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Hello and welcome to noom Conference hosted by modality.

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Noom Conference connects the global radiology community

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through free live educational webinars that are accessible

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for all and is an opportunity

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to learn alongside top radiologists from around the world.

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Today we are honored to welcome Dr.

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Deborah Baumgarten

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for a case space lecture entitled Scrotal Imaging in the ed.

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Dr. Baumgarten completed medical school

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and all of her radiology training at Emory University.

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She was on staff there for over 25 years

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before moving to the Mayo Clinic in Jacksonville, Florida

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where she specializes in abdominal imaging

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with a special interest in ultrasound and NGU imaging.

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At the end of this case review, please join her in a q

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and A session where she will address questions you may

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have on today's topic.

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Please remember to use that q

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and a feature to submit your questions so we can get to

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as many as we can before our time is up.

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With that, we're ready to begin today's case review. Dr.

0:55

Baumgarten, please take it from here.

0:58

Hi, thank you very much. Good, awesome.

1:01

So I am gonna be talking,

1:02

as Ashley mentioned about scrotal imaging in the ed.

1:05

I know for those of you

1:06

that tune into this noon conference regularly,

1:09

you had a lecture on the scrotum about a month ago,

1:13

but this one's a little different in

1:14

that we're just gonna be looking at cases

1:16

and we'll be looking at cases that might prompt a gentleman

1:19

to show up in the emergency room.

1:22

So I have no financial disclosures that are relevant

1:25

to this presentation.

1:27

I am a section editor for up to date.

1:29

I am the current president of the rank and Ray

1:33

and I'm on the editorial board of radiology

1:35

and Radiology Imaging Cancer.

1:38

So the learning objectives for this presentation are

1:41

to recognize some common

1:42

and uncommon scrotal conditions that lead

1:45

to emergency room visits to be able

1:48

to formulate a reasonable differential based solely on

1:51

presenting symptoms and other history.

1:53

So we'll think about what might be going on even

1:55

before we do any imaging is a case-based format

2:00

and they are grouped by general themes.

2:03

So with that, let's start our first case.

2:05

We have a 16-year-old

2:07

who was woken from sleep about two hours prior

2:10

to showing up at the emergency room with right-sided pain.

2:15

Does anybody, if you want to type in the chat section

2:17

and anybody have any ideas about what we might be dealing

2:20

with even before we see the patient?

2:24

That's okay. Uh, torsion, somebody put torsion,

2:26

multiple people are putting torsion.

2:28

Yes, that is actually a really good thought.

2:30

16 year olds you wouldn't think would be woken from sleep

2:33

with something like epididimitis.

2:35

It's certainly not trauma. So torsion is a good thought.

2:37

So let's look at that. So here is our initial imaging exam

2:41

where we have gray scale images of the right

2:44

and left testis here.

2:46

And does anybody see anything on these images?

2:52

Well, there's a trace, right hydro seal

2:55

and that fits the side that he was having pain on.

2:58

The gray scale images are otherwise pretty identical.

3:00

There's really no gray scale changes in either testis.

3:04

Here's the color doppler

3:07

and there's really very, very asymmetric flow here

3:10

where there's virtually nothing.

3:12

In fact, the technologist took a couple of areas here

3:14

that had little dots

3:15

and really couldn't get a good wave tracing.

3:18

And on the left side we see pretty good flow.

3:21

So here's a syn clip through the top

3:23

of the scrotum on the right

3:28

and it's gonna play, it'll play again

3:31

and you really do get a sense of that kind of twisting

3:34

of the cord here.

3:37

So this is indeed right-sided torsion

3:40

and in fact it was complete torsion.

3:43

Here's another case. So this was a 12-year-old

3:45

who had left-sided pain following a pillow fight,

3:48

but the pillow fight was, was uh, a day and a half ago.

3:51

So it's been 36 hours since he had the pillow fight

3:57

and this is what his testes looked like, the right and left.

3:59

And these are magnified to the same scale.

4:02

This may be showing um, maybe only a portion

4:05

of the test is not truly through the center,

4:07

but this is through the center of the left testes.

4:10

Has anybody notice anything In this case so far,

4:15

somebody thought maybe testicular rupture.

4:16

So that is a really good thought

4:18

with somebody who's been in a pillow fight.

4:20

You know, perhaps trauma.

4:24

What we see really here is a little bit

4:25

of scrotal skin thickening compared to the opposite side.

4:28

There's a little bit of hetero heterogeneity of this testes.

4:33

So someone else is suggesting post-traumatic oris possibly.

4:37

So what do we want next? We want color flow of course.

4:40

So here's our color imaging

4:43

and we see that the right side has robust flow

4:46

and the left side there's flow around the testes

4:51

but no flow within the testis.

4:54

And here's a cine clip here.

4:59

And does anybody know what we call the sign

5:01

where you see robust flow around the testis

5:03

but no flow within the testis?

5:08

It's called the donut sign

5:11

and it's really a sign of increased flow

5:12

around a necrotic testis.

5:14

And unfortunately this one was dead at surgery.

5:18

So what features can help you decide if a

5:20

testis is salvageable?

5:22

Well, the more there is a difference in the gray scale

5:25

features of the two testes when comparing them,

5:27

the more likely it is to be unsalvageable.

5:30

Meaning the, the side that is affected,

5:33

the more hypoechoic it becomes, the more emini

5:36

and then going onto necrosis,

5:38

the less likely it'll be salvageable.

5:40

About 90% of testes are saved if they are untoured

5:44

or detoured within six hours.

5:46

That rate drops to 50% at 12 hours

5:49

and then less than 10% and 24 hours.

5:52

And remember this person had pain for 36 hours,

5:56

so it was kind of unlikely

5:57

that it would've been salvageable.

6:00

How about this one? There's a patient who was 16,

6:03

he had right-sided pain

6:05

and he presented within five to six hours

6:07

after the onset of pain.

6:10

So here we go. We have the right and the left.

6:14

There are some mild gray scale changes here.

6:18

And then again when we do color flow,

6:22

absolutely no flow within this testes.

6:24

However, because it was within that six hour window

6:28

and the gray scale changes are mild,

6:30

this was actually salvaged at surgery.

6:35

Here's one who was a 38-year-old who had right-sided pain

6:38

and he was seen at an urgent care center a few days

6:41

before he was sent away with antibiotics

6:45

for presumed epidemo or but did not have any imaging.

6:50

So then he presented to the emergency room again a couple

6:53

of days later because he had persistent pain.

6:56

And this is what his testes looked like on gray scale.

