Imaging in scrotal trauma: a European Society of Urogenital Radiology Scrotal and Penile Imaging Working Group (ESUR-SPIWG) position statement.

Imaging plays a crucial role in the evaluation of scrotal trauma. Among the imaging modalities, greyscale ultrasound and Colour Doppler ultrasound (CDUS) are the primary techniques with the selective utilisation of advanced techniques such as contrast-enhanced ultrasound (CEUS) and elastography. Despite ultrasound being the mainstay of imaging scrotal trauma, its diagnostic performance is not fully established. Considering these difficulties and their impact on clinical practice, the Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology (ESUR-SPIWG) established an expert task force to review the current literature and consolidate their expertise on examination standards and imaging appearances of various entities in scrotal trauma. This paper provides the position statements agreed on by the task force with the aim of providing guidance for the use of imaging especially multiparametric US in scrotal trauma.Key Points• Greyscale and Colour Doppler ultrasound are the mainstay of imaging in patients with scrotal trauma.• Contrast-enhanced ultrasound and elastography are the advanced techniques useful as a problem-solving modality in equivocal cases.• This paper summarises the position statements of the ESUR-SPIWG on the appropriate utilisation of multiparametric ultrasound and other imaging modalities in the evaluation of scrotal trauma.

Ultrasound evaluation of varicoceles: guidelines and recommendations of the European Society of Urogenital Radiology Scrotal and Penile Imaging Working Group (ESUR-SPIWG) for detection, classification, and grading.

Varicoceles are relatively common particularly in asymptomatic men and are even more prevalent in subfertile men, representing the most common potentially correctable cause of male infertility. Ultrasound (US) is the imaging modality of choice for varicocele evaluation, but there is no widely accepted consensus on examination technique, diagnostic criteria, or classification. In view of this uncertainty, the guideline writing group (WG) of the European Society of Urogenital Radiology (ESUR) Scrotal and Penile Imaging Working Group (ESUR-SPIWG) undertook a literature review and assessment of the quality of relevant evidence. The group then produced evidence-based recommendations for varicocele US examination, interpretation, and classification by consensus agreement. The results are presented in the form of 15 clinical questions with a brief summary of the relevant evidence and the authorised recommendations from the SPIWG. This paper provides a short summary of the evidence evaluation and the complete recommendations.Key Points• Varicocele is a common clinical problem; it is highly prevalent amongst subfertile men and the most common potentially correctable cause of male infertility. • Ultrasound is the imaging modality of choice for varicocele assessment, but there is no generally agreed consensus on the US examination technique or the criteria that should be used for diagnosis, grading, and classification. • This paper summarises the recommendations of the ESUR-SPIWG for standardising the US assessment of varicoceles. This includes examination technique, image interpretation, classification, and reporting.

MRI of the scrotum: Recommendations of the ESUR Scrotal and Penile Imaging Working Group.

OBJECTIVES: The Scrotal and Penile Imaging Working Group (SPI-WG) appointed by the board of the European Society of Urogenital Radiology (ESUR) has produced recommendations for magnetic resonance imaging (MRI) of the scrotum. METHODS: The SPI-WG searched for original and review articles published before September 2016 using the Pubmed and Medline databases. Keywords used were 'magnetic resonance imaging', 'testis or testicle or testicular', 'scrotum', 'intratesticular', 'paratesticular', 'extratesticular' 'diffusion-weighted', 'dynamic MRI'. Consensus was obtained among the members of the subcommittee. The expert panel proposed recommendations using Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence. RESULTS: The recommended MRI protocol should include T1-, T2-weighted imaging, diffusion-weighted imaging and dynamic contrast-enhanced MRI. Scrotal MRI can be clinically applied for lesion characterisation (primary), including both intratesticular and paratesticular masses, differentiation between germ-cell and non-germ-cell neoplasms (evolving), characterisation of the histological type of testicular germ cell neoplasms (TGCNs, in selected cases), local staging of TGCNs (primary), acute scrotum (in selected cases), trauma (in selected cases) and undescended testes (primary). CONCLUSIONS: The ESUR SPI-WG produced this consensus paper in which the existing literature on MRI of the scrotum is reviewed. The recommendations for the optimal imaging technique and clinical indications are presented. KEY POINTS: • This report presents recommendations for magnetic resonance imaging (MRI) of the scrotum. • Imaging acquisition protocols and clinical indications are provided. • MRI is becoming established as a worthwhile second-line diagnostic tool for scrotal pathology.

Incidentally detected non-palpable testicular tumours in adults at scrotal ultrasound: impact of radiological findings on management Radiologic review and recommendations of the ESUR scrotal imaging subcommittee.

