Research Article

Gynecol Obstet Invest 2021;86:299–306 Received: November 16, 2020

Accepted: April 19, 2021
DOI: 10.1159/000516634 Published online: June 22, 2021

Ultrasonographic 3D Evaluation in the Diagnosis

of Bladder Endometriosis: A Prospective
Comparative Diagnostic Accuracy Study
Fabio Barra a, b, c Franco Alessandri d Carolina Scala c, e Simone Ferrero a, b, c
       

aDepartment of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI),

University of Genova, Genova, Italy; bAcademic Unit of Obstetrics and Gynecology, IRRCS Ospedale Policlinico
San Martino, Genova, Italy; cPiazza della Vittoria 14 SRL, Genova, Italy; dUnit of Obstetrics and Gynecology, IRRCS
Ospedale Policlinico San Martino, Genova, Italy; eUnit of Obstetrics and Gynecology, Gaslini Institute, Genova, Italy

Keywords ical results. Results: Overall, BE was intraoperatively found in

Ultrasonography · Bladder endometriosis · Deep
endometriosis · 3D ultrasound · Transvaginal ultrasound ·
Ultrasound accuracy · 3D reconstruction · Ureteral meatus ·
Virtual organ computer-aided analysis
Abstract
Objective: The use of three-dimensional (3D) transvaginal
ultrasonography (TVS) has been investigated for the diagno-
sis of deep endometriosis (DE). This study aimed to evaluate
if 3D reconstructions improve the performance of TVS) in as-
sessing the presence and characteristics of bladder endome-
triosis (BE). Design: This was a single-center comparative di-
agnostic accuracy study. Participants/Materials, Setting,
Methods: Patients referred to our institution (Piazza della
Vittoria 14 Srl, Genova, Italy) with clinical suspicion of DE
were included. In case of surgery, women underwent sys-
tematic preoperative ultrasonographic imaging; an experi-
enced sonographer performed a conventional TVS; another
experienced sonographer, blinded to results of the previous
exam, performed TVS, with the addition of 3D modality. The
presence and characteristics of BE nodules were described
in accord with International DE Analysis group consensus.
Ultrasound data were compared with surgical and histolog-
34 out of 194 women who underwent surgery for DE (17.5%;
95% confidence interval: 12.8–23.5%). TVS without and with
3D reconstructions were able to detect endometriotic BE in
82.2% (n = 28/34) and 85.3% (n = 29/34) of the cases (p =
0.125). Both the exams similarly estimated the largest diam-
eter of BE (p = 0.652) and the distance between the endome-
triotic nodule and the closest ureteral meatus (p = 0.341).
However, TVS with 3D reconstructions was more precise in
estimating the volume of BE (p = 0.031). In one case (2.9%),
TVS without and with 3D reconstructions detected the infil-
tration of the intramural ureter, which was confirmed at sur-
gery and required laparoscopic ureterovesical reimplanta-
tion. Limitations: The extensive experience of the gynecolo-
gists performing the ultrasonographic scans, the lack of
prestudy power analysis, and the population selected, which
may have been influenced by the position of the institution
as a referral center specialized in the treatment of severe en-
dometriosis, are limitations of the current study. Conclusion:
Our results demonstrated the high accuracy of ultrasound
for diagnosing BE. The addition of 3D reconstructions does
not improve the performance of TVS in diagnosing the pres-
ence and characteristics of BE. However, the volume of BE
may be more precisely assessed by 3D ultrasound.
© 2021 S. Karger AG, Basel
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karger@karger.com © 2021 S. Karger AG, Basel Correspondence to:

