Contrast media for hysterosalpingography: systematic search and review providing new guidelines by the Contrast Media Safety Committee of the European Society of Urogenital Radiology

OBJECTIVES

Hysterosalpingography (HSG) is widely used for evaluating the fallopian tubes; however, controversies regarding the use of water- or oil-based iodine-based contrast media (CM) remain. The aim of this work was (1) to discuss reported pregnancy rates related to the CM type used, (2) to validate the used CM in published literature, (3) to discuss possible complications and side effects of CM in HSG, and (4) to develop guidelines on the use of oil-based CM in HSG.

METHODS

A systematic literature search was conducted for original RCT studies or review/meta-analyses on using water-based and oil-based CM in HSG with fertility outcomes and complications. Nine randomized controlled trials (RCTs) and 10 reviews/meta-analyses were analyzed. Grading of the literature was performed based on the Oxford Centre for Evidence-Based Medicine (OCEBM) 2011 classification.

RESULTS

An approximately 10% higher pregnancy rate is reported for oil-based CM. Side effects are rare, but oil-based CM have potentially more side effects on the maternal thyroid function and the peritoneum.

CONCLUSIONS

1. HSG with oil-based CM gives approximately 10% higher pregnancy rates. 2. External validity is limited, as in five of nine RCTs, the CM used is no longer on the market. 3. Oil-based CM have potentially more side effects on the maternal thyroid function and on the peritoneum. 4. Guideline: Maternal thyroid function should be tested before HSG with oil-based CM and monitored for 6 months after.

CLINICAL RELEVANCE STATEMENT

Oil-based CM is associated with an approximately 10% higher chance of pregnancy compared to water-based CM after HSG. Although side effects are rare, higher iodine concentration and slower clearance of oil-based CM may induce maternal thyroid function disturbance and peritoneal inflammation and granuloma formation.

KEY POINTS

• It is unknown which type of contrast medium, oil-based or water-based, is the optimal for HSG. • Oil-based contrast media give a 10% higher chance of pregnancy after HSG, compared to water-based contrast media. • From the safety perspective, oil-based CM can cause thyroid dysfunction and an intra-abdominal inflammatory response in the patient.

Tips and tricks for a correct interpretation of contrast-enhanced ultrasound

Although contrast-enhanced ultrasound (CEUS) is a widespread and easily manageable technique, image interpretation errors can occur due to the operator's inexperience and/or lack of knowledge of the frequent pitfalls, which may cause uncertain diagnosis and misdiagnosis. Indeed, knowledge of the basic physical and technical principles of ultrasound is needed both to understand sonographic image findings and to evaluate the potential and limits of the method. Like the B-mode ultrasound, the quality of the CEUS examination is also subject not only to the adequate manual skill of the operator but also to his/her deep knowledge of the technique which improves the quality of the image helping avoid misleading artifacts. In this review, the main parameters influencing a CEUS examination will be described by taking into account the most common errors and pitfalls and their possible solutions.

Waiting times between examinations with intravascularly administered contrast media: a review of contrast media pharmacokinetics and updated ESUR Contrast Media Safety Committee guidelines

The pharmacokinetics of contrast media (CM) will determine how long safe waiting intervals between successive CT or MRI examinations should be. The Contrast Media Safety Committee has reviewed the data on pharmacokinetics of contrast media to suggest safe waiting intervals between successive contrast-enhanced imaging studies in relation to the renal function of the patient. CLINICAL RELEVANCE STATEMENT: Consider a waiting time between elective contrast-enhanced CT and (coronary) angiography with successive iodine-based contrast media administrations in patients with normal renal function (eGFR > 60 mL/min/1.73 m2) of optimally 12 h (near complete clearance of the previously administered iodine-based contrast media) and minimally 4 h (if clinical indication requires rapid follow-up). KEY POINTS: • Pharmacokinetics of contrast media will guide safe waiting times between successive administrations. • Safe waiting times increase with increasing renal insufficiency. • Iodine-based contrast media influence MRI signal intensities and gadolinium-based contrast agents influence CT attenuation.

Analytical interference of intravascular contrast agents with clinical laboratory tests: a joint guideline by the ESUR Contrast Media Safety Committee and the Preanalytical Phase Working Group of the EFLM Science Committee

The Contrast Media Safety Committee of the European Society of Urogenital Radiology has, together with the Preanalytical Phase Working Group of the EFLM Science Committee, reviewed the literature and updated its recommendations to increase awareness and provide insight into these interferences.

Analytical interference of intravascular contrast agents with clinical laboratory tests: a joint guideline by the ESUR Contrast Media Safety Committee and the Preanalytical Phase Working Group of the EFLM Science Committee

The Contrast Media Safety Committee of the European Society of Urogenital Radiology has, together with the Preanalytical Phase Working Group of the EFLM Science Committee, reviewed the literature and updated its recommendations to increase awareness and provide insight into these interferences. CLINICAL RELEVANCE STATEMENT: Contrast Media may interfere with clinical laboratory tests. Awareness of potential interference may prevent unwanted misdiagnosis. KEY POINTS: • Contrast Media may interfere with clinical laboratory tests; therefore awareness of potential interference may prevent unwanted misdiagnosis. • Clinical Laboratory tests should be performed prior to radiological imaging with contrast media or alternatively, blood or urine collection should be delayed, depending on kidney function.

