Scrotal Ultrasonography Features of Testicular Adrenal Rest Tumors in Male Congenital Adrenal Hyperplasia Patients: A Systematic Review

Abstract

Introduction:

Testicular Adrenal Rest Tumors (TART) is one of the complications in male Congenital Adrenal Hyperplasia (CAH) patients that need early detection using scrotal ultrasonography. This systematic review aims to provide an up-to-date summary of the current understanding of scrotal ultrasonography features of testicular adrenal rest tumors in male congenital adrenal hyperplasia patients to help medical professionals diagnose TART in male CAH patients.

Methods:

A systematic review was conducted using the PRISMA methodology. The authors searched for studies through PubMed from the last ten years until August 2023. Male CAH patients diagnosed by clinical and hormonal examination or genetic analysis with at least one of the features of TART in scrotal ultrasonography were included.

Results:

This systematic review involved fourteen studies that were classified into retrospective cohort study (n = 5), cross-sectional study (n = 4), and prospective cohort study (n = 5). The total number of participants from fourteen studies was 597 patients, and 186 patients were found to have TART (31.16%). Studies showed that bilateral lesions (78.49%), lesions located near the mediastinum testes (89.61%), hypoechoic (81.94%), clear border (76.74%), round to oval lesions (44.44%, 55.56%, respectively), and hypervascular (69.39%) in color doppler ultrasound were found in male CAH patients with TART.

Conclusion:

Scrotal ultrasonography features of TART in male CAH patients were primarily bilateral, located near the mediastinum testes, hypoechoic, clear border, round to oval shape, and hypervascular in color Doppler ultrasound.

INTRODUCTION

Congenital Adrenal Hyperplasia (CAH) is a congenital disease in which one of the enzymes is deficient in adrenal steroidogenesis.[1,2] It is an autosomal recessive disorder with an incidence from 1:14,000 to 1:18,000 births globally.[3] About 90–99% of CAH was caused by a mutation in the CYP21A2 gene, resulting in a 21-hydroxylase deficiency that will result in cortisol and aldosterone deficiency.[1,2] It will lead to an increased production of adrenocorticotropic hormone (ACTH) that results in an increased amount of cortisol precursors before the enzymatic block (21-OHD) and also adrenal androgens.[1,2] CAH is classified into classic form and non-classic form, in which the classic form is then further divided into salt-wasting type (SW) or simple virilizing type (SV).[1,2] The classification is based on the clinical manifestation and residual enzymatic activity.[1,2] The recommended treatment involves lifelong replacement therapy of cortisol and aldosterone that will also help suppress the androgen production.[1,4]

One of the main long-term complications of CAH in adult males is infertility, which is commonly caused by a benign tumor within the rete testes with a morphological and functional resemblance to adrenal tissue called Testicular Adrenal Rest Tumors (TART) that was first reported by Wilkins et al. in 1940.[4,5] From previous studies, the prevalence of TART could be up to 94% depending on the detection method and patient selection, such as age, hormonal control, and severity of CAH.[4,6,7]

Although it is a benign tumor, TART may cause compression of the seminiferous tubules, which causes obstructive azoospermia, irreversible damage to the surrounding testicular tissue, and ultimately infertility.[2,8,9,10] Therefore, early detection of TART using ultrasonography in male CAH patients, especially in younger children, is needed.[11]

There were different results of scrotal ultrasonography features of TART in male CAH patients based on its bilateralism, location, echogenicity, border, shape of lesions, and vascularity by color Doppler ultrasound.[4,10,11,12,13,14,15,16] At the same time, no literature summarized the scrotal ultrasonography features of TART yet to guide the clinician in diagnosing TART. With this systematic review, we aim to provide an up-to-date summary of the current understanding of scrotal ultrasonography features of testicular adrenal rest tumors in male congenital adrenal hyperplasia patients to help guide medical professionals in diagnosing TART in male CAH patients.

METHOD

This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline.[17,18] This systematic review reviewed the scrotal ultrasonography features of testicular adrenal rest tumors in male congenital adrenal hyperplasia patients. Since the study is a systematic review, no ethical approval was required.

