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Buch Kjeldgaard A, Kinder-Klausen MS, Nerstrøm M, Cohen J, Henriksen BM, Thorup JM. The impact of ultrasound on testicular loss in cases of testicular torsion in children. Pediatr Surg Int 2024; 40:83. [PMID: 38507099 PMCID: PMC10954916 DOI: 10.1007/s00383-024-05663-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/22/2024]
Abstract
PURPOSE Ultrasound as a diagnostic tool in suspicion of testicular torsion is still highly debated. In this investigation, we aimed to evaluate whether time spent on scrotal ultrasonography had a negative impact on testicular loss. METHODS Patients' records containing a scrotal ultrasound and/or surgical procedure codes for testicular interventions on suspicion of testicular torsion were examined. Patients aged 0-15 years admitted during 2015-2019 at Copenhagen University Hospital, Rigshospitalet were included. RESULTS In total, 1566 patients underwent an ultrasound and 142 of these proceeded to surgery while 13 patients proceeded directly to surgery without an ultrasound. The rate of testicular loss with a preceding ultrasound was 23% versus 42% without (p = 0.18). Four cases of testicular torsion were misdiagnosed by ultrasound resulting in a sensitivity of 95.4% and specificity of 95.6%. The mean diagnostic delay from ultrasound examination was 55 ± 39 min, and the mean time from ultrasound to surgery was at 169 ± 76 min versus 171 ± 72 min without ultrasound. CONCLUSION In a clinical setting, ultrasound provided a reliable tool for the diagnosis of testicular torsion and did not seem to increase the orchiectomy rate.
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Affiliation(s)
- Anastasia Buch Kjeldgaard
- Department of Pediatric Surgery, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Laboratory of Tissue Engineering, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | | | - Malene Nerstrøm
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jonathan Cohen
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Birthe Merete Henriksen
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jørgen Mogens Thorup
- Department of Pediatric Surgery, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Yen CW, Chang YJ, Ming YC, Gau CC, Wu CT, Lee J. Factors Determining Testicular Torsion and Consequent Orchiectomy in Pediatric Patients Presenting With Scrotal Pain. Pediatr Emerg Care 2023; 39:744-750. [PMID: 37624776 PMCID: PMC10547102 DOI: 10.1097/pec.0000000000003037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Abstract
OBJECTIVE Factors associated with testicular torsion (TT) and consequent orchiectomy in patients presenting to pediatric emergency departments (PEDs) with scrotal pain (SP) are not well described. We report the factors predicting TT and consequent orchiectomy in children with SP. METHODS The data on patients (aged ≤18 years) who presented with SP to PEDs at 4 branches of the Chang Gung Hospital through 10 years were analyzed. RESULTS In all, 256 pediatric patients presented with SP. Their mean age was 11.60 ± 4.61 years and 72.7% (n = 186) were aged 10 to 18 years. The pain was left-sided in 54.7% (n = 140) and the interval between SP onset and PED arrival was 22.45 ± 31.27 hours. Overall, 84 (32.8%) patients needed surgery and 72 (28.1%) had TT. Of the patients with TT, 28 (38.9%) patients needed an orchiectomy. After analysis, TT and consequent orchiectomy were associated with a longer interval between SP onset and PED arrival, absent of testicular ultrasonic blood flow, interval between SP onset and surgery of more than 24 hours, and a high degree of TT. None of them experienced recurrent SP symptoms or TT again. CONCLUSIONS The rate of TT in patients presenting to PEDs with an SP was 28.1%, and 38.9% of the patients with TT needed an orchiectomy. Early diagnosis and intervention helped to prevent subsequent orchiectomy in pediatric patients with TT.