www.karger.com/goi Fabio Barra, fabio.barra @ icloud.com
Glasgow Univ.Lib.
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 Introduction
Bladder endometriosis (BE), defined as endometrial
glands and stroma infiltrating the detrusor muscle, is the
most frequent type of urinary tract endometriosis, occur-
ring in 70–85% of cases [1]. The symptoms caused by BE
vary considerably and depend on the location and size of
the lesion; in general, BE coexists with other localizations
of deep endometriosis (DE), resulting in a wide variety of
abdominal and urinary symptoms [2], which may signif-
icantly affect women’s professional life with important
socioeconomic implications [3, 4]. Nevertheless, up to
30% of the women with nodules of BE are asymptomatic
and undergo occasional diagnosis of the disease because
of follow-up procedures both for DE and/or for clinical
investigation for infertility [5].
Transvaginal ultrasonography (TVS) is the first-line
investigation in women with suspicion of DE, including
those with symptoms suggestive for BE; in most of these
cases, the ultrasonographic appearance of BE consists in
isoechoic and hypoechoic nodules of 1–2 cm thickening
of the bladder wall, with eventual protrusion into the lu-
men [6]; TVS allows to evaluate the location and size of
BE nodules and to estimate the distance between lesion
margins and ureteral meatuses [7]. Additionally, TVS ex-
amination, if performed, by expert operators in diagnos-
ing endometriosis, allows the detection of pelvic DE nod-
ules that can be associated to BE [8]. Magnetic resonance
imaging (MRI) can be considered as completing or sup-
plementing TVS for the presurgical workup of women
with suspicion of urinary tract endometriosis [5].
The optimal treatment of BE depends on several fac-
tors, such as age, extent of disease, severity of pain and
other urinary symptoms, presence of other pelvic lesions,
fertility preferences, and degree of menstrual dysfunction
[9]. In the case of surgical approach, an accurate preop-
erative investigation by imaging may help the gynecolo-
gist to plan the optimal procedure, including segmental
bladder dome resection and trigone resection with ure-
teral replantation [1]. A critical factor in choosing the sur-
gical approach is the distance between the margin of the
endometriotic lesion and the ureteral meatuses; whenev-
er the endometriotic lesion is close to or involves the ure-
teral orifices, ureterovesical reimplantation should be
planned [1]. In the current literature, accuracy values of
TVS for diagnosing BE are heterogenous, as the majority
of studies have a retrospective design and have a small
sample size [1]; a recent systematic review and meta-anal-
ysis revealed overall pooled sensitivity and specificity of
62 and 100%, respectively, for BE detection by TVS [10].
300 Gynecol Obstet Invest 2021;86:299–306
DOI: 10.1159/000516634
Three-dimensional (3D) modality, which has been
increasingly introduced in the clinical practice for the
evaluation of gynecological diseases, such as uterine
malformations [11], allows the conversion of standard
2D grayscale acquisitions into a volumetric dataset; in
the last years, it has also been proposed for the charac-
terization of DE [12, 13]. A French prospective study
reported that 3D TVS is characterized by a higher diag-
nostic accuracy than cystoscopy and is at least as effec-
tive as MRI in diagnosing and planning the surgery for
BE [14]. Until now, 3D ultrasound has never been eval-
uated in comparison to conventional TVS. Our study
aimed to evaluate if 3D acquisitions can improve the
performance of TVS in assessing the presence and char-
acteristics of BE.
Material and Methods
This was a single-center prospective diagnostic accuracy study;
the primary aim was to compare the performance of TVS with or
without 3D reconstructions in the diagnosis of BE. The secondary
objectives were to compare the precision of the two techniques in
estimating the dimension of BE, the distance between the endome-
triotic nodule and the ureteral meatus and eventually, the infiltra-
tion of the intramural ureter. The local Ethics Committee ap-
proved the study protocol (CE Liguria N 10074/2019). Women
participating in the study provided written informed consent. The
study designed was checked by the “Standards for reporting Diag-
nostic accuracy studies” (STARD 2015; online suppl. Document 1;
see www.karger.com/doi/10.1159/000516634 for all online suppl.
material) [15].
After being referred to our institution (Piazza della Vittoria 14
Srl, Genova 16121, Italy), all the consecutive premenopausal pa-
tients who underwent surgery for clinical suspicion of DE in our
department between March 2016 and March 2020 were prospec-
tively included. Previous surgical or radiological diagnosis of BE,
history of vesical surgery, previous bilateral oophorectomy, or psy-
chiatric disorders were exclusion criteria.
Patients underwent an accurate ultrasonographic exam for
assessing the presence of DE: an experienced sonographer per-
formed a conventional TVS (S.F.); another experienced sonog-
