Scrotal Doppler Ultrasonography Research Articles

Predictive value of hematologic parameters and HALP score for testicular viability in adults with testicular torsion: A multicentric study.

To evaluate the predictivity of haematologic parameters and HALP score on testicular viability in adults with testicular torsion. We retrospectively analyzed the clinical data of 139 men ≥18 years of age who underwent testicular detorsion with fixation (n = 90) or orchiectomy (n = 49) due to testicular torsion in five different tertiary centers between May 2019 and August 2023. Demographic, pre-, peri- and postoperative data were analyzed. The hemoglobin, albumin, lymphocyte, and platelet (HALP) score in the orchiectomy group was significantly lower compared to the detorsion group (adjusted p = 0.032). Platelet to lymphocyte ratio and duration of torsion were significantly higher in the orchiectomy group (adjusted p = 0.048, adjusted p = 0.000, respectively). Neutrophil-lymphocyte ratio did not reach statistical significance between the groups (adjusted p = 0.074) Furthermore, the orchiectomy group had statistically significantly more heterogeneous echotexture on scrotal ultrasonography (adjusted p = 0.000). On binary logistic regression analysis; platelet-lymphocyte ratio and HALP score were not found as significant predictors for surgical outcome (p = 0.296, p = 0.078, respectively). Multivariate logistic regression analysis revealed that only heterogeneous echotexture on scrotal Doppler ultrasonography and duration of torsion were independent risk factors for testicular necrosis development (p = 0.004, p < 0.001, respectively). This study demonstrates that heterogeneous echotexture on ultrasound and longer duration of torsion seem to be independent risk factors for testicular necrosis after testicular torsion in adults. However, neither haematologic parameters nor HALP score provided valuable information for testicular viability before scrotal exploration in our series.

Epididimal cyst in children: a single-institutional experience.

Simple epididymal cysts (EC) are rare in childhood and are mostly diagnosed at puberty. Although there is no consensus on the treatment, a conservative approach is generally preferred. To evaluate patients diagnosed with EC at our clinic in terms of presenting symptoms, diagnosis, and treatment methods. Data of patients treated for epididymal cysts at our institution between March 2012 and March 2023 were retrospectively analyzed in terms of age, symptomatology, diagnostic method, treatment method, and outcomes. In all cases, the diagnosis of EC was based on physical examination with scrotal ultrasonography (US) confirmation. A total of 1829 patients underwent scrotal Doppler US, and EC was detected in 72 patients (10.7%). The median follow-up period of the 43 patients was 21.7 (6-80 months). Of these, 9 were bilateral (12.5%). The mean age of the patients at presentation was 14.8 years. Forty-one patients had scrotal pain, 12 had scrotal swelling, and 19 incidentally had EC. The cysts were between 1.2- 37 mm. Only 3 (4.1%) patients required surgical excision due to persistent pain. EC is a benign lesion, and treatment approaches are usually conservative. Surgical excision is recommended for patients with persistent scrotal pain or an acute scrotum.

Late Phase Testicular Torsion in Pre-Geriatic Age: A Case Report

Background: Testicular torsion is a urological emergency caused by a twist of spermatic cord, which result in testicular tissue ischemia and requiring immediate surgery. The incidence occurred generally in children and adolescents, rarely found in adults. Severe Scrotal pain is the most common manifestation of testicular torsion. The definitive treatment for testicular torsion is surgery, either one of orchidopexy or orchidectomy. The prognosis of testicular torsion depends on the onset of symptoms and the decision time for surgery. Case Report: A 52-year-old man presented to emergency department with a history of gradual severe right-sided scrotal pain (visual analogue scale 8) radiated to the right groin in the last 3 day before admission. Previously, the patient's genitals were hit by the table. On physical examination, the testicles were found to be asymmetrical, swollen, redness, tenderness, and the testicle felt hard and immobilized, either the cremaster reflex or the Phren sign test were negative. The TWIST score was 6 (high risk for testicular torsion). Orchidopexy and orchidectomy were performed immediately without Scrotal Doppler Ultrasonography due to operational problems. Histopathology examination of the orchidectomy specimen impression showed an inflammation sign with exudative fluid presentation. Conclusion: Gradual Severe scrotal pain manifestations should be suspected as testicular torsion as soon as possible before it evolves into later phase. One of the causes of late phase testicular torsion is late admission to Hospital. Surgical emergency action should be taken considering theemergency state without waiting for ideal sonography

Epithelioid (Histiocytoid) hemangioma of the testis: A case report and literature review of a rare benign tumor.

