Varicoceles. Radiologic diagnosis and treatment

The association of clinically apparent varicoceles with male subfertility and infertility has been noted in the urology literature since the late nineteenth century, and surgical ligation of varicoceles has been considered appropriate therapy in an attempt to improve semen quality and increase fertility for the past 40 years. It has been established by several authors cited herein that varicocele size does not predict prognosis after ligation reliably. Because subclinical varicoceles may affect testicular function and histologic characteristics adversely and because age at time of therapy may affect probability of successful enhancement of fertility, the interest of radiologists and urologists has been directed toward diagnosis and treatment of both clinically obvious and clinically occult varicoceles, particularly in young adult men or adolescent boys. Testicular growth after varicocele ligation in adolescent boys also suggests a benefit from early intervention. Sonographic evidence of a varicocele must be correlated with analysis of semen for sperm density, motility, and morphology, as not all patients with varicoceles are infertile. Although surgical therapy is standard for varicocele occlusion, fairly extensive evidence exists to show that percutaneous transvenous occlusion of varicoceles is feasible, safe, and effective, particularly in the setting of varicocele recurrence after conventional surgical treatment.     

Acute scrotal abnormalities in children: diagnosis by combined sonography and scintigraphy

Both scintigraphy and real-time sonography have been used to assess acute symptoms involving the scrotum. However, because of its high sensitivity and ability to document physiologic abnormalities, scintigraphy has been the procedure of choice. Scintigraphy, however, lacks specificity; its value lies mainly in serving to distinguish torsion from nontorsion. The purpose of this study was to supplement scrotal scintigraphy with sonography to determine if the combination improves diagnosis and management compared with scintigraphy alone. Forty-three scrotal scintigrams and sonograms were performed on 40 consecutive patients with acute scrotal symptoms. The interpretation of the scintigram was altered by sonography in six (14%) of the combined scans, directly affecting clinical management. In three patients with acute hydroceles diagnosed by sonography, exploratory surgery was avoided despite scintigraphic findings suggesting testicular torsion. Scintigraphy was normal in two patients with spontaneous testicular detorsion, whereas sonography showed recent spermatic-cord torsion that required subsequent orchiopexy. In a patient with epididymitis and orchitis, sonography showed a complicating scrotal abscess, which was not apparent on scintigraphy and which required antibiotic treatment. The addition of sonography to the scintigraphic evaluations of children with acute scrotal abnormalities changed the diagnosis and clinical management in 14% of the patients studied.     

Analysis of errors in imaging diagnosis of varicocele. Duplex sonography, plate thermography and phlebography

Comparative investigations were done by duplex sonography, thermography and phlebography in 142 patients with 158 varicoceles. Verification of clinical varicoceles (130/158) was performed by duplex sonography in all cases and by thermography in 93%. Measurement errors were due to dorsally located varicoceles near the radix of the penis (3/130) and by small, two-sided varicoceles (6/130). Small subclinical varicoceles (28/158) were detected by real-time sonography in 89%, by Doppler sonography in 64%, and by thermography in 53%. In three patients with normal real-time sonography, subclinical varicoceles were found by Doppler sonography alone. The combination of both sonographic methods is highly sensitive for the detection of subclinical varicoceles and should be done in all cases without therapeutic results.     

Prostatic evaluation by transrectal sonography: criteria for diagnosis of early carcinoma

Over a 7-month period, from a total of 417 transrectal ultrasound (US) studies, 45 transperineal biopsies of the prostate were performed in the radiology department. Transrectal US guidance and local anesthesia were used. Twenty-two of 32 hypoechoic lesions, located within the peripheral zone tissue of the gland, were proved by histologic study to be cancerous. Hyperechoic lesions were all histologically benign hyperplasias. The patients experienced no major complications necessitating hospitalization or increased length of hospital stay as a result of the procedure.     

Liver abscess: sonography in diagnosis and treatment

Over 24 months, 22 patients with intrahepatic abscesses were diagnosed by sonography. The sonographic appearance of the abscesses was nonspecific and varied from anechoic lesions to highly echogenic solid masses. Septations, fluid-fluid interfaces, and debris were also observed. In 19 of 22 patients, the diagnosis was confirmed by needle aspiration. Subsequently, 12 patients were treated with percutaneous catheter drainage; in 10 patients this therapy obviated the need for further surgery.     

Transvaginal sonography: comparison with transabdominal sonography in the diagnosis of pelvic masses

In a retrospective study, we compared transvaginal sonograms with transabdominal sonograms in 67 women referred for evaluation of palpable pelvic masses. The diagnoses included ovarian cyst (27), endometrioma (12), complex cyst (four), dermoid (three), infection (three), ovarian malignancy (two), and uterine fibroid (three). The final diagnosis was made surgically in 41 patients (61%) and by a combination of sonographic and clinical correlation in the remaining patients. More information about the internal architecture or anatomy of the mass was provided by the transvaginal images than by the transabdominal scans in 51 (76%) of the patients. Transabdominal sonography did not provide more diagnostic information in any of the patients examined. Transvaginal sonography was helpful in obese patients, in those with a large amount of bowel gas, and in those unable to achieve adequate bladder filling. Six simple cysts and four complex pelvic masses were identified solely on transvaginal sonograms. The results suggest that transvaginal sonography has considerable advantages over conventional transabdominal sonography in the evaluation of pelvic masses in women.     

