Department of Obstetrics and Gynecology, Blocco Q, Azienda Ospedaliero Universitaria, Polo di Monserrato s.s. 554, Monserrato 09045, Italy.
Hum Reprod. 2014 Jun;29(6):1189-98. doi: 10.1093/humrep/deu054. Epub 2014 Mar 23.
In the use of 'tenderness-guided' transvaginal ultrasound, is the diagnostic accuracy of three-dimensional (3D) ultrasonography better than two-dimensional (2D) ultrasonography in the identification of deep endometriosis?
Three-dimensional ultrasonography has a significantly higher diagnostic accuracy in the diagnosis of posterior locations of deep endometriosis without intestinal involvement, such as the uterosacral ligaments, vaginal and rectovaginal endometriosis.
The only previous study of the diagnosis of posterior compartment endometriosis reported an poor sensitivity of 3D ultrasonography for uterosacral and sigmoid colon involvement.
STUDY DESIGN, SIZE, DURATION: This diagnostic test study included 202 patients scheduled for surgery because of clinical suspicion of deep pelvic endometriosis and was carried out between January 2009 and September 2012.
PARTICIPANTS/MATERIALS, SETTING, METHODS: Modified transvaginal ultrasonography was performed on all of the women by a single examiner. Two locations of deep endometriosis were considered: intestinal involvement and other posterior lesions (including vaginal location, rectovaginal septum and uterosacral ligaments). Once the 2D ultrasonography had been performed, the 3D acquisition was performed and the obtained volume was stored. To avoid the risk of recall bias, the same operator evaluated the 3D volumes 6 months after the last examination using virtual navigation to provide a presumptive diagnosis of the presence and localization of deep endometriosis. In addition, to evaluate the reproducibility of 3D, two operators with different levels of expertise performed a retrospective review of 3D volumes from a random sample of 35 patients, twice, 1 week apart to also assess intraobserver agreement. The diagnostic performance of both tests was expressed as area under the receiver-operating characteristics curve (AUC), sensitivity, specificity, positive and negative predictive values, positive (LR+) and negative (LR-) likelihood ratios, with their respective 95% confidence interval (CI). Reproducibility was evaluated using kappa statistics.
Surgery revealed deep endometriosis in 129 patients. The AUCs for endometriosis of intestinal location were similar for both ultrasound techniques. The AUCs for endometriosis of other posterior locations were significantly different (0.891, 95% CI 0.839-0.943 for 3D versus 0.789, 95% CI 0.720-0.858 for 2D; P = 0.0193). For the intestinal involvement, the specificity, sensitivity, positive and negative predictive value, and LR+ and LR- were 93% (89-95%), 95% (88-98%), 89% (83-92%), 97% (93-99%), 13, and 0.06, respectively, for 2D ultrasound and 97% (93-99%), 91% (84-94%), 95% (88-98%), 95% (91-96%), 25, and 0.09, respectively, for 3D ultrasound. For other posterior locations, the specificity, sensitivity, positive and negative predictive value, and LR+ and LR- were 88% (82-93%), 71% (64-77%), 83% (75-90%), 79% (74-83%), 6.10, 0.32, respectively, for 2D ultrasound and 94% (89-97%), 87% (81-91%), 92% (86-96%), 90% (85-93%), 14.0, 0.14, respectively, for 3D ultrasound. Intraobserver agreement was substantial for both examiners (kappa 0.8754, for operator A and 0.7087, for operator B, respectively). Interobserver agreement was also substantial.
LIMITATIONS, REASONS FOR CAUTION: The disadvantages of 3D ultrasound to be considered are the necessity of newer ultrasonographic equipment and that fewer sonographers completely know the 3D technique. There are also some limitations within this study. First, an expert examiner performed the real-time ultrasound and 3D volume acquisitions. Second, the same operator also performed the 3D evaluations but at least 6 months after the last acquisition to avoid a possible recall bias.
