Supplementary Material for: Ultrasonographic 3D Evaluation in the Diagnosis of Bladder Endometriosis: A Prospective Comparative Diagnostic Accuracy Study

Objective: The use of three-dimensional (3D) transvaginal ultrasonography (TVS) has been investigated for the diagnosis of deep endometriosis (DE). This study aimed to evaluate if 3D reconstructions improve the performance of TVS) in assessing the presence and characteristics of bladder endometriosis (BE). Design: This was a single-center comparative diagnostic 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 systematic preoperative ultrasonographic imaging; an experienced 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 histological results. Results: Overall, BE was intraoperatively found in 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 diameter of BE (p = 0.652) and the distance between the endometriotic 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 infiltration of the intramural ureter, which was confirmed at surgery and required laparoscopic ureterovesical reimplantation. Limitations: The extensive experience of the gynecologists 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 endometriosis, 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 presence and characteristics of BE. However, the volume of BE may be more precisely assessed by 3D ultrasound.

研究目的：已有研究探讨三维经阴道超声（3D transvaginal ultrasonography, TVS）在深部子宫内膜异位症（deep endometriosis, DE）诊断中的应用价值。本研究旨在评估三维重建是否可提升经阴道超声在评估膀胱子宫内膜异位症（bladder endometriosis, BE）的存在及其特征时的诊断效能。

研究设计：本研究为单中心比较诊断准确性研究。

研究对象、材料、场景与方法：纳入因临床疑似深部子宫内膜异位症，转诊至意大利热那亚Piazza della Vittoria 14 Srl机构的患者。若接受手术，所有女性均行系统性术前超声影像学检查：一名经验丰富的超声医师行常规经阴道超声检查；另一名对前一次检查结果设盲的经验丰富超声医师，在检查中加用三维成像模式。按照国际深部子宫内膜异位症分析小组的共识标准，对膀胱子宫内膜异位症结节的存在及其特征进行描述。将超声检查结果与手术及组织病理学结果进行对比。

研究结果：总计194例因深部子宫内膜异位症接受手术的女性中，术中发现34例存在膀胱子宫内膜异位症（占比17.5%；95%置信区间：12.8~23.5%）。常规经阴道超声与加用三维重建的经阴道超声对膀胱子宫内膜异位症的检出率分别为82.2%（n=28/34）与85.3%（n=29/34），组间差异无统计学意义（p=0.125）。两种检查方式对膀胱子宫内膜异位症最大直径的评估结果相近（p=0.652），对异位结节与最近侧输尿管口的距离评估结果亦无显著差异（p=0.341）。然而，加用三维重建的经阴道超声在评估膀胱子宫内膜异位症体积时更为精准（p=0.031）。另有1例（2.9%），两种超声检查均检出壁内输尿管浸润，该结果经手术证实，患者随后接受了腹腔镜下输尿管膀胱再植术。

研究局限性：本研究存在以下局限性：实施超声扫描的妇科医师经验丰富；未进行预试验效力分析；研究人群为转诊至本机构的患者，而本机构作为重症子宫内膜异位症治疗的转诊中心，可能对入组人群存在选择偏倚。

研究结论：本研究结果证实，超声检查在诊断膀胱子宫内膜异位症中具有较高的准确性。加用三维重建并未提升常规经阴道超声对膀胱子宫内膜异位症的检出效能及其特征评估能力，但可更精准地评估膀胱子宫内膜异位症的体积。