Is ipsilateral testis mandatory for contralateral testicular deterioration encountered following spermatic cord torsion?

Parenchymal echo texture predicts testicular salvage after torsion: potential impact on the need for emergent exploration

PURPOSE

In the setting of signs and symptoms of testicular torsion the absence of diastolic flow and/or color flow on Doppler ultrasound has traditionally prompted emergent scrotal exploration. This practice emanates largely from the difficulty on ultrasound of distinguishing salvageable torsed testes from those that are not salvageable. We identified ultrasound findings predictive of testicular viability or the lack thereof.

MATERIALS AND METHODS

We retrospectively reviewed the charts of all boys who underwent scrotal exploration for signs and symptoms of torsion during a 4-year period. In those who underwent preoperative Doppler ultrasound of the scrotum ultrasound findings were reviewed, as were the operative dictations. In patients who underwent orchiectomy the pathology reports were also reviewed. In patients in whom the torsed testis appeared viable and who underwent orchiopexy followup data were reviewed when available. Emergency room charts were also reviewed to ascertain, when documented, the duration of pain before presentation to the emergency room and the interval between ultrasound and operating room.

RESULTS

During this period 55 boys underwent exploration after preoperative scrotal Doppler ultrasound revealed absent diastolic flow and/or color flow Doppler in the symptomatic testis. Assessment of parenchymal echogenicity revealed heterogeneity in 37 testes (67%), of which none were deemed viable at exploration. Orchiectomy was performed in 34 of 37 cases. Pathological examination revealed necrosis in all 34 cases, a finding consistent with late torsion. The remaining 3 testes underwent orchiopexy by parental directive despite nonviability, as confirmed by biopsy and subsequent atrophy. Thus, heterogeneity on preoperative ultrasound was universally predictive of organ loss (chi-square p <0.001). Of the 18 symptomatic testes (33%) demonstrating homogeneity and isoechogenicity on ultrasound 16 (89%) were deemed viable at exploration. Boys in whom the torsed testicle was nonviable on exploration experienced an average of 27.5 hours of pain preoperatively (range 5 to 72), whereas boys in whom the torsed testis was salvaged experienced an average of 20.5 hours of pain (range 2 to 96) (p = 0.073). The nonviable group underwent surgery an average of 49 minutes after ultrasound, whereas the viable group underwent surgery 52 minutes after ultrasound (p = 0.92). None of the 55 patients experienced any surgical or anesthetic complications and no pathological condition was noted intraoperatively in the contralateral asymptomatic testis.

CONCLUSIONS

In the setting of Doppler proven testicular torsion heterogeneous parenchymal echo texture indicates late torsion and testicular nonviability. Therefore, the case may not require emergent scrotal exploration. On the other hand, homogeneous echo texture portends extremely well for testicular viability. Thus, such testes should be explored emergently.

Unilateral spermatic cord torsion without ipsilateral spermatogenetic material: effects on testicular blood flow and fertility potential

This experiment was planned to answer the question of how the elimination of ipsilateral spermatogenetic material, which is necessary for contralateral testicular damage caused by an autoimmune response, affects contralateral testicular blood flow and fertility potential in unilateral spermatic cord torsion (USCT). Thirty-four male and 68 female adult albino rats were divided into three groups. Group 1 rats underwent a control operation, group 2 rats underwent subepididymal orchiectomy to eliminate spermatogenetic material, and group 3 rats underwent USCT after subepididymal orchiectomy. Testicular blood flows of the rats were measured by (133)Xe clearance technique. Additionally, to determine fertility potential, each male rat was housed with two female rats. Numbers of impregnated and delivered rats were recorded. Both mean testicular blood flow and fecundity of group 3 were significantly lower than those of groups 1 and 2. When compared with groups 1 and 2, fertility and mean number of the impregnated rats of group 3 were lower but the differences were not significant. These findings suggest that absence of spermatogenetic material in USCT reduces contralateral blood flow and fertility potential. Therefore, contralateral testicular damage originating from blood flow alterations rather than autoimmune mechanism should be considered to explain fertility problems encountered following USCT.

