Varicocele ATHENS. Section VII- Recommendations/guidelines issued by the working group. Michele Bertolotto. 4-6 October 2018

Transcription

1 ATHENS 4-6 Octber 2018 Eurpean Sciety f Urgenital Radilgy Sectin VII- Recmmendatins/guidelines issued by the wrking grup Variccele Michele Bertltt Dept Radilgy - University f Trieste (IT)

2 A histry f increasing varicsities Or.the histry f the variccele paper f the SPIWG Meeting f the SIWG Vienna, March 5, 2015 Series f technical hw t d prperly guidelines suggested starting with imaging varicceles August 26, 2015 In preparatin f the meeting in Cpenhangen «I wuld like t suggest we discuss a prject t issue standard practice fr the ultrasund assessment f a variccele t get this examinatin prcedure similar acrss Eurpe. It shuld be evidence based, particularly fr lking at the left kidney fr a tumur!» Cpenhagen, September 17, 2015 Imaging varicceles - PS t lead and crdinate. Hw t quantify, shuld the kidneys be scanned etc. The paper shuld have justificatin and needs t be evidence based t prvide guidance fr imaging. Others keen t participate MB, PP, JB, SF, JR. Need t start with literature search

3 A histry f increasing varicsities Or.the histry f the variccele paper f the SPIWG Octber 30, MB cntacts VD and PP fr discussin In preparatin f the 25 th Natinal Cngress SIUMB Nvember 16, 2015 Fcus: «Variccele: Diagnsis» «In USA, clr Dppler and ultrasngraphic grading is nt perfrmed fr variccele. Patients are managed based n clinical basis nly (WHO grading and spermigram)» «Variccele is a mess bth frm the clinical and frm the therapeutic pint f view. There is n establish clinical evidence. We d nt knw why it cmes, and hw t make diagnsis. Clinical appearance is subjective, imaging is definitely useful»

4 A histry f increasing varicsities Or.the histry f the variccele paper f the SPIWG Nw aware f the extreme cmplexity f the tpic Decisin t fcus n imaging nly Decisin t define clinical questins in terms f specific patient prblems and fund clinically relevant evidence in literature (PICO mdel) Decisin t share the questins amng the members February 29, 2016 First pl f questins addressing the imaging apprach t varicceles March 10, 2016 Systematic literature search June 6, 2018: first cmplete draft f the paper Six weeks f discussin n the single pints amng all the members f the SPIWG July 22, 2018: final cmplete draft released

5 A histry f increasing varicsities Or.the histry f the variccele paper f the SPIWG Barcelna, September 14, 2018 Vting recmmendatins Simn, Jane and Jnathan in charge t edit Where t submit? (several ptins under discussin)

6 Systematic review - Methds Establishment f the guidelines WG Inventry f prblems in imaging variccele Frmulatin f 15 clinically relevant questins Systematic literature search (PubMed, Web f Science, Embase, Cchrane Library) Additinal systematic searches n selected tpics (when needed) Titles and abstracts screened fr rilevance Additinal rilevant literature frm the reference list f the retrieved articles and using the PubMed functin «Cited References»

7 Systematic review - Methds Frmulatin f recmmendatins based n available literature and cnsensus f the guidelines WG Quality f studies graded accrding t the Oxfrd Centre fr Evidence Based Medicine (OCEBM) 2011 Strenght f recmmendatins scred accrding with the GRADE system A: High B: Mderate C: Lw D: Very Lw (expert pinin) OCEBM Levels f Evidence Wrking Grup (2011), Essential Evidence Plus,

8 Questin #1 What is the evidence fr crrelatin between variccele, spermatgenesis damage and infertility? The facts: It is difficult t assciate variccele and infertility, since the latter has been ften studied withut taking int accunt the female factrs f infertility, particularly age Variccele has a detrimental effect n spermatgeneis There is evidence that clinically palpable, rather than nn-palpable, varicceles are assciated with infertility There is assciatin between clinical variccele and ipsilateral testicular atrphy There is n prven crrelatin between the degree f testicular tissue damage and the degree f the variccele There is cnflicting evidence regarding the value f variccele repair in male infertility

