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Ultrasound evaluation of varicoceles: guidelines and recommendations of the European Society of Urogenital Radiology Scrotal and Penile Imaging Working Group (ESUR-SPIWG) for detection, classification, and grading

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Abstract

Varicoceles are relatively common particularly in asymptomatic men and are even more prevalent in subfertile men, representing the most common potentially correctable cause of male infertility. Ultrasound (US) is the imaging modality of choice for varicocele evaluation, but there is no widely accepted consensus on examination technique, diagnostic criteria, or classification. In view of this uncertainty, the guideline writing group (WG) of the European Society of Urogenital Radiology (ESUR) Scrotal and Penile Imaging Working Group (ESUR-SPIWG) undertook a literature review and assessment of the quality of relevant evidence. The group then produced evidence-based recommendations for varicocele US examination, interpretation, and classification by consensus agreement. The results are presented in the form of 15 clinical questions with a brief summary of the relevant evidence and the authorised recommendations from the SPIWG. This paper provides a short summary of the evidence evaluation and the complete recommendations.

Key Points

• Varicocele is a common clinical problem; it is highly prevalent amongst subfertile men and the most common potentially correctable cause of male infertility.

• Ultrasound is the imaging modality of choice for varicocele assessment, but there is no generally agreed consensus on the US examination technique or the criteria that should be used for diagnosis, grading, and classification.

• This paper summarises the recommendations of the ESUR-SPIWG for standardising the US assessment of varicoceles. This includes examination technique, image interpretation, classification, and reporting.

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Abbreviations

AGREE:

Appraisal of Guidelines for Research and Evaluation

AVMs:

Arteriovenous malformations

ESUR:

European Society of Urogenital Radiology

GRADE:

Grading of Recommendations Assessment, Development and Evaluation

H:

Height

L:

Length

OCEBM:

Oxford Centre for Evidence Based Medicine

PICO:

Patient Problem (or Population), Intervention, Comparison or Control, Outcome

Sec:

Seconds

SPIWG:

Scrotal and Penile Imaging Working Group

V:

Volume

W:

Width

WG:

Guideline writing group

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Author notes

  1. Simon Freeman and Michele Bertolotto are joint first authors (making an equal contribution to this manuscript).

Authors and Affiliations

  1. University Hospitals Plymouth NHS Trust, Derriford Hospital, Derriford Road, Crownhill, Plymouth, Devon, PL6 8DH, UK

    Simon Freeman

  2. Department of Radiology, Ospedale di Cattinara, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy

    Michele Bertolotto

  3. Brighton and Sussex University Hospitals NHS Trust, Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, UK

    Jonathan Richenberg

  4. Royal Liverpool University Hospital, Prescot street, Liverpool, L7 8XP, UK

    Jane Belfield

  5. Department of Radiology, University of Rochester, 601 Elmwood ave, Rochester, NY, 14642, USA

    Vikram Dogra

  6. King’s College Hospital NHS Foundation Trust, Department of Radiology, King’s College Hospital, Denmark Hill, London, SE5 9RS, UK

    Dean Y. Huang & Paul S. Sidhu

  7. Andrology, Female Endocrinology and Gender Incongruence Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Viale Pieraccini 6, I-50139, Florence, Italy

    Francesco Lotti

  8. Department of Radiology, Medical University of Gdansk, Mariana Smoluchowskiego 17, 80-214, Gdansk, Poland

    Karolina Markiet, Katarzyna Skrobisz & Michal Studniarek

  9. Faculty of Medicine, Center of Radiology, Clinical Center of Vojvodina, University of Novi Sad, Hajduk Veljkova 1-9, Novi Sad, 21000, Serbia

    Olivera Nikolic

  10. Department of Clinical Imaging, Weill Cornell Medical College, Al-Wakra Hospital, Hamad Medical Corporation, PO Box 82228, Doha, Qatar

    Subramaniyan Ramanathan

  11. Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA

    Parvati Ramchandani

  12. Department of Adult Diagnostic and Interventional Radiology, Bicetre University Hospital, 78 avenue du Général Leclerc, 94270, Le Kremlin Bicêtre, France

    Laurence Rocher

  13. Imagerie par Résonance Magnétique Médicale et Multi-Modalités, CNRS UMR8081, Service Hospitalier Frédéric Joliot, 4, Place du Gal Leclerc, 91401, Orsay Cedex, France

    Laurence Rocher

  14. Faculty of Medicine, Department of Radiology, Dokuz Eylul University, Izmir, Turkey

    Mustafa Secil

  15. Department of Clinical Radiology, Medical School, University of Ioannina, University Campus, 45110, Ioannina, Greece

    Athina Tsili

  16. Department of Radiology, Faculty of Medicine, Istinye University, Istanbul, Turkey

    Ahmet Tuncay Turgut

  17. Private Hospital S.M. Maddalena, Occhiobello, Rovigo, Italy

    Pietro Pavlica

  18. Department of Health Sciences (DISSAL), Emergency Radiology, University of Genoa, Policlinico San Martino, Largo R. Benzi, I16122, Genoa, Italy

    Lorenzo E. Derchi

Authors
  1. Simon Freeman
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  2. Michele Bertolotto
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  3. Jonathan Richenberg
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  4. Jane Belfield
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  5. Vikram Dogra
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  6. Dean Y. Huang
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  7. Francesco Lotti
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  20. Lorenzo E. Derchi
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Consortia

members of the ESUR-SPIWG WG

Corresponding author

Correspondence to Simon Freeman.

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Guarantor

The scientific guarantor of this publication is Dr. Simon Freeman on behalf of the Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology (ESUR-SPIWG).

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was not required for this study because this paper provides a summary of available evidence and expert opinion; no new studies on patients were involved.

Ethical approval

Institutional Review Board approval was not required because this is an evidence summary and expert recommendation paper. No new studies on human patients were undertaken specifically for this paper.

Study subjects or cohorts overlap

All previous studies cited as evidence in this paper are acknowledged in the references.

Methodology

• Multicentre authored paper on behalf of the Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology (ESUR-SPIWG). Literature review, evidence summary, and expert recommendations.

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Freeman, S., Bertolotto, M., Richenberg, J. et al. Ultrasound evaluation of varicoceles: guidelines and recommendations of the European Society of Urogenital Radiology Scrotal and Penile Imaging Working Group (ESUR-SPIWG) for detection, classification, and grading. Eur Radiol 30, 11–25 (2020). https://doi.org/10.1007/s00330-019-06280-y

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  • DOI: https://doi.org/10.1007/s00330-019-06280-y

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