Stesura Seveso Archivio Italiano di Urologia e Andrologia 2014; 86, 156 Practical recommendations for performing ultrasound scanning in the urological and andrological fields Aim: US scanning has been defined as the urologist’s stethoscope. These recommendations have been drawn up with the aim of ensuring minimum standards of excellence for ultrasound imaging in urological and andrological practice. A series of essential recommendations are made, to be followed during ultrasound investigations in kidney, prostate, bladder, scrotal and penile diseases. Methods: Members of the Imaging Working Group of the Italian Society of Urology (SIU) in collaboration with the Italian Society of Ultrasound in Urology, Andrology and Nephrology (SIEUN) identified expert Urologists, Andrologists, Nephrologists and Radiologists. The recommendations are based on review of the literature, previously published recommendations, books and the opinions of the experts. The final document was reviewed by national experts, including members of the Italian Society of Radiology. Results: Recommendations are listed in 5 chapters, focused on: kidney, bladder, prostate and seminal vesicles, scrotum and testis, penis, including penile echo-doppler. In each chapter clear definitions are made of: indications, technological standards of the devices, the method of performance of the investigation. Pasquale Martino 1, Andrea Benedetto Galosi 2, Marco Bitelli 3, Paolo Consonni 4, Fulvio Fiorini 5, Antonio Granata 6, Roberta Gunelli 7, Giovanni Liguori 8, Silvano Palazzo 1, Nicola Pavan 8, Vincenzo Scattoni 9, Guido Virgili 10, and Imaging Working Group - Società Italiana Urologia (SIU) in collaboration with the Società Italiana Ecografia Urologica Andrologica Nefrologica (SIEUN) Reviewers: Libero Barozzi 11, Michele Bertolotto 12, Andrea Fandella 13, Paolo Rosi 14, Carlo Trombetta 8 1 Department of Emergency and Organ Transplantation-Urology I, University “Aldo Moro”, Bari, Italy 2 Division of Urology, “Murri” General Hospital, ASUR Marche, Fermo, Italy 3 Department of Urology - Andrology Unit, Ospedale San Sebastiano Martire, Frascati, Roma 4 U.O. Urologia - Casa di Cura “S. Maria”, Castellanza, Italy 5 Nefrologia SOC - Azienda Sanitaria ULSS 18 Rovigo, Rovigo, Italy 6 U.O. Nefrologia e Dialisi - ASP Agrigento, Agrigento, Italy 7 U.O. Urologia Ospedale G.B. Morgagni-L. Pierantoni - Azienda USL di Forlì, Forlì, Italy 8 Department of Urology, University of Trieste, Ospedale di Cattinara, Trieste, Italy 9 Department of Urology, University Vita-Salute, Scientific Institute San Raffaele, Milan, Italy 10 Department of Urology, University of Tor Vergata, Rome, Italy 11 Emergency, Surgery and Transplants Department - Radiology Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy 12 UCO di Radiologia, Dipartimento di Scienze Mediche, Chirurgiche e della Salute Università degli Studi di Trieste, Ospedale di Cattinara, Trieste, Italy 13 Divisione Urologica, Casa di Cura Giovanni XXIII, Monastier (Treviso), Italy 14 Clinica Urologica ed Andrologica, University of Perugia, Perugia, Italy. Summary REVIEW The findings to be reported are described and discussed, and examples of final reports for each organ are includ- ed. In the tables, the ultrasound features of the principal male uro-genital diseases are summarized. Diagnostic accuracy and second level investigations are considered. Conclusions: Ultrasound is an integral part of the diagno- sis and follow-up of diseases of the urinary system and male genitals in patients of all ages, in both the hospital and outpatient setting. These recommendations are dedicated to enhancing communication and evidence-based medicine in an inter- and multi-disciplinary approach. The ability to perform and interpret ultrasound imaging correctly has become an integral part of clinical practice in uro-andrology, but intra and inter-observer variability is a well known limitation. These recommendations will help to improve reliability and reproducibility in uro-andrological ultrasound scanning. KEY WORDS: Recommendation; Ultrasound scanning; Kidney; Bladder; Prostate; Scrotum; Penis. History of the papers Submitted 24 February 2014; Accepted 3 March 2014 No conflict of interest declared DOI: 10.4081/aiua.2014.1.56 LineeGuida engl ok_Stesura Seveso 26/03/14 10:51 Pagina 56 57Archivio Italiano di Urologia e Andrologia 2014; 86, 1 Practical recommendations for performing ultrasound scanning in the urological and andrological fields Introduction These recommendations have been drawn up by the “Imaging” working group of the Società Italiana di Uro - logia (SIU) in collaboration with the Società Italiana di Ecografia Urologica Andrologica Nefrologica (SIEUN). The specialists involved in the work include Urologists, Andrologists, Nephrologists and Radiologists. The aim of this work is to support Urologists in clinical practice, supplying a series of recommendations to be followed during the phases of ultrasound diagnosis of renal, prostatic, bladder, scrotal and penile diseases. These recommendations are based on a review of the lit- erature, on previous recommendations and on the opin- ions of the experts (1-3). This document is the first to be devoted to this sector, although the American Urological Association (AUA) and the American Institute of Ultrasound in Medicine (AIUM) recently (November 2011) published practical guide- lines for the performance of ultrasound in the urological field [www.aium.org] (2). The references will serve to make a constructive comparison with other clinical experiences. These recommendations were developed and drawn up with the aim of ensuring minimum standards of excel- lence for ultrasound imaging in urological practice, based on the assumption that ultrasound plays an essential part in this practice. Doctors specializing in Urology can gain particular skills and training in the use of ultrasound scan- ning during their residency years, in post-graduate dedi- cated courses organized by Universities, in training cours- es organized by urological scientific societies (SIU, SIA, EAU, AUA) and dedicated societies (ESUI, SIEUN), both nationally and internationally. For the urologist, US scanning is an integral part of the processes of diagnosis and follow-up to manage diseases of the urinary tract and male genitals in patients of all ages, in both a hospital and an outpatient setting. The ability to per- form and interpret imaging studies has become an integral part of clinical practice in all nations, also in order to opti- mize resources and provide patients with efficacious, rapid care. US scanning has been defined as the urologist’s stethoscope. This also applies in the Andrological field. Urologists must combine skilful use of sophisticated imaging devices with a deep knowledge of the physio- logical and pathological processes affecting the human body. If the diagnostic test will be performed in another Department they must be able to select the best test or series of tests to be made for the specific patient, to opti- mize the management of the urological patient. These recommendations may be useful to ensure mini- mum shared or reference standards in the urological and andrological fields also for other medical specialists who perform urological US scanning, such as radiologists, internists, geriatricians, gynecologists or other doctors who study the urinary tract. The aims of the present recommendations are: • To define the purpose of each specific ultrasound investigation (to clarify what each investigation aims to discover). • To define the indications. • To establish the requisite technological standards of the devices. • To outline the method of performance of the investi- gation. • To establish the expected accuracy of the investigation in question. • To indicate the reporting method. Apart from their utility as a theoretical-practical tool for making a correct ultrasound examination of the genito-uri- nary apparatus, these recommendations we propose have the aim of guiding the Urologist in the assessment of the risks and benefits of diagnostic imaging so as to optimize the management of the urological patient [“Patient care is optimized when Urologists coordinate the use of imaging tech- niques and dedicated devices in the most advantageous place for their patients” – see (AUA, AIUM develop joint guidelines for urologic ultrasound exams)] (2). Below, brief recom- mendations regarding the equipment, documentation, reporting of the findings, training requirements and patient safety in ultrasound studies, are listed. EQUIPMENT Ultrasound scanning must be performed with devices that can provide images in real-time, thanks to the use of trans- ducers that can optimize the penetration of the ultrasound waves inside the tissues, with excellent resolution obtained by setting appropriate frequency intervals. The advised transducer frequencies are 3.0-5.0 MHz for abdominal scanning, 6.0-9 MHz for transrectal and 7.0- 12.0 MHz for genital scanning, while intraoperative renal or testicular scanning can be done with the trans- ducer set at 6-10 MHz in linear mode. The correct set- ting of the device must also include the generation of good documentation of the investigations made. DOCUMENTATION Each ultrasound investigation must be concluded with the production of appropriate, unequivocally clear images, recorded on a durable support (digital format is preferable) and saved in the patient's clinical files. The operator must check that the images are correctly record- ed on the electronic support and readable in terms of contrast and luminosity. The ultrasound images must also be labeled with the patient's personal data and those of the health care facil- ity where the investigation is made (hospital department or outpatients clinic). The date and type of probe are automatically specified by the device. REPORTING OF FINDINGS Apart from acquiring full documentation of the investiga- tion, complete reporting of the findings must be made, specifying any conditions during the execution phase that could affect the reliability or accuracy of the test (e.g. anatomical causes [bowel gas, malformations], causes depending on the patient [poor compliance, pain during LineeGuida engl ok_Stesura Seveso 26/03/14 10:51 Pagina 57 Archivio Italiano di Urologia e Andrologia 2014; 86, 1 P. Martino, A.B. Galosi 58 the test], conduction in emergency regime, etc.). The report must include the name and signature of the doctor. Ultrasound scanning is performed for specific purposes and the simple production of images, even of good quali- ty, can never replace a description of the clinical picture and the interpretation of the findings by the operator. TRAINING REQUIREMENTS Adequate training is an essential prerequisite for the cor- rect performance and interpretation of ultrasound investi- gations. This training must be obtained both by residents at the specialist schools and by those who are already spe- cialists in Urology. They should all undergo regular updat- ing of their ultrasound scanning skills, the former during their specialist studies and the latter at regular periodical