Data sources

Two independent authors searched the online database through PubMed on 3 August 2023 for data collection. The authors used the following keywords in advanced search; (((((testicular adrenal rest tumor[Title/Abstract]) OR (testicular adrenal rest tumors[Title/Abstract])) OR (testicular adrenal rest tumour[Title/Abstract])) OR (testicular adrenal rest tumours[Title/Abstract])) OR (TART[Title/Abstract])) AND (((((ultrasound[Title/Abstract]) OR (ultrasonography[Title/Abstract])) OR (ultrasonographic[Title/Abstract])) OR (sonography[Title/Abstract])) OR (sonographic[Title/Abstract])).

Study selection and data extraction

Specific inclusion criteria were male CAH patients as the participants, diagnosed with CAH by clinical and hormonal examination or genetic analysis, at least one of the features of TART in scrotal ultrasonography presented in the article, and articles published in the last ten years from the search. Exclusion criteria were review articles, case reports, case series, editorials, comments, letters, recommendations, non-English articles, female or non-CAH patients, and non-human studies. The study flow diagram can be seen in Figure 1.

Figure 1.

Study flow diagram of the systematic review

To choose the appropriate papers for a complete review, the authors conducted two screening phases: screening the titles and abstracts and screening the full text. After removing duplicate records and records published more than ten years before, the authors reviewed each title and abstract individually. The full text was requested for further review if any author deemed the research appropriate. If there was a disagreement, the authors discussed their reasons before coming to a final agreement.

The studies were extracted using Microsoft Excel, and the authors checked and confirmed the data extraction. The extracted data of each study included the following information: the authors’ names, country, type of study, participants, age, detection of TART, and scrotal ultrasonography findings.

RESULT

Study selection

There were 84 studies obtained from PubMed by inserting the keyword. Before the screening phase, we removed 15 studies of records published more than ten years before the search (n = 14) and duplicate records (n = 1), leaving us with 69 studies to screen. After investigating the 69 studies through title and abstract screening, 28 were included in preparation for full-text screening. Four studies were excluded because a full text was not found. Subsequently, after applying the inclusion and exclusion criteria, fourteen studies were included in this systematic review.

General characteristic

Two studies were from the American continent (USA and Brazil), six studies were from the European continent (Germany, Croatia, Italy, France, and the Netherlands), three studies were from the Middle East (Saudi Arabia and Turkey), one study was from the African continent (Tunisia), and two studies were from the Asian continent (India and South Korea). Five were retrospective cohort studies, four were cross-sectional, and five were prospective cohort studies. The total number of participants from the fourteen articles the authors used was 597; from those studies, there were 186 patients with TART (31.16%). The baseline information of scrotal ultrasonography features of TART in male CAH patients can be seen in Table 1.

Table 1.

Baseline information of the scrotal ultrasonography features of TART in male CAH patients