Histopathological examination of both ipsilateral and contralateral testes with different obstructive models in prepubertal and adult rats

OBJECTIVE

To determine the histopathological changes in both the ipsilateral and contralateral testes of prepubertal and adult male rats 60 days after creating different obstructive models.

MATERIAL AND METHODS

Thirty-six prepubertal and 32 adult albino male rats were examined in three different obstructive models of the right testis. In group 1 the spermatic cord was ligated, in group 2 the ligation was between the caput epididymis and testis, and in group 3 the vas deferens was ligated. Sixty days after ligation both testes were removed and evaluated for testis diameter, mean seminiferous tubule diameter (MSTD), and degenerative, obstructive and inflammatory changes.

RESULTS

The diameter of the obstructed right testis and MSTD were significantly greater in prepubertal rats but there was no apparent difference in adult rats. For obstructive changes, sloughing of germ cells in the prepubertal rats and germ cell absence in adult rats were significantly more common in group 3. The contralateral testis diameter and MSTD of group 3 was significantly greater only in prepubertal rats. Statistically significant values of obstructive change, e.g. sloughing of germ cells and apical vacuolation in Sertoli cells, were apparent in prepubertal rats, but tubular ectasis was the only statistically significant criterion of obstruction in adult rats.

CONCLUSION

The testes are more susceptible to obstruction of the vas deferens in prepubertal than in adults rats, resulting in increased hydrostatic pressure and oedema of both the ipsilateral and contralateral testes, which might be caused by collateral circulation and rat testicular microcirculation, with a rhythmic pattern of arteriolar dilatation and constriction (vasomotion). Although the presence of oedema and high hydrostatic pressure was not prominent in adults, formation of spermatic granulomas and absence or sloughing of germ cells in the obstructed and contralateral testes reflect the early effects of vas ligation on spermatogenesis in adulthood.

The protective effects of nitric oxide on the contralateral testis in prepubertal rats with unilateral testicular torsion

OBJECTIVE

To investigate histological changes in the contralateral testis of rats with unilateral testicular torsion and the protective effects of nitric oxide (NO) on possible damage.

MATERIAL AND METHODS

Twenty-eight prepubertal male Sprague-Dawley rats were divided into four equal groups. Group 1 underwent a sham operation of the right testis under general anaesthesia. Group 2 underwent a similar operation but the right testis was rotated 720 degrees clockwise for 6 h, maintained by fixing the testis to the scrotum, and saline infused during the procedure. Group 3 underwent similar torsion but L-arginine methyl ester (a precursor of NO) was infused during the procedure. In Group 4, NG-nitro-L-arginine-methyl ester, a NO synthase inhibitor, was infused separately during the administration of L-arginine methyl ester and torsion. All the left (untwisted) testes were removed from rats 21 days after surgery and evaluated histologically, assessing seminiferous tubule diameter, loss of sperm and spermatids, loss of germ cell layers, disarray of germ cell layers, rupture of tubules, Leydig cell proliferation and reaction in the ruptured tubules, and oedema.

RESULTS

There was a significant difference in the indicators of histological damage between groups 2 and 4 and groups 1 and 3, except for the Leydig cell reaction in the ruptured tubules and oedema. The damage was significantly less in group 3 than in groups 2 and 4.

CONCLUSION

These results suggest that long-term histopathological changes in the contralateral testes are important after unilateral testicular torsion and that NO has a protective effect on the contralateral testis.

Do experimentally induced ipsilateral testicular torsion, vas deferens obstruction, intra-abdominal testis or venous obstruction damage the contralateral testis through a common mechanism?

OBJECTIVE

To evaluate if various conditions affecting the ipsilateral testis which also damage the contralateral testis share a common pathway for their effects.