rapher (F.B.), blinded to results of the previous exam, performed
TVS with the addition of 3D modality. The scans were per-
formed using a Voluson E10 or a Voluson E8 machine (GE
Healthcare Ultrasound, Milwaukee, WI, USA) with a full blad-
der. The bladder nodules were localized according to the Inter-
national DE Analysis group criteria in 4 localizations: trigone,
bladder base, bladder dome, and extra-abdominal bladder [7].
According to International DE Analysis group consensus [7],
the uterovesical region was evaluated for tethering to the uterus
(i.e., obliteration of the space). The transvaginal probe was held
in the anterior fornix with one hand, whereas the other opera-
tor’s hand was placed over the suprapubic region. By the bal-
lottement of the uterus between the probe and hand, it was as-
sessed if the posterior bladder slid freely over the anterior uter-
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a b
c d
Fig. 1. Ultrasonographic acquisition of BE nodule of the posterior wall of the bladder base sagittal plane (a), ax-
ial plane (b), coronal plane (c), and 3D reconstruction (d). * Endometriotic nodule. BE, bladder endometriosis.
ine wall. During each ultrasonographic exam, the following
parameters were evaluated: presence of BE, largest diameter and
volume of BE, distance between the endometriotic nodule, and
the closest ureteral meatus.
The location of the ureteral meatus for estimating its distance
from the nodule was identified by visualization streaming of urine
from the ureteric orifice by color Doppler, as previously described
[14]. The size of the nodule was measured in 3 orthogonal planes.
The volumes of BE nodules were calculated using the ellipsoid for-
mula (volume = 0.523 × length × depth × width). During 3D ren-
dering, multiple acquisitions were made in the sagittal and coronal
planes. Tomographic ultrasound imaging (TUI) was used for eval-
uating the infiltration of the bladder muscular layer. The volume
of the nodule was assessed using the virtual organ computer-aided
analysis (VOCAL; online suppl. Fig. 1), as reported in our previous
experience [16]. Two specific quality enhancement tools (GE
Healthcare Ultrasound, Milwaukee, WI, USA) were applied dur-
ing 3D acquisitions in surface mode: the advanced Speckle Reduc-
tion Imaging, which improves the visibility of nodules by high-
definition contrast resolution and the CrossXBeamCRITM, allow-
ing a high enhancement of tissue and border differentiation.
In TVS, BE lesions appear as a filling defect of the posterior
wall, with a variable protrusion into the lumen, with an iso/hy-
poechoic aspect sometimes visible with small transonic formations
that usually are not vascularized. In the 3D, BE lesions can be vi-
sualized as intraluminal spiculated nodules, with a retracting line
all around the nodule (Fig. 1). Patients underwent surgery within
8 weeks from the ultrasonographic exams. Imaging findings were
compared to surgical and histopathological results.
3D Ultrasound for Bladder Endometriosis
Color version available online
Statistical Analysis
Accuracy, sensitivity, specificity, positive predictive value, neg-
ative predictive value, positive likelihood ratio, and negative likeli-
hood ratio were evaluated for TVS with and without 3D acquisi-
tions. Efficacy parameters were calculated with 95% confidence
intervals (CIs). The accuracy of diagnostic procedures in the diag-
nosis of BE was compared by using McNemar’s test with the Yates
continuity correction. The limits of agreement between the mea-
surements were calculated as mean difference ±2 standard devia-
tions (SDs) of the difference. The Kolmogorov-Smirnov normal-
ity test was employed to assess the normality of distribution of
continuous variables. A post-power calculation was performed to
calculate the statistical power of the study in evaluating the preva-
lence of disease and the ultrasound accuracy based on the previous
data reported in the literature. The data were analyzed by SPSS
software version 24.0 (SPSS Science, Chicago, IL, USA). p values
<0.05 were considered statistically significant.
Results
Figure 2 shows the flow of participants in the study.
During the study period, 523 patients referred to our in-
stitution with clinical suspicion of DE; 194 (37.1%) pa-
tients underwent surgical approach; among these latter,
BE was found in 34 patients (17.5%; 95% CI: 12.8–23.5%)
from the surgery and confirmed with histopathologic
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DOI: 10.1159/000516634
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 Color version available online
523 patients referred to
our institution with clinical
suspicion of DE
The surgical approach was
planned in the following groups:
• Women refusing hormonal
treatment (n = 12; 6.2%)
• Women with contraindications
194 (37.1%) patients to receive hormonal therapy
underwent (n = 3; 1.5%)
surgical approach • Women suffering from
pain persistent under hormonal
therapy (n = 65; 33.5%)
• Women suffering from pain
with desire of pregnancy
(n = 114; 58.8%)
One operator
performed convectional
2D ultrasound