7:00

And I think you'll all agree

7:01

that this testes has marked gray scale changes compared

7:05

to the left side.

7:07

And again, if we look at power doppler here, clearly

7:11

torsion no flow at all.

7:14

Now surgery might still be indicated,

7:16

it just might not be indicated emergently.

7:19

For example, if there's no urologist in house at three in

7:21

the morning, they won't call somebody in.

7:23

They'll do supportive care until the patient can be taken

7:25

to the or at a reasonable hour

7:27

because a necrotic test is, is a setup for infection.

7:31

Plus you want to uh, make sure

7:35

that you can avoid torsion on the opposite side.

7:39

So here's another one, a 20-year-old

7:41

who was woken from sleep with right-sided pain.

7:47

Okay, and uh, really no gray scale changes here.

7:52

And if we look at the color doppler,

7:56

perhaps minimally decreased, right-sided pain, uh,

7:59

right-sided flow, excuse me,

8:02

but not a whole lot of difference.

8:06

So here are buddy views

8:07

where we have both testes side by side.

8:10

Again, it looks like there might be

8:12

slightly decreased flow on the right compared to the left.

8:17

And here are the wave tracings.

8:19

The wave tracings are really important

8:21

when you have a suspicion for

8:23

for something else going on here.

8:25

So if we look, the peak systolic velocity on the right is

8:30

around two centimeters per second.

8:32

They look similar but the peak systolic velocity on the left

8:36

is really almost 10.

8:38

And you've gotta be careful because the

8:39

scales here are different.

8:41

This is only displaying up to six centimeters per second

8:44

and this is displaying up to 10 centimeters per second.

8:48

Ideally these scales would be the same so

8:50

that you can compare them directly,

8:52

but if you, again, you look very carefully, you can see

8:55

that there is actually more flow on the left than the right.

8:59

So there is a blunted peak systolic velocity on the side

9:03

that's painful and here is an image through the top

9:08

of that scrotum on the right.

9:11

And again you can see that twirling here.

9:15

So this is not complete torsion.

9:17

What is, what is this instead?

9:25

This is partial torsion.

9:31

Here's another one, a 14-year-old with exquisite right pain

9:34

for about six and a half hours.

9:36

But he said that his pain actually improved

9:37

during the examination.

9:41

So here are our images again,

9:44

it was again right-sided pain

9:47

and we see a trace,

9:48

right hydro seal on the side that is affected.

9:51

Gray scale looks pretty symmetric

9:54

but here are the wave tracings for this patient

9:58

and we see that there is no diastolic

10:00

flow on the right side.

10:04

There is good diastolic flow on the left side

10:07

and the scales are the same.

10:08

So we can directly compare the peak systolic velocity is

10:12

only minimally decreased but

10:14

because there's no diastolic flow that indicates

10:16

that flow in this testes is high resistance.

10:22

So here is later in the exam

10:24

the color doppler pictures look a little bit more symmetric

10:28

but this is the original way of form with that lack

10:30

of flow and diastole.

10:33

And here's how it looked.

10:34

Once the patient reported that he felt a little bit better

10:37

and you can see we now have some diastolic flow.

10:41

So what has happened to this testis during the course

10:43

of the examination?

10:49

It actually detours, yes, somebody wrote detorsion.

10:53

Excellent. And again here's that twirling of the cord

10:59

at the top of the testicular at the top

11:02

of the testes at the top of the scrotal sac.

11:05

This is a really important area for the technologist

11:08

to image and to get a cine clip through.

11:12

'cause even with partial torsion

11:13

and you get partial detour which is what restored

11:16

that flow in that testes.

11:18

So that's what this was.

11:20

So this patient was brought to the,

11:22

or the torsion on the right side had resolved

11:24

but he underwent uh, pxi orchiopexy,

11:28

meaning tacking the testis down in the sac

11:30

so that it won't twist again.

11:31

And you normally do that on both sides

11:33

to prevent it from happening on the opposite side.

11:38

So here's another patient who's 24 woken from sleep

11:41

with right sided pain.

11:43

He had surgery for prior undescended left testis,

11:46

so he might expect his left testis

11:48

to be slightly atrophic compared to the right,

11:50

but this is what he looked like.

11:52

Here's the right side and the left side.

11:55

So clearly here we actually even went more sensitive looking

12:00

for flow on this side.

12:01

So they've lowered the, the, the uh, scale a little bit

12:04

and we still can't find much flow on the right side

12:09

here it is on power doppler.

12:10

Again, not seeing much flow on the right side

12:14

and this is what the wave tracings looked like.

12:17

Normal on the left with robust diastolic flow.

12:21

But look at here we have reversal

12:23

of flow in diastole in this case.

12:25

So this is even higher resistance to flow than just lack

12:29

of diastolic flow or a blunted peak systolic velocity.

12:36

So this again is at the top of that testes

12:39

and again, I'll just put up that little arrow.

12:42

The twisting is not quite as obvious in this case

12:45

but we do see some sense of that twisting in this case.

12:50

And this again was partial torsion.

12:55

So this is an interesting one.

12:57

Uh, I I think this is a 20-year-old who came in

13:00

with right pain two days, times two days

13:03

and he had some swelling

13:04

and it worsened about two hours ago.

13:05

So he decided to come in and he ended up with a CT first

13:10

because he also had some complaints

13:12

of right lower quadrant pain And I was reviewing the cases

13:15

to try to pull some some new cases for this uh, talk.

13:19

And I noticed that the patient had had a CT first

13:21

and I also noticed that when I looked at the right testis

13:24

there was a small right hydrae which would go along

13:28

with his pain on that side

13:30

and the right testis itself was a little bit ill-defined

13:33

and a little bit less dense than the opposite testis.

13:36

Um, as an aside we can actually pick up about five

13:39

hound shield unit difference.

13:41

That's about the minimum that we can tell just

13:43

by looking at something but we can confirm it.

13:47

This one was 16 hounds field units,

13:49

the other side was 31 hounds field units.

13:51

So clearly this right testes is emus.

13:56

He then went on to have an ultrasound

13:59

and we can see the gray scale, they look fairly symmetric.

14:02

There is that hydro seal on the right side

14:05

with color doppler.

14:06

There is diminished flow in that testes

14:10

and here are the wave tracings which are actually not

14:12

that helpful in this particular case

14:14

because the scales are roughly the same.

14:17

This one's slightly higher

14:18

but they look like there's fairly um,

14:20

equivalent peak systolic velocity.

