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Mineral foreign bodies (stones) are infrequent findings in clinical and radiological practice. However, a growing number of reports indicate that they raise clinical and diagnostic concern in ophthalmology, neurosurgery, maxillofacial surgery, otolaryngology, gastroenterology, and vascular surgery. Dense finding in the soft tissue without clear history of foreign body penetration may represent diagnostic challenge mimicking calcifications or bony fragments. The aim of this work is to analyze the appearance of stone foreign bodies on radiographs and computed tomography. A collection of minerals and rocks was used for analysis. The clinical case of a stony foreign body which penetrated into the soft tissue of the leg is used to demonstrate the diagnostic challenge and management. Available literature describing imaging characteristics of stones was reviewed. The results of this work will help in diagnostic interpretation and assessment of stone foreign body composition. [ABSTRACT FROM AUTHOR]

Background and Objective: Disk displacement frequently causes dysfunction of the temporomandibular joint (TMJ). Magnetic resonance imaging (MRI) of the TMJ is 95% accurate in the assessment of disk position and form. Various restorative procedures are used for treatment of disk displacement. However, several authors have noted a lack of correlation between MRI findings of disk displacement and the extent of pain and dysfunction of the TMJ. The purpose of this study was to evaluate whether MRI findings of various degrees of disk displacement could be correlated with the presence of clinical signs and symptoms in patients with a clinical disorder of the TMJ. Materials and Methods: One hundred and forty-four TMJs (in 72 patients) were imaged. Displacement of the posterior band in relation to the condyle was quantified as mild or significant. Results: Disk displacement was found in 45 (54%) of the 84 symptomatic joints and 13 (22%) of the 60 asymptomatic joints. Among the 84 symptomatic joints, 31 (37%) had disk displacement with reduction and 14 (17%) had disk displacement without reduction. In the latter group, 11 (79%) of the 14 joints had significant displacement of the posterior band (8 or 9 o'clock) and 21% had mild displacement of the posterior band (10 o'clock). Of the 60 clinically asymptomatic joints, 47 (78%) had no signs of disk displacement on MRI, whereas 13 (22%) had disk displacement with reduction. None of the asymptomatic joints had disk displacement without reduction. The difference in occurrence of disk displacement between symptomatic and asymptomatic joints was statistically significant (54% vs. 22%; p < 0.001). However, the difference in occurrence of disk displacement with reduction of the disk on mouth opening was not statistically significant (37% vs. 22%; p = 0.06). Conclusions: Disk displacement on MRI correlated well with clinical symptoms in cases of significant disk displacement and in cases of disk displacement without reduction. When disk displacement with reduction was mild, there was no statistically significant difference between symptomatic and asymptomatic joints, which suggests that other causes should be considered. [ABSTRACT FROM AUTHOR]

Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The pathophysiology of elbow flexion contracture (EFC) in obstetrical brachial plexus injury (OBPI) is not established. In basic science models, neonatal denervation leads to impaired muscle growth. In clinical studies, diminished growth is correlated with extent of denervation, and improved with surgical repair. In EFC, the biceps are clinically short and round vs the contralateral size, termed the "Popeye muscle". The objective of this study was to determine if the biceps morphology (muscle belly and tendon length) in arms with EFC secondary to OBPI is different vs the contralateral., Methods: This is a retrospective matched-cohort study. Patients with unilateral EFC (>20°) secondary to OBPI were identified (median = 6.6 years, range = 4.7-16.8). A blinded radiologist used computed tomography to measure length of the biceps short head muscle belly, and tendon bilaterally using standardised anatomical landmarks., Results: Twelve patients were analyzed. The biceps muscle belly in the injured arm was shorter in all patients vs contralateral, mean difference = 3.6 cm (80%), p < 0.001. The biceps tendon in the injured arm was longer in all patients vs contralateral, mean difference = 1.13 cm (127%), p < 0.001. The total biceps length in the injured arm was shorter in all patients vs contralateral, mean difference = 2.5 cm (89%), p < 0.001., Conclusions: This is the first human study confirming growth discrepancy of an elbow flexor in EFC. Distinct biceps morphology is demonstrated, with a significantly shorter muscle belly and overall length, but longer tendon vs normal. This is termed the "Popeye muscle" for its irregular morphology. Findings are consistent with impaired limb growth in denervation.

