Contrast-enhanced ultrasound (CEUS) for the characterization of intra-scrotal lesions.

Contrast-enhanced ultrasound (CEUS) has emerged as a promising imaging modality for the characterization of hepatic and renal lesions. However, there is a paucity of data describing the use of CEUS for the evaluation of intra-scrotal pathology. In the following review, we describe the clinical utility of CEUS for the characterization and differentiation of common and uncommon intra-scrotal conditions, including testicular torsion, infection, trauma, and benign and malignant intratesticular and extratesticular neoplasms. In addition, we outline key principles of CEUS and provide case examples from our institution.

Clinical and ultrasonographic findings associated with testicular infiltration in pediatric patients with leukemia.

BACKGROUND: Testicular infiltration is infrequent in pediatric patients with leukemia and can be confused with other testicular conditions. OBJECTIVE: To analyze the presence of clinical and radiological features suggestive of testicular disease and its histological association with leukemia infiltration. METHOD: Retrospective and analytical observational study that included patients with diagnosis of leukemia who underwent biopsy for suspected testicular infiltration. The relationship with the variables analyzed were diagnosis, reason for taking the biopsy, ultrasound findings, stage of treatment, induration, increased volume and pain, with testicular infiltration. RESULTS: Eighteen patients were included; 11 of them with microlithiasis, of which one 1 reported infiltration (odds ratio: 0.075; p = 0.026), no association was found between ultrasound findings and the presence of infiltration. Clinical findings were significantly associated with positive biopsies. CONCLUSIONS: No risk association was found with the ultrasound findings such as microlithiasis and hypoechoic imaging. The clinically evident testicular disease (testicular enlargement and testicular induration) has a significant statistic association with the presence of leukemia infiltration.

ANTECEDENTES: La infiltración testicular en pacientes pediátricos con leucemia es infrecuente y puede ser confundida con otros padecimientos testiculares. OBJETIVO: Analizar la presencia de características clínicas y radiológicas sugestivas de enfermedad testicular y su asociación histológica con infiltración por leucemia. MÉTODO: Estudio observacional retrospectivo y analítico que incluyó a los pacientes con diagnóstico de leucemia sometidos a biopsia por sospecha de infiltración testicular. Se analizó la relación con las variables diagnóstico de base, motivo de toma de biopsia, hallazgos ultrasonográficos, etapa del tratamiento, induración, aumento de volumen y dolor, con infiltración a testículo. RESULTADOS: Se incluyeron 18 pacientes; de ellos, 11 con microlitiasis, de los cuales solo uno reportado con infiltración (odds ratio: 0.075; p = 0.026). No se encontró una asociación entre los hallazgos ultrasonográficos y la presencia de infiltración. Los hallazgos clínicos se asociaron significativamente con biopsias positivas. CONCLUSIONES: No se encontró una asociación de riesgo con los hallazgos por ultrasonido, como microlitiasis e imágenes hipoecogénicas. La enfermedad testicular clínicamente evidente (incremento de volumen e induración testicular) tiene una asociación estadísticamente significativa con la presencia de infiltración por leucemia.

Is testicular microlithiasis associated with testicular pathologies in children?

PURPOSE: To analyze the association of testicular pathologies with TM. METHOD: The retrospective study included pediatric patients who underwent scrotal ultrasonography (US) due to complaints, including testicular pain, discomfort, swelling, scrotal redness in our clinic between June 2020 and January 2022. The patients were divided into two groups. Group 1; patients were diagnosed with testicular pathology or presented with testicular pain. Group 2; patients without testicular pathology or complaints. Patients were also classified as having undescended testis, epididymo-orchitis, varicocele and testicular pain without testicular pathology in group 1. Group 1 and subgroups of group 1 were compared with group 2 for the presence of TM. RESULTS: A total of 516 patients were included in the study. Median age at the time of US examination was 24 months (range 1 month-17 years). There was no significant difference between groups 1 and 2, and boys with undescended testis and group 2 with regard to the presence of TM (p = 0.85, p = 0.55, respectively). TM was significantly higher in patients who had undergone orchiopexy and presented with testicular pain compared to group 2 (p = 0. 013, p = 0.03, respectively). TM was not detected in patients with epididymo-orchitis, varicocele. CONCLUSION: We found no association between TM and testicular pathologies. Testicular pain may be a symptom of microlithiasis.

Microvascular Doppler Assisted Microsurgical Denervation of the Spermatic Cord in Treating Chronic Orchialgia.

