Testicular torsion: orchiectomy or orchiopexy?

New insights about prognosis of Spermatic Cord Torsion

Spermatic Cord Torsion (SCT) is a serious surgical emergency. Prospective studies regarding the prognosis of the torsed testis lack in the global literature. Prompt diagnosis and treatment are crucial to increase the risk of saving the torsed testis. Testicular salvage can be predicted by the duration of symptoms, along with the degree of twisting and the ultrasound findings, regarding the homogeneity of the testicular parenchyma. The "golden window" to salvage the testicular function is suggested to be at 4-8 h, after the symptoms' onset. As the time passes, the ischemia is settled and the risk of necrosis is increased. It is generally accepted, that the possibilities of conducting orchiectomy are increased when not promptly intervening after the symptoms' onset. A few studies, tried to describe the impact of SCT on long- term fertility. The aim of this study is to collect them and elucidate with some general perceptions on this topic.

Testicular torsion and subsequent testicular function in young men from the general population

STUDY QUESTION

Is prior testicular torsion associated with testicular function (semen quality and reproductive hormones) in young men from the general population?

SUMMARY ANSWER

In young men from the general population, no differences in semen parameters were observed in those who had experienced testicular torsion compared to controls and observations of higher FSH and lower inhibin B were subtle.

WHAT IS KNOWN ALREADY

Testicular function may be impaired after testicular torsion, but knowledge is sparse and based on studies with small sample sizes and no control group or a less than ideal control group.

STUDY DESIGN, SIZE, DURATION

A cross-sectional population-based study was carried out including 7876 young Danish men with unknown fertility potential, examined from 1996 to 2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All men (median age 19.0 years) had a physical examination, provided a blood and semen sample, and filled in a questionnaire including information about prior testicular torsion, birth, lifestyle and current and previous diseases. Markers of testicular function, including testis volume, semen parameters and reproductive hormones, were compared between men operated for testicular torsion and controls, using multiple linear regression analyses.

MAIN RESULTS AND THE ROLE OF CHANCE

The average participation rate was 24% for the entire study period. In total, 57 men (0.72%) were previously operated for testicular torsion (median age at surgery 13.4 years) of which five had only one remaining testicle. Men with prior testicular torsion were more often born preterm (25% versus 9.5% among controls), and they had significantly higher FSH and lower inhibin B levels, and a lower inhibin B/FSH ratio than controls in crude and adjusted models. The association was mainly driven by the subgroup of men who had undergone unilateral orchiectomy. No differences in semen parameters were observed.

LIMITATIONS, REASONS FOR CAUTION

A limitation is the retrospective self-reported information on testicular torsion. Also, results should be interpreted with caution owing to the high uncertainty of the observed differences.

WIDER IMPLICATIONS OF THE FINDINGS

Overall, the results of our study are reassuring for men who have experienced testicular torsion, especially when treated with orchiopexy, for whom reproductive hormone alterations were subtle and without obvious clinical relevance. Our study found no differences in semen parameters, but follow-up studies are needed to assess any long-term consequences for fertility.

STUDY FUNDING/COMPETING INTEREST(S)

Financial support was received from the Danish Ministry of Health; the Danish Environmental Protection Agency; the Research fund of Rigshospitalet, Copenhagen University Hospital; the European Union (Contract numbers BMH4-CT96-0314, QLK4-CT-1999-01422, QLK4-CT-2002-00603, FP7/2007-2013, DEER Grant agreement no. 212844); A.P. Møller and wife Chastine Mckinney Møllers Foundation; Svend Andersens Foundation; the Research Fund of the Capital Region of Denmark; and ReproUnion (EU/Interreg). The authors have nothing to declare.

TRIAL REGISTRATION NUMBER

N/A.

Testicular salvage: using machine learning algorithm to develop a predictive model in testicular torsion

PURPOSE

To compare the models developed with a classical statistics method and a machine learning model to predict the possibility of orchiectomy using preoperative parameters in patients who were admitted with testicular torsion.

MATERIALS AND METHODS

Patients who underwent scrotal exploration due to testicular torsion between the years 2000 and 2020 were retrospectively reviewed. Demographic data, features of admission time, and other preoperative clinical findings were recorded. Cox Regression Analysis as a classical statistics method and Random Forest as a Machine Learning algorithm was used to create a prediction model.