Background: The aim of this study was to investigate if an association existed between the reflected head of rectus femoris avulsion injuries and labral tears in pediatric patients referred for magnetic resonance arthrography (MRA) or magnetic resonance imaging (MRI) evaluation., Methods: Electronic medical records of the patients between the ages of 12 and 18 who were treated at the hospitals affiliated by McMaster University between June 2000 and November 2010 with a diagnosis of rectus femoris avulsion injuries were retrospectively identified and analyzed. Patients were included if they had magnetic resonance imaging or MRA images of their hip., Results: Nine patients with avulsion injuries of the rectus femoris muscle were identified. The patient population consisted of 4 females and 5 males (range, 8 to 17 y, mean age 14 y). All injuries occurred during sports activity, which included running and kicking during soccer, skating in hockey, and a squatting exercise. MRA examination of 7 of these patients demonstrated associated labral tears. All patients were initially treated conservatively. Five patients continued to sustain from residual pain in the 9 months after the initial injury. Two of these patients with significant refractory pain were subsequently treated with hip arthroscopy. Intraoperatively, 1 small labral tear and 1 labral avulsion were identified and treated., Conclusions: This study suggests that there may be an association between avulsion of the reflected head of rectus femoris and labral injuries and that there may be an underlying spectrum of traction injuries. Patients with rectus femoris avulsion injuries with persistent symptoms may be at risk for concurrent traumatic labral tears., Level of Evidence: Level 4, retrospective case series.

The measurement of angles between anatomical structures is common in radiological and orthopedic practice. Frequently used measurements include scapholunate angle for assessment of wrist instability and Cobb's angle used for assessment of scoliosis. Measurements of these angles are easily performed on plain X-ray radiographs. However, the situation is more complicated when these measurements are to be performed on cross-sectional (CT or MRI) examinations. On some of the diagnostic workstations, it is not possible to perform angle measurements between the structures if they are not identified on the same image and are located on different images of the same projection or plane. We present a simple solution to measure angles between structures on different images that can be used both in CT and MR.

It is commonly believed that the revenues from the selling of the Beatles' records by Electric and Musical Industries (EMI) allowed the company to develop the computed tomography (CT) scanner. Some went to define this as the Beatles' gift to medicine. However, significant controversies and discrepancies arise from analysis of this statement, making its correctness doubtful. The details of financing required for the CT development and the part of EMI in financial input have never been publicly announced. This work analyzes the financial contributions to the CT development and investigates if the revenues received from the sales of the Beatles' records were used for the creation of the CT scanner. Timeline of the development of the EMI CT scanner and the financial inputs of EMI and British Department of Health and Social Security (DHSS) were assessed. Without salary expenses to Godfrey Hounsfield and his team, the development of the CT scanner cost EMI approximately £100,000. The British DHSS's expenses were £606,000. Hence, the financial contribution of DHSS into the development of the CT scanner was significantly bigger than that of EMI. Accordingly, British tax payers and officials of British DHSS are to be thanked for the CT scanner. The Beatles' input into the world's culture is valuable and does not require decoration by nonexistent connection to the development of CT. A positive aspect to this misconception is that it keeps in public memory the name of the company that developed the CT scanner.

Background: the term posterior reversible encephalopathy syndrome (PRES) was first proposed in 2000. Since then, the acronym PRES has become very popular in imaging and clinical literature as it is short, easy to say and remember, and neatly couples the frequent localization of neuroimaging findings along with the typical outcome of this syndrome. Another possible reason for the popularity of this acronym in clinical circles is the connotation of PRES with (elevated blood) PRESsure, as a majority of cases are believed to be associated with hypertension. However, problems exist with the interpretation and common understanding of PRES, questioning the appropriateness of "P" and "R" in the acronym. The linguistic issues related to the acronym of PRES are interesting., Objectives: the aim of this work is to analyze the controversies related to the acronym of PRES., Results: in 2006, modifying the meaning of the acronym was suggested, renaming it Potentially Reversible Encephalopathy Syndrome in order to adjust to the cases when posterior involvement is not prominent and emphasize that the reversibility is not spontaneous. This meant the creation of a backronym, where the new phrase is constructed by starting with an existing acronym., Conclusion: this new backronym indicates that the original acronym of PRES has become a misnomer.