OBJECTIVES: The increasing detection of small testicular lesions by ultrasound (US) in adults can lead to unnecessary orchiectomies. This article describes their nature, reviews the available literature on this subject and illustrates some classical lesions. We also suggest recommendations to help characterization and management. METHODS: The ESUR scrotal imaging subcommittee searched for original and review articles published before May 2015 using the Pubmed and Medline databases. Key words used were 'testicular ultrasound', 'contrast-enhanced sonography', 'sonoelastography', 'magnetic resonance imaging', 'testis-sparing surgery', 'testis imaging', 'Leydig cell tumour', 'testicular cyst'. Consensus was obtained amongst the members of the subcommittee, urologist and medical oncologist. RESULTS: Simple cysts are frequent and benign, and do not require follow up or surgery. Incidentally discovered small solid testicular lesions detected are benign in up to 80 %, with Leydig cell tumours being the most frequent. However, the presence of microliths, macrocalcifications and hypoechoic areas surrounding the nodule are findings suggestive of malignant disease. CONCLUSION: Asymptomatic small testicular lesions found on ultrasound are mainly benign, but findings such as microliths or hypoechoic regions surrounding the nodules may indicate malignancy. Colour Doppler US remains the basic examination for characterization. The role of newer imaging modalities in characterization is evolving. KEY POINTS: • Characterization of testicular lesions is primarily based on US examination. • The role of MRI, sonoelastography, contrast-enhanced ultrasound is evolving. • Most small non-palpable testicular lesions seen on ultrasound are benign simple cysts. • Leydig cell tumours are the most frequent benign lesions. • Associated findings like microliths or hypoechoic regions may indicate malignancy.

Testicular microlithiasis imaging and follow-up: guidelines of the ESUR scrotal imaging subcommittee.

OBJECTIVES: The subcommittee on scrotal imaging, appointed by the board of the European Society of Urogenital Radiology (ESUR), have produced guidelines on imaging and follow-up in testicular microlithiasis (TML). METHODS: The authors and a superintendent university librarian independently performed a computer-assisted literature search of medical databases: MEDLINE and EMBASE. A further parallel literature search was made for the genetic conditions Klinefelter's syndrome and McCune-Albright syndrome. RESULTS: Proposed guidelines are: follow-up is not advised in patients with isolated TML in the absence of risk factors (see Key Points below); annual ultrasound (US) is advised for patients with risk factors, up to the age of 55; if TML is found with a testicular mass, urgent referral to a specialist centre is advised. CONCLUSION: Consensus opinion of the scrotal subcommittee of the ESUR is that the presence of TML alone in the absence of other risk factors is not an indication for regular scrotal US, further US screening or biopsy. US is recommended in the follow-up of patients at risk, where risk factors other than microlithiasis are present. Risk factors are discussed and the literature and recommended guidelines are presented in this article. KEY POINTS: • Follow up advised only in patients with TML and additional risk factors. • Annual US advised for patients with risk factors up to age 55. • If TML is found with testicular mass, urgent specialist referral advised. • Risk factors - personal/ family history of GCT, maldescent, orchidopexy, testicular atrophy.

Investigation and assessment of adrenal incidentalomas.

With the increasing volume of diagnostic imaging undertaken in an ageing population, adrenal incidentalomas (AIs) are increasingly commonly seen. These masses are most likely to be benign, but a small proportion may be malignant. Similarly, they are usually non-functional, but ∼14% are functional, ie hormone-secreting tumours. Clinical, biochemical and radiological assessment is mandated to stratify patients into those requiring radiological surveillance, medical management or surgical intervention or who can be discharged. Mass characteristics on cross-sectional (CT/MRI) imaging influence the need for radiological surveillance. Functional tumours where excess cortisol, aldosterone or catecholamine are secreted should be excluded, with mild autonomous cortisol secretion (MACS) and primary aldosteronism (PA) as the two most common functional states. MACS and PA are associated with an increased risk of cardiometabolic disease (eg hypertension, type 2 diabetes) and cardiovascular morbidity/mortality (eg coronary heart disease). Multidisciplinary management is critical for selected cases; the majority of adrenal incidentalomas only require a single assessment.

Testicular Germ Cell Tumours-The Role of Conventional Ultrasound.

Testicular tumours are the most common tumours found in young males and germ cell tumours account for 95% of testicular tumours. Ultrasound is the first-line radiological investigation for imaging of the testis. This article outlines how to undertake an ultrasound examination, including optimal patient position, scanning technique and imaging parameters. Classification of germ cell tumours is provided, and salient imaging features of different tumours are described. Difficulties and pitfalls of ultrasound are described, including tumours found after a trauma presentation, orchitis causing diagnostic difficulties and imaging of small testicular lesions. Other uses of ultrasound are outlined, including looking for a primary testicular tumour following the discovery of retroperitoneal lymph nodes, imaging when tumour-makers increase, local recurrence in the scrotum, and for solid organ biopsy in metastatic disease. Conclusion: Ultrasound remains the first-line of investigation for imaging of the testis, and conventional ultrasound still plays a large role in imaging. On ultrasound alone, accurate morphological characterisation of tumours remains a challenge, despite the imaging features that can be seen in different tumour types. Therefore, histology following orchidectomy of a germ cell tumour remains the gold standard for accurate tumour characterisation.

