Purpose: Although most avascular hypoechoic testicular lesions on colour Doppler US (CDUS) are often considered benign, the diagnosis may be unreliable due to inherent limitation of CDUS. The purpose of this study is to determine the added value of contrast-enhanced US (CEUS) to conventional CDUS in assessing hypoechoic testicular pathology in differentiating benign from malignant aetiology detected at scrotal US.
Methods and Materials: This retrospective study included 102 avascular hypoechoic testicular lesions detected at colour Doppler testicular ultrasound. The sonographic features recorded include lesion size and presence of vascularity on CEUS and CDUS. The reference standard was pathologic results or at least 6 months stability documented with serial follow-up ultrasound studies.
Results: 102 lesions with no vascular signal on CDUS were identified. 18 of these lesions (17.6%) showed enhancement on CEUS despite lack of signal on CDUS. 6 of lesions with CEUS enhancement were malignant (6/18, 33.3%). The remaining lesions (12) include pathology such as sarcoidosis, post biopsy change, intra-testicular adenomatoid tumour, focal scarring with history of previous orchiopexy, and focal atrophy in patient with klinefelter syndrome. All lesions with no enhancement on CEUS (84) were of benign nature.
Conclusion: Although most avascular hypoechoic testicular lesions on CDUS are benign, a proportion of these lesions are malignant and demonstrate CEUS enhancement. CEUS provides a more definitive characterisation of vascularity of a focal testicular lesion and would therefore add value to conventional CDUS in differentiating malignant from benign lesions.
Purpose: The purpose of this study is to identify the diagnostic value of ADC combined with DWI in benign lesions and malignant lesions of testis.
Methods and Materials: 35 patients with testicular lesions confirmed by operation and pathological examination in our hospital were retrospectively analysed, including 18 benign lesions and 17 malignant lesions. The mean ADC values of normal tissue and parenchyma of testicular lesions were measured and statistically analysed by Kruskal-Wallis test and receiver operating characteristic (ROC) curve was delineated. The optimum ADC value for differential diagnosis of malignant testicular lesions was analysed and determined.
Results: In 33 cases of normal testicular tissue, DWI showed homogeneous high signal, mean ADC was (1.137±0.119)×10-3 mm2/s. 18 cases of benign lesions mostly showed unrestricted diffusion, mean ADC was (1.104±0.463)×10-3 mm2/s. In 17 cases of malignant lesions, DWI showed high signal, mean ADC was (0.778±0.198)×10-3 mm2/s. The comparison of ADC mean values between malignant testicular lesions and normal tissue as well as benign lesions of testis showed significant difference (P<0.05). The optimum ADC to distinguish malignant testicular lesions from benign testicular lesions was 0.911×10-3 mm2/s (82.4% sensitivity and 82.4% specificity).
Conclusion: DWI combined with ADC value is beneficial to the preoperative diagnosis and differential diagnosis between malignant testicular lesions and benign lesions of testis.
Purpose: To assess possible differences of testicular apparent diffusion coefficient (ADC) and fractional anisotropy (FA) values in different histological states of spermatogenesis in men with non-obstructive azoospermia (NOA).
Methods and Materials: Twenty infertile men with NOA and 21 age-matched controls were retrospectively evaluated. All subjects underwent 1.5 T MRI of the scrotum, including diffusion tensor imaging (DTI). ADC and FA in NOA and normal testes were measured. NOA testes were classified as NOA with highest Johnsen score (JS) ≥8 (group 1) and JS <8 (group 2), based on the presence of tubules with spermatozoa at histologic analysis. The same classification was used for mean JS (mJS). Parametric and non-parametric statistical tests were used to compare ADC and FA between NOA groups and normal testes (group 3).
Results: Statistical analysis showed differences in ADC and FA between groups 1 and 3 (P=0.047 and P<0.001, respectively) and between groups 2 and 3 (P=0.003 and P<0.001), but not between groups 1 and 2 (P=0.241 and P=0.976), when using the highest JS. When classification was based on mJS, ADC (P=0.014) and not FA (P=0.849) enabled the discrimination between groups 1 and 2.
Conclusion: Our preliminary data show promising results in the identification of spermatogenesis in NOA testes using DTI parameters. Both ADC and FA are increased in NOA testes compared to controls. However, ADC and not FA proved useful in differentiating NOA testes, based on histology.
Purpose: To investigate the diagnostic value for micro-penile lesions after penile injury using high-resolution MR imaging with small surface coil.
Methods and Materials: There were 13 patients with history of penile injury including intense intercourse or masturbation recently without clinical manifestations of penile fracture. In all patients, the complaints were mild and the sonographic results were negative. MR scan with both small surface coil (loop coil, diameter 11 cm) and body coil was performed in all 13 cases, respectively. MR findings were analysed by two experienced radiologists.
