Testicular stiffness in varicocele: evaluation with shear wave elastography

The role of testicular stiffness derived from shear wave elastography in the assessment of spermatogenesis in men with varicocele

Background

Varicocele is a major correctable cause of male infertility. Shear wave elastography (SWE) represents a valuable approach for assessing spermatogenesis in infertile men; however, its application in infertile men with varicocele remains unreported in the literature to date. The objective of this study was to investigate the correlation between testicular stiffness and spermatogenesis in individuals with varicocele.

Methods

A total of 568 participants with left-side varicocele and 475 age-matched healthy controls were enrolled. The mean, left, and right testicular volumes (Volume-mean, Volume-L, and Volume-R), the mean elastic modulus of bilateral, left, and right testes (Emean, Emean-L, and Emean-R); the maximum elastic modulus of bilateral, left, and right testes (Emax, Emax-L, and Emax-R); the minimum elastic modulus of bilateral, left, and right testes (Emin, Emin-L, and Emin-R) were calculated.

Results

Receiver operating characteristic (ROC) curves for Volume-R and Emax were constructed to identify participants with sperm concentrations below 5 million/mL. The areas under the ROC curves (AUCs) were 0.801 and 0.775, respectively. Combining these 2 markers improved their diagnostic value with an AUC of 0.820 and sensitivity and specificity of 94.6% and 59.8% [95% confidence interval (CI): 0.772-0.867, P<0.01], respectively. A total of 69 participants underwent microsurgical varicocelectomy (including 42 cases with improved semen results and 27 without). The ROC curves of Emax-L and Volume-L were constructed for the differential diagnosis between the improved and unimproved groups; the AUCs were 0.723 and 0.855, respectively. Combining these 2 markers improved their diagnostic value with an AUC of 0.867 (95% CI: 0.772-0.961, P<0.01) and sensitivity and specificity of 81.5% and 81.0%, respectively.

Conclusions

Our findings suggest that SWE can be used for varicocele to assess testicular parenchyma damage and Volume-L combined with Emax-L offers a more accurate method for predicting semen parameter improvement after microscopic subinguinal varicocelectomy in men with varicocele.

Nomograms for Predicting Postoperative Sperm Improvements in Varicocele Patients

Background

Varicocele is a condition that seriously affects male fertility. It can cause pathological changes in the testicles and affect their spermatogenesis and endocrine function.

Objective

To formulate nomograms to predict sperm improvements after microscopic varicocelectomy.

Design setting and participants

A retrospective analysis was conducted on varicocele patients who met the research criteria and were enrolled from March 2020 to June 2022. They were divided into a development and a validation cohort in a 2:1 ratio.

Outcome measurements and statistical analysis

Data on preoperative testicular atrophy index, bilateral testicular elastic modulus, testosterone, pre- and postoperative 6-mo total sperm count, sperm concentration, and sperm vitality were collected. An increase of ≥25% is considered a postoperative improvement in sperm parameters. Predictive nomograms were constructed through forward stepwise LR regression, based on independent risk factors filtered by univariate and multivariate logistic regression analyses. Receiver operating characteristic curve analysis, calibration curve, and decision curve analysis were employed to assess the performance of the models.

Results and limitations

The areas under the curve of nomograms for predicting the postoperative improvement of total sperm count, sperm concentration, and sperm vitality were 0.915, 0.986, and 0.924 respectively. The nomogram models demonstrated good predictive performance. The single-center sample size was a limitation of this study.

Conclusions

In this study, we developed effective predictive nomogram models for anticipating postoperative improvements in sperm quality among varicocele patients. These models offer a significant value in providing accurate predictions of surgical outcomes. However, it is crucial to conduct further external validation.

Patient summary

In this study, a predictive nomogram model was constructed for assessing the improvement of sperm quality in varicocele patients after surgery. The model offered satisfactory results.

Testicular Evaluation Using Shear Wave Elastography (SWE) in Patients with Varicocele

PURPOSE

To assess the possible influence of the presence of varicocele on the quantification of testicular stiffness.

METHODS

Ultrasound with shear wave elastography (SWE) was performed on 48 consecutive patients (96 testicles) referred following urology consultation for different reasons. A total of 94 testes were studied and distributed in three groups: testes with varicocele (group A, n = 19), contralateral normal testes (group B; n = 13) and control group (group C, n = 62). Age, testicular volume and testicular parenchymal tissue stiffness values of the three groups were compared using the Kruskal-Wallis test.

