Novel Assessment of Adolescent Testicular Sonographic Heterogeneity: An Analysis of Normal Variation, Comparison of Matched Adolescent Varicocele Populations and Adult Infertility Patients
Bradley A. Morganstern, MD1, Vinaya Vasudevan, MD1, Michael Jurewicz, MD2, Matthew Elsmari, BS2, Wayland Wu, MD1, Megan Murphy, None3, Bruce Gilbert, MD2, Lane S. Palmer, MD1, Sleiman R. Ghorayeb, PhD3.
1Cohen Children's Medical Center of New York, Hofstra Northwell School, New Hyde Park, NY, USA, 2Smith Institute for Urology, Hofstra Northwell School of Medicine, New Hyde Park, NY, USA, 3Departments of Radiology and Molecular Medicine, Hofstra Northwell School of Medicine, Hempsted, NY, USA.
We recently reported significant subtle differences in testicular heterogeneity in adolescents with varicoceles compared to normals. Moreover, we demonstrated that the unilateral process appears to have a bilateral effect that may correlate to global abnormal semen analysis sometimes seen in these patients. Herein, we report further investigations that may allow development of a novel method to help manage and counsel these patients by assessing normal variations, and comparing adolescents with varicoceles to aged matched norms and adult patients with varicoceles and infertility.
We sought to determine the normal heterogeneity index (HI) of adolescent testes and then compare the testes of adolescents with grade 2-3 varicoceles to the testes of adolescents with normal testicular sonograms, presenting with scrotal pain, in a 2:1 ratio. In addition, we compared the testes of adolescents with varicoceles to an adult population with known infertility and varicoceles. Representative static transverse images were examined using a novel program where the pixels of gray-scale images were transformed into a binary map to determine HI. Linear mixed models were used to compare HI and clinical parameters and ANOVAs were used to model each outcome as a function of group and surgery status.
Controls: Among 100 adolescent males; mean age 17.25 ± 1.44 years (range 15 to 21), there was a significant interaction between HI and age and laterality (p = 0.0141). The HI of the left testis increased with age while the HI of the right testis decreased.
Adolescent varicocele (n=50) vs. control (n=100): There was a significant association between HI and group (p < 0.0001). Specifically, the HI in varicocele subjects was significantly higher (mean 2.54, 95% CI: 2.37, 2.70) as compared to their normal controls (mean: 1.91, 95% CI: 1.79, 2.02). Laterality was not significantly associated with HI (p = 0.84) (Left: mean 2.23, 95% CI: 2.11, 2.33, Right: mean 2.22, 95% CI: 2.11, 2.33).
Adolescent varicocele (n=50) vs. adult infertile and varicocele (n=44): There was no significant testicular percent size discrepancy between adolescents and adults with 17.37% (95% CI: 11.93%, 22.81%) and 21.15% (95% CI: 14.51%, 27.79%), respectively (p = 0.27). There was a significant association between group and HI (p = 0.002): adolescents had significantly higher HI (2.52, 95% CI: 2.31, 2.74) as compared to adults (2.09, 95% CI: 1.82, 2.35). There was a significant association between group and sperm count (p = 0.04), after adjusting for surgery status (p = 0.0076) as adolescents tended to have higher sperm counts (median: 33.50, Q1: 12.50, Q3: 66.00) as compared to adults (median: 10.15, Q1: 0.10, Q3: 96.10). There was no significant association between groups and semen volume (p = 0.45).
The sonographic heterogeneity of adolescent testicles changes with age. Varicocele patients have bilaterally increased HI compared to norms. As patients with varicocele age, a drop in the HI may signal an increased risk for decreasing semen parameters and hence may be at jeopardy for infertility. This decrease in HI may be another tool to help surgeons to know when to intervene.
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