14:24

This was only a 180 degree torsion when the patient was

14:28

went, went to surgery but they did perform

14:30

bilateral orchiopexy.

14:33

So here are some additional companion cases.

14:35

This was an interesting one

14:37

because the patient had a pain that woke him from sleep

14:39

but then tends to resolve

14:41

and it wakes 'em up and then it resolves.

14:43

But this time it was really severe and persistent.

14:46

So here's what he looks like.

14:47

It's very obvious that there's decreased flow

14:50

on the left side.

14:53

The epididymus was slightly enlarged

14:55

and maybe a little bit hyperemic.

14:57

You can get reactive hyperemia in the epididymus

15:01

when you have torsion.

15:05

And again this is one of those patterns of partial torsion.

15:09

There is decreased peak systolic flow three centimeters per

15:13

second on the affected side

15:15

and four centimeters per second on the non-affected side,

15:22

This patient was 26 with right-sided pain for two days

15:25

and then had swelling that worsened a couple of hours ago.

15:31

So here again the gray scale features,

15:33

they look pretty symmetric.

15:34

There is decreased flow in that right testis compared

15:38

to the left and this buddy view is really the best way

15:41

to compare the two here We tried to find flow

15:46

with power doppler and maybe got a few more areas with flow.

15:51

And here again is the wave tracing

15:54

a really blunted peak systolic velocity on that right side

15:59

compared to the left side and in this case

16:02

the scales are the same.

16:03

So we see that nice sharp upstroke and the normal side

16:06

and that really sort of wavy blunted on the other side.

16:10

And again this is partial torsion

16:14

and I am showing you multiple of these cases

16:17

because this is one of those diagnoses

16:19

that you just do not wanna miss.

16:21

So seeing multiple of these is helpful.

16:25

Here's a 33-year-old who had abrupt left inguinal

16:28

and scrotal pain about three hours ago.

16:29

And again this was another case that had a CT scan first

16:34

because they thought maybe he had an inguinal hernia.

16:38

But again, as we compare the right and the left

16:41

and we can put them in the sort of a buddy view equivalent,

16:44

we can see that the left side is less dense than the right

16:48

and again we can confirm that 32 on the right

16:51

and 23 on the left.

16:54

So here's the ultrasound which is extremely helpful

16:57

where we see markedly diminished flow in that left testis

17:01

and that really blunted velocity

17:05

where we barely pick up a little blip and no diastolic flow.

17:09

This line here is just noise.

17:12

So again this is another case of partial torsion

17:15

and in the OR in this case they found a three, excuse me,

17:18

a 270 degree twist but the testis was viable.

17:23

So I wanna emphasize changes in torsion and partial torsion.

17:29

In complete torsion there is no flow

17:31

and in fact you may get reactive hyperemia around the testis

17:36

and gray scale changes will help you decide if the testis is

17:39

salvageable as well as

17:41

how long it's been since the patient had symptoms starting

17:48

in partial torsion you can have a

17:53

blunted peak systolic velocity,

17:57

you can have no diastolic flow

18:01

or you can have reversal in diastole.

18:03

So those are three of the wave form changes

18:07

that I see most frequently.

18:10

In fact, this reversal is probably the least common.

18:13

The one I've seen most frequently is a

18:14

peak blunted velocity.

18:18

But your color doppler

18:19

and your power doppler pictures are also extremely important

18:22

in helping you at least think about the

18:24

possibility of torsion.

18:28

So somebody asked what the explanation

18:30

for the epidermal hyperemia in the setting of torsion.

18:33

I think what happens is in,

18:35

especially in partial torsion you get that torsion

18:37

and detour and you get an increase in blood flow

18:40

and the testis does detours and then it might reto

18:43

and it hasn't quite finished draining all

18:46

that blood from the epididymus.

18:48

So that's probably what's going on.

18:51

So what causes torsion?

18:55

So here's an image through the scrotum on the left you can

18:58

see that there's a moderate to large hydros eal

19:01

and you see that that testis

19:02

and its corridor just freely floating in the scrotal sac.

19:07

So does anyone know what this is is called?

19:16

It's a deformity. This is a bell

19:20

clapper deformity.

19:22

So that was a predisposing factor for torsion

19:25

that was first described in 1932.

19:28

Um, it's the testis hanging freely in the scrotal sac.

19:31

It's, it's like a clapper

19:33

or the, the thing that makes a bell ring when you uh, jolt

19:38

or or move a bell, the thing that's inside

19:40

that moves back and forth.

19:42

The reason that we can see the bell clapper deformity is

19:45

'cause there is fluid around the testis.

19:46

It's not something you can see if there's no fluid.

19:51

Let's uh, compare that to a normal.

19:54

So this person does have a hydros eal

19:57

which is surrounding portions of the testis

20:00

but does not surround this port part here

20:03

where the testis is tacked to the scrotal wall.

20:07

So it is not freely hanging in there, it's,

20:09

it's just surrounded on some sides by fluid.

20:15

So again, this is normal

20:17

and you can see the attachments despite the fact

20:20

that there's a hydros seal

20:21

and here's the bell clapper

20:22

where it's just freely floating in there.

20:28

So again, this is usually bilateral so

20:31

that when you have one torsion on one side they usually go

20:35

ahead and do pxi on both sides so that you can make sure

20:38

that it doesn't recur.

20:42

So somebody asked if a blunted peak velocity meant a

20:45

reduced peak velocity.

20:47

It is both a reduction in the amplitude

20:50

but it also has almo almost that parvis tardis

20:53

or a more does it not have a nice sharp upstroke?

20:56

It's more um, rounded

20:58

so it can be a little different in in appearance.

21:03

Okay, how about this patient?

21:04

He's 11 and he had abrupt right at sided pain

21:08

but had a faint blue dot on his scrotum.

21:11

Does that blue dot mean anything to anybody?

21:17

Maybe, maybe not. Ah, testicular appendage. Excellent.

21:22

So here we have some images from that patient.

21:25

We have gray scale that look fairly symmetric.

21:27

We have good color flow to both sides.

21:29

Maybe even, I don't know, we have more

21:32

of the testes in this frame than we do the opposite side.

21:35

This is up in the epidermal area on the right and left

21:41

and a closeup showing you this sort

21:42

of multicystic structure without flow in the region

21:46

of the right epididymus.

21:50

So here's gray scale

21:52

and color showing the

21:57

epididymus and the top of the testes.

21:59

And I'll draw your attention to that area there.

22:02

That's that multicystic structure without flow.