Multiparametric Ultrasound for Diagnosing Testicular Lesions: Everything You Need to Know in Daily Clinical Practice

BACKGROUND

Ultrasonography (US) represents the gold standard imaging method for the assessment of testicular lesions (TL). The gray-scale (GSUS) and color-Doppler (CDUS) ultrasound examination allow sonographers to investigate the size, margins, echotexture, and vascular features of TLs with the aim to differentiate benign from malignant lesions. Recently, the use of contrast-enhanced US (CEUS) and sonoelastography (SE) has led to further improvements in the differential diagnosis of TL. Although GSUS and CDUS are often sufficient to suggest the benign or malignant nature of the TL, CEUS can be decisive in the differential diagnosis of unclear findings, while SE can help to strengthen the diagnosis. The contemporary combination of GSUS, CDUS, CEUS, and SE has led to a new diagnostic paradigm named multiparametric US (mp-US), which is able to provide a more detailed characterization of TLs than single techniques alone. This narrative and pictorial review aimed to describe the mp-US appearance of several TLs.

METHODS

An extensive Medline search was performed to identify studies in the English language focusing on the mp-US evaluation of TLs.

RESULTS

A practical mp-US "identity card" and iconographic characterization of several benign and malignant TLs is provided herein.

CONCLUSIONS

The mp-US characterization of TL reported herein can be useful in daily clinical practice.

CEUS Bosniak Classification-Time for Differentiation and Change in Renal Cyst Surveillance

It is time for a change. CEUS is an established method that should be much more actively included in renal cyst monitoring strategies. This review compares the accuracies, strengths, and weaknesses of CEUS, CECT, and MRI in the classification of renal cysts. In order to avoid overstaging by CEUS, a further differentiation of classes IIF, III, and IV is required. A further development in the refinement of the CEUS-Bosniak classification aims to integrate CEUS more closely into the monitoring of renal cysts and to develop new and complex monitoring algorithms.

Utility of contrast enhanced ultrasound (CEUS) in penile trauma

Penile traumatic injuries are rare with potentially severe consequences, with clinical assessment challenging due to pain and swelling. Ultrasound is the primary imaging modality for assessing the penis. It has a high spatial resolution and rapid availability and is portable. Contrast enhanced ultrasound is an advanced ultrasound technique that adds real-time dynamic vascular imaging safely, increasing diagnostic precision and confidence, allowing for better therapeutic management of traumatic penile injuries. Contrast enhanced ultrasound helps to delineate the extent of a haematoma, distinguishing this from the herniated corpus cavernosum, detecting the point of rupture of the tunica albuginea, showing vascular abnormalities, localising a dislocated penis and determining penile viability. The integrity of the urethra may be assessed with intracavitary contrast enhanced ultrasound. Additionally, contrast enhanced ultrasound allows monitoring of the response to endovascular and surgical treatment. This review aims to detail the anatomy and pathogenesis of penile trauma, to give guidance on optimising the contrast enhanced ultrasound technique and to obtain diagnostic examinations. Illustration of the spectrum of aspects of penile trauma will be complemented with a literature review.Critical relevance statement Contrast enhanced ultrasound is a safe and efficient imaging modality that allows for highly accurate diagnoses, helping achieve more successful and conservative treatments of penile trauma complications.Key points• Ultrasound is an accurate and safe imaging test for penile trauma.• CEUS adds dynamic vascular imaging in real-time increasing diagnostic confidence.• CEUS can delineate penile haematomas, locate fractures and demonstrate vessel integrity.• CEUS potentially allows for more conservative treatment of penile trauma complications.

SIUMB recommendations on the use of ultrasound in neoplastic lesions of the gallbladder and extrahepatic biliary tract

Extrahepatic biliary tract and gallbladder neoplastic lesions are relatively rare and hence are often underrepresented in the general clinical recommendations for the routine use of ultrasound (US). Dictated by the necessity of updated summarized review of current literature to guide clinicians, this paper represents an updated position of the Italian Society of Ultrasound in Medicine and Biology (SIUMB) on the use of US and contrast-enhanced ultrasound (CEUS) in extrahepatic biliary tract and gallbladder neoplastic lesions such as extrahepatic cholangiocarcinoma, gallbladder adenocarcinoma, gallbladder adenomyomatosis, dense bile with polypoid-like appearance and gallbladder polyps.

Neoclitoral location may affect sexual function in transgender women: a preliminary pelvic MRI study

Assigned female at birth with anorgasmia possess a smaller clitoral glans and clitoral components farther from the vagina lumen than women with normal orgasmic function. There are no studies evaluating this correlation in operated transgender women. We evaluated whether differences in MRI measurements of neoclitoris volume and distance between the neoclitoris and the neovagina were correlated with differences in sexual function. We recruited for a prospective survey study 40 operated male to female patients (oMtF) who had undergone genital gender affirming surgery and postoperative pelvic MRI. Individual pelvic MRIs were reviewed by two blinded investigators, the three axes of the neoclitoris were measured and the volume was calculated using the ellipsoid formula. The distance between the neoclitoris and the neovagina was also measured. Sexual functioning was assessed using the Female Sexual Function Index (FSFI) and the operated Male to Female Sexual Function Index (oMtFSFI). Mean scores differences in FSFI, oMtFSFI were examined; associations with clitoral size, location, sexual functioning and demographical variables were investigated as well. The response rate was 55%, 11 MtFs operated with pubic neoclitoris technique (PNT) and 11 with neo-urethroclitoroplasty according to Petrović (NCP). The NCP group presented a neoclitoris mean volume of 1.04 (SD 0.39) cc vs 1.31 (SD 0.78) cc of the other group (p = 0.55). The mean distance between neoclitoris and neovagina was 4.20 (SD 0.57) cm in the PNT group and 2.55 (SD 0.45) in the NCP group (p < 0.001). Patients who had undergone NCP achieved a higher FSFI and oMtFSFI mean Total Score than those operated with the previous technique (FSFI 25.81 SD 3.02 vs 18.62 SD 9.92 p = 0.08; oMtFSFI 37.63 SD 8.28 vs 43.36 SD 13.02 p = 0.23). According to pelvic MRI measurements, this study suggests a correlation between neoclitoral location and oMtF sexual satisfaction.

