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Clennon EK, Stefanko A, Guerre M, Hecht SL, Austin JC, Seideman CA. The ball's in your court: Trends, causes, outcomes, and costs of patient transfer for pediatric testicular torsion. J Pediatr Urol 2024:S1477-5131(24)00268-7. [PMID: 38866647 DOI: 10.1016/j.jpurol.2024.05.010] [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: 01/17/2024] [Revised: 04/23/2024] [Accepted: 05/16/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND The transfer of pediatric patients with testicular torsion from community hospitals to pediatric centers can be a time and resource-intensive step toward emergent surgical intervention. OBJECTIVE We sought to describe trends of patient transfer in our state and compare clinical outcomes and health system costs between patients transferred and treated primarily at a pediatric center. STUDY DESIGN This retrospective cohort study compared patients aged 1-18 years who presented directly to a pediatric center to those transferred for acute testicular torsion from 2018 to 2023. Exclusion criteria included age <1 year, non-urgent surgery, and admission from clinic. Patient age, BMI, Tanner stage, ASA class, insurance coverage, and presentation time were covariates. Group characteristics and times from symptom onset to initial ED presentation to surgery were compared via two-sided Student's t-tests. Clinical outcomes (orchiectomy, testicular atrophy) were compared via Fisher's exact tests. Costs from transferring hospitals were estimated from costs at our institution, and medical transport costs were extrapolated from contract prices between transport agencies and the pediatric center to compare total episode-of-care cost. RESULTS A total of 133 cases (37 primaries, 96 transfers) met inclusion criteria. Transfers increased over the study period (67%-75%). There were no significant differences in age, Tanner stage, ASA score, BMI, or time of day of presentation between groups. Median transfer distance was 12 miles (IQR 7-22) and time was 1 h (IQR 1-2). More than half of cases (53%) were transferred due to hospital policy regarding surgical treatment of minors, and 25% due to lack of urology coverage. Time from initial ED site to OR was nearly doubled for the transfer group (median 4.5 vs 2.5 h, p = 0.02). Despite a higher rate of orchiectomy in the primary group (43 vs 22%, p = 0.01), this difference was not significant after stratification by symptom duration. The estimated average cost of care for patients transferred was twice that of primary patients ($15,082 vs $6898). DISCUSSION Transfer of pediatric patients in our state for testicular torsion has increased in recent years. Hospital policies and local urology coverage are primary drivers of patient transfer which nearly doubled time to surgical intervention and more than doubled cost of care. Clinical outcomes were driven by delayed presentation. CONCLUSION Transfer of pediatric patients for testicular torsion nearly doubles time to surgical intervention and more than doubles cost of care. Restrictive hospital policies and gaps in rural hospital urology coverage present opportunities to improve the quality and efficiency of care for these children.
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Affiliation(s)
- Emily K Clennon
- Department of Urology, Oregon Health & Science University, Portland, OR, USA.
| | - Alexa Stefanko
- School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Megan Guerre
- Department of Urology, Oregon Health & Science University, Portland, OR, USA
| | - Sarah L Hecht
- Department of Urology, Oregon Health & Science University, Portland, OR, USA
| | | | - Casey A Seideman
- Department of Urology, Oregon Health & Science University, Portland, OR, USA
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Zhao K, Lu JY, Shkolnik B, Davis RB. Practice Patterns Affecting Delays in Care of Testicular Torsion. Urology 2024; 184:83-86. [PMID: 38043906 DOI: 10.1016/j.urology.2023.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 11/03/2023] [Accepted: 11/16/2023] [Indexed: 12/05/2023]
Abstract
OBJECTIVES To compare impact of day or on-call team, pediatric or adult attending, and patient age on testicular torsion management and outcomes. METHODS A retrospective study of patients with testicular torsion between 2012 and 2022 at a single institution was conducted. Variables impacting management time were assessed using univariate analyses. RESULTS One hundred and thirty-four patients were included: 49 underwent orchiectomies and 84 underwent orchiopexies. There was no significant difference between efficiency of on-call vs day team regarding time to ultrasound or time to operating room (OR). There were no significant differences between pediatric vs adult attending surgeons for time to surgery, intraoperative length of surgery, or testicular salvage rates. However, when patients were stratified by age greater or younger than 18years, older patients had significantly longer symptom duration (91.9 vs 20.0 minutes, P = .005), time to receive an ultrasound from emergency room registration (152 vs 87 minutes, P < .001), time to OR from emergency room registration (268 vs 185 minutes, P < .001), and time to OR from ultrasound read (187 vs 123 minutes, P = .03). Older patients also had lower rates of testicular salvage approaching significance (orchiectomy rate 48.8% vs 31.5%, P = .057). CONCLUSION While no significant delays in testicular torsion management were detected between management by on-call vs day team nor pediatric vs adult attending, increased age of patient was associated with delays in definitive surgical management. Greater index of suspicion for testicular torsion diagnosis in adult patients may improve the rate of testicular salvage.
