A large dermoid cyst of the spermatic cord.

Dermoid cysts of the spermatic cord are rare, with only a few adult cases published in the literature. We report a patient with a 10cm inguinal mass referred to us for a suspected paratesticular sarcoma. Imaging suggested a cyst but, due to the recent increase in size, the cyst contents were evacuated and the cyst wall was biopsied. Histopathology revealed a dermoid cyst, which is a benign variant of cystic teratomas. Histopathological examination was required here due to the uncertainty. Careful interpretation was required, as cystic teratomas very occasionally undergo a malignant transformation.

18 F-FDOPA PET/CT of Paraganglioma in the Spermatic Cord.

ABSTRACT: A 53-year-old man with chronic kidney failure was referred to perform an 18 F-FDOPA PET/CT to characterize a mass located on the right spermatic cord. Previously, the pathological analysis of CT-guided biopsies suggested paraganglioma or metastatic lesion of pheochromocytoma. Serum normetanephrine and serum metanephrine values were respectively 2- and 1.5-fold greater than the normal upper limit, which could be explained by the chronic kidney failure. PET/CT images revealed intense 18 F-FDOPA uptake of the mass without any other pathological findings, suggesting the diagnosis of paraganglioma. Pathological examination of surgical specimen confirmed the diagnosis of paraganglioma of the spermatic cord, which is exceptional.

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.

[A Case of Dedifferentiated Liposarcoma of the Spermatic Cord].

A 52-year-old man was referred to our hospital for evaluation of painless right scrotal swelling persisting for 3 months. Palpation detected swelling and induration centered on the head of the upper epididymis, and ultrasonography revealed a blood-filled nodular mass at the same site continuing to the spermatic cord. No abnormalities were observed in the bilateral testes. Blood tests were negative for tumor markers such as α fetoprotein and human chorionic gonadotropin-ß. Right radical inguinal orchiectomy was performed, and the pathological diagnosis was dedifferentiated liposarcoma of the spermatic cord. Although the spermatic cord stump was negative, the peri-spermatic cord stump, which had an exfoliated surface, was positive. No residual tumor was found on magnetic resonance imaging, but the tumor was suspected to remain. Thus, after approximately 1month, the tissue around the spermatic cord was resected. Eight months after the initial operation, no recurrence was observed. Here, we report a case of dedifferentiated liposarcoma of the spermatic cord, which is relatively rare, and review the related literature.

FDG PET/CT in Isolated Spermatic Cord Metastasis From Colon Cancer.

ABSTRACT: Isolated spermatic cord metastasis is extremely rare. We describe FDG PET/CT findings in a case of isolated spermatic cord metastasis from colon cancer detected 27 months after colectomy. The tumor showed intense focal FDG uptake in the right spermatic cord mimicking a primary spermatic cord malignancy.

[Intra-abdominal recurrence with bleeding 7 years after curative resection of primary synovial sarcoma of the spermatic cord with localized dissemination:a case report].

Primary synovial sarcoma of the spermatic cord is quite rare and has not been reported in Japanese literature. We report a case of primary synovial sarcoma of the spermatic cord and localized dissemination of the tumor in a patient who experienced recurrence of intra-abdominal bleeding 7 years after curative resection of the primary lesion. A 70-year-old man was admitted with disturbance on urination and lower abdominal pain. Computed tomography (CT) of the abdomen revealed two lesions:a 10-cm intrapelvic tumor with hemorrhage and a 4-cm tumor adjacent to the bladder. Curative excision of the tumors was performed. Histological examination revealed that the larger lesion was a primary tumor of the spermatic cord with proliferation of spindle cells in cellular fascicles in a monotonous pattern, which was compatible with histologic findings of monophasic fibrous synovial sarcoma. The smaller lesion was a disseminated tumor. The diagnosis of synovial sarcoma was confirmed by the detection of a SS18 (SYT) -SSX1 fusion gene. After discharge, the patient received adjuvant chemotherapy, including ifosfamide and doxorubicin. No recurrence was evident thereafter. Seven years after the operation, the patient experienced sudden abdominal pain and swelling and was transferred to our hospital. CT showed a 17-cm tumor with massive hemorrhage in the omental bursa. Through catheterization of the superior mesenteric artery, bleeding from a branch of the dorsal pancreatic artery was identified. Because of the difficulty of catheterizing the bleeding branch, he underwent emergency resection of the tumor and partial resection of the colon. Histologic examination and genetic testing revealed that the tumor was a recurrence of the synovial sarcoma. After discharge, the patient received treatment with gemcitabine and docetaxel. However, 7 months after the second surgery, intraperitoneal manifestations recurred. The patient died 14 months after the second resection. This case suggests that curative surgical resection of the primary synovial sarcoma of the spermatic cord contributes to prolonged survival. However, because the recurrence rate of synovial sarcoma is high, multidisciplinary treatment, including chemotherapy and radiotherapy, might be necessary.