Testicular torsion: an avascular testis at color Doppler ultrasound is not enough to prove the diagnosis

BACKGROUND

A Doppler ultrasound (US) of the scrotum is commonly used to improve the diagnostic confidence for testicular torsion in an emergency setting. However, the sensitivity of this investigation to identify torsion varies largely. This is due, in part, to a lack of guidelines on how-to perform the US and therefore training is necessary.

METHODS

The Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology (ESUR-SPIWG) and the Section of Urological Imaging of the European Association of Urology (ESUI) established a joint panel of experts to standardize Doppler US investigation of patients with testicular torsion. The panel reviewed the available literature, identified accumulated knowledge and limitations, and released recommendations on how-to perform Doppler US in patients with acute scrotal pain.

RESULTS

Diagnosis of testicular torsion is based on clinical evaluation and investigation of the cord, the testis, and the paratesticular structures. A preliminary clinical evaluation, including history and palpation, is necessary. Grey scale US, color Doppler US and spectral analysis must be performed by a sonologist with at least level 2 competence. Modern equipment with adequate grey-scale and Doppler capabilities are required.

CONCLUSIONS

Standardization of Doppler US in suspicious testicular torsion is presented, with the aim to obtain comparable results among different centres, prevent unnecessary operations, and improve patient management.

Role of Multiparametric-MRI in Bladder Cancer

Purpose of Review

This narrative review article aims to show the actual role of imaging, in particular MRI, and the role of VI-RADS Score, in recognition and follow-up of the tumor.

Recent Findings

A team of professionals created VI-RADS with the goal of standardizing the acquisition and interpretation of multiparametric-MRI in bladder cancer.

Summary

Bladder cancer is the most common cancer involving the urinary system. It is the fourth most common urological cancer in men and the second most frequent cancer affecting the urinary tract. Main risks factors are advanced age, male sex, and cigarette smoking. Bladder cancer ranges from unaggressive and usually non-invasive tumors that recur and commit patients to long-term invasive surveillance, to aggressive and invasive tumors with high disease-specific mortality. At the time of diagnosis, 70% of patients are experiencing non-muscle-invasive bladder cancer. Vesical imaging-reporting and data system score (VI-RADS) is a scoring system useful to standardize the approach to multiparametric-MRI interpretation, and reporting for bladder cancer.

Percutaneous Microwave Ablation is Comparable to Cryoablation for the Treatment of T1a Renal Masses: Results From a Cross-Sectional Study

INTRODUCTION

Percutaneous microwave ablation (MWA) of renal masses (RM) is still considered experimental as opposed to established procedures such as cryoablation (CA). We aimed to compare perioperative, functional and oncological outcomes of patients with RM treated with CA and MWA.

MATERIALS AND METHODS

Data from 116 (69.9%) and 50 (30.1%) patients treated with CA and MWA for RM were analyzed. Patients' demographics and perioperative data were collected including nephrometry scores, complications, pre- and postprocedural renal function. Tumor persistence and recurrence were recorded. Descriptive statistics compared functional outcomes between groups. Cox regression analyses tested risk factors associated with recurrence.

RESULTS

Groups were similar in terms of RM diameter, nephrometry scores and histology distribution. Median follow-up was 26 (13-46) and 24 (14-36) months for CA and MWA, respectively. The rate of overall (36.2% for CA vs. 24% for MWA, P= .1) and major (Clavien ≥ 3a) complications (1.7% vs. 5.4%, P = .1) were similar among groups. The median decline of renal function after 6 months follow-up did not differ between CA and MWA (P = .8). Tumor persistence [4.3% vs. 12%] and recurrence [9.5% and 7.1%] rates were similar for CA and MWA. Three years recurrence free and overall survival were 91% versus 95% (log-rank P = .77) and 80 versus 88% (log-rank P = .23) in the CA and MWA groups, respectively. At Cox analysis no predictors were found associated with recurrence.

CONCLUSION

Despite being considered still experimental, MWA showed comparable outcomes relative to CA in terms of safety, preservation of renal function and oncological efficacy.

Role of Contrast-Enhanced Voiding Urosonography in the Evaluation of Renal Transplant Reflux - Comparison with Voiding Cystourethrography and a New Classification

Vesicoureteral reflux (VUR) is a common urological complication in renal transplant patients.

THE AIM

of this study is to evaluate the performance of contrast-enhanced voiding urosonography (CEvUS) in the diagnosis and classification of reflux into the renal allograft, to evaluate and classify VUR into the allograft using voiding cystourethrography (VCUG) and CEvUS, to compare the two methods, and to propose a new classification of reflux into the allograft based on CEvUS and VCUG assessment, in line with the international reflux grading system.

MATERIALS AND METHODS

 From January 2017 to July 2019, 84 kidney transplant patients were enrolled. All patients underwent VCUG and CEvUS.

RESULTS

 In 76 cases there was agreement between VCUG and CEvUS (90 %) (Kappa = 0.7). The sensitivity of CEvUS using VCUG as the gold standard was 90 %, and the specificity was 92 %. Of the 7 cases diagnosed by VCUG and not by CEvUS, 6 were grade 1 and 1 was grade 2.

CONCLUSION

 Transplant patients with reflux symptoms should undergo CEvUS. If the outcome is negative, VCUG should be performed. The classification that we propose is better suited to describe VUR in transplant patients, because it is simpler and takes into account whether reflux occurs not only during urination but also when the bladder is relaxed.