Objective: The purpose of this work was to show the radiologic signs named after weapons and munitions along with their military counterparts to help radiologists recognize these signs, which will allow confident interpretation and diagnosis., Conclusion: Numerous pathologic conditions have classic radiologic manifestations that resemble weapons and ammunition. Most of these signs are highly memorable and easy to recognize. However, the names of the weapons (some of them antique and some not commonly known) may confuse radiologists who are not familiar with the appearance of such weapons as the scimitar, bayonet, or dagger. The value of the signs is reduced if the radiologist is unfamiliar with the appearance of the corresponding weapon.

An accessory spleen is present in about 10-30% of the population and, usually, does not cause symptoms. We present a case report of an unusual presentation of accessory spleen infarction, with a literature review. A 12-year old male presented with acute left-upper quadrant pain that slowly resolved. An ultrasound and computed tomography scan showed a 3.5 x 2.5 x 2 cm solid mass abutting and displacing the splenic flexure of the colon, with surrounding inflammatory changes. This was interpreted as a colonic duplication cyst, and the boy was treated with antibiotics and underwent elective laparoscopic exploration. It was removed laparoscopically without complication and, on pathologic examination, proved to be consistent with an infarcted accessory spleen. Less than two dozen similar cases of accessory spleen infarction have been reported in the literature, most presenting with acute abdominal pain. Preoperative diagnoses included appendicitis, ovarian torsion, neoplasm, and, in our case, colonic duplication. The natural course of infarcted accessory spleen would be to atrophy, but, even with advanced imaging techniques, it may be impossible to diagnose infarcted accessory spleen with enough confidence to avoid surgery.

Unlabelled: The surgical circumferential resection margin in total mesorectal excision surgery is defined by the relationship of the tumor to the mesorectal fascia. Patients with anticipated tumor invasion of the mesorectal fascia receive neoadjuvant therapy to downstage/downsize the tumor and to obtain tumor-free resection margins.Tumor relationship to the mesorectal fascia is accurately determined by MRI. Compared with MRI, multidetector-row computed tomography is more widely available, faster, less costly, and provides the ability to simultaneously assess the liver, peritoneum, and retroperitoneum for metastases., Purpose: The objective of this study was to compare the accuracy of multidetector-row CT with conventional MRI in diagnosis of rectal cancer invasion of the mesorectal fascial envelope., Materials and Methods: During a 2-year period, all patients were enrolled in this study who had biopsy-proven rectal carcinoma and were referred, as a part of the routine preoperative staging workup, for a CT scan of the abdomen and pelvis and also an MRI of the pelvis.All examinations were reviewed independently by 2 radiologists who were blinded from one another, from the findings of the other modality, and from clinical information. Both observers were dedicated abdominal radiologists who are experienced in reading pelvic CT and MRI. Categorical agreement between MRI and multidetector-row CT for all the evaluated parameters of the tumor position, mesorectal fascia, and lymph nodes, as well as the interobserver agreement between CT and MRI, was determined by the intraclass correlation weighted kappa statistic to measure the data set's consistency., Results: Among the study's 92 patients, the tumor characteristics suggested by multidetector-row CT agreed with those of MRI, with a weighted kappa ranging from 0.488 to 0.748 for the first reader and 0.577 to 0.800 for the second reader. Interobserver agreement ranged from 0.506 to 0.746.Agreement regarding mesorectal fascia characteristics differed significantly between multidetector-row CT and MRI, depending on the level of assessment. In the distal rectum, agreement was 0.207 for the first reader and 0.385 for the second reader. In the mid rectum, agreement was 0.420 and 0.527, respectively, and in the proximal rectum agreement was 0.508 and 0.520. Interobserver agreement was 0.737 at the distal level and 0.700 at the mid and proximal levels. Agreement regarding measurement of the distance from the tumor to the mesorectal fascia was 0.425 for the first reader and 0.723 for the second reader, with interobserver agreement of 0.766. Agreement in assessment of the number of lymph nodes ranged from 0.743 to 0.787 for the first reader and 0.754 to 0.840 for the second reader. Interobserver agreement ranged from 0.779 to 0.841. Agreement in assessment of the size of the lymph nodes ranged from 0.540 to 0.830 for the first reader and 0.850 to 0.940 for the second reader. Interobserver agreement ranged from 0.900 to 0.920. Agreement in assessment of the distance from nodes to the mesorectal fascia was 0.320 for the first reader and 0.401 for the second reader, with interobserver agreement of 0.950., Conclusion: The results of this study differ from previously published data by demonstrating substantial agreement between readers in multidetector-row CT assessment of the tumor, mesorectal fascia, and lymph nodes. With the exceptions of mesorectal fascia in the distal rectum and the distance from the nodes to mesorectal fascia, other evaluated parameters were assessed with moderate and substantial agreement between multidetector-row CT and MRI. However, our findings suggest that multidetector-row CT does not correlate well enough with MRI findings to replace it in rectal cancer staging.

