The ultrasonographic "whirlpool sign" in testicular torsion: valuable tool or waste of valuable time? A systematic review and meta-analysis

Predictive factors for manual detorsion success in testicular torsion

PURPOSE

In cases of testicular torsion (TT), prompt diagnosis and treatment are highly associated with organ salvage, and manual detorsion (MD) is a recommended maneuver as a first intervention. In our study, we aimed to investigate the effect of predictive factors of TT in predicting the success of MD.

METHODS

A retrospective, 2-center study was conducted on patients diagnosed with TT between January 2015 and 2024. Demographic, clinical, ultrasound, and laboratory characteristics at presentation were analyzed. MD was routinely performed as the first intervention in all patients. Predictive parameters were compared in the MD success and failure groups. Univariate and multiple logistic regression analysis was used to identify risk factors for MD failure.

RESULTS

A total of 94 patients were included in the study. The median age of the patients was 20 (IQR: 12-69) years, and the median symptom duration was 6 (IQR: 4-12) hours. MD confirmed by Doppler ultrasonography was successful in 52 (55.3%) patients and unsuccessful in 42 (44.7%). Age, symptom duration, Testicular Workup for Ischemia and Suspected Torsion (TWIST) score, TWIST risk groups, WBC, neutrophil, monocyte counts, and Monocyte/Eosinophil ratio (MER) were statistically different between the two groups. In multiple logistic regression analysis, the risk factors for failure of MD were found to be being over 18 years of age, the duration of symptoms being longer than 9 h, and MER > 28.

CONCLUSION

Current urology guidelines suggest that age, symptom duration, and MER are reliable predictors of the success of MD, which is recommended in all cases of TT.

Laparoscopic-Assisted Scrotal Approach for the Treatment of Inguinal Cryptorchidism with Patent Processus Vaginalis: Clinical Efficacy Analysis

Objective: This study aimed to compare the clinical outcomes of two surgical approaches, laparoscopic-assisted scrotal incision and conventional inguinal-scrotal incision, for treating cryptorchidism with unobliterated processus vaginalis. Methods: Clinical data from 60 pediatric patients with inguinal cryptorchidism who were admitted to our institution between January 2018 and January 2022 were retrospectively analyzed. Depending on the surgical technique used, the patients were split into two groups: the laparoscopic group (n = 30) underwent a laparoscopic-assisted scrotal incision, whereas the conventional group (n = 30) underwent a conventional inguinal-scrotal incision for testicular descent and fixation. The length of the procedure, intraoperative blood loss, and the typical hospital stay following the procedure were compared between the two groups. Also assessed was the frequency of postoperative complications including wound infection and hematoma development. Results: The laparoscopic group demonstrated a notably shortened average surgical duration compared with the traditional group, and this discrepancy held statistical significance (P = .017). Moreover, the laparoscopic approach resulted in a reduced volume of intraoperative blood loss, with a statistically significant distinction (P = .002), along with a decreased average length of hospital stay after surgery, also statistically significant (P = .009). Testicular retraction, atrophy, inguinal hernias, or hydrocele were not present in any group. Although the difference between the laparoscopic and open groups was not statistically significant (P > .05), the laparoscopic group saw a reduced frequency of scrotal hematoma. The frequency of wound infection was also decreased in the laparoscopic group compared with the open group, although there was no statistically significant difference (P > .05). Conclusion: The laparoscopic-assisted scrotal incision approach for testicular descent and fixation offers precise localization of cryptorchidism, reduced surgical trauma, shorter postoperative recovery time, and results in smaller scars with minimal tissue damage. The procedure showcases enhanced overall clinical effectiveness, fewer postoperative complications, heightened safety, and superior cosmetic outcomes.

Emergency scrotal exploration in children: Following a change in mindset in the UK

A survey of 200 emergency scrotal explorations done over four paediatric surgical centres in the UK revealed that the incidence of finding testicular torsion (TT) was 24% and the preoperative utilisation of Doppler ultrasound (DUS) was 10% [1]. We changed our practice to include better preoperative utilisation of a clinical risk score (TWIST) and DUS. This led to a significant increase in the incidence of finding TT from 18% to 53%. Obtaining a DUS did not lead to an increase in our orchidectomy rate. Adopting this change is possible in an NHS setting and it has significant clinical and economic benefits.