MATERIALS AND METHODS

The study comprised five groups of 10 adult rats which underwent surgery to produce (on their left sides); group 1, a sham operation (control); group 2, testicular torsion; group 3, vas deferens obstruction; group 4, an intra-abdominal testis; and group 5, venous obstruction. The ipsilateral and contralateral testes were harvested 4 weeks after surgery. The relative proportions of haploid cells, the mean seminiferous tubular diameter (MSTD), mean testicular biopsy scores (MTBS), and lactate and hypoxanthine levels were determined and compared.

RESULTS

The proportions of haploid cells in the ipsilateral and the contralateral testes of groups 2-5 were significantly lower than those of the corresponding testes of the control group. The MSTD and MTBS of the ipsilateral testes in groups 2-5 were also significantly lower than the ipsilateral testes of controls and the contralateral testes within the same groups. While the MSTD and MTBS of the contralateral testes of groups 1 and 5 were not significantly different, those of the contralateral testes of groups 2-4 were significantly less than that of group 1. The lactic acid and hypoxanthine levels of the ipsilateral and contralateral testes were significantly increased in groups 2 and 3. While only the hypoxanthine level of group 5 increased significantly, both variables were not significantly different between the ipsilateral testes of groups 1 and 4.

CONCLUSIONS

These four treatments damaged both the ipsilateral and contralateral testes. As the lactic acid and hypoxanthine levels within the contralateral testis were greater than in the controls, testicular torsion and vas deferens obstruction seem to share a common pathway (which may be a reflex decrease in contralateral testicular blood flow) for their effects on the contralateral testis.

The evaluation of sympathetic system-related contractile activity of the rat vas deferens after ligation and intra-abdominal placement of the testis

OBJECTIVE

To evaluate the contractile response of the vas deferens in a model of stress, to determine any changes in sympathetic activity as a result of stress in the ipsilateral testis, which decreases blood flow to the contralateral testis.

MATERIALS AND METHODS

The study comprised two groups of six rats each; group 1 underwent a sham operation, and in group 2 the right testis was placed into the abdominal cavity and the vas deferens ligated. After 30 days, the vasa deferentia were resected bilaterally and their isometric contractions recorded. Electrical-field stimulation (EFS) was applied through a pair of platinum electrodes and concentration-response curves constructed for noradrenaline at 37 degrees C and to a solution containing 80 mmol/L K+.

RESULTS

The vasa deferentia in both groups showed similar contractile responses to EFS, which were frequency-dependent and maximal at 80 Hz. Noradrenaline-induced contractile activity was lower in amplitude in the vasa deferentia of group 2 than in the contralateral and ipsilateral vasa deferentia of group 1, which were not significantly different from each other. All groups responded similarly to high K+.

CONCLUSION

Intra-abdominal placement of the testes with vas deferens ligation decreased the contractile response to noradrenaline in the ipsilateral vas deferens without altering the contractile response to EFS and high K+. This difference could be caused by a reduction in the number of postjunctional alpha-adrenergic receptors or decreased receptor sensitivity. Both possibilities suggest that the vas deferens may initiate sympathetic activity, which may be responsible for contralateral testicular deterioration.

Noradrenaline and nitrite-nitrate concentrations in the contralateral testes during ipsilateral spermatic cord torsion in the presence or absence of a testis and epididymis

OBJECTIVE

To determine the changes occurring during ipsilateral spermatic cord torsion either in the presence or absence of the ipsilateral testis and epididymis, by evaluating noradrenaline and nitrite-nitrate concentrations in the contralateral testes.

MATERIALS AND METHODS

Forty male albino rats were allocated randomly to one of four equal groups undergoing: group 1, a sham operation; group 2, ipsilateral spermatic cord torsion; group 3, epididymo-orchidectomy only; and group 4, spermatic cord torsion after epididymo-orchidectomy. The contralateral testes were harvested after 24 h and the noradrenaline and nitrite-nitrate contents determined. The levels in each group were compared using the Kruskal-Wallis and Mann-Whitney U-tests.