updating courses. The main scientific societies are active in organizing such updates, and issue certificates of attendance at such training and updating courses. PATIENT SAFETY Ultrasound procedures must be performed only for the specific indications of the case, like any other imaging technique. In fact, like all specialists, urologists should comply with the principles of Alara (4), reducing to a minimum patients' exposure to acoustic energy (5). In addition, the operator must ensure that the ultrasound probe is clean and protected, to comply with the guidelines of the CDC (Centers for disease control and prevention) for the standards of disinfection and sterilization of the devices (6, 7), as well as the technical recommendations specified by the manufacturers of the various devices. Regular periodical controls of the devices must be made, with the collaboration of the manufacturers and comply- ing with the safety norms they list. PROCESS OF ASSESSMENT OF THE RECOMMENDATIONS An assessment of the true effectiveness of these recom- mendations in modifying behavior and improving the clinical outcome will be made using control procedures that are currently being defined. UPDATING In the expectation of upcoming technological and/or diag- nostic advances, the present recommendations will be integrated by further publications, likely every 3 years. Ultrasound scanning of the kidney INTRODUCTION The kidneys are a pair of organs located at the retroperi- toneal level: each kidney is situated along the lateral mar- gin of the psoas muscle, that lines it posteriorly, while it is adjacent to the bowel anteriorly. The right kidney lies about 2-3 cm lower than the left. The kidneys have the function of purging the organism of a great number of sub- stances, and also play a part in many metabolic pathways (protein, lipid and glucides), including the metabolism of hormones and vitamins, as well as control of the blood pressure. Healthy kidneys are easily assessed by ultrasound scanning because the parenchymal component is well delineated by the capsule and has a different echostructure from the perirenal fat and the pyelic structures. MEASUREMENTS Measurements of the kidney length are made by scanning along the major axis parallel to the adjacent psoas muscle. The oblique plane of this long axis is measured by scan- ning the superior pole more medially and the inferior plane more laterally/anteriorly. The angle between the long axis and the sagittal plane ranges between 8 and 10 degrees (1). Variations in this angle produce the variability between ultrasound measurements of the length and measurements made with conventional radiology or urography (2). With ultrasound scanning it is easy to make reliable, repeatable real-time measurements of the kidney long axis. It is clear that to make a precise measurement of the kid- ney axis it is necessary to identify the superior and infe- rior poles: this may be complex in cases of a malrotated, ectopic, ptosic, or scoliotic kidney, etc. Measurement of the interpolar renal diameter is more accurate when the patient is placed in supine decubi- tus, slightly turned toward the contralateral side. Oblique posterior longitudinal scanning is performed with the patient holding the homolateral arm above the head and breathing deeply, to shift the kidney under the ribs. Measurements in prone position tend to result in an underestimation of the kidney length, but may need to be done if the kidney is poorly visualized in other scans (3). In clinical practice ultrasound measurement of the kid- ney volume is not performed because it is difficult to do and highly error-prone, even if it can be useful to assess renal anomalies (4). Renal volume can be assessed by measuring the 3 orthog- onal diameters and applying the following formula: volume V = 0.49 x L x W x AP where L is the length of the major axis (longitudinal scan), W is the length measured at the renal hilum (transverse scan) and AP the anteroposterior diameter again measured at the hilum (transverse scan) (5). The photos on which the measurements were based should be stored in the documentation of the investigation. It may soon be possible to make ultrasound measure- ments of the renal volume using 3D probes, that allow a greater precision than the common 2D probes (6). In any case, correct measurement of the volume of the kid- neys requires good operator skills and knowledge of the renal anatomy, consisting of three different components: 1) The hyperechogenic external capsule; 2) The hypo-isoechogenic parenchyma as compared to the echostructure of the liver and spleen, between the capsule and pelvis, consisting of LineeGuida engl ok_Stesura Seveso 26/03/14 10:51 Pagina 58 59Archivio Italiano di Urologia e Andrologia 2014; 86, 1 Practical recommendations for performing ultrasound scanning in the urological and andrological fields a. the external echogenic cortex, being the functional portion b. the internal hypoechogenic medulla, correspon- ding to the medullary pyramids with a triangular structure and the base toward the outside. 3) The kidney sinus, hyperechogenic due to the pres- ence of many interfaces consisting of intrarenal adi- pose tissue. INDICATIONS Renal ultrasound scanning is indicated in the first approach to patients with renal disease and in the follow-up. The investigations include: • assessment of the kidneys, in normal or ectopic sites; • assessment of the ultrasound morphology; • diagnostic workup in patients with acute or chronic kidney disease; • assessment of any dilation of the excretion pathways and differential diagnosis between obstructive and non obstructive acute renal failure (ARF); • identification of space-occupying lesions (cysts and tumors); • searching for stones; • EchoColorDoppler assessment of the renal vascular- ization (both with color-powerDoppler and, in select- ed cases, contrast enhanced ultrasound [CEUS]) (11); • assessment of the intrarenal resistance indexes (RI) at the level of the interlobar and/or arcuate arteries in nephropathic, hypertense, diabetic, nephroangioscle- rotic patients; • guidance of renal needle biopsy performed in the course of kidney disease or to exclude cancer; • guidance of renal puncture in the course of hydrone - phrosis, abnormal cysts inducing symptoms; • assessment of kidney transplant/s (just like the native kidney) and complications. • intraoperative guidance in conservative kidney sur- gery, percutaneous lithotrypsy, non surgical ablation of expanding lesions; • post-surgical monitoring or endourological treatments. PREPARATION FOR THE INVESTIGATION Although no specific preparation is considered strictly nec- essary, some suggestions are made with the aim of opti- mizing the performance of the investigation. It is better if the patient is asked to refrain from drinking fizzy drinks, fermented cheeses, vegetables, fruit and wholemeal foods, pulses. In cases of a “sluggish” bowel the patient should take a laxative the evening before. Since renal studies should always include a study of the bladder, this should be replete but not distended. SPECIFICATIONS OF THE MINIMUM REQUIREMENTS FOR THE ECHOGRAPH AND PROBES To study the kidney, a latest generation echograph, if nec- essary portable, should be used, of average range equipped with color-powerDoppler module and if possible, suitable software for contrast enhancement. Multi fre quency convex probes allow study of the native and transplanted kidney, but for facilities that receive kidney transplant patients it is very useful to be able to employ a multifrequency linear probe. A thermal printer is indispensable, as is a magnetic image storing system. A recent generation US device offers pre-settings of the parameters to be assessed for each organ and probe, especially during echocolor-doppler investiga- tions. These settings are defined during the installation but must be checked by the operator, updated or modified according to need and the characteristics of the tools avail- able, as approved by the manufacturer. PARAMETER ASSESSED 1. Position of each kidney, including malpositioning: unilateral agenesis, ptosic, malrotated, or dysmor- phic kidney, (horseshoe, etc.); 2. KIdney size (7): - maximum interpolar diameter (normal.: right cm 10.646 ± 1.345, left cm 10.130 ± 1.165) - transverse diameter (normal.: right cm 4.920 ± 0.638, left cm 5.303 ± 0.744) - parenchymal thickness (normal: 1.5-2.0 cm) [mea- surement of cortical thickness is not always possible due to poor cortico-medullary differentiation, and suffers from high inter and intraobserver variability, so it is not commonly used] (8, 9); 3. Assessment of the kidney outline, that may feature the persistence of fetal lobes in the tract between two consecutive pyramids and/or the presence of grooves (scars after pyelonephritis) at one or more calyces; 4. Check for stones (hyperechogenic image measurable by posterior shadow cast); 5. Check for distension of the kidney ampulla and calyces (pyelic ectasia, calico-pyelic ectasia or hydronephrosis); 6. Check for distension of the ureter (hydrouretero - nephrosis); 7. Check for space-occupying lesions and differentiate between fluid (cysts) and solid lesions (neoplasia); 8. Assess renal vascularization using color and powerDoppler to identify “minus” signs (9); 9. Assess renal vascularization by contrast enhancement (CEUS), that improves diagnostic confidence in the assessment of deficiency signs (11); 10. Assess the intrarenal resistance indexes (RI): vn < 0.70 (10) (optional, depending on the clinical picture). EXAMPLE OF REPORT KIDNEY ULTRASOUND Kidneys in situ, maximum longitudinal/transverse size with- in normal limits (right cm____/____; left cm____/____), regular outlines. Parenchyma thickness normal (_____mm). Regular echogenicity of parenchyma. No direct or indirect signs of kidney stones. Regular excretion pathways with no ectasia or calicopyelic dilation (or distinguish ectasic/ pyelic, calico-pyelic dilation, associated or not with ureteral dilation). No space-occupying lesions. Adrenal loggia, no expanding lesions. LineeGuida engl ok_Stesura Seveso 26/03/14 10:51 Pagina 59 Archivio Italiano di Urologia e Andrologia 2014; 86, 1 P. Martino, A.B. Galosi 60 Renal Echo-Color-Doppler Intrarenal resistance indexes (interlobar or arcuate arteries) within normal limits (RI < 0.70) Systolic peak velocity (SPV) of the renal arteries at the ostium, initial, medial, distal and anterior and posterior seg- mentary tracts within normal limits. Flowmetry normal. Pervious renal veins. At powerDoppler, good vascular appearance of parenchyma. Minimum imaging documentation to be included: 1. Two images per kidney: transverse and longitudinal scans with measurements. 2. Orientation of images (liver/spleen on left). 3. Arrow on photo, indicating organ analyzed and side 4. Accessory images illustrating any anomalies. 