Study	Country	Type of Study	Participants	Age (years)	Detection of TART	Scrotal Ultrasonography Findings
Claahsen-van der Grinten HL, et al.[4]	The Netherlands	Retrospective study	Forty-one male CAH patients were classified into CAH due to 21-OHD in 40 patients (35 patients with SW form, four patients with SV form, and one with NC form) and CAH due to 11-hydroxylase deficiency in one patient.	0–19	TART was detected in 16/41 patients (39%).	Male CAH patients with TART (n=16):  • Bilateral lesions: n=5  • Located near the rete testes: 16  • Hypoechoic round lesions: 16
Bouvattier C, et al.[8]	France	Cohort	Data of 219 men with 21-OHD were classified into SW form (73.6%) and SV form (26.4%). Scrotal ultrasonography was performed on 164 participants.	18–70 (mean±SD: 32.1±10.2)	TART was detected in 56/164 patients (34%).	Male CAH patients with TART (n=56):  • Bilateral lesions: 79% of 56 patients
Mazzilli R, et al.[10]	Italy	Longitudinal cohort study	Twenty-five male patients with CAH due to 21-OHD.	18–43 (mean±SD: 32.2±7.5)	TART was detected in 14/25 patients (56.0%)	Male CAH patients with TART (n=14)  • Bilateral lesions: n=11/14 (78.6%)  • Unilateral lesions: n=3/14 (21.4%)  • Hypoechoic lesions: n=12/14 (85.7%)  • Hyperechoic lesions: n=2/14 (14.3%)  • Color Doppler US showed an absence of flow: n=10/14 (71.4%)  • Color Doppler US showed perilesional flow: n=3/14 (21.4%)  • Color Doppler US showed perilesional and intralesional flow: n=1/14 (7.1%).
Kim MS, et al.[11]	USA	Cross-sectional study	Thirty-five males with CAH due to 21-OHD were classified into classical (n=32) and non-classical (n=3) CAH.	<5–12	TART was detected in 5/35 patients (14%).	Male CAH Patients with TART (n=5)  • Bilateral findings: n=5
Al-Ghamdi WM, et al.[12]	Saudi Arabia	Retrospective study	Twenty-one males with CAH were classified into 17 SW and four non-SW types.	4–20 (median: 11)	TART was detected in 6/21 patients (28%). Median age: 12.5 years old The youngest is eight years old).	Male CAH patients with TART (n=6)  • Bilateral lesion: n=5 (83%)  • Located near the mediastinum: n=3 (50%)  • Hypoechoic: n=5 (83%)  • Eccentric hyperechoic: n=1 (16%)  • Highly vascular: n=5 (83%)  • Ill-defined borders: n=2 (33%) Additional Findings:  • Unilateral bright echogenic foci representing microlithiasis in two CAH patients were found, and one was diagnosed with TART.
Chihaoui M, et al.[13]	Tunisia	Prospective study	Six young adult male CAH patients.  • Four patients with a 21-OHD with SW form.  • Two patients with an 11β-hydroxylase deficiency (11 β-OHD).	20–31 (mean: 25)	TART was detected in 4/6 patients (66.67%)	Male CAH patients with TART (n=4)  • Bilateral lesions: n=3  • Located adjacent to the mediastinum testis: n=4  • Hypervascular on color Doppler: n=4  • Total lesions: n=10; hypoechoic lesions: n=8/10 and hyperechoic lesions: n=2/10.
Meena H, et al.[14]	India	Cohort	Twenty-one male CAH patients were classified into SW form (n=15) and SV form (n=6).	Mean: 6.2±4.9	• TARTwase detected in 5/21 males (23.8%). SV CAH with TART were 3/6 patients (50%), and SW CAH with TART were 2/15 patients (13%).  • The youngest patient with TART was 5.8 years old.	Male CAH patients with TART (n=5)  • Bilateral lesion: n=1  • Located near the mediastinum testis: n=2  • Hypoechoic lesions: n=5
Rohayem J, et al.[15]	Germany	Combined cross-sectional and retrospective clinical study	• Twenty-nine post-pubescent (Tanner stage 4–5) males with CAH due to 21-OHD were classified into 21 SW forms, six SV forms, and two NC forms.  • Twenty-nine healthy age-matched males (controls).	13–27	TART was detected in 12/29 patients (41%).	Male CAH patients with TART (n=12)  • Bilateral lesion: n=12  • Located around the rete testis: n=12  • Distinct margins: n=12