RESULTS

The noradrenaline content of testes from group 2 was significantly lower than in those of groups 1 and 3, but there were no significant differences in content between groups 1 and 3, 1 and 4, and 2 and 4. The content in group 4 was significantly less than that in group 3. There were no significant differences in nitrite-nitrate contents among any of the groups.

CONCLUSION

Spermatic cord torsion for 24 h, either in the presence or absence of a testis and epididymis, significantly decreased the noradrenaline content in the contralateral testis. This finding supports the suggestion that the sympathetic system is activated by exposure to noradrenaline in the contralateral testis during ipsilateral spermatic cord torsion, with no dependency on the presence of a testis and epididymis. As the nitrite-nitrate concentrations were unaffected, nitric oxide seems to have no role in contralateral testicular deterioration.

The effects of vasodilatation and chemical sympathectomy on spermatogenesis after unilateral testicular torsion: a flow cytometric DNA analysis

OBJECTIVE

To evaluate the effects of vasodilator therapies and chemical sympathectomy on ipsilateral and contralateral testicular spermatogenetic activity after unilateral testicular torsion using DNA flow cytometry and thus determine whether contralateral testicular damage occurs through a reflexively decreased blood flow.

MATERIALS AND METHODS

The study comprised four groups of 20 rats each (groups 1-4) respectively receiving isotonic saline, verapamil, pentoxifylline and 6-hydroxy dopamine hydrobromide (6-OHD) intraperitoneally. Each group was further divided into two subgroups containing 10 rats which respectively underwent either a sham operation or 720 degrees clockwise torsion applied to the left testis. The testes were harvested after 24 h and the relative proportions of haploid, diploid and tetraploid cells determined by DNA flow cytometry for each testis. The proportion of haploid cells was used as an estimate of spermatogenesis. The mean proportions of haploid cells in the groups were compared using a one-way ANOVA and paired groups were compared using Student's t-test.

RESULTS

The proportions of haploid cells in the ipsilateral testes of rats undergoing torsion were significantly lower than in their contralateral testes and in the ipsilateral testes of the control groups. In group 4 (6-OHD) the proportion of haploid cells in the contralateral testes was significantly higher than those in the other groups after unilateral testicular torsion, but significantly lower than those in groups 1 and 4 after a sham operation. After unilateral testicular torsion the haploid cell proportions of the contralateral tests of groups 1-3 were not significantly different from each other.

CONCLUSIONS

Because the spermatogenetic activity in the contralateral testis is depressed within 24 h of ipsilateral testicular torsion, contralateral testicular damage is an acquired effect: 6-OHD offers some protection and thus the damage seems to result from the involvement of the sympathetic system.

Torsion of only spermatic cord in the absence of testis and/or epididymis results in contralateral testicular hypoxia

Unilateral spermatic cord torsion in the presence or absence of ipsilateral testis causes hypoxia in the contralateral testis. An experimental study was conducted to find the most important structure that causes contralateral testicular hypoxia following ipsilateral twisting. In five groups each consisting of 10 rats sham operations, epididymoorchiectomy, spermatic cord torsion, spermatic cord torsion following subepididymal orchiectomy or spermatic cord torsion following epididymoorchiectomy were performed. Lactic acid, hypoxanthine and thiobarbituric acid reactive products of lipid peroxidation (TBAR) were determined in the contralateral testis. While lactic acid, hypoxanthine and TBAR values did not differ significantly following sham and epididymoorchiectomy procedures, evaluation of other groups revealed significantly increased values compared with sham and epididymoorchiectomy groups. Since torsion of only spermatic cord and testicular vasculature causes contralateral testicular hypoxia, testis and epididymis do not seem to be mandatory for occurrence of contralateral testicular hypoxia. Testicular artery under distress seems to be the most important structure that results in contralateral testicular hypoxia following torsion.