Results: Only 2 cases with suspected lesions were found by MR scan with body coil. 10 cases with slight lesions of penis were detected by MR scan with small surface coil. 8 out of 10 cases with slight albuginea tear presented as focal interruption (about 1~2mm) of the hypointensity tunica albuginea and a small amount overlying effusion. Tiny haematomas with diameter 2-3mm between tunica albuginea and the buck fascia were seen in the remaining 2 cases, presenting as a small nodule with hyperintensity on T2WI, hypo- or iso-intensity on T1WI without enhancement. MR scan with small surface coil detected more tiny lesions of penis than routine scan with body coil (P<0.05), and showed the MR imaging features for diagnosis.
Conclusion: MR scan with small surface coil can provide higher diagnostic sensitivity for slight penile lesions after penile injury, and avoid misdiagnosis.
Purpose: To evaluate whether MR investigation of neoclitoris size and location can help predict sexual function after male-to-female sex reassignment surgery (MtF-SRS).
Methods and Materials: The Female Sexual Function Index (FSFI) was calculated in 40 consecutive transsexual women who had postoperative MRI after MtF-SRS. An investigator blinded to sexual function data measured the distance between the neoclitoris and the neovagina and calculated the coronal and sagittal area of the neoclitoris and the volume from the three axes using the ellipsoid formula.
Results: 22 patients completed the study. The mean age was 34±7.44 years. The majority were Caucasians (n=20, 91%) and in a relationship (n=13, 51%). The volume of the neoclitoris was 1.18±0.43 cm3. Coronal and sagittal areas were 6.80±2.4 cm2 and 5.33±1.34 cm2, respectively. There was an inverse relationship between the distance of the neoclitoris from the neovagina and the FSFI total score (p < 0.0001). Neoclitoris size did not significantly correlate with FSFI total score (p=0.76).
Conclusion: In patients with MtF-SRS MRI allows evaluation of the neoclitoris. Our data suggest that neoclitoris localisation affects sexual function, with reduction of the distance between the neovagina and the neoclitoris associated with greater sexual satisfaction. Conversely, neoclitoris size does not to affect sexual function.
Purpose: In early male-to-female sex reassignment surgery (MtF-SRS) operations a variable portion of the cavernosal crura was preserved. This residual erectile tissue undergoes engorgement during sexual arousal, causing dyspareunia and limiting patient's life. Surgical removal is the most commonly used treatment. It consists in a wide dissection of the perineum with significant morbidity and a high risk of complications. Development of mini-invasive techniques is therefore necessary. The aim of this study is to describe US-guided sclerotherapy of the cavernosal stumps as an alternative to surgery, and to illustrate the results obtained in a series of 3 consecutive patients treated with this technique.
Methods and Materials: US-guided sclerotherapy was performed in 3 patients (mean age 29-38 years) with severe dyspareunia after MtF-SRS caused by residual cavernosal stumps. 2.5 micrograms of PGE1 were injected in each stump under US guidance to achieve erection. A 3% sodium tetradecyl sulphate (Fibrovein®) solution diluted 1/5 with saline was injected bilaterally. A variable amount (max.3.5 cc) was injected depending on the volume of the erectile tissue. In 2 patients, the treatment was repeated monthly for 7 and 8 sessions, respectively. The 3rd patient developed an abscess after the 5th session with prompt resolution of clinical symptoms after drainage.
Results: A good aesthetic and functional result was achieved in all patients with disappearance of the erections during sexual arousal and improvement of the sexual quality of life.
Conclusion: In patients with MtF-SRS US guided sclerotisation is a suitable mini-invasive alternative to surgical excision of the cavernosal stumps.
Purpose: To assess the role of diffusion-weighted MRI and 3D/4D ultrasound and power Doppler scanning in the detection of placental insufficiency in high-risk pregnancies with hypertension.
Methods and Materials: This prospective analysis included 50 pregnant females; 40 hypertensive and 10 control with the gestational age range from 20 to 34 weeks. All cases had undergone 3D/4D transabdominal ultrasound aided by power Doppler scanning and diffusion-weighted MR imaging. No contrast administration was used.
Results: There was a significant relation between right uterine artery RI (mean) of both cases and control groups when measured by power Doppler ultrasound (P=0.014). There was also a positive correlation between the presence of diastolic notch and RI value (P value= 0.012). There was also a significant difference between patients with normal and those with the abnormal placental signal in diffusion images as P value is significant (0.047). The mean of placental volume by MRI was 500.5+223.12 with median (IQR) 507.08 (311.22-721.85) and by 3D ultrasound was 374.11+251.52 with median (IQR) 329.02 (162.66-596.75). There was a significant difference between the measurement of placental volume by MRI and US among both cases and control groups where P value<0.001 and 0.017, respectively. There was significant relation between results of both US and diffusion imaging in cases group (P value=0.006 and kappa value=0.318).