Clinical risk factors for testicular torsion and a warning against falsely reassuring ultrasound scans: a 10-year single-centre experience

BACKGROUND

We sought to determine which demographic, clinical and ultrasonography characteristics are predictive of testicular torsion (TT) and to determine factors associated with time to treatment.

METHODS

We retrospectively reviewed all medical records of patients (0-17 years) with acute scrotal syndrome (ASS) who were treated in our hospital in Lithuania between 2011 and 2020. We extracted patients' demographic data, in-hospital time intervals, clinical, US and surgical findings. TT was determined at surgery or clinically after manual detorsion. Test characteristics of demographic, clinical and US findings for the diagnosis of TT versus other causes of ASS were determined. We performed a multivariate analysis to identify independent clinical predictors of torsion, and factors associated with surgical delay.

RESULTS

A search of medical records yielded 555 cases: 196 (35%) patients with TT and 359 (65%) patients with other ASS causes. Multivariate logistic regression analysis showed that age between 13 and 17 years (OR 8.39; 95% CI 5.12 to 13.76), duration of symptoms <7 hours (OR 3.41; 95% CI 2.03 to 5.72), palpated hard testis (OR 4.65; 95% CI 2.02 to 10.67), scrotal swelling (OR 2.37; 95% CI 1.31 to 4.30), nausea/vomiting (OR 4.37; 95% CI 2.03 to 9.43), abdominal pain (OR 2.38; 95% CI 1.27 to 4.45) were independent clinical predictors of TT. No testicular blood flow in Doppler US had a specificity of 98.2% and a positive predictive value of 94.6%. However, 75 (41.7%) patients with TT had normal testicular blood flow, yielding low sensitivity (58.3%) and negative predictive value of 81.3% for this US finding. In-hospital waiting time for surgery was longer in patients with TT with normal testicular blood flow by USS (195 min) compared with no blood flow (123 min), p<0.01. Higher orchiectomy rates were associated with longer duration of symptoms (p<0.001) and longer waiting time for USS (p=0.029) but not with false-negative US.

CONCLUSIONS

Pubertal age, symptoms duration of <7 hours, nausea/vomiting, palpated hard testis, abdominal pain and scrotal swelling are predictive factors for TT. Time lost between symptom onset and seeking medical care, and between arrival and US are associated with the need for orchiectomy. Preserved blood flow in USS does not rule out TT and may contribute to delays to surgery.

Diagnostic accuracy of point-of-care ultrasound for paediatric testicular torsion: a systematic review and meta-analysis

BACKGROUND

Previous studies have examined the utility of ultrasonography performed by radiologists for diagnosing paediatric testicular torsion. While point-of-care ultrasound (POCUS) is used in paediatric emergency medicine, its diagnostic accuracy is still unknown.

OBJECTIVES

The present systematic review and meta-analysis aimed to clarify the accuracy of POCUS in diagnosing testicular torsion in children.

METHODS

Following the Preferred Reporting Items for Systematic Review and Meta-analysis of Diagnostic Test Accuracy guidelines, a systematic review was performed using the indices of MEDLINE, EMBASE plus EMBASE classics, PubMed and the Cochrane database from inception to November 2020. Any study investigating the diagnostic accuracy of POCUS for paediatric testicular torsion was extracted. The primary outcome was the assessment of the diagnostic accuracy of POCUS for paediatric testicular torsion. The pooled sensitivity and specificity were calculated. Quality analysis was conducted using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2).

RESULTS

Four studies enrolling 784 patients in total were included. The pooled sensitivity, specificity, and positive and negative likelihood ratios of POCUS were 98.4% (95% CI: 88.5% to 99.8%), 97.2% (95% CI: 87.2% to 99.4%), 34.7 (95% CI: 7.4 to 164.4) and 0.017 (95% CI: 0.002 to 0.12), respectively. Risk-of-bias assessment using QUADAS-2 revealed that two of the studies had a high risk of bias in patient selection.

CONCLUSION

The present systematic review and meta-analysis showed that POCUS had high sensitivity and specificity for identifying testicular torsion in paediatric patients although the risk of bias was high in the studies analysed.

Recurrent testicular torsion post orchidopexy - an occult emergency: a systematic review

Background

Recurrent Testicular Torsion (RTT) is a rarely reported event after previous testicular torsion (TT) repair. Both conditions have similar signs and symptoms. Various techniques have been attempted to reduce the incidence of retorsion. This review assesses the presentation, diagnosis, risk factors, management and outcomes associated with RTT.

