On the basis of our experience, CDUS is irreplaceable as an initial approach to patients affected by scrotal disease, whereas MRI is an ideal second-line investigation. MRI offers useful, and in some cases decisive, information, as it is capable of revealing unexpected findings and elucidating complex aspects. MRI helps improve patient management, with an overall reduction in costs.

The aim of this article is to describe the role of second-level imaging techniques after an initial ultrasonography evaluation in the assessment of scrotal diseases. While ultrasonography remains central as the primary imaging modality for the evaluation of pathologic conditions of the scrotum, the role of magnetic resonance imaging continues to evolve: it can actually be valuable as a problem-solving tool when sonographic findings are equivocal or inconclusive. Magnetic resonance imaging of the scrotum may provide accurate detection and characterization of scrotal diseases, well depicting the precise location of scrotal masses (intratesticular or extratesticular) and reliably characterizing benign conditions simulating neoplastic processes, thus preventing unnecessary radical surgery. Advanced magnetic resonance techniques, most of all diffusion weighted imaging and magnetic resonance spectroscopy, play in the meanwhile a more significant role in evaluating scrotal diseases.Teaching points • Multiparametric ultrasonography usually represents the initial imaging modality for approaching scrotal diseases. • MRI is well established as a problem-solving tool for inconclusive sonographic findings. • Advanced MRI techniques can be successfully applied in scrotal pathology assessment. • MRI is valuable in differentiating benign conditions from neoplastic processes. • CT plays a role in trauma assessment and cancer staging alongside PET/CT.

Purpose: Proton magnetic resonance spectroscopy (1 H-MRS) has been proposed as a tool to assess male infertility providing metabolic signatures related to the spermatogenesis in the testis. This study sought to identify the role of 1 H-MRS in the diagnosis of infertility in patients with semen analysis altered. Materials and Methods:14 patients (27 testicles) with fertility problems and with an altered semen analysis (5 oligospermia, 3 asthenospermia, 6 oligoasthenospermia) and 9 controls (18 testicles) with normal spermatogenesis assessed (men with prior paternity and normal semen analysis) and normal testicles at magnetic resonance (MR) and ultrasonography (US) with colour Doppler (CD) examination were included. All patients underwent testis US and CD investigation, conventional MR examination at 1.5T including T1 and T2 weighted images in three orthogonal planes and proton magnetic resonance spectroscopy (1 H-MRS) with single-voxel PRESS (TR 2000 ms / TE 31 ms). Major metabolites peaks (choline, creatine, lipids, lactate) were calculated and compared between the patients and controls.Results: Mean choline peak in the semen analysis altered group was statistically significantly lower than the normal group (0.69 vs 1.34, 95% CI: 0.52 -0.85; p < 0.001). 18 testicles within semen analysis altered group (66,7%) had both MR and US examination negative but mean choline peak lower then controls (1.09 vs 1.34, p < 0.001). 7 testicles of those presented also varicocele at CD investigation. Conclusion:1 H-MRS revealed a significant shift towards lower choline peak in patients with semen analysis altered compared to controls with normal spermatogenesis. Moreover 1 HMRS provided to find out spermatogenesis disorder in patients with normal testis at MR and US examination.

How to differentiate with MRI-based techniques testicular germ (TGCTs) and testicular non-germ cell tumors (TNGCTs) is still under debate and Radiomics may be the turning key. Our purpose is to investigate the performance of MRI-based Radiomics signatures for the preoperative prediction of testicular neoplasm histology. The aim is twofold: (i), differentiating TGCTs and TNGCTs status and (ii) differentiating seminomas (SGCTs) from non-seminomatous (NSGCTs). Forty-two patients with pathology-proven testicular neoplasms and referred for pre-treatment MRI, were retrospectively enrolled. Thirty-two out of 44 lesions were TGCTs. Twelve out of 44 were TNGCTs or other histologies. Two radiologists segmented the volume of interest on T2-weighted images. Approximately 500 imaging features were extracted. Least Absolute Shrinkage and Selection Operator (LASSO) was applied as method for variable selection. A linear model and a linear support vector machine (SVM) were trained with selected features to assess discrimination scores for the two endpoints. LASSO identified 3 features that were employed to build fivefold validated linear discriminant and linear SVM classifiers for the TGCT-TNGCT endpoint giving an overall accuracy of 89%. Four features were employed to build another SVM for the SGCT-SNGCT endpoint with an overall accuracy of 86%. The data obtained proved that T2-weighted-based Radiomics is a promising tool in the diagnostic workup of testicular neoplasms by discriminating germ cell from non-gem cell tumors, and seminomas from non-seminomas.

Testicular microlithiasis and poor sperm function represent risk factors for testicular cancer: in our study, 30.6% of the patients who developed cancer presented these features. At US examination, testicular microlithiasis is often associated with testicular cancer (53.8%). A high accuracy has been demonstrated for US in detecting microlithiasis (53.8%) compared with histological evaluation (69.2%). At histology, tubular hyalinisation (92.3% of cases) is, with testicular microlithiasis, the most frequent finding in the parenchyma adjacent to testicular cancer.