Systemic lupus erythematosus is an immune-mediated syndrome in which the immune response is to non-organ-specific antigens, and virtually every organ in the abdominal cavity may become involved. Only renal involvement forms part of the diagnostic criteria, however, a combination of typically nonspecific findings, including peritoneal surface, enteric, renal, renal tract, pancreatic, adrenal, hepatobiliary, and splenic manifestations, should be looked for in patients with known lupus or other connective tissue disease who are undergoing abdominal imaging and may suggest the diagnosis in patients presenting with an acute abdomen. Our work presents the spectrum of imaging findings of abdominal manifestations of systemic lupus erythematosus.

Magnetic resonance arthrography (MRA) has become the preferred modality for imaging patients with internal derangement of the wrist. However, several aspects of MRA use need to be clarified before a standardized approach to the imaging of internal derangement of the wrist can be developed. The objective of the study is to evaluate the efficiency of different magnetic resonance (MR) sequences in the detection of lesions of the triangular fibrocartilage complex (TFCC) and scapholunate and lunotriquetral ligaments on direct MRA. Thirty-one consecutive direct magnetic resonance arthrographic examinations of the wrist using a wrist surface coil were performed for the assessment of the TFCC and intrinsic ligaments on a 1.5-T MR imaging system (Signa; 16 channel, Excite, GE Healthcare, Milwaukee, WI, USA). All patients had wrist pain, and in six cases, there was associated clinical carpal instability. The presence, location, and extent of TFCC, scapholunate ligament (SLL), and lunotriquetral ligament (LTL) lesions on T1 fat-saturated, multiplanar gradient recalled (MPGR) and short tau inversion recovery (STIR) images were identified, compared, and analyzed. Forty-one lesions of the TFCC, SLL, and LTL were visualized on contrast-sensitive (T1 fat-saturated) images in 23/31 (74.2%) patients. Twenty-one lesions of the TFCC and intrinsic ligaments were visualized on noncontrast-sensitive (MPGR and STIR) images (15 tears of the TFCC and six tears of the SLL and LTL). All of these lesions were seen on T1 fat-saturated images; 48.8% (20/41) lesions seen on T1 fat-saturated images (eight tears of TFCC and 12 tears of SLL and LTT) were not seen on MPGR and/or STIR images. Superior contrast resolution, joint distention, and the flow of contrast facilitate the diagnosis of lesions of the TFCC and intrinsic ligaments on contrast-sensitive sequences making MRA the preferred modality for imaging internal derangements of the wrist. Little agreement exists regarding the value and location of perforations of the intrinsic ligaments given that both traumatic and degenerative perforations may be symptomatic. Noncommunicating defects of the ulnar attachments of the triangular fibrocartilage (TFC), tears of the dorsal segment of the SLL, and defects at the lunate attachment of the SLL have a higher likelihood of being symptomatic and caused by trauma rather than by degenerative perforation. Although no consensus exists, it would appear that most arthrographies should be started with a radiocarpal injection. Injection into the distal radioulnar joint should be added if no communicational defects are visualized following radiocarpal injection in patients with ulnar-sided wrist pain.