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Affiliation(s)
- Kelley Zhao
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Jennifer Y Lu
- Department of Urology, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY.
| | - Brian Shkolnik
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Rachel Bennett Davis
- Department of Urology, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
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Hayashi RM, Hidaka AK, Glina FPA, Smaidi K, Pazeto CL, Nascimento FJ, Baccaglini W, Leite PHB, Lopes Neto AC, Glina S. Spermatic cord torsion: a retrospective analysis. EINSTEIN-SAO PAULO 2023; 21:eAO0238. [PMID: 37341219 DOI: 10.31744/einstein_journal/2023ao0238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/22/2022] [Indexed: 06/22/2023] Open
Abstract
OBJECTIVE To evaluate the time interval and possible delay in transportation to referral units for the treatment of testicular torsion. METHODS We retrospectively analyzed all cases of spermatic cord torsion surgically treated at a university hospital between January 2018 to December 2021. We evaluated the time intervals, including pain onset until the first presentation (D1), interhospital transference time (D2), pain onset until urological evaluation in a tertiary service (D3), urological evaluation until surgery (D4), and time from pain onset to surgical treatment (D5). We analyzed demographic and surgical data, orchiectomy rates, and time intervals (D1-D5). Torsions presented to the first medical presentation within 6h were considered early for testicular preservation. RESULTS Of the 116 medical records evaluated, 87 had complete data for the time interval analysis (D1 to D5) and were considered the total sample. Thirty-three had D1 ≤6h, 53 had D1 ≤24h (includes patients in the D1 ≤6h subgroup), and 34 had D1 >24h. The median time intervals of the total samples and subgroups D1 ≤6h, D1 ≤24h, and D1 >24h were D1 = 16h 42min, 2h 43min, 4h 14min and 72h, D2 = 4h 41min, 3h 39min, 3h 44min and 9h 59min; D3 = 24h, 6h 40min, 7h and 96h; D4 = 2h 20min, 1h 43min, 1h 52min and 3h 44min; D5 = 24h 42min, 8h 03min, 9h 26min and 99h 10min, respectively. Orchiectomy rates of the total sample, subgroups D1 ≤6h, D1 ≤24h, and D1 >24h were 56.32%, 24.24% (p<0.01), 32.08% (p<0.01), and 91.18% (p<0.01), respectively. CONCLUSION Late arrival at the emergency department or a long interhospital transference time determined a large number of patients who underwent orchiectomy. Thus, public health measures and preventive strategies can be developed based on the data from this study aiming to reduce this avoidable outcome.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Sidney Glina
- Centro Universitário FMABC, Santo André, SP, Brazil
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Shields LBE, Daniels MW, Peppas DS, Rosenberg E. Differences in Clinical Characteristics Between Prepubescent and Postpubescent Males With Testicular Torsion. Clin Pediatr (Phila) 2023; 62:209-214. [PMID: 35982605 DOI: 10.1177/00099228221116705] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Testicular torsion represents a pediatric surgical emergency. In this 6-year study with 140 patients, prepubescent (<13 years) and postpubescent (≥13 years) males with testicular torsion were identified. Prepubescent boys had a longer symptom duration (P = .016) and underwent more orchiectomies (P = .005) compared with postpubescent boys. The risk of orchiectomy decreased by 15% per 1-year increase in age (P = .002). Boys who underwent an orchiectomy had a longer symptom duration (P < .001), were younger (P = .002), had scrotal swelling (P = .001), scrotal erythema (P < .001), higher degrees of torsion (P = .036), and more left-sided surgeries (P = .014) compared with those who had an orchiopexy. Postpubescent boys were 63% less likely to receive an orchiectomy versus an orchiopexy compared with prepubescent boys. Pediatricians should be cognizant of the age discrepancies between prepubescent and postpubescent males with testicular torsion and educate parents about the importance of urgent evaluation in the Emergency Department to reduce the likelihood of an orchiectomy.