Penile Ultrasound: An Essential Tool in an Emergency Setting (Traumatic and Non-Traumatic Diseases)

Penile conditions requiring urgent care are uncommon and result from trauma and a variety of non-traumatic causes. Some cases could rapidly evolve into an emergency situation and require prompt treatment to prevent severe complications. Therefore, correct and rapid diagnosis is fundamental. Although clinical history and physical examination are essential, diagnostic imaging is usually required to confirm the clinical diagnosis. In this setting, the sonologist in the emergency department has to be familiar with the basic US penile anatomy and with the most common US findings in urgent penile care. US is the key imaging method because it is readily available, safe, cost-effective, and well-tolerated by the patient. US can differentiate intracavernosal from extracavernosal hematomas and detect rupture of the tunica albuginea, consistent with penile fracture, that requires early surgical exploration. Color Doppler evaluation and spectral analysis are necessary to depict vascular abnormalities.

Intravenous contrast medium extravasation: systematic review and updated ESUR Contrast Media Safety Committee Guidelines

NEED FOR A REVIEW

Guidelines for management and prevention of contrast media extravasation have not been updated recently. In view of emerging research and changing working practices, this review aims to inform update on the current guidelines.

AREAS COVERED

In this paper, we review the literature pertaining to the pathophysiology, diagnosis, risk factors and treatments of contrast media extravasation. A suggested protocol and guidelines are recommended based upon the available literature.

KEY POINTS

• Risk of extravasation is dependent on scanning technique and patient risk factors. • Diagnosis is mostly clinical, and outcomes are mostly favourable. • Referral to surgery should be based on clinical severity rather than extravasated volume.

Magnetic resonance urography of congenital abnormalities - what the radiologist needs to know

Congenital abnormalities of the kidney and urinary tract include a wide range of malformations ranging from asymptomatic to life-threatening conditions. Although pediatric urogenital system imaging is based on the use of US (pre- and postnatal), voiding cystourethrography and scintigraphic study, magnetic resonance (MR) urography plays a fundamental role in the classification and management of congenital abnormalities of the kidney and urinary tract, giving an overview of the different clinical pictures, thanks to its panoramicity and high anatomical detail. In fact the anomalies of the urinary tract are phenotypically variable because they can affect simultaneously several segments of different embryonic derivation, with complex clinical pictures; they can appear both as isolated phenotypes or as complex malformative conditions, involving renal parenchyma, collecting system and bladder. A deep knowledge of this complex embryogenesis and its possible phenotypic patterns allows a correct interpretation of MR urography images. We describe the embryology and pathophysiology of congenital abnormalities of the kidney and urinary tract as well as MR urography technique and findings. Congenital abnormalities of the kidney and urinary tract are classified into four groups: (1) obstruction (proximal, middle and distal), (2) budding with respect to the Wolffian duct (site and number of ureter), (3) ascent and rotation (ectopia, malrotation and fusion of kidney) and (4) anomaly of metanephric differentiation (dysplasia, megapolicalycosis).

Inter-reader agreement of the Prostate Imaging Quality (PI-QUAL) score: A bicentric study

PURPOSE

To investigate the inter-reader agreement of the Prostate imaging quality (PI-QUAL) for multiparametric magnetic resonance imaging (mpMRI).

METHODS

We included 66 men who underwent 1.5 T mpMRI in June 2020-July 2020 in center 1, with no exclusion criteria. mpMRI included multiplanar T2-weighted imaging (T2WI), Diffusion-weighted imaging (DWI), and dynamic contrast-enhanced imaging (DCE). Two readers from center 2 (experience <1000 to >1500 examinations), blinded to clinical history but not to acquisition parameters, independently assessed PI-QUAL qualitative/anatomical items of each mpMRI sequence, final PI-QUAL score (1-5), and the Prostate imaging reporting and data system version 2.1 (PI-RADSv2.1) category of the index lesion. Cohen's kappa statistics (k) or prevalence-adjusted-bias-adjusted kappa (PABAK) were used to calculate the inter-reader agreement in assessing the PI-QUAL (1-to-5 scale and 1-2 versus 3 versus 4-5), the diagnostic quality of each mpMRI sequence, qualitative/anatomical items, and PI-RADSv2.1 category.

RESULTS

The inter-reader agreement for PI-QUAL category was moderate upon 1-5 scale (k = 0.55; 95%CI 0.39-0.71) or 1-3 scale (k = 0.51; 95%CI 0.29-0.72), with 90.9% examinations categorized PI-QUAL ≥ 3 by readers. The agreement in assessing a sequence as diagnostic was higher for T2WI (k = 0.76) than DCE (PABAK = 0.61) and DWI (k = 0.46), ranging moderate-to-substantial for most of the items. Readers provided comparable PI-RADSv2.1 categorization (k = 0.88 [excellent agreement]; 95%CI 0.81-0.96), with most PI-RADSv2.1 ≥ 3 assignments found in PI-QUAL ≥ 3 examinations (43/46 by reader 1, and 47/47 by reader 2).

CONCLUSIONS

The reproducibility of PI-QUAL was moderate. Higher PI-QUAL scores were associated with excellent inter-reader agreement for PI-RADSv2.1 categorization.

Gas-containing renal stones: a red flag for renal infection

BACKGROUND

Gas in the renal excretory system is described as a consequence of recent procedures but it can be a sign of severe conditions such as fistulas or infections; however, gas-containing renal stones are only rarely encountered.

PURPOSE

To describe the association of gas-containing renal stones and urinary tract infection.

MATERIAL AND METHODS

We performed a retrospective evaluation of the clinical and imaging findings in a series of six patients with gas-containing renal stones and compared our findings with those of patients with gas-containing renal stones reported in the literature. Urine and stone cultures were used as a diagnostic standard for urinary tract infection.