22:06

And as a person suggested torsion of the appendix

22:12

and that causes a pretty pathognomonic look

22:16

and that blue.is a result of the uh, lack of flow

22:20

to that appendage.

22:22

And here's a companion case.

22:24

This is a 30-year-old

22:26

who had pain in the right epidermal area.

22:29

So here are the testes, they look fairly symmetric.

22:32

Here's our wave forms. They also look fairly symmetric.

22:37

But this structure was seen in the region of the epididymus

22:40

and again this multicystic without flow

22:43

and here it is on a cine clip right in here.

22:48

And this again was appendix torsion.

22:51

So the blue.is not seen in all patients.

22:54

It's helpful if you see it

22:56

'cause it will remind you to look in that area.

22:58

But this kind of multicystic structure in the epidermal

23:03

region without any flow.

23:05

What should lead you to think about an appendix torsion?

23:10

Okay, so here's an 89-year-old

23:13

who has had pain since he had a right inguinal hernia

23:16

repair two weeks previous.

23:17

So this is a patient who's had surgery.

23:20

So our differential is gonna be a little bit different.

23:23

We're not thinking about torsion in this case.

23:25

Do you have any ideas about what we might think about

23:29

in a patient who's postoperative in the region?

23:32

So yes, a hematoma absolutely hematomas can cause issues

23:37

by compressing structures.

23:40

Anything else you wanna add?

23:44

Ischemia also really good reactive.

23:48

So let's see with this case vessel injury also good.

23:52

So let's see what we have. So here are gray scale pictures.

23:56

Remember the hernia was on the right,

23:58

this is the right side,

23:59

this is the left side gray scale on the left looks normal.

24:03

Flow on the right, on the left looks normal. He's 89.

24:05

We don't necessarily expect a huge amount

24:08

of flow in the testis

24:10

but the right side is markedly abnormal.

24:13

We have a small wedge-shaped area here which has kind

24:17

of normal gray scale features compared to the opposite side

24:20

and it does have flow

24:22

but the remainder of the testes is without flow.

24:26

When we take a waveform from that part of the right testes,

24:30

we have a very blunted look to it.

24:36

When we take waveform on the opposite side,

24:38

we get a very normal, nice robust flow

24:40

with good diastolic flow.

24:42

So yes somebody expect said infarction

24:45

and absolutely this is what infarction looks like.

24:48

It is a different mechanism than torsion.

24:53

The there are three arteries that supply the testis.

24:56

There's the testicular artery, the cremasteric artery

24:59

and the artery to the ductus deens.

25:01

And you need to interrupt one of these

25:03

to get these segmental infarctions.

25:05

And the few that I have seen all kind of look like this

25:08

with this wedge-shaped area that's more normal echogenicity

25:12

and really the only area that has good flow.

25:15

But when you look at the flow in that area,

25:17

it's often abnormal.

25:19

So here are a couple of companion cases.

25:22

This is a 56-year-old who had waxing

25:25

and waning left pain for a few days.

25:30

And again we have a normal right sided gray scale

25:34

and the left has just that little wedge shaped area

25:36

that looks a little normal, maybe it's very heterogeneous

25:40

and really not a lot of good flow here.

25:44

And this was a left infarction at surgery.

25:49

And here's another one, a similar case

25:53

where here's the normal left side

25:55

and the right side just has that one area with flow.

25:59

And when we take a wave tracing there,

26:01

it's a very blunted wave form.

26:03

So again this was another right infarction.

26:07

Alright, how about we have an an older gentleman

26:12

who's having right-sided pain

26:14

but he's also complaining

26:15

that his urine doesn't look or smell right.

26:18

What are you thinking about in this case?

26:23

Infection. Great epididimitis, great, great, great thoughts.

26:29

So here's what he looks like. There is no doubt about it.

26:33

That right side has just

26:36

abundant flow not only in the testis

26:38

but also the epididymus here.

26:41

Here we have a reactive hydro seal

26:43

and again lots of flow in the epididymus

26:46

and in the testis normal flow on the opposite side.

26:50

So this is right epidemo

26:53

and his urine cultures happened

26:55

to grow enterobacter Cloe complex for some reason.

27:00

How about our 57-year-old who had right scrotal pain

27:03

and he had some epidermal tenderness on exam

27:08

and this is what he looked like.

27:10

If we look at the right and left testes,

27:12

the gray scale is normal, the color flow is normal.

27:15

But when you compare the epididymus on the left

27:18

to the EPIs on the right,

27:20

the right is markedly enlarged and hyperemic.

27:24

So here we have just epididimitis.

27:30

Now could this have been reactive hyperemia say related

27:35

to torsion and detour?

27:36

In this case when they come in

27:38

and they're still having pain, it's unlikely

27:41

that this was torsion and detour

27:43

because the pain should go away if they have detour.

27:47

So you can be pretty confident when you see an enlarged

27:50

hyperemic epididymus that it's more likely

27:53

to be epididimitis if they are still having symptoms.

27:57

Now although Oras is rarely isolated,

28:00

you can get isolated oras with uh, viral illness such

28:04

as mumps epididimitis can be isolated, you don't have

28:08

to have oras at the same time that you have epididimitis.

28:12

The only difference in treatment is they'll usually leave a

28:14

patient on antibiotics longer if they have oras in addition

28:18

to epididimitis.

28:21

So here's an 82-year-old who had bilateral pain

28:24

and he also had a urine that was positive for uh bacteria.

28:30

So here we have gray scale buddy view,

28:32

they look fairly symmetric.

28:34

Here we have the epidemy epi or the right

28:38

and left epididymus and they both look enlarged.

28:42

So what do you suspect that the color flow is gonna show?

28:48

Well, lots of flow everywhere

28:51

so every once in a while you can have bilateral

28:53

epididymal oras.

28:55

It tends to be in my experience, unilateral

28:58

but can be bilateral.

29:00

So in this case this patient would need a long course

29:02

of antibiotics to treat both the epididimitis and the oras.

29:10

Here's a patient who had left-sided pain

29:12

and initially the patient was very stable in the emergency

29:14

room just complaining of the left-sided pain,

29:17

but then he became febrile

29:18

and actually had signs of sepsis

29:21

during his stay in the emergency room

29:24

and this is what he looked like.

29:26

So here we have the right and the right side

29:29

and the left with the left side.

29:32

So here we have a hydrae on the left side,

29:34

the epididymus is enlarged.

29:36

There's a little bit more flow in the testis itself

29:40

and look at the wave forms.

29:43

We have a peak systolic velocity

29:46

of six on the unaffected right side

29:49

with nice diastolic flow.