Testicular hemangioma is a rare benign vascular neoplasm originating from the inner layer of the tunica albuginea, predominantly affecting the pediatric population and often associated with hemangiomas in other organs. Histopathologically can be categorized into four types, including capillary, cavernous, papillary endothelial hyperplasia, and epithelioid (histiocytoid). We report a case of a 24-year-old presenting with left inguinal pain, diagnosed with an epithelioid (histiocytoid) hemangioma of the testis. Diagnostic evaluation included scrotal doppler ultrasonography, which revealed a small, hypoechoic formation with evident vascularization. Serum tumor markers were within normal limits. Surgical excision via testis-sparing surgery (TSS) was performed based on frozen section analysis. A literature review underscores the rarity of testicular histiocytoid hemangiomas. Advancements in diagnostic technique have improved the accuracy of diagnosis and allowed for more conservative surgical approaches, preserving fertility and minimizing long-term adverse effects. In conclusion, while testicular hemangiomas may present characteristic features on ultrasound, frozen section examination remains crucial in guiding surgical decision-making. TSS offers significant advantages over traditional excisional surgery, including reduced morbidity and preservation of cancer control, making it an essential option in the management of testicular hemangiomas, particularly in young patients concerned about fertility preservation.

The Clinical Management of Intrascrotal Extratesticular Masses With Evaluation of Histopathologic Findings

ObjectiveTo contribute to the literature by sharing the clinical presentation, surgical approach, postoperative complications management and follow-up protocols of the patients we operated on due to intrascrotal extratesticular mass. MethodsThirty-two patients admitted due to intrascrotal extratesticular mass were included in the study. Demographic and clinical characteristics of the patients such as age, initial clinical presentation, physical examination, radiological imaging findings such as scrotal Doppler ultrasonography and magnetic resonance imaging, mass size and characteristics, surgical treatment procedures, operation notes, and patient follow-up visits were retrospectively examined and evaluated from the patient files. ResultsThe median age of the 21 32 individuals included in the study was 52(interquartile range (IQR):[45.0-60.5]) years. The primary reason for initial presentation was a palpable mass in 25 (78.1%) patients, pain in 13 (40.6%) patients, and scrotal swelling in 8(25%) patients. The median mass diameter was 4.4 (IQR:[3.1-5.7]) cm. Surgical treatment involved inguinal excision in 29 cases (90.6%) and inguinoscrotal excision in 3 cases(9.4%). All patients were treated with testicle sparing surgery. The most common tumor location, observed in 27 cases (84.3%), was the epididymis. The most frequent histopathological diagnosis was epididymal cyst, identified in 13 patients(40.6%). Pathology results showed that the mass was removed with negative margins in all patients. ConclusionTesticular-sparing surgery through the inguinal approach is one of the surgical methods that can be preferred for intrascrotal extratesticular masses. This approach can both preserve the testicle and achieve successful surgical results. Studies with larger samples are needed on this subject. Trial registrationThis study was approved by the Erzurum Medicine Faculty University Local Ethics Committee (approval number: BAEK 2023/08-105).

The management of testicular torsion: A survey of Turkish pediatric surgeons and pediatric urologists.