LIPOSARCOMA OF THE SPERMATIC CORD - DIAGNOSTIC AND THERAPEUTIC ISSUE.

Liposarcoma of the spermatic cord is a malignant tumor so rare that there are less than 200 cases reported in the literature worldwide. Liposarcoma is a malignancy which originates from fat tissue. Although only 3%-7% of all paratesticular sarcomas primarily arise from structures of the spermatic cord, clinical significance of these tumors must not be neglected because they are often preoperatively misdiagnosed. A 66-year-old male presented with a painless swelling on the left side of the scrotum. Local examination revealed a solid, smooth, limited mass of approximately 4x3 cm in the left side of the scrotum. Tumor markers were within the reference range. Ultrasound examination showed a solid, clearly limited non-homogeneous mass of 40x20 mm localized in the left spermatic cord. Magnetic resonance imaging showed an expansive mass measuring 60x85x60 mm in the left inguinoscrotal region without propagation into the abdominal cavity. Both testicles and epididymides appeared normal on magnetic resonance examination and no locoregional enlarged lymph nodes were seen. The patient was treated operatively with radical inguinal orchiectomy. In conclusion, liposarcomas of the spermatic cord are extremely rare neoplasms that clinically present as slow-growing, painless, palpable inguinal or scrotal masses. Radical orchiectomy with high ligation of the spermatic cord and wide excision of the surrounding soft tissues within the inguinal canal remains the gold standard treatment option. Recurrence of the disease is frequent even several years after primary therapy, therefore long-term follow-up is mandatory.

An Analysis of Major Causes of Surgical Failure Using Bähren System in Intraoperative Venography During Varicocelectomy.

PURPOSE: In young patients with varicocele, preservation of the internal spermatic artery may be advantageous for catch-up growth, but it may also increase the likelihood of treatment failure. Intraoperative venography reduces the likelihood that unsealed veins will remain after varicocelectomy. We analyzed the characteristics of remnant veins visualized through intraoperative venography to investigate the cause of surgical failure in artery-sparing varicocelectomy (ASV). MATERIALS AND METHODS: We retrospectively analyzed clinical characteristics and outcomes of patients aged 18 years or younger who underwent varicocelectomy with intraoperative venography from January 2005 to December 2017. During varicocelectomy, intraoperative venography was performed to distinguish veins from other structures. Any unsealed veins that were discovered were ligated and classified using the Bahren system. RESULTS: One hundred and sixty-two patients underwent intraoperative venography: 153 cases (94.4%) were for primary varicocelectomy, and 9 cases (5.6%) were for repeat varicocelectomy. Open varicocelectomy was performed in 105 cases (64.8%), and laparoscopic varicocelectomy was performed in 57 cases (35.2%). Venography revealed remnant veins after the first ligation in 51 cases (31.2%), 46 (90.2%) and 5 (9.8%) of which were Bähren types 3 and 4, respectively. Five patients (3.1%) experienced varicocele recurrence, classified as persistence in 1 patient (0.6%) and relapse in 4 patients (2.5%). CONCLUSION: Remnant collateral veins of the internal spermatic vein (ISV) (Bahren type 3) are the most common cause of failure in ASV. In a few patients, an external spermatic vein merges with the ISV at a higher level (Bahren type 4) and is unidentifiable without venography.

