DOI:10.2214/AJR.07.2561
AJR 2008; 190:W227-W233
© American Roentgen Ray Society
Sonohysterography: Do 3D Reconstructed Images Provide Additional Value?
Sujata V. Ghate1,
Michele M. Crockett2,
Brita K. Boyd3 and
Erik K. Paulson1
1 Department of Radiology, Duke University Medical Center, Duke South Hospital,
Box 3808, Durham, NC 27710.
2 Radiology Associates, Monroe, LA.
3 Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology,
Duke University Medical Center, Duke South Hospital, Durham, NC.
Received May 14, 2007;
accepted after revision October 12, 2007.
Address correspondence to S. V. Ghate.
WEB
This is a Web exclusive article.
Abstract
OBJECTIVE. The purpose of this study was to retrospectively
determine the value of adding 3D multiplanar sonography to 2D
sonohysterography.
MATERIALS AND METHODS. Between September 2003 and April 2005, 80
women (mean age, 43.5 years; range, 26–78 years) underwent
sonohysterography with both conventional 2D sonohysterography and 3D
multiplanar imaging (volume of data acquired and reconstructed in the
transverse, sagittal, and coronal planes). Three blinded readers interpreted
the 2D scans alone and then the 2D and 3D images together. Visualization of
endometrial abnormality (polyps, fibroids, or septations) and definition of
fundal contour were scored by each reader on a three-point scale (1,
visualized; 2, unsure; 3, not visualized). Wilcoxon's signed rank test was
used to assess mean differences between findings. Reader agreement was
determined with the kappa statistic. Pathologic correlation was performed when
the findings were available.
RESULTS. Average (mean ± SD) reader scores for identification
of endometrial abnormality were not significantly different: 1.70 ±
0.91 for 2D alone versus 1.69 ± 0.92 for 2D and 3D combined (p
= 0.38). There also was no significant difference when polyps (2.14 ±
0.90 vs 2.12 ± 0.93), fibroids (2.57 ± 0.79 vs 2.53 ±
0.82), and septations (2.88 ± 0.39 vs 2.87 ± 0.42) were
evaluated separately. Average scores for definition of fundal contour were
significantly (p < 0.0001) different (2.93 ± 0.34 for 2D
alone versus 1.45 ± 0.80 for 2D and 3D combined). Agreement between
readers was found with average kappa values of 0.72 for 2D alone and 0.78 for
2D and 3D. For the 42 subjects for whom pathologic findings were available,
readers identified 92% of the abnormalities.
CONCLUSION. Three-dimensional reformations improve visualization of
the uterine fundus and aid in identification or exclusion of a fundal contour
abnormality but do not add value in the detection of endometrial
abnormalities.
Keywords: pelvic sonography • sonohysterography • 3D sonography
Introduction
Conventional 2D saline infusion sonohysterography (SIS) is the accepted
diagnostic procedure for evaluation of abnormal uterine bleeding. SIS is less
invasive, less expensive, and more comfortable for the patient than are
traditional methods of diagnosis, such as dilation and curettage and
hysteroscopy
[1–4],
and is as accurate as hysteroscopy for detection of intracavitary
abnormalities [2,
5,
6]. For detection of
endometrial abnormalities, SIS has had higher sensitivity (83–88%) than
pelvic MRI (76%) and transvaginal sonography (60–69%)
[2,
6,
7–9].
Three-dimensional sonographic technology has become more widely available
in clinical practice. This technology entails acquisition of a volume of data
and rapid reconstruction of images in the transverse, sagittal, and coronal
planes. Three-dimensional sonography technology to date has been used for
obstetric and gynecologic disease, but studies
[10–14]
have shown that 3D combined with conventional 2D sonography enhances
characterization of fetal facial and skeletal anomalies and improves
evaluation of adnexal lesions. In addition, 3D multiplanar surface-rendered
views may yield important information to assist in the diagnosis or exclusion
of congenital uterine anomalies
[15–17].