RESULTS

The mean age of the patients was 42.1 ± 11.1 years. The main reason for consultation was infertility (64.6%). The mean SWE value was 4 ± 0.4 kPa (kilopascal) in group A, 4 ± 0.5 kPa in group B and 4.2 ± 0.7 kPa in group C or control. The testicular volume was 15.8 ± 3.8 mL in group A, 16 ± 4.3 mL in group B and 16.4 ± 5.9 mL in group C. No statistically significant differences were found between the three groups in terms of age, testicular volume and tissue stiffness values.

CONCLUSION

Tissue stiffness values were higher in our control group (healthy testicles) than in patients with varicocele.

The Relationship of Testicular Sonoelastography with Gonadotropin Hormone Levels and Sperm Parameters

Background: Elastography is a non-invasive medical imaging technique that helps determine the stiffness of organs and other structures in our body. In this study, we investigated the effectiveness of elastography in the diagnosis of infertility. Aim

In this study, we aimed to examine the relationship between testicular elastography and hormonal parameters and sperm parameters.

Patients and Methods

The study included 136 patients, 272 testicles were examined, and the mean age of the study participants was 30.1 years. Testicular tissue stiffness was measured by scrotal ultrasonographic shear wave elastography. Gonadotropin and testosterone hormones were measured from blood samples. Spermiogram parameters were studied manually.

Results

The control group included 66 patients, and the varicocele group consisted of 70 patients. Testicular stiffness degrees of the control group were measured as 4.29 kPa for the right testis and 4.23 kPa for the left testis. The varicocele group was divided into grades 1, 2, and 3 according to physical examination. In group 1 (grade 1), the right testis was 4.07 ± 1.24 kPa and the left testis was 3.77 ± 0.98 kPa. In group 2 (grade 2), the right testis was 4.31 ± 1.40 kPa and the left testis was 3.98 ± 0.93 kPa. In group 3 (grade 3), the right testis was 4.73 ± 1.50 kPa and the left testis was 3.99 ± 1.68 kPa. Hormone and sperm parameters were not statistically significant when comparing the control and varicocele groups. There was no statistical significance between the testicular tissue stiffness degrees of the control and varicocele groups. Hormone and spermiogram findings were also similar in groups.

Conclusion

It is known that varicocele leads to histological tissue changes in the testes. These changes result in tissue softness and loss while affecting sperm parameters and testosterone levels in a negative way. Before varicocele surgery, there is a need for new imaging methods with more sensitivity that can detect tissue changes in the testes.

Shear wave elastography for the evaluation of testicular salvage after testicular torsion

The aim of this study was to assess the utility of shear wave elastography in the follow-up of testicular detorsion, evaluate long-term outcomes, and explore its relationship with parameters such as tissue stiffness values, pain duration, and torsion type. Elastography examinations were independently performed by two radiologists to evaluate patients who presented to our hospital for follow-up after being diagnosed with testicular torsion and age-matched controls. Inter-observer variability of the mean testicular tissue elasticity was excellent (Intraclass correlation coefficient: 0.939, p < 0.001). Median time between testicular detorsion and follow-up ultrasound examination was 18 months (range, 11-36 months). Torsion side, torsion degree, and pain duration were recorded, and testicular volumes were calculated. The study population comprised 24 patients (48 testes) with a mean age of 21.1 ± 7.8 years. The mean testicular volume was measured as 12.3 ± 5.4 ml for the testicular salvage group, 13.9 ± 3.8 ml for the contralateral testes, and 13.7 ± 2.7 ml for the control group (p = 0.553). The mean testicular speed mode values were higher in the testicular salvage group (1.34 ± 1.21 m/s) compared with the contralateral testes group (1.00 ± 0.08 m/s), and the control group (1.01 ± 0.06 m/s), however there was no statistically significant difference between the three groups (p = 0.861). While testicular atrophy was detected in three patients, an intraparenchymal wedge-shaped focal hypoechoic area developed after torsion in a further three patients. The elastography examination for focal hypoechoic areas revealed an increase or decrease in tissue stiffness compared to the normal parenchyma. The tissue stiffness values of the testicular salvage group were higher in complete torsion compared to incomplete torsion. The elastography method contributes to other imaging methods in distinguishing focal lesion areas that can be seen after testicular torsion from malignant conditions. Elastography presents as a feasible and practical complementary modality for the follow-up of testicular salvage after torsion.