Tailgut cyst: diagnosis with CT and sonography

Tailgut cyst is a rare congenital lesion that presents as a presacral mass, found in infancy or persisting undetected into adulthood, and characterized by multiple cysts lined with a gastrointestinal type of epithelium. In a retrospective review of five patients whose ages ranged from 1 month to 42 years--three cases with CT and two with sonograms--tailgut cyst appeared as a complex mass on both procedures, representing its composition of multiple small cysts filled with keratinous material and other debris. Other CT and sonographic features include well-defined borders, and, in one case, presentation as a mass lateral to the midline. CT also shows preservation of adjacent fat planes. Tailgut cyst should be included in the differential diagnosis of a retrorectal mass at any age.     

Late sequelae of percutaneous nephrolithotomy: evaluation by high-resolution sonography and colour-coded sonography

We examined 50 asymptomatic patients 6–60 months after percutaneous nephrolithotomy (PCNL) by high-resolution sonography and additional colour-coded sonography and compared our results with the preoperative sonograms and the operative records. No lesions of larger vessels were detected, either arteriovenous fistulate or pseudoaneurysms. Avascular band-shaped hyperechoic parenchymal stripes were found in 17 of 50 patients (35%). As these did not appear in the preoperative sonograms, and as the stripes were in the same orientation as the neprrostomy canal, we believe them to be scar tissue. Correspondence to: R. Knapp     

Computed tomography of Grave's ophthalmopathy. Diagnosis, management, and posttherapeutic evaluation

Computed tomography (CT) is emphasized in the diagnosis and management of Grave's ophthalmopathy. This report illustrates the value of CT in evaluating the extent of disease, choice and timing of treatment, radiation therapy planning, and posttreatment follow-up of nine patients with Grave's ophthalmopathy. Eight patients had bilateral disease, and three patients had evidence of optic nerve compression. Postirradiation follow-up CT was done in three patients. Eight patients treated with radiation obtained good response.     

Pitfalls and differential diagnosis in biliary sonography

Ultrasonography has a primary role in the imaging of biliary disease. Most cases are straightforward, but the authors emphasize unusual manifestations, uncommon diseases, and artifacts that may present diagnostic challenges. Issues in differential diagnosis are discussed for the following findings: internal gallbladder echoes (calculi vs tumefactive sludge, air, hematobilia, parasitic infestation, cholecystosis, neoplasia, and artifacts), gallbladder wall thickening (acute cholecystitis vs acalculous cholecystitis, artifacts, ascites, hypoalbuminemia, hepatitis, and sclerosing cholangitis), pericholecystic fluid (cholecystitis vs ascites, perforated ulcer, and trauma), bile duct dilatation (biliary obstruction vs sclerosing cholangitis, biliary air, anomalous portal system, biliary atresia, Caroli disease, and cholangiocarcinoma), perinatal and neonatal biliary disease, and sclerosing cholangitis.     

Transrectal sonography in prostate evaluation

Prostate cancer is the most prevalent newly diagnosed noncutaneous malignancy in men. With the continued use of prostate-specific antigen screening, there has been a dramatic rise in the number of prostate biopsied performed. Transrectal ultrasonography (TRUS) is an essential tool used for detecting prostate pathology and performing prostate biopsies. This article review the indications and principles of TRUS of the prostate, the technique of TRUS, and controversies pertaining to prostate core biopsy.     

Rotator cuff tears: diagnosis with sonography

The purpose of this study was to determine the accuracy of sonography in the detection of rotator cuff tears. Eighty-one patients were referred by orthopedic specialists because of a clinical suspicion of rotator cuff tear. The standards of comparison were arthrography in 79 cases and surgery in two cases. The sonographic technique used was based on a review of the literature and experience gained by scanning normal subjects. The sonographic criteria for the diagnosis of a complete rotator cuff tear were a focal defect in the cuff or complete absence or nonvisualization of the cuff. All sonograms were interpreted prospectively without knowledge of arthrographic or surgical results. With arthrography as the standard of comparison for the diagnosis of rotator cuff tear, sonographic results included 15 true-positives, 52 true-negatives, eight false-negatives, and four false-positives. With surgery as the standard of comparison, the results were one true-positive and one true-negative sonogram. The sensitivity of sonography in detecting rotator cuff tear was 0.67, the specificity was 0.93, and the accuracy was 0.85. Our study found lower sensitivity and accuracy results for shoulder sonography than have been previously reported.     

Laparoscopic cholecystectomy: evaluation with sonography.

To determine the normal postoperative appearance of gallstones in the common duct at ultrasound (US) examination, the significance of fluid collections after surgery, and the usefulness of routine postoperative scanning, US of the right upper quadrant was performed in 106 consecutive patients 24 hours after laparoscopic cholecystectomy. The location, volume, and appearance of fluid collections were recorded. The maximum diameter of the common duct was measured in all patients and compared with preoperative measurements in 58 patients. Small fluid collections were identified in the gallbladder fossa in 56 patients (53.0%). Fluid collections did not correlate with fever or white blood cell count. In 15 of 58 patients, the diameter of the common duct had increased on the postoperative scan. This did not correlate with alkaline phosphatase or bilirubin levels. One hundred one patients (95.3%) were discharged the day after surgery. Routine US performed the day after surgery did not alter management; the authors conclude that it is unwarranted in their group of patients.