Three-dimensional transvaginal sonographic assessment of uterine volume as preoperative predictor of need to morcellate in women undergoing laparoscopic hysterectomy.
OBJECTIVE
In light of recent statements from the United States Food and Drug Administration warning against the use of power morcellation of uterine leiomyomas during laparoscopy, we sought to evaluate the use of preoperative two- (2D) and three- (3D) dimensional transvaginal ultrasound (US) assessment of uterine volume to predict the need for morcellation in women undergoing laparoscopic hysterectomy (LH).


METHODS
This was a prospective observational study performed between October 2008 and November 2011 in a tertiary referral laparoscopic unit. All women scheduled to undergo LH were included and underwent detailed preoperative transvaginal US. Uterine volumes were calculated using 2D-US measurements (ellipsoid formula), and using Virtual Organ Computer-aided AnaLysis (VOCAL™) having acquired 3D-US volumes of the uterus. Age, parity, need to morcellate and final uterine dry weight at histology were recorded. The estimated uterine volumes were then incorporated into a previously published logistic regression model to predict the need to morcellate for both nulliparous and parous women. The probability threshold cut-off of 0.14 (95% sensitivity) was evaluated in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and likelihood ratios (LRs). The performance of the models incorporating 2D- and 3D-US calculations were compared with 2D- and 3D-US-generated volumes alone, using receiver-operating characteristics (ROC) curves.


RESULTS
Of 76 women who underwent LH during the study period, 79% (n = 60) had complete background and 3D-US data. Their mean age was 43.7 years, 91.7% were parous and 35% underwent morcellation. The greatest uterine volume that did not require morcellation was 404 mL estimated using 3D-US, which corresponded to a uterine volume of 688.8 mL using 2D-US. The smallest uterine volume that required morcellation was 118.9 mL using 3D-US, which corresponded to a uterine volume of 123.4 mL using 2D-US. The 3D-US uterine volume for parous women with a sensitivity of 95% based on ROC-curve analysis was approximately 120 mL, which equated to a predicted probability of morcellation cut-off of 0.14. For this cut-off, specificity was 55.00%, PPV was 51.35%, NPV was 95.65%, LR+ was 2.11 and LR- was 0.09. Areas under the ROC curves for the morcellation logistic regression model were 0.769 (95% CI, 0.653-0.886) and 0.586 (95% CI, 0.419-0.753) using uterine volumes obtained by 3D-US and by 2D-US, respectively, and they were 0.938 (95% CI, 0.879-0.996) and 0.815 (95% CI, 0.681-0.948) using 3D-US and 2D-US volumes alone.


CONCLUSIONS
The need to morcellate can be predicted preoperatively using 3D-US uterine volumes obtained by transvaginal US with a fair degree of accuracy. Uteri with volumes smaller than 120 mL at 3D-US are very unlikely to require morcellation. The incorporation of 3D-US-estimated uterine volume into the previously published logistic regression model does not seem to confer any significant improvement when compared with 3D-US uterine volume alone to predict the need to morcellate in women undergoing total LH. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
Acute Gynaecology, Early Pregnancy and Advanced Endosurgery, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Penrith, NSW, Australia.
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http://orcid.org/0000-0001-8559-7050
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Gerges
Nepean Medical School, Nepean Hospital, University of Sydney, Nepean Hospital, Kingswood, NSW, Australia.
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Mongelli
Acute Gynaecology, Early Pregnancy and Advanced Endosurgery, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Penrith, NSW, Australia.
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Casikar
Department of Obstetrics and Gynecology, A.O. Niguarda Ca' Granda, Milan, Italy.
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Bignardi
Acute Gynaecology, Early Pregnancy and Advanced Endosurgery, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Penrith, NSW, Australia.|OMNI Gynaecological Care Centre for Women's Ultrasound and Early Pregnancy, St Leonards, NSW, Australia.
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Condous
D000328:Adult; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000379:methods*; D010535:Laparoscopy / Q000379:methods*; D007889:Leiomyoma / Q000000981:diagnostic imaging / Q000601:surgery*; D000069577:Morcellation / Q000379:methods*; D011237:Predictive Value of Tests; D012680:Sensitivity and Specificity; D014463:Ultrasonography; D014594:Uterine Neoplasms / Q000000981:diagnostic imaging / Q000601:surgery*
hysterectomy; laparoscopy; leiomyosarcoma; morcellation; preoperative ultrasound; probability; uterine volume