RESULTS

Including the present series, there is a total of 21 patients with gas-containing renal stones in the literature. Based on clinical presentation, urinary tract infection could be suspected in 10 (57%) patients, while urine and/or stone cultures showed infection in 18 of 19 (95%) patients, with only one case with no bacterial growth in both (5%); in the remaining patient the information was not available.

CONCLUSION

Gas-containing renal stones are a rarely reported entity usually diagnosed with computed tomography. They are a radiological sign often associated with urinary tract infection that can also be encountered in patients with non-specific renal symptoms.

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.

Cryoablation of renal tumors: long-term follow-up from a multicenter experience

Purpose

To retrospectively investigate long-term outcomes of renal cryoablation from a multicenter database.

Methods

338 patients with 363 renal tumors underwent cryoablation in 4 centers in North-Eastern Italy. 340/363 tumors (93.7%) were percutaneously treated with CT guidance. 234 (68.8%) were treated after conscious sedation, 76 (22.3%) under local lidocaine anesthesia only and 30 (8.8%) under general anesthesia. Treatment efficacy and complication rate considered all procedures. Oncologic outcomes considered a subset of 159 patients with 159 biopsy proven renal cell carcinoma.

Results

Mean tumor size was 2.53 cm. Technical success was achieved in 355/363 (97.8%) treatments. Treatment efficacy after the first treatment was achieved in 348/363 (95.9%) tumors. Statistical analysis revealed a significant lower treatment efficacy for ASA score >3, Padua score >8, tumor size >2.5 cm, use of >2 cryoprobes, presence of one single kidney. In the subset of 159 patients, recurrence-free survival rates were 90.5% (95% CI 83.0%, 94.9%) at 3 years and 82.4% (95% CI 72.0%, 89.4%) at 5 years; overall survival rates were 96.0% (95% CI 90.6%, 98.3%) at 3 years and 91.0% (95% CI 81.7%, 95.7%) at 5 years; no patient in this subset developed metastatic disease. Clavien-Dindo >1 complications were recorded in 14/369 procedures (3.8%) and were related to age >70 years, tumor size >4 cm and use of >2 cryoprobes.

Conclusion

Cryoablation performed across four different centers in a large cohort of predominantly small renal tumors showed that this technique provides good recurrence-free survival rates and overall survival rates at three- and five-year with very low major complications rate.

Electronic supplementary material

The online version of this article (10.1007/s00261-021-03082-z) contains supplementary material, which is available to authorized users.

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.

Role of Contrast-Enhanced Ultrasound (CEUS) in Native Kidney Pathology: Limits and Fields of Action

Gray scale ultrasound has an important diagnostic role in native kidney disease. Low cost, absence of ionizing radiation and nephrotoxicity, short performance time, and repeatability even at the bedside, are the major advantages of this technique. The introduction of contrast enhancement ultrasound (CEUS) in daily clinical practice has significantly reduced the use of contrast enhancement computed tomography (CECT) and contrast enhancement magnetic resonance (CEMR), especially in patients with renal disease. Although there are many situations in which CECT and CEMRI are primarily indicated, their use may be limited by the administration of the contrast medium, which may involve a risk of renal function impairment, especially in the elderly, and in patients with acute kidney injury (AKI) and moderate to severe chronic kidney disease (CKD). In these cases, CEUS can be a valid diagnostic choice. To date, numerous publications have highlighted the role of CEUS in the study of parenchymal micro-vascularization and renal pathology by full integration with second level imaging methods (CECT and CEMRI) both in patients with normal renal function and with diseased kidneys. The aim of this review is to offer an updated overview of the limitations and potential applications of CEUS in native kidney disease.

Historical trends for the standards in scrotal ultrasonography: What was, what is and what will be normal

BACKGROUND

Ultrasonography is the gold standard imaging method for scrotal investigation. Colour Doppler ultrasonography, contrast-enhanced ultrasonography and sonoelastography allow sonographers to assess size, echotexture, vascular features and stiffness of the scrotal organs and abnormalities. Scrotal ultrasonography has been used to investigate male reproductive health, scrotal pain, masses and trauma. However, ultrasonography thresholds/classifications used to distinguish normal and pathologic features of the scrotal organs have changed over time, and have not yet been fully standardized.

OBJECTIVES

To evaluate historical trends for the standards in scrotal ultrasonography: what was, what is and what will be normal.

METHODS

An extensive Medline search was performed identifying the most relevant studies in the English language from inception to date.

RESULTS

We provide here (i) a brief overview of the history of ultrasonography, (ii) current indications for scrotal ultrasonography and (iii) previous and current normal values, cut-offs and classifications of the main colour-Doppler ultrasonography parameters/characteristics of the scrotal organs, as derived from recent guidelines and evidence-based studies. In addition, we report recommendations and the clinical utility of contrast-enhanced ultrasonography and sonoelastography. Finally, we discuss critical issues needing further evidence and future directions to fill in the current gaps.

DISCUSSION

Several studies on scrotal ultrasonography are available. However, guidelines/recommendations dealing with specific ultrasonography applications have been published only in recent years. More recently, the European Academy of Andrology published evidence-based scrotal colour-Doppler ultrasonography reference ranges/normative parameters derived from a cohort of healthy, fertile men. In addition, a standardization of the methodology to evaluate qualitative and quantitative colour-Doppler ultrasonography parameters was reported. Other international societies reported indications, methodological standards, clinical utility and limitations of contrast-enhanced ultrasonography and sonoelastography.

CONCLUSIONS

To date, colour-Doppler ultrasonography normative values for the scrotal organs are available. However, a wide international consensus on assessment and classification of several ultrasonography parameters is still lacking. An alignment of the world societies on these issues is advocated.

Varicocoele. Classification and pitfalls

Background

Varicocoeles have been considered for a long time potentially correctable causes for male infertility, even though the correlation of this condition with infertility and sperm damage is still debated.

