Contrast-enhanced ultrasonography vs MRI for indeterminate testicular lesions: a systematic review and meta-analysis

To conduct a systematic review and meta-analysis to indirectly compare the diagnostic performance of contrast-enhanced ultrasonography (CEUS) and magnetic resonance imaging (MRI) in the evaluation of indeterminate testicular lesions and to explore their potential roles in guiding clinical decision-making.

PubMed, Web of Science, and Scopus were searched in August 2025. Eligible studies were prospective or retrospective cohorts evaluating CEUS or MRI in small, impalpable, or incidentally detected testicular lesions, with histopathology or clinical/radiological follow-up as reference standard. Two reviewers independently performed selection, data extraction, and Quality Assessment of Diagnostic Accuracy Studies-2 tool assessment. Random-effects meta-analyses and meta-regression were conducted in R (R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria). This review was registered in the Prospective Register of Systematic Reviews (CRD420251113920).

A total of 12 studies including 912 patients with 920 lesions (279 malignant, 641 benign) were analysed. CEUS showed a sensitivity of 90% (95% confidence interval [CI] 80-95%) and specificity of 74% (95% CI 47-91%), while MRI achieved a sensitivity of 94% (95% CI 88-97%) and specificity of 84% (95% CI 72-91%). CEUS provided a higher negative predictive value (NPV; 96% vs 88%), whereas MRI demonstrated superior positive predictive value (PPV; 83% vs 65%) and accuracy (91% vs 80%). Differences in PPV and accuracy significantly favoured MRI (P = 0.025 and P = 0.031). Limitations included protocol heterogeneity, operator dependence, and small sample sizes.

Both CEUS and MRI demonstrated a high sensitivity and NPV, supporting their role in excluding malignancy. CEUS, with accessibility, low cost, and particularly high NPV, may serve as the first-line adjunct, while MRI is best reserved for equivocal or higher-risk cases. No funding was received for this study.