This study aimed to evaluate the approaches of pediatric surgeons and pediatric urologists in Türkiye regarding the diagnosis and treatment of testicular torsion (TT) and their adherence to the European Association of Urology (EAU) pediatric urology guideline. A survey consisting of 19 questions, accompanied by an annotation describing the objective of the study, was emailed to pediatric surgeons and pediatric urologists in June and July 2023. Of the 95 respondents, 62.1% had over 10 years of experience, and 48.4% treated more than five cases of TT annually. Of the participants, 87.4% stated that scrotal Doppler ultrasonography (US) was always used, and 12.6% stated that US was used in cases of doubtful diagnosis. Concerning treatment, 14.7% reported performing manual detorsion, 70.5% never did, and 14.7% did so only if the operating room was unavailable soon. A total of 92.6% of participants opted for emergency surgery. Among participants who perform manual detorsion, 71.4% perform surgery within 24 hours after successful manual detorsion. Regarding fixation of the contralateral testicle, 14.7% never performed it, and 27.4% did so only when they performed an orchiectomy on the torsion testicle. While most participants follow EAU pediatric urology guidelines by performing emergency surgery, the rate of manual detorsion is low. Few participants stated that emergency surgery may not be performed after manual detorsion. While all of the participants performed fixation of the torsion testicle in accordance with the guidelines, the same adherence was not observed in the contralateral testicle.

Indocyanine green (ICG)-GUIDED lymphatic sparing laparoscopic varicocelectomy in children and adolescents. Is intratesticular injection of the dye safe? A mid-term follow-up study

Laparoscopic Palomo varicocelectomy using indocyanine green (ICG) fluorescent lymphography (FL) is standardized technique to perform lymphatic sparing and avoid post-operative hydrocele. No data regarding the safety of intratesticular injection of ICG are currently available. The study aimed to assess the safety and efficacy of this procedure at mid-term follow-up. Seventy-two patients (median age 14.5 years) undergoing laparoscopic Palomo varicocelectomy using ICG-FL from January 2019 to July 2022, were enrolled. Operative indication was high-grade varicocele in all patients, associated symptoms in 30/72 (41.7%) and left testicular hypotrophy in 42/72 (58.3%). Follow-up included clinical examination at 1, 6, 12 months and scrotal Doppler ultrasonography (US) at 12 months postoperatively to assess varicocele persistence, hydrocele, and injections-related complications. Lymphatic sparing was achieved using ICG-FL in all cases. No intra-operative complications or adverse reactions secondary to ICG occurred. The median follow-up was 22.8 months (range 11-49). Self-limited scrotal hematoma at the injection site occurred in 1/72 (1.4%). Intratesticular hypoechoic millimetric area was detected at the injection site in3/72 (4.2%) on US. This finding disappeared after 1-year observation in 2/3 cases (66.7%) (Figure). Persistent grade II varicocele was observed in 4/72 (5.5%), not requiring re-intervention. No hydrocele occurred and 14/22 (63.6%) with pre-operative hypotrophy showed catch-up growth. ICG-FL was clinically safe, with no allergy or systemic adverse reactions to the dye reported in this series. No injury directly related to the injection of the dye was clinically observed, except for self-limiting scrotal hematoma in one patient. A millimetric hypoechoic and avascular area in the body of the left testicle at the injection site was found on scrotal US at 1-year follow-up in 3 patients of our series. This finding does not seem to be clinically relevant as patients were asymptomatic and serum tumor markerswere normal in all cases. Furthermore, the hypoechoic area with calcifications resolved 1 year later in 2/3 patients. The absence of evolution of this finding seems to exclude the heteroplastic nature. We hypothesized that this finding may be linked to elevated volume and/or pressure of intratesticular injection. Future prospective study with larger series and longer follow-up is needed to assess long-term testicular outcomes. Laparoscopic Palomo varicocelectomy using ICG-FL reported excellent outcomes with low incidence ofvaricocele persistence and no post-operativehydrocele. These preliminary data also confirmed safety of intratesticular injection of ICG at mid-term follow-up, without specific risks for both testis and patient.

Testicular involvement of Brucellosis: A 10-year, multicentre study.