Objective

To present a summary of the evidence evaluation for imaging varicocoeles, to underline the need for a standardized examination technique and for a unique classification, and to focus on pitfalls in image interpretation.

Methods

Based on the evidence of the literature, the current role of ultrasound (US) imaging for varicocoeles has been reported and illustrated, with emphasis on examination technique, classification, and pitfalls.

Results

US is the imaging modality of choice. It is widely used in Europe, while in other countries clinical classification of varicocoeles is considered sufficient to manage the patient. A number of US classifications exist for varicocoeles, in which the examinnation is performed in different ways.

Discussion

An effort toward standardization is mandatory, since lack of standardization contributes to the confusion of the available literature, and has a negative impact on the understanding of the role itself of imaging in patients with varicocoeles.

Conclusion

Use of the Sarteschi/Liguori classification for varicocoeles is recommended, since it is the most complete and widely used US scoring system available today.

Tubular extratesticular structures resembling varicocoeles, either at palpation or at US, should be identified and correctly characterized.

EFSUMB 2020 Proposal for a Contrast-Enhanced Ultrasound-Adapted Bosniak Cyst Categorization - Position Statement

The well-established Bosniak renal cyst classification is based on contrast-enhanced computed tomography determining the malignant potential of cystic renal lesions. Ultrasound has not been incorporated into this pathway. However, the development of ultrasound contrast agents coupled with the superior resolution of ultrasound makes it possible to redefine the imaging of cystic renal lesions. In this position statement, an EFSUMB Expert Task Force reviews, analyzes, and describes the accumulated knowledge and limitations and presents the current position on the use of ultrasound contrast agents in the evaluation of cystic renal lesions.

Oncological outcomes of active surveillance and percutaneous cryoablation of small renal masses are similar at intermediate term follow-up

BACKGROUND

Active surveillance (AS) and minimally invasive ablative therapies such as percutaneous cryoablation (PCA) are emerging as alternative treatment modalities in the management of small renal masses (SRMs).

METHODS

Fifty-nine patients underwent PCA since 2011 and 75 underwent AS since 2010 at two different institutions. Only patients with follow-up ≥ 6 months were included. All patients were followed with a standardized protocol. Treatment failure was defined by dimensional progression for AS and renal recurrence for PCA, in addition to stage and/or metastatic progression for both groups.

RESULTS

Treatment failure was observed in 14 cases (18,7%) during AS (mainly due to dimensional progression) and 12 patients (16%) underwent delayed intervention with a mean follow-up of 36,83 months. Seven patients (11,9%) in the PCA group experienced treatment failure with a mean follow-up of 33,39 months and 3 of them underwent re-ablation successfully. Cancer-specific-survival at 2 and 5 years was 100% and 95,8% in AS-group vs. 98,2% and 98,2% in PCA-group (p=0,831). One patient in both groups died from metastatic disease. Overall-survival at 2 and 5 years was 91,7% and 82,4% in the AS-group vs. 96,5% and 96,5% in the PCA-group (p=0,113). Failure-free survival at 2 and 5 years was 90,9% and 70,1% in the AS-group vs. 93,1% and 70,9% in the PCA-group (p=0,645).

CONCLUSIONS

AS and PCA provide similar survival outcomes and are safe and valid treatment options for elderly and comorbid patients with SRMs.

Percutaneous cryoablation for high-complexity renal masses: complications, functional and oncological outcomes

BACKGROUND

During the past two decades cryoablation (CA) has become a therapeutic option for the management of localized cT1 renal masses in comorbid patients. We analyzed the mid-term functional and oncological outcomes of CA in the treatment of cT1 renal masses which were classified as high-complexity masses according to the PADUA system.

METHODS

A total of 299 patients underwent percutaneous CA between November 2007 and December 2018 in 4 institutions for cT1N0M0 renal masses. All patients with high-complexity (PADUA≥10) renal tumors were included. Technical failure of CA was considered an exclusion criterion.

RESULTS

Inclusion criteria were met by 45 patients. Median Charlson Comorbidity Index (CCI) was 6.0 (IQR: 5.0-7.0), median age was 74 years (IQR: 64.5-79.5). Seven Clavien 1 and 1 Clavien 2 procedure-related complications were reported. Median eGFR at baseline was 64.3mL/min (IQR: 52.0-82.3) while at the 1-year follow-up was 61.4 mL/min (IQR: 44.0-74.5). The median follow-up was 32 months (IQR: 13.25-47.5). Local recurrences were detected in 6 patients; 3 of them underwent re-cryoablation while the others started active surveillance. Median time to recurrence was 17.5 months (IQR: 7.8-27.3). Cancer-specific survival and metastasis-free survival were 100%, while overall survival was 86.7%.

CONCLUSIONS

CA proved to be a valuable therapeutic option for the management of patients with cT1 high-complexity PADUA≥10 renal tumors as it provides a low rate of procedural morbidity and good preservation of renal function. However, these results are counterbalanced by a recurrence rate that appears to be higher than those reported on surgically treated patients.

Nonscrotal Causes of Acute Scrotum

Acute scrotum is characterized by intense acute scrotal pain, which may be associated with other symptoms and signs such as abdominal pain, inflammation, and fever. Many pathologic conditions can present in this way, most which involve the scrotal contents. Nonscrotal conditions, however, can rarely present clinically only as acute scrotum: among them, renal colic, aneurysm rupture or other causes of retroperitoneal hemorrhage, primary abdominal or pelvic tumors and metastases, pancreatitis, pelvic inflammation, and muscle injuries. The pathophysiologic characteristics of the clinical presentation, clues for diagnosis, and imaging features of a series of nonscrotal lesions presenting clinically with acute scrotal pain are herein reported and illustrated. In patients presenting with acute scrotal symptoms and normal scrotal ultrasound findings, nonscrotal causes of acute scrotal pain should be considered in the differential diagnosis. Therefore, an ultrasound investigation of the abdomen, groin, and thighs is indicated.