5. If the bladder is described in the findings, at least one bladder scan image must be included. Ultrasound of the bladder INDICATIONS • To measure post-voiding residue. • To measure bladder filling volume. • To assess anatomic modifications/complications associ- ated with obstruction (diverticuli, trabeculation/colum- nar thickening, stones, detrusor thickness). • To assess hypermobility of the bladder neck in women with stress incontinence. • To assess hematuria originating in the lower urinary tract. • To assess lower urinary tract symptoms - LUTS. • To check for suspected ureteral stone migrating intra- murally. • To check for congenital malformations (ureterocele, diverticuli, etc.). • Post-surgical monitoring (vesical bleeding, position of catheter, etc). • Follow-up in non infiltrating cancer. • Follow-up of bowel loop orthotopic bladder after cys- tectomy. TOOLS During standard investigations in the adult a Convex 3.5MHz probe (range 3-5.5 MHz) is used (in pediatric patients a higher frequency transducer can be used). To measure bladder volume in post voiding controls, auto- matic equipment can be used. In dynamic studies (e.g. assessment of cystocele) trans-rectal or trans-vaginal probes can be used. To stage bladder tumors trans-rec- tal probes can be used. TECHNIQUE Use adequate amounts of gel. For optimal imaging of the bladder it should be full but not overdistended, especially in cases of obstruction. The patient should be lying supine (supine or lithotom- ic or in orthostatic position in cases of use of a trans-rec- tal probe). The bladder wall and lumen will be assessed during the investigation, with both transverse and sagittal scans (1). Systematic search and documentation must be made of: any changes in the echographic appearance of the blad- der wall and neck at rest, trabeculature of the detrusor, endophytic neoplasia, diverticuli, stones, the presence of a third prostatic lobe. Any focal lesions observed (in particular masses) and other diseases (diverticuli, stones, clots, etc.) must be described, specifying site and size. When indicated, the distal ureters should be assessed to exclude dilation or other anomalies (intramural or jux- tavesical stones, ureterocele). Echo-Doppler study may be useful to assess ureteral jet and make a differential diagnosis of bladder tumors (2). Fine regulation of the light is essential to obtain a sig- nificantly improved image quality and correctly visualize the anterior wall (superficial as compared to the skin) and posterior wall (deep). Use the second tissue har- monic imaging tool to improve the imaging and reduce reverberation artefacts. Calculate bladder volume: (ellipsoid formula) v = 0.52 ! r1 ! r2 ! r3. It is recommendend to assess post-voiding urine residue by ultrasound using automatic measurement tools or using the ellipsoid formula based on bladder diameters. In cases of a significant post voiding residue the patient should be asked to make a further attempt to void and then the measurements repeated until a reliable indica- tion of the voiding capacity is obtained. In cases of assessment of the detrusor thickness (not nor- mally more than 3 mm) the study will be conducted with moderate bladder filling (calculated as between 250 and 350 ml, with 250 ml as threshold value), the mean of 3 measurements made on the same image is calculated. To obtain the best results the assessment must be made at the level of the anterior wall/apex and it is better if a high fre- quency (7.5 MHz) convex or linear probe is employed (1). The ultrasound appearance of the detrusor is as a sand- wich structure (hypoechogenic muscular wall between the mucosa and adventitial layers, that are slightly hyper- echogenic). The detrusor thickness must always be measured in areas that are orthogonal to the ultrasound focus (3-8). The findings report should include: • The patient’s name and surname; • The name of the Service where the investigation was performed and the telephone number (in case further clarification should be required); • The date of the ultrasound examination; • If possible include all pertinent clinical information, including the indications for the investigation; • The type of ultrasound examination performed, and if endocavitary techniques are employed the method must be specified; LineeGuida engl ok_Stesura Seveso 26/03/14 10:51 Pagina 60 61Archivio Italiano di Urologia e Andrologia 2014; 86, 1 Practical recommendations for performing ultrasound scanning in the urological and andrological fields • Specify the orientation of the image, if different from standard (superior part on the right of the screen); • Use appropriate anatomical and ultrasound terminol- ogy; in cases of variations from normal sizes the meas- urements must be specified (e.g. increased detrusor thickness, diverticuli, endoluminal masses, etc.); • Compare with previous imaging studies if available; suggest types of studies for further investigation, any differential diagnosis hypotheses; • Name and signature of the examiner, date; • If the results of the ultrasound are considered by the doctor performing the investigation to be of particu- lar clinical importance and unexpected, such as to require urgent intervention to guarantee proper patient care, ideally the doctor who did the investiga- tion should contact the patient’s doctor directly to check that the findings report has been received; • Describe the state of other organs in the abdomen only if qualified to do so; • Pay attention to the degree of distension of the bladder, that can negatively affect the visualization of the ureters in the juxtavesical tract, and the seminal vesicles; • Use the tissue harmonic imaging tool to reduce rever- beration artifacts and obtain better detail; • Indicate any difficulties encountered while perform- ing the investigation (patient’s collaboration and con- stitution, presence of bowel gas), underlining any lim- its of the test and so its diagnostic value. EXAMPLE OF FINAL REPORT 1. Presence or absence of bladder. 2. Orthotopic site and symmetry. 3. Shape. 4. Degree of bladder distension (essential for reliability of investigation). 5. Presence or absence of wall alterations (assessment of lesions > 3 mm). 6. Presence or absence of third lobe (in cases where present, volume and/or degree of extension into the bladder: Intravesical prostatic protrusion). 7. Presence and size of calcifications (diameter > 3 mm), fixed or mobile with patient’s movements in decubitus. 8. Characteristics of bladder neck (in man, protrusion of prostate). 9. Presence of the ureters and any dilation or abnormal outlet or stones. 10. Presence of pelvic masses and ab-extrinseco com- pression of the bladder. 11. Quantification of post voiding residue. Note: It is necessary to calculate the bladder filling volume only if needed to measure the detrusor thickness or esti- mate the bladder weight (reliable for values ! 250 ml) or if needed for clinical reasons. Describe any clinical con- ditions that prevent adequate bladder filling (inconti- nence, pain due to reduced compliance). Images to be included (not all are always indispensable, depending on the clinical picture) 1. One image of the bladder in transverse scan. 2. One image of the bladder in longitudinal scan. 3. One image of the bladder in transverse/longitudinal scan showing the bladder neck. 4. One or more images of any anomaly. 5. In cases of a lesion obstructing the juxtavesical ureter (stone or vegetating lesion) oblique scanning must be done. PREPARATION FOR INVESTIGATION AND PATIENT POSITION 1. The patient does not need to be fasting. 2. The bladder must be replete with at least 300 cc; to ensure this it is necessary: a. for the patient to drink at least 500 cc of fluids dur- ing the three hours before the investigation; b. for the patient to refrain from urinating within two hours before the investigation; c. for the patient to feel the urge to urinate (this latter parameter is extremely subjective and not always reliable). The investigation is normally performed with the patient in supine position. Lateral right or left decubitus may rarely be necessary, in cases where a lesion extends into the lumen (neoplastic disease, clots, “intravescical prostatic protrusion”) and its mobility must be checked. In cases requiring oblique scanning, this is done by rotating the probe by about 40° to its longitudinal axis, taking care that the bladder filling is not more than 250-300 cc (otherwise the ureters would appear crushed by the bladder volume itself). US PAREMETERS TO EVALUATE BLADDER MODIFICATIONS IN PATIENTS WITH BLADDER OUTLET OBSTRUCTION Progressive changes in the bladder wall are observed in men with lower urinary tract obstruction secondary to benign prostatic enlargement (BPE). The high pressure discharge cause initially an increase in the proportion of smooth muscle (hyperplasia/hypertro- phy of the detrusor) to changes in the advanced stages of bladder decompensation (fibrosis), hyperactivity and decreased functional capacity. Early identification of bladder changes by noninvasive transabdominal ultra- sound can move towards therapeutic choices that can prevent further organ damage in the bladder wall. Measurement of the Bladder Wall Thickness (BWT) or Detrusor Wall Thickness (DWT) by US is reliable, at least 3 measurements of the anterior bladder wall taken at a filling volume of ! 250 ml. In particular, the DWT [thickness of the muscle hypoechoic between two layers hyperechoic serosa and mucosa] is considered the best diagnostic tool to measure detrusor hypertrophy using cut-off value > 2.9 mm in men. US derived measure- ments of bladder weight (Estimated Bladder Weight, EBW) is another noninvasive tool for assessing bladder modifi- cations in patients with Bladder Outlet Obstruction (BOO): cut-off value 35 gr. Technique for measuring the BWT and LineeGuida engl ok_Stesura Seveso 26/03/14 10:51 Pagina 61 Archivio Italiano di Urologia e Andrologia 2014; 86, 1 P. Martino, A.B. Galosi 62 EBW relies in conventional US 7.5-4 MHz or using the automatic system of calculation (BVM 6500 3.7 MHz). The variability of measuring intra (4.6 to 5.1%) and inter- operator (12.3%) is acceptable. Also conventional US detects established signs of bladder damage: diverticulosis, trabecolations in the bladder wall (pseudo-diverticula), cal- culi and post-void residual urine (> 50 cc). Furthermore the Intravescical Prostate Protrusion (IPP), easy measured by transabdominal ultrasound, is strongly correlated to obstruction in men with BPE (cut-off 12 mm). Measure, quantify and monitor the cervico-urethral obstruction in men with symptomatic BPE is possible by non-invasively US monitoring the response of the blad- der wall. Early identification has the advantage of adopt- ing therapeutic measures sufficient to prevent progres- sion of bladder damage measuring DWT, EBW in addi- tion to established US paremeters (3, 5-10). DIAGNOSTIC ACCURACY In the diagnosis and follow-up of bladder tumors or hematuria, it should be noted that the standard method is uretero-cystoscopy. Ultrasound scanning is an alternative for non invasive low grade tumors and for the initial assessment of hematuria. Cystoscopy allows the operator to assess and solve any doubts about the integrity and regularity of the bladder wall raised at ultrasound scanning. Bladder lesions small- er than 5 mm may not be identified at ultrasound. Not all bladder tumors are observed at ultrasound: slow-growing non vegetative tumors like carcinoma in situ are not diag- nosed by imaging. The diagnostic capacity for vegetating/papillary lesions > 5 mm is high, even if in some circumstances differential diagnosis with clots may be difficult despite echocolor- doppler. Parameter Pattern Acute cystitis Wall thickness and echogenicity. Increased hypoechogenicity, increased thickness of bladder wall, between the serosa and mucosa. Chronic cystitis No characteristic pattern, assessment of post-micturition residue, search for foreign bodies in bladder. Bullous cystitis Wall thickness, echogenicity. Increased bladder wall thickness, anechogenic areas Wall hypoechogenicity. Diverticuli Presence/absence. Formation of anechogenic paravesical areas with the presence of asonic funnelling to bladder (diverticular neck): Transrectal scanning can better reveal the diverticular neck. Color-doppler can enable DD between tumors and endodiverticular clots, although it is not the ultimate test. In doubtful cases CEUS or other radiological or endourological imaging should be done. Detrusor hypertrophy Thickness detrusor wall (calculated Increased (> 3 mm) with irregularities (trabeculatures or even pseudo (5-7, 9) at ! 