Elastography in the Urological Practice: Urinary and Male Genital Tract, Prostate Excluded—Review

The aim of this article is to review the utility of elastography in the day-to-day clinical practice of the urologist. An electronic database search was performed on PubMed and Cochrane Library with a date range between January 2000 and December 2021. The search yielded 94 articles that passed the inclusion and exclusion criteria. The articles were reviewed and discussed by organ, pathology and according to the physical principle underlying the elastographic method. Elastography was used in the study of normal organs, tumoral masses, chronic upper and lower urinary tract obstructive diseases, dysfunctions of the lower urinary tract and the male reproductive system, and as a pre- and post-treatment monitoring tool. Elastography has numerous applications in urology, but due to a lack of standardization in the methodology and equipment, further studies are required.

Elastographic evaluation of the effect of sickle cell anemia on testicles: a prospective study

To quantitatively determine testicular tissue stiffness values using shear wave elastography (SWE) in males that have sickle cell anemia (SCA) and to evaluate the relationship between elastography results and semen analysis parameters and hormone levels. Fifty patients diagnosed with SCA and followed up in the hematology outpatient clinic were evaluated in the urology outpatient clinic as the study group. In addition, there were 88 patients without any SCA-related complaints in the control group. We compared these groups with respect to their values, spermiogram parameters, testicular volume, and SWE values. Among patients in the SCA group, 28% had impaired sperm parameters. When testicular elastography was assessed, the testicular volumes were materially lower in the SCA group in comparison to the control group [right testicular volume: 14.76 (12.77-18.12) and 19.68 (15.12-24.18), respectively, p < 0.001; left testicular volume: 14.11 (11.06-17.32) and 16.59 (13.38-20.13), respectively, p = 0.015]. Additionally, the left testis central stiffness and the left testis inferior stiffness were significantly higher in the SCA group (p < 0.001 and p = 0.014, respectively). The age and hydroxyurea use had a worse effect on sperm parameters in patients with SCA (odds ratio: -0.161 and -1.914, standard deviation: 0.071 and 0.921, and p = 0.024 and p = 0.038, respectively). We consider that the technique utilized in this study for SWE values is fast and can be adopted as a reliable diagnostic tool and follow-up practice in routine clinical practice to evaluate the acuteness of damage to the testicles in patients having SCA.

Shear Wave Elastography for Assessment of Testicular Stiffness in Patients with Varicocele: A Prospective Comparative Study

Background

The purpose of this study was to use ultrasonography and shear wave elastography (SWE) to assess stiffness and volume of testes in adult patients with varicocele, to compare the results with those of normal contralateral testes of the same patients and healthy testes of control subjects.

Methods

In this IRB-approved prospective comparative study, 58 patients with varicocele (116 testes) and 58 control patients (116 testes) were enrolled. A total of 66 testes with varicocele were added to group A, their 50 healthful contralateral testes were added to Group B, and 116 healthy control testes were added to Group C. Analysis of variance (one way ANOVA) test was used to compare groups and Student's t-test was used for their binary comparisons. The correlation between the testicular stiffness and volume was studied using Pearson's correlation test.

Results

There was not a significant difference in the mean SWE values between three groups and also, between two-group comparisons (P < 0.05). In the mean testicular volumes, a significant difference was observed between Groups A and C (P = 0.028). Conversely, there was not a significant difference between Groups A and B (P = 0.907) or Groups B and C (P = 0.094). A meaningful correlation between testicular stiffness and volume was not detected for each group.

Conclusion

A significant correlation was not determined between SWE values and varicocele, and also between SWE values and testicular volume. We advise that more studies with larger populations of patients are required to verify the effectiveness of SWE in predicting testicular parenchymal damage.

Application of real-time shear wave elastography in the assessment of male infertility

BACKGROUND

Shear wave elastography (SWE) is recognized as a suitable imaging modality for identifying and characterizing testicular diseases. Recent exploration of SWE has focused on its feasibility in evaluating histopathological changes in the testicular parenchyma, with researchers increasingly focusing on the relationship between testicular stiffness and male fertility. In this study, we aimed to investigate the diagnostic value of SWE for distinguishing the relationship between spermatogenic defects and testicular stiffness in males of reproductive age.

METHODS

This was a single center, cross-sectional study conducted from July 2017 to December 2019. A total of 1,116 consecutive patients who were voluntarily participating in in-vitro fertilization (IVF)-assisted conception at our hospital were recruited to the study. The cohort included 497 normozoospermia patients (Group I), 335 with normozoospermia and decreased motility and agglutination (Group II), 138 with oligozoospermia (Group III), 105 with non-obstructive azoospermia (Group-NOA), and 41 with obstructive azoospermia (Group-OA). We conducted SWE of each participant's testes and the testicular elastic modulus was calculated. The differences of testicular elastic modulus were compared among groups. Linear regression analysis was conducted to determine the correlation between sperm concentration and either testicular volume or testicular elastic modulus. Receiver operating characteristic (ROC) curves were drawn to evaluate the diagnostic efficiency of the maximum elastic modulus (Emax), mean elastic modulus (Emean), and maximum minus the minimum elastic modulus {E[max-min]}.

