Audit of scrotal ultrasoundAudit of scrotal ultrasound and its relevance to detection

of testicular cancer

Jonathan RichenbergConsultant UroradiologistConsultant Uroradiologist

RSCH, Brighton

B k dBackgroundI iti l i t d b l itiInitial review prompted by long waiting lists (16 or more weeks)E i l 2 ti t ith t ti lEspecial concern: 2 patients with testicular cancer waiting for this periodFi 1042 i ti 10 9Figures: 1042 examinations, 10 cancers, 9 clinically suspectedMission: prospecti e look at req estMission: prospective look at request patterns to identify safe robust referral guidelinesguidelines

Th diThe auditD t 20/2 t 30/10 2003 (254 d )Dates – 20/2 to 30/10 2003 (254 days)Sites – 4 hospitals within Brighton/HoveScans – 541 requests, 34 DNA, 31 follow-up. 498 patients finally includedData analysed

Waiting timesReferrer demographicsClinical details (16 categories)US fi di (13 i )US findings (13 categories)

A dit i i !Audit vision!Long waiting lists

AnalysisReaudit

BEGINg g

Look at nature of requests for US

StatisticsWe are here

Supposition – category exclusion

We are here

Anticipate 50% reduction

W i i iWaiting time summaryMinimum Maximum Median CountMinimum Maximum Median Count

Time between request & attendance 0 416 42.00 541

…..and excluding patients who had a previous DNA or follow-up

Minimum Maximum Median Count

i b & dTime between request & attendance 0 82 41.00 298

S f f iSummary of referring team

Urology 164 30.31

GU 28 5.18

GP 309 57.12

Other 26 4.81

Not recorded 14 2.59

541 100.00

Clinical detailsAbsent Testis/Orchidopexy 13

Atrophy 7

Epididymal Cyst 141Epididymal Cyst 141

Epididymitis 26

Epididymo-Orchitis 21

Haematospermia 9Haematospermia 9

Hernia 2

Hydrocele 37

Normal Clinical exam 8Normal Clinical exam 8

Other 5

Pain 90

T ti l M 75Testicular Mass 75

TML/Microlithiasis 9

Torsion 3

i l 1Varicocele 51

Varicocele & Hydrocele 1

TOTAL 498

Ultrasound categoriesNormal 192

Hydrocoele 41

Varicocoele 60Varicocoele 60

Epididymal cyst 119

Epididymitis 17

idid hi iEpididymo-orchitis 7

Tumour 7

Absent/orchidopexy 4

Epididymal cyst and varicocoele 13

Hydrocoele and varicocoele 6

Atrophy 8

Trauma 3

TML 17

Other 4

Fancy coloured chart: vivid demonstration of correlation between clinical and ultrasound findings

(well what do you expect from a radiologist?)(well, what do you expect from a radiologist?)

70

80PainTesticular MassEpididymal Cyst

NormalHydroceleVaricoceleEpididymal cystEpididymitis30

40

50

60

Number

Epididymal CystVaricoceleEpididymitisEpididymo-OrchitisHydroceleNormal Clinical examp y

Epididymo-OrchitisTumourOtherVaricocele & Epididymal cystHydrocele & VaricoceleAtrophyTraumaTML/MicrolithiasisAbsent Testis/ Orchidopexyai

nas

sys

tel

e is is e m r

0

10

20

US diagnosis

Normal Clinical examOtherVaricocele & HydroceleTorsionHaematospermiaHerniaAbsent Testis/ OrchidopexyP

Test

icul

ar M

aEp

idid

ymal

Cy

Varic

oce

Epid

idym

itpi

didy

mo-

Orc

hiti

Hyd

roce

lem

al C

linic

al e

xam

Oth

erel

e &

Hyd

roce

leTo

rsio

nae

mat

ospe

rmia

Her

nia

Atro

phy

L/M

icro

lithi

asis

HerniaAtrophyTML/Microlithiasis

Ep

Nor

m

Varic

oc Ha

TML

Clinical diagnosis

N l i iNormal examination8 f d ll 8 l8 referred, all 8 normalGood newsAre other clinical labels as accurate?