The evaluation of articular cartilage currently relies primarily on the identification of morphological alterations of the articular cartilage. Unlike anatomic imaging, T2 mapping is sensitive to changes in the chemical composition and structure of the cartilage. Clinical evaluation of T2 mapping of the glenohumeral joint has not been previously reported. The objectives of this study were to evaluate the feasibility of magnetic resonance T2 mapping of the glenohumeral joint in routine clinical imaging, to assess the normal T2 mapping appearance of the glenohumeral joint, and to compare the findings on T2 maps to conventional MR pulse sequences. Magnetic resonance imaging (MRI) examinations of 27 shoulders were performed in a routine clinical setting. All studies included acquisition of T2 mapping using a dedicated software. The T2 maps were analyzed along with the routine MR exam and correlation of cartilage appearance on T2 map and on conventional MR sequences. T2 imaging maps were obtained successfully in all patients. T2 maps and routine MRI correlated in cases of normal cartilage and prolonged T2 values and cartilage defects. In four cases, increased T2 relaxation times in the cartilage and cartilage defects were more apparent on T2 maps. Acquisition of T2 maps at the time of routine MRI scanning is feasible and not time-consuming.

Objective: The purpose of this study was to determine the sonographic features of Hürthle cell neoplasms (HCNs) of the thyroid., Methods: We retrospectively analyzed the sonographic appearance of 15 histologically proven HCNs in 15 patients aged 16 to 70 years (mean age, 44 years). Sonographic features that were reviewed included the size and echogenicity of the tumors, the presence of cystic areas or calcifications, and detectable blood flow on color Doppler imaging. Correlation of sonographic findings with pathologic results was performed., Results: The tumors ranged from 0.4 to 7 cm in diameter, but most were less than 3 cm in diameter. Four (27%) of the 15 tumors were homogeneously hypoechoic. Two tumors (13%) were predominantly hypoechoic with isoechoic areas to thyroid parenchyma. Two (13%) neoplasms were isoechoic to thyroid parenchyma. Four (27%) tumors were predominantly isoechoic, containing hypoechoic areas, and 3 (20%) tumors were hyperechoic. Three neoplasms contained cystic components. None of the tumors contained calcifications. One tumor was avascular on Doppler examination. One neoplasm showed only peripheral blood flow. Thirteen tumors showed internal vascularity, 7 of them with peripheral blood flow. Twelve HCNs were benign, and 3 were malignant on pathologic examination., Conclusions: Hürthle cell neoplasms show a spectrum of sonographic appearances from predominantly hypoechoic to hyperechoic lesions and from peripheral blood flow with no internal flow to extensively vascularized lesions. Pathologic criteria differentiating benign and malignant HCNs (absence or presence of a capsular breach, vascular or extrathyroidal tissue invasion, nodal involvement, and distant metastasis) are beyond the resolution of sonography and fine-needle aspiration biopsy and require removal of the entire lesion. This precludes diagnosis and characterization of HCNs by sonography.

Objective: To evaluate the performance of a computer-aided detection (CAD) system for diagnosis of pulmonary embolism on computed tomography (CT) pulmonary angiography., Materials and Methods: One hundred and four pulmonary CT angiograms for pulmonary emboli (PE) were reviewed both by radiologists and a CAD detection system (ImageChecker CT V2.0, R2 Technology Inc, Sunnyvale, CA). CT scans, read and reported by radiologists in a routine daily clinical setting, were later processed by the CAD system. The performance of the CAD system was analyzed., Results: Forty-five PE were identified by the radiologists in 15 patients. The CAD system revealed 123 findings, interpreted by the system as PE. Twenty-six of them, detected in 8 patients, represented true-positive results. Ninety-seven (78.9%) CAD findings were not true PE and were defined as false-positive. Nineteen true PE in 7 patients were missed by the CAD system constituting 42% false-negative rate. Sensitivity of the CAD system was 53.3% and the specificity was 77.5%. The positive predictive value of CAD system was 28.5% and the negative predictive value was 90.7%., Conclusions: With the evaluated CAD system, it is relatively simple and fast to check all detected findings and decide if they represent true PE. However, high false-negative results demand technologic improvement, to increase the sensitivity of the system. It is anticipated to become a promising supplement to the work and eyes of the radiologist in detecting PE on pulmonary CT angiography.

Acute appendicitis with the vermiform appendix located in a groin hernia is a rare condition. The preoperative diagnosis is important to decrease morbidity. We describe the computed tomography imaging characteristics of three cases of normal and inflamed appendices in inguinal and femoral hernias. We provide a review of the literature and consider the implications for surgical management.