The genito-urinary system is one of the most common areas of involvement in brucellosis. To present the epidemiological, clinical, and laboratory characteristics of patients with testicular involvement associated with brucellosis, together with the diagnostic and therapeutic approaches. Patients followed up for brucellosis-related testicular involvement between January 2012 and November 2022 were included in the study. Brucellosis is defined as the production of Brucella spp. in cultures, or clinical symptoms together with the serum standard tube agglutination test titer of ≥ 1/160. Inflammation in scrotal Doppler ultrasonography was based on testicular involvement. A retrospective evaluation was made of the data of 194 patients with brucellosis-related testicular involvement. The rate of determination of testicular involvement in brucellosis was 2.57%. The most affected patients were determined in the 16-30 years age range. On presentation, brucellosis was in the acute stage in 83.7% of patients. The most common symptoms on presentation were swelling and/or pain in the testes (86.6%). In the patients where a spermiogram could be performed, oligospermia was determined in 41.7%, and aspermia in 8.3%. When the testicular involvement of brucellosis was evaluated, epididymo-orchitis was present at the rate of 55.7%, epididymitis at 27.3%, and testis abscess at 5.1%. Although epididymo-orchitis was the most frequently determined form of involvement in this study, there was also seen to be a significant number of patients presenting with epididymitis. Male patients presented with the clinical status of brucellosis should be questioned about swelling and pain in the testes to avoid overlooking testicular involvement.

Echocardiographic and hemodynamic changes in patients with high-grade varicocele.

Varicocele is abnormal tortuosity and dilatation of the pampiniform plexus veins within the spermatic cord. Varicocele is associated with testicular atrophy, hypogonadism, impaired semen analysis values, or decreased testosterone production. Varicocele is a progressive disease and should be treated because it may be a systemic disease that can be associated with cardiovascular abnormalities. We hypothesize in this study that cardiovascular and hemodynamic pathologies may occur in varicocele patients. In this prospective, multicentric, multidisciplinary study, patients diagnosed with high-grade left varicocele in the urology clinic underwent semen analysis, total testosterone determination, and scrotal Doppler ultrasonography. In addition, blood pressure measurement and echocardiographic evaluation were performed by blinded cardiologists in both the varicocele patients and the healthy control group. The study was carried out with 103 varicocele patients and 133 healthy individuals who formed the control group. Diastolic blood pressure (P = 0.016), left ventricular end diastolic (P < 0.001) and systolic diameter (P < 0.001), ejection fraction (P < 0.001), pulmonary arterial pressure (P < 0.001), and aortic distensibility (P < 0.001) values were significantly higher in varicocele patients compared with controls; interventricular septum wall thickness (P = 0.022), aortic systolic (P < 0.001) and diastolic diameter (P < 0.001), aortic systolic (P < 0.001) and diastolic diameter index (P < 0.001), and aortic stiffness index (P < 0.001) values were significantly lower in varicocele patients. The mean aortic distensibility of non-normozoospermic group was lower than that of normozoospermic group (P = 0.041). There was no statistically significant relationship between thickest vein diameter in spermatic cord and cardiological parameters. This study showed that symptomatic patients with high-grade varicocele had a higher risk of cardiovascular and hemodynamic disease. We recommend that men with high-grade symptomatic varicocele with impaired semen analysis undergo cardiovascular and hemodynamic evaluation regardless of their spermatic vein diameter.

Intense venous reflux, quantified by a new software to analyze presurgical ultrasound, is associated with unfavorable outcomes of microsurgical varicocelectomy.