Ultrasound findings in patients referred for scan with EPIDYMAL CYST

Total 141 patients

75

60

70

80

44

30

40

50

Num

ber

Series1

2

11

3 1 1 3 10

10

20

mal ele ele yst

mitis hitis ou

r

yst

asis

Norma

Hydroc

ele

Varico

cele

Epididym

al cy

s

Epididym

itEpid

idymo-O

rchiti

Tumou

ricoc

ele &

Epididy

mal cy

sTML/M

icroli

thias

Varic

Ultraound finding

Ultrasound findings in patients referred for scan with PAIN

TOTAL 90

54

40

50

60

1214

20

30

40

Num

ber

Series1

1 2 1 1 2 3

0

10

Normal

Hydroc

ele

Varico

cele

dymal

cyst

pididym

itis

o-Orch

itis

ymal

cyst

Atroph

y

crolith

iasis

Hy

Var

Epididy

Epid

Epididym

oVari

coce

le & Epid

idym A

TML/Micr

o

Finding

Ultrasound findings in patients referred for scan with TESTICULAR MASS

TOTAL 75

26

20

25

30

1112

75

10

15

20

Num

ber

Series1

3 2

5

2 31

3

0

5

Normal

Hydroc

ele

Varico

cele

dymal

cyst

pididym

itis

o-Orch

itis

Tumou

r

Other

ymal

cyst

Atroph

y

crolith

iasis

Hy

Var

Epididy

EpidEpid

idymo

Varico

cele

& Epididy

m A

TML/Micr

o

US finding

Clinical information in patients with ultrasound diagnosis of TESTICULAR MASSSS

TOTAL 7

6

5

3

4

Num

ber

Series1

2

N

0

1

T ti l M E idid l C t E idid itiTesticular Mass Epididymal Cyst Epididymitis

Clinical details

Th i id lThe incidental tumourE idid l l l lEpididymal cyst, contra lateral occult tumour13 week delay from initial examinationStatistically expectedy pWould have presented anyway

S i i i i f diSupposition arising from auditAppropriate referral

T i l InappropriateSignificant finding Non-significant fi diTesticular mass

VaricocoeleEpididymitisEpididymo-orchitisH d l

Inappropriate referral

PainEpididymal cyst(Normal)

Significant finding

•Tumour

•Trauma

finding

•Normal

•HydrocoeleHydrocoeleTorsionHaematospermiaHerniaA h

(Normal)•Epididymitis

•Epididymo-orchitis

TML

y

•Varicocoele

•Epididymal cystAtrophy

TorsionAbsentPrevious orchidopexy

•TML cyst

•Atrophy

•OrchidopexyorchidopexyTML •Absent testis

S i iStatisticsU/S

Outcome Total

Significant finding

Non-significant finding

I i t fClinical Details

Inappropriate reason for referral Count 12 227 239

Expected Count 24.47590361 214.5240964 239

Appropriate reason for referral Count 39 220 259

Expected Count 26.52409639 232.4759036 259

Total 51 447 498

Expected Count 51 447 498

Chi SChi-SquareAsymp.

Value df

y pSig. (2-sided)

Exact Sig. (2-sided)

Exact Sig. (1-sided)

Pearson Chi-Square 13.6224959 1 0.000223491q

Continuity Correction 12.55247162 1 0.000395683

Likelihood Ratio 14 35656114 1 0 000151252Ratio 14.35656114 1 0.000151252

Fisher's Exact Test 0.000192553 0.000145636

Linear-by-LiLinear

Association 13.59514149 1 0.000226772

N of Valid Cases 498

aComputed only for a 2x2 table

b0 cells (.0%) have expected count less than 5. The minimum expected count is 24.48.

Wh d hi ?What does this mean?P l f hi 0 00P value from chi-square test <0.00The degrees of freedom is equal to 1Yates’s continuity correction applied: P=0.001 –i.e. highly significantg y g

A dit i i !Audit vision!Long waiting lists

AnalysisReaudit

BEGINg g

Look at nature of requests for US

Clinical Clinical i tii ti

StatisticsWe are here

Supposition – category exclusionexaminationexamination

More More attention to attention to We are here

Anticipate 50% reduction

information information on formson forms

Re-audit 2005

35 40% D i GP35-40% Decrease in GP requestsWaiting time 2 weeks for routineUrgent requests within 24 hours

Dr. J Richenberg bsuh.nhs.uk