Methods

After PROSPERO Registration (CRD42021258997), a systematic search of PubMed, Google Scholar, Embase, Scopus, Web of Science, Cochrane Database of Systematic Reviews, Global Index Medicus and Cumulative Index to Nursing and Allied Health Literature (CIANHL) was performed using specific search terms. Study metadata including patient demographics, orchidopexy techniques, RTT rates and RTT timing were extracted.

Results

Twenty‐six articles, comprising 12 case series and 14 case reports, with a total of 46 patients were included. Overall, the median (IQR) age of the pooled cohort was 18 (15–26) years, the median (IQR) time to presentation was 6 (3–36) hours from the onset of testicular pain. The most common presenting features were testicular pain (100%), testicular swelling (60.9%) and a high riding testicle (34.8%). The left testicle was most commonly affected (63.0%), RTT was on the ipsilateral side in relation to the primary episode of TT in 52.2% of cases, the median (IQR) interval between torsion and retorsion events was 4 (1.3–10.0) years, non‐absorbable sutures were the most common suture material used during orchidopexy after RTT (88.9%).

Conclusion

RTT is a rare presentation to the Emergency Department. Even with a prior history of TT, RTT should be considered in patients presenting with classic symptoms.

The diagnostic value of ultrasound in pediatric testicular torsion with preserved flow

BACKGROUND

Testicular torsion is the reduction of blood flow to the testis after spermatic cord torsion. For patients, the diagnosis of testicular torsion is controversial and complicated by the fact that ultrasound blood flow signals are not significantly reduced in comparison to the unaffected, healthy, testis, despite persistent symptoms on the affected side. Our study aims to investigate the diagnostic characteristics of high-resolution ultrasonography (US) in pediatric testicular torsion with the preserved flow to increase diagnostic accuracy.

METHODS

Seven pediatric patients aged 49 days to 15 years old, with the preserved blood flow, but surgically diagnosed as testicular torsion, from October 2017 to August 2019, were retrospectively included in the study. The imaging manifestations of high-frequency ultrasonography were evaluated.

RESULTS

All cases had preserved testicular blood flow, but the surgical findings showed various degrees of twist, from 90 to 540 degrees. Preoperative ultrasound showed spermatic cord distortion in all cases, and testicular long axis tilting in four cases (4/7 = 57.1%).

CONCLUSION

In some testicular torsion cases, Color Doppler may show normal or increased blood flow signals in the testis. We should further observe the morphology and position of the testes and epididymides, the echo of the testicular parenchyma, and, especially evaluate the "whirlpool sign" in the spermatic cord, to avoid missing testicular torsion with blood flow signals.

Neonatal testicular torsion

Rotation of the testis around the axis of the spermatic cord results in tissue ischaemia and testicular torsion (TT). TT in the newborn infant in the 1st month of life is referred to as neonatal TT (NTT) or perinatal TT and occurs in 6.1/100, 000 live births. The true incidence could be higher as some of these occur prenatally and can be asymptomatic. TT can be extravaginal, intravaginal and mesorchial and NTT is usually extravaginal. Physical examination can be adequate for the diagnosis, and utility of ultrasound (US) is mainly to exclude other conditions. If the timing of the torsion is prenatal, the testicle may not be salvageable. But, in certain situations, these could be asymptomatic bilateral TT. When the timing of torsion is not simultaneous (asynchronous torsion) early contralateral orchiopexy done at the time of exploration would prevent the occurence of asynchronous torsion. Non.operative maneuvres to detorse in NTT are not successful and not recommended. This review focuses on the diagnostic approach and management.

The limits of diagnosis of testicular torsion in the child: Medicolegal implications in clinical practice

Testicular torsion is a pediatric urological emergency. We report a case of testicular torsion that occurred in a 10-year-old child. The case shows that it is a disease with risk of medicolegal litigation. We demonstrate the role of proper triage, and we analyze the limits and critical points for diagnosing it.

Microvascular imaging ultrasound (MicroV) and power Doppler vascularization analysis in a pediatric population with early scrotal pain onset

INTRODUCTION

The power Doppler is a useful tool in the evaluation of pediatric acute scrotal pain. Nonetheless, it may have some inherent limitations in scrotal vascularization analysis, potentially causing unnecessary surgery. The microvascular imaging ultrasound (MicroV) is an innovative Doppler technique able to improve the detection of very low flow. This retrospective study aims to compare both power Doppler and MicroV in the evaluation of a pediatric population with early-stage scrotal pain onset, first in testis vascularization analysis, and second in their diagnostic performances.