Chronic orchialgia is a common disease in department of urology and andrology. The etiology is complex, and the treatment is difficult. In severe cases, orchiectomy is even necessary. In recent years, microsurgical denervation of the spermatic cord (MDSC) is a minimally invasive and effective surgical method for the treatment of chronic orchialgia. Its greatest advantage is to preserve the testis and epididymis, avoid the possible organ resection. The key of the operation is to dissect all the fibrous tissues in the spermatic cord, while protecting the arteries (especially the testicular arteries) and several lymphatic vessels. Combined with the use of microvascular doppler in the operation, when separating the structure of spermatic cord under the microscope, the testicular arteries can be objectively and accurately protected (pulse "whistle" sound can be heard when the microvascular doppler probes the arterial surface), while artery injury and venous missed ligation can be avoided. The postoperative blood supply of the testis is also maximumly safeguarded. At the same time, we can be more fearless to cut the cremaster muscle, fatty and connective tissues surrounding the spermatic cord blood vessels and vas deferens after the arteries and lymphatic vessels being accurately protected under the microscope, finally achieve the spermatic cord completely "skeletonized" (only the testicular arteries, lymphatic vessels and vas deferens remained after the surgery). Thus we can better ensure the clinical curative effect (denervation thoroughly), avoid serious complications (testicular atrophy), and achieve better surgical results.

Pathologic Conditions at Imaging of the Spermatic Cord.

A wide range of benign and malignant processes can affect the spermatic cord (SC). Familiarity with and recognition of the characteristic imaging features of these entities are imperative for accurate diagnosis and optimal clinical care. While some SC diseases are self-limiting, others can result in infertility and potentially life-threatening infection or bleeding if they are left untreated. Therefore, correct diagnosis is important for life-saving treatment and preservation of fertility. Disorders including anomalies of the vas deferens and the processus vaginalis, arterial and venous diseases (torsion of the SC and varicoceles), infection, trauma, and neoplasms are the most pertinent entities with which radiologists should be familiar when assessing the SC. Knowing what to expect in a patient who has undergone SC interventions is imperative. US has a fundamental role in the initial examination of patients who present with symptoms that indicate abnormalities of the SC, such as suspected posttraumatic testicular retraction or SC torsion. Other imaging techniques including abdominal and pelvic MRI and CT have their own importance. For correct interpretation of the findings and to establish an accurate diagnosis, it is crucial to have a thorough knowledge of the anatomy, the utility and limitations of various imaging modalities, optimal imaging and scanning techniques, and the imaging features of various benign and malignant pathologic conditions that can involve the SC. Online supplemental material is available for this article. ©RSNA, 2022.

[Testicular Preservation in a Patient with a Testicular Epidermoid Cyst Achieved by Preoperative Diagnosis : A Case Report].

Testicular epidermoid cysts are relatively rare, accounting for about 1% of all testicular tumors, and are often treated by high orchiectomy. We describe here the case of a testicular epidermoid cyst treated by testicle-sparing surgery due to a preoperative diagnosis. A 23-year-old man complained of a painless mass in the right scrotum. Physical examination revealed a firm little fingertip-sized smooth-surfaced mass in the right testis. Ultrasonography showed a hypoechoic lesion with an echogenic rim in the right testis. A T2-weighted magnetic resonance image showed a well-demarcated mass with a low signal outline. On the basis of a preoperative diagnosis of epidermoid cyst, intraoperative testicular frozen section was performed, and the mass was resected surgically while preserving the testis.

Pentaorchidism diagnosed on ultrasound examination: A case report and literature review.

Polyorchidism is a congenital malformation of the urogenital system that is usually found incidentally in adolescent age groups. Ultrasound and MRI are effective non-invasive diagnostic modalities which can differentiate this condition from other intrascrotal pathologies. Ultrasonography is mostly used in initial steps of diagnostic approach; however, MRI is considered as a modality to confirm diagnosis and evaluate possible malignancy. We report an extremely rare case of pentaorchidism (five testicles), presented with a left hemiscrotum mass. Diagnosis was made based on physical examination, laboratory analysis (testicular germ cell tumour markers and semen analysis) and imaging. Finally, close surveillance with ultrasound and physical examination was recommended for follow-up of this uncomplicated patient.

Polyorchidism: A Review of the Literature and Case Report of a Third Testicle Presenting as an Inguinal Hernia.