The hemodynamic characteristics of venous reflux are associated with infertility in patients with varicocele; however, an effective method for quantifying the structural distribution of the reflux is lacking. This study aimed to predict surgical outcomes using a new software for venous reflux quantification. This was a retrospective cohort study of a consecutive series of 105 patients (age range: 22-44 years) between July 2017 and September 2019. Venous reflux of the varicocele was obtained using the Valsalva maneuver during scrotal Doppler ultrasonography before microsurgical varicocelectomy. Using this software, the colored reflux signals were segmented, and the gray scale of the color pixels representing the reflux velocity was comprehensively quantified into the mean reflux velocity of the green layer (MRVG) and the reflux velocity standard deviation of the green layer (RVSDG). Spontaneous pregnancy and changes from baseline in the semen parameters were assessed during a 12-month follow-up period. Data were analyzed using logistic regression analysis. An association of the high MRVG group with impaired progressive motility (odds ratio [OR] = 2.868, 95% confidence interval [CI]: 1.133-7.265) and impaired sperm concentration (OR = 2.943, 95% CI: 1.196-7.239) was found during multivariate analysis. High MRVG (OR = 2.680, 95% CI: 1.086-6.614) and high RVSDG (OR = 2.508, 95% CI: 1.030-6.111) were found to be independent predictors of failure to achieve pregnancy following microsurgical repair. In summary, intense venous reflux is an independent predictor of impaired progressive motility, sperm concentration, and pregnancy outcomes after microsurgical varicocelectomy.

Prospective Randomized Controlled Trial Comparing Laparoscopic Palomo Surgery versus Scrotal Antegrade Sclerotherapy in Adolescent Varicocele.

Varicocele is a common condition in adolescence and the most common correctable cause of infertility. This study aimed to analyze and compare the outcomes of scrotal antegrade sclerotherapy (SAS) and laparoscopic Palomo surgery (LPS) in a tertiary referral centre. Patients with left grade 3 varicocele indicated for surgery were prospectively enrolled and randomly allocated to the SAS and LPS groups, with their respective contralateral normal testes taken as controls. The primary outcome measures were clinical varicocele recurrence, testicular catch-up growth, and post-operative hydrocele. All patients were evaluated clinically and using Doppler ultrasound by radiologists. From 2015 to 2020, 113 patients completed the study and were statistically analyzed (SAS, n = 57; LPS, n = 56). All patients had significantly smaller testes pre-operatively that the testicular volume differences with control testes were -23% in SAS and -19% in LPS. At 12-month follow-up, there were no statistical significant difference in clinical recurrences between the 2 groups (SAS = 5.3% vs LPS = 5.4%, P>.05, non-inferiority test). Testicular catch-up growths were observed in both groups, the mean testicular volume difference between the treatment and control testes reduced from -23% to -8.1% in SAS (P<.001) and -19% to -9.3% in LPS (P<.001) at 12-month follow-up. There was no post-operative hydrocele in SAS compared to 7 in LPS (0% vs 13%, P = .006). Both SAS and LPS are safe and effective procedures for treatment of adolescent varicocele with significant positive effect on testicular catch-up growth. SAS is not inferior to LPS in terms of clinical recurrence rate and with significantly less post-operative hydrocele.

Determining an Approach to Small Testicular Masses by Examining Scrotal Doppler Ultrasonography and Serum Tumor Markers

Determining an Approach to Small Testicular Masses by Examining Scrotal Doppler Ultrasonography and Serum Tumor Markers

Outcome of Extended Varicocelectomy in Case of High Grade Varicocele

Abstract Background Varicocele is defined as abnormal dilation and tourtousity of the internal spermatic veins within the pampiniform plexus. It is common among adolescents and may contribute significantly to the risk of subfertility in adulthood. Objective To evaluate the outcome of extended varicocelectomy in case of high grade varicocele. Patients and methods In all, 30 varicocele cases including 12 left sided and 18 bilateral, comprising 48 spermatic cord units with clinically palpable varicocele and affected semen analysis underwent extended varicocele ligation. Testicular delivery was done in all the cases and assessment of the gubernacular veins was reported. The patients underwent clinical evaluation, scrotal doppler ultrasonography, as well as semen analysis to detect varicocele recurrence, hydrocele formation and early changes in semen parameters. The postoperative evaluation period was 3 months. Results No varicocele recurrences were clinically detectable after our surgical approach, No hydrocele formation, and There was improvement in the parameters of semen analysis in the entire patients presented with infertility associated with varicocele as regard improvement in the count, motility, and decrease in the abnormal forms 3 months after varicocelectomy. Conclusion Extended varicocele ligation with delivery of the testis achieve good surgical outcome with minimal varicocele recurrence and hydrocele formation, and offer beneficial effect on semen parameters.