MATERIALS AND METHODS

69 patients met the following inclusion criteria, age < 18-year-old, a clinical diagnosis of acute scrotal disease, pain onset ≤ 6 h, ultrasound examination (including B-mode, power Doppler, and MicroV), 3-months follow-up. For both power Doppler and MicroV, through a defined vascularization scale, it was evaluated the agreement in vascularization detection, and the sensitivity and specificity in US diagnostic abilities.

RESULTS

Retrospective diagnoses were of 8 testicular torsion, 15 orchi-epididymitis, and 46 children with other scrotal conditions. Power Doppler provided inconclusive US evaluation in 37.68% of the cases, while MicroV only in the 1.45% (p < 0.0001). Testicular torsion and orchi-epididymitis were identified, respectively, with MicroV in 100% (sensitivity, specificity, PPV, NPV, and accuracy of 100%) and 80% of patients (80% sensitivity, 100% specificity and PPV, 94.73% NPV, 95.65% accuracy); with power Doppler the identification was, respectively, of 87.5% (87.5% sensitivity, 100% specificity and PPV, 98.38% NPV and accuracy) and of 73.3% (73.33% sensitivity, 98.14% specificity, 91.66% PPV, 92.98% NPV, 92.75% accuracy).

CONCLUSIONS

Our findings indicate that MicroV is a reliable technique in vascularization detection of pediatric testes, being able also to detect vascularization in healthy testicles with no-flow at power Doppler examination. Moreover, MicroV could be a valuable ally in the US diagnostic of children with early-stage scrotal pain onset.

Testicular Torsion in Monorchism Diagnosed with Point-of-care Ultrasound: A Case Report

Introduction

Emergency department physicians should incorporate point-of-care-ultrasound (POCUS) in the assessment of patients presenting with acute scrotal pain for rapid identification of the time sensitive urologic emergency, testicular torsion.

Case Report

A 20-year-old otherwise healthy male, with a history of monorchism, presented to the emergency department with vague testicular pain. A POCUS was performed, which demonstrated attenuated arterial flow of the patient’s single testicle as well as twisting (“whirlpool sign”) of the spermatic cord, both highly specific ultrasonographic findings of testicular torsion.

Conclusion

These findings expedited definitive management resulting in the salvage of the single ischemic testicle.

A systematic review on the utility of ultrasonography in the diagnosis of testicular torsion in acute scrotum patients

INTRODUCTION

Ultrasound is a valuable tool in establishing the cause of acute scrotum pain. However, its role in testicular torsion (TT) detection remains controversial. This review aims integrate pre-existing data to assess the value of B-mode and colour Doppler ultrasound (CDS) features combined in the detection of TT in acute scrotum pain patients of all ages.

METHODS

A search through electronic databases, grey literature and hand searching using specific search terms was conducted to identify relevant literature. Search results were subjected to a three-step selection process to ensure the inclusion criteria of this review were met. Statistical data pertaining to the accuracy, sensitivity, and specificity of the B-mode, CDS and combined B-mode CDS features were extracted. These results subsequently underwent a narrative analysis.

RESULTS

Five studies met the inclusion criteria. A variety of B-mode features were identified. Most studies showed that reliance on CDS alone can be prone to false-negative results. The combination of B-mode and CDS features were found to increase the overall sensitivity of ultrasound towards TT (up to 100% in 3 studies). All studies recommended correlation with clinical examination findings. Several limitations in methodology of the included studies were noted: small sample populations and lack of information on the experience of ultrasound practitioners. This highlighted the need for a primary study with a larger sample population to validate the findings of this review.

CONCLUSION

The combination of B-mode and CDS ultrasound is a useful and reliable triage tool in the detection of TT, particularly in equivocal or low suspicion cases but its findings should always be adjunct with clinical examination. Nevertheless, it is noted that appropriate service level agreements, pathways, and training are key factors in ensuring effectiveness of the process.

IMPLICATIONS FOR PRACTICE

Dedicated training and appropriate departmental protocol are key in ensuring accurate diagnosis across all levels of practice.