Combined with conventional 2D SIS, 3D technology facilitates retrospective
review of both the uterine contour and the fluid-filled endometrial cavity in
any plane [18]. Findings with
the combination of 3D sonographic technology with 2D SIS have had excellent
correlation with those of hysteroscopy in the diagnosis of congenital uterine
anomalies such as septate and bicornuate uterus
[15–17].
However, the clinical relevance of 3D sonography as an adjunct to 2D SIS in
the detection of endometrial abnormalities remains controversial
[8,
18–22].
The purpose of our study was to retrospectively evaluate the value of addition
of 3D reformatted images to conventional 2D SIS in examinations of patients
referred because of abnormal uterine bleeding or infertility.
Materials and Methods
Subjects
This retrospective study was approved by our institutional review board,
and informed consent was waived. From September 1, 2003, to April 15, 2005,
122 women underwent SIS at our institution. Conventional transabdominal and
transvaginal sono graphy was required for all patients within 6 months of the
scheduled SIS procedure to determine orientation of the cervix and uterus and
to evaluate the adnexa. All premenopausal patients were scheduled for SIS
during the follicular phase of the menstrual cycle, and a negative result of a
urine pregnancy test was required of all premenopausal patients before the
procedure.
Imaging and interpretation were performed by one radiologist or by one of a
group of four specialists in obstetrics and gynecology. Indications for
referral included abnormal uterine bleeding, infertility, and recurrent
abortion. Static sono graphic images from these studies were retrospectively
reviewed by one author to determine whether both 2D and 3D sonography had been
performed. Of the original 122 patients, 80 pa tients (mean age, 43.5 years;
range, 26–78 years) had both 2D and 3D images (sagittal, transverse, and
coronal reformatted images) for comparison and were included in the study.
Scanning Procedure
The SIS protocol was as follows. A speculum was placed in the vaginal
canal, and the cervical canal was identified and prepared with 4%
chlorhexidine gluconate solution (Scrubcare, Exidine). A 5-French flexible
catheter was introduced into the cervical canal, and a balloon at the catheter
tip was inflated in the lower uterine segment. The speculum was removed, and a
vaginal probe was placed. Under sonographic guidance, the balloon was pulled
back slightly to occlude the cervical canal. Sterile normal saline solution
(5–10 mL) was slowly introduced in the retrograde direction, just enough
to distend the endometrial canal. Endovaginal imaging was performed with both
transverse and sagittal imaging, and the resulting static images were recorded
on a magnetooptical disk. An additional 5–10 mL of sterile normal saline
solution was sometimes required before 3D volume acquisition.
When optimal distention of the endometrial canal was achieved, an
adequately sized volume region-of-interest box was selected, and volume mode
was activated. A volume sweep was performed with the automated transducer in
the sagittal plane, and a second sweep was made in the transverse plane. All
volume data were stored on a magnetooptical disk. Images in the three
orthogonal planes (sagittal, transverse, and reformatted coronal) were later
reviewed. Both 2D and 3D endovaginal images were acquired with a dedicated
vaginal probe (RIC 5-9H, Voluson Expert 730, GE Healthcare).
Scan Evaluation
Static sonographic images of all subjects were loaded in an anonymously
coded format onto a workstation (HP Compaq DWS-220, McKesson Inform ation
Systems) for review. All patient identifiers were masked. A panel of three
independent subspecialists, one in women's imaging, one in abdominal imaging,
and one in obstetrics and gynecology, with 1–11 years of experience in
pelvic sonography reviewed the 2D images and immediately compared 2D and 3D
images of the same subject. Readers were blinded to the final outcome. Readers
interpreted the 2D images followed by the combined 2D and 3D images for
visualization and characterization of endometrial abnormalities such as
polyps, fibroids, and septations and for definition of the uterine fundal
contour. Each finding was marked as yes (visualized), unsure, or no (not
visualized) by each reader on a data sheet. Readers then subjectively
determined whether 3D images contained information additional to that on the
2D images for identification of an endometrial cavity abnormality or a uterine
contour anomaly and for exclusion of uterine contour abnormalities. These
responses also were marked yes, unsure, or no on a data sheet. For data entry,
each yes, unsure, and no response was assigned a score of 1, 2, or 3,
respectively, and entered into a computerized spread sheet for data
analysis.