Pure embryonal carcinoma of the testis in an adult male patient: case report

As a case presentation, the present paper aims to present a patient with pure embryonal carcinoma, which is rarely seen, together with the relevant literature. Th e case is a 36-year-old male patient, who applied to the clinic with complaints of pain and swelling in the left testis. In the scrotal doppler ultrasonography, hypoechoic solid lesion contoured to the lobule almost fi lling the left testis and having the size of 25x60 mm were observed. Histopathological and immunohistochemical analysis of the this case was diagnosed with pure embryonal carcinoma. All the patients with complaint of pain-free mass in testis should be investigated. Although the pure embryonal carcinoma is rarely seen, it is one of the tumors that can be clinically and histopathologically confused with other testis tumors and should be considered for the patients applying to the clinic with complaints of pain-free mass in testis.

The effect of ejaculation time on varicose vein diameter and reflux level.

The aim of this study was to investigate whether the time interval between ejaculation and scrotal Doppler ultrasonography affects the results of the varicose vein diameter and reflux time. Age, medication use, operation history, physical examination and semen analysis findings, varicose vein diameters and the presence of reflux and reflux time were evaluated prospectively in the patients older than 18years of age who presented to the urology outpatient clinic with infertility and underwent scrotal Doppler ultrasonography and semen analysis. The time interval between the two scrotal Doppler ultrasonography for semen analysis was noted, the two results were compared. The patients were divided into four groups according to the time interval between ejaculation and scrotal Doppler ultrasonography. The study included 81 varicocele cases, with 57 left-sided and 12 bilateral varicocele. The varicose vein diameters were significantly larger after ejaculation than before ejaculation (p<.001). Similarly, the reflux time after ejaculation in all patients was significantly higher in scrotal Doppler ultrasonography performed before and after ejaculation at rest and during Valsalva manoeuvre (p<.001). In conclusion, the results of the present study suggest that a waiting time of at least 90min must be allowed between ejaculation and scrotal Doppler ultrasonography.

Is serum vitamin D level a risk factor for idiopathic male fertility?

Background: Idiopathic male infertility is a health problem that is increasingly common worldwide. Aetiology of idiopathic male infertility is still controversial. In this cross-sectional retrospective study, we aimed to investigate the relationship between serum vitamin D level and sperm quality in patients with idiopathic male infertility.Methods: Between June 2018 and June 2020, 297 patients including 147 men with idiopathic infertility (as a study group) and 150 fertile men (as a control group) were retrospectively enrolled into the study. Blood samples were collected, and these samples included serum sex steroids, serum vitamin D levels, glucose tests, lipid profiles, liver function tests and kidney function tests. At least two sperm analyses, scrotal doppler ultrasonography and karyotype analysis were performed on each of the patients. Demographic, laboratory and radiological features were also recorded. The Mann Whitney-U test was used to compare groups and quantitative independent data. The Chi-square test was used for qualitative independent data. Spearman's correlation analysis was applied for correlation. Significant results were investigated and analysed further using the logistic regression test.Results: The mean age of the patients was 31.98 ± 6.97 years. The mean serum vitamin D level of the patients was 23.16 ± 10.40 ng/dL and the mean infertility duration of patients with idiopathic infertility was 29.88 ± 28.86 months. We observed statistical significance in terms of serum vitamin D levels, impaired total sperm motility, progressive sperm motility and sperm morphology in idiopathic infertile men when compared to fertile men. There were no statistically significant between idiopathic infertile men and fertile men in terms of serum testosterone levels.Conclusions: We observed a positive correlation between serum vitamin D levels and impaired sperm parameters, specifically in terms of sperm morphology, total sperm motility and progressive sperm motility. Vitamin D supplementation may be a beneficial contribution to achieving high paternity rates in men with idiopathic male infertility.