Contrast-enhanced ultrasound after successful cryoablation of benign and malignant renal tumours: how long does tumour enhancement persist?

INTRODUCTION

To investigate how long successfully ablated tumours take to become completely avascular at CEUS after cryoablation.

METHODS

Ninety-five patients had percutaneous cryoablation of 103 renal tumours investigated at CEUS on post-operative day one. If the lesion was avascular, a contrast-CT/MR was scheduled six months after the procedure, while CEUS was repeated if the lesion still displayed enhancement, until the disappearance of intralesional vascularity. Technical success was defined when the tumour was covered completely by the ablation zone. Technique efficacy was assessed at six months of follow-up.

RESULTS

Technical efficacy was obtained for 101/103 cryoablations, 56% of which (57/101) were avascular on post-operative day one. After one week, two weeks, one month 83%, 91% and 100% of these 101 lesions, respectively, were avascular. Two tumours were unsuccessfully treated. They displayed persistent intralesional vascularity at CEUS one month after the procedure.

CONCLUSIONS

After cryoablation, obtaining CEUS before one month may be misleading. When technical efficacy is obtained, disappearance of intralesional enhancement is observed within two weeks in the majority of cases (91%), but can persist until one month. Identification of tumour enhancement after one month may be concerning for residual viable tumour.

Emergency Ultrasound in Trauma Patients: Beware of Pitfalls and Artifacts!

BACKGROUND

Ultrasonography (US) is highly dependent on operators' skills. It is not only a matter of correct scan techniques; there are anatomical structures and variants, as well as artifacts, which can produce images difficult to interpret and which, if not properly understood, can be causes of errors.

OBJECTIVES

This paper will review relatively common US pitfalls and artifacts that can be encountered in trauma patients and will offer tips to recognize and avoid them.

DISCUSSION

Normal anatomical structures and anatomical variants can mimic fluid collections or perisplenic lesions. Examination along multiple scan planes, real-time observation of movements or repetition of the study after the patient has drunk some fluid or after placing a finger on her/his body wall can help proper identification. The term artifact in US imaging refers to display phenomena not properly representing the imaged structures. This can result in images suggesting fracture lines within organs or at their borders, lung consolidations, or pleural effusions, and abdominal fluid collections. Their knowledge is the first step to recognize them; then, use of multiple scan planes or repetition of the study after voiding or changes of equipment setting can make them disappear or clarify their nature.

CONCLUSION

We present possible anatomic pitfalls and artifacts that may affect correct interpretation of US images in patients with abdominal trauma and suggest how to avoid or to clarify them during the examination. Knowing their existence, their appearances, and the reasons why they are produced is important for proper use of this diagnostic technique.

SIUMB recommendations for focal pancreatic lesions

Contrast-enhanced ultrasonography (CEUS) is increasingly being performed in Italy and Europe, particularly in the field of hepato-gastroenterology. Initially, it was mainly carried out to characterize focal hepatic lesions, but, since then, numerous studies have demonstrated its efficacy in the differential diagnosis of focal pancreatic pathologies (D’Onofrio et al. in Expert Rev Med Devices 7(2):257–273, 2010; Vidili et al. in J Ultrasound 22(1):41–51, 2019). The purpose of this paper is to provide Italian Medical Doctors with recommendations and thereby practical guidelines on the management of these patients. The present paper reports the final conclusions reached by the SIUMB guideline commission. This paper addresses particularly percutaneous ultrasound (US) examination (transabdominal US) and is drawn up specifically for publication.

Sonography of the penis/erectile dysfunction

Erectile dysfunction (ED) is defined as the persistent inability to achieve and/or maintain an erection for a satisfactory sexual activity. It is secondary to several organic, psychogenic, and combined causes, and represents a serious health dilemma affecting both men and their partners. The diagnostic approach to erectile dysfunction has significantly changed in the last years with the advent of phosphodiesterase-5 (PDE5) inhibitors, and with the recognition that surgical treatment of both arterial insufficiency and penile venous leak have poor long-term clinical outcomes. Although imaging modalities have diminished in importance, differentiating among causes of erectile dysfunction remains mandatory in good medical practice, and ultrasound (US) still remains the cornerstone of the diagnostic workup. US provides an objective, minimally invasive evaluation of penile hemodynamics. Moreover, it provides an excellent depiction of the penile anatomy and of its changes in pathological conditions such as in patients with Peyronie's disease, priapism, and posttraumatic erectile dysfunction.

Needle tract seeding after percutaneous cryoablation of small renal masses; a case series and literature review

Neoplastic cell seeding due to needle tumor manipulation during renal mass biopsy (RMB) or thermal ablative treatment is a rare but potentially serious event that can turn an organ-confined and curable tumor in a nonorgan-confined and non-curable disease. Despite the widespread use of percutaneous thermal ablative treatment for small renal masses (SRMs), this complication has been described in few case reports and small case series and has never been reported after ablative treatment alone. We report a series of two patients that underwent cryoablation for SRMs and developed recurrence along the needle tract. Available knowledge on the controversial topic of tumor seeding following needle manipulation are poor. So far, reporting cases of tumor cell seeding due to needle manipulation is useful to permit a better understanding of this complication.

The management of stuttering priapism

INTRODUCTION

Stuttering priapism is a variation of ischemic priapism, generally transient and self-limiting, occurring during sleep and lasting less than 3-4 hours. It may progress to episodes of complete ischemic priapism in approximately one third of cases, necessitating emergent intervention.