Yilmaz R, et al.[16]	Turkey	Retrospective study	Forty-one male patients with CAH were classified into 21-OHD (n=31) and 11-hydroxylase deficiency (n=10).	3.5–23.3 (Mean±SD: 12.1±4.7)	TART was detected in 9/41 patients (21.9%), with seven patients aged <18. There are six patients with 21-OHD and three patients with 11-OHD.	Male CAH patients with TART (n=9)  • Bilateral lesions: n=9  • Located near the mediastinum testis: n=9  • The shape of the lesions  • Oval: n=5  • Round: n=4  • Total lesions: 18 lesions  • The echogenicity of the lesions  • Hypoechoic: n=12/18  • Hyperechoic: n=6/18  • Margins of the lesions were sharply delineated from the normal parenchyma in all lesions (n=18/18)  • Color Doppler:  • Hypervascular: n=10/18  • Hypovascular: n=8/18  • Presence of microlithiasis: n=4/9 patients (44.44%).  • One patient (11.11%) had varicocele and TART.
Corcioni, et al.[19]	Italy	Prospective Study	• Fifty-two male patients with CAH	16–48 (median: 22.5)	TART was detected in 16/52 patients (31%).	Male CAH Patients with TART (n=16)  • The bilateral lesion in TART: n=15/16 (93.8%) vs. in the control group: n=1 (6.2%); P<0.001.
			• Control group: 16 people without CAH that were affected by testicular lesions at ultrasonography other than TART (eight leydigioma, five seminomas, and three mixed germ cell tumors)			• There was a total of 51 lesions in CAH patients with TART that were classified into eight patients (50%) had two TART, and the remaining eight patients (50%) had >3 lesions. On the contrary, the control group had 17 lesions; only one patient presented with two lesions.  • Right testicular lesions were significantly higher in patients with TART (62.5%) than in the control group (31.3%); P=0.002.  • Mainly, the lesion was located in the medium third of the testis near the rete testis in TART: n=14/16 (87.5) vs. in the control group: n=6/16 (37.5%); P=0.013  • Hypoechoic lesion in TART: n=10/16 (62.5%) vs in control group: n=11/16 (68.8%); P=0.827  • The hyperechoic lesion in TART: n=2/16 (12.5%) vs. in control group 1/16 (6.2%); P=0.827%.  • The irregular testicular lesion in TART: n=8/16 (50%) vs. in the control group: n=7/16 (43.7%). Oval testicular lesion in TART: n=8/16 (50%) vs. in the control group: n=9/16 (56.3%); P=0.723.  • Intralesional signal on color Doppler in TART: 12/16 (75.0%) vs in control group: n=11/16 (68.88%); P=0.694.
Aycan Z, et al.[20]	Turkey	Retrospective study	Sixty males with CAH were classified into 55 patients with 21-OHD and five patients with 11β-OHD.	2–18	• TART was detected in 11/60 patients (18.3%), classified into eight patients with 21-OHD (four with SW form and four with SV form) and three with 11β-OHD.  • The youngest patient with TART was four years old.	Male CAH patients with TART (n=11):  • Bilateral lesions: n=9
Dumic, et al.[21]	Croatia	Cross-sectional study	Fifty-one male CAH patients were classified into SW form (n=25), SV form (n=14), and	1.8 to 40	TART were detected in 15/51 patients (29,41%).	Male CAH Patients with TART (n=15)  • Bilateral lesions: n=12  • Unilateral lesions: n=3  • Round lesions: n=12  • Echogenicity:
			NC (n=8). The patient’s ages were classified into 0-6 years and 11 months (n=8), 7-11 years and 11 months (n=8), 12-17 years and 11 months (n=17), and 18-42 years (n=18)		• Patients aged 0 to 6 years and 11 months: 1/8 (12.5%)  • Patients aged 7 to 11 years and 11 months: 1/8 (12.5%)  • Patients aged 12 to 17 years and 11 months: 5/17 (29.4%)  • Patients aged 18-42 years: 8/18 (44.4%).	• Hypoechoic: n=11  • Hypoechoic in one testis and hyperechoic on the other testis: n=2  • Hypoechoic and hyperechoic in both testes: n=2
Mendes-dos-Santos CT, et al.[22]	Brazil	A descriptive and analytical cross-sectional study	Thirty-eight males with the classical form of CAH	3 to 27 (mean: 15.2±6.7)	TART were detected in 9/38 patients (23.7%).	Male CAH Patients with TART (n=9)  • Bilateral lesions: n=9  • Located at para mediastinum of the testis: n=9
Yu MK, et al.[23]	South Korea	Retrospective study	Thirteen male CAH patients due to 21-OHD were classified into SW form (n=8) and SV form (n=5). All patients were in the Tanner 5 pubertal stage.	15.5 to 29.4 (median: 20.5)	• TART were detected in 8/13 patients (61.5%) that were classified into 6/8 patients (75%) with SW form and 2/5 patients (40%) with SV form.  • The youngest patient with TART was 15.5 years old	Male CAH patients with TART (n=8)  • Bilateral lesion: n=6 (75%)