29:51

The peak systolic velocity is increased in this case

29:54

but the diastolic flow is actually diminished.

29:57

So we're having some early signs

30:00

that perhaps this infection is more severe than we thought

30:03

it initially was, especially with the signs

30:06

of sepsis in the ed.

30:09

So this is the patient two days later

30:12

and you can see that that hydro seal is now very complex.

30:16

There's debris in it, some septations, it's larger.

30:21

We now have some diminished flow on that side compared

30:25

to the opposite side.

30:27

And this is what the waveforms looked like.

30:29

The right side which was unaffected had a normal waveform

30:33

and now we have reversal of flow on the left side.

30:38

So do we think this patient suddenly had torsion?

30:41

Well we can see in this picture quite clearly

30:43

that there are good attachments here of this testis

30:47

to the scrotal wall.

30:49

So this is not a patient who has a bell clapper deformity.

30:52

What can happen with severe infection

30:54

as you get a compartment syndrome.

30:57

So yes, a tension hydro seal or PSE

31:01

or an abscess can form

31:03

that can put pressure on the testis diminishing its flow.

31:07

You can also get edema within the testis itself,

31:10

which might compress the vessels

31:12

or there are have been reports of some microvascular, um,

31:16

thrombus, thrombus.

31:17

So maybe some, some venous thrombosis within the testis

31:20

that might also give you this reversed flow.

31:23

So it indicates a severe infection,

31:25

it indicates the patient needs to be admitted

31:27

and given IV antibiotics

31:29

and potentially have a drainage of the peoe in order

31:33

to relieve the pressure.

31:34

So it is a part of um, a

31:37

of a compartment syndrome basically in the scrotal sac,

31:42

this person was 77, they had a urinary tract infection

31:45

with enterococcus they were having increasing right pain

31:49

and there was a question of whether they might have some

31:51

cellulitis on the scrotal sac

31:54

and this is what this person looked like.

31:57

So what do you think is going on here?

32:01

We have a lot of flow in that right testis here,

32:04

but then we have an area that does not have any flow,

32:07

just flow around it and the opposite testis is normal.

32:11

So yes, an abscess, an intra testicular abscess.

32:16

So this has to be debrided surgically.

32:18

An abscess of this size is probably not going

32:21

to resolve just with i IV antibiotics.

32:24

So yes this was an abscess.

32:26

So this is another complication of epidemo oris.

32:30

You can get PIOs seals around the testis

32:33

but you can also get abscesses within the testis itself.

32:38

Okay, okay, we have a 45-year-old with diabetes

32:43

and he said several days of scrotal pain

32:45

and his skin has been progressively changing.

32:48

It's gotten red, it's the skin itself may be painful.

32:53

History of diabetes is somewhat helpful.

32:55

What else do you all think could be going on in a

32:58

patient like this?

32:59

Four neers gangrene.

33:01

Somebody wrote, oh somebody's seen my slides.

33:04

So here we have a series

33:05

of images from this particular patient.

33:09

So we have the right and the left, the right and the left

33:12

and again the right and the left.

33:14

And this is labeled transverse, left scrotum

33:18

inferior to testis.

33:19

And what are we seeing here?

33:24

What we're seeing is dirty shadowing.

33:27

We're seeing actually air gas exactly

33:30

and here on the cine clip I think it shows much better all

33:34

of that air that's within the scrotal wall.

33:37

You can see the, it's emanating from the wall

33:40

of the scrotum here.

33:42

It's not outside, it's not a an artifact

33:45

of gel or anything like that.

33:47

And this is what the patient's CT scan looked like

33:50

where you clearly see the air in the wall

33:51

of the scrotal sac.

33:53

And this is a surgical,

33:54

practically a surgical emergency if there is one.

33:57

Yes, absolutely this has to be debrided.

34:01

Often the area of uh, revitalization of the, of the skin

34:05

and subcutaneous tissues is a little bit larger than the

34:07

area that just has the air in it.

34:09

So they have to do a fairly wide debridement.

34:11

So this is something again you do not wanna miss is air in

34:15

the scrotal sac or fornier gangrene.

34:19

And here are a few companion cases to go along

34:21

with our section on infections.

34:24

So here we have a 60-year-old

34:26

who had urinary tract infection

34:28

and increased white cell count

34:29

and he came in with left sided pain.

34:33

So again, we're thinking about infection if we compare the

34:36

right and the left, the epididymus is hyperemic,

34:39

the testis is hyperemic

34:41

and we have that hydro seal around here

34:45

with pulse wave doppler we have

34:51

a lot of flow on that left side,

34:53

12 centimeters per second versus six centimeters per second.

34:56

An abundant diastolic flow,

34:59

you gotta be careful here Again these scales are different.

35:02

So even though they look equivalent,

35:04

look carefully at the numbers

35:05

and look carefully at the scale.

35:08

So this was a diagnosis of epididimitis

35:11

and the patient was put on antibiotics,

35:16

then he came back three days later

35:19

and again we have normal flow on the right.

35:22

We now start to see maybe a little bit

35:24

of diminished flow on the left.

35:25

The epididymis is still hyperemic, there is still

35:29

a hydro seal on doppler.

35:32

The right waveform was normal

35:34

but now we have reversal of that

35:37

flow on the left side.

35:41

So again, this is another yes compartment syndrome exactly.

35:46

Again, there's no bell clapper deformity in this patient.

35:48

We can see the good attachments here even though

35:51

we have a hydros eal.

35:53

So this was again severe persistent infection

35:57

and the patient had to be admitted for IV antibiotics

36:00

and then they actually stayed on antibiotics

36:02

for an additional 21 days as an outpatient

36:05

because of the severity of their infection.

36:10

Here's another case. This is an older case.

36:13

And again note

36:17

that there's shadowing here from the scrotal wall.

36:21

So here's the surface of the scrotum, the edge

36:25

of the scrotal sac, a little hydros eal

36:28

and the edge of the testes here.

36:30

And utilizing a larger transducer,

36:33

we can see the air again emanating from the wall.

36:37

Testes looked pretty symmetric with color flow.

36:40

There might have been a little bit

36:41

of hyperemia on this left side in the wall itself

36:44

and the wall is very thick.

36:46

But because this was an older case,

36:48

how do you suppose we confirmed the air,

36:51

we did not do a CT scan in this case we

36:56

did a plain film and I'm gonna just give you a closeup

37:00

of the scrotum and you can confirm the air

37:03

within the scrotal sac.