To determine the prevalence and spectrum of extrarenal findings in a screening population of potential living kidney donors undergoing renal Computed tomography angiography (CTA) and evaluate their impact on subsequent patient management and imaging costs. Two radiologists retrospectively reviewed 175 consecutive renal CTA's performed for assessment of potential living kidney donors. Extrarenal radiological findings were recorded and classified according to high, medium, or low importance based on clinical relevance and the need for further investigations and/or treatment. The cost of additional imaging examinations was calculated using 2002 Canadian (British Columbia) reimbursements. There were 73 extrarenal findings in 71/175 (40.6%) of the potential kidney donors in the study population. Findings were categorized as of high clinical importance in 18 (10.3%) cases, including lung lesions, bowel tumors, and liver tumors and as medium importance in 31 (17.7%). Twenty-two (12.6%) individuals had findings categorized as low importance, probably of no clinical significance and requiring no follow-up. Further potential evaluation of the 49 patients (28%) with highly and moderately significant extrarenal findings may require an additional $6137 (mean $35.1 per each case of all the screened patients). Transplantation of a kidney from a living donor is an excellent alternative to cadaveric allografts. Potential living kidney donors are a highly selected population of healthy individuals, screened for significant past or current medical conditions before undergoing CTA. Despite this screening, potentially significant extrarenal findings (classified as high or medium importance) were revealed in 28% of patients. These patients may require further investigations and/or treatment. The referring physician and patient should be aware of such potentially high probability, which may require further nontransplant related evaluation and treatment. This has medical, legal, economic, and ethical implications.

Objective: The classic sonographic description of an epidermoid cyst is a mass with a target or onion ring appearance of alternating rings of hyperechogenicity and hypoechogenicity. This study presents a pathologic-sonographic assessment of classic and nonclassic appearances of an epidermoid cyst of the testis and reports the possible similarity between a classic epidermoid cyst and a teratoma on sonography., Methods: We reviewed the sonographic and histologic features of 8 testicular tumors that either had a classic onion ring pattern or were found at pathologic examination to be epidermoid cysts but did not have the classic sonographic pattern., Results: Three epidermoid cysts had a typical onion ring appearance. Histologic sections of these tumors revealed a squamous epithelial layer lining the cyst and multiple concentric laminated layers of keratin. Two tumors did not have a typical sonographic appearance of epidermoid cysts but were found to be epidermoid cysts at pathologic examination. One was homogeneously hypoechoic, and the other had irregular cystic and solid components, but neither had a target or onion ring appearance. Histologically, both of these tumors consisted of cystic cavities lined by squamous epithelium and contained desquamated keratinized epithelium. Notably, 3 other tumors pathologically diagnosed as teratomas had a sonographic appearance of classic epidermoid cysts. These tumors contained layers of keratin, but the cyst was lined by both squamous cells (ectodermal origin) and cylindrical epithelium (endodermal origin), thereby precluding the diagnosis of epidermoid cysts., Conclusions: There is considerable overlapping of the sonographic appearances of teratomas and epidermoid cysts of the testis. Although the onion ring appearance of an intratesticular tumor is suggestive of an epidermoid cyst, this appearance may also be found in cases of a teratoma. Whereas the former condition can be treated by local enucleation, the latter requires radical orchiectomy.

Objective: To determine the gray scale and color Doppler sonographic features of Leydig cell tumors of the testis in a series of patients., Methods: We retrospectively analyzed the sonographic appearance of 10 proven Leydig cell tumors in 9 patients aged 26 to 47 years. Sonographic features that were reviewed included the size and echogenicity of the tumors, presence of cystic areas or calcifications, and distribution pattern of detectable blood flow on color or power Doppler imaging., Results: The tumors ranged from 0.4 to 3.0 cm in diameter, but most were less than 1.0 cm in diameter. In 1 testis, 2 discrete Leydig cell tumors were found. Nine (90%) of the 10 tumors were homogeneously hypoechoic. Only 1 tumor was isoechoic with the testis. None of the tumors contained calcifications. Of 8 tumors with color Doppler imaging, 7 (88%) showed a characteristic pattern of increased peripheral blood flow, which was either circumferential or punctate. Only 1 tumor was found with internal hypervascularity., Conclusions: Peripheral hypervascularity in a hypoechoic testicular tumor that has little or no internal color Doppler flow should suggest the possibility of a Leydig cell tumor, and consideration should be given to testicle-sparing surgery.