Within 1 week

Another operator
performed ultrasound
with 3D acquisition

Within 8 weeks

BE was confirmed at
Fig. 2. Flow of participants of the study. surgery in
34 patients
DE, deep endometriosis; BE, bladder endo-
metriosis.

analysis, detecting the infiltration of the bladder muscular
layer by endometriotic tissue. After performing a post hoc
power calculation based on the previous studies [17–20],
the sample size of the study was judged appropriately for
the prevalence observed (power 98.1% and alpha 0.05).
The mean (±SD) largest diameter of BE was 20.2 (±9.1)
mm. Eighteen nodules (52.9%) were located in the blad-
der base, 8 (23.5%) were in the bladder dome, 3 (8.8%)
were in the bladder trigone, and 5 (14.7%) in the extra-
abdominal bladder. At least another concomitant DE
nodule was found in 27 patients (79.4%) and a concomi-
tant endometrioma in 7 patients (20.5%). Evidence of fo-
cal/diffuse adenomyosis was detected in 12 patients
(35.3%); among these, 6 women had BE located in the
bladder dome, 4 in the bladder base, and 1 in the bladder
trigone; in 4 cases, BE was considered an extension of dis-
ease for the anterior uterine adenomyotic wall. The other
demographic characteristics of the study population are
reported in Table 1.
Both the exams were able to detect the endometriotic
bladder nodule in 82.4% (n = 28/34) and 85.3% (n =
29/34) of the cases, respectively; the McNemar test dem-
onstrated that the 2 techniques have similar diagnostic
performance (p = 0.125). After performing a post hoc
power calculation based on a previous meta-analysis [10],
the sample size of the study was judged appropriately for
the diagnostic accuracy estimated (power 100% and alpha
0.05). Table 2 reports the diagnostic parameters of both
techniques, and Figure 3 shows their ROC curves.
Both exams similarly estimated the largest diameter of
BE (mean difference ± SD, 95% CI: −3.12 ± 4.5 mm; −6.7
to 2.3 mm; −2.98 ± 3.9 mm; −5.8 to 2.1 mm; and p = 0.652)
and the distance between the endometriotic nodule and
the closest ureteral meatus (−8.62 ± 7.2 mm; −11.6 to −2.9
mm; −7.44 ± 6.5 mm; −9.2 to −1.1 mm; and p = 0.341)
(Fig. 4). The ureteral meatus was bilaterally identified by
both techniques in 30 of 32 (93.8%) women.
However, TVS with 3D reconstructions was more
precise in estimating the volume of BE (5.44 ± 4.1 cm3;
−1.3 to 8.1 cm3; 3.11 ± 2.8 cm3; −1.5 to 5.3 cm3; and p =
0.031). In one case (2.9%), TVS without and with 3D re-
constructions detected the infiltration of the intramural
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DOI: 10.1159/000516634
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Table 1. Characteristics of the study population with surgical atus; the volume of BE has been more precisely assessed
diagnosis of BE by 3D ultrasound.
TVS is considered the first-line imaging technique in
N = 34
the workup of patients with suspicion of DE because in
Age, years; mean ± SD 34.9±2.6 hands skilled in endometriosis assessment, it allows ex-
Body mass index, kg/m2; mean ± SD 24.1±2.1 tensive exploration of DE implants and ovarian endome-
Race, n (%) triomas [7]. In case of BE, the presence of at least one
Caucasian 30 (94.1) other site involved by endometriosis (superficial perito-
African 1 (4.4)
Asian 1 (1.5) neal endometriosis and other DE lesions and ovarian en-
Previous live birth, n (%) 8 (27.9) dometriomas) has been documented in up to 90% of cas-
Previous surgery for endometriosis, n (%) 12 (44.1) es [21]. An accurate assessment of the urinary tract should
Lower urinary symptoms, n (%) 7 (21.9) become part of the diagnostic management of these pa-
Dysmenorrhea, n (%) 11 (34.4)