EVIDENCE ACQUISITION

This review aims to provide an up-to-date picture of the pathophysiology and management of stuttering priapism. A search using Medline and EMBASE for relevant publications using the terms "priapism", "stuttering", "diagnosis", "treatment", "fibrosis", was performed.

EVIDENCE SYNTHESIS

Stuttering priapism shares its etiologies with ischemic priapism and a large number of diseases or clinical situations have risk association for developing the disorder. The most common causes are sickle cell disease or other hematologic and coagulative dyscrasias especially in children. In the adult population, idiopathic priapism occurring without any discernible cause is considered to be the most common form in adults. The medical management of priapism represents a therapeutic challenge to urologists. Unfortunately, although numerous medical treatment options have been reported, the majority are through small trials or anecdotal reports. Understanding the underlying pathophysiology and understanding the current and emerging future agents and therapeutic options are mandatory in order to provide the best solution for each patient.

CONCLUSIONS

The goal of management of priapism is to achieve detumescence of the persistent erection in order to preserve erectile function. To achieve successful management, urologists should address this emergency clinical condition. In the present article, we review the diagnosis and clinical management of the three types of priapism.

SIUMB guidelines and recommendations for the correct use of ultrasound in the management of patients with focal liver disease

The present document describes the SIUMB (Italian Society of Ultrasound in Medicine and Biology) guidelines for the use of ultrasound in the management of focal liver disease. The aim of the paper is to provide a clinical practice guideline for Italian physicians who are approaching the ultrasound study of a focal liver lesion. In particular, these guidelines provide simple indications, recommendations and general practice advices for the correct use of contrast-enhanced ultrasound (CEUS) in this scenario. They represent the SIUMB position of the ultrasound role in the diagnostic flow charts of the principal focal liver lesions, and are in agreement with other, previously published national and international guidelines.

Evaluation of Intratesticular Lesions With Strain Elastography Using Strain Ratio and Color Map Visual Grading: Differentiation of Neoplastic and Nonneoplastic Lesions

OBJECTIVE

To investigate the role of strain elastography using calculated strain ratio and visual elastography score in differentiating nonneoplastic, benign, and malignant neoplastic intratesticular lesions.

MATERIALS AND METHODS

The study was approved by the hospital review board as a retrospective review of 86 patients examined with gray scale, color Doppler ultrasonography and strain elastography (visual elastography score and strain ratio). Sensitivity, specificity, and positive and negative likelihood ratio of color Doppler and stain elastography were documented. Receiver operator characteristic curves assessed the diagnostic accuracy of strain elastography to discriminate nonneoplastic, benign, and malignant neoplasms. Histology or follow-up ultrasonography determined lesion character.

RESULTS

Thirty-one of 86 (36.0%) intratesticular malignant neoplasms, 17 of 86 (19.8%) benign neoplasms, and 38 of 86 (44.2%) nonneoplastic lesions were confirmed with histology (n = 52) or follow-up sonography (n = 34); 89.5% of intratesticular lesions were heterogeneous or hypoechoic on gray scale, with no difference between benign and malignant. Sensitivity, specificity, positive and negative likelihood ratio for nonneoplasm versus neoplasm were documented: color Doppler: 68.8%, 97.4%, 26.5, 0.32; visual elastography score: 81.3%, 57.9%, 1.93, 0.32; strain ratio: 68.8%, 81.6%, 3.73, 0.38. Neoplastic lesions showed a higher strain ratio than nonneoplastic lesions (P < .001), with strong correlation between median strain ratio and visual elastography score (Spearman's coefficient, 0.693; P < .001). Strain ratio is a significantly better assessment than visual elastography score for malignant lesions (P = .025). Logistic regression analysis revealed significant associations between size (P = .001), hypervascularity (P < .001), and malignancy.

CONCLUSION

Higher strain ratio and visual elastography score are associated with neoplastic lesions and offer an alternative to assess tissue characteristics but do not improve the diagnostic accuracy when compared with the color Doppler pattern.

Sonographically indeterminate scrotal masses: how MRI helps in characterization

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

Serum levels of osteopontin predict diabetes remission after bariatric surgery

AIM

Bariatric surgery has been shown to effectively improve glycaemic control in morbidly obese subjects. However, the molecular bases of this association are still elusive and may act independently of weight loss. Here, our retrospective study has investigated the inflammatory molecule osteopontin (OPN) as a potential predictor of type 2 diabetes mellitus (T2DM) remission.

METHODS

Baseline serum levels of OPN were analyzed in 41 T2DM patients who underwent bariatric surgery. Anthropometric measures and biochemical variables, including insulin sensitivity indices (HOMA2), were assessed at baseline and at 1 and 3 years after surgery.

RESULTS

At baseline, patients who experienced T2DM remission had increased waist circumference, body weight and BMI, and higher serum OPN, compared with non-remitters. Patients with and without T2DM remission improved their lipid and glucose profiles, although insulin resistance indices were only improved in the T2DM remission group. In the overall cohort of both T2DM remission and non-remission patients, baseline circulating levels of OPN significantly correlated with reductions of body weight and BMI over time, and insulin sensitivity improved as well. However, only the HOMA2-%S remained independently associated with serum OPN on multivariate linear regression analysis (B: 0.227, 95% CI: 0.067-0.387, β = 0.831; P = 0.010). Baseline values of OPN predicted 3-year T2DM remission independently of body weight loss, lower BMI and duration of diabetes (OR: 1.046, 95% CI: 1.004-1.090; P = 0.033).

CONCLUSION

Although larger studies are still needed to confirm our preliminary results, pre-operative OPN serum levels might be useful for predicting 3-year T2DM remission independently of weight loss in patients undergoing bariatric surgery.