Microscopic subinguinal varicocelectomy in 100 consecutive cases: Spermatic cord vascular anatomy, recurrence and hydrocele outcome analysis

ObjectiveTo evaluate the detailed vascular anatomy of the spermatic cord during subinguinal microscopic varicocelectomy and to assess the outcome of the cases with regard to varicocele recurrence and hydrocele formation. Patients and methodsIn all, 100 varicocele cases including 74 left-sided and 26 bilateral, comprising 126 spermatic cord units with clinically palpable varicoceles underwent microscopic subinguinal varicocelectomy. Detailed description of vascular anatomy of the spermatic cords was reported. The number of spermatic, cremasteric, and inguinal veins was recorded. A record of testicular arteries and lymphatics was noted. Testicular delivery was done in all the cases and assessment of the gubernacular veins was reported. The patients underwent clinical evaluation, as well as scrotal Doppler ultrasonography, to detect varicocele recurrence and hydrocele formation. The mean (range) postoperative evaluation period was 6 (3–12) months. ResultsThe mean number of spermatic veins was 14 on both sides. The mean number of spermatic arteries on both sides was 1.3. For lymphatics, the mean number was around three on both sides. The gubernacular veins were noted in 75% of the cases on the left side (mean number of 1.2) and in 85% on the right-side, (mean number of 1). The mean number of cremasteric veins on the left and right sides was 1.4 and 1.2, respectively. Finally, inguinal floor vessels were noted in 9% on the left-side and were not seen in the right-side cases. The incidence of varicocele recurrence was 2% and for hydrocele that was not clinically significant was 0.07%. ConclusionMicroscopic subinguinal varicocelectomy accurately evaluated the detailed vascular anatomy of the spermatic cord, achieving excellent surgical outcome with minimal varicocele recurrence and hydrocele formation. Microscopic subinguinal varicocelectomy should be the ‘gold standard’ for varicocelectomy.

Role of Doppler Ultrasonography and C-Reactive Protein in Patients with Acute Scrotum

This research was designate with an intention to find the role of Doppler ultrasonography (DUS) and C-reactive protein (CRP) in patients with acute scrotum. A sum of 80 (mean age 23±2.1 years) consequential patients were recruited for a period of six months between July 2015 and January 2016 in this prospective study. Collected data confined age, medical history, and clinical symptoms. DUS was performed with a linear array transducer (10-15 MHz) connected to HI vision Avius ultrasound unit; Hitachi. CRP was measured using turbidimetric analysis through the Cobas Integra analyzer system (Test CRPL2, 0-293); Roche Diagnostics. Statistical analysis was accomplished using the standard Statistical Package for the Social Sciences version 20 for Windows; Microsoft. Fitted achievement values for DUS in the diagnosis of testicular torsion, epididymo-orchitis, and varicocele were respectively 100%, 91% and 88% for sensitivity, 92%, 71%, and 90% for specificity, and 94%, 83%, and 89% for accuracy. An increased in the serum CRP level (63.2±40.2 mg/L) was seen in an inflammatory cause of the acute scrotum. In contrast, there was no increase in CRP level (8±3.1 mg/L) in the non-inflammatory cases (P &lt; 0.0001). Scrotal DUS is a highly precise preoperative diagnostic instrument, thereby confirm its course application in the incipient triage of patients with acute scrotum. Serum level of CRP can afford useful advice for differentiation between inflammatory and other reasons of the acute scrotum.