Dyspareunia, n (%) 18 (56.3)
tients [22]; in particular, the visualization of pelvic ureters
Chronic pelvic pain, n (%) 17 (53.3) by TVS and the evaluation of the appearance of the renal
Dyschezia, n (%) 4 (12.5) pelvis by abdominal ultrasound should be integrated into
Concomitant adenomyosis, n (%) 12 (35.3) the routine pelvic ultrasound examination to exclude hy-
Concomitant endometriomas, n (%) 7 (21.9) dronephrosis, which tends to be due to extrinsic ureteral
Right 4
Left 3
obstruction by nodules in the posterior compartment
Concomitant deep endometriotic implants, n (%) 27 (84.4) rather than BE [23, 24].
Recto sigmoid 3 After the diagnosis of BE, in case of planning the surgi-
Recto vaginal septum 6 cal approach, the ultrasonographic characterization of BE
Uterosacral ligaments 18 may help the surgeon to plan the optimal approach (seg-
Use of hormonal treatment at the time of study
inclusion and surgical approach, n (%) 24 (75.0) mental bladder dome resection or trigone resection with
Oral estroprogestin pill 14 ureteral replantation) and to inform patients before sur-
Contraceptive vaginal ring 1 gery by defining the exact location of the nodule and its
Desogestrel 1 relationship to the ureteral meatuses [5, 25, 26]; in case of
Norethindrone acetate 2 partial bladder resection, the decision to perform ureter-
Dienogest 2
Levonorgestrel-releasing intrauterine device 1 al cannulation is often done evaluating the distance be-
tween the margin of the endometriotic lesion and the
BE, bladder endometriosis; SD, standard deviation. closest ureteral meatus. Moreover, when the endometri-
otic lesion is near to or involves the ureteral orifices, ure-
terovesical reimplantation should be considered by a
multidisciplinary approach including an expert urologist
ureter, which was confirmed at the surgery and histo- [1]. Taking into account that the accuracy of the measure-
logical analysis, and required left ureterovesical reim- ment of the exact distance from the nodule to the meatus
plantation. by TVS remains to be determined, ureteral meatus is con-
sidered to be involved, when located at <10 mm from the
endometriotic nodule [24]. A systematic review and me-
Discussion ta-analysis demonstrated that TVS has an overall pooled
sensitivity of 62% (95% CI, 40–80%), a specificity of 100%
To the best of our knowledge, this is the first study (95% CI, 97–100%), a positive likelihood ratio of 208.4
evaluating the addition of 3D modality on the diagnos- (95% CI, 21.0–2066.0), and a negative likelihood ratio of
tic accuracy of TVS for diagnosing BE. Our preliminary 0.38 (95% CI, 0.22–0.66) for detecting BE; notably, Fagan
results demonstrated that ultrasound has a high accu- nomograms demonstrated that a positive test increased
racy for diagnosing BE. The addition of 3D reconstruc- significantly the pretest probability of detecting BE, from
tions does not improve the performance of TVS in de- 5 to 92%; a negative test decreased significantly this pre-
tecting the presence of BE. Moreover, there was no sig- test probability, from 5 to 2% [10].
nificant difference between the 2 procedures in More than 10 years ago, DE was first characterized by
estimating the largest diameter of BE and its distance 3D TVS, and it was suggested that the higher spatial res-
between the endometriotic nodule and the ureteral me- olution of 3D acquisitions could improve the character-
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DOI: 10.1159/000516634
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Table 2. Diagnostic parameters related to
the detection of the presence of BE TVS TVS plus 3D
reconstructions