Conclusion: Diffusion-weighted imaging can detect early subtle findings of placental dysfunction more than detected with 3D/4D ultrasound, so it can add to the diagnostic accuracy of imaging in pregnancies at high risk of placental insufficiency.
Purpose: To study the role of placenta accreta index (PAI) in detection of morbidly adherent placenta and to analyse the inter-observer reliability in its calculation.
Methods and Materials: 42 pregnant females with sonographically confirmed placenta previa in their third trimester and history of ≥1 caesarean section were subjected to ultrasonography for calculation of placenta accreta index (PAI). The index was calculated on the basis of placental morphology, retro-placental zone, uterine-bladder interface, myometrial thickness, bridging vessels and previous history of caesarean sections. Each parameter was weighted to produce a 9-point score (PAI) which predicted the probability of adherent placenta. PAI score of <5 was considered unfavourable and ≥5 as favourable for accreta. Statistical analysis was done to find the sensitivity, specificity and predictive values of PAI. The PAI was calculated by two radiologists separately, to determine the reproducibility of the technique. Cohen’s Kappa and intra-class correlation co-efficient (ICC) were calculated for categorical and scale variables, respectively, to determine the inter-rater agreement in calculation of scores.
Results: Among 42 patients, 15 were placenta accreta on caesarean section. PAI ≥5 (favourable for accreta) was found in 17 and 14 patients by the two radiologists, respectively. The index showed highest sensitivity of 93.3% and specificity of 92.6% with negative predictive value of 96%. A perfect agreement was also found in calculation of PAI by the two radiologists with ICC of 0.959; p value<0.001.
Conclusion: PAI can be utilised as a standard criterion for prediction of adherent placenta and thus decreasing maternal and foetal morbidity.
Purpose: To simplify and implement limited strategies for a improving quality of performing fetal MRI and to evaluate the effect on exam time and radiologist satisfaction
Methods and Materials: We designed a limited extra education strategy for MRI technicians which included a limited fetal brain MRI a±natomy, practical solutions for obtaining perfect orthogonal images using a knowledge of the anatomy of the corpus callosum and vermis as key sagittal landmarks. We also included an extra orientation to motion insensitive MRI protocols tailored to our 1.5 Seimens Avanto and 8channel body coil. We measured the duration of the study with retrospective evaluation of the metadata on our PACS database. In addition we measured radiologist satisfaction of the quality of the images on a scale of 1 to 10 and recorded the time spent by the radiologist at the scanner before and after implementing the strategies. Independent samples T test was used to compare results.
Results: Last 100 patients before implementing the quality measures and first 100 patients with fetal MRI’s performed immediately after implementing the qualities entered the study. Mean exam duration time changed from 36.57±9.69 minutes to 24.86±5.39 minutes (p=0.002). Mean radiologist supervision time was reduced from 9.58±5.76 minutes to 5.43±2.74 minutes (p=0.020). Radiologist satisfaction score with the quality of the images increased significantly from 7.35±2.65 to 8.98±2.31.
Conclusion: Implementing a limited extra education strategy for technologists involved in fetal MRI can significantly improve the quality of the images and in the meantime reduce the exam time.
Purpose: To retrospectively correlate all foetal MRI’s performed over the last 5 years in our center with lung anomalies detected either primarily in ultrasound or unexpectedly in MRI with post-delivery results.
Methods and Materials: From a total of 456 foetal MRI’s performed 53 studies (GA=30+/-8 wks) were performed either for evaluation of a lung finding detected in ultrasound or had an incidental lung finding detected in MRI. In 36 patients post delivery confirmation in form of phone calls, national registry search results or post-delivery CT scans, operation notes or pathology results was available.
Results: Patients included 11 cases of pure CPAM, 3 patients with hybrid lesions (two of which were correctly identified by MRI as such), 3 cases of bronchopulmonary sequestration (correctly diagnosed both by ultrasound and MRI, one fetus with pulmonary blastoma, one case of CHAOS, one case of LAM, 3 cases of pleural effusion, including one proven chylothorax. MRI ruled out focal lung abnormality suspected in ultrasound in 3 suspected cases, all asymptomatic after birth, showed two unsuspected cases of possible CO, both of which subsequently resolved spontaneously. Other patients had some form of uni or bilateral pulmonary hypoplasia.
Conclusion: Foetal MRI detected unsuspected non-significant foetal lung pathology in a small number of cases and also more accurately characterized two lesions. This detailed characterization however did not alter patient management or course.