Laparoscopic Excision of Paravertebral Schwannoma

Introduction: Retroperitoneal schwannoma is rarely excised laparoscopically, and the laparoscopic management of retroperitoneal neural tumors remains controversial. We herein report a case of laparoscopic excision of paravertebral schwannoma. Patient and Methods: In September 2015, we performed laparoscopic excision of paravertebral mass in a 21-year-old male patient who was admitted to our clinic with right flank pain. Physical examination revealed no evidence of any pathology. Abdominal computed tomography (CT), magnetic resonance imaging, and positron emission tomography (PET) revealed a well-defined 28 × 30 × 44 mm sized tumor in right paravertebral region between the inferior vena cava and the renal vein. Scrotal Doppler ultrasonography was performed to execute any testicular tumor. Testicular tumor markers were negative. Laparoscopic excision was performed to dissect the tumor from adjacent structures using harmonic and blunt maneuvers. The operative time was 70 minutes and the estimated blood loss was 45 mL. The surgery was uneventful, with no operative complications or evidence of intra-abdominal bleeding. Results: Histopathologic examination revealed an ancient schwannoma. The patient had an uneventful post-operative course and was discharged on the following day. The patient was well with no signs of peripheral neuropathy or radiculopathy and was still doing well at 1-month follow-up. CT and/or FDG PET/CT will be performed during future follow-up to indicate any evidence of disease. Conclusions: Laparoscopic treatment is useful and feasible for retroperitoneal schwannoma, with minimal invasiveness and an early post-operative recovery. Laparoscopic procedure may be preferable for retroperitoneal schwannomas. No competing financial interests exist. Runtime of video: 7 mins 47 secs

Is contrast-enhanced MRI efficient in testicular infarction mimicking testicular tumor on scrotal ultrasound?

A 4-year-old boy was admitted to emergency department of our institution with left testicular swelling and pain started 48 h ago. Physical examination revealed left sided erythema and tenderness in scrotum which was refractory to testicular elevation. The parents did not describe undescended testis, trauma or recent mumps history that may explain acute swelling of left scrotum. Immediately after the physical examination, a scrotal Doppler ultrasonography was performed using a high frequency linear transducer. Ultrasonographic evaluation showed heterogeneously enlarged left testis and edema in the left scrotum. Blood supply was decreased in left testis in comparison to the right, however, arterial waveforms were still preserved in the left epididymis. In addition to Doppler and gray scale ultrasonography features, a smooth contoured demarcation line in the left testis was also observed which simulated mass lesion in the left testis. Based on the ultrasonography findings a concurrent testicular neoplasia could not be ruled out completely and the patient was referred to contrast-enhanced magnetic resonance imaging (MRI) promptly after ultrasound examination. MRI revealed left testicular enlargement, scrotal edema, and heterogeneous hypointense areas in T2-weighted images, but there was no solid or cystic mass lesion within the left testis. The affected testis was observed to be prominently hypointense on T1-weighted images compared to right. At post-contrast and subtraction MRI sequences avid contrast enhancement was detected in left paratesticular tissue however, left testis was completely avascular at post-contrast MRI sequences (Fig. 1). Based on the MRI findings, the diagnosis of testicular torsion was made confidently. Emergency surgical exploration confirmed intravaginal testicular torsion but, unfortunately detorsion operation could not have been performed and left sided orchiectomy was required because left testis was observed to be totally necrotic during surgical intervention (Fig. 2). Fig. 1 Post-contrast subtraction axial MRI image reveals left testicular enlargement and left paratesticular enhancement. Note that the affected left testis is hypointense and no contrast enhancement is observed diagnostic for testicular torsion (arrows). However, ... Fig. 2 Photographic view of the left testis during operation shows left testicular necrosis. Intravaginal torsion accounts for most cases of testicular torsion. Most cases are spontaneous but, rarely intravaginal testicular torsion may result from testicular trauma.1 Since irreversible damage may occur within 4–6 h of symptom onset, early diagnosis and urgent surgical intervention are critical.2 In the early stage of torsion, the echogenicity and size of the affected testis may be normal. Later findings include testicular enlargement and increased parenchymal echogenicity. If left untreated, the torsion will eventually progress into infarction which is seen as decreased or absent blood flow in color Doppler ultrasonography.1 The latter is sometimes diagnostic challenge in ultrasonography since, demarcation line of the infarcted testis tissue may simulate tumor particularly in late testicular torsion.3 In the current case, as reported in the literature,4 a testicular tumor was accurately ruled out via emergency contrast-enhanced MRI. In conclusion, late testicular torsion may mimic testicular mass lesion in ultrasonography which may cause a diagnostic challenge in Emergency Medicine. Contrast-enhanced MRI is helpful in the diagnosis as well as in the differential diagnosis in such complex cases.