True positive, n 28 29
True negative, n 147 144
False negative, n 6 5
False positive, n 13 16
Sensitivity1 82.2% (63.1–93.9%) 85.3% (67.3–96.0%)
Specificity1 91.9% (83.2–97.0%) 90.0% (84.3–94.2%)
Positive likelihood ratio2 10.1 (4.6–22.2) 8.5 (5.3–13.9)
Negative likelihood ratio2 0.2 (0.09–0.4) 0.2 (0.07–0.4)
PPV1 79.3% (63.6–89.4%) 64.4% (52.7–74.7%)
NPV1 93.6% (86.0–96.8%) 96.6% (92.8–98.5%)

BE, bladder endometriosis; PPV, positive predictive value; NPV, negative predictive
value; CI, confidence interval. 1 Values presented as percentages and 95% CI. 2 Values
presented as ratio and 95% CI.

planes, and they can be easily assessed off-line. Other ad-

Color version available online
1.0 vantages of 3D ultrasound are the calculation of volumes
with the VOCAL mode; this latter technique allowed a
significantly better BE volume assessment in our study.
0.8 Moreover, 3D ultrasound includes TUI and surface
modes; the TUI allows to assess the infiltration of BE in
the layers of the bladder wall, whereas the surface mode
0.6
consists of a kind of virtual cystoscopy that is valuable to
Sensitivity