The diagnostic performance obtained in the present study is superior to the accuracy reported in other studies of 3D ultrasonography, but not superior to all other published articles of 2D ultrasonography. The reported high diagnostic accuracy of 3D ultrasound could be widely generalizable because good reproducibility was demonstrated even with an operator with less expertise.
STUDY FUNDING/COMPETING INTEREST(S): This study was supported in part by the Regione Autonoma della Sardegna (project code CPR-24750).
在使用“触诊引导”经阴道超声时，三维（3D）超声在识别深部子宫内膜异位症中的诊断准确性是否优于二维（2D）超声？
三维超声在诊断无肠道受累的深部子宫内膜异位症的后位部位（如子宫骶骨韧带、阴道和直肠阴道子宫内膜异位症）方面具有更高的诊断准确性。
之前唯一一项关于后位子宫内膜异位症诊断的研究报告称，3D 超声对子宫骶骨和乙状结肠受累的敏感性较差。
研究设计、规模、持续时间：这项诊断性测试研究纳入了 202 名因临床疑似深部盆腔子宫内膜异位症而计划手术的患者，研究于 2009 年 1 月至 2012 年 9 月进行。
参与者/材料、设置、方法：由一名单独的检查者对所有女性进行改良经阴道超声检查。深部子宫内膜异位症的两个位置被考虑在内：肠道受累和其他后位病变（包括阴道位置、直肠阴道隔和子宫骶骨韧带）。在完成 2D 超声检查后，进行 3D 采集，并存储获得的体积。为避免回忆偏倚的风险，同一名操作者在最后一次检查后 6 个月使用虚拟导航进行 3D 体积评估，提供深部子宫内膜异位症存在和定位的假定诊断。此外，为了评估 3D 的可重复性，两名具有不同专业水平的操作人员对随机抽取的 35 名患者的 3D 体积进行了两次回顾性评估，两次评估间隔一周，以评估观察者内的一致性。两种检查的诊断性能均以受试者工作特征曲线（ROC）下面积（AUC）、敏感性、特异性、阳性和阴性预测值、阳性（LR+）和阴性（LR-）似然比及其各自的 95%置信区间（CI）表示。使用kappa 统计量评估可重复性。
手术显示 129 名患者存在深部子宫内膜异位症。两种超声技术的肠道受累子宫内膜异位症的 AUC 相似。其他后位病变的 AUC 差异有统计学意义（3D 为 0.891，95%CI 0.839-0.943，2D 为 0.789，95%CI 0.720-0.858；P = 0.0193）。对于肠道受累，2D 超声的特异性、敏感性、阳性和阴性预测值、LR+和 LR-分别为 93%（89-95%）、95%（88-98%）、89%（83-92%）、97%（93-99%）、13 和 0.06，3D 超声分别为 97%（93-99%）、91%（84-94%）、95%（88-98%）、95%（91-96%）、25 和 0.09。对于其他后位病变，2D 超声的特异性、敏感性、阳性和阴性预测值、LR+和 LR-分别为 88%（82-93%）、71%（64-77%）、83%（75-90%）、79%（74-83%）、6.10 和 0.32，3D 超声分别为 94%（89-97%）、87%（81-91%）、92%（86-96%）、90%（85-93%）、14.0 和 0.14。两名操作人员的观察者内一致性均较高（A 操作者为 0.8754，B 操作者为 0.7087）。观察者间一致性也较高。
局限性、谨慎原因：需要考虑的 3D 超声的缺点是需要较新的超声设备，而且并非所有超声医师都完全掌握 3D 技术。本研究还存在一些局限性。首先，一位专家检查者进行了实时超声和 3D 体积采集。其次，同一名操作者在最后一次采集后至少 6 个月进行 3D 评估，以避免可能的回忆偏倚。
本研究获得的诊断性能优于其他 3D 超声研究报告的准确性，但不如所有其他已发表的 2D 超声文章的准确性高。报告的 3D 超声具有较高的诊断准确性，这可能具有广泛的普遍性，因为即使是经验较少的操作人员也表现出了良好的可重复性。
研究资金/利益冲突：本研究部分由撒丁岛自治大区（项目代码 CPR-24750）资助。
