Predicting bladder‐to‐uterine adhesions in patients undergoing hysterectomy using sliding‐bladder sign technique with preoperative ultrasound: a diagnostic accuracy study

OBJECTIVE: This study aimed to determine the accuracy of the sliding-bladder sign assessed using preoperative transvaginal ultrasound (TVS) for identifying the presence of bladder-to-uterine (BTU) adhesions in patients undergoing hysterectomy. METHODS: This was a prospective diagnostic test-accuracy study conducted at Hamilton Health Sciences, Hamilton, ON, Canada. Patients scheduled for a planned laparascopic hysterectomy for a benign gynecological condition between October 2021 and December 2024 were included and all underwent preoperative TVS examination that included assessment of the sliding-bladder sign. The presence of BTU adhesions was assessed using TVS (index test) and confirmed at hysterectomy (reference standard) by independent assessors who were blinded to the outcome of the other test. The accuracy, specificity, sensitivity, positive and negative predictive values and positive and negative likelihood ratios of the sliding-bladder sign were calculated. RESULTS: Of 128 included women, 28.1% had BTU adhesions confirmed at hysterectomy. The sliding-bladder sign on preoperative TVS demonstrated an accuracy of 89.1% (95% CI, 82.3-93.9%), with a sensitivity of 69.4% (95% CI, 51.9-83.6%) and a specificity of 96.7% (95% CI, 90.1-99.3%). The positive predictive value was 89.3% (95% CI, 72.8-96.3%), while the negative predictive value was 89.0% (95% CI, 83.2-93.0%). The positive likelihood ratio was 21.3 (95% CI, 6.8-66.2) and the negative likelihood ratio was 0.3 (95% CI, 0.2-0.5). CONCLUSIONS: The sliding-bladder sign assessed using TVS is a non-invasive tool for predicting the presence of BTU adhesions that is reliable when bladder sliding is absent. Incorporating this assessment into preoperative ultrasound examinations may support anatomical anticipation of anterior-compartment adhesions and perioperative preparedness as part of a comprehensive evaluation. © 2026 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.