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.

Sonographic appearance of a large lipoma of the spermatic cord presenting clinically as an inguinoscrotal hernia.

Lipoma of the spermatic cord or the round ligament is called inguinal canal lipoma. It may present as an inguinal herniating mass of fat tissue, with or without an accompanying herniating sac. There are few reports about large lipomas of the spermatic cord. We describe a case of a large spermatic cord pure lipoma, initially suspected to be an inguinal hernia upon physical examination. We diagnosed the lipoma with ultrasound and magnetic resonance imaging. The patient subsequently underwent left orchiectomy.

The relationship between saphenofemoral junction insufficiency and varicocele.

The aim of the study was to investigate whether or not there is a significant relationship between varicocele and SFJ insufficiency. This study included 200 men with (study group) and 200 men without (control group) primary varicocele which was initially diagnosed by observation during the Valsalva manoeuver. Subsequently, scrotal and lower extremity venous Doppler ultrasonography (USG) was performed by a senior radiologist, and participants with testicular veins >3.0 mm in diameter and reverse blood flow were determined to have varicocele. SFJ insufficiency was defined as retrograde flow in the SFJ of longer than 0.5 s. Retrograde venous flow in the pampiniform plexus was determined 3.5% (study) versus 0.0% (control) and 77.0% (study) versus 0.0% (control) in the right testis and left testis, respectively, and bilaterally at 11.5% (study) versus 0.0% (control). The presence of SFJ insufficiency was also found to be higher in the study group than in the control group (unilaterally: 26.0% versus 15.0%; bilaterally: 14.0% versus 5.0%). The current study demonstrates a statistically significant relationship between varicocele and SFJ insufficiency and supports the argument that varicocele is not a local disease and may be attributable to a systemic vascular insufficiency. Additional studies with larger series are needed to further elucidate this topic.

Ultrasound evaluation of testicular vein diameter in suspected cases of varicocele: Comparison of measurements in supine and upright positions.

BACKGROUND: Scrotal ultrasonography has high sensitivity in the detection of intra-scrotal abnormalities. Various ultrasonographic parameters such as the spermatic cord diameter, venous diameter, and venous retrograde flow in either supine or upright positions with or without Valsalva maneuver have been investigated to assess patients suspected of having varicocele. AIMS: This study aimed at comparing testicular vein diameter in supine and upright positions using ultrasonography. METHODOLOGY: This is a prospective multicenter study conducted between September 2018 and June 2019. Eighty-two consenting suspected cases of varicocele, 20 years and above, referred for scrotal ultrasonography were included in this study. RESULTS: The study population had a mean age of 42.9 + 14.89 (SD) with a range of 20-96 years. The highest number of participants fell within the age range of 30-39 years 23 (28%). Varicocele was demonstrated in 96.3% of the patients. More patients showed sonographic evidence of varicocele in the upright position, on the right 50 (61%) as well as left 50 (61%). Bilateral varicocele had a higher frequency in the upright position 45 (54.9%), while supine was 23 (28%). Upright position had the widest diameter in 72% of participants on the right and 82% on the left. The upright position also showed higher average vein diameter of 2.6 mm and 2.9 mm on the right and left, respectively, while it was 2.2 mm and 2.3 mm for right and left in the supine position. CONCLUSION: The upright position is more predictive of varicocele in scrotal ultrasound examination for suspected cases of varicocele. We recommend an upright position where one position is to be used.

Mechanism of metastasis to the spermatic cord and testis from advanced gastric cancer: a case report.

