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Perysinakis I, Vassalou EE. Non-traumatic lower abdominal pain: ultrasonographic and clinical differential diagnosis. Ultrasonography 2024; 43:151-168. [PMID: 38443147 PMCID: PMC10915120 DOI: 10.14366/usg.23227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/25/2024] [Accepted: 01/27/2024] [Indexed: 03/07/2024] Open
Abstract
Lower abdominal pain is frequently reported and has a diverse differential diagnosis. In cases with atypical presentation and nonspecific findings, further imaging evaluation is required to confirm the clinical suspicion and to distinguish between self-limiting disorders and those requiring immediate intervention. In line with European guidelines, transabdominal ultrasonography is recommended as a first-line imaging modality for clinically suspected acute appendicitis and acute diverticulitis, which respectively represent the predominant causes of right and left lower quadrant abdominal pain. It is similarly the preferred method for evaluating suspected obstetric/gynecologic and genitourinary diseases. Computed tomography is utilized as a secondary option when ultrasonography results are inconclusive. This pictorial essay illustrates the sonographic features of the most common conditions associated with lower abdominal pain and outlines the clinical characteristics of each entity.
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Affiliation(s)
- Iraklis Perysinakis
- Department of Surgical Oncology, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Evangelia E. Vassalou
- Department of Medical Imaging, University Hospital of Heraklion, Heraklion, Crete, Greece
- Department of Medical Imaging, General Hospital of Sitia, Sitia, Crete, Greece
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Hosokawa T, Tanami Y, Sato Y, Oguma E. Point-of-care ultrasonography for the diagnosis and manual detorsion of testicular torsion. J Med Ultrason (2001) 2024; 51:59-70. [PMID: 37863980 PMCID: PMC10937765 DOI: 10.1007/s10396-023-01374-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 09/11/2023] [Indexed: 10/22/2023]
Abstract
Testicular torsion is a urological emergency caused by the loss of testicular tissue due to ischemic damage. Rapid diagnosis and urgent treatment play a crucial role in the management of testicular torsion. Manual detorsion can be performed at the bedside, thereby reducing the duration of ischemia. Recent studies have reported the use of point-of-care ultrasonography for diagnosing testicular torsion; however, no review article has focused on the ultrasonographic findings pertaining to manual detorsion. This review describes the diagnosis of testicular torsion and the ultrasonographic indications for manual detorsion. Spermatic cord twisting or the whirlpool sign, absence of or decreased blood flow within the affected testis, abnormal testicular axis, abnormal echogenicity, and enlargement of the affected testis and epididymis due to ischemia are the sonographic findings associated with testicular torsion. The following findings are considered indications for manual detorsion: direction of testicular torsion, i.e., inner or outer direction (ultrasonographic accuracy of 70%), and the degree of spermatic cord twist. The following sonographic findings are used to determine whether the treatment was successful: presence of the whirlpool sign and the degree and extent of perfusion of the affected testis. Misdiagnosis of the direction of manual detorsion, a high degree of spermatic cord twisting and insufficient detorsion, testicular compartment syndrome, and testicular necrosis were found to result in treatment failure. The success of manual detorsion is determined based on the symptoms and sonographic findings. Subsequent surgical exploration is recommended in all cases, regardless of the success of manual detorsion.
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Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children's Medical Center, 1-2 Shintoshin Chuo-ku Saitama, Saitama, 330-8777, Japan.
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, 1-2 Shintoshin Chuo-ku Saitama, Saitama, 330-8777, Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children's Medical Center, 1-2 Shintoshin Chuo-ku Saitama, Saitama, 330-8777, Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children's Medical Center, 1-2 Shintoshin Chuo-ku Saitama, Saitama, 330-8777, Japan
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Barkai E, Dekalo S, Yossepowitch O, Ben-Chaim J, Bar-Yosef Y, Beri A, Mano R. Complete Blood Count Markers and C-Reactive Protein as Predictors of Testicular Viability in the Event of Testicular Torsion in Adults. Urol Int 2023; 107:801-806. [PMID: 37423214 PMCID: PMC10614481 DOI: 10.1159/000531145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/15/2023] [Indexed: 07/11/2023]
Abstract
INTRODUCTION The association between blood markers and testicular viability after testicular torsion (TT) is not well known. We evaluated the role of complete blood count markers and C-reactive protein (CRP) in predicting testicular viability after TT. METHODS Fifty men, ≥18 years of age, operated for TT between the years 2015-2020 were enrolled. Blood markers including neutrophil-, lymphocyte-, and platelet count, and CRP were obtained. Neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) were calculated. The study outcome was testicular salvage. RESULTS Median age was 23 years (interquartile range [IQR]: 21, 31). Median duration of torsion was 10 h (IQR: 6, 42). Sonographic texture of the testis was homogenous in 27 (56%) patients and heterogenous in 21 (44%). During scrotal exploration, 36 patients (72%) underwent orchiopexy and 14 (28%) underwent orchiectomy. Patients who underwent orchiopexy were younger (22 years vs. 31 years, p = 0.009), had a shorter duration of torsion (median 8 h vs. 48 h, p < 0.001), and a homogenous texture on scrotal ultrasound (76.5 vs. 7.1%, p < 0.001). Median NLR, PLR, and CRP were higher among patients who underwent orchiectomy; however, these differences did not reach statistical significance. Patients with heterogenous echotexture were significantly more likely to undergo orchiectomy (odds ratio = 42, 95% confidence interval: 7, 831, adjusted p value = 0.009). CONCLUSIONS We found no association between blood-based biomarkers and testicular viability after TT; however, testicular echotexture significantly predicted outcome.