9 Questin #1 What is the evidence fr crrelatin between variccele, spermatgenesis damage and infertility? Answer: The current level f evidence is insufficient fr prviding a definite ptin

10 Questin #2 Hw is varicceles classified at ultrasund? The facts: There is a general agreement in Eurpe that evaluatin f the presence and characteristics f the venus reflux is useful Patients with reflux have significantly impaired semen analysis parameters cmpared t patients withut reflux The main predictive factr f a better seminal respnse after variccele crrectin is the evidence at preperative clur Dppler US f venus reflux at baseline examinatin A number f classificatins fr variccele have been prpsed The purpse f every classificatin system is t prvide useful mrphlgical and hemdynamic infrmatin fr treating variccele and predict treatment utcme

11 Questin #2 Hw is varicceles classified at ultrasund? Variccele classificatins - shrtcmings Classificatins differ regarding the examinatin technique and the parameters used The threshlds used t differentiate between nrmal and pathlgical findings are ften different There is n universal and recgnized system t classify variccele severity. A clear cnsensus has nt been reached Recmmendatin #1 Grey scale and Dppler US mdes are used t assess the parameters required fr variccele classificatin. There is n universally recgnized classificatin system (LE 3, GR C). Strng cnsensus (21/0/0, 100%)

12 Questin #3 Shuld the size f the dilated veins be measured? If s, shuld measurements be perfrmed standing r supine, at rest r during the Valsalva maneuvre? Which size threshld shuld be used fr the dilated veins? The facts: The size threshld f the veins that meets the definitin f variccele varies in the different studies, as well as the examinatin technique emplyed, and the measurement sites. The largest vein is measured in the majrity f cases, irrespective f its lcatin There is n cnsensus n the cut-ff values t define variccele by the maximum venus diameter 3mm r mre is cmmnly cnsidered diagnstic fr variccele

13 Questin #3 Recmmendatin #2 Given the widespread methdlgical variability that exists in measurements f venus diameter in variccele assessment, it is critically imprtant t dcument the patient s psitin, whether measurement was made at rest r during the Valsalva maneuvre, and the lcatin f the measured veins relative t the spermatic crd r testis (LE 1, GR A). Strng cnsensus (21/0/0, 100%) Recmmendatin #3 Measurement f the largest vein, irrespective f lcatin, with the patient in the upright psitin and during the Valsalva maneuvre is recmmended (LE 5, GR D). Strng cnsensus (21/0/0, 100%) Recmmendatin #4 A maximum venus diameter f 3mm r mre can be cnsidered diagnstic fr a variccele when measured with the patient in the upright psitin and during the Valsalva maneuvre, (LE 2, GR B). Strng cnsensus (20/1/0, 95%)

14 Questin #4 When t measure testicular size at ultrasund, and hw? The facts: Reductin in germ-cell number results in a reductin f the testicular vlume The pled data fr nrmal testicular vlume measured at ultrasund vary widely. a ttal testicular vlume f ml r mre is indicative f nrmal testicular functin fr Caucasians and Africans There are different methds t measure testicular vlume with US. the Lambert s frmula (V=LxWxHx0.71) best estimates the true vlume H W L

15 Questin #4 Recmmendatin #5 Testicular vlume shuld be measured in all cases as it crrelates with testicular functin in bth infertile patients and patients with a variccele (LE 1, GR A). Strng cnsensus (21/0/0, 100%) Recmmendatin #6 Accurate measurement f the three diameters f the testis is required t btain a testicular vlume estimatin. Use f Lambert s frmula (V=LxWxHx0.71) is recmmended. The mathematical frmula used t calculate the vlume shuld be reprted (LE 2, GR B). Brad cnsensus (19/1/1, 95%)

16 Questin #5 Hw shuld US be perfrmed in patients with variccele? The facts: Lack f technical standardizatin leads t cnflicting results Vein diameter and flw measurements depend n prbe psitin, patient psitin, patient breathing, degree f Valsalva The machine needs t be set accurately t lk fr slw flw Recmmendatin #7 A standardised prtcl is required fr variccele ultrasund examinatin. A grey-scale and clur Dppler examinatin, with spectral Dppler analysis, shuld be perfrmed bilaterally with the patient supine and standing, during spntaneus breathing and during the Valsalva maneuvre. (LE 2, GR B). Strng cnsensus (21/0/0, 100%)