Statistical Analysis
Statistical analysis was performed with SAS software (version 8.2, SAS
Institute). For detection of endometrial abnormality and for definition of
fundal contour for both 2D and combined 2D and 3D scans, the average scores
for responses from the three readers were determined. The probability
comparisons of the average scores were calculated with Wilcoxon's signed rank
test. A value of p < 0.05 indicated a statistically significant
difference. Agreement between readers on the pre sence of endometrial
abnormality or the diagnosis of a uterine contour abnormality for 2D and
combined 2D and 3D imaging was determined with Cohen's weighted kappa
coefficient.
Pathologic Correlation
Pathology reports were available for 42 of the 80 patients. Pathologic
correlation was determined by review of the subjects' medical records. The
available findings reported by pathologists at hysteroscopy, dilatation and
curettage, or examination of a hysterectomy specimen were compared with the 2D
and 3D SIS findings. Pathologists had no knowledge of the SIS results. The
accuracy and positive predictive value for each reader for intracavitary
abnormalities were determined.
Results
Diagnosis of Endometrial Cavity Abnormalities and Definition of Fundal Contour
There was no statistically significant difference in average scores between
2D and the combination of 2D and 3D sonohystero g-raphy for identification of
any endometrial abnormality (p = 0.38) (Figs.
1A,
1B, and
1C). There also was no
significant difference in average reader scores when polyps, fibroids, and
septations were evaluated separately (Table
1). Numbers of abnormalities identified by each reader are shown
in Table 2. The median scores
for fundal contour definition (Figs.
2A and
2B) were 3 for 2D imaging alone
(mean, 2.93 ± 0.34) and 1 for the combination of 2D and 3D imaging
(mean, 1.45 ± 0.80) with no significant difference between the groups.
The numbers for each reader are shown in
Table 3.
View larger version (110K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A —45-year-old woman who presented with abnormal uterine
bleeding. Static 2D transverse saline infusion sonohysterographic image shows
homogeneous echogenic mass along posterior fundus (arrows). Findings
are consistent with polyp.
|
|
View larger version (96K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B —45-year-old woman who presented with abnormal uterine
bleeding. Transverse saline infusion sonohysterographic image of midbody of
uterus shows second hypoechoic mass (arrows) along posterior wall
with heterogeneous shadowing. Broad-based attachment and echogenicity suggest
submucosal fibroid with greater than 50% protrusion into endometrial
canal.
|
|
View larger version (124K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1C —45-year-old woman who presented with abnormal uterine
bleeding. Three-dimensional coronal reformation shows both polyp
(arrows) and fibroid (arrowheads) and their relation to each
other. All readers were able to identify and characterize both lesions equally
with 2D imaging alone and combined 2D and 3D imaging.
|
|
View larger version (104K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2B —35-year-old woman who presented with abnormal uterine
bleeding. Three-dimensional coronal reformation shows normal endometrium and
defines complete fundal contour (arrows). Readers were more confident
is excluding fundal contour abnormality with 3D reformation.
|
|
Reader Agreement
In the diagnosis of intracavitary abnormalities, good agreement was found
between readers for 2D imaging alone (
= 0.69–0.74). For 2D and
3D imaging together, the agreement was slightly stronger ( =
0.74–0.81). The differences, however, were not statistically significant
(p = 0.09) (Table
4).
Added Value of 3D Imaging
All three readers found that combined 2D with 3D imaging subjectively
enhanced confidence in exclusion of congenital uterine anomaly compared with
2D imaging alone but did not enhance confidence in identification of uterine
cavity abnormalities (Table 5).