250 ml of filling, as mean of 3 diverticuli). measurements, hypoechogenic tissue Low Level Evidence, recommendations need to be verified on vast scale, included between two lines of evidence levels based on opinions of experts and case series. hyperechogenic tissue: mucosa Parameter to be assessed, advised by experts. For use in clinical studies. and bladder serosa). Ureterocele Anechogenic formation (cyst) at the level of the ureteral meatus with evidence at color-doppler of ureteral jet. Juxtavesical Juxtavesical ureter obstructive lesion Hyperechogenic image with posterior shadow included in the thickness Ureter lesion (stone or vegetating lesion). of the ureteral wall (between hyperechogenic serosa). Eco-color-doppler: useful to identify color signals (artifacts) in the shadow area and in DD of vegetating lesions also with eco-power-doppler. Evidence or not of Urethral Jet at color-doppler. Stones Hyperechogenic images with shadow, mobile depending on decubitus movements. Hyperactive bladder Bladder weight (UEBW-ultrasound- No consensus in literature as to standardized cut-off values to be used (5, 10) estimated bladder weight). in clinical studies. Non neoplastic diseases Parameter Pattern Superficial lesions Bladder wall structure Generally no echostructural alterations of the wall. Endophytic tumors appear as hypoechogenic, fixed proliferative lesions, but sometimes they are hyperechogenic due to the presence of superficial calcifications. At color-Doppler hypervascularization is observed. Infiltrating lesions Bladder wall structure Interruption/deformation of the wall, that appears thickened, sometimes extension beyond the bladder wall. Neoplastic diseases Although staging is not currently approved on the basis of the ultrasound findings, we report indications for a possible interpretation. LineeGuida engl ok_Stesura Seveso 26/03/14 10:51 Pagina 62 63Archivio Italiano di Urologia e Andrologia 2014; 86, 1 Practical recommendations for performing ultrasound scanning in the urological and andrological fields Addendum: Possible use of 3D studies, especially for post surgical assessment (sling). Clinical studies to assess the presence of funneling of the neck, hypermobility of the neck-urethra complex, cystocele, ureteral fixity. No standards have yet been established for mobility parameters (among proposals see Schaer et al. Int Urogynecol J Pelvic Floor Dysfunc 1996, Pajoncini C. in Atlante di ecografia uro nefrologica ed andrologica 1996 ed. CIC, Merz et al. Ultraschall Med 2004, Tunn R. et al. Update recommendations on ultrasonography in urogynecology. Int Urogynecol J 2005 16, 236-241). Trans-perineal Introital Trans-vaginal Trans-rectal Instruments Convex Sector endfire Linear biplanar Linear biplanar 3.5-5 Mhz probe 5- 7.5 Mhz probe 7.5 Mhz probe 7.5 Mhz probe Patient position lithotomic lithotomic orthostatic lithotomic orthostatic Quality of image + + +++ +++ Measurement of mobility ++ ++ +++ +++ Invasiveness + + ++ +++ Artifacts in 3-4 grade cystocele ++ ++ +++ + Ultrasound of the pelvic floor (4, 11-24) Prostate and seminal vesicles PROSTATIC ULTRASOUND SCANNING WITH THE SUPRAPUBIC TECHNIQUE METHOD The prostate must be analyzed on two orthogonal planes: transverse and longitudinal. In this study it is essential to examine: • Juxtavesical ureters. • Bladder. • Prostate. • Seminal vesicles (1-6). The prostate diameters to be assessed are: latero-lateral, antero-posterior and cranio caudal. In cases of an obstructive lesion of the juxtavesical ureter (stone or vegetating lesion) oblique scans must be made. Images to be included (not all are always indispensable, depending on the clinical picture). 1. One image of the bladder in longitudinal/transverse scan. 2. One image of the prostate in transverse scan showing the bladder. 3. One image of the prostate in longitudinal scan show- ing the bladder. 4. One image of the right juxtavesical ureter in oblique scan. 5. One image of the left juxtavesical ureter in oblique scan. 6. One or more images of any anomalies. Report of the findings 1. Date and place of performance of the investigation. 2. Patient data (including birth date). 3. Mention of clinical history and diagnostic purpose. 4. Value of last total PSA blood test. 5. Comparison with previous tests if available. Both the images and findings must be easy to read by other operators and at later dates. The findings must therefore be reported as unambiguous- ly as possible. In cases of any diagnostic doubt, this must be pointed out, indicating possible hypotheses and sug- gesting any further instrumental investigations that may help to solve any doubts. TERMINOLOGY 1. Identification of the medial lobe and its size and rela- tions with the pelvic floor 2. Any picture of cervico-ureteral obstruction due to pro- static hypertrophy causing severe detrusor impairment, any presence of bladder stones (Table 1). INDICATIONS 1. To assess the size and volume of the prostate gland before medical, surgical or radiation treatment (in particular, to assess the volume displacement caused by the third lobe and correlations with detrusor hypertrophy, the presence of bladder pseudodiverticuli and diverticuli (1, 6). 2. To assess the patient with Lower Urinary Tract Symptoms (1). 3. To assess congenital anomalies. ESSENTIAL PARAMETERS TO BE SPECIFIED IN THE FINAL REPORT Prostate 1. Presence or absence of the prostate. 2. Orthotopic or heterotopic site. 3. Shape. 4. Size. LineeGuida engl ok_Stesura Seveso 26/03/14 10:51 Pagina 63 Archivio Italiano di Urologia e Andrologia 2014; 86, 1 P. Martino, A.B. Galosi 64 5. Presence or absence of third lobe (if present, volume and/or size of protrusion into the bladder: Intravesical prostatic protrusion). 6. Presence and size of any gross calcifications (diameter > 5 mm). 7. Presence and size of any gross abscesses/cysts (diame- ter > 5 mm). 8. Presence of the ureters and any dilation or anomalous outlet. 9. Quantification of post voiding residue. Note: Lesions of any nature with a diameter of " 5 mm are not identifiable with suprapubic ultrasound scanning. The suprapubic technique cannot visualize the echostructure of the peripheral zone of the prostate due to technical image resolution limitations. Seminal vesicles 1. Presence or absence. 2. Site. 3. Symmetry. Bladder An accurate description of the bladder is essential, see previous chapter. PREPARATION FOR INVESTIGATION AND PATIENT POSITION 1. The patient does not need to be fasting 2. The bladder must be replete with at least 300 cc; to ensure this it is necessary: a. for the patient to drink at least 500 cc of fluids dur- ing the three hours before the investigation; b. for the patient to refrain from urinating within two hours before the investigation; c. for the patient to feel the urge to urinate (this latter parameter is extremely subjective and not always reli- able). The investigation is normally performed with the patient in supine position. Lateral right or left decubitus may rarely be necessary, in cases where a lesion extends into the lumen and its mobility must be checked. EXAMPLE OF FINAL REPORT Mention of clinical history: _______________________ Diagnostic purpose_____________________________ Last total PSA value: The bladder… Yes/No Hyperechogenic bladder images depicting stones, nor dilation of the juxtavesical and intramural bilateral ureters. The prostate is shown in orthotopic/heterotopic site and is grossly triangular, size within normal limits (more/less), (LL X AP X CC), having a theoretical calculated volume of about ___ml. Presence of third lobe protruding into the bladder by __cm. Post voiding residue is about cc. Non/mild/fair/marked tenderness or pain on palpation of the hypogastrium at the start/throughout the duration of the investigation. DIAGNOSTIC ACCURACY It is important to note that the elective method for the study of the prostate gland includes the use of endocavitary probes (7, 8). In fact, suprapubic ultrasound scanning is not contemplated in the guidelines for the study of the prostate drawn up by the main scientific societies due to its limited diagnostic power (2-5). In particular, it is thought that prostate ultrasound results in an overestimation by more than 30% to 50% of the true prostate volume. According to some Authors, moreover, the use of the ellipsoid formula to calculate the prostate gland volume with the aid of suprapubic ultrasound leads to an error of about 20% (9). NOTES ON CLINICAL PRACTICE A. Attention must be paid to the degree of distension of the bladder, that can affect the visualization of the juxtavesical ureters and seminal vesicles B. Use the tissue harmonic imaging tool to reduce rever- beration artifacts and obtain better detail C. Indicate any difficulties encountered while perform- ing the investigation (patient’s collaboration and con- stitution, presence of bowel gas), underlining any lim- its of the test and so its diagnostic value. D. Remember that if the prostate is larger than normal, its morphology may vary, especially in cases of pro- static hyperplasia. DEVICES AND TRANSDUCERS USED Convex transducer with a frequency of 3.5 MHz, or mul- tifrequency 5-2 MHz probes depending on the patient’s constitution and how deeply the gland is located. TRANSRECTAL PROSTATIC ULTRASOUND METHOD The investigation is dynamic and apart from longitudinal and transverse scans, with the probe inclined more cranio- caudally than for the study of the bladder, oblique scans will also be performed to study the seminal vesicles, that generally lie on the transverse/oblique plane. The prostate must be analyzed on two orthogonal planes: transverse and longitudinal, from the apex to the base of the gland. At the same time, it is essential to study: • the urethra sphincter, Cowper’s glands; • the seminal vesicles; • the juxtavesical tract of the ureters; • the deferens ducts; • the bladder (insofar as it is explorable). Additionally, any gross alterations of the rectal wall should be pointed out, and referred to the competent specialist colleague. LineeGuida engl ok_Stesura Seveso 26/03/14 10:51 Pagina 64 65Archivio Italiano di Urologia e Andrologia 2014; 86, 1 Practical recommendations for performing ultrasound scanning in the urological and andrological fields The diameters to be assessed is latero-lateral, antero-pos- terior and cranio-caudal, to calculate the total volume, and also the volume of the transition zone (periureteral hypertrophy). For the seminal vesicles the diameters assessed are: antero-posterior. The apparent size of the latter may be affected by the degree of distension of the bladder, by ejaculation and by forms of obstruction (1-4). Images to be included (not all are always indispensable, depending on the clinical picture) 1. One image of the prostate in transverse scan (indicating the diameters of both the entire gland and adenoma). 