US of the Inguinal Canal: Comprehensive Review of Pathologic Processes with CT and MR Imaging Correlation

QUALITY OF LIFE USING EURAHS-QoL SCORES AFTER SURGICAL TREATMENT OF INGUINAL HERNIA: LAPAROSCOPIC TRANSABDOMINAL PREPERITONEAL (TAPP) AND LICHTENSTEIN TECHNIQUES

BACKGROUND

Results on quality of life after inguinal hernia surgery, such as esthetics, postoperative pain, period of absence from activities, and recurrence are a relevant topic since inguinal hernia affects 27% of men and 3% of women at some point in their lives, and should guide health policies to allocate resources more efficiently.

AIMS

To evaluate the quality of life in the late postoperative period of inguinal herniorrhaphy regarding recurrence, pain, esthetics, and restriction in activities, comparing the minimally invasive techniques - the transabdominal preperitoneal (TAPP) and the conventional Lichtenstein.

METHODS

A cross-sectional observational clinical study was conducted with the EuraHS-QoL questionnaire validated and translated into Portuguese, applied to patients after an average of 65 months postoperatively. Forty-five patients were assessed, 28 undergoing Lichtenstein and 17 undergoing TAPP. All were males aged between 18 and 87 years with a primary unilateral inguinal hernia. Recurrent or bilateral hernias, other concomitant abdominal wall hernias, patients who chose not to participate or who were not found, and female patients were excluded from the study.

RESULTS

Regarding the domains pain, restriction, and esthetics, there was no difference between the two groups when examining quality of life. Neither group presented recurrence in the studied period.

CONCLUSIONS

Both TAPP and Lichtenstein techniques presented similar results concerning quality of life when compared in the long-term.

The Role of Imaging in the Pre- and Postoperative Evaluation of Inguinal Hernia

Inguinal hernia repair is the most frequently performed surgical procedure. Imaging has a fundamental role in initial assessment and postoperative evaluation of inguinal hernias. Clinical implications of radiology in the preoperative setting include diagnosis of occult/complicated hernias and enhancement of diagnostic certainty. Postoperatively, imaging may assist the detection and characterization of complications. Familiarity with the normal appearance of the postoperative groin area and surgical techniques is required to avoid misinterpretation. This pictorial essay provides an overview of the expected postoperative imaging findings and highlights the role of imaging in the pre- and postoperative evaluation of inguinal hernias, with emphasis on ultrasonography.

Extraprostatic incidental findings on prostate mpMRI: A pictorial review from the ESUR junior network

The role of multiparametric MRI (mpMRI) in prostate cancer setting is increasingly consolidated and, as a result, its usage in clinical practice is in exponential growth. However, beyond the prostate gland, several key structures are included in the field of view of mpMRI scans. Consequently, various extra-prostatic incidental findings (IFs) belonging to different anatomical systems can be accidentally recognized. Therefore, it is mandatory for a radiologist to be familiar with the wide range of pathologies potentially encountered, to guide management and avoid patient anxiety and costs due to additional work-up prompted by clinically insignificant extra-prostatic findings. With this pictorial review, we aim to illustrate a wide range of IFs that can be detected when performing mpMRI of the prostate, focusing on their imaging characteristics, differential diagnosis, and clinical relevance. Additionally, we propose the CheckDEEP, the Checklist for DEtection of ExtraProstatic findings, to be used for a thorough evaluation of target areas within each anatomical system.

A Radiological Review of the Unusual Contents of Inguinal Region

Background  The inguinal region is an area of complex anatomy that could contain diverse uncommon contents in routine clinical practice. Although inguinal hernia repair is one of the commonest surgeries done routinely, thorough preoperative imaging has a significant impact on the outcome of the surgery, by revealing the presence of unusual contents in the inguinal region. Aim  The aim of this article is to review the differential diagnosis of the uncommon inguinal pathologies, which can simulate an inguinal hernia, to determine, and to simplify the treatment approach. Conclusions  A profound understanding of the imaging characteristics of uncommon inguinal pathologies is crucial for both the radiologists (to prevent misdiagnosis) and the treating physicians (to avoid surgical complications) and ensure optimal management.