There was one exception. In one subject, septum was diagnosed by the three
readers, who suspected the septum might have been acquired rather than
congenital because of clinical suspicion of Asherman's syndrome, which was
later validated at hysteroscopy. In this subject, the readers found enhanced
visualization and char acterization of the septum on the coronal re formatted
images (Figs. 3A,
3B, and
3C).
View larger version (116K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3A —34-year-old woman who presented with multiple pregnancy
losses and history of dilation and curettage. Static sagittal (A) and
transverse (B) saline infusion sonohysterographic images suggest
presence of septum (arrows).
|
|
View larger version (104K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3B —34-year-old woman who presented with multiple pregnancy
losses and history of dilation and curettage. Static sagittal (A) and
transverse (B) saline infusion sonohysterographic images suggest
presence of septum (arrows).
|
|
View larger version (103K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3C —34-year-old woman who presented with multiple pregnancy
losses and history of dilation and curettage. Three-dimensional coronal
reformation defines and characterizes septum (arrows) better than do
A and B. Irregularity suggests acquired rather than congenital
septum.
|
|
Pathologic Correlation
On combined 2D and 3D SIS, readers determined that an average of 24 (30%)
of 80 subjects had no evidence of endometrial cavity abnormalities, 48 (60%)
had definite abnormalities, and eight (10%) had possible abnormalities (four
questionable polyps, four possible septations). In 51 subjects, one or more
lesions (polyps, fibroids, or septa) were suspected at initial clinical
interpretation of SIS images. Forty-two of these subjects underwent additional
intervention, including dilation and curettage, hysteroscopy, and hysterectomy
with pathologic analysis. Nine subjects had no additional intervention or
pathologic correlation and were lost to follow-up. The three readers
interpreting images of the 42 subjects with positive pathologic findings had
no statistically significant difference in the accuracy values for the two
scanning techniques (p = 0.32)
(Table 6). The mean positive
predictive value for 2D alone was 0.97 and for combined 2D and 3D was
0.98.
Discussion
The role of 3D sonography in gynecologic imaging continues to evolve, a
number of studies showing potential advantages of 3D technology in clinical
practice. For example, Benacerraf et al.
[18] determined that storage
of rapidly acquired real-time volume data may allow manipulation and review of
the data in any plane after the patient has completed the examination,
potentially increasing patient throughput and practice efficiency. This
application would be useful to radiologists who interpret images acquired by
sonographers, residents, and fellows and for review of studies transferred
digitally from distant sites. For sonohysterography, Weinraub et al.
[19] found that rapid
acquisition of 3D volumes and subsequent interpretation of the saved volume
data may reduce the amount of time the uterine cavity is distended with saline
solution, decreasing patient discomfort.
An important advantage of 3D volume imaging over conventional 2D sonography
is the ability to reconstruct images in any of the three orthogonal planes.
Jurkovic et al. [17], Nicolini
et al. [23], and Pellerito et
al. [24] found that although
2D transvaginal sonography performed by experienced practitioners is sensitive
for the diagnosis of major uterine anomalies, it also can lead to a large
number of false-positive findings and cannot be used to differentiate the most
frequently encountered uterine anomalies: arcuate, bicornuate, and septate
uteri. Combined with SIS, 3D reconstructions in the coronal plane overcome the
limitations by facilitating complete evaluation of the fundal contour, as with
hysterosalpingography, and of the uterine cavity
[17]. Differentiation of a
bicornuate from a septate uterus is important because septate uterus is
associated with early fetal loss but is surgically correctable
[15,
17].