RESULTS

Among patients, 215 (71.6%) were performed orchidopexy and 85 (28.3%) were performed orchiectomy. The multivariate analysis revealed that monocyte count, symptom duration, and the number of previous Doppler ultrasonography were predictive of orchiectomy. Classical Cox regression analysis had an area under the curve (AUC) 0.937 with a sensitivity and specificity of 88 and 87%. The AUC for the Random Forest model was 0.95 with a sensitivity and specificity of 92 and 89%.

CONCLUSION

The ML model outperformed the conventional statistical regression model in the prediction of orchiectomy. The ML methods are cheap, and their powers increase with increasing data input; we believe that their clinical use will increase over time.

Effect of testosterone replacement therapy and mate tea (Ilex paraguariensis) on biochemical, functional and redox parameters of saliva in orchiectomized rats

OBJECTIVE

Evaluate the effects of testosterone replacement therapy (TRT) and mate tea (MT) [Ilex paraguariensis] on biochemical, functional, and redox parameters of saliva in orchiectomized rats (ORX) DESIGN: Sixty young adult male Wistar rats (3 months old) were either castrated bilaterally or underwent fictitious surgery (SHAM) and were distributed into 5 groups: SHAM, ORX, TU (castrated rats that received a single intramuscular injection of testosterone undecanoate 100 mg/kg), MT (castrated rats that received MT 20 mg/kg, via intragastric gavage, daily), and TU + MT. All treatments started 4 weeks after castration (4 months old) and lasted 4 weeks (5 months old). At the end of treatment, pilocarpine-induced salivary secretion was collected to analyze salivary flow rate (SFR) and biochemistry composition through determination of total protein (TP), amylase (AMY), electrolyte, and biomarkers of oxidative stress.

RESULTS

ORX increased SFR, salivary buffering capacity, calcium, phosphate, chloride, total antioxidant capacity, thiobarbituric acid reactive substances (TBARs), and carbonyl protein, reduced TP and AMY activity, and did not change pH, sodium, and potassium compared to SHAM. TU and TU+MT restored all salivary parameters to values of SHAM, while only TBARs and AMY returned to SHAM levels in the MT group.

CONCLUSIONS

TRT with long-acting TU restored the biochemical, functional, and redox parameters of saliva in orchiectomized rats. Although MT did not have a TRT-like effect on salivary gland function, the more effective reduction in lipid oxidative damage in the MT and TU + MT groups could be considered as adjuvant to alleviate the salivary oxidative stress induced by orchiectomy.

Effect of Pediatric Testicular Torsion on Testicular Function in the Short Term

PURPOSE

To evaluate short-term testicular outcome after torsion in children.

METHODS

Fifty-four children and adolescents were evaluated after 6 months of the operation for testicular torsion. Testicular volume was measured and circulating Inhibin B, FSH, LH and testosterone levels were checked.

RESULTS

Delay from the onset of symptoms to surgery was shorter in the orchidopexy group (n = 47), than in the orchiectomy group (n = 7, p = 0.001). In the orchidopexy group, the median volume of the affected testis was 83% (IQR 43-104) of the contralateral testis (p = 0.002). The plasma hormone levels in orchidopexy and orchiectomy groups were: 148 ng/l (IQR 108-208) vs. 129 ng/l (IQR, 123-138, p = 0.269) for Inhibin B; 4.5 IU/L (IQR2.6-6.9) vs. 11.7 IU/L (IQR 4.3-12.8, p = 0.037) for FSH; 2.9 IU/L (IQR 1.3-3.7) vs. 4.8 (IQR 3.0-5.6, p = 0.066) for LH; and 13.6 nM (IQR 6.5-18.0) vs. 14.5 nM (IQR 6.7-15.9, p = 0.834) for testosterone. The association between FSH, LH as well as testosterone levels was most clear with the volume of the contralateral testis (Rho = 0.574, p < 0.001, Rho = 0.621, p = 0.001 and Rho 0.718, p < 0.001 respectively).

CONCLUSIONS

Testicular function is mainly dependent on the volume of contralateral testicle after testicular torsion. However, testis preserving surgery tends to maintain better function than orchiectomy.