Contemporary Review of Masses in the Canal of Nuck

Canal of Nuck masses is a rare occurrence that can cause swelling in the abdominal-inguinal region of females for various reasons. This condition arises due to an abnormal persistence of the processus vaginalis opening. Although Canal of Nuck pathology is not widely known among general surgeons or gynecologists due to its rarity, it has been associated with significant morbidity and requires further research. In this comprehensive review, we aim to summarize the embryology and anatomy of the Canal of Nuck, followed by a description of the various types of masses that can occur in this region. We discuss the clinical presentation and diagnostic workup of Canal of Nuck masses, including imaging modalities and differential diagnoses. Next, we review the surgical management of these masses, including open and laparoscopic approaches. Finally, we discuss the potential complications and long-term outcomes associated with Canal of Nuck pathology. This review aims to compile the presently accessible literature on anomalies occurring in the Canal of Nuck in females, with a particular focus on describing their pathological nature, diagnosis, and management. In summary, this review provides an up-to-date understanding of the pathology, diagnosis, and management of Canal of Nuck masses and aims to raise awareness of this under-recognized surgical challenge among healthcare providers.

[Inguinal and Scrotal Diseases in Children and Adolescents]

In children and adolescents, inguinal and scrotal diseases are relatively common, and imaging is very useful for the diagnosis and differential diagnosis of these diseases. Therefore, it is important to understand the imaging findings of these diseases. In this article, we classify these diseases into small testes, cryptorchidism, patent processus vaginalis, acute scrotum pain, trauma, testicular tumors, and others and describe their characteristic findings.

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.

Hydrocele of the Canal of Nuck: A Review

Canal of Nuck abnormality is a rare surgical condition. The pathologies are mostly encountered in young girls, less than five years of age. The incidence is even less in adults. Various pathologic conditions related to the failure of processus vaginalis obliteration can occur, involving herniation of intraabdominal structures including intestinal and genital contents such as the uterus, fallopian tube, and ovary and hydrocele of the canal of Nuck.

According to its rarity, hydrocele of canal of Nuck is often misdiagnosed for common groin masses. This review summarizes and simplifies embryology, the pathophysiology of the canal of Nuck abnormalities, imaging findings, and treatment options with emphasis on the hydrocele. 

Canal of Nuck Abnormalities in Pediatric Female Patients

A groin lump is not an uncommon condition in girls and female infants, and US plays a fundamental role in its exploration. The main pathologic conditions are related to the failure of obliteration of the canal of Nuck. Radiologists should gain a full understanding of the embryology and US anatomy of the inguinal canal before assessing this entity for the first time. An optimal age-adjusted US technique-including examinations at rest and during straining-is essential to help assess the canal of Nuck, diagnose a hernia, and analyze its content. The radiologist must be aware of the various types of hernial content depending on the patient's age, including intestinal, omental, ovarian, or tubouterine hernia, and the US features of each. Incarcerated hernias are common in girls and mostly contain an ovary. In such cases, it is crucial to screen for US signs suggestive of ovarian ischemic damage, thereby calling for urgent surgery. US can also depict a cyst or hydrocele of the canal of Nuck and its complications. Moreover, other rare pathologic conditions involving the inguinal area may be depicted at US, which helps guide appropriate treatment. US is the ideal modality for evaluating an inguinal lump in girls and female infants. Online supplemental material is available for this article. ^©RSNA, 2022.

Ultrasound imaging for inguinal hernia: a pictorial review

Inguinal hernia is the most prevalent type of abdominal wall hernia. Indirect inguinal hernia is twice as common as direct inguinal hernia. Computed tomography and magnetic resonance imaging can be used to evaluate inguinal hernia, but these modalities are greatly limited by their cost and availability. Ultrasonography has emerged as the most convenient imaging tool for diagnosing inguinal hernia due to its advantages, such as portability and absence of radiation. The present pictorial review presents an overview on the use of ultrasonography in the evaluation of inguinal hernia with a particular emphasis on the regional anatomy, relevant scanning tips, identification of subtypes, postoperative follow-up, and diagnosis of pathologies mimicking inguinal hernia.

Diagnosis and treatment of cryptorchid testicular torsion in children: A 12-year retrospective study

PURPOSE

To investigate the clinical characteristics, treatment, and prognosis of cryptorchid testicular torsion in children.

