Imaging of azospermia and varicocele

Transcription

1 European Society of Urogenital Radiology Imaging of azospermia and varicocele Michal Studniarek Katarzyna Skrobisz Department of Radiology Medical University of Gdansk POLAND

2 What the radiologist needs to know about male infertility infertility impotence A vasectomy won't affect your sex drive An adult man who has been castrated will still have a sexual urge.

3 Impotent can be fertile

4 Infertility Definition No pregnancy during 1 year of frequent, unprotected intercourse 15-20% of couples can not have a child Male factor are implicated as a causal one in up to 50% of infertile couples Low quality of semen is the only reason of male infertility Ammar T et al. BJR 2012

5 Background 1. Low semen quality can be due to some diseases: - Post infection (chlamydia, gonorrhea) - Post traumatic (testis, prostate, urethra) - Genetic (cystic fibrosis) - Autoimmune - Hormonal

6 Background 2. As well as - Varicocele - Post therapeutic (vasectomy, prostatectomy) - Others (metabolic syndrome, obesity, drugs: cocaine, steroids, marijuana, tobacco, pesticides, lead, radiation, etc)

7 Causes Pre-testicular - Hormonal - Pharmacological Testicular - Genetics - Cryptorchidism - Gonadotoxins - Varicocele Post testicular - Obstruction - Immunologic - Disorders of ejaculation - Erectile dysfunction Edey A et al. Imaging 2008:

8 ..about obstruction? No sperm cells?

9 Obstruction Low semen quality can be due to obstruction at the level of: - Testis (rete testis) - Epididymis - Vas deferens - Prostate

10 Obstructive azoospermia (larger testis) Epididymal Congenital Idiopathic Cystic fibrosis Acquired Post infective, post surgical (cyst) Vas deferens Aplasia Vasectomy, post surgical - hernia Ejaculatory duct Mullerian cyst often hemmorhagic (other midline cyst) Post infective, post surgical (bladder neck and prostate surgery)

11 Rete testis Obstruction Chronic obstruction Ammar et al. The British Journal of Radiology 2012

12 Obstruction Low semen quality can be due to obstruction at the level of: - Testis (rete testis) - Epididymis - Vas deferens - Prostate Cystic fibrosis

13 Obstruction Epididymis How to measure the size? a value of Caput-M >10.85 mm in cases with FSH<7.8 IU/mL increased the probability of obstructive azoospermia from 63.6% to 92.3% (CI %). Worth mentioning is the finding that the sequential application of size measurements and FSH to diagnosis of azoospermia reached the probability for excretory azoospermia of 97.6% (CI %). Pezzelli et al. Andrology 2013,

14 Epididymis Obstruction a value of Caput-M >10.85 mm 17x14mm - obstruction

15 Vas deferens Obstruction 1. Vasectomy 2. Other obstructions (post inflamative) Du J, Radiology 2010

16 Prostate Obstruction Midline cyst (utricle, Mullerian, abscesses..) Stones Ejaculatory duct dilation (stenosis) BPH Prostate cancer

17 Department of Radiology University of Gdansk

18 Department of Radiology University of Gdansk

19 Department of Radiology University of Gdansk

20 Obstruction Prostatectomy, RT Prostate cancer treatment - Open surgery - Laparoscopy - Robotic surgery - Radiotherapy

21 Prostatectomy

22 Abnormalities typical for seminal tract obstruction were found in 78% (14/18) patients in OA group. Ejaculatory duct or vas deferens dilatation 6 Absence of the vas deferens 4 Prostatic cyst 3 Seminal vesicle cyst 2 Seminal vesicle atresia - 1 Own work

23 ADC value of every testis was measured by placing at least 1cm2 circular ROI in the midsection of the organ.

24 Obstruction vs non-obstruction TV + changes in seminal tract AUC>0.95 Du J et al. Radiology 2010

25 RESULTS T1 SR T2 SR ADC VOLUME AGE OA 1.69 (0.19) (1.50) 876 (101) (6.89) 32 (6) NOA 1.68 (0.27) (2.37) 1114 (147) (5.12) 33 (5)

26 Sensitivity Sensitivity ROC curve analysis was used to determine the cutoff ADC value and cutoff testicular volume for distinguishing between OA and NOA. ADC VOLUME 1-Specificity 1-Specificity Parameters Cut-off AUC Sensitivity Specificity ADC 969,5 0,92 84% 88% VOLUME 12,4 0,81 94% 65%

27 Normal testicular volume indicates obstructive azoospermia Low ADC values indicate obstructive azoospermia Seminal tract disorders indicate obstructive azoospermia Midline cyst in prostate (or other changes stones, etc close to verumontanum) indicates obstructive azoospermia

28 Test? OA vs NOA TVsin = 15ml TVdx = 24ml

29 OA TVsin = 15ml TVdx = 24ml

30 Non-obstructive azoospermia (usually testes are smaller TAI >20%) - i.e. XXY Klinefelter syndrom (small and hard testes) - Cryptorchidism testicular hypotrophy - Testicular atrophy (post infective, liver cirrhosis, estrogen treatment, endocryne pituitary disorders, aging) - Orchitis (mumps virus) - Epididymo-orchitis (chronic) - Testicular tumors Pezzella et al. Human Reproduction 2014