TYPE OF STUDY

Retrospective review.

LEVEL OF EVIDENCE

III.

Going, gonad, gone. Gender inequalities in the management of gonadal torsion: a cohort study

Gonadal torsion (when the gonad twists on its ligamentous supports) is a surgical emergency in both men and women. Prompt management is essential to preserve gonadal function. Our aim was to compare the timeliness with which men and women who underwent surgery for suspected gonadal torsion are managed. All adult patients who underwent surgery for suspected gonadal torsion between 1/4/16 and 31/3/18 were reviewed and the following times recorded: symptom onset; hospital presentation; gynaecological/surgical review; decision for theatre; and knife-to-skin (KTS). The surgical procedure(s) and intra-operative findings were also documented. In total, 31 women (mean age 29.4 ± 7.1yrs) and 49 men (mean age 23.2 ± 7.0yrs) were identified. Women waited significantly longer than men at every stage (p < 0.01). Time intervals between hospital presentation and review, review and decision for theatre, and decision and KTS were 1.6 (1.2-2.6 hrs), 0.3 (0.0-0.9 hrs) and 1.7 (1.5-2.5 hrs) for men and 4.3 (3.1-15.3 hrs), 10.3 hrs (2.4-20.7 hrs) and 4.7 (2.3-9.3 hrs) for women, respectively. Torsion was confirmed in 20 (64.5%) women and 25 (51.0%) men. Intraoperatively, 13(65%) ovaries were reportedly necrotic compared to only 6 (24%) testes (p = 0.0076). All necrotic gonads were removed despite conservative surgery being recommended practice during the study period. Women with suspected gonadal torsion received suboptimal care compared to their male counterparts, which has potentially catastrophic consequences for the subsequent fertility of this predominantly young population.

Effect of unilateral testicular torsion on contralateral testis in a rat model

OBJECTIVE

The aim of this study was to investigate the function of the contralateral testis after unilateral testicular torsion (UTT) and its possible mechanism.

METHODS

56 rats were randomly divided into four groups: Group A: Sham operation, Group B: Testicular torsion (TT)+normal saline (NS), Group C: Testicular torsion (TT)+cyclosporine, Group D: Testicular torsion (TT)+NG-Monomethyl-L-arginine (L-NMMA). The right testes were removed 1 week and 8 weeks after surgery, respectively. Biochemistry and histopathologic evaluations were used to evaluate the germ cell damage.

RESULTS

Compared with Group A, the levels of malondialchehyche (MDA) and nitric oxide (NO)/nitricoxide synthase (NOS) were increased remarkably in Group B. Significant differences were shown between histopathological damages and density and motility of sperm in two groups. Compared with Group B, the levels of MDA and NO/NOS in Group D decreased significantly while mean seminiferous tubule diameter (MSTD) and mean testicular biopsy scoring (MTBS) maintained in a better condition. The levels of major histocompatibility complex (MHC) peptide-tetramer complex in Group C and Group D decreased significantly than Group B, while sperm density and motility were significantly higher than Group B. It was also known that the histopathological damages in Group C and Group D were less than those in Group B in the 8 weeks after operation.

CONCLUSION

UTT can cause impairment of contralateral testicular function and decrease of spermatogenic function. The mechanism may be related to ischemia-reperfusion (IR) in early stage and autoimmune response in late stage.

Estimating the time of onset of testicular torsion using ultrasonography in an experimental rat model

Purpose

We aimed to document the time of onset of ultrasonographic and histologic changes in the testes of a rat model following testicular torsion.

Methods

Twenty-five Sprague-Dawley rats were divided into four groups. All animals underwent preoperative Doppler ultrasonography. Groups 1, 2, and 3 underwent unilateral surgical torsion of the testis lasting for 72, 24, and 6 hours, respectively. Group 4 underwent a sham operation. The animals were followed with Doppler ultrasonography at 6, 24, 48, and 72 hours postoperatively. Histologic examinations were performed at the designated final time point for each group.

