Objectives: To assess the concordance of the preoperative application of the #Enzian
classification (#ENZIANi) with the postoperative result (#ENZIANs) using surgical findings as the
reference standard. Methods: This retrospective study included 282 consecutive patients with
deep endometriosis undergoing surgical treatment. Preoperative assessment with transvaginal
sonography and magnetic resonance imaging was compared with postoperative assessment.
Concordance and diagnostic test evaluation were calculated. Results: The highest concordance
was observed in the F (abdominal wall endometriosis) with k Cohen of 0.837, following the values
for pelvic locations, with 0.795 for T left, 0.791 for T right, 0.776 for F (adenomyosis), 0.766 for C
(rectum), and 0.75 and 0.72 for O right k and O left, respectively. The highest sensitivity was
demonstrated for the P compartment *(98%), T compartment (both sides 97%), and A, B, C (94%-
96%), corresponding with deep endometriosis. Conclusions: Preoperative assessment using
TVS/TAS+MRI with the ENZIANi score correlates well with the ENZIANs postoperative score and
demonstrates good concordance in the detection and localization of deep endometriosis, thereby
minimizing false negative results and ensuring accurate preoperative staging. The ENZIAN
classification is well-suited to surgeons' needs and benefits from continuous development. Future
improvements, such as adding the expanded C module, may be considered in the next edition.