RESULTS

The Emax, Emean, and E[max-min] increased gradually in groups I, II, III, and Group-NOA, with statistical differences between groups (P<0.01). Testicular volume was shown to be positively correlated with sperm concentration (r=0.476; P<0.01), while the Emax, Emean, and E[max-min] were negatively correlated with sperm concentration (r=-0.511, -0.357, and -0.524, respectively; P<0.01). The ROC curves were established based on the Emax, Emean, and E[max-min] and were used to distinguish Group-OA from Group-NOA. The areas under the ROC curve (AUCs) were 0.910, 0.863, and 0.900, respectively. We also used ROC curves to distinguish the severe oligozoospermia subgroup and Group-NOA from other groups, for which the AUCs were 0.877, 0.791, and 0.878, respectively.

CONCLUSIONS

The SWE is an effective supplement to routine ultrasound examination and can be used to diagnose and differentiate spermatogenetic dysfunction.

Utility of shear wave ultrasound elastography in evaluation of testicular stiffness in patients with varicocele

Background

Testicular varicocele is the most frequent cause of male infertility. The study aimed at evaluation of testicular stiffness in patients with varicocele measured by shear wave ultrasound elastography (SWE) in correlation to patient semen analysis (total sperm count) and varicocele grade. This case–control study involved 50 patients (40 patients with bilateral testicular varicocele and 10 patients with unilateral Lt. testicular varicocele of different grades) and 25 healthy controls. All participants underwent physical examination, semen analysis (patient group subdivided in two groups: group A; normospermic and group B; oligospermic), scrotal grey scale and Doppler ultrasound, and shear wave ultrasound elastography with measurement of mean testicular stiffness. Evaluation of testicular stiffness and correlation to varicocele grade and semen analysis (total sperm count) were done.

Results

The mean testicular stiffness value measured by SWE in patients with testicular varicocele was greater than that of healthy controls (7.46 ± 1.64 kPa vs. 3.84 ± 0.62 kPa, P < 0.001). The mean testicular stiffness value in group B exceeded that of group A (8.57 ± 1.53 kPa vs. 6.34 ± 1.76 kPa, P = 0.001). A moderate positive correlation was found between mean testicular stiffness value and the varicocele grade (P = 0.01) which was more evident in group B than in group A (P = 0.01).

Conclusions

Testicular ultrasound SWE is a quantitative noninvasive imaging method which helps in the assessment of testicular parenchymal changes due to varicocele. Higher testicular stiffness values were found in testes of patients with varicocele, more in oligospermic patients than the testes of healthy controls. Testicular stiffness is moderately correlated to varicocele grade.

Incidental Findings and How to Manage Them: Testis- A WFUMB Position Paper

Testicular incidentalomas are non-palpable, asymptomatic lesions, most frequently detected on ultrasound examinations. Each incidentaloma should undergo a standardized diagnostic workup to exclude malignancy and recognize other potentially significant non-malignant conditions that may first present with an incidental finding on scrotal ultrasound. This position statement of the World Federation of Ultrasound in Medicine and Biology (WFUMB) summarizes the available evidence on management of testicular incidentalomas and describes efficient management strategies with particular reference to the role of ultrasound techniques.

The usefulness of elastography in the evaluation and management of adult men with varicocele: A systematic review

Objective

To review the role of elastography in the evaluation and decision-making of adult, infertile men with varicocele.

Methods

A systematic search using the terms (Elastography) AND (Varicocele), (Stiffness) AND (Varicocele), (Elastography) AND (Male infertility) was performed in Pubmed/Medline. Studies reporting a) elastographic characteristics in varicocele-bearing comparing to normal testicles, and b) the correlation of elastography with varicocele grading, parameters of spermatogenesis, and outcomes of varicocele treatment were selected. Exclusion criteria were animal, adolescents, abstracts, and non-English language studies.