Results

After torsion, enlargement of the epididymal head and thickening of the spermatic cord over time were noted. Based on the ultrasonographic dimensions, the ratio of the epididymal volume increased with time following torsion (p=0.002). The torsed testes had an average weight gain of 0.27 g at 6 hours compared to the control testes, but an average weight loss of 0.22 g at 72 hours (P=0.006). Changes in testicular echotexture were noted as soon as 6 hours after torsion, but there was no consistent pattern of echotexture change thereafter. Histologically, viable tubules were seen 6 hours after torsion, while extensive hemorrhagic necrosis was found at 72 hours.

Conclusion

In evaluating testicular torsion, the enlargement ratio of the epididymis and thickening of the spermatic cord on Doppler ultrasonography may be useful for determining the urgency of immediate surgery. Changes in testicular echotexture may not be a reliable indicator of the time of onset.

Paternity, erectile function, and health-related quality of life in patients operated for pediatric testicular torsion

INTRODUCTION

Spermatic cord torsion (SCT) may lead to organ loss and can potentially influence fertility. Long-term effects of SCT are not fully investigated.

OBJECTIVE

The purpose was to evaluate paternity rates in adults who have had SCT in childhood and to compare the results to those of a control population. The secondary purposes were to compare paternity rates after testis-preserving surgery with those after orchiectomy and to evaluate erectile function and health-related quality of life (HRQoL).

STUDY DESIGN

Questionnaires concerning paternity, erectile function (International Index of Erectile Function [IIEF]-5 questionnaire), and HRQoL (15D questionnaire) were mailed to 74 men who had been treated for SCT and to 92 controls treated for testicular appendage torsion in 1977-1995 and who were currently older than 30 years.

RESULTS

Thirty-five of the 74 (47%) patients with SCT and 58 of the 92 (63%) controls responded. A same-aged control was selected for each patient with SCT. The median age at investigation was 41 (interquatile range [IQR]: 36 to 46) years in the SCT group and 41 (IQR: 38 to 46) years in the control group (p = 0.81). The paternity rate was 23 of 35 (66%) in the SCT group and 26 of 34 (76%) in the control group (p = 0.43). Nine percent of patients and controls suffered from infertility. Of the 30- to 50-year-old patients with SCT, 9 of 16 (56%) had children after orchiectomy, and 13 of 16 (81%), after detorsion (p = 0.25). Significant or moderate erectile dysfunction (IIEF-5 total score <12) was observed in 3 of 32 (9%) patients and in 1 of 35 (3%) controls (p = 0.34). Erectile dysfunction was similarly rare in both the orchidopexy and orchiectomy group. Total HRQoL scores were similar in the SCT and control groups (p = 0.69) as well as in patients with orchidopexy and orchiectomy (p = 0.50).

DISCUSSION

Paternity, erectile function, or HRQoL was not impaired in the general level in the patients with SCT in comparison with controls. Both the modes of treatment, orchiectomy or detorsion, had no significant impact on the results. However, the results cannot be generalized to the individual level. The limitations were a small sample size and inability to investigate maternal factors to the paternity. However, the results are encouraging for the patients and families.

CONCLUSION

Paternity rate and HRQoL were similar in patients with SCT and controls. The type of surgery (orchiectomy vs. detorsion) did not affect paternity rates statistically. Moderate or significant erectile dysfunction was rare in both groups.

A systematic review and meta-analysis revealing realistic outcomes following paediatric torsion of testes

INTRODUCTION

Reported testicular loss rates following paediatric testicular torsion often reflect the surgical decision-making process, rather than long-term survival of the testes.

OBJECTIVES

We aim to perform systematic analysis and meta-analysis to investigate testicular salvage rates and to assess predictors of long-term viability.

STUDY DESIGN

Systematic review according to PRISMA guidelines was performed to investigate immediate and long-term (>12 months) testicular loss rates following torsion in the paediatric population. Literature search and study inclusion were performed by two investigators. A study quality score was derived and attributed to each study. Predictors of testicular loss were described. Proportions meta-analysis was performed with random effects modelling, and testing for heterogeneity.

RESULTS

Twelve studies were includedm, 6 reporting early orchidectomy rates, and 6 reporting long-term outcomes. Study quality was generally low.

DISCUSSION

The mean early testicular loss rate was 39%, whereas meta-analysis revealed late loss to approach 50%. Predictors of outcomes include prehospital symptom duration, location of presentation, transfer to a tertiary centre, social affluence and use of ultrasound prior to diagnosis or transfer.

