Minimizing surgical complications during a laparoscopic hysterectomy requires thorough preoperative planning. Consequently, gynecologists actively seek reliable methods to identify pelvic adhesions before making the first incision. Specifically, mapping bladder-to-uterine (BTU) adhesions helps surgeons anticipate anatomical challenges and prevent accidental bladder injury. Fortunately, evaluating the preoperative sliding-bladder sign using transvaginal ultrasound (TVS) offers a non-invasive way to predict these adhesions.
Clinical Utility of the sliding-bladder sign
Recently, a prospective diagnostic test-accuracy study investigated how well this sonographic sign predicts BTU adhesions. In this study, they recruited 128 women scheduled to undergo benign laparoscopic hysterectomies. Before the operations, all patients underwent a transvaginal ultrasound to assess bladder mobility. Specifically, the sonographer assessed whether the bladder glided smoothly against the lower uterine segment. Meanwhile, independent surgical assessors remained fully blinded to the ultrasound results as they confirmed the presence of adhesions during the subsequent hysterectomy.
Impressive Accuracy and Predictive Values
Overall, the final surgical findings confirmed BTU adhesions in 28.1% of the patients. Furthermore, the preoperative ultrasound assessments demonstrated excellent diagnostic performance. Indeed, the sliding-bladder sign achieved a remarkable overall diagnostic accuracy of 89.1%. The technique also recorded a specificity of 96.7% and a sensitivity of 69.4%. Consequently, this high specificity means that a normal, positive sliding sign almost certainly rules out severe BTU adhesions. Additionally, the positive predictive value (PPV) reached 89.3%, while the negative predictive value (NPV) stood at 89.0%. Most importantly, the positive likelihood ratio reached 21.3, which indicates a highly reliable prediction when bladder sliding is absent.
Improving Preoperative Preparation
Therefore, integrating this simple ultrasound technique into routine preoperative workups offers massive benefits for gynecological surgeons. Knowing about adhesions beforehand allows the surgical team to adjust their technique and schedule more operating time. Moreover, this preparation helps the team select the safest instruments and secure appropriate surgical assistance. As a result, the surgeon can avoid unexpected bladder dome lacerations and ensure a smoother dissection. Ultimately, adopting this ultrasound assessment enhances patient safety and improves perioperative preparedness in modern gynecological practice.
Frequently Asked Questions
Q1: What is the sliding-bladder sign in pelvic ultrasound?
The sliding-bladder sign is a real-time ultrasound technique where the clinician uses the transvaginal probe to press against the cervix or lower uterine segment. During this movement, the clinician observes whether the urinary bladder slides freely against the uterus. An absent sliding motion (a negative sign) strongly suggests that adhesions have fixed the bladder to the uterus.
Q2: How accurate is this technique in predicting bladder-to-uterine adhesions before a hysterectomy?
According to recent clinical data, the technique boasts an overall diagnostic accuracy of 89.1%. It also exhibits a very high specificity of 96.7% and a positive predictive value of 89.3%. Consequently, a negative sign reliably alerts surgeons to the presence of anterior pelvic adhesions.
Q3: Why should gynecologists routinely check for bladder sliding before laparoscopic surgery?
Identifying bladder-to-uterine adhesions before surgery allows surgeons to anticipate challenging dissections in the anterior pelvic compartment. As a result, the surgical team can optimize their approach, schedule sufficient operating time, and significantly reduce the risk of accidental bladder injuries.
References
- van Keizerswaard J et al. Predicting bladder-to-uterine adhesions in patients undergoing hysterectomy using sliding-bladder sign technique with preoperative ultrasound: a diagnostic accuracy study. Ultrasound Obstet Gynecol. 2026 Jul 10. doi: 10.1002/uog.70281. PMID: 42427219.
- van Keizerswaard J et al. Prediction of vesicouterine adhesions by transvaginal sonographic sliding sign technique: validation study. Ultrasound Obstet Gynecol. 2024 Nov 25. doi: 10.1002/uog.29104.
- Kizildemir YZ. The impact of the uterocervical angle, cervical length, sliding sign, and pelvic organ prolapse stage on surgical difficulty in V-NOTES hysterectomy for benign conditions: a prospective cohort study. Ginekol Pol. 2026 Mar. doi: 10.5603/GP.a2026.0012.