ABSTRACT: Polyorchidism, a very rare congenital anomaly, refers to the presence of more than 2 testes. It is often associated with many other pathologies including cryptorchidism, varicocele, testicular malignancy, and inguinal hernias.In this report, we describe a 40-year-old man who presented with an intermittently painful left groin, initially appearing as inguinal hernia. On ultrasound examination, a supernumerary testes and epididymis were found in the inguinal canal. The testes appeared sonographically normal with no evidence of associated pathologies. There was no evidence of an inguinal hernia containing fat or bowel.Ultrasound is essential in first-line diagnosis and classification of polyorchidism. Color Doppler ultrasound and magnetic resonance imaging can be used to clarify findings if sonographic images are inconclusive. We also review relevant literature as it pertains to classification, embryology, and treatment options. Patient treatment is based on imaging findings; if associated pathologies or malignancy is suspected, aggressive treatment such as surgical excision may be necessary. Otherwise, conservative treatment may be all that is needed.

Supernumerary testicle presented as an extra scrotal lump.

A 28-year-old patient was admitted to radiology department due to a painless left-sided extra scrotal lump and discomfort in the ipsilateral lower inguinal region. Scrotal ultrasound revealed an oval circumscribed soft tissue mass, located in the proximity of the distal part of spermatic cord, without visible flow at Color Doppler. Scrotal MRI depicted T2 hyperintense, T1 hypo- to isointense oval mass with diffusion restriction and no fat suppression, surrounded by T1/T2 hypointense rim, located close to the spermatic cord. Additionally, MRI revealed coma-shaped T1 iso-/T2 hypointense related to the testicle formation. Following the intravenous administration of gadolinium-based contrast agent, both previously described structures enhanced. Taking into account that malignancy could be the potential complication of polyorchidism our patient was operated and histopathology confirmed supernumerary testicle with cribriform epididymal hyperplasia.

Nodular Maturation of the Testis: A Non-neoplastic Lesion of Boys That May Present as a Mass on Clinical and Ultrasound Examination.

We have encountered a lesion of the pediatric testis, termed "nodular maturation," that clinically mimics a testicular neoplasm causing ultrasound abnormalities that may lead to surgical excision. To our knowledge, it has only been described anecdotally in textbooks without a series or description in the literature. We, therefore, report 8 cases in pediatric patients emphasizing the clinical presentation, ultrasound findings, histologic features, and clinical follow-up information. Patients ranged in age from 5 to 11 years (mean: 7.9 y). Precocious puberty was identified in 1 patient as isolated penile enlargement without other signs; another had a history of McCune-Albright syndrome, but did not have signs of precocious puberty; others had no clinical manifestations. All patients had testicular abnormalities on ultrasound; 6 had a discrete lesion and 2 showed diffuse testicular enlargement. In the 6 cases with available data, mean size of the lesion on ultrasound was 0.9 cm (range: 0.4 to 1.7 cm). In the 3 cases for which macroscopic descriptions were available, no gross abnormalities were noted in the testicular parenchyma, despite the ultrasound findings. Histologically, nodular maturation occurred as a zone of more mature testicular parenchyma having larger, lumen-bearing seminiferous tubules that contrasted with the smaller, immature cords of the remaining parenchyma. The mature tubules showed germ cell maturation (to the level of late spermatids/spermatozoa in 6 cases), mature Sertoli cells, and, in 4 cases, admixed nodules of mature Leydig cells. Of the 6 patients with available follow-up information, none developed a testicular neoplasm. Given its ability to cause a lesion on ultrasound leading to surgical intervention, pathologists, radiologists, and urologists should be aware of nodular maturation.

The Rare, the Odd, and the Atypical: A Pictorial Essay of Testicular and Paratesticular Diseases.

ABSTRACT: Understanding a variety of scrotal diseases is essential to developing an accurate differential diagnosis and is critical in providing optimal patient care. Ultrasound is the imaging modality of choice when evaluating for scrotal pathology, with the major purpose of locating such pathology to either the testis, or epididymis, or other intrascrotal structures, as well as characterizing lesions as solid or cystic. It is generally assumed that most solid intratesticular masses are more likely malignant, whereas most extratesticular ones are benign, although some exceptions to that rule exist. This pictorial essay will focus on rare and less commonly encountered benign and malignant testicular and paratesticular pathologies, which may pose a diagnostic dilemma for interpreting radiologists and treating physicians. Knowledge of their imaging characteristics will help narrow the differential diagnosis and assist in proper patient management and care.

