Department of Obstetrics and Gynaecology, King's College Hospital, London, UK
1 To whom correspondence should be addressed at: Early Pregnancy and Gynaecology Assessment Unit, Suite 8, Golden Jubilee Wing, King's College Hospital, London SE5 8RX, UK. Email: davor.jurkovic{at}kcl.ac.uk
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Abstract |
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Key words: hysteroscopy/saline infusion sonohysterography/submucous fibroids/three-dimensional ultrasound
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Introduction |
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Two dimensional (2D) B-mode transvaginal ultrasound with sterile saline instillation into the endometrial cavity provides a clear view of the uterine cavity (Cicinelli et al., 1995; Widrich et al., 1996
; de Kroon et al., 2003
). This enables accurate detection of structural pathology affecting the uterine cavity including submucous fibroids, comparable to diagnostic hysteroscopy (Farquhar et al., 2003
). In addition, ultrasound enables accurate measurement of the size of the uterine fibroids. However, 2D ultrasound is not an accurate method of assessing the extent of submucous fibroid protrusion into the uterine cavity (Vercellini et al., 1997
; Dueholm et al., 2001a
,b
).
Three-dimensional (3D) transvaginal ultrasound has been commercially available for >10 years. This technique allows detailed evaluation of pelvic organs by collecting a series of sequential ultrasound images and converting them into an ultrasound volume. This information is digitally stored as a dataset, which may then be analysed on line. The dataset is reconstructed in such a way as to allow visualization of an organ from any chosen angle and in any arbitrary plane (Jurkovic, 2002).
In this study, we compared 3D transvaginal ultrasound combined with saline instillation into the uterine cavity to diagnostic hysteroscopy for the assessment of submucous fibroids. In particular we examined the assessment of myometrial extension of fibroids by the two techniques.
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Materials and methods |
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A dedicated database was set up for data collection and Cohen's kappa for inter-observer agreement was calculated (Cohen, 1960).
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Results |
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A total of 61 submucous fibroids was identified by both 3D SIS and diagnostic hysteroscopy. The results are summarized in Table I. Overall, there was agreement in the classification of 54/61 (89%) fibroids (kappa 0.80). Eleven fibroids were classified as Type 0, 34 as Type I and 9 as Type II by both 3D SIS and hysteroscopy. One fibroid classified as Type I on 3D SIS was described as Type 0 on hysteroscopy. In a further six cases of discordant findings, 3D SIS indicated deeper myometrial involvement in half of the cases and hysteroscopy in the other half.
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Discussion |
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There was also good overall agreement between diagnostic hysteroscopy and 3D ultrasound in the assessment of myometrial extension of fibroids. Using the European Society of Hysteroscopy Classification of Submucous Fibroids (Wamsteker, 1993a) the best level of agreement was achieved in women with fibroid polyps (Type 0). These are the fibroids in which hysteroscopic resection is likely to be relatively simple and successful. The level of agreement decreased with increasing degree of myometrial involvement. This is not surprising as hysteroscopy can only assess the segment of the fibroid protruding into the cavity, whilst ultrasound can also provide information about the part of the fibroid buried within the myometrium. In cases of discordant findings the differences were random with no clear tendency of either method to overestimate myometrial involvement. These results are better than findings by Vercellini et al. (1997)
, who reported less agreement between non-enhanced 2D transvaginal ultrasound and hysteroscopy, with the methods giving discordant results in 55/228 cases (24.1%). In their study there was also no clear pattern of differences between the methods and discordant results were randomly distributed.
A more recent study by Leone and Lanzani (2003) using 2D SIS showed complete agreement with diagnostic hysteroscopy in all cases of submucous fibroids. They used the angle formed between the intracavitary portion of the fibroid and the endometrium to classify the fibroids. Although these results were impressive, the reproducibility of the angle measurements used in the study has not been tested. In addition the angle measurement is based on the assumption that all fibroids are spherical in shape, which is clearly not always the case. Therefore it remains to be seen whether these results will be successfully reproduced by other investigators.
This raises the issue of which method should be considered as the gold standard for the evaluation of myometrial involvement of submucous fibroids. Although most studies use diagnostic hysteroscopy as the gold standard, the value of this approach has been questioned by others. Dueholm et al. (2001b) compared the accuracy of magnetic resonance imaging (MRI), non-enhanced transvaginal ultrasound, SIS and hysteroscopy in the evaluation of abnormalities of the uterine cavity using hysterectomy specimens as the gold standard. Although all the methods performed reasonably well in the detection of uterine cavity lesions, for the assessment of submucous fibroids MRI and SIS were superior to hysteroscopy. The authors' conclusion was that MRI, rather than hysteroscopy, should be used for pre-operative assessment of submucous fibroids.
However, the critical issue when evaluating submucous fibroids is not the relative accuracy of different diagnostic methods, but the prediction of the success of hysteroscopic resection in symptomatic women. This subject has been less extensively investigated and there is only limited data on the predictive value of hysteroscopy in the pre-operative selection of submucous fibroids for hysteroscopic resection. In a study by Vercellini et al. (1997) only 69% of women deemed suitable for endoscopic fibroid resection on hysteroscopic assessment had fibroids successfully removed using this technique. Although the cause of this discrepancy was not addressed in the paper, it does suggest that diagnostic hysteroscopy may not be the optimal method for pre-operative assessment of submucous fibroids.
A classification of submucous uterine fibroids into three sub-types (0, I and II) depending on the degree of myometrial extension was adopted by the European Society of Hysteroscopy in order to improve pre-operative selection of women for hysteroscopic resection. However, a prospective study conducted by the team which designed this classification showed that the degree of myometrial involvement had very little influence on the success of hysteroscopic resection of submucous fibroids (Wamsteker, 1993b). In a subgroup of women with Type I fibroids (<50% myometrial extension), complete resection was achieved in 12/20 (60%) of the procedures compared to 10/20 (50%) in Type II fibroids (>50% myometrial extension). Taking into account repeated procedures, complete resection was achieved in 12/14 cases (85.7%) of Type I fibroids, which was almost identical to 10/12 (83.3%) in Type II fibroids.
In clinical practice it is not uncommon to find multiple fibroids affecting the uterine cavity. Apart from the number of fibroids, their size is also likely to be a factor in determining the success of hysteroscopic resection. None of the current methods used in routine clinical practice is able to assess more complex distortion of uterine cavity in sufficient detail.
Three-dimensional ultrasound may overcome some of the limitations associated with fibroid classification using a 2D model (Weinraub and Herman, 1998). 3D ultrasound enables us to examine the uterus from any angle and in any arbitrary plane and it is possible to assess both the size and the depth of myometrial extension in each individual fibroid. The saved volume can be manipulated in such a way as to provide measurements of the depth of myometrial extension exactly at the widest fibroid diameter, taken in a plane perpendicular to the endometrium. This cannot be achieved by using 2D ultrasound or any other conventional diagnostic technique. Further research will show whether this increased diagnostic capability of 3D ultrasound may be translated into a more meaningful system of classification of submucous fibroids, which could predict the success of hysteroscopic fibroid resection with a high degree of accuracy.
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Submitted on July 21, 2004; accepted on September 17, 2004.
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