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Affiliation(s)
- Chen-Wei Yen
- From the Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yi-Jung Chang
- Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yung-Ching Ming
- Division of Pediatric Surgery, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chun-Chun Gau
- Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan
| | - Chang-Teng Wu
- From the Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jung Lee
- From the Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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Cabo J, Graham K, Chen H, Zhao S, Burger C, Arnold D, Taylor A, Pope J, Clayton D, Brock JW, Adams M, Adams C, Thomas J. Increasing utilization of the TWIST score in workup of patients with acute scrotal pain: Role in diagnosis and risk stratification. J Pediatr Urol 2022; 18:845.e1-845.e8. [PMID: 36244901 DOI: 10.1016/j.jpurol.2022.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 08/25/2022] [Accepted: 09/20/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The TWIST score is a 5-component physical examination score used to aid in diagnosis of testicular torsion (TT) and could lessen need for radiologic testing in certain clinical scenarios. OBJECTIVE TWIST use was not previously widespread at our institution. The primary objective of this quality improvement study was to achieve 100% compliance in TWIST utilization among urology and ED residents and to assess for score concordance between ED and urology assessments. Secondary goals were correlation of TWIST components with need for orchiectomy. METHODS ED staff were educated about the TWIST score and asked to complete assessment for patients presenting with acute scrotal pain. Simultaneously, an electronic medical record-based dot phrase was introduced for urology trainees to complete an independent TWIST evaluation. Spearman correlation was performed to assess association between ED and Urology TWIST scores. Multivariable logistic regression was performed to assess association of TWIST score components and need for orchiectomy. RESULTS 103 patients presented to the ED from 3/2018-11/2020 with a complaint of acute scrotal pain; 47 were diagnosed with torsion. As compared to our retrospective cohort, the documentation rate of complete TWIST score components on exam rose from 9% to 98% (P < 0.001) on ED evaluation and 16%-66% on urology evaluation (P < 0.001). Rates of repeat ultrasound for patient's transferred between facilities was similar (58% vs. 63%; p = 0.66) as was median time to OR (160 min vs. 145 min; p = 0.5). Using TWIST cutoff of >5 yielded a specificity of 94.5% for diagnosis of torsion, with corresponding strong correlation between ED and urology scores (rho = 0.71). A firm testicle was noted on urology evaluation in 100% of orchiectomy patients (vs. 61% of salvage patients) with persistent association after controlling for duration of symptoms (OR 28.1; P = 0.016). DISCUSSION Through two-pronged quality improvement efforts, we significantly improved utilization of the TWIST score by ED and urology staff for workup of patients with acute testicular pain. We confirmed the high sensitivity and specificity of the TWIST score and demonstrated inter-rater reliability between ED and urology assessments. On prospective analysis, testicular firmness on exam was predictive of need for orchiectomy. CONCLUSION The TWIST score is an accurate diagnostic tool for both ED and urology providers in workup of children with acute scrotal pain, with a normal score essentially ruling out the condition. Future work should aim at minimizing unnecessary testing in patients demonstrated to be at high risk for torsion.
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Affiliation(s)
- Jackson Cabo
- Department of Urology, Vanderbilt University Medical Center, 1301 Medical Center Dr Suite 3823, Nashville, TN 37232, USA.
| | - Kyle Graham
- Surgical Outcomes Center for Kids-Monroe Carrell Jr Children's Hospital, Department of Biostatistics, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN 37232, USA
| | - Heidi Chen
- Surgical Outcomes Center for Kids-Monroe Carrell Jr Children's Hospital, Department of Biostatistics, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN 37232, USA
| | - Shilin Zhao
- Surgical Outcomes Center for Kids-Monroe Carrell Jr Children's Hospital, Department of Biostatistics, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN 37232, USA
| | - Catherine Burger
- Department of Emergency Medicine, Vanderbilt University Medical, Center1211 Medical Center Dr, Nashville, TN 37232, USA
| | - Donald Arnold
- Department of Emergency Medicine, Vanderbilt University Medical, Center1211 Medical Center Dr, Nashville, TN 37232, USA
| | - Abby Taylor
- Department of Urology, Vanderbilt University Medical Center, 1301 Medical Center Dr Suite 3823, Nashville, TN 37232, USA
| | - John Pope
- Department of Urology, Vanderbilt University Medical Center, 1301 Medical Center Dr Suite 3823, Nashville, TN 37232, USA
| | - Douglass Clayton
- Department of Urology, Vanderbilt University Medical Center, 1301 Medical Center Dr Suite 3823, Nashville, TN 37232, USA
| | - John W Brock
- Department of Urology, Vanderbilt University Medical Center, 1301 Medical Center Dr Suite 3823, Nashville, TN 37232, USA
| | - Mark Adams
- Department of Urology, Vanderbilt University Medical Center, 1301 Medical Center Dr Suite 3823, Nashville, TN 37232, USA
| | - Cyrus Adams
- Department of Urology, Vanderbilt University Medical Center, 1301 Medical Center Dr Suite 3823, Nashville, TN 37232, USA
| | - John Thomas
- Department of Urology, Vanderbilt University Medical Center, 1301 Medical Center Dr Suite 3823, Nashville, TN 37232, USA
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Erlich T, Ghazzaoui AE, Pokarowski M, O'Kelly F, Lorenzo AJ, Bagli DJ, Koyle MA. Perinatal testicular torsion: The clear cut, the controversial, and the "quiet" scenarios. J Pediatr Surg 2022; 57:288-297. [PMID: 34753560 DOI: 10.1016/j.jpedsurg.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 09/17/2021] [Accepted: 10/01/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Perinatal testicular torsion (PTT) is a catastrophic event that occurs in utero or up to 30 days postnatally, with testicular loss being the most common outcome. OBJECTIVE To assess clinical evaluation, surgical management and clinical outcomes in patients with PTT in a quaternary referral pediatric center, to determine testicular salvageability and propose future management options. METHODS We retrospectively reviewed a cohort of males born outside the quaternary center with a diagnosis of PTT, from May 2000 to July 2020. Data collection included mode of delivery, gestational age, birth weight, testicular examination at birth, clinical presentation, ultrasound results at diagnosis, surgical management and findings, perioperative complications, and follow-up. RESULTS 62 patients, including 2 patients with bilateral asynchronous PTT, were identified. Median (IQR) gestational age and birth weight were 39 (38-39.4) weeks and 3.4 (3.1-3.72) kg, respectively. Abnormal testicular examination at birth was found in 69% (Table 1). Doppler ultrasound was performed in all but 1 patient. 59 patients underwent surgery, 21 within 4 h, with bilateral exploration in 44 cases. Affected and non-affected testicles were explored in 76% and 98% of cases, respectively. 3 "nubbins" were found, of which 2 were excised. 3 nonsurgical complications were identified. During a median (IQR) follow-up of 3 (3-3) months, 63 testicles were removed or found to be non-functional, with compensatory hypertrophy in 38% of patients. CONCLUSION Given that 3% of our patients presented with asynchronous bilateral PTT, as well as the safety of general anesthesia in a referral pediatric hospital, early bilateral scrotal exploration of PTT is recommended. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Tomer Erlich
- Division of Pediatric Urology, The Hospital for Sick Children, SickKids, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Department of Surgery, University of Toronto, Toronto, Canada.