assess the protrusion of the BE nodule in the bladder lu-

0.4
0.2
0 including BE, by 3D acquisitions. Moreover, the cost-
0 0.2 0.4 0.6 0.8
1 – specificity
Fig. 3. ROC curve related to the study methods (blue line: TVS;
green line: TVS plus 3D reconstructions). TVS, transvaginal ultra-
sonography.
ization of nodules [27]. Subsequently, it has been dem-
onstrated to have good diagnostic accuracy of 3D TVS
for diagnosing DE in the posterior compartment, such as
the rectosigmoid colon, uterosacral ligaments, and the
vagina [13, 28, 29]. 3D TVS is characterized by a wide
spatial orientation with an expense range of different dis-
plays of the images in the 3 orthogonal planes. Moreover,
acquisitions done by 3D modality can be selected and
rotated or scrolled through an infinite number of viewing
men. On the other hand, a learning curve has to be con-
sidered because the sonographer acquired optimal ex-
pertise in 3D acquisitions and interpretation. In the near
future, it would be of interest to assess the learning curves
of operators during a structured off-line/hands-on train-
ing program for the ultrasonographic diagnosis of DE,
1.0 effectiveness of 3D ultrasound may be limited by the ne-
cessity of relatively high-cost last-generation ultrasound
scanners.
In 2014, Thonnon et al. [14] assessed the performance
of 3D ultrasound with color Doppler in the diagnosis of
BE in comparison to MRI and cystoscopy in 8 women
who reported urinary tract symptoms suggestive of BE.
There was no significant difference between imaging and
pathology findings (p = 0.20) or between the 2 imaging
findings (TVS and MRI) (p = 0.73); results showed a trend
toward better accuracy for 3D ultrasound than MRI with
smaller SDs (p = 0.08). However, the results of this study
may have been likely limited by small sample size. Al-
though the diagnostic accuracy of 3D ultrasound was
compared to that obtained by MRI, we deem that this lat-
ter exam should be performed in centers in which ad-
vanced TVS for DE is not yet available or in patients with
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DOI: 10.1159/000516634
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Fig. 4. Distance between the BE nodule and
the closest ureteral meatus at 2D (a) and 3D
ultrasound (b). UT, uterus; UVP, uteroves-
ical pouch; UR, ureter; URM, ureteral me-
atus; BW, bladder wall; BL, bladder lumen;
VW, vaginal wall; BE, bladder endometrio-
a b
sis. * Endometriotic nodule.
high clinical suspicion of BE after ultrasonographic nega-
tive findings. Furthermore, different from our study, the
authors preoperatively compared TVS results with those
obtained by cystoscopy, in particular for estimating the
distance between the ureteral meatus and the endome-
triosis lesion. When a nodule of BE is diagnosed by ultra-
sound, cystoscopy may be considered for assessing the
grade of infiltration and ureteral meatus involvement.
However, as previously reported [30], nodules that par-
tially affect the muscular layer tend to have normal cysto-
scopic findings, thereby minimizing the need for this
technique.
Our study has some limitations. First, a second expert
sonographer performed real-time 3D acquisitions. As
done in a previous study done by our research group [12],
evaluating off-line 3D reconstructions would have avoid-
ed the bias related to the influence of 2D scan, which was
necessary for acquiring 3D images. However, the current
study aimed to investigate if 3D reconstructions improve
the performance of TVS in assessing the presence and
characteristics of BE. Overall, in our clinical practice, we
deem that 3D modality should be complementary to 2D
scan and should be dynamically done during convection-
al TVS. Additionally, although a post-power calculation
was performed to calculate the statistical power (based on
results of previous studies) for evaluating the prevalence
of BE and the ultrasound accuracy, we did investigate the
optimal sample size a priori. In our study, the prevalence
of BE was approximately 17%; this prevalence may have
been influenced by the selected study population due to
the position of the institution as the referral center spe-
cialized in the diagnosis and treatment of severe endome-
triosis; the majority of patients underwent surgery suf-
fered from pain persistent to the medical treatment (n =
3D Ultrasound for Bladder Endometriosis
Color version available online
114/194; 58.8%); moreover, there was no negligible prev-
alence of urinary symptoms; this may justify the presence
of multiple nodules of DE, including BE, in this popula-
tion. Indeed, the extensive experience of the gynecolo-
gists performing ultrasonographic scans, respectively,
may have influenced the accuracy of TVS with and with-
out 3D modality in assessing the presence and character-
istics of BE.
Conclusion
This diagnostic accuracy study confirmed that trans-
vaginal ultrasound has an elevated accuracy for diagnos-
ing BE. The addition of 3D reconstructions does not im-
prove the performance of TVS in diagnosing the presence
and characteristics of BE. However, the volume of BE may
be more precisely assessed by 3D ultrasound.
Acknowledgements
This preliminary analysis will be presented as a virtual poster
in the ISUOG 30th World Congress on Ultrasound in Obstetrics
and Gynecology.
Statement of Ethics
All the procedures performed in studies involving human par-
ticipants were in accordance with the ethical standards of the in-
stitutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable eth-
ical standards. The local Ethics Committee approved the study
protocol (CE Liguria N 10074/2019). Women participating in the
study provided written informed consent.
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Gynecol Obstet Invest 2021;86:299–306 305
DOI: 10.1159/000516634
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 Conflict of Interest Statement
The authors have no conflicts of interest to declare.
Funding Sources
This study has not been funded.
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