CONCLUSIONS

This study has shown a considerable late testicular loss rate, which must be relayed to families even after testicular salvage. Delay in time to presentation is consistently found to predict poor outcomes.

Prospective Evaluation of Predictors of Testis Atrophy After Surgery for Testis Torsion in Children

OBJECTIVE

To prospectively correlate pain duration, red scrotal skin, ultrasound appearance of testis, and intraoperative testis color to future testis atrophy after acute testicular torsion.

METHODS

Patients 2 months-18 years old with unilateral acute scrotum were consecutively enrolled in a National Institutes of Health transcutaneous near-infrared spectroscopy study, with a subgroup analysis of the true torsion group. Presence or absence of red scrotal skin, pain duration, testicular heterogeneity on preoperative ultrasound, and intraoperative testis color based on a novel visual chart 5 minutes after detorsion were recorded. All testes underwent orchiopexy regardless of appearance. Percent volume difference between normal and torsed testicles on follow-up ultrasound was compared between patients with and without risk factors.

RESULTS

Thirty of 56 patients who had surgical detorsion underwent scrotal ultrasound at a mean of 117 days after surgery. A color of black or hemorrhagic 5 minutes after detorsion, pain duration >12 hours, and heterogeneous parenchyma on preoperative ultrasound were associated with significant testis volume loss in follow-up compared with normal testis. All patients with a black or hemorrhagic testis had >80% volume loss. Erythematous scrotal skin was not significantly associated with smaller affected testis volume in follow-up.

CONCLUSION

Based on the high atrophy rate, orchiectomy can be considered for testes that are black or hemorrhagic 5 minutes after detorsion. Pain duration >12 hours and parenchymal heterogeneity on preoperative ultrasound were also associated with testis atrophy. Red scrotal skin was not a reliable predictor of atrophy and should not delay exploration.

Perspectives in Pediatric Pathology, Chapter 19. Testicular Torsion, Testicular Appendix Torsion, and Other Forms of Testicular Infarction

Among the most frequent specimens at the pediatric surgical pathology bench, orchiectomy performed after testicular torsion deserves significant attention. Multiple implications, including fertility, legal complications, possibility of occult lesion, and others, need to be considered. Furthermore, torsion of testicular and other appendices represents common urological emergencies frequently encountered in surgical pathology. Here we present a review of testicular torsion and infarction, including theories about their pathogenesis and the appropriate handling by the diagnostic pathologist.

Long-term effects of the testicular torsion on the spermatogenesis of the contralateral testis and the preventive value of the twisted testis orchiepididymectomy

PURPOSE: To determine whether the testicular torsion causes long-term effects on the spermatogenesis of the contralateral testis, and whether the orchiepididymectomy of the twisted testis could prevent them, using specific spermatogenesis parameters to elucidate the conflicting results in the literature. METHODS: Seventy-four pubertal male Wistar rats were randomly selected. The experimental group consisted of 40 rats, divided into four subgroups, submitted to 1.080 degrees counterclockwise left testicular torsion and its scrotal fixation at the beginning of the experiment, and left orchiepididymectomy at one, five, ten and 90 days, respectively. The control group consisted of 24 rats, divided into four sham operation control subgroups. An additional control subgroup consisted of the ten remaining rats, submitted only to the left orchiepididymectomy at the beginning. At 90 days, the contralateral testes of the experimental and control subgroups were collected for the evaluation of their spermatogenesis parameters: testicular weight, seminiferous tubular diameter, Johnsen score and differential counting of the germ cells. RESULTS: No statistically significant differences were observed among the experimental and control subgroups for all of the spermatogenesis parameters of the contralateral testes. CONCLUSIONS: Testicular torsion does not cause long-term effects on the spermatogenesis of the contralateral testis in pubertal rats, and the orchiepididymectomy of the twisted testis is not necessary for preventive purposes for the contralateral spermatogenesis.