Establishment and internal validation of preoperative nomograms for predicting the possibility of testicular salvage in patients with testicular torsion

This study aimed to establish nomograms to preoperatively predict the possibility of testicular salvage (TS) in patients with testicular torsion. The clinical data of 204 patients with testicular torsion diagnosed at Xijing Hospital and Tangdu Hospital (Xi'an, China) between August 2008 and November 2019 were retrospectively analyzed. Univariate and multivariate logistic regression analyses were used to determine the independent predictors of TS. Based on multivariate regression coefficients, nomograms to predict possibility of TS were established. The predictive ability of the nomograms was internally validated by receiver operating characteristic (ROC) curves and calibration plots. The duration of symptoms ranged from 2 h to 1 month, with a median of 3.5 days. Thirty (14.7%) patients underwent surgical reduction and contralateral orchiopexy, while the remaining 174 (85.3%) underwent orchiectomy and contralateral orchiopexy. Finally, long symptom duration was an independent risk predictor for TS, while visible intratesticular blood flow and homogeneous testicular echotexture under color Doppler ultrasound were independent protective predictors. Internal validation showed that the nomograms, which were established by integrating these three predictive factors, had good discrimination ability in predicting the possibility of TS (areas under the ROC curves were 0.851 and 0.828, respectively). The calibration plots showed good agreement between the nomogram-predicted possibility of TS and the actual situation. In conclusion, this brief preoperative prediction tool will help clinicians to quickly determine the urgency of surgical exploration.

Perinatal testicular torsion

Testicular torsion (TT) occurs when the testis rotates around the axis of the spermatic cord attachments and prevents blood flow to the testis, resulting in tissue ischemia. If this occurs in the first month of life it is referred to as "perinatal TT" (PTT) or "neonatal TT" (NTT). PTT has an incidence of 6.1 per 100,000 live births. Some of these cases occur prenatally. It can be missed on the initial newborn examination, as it can be asymptomatic. Hence, the true incidence is much higher since it is underdiagnosed. The types of TT include extravaginal, intravaginal, and mesorchial. Most cases of PTT are extravaginal. The diagnosis can generally be made on physical examination. Ultrasonography (US) can help exclude other rare diagnoses as long as surgical intervention is not delayed. There has been some debate regarding the timing of surgery. Although the torsed testicle may not be salvageable, the likelihood of asymptomatic bilateral TT has to be borne in mind and contralateral orchiopexy done at the time of exploration would prevent an asynchronous torsion. Nonoperative maneuvers to detorse in PTT are not recommended. The evaluation, diagnostic approach, and management of this relatively rare condition are described.

Consideration of Testicular Torsion in Young Males With Abdominal Pain Is Essential: A Case Review

Testicular torsion is a surgical emergency and requires prompt recognition and treatment. Health care personnel often forget this differential diagnosis in males who present with abdominal pain as their only complaint. There is a 4- to 6-hour window from the onset of symptoms to the surgical intervention to salvage the testes. It is imperative for health care personnel to consider testicular torsion in any male presenting with abdominal pain and to complete a genitourinary examination. The purpose of this case review is to highlight the importance of a genitourinary examination in recognizing testicular torsion.

Testicular Torsion in the Emergency Room: A Review of Detection and Management Strategies

Testicular torsion is a challenging and time-sensitive diagnosis that is encountered frequently in daily practice, especially in the emergency room. A thorough history, the presence of a painful and swollen testis and testicular ultrasonography plays a vital role in the prompt diagnosis of testicular torsion. Prompt diagnosis is essential to prevent complications of testicular torsion which include testicular infarction, necrosis, and sub/infertility. This can be challenging as there are various other conditions that may mimic the presentation of testicular torsion. Since testicular torsion is an extremely time-sensitive diagnosis, it may also be a subject of many medicolegal challenges. This review article serves as a guide for clinicians involved with the diagnosis and management of testicular torsion. We review and discuss detection and management strategies based on their validity, statistical significance, and effectiveness in enabling prompt diagnosis and management of testicular torsion. Medicolegal implications of testicular torsion are also highlighted.

Characteristics and management of testicular torsion in patients admitted to the Urology Department at Chris Hani Baragwanath Academic Hospital

Background

The study was carried out to determine the trend of referrals with testicular torsion; the pre-surgery duration of symptoms; the rate of orchidectomy; as well as the seasonality and the age-related laterality of testicular torsion.