17 Questin #6 Is spectral Dppler evaluatin f venus reflux needed and which parameters shuld be measured? The facts: Reflux is cnsidered the primary cause fr testicular damage It is thught that if reflux is eliminated, the negative effect n spermatgenesis culd reverse. This is at the basis f the therapeutic strategies fr variccele crrectin Supprting this scenari, Dppler evaluatin f reflux is critical Diagnsis f reflux is btained cmbining clur Dppler and spectral analysis The examinatin technique is crucial

18 Questin #6 Recmmendatin #8 Demnstrating and evaluating reflux flw in patients being assessed fr varicceles is the mst imprtant part f the Dppler ultrasund study (LE 3, GR C). Strng cnsensus (21/0/0, 100%) Recmmendatin #9 Clur Dppler interrgatin shuld be supplemented with spectral Dppler analysis. Reflux duratin is the essential parameter t be measured (LE 3, GR C). Measurement f the reflux peak velcity is ptinal (LE 5, GR D). Strng cnsensus (21/0/0, 100%)

19 Questin #7 Hw lng shuld reflux last t make diagnsis f variccele? The facts: A variety f descriptins exist regarding the characteristics and the duratin f reflux Different classificatin systems use different duratin threshlds The majrity f investigatrs classify as permanenent a reflux lasting >2s Recmmendatin #10 Reflux in the testicular veins lasting mre than 2s with the patient standing and during the Valsalva maneuvre shuld be cnsidered t be abnrmal (LE 4, GR C). Strng cnsensus (21/0/0, 100%)

20 Questin #8 Is the reflux velcity clinically imprtant, and hw shuld it be measured? The facts: There is a lack f cnsensus n where and hw t perfrm the measurement In mst studies angle crrectin was nt perfrmed and, therefre, the velcity values btained culd nt be regarded as crrect Recmmendatin #11 There is insufficient data t recmmend using reflux peak velcity measurements as a factr in determining the need fr variccele repair (LE 5, GR C). Strng cnsensus (21/0/0, 100%)

21 Questin #9 Hw shuld US examinatins be reprted in patients with varicceles? The facts: The variability encuntered in clinical practice in reprting patients with varicceles reflects the differences in examinatin techniques It is critical t reprt hw the examinatin has been perfrmed It is nt mandatry t grade variccele accrding t ne f the many classificatins, but this may be helpful in the clinical practice A standardized reprt cntaining all relevant parameters culd be useful

22 Questin #9 Recmmendatin #12 When issuing reprts n patients with varicceles the examinatin technique shuld be described (LE 1, GR A). Strng cnsensus (21/0/0, 100%) Recmmendatin #13 Grading varicceles accrding t the Sarteschi s classificatin may be helpful in clinical practice. Fr standardisatin purpses it is recmmended that all the US parameters used t evaluate the patient are als reprted. (LE 5, GR D). Strng cnsensus (21/0/0, 100%)

23 Questin #9 Sarteschi s classificatin Patient psitin: supine & standing Identificatin f enlarged veins Evaluatin f testicular vlume and echtexture Evaluatin f reflux Sarteschi LM, Pali R, Bianchini M, Menchini Fabris GF, Girnale Italian di Ultrasnlgia 1993; 4:43-49 Inguinal Supra-testicular Peri-testicular Intra-testicular

24 Questin #9 Sarteschi s classificatin Grade I - Inguinal reflux nly during Valsalva in nt enlarged vessels Grade II - Supra-testicular varicsities with reflux nly during Valsalva Grade III - Peri-testicular reflux nly during Grade IV - Enlarged vessels in supine and Valsalva in enlarged vessels. Visible but nt dilated standing psitin, with increasing caliber with vessels when supine. Enlarged when standing Valsalva. Reflux at rest, increasing during Valsalva. Pssible testicular hypthrphy