37:05

So you don't necessarily have to do a CT scan if a,

37:08

if a plain film is available

37:10

and quick to get a portable is absolutely fine.

37:14

Fornier is gangrene is is confirmed

37:17

and the patient went to the

37:18

or here's a 64-year-old

37:22

who had worsening scrotal pain

37:25

and these are all images of the left side.

37:27

You see a little bit of the right

37:29

over here, which was normal.

37:31

What do you think is going on in this case?

37:35

Maybe a compartment syndrome.

37:37

Yeah, I mean we have a lot of gray scale changes in

37:41

that left testis compared to the right side.

37:43

Even if the patient didn't have a right testis,

37:45

you would still describe these gray scale changes

37:47

because it's very heterogeneous.

37:50

We also have that complex collection around the testis

37:55

and this is a patient who went for a CT as well

37:59

and you can actually see that the collection around it

38:03

as well as the fact that the testis is not normal.

38:06

And this was a left pitis with some areas

38:11

of necrosis as well as a PIO seal.

38:13

And this entire testis was debrided, it was tense

38:17

and erythematous

38:18

and they drained just frank puss from the scrotal sac

38:22

and had to do a debridement of the testis itself as well.

38:27

So then I was just looking at the time here, we do have time

38:29

for these cases, so we're going to continue here.

38:34

We have a 22-year-old who came in with left scrotal aching

38:38

after he was, uh,

38:39

injured riding a skateboard the week previous.

38:45

So now we are moving on

38:47

to something a little different, right?

38:48

So you've got a skateboarding injury,

38:53

so a testicular contusion absolutely can be an issue,

38:57

but we're thinking about trauma.

38:59

So somebody mentioned hematoma previously,

39:02

we can get testicular contusions.

39:05

So let's take a look at this case.

39:07

So here's the right side, he's complaining

39:08

of left sided pain, the right side we have flow,

39:11

we have a normal looking wave form.

39:13

Here's the left side and we can't detect any flow.

39:18

So I did show you a case of a pillow fight

39:22

that had a torsion, but is is this a torsion from

39:24

a skateboarding injury?

39:27

Well the technologist looked superior to the testis

39:30

and saw that the spermatic cord was markedly enlarged

39:36

and very heterogeneous

39:38

and this turned out to be a spermatic cord hematoma.

39:43

So he had a hematoma

39:44

that was compressing the vasculature leading to his pain

39:48

and lack of flow in the left testis.

39:51

So once it was evacuated, this is his follow up, the right

39:55

and left look normal on gray scale

39:58

and this is the lovely flow in that testis

40:00

and the normal waveform

40:03

with exactly the same peak systolic velocity once that

40:06

evacu hematoma was evacuated.

40:09

So in is in cases of trauma be ca be sure

40:13

to look again at that cord.

40:14

That one was just enlarged, it wasn't twirling,

40:19

there was no reactive hydro seal, which you often can see

40:22

with um, torsion.

40:27

How about this one? So this poor guy went over the

40:29

handlebars of his BMX bike.

40:34

So here's a picture of the left testes

40:40

and here's a again the left testes

40:46

and wow we see a lot of complex fluid

40:50

and we see all of this, uh, debris,

40:55

probably blood clot, right?

40:57

So a hemato seal as somebody has suggested.

40:59

So we're thinking about a testicular fracture.

41:02

Well it's very hard to see the fracture on these images,

41:07

but you can with this much blood it's, it's probably there

41:11

maybe disrupted over here.

41:14

Hard to tell. We can see the tunica a little bit

41:16

and then you really don't see it.

41:18

Here are some still pictures.

41:21

And in this case again we can see the tunica

41:26

as that bright line.

41:27

It's supposed to go all the way around the testis.

41:30

We don't really see it that well.

41:32

Here we see that pi uh, hydro, uh, excuse me, hemato seal.

41:37

And this again was, this was absolutely testicular rupture

41:41

with this much blood around it.

41:43

It just has to be suggested even if you can't see the area

41:46

that's ruptured sometimes you can, for example,

41:49

here's a 15-year-old who had a hockey puck

41:52

to a scrotum three days previous.

41:56

And here we have the left testes

42:01

and the shape of it's a little unusual.

42:04

I wanna draw. You also have some blood clot and some debris.

42:07

Look in this region here it looks a little funny

42:12

like it doesn't conform to that normal ovoid shape.

42:16

And then we have these little areas,

42:20

it'll pop up over here too,

42:23

these little areas here that are abnormal.

42:26

So this is what it looked like on the still images

42:30

and again it has kind of a funny shape,

42:33

like almost like a little dent there.

42:37

And here's a closeup

42:39

and that's where the tunica was disrupted.

42:42

So you can see the tunica

42:43

and then it's kind of extruding this area here.

42:47

Now there is a little bit of flow in that material in that,

42:50

uh, extruded area here.

42:52

Here's a, a hematoma area within the testis itself

42:56

and again an extra testicular hematoma.

42:59

And this is the follow up, oh again, sorry, flow in there.

43:03

And this is the follow up of that patient

43:05

who had testicular rupture.

43:09

I'm gonna draw your attention here.

43:15

You can see that there are little surgical clips here

43:19

and surgical clips here.

43:21

Suture material. So they were able to sew the tunica back up

43:25

because there was flow in the extruded seus tubules there

43:29

were able to put it back together.

43:30

And this testes is generally normal

43:32

or a relatively normal size.

43:37

A few companion cases, another person

43:39

who went over their handlebars while riding a mountain bike.

43:46

And in this case it's very hard to even find

43:49

what is normal testicular tissue on this sin clip.

43:53

Maybe a little bit there.

43:54

But then we have all of these areas of presumably hematoma

43:59

and I'll show you a still picture here.

44:03

All of these areas. So this looks like normal testicular

44:06

tissue, the gray scale and then these other areas

44:11

and here is where we can see that rupture.

44:14

So here is where the tunica should be.

44:17

There is material beyond it, but it does not have flow.

44:21

So at the or they had to repair the tunica, they had

44:25

to evacuate the hematomas

44:27

and then they had to also resect the extruded feral tubules

44:31

that did not have flow.

44:33

So ruptures can occur with um,

44:36

flow still remaining within the portion that's extruded

44:39

or you can have rupture

44:41

and the extruded portion is no longer viable In any case,

44:44

they will repair the testis if there's enough tissue

44:47

that's viable that's left so

44:49

that the patient still has a second testis.

44:56

Um, this poor guy, um, got fireworks to the scrotum

45:00

and this is what he looked like.