BACKGROUND: The spermatic cord and testis are very rare sites for metastasis from gastric cancer. Although several mechanisms have been suggested to explain this unusual metastasis, the actual mechanism remains unclear. We report a case of right spermatic cord and testicular metastasis, review its imaging findings, and suggest a mechanism of tumor spread. CASE PRESENTATION: A 61-year-old man complained of a palpable mass in the right inguinal area. He had been treated with distal gastrectomy with chemotherapy for advanced gastric cancer 5 years ago. Computed tomography, ultrasound, and magnetic resonance imaging showed a mass surrounding the right spermatic cord, involving the right testis. Another mass was observed in the aortocaval space, presumed to be a metastatic lymph node. The imaging features of the right testicular lesion were different than those of the primary testicular cancer. The lesions at both sites showed similar radiologic features of abundant internal necrosis, which is consistent with metastatic lesions. Pathology confirmed metastatic adenocarcinoma. He underwent a series of chemotherapy sessions, and all metastatic masses had partially decreased in size at the 5-month outpatient follow-up. CONCLUSIONS: The imaging features of testicular mass and spermatic cord involvement are important clues for accurate differential diagnosis of metastasis from other primary tumors in patients with a history of stomach cancer. This unusual metastasis can be explained via retrograde tumor spread along the lymphatic channels in terms of concurrent aortocaval lymph node metastasis. A suspicion of metastasis should not be overlooked, even if a patient has undergone curative treatment, including surgery and adjuvant chemotherapy, many years ago.

Pediatric groin lesions: imaging findings. / Lesiones inguinales pediátricas: hallazgos radiológicos.

OBJECTIVES: The groin is a complex anatomic region that has traditionally been ignored by radiologists because most lesions can be diagnosed from clinical data and physical examination. Nevertheless, ultrasound examinations of the groin are increasingly being requested to confirm injury or to resolve diagnostic uncertainty. On the other hand, some conditions involving the groin are found only in pediatric patients. This article describes the key imaging findings in pediatric groin injuries, placing special emphasis on the ultrasound appearance. CONCLUSIONS: Knowledge about conditions that can affect the groin in pediatric patients and the key imaging findings associated with them helps improve the diagnostic performance of ultrasound.

Improved Arterial Preservation Achieved by Combined Use of Indocyanine Green Angiography and Doppler Detector During Microsurgical Subinguinal Varicocelectomy.

Objectives: The microsurgical approach is considered the most reliable procedure in varicocelectomy. However, as there are difficulties in identifying the spermatic artery at the peripheral level, we had introduced intraoperative indocyanine green angiography (ICGA) for identification of arteries. In this study, we further investigated the usefulness of intraoperative ICGA in combination with an ordinary Doppler detector in microsurgical subinguinal varicocelectomy. Methods: A total of 140 men who underwent microsurgical subinguinal varicocelectomy at Gunma University Hospital were included. An operating microscope equipped with a near-infrared charge-coupled device was used for intraoperative ICGA. After exposing the vessels, arteries were identified using endoscopic vision only or with assistance of Doppler detector or ICGA, or of both. The number of preserved arteries was compared among the groups. Results: ICGA clearly visualized the internal spermatic arteries in all cases, allowing the surgeon to perform real-time identification and isolation of the spermatic artery intraoperatively. The use of ICGA or Doppler detector significantly increased the number of preserved arteries compared to the microscope-only operation from 1.11 to 1.75 (p < 0.05) and 1.57 (p < 0.05), respectively. The additional use of ICGA with Doppler detector further increased the number of preserved arteries to 2.41 (p < 0.05). Conclusions: Intraoperative ICGA facilitated safe and quick microsurgical subinguinal varicocelectomy by enabling visualization of thin spermatic cord blood vessels. Improved preservation of thin arteries, which is essential for patients with infertility, can be achieved with the combined use of ICGA and ordinary Doppler detector.

Diagnostic Accuracy of Ultrasound for the Directionality of Testicular Rotation and the Degree of Spermatic Cord Twist in Pediatric Patients With Testicular Torsion.