Polyorchidism in pediatric patients: a case report and a literature review. / Poliorquidismo en la edad pediátrica: a propósito de un caso y revisión de la literatura.

Polyorchidism or testicular duplication is defined as the histologically confirmed presence of more than two testes. This is the case of a full left testicular duplication in an 11-year-old patient presenting with occasional pain in the left hemiscrotum. At physical exploration, a palpable scrotal mass was detected. An ultrasonography was performed, which revealed the presence of testicular duplicity. Diagnostic suspicion was confirmed by means of a nuclear MRI and a histopathological study following excision. Polyorchidism is a rare abnormality requiring a high degree of suspicion in the presence of an extratesticular mass. Most authors advocate conservative treatment and follow-up in the absence of pain, cryptorchidism, tumors, and unclear diagnosis.

El poliorquidismo o duplicación testicular se define como la presencia de más de dos testículos confirmados mediante histología. Se presenta un caso de duplicación testicular izquierda completa en un niño de 11 años de edad que consultó por dolor ocasional en el hemiescroto izquierdo. En su exploración física destacaba una masa escrotal palpable. Se practicó ecografía que reveló la presencia de una duplicidad testicular. La sospecha diagnóstica fue corroborada mediante resonancia magnética nuclear y el estudio histopatológico tras la exéresis, confirmó el diagnóstico. El poliorquidismo es una anomalía excepcional que require un alto índice de sospecha ante la presencia de una masa extratesticular. La mayoría de autores abogan por un tratamiento conservador y seguimiento si no causa dolor o si no existen dudas diagnósticas, criptorquidia o excepcionalmente, tumores.

The Application Value of Contrast-Enhanced Ultrasound in Testicular Occupied Lesions.

OBJECTIVE: To discuss the clinical application value of contrast-enhanced ultrasound (CEUS) in testicular occupied lesions. METHODS: Nine conventional-ultrasound-found testicular occupied lesions which underwent CEUS meantime were analyzed retrospectively. The CEUS perfusion pattern was compared with the surgical pathological result or follow-up findings. RESULTS: Among all the 9 testicular occupied lesions, there were 5 testicular malignant tumors, 1 testicular benign tumor, 1 testicular tuberculosis, and 2 testicular hematomas. CEUS diagnosed 6 testicular malignant tumors, 1 testicular benign tumor, and 2 testicular hematomas, and its diagnostic accuracy was about 88.9%. CONCLUSION: CEUS has high clinical application value in the differential diagnoses of benign and malignant testicular occupied lesions.

Tubular ectasia of the rete testis in an Angus bull.

An 18-month-old Angus bull presented to Auburn University College of Veterinary Medicine for a routine breeding soundness evaluation and lameness evaluation. He was classified as deferred potential breeder due to a lameness and was donated to the university. Following treatment, the bull's lameness resolved. He passed the breeding soundness examination in accordance with the Society for Theriogenology standards. However, avascular dilated areas at the level of the mediastinum testis of the right testicle were detected via Doppler ultrasonography. A high level of vascularity is routinely seen with neoplasia, such as teratomas. Due to the lack of vascularity, a presumptive diagnosis of tubular ectasia of the rete testis was made. The bull was castrated. The right testicle was submitted for histopathology revealing a definitive diagnosis of tubular ectasia of the rete testis.

When to ask for an MRI of the scrotum.

BACKGROUND: Multiparametric MRI (mpMRI) of the scrotum has been established as a useful second-line diagnostic tool for the investigation of scrotal diseases. Recently, recommendations on clinical indications for scrotal MRI were issued by the Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology. OBJECTIVE: To update current research on when to ask for an MRI of the scrotum. METHODS: PubMed database was searched for original articles and reviews published during 2010-2021. RESULTS: Eighty-three articles fulfilled the search criteria. Scrotal MRI is mainly recommended after inconclusive US findings or inconsistent with the clinical examination and should be asked in the following cases: differentiation between intratesticular and paratesticular lesions (in rare cases of uncertain US findings), characterization of paratesticular and intratesticular lesions (when US findings are indeterminate), discrimination between germ cell and sex cord-stromal testicular tumors, local staging of testicular malignancies (in patients planned for testis-sparing surgery), differentiation between seminomas and non-seminomatous tumors (when immediate chemotherapy is planned and orchiectomy is delayed), assessment of acute scrotum and scrotal trauma (rarely needed, in cases of non-diagnostic US findings) and detection and localization of undescended testes (in cases of inconlusive US findings). Although preliminary data show promising results in the evaluation of male infertility, no established role for mpMRI still exists. CONCLUSION: Multiparametric MRI of the scrotum, by assessing morphologic and functional data represents a valuable problem-solving tool, helping to improve our understanding on the nature of scrotal pathology and the process of spermatogenesis. The technique may improve patient care and reduce the number of unnecessary surgical procedures.

