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Unintended Consequences of Ultrasound in Evaluation of Undescended Testes
Kristina D. Suson, MD, Cortney Wolfe-Christensen, PhD, J. Michael Zerin, MD, Jack S. Elder, MD, Yegappan Lakshmanan, MD.
Children's Hospital of Michigan, Detroit, MI, USA.

BACKGROUND: In 2013, the AUA in participation with the Choosing Wisely campaign, recommended that scrotal ultrasound not be ordered in evaluation of boys with undescended testes (UDT). We questioned the utilization of ultrasound in evaluation of UDT at our institution.
METHODS: After obtaining IRB approval, a retrospective analysis of all scrotal ultrasounds performed between January 1, 2010 and December 31, 2012 was performed. The radiographic studies, medical records, and operative reports were reviewed for boys on whom ultrasounds were performed for an indication of either UDT or retractile testis. Data points included result of study, referral to pediatric urology or pediatric surgery at this institution, and surgical treatment. A normal ultrasound was one in which both testes were visualized within the scrotum; an abnormal ultrasound was one in which one or both testes was either visualized outside of the scrotum or was not visualized. Statistical analyses included student’s T-test.
RESULTS: Of 616 scrotal ultrasounds performed on 535 boys, 146 were performed on 126 boys to evaluate for UDT or retractile testes without history of previous orchiopexy. Mean age at first ultrasound was 35.2±3.5 months. Ultrasound results and subsequent management for children referred to our institution prior to outside intervention are presented in Table 1. Of those referred, 77.8% had palpable testes. The mean age at surgery was 49.7±6.2 months. There was no difference in age at surgery between boys treated by pediatric urology or pediatric general surgery (p=0.42). Mean delay between ultrasound and surgical procedures was 9.3±1.3 months. The results of follow-up ultrasounds ordered for the same indication are presented in Table 2. Children who underwent multiple ultrasounds tended to be older at the time of surgery, but this did not reach statistical significance (47.1±6.8 versus 84.4±13.4 months, p=0.09).
CONCLUSIONS: Scrotal ultrasounds are ordered at a rate that is likely underestimated by pediatric urologists, as many patients with ultrasounds read as “normal” may not be referred. Of significant concern, scrotal ultrasound was associated with delayed orchiopexy. Initial abnormal ultrasounds are unlikely to change with repeated exams and may lead to even greater surgical delay. Adherence to the Choosing Wisely recommendations will not only decrease cost, but more importantly, may improve compliance with early referral/surgery recommendations.
Table 1: Ultrasound Results and Subsequent Management
N
(pts)
Referral to this InstitutionUrology EvaluationGeneral Surgery EvaluationSurgical Management
Normal Ultrasound31131212
8 Descended
3 Retractile
1 UDT
0 Nonpalp
1 Nonpalp1 Urology
1 General Surgery
Abnormal Ultrasound9454441042
3 Descended
10 Retractile
22 UDT
9 Nonpalp
4 UDT
6 Nonpalp
31 Urology
11 General Surgery

Table 2: Results of Subsequent Scrotal Ultrasounds
Initial UltrasoundSecond UltrasoundThird Ultrasound
Normal3 Normal
1 Abnormal
Abnormal1 Normal
9 Abnormal
2 Abnormal


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