OBJECTIVES: To evaluate the diagnostic accuracy of ultrasound (US) to diagnose the directionality of testicular rotation and the degree of spermatic cord twist in pediatric patients with testicular torsion. METHODS: A retrospective review of 14 pediatric patients with testicular torsion was conducted. The directionality of testicular rotation was classified as an inner or outer direction (inner, counterclockwise in the left testis [viewed from below] and clockwise in the right testis; and outer, counterclockwise in the right testis and clockwise in the left testis). The Clopper-Pearson method and the Fisher exact, Mann-Whitney U, and Wilcoxon signed rank sum tests were used for the statistical analyses. RESULTS: The diagnostic accuracy of US in the directionality of testicular rotation and the degree of spermatic cord twist were 78.6% (11 of 14; 95% confidence interval, 49.2%-95.3%) and 36.4% (4 of 11; 95% confidence interval, 10.9%-69.2%), respectively. Outer rotation was seen in 50.0% of the cases. The directionality of testicular rotation and the degree of spermatic cord twist as determined by US were not significantly different between the patients with salvaged testis and those with testicular loss (inner/outer direction, 4/2 versus 4/4; P = .627; mean twist ± SD, 330.0° ± 73.5° versus 337.5° ± 115.4°; P > .999). There was no significant difference in the degree of spermatic cord twist determined by US and surgical results (343.0° ± 97.1° versus 458.2° ± 168.2°; P = .063). CONCLUSIONS: The accuracy of US in determining the directionality of testicular rotation was relatively high in our small cohort. This information may be useful for pediatric surgeons and urologists when performing early manual reduction for testicular torsion.

Novel prognostic grayscale ultrasonographic findings in the testis from a comprehensive analysis of pediatric patients with testicular torsion.

INTRODUCTION: Although grayscale and Doppler ultrasound (US) findings of testicular torsion (TT) have previously been described in the literature, other US findings may provide more prognostic information to families. OBJECTIVE: The authors hypothesized that a comprehensive analysis of US findings of TT that focused on time-dependent changes would lead to additional ultrasonographic morphologic findings and clinically relevant prognostic information. STUDY DESIGN: The authors reviewed the records of pediatric patients with acute TT from 2010 to 2017. The sizes and parenchymal characteristics of the torsed and contralateral testes on US were analyzed in relation to the time duration from the onset of scrotal pain to the time of surgery (0-6 h, 6-12 h, 12-24 h, 24-48 h, and >48 h), torsion degree, and clinical outcomes of the testes. RESULTS: Patient demographics, time intervals, and US measurements of the torsed and contralateral testes showed significant differences with respect to testicular viability (Summary Table). The mean volume ratios of torsed to contralateral testis showed significant differences between the 0-6 h and the 12-24 h time groups as well as the 6-12 h and the 12-24 h time groups (P = 0.003 and P = 0.035, respectively), as well as significant differences between the viable and non-viable testes (P = 0.005). Regarding testicular heterogeneity, two novel grayscale sonographic findings were noted: (1) multiple hypoechoic lines that were termed 'testicular fragmentation' and (2) hyperechoic patches that were termed 'testicular patching'. The presence of these two findings were significantly increased as TT time duration increased (P < 0.001), and these findings were significantly associated with testicular non-viability (P < 0.001). Torsion degree was also noted to be significantly higher in the non-viable testes (P < 0.001). Presence of hydrocele or scrotal edema also showed significant differences between the TT time groups (P < 0.001). DISCUSSION: The results of this study demonstrated ultrasonographic findings related to time dependent changes in TT and provided prognostic information regarding testicular viability. CONCLUSIONS: Specific US grayscale findings in torsed testes (testicular fragmentation and testicular patching) were identified that provide prognostic information regarding time duration of testicular torsion and testicular viability. Testicular fragmentation and testicular patching significantly increased as TT time increased, with increasing risk for testicular non-viability.

Vasitis: a clinical confusion diagnosis with inguinal hernia

Abstract Vasitis or inflammation of the vas deferens is a rarely described condition categorized as either generally asymptomatic vasitis nodosa or the acutely painful infectious vasitis. Vasitis nodosa, the commonly described inflammation of the vas deferens, is benign and usually associated with a history of vasectomy. Clinically, patients present with a nodular mass and are often asymptomatic and require no specific treatment.