Use of contrast enhanced ultrasound in testicular diseases: A comprehensive review.

BACKGROUND: Contrast-enhanced ultrasound (CEUS) is a sonographic technique that increases the diagnostic accuracy of ultrasound and color Doppler ultrasound (CDUS) when studying testicular abnormalities. However, its role in clinical practice is still debatable because there are no accepted standards regarding how and when this technique should be used for patients with testicular disease. OBJECTIVES: To perform a nonsystematic review of the current literature to highlight the strength and flaws of performing CEUS and to provide a critical overview of current research evidence on this topic. MATERIALS AND METHODS: A thorough search of published peer-reviewed studies in PubMed was performed using proper keywords. RESULTS: Strong enhancement of neoplastic lesions (both benign and malignant) during CEUS aids in differential diagnosis with non-neoplastic lesions, which usually appears either nonenhanced or enhanced in a manner similar to that of the surrounding parenchyma. CEUS enhancement has a high predictive value in the identification of neoplastic lesions, whereas a similar or complete absence of enhancement may be interpreted as strong evidence of benignity, although there are exceptions. Literature on quantitative analysis is still scarce, though promising, particularly in distinguishing benign from malignant neoplasms. Furthermore, CEUS may be useful in many emergency situations, such as acute scrotum, blunt scrotal trauma, and focal infarction of the testis. Finally, CEUS can help increase the probability of sperm recovery in azoospermic males. DISCUSSION AND CONCLUSION: CEUS is a safe, easy-to-perform, and cost-effective diagnostic tool that can provide a more accurate diagnosis in testicular lesions and acute scrotal disease. However, further studies with larger cohorts are required to refine the differential diagnosis between benign and malignant neoplasms. Finally, these preliminary results can instigate the development of innovative research on pre-testicular sperm extraction to increase the chances of sperm recovery.

Paratesticular lesions: Aetiology and appearances on ultrasound.

BACKGROUND: Ultrasound (US) is the primary modality for the investigation of scrotal pathology, including both intra- and paratesticular abnormalities. OBJECTIVE: To describe the abnormalities of the paratesticular space. MATERIALS/METHODS: The paratesticular space contains the epididymis, spermatic cord and the tunica vaginalis cavity and is affected by a variety of inflammatory or tumoral entities. Differential diagnosis based on US criteria is frequently problematic, as the findings are non-specific. RESULTS: Some general rules apply: (i) unlike testicular lesions, extra-testicular entities are usually benign in the adult, (ii) the first steps to accurate diagnosis include careful localization of the lesion and assessment of its consistency (solid or cystic) and (iii) magnetic resonance imaging can be useful for further tissue characterization of lesions suspected to contain fat, but surgical biopsy will often provide the definite diagnosis. Contrast-enhanced ultrasound (CEUS) has been applied with limited experience indicating a narrow role, primarily for the differential diagnosis of echogenic cystic entities and the delineation of a necrotic abscess from a solid neoplasm. DISCUSSION: The various abnormalities are discussed and illustrated. CONCLUSION: This manuscript summarizes the literature on paratesticular lesions and the value of US in diagnosis.

A Systematic Review on the Use of Qualitative and Quantitative Contrast-enhanced Ultrasound in Diagnosing Testicular Abnormalities.

Greyscale and color doppler ultrasound are the standard when investigating testicular lesions. However, they cannot provide information on the microvasculature. As such, differentiating benign from malignant tumors is challenging. Contrast-enhanced ultrasound (CEUS) uses ultrasound contrast agents that are exclusively intravascular to image the microvasculature. This review assessed CEUS outcomes in investigating intratesticular lesions and concluded that qualitative CEUS provides the most advantage by confirming vascularity, thus differentiating non-neoplastic from neoplastic lesions with added confidence, allowing for appropriate management. Whilst results for quantitative CEUS are promising in distinguishing malignant from benign neoplasms, further research on its benefits is required.