METHODS

The clinical data of 25 children who received treatment for cryptorchid testicular torsion between January 2010 and December 2021 were retrospectively reviewed. The median age of the patients was 64.5 months (range: 2 months to 15 years). All patients had unilateral torsion, and the duration of symptoms ranged from 3 to 192 h.

RESULTS

Among the 25 patients, five underwent orchidopexy, while the remaining 20 underwent orchiectomy. After 6 months to 8 years of follow up, the 20 patients who had undergone orchiectomy had a well-developed testis on the healthy side. Four of the five patients who had undergone orchidopexy of the affected testis had well-developed testes bilaterally, while one experienced testicular atrophy.

CONCLUSION

Cryptorchid testicular torsion is a rare urological emergency that displays a delayed presentation and is often misdiagnosed. Clinicians need to carefully review the patient's medical history and ultrasound findings and perform a thorough physical examination to make a correct diagnosis. Active testicular exploration is required for patients suspected to have cryptorchid testicular torsion, and the decision to perform orchidopexy or orchiectomy depends on the intraoperative situation.

A rare case of left Nuck’s canal cystic endometriosis: Computed Tomography findings

Introduction:

Endometriosis is a common and chronic gynaecological condition but the implant in the canal of Nuck constitutes a very unusual state with an estimated prevalence of 0.3%–0.6% of all endometriosis cases. The canal of Nuck is an abnormal patent pouch of parietal peritoneum extending anteriorly from the round ligament of the uterus into the labia majora, thus represents a communication between the peritoneal cavity and the female inguinal canal. This condition may permit the seeding of endometriotic tissue in the inguinal soft tissues, becoming a possible cause of inguinal swelling or pain.

Case description:

A 43-years-old woman presented with painful swelling in her left groin. Ultrasound and a subsequent pelvic computed tomography showed a cystic lesion as for a Nuck’s canal encysted hydrocele. The patient underwent an anterior open surgery and the histologic examination revealed an endometrium-like tissue in the cystic wall.

Conclusion:

In women presenting with painful swelling of the groin, despite its rarity, endometriosis of the Nuck’s canal must be differentiated from other more common pathologies like hernias, varicoceles, neoplasms, and lymphadenopathies. Imaging can aid in differential diagnosis, but the final diagnosis is entrusted to histology, which enable to exclude an underlying malignancy.

How embryology knowledge can help radiologists in the differential diagnosis of canal of Nuck pathologies

The Canal of Nuck (CN) is an anatomical structure which is often forgotten. It is the female equivalent of the male processus vaginalis and corresponds to a protrusion of parietal peritoneum that extends from the inguinal canal to labia majora. Radiologists rarely encounter patients with pathology of CN, especially in adult population. It is well known that CN diseases can occur in paediatric patient (especially younger than 5 years of age) and they are associated to high morbidity (for example ovarian hernia with high risk of incarceration and torsion). The aim of our work is to review embryology, anatomy and pathologies of the CN thanks to a multi modal approach-ultrasound (US), Computed Tomography (CT) and Magnetic Resonance imaging (MRI)-to make radiologists more aware of such conditions and guarantee a prompt and correct diagnosis not only in paediatric patients but also in the adult population.

Spermatic Cord Lipoma-A Review of the Literature

Introduction: A spermatic cord lipoma is found in 20–70% of all inguinal hernia repairs. The clinical picture of an inguinal hernia with bulging and pain but without an actual indirect hernia sac may become manifest in up to 8% of these cases. Missed spermatic cord lipoma can result in recurrence or pseudo-recurrence. This review presents the relevant literature on this topic.

Materials and Methods: A systematic search of the available literature was performed in February 2020 using Medline, PubMed, Google Scholar, Scopus, Embase, Springer Link, and the Cochrane Library, as well as a search of relevant journals and reference lists. Forty-two publications were identified as relevant for this topic.

Results: Spermatic cord lipoma seems to originate from preperitoneal fatty tissue within the internal spermatic fascia in topographical proximity to the arteries, veins, lymphatics, nerves, and deferent duct within the spermatic cord. Reliable diagnosis cannot be made clinically, but rather with ultrasound, CT, or MRI. In the absence of a real hernia sac, a spermatic cord lipoma is classified as a lateral inguinal hernia with a defect size <1.5 cm according to the European Hernia Society (EHS LI). Missed or inadequately treated spermatic cord lipoma results in recurrence or pseudo-recurrence. Since spermatic cord lipoma obtains its vascular supply from the preperitoneal space, it can be reduced or resected.