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Affiliation(s)
- Lisa B E Shields
- Norton Neuroscience Institute, Norton Healthcare, Louisville, KY, USA
| | - Michael W Daniels
- Department of Bioinformatics & Biostatistics, University of Louisville, Louisville, KY, USA
| | - Dennis S Peppas
- Norton Children's Urology, Norton Healthcare, Louisville, KY, USA
| | - Eran Rosenberg
- Norton Children's Urology, Norton Healthcare, Louisville, KY, USA
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Peeraully R, John M, Ellis R, Green S, Jancauskaite M, Smart T, Thompson A, Sarmah P, Fraser N. Does decentralisation of surgical management improve outcomes for paediatric testicular torsion? J Pediatr Urol 2022; 18:302.e1-302.e8. [PMID: 35410806 DOI: 10.1016/j.jpurol.2022.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 01/26/2022] [Accepted: 03/19/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION In testicular torsion (TT), delayed emergency scrotal exploration (ESE) increases the risk of orchidectomy. Transfer of a patient with suspected TT from a district general hospital (DGH) to a paediatric surgical centre (PSC) delays ESE and potentially puts them at increased risk of testicular loss. Prior to 1st January 2017, all boys under aged <16 years presenting to a DGH within the East Midlands Clinical Network (EMCN) would be referred to the PSC. From this date, it was agreed within the EMCN that boys aged ≥5 years with suspected TT presenting to a network DGH would be managed locally, barring exceptional circumstances. Boys aged <5 years would be referred to the PSC for management. AIM This study aimed to assess the impact of decentralisation of ESE for suspected TT on orchidectomy rates in the EMCN. METHODS All patients who underwent ESE under the care of paediatric surgery in the PSC, and all patients <16 years old who underwent ESE in 4 EMCN DGHs between January 2017 and December 2019 were identified. Neonatal cases and inpatient referrals were excluded. Comparison was made with published data on ESE performed in the PSC over the 9 years 2008-2016 prior to decentralisation. RESULTS In the 9 years prior to decentralisation, there were 110 cases of TT in the PSC. In the subsequent 3 years, there were 40 in the PSC and 37 in the DGHs. The orchidectomy rate of boys with TT presenting to DGHs and undergoing exploration locally (16%, 6/37) contrasts with the rate in those transferred from DGHs to the PSC for exploration (58%, 15/26). The difference is highly significant (p = 0.00059, RR 0.28 [95% CI 0.13-0.63]) and indicates that in the EMCN, avoiding hospital transfer and performing ESE at the presenting DGH reduces the risk of orchidectomy by 72%. CONCLUSION Decentralisation of the provision of ESE in boys with TT has resulted in a significantly lower orchidectomy rate in boys undergoing ESE in the presenting hospital than when transferred to the PSC. This study reinforces existing literature that demonstrates the effect of delayed ESE on orchidectomy rate, and supports the recommendations of national guidelines in the UK that transfer of boys to a PSC for ESE should only occur in exceptional circumstances.
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Affiliation(s)
- Riyad Peeraully
- Queen's Medical Centre, Nottingham, NG7 2UH, United Kingdom.
| | - Michael John
- Queen's Medical Centre, Nottingham, NG7 2UH, United Kingdom
| | - Ricky Ellis
- King's Mill Hospital, Mansfield, NG17 4JL, United Kingdom
| | - Sophie Green
- Queen's Medical Centre, Nottingham, NG7 2UH, United Kingdom
| | | | - Thomas Smart
- Royal Derby Hospital, Derby, DE22 3NE, United Kingdom
| | - Amari Thompson
- Lincoln County Hospital, Lincoln, LN2 5QY, United Kingdom
| | | | - Nia Fraser
- Queen's Medical Centre, Nottingham, NG7 2UH, United Kingdom
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Testicular volume loss in the long-term follow-up after surgical detorsion of the testis. Pediatr Surg Int 2022; 38:907-911. [PMID: 35366086 DOI: 10.1007/s00383-022-05118-x] [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] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
Abstract
AIM The aim of this study is to evaluate sonographic testicular volume of patients who underwent surgical detorsion due to testicular torsion and to reveal the frequency of long-term testicular volume loss and the factors affecting it. METHOD The files of patients who underwent surgical detorsion due to unilateral testicular torsion in our hospital between 2011 and 2019 were reviewed retrospectively. Age at the time of detorsion surgery, time from the onset of pain to surgery, degree of torsion, and ultrasonographic testicular volumes before detorsion were noted. Afterward, patients with at least 6 months of follow-up were contacted by phone and testicular volumes were measured by scrotal ultrasonography (US). The sonographic formula Length × Width × Height × 0.72 was used to determine testicular volumes. RESULTS There were 97 patients who underwent surgical detorsion within the given time frame. However, 43 of these patients accepted to be involved in the study and a follow-up scrotal US was performed. The mean age at the time of detorsion was 13.6 ± 5.6 years, whereas it was 16.7 ± 6.2 years at the time of the follow-up visit. The median time from the onset of pain to surgery was 4 h (range 1-36 h). In the preoperative US, the mean volume of the affected testis was 10.8 ± 5.6 mm3, while the mean contralateral testis volume was 10.2 ± 5.4 mm3 (p = 0.134). The median follow-up time in our study was 24 months (range 6-96 months). In the control US, the mean volume of the affected testis was 9.5 ± 7.1 mm3, while the mean volume of the contralateral testis was 14.4 ± 9 mm3 (p = 0.001). The affected testicular volumes decreased in 23 patients (range 1.1-100%), there was no change in testicular volumes in two patients, and there was an increase in testicular volumes in 18 patients (range 3.8-100%). In the ROC analysis, risk of testicular volume loss can be predicted with 87.5% sensitivity and 83.9% specificity when the time from the onset of pain to surgery exceeds 5.5 h (AUC = 0.904). CONCLUSION Our results indicated that if the time from the onset of pain to surgery exceeds 5.5 h, the testicular volume loss may be expected in the long term. Thus, patients and parents should be informed accordingly.