Results

In total, 453 articles were identified; 11 eligible studies were selected. Several modalities were used (shear wave elastography, strain elastography, quasistatic ultrasound elastography, acoustic radiation force impulse). Varicocele-bearing testicles have significantly different stiffness and elasticity in comparison to normal and non-varicocele testicles. Although not in full agreement, elastography readings are correlated with semen parameters. Conflicting results were reported regarding grading as most of the studies failed to demonstrate a significant correlation. Shear wave elastography showed a significant correlation with the improvement in semen parameters after varicocelectomy, but the association with pregnancy rates is unknown. Finally, no studies were identified comparing elastography with other modalities.

Conclusions

Elastography can detect changes in the architecture of varicocele-bearing testicles. Although the role of the modality in grading is uncertain, elastography showed a meaningful correlation with spermatogenesis parameters. Importantly, elastography readings could predict the improvement in semen parameters after varicocelectomy which is useful in terms of decision-making in infertile men with varicocele.

Abbreviations

ARFI: acoustic radiation force impulse; CDUS: colour Doppler ultrasonography; DWI: diffusion-weighted imaging; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; SWE: shear wave elastography; VC: varicocele.

Shear-wave elastography for the assessment of testicular involvement of hematologic malignancies in children and young adults: a feasibility study

Purpose

This study aimed to assess the feasibility of shear-wave elastography (SWE) for assessing the testicular involvement of hematologic malignancies in children and young adults.

Methods

Eight patients (mean age, 11.0 years; range, 0.8 to 20 years) with biopsy-confirmed testicular involvement of hematologic malignancy between January 2018 and December 2020 were retrospectively evaluated. Multiparametric ultrasound examinations, including grayscale, color Doppler ultrasonography (CDUS), and SWE, were performed. Stiffness was measured in the involved testicular area and contralateral normal parenchyma. If there was bilateral testicular involvement, the stiffness of the involved area and the adjacent normal echoic parenchyma was measured on one testis. The Mann-Whitney U test was used to compare stiffness values.

Results

On grayscale, the testicular lesions were noted as a solitary mass in one patient, multiple lesions in four patients, and diffuse involvement in three patients. On CDUS and SWE, all patients demonstrated increased vascularity, and the stiffness of the involved area was higher than the values of normal parenchyma (the involved area vs. normal parenchyma, 11.6 kPa [3.9-20.2 kPa] vs. 2.9 kPa [1.1-3.7 kPa], P=0.003). The ratio of stiffness between the involved area and normal parenchyma was 3.4, ranging from 1.9 to 5.1. One patient showed decreased stiffness on follow-up SWE after treatment (affected testis vs. normal testis: initial, 13.8 vs. 3.2 kPa; 1 year later, 2.2 vs. 2.4 kPa).

Conclusion

Increased testicular stiffness on SWE in children and young adults with hematologic malignancies suggests the possibility of testicular involvement.

Role of multiparametric ultrasound in testicular focal lesions and diffuse pathology evaluation, with particular regard to elastography: Review of literature

BACKGROUND

Ultrasound is the main requested technique for the assessment of traumatic, vascular, neoplastic, and inflammatory testicular pathology. Moreover, the role of ultrasound has broadened over the years along with the introduction of new techniques, such as contrast enhanced ultrasound and ultrasound elastography.

OBJECTIVE

An updated representation of the pre-existing Literature evidence for multiparametric ultrasound imaging with particular regard to elastography, in the evaluation of focal and diffuse testicular pathologies, has been presented.

METHODS

The search was performed in PubMed, Cochrane, EMBASE, Web of Science and Scopus databases from the earliest available article (1977) until January 2021. Based on the evidence of the Literature, the current role of US imaging for focal and diffuse testicular pathologies has been reported and illustrated, with emphasis on examination technique, classification, and pitfalls.

RESULTS

Multiparametric Ultrasound has a recognized role for testicle focal and diffuse disease. Elastography is nowadays recognized as an essential part of the multiparametric ultrasound examination. However, in the setting of testicular pathology this method showed some promising results in the setting of varicocoele and for focal lesions characterization. In the remaining field its role is still under debate.

DISCUSSION

B-mode ultrasound and color Doppler ultrasound have been for a long time the diagnostic gold standard for testicular pathologies. The introduction of both contrast enhanced ultrasound and elastography in the last two decades has brought to the emergence of the multiparametric ultrasound concept. These methods are currently able to increase diagnostic confidence especially for testicular lesions characterization, with different relevance depending on the pathology under consideration.

CONCLUSION

Multiparametric ultrasound testis assessment, with specific regard to elastography is nowadays recommended for focal and diffuse disease evaluation. Further and larger studies are however needed to validate these results and to understand if the role of elastography in testicular pathology may be broadened.