Conclusion: Spermatic cord lipoma is a common finding in inguinal hernia repairs and must be properly diagnosed and treated with care respecting the anatomy of the spermatic cord.

Pediatric groin lesions: imaging findings

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.

Persistence of the processus vaginalis and its related disorders

The processus vaginalis is a blind-ended evagination of the abdominal wall that develops during fetal life and typically undergoes obliteration in early life. Persistence of the processus vaginalis is associated with a number of pathologies including congenital indirect inguinal hernias, communicating hydroceles, funicular and encysted hydroceles, canal of Nuck cysts, and acquired undescended testis. Whilst all are detectable sonographically, there is little educational material relevant to the field of ultrasound with much of the literature directed at surgical and primary care physicians. Furthermore, within the literature there is a lack of consensus on several areas including the anatomy and embryology of the processus vaginalis and the mechanisms behind its obliteration. As such the objective of this paper is to distil the information regarding the persistent processus vaginalis as it is relevant to ultrasound and in doing so address the literature gap for sonographers and sonologists. The anatomy and embryology of the persistent processus vaginalis will be discussed including causative mechanisms for anomalies with their sonographic appearance highlighted.

Inguinal herniation of left ovary, fallopian tube and rudimentary left horn of bicornuate uterus associated with type 2 Mayer-Rakitansky-Kuster-Hauser (MRKH) syndrome in a teenage girl: A case report and literature review

The incidence rate of ovarian herniation in the inguinal canal is 3 %. Nevertheless, the herniation of ovary with uterus is extremely scarce. Most of these cases are accompanied with congenital genitourinary malformations such as Mayer-Rakitansky-Kuster-Hauser (MRKH) syndrome and Mullerian duct malformations. Herein, a 13-year-old girl presented with type2 MRKH syndrome together with left groin swelling and pain. Sonography reports ovarian herniation into left inguinal canal and magnetic resonance imaging (MRI) confirmed the diagnosis and demonstrated the left ovary, fallopian tube and rudimentary left horn of bicornuate uterus in the left inguinal canal accompanied with ectopic renal of left lower quadrant. Finally, the patient was designed for surgical inguinal exploration and left normal ovary, fallopian tube and rudimentary left horn of bicornuate uterus were replaced in the pelvis.

Canal of Nuck hernias

The canal of Nuck, caused by the failed closure of the processus vaginalis in the female, is the continued outpouching of parietal peritoneum through the inguinal canal to the labia majora. Disorders of the canal of Nuck include hernia and hydrocele. Some canal of Nuck hernias, especially of the ovary, may result in emergent complications such as incarceration, strangulation, and ovarian torsion. Knowledge of canal of Nuck disorders and prompt diagnosis are important to avoid serious complications. Imaging, especially ultrasound, is essential for timely diagnosis, leading to appropriate management and better patient care.

Differential diagnosis of fat-containing lesions in the inguinal canal using ultrasound

Abdominal hernias are usually located in the inguinal canals. Differential diagnosis of hernias should consider other pathologies, which typically occur at this site. The aim of this review paper is to present fat-containing lesions located in the inguinal canal based on both our own experience and literature. The first part of the paper describes the embryogenesis and differences in the structure and content of male and female inguinal canal. The canal is clearly wider in men, which results from the presence of the spermatic cord and its components. The female canal contains only the narrow round ligament of the uterus. The second part of the paper discusses the incorrect use of the term “lipoma” for retroperitoneal fat, which penetrated into the lumen of the patent processus vaginalis – the authors using this term acknowledge its incorrectness. These lesions often coexist with oblique inguinal hernia and should be excised during a surgery as they may cause inguinal pain. As for other fat-containing inguinal pathologies, we discussed lipomatosis of the spermatic cord, liposarcoma and the greater omentum. Differential diagnosis of these lesions considers their echogenicity, echostructure and vascularity. Furthermore, attention was paid to the adipose tissue surrounding the lower epigastric vessels, which may be incorrectly localized in the inguinal canal. Finally, the importance of proper diagnostic methodology and knowledge of the inguinal anatomy for the correct ultrasonographic diagnosis was emphasized.