31 Test? OA vs NOA TVsin = 11ml TVdx = 11ml

32 NOA Small testes Normal seminal tract

33 Disscusion and Conclusions Imaging in male infertility - Scrotal ultrasound - Transrectal Ultrasound - Magnetic Resonance Imaging - No role of CT (except testicular tumors)

34 Disscusion and Conclusions TRUS/TAUS - Non-obstructive vs obstructive azoospermia - Proximal vs distal obstruction (vasoepididymostomy) - Midline cyst - Cyst content aspiration

35 Disscusion and Conclusions MRI - Postsurgical evaluation - Non-obstructive vs obstructive azoospermia - Proximal vs distal obstruction (vasoepididymostomy) - Midline cyst - Testicular volumetry - Testicular structure

36 What the radiologist needs to know about varicocele

37 ...about varicocele Pampiniform plexus

38 What is varicocele? dilatation and tortuosity of the pampiniform plexus commonly on the left side ~15% of general male population ~40% of subfertile and infertile men

39 Commonly on the left side - why?

40 Varicocele? Primary due to incompetent or congenitally absent venous valves Secondary due to vein compression or obstruction - Nutcracer syndrome - Retroaortic left renal vein - Splenorenal shunting (portal hypertension) cm longer left TV

41 Anatomical variants of the left testicular veins Bahren s classification Bahren et al. Rofo 1992 Oct;157(4):

42 Clinical presentation asymptomatic, detected during medical examination or evaluation of infertile male scrotal mass/swelling scrotal pain testicular atrophy infertility or sub-fertility

43 Clinical presentation (grade III) bag of worms affected testis hangs down

44 Clinical classification (Dubin L and Amelar R. 1970) Grade I is detectable by palpation during VM Grade II is detectable by palpation but not visible on inspection Grade III is visible on inspection Clinical grade III Subclinical seen only in imaging

45 Grading of varicocele - short version Grade I Palpable only during Valsalva maneuver Grade II Palpable without Valsalva in standing upright position Grade III Visible through scrotal skin Subclinical detected during USG

46 Other classifications (real CHAOS) Based on venous size, blood pool, blood flow with the reflux during VM, presence of testicular hypotrophy, presence of subfertility No commonly accepted grading

47 Proposed classifications (WHO and Sarteschi et al) Grade III

48 My way to detect varicocele

49 Intratesticular varicocele not classified Bell D., Namdev R.

50 Pathophysiology of testicular changes in varicocele Adverse effects on spermatogenesis Reflux of renal and adrenal metabolites Hyperthermia - increases metabolic activity - depletion of glycogen storage - injury of testicular parenchyma (fibrosis) - oligospermia Hypoxia - Leydig cell dysfunction - low testosterone Local testicular hormonal imbalance

51 Histopathological changes Both testes affected evenly by unilateral varicocele Tubular thickening Interstitial fibrosis Maturation arrest Leydig cell dysfunction

52 Varicocele imaging Ultrasonography / Doppler ultrasonography Magnetic Resonance Imaging Computed Tomography Nuclear Medicine Venography Thermography

53 Color Doppler ultrasound tortuous anechoic tubular structures adjacent to the testis the diameter of the dominant vein at the inguinal canal measures more than 2.5 mm and is associated with an increase in diameter of at least 1 mm during a Valsalva maneuver. Using the diameter as the criteria of venous channel dilation, Hamm et al found that ultrasonography had a sensitivity of 92.2%, a specificity of 100%, and an accuracy of 92.7% (*) (*) Hamm B, Fobbe F, Sörensen R, Felsenberg D. Varicoceles: combined sonography and thermography in diagnosis and

54 Grading of varicocele size Preoperative duplex ultrasound parameters predicting male fertility after successful varicocelectomy Fahad M. Alshehri, MBBS, JBR-CMR, Mahboob H. Akbar. MCPS, FCPS, Adel K. Altwairgi, MBBS, SSCU, Omar J. AlThaqufi, MBBS, Saudi Board (Rad).

55 VM later

56 G.Iossa, D. Lazzarin J Ultrasound 2013 Jun; 16(2):

57 Reflux

58 Ultrasound 1. Testicular morphology (size, shape, echotexture, TV, TAI ) 2. Vascularization (size, reflux, spontaneous flow) 3. Follow-up (post therapeutic) 4. Masses

59 Magnetic Resonance Imaging gadolinium - enhanced delayed imaging in venous phase > mass of dilated serpiginous vessels, usually adjacent to the epididymal head the spermatic cord has a heterogeneous signal intensity Three-dimensional (3-D) phase-contrast magnetic resonance angiography (MRA) has been described in a series of 4 patients with recurrent varicoceles. The scrotal part of the varicocele was demonstrated in 3 patients, and the spermatic vein was shown in 2 patients. Some have suggested that this technique can provide an alternative to spermatic venography in the radiologic mapping of dilated spermatic veins von Heijne A. Acta Radiol Nov. 38(6):1020-2

60 Testicular morphology Pampiniform plexus TV and TAI Blood pool Blood flow Massess Magnetic Resonance Imaging T1 cor T2 cor T2 ax T2 sag DCE ax

61 Magnetic Resonance Imaging Apparent diffusion coefficient (ADC) values were significantly lower in patients with varicocele compared to healthy controls. Based on ADC values, the series demonstrated 90% sensitivity and 96% specificity for the diagnosis of these varicoceles while potentially providing the ability to detect fibrosis of the testicular parenchyma. Karakas E, Karakas O, Cullu N, Badem OF, Boyaci FN, et al. Diffusion weighted MRI of the testes in patients with varicocele: a preliminary study. AJR Am J Roentgenol 2014.

