jats:p> </jats:sec> <jats:sec> <jats:title>Conclusion</jats:title> <jats:p>Smaller endometriomas (O1/2) are associated with more extensive pelvic disease, including higher rates of adenomyosis, rectal involvement, and pelvic adhesions, whereas larger endometriomas (O3) may represent a more localized disease phenotype. These findings support the use of the #ENZIAN classification for more accurate preoperative assessment and individualized surgical planning.</jats:p> </jats:sec>