2. One image of the prostate in longitudinal scan (indi- cating the diameters of both the entire gland and ade- noma). 3. One image of the prostate in transverse scan showing the bladder. 4. One image of the prostate in longitudinal scan show- ing the bladder. 5. One image of the seminal vesicles in transverse scan. 6. One or more images of any anomalies. 7. Any images of the juxtavesical ureter in longitudinal scan. Calculate total prostatic volume and transition zone volume It is important to note that all latest generation ultra- sound devices automatically calculate the volume of the prostate, bladder and seminal vesicles. If this is not pos- sible, multiply the 3 diameters by 0.52 according to the ellipsoid formula. Data on the volume of the entire gland and adenoma are clinically essential for therapeutic and surgical workup purposes (5-11). Orientation of the ultrasound images The ultrasound probe always appears at the bottom of the image. In transverse scans: the patient’s right side is con- ventionally on the left side of the image (as also in CT and MR images). In longitudinal scans: the superior/proximal part/patient’s head is conventionally on the left side (as in abdominal ultrasound imaging), and the distal part on the right side. Documenting the findings 1. Date and place where the investigation was per- formed. 2. Patient data (including birth date). 3. Mention of clinical history and diagnostic query. 4. Value of last total PSA blood test. 5. Outcome of rectal exploration, that should always be done before the investigation. 6. Comparison with previous examinations, if available. Both the images and findings must be easy to read by other operators and at later dates. The findings must therefore be reported as unambigu- ously as possible. In cases of any diagnostic doubt, this must be pointed out, indicating possible hypotheses and suggesting any further instrumental investigations that may help to solve any doubts. TERMINOLOGY 1. Hypoechogenic pars adenomatosa, as compared to pars peripherica of the prostate (6, 8). 2. Identification of medial lobe, and its size and relation- ships with the bladder floor (5). 3. Presence of calcifications (diameter ! 3 mm), that appear hyperechogenic with a posterior shadow (pos- sibly showing signs of previous inflammation). 4. Presence of focal hyperechogenic areas with no poste- rior shadow (diameter ! 3 mm) (possibly showing signs of previous inflammation). 5. Presence of abscesses and/or hypo/anechogenic areas (diameter ! 3 mm), that appear prevalently with a fluid anechogenic or dyshomogenenous component, possibly showing inflammation processes in active phase. Anechogenic/echogenic areas of inflamed abscesses Table 2. 6. In a picture of cervico-ureteral obstruction due to pro- static hypertrophy causing severe detrusor impair- ment, any presence of bladder stones Table 1. 7. Dilation/cysts of the ejaculatory ducts. 8. Perviousness and funneling of the cervical or anasto- motic region in surgical scars. INDICATIONS 1. To assess the size and volume of the gland for med- ical/surgical workup, regardless of the type of treat- ment or underlying disease (1-14). 2. Prostatic biopsy guidance. 4. Suspected prostatitis and/or prostatic abscess. 5. To examine congenital anomalies. 6. In infertility of the couple (morphological study of the seminal tracts). 7. Study of the bladder neck – Functional diseases of the bladder neck (sclerosis, iatrogenic stenosis or ndd); – Neurological bladder; – Outcome of surgery of the cervico-prostatic region (prostatic trans-vesical adenomectomy, endoscopic resection or enucleation of prostatic adenoma, endoscopic incision of bladder neck); – Identification and examination of cysts of bladder neck or third prostatic lobe; 8. Postoperative controls (post disobstructive surgery or radical prostatectomy). 9. Post-treatment controls for prostatic tumors (radio- therapy, HIFU, cryotherapy) (8). ESSENTIAL PARAMETERS THAT MUST BE SPECIFIED IN FINAL REPORT For all types of report Preliminarily, transrectal exploration must be performed, indicating the presence, size (x 2-3), surface, consisten- LineeGuida engl ok_Stesura Seveso 26/03/14 10:51 Pagina 65 Archivio Italiano di Urologia e Andrologia 2014; 86, 1 P. Martino, A.B. Galosi 66 cy, margins, presence or absence of a medial groove, any nodules, their characteristics and localization), tender- ness or pain on palpation of the gland. PROSTATE 1. Presence or absence of the prostate. 2. Orthotopic or heterotopic site. 3. Symmetry. 4. Size/volume of the gland (latero-lateral, antero-pos- terior and cranio-caudal, to be multiplied by 0.52, according to the ellipsoid formula, if the device does not make an automatic calculation). 5. Size/volume of the transition zone/adenoma. 6. Presence or absence of third lobe (if present, volume and/or measurements of protrusion into the bladder) (5, 16). 7. Presence and size of calcifications (diameter ! 3 mm) Table 1. 8. Presence and size of abscesses/cysts (diameter ! 3 mm) (17). 9. Presence and size of intra-prostatic cysts or bladder neck cysts (diameter ! 3 mm) (17). 10. Echostructure of the peripheral portion (18). 11. Integrity of prostatic capsule. 12. Presence of the ureters and any dilation or anom- alous outlet. 13. Any pain elicited during the investigation Table 2. ADDENDUM IN PARTICULAR CASES Presence of the deferens and any dilation. URETHRA Any lesions evident at ultrasound. Morphology and function of the internal urethral sphincter (only in cases of ultrasound performed for functional pur- poses). SEMINAL VESICLES 1. Presence or absence. 2. Site. 3. Symmetry. 4. Morphology. 5. Any dilation (> 12 mm in antero-posterior site). BLADDER 1. Morphology of walls. 2. Morphology of content. 3. Presence of vegetation and description. 4. Presence of stones. A. PROSTATIC BIOPSY GUIDANCE 1. In cases of suspected tumor areas, describe: – site; – size; – morphology; – ultrasound appearance; – margins; – relations of lesion with the capsule, bladder neck, seminal vesicles in cases of basal nodules with extracapsular extension. If several nodules are present, each must be detailed as described above (19-20). 2. In cases of multiple prostatic biopsy sampling, indicate: – type of patient preparation; – antibiotic prophylaxis administered*; – results of preliminary rectal exploration (and any agreement between increased consistency areas at palpation and suspicious ultrasound images); – type of anesthesia (site, drug and dosage); – number of samples, specifying scheme adopted – course of procedure; – indications for patient care in days after the manoeuvre; – any home antibiotic therapy*. B. ASSESSMENT OF CONGENITAL ANOMALIES In particular, apart from studying alterations of the course of the juxtavesical ureters, transrectal prostatic ultrasound is able to demonstrate intraprostatic cysts. Cystic lesions appear as round or oval, with distinct mar- gins and an asonic content. The definition of the site is particularly important, namely: 1. Vesical. 2. Medial posterior: mullerian/prostatic utricle. 3. Paramedial/lateral: ductal dilatation/cysts of ejaculato- ry duct. 4. Due to retention (17). C. MORPHOLOGIC STUDY OF THE SEMINAL TRACT EJACULATORY DUCTS 1. Presence or absence. 2. Presence or absence of calcifications and any obstruc- tion caused. 3. Any dilation. DEFERENS DUCTS 1. Presence or absence. 2. Presence or absence of calcifications or lesions and any obstruction caused. 3. Any dilation. SEMINAL VESICLES 1. Diameters (latero-lateral, antero-posterior and cranio- caudal). 2. Any dilation. 3. Any congestion. 4. Anomalies with the deferens. * Antibiotic prophylaxis has proven useful for the preven- tion of complications such as asymptomatic bacteriuria, uri- nary tract infections, bacteremia and sepsis (1). The fluoroquinolones (such as ciprofloxacin XR 1000 mg), due to a better prostatic penetration, allow maintenance of constant levels of antibiotic in tissue, thus ensuring opti- mum prophylactic efficacy (2). REFERENCES 1. Zani EL, Clark OA, Rodrigues Netto N Jr. Antibiotic prophylaxis for transrectal prostate biopsy. Cochrane Database Syst Rev. 2011; (5):CD006576. 2. Grabe M (chairman), Bjerklund-Johansen TE, Botto H, et al. Guidelines on Urological Infections. European Association of Urology 2013. LineeGuida engl ok_Stesura Seveso 26/03/14 10:51 Pagina 66 67Archivio Italiano di Urologia e Andrologia 2014; 86, 1 Practical recommendations for performing ultrasound scanning in the urological and andrological fields D. STUDY OF THE BLADDER NECK 1. Morphology (5). 2. Symmetry. 3. Any calcifications. 