45:09

So there's a lot of very, very epigenic material superior

45:13

to the testis.

45:15

And then again, it's very hard to find any testicular tissue

45:20

that really looks normal.

45:22

And this is what it looked like on some still pictures.

45:24

This is the right side which looked okay.

45:26

This is the left side that had that sort of fluid, uh,

45:30

blood level at the top of the testis.

45:32

The testis itself.

45:34

There were some areas that had flow,

45:37

but then there were these segmental areas

45:39

that did not have flow.

45:42

And does anybody, does this uh, make any sense

45:45

to anybody about why there'd still be flow in one segmental

45:48

area but not the other?

45:54

So this is a traumatic testicular infarction

45:58

with marked areas of hemorrhage.

46:01

So again, this was taken to the or debrided.

46:05

This testis was not salvageable

46:07

and he was just rep, his choroidal was repaired.

46:10

I how about abrupt pain following minor trauma.

46:15

So again, the key here is there was very minimal trauma

46:19

but he had abrupt side abrupt cane

46:22

on the left side.

46:26

Anybody have any thoughts about this one

46:27

before I show you the color pictures?

46:31

Well, here's the color pictures.

46:36

So there is some flow on that side.

46:38

There is some tissue that's,

46:39

that looks like it's extra testicular,

46:41

but all these other areas, the side is normal.

46:46

Now something else to keep in mind is that

46:50

patients sometimes have preexisting conditions

46:52

that they may be ignoring.

46:55

So at surgery this turned out

46:57

to be a ruptured multifocal seminoma.

47:00

So I have a feeling given the differences in size

47:03

of these testes that this person was ignoring, the fact

47:06

that the left testes had been

47:07

enlarging for some amount of time.

47:09

Seminomas don't pop up overnight

47:11

and they certainly don't pop up after minor trauma.

47:14

So you do need to keep in mind

47:16

that sometimes patients come in with pain

47:18

and it isn't trauma, it isn't infection, it isn't torsion

47:22

or partial torsion.

47:23

They may have an underlying testicular carcinoma

47:26

and something's just bothering them

47:27

or they say that they had had abrupt pain

47:30

and that's the reason they can talk themselves into going

47:33

to the emergency room.

47:34

So just keep that in mind.

47:37

So I'm gonna draw some conclusions

47:38

and then I think we might have time for a couple more cases.

47:42

So I think you should hopefully be able

47:44

to recognize some scrotal conditions that lead

47:46

to emergency room visits.

47:49

Try to think about what's going on based on the history

47:51

and presenting symptoms before you even see the case.

47:55

Don't let it bias you too much,

47:57

but it will clue you into things that you need to look at.

48:01

You wanna be able to distinguish complete torsion from

48:04

partial torsion, differentiate different types of infection

48:08

and the complications such as abscess and

48:11

and compartment syndrome and POCs seals

48:15

and evaluate possible traumatic injury.

48:18

So I think we'll run through a couple of more cases.

48:22

We had a patient who was 14, he had left pain

48:25

and interestingly had a twin

48:27

with recent surgery for torsion.

48:30

So what are you thinking about immediately in someone

48:33

who has an identical twin that already had torsion.

48:37

Torsion exactly. So here we have right, right,

48:42

left, left, no flow on the left, a little bit

48:46

of a hydro seal here, clearly left-sided torsion.

48:51

All right, this poor guy had a crush injury

48:54

to his right leg four days ago.

48:55

He's been sitting in the ICU and he's complaining of,

48:59

or somebody noticed that his scrotum was also swollen

49:05

and this is what he looks like.

49:11

So clearly a very complex collection around the testis,

49:17

the testis gray scale looks pretty good in most areas

49:20

and here's what the flow looks like,

49:24

but then it really has a very odd shape

49:27

and that odd shape should clue you into the fact plus the

49:30

severity injury

49:32

and the surrounding, um, hemato seal

49:36

that this is ruptured.

49:40

This is a 74-year-old who had right sided tenderness.

49:48

His testis looks pretty good,

49:50

but his epididymus is absolutely enormous

49:54

and we have a small reactive hydros eal.

49:57

So here again, his right

49:58

and left, the right epididymus is markedly enlarged.

50:02

And hyperemic left side looked fine.

50:08

So we have right IMO and plus minus oris.

50:12

It looks a little bit hyperemic compared

50:14

to the opposite side.

50:16

Again, if you call the, the testis increased as well,

50:20

they would just treat the patient a little bit longer

50:23

for um, infection.

50:25

So you're not really doing him any harm if you overcall oras

50:30

and this one 61-year-old with left-sided swelling, redness,

50:34

firmness, tenderness with palpation,

50:40

Right side looks pretty good.

50:42

Left side

50:47

enlarged markedly abnormal way.

50:51

Uh, gray scale features

50:54

and this is what it looked like right and left.

50:59

So I think this is my last case

51:00

and this was another case

51:05

where the patient had an infiltrating tumor.

51:08

So again, think about other things

51:11

that may cause testicular enlargement

51:13

in addition to infection.

51:16

Oh nope, one more case here.

51:17

I think a 50-year-old with rectal perineal

51:20

and left scrotal pain dysuria, he's a smoker

51:23

with hypertension, really not a great, uh,

51:26

really not in great shape.

51:29

And this here he was, this was on 3 9 20 19.

51:33

We have images of the left testis, left testis laterally,

51:39

and you'll notice that there's dirty shadowing.

51:43

Unfortunately this was not noted at the time

51:47

that the patient showed up on three nine.

51:49

This was not called on the report.

51:53

This was the same patient on a cine clip on three nine

51:57

and clearly there's air here, but it was missed.

52:01

Fortunately the patient came back the next day.

52:05

Here we have the right and left.

52:08

And in the epidermal area again, there's lots of stuff

52:11

that looks like air and here's a sin clip from the next day.

52:17

And now not only is there air on the left side,

52:21

there's also air on the right side in the scrotal wall.

52:25

And this is what he looked like when he got his CT scan.

52:28

So his four neer's gangrene in a day had gone from just the

52:32

left side to also involving the right side

52:34

of the scrotal wall.

52:42

All right, that's all my cases, but I am going to,

52:44

in the next five or six minutes look at the q

52:47

and a section here and see if I can answer

52:50

any of these questions.

52:52

So the first question I have here is,

52:55

is high resistance flow a criteria for partial torsion?

52:59

It can be one of the things

53:00

that you see with partial torsion.

53:02

Again, we can either have a blunted peak systolic velocity

53:07

or that high resistance flow, which may show up as lack

53:10

of diastolic flow or reversal of flow in diastole.