Our results show that compared with 2D SIS alone, 3D reconstructions added
substantial value to the evaluation of the uterine fundus. Using 2D imaging
alone, readers identified the complete fundal contour in only 3% of subjects,
but with the addition of 3D images they identified the complete fundal contour
in 74% of subjects. A probable explanation for the large difference is that
during conventional 2D imaging of most women it is impossible to angle a
transvaginal probe to completely visualize the entire uterus in the coronal
plane. With 3D technique, the entirety of the uterus can be readily visualized
in the coronal plane. Although we evaluated 3D sonohysterography, it seems
likely that the fundal contour would also be well visualized with 3D
transvaginal sonography. Our study included only one patient with acquired
septum; however, we surmise that septum and subseptum can be much better
evaluated with the introduction of saline solution into the endometrial
cavity.
For detection of intracavitary abnormalities, the use of 3D imaging as an
adjunct to 2D SIS has had inconsistent results. In an early pilot study with
10 patients, Ayida et al. [20]
found no added value for the addition of 3D technology to standard 2D
sonohysterography in the detection and characterization of focal endometrial
lesions. Bonilla-Musoles et al.
[21] found in a study with 36
patients that 3D SIS was equivalent to 2D SIS for detection of endometrial
atrophy (n = 11), polyps (n = 4), and malignancy (n
= 11) but superior to 2D transvaginal sonography alone. Lev-Toaff et al.
[22] found that in 13 of 20
patients who underwent both 2D and 3D SIS, the two procedures combined
depicted most focal endometrial abnormalities, although 2D SIS alone did not
depict one case of adhesions. In the other patients, improved subjective
visualization of focal endometrial abnormalities was found with 3D SIS. In a
prospective study with 49 patients, de Kroon et al.
[8] found no statistically
significant difference between 2D SIS and 3D SIS, but there was a trend toward
improved accuracy with 3D SIS.
Our results showed no significant difference between combined 2D and 3D SIS
and 2D SIS alone in the detection of focal endometrial abnormalities. The
readers detected intracavitary lesions in 60% of cases with 2D SIS alone and
62% of cases with combined 2D and 3D SIS with no statistically significant
difference in averaged confidence scores. The differences between our findings
and those in some previous reports may be related to our study design. We
evaluated a larger number of subjects and therefore had the statistical power
to detect a difference. Our interobserver agreement among the three readers
was very good with mean kappa values of 0.71 for 2D alone and 0.78 for
combined 2D and 3D SIS with no statistically significant difference between
the two groups.
We compared conventional 2D SIS with combined 2D and 3D SIS, rather than 3D
SIS alone, to determine the added value of 3D technology. In our experience,
2D SIS is essential for evaluation of the entire pelvis, including the adnexa,
and for real-time detection of subtle intracavitary abnormalities.
Three-dimensional reformatted images, although much improved with current
technology, lack the spatial resolution of conventional 2D images
[18]. When the uterus is
enlarged or acutely angulated, more than one volume sweep may be needed to
optimally visualize the entire endometrium, resulting in reconstructed images
that are difficult to interpret, which can lead to misinterpretation. In
addition, the presence of anterior fibroids can produce shadowing, which
obscures visualization on coronal reformations
[17]. For these reasons, we
believe 3D SIS cannot replace 2D SIS at this time but is valuable as an
adjunct to 2D imaging, particularly for evaluation of the uterine contour.
An important limitation of our retrospective study was that only static 2D
and 3D images were reviewed without the benefit of real-time imaging. Because
real-time imaging can increase the sensitivity of detection of endometrial
lesions with both techniques, the final comparison results would likely not
have changed. A second limitation was that pathologic correlation was not
available for all subjects, even when intracavitary abnormalities were
suspected on SIS images. This limitation is unavoidable in clinical practice
because some patients decline further intervention for a variety of reasons,
including resolution of symptoms or other more urgent health concerns. Studies
[7,
25] have shown equal
diagnostic accuracy of SIS, hysteroscopy, and examination of hysterectomy
specimens; therefore, additional invasive intervention is not indicated for
patients with normal findings on SIS studies.