Methods

This was a retrospective study conducted at Chris Hani Baragwanath Academic Hospital using patients’ records from 2006 to 2018 from which data were obtained and analyzed.

Results

A total of 308 patients with testicular torsion were included in this study; the mean age was 17.2 ± 4.12 (10–33) years. The median (IQR) time from onset to hospital was 47 h, and 194/308 (63%) underwent orchidectomy. Although the orchidectomy rate was higher (95%) in those who had surgery beyond 72 h, 3.6% had reperfusion after detorsion in theater followed by orchidopexy. In the 112 patients who underwent a bilateral orchidopexy, the time from onset of symptoms to surgery was significantly shorter at a median (IQR) of 13 (9–26) h, compared to 144 (40–264) h in the 194 patients who had an orchidectomy (p < 0.0001). The odds of presenting with a right -sided testicular torsion increases by 6% (p = 0.047) for every 1-year increase in age.

Conclusion

This study shows that there is a significant association between the pre-surgery duration of symptoms and the testicular salvage rate. Testicular salvage is possible beyond 72 h from the onset of symptoms, although the salvage rate reduces from 75% within 24 h to 3.6% beyond 72 h. In addition, it also shows that older patients tend to present with right-sided torsion.

Acute scrotal pain in pediatric patients: diagnosis with an innovative Doppler technique (MicroV)

Acute scrotal pain is one of the most frequent symptoms in pediatric patients visited in the Emergency Department. Ultrasonography with color and power Doppler represents the first-line method that clinicians use to carry out the differential diagnosis between spermatic cord torsion and inflammation, but sensitivity and specificity are 63-100% and 97-100%, respectively; this variability may be related to operator's experience and testis vascular hemodynamics and also to machine performance and patient age. Recent technological innovations have made possible to create a new Doppler mode called ultrasound microvascular imaging. This technique exploits algorithms capable of separating low frequencies of static tissue artifacts from ones of very weak flows. It is known as MicroV (from Esaote) and Superb microvascular imaging (from Toshiba). It provides both macrocirculation vascular maps, as a typical Doppler feature, and microcirculation vascular maps. Furthermore, the use of background subtraction could improve the visibility of small vascular structures. We report a case of a pediatric patient suffering from acute scrotal pain assessed ultrasonographically with this innovative Doppler technique (MicroV) that may give more confidence in detecting testicular vascular signals if compared with traditional Doppler techniques.

Near-infrared spectroscopy in the diagnosis of testicular torsion: valuable modality or waste of valuable time? A systematic review

BACKGROUND

Testicular torsion (TT) is a urological emergency that affects one in 4000 males younger than 25 years. Delays in the management of TT may result in testicular ischaemia, testicular necrosis, orchidectomy and infertility. This review assesses the validity of near-infrared spectroscopy (NIRS) as a diagnostic tool in the assessment and diagnosis of TT.

METHODS

A systematic search of Cochrane Database of Systematic Reviews, EMBASE, Google Scholar, PubMed, Scopus and Web of Science databases was performed in January 2019 using specific search terms. Selected studies were ranked and evaluated using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Quality Assessment of Diagnostic Accuracy Studies-2 tool.

RESULTS

A total of nine studies that included 253 subjects (88 animals and 165 humans) with a mean sample size of 28.1 (standard deviation 40.8) subjects were included. The mean difference in testicular tissue oxygen saturation between torsed and non-torsed testes (Δ%StO₂ ) were 45%, 42% (±5%), 26% and 5-18% in four animal studies and 2.0%, 3.0%, 6.7%, 6.8% and 23.0% in five human studies. The tissue oxygen saturation difference between contralateral healthy testes (controls) ranged from 1% to 10% in the five studies that alluded to this.

CONCLUSION

The current body of evidence does not support the use of NIRS in the work-up of TT. Well-designed clinical trials with large patient samples are required to determine whether NIRS may have some future role as a diagnostic modality in TT.

Frontiers in pediatric testicular torsion: An integrated review of prevailing trends and management outcomes

Testicular torsion remains the most frequent cause of testicular ischemia, especially in adolescents and young adults. Timely diagnosis and intervention are keys to saving the affected testicle. This review presents current trends in the diagnosis and treatment of torsion, potential pitfalls and consequent outcomes. Additionally, other salient issues surrounding testicular torsion are also discussed, including: pathogenesis of injury, legal ramifications, fertility outcomes, novel management techniques, and recent advances in diagnostic technology.