62 Magnetic Resonance Imaging Group 1 ipsilateral to V Group 2 contralateral to V Group 3 - healthy volunteers Karakas E, AJR Am J Roentgenol 2014.

63 Magnetic Resonance Imaging Apparent diffusion coefficient (ADC) values were significantly lower in patients with varicocele compared to healthy controls. ADC = 0.9 x10-3mm2/s Testicular morphology Pampiniphorm plexus TV and TAI Blood pool Blood flow Massess

64 Computed tomography in varicocele CT imaging to study retroperitoneal anatomy

65 Computed tomography (CT) CT imaging of nutcracker syndrome

66 Computed tomography (CT) in patients identified with a retro-aortic left renal vein on CT imaging - 77% were found to have varicoceles on scrotal ultrasound, which supports the hypothesis of increased hydrostatic pressures resulting in higher incidence of left-sided varicoceles * Retroperitoneal space Vessels TV and TAI Massess *Arslan H, Etlik O, Ceylan K, Temizoz O, Harman M, et al. Incidence of retro aortic left renal vein and its relationship with varicocele. Eur Radiol 2005

67 Scintigraphy labeled blood-pool scintigraphy detects varicoceles by demonstrating pooling of tracer on static images and reflux of tracer on dynamic images can evaluate and quantify the degree of spermatic vein reflux lack of standard diagnostic criteria make widespread practice impractical Freund J, Handelsman DJ, Bautovich GJ, Conway AJ, Morris JG. Detection of varicocele by radionuclide blood-pool scanning. Radiology 1980; 137: Geatti O, Gasparini D, Shapiro B. A comparison of scintigraphy, thermography, ultrasound and phlebography in grading of clinical varicocele. J Nucl Med: official Publication Soc Nucl Med 1991; 32: Paz A, Melloul M. Comparison of radionuclide scrotal blood-pool index versus gonadal venography in the diagnosis of varicocele. J Nucl Med: official Publication Soc Nucl Med 1998; 39: Kulis T, Kolaric D, Karlovic K, Knezevic M, Antonini S, et al. Scrotal infrared digital thermography in assessment of varicocele - pilot study to assess diagnostic criteria. Andrologia 2012; 44 Suppl 1:

68 Scrotal scintigraphy Koc Z, BMJ Case Reports 2012;

69 Scrotal scintigraphy Grade 0 Grade 1 Grade 2 Grade 3 Geatti et al. J Nucl Med. 1991

70 Scrotal scintigraphy Detection Dynamic, quantitative evaluation Objective, post treatment evaluation and FU

71 Venography left testicular venogram left testicular varicocele before embolization Varicocele Imaging. Khan AN et al. Emedicine, medscape

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74 Venography Venography following transjugular access. ć A: Left gonadal venogram with transjugular access demonstrating large left varicocele; B: Left gonadal venogram, following coil occlusion of the gonadal vein at the internal inguinal ring, demonstrating extensive retroperitoneal collateralization. Antegrade pampiniform plexus venography in recurrent varicocele: Case report and anatomy review. Gendel V et al, World J Radiol, 2011 Jul 28

75 Thermography infrared digital thermography of scrotum is a non-invasive diagnostic method for early varicocele detection by means of temperature measurement on the scrotal skin surface thermography of scrotum also proved as a useful diagnostic method in low-grade varicocele and as a follow-up method after the operative treatment Kulis T, Kolaric D, Karlovic K, Knezevic M, Antonini S, et al. Scrotal infrared digital thermography in assessment of varicocele - pilot study to assess diagnostic criteria. Andrologia 2012; 44 Suppl 1: Gat Y, Gornish M, Chakraborty J, Perlow A, Levinger U, Pasqualotto F. Azoospermia and maturation arrest: malfunction of v

76 Elevated scrotal temperature is restrained to left pampiniform plexus T. Kulis, M. Knezevic, K. Karlovic, D. Kolaric, S. Antonini, Z.Kastelan. Infrared digital thermography of scrotum in early selection of progressive varicocele. Med Hypotheses Oct;81(4):544-6

77 Take home messages 1. Working horse ultrasound 2. To diagnose azoospermia MRI 3. To treat varicocele interventional radiology 4. To diagnose early reccurent varicocele IR To look at - Visual inspection and thermography?

78 it s nice to know - Do you know this?

79 Thank you for your attention Medical University of Gdansk