4. Any cysts (17). E. STUDY OF THE PROSTATIC LOGGIA AFTER RADICAL PROSTATECTOMY OR OTHER TREATMENTS Presence of areas suggesting disease recurrence in the perianastomotic region: – site; – size; – localization with respect to the anastomotic region and rectal wall; – ultrasound appearance; – margins; – vascularization; – presence/absence of seminal vesicles residues. The ultrasound data must necessarily be correlated with the total PSA values and clinical history, because subse- quent treatments for postoperative urinary incontinence may modify the echostructure and mimic lesions (macroplastique, collagen, bulkamid). If biopsy samples are taken of the perianastomotic region, all suspicious areas should be sampled; this can be done under ultrasound guidance (15). PREPARATION FOR THE INVESTIGATION AND PATIENT POSITION The patient must undergo at least one enema two hours before the investigation, to avoid artifacts caused by fecal matter in the rectum. Fasting is not necessary. The patient must not urinate for at least two hours before the investigation (the bladder must be replete). The investigation is normally performed with the patient in lateral left decubitus. If this is impossible, it can be done in lateral right decubitus or semilithotomic position. EXAMPLE OF FINAL REPORT Standard transrectal prostatic ultrasound Mention of clinical history:________________________ Last total PSA value:____________________________ Preliminary rectal exploration shows the prostate in situ, enlarged (X), with a smooth surface, parenchymatous con- sistency, distinct margins, flattened medial groove. No tenderness or pain on palpation. The prostate, investigated with a transrectal “end-fire” ultrasound probe with variable frequency, is visible in situ and roughly triangular in shape; the size is X X mm (LL X AP X CC), for a theoretical calculated volume of about cc. A central nodular area of hyperplasia is present, with a dyshomogeneous echostructure, and theoretical calculated volume of about cc. Along the cleavage plane of the nodular hyperplasia, and in the periureteral site, calcifications are evident, likely the outcome of previous inflammatory processes. Within the nodular hyperplasia area there are gross calcifications as well as some anechogenic images compati- ble with cysts due to retention/microabscesses. The peripheral gland shows a substantially homogeneous structure, with no signs of disease foci in course. The seminal vesicles are orthotopic and normal in shape. The bladder is in situ, moderately distended. No ultrasound alterations of the posterior bladder wall are apparent, insofar as the area is visible through the transrectal acoustic window. Post-voiding urinary residue is … Transrectal prostatic ultrasound to study the seminal vesicles The prostate is described as above. No evidence of obstructive lesions of the ejaculatory ducts and deferens ducts bilaterally. The seminal vesicles are orthotopic and normal in shape. The maximum diameters of the right seminal vesicles are X X X mm (CC X AP X LL), for a theoretical calculated volume of about cc. The maximum diameters of the left seminal vesicle are X X X mm (CC X AP X LL), for a theoretical calculated volume of about cc. Post-voiding urinary residue is cc. Deferens present, symmetrical and not dilated. Prostatic ultrasound of the perianastomotic region after prostatectomy The perianastomotic region appears homogeneous/dyshomogeneous, showing areas of .. in size, localized at the level of .., with …margins, vascularized, suspicious for growth processes. DIAGNOSTIC ACCURACY The diagnostic accuracy of transrectal prostatic ultra- sound varies according to the diagnostic query. In particular, as regards assessing the size of the prostat- ic adenoma, the diagnostic accuracy of transrectal pro- static ultrasound is extremely high, while the risk of overestimation of the true prostatic volume and weight (later measured in the various studies on the anatomic piece) ranges between 4 and 10% (21-28). As regards the identification of prostatic nodules sus- pected of growth processes, it should be noted that 60% of them appear hypoechogenic, 30% isoechogenic and 10% hyperechogenic. Therefore, the overall diagnostic accuracy of this method alone is about 30% (this is why in most cases prostatic biopsy sampling is done randomly, in the absence of ultrasound areas raising suspicion (19-20). The presence of a hypoechogenic image alone is not the only criterion indicating the need for prostatic biopsy. The criteria for mapping prostatic biopsies are clinical and based on the PSA values and trend, on rectal exploration, the presence of risk factors, and also on the prostatic vol- ume and ultrasound findings. Granulomatous prostatitis (acute or chronic) can induce hypoechogenic modulations that are indistinguishable from those of neoplasia. Finally, as regards the use of transrectal ultrasound to assess the perianastomotic region, the diagnostic accu- racy of this investigation is strictly linked to the total LineeGuida engl ok_Stesura Seveso 26/03/14 10:51 Pagina 67 Archivio Italiano di Urologia e Andrologia 2014; 86, 1 P. Martino, A.B. Galosi 68 PSA value. The positive predictive value is about 65%, and the negative predictive value about 20% (15). For all lesions suspected to be cancerous, ultrasound alone can never replace biopsy. NOTES ON CLINICAL PRACTICE • Use tissue harmonic imaging to reduce reverberation artifacts and obtain better detail. • Indicate any difficulties encountered while perform- ing the investigation (patient’s collaboration and con- stitution, presence of bowel gas, presence of artifacts due to insufficient bowel cleansing), underlining any limits of the test and so its diagnostic value. • If the prostate is larger than normal, its morphology may vary, especially in cases of prostatic hyperplasia. • When performing ultrasound guidance for prostatic biopsy sampling, it is useful to ask the patient to void the bladder after the diagnostic phase • The longitudinal diameter of the seminal vesicles varies according to the size of the gland and also the degree of bladder repletion. • In cases with many gross calcifications along the cleav- age plane between the pars adenomatosa and pars peripherica, in the periureteral intra-adenomatous site, the shadow created by the calcifications may make ultrasound exploration of the bladder or pars peripher- ica difficult. THE ROLE OF ECOCOLORDOPPLER Color Doppler and power Doppler are generally used to identify neovascularization foci, possibly expressing abscesses (vascularization absent in the center) or tumors (29-31). NEW TECHNOLOGIES The limited sensitivity and specificity of gray-scales ultrasound in transrectal prostatic ultrasound has led to the adoption of new technologies based on the different vascular pattern identifiable in neoplastic foci, and hence on Doppler techniques. The use of 3D ultrasound and Histoscanning seems to be able to reduce the overall number of cores necessary, contributing to a better defi- nition of the target, but such investigations should only be considered in clinical studies (20, 32). The use of contrast medium Recent studies have not reported any increased sensitiv- ity in the detection rate of prostatic tumors by contrast enhanced ultrasound (CEUS), as compared to extensive mapping (33, 34). Elastosonography The use of elastosonography increases the detection rate by about 20% as compared to traditional ultrasound, ultimately leading to a reduction in the number of nec- essary cores. However, operator experience and the degree of pressure exerted on the tissues strongly limit large scale use of this technique (35). 3D ultrasound Thanks to the inclusion of the coronal plane, 3D ultra- sound provides information helping to assess the semi- nal vesicles and ejaculatory ducts, as well as offering a better detection rate of prostatic tumors, according to some studies (20). DEVICES AND TRANSDUCERS Real time endocavitary transducer (transrectal) with a frequency ! 6 MHz (or anyway high). High frequency is used because the prostate is superficial as compared to the probe plane (internal rectal wall): • A linear monoplanar probe: for prostate sections along the longitudinal plane. • A convex-linear or bi-convex biplanar probe: associ- ates transverse and longitudinal scanning, through two orthogonal convex probes. • A variable frequency probe (end-fire): allows trans- verse, longitudinal and oblique scanning. Pathologic mechanism Size Macroscopic evidence Number Site (increased intraprostatic pH and increased precipitation of calcium salts) Endogenous - Amyloid bodies Macrolithiasis Disseminated Single Periurethral - Reaction to foreign body in intra-acinar site (max. diameter ! 2 mm) +/- posterior shadow Exogenous - Stasis of prostatic secretion Microlithiasis Thickened Multiple Lobar - Intraprostatic reflux (max. diameter " 2 mm) +/- posterior shadow Perinodular - Prostatitis Ejaculatory ducts Table 1. Stones and hyperechogenic prostatic images. LineeGuida engl ok_Stesura Seveso 26/03/14 10:51 Pagina 68 69Archivio Italiano di Urologia e Andrologia 2014; 86, 1 Practical recommendations for performing ultrasound scanning in the urological and andrological fields Ultrasound of the scrotum INDICATIONS 1. To evaluate the acute scrotum: testicular trauma, ischemia, suspected torsion and infectious or inflam- matory diseases (4, 7, 16). 2. To assess palpable masses in the inguinal or scrotal site (18, 22). 3. To assess any asymmetry and increased volume of the scrotum (21). 4. To assess a possible scrotal hernia (13). 5. For diagnosis and staging of varicocele. 6. To evaluate male infertility. 7. In follow-up of previous lesions shown at ultra- sound (10). 8. To assess cryptorchidism (12). 9. To search for an occult primitive tumor in a patient with germinal tumor metastases. 10. In follow-up of patients with a primitive testicular tumor, lymphoma or leukemia (23). 11. In follow-up after testicular surgery. 12. In diagnostic workup for anomalies observed at other imaging studies like CT, MRI or PET. 13. To assess intersexual conditions. ESSENTIAL PARAMETERS IN THE STUDY OF THE SCROTUM (20) 1. The scrotal wall. 2. The testicular volume. 3. The testicular echostructure. 4. The epididymis (volume and echostructure). 5. Vascularization. 6. The pampiniform plexus. PREPARATION FOR THE INVESTIGATION AND PATIENT POSITION The investigation must be performed in a darkened room, to protect the patient’s privacy, and the room tem- perature must not be cold because this could elicit the cremasteric reflex, in a more accentuated form in chil- dren, that could cause the testicle to rise up. Initially, the patient should lie supine with a scrotal support to facili- tate exposure. The penis will be positioned superiorly or supero-laterally (5, 8).After examining the content of the scrotal sac in clinostatic position, the investigation should be continued with the patient in orthostatic position, making a careful evaluation of the venous flow of the spermatic cords. B-Mode study will already reveal Table 2. Definition of ultrasound characteristics of different disease pictures. Peculiarities Shows pars peripherica separated from pars adenomatosa thanks to a cleavage plane and different echogenicity (pars adenomatosa is more hypoechogenic than pars peripherica) There may be nodular oval or rounded areas, with distinct margins, and an isoechogenic appearance to the surrounding parenchyma, expressing prostatic hyperplasia intra-adenomatous areas or focal prostatitis areas In cases of abscess, this will show distinct margins and a highly hypo/anechogenic content. Hyperechogenic lesions may be present within the abscess area, showing an irregular morphology demonstrating partial colliquation of such abscesses. In cases of inveterate chronic prostatitis, there may be a dyshomogeneous appearance, with alternating hypo-isoechogenic and hyperechogenic areas Differential diagnosis Abscess areas, in very hypoechogenic images Calcification areas, in very hypere- chogenic images Tumoral areas (possible only with biopsy) Neoplasia, espe- cially in cases of suspected abscess colliquation Neoplasia, espe- cially in cases of granulomatous pro- statitis observed in subjects with a his- tory of endovesical chemo-immunopro- phylaxis with BCG. Disease picture Prostatic hypertrophy Acute prostatitis Chronic prostatitis Morphology Increased size due especially to enlarged pars adeno- matosa Increased gland size Increased size or no change Echogenicity Showing pars peripherica sepa- rated from pars adenomatosa thanks to an evi- dent cleavage plane and different echogenicity (pars