Ultrasound evaluation of varicoceles: systematic literature review and rationale of the ESUR-SPIWG Guidelines and Recommendations.

Although often asymptomatic and detected incidentally, varicocele is a relatively common problem in patients who seek medical attention for infertility problems. Ultrasound (US) is the imaging modality of choice for evaluation, but there is no consensus on the diagnostic criteria, classification, and examination technique. In view of this uncertainty, the Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology (ESUR-SPIWG) undertook a systematic review of the available literature on this topic, to use as the basis for evidence-based guidelines and recommendations. This paper provides the results of the systematic review on which guidelines were constructed.

Sonographically indeterminate scrotal masses: how MRI helps in characterization.

Magnetic resonance imaging (MRI) of the scrotum represents a useful supplemental imaging technique in the characterization of scrotal masses, particularly recommended in cases of nondiagnostic ultrasonographic findings. An accurate characterization of the benign nature of scrotal masses, including both intratesticular and paratesticular ones may improve patient management and decrease the number of unnecessary radical surgical procedures. Alternative treatment strategies, including follow-up, lesion biopsy, tumor enucleation, or organ sparing surgery may be recommended. The aim of this pictorial review is to present how MRI helps in the characterization of sonographically indeterminate scrotal masses and to emphasize the key MRI features of benign scrotal masses.

Complex central venous catheter insertion for hemodialysis.

Despite the introduction of payment by results in the UK, there has been no decrease in central venous catheter (CVC) use. In part, this may relate to a requirement to dialyse through a CVC while autogenous access matures. Mortality data have improved in parallel and patients on hemodialysis live longer, which may lead to an increased exposure to CVCs.Exposure to CVCs carries a significant risk of infection and occlusion requiring their repositioning or exchange. The mid to long-term sequelae of CVC use is central venous occlusion leaving clinical teams with an ever increasing challenge to find adequate venous access.In this article, we will discuss the challenges faced by operators inserting CVCs into the hemodialysis-dependent patient who has exhausted more tradition insertion sites. These include translumbar caval catheters, transocclusion and transcollateral catheters, transjugular Inferior Vena Cava catheter positioning, and transhepatic catheters. We will demonstrate the techniques employed, complications, and anticipated longevity of function.

Calyceal diverticulum - a mimic of different pathologies on multiple imaging modalities.

Calyceal diverticula are outpouchings of a renal calyx. Often found incidentally on radiological imaging, they are generally benign and usually asymptomatic, although complications include infection and stone formation. More importantly, calyceal diverticula may mimic other potentially more serious pathology on imaging, such as renal tumour or abscess on ultrasound or computed tomography and even rib metastasis on bone scintigraphy. We present a case of a patient with a calyceal diverticulum found incidentally on imaging, in which the diverticulum is demonstrated on ultrasound, computed tomography, intravenous urogram and bone scintigraphy, and discuss the potential differential diagnoses that need to be excluded in this condition.

Large bowel obstruction due to impaction of a gallstone.

Gallstone ileus is a complication of cholelithiasis resulting from a fistula between the gallbladder and the gastrointestinal tract. If sufficiently large, a gallstone may lodge at the narrowest part of the gastrointestinal tract, usually the terminal ileum, and present with small bowel obstruction. Here the authors present the unusual case of an 82-year-old man who developed symptoms and signs of large bowel obstruction due to an untreated gallstone, measuring 7×4.5 cm, that fistulated into the transvere colon and subsequently impacted in the sigmoid colon. An emergency laparotomy with sigmoid colotomy was undertaken to remove the obstructing gallstone, and the patient made a full recovery.

Using Gagne's theory to teach chest X-ray interpretation.

BACKGROUND: as a Radiologist providing teaching for medical students and junior doctors, I have spent time devising lesson plans. It is vital to know the aims and objectives prior to teaching sessions in order that the students benefit as much as possible. This article describes a lesson plan for interpretation of a chest X-Ray using a theory described by Robert Gagne. CONTEXT: Gagne developed a model of instructional design, which provides information and interaction to enhance the learning process. This model is based on nine instructional events used during a teaching session. These are: gaining attention, informing the learner of the objective, stimulating recall of prior material, presenting the stimulus material, providing learning guidance, eliciting the performance, providing feedback, assessing the performance and enhancing retention and transfer. INNOVATION: this article uses the nine points described by Gagne and describes a model of how to teach chest X-ray interpretation. Each of Gagne's points is illustrated with a specific example of how this would fit into the Radiology teaching session. IMPLICATIONS: Gagne's theory of instructional design can be adapted depending on the subject being taught. It is useful, both for the teacher and the student, to prepare a lesson plan in advance with knowledge of required aims and objectives. Having run teaching sessions which use Gagne's theory, students have given very positive feedback and as a teacher I found the lesson ran more smoothly.