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Four-dimensional (4D) ultrasound imaging extends the real-time capability of ultrasound to visualize a realtime volume that can be manipulated by the sonographer. Among the different visualization methods, surface rendering is a common mode for displaying volumetric datasets such as in obstetrical applications. A challenge in this mode is that surface shading is required to visualize the surface and enhances the surface contrast and this has very demanding computational requirements for 3D surfaces. Here, we present an optimized highperformance rendering pipeline based on four stages for preprocessing, volume rendering, surface shading, and postprocessing. The new approach is implemented to render volumes acquired on a 4D commercial ultrasound imaging system to illustrate its practicality. The results demonstrate diagnostic quality of rendered volumes at a computational time cost that is suitable for 4D real-time processing. Given its low cost of required hardware, the new pipeline has potential for making 4D imaging systems more affordable while maintaining diagnostic quality and performance.