Association Between 3D Transvaginal Ultrasound-Based XI VOCAL Counting Severity and Tissue MMP-9 Levels in Patients with Adenomyosis.

Purpose: Adenomyosis severity assessment remains challenging due to the lack of objective imaging parameters associated with underlying tissue characteristics. This study aimed to investigate the association between 3D transvaginal ultrasound-based XI VOCAL Counting severity and tissue MMP-9 levels in patients with adenomyosis. Patients and Methods: This study employed an analytical observational design with a cross-sectional approach, focusing on adenomyosis patients who underwent surgery at Dr. Hasan Sadikin and Bandung Kiwari Hospitals. Diagnosis and severity were assessed using 3D transvaginal ultrasound-based XI VOCAL Counting, which quantifies transverse uterine sections showing MUSA direct signs, including subendometrial lines and buds, hyperechoic islands, and intramyometrial cysts. Tissue MMP-9 levels were measured by ELISA, and statistical analysis evaluated group differences and variable correlations, with significance set at p ≤ 0.05. Results: A total of 54 patients were included. XI VOCAL Counting severity was positively associated with tissue MMP-9 levels. The correlation was moderate during the proliferative phase ( Conclusion: XI VOCAL Counting severity was positively associated with tissue MMP-9 levels in patients with adenomyosis, with a stronger association observed during the secretory phase. These findings suggest that XI VOCAL Counting may provide a potential imaging-based severity assessment associated with molecular characteristics related to extracellular matrix remodeling. Further prospective multicenter studies are required to validate its reproducibility, clinical utility, and association with clinical outcomes.