| | - Ali El Ghazzaoui
- Division of Pediatric Urology, The Hospital for Sick Children, SickKids, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Department of Surgery, University of Toronto, Toronto, Canada
| | - Martha Pokarowski
- Division of Pediatric Urology, The Hospital for Sick Children, SickKids, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
| | - Fardod O'Kelly
- Division of Pediatric Urology, The Hospital for Sick Children, SickKids, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Department of Pediatric Urology, Beacon Hospital, Dublin, and School of Medicine, University College Dublin, Ireland
| | - Armando J Lorenzo
- Division of Pediatric Urology, The Hospital for Sick Children, SickKids, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Department of Surgery, University of Toronto, Toronto, Canada
| | - Darius J Bagli
- Division of Pediatric Urology, The Hospital for Sick Children, SickKids, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Department of Surgery, University of Toronto, Toronto, Canada
| | - Martin A Koyle
- Division of Pediatric Urology, The Hospital for Sick Children, SickKids, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Department of Surgery, University of Toronto, Toronto, Canada
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Kwenda EP, Locke RA, DeMarco RT, Bayne CE. Impact of hospital transfer on testicular torsion outcomes: A systematic review and meta-analysis. J Pediatr Urol 2021; 17:293.e1-293.e8. [PMID: 33610457 DOI: 10.1016/j.jpurol.2021.01.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/08/2021] [Accepted: 01/19/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Testicular torsion is an emergent condition requiring prompt treatment. Previous studies have suggested transfer of pediatric testicular torsion cases may be detrimental to patient outcomes. Findings have not reached statistical significance. No study has quantitatively analyzed all literature reporting outcomes for transferred torsion patients. The aim of this study was to elucidate the impact of hospital transfer on pediatric testicular torsion outcomes through a systematic review and meta-analysis. METHODS A predefined study protocol registered with PROSPERO was developed according to PRISMA. A comprehensive literature review of articles investigating outcomes for pediatric testicular torsion for transferred and non-transferred (treated "directly" at presentation institution) patients with orchiectomy as the primary outcome was conducted by systematically searching PubMed and Embase. Potential studies were screened against a predefined study protocol. Meta-analysis using a random effects model with transferred status as the "intervention" was performed using Review Manager 5.3. RESULTS Of 18 eligible studies, 9 retrospective studies comprised of 2564 patients (532 transferred and 2032 direct) were suitable for quantitative analysis. Main analysis showed transfer status does not have a significant effect on torsion outcomes (RR 0.96 [95% CI 0.78-1.17]; I2 = 44%). Subgroup analysis for torsion patients presenting within 24 h of symptom onset shows patients who are transferred to another facility for management are more likely to undergo orchiectomy than those treated at their presenting institution (RR 0.35 [95% CI 0.24-0.51]; I2 = 4%). CONCLUSIONS In this meta-analysis, hospital transfer does not affect orchiectomy rate in pediatric patients with testicular torsion when pooling data from all presentation timeframes. Subgroup analysis of patients presenting with testicular torsion in an acute setting (<24 h of symptom onset) suggests the delay associated with hospital transfer has a deleterious effect on testicular viability.
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Affiliation(s)
- Elizabeth P Kwenda
- Department of Urology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Rachel A Locke
- Department of Urology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Romano T DeMarco
- Department of Urology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Christopher E Bayne
- Department of Urology, University of Florida College of Medicine, Gainesville, FL, USA.
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