adenomatosa is hypoechogenic and dyshomogeneous as compared to pars peripherica) Less than normal Tendency to be increased, in cases with calcifi- cations as inflam- matory outcomes Vascularization No variation Increased doppler signal, correlated to increased vas- cularization due to inflammatory processes Variable Margins Free Normally free, sometimes blurred in cases of sub capsular abscess and direct involve- ment of the margins Free LineeGuida engl ok_Stesura Seveso 26/03/14 10:51 Pagina 69 Archivio Italiano di Urologia e Andrologia 2014; 86, 1 P. Martino, A.B. Galosi 70 the presence of varicose veins, but it is convenient to go on immediately to color Doppler study to examine the characteristic patterns of varicocele (11). NOTES ON CLINICAL PRACTICE AND INDICATIONS FOR ECHOCOLORDOPPLER The first task in scrotal ultrasound is to make a correct calculation of the testicular volume. The formula most commonly used today is the ellipsoid (volume in ml = product of the three diameters (in cm) x 0.52) (3). The testicles must be assessed on two planes: longitudi- nal and transverse. The transverse plane is focused on the superior medial and inferior testicular portions, and the longitudinal plane on the central portion, as also medial and lateral. Once the whole testicle has been measured, the investigation con- tinues with the epididymis (head, body and tail) (6). The testicular measurements and echogenicity should then be compared with those of the contralateral testi- cle. Color Doppler can be helpful, especially in cases of acute pain (2). In this case, both longitudinal and trans- verse scanning is useful, as well as comparison of the two testicles. The doppler parameters must be set to analyze slow flow. Should it be impossible to visualize the flow, power Doppler can be employed to highlight the images (9). Color Doppler is essential in the diagnosis and staging of varicocele. DEVICES AND TRANSDUCERS The investigation is conducted using a real time scanner, preferably with a linear transducer. The transducer is set to scanning mode at the highest fre- quency of the device. In the latest ultrasound devices the frequency may range from 8 to 15 MHz or more (1, 19). The transducer length may range between 4 and 8 cm. Resolution must be sufficient to discriminate different ultrasound characteristics in any lesions observed. If there is a markedly increased volume of the scrotum, the use of lower frequencies is indicated to make a correct study of the gonads (15); alternatively it is possible to rely on the trapezoid assessment available in more mod- ern ultrasound devices (14). The doppler frequencies must be as high as possible to optimize the resolution and show the blood flow. Modern devices offer a frequency range of 5 to 10 MHz (17). EXAMPLE OF FINAL REPORT Scrotal Echocolor Doppler Toshiba Aplio; Examination performed with linear probe 11.5 MHz History: Previous right orchiectomy for embryonal testicular K. Known left varicocele. Didymi: left didymis in situ with normal echostructure and volume, markedly hyopotrophic approx 3.5 cc (ellipsoid for- mula calc. 0.52 x 3 diameters) Epididymi: normal echostructure and size; small cyst of head of left epididymis. Small scrotolite present. Vascularization of didymis-epididymis: within normal limits Left pampiniform plexus: severe peritesticular ectasia with vessel diameter exceeding 4mm. ColorDoppler investigation of pampiniform plexus in ortho- static position. Left pampiniform plexus: basal reflux little modified by functional manoeuvers. Diagnostic conclusion: left Varicocele, grade V according to Sarteschi classification. Images to be included (not all are always indispensable, depending on the clinical picture) 1. One image of each testicle and epididymis in trans- verse scan. 2. One image of each testicle and epididymis in longitu- dinal scan. 3. One image of both testicles and epididymi for direct comparison. 4. One image of the prostate in longitudinal scan show- ing the bladder. 5. One or more images of the pampiniform plexus at rest and under Valsalva. 6. One or more images of any palpable anomalies. IMPORTANT NOTES IN CLINICAL PRACTICE Cause Ultrasound appearance Second level investigations Non inflammatory Heart failure Thickened scrotal wall, with alternating Idiopathic lymphedema hyperechogenic and hypoechogenic layers Lymphatic and venous obstruction (onion-like appearance) Epidermoid cysts Inflammatory Cellulitis Thickening of the scrotal wall and presence of hypoechogenic areas, showing increased blood flow Fournier gangrene Thickening of the scrotal wall with signs CT; MRI of inflammation; gas may be visible as numerous hyperechogenic foci Table 1. Lesions of the scrotal wall. LineeGuida engl ok_Stesura Seveso 26/03/14 10:51 Pagina 70 71Archivio Italiano di Urologia e Andrologia 2014; 86, 1 Practical recommendations for performing ultrasound scanning in the urological and andrological fields Ultrasound appearance Second level investigations Non inflammatory Shows bowel wall, presence of peristalsis, hyperechogenic area if omentum present. CT Distinguish direct or indirect if inferior epigastric artery shown by Doppler. Presence of stricture (SS 90%; SP 93%) Hydrocele Anechogenic fluid collection surrounding the testicular parenchyma Hematocele Appearance similar to cysts, with septs and loculi Pyocele Table 2. Inguinal or scrotal swelling. Ultrasound appearance Second level investigations Varicocele Multiple tortuous vascular structures, hypoechogenic with variable diameters Spermiogram exceeding 2 mm. Color Doppler set for low flow to show a characteristic flow pattern, with phase alterations and retrograde filling during Valsalva (SS and SP 100%) Grading varicocele accordig to an established classification. The suggested classification is the grading system according to Sarteschi Classification. Tumors Lipoma, sarcoma and rhabdomyosarcoma have the same non specific CT, and better MRI, to enhance of spermatic cord ultrasound appearance visualization of the tissues Table 3. Spermatic cord (22). Ultrasound appearance Orchi-epididymitis Epididymis enlarged and hyperechogen or hypoechogenic. A reactive hydrocele may be present, and if there is testicular involvement the didymis will be enlarged, with a dyshomogeneous ultrasound appearance. Doppler will show hyperemia and increased blood flow (peak systolic rate > 15 cm/sec) Chronic epididymitis Epididymis enlarged, increased echogenicity and possibly calcifications Epididymis masses Spermatocele and epididymis cysts are shown as hypoechogenic lesions that may be as much as 1-2 cm in diameter, with acoustic enhancement in the posterior wall. They may contain protein fluid or spermatozoa with a low echogenicity. Adenomatoid tumors can be hypoechogenic, isoechogenic or hyperechogenic Table 4. Epididymis (18). Ultrasound appearance Second level investigations Testicular torsion Absence of intratesticular blood flow (SS 86%, SP 100%) Increased testicular volume and reduced echogenicity (4-6 h) After 24 h, dyshomogeneous echostructure due to vessel congestion, hemorrhage and infarction. Spiral appearance under the torsion point, that appears as a homogeneous extratesticular oval or rounded mass, with or without blood flow Orchitis Hyperemia and dyshomogeneous ultrasound appearance. Increased or enhanced intratesticular blood flow Testicular microlithiasis Multiple echogenic foci with no shadow (at least 5 microliths per field) Benign lesions Cysts of tunica albuginea: may be unilocular or multilocular, with calcifications Simple cysts: may be multiple or solitary, generally adjacent to the mediastinum. They appear anechogenic and with no wall. Epidermoid cysts: ultrasound appearance of a halo with a central area and increased echogenicity or else as a mass defined by an echogenic circle, or else a classic “onion” appearance. Doppler will not show blood flow Ectasia of rete testis: visible at US as fluid-filled tubular structures. Possible presence of cysts Intratesticular varicocele: multiple, anechogenic tortuous tubular structures. Bloodflow shows characteristic reflux during Valsalva Malignant lesions Seminomatous tumors: homogeneous hypoechogenic lesions, with uniform Tumoral markers smooth margins. Very often the tumor occupies much of the parenchyma Non seminomatous tumors: may have very variable US appearance: Tumoral markers dyshomogeneous echostructure (71%), irregular or with poorly defined margins (45%), echogenic foci (35%) and a cystic component (61%) Lymphomas: testicles homogeneously hypoechogenic or with multifocal hypoechogenic lesions of various diameters. The didymis, in diffuse forms, appears hypervascularized (d.d. with orchitis) Testicular trauma Rupture or interruption of the albuginea, irregular echostructure with poorly MRI defined margins. Color /power Doppler can help to show the vascular pattern of the parenchyma, capsule Table 5. Testicle (4, 12). LineeGuida engl ok_Stesura Seveso 26/03/14 10:51 Pagina 71 Archivio Italiano di Urologia e Andrologia 2014; 86, 1 P. Martino, A.B. Galosi 72 Ultrasound of the penis INTRODUCTION Penile US is an essential tool in urological clinical prac- tice both as an investigation in itself and integrated with color Doppler of the penile vascularization (1). INDICATIONS Indications for penile US: 1. Erectile dysfunction. 2. Priapism. 3. Penile fibrosis and Plastic Induratio Penis. 4. Penile or urethral anomalies observed at physical examination. 5. Neoplasia of the penis. 6. Penile trauma. 7. Thrombosis of the dorsal vein. 8. Urethral disorders (cysts, diverticuli, stenosis). 