Effect of inguinal hernia on the thickness and blood flow of spermatic cord in boys

Objective

To evaluate the effect of inguinal hernia (IH) on the spermatic cord using spermatic cord ultrasonography (SCU).

Methods

From January 2016 to January 2017, boys with IH who received SCU at the start of open herniorrhaphy (OH) were enrolled in this study. The age and weight at SCU, width of the spermatic cord (SC-W), peak systolic velocity (PSV) in the spermatic artery (SA-PSV) and velocity in the pampiniform plexus (PP-V), and the interval between the initial and the second OH in boys with metachronous inguinal hernia (MIH) were recorded, and the relationship among them was studied. Boys with unilateral IH comprised the IH group, and boys with MIH comprised the MIH group. Boys with polydactylism served as the control. One-way analysis of variance tested the differences among groups. Spearman's r tested the relationship between SC-W in the MIH group and the interval.

Results

A total of 80 boys were enrolled in this study (IH group 29, MIH group 26, and control group 25). SA-PSV and PP-V in the hernia side were faster and slower than the control, respectively. There was no significant difference in PP-V and SA-PSV of the treated side in the MIH group and in the control group. After herniorrhaphy, SC-W was tapered down to normal size. SC-W, SA-PSV, and PP-V in the treated side were all highly correlated to the interval in a curvilinear manner.

Conclusion

PSV was positively correlated with SC-W in boys with IH, and PP-V was negatively correlated; herniorrhaphy could reverse the impairment.

The Sonographic Spectrum of Pelvic Endometriosis: Pearls, Pitfalls, and Mimics

Endometriosis is a common disease of reproductive-age women that is often first encountered with ultrasound. Therefore, familiarity with the variety of manifestations of endometriosis is important for appropriate diagnosis and management. The aim of this article is to review the spectrum of appearance of pelvic endometriosis and to discuss potential mimics on ultrasound. Given that magnetic resonance imaging is an important problem-solving tool in female pelvic imaging, magnetic resonance imaging correlation is also provided.

Ultrasound of Soft Tissue Masses and Fluid Collections

Soft tissue masses and fluid collections are frequently encountered in sonographic practice, either as principal indication for diagnostic examination or as an incidental finding during an examination performed for other indications. Sonography is a good first-line imaging modality for evaluation of superficial masses and fluid collections, but requires meticulous attention to technique to avoid diagnostic pitfalls. Although many superficial masses are diagnosed with ultrasound, there are several potential diagnostic challenges, including differentiating hematomas from sarcomas. This article provides an image-rich review of the sonographic features of common soft tissue masses, with emphasis on practical tips to accurately recognize important pathology.

Imaging of inguinal-related groin pain in athletes

Inguinal canal-related groin pain is common in athletes and may involve numerous structures such as the conjoint tendon and the transversalis fascia. Ultrasound is the only dynamic tool that shows the passage of preperitoneal fat at the level of the Hesselbach triangle and allows excluding true inguinal hernias. Fascia transversalis bulging and inguinal ring dilatation may also be described. MRI assesses injuries of rectus abdominis and adductor longus enthesis and osteitis symphysis but its accuracy for the diagnosis of inguinal-related groin pain remains debated.

The utility of scrotal ultrasonography in the emergent setting: beyond epididymitis versus torsion

Scrotal pain is a common acute presentation for medical care. Testicular torsion and epididymo-orchitis are two diagnoses for which early detection is critical and their sonographic imaging features have been thoroughly described in the radiologic literature. Other important conditions for which radiologists must be aware have received less attention. This article will highlight key traumatic and non-traumatic causes of acute scrotal pain other than testicular torsion and epididymo-orchitis that may present in the emergency department setting.

Anatomy and pathology of the canal of Nuck

The canal of Nuck is the female equivalent of the processus vaginalis in the male but is less well known than its male counterpart. It is a rare entity not commonly encountered by radiologists, particularly in the adult population. Knowledge of the embryology and anatomy of the canal of Nuck is essential for identification of the various pathologic conditions that may occur in this location. Moreover, radiologists should be familiar with this entity to compose an appropriate and thorough differential diagnosis of a labial mass/swelling. In this review, we discuss both the anatomy and the more common pathology that can be encountered within it.