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Shields LB, Daniels MW, Peppas DS, Rosenberg E. Impact of Distance From the Hospital and Patient Transfer on Pediatric Testicular Torsion Outcomes. Cureus 2022; 14:e25284. [PMID: 35755550 PMCID: PMC9225051 DOI: 10.7759/cureus.25284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Testicular torsion is the most common pediatric emergency that requires prompt diagnosis and surgical treatment to prevent testicular loss. Distance from the hospital where the patient will be undergoing treatment for testicular torsion and transfer from an outside facility are factors that may impact whether a testis is salvageable. We sought to determine whether these factors play a role in pediatric testicular torsion outcomes. Materials and Methods: We identified males aged 1-18 years with testicular torsion between January 1, 2015 and December 31, 2020. The patients’ distance from our hospital and whether they were transferred from an outlying hospital were a particular focus. Results: The number of miles from our hospital and transfer from an outlying hospital were not significantly different between boys who underwent an orchiectomy versus an orchiopexy (p=0.258 and p=0.574, respectively). The number of miles from our hospital was negatively correlated to age at surgery (rho=-0.22, p=0.01). Significantly (p<0.001) more transfers were seen in patients who lived far (>22.1 miles) from our hospital (32/69 (46%)) versus near our hospital (10/68 (15%)). For every mile boys lived from our hospital, there was no difference (adjusted odds ratio (OR)=0.98 (0.96, 1.00), p=0.10) in the likelihood of receiving an orchiectomy versus an orchiopexy when adjusting for age, symptom duration, and degrees of torsion. Conclusions: Our study determined that neither distance from our hospital nor transfer from an outlying hospital affected the orchiectomy rate. An expedited medical evaluation and surgery offer the best prognosis for salvaging the testes.
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Anand S, Kainth D. Fragility Index of Recently Published Meta-Analyses in Pediatric Urology: A Striking Observation. Cureus 2021; 13:e16225. [PMID: 34367825 PMCID: PMC8343562 DOI: 10.7759/cureus.16225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 11/25/2022] Open
Abstract
Background and objective Fragility Index (FI) of meta-analyses determines their stability in terms of the level of confidence and strength behind the results depicted by them. The present study was conducted to estimate the FI of recently published meta-analyses in the Journal of Pediatric Urology (JPUrol). Method Twenty recently published articles on meta-analyses were screened to identify the eligible ones. The baseline data of each meta-analysis including the details of the author, number of included studies, total sample size, the total number of events, the status of the overall outcome (significant or non-significant), type of effect measure, type of method used for pooling the estimates, and type of effects model were recorded. FI was calculated by doing each single status modification. The 95% CI of the treatment effect was re-calculated until the statistical significance of the meta-analysis was reversed. Results A total of seven articles incorporating 22 meta-analyses were included. Seven (32%) of them had a statistically significant outcome prior to FI estimation. The risk ratio (17/22; 77%) was the most commonly used effect measure. The random-effects model (15/22; 68%) and the Mantel-Haenszel method (20/22; 91%) of pooling the estimates were utilized in the majority of meta-analyses. The median (Q1-Q3; range) FI of statistically significant, non-significant, and total meta-analyses were 5 (3-19.5; 2-39), 5 (3.5-6; 1-17), and 5 (3-13; 1-39) respectively. FI of ≤5 was noticed in four out of seven (57%), 9/15 (60%), and 13/22 (59%) of these meta-analyses respectively. Conclusion Based on our findings, the majority of the recently published meta-analyses in the field of pediatric urology are fragile and depend upon the event status of ≤5 participants.
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Affiliation(s)
- Sachit Anand
- Pediatric Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, IND.,Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, IND
| | - Deepika Kainth
- Pediatrics, All India Institute of Medical Sciences, New Delhi, IND
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