25 Questin #9 Sarteschi s classificatin Intratesticular variccele Grade V - Enlarged vessels in supine and standing psitin, with caliber nt increasing with Valsalva. Reflux at rest, nt increasing during Valsalva. Testicular hypthrphy. Intratesticular varices may be present Rest Valsalva Right Left

26 Questin #9 The SPWIG believes that a number f infrmatin shuld be enclsed in the ultrasngraphic reprt: Testicular vlume, echgenicity and echtexture; Presence f the varices and relatinships with testis (inguinal canal, supra-testicular, arund the testis, intratesticular); Diameter f the largest vein (irrespective f the lcatin) measured while standing and during the Valsalva maneuvre; Changes f flw at clur Dppler interrgatin and spectral analysis in the spermatic veins accrding with patient s psitin and befre and during Valsalva

27 Questin #9 Example f standardized reprt Testicular diameters (L, W, H) in mm Testicular vlume (Lambert's frmula: LxWxHx0.71) Testicular echgenicity abnrmality Yes/N Intratesticular variccele Yes/N R L SUPINE psitin Diameter f the largest vein (mm) Lcatin f the largest vein (Spermatic crd /peritesticular) Spntaneus reflux at clur Dppler (Yes/N) Reflux during Valsalva maneuvre Yes/N Level where reflux is identified (inguinal canal, supratesticular, peritesticular) Reflux velcity (ptinal) STANDING psitin Diameter f the largest vein (mm) Lcatin f the largest vein (Spermatic crd /peritesticular) Spntaneus reflux at clur Dppler (Yes/N) Reflux during Valsalva maneuvre Yes/N Duratin f reflux (s) Level where reflux is identified (inguinal canal, supratesticular, peritesticular) Reflux velcity (ptinal) CONCLUSION: Testicular atrphy: Yes/N Variccele: Yes/N Variccele Grade (Sarteschi s classificatin) Any ther relevant findings:

28 Questin #10 Is evaluatin f intratesticular Dppler wavefrms wrthwhile in imaging varicceles? The facts: It is hypthesized that impaired venus drainage culd increase venus pressure in the spermatic veins Sme studies failed t demnstrate alteratin f testicular bld flw in variccele patients. Other studies claimed fr presence f alteratins Recmmendatin #14 Evaluatin f intra-testicular bld flw in patients with varicceles is an active research field which might prvide a valuable insight int the mechanisms that create testicular parenchymal damage. At present hwever, this evaluatin cannt be recmmended fr clinical use. (LE 3, GR C). Strng cnsensus (21/0/0, 100%)

29 Questin #11 Can evidence-based recmmendatins be prvided fr imaging right-sided varicceles? The facts: Althugh clinical variccele may be bilateral, it is unilateral in mst patients and almst always n the left side Subclinical right-sided variccele is relatively frequent Several authrs cnsider variccele a bilateral disease Islated right-sided variccele is subclinical in the majrity f cases, fund in less than 1% f patients. Literature is scarce and is rarely fcused n this tpic A variety f causes can result in right-sided clinical variccele (venus thrmbsis, tumur invasin r cmpressin, anatmical variatins )

30 Questin #11 Recmmendatin #15 Bilateral clur Dppler US shuld be perfrmed in patients with left-sided varicceles as it will frequently reveal subclinical right-sided varicceles (LE 3, GR B). Strng cnsensus (21/0/0, 100%) Recmmendatin #16 In patients with an islated clinical right-sided variccele, US can be extended t the abdmen t lk fr abdminal and retrperitneal pathlgy, as well as cngenital vascular anmalies. (LE 5, GR D). Strng cnsensus (21/0/0, 100%)

31 Questin #12 Is imaging fllw-up necessary fr subclinical varicceles? The facts: Variccele repair significantly imprves semen parameters nly in men with clinical varicceles Subclinical varicceles can prgress t clinically evident disease Testicular hyptrphy is the mst cmmn indicatin fr prphylactic variccele repair in adlescents. Sme studies suggest fllw-up in patients with nrmal semen analysis Fllw-up is advised fr nn-perated patients. With cnsideratin t thse at increased risk fr prgressive testicular dysfunctin Recmmendatin #17 In patients with subclinical varicceles imaging fllw-up is recmmended in all adlescents wh have nt undergne surgical repair and in yung adults with nrmal semen analysis and nrmal testicular vlume (LE 3, GR C). Strng cnsensus (20/0/1, 100%)