All three readers interpreted 2D with 3D images immediately after
interpreting 2D images alone. Such a design might have biased the results in
favor of the subsequent 3D interpretations because review of a case for a
longer time can improve reader perception. For fundal contour abnormality, all
three readers strongly favored 3D images. Although this bias might have been a
small factor, it likely would not have changed the final results because the
differences were substantial.
Since the time of this study, we have adopted routine use of 3D
reconstructions in imaging of patients with infertility in whom a uterine
congenital abnormality such as presence of a septum is suspected.
Three-dimensional reformations are a helpful adjunct to 2D images alone for
the evaluation and exclusion of uterine contour abnormalities. However, 3D
combined with 2D transvaginal sonohysterography is not a significant
improvement over 2D imaging alone for detection of endometrial
abnormalities.
References
- Rogerson L, Bates J, Weston M, Duffy S. A comparison of outpatient
hysteroscopy with saline infusion hysterosonography. Br J Obstet
Gynaecol 2002; 109:800
-804
- de Vries LD, Dijkhuizen PH, Mol BW, Brolmann HA, Moret E, Heintz
PM. Comparison of transvaginal sonography, saline infusion sonography, and
hysteroscopy in premenopausal women with abnormal uterine bleeding.
J Clin Ultrasound 2000;28
: 217-223[CrossRef][Medline]
- Dijkhuizen FP, Mol BW, Bongers MY, Brolmann HA, Heintz AP.
Cost-effectiveness of transvaginal sonography and saline infused sonography in
the evaluation of menorrhagia. Int J Gynecol Obstet2003; 83:45
-52[CrossRef][Medline]
- Carlos RC, Bree RL, Abrahamse PH, Fendrick AM. Cost-effectiveness
of saline-assisted hysterosonography and office hysteroscopy in the evaluation
of postmenopausal bleeding: a decision analysis. Acad
Radiol 2001; 8:835
-844[CrossRef][Medline]
- Widrich T, Bradley LD, Mitchinson AR, et al. Comparison of saline
infusion sonography with office hysteroscopy for evaluation of the endo
metrium. Am J Obstet Gynecol 1996;174
: 1327-1332[CrossRef][Medline]
- O'Connell LP, Fries MH, Zeringue E, et al. Triage of abnormal
postmenopausal bleeding: a comparison of endometrial biopsy and transvaginal
sonohysterography versus fractional curettage with hysteroscopy. Am
J Obstet Gynecol 1998; 178:956
-961[CrossRef][Medline]
- Dueholm M, Lundorf E, Hansen E, Ledertoug S, Olesen F. Evaluation
of the uterine cavity with magnetic resonance imaging, transvaginal
sonography, hysterosonographic examination, and diagnostic hysteroscopy.
Fertil Steril 2001;76
: 350-357[CrossRef][Medline]
- de Kroon CD, Louwé LA, Trimbos JB, Jansen FW. The clinical
value of 3-dimensional saline infusion sonography in addition to 2-dimensional
sonography in women with abnormal uterine bleeding. J Ultrasound
Med 2004; 23:1433
-1440[Abstract/Free Full Text]
- Dijkhuizen FP, De Vries LD, Mol BW, et al. Comparison of
transvaginal ultrasonography and saline infusion sonography for the detection
of intracavitary abnormalities. Ultrasound Obstet
Gynecol 2000; 15:1
-6[CrossRef]
- Mangione R, Lacombre D, Carles D, Guyon F, Saura R, Horovitz J.
Craniofacial dysmorphology and three-dimensional ultrasound: a prospective
study on practicability for prenatal diagnosis. Prenat
Diagn 2003; 23:810
-818[CrossRef][Medline]
- Krakow D, Williams J, Poehl M, Rimoin D, Platt L. Use of
three-dimensional ultrasound imaging in the diagnosis of prenatal-onset
skeletal dysplasias. Ultrasound Obstet Gynecol2003; 21:467
-472[CrossRef][Medline]
- Alcazar JL, Castillo G. Comparison of 2-dimensional and
3-dimensional power-Doppler imaging in complex adnexal masses for the
prediction of ovarian cancer. Am J Obstet Gynecol2005; 22:249
-254
- Alcazar JL, Galan MJ, Garacia-Manero M, Guerriero S.