9. Stones or foreign bodies in urethra or penis. TECHNIQUE OF INVESTIGATION At least two scans must be performed: transverse and longitudinal. The probe is positioned dorsally or central- ly to obtain a better visualization of the corpi cavernosi, the intercavernous septum, the tuniche albuginea and Buck’s fascia and the urethra (3). The transverse scan must be done in the proximal, medi- al and distal portions of the penis. The longitudinal scan must be done on the two corpi cav- ernosi, visualizing the cavernosum artery. In addition, to study the crural portion of the corpi cavernosi, the trans- ducer is placed perineally (4). Size, echogenicity (hyper, hypo, iso) and symmetry of the corpi cavernosi must be described and documented with appropriate images. Any alterations of the tuniche, either echogenic or struc- tural, must be documented by accurate measurements both on longitudinal and transverse scans. Any palpable alteration or penile anomaly must be closely studied directly on the involved zone, documented by appropriate images. Assessment of the vascular integrity is done by integrating Color Doppler (6). To study of the urethra (2, 5), hydrosoluble gel is injected through a catheter positioned at the level of the navicular fossa; longitudinal scans are done to study any alterations of the urethral lumen (7-9) . SPECIFIC DEVICES Penile US is done in real time B-mode scanning, using a linear probe with a frequency of 7.5/10 MHz and more (10). PENILE ECHO COLOR DOPPLER Penile echocolor Doppler (1) is generally performed in the following cases: • Erectile dysfunction [after Intra Cavernous injection (FIC) of PGE1). • Peyronie’s disease. • To assess penile morphology and vascularization after trauma. • In cases of blood collection or infection. METHODOLOGY Assessment pre FIC: • The investigation must be performed in calm sur- roundings avoiding outside interruptions. Detailed explanation of the different phases must be given, as • Grade 1: prolonged reflux in vessels in the inguinal channel only during Valsalva’s manoeuvre, while scrotal varicosity is not evident in the previous grey-scale study. • Grade 2: small posterior varicosity that reaches the superior pole of the testis and whose diameter increases after Valsalva’s manoeuvre. The CDU evaluation clearly demonstrates the presence of a venous reflux in the supratesticular region only during Valsalva’s manoeuvre. • Grade 3: is characterised by vessels that appear enlarged to the inferior pole of the testis when the patient is evaluated in a standing position, while no ectasia is detected if the examination is performed in a supine position. CDU demonstrates a clear reflux only under Valsalva’s manoeuvre. • Grade 4: is diagnosed if vessels appear enlarged, even if the patient is studied in a supine position; dilatation increases in an upright position and during Valsalva’s manoeuvre. Enhancement of the venous reflux after Valsalva’s manoeuvre is the criteria that allows the distinction between this grade from the previous and the next one. Hypotrophy of the testis is common at this stage. • Grade 5: is characterised by an evident venous ectasia even in an upright position. CDU demonstrates the presence of an important basal venous reflux that does not increase after Valsalva’s manoeuvre. Table 6. Color Doppler Ultrasound (CDU) grading classification of varicocele. In accordance with Sarteschi, varicocele can be divided into five grades according to the characteristics of the reflux and its length, and to changes during Valsalva’s manoeuvre (24, 25). LineeGuida engl ok_Stesura Seveso 26/03/14 10:51 Pagina 72 73Archivio Italiano di Urologia e Andrologia 2014; 86, 1 Practical recommendations for performing ultrasound scanning in the urological and andrological fields well as of the possible complications, obtaining writ- ten informed consent. • The basal study must include longitudinal and trans- verse scans to make an accurate study of the corpora cavernosa, corpus spongiosum, intercavernous sep- tum, the morphology of the cavernous arteries, the gland and the urethra. The cavernous arteries are shown as parallel lines, fine and echogenic, and any anatomical variants, even lacking clinical significance (e.g. duplication of the cavernous artery must be doc- umented) (2). FIC: • Single intracavernous injection of PGE1 in basal cav- ernous site, at variable doses (2.5 mcg in young, psy- chogenic men with a high risk of priapism due to cor- related disease) and if necessary redosing. Remember that a state of anxiety in the patient could delay the effect of the drug. Post FIC assessment: • Spectral Doppler must be done at 0,5,10,15,20,25 and 30 minutes after FIC at the level of the proximal third of the cavernous arteries and/or in crural site. • Measurement of Peak Systolic Velocity (PSV), Telediastolic Velocity (TDV) and Resistence Index (RI) using an ideal spectral angle of 60°. • Manual or visual stimulation is not usually necessary to obtain an adequate erection. • If the flowmetry result is considered adequate, the investigation can be interrupted before the measure- ments at 25 and 30 minutes. • After flowmetry it is useful to make a morphological study of the penile vascularization by Power Imaging, to assess the microcirculation, describing whether the helical branches are visible or not, and their angle of incidence on the cavernous artery (normally > 90°) (3). This method is also used to visualize traumatic lesions (4). • The dynamic phase after FIC is also useful to study Peyronie’s disease plaques, both in B-mode and Color Power Imaging, as well as fibrosis, structural varia- tions and any zones of venous leakage around the plaques. • Describe the degree of erectile response in terms of tumescence and rigidity at 20/30 minutes after FIC. Diagnostic criteria: • B-mode: Detailed description of the anatomical sym- metry of the corpi cavernosi, fibrous septum, any plaques or calcifications of the intracavernous zone or tuniche, any hypoechogenic lesions. • Arterial compartment: Any increased diameter post FIC, intravascular flow. Values of PSV > 35 cm/sec are considered normal in the literature, between 25 and 35 cm/sec “borderline”, that should be integrated with the degree of erectile response, values < 25 cm/sec are considered pathologic (5). • Venous compartment: With an increased intracav- ernous pressure and so increased PSV there is a decrease in TDV that may become negative with inver- sion of the diastolic wave, a sign of integrity of the venoocclusive mechanism. A persistence of TDV values > 5-7 cm/sec throughout all the phases of the test indi- cates a deficit of the venoocclusive mechanism. • It is important always to integrate flowmetry data with the degree of erectile response to FIC because a poor rigidity (low dosage of PGE1, a state of anxiety) and hence a minor arterial inflow will limit the degree of response of the venous compartment and hence the sensitivity and specificity of the test (6). • In the findings, note the patient’s psychoemotional approach to the test. After the test: • Ascertain complete detumescence before the patient leaves, informing him of the possibility of a prolonged erection/priapism and the management of this com- plication, as well as how to obtain further assistance if necessary. • Produce an accurate report with appropriate images both of the flowmetry and the morphology. TOOLS High frequency 7.5 MHz or more linear transducer, US device equipped with Color-Power Spectral Doppler; high Doppler frequencies are advisable (higher than 10 MHz) because they provide optimal resolution and facil- itate the examination of intravasal flow (7). EXAMPLE OF FINAL REPORT Test performed with linear probe (7.5/10) MHz. Test performed in basal conditions and after drug infusion of … mcg. of prostaglandins (PGE1); patient gave written informed consent to the procedure. Normal conformation of the corpi cavernosi, that appear symmetrical and of the corpus spongiosus of the urethra.; otherwise describe any alterations/irregularities of the tunica and septum, such as hyper-reflection, hypere- chogenicity and any images suggesting Induratio Penis Plastica. Cavernous arteries present, with a twisted course, pulsating. After FIC, increased volume of the corpi cavernosi with dila- tion and straightening of the cavernous arteries, that appear pulsating/non pulsating. Erectile response to FIC at ….minutes (poor/fair/good/excellent) for tumescence and rigidity with/without deviation of the penile axis (in cases of devia- tion describe whether it is dorsal, ventral or lateral, and the degree) Grade of EAS (Erection Assessment Scale): 1 to 5 (No erec- tile response/full rigidity) Flowmetry study performed in crural site: measurement of the systo-diastolic velocities with spectral Doppler analysis at 5,10,15,20,25 and 30 minutes after FIC. PSV (peak systolic velocity) equal to ….cm/sec on left and …cm/sec on right at …minutes after FIC showing normal/reduced arterial inflow. TDV (tele diastolic velocity) …cm/sec with/ without pro- gressive reduction or with/without negativization of the dias- LineeGuida engl ok_Stesura Seveso 26/03/14 10:51 Pagina 73 Archivio Italiano di Urologia e Andrologia 2014; 86, 1 P. Martino, A.B. Galosi 74 tolic wave at 20/30 minutes after FIC, showing integrity/deficit of the veno-occlusive mechanism. IR 1 Phase 3 obtained at …minutes Phase 4 obtained/not obtained at ….minutes Morphological study performed with Color Power Doppler: Cavernous arteries morphologically normal, well distended and straightened. Good/Fair/Poor visualization of the helicine branches by 1°,2°and 3° presenting an angle of incidence 90°, demonstrating integrity/deficit of the microcirculation (In cases of IPP) Presence/absence of peri-plaque Venous Leakage At ….. minutes after FIC there is/is not progressive penile detumescence. Psychoemotional attitude to test: poor/fair/good Images to include (not all are indispensable, depending on clinical picture) 1. Two basic images. 2. Six doppler spectral images with relative flowmetry values. 3. Two images showing microcirculation. REFERENCES Introduction 1. Documento SIUMB per le Linee Guida in Ecografia. Giornale Italiano di Ecografia (SIUMB Editore) I.R. al vol. 8-n 4. December 2005: 2. AUA, AIUM Practice Guideline for the Performance of an Ultrasound examination in the practice of urology, 2011. www.aium.org 3. Linee guida SIEOG Società Italiana di Ecografia Ostetrico Gine - co logica, Edition 2010. 4. Bevelacqua JJ. Practical and effective ALARA. 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Galosi 78 Correspondence Coordinators Pasquale Martino, MD (Corresponding Author) Department of Emergency and Organ Transplantation-Urology I, University "Aldo Moro", Bari, Italy pasqualeluciomartino@libero.it Andrea Benedetto Galosi, MD Division of Urology, “Murri” General Hospital, ASUR Marche, Fermo, Italy galosiab@yahoo.it Authors Marco Bitelli, MD Urologist, Rome, Italy Paolo Consonni, MD U.O. Urologia - Casa di Cura “S. Maria”, Castellanza (VA), Italy Fulvio Fiorini, MD Nefrologia SOC - Azienda Sanitaria ULSS 18 Rovigo, Italy fiorini.fulvio@azisanrovigo.it Antonio Granata, MD U.O. Nefrologia e Dialisi - ASP Agrigento, Agrigento, Italy Roberta Gunelli, MD U.O. Urologia Ospedale G.B. Morgagni-L. Pierantoni Azienda USL di Forlì Via Carlo Forlanini, 34 - Forlì, Italy Giovanni Liguori, MD Department of Urology, University of Trieste, Ospedale di Cattinara, Trieste, Italy Silvano Palazzo, MD Department of Emergency and Organ Transplantation-Urology I, University "Aldo Moro", Bari, Italy silvano.palazzo@alice.it Nicola Pavan, MD Urologist, Trieste, Italy Vincenzo Scattoni, MD Department of Urology, University Vita-Salute, Scientific Institute San Raffaele, Milan, Italy scattoni.vincenzo@hsr.it Guido Virgili, MD Department of Urology, University of Tor Vergata, Rome, Italy guidovirgili@tiscali.it Reviewers Libero Barozzi, MD Società Italiana Radiologia Emergency, Surgery and Transplants Department Radiology Unit S. Orsola-Malpighi University Hospital Via Albertoni 10, Bologna, Italy Michele Bertolotto, MD UCO di Radiologia, Dipartimento di Scienze Mediche, Chirurgiche e della Salute, Università degli Studi di Trieste, Ospedale di Cattinara - Strada di Fiume 447, Trieste, Italy Andrea Fandella, MD Divisione Urologica, Casa di Cura Giovanni XXIII Monastier (Treviso), Italy afandella@alice.it Paolo Rosi, MD Clinica Urologica ed Andrologica, University of Perugia, Perugia, Italy uropg@unipg.it Carlo Trombetta, MD Member of ESUI-EAU - Department of Urology, University of Trieste, Trieste, Italy trombcar@units.it LineeGuida engl ok_Stesura Seveso 26/03/14 10:51 Pagina 78