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Affiliation(s)
- Eyal Barkai
- Department of Urology, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel
- Department of Urology, Samson Assuta Ashdod University Hospital, Ashdod, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Snir Dekalo
- Department of Urology, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Ofer Yossepowitch
- Department of Urology, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Jacob Ben-Chaim
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
- Department of Pediatric Urology, Dana-Dwek Children’s Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel
| | - Yuval Bar-Yosef
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
- Department of Pediatric Urology, Dana-Dwek Children’s Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel
| | - Avi Beri
- Department of Urology, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Roy Mano
- Department of Urology, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
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Hosokawa T, Urushibara A, Tanami Y, Sato Y, Ishimaru T, Ohashi K, Kawashima H, Oguma E. Prediction of testicular atrophy based on sonographic findings immediately after successful manual detorsion. Australas J Ultrasound Med 2023; 26:26-33. [PMID: 36960131 PMCID: PMC10030091 DOI: 10.1002/ajum.12325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Purpose To investigate and determine the sonographic findings obtained from manually distorted testes to predict testicular atrophy following manual detorsion. Materials and methods Twenty-two patients who had been diagnosed with testicular torsion and undergone manual detorsion were included. These patients were classified according to the presence or absence of testicular atrophy. The duration of symptoms, presence or absence of hyperperfusion within the entire affected testis, and echogenicity (homogeneous or heterogeneous) within the affected testis were compared using the Mann-Whitney U-test or Fisher's exact test, as appropriate. Results Testicular atrophy was detected in seven patients. There was a significant difference in the frequency of hyperperfusion within the entire affected testis (with atrophy [present/absent] vs. without atrophy [present/absent] = 0/7 vs. 8/7, P = 0.023) between patients with and without testicular atrophy. No significant differences in the duration of symptoms (with atrophy vs. without atrophy = 7 ± 3.3 h vs. 4.7 ± 3.6 h, P = 0.075) or frequency of echogenicity within the testis (with atrophy [heterogeneous/homogeneous] vs. without atrophy [heterogeneous/homogeneous] = 2/5 vs. 2/13, P = 0.565) were observed between the groups. Conclusions This small cohort study suggests that the presence of hyperperfusion within the entire affected testis immediately after successful manual detorsion is useful in predicting the avoidance of testicular atrophy.
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Affiliation(s)
- Takahiro Hosokawa
- Department of RadiologySaitama Children's Medical Center1‐2 Shintoshin Chuo‐ku SaitamaSaitamaJapan
| | - Aiko Urushibara
- Department of RadiologySaitama Children's Medical Center1‐2 Shintoshin Chuo‐ku SaitamaSaitamaJapan
| | - Yutaka Tanami
- Department of RadiologySaitama Children's Medical Center1‐2 Shintoshin Chuo‐ku SaitamaSaitamaJapan
| | - Yumiko Sato
- Department of RadiologySaitama Children's Medical Center1‐2 Shintoshin Chuo‐ku SaitamaSaitamaJapan
| | - Tetsuya Ishimaru
- Department of SurgerySaitama Children's Medical Center1‐2 Shintoshin Chuo‐ku SaitamaSaitamaJapan
| | - Kensuke Ohashi
- Department of UrologySaitama Children's Medical Center1‐2 Shintoshin Chuo‐ku SaitamaSaitamaJapan
| | - Hiroshi Kawashima
- Department of SurgerySaitama Children's Medical Center1‐2 Shintoshin Chuo‐ku SaitamaSaitamaJapan
| | - Eiji Oguma
- Department of RadiologySaitama Children's Medical Center1‐2 Shintoshin Chuo‐ku SaitamaSaitamaJapan
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Parenchymal echotexture changes as a predictor of viability in testicular torsion. Emerg Radiol 2022; 29:359-363. [PMID: 34994880 DOI: 10.1007/s10140-021-02014-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 12/27/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Preoperative test that can predict the salvageability of the torsed testis may add essential information to the surgeon managing testicular torsion (TT), this can assist with patients' and parents' expectations, particularly with nonviable testes. We aimed to examine if parenchymal echotexture changes in preoperative ultrasound can predict irreversible hemorrhagic necrosis. MATERIALS AND METHODS Preoperative ultrasound studies of 154 patients with TT were reviewed by 3 raters (2 radiologists and 1 urologist). The raters were asked to categorize the affected testicular parenchymal echotexture into one of the following categories: (1) normal (identical to the contra-lateral testis), (2) homogenous hypoechoic, or (3) focal heterogeneous echotexture. Testis non-viability was defined macroscopically during surgical exploration and correlated with the US results. Sensitivity, specificity, and positive and negative predicting values of the proposed diagnostic test were calculated. Cohen's kappa coefficient was used to determine inter-rater agreement