Three-dimensional ultrasound morphologic assessment in complex adnexal masses:
a preliminary experience. J Ultrasound Med2003; 22:249
-254[Abstract/Free Full Text]
- Merz E, Weber G, Bahlmann F, Miric-Tesanic D. Application of
transvaginal and abdominal 3D ultrasound for the detection or exclusion of
malformations of the fetal face. Ultrasound Obstet
Gynecol 1997; 9:1
-7[Medline]
- Woelfer B, Salim R, Banerjee S, Elson J, Regan L, Jurkovic D.
Reproductive outcomes in women with congenital uterine anomalies detected by
three-dimensional ultrasound screening. Obstet Gynecol2001; 98:1099
-1103[CrossRef][Medline]
- Salim R, Woelfer B, Backos M, Regan L, Jurkovic D. Reproducibility
of three-dimensional ultrasound diagnosis of congenital uterine anomalies.
Ultrasound Obstet Gynecol 2003;21
: 578-582[CrossRef][Medline]
- Jurkovic D, Geipel A, Gruboeck K, Jauniaux E, Natucci M, Campbell
S. Three-dimensional ultrasound for the assessment of uterine anatomy and
detection of congenital anomalies: a comparison with hysterosalpingography and
2-dimensional sonography. Ultrasound Obstet Gynecol1995; 5:233
-237[CrossRef][Medline]
- Benacerraf BR, Benson CB, Abuhamd AZ, et al. Three- and
4-dimensional ultrasound in obstetrics and gynecology: procedings of the
American Institute of Ultrasound in Medicine consensus conference.
J Ultrasound Med 2005;24
: 1587-1597[Abstract/Free Full Text]
- Weinraub Z, Maymon R, Shulman A, et al. Three-dimensional saline
contrast hysterosonography and surface rendering of uterine cavity pathology.
Ultrasound Obstet Gynecol 1996;8
: 277-282[CrossRef][Medline]
- Ayida G, Kennedy S, Barlow D, Chamberlain P. Contrast sonography
for uterine cavity assessment: a comparison of conventional two-dimensional
with three-dimensional transvaginal ultrasound—a pilot study.
Fertil Steril 1996;66
: 848-850[Medline]
- Bonilla-Musoles F, Raga F, Osborne NG, Blanes J, Coelho F.
Three-dimensional hysterosonography for the study of endometrial tumors:
comparison with conventional transvaginal sonography, hysterosalpingography,
and hysteroscopy. Gynecol Oncol 1997;65
: 245-252[CrossRef][Medline]
- Lev-Toaff AS, Pinheiro LW, Bega G, Kurtz AB, Goldberg BB.
Three-dimensional multiplanar sonohysterography: comparison with conventional
two-dimensional sonohysterography and x-ray hysterosalpingography.
J Ultrasound Med 2001;20
: 295-306[Abstract]
- Nicolini U, Bellotti M, Bonazzi B, Zamberletti D, Candiani GB. Can
ultrasound be used to screen uterine malformations? Fertil
Steril 1987; 47:89
-93[Medline]
- Pellerito JS, McCarthy SM, Doyle MB, Glickman MG, DeCherney AH.
Diagnosis of uterine anomalies: relative accuracy of MR imaging, endovaginal
sonography and hysterosalpingography. Radiology1992; 183:795
-800[Abstract/Free Full Text]
- Cininelli E, Romano F, Anastasio PS, Blasi N, Parisi C, Galantino
P. Transabdominal sonohysterography, transvaginal sonography and hysteroscopy
in the evaluation of submucous myomas. Obstet Gynecol1995; 85:42
-47[CrossRef][Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
Abstract
Introduction