Additional findings of factors associated with TART

From those 14 studies, we also found additional interesting information regarding the factors associated with TART appearance. It will be illustrated in Table 2, which consists of 21-OHD phenotype, steroids dose, tanner staging, genotype, bone age advancement, 17-hydroxyprogesterone (17-OHP) concentration, Adrenocorticotropic Hormone (ACTH) concentration, Inhibin B concentration, semen analysis, whether patients had fathered a child or not, and about the change in tumor size.

Table 2.

Additional Findings of Factors Associated with TART

Variables	Results	Reference
21-OHD Phenotype (SW, SV, or NC)	Significantly more patients with TART in SW groups than those without TART	[19]
Fludrocortisone Dose	Significantly higher FC dose in TART patients than those without TART	[11]
Tanner Staging	TART were significantly more prevalent after the onset of puberty	[1,14]
Genotype	Severe CYP21A2 mutations were more prevalent in patients with TART than those without TART	[15,21]
Bone Age Advancement	Patients with TART were more likely to have advanced bone age than those without TART	[11,12,21]
17-OHP Concentration	Significantly higher 17-OHP concentration in patients with TART than those without TART	[10]
ACTH Concentration	Significantly higher ACTH concentration in patients with TART than those without TART	[10,12,19,23]
Inhibin B Concentration	Significantly lower Inhibin B concentration in patients with TART than those without TART	[8]
Semen Analysis	Sperm concentrations were significantly lower (oligospermia or even azoospermia) in patients with TART than those without TART	[8,10,13,15]
	Sperm motility was significantly lower in patients with TART than those without TART	[10]
Fathered a Child	TART were more prevalent in patients who had not fathered children (among men living with female partners) than those without TART	[8]
Change in Tumor Size	Significant correlation between ACTH level reduction and TART diameter reduction	[10,23]

DISCUSSION

Scrotal ultrasonography features of TART

Since TART may cause compression of the seminiferous tubules, which ultimately causes infertility, early detection of TART at a young age is needed.[2,8,9,10] Physical examination may only detect TART as a palpable mass if the lesion is at least 2 cm in diameter and the detection rate is 5–35%.[6,7,19] Ultrasonography and Magnetic Resonance Imaging (MRI) can be used to detect TART, but ultrasonography is the best modality because it is cheaper and quicker than MRI.[16]

However, scrotal ultrasonography features of TART in male CAH patients can vary in its bilateralism, location, echogenicity, border, shape, and vascularity.[4,8,10,11,12,13,14,15,16,19,20,21,22,23,24] Below, the authors summarize studies to help guide medical professionals in diagnosing TART by scrotal ultrasonography.[4,8,10,11,12,13,14,15,16,19,20,21,22,23,24]

Regarding bilateralism, from 186 patients detected with TART, there were 146 patients (78.49%) with bilateral lesions.[4,8,10,11,12,13,14,15,16,19,20,21,22,23,24] Almost all studies included in this systematic review show that TART is primarily bilateral.[8,10,11,12,13,15,16,19,20,21,22,23,24] Bilateral lesions in all patients with TART were described by Rohayem J et al., Kim MS et al., Mendes-dos-Santos CT et al., and Yilmaz R et al.[11,15,16,22] However, Claahsen-van der Grinten HL et al. and Meena H et al. showed the contrary.[4,14] Bilateral lesion was found in five out of 16 patients with TART (31.25%) in Claahsen-van der Grinten HL et al. study’s, and one out of five patients with TART (20%) in Meena H et al. study’s.[4,14]

Regarding the location, 89.61% of TART is located primarily near the mediastinum testes (69 out of 77 patients with TART that the location is being reported).[4,13,14,15,16,19,22] All participants with TART had nodules located near the mediastinum testes from studies described by Rohayem J et al., Mendes-dos—Santos CT et al., Chihaoui M et al., Claahsen-van der Grinten HL et al., and Yilmaz R et al.[4,13,15,16,22] There were 40% of participants with TART had nodules located near the mediastinum testes, as reported by Meena H et al., and 50% reported by Al-Ghamdi WM et al.[12,14]

Regarding the echogenicity, 81.94% of TART were hypoechoic lesions (59 out of 72 patients with TART).[4,10,12,14,19,21] All of the participants with TART had hypoechoic lesions reported by Claahsen-van-der Grinten HL et al. and Meena H et al.[4,14] There were 62.5% hypoechoic lesions in TART patients, as reported by Corcioni et al.[19]

Regarding the border or margin, 76.74% of TART had a clear border (33 out of 43 patients).[12,15,16,19] All participants with TART (100%) had a clear border of the lesions described by Rohayem J et al. and Yilmaz R et al.[15,16] Four out of six patients (66.67%) with TART had a clear border, as reported by Al-Ghamdi W M et al., and 8 out of 16 patients (50%) with TART had a clear border and the other 50% had an irregular border were reported by Corcioni et al.[12,19]