Psoralea corylifolia protects against testicular torsion/detorsion-induced ischemia/reperfusion injury

ETHNOPHARMACOLOGICAL RELEVANCE

The pathophysiology of testicular torsion-detorsion is ischemia-reperfusion injury of the testis. In the course of testicular ischemia and reperfusion, overgeneration of reactive oxygen species is a major initiating component of the testicular spermatogenic injury. Reactive oxygen species regulate many genes whose expression affects cell-cycle regulation, cell proliferation, and apoptosis. The transcription factor cAMP-responsive element modulator-τ (CREMτ) plays an essential role in spermatogenesis. Psoralea corylifolia, a medicinal herb with anti-oxidative activity, has been used to treat male reproductive dysfunction in traditional Chinese medicine. In this study, we investigated the effect of Psoralea corylifolia on testicular torsion/detorsion-induced injury.

MATERIALS AND METHODS

Sixty adult male Sprague-Dawley rats were randomly divided into 3 groups, each containing 20 rats. Rats in the control group underwent a sham operation of the left testis. In the torsion-detorsion group, the left testis was rotated 720° for 2h. Rats in the treatment group received the same surgical procedure as the torsion-detorsion group, but Psoralea corylifolia was administered orally. Bilateral orchiectomy was performed on half of the rats in each experimental group at 4h after detorsion for measurement of malondialdehyde which is an indicator of intratesticular reactive oxygen species content. Orchiectomy was performed on the remaining rats at 3 months after detorsion for analysis of testicular CREMτ expression and spermatogenesis.

RESULTS

Unilateral testicular torsion-detorsion caused a significant increase in malondialdehyde level and caused significant decreases in CREMτ expression and spermatogenesis in ipsilateral testes. Psoralea corylifolia treatment significantly decreased malondialdehyde level and significantly increased CREMτ expression and spermatogenesis in ipsilateral testes, compared with torsion-detorsion group.

CONCLUSIONS

These results suggest that Psoralea corylifolia may protect testicular spermatogenesis by enhancing CREMτ expression by scavenging reactive oxygen species.

Threatened fertility and gonadal function after a polytraumatic, life-threatening injury

Trauma literature regarding management of genitalia trauma affecting future fertility and gonadal function in the face of coexisting life-threatening injuries is underdeveloped. We present a unique case that necessitated integrative management of a 24-year-old male who became entangled within the blades of a manure spreader and presented with life-threatening trauma in addition to severe genital trauma, including penile degloving, bilateral testicular avulsion and bilateral spermatic cord laceration. During the initial stabilization and surgical management, urology and plastic surgery were consulted to assess the urogenital injuries. Together, the surgical team orchestrated potentially life-saving interventions while successfully performing both a testicular sperm extraction and a testicular revascularization. Viable sperm was collected on the day of surgery and initial follow-up showed preserved sexual function and adequate perfusion to the testicle. This report presents a case and provides a review discussing the management of traumatic genital injuries and the importance of early involvement of surgical specialties in genitalia trauma to optimize future fertility and gonadal function. The literature search was performed in August 2008 using Medline for articles only in English, including any of the following terms: polytrauma, trauma, penis, testicle, degloving, avulsion, spermatic cord, laceration, fertility, reproduction or revascularization.

Late hormonal function after testicular torsion

INTRODUCTION

Testicular torsion may be an important cause of male infertility. We aimed to investigate the late hormonal function in patients with testicular ischemia/reperfusion injury of the testis after orchidectomy or detorsion.

METHODS

Twenty patients (mean age, 13.6 years) were prospectively evaluated at a mean of 5 years after testicular torsion. The serum follicle-stimulating hormone, luteinizing hormone (before and after gonadotropin-releasing hormone stimulation), testosterone, and inhibin B were measured. Fifteen age-matched adolescents without evidence of endocrine disease were used as controls for inhibin B values. Data are quoted as mean +/- SEM.

RESULTS

Twelve patients were treated with detorsion and orchidopexy, and 8 underwent orchidectomy. Serum follicle-stimulating hormone, luteinizing hormone, and testosterone were all within the reference range. Inhibin B levels were significantly reduced in the 2 groups compared with the controls (34.5 +/- 5.2 vs 63.9 +/- 12.8 pg/mL, P = .02), but were not significantly different between the orchidectomy group and the group that underwent detorsion (41.3 +/- 9.7 vs 30.4 +/- 5.9 pg/mL, P = .41).

CONCLUSION

Hormonal testicular function can be compromised after testicular torsion, although the type of surgery (orchidectomy or orchidopexy) does not seem to change the effect of this ischemia/reperfusion injury.