32 Questin #13 Shuld patients be fllwed-up after variccele treatment? The facts: There is agreement that ultrasngraphy can be used early after the treatment in case f pstperative cmplicatins, and later, when needed, t evaluate mrphlgy f the pampinifrm plexus, testicular vlume and signs f persistent r recurrent disease A clinical evaluatin after surgery can detect enlarged veins, but nly clur Dppler with spectral analysis can discriminate if there is still venus bld reflux The clinical wrkup f patients differs as regards indicatins f imaging fllwing variccele repair, timing, and length f the sngraphic fllw-up

33 Questin #13 Recmmendatin #18 After variccele repair US can be used t identify early pstperative cmplicatins (LE 3, GR C). Strng cnsensus (21/0/0, 100%). Strng cnsensus (21/0/0, 100%) Recmmendatin #19 Sperm analysis frms the basis f fllw-up fllwing variccele repair. The data available des nt supprt the rutine use f US (LE 1, GR A). Brad cnsensus (18/1/2, 95%) Recmmendatin #20 Clur Dppler US can be used after variccele repair if semen analysis remains unsatisfactry t evaluate testicular vlume and identify signs f persistent r recurrent disease (LE 2, GR B). Strng cnsensus (21/0/0, 100%)

34 Questin #14 Is it always necessary t examine the abdmen fr tumurs in patients with a newly discvered variccele? The facts: Variccele is almst never a sle feature f a renal r retrperitneal tumur and sme ther features f the tumur are evident frm the histry r examinatin There are n data that currently supprt extended US examinatin in all patients with a newly diagnsed variccele. An exceptin t this is in children less than 9 years f age presenting with variccele The pssibility t meet a previusly undetected retrperitneal lesin during a Dppler investigatin fr variccele is very unlikely, but cannt be cmpletely excluded in clinical practice. The snlgist is fully justified in getting suspicin f a secndary variccele and extend US t the abdmen when the variccele is f acute nset, whatever the side, and particularly when it remains unchanged in the supine psitin

35 Questin #14 Recmmendatin #21 Extended US examinatin t the abdmen is recmmended in children less than 9 years f age presenting with acute variccele (LE 2, GR B). Strng cnsensus (21/0/0, 100%) Recmmendatin #22 There is insufficient evidence t cnclude that an extensin f the ultrasund examinatin f the abdmen is mandatry in all adult patients with a variccele. The ultrasund practitiners shuld use their clinical judgement t decide whether t prceed t an abdminal examinatin, particularly if the variccele is large, f recent nset and persists with the patient in the supine psitin (LE 5, GR D). Strng cnsensus (21/0/0, 100%)

36 Questin #14 Right Left 57y men presenting with left variccele Right Left

37 Questin #15 What are the pitfalls in US when imaging varicceles? The facts: Patients with extratesticular cavernus haemangimas, lymphangimas, and arterivenus malfrmatins can present with a nn-specific diagnsis, r with suspicius variccele based n clinical presentatin Clur Dppler interrgatin is imprtant t differentiate between variccele and ther tubular structures n grey-scale ultrasngraphy Recmmendatin #23 In patients being investigated fr a clinically detected variccele, the pssibility f rare variccele mimics shuld be cnsidered. The crrect diagnsis can usually be made by cmbining the grey-scale and Dppler US features (LE 5, GR D) Strng cnsensus (21/0/0, 100%)

38 Take-hme Cmmn urlgical prblem Regarded as a majr cause f impaired spermatgenesis and the mst cmmn cause f male infertility The clinical rle f imaging remains cntrversial Examinatin techniques needs t be standardized Evidence based recmmendatins prvided, r expert pinin when evidence is lacking

39 Take-hme Cmmn urlgical prblem Regarded as a majr cause f impaired spermatgenesis and the mst cmmn cause f male infertility The clinical rle f imaging remains cntrversial Examinatin techniques needs t be standardized Evidence based with recmmendatins a little help frm prvided, ur friends r expert pinin when evidence is lacking Of the SPIWG Thank yu