53:15

Someone else asks, any tips on

53:17

how I differentiate post vasectomy appearance

53:20

of the epididymus from epi mitis?

53:23

Epididimitis will have hyperemia post vasectomy changes.

53:27

Do not. All you see is, uh,

53:29

and I wish I um, I I could probably

53:32

pick up, pull up a picture.

53:34

Lemme see if I can pull up a picture real quickly of, uh,

53:37

post vasectomy changes.

53:38

I'm gonna just do this as I'm talking.

53:41

Um, post vasectomy changes look the same pretty

53:44

much in every patient.

53:46

Um, you have these, uh,

53:47

it almost looks like dilated red at testes

53:49

but involving the testicle

53:51

and not the um, not the involving the epi is,

53:56

sorry and not the testicle itself.

53:58

So let me see here. Uh, let me pull a slide.

54:02

I can pull it over, I hope so.

54:04

This is congestive epididimitis, this area right here.

54:07

Lemme see. So you can see

54:12

here it is right here.

54:13

This is congestive epididimitis.

54:16

It all looks like that if I were to put color flow on this,

54:18

it does not have increased flow.

54:20

So that is one way to differentiate that.

54:23

In terms of primary appendic, excuse me, epidermal tumors,

54:28

they tend to be very focal rounded areas

54:31

within the epididymus.

54:32

They're usually benign. They can mimic sperm.

54:35

Granulomas can look very similar to adenoid tumors,

54:38

but they're more focal,

54:40

they're not diffusely enlarged like that.

54:43

Okay, for segmental infarction are these surgical cases,

54:46

they're surgical in that you have to remove the testis

54:49

because an infarct dis testis is a setup for infection

54:53

and ongoing pain,

54:54

but they're not surgical in that you can't

54:56

usually revitalize them.

54:58

You can't ev you never,

55:00

they they generally just take the testis out.

55:02

They don't try to, um, correct the, um, vessel that's, uh,

55:07

not supplying blood anymore.

55:10

In the abscess case you showed there is no internal flow.

55:12

How do you differentiate that from infarct?

55:15

I think it's the setting of the patient.

55:17

So in a setting of abscess,

55:19

you will have other signs of infection.

55:21

So you might have started with epidermal arthritis

55:23

and then they don't get better with appropriate antibiotics.

55:27

You end up scanning them again

55:28

and you find that there is now a fluid

55:30

collection or abscess.

55:32

They also abscesses tend to be more round

55:34

and in those areas of infarction, it's that area

55:38

that's wed shaped that stays the right gray scale,

55:41

echo texture and the rest of it is infarcted

55:44

or you may have smaller wed shaped areas.

55:49

Do you sometimes give a differential diagnosis rather than a

55:51

single definitive diagnosis?

55:53

Absolutely. Um, it, it, it, it, especially with, uh, things

55:58

that look mass like or infiltrative,

55:59

sometimes you can't tell if it's multifocal seminoma

56:02

or an infiltrative process like lymphoma or leukemia.

56:07

Um, for things like torsion

56:09

or partial torsion,

56:10

I feel like I can come down a little more

56:14

heavily on one diagnosis.

56:15

In that case suggesting torsion

56:18

or partial torsion,

56:19

I might haw a little bit about whether the, uh,

56:23

testis is also involved in epidermal oris

56:25

or just epididimitis.

56:27

Um, and occasionally we'll see things again like a sperm

56:31

granuloma versus a adenoid tumor.

56:34

And sometimes we just don't know the d you know,

56:36

we can't tell the difference between the two very easily,

56:38

so we'll call it one versus the other.

56:41

So yes, I do sometimes give a differential.

56:45

And then what is your differential

56:47

for focal hypoechoic testicular lesion

56:50

and focal hypoechoic testicular lesion.

56:53

So focal hypoechoic, I guess the, you have to know one,

56:57

whether it has flow in it or not.

56:59

If it does not have flow,

57:01

then you're looking at an abscess potentially

57:03

or an hematoma depending upon the patient's situation.

57:07

If a focal hypo coic lesion does have flow, then yes,

57:12

you're gonna call it a tumor likely.

57:14

Um, most of those inside the testes,

57:16

you gotta worry about seminoma.

57:18

It's hard to tell the difference between seminoma

57:20

and other germ cell tumors

57:22

or non germ cell tumors

57:24

for a focal hyper coic testicular lesion.

57:27

If they're really small

57:28

and they have very focal flow,

57:30

I have seen small testicular hemangiomas and little lipomas.

57:35

Um, sometimes it's a question of how large is it, how, uh,

57:39

risk averse is the patient?

57:41

Meaning are they likely to be okay following it?

57:44

Or you can also get an MRI in a lot of cases

57:46

that will help you differentiate, uh, the, especially, um,

57:51

small tumors that have, uh, benign tumors

57:54

that have fat in them.

57:55

I've also seen echogenic lesions that turn out to be, um,

58:00

derm, uh, uh, teratomas.

58:02

So that's also in the differential.

58:04

Um, somebody else in the testicular rupture,

58:07

what would be the next step?

58:08

It should be removed surgically, is that right?

58:10

With testicular rupture? Yes.

58:12

If the patient is stable

58:14

and it looks like the, the area

58:16

that's extruded may be revitalized, maybe they don't have

58:19

to go so quickly, but in my experience

58:21

with testicular rupture, they do tend to bring the patients

58:24

to the operating room more quickly than less quickly

58:28

because one, they tend to be bleeding

58:30

and two, it tends to be painful

58:31

and they do wanna try to salvage as much

58:33

of the testicular tissue as possible.

58:36

So I think I've answered all the questions

58:39

and it is now 1259.

58:41

So I think we're, um, we're, we're, we're good.

58:44

Hopefully, I hope you enjoyed the cases

58:47

and, um, I can, I, my, I had flashed my uh,

58:52

email up there before.

58:54

I guess I, uh, I don't have it up here now

58:56

because I put a different case up,

58:59

but, uh, you can certainly get ahold

59:00

of me if you have any other questions. Thank you.

59:03

Thank you so much Dr. Buer, and that was awesome.

59:05

As usual, appreciate your time

59:08

and, um, going through all those cases

59:11

and thanks for everyone else for participating

59:13

and asking such great questions.

59:16

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59:18

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59:21

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59:25

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59:27

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59:29

Mylan Ho will deliver a lecture entitled

59:31

Congenital Brain Anomalies.

59:33

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59:35

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59:39

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