Page 138 - Remedial Andrology

Small hypoechoic/hyperechoic areas may be diagnosed as intra-testicular cysts, focal Leydig cell hyperplasia,
fibrosis and focal testicular inhomogeneity after previous pathological conditions. Hence, they require careful
periodic US assessment and follow-up, especially if additional risk factors for malignancy are present (i.e.,
infertility, bilateral TM, history of cryptorchidism, testicular atrophy, inhomogeneous parenchyma, history of
testicular tumour, history of/contralateral tumour) [1458].

In the case of interval growth of a lesion and/or the presence of additional risk factors for malignancy, testicular
biopsy/surgery may be considered, although the evidence for adopting such a management policy is limited.
In 145 men referred for azoospermia who underwent US before testicular biopsy, 49 (34%) had a focal
sonographic abnormality; a hypoechoic lesion was found in 20 patients (14%), hyperechoic lesions were seen
in 10 patients (7%); and, a heterogeneous appearance of the testicular parenchyma was seen in 19 patients
(13%). Of 18 evaluable patients, 11 had lesions < 5 mm; all of which were confirmed to be benign. All other
patients with hyperechoic or heterogeneous areas on US with subsequent tissue diagnoses were found to
have benign lesions. The authors concluded that men with severe infertility who have incidental testicular
lesions, negative tumour markers and lesions < 5 mm may be observed with serial scrotal US examinations and
enlarging lesions or those of greater dimension can be considered for histological biopsy [1610].

Other studies have suggested that if a testicular lesion is hyperechoic and non-vascular on colour Doppler US
and associated with negative tumour markers, the likelihood of malignancy is low and consideration can be
given to regular testicular surveillance, as an alternative to radical surgery. In contrast, hypoechoic and vascular
lesions are more likely to be malignant [1611-1615]. However, most lesions cannot be characterised by US
(indeterminate), and histology remains the only certain diagnostic tool. A multidisciplinary team discussion
(MDT), including invasive diagnostic modalities, should therefore be considered in these patients.

The role of US-guided intra-operative frozen section analysis in the diagnosis of testicular cancer in
indeterminate lesions remains controversial, although several authors have proposed its value in the intra-
operative diagnosis of indeterminate testicular lesions [1616]. Although the default treatment after patient
counselling and MDT discussion may be radical orchidectomy, an US-guided biopsy with intra-operative frozen
section analysis may be offered as an alternative to radical orchidectomy and potentially obviate the need for
removal of the testis in a patient seeking fertility treatment. In men who have severe abnormalities in semen
parameters (e.g., azoospermia), a concurrent mTESE can also be performed at the time of diagnostic biopsy
(Panel recommendations).

In summary, if an indeterminate lesion is detected incidentally on US in an infertile man, MDT discussion is
highly recommended. Based upon the current literature, lesions < 5mm in size are likely to be benign and
serial US and self-examination can be performed. However, men with larger sized lesions (> 5mm), which are
hypoechoic or demonstrate vascularity, may be considered for open US-guided testicular biopsy, testis sparing
surgery with tumour enucleation for frozen section examination or radical orchidectomy. Therefore, in making
a definitive treatment decision for surveillance vs. intervention, consideration should be given to the size of the
lesion, echogenicity, vascularity and previous history (e.g., cryptorchidism, previous history of germ cell tumour
[GCT]). If intervention is to be undertaken in men with severe hypospermatogenesis (e.g., azoospermia), then a
simultaneous TESE can be undertaken, along with sperm banking.

10.3.6.1.2 Varicocele
At present, the clinical management of varicocele is still mainly based on physical examination; nevertheless,
scrotal colour Doppler US is useful in assessing venous reflux and diameter, when palpation is unreliable and/or
in detecting recurrence/persistence after surgery [1458]. Definitive evidence of reflux and venous diameter may
be utilised in the decision to treat (Refer to Section 10.4.3.1 and 10.4.3.2).

10.3.6.1.3 Other
Scrotal US is able to detect changes in the proximal part of the seminal tract led due to obstruction. Especially
for CBAVD patients, scrotal US is a favourable option to detect the abnormal appearance of the epididymis.
Given that, three types of epididymal findings are described in CBAVD patients: tubular ectasia (honeycomb
appearance), meshwork pattern, and complete or partial absence of the epididymis [1617, 1618].

10.3.6.2 Transrectal US
For patients with a low seminal volume, acidic pH and severe oligozoospermia or azoospermia, in whom
obstruction is suspected, scrotal and transrectal US are of clinical value in detecting CBAVD and presence or
absence of the epididymis and/or seminal vesicles (SV) (e.g., abnormalities/agenesis). Likewise, transrectal US
(TRUS) has an important role in assessing obstructive azoospermia (OA) secondary to CBAVD or anomalies

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