The shape of the lesions of TART is round to oval.[16,19,21] TART with round lesions was reported in 80% of patients (12 out of 15 patients) by Dumic et al. and 44.44% (four out of nine patients) by Yilmaz R et al.[16,21] TART with oval lesions was reported in 50% (eight out of 16 patients) by Corcioni et al. and 55.56% (five out of nine patients) by Yilmaz R et al.[16,19]

Regarding vascularity by color Doppler ultrasound, 69.39% had hypervascular color Doppler ultrasound (34 out of 49 patients).[10,12,13,16,19] Hypervascularity by color Doppler ultrasound was reported by Chihaoui M et al. in 4 out of 4 patients (100%), Yilmaz R et al. in 18 out of 18 total lesions or 9 out of 9 patients (100%), Al-Ghamdi WM et al. in five out of six patients (83.33%), and Corcioni et al. in 12 out of 16 patients (75%).[12,13,16,19] However, there were only 4 out of 14 patients (28.57%) had hypervascularity, and the other 10 patients (71.43%) had hypovascular with color Doppler ultrasound that was reported by Mazzilli R et al.[10]

Additional features reported in scrotal ultrasonography of male CAH patients with TART were microlithiasis and varicocele.[12,16] Microlithiasis was described in 5 out of 15 TART patients (33.33%) by Al-Ghamdi WM et al. and Yilmaz R et al.[12,16] Furthermore, varicocele was also found in 1 out of 9 patients (11.11%) with TART by Yilmaz R et al.[16]

Additional findings of factors associated with TART

Patients with TART were mainly in the SW groups and had a higher Fludrocortisone dose than those without TART.[11,19] It showed that a more severe salt-wasting occurred in patients with TART, which was proven by the more prevalent severe CYP21A2 mutations (class null and A) in TART patients than those without TART.[11,15,21]

TART was also reported to be significantly more prevalent after the onset of puberty.[1,14] It was in line with previous studies that explained that the increased number of TART in patients at or after pubertal periods might be because of the presence of LH receptors in TART that would be stimulated by higher LH concentrations after puberty.[4,22]

Patients with TART were more likely to have advanced bone age and significantly higher 17-OHP and ACTH concentrations.[10,11,12,19,21,23] ACTH is also a significant predictor of TART (P < 0.01) from logistic regression analysis that was reported by Mazzilli R et al.[10] Those findings showed poor hormonal control in patients with TART.[10,11,12,19,21,23] Also, TART development was correlated in male CAH patients with poor hormonal control, as reported by Dumic et al.[21]

Patients with TART also had significantly lower Inhibin B concentrations than those without TART.[8] It showed that patients with TART had a gonadal dysfunction, especially in the Sertoli cell.[8]

Semen analysis in patients with TART was significantly lower in concentration and motility than in patients without TART.[8,10,13,15] It showed that patients with TART were associated with impaired spermatogenesis.[13] It was in line with data that showed that among male CAH patients who live with female partners, TART was more prevalent in patients who had not fathered a child.[8]

Regarding the change in tumor size, there was a significant correlation between ACTH level reduction and TART diameter reduction reported by Mazzilli R et al. and Yu MK et al.[10,23] Furthermore, there was no association between hydrocortisone dose and the tumor size changes based on the study reported by Yu MK et al.[23]

Limitation and recommendation

This article summarizes the scrotal ultrasonography features of TART in male CAH patients that can help clinicians, especially radiologists, in diagnosing TART. However, we are aware of several limitations in writing this article, including the small numbers of samples in some studies, not all variables of scrotal ultrasonography are presented in all studies, and the study reviewed was a single-center study. We hope future studies will provide a larger sample size with more complete variables of the ultrasonography features in a multicenter study.

CONCLUSION

Scrotal ultrasonography is needed for the detection of TART in male CAH patients.[11] Ultrasonography is the method of choice superior to MRI and testis palpation.[25,26] From this systematic review, we concluded that the scrotal ultrasonography features of TART in male CAH patients were primarily bilateral, located near the mediastinum testes, hypoechoic, clear border, round to oval shape, and hypervascular with color doppler ultrasound.[4,8,10,11,12,13,14,15,16,19,20,21,22,23]

Author contributions

Both authors contributed equally to the study concepts, design, definition of intellectual content, literature search, data acquisition, data analysis, manuscript preparation, manuscript editing, manuscript review, and served as guarantors for the study.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

This study was supported by Faculty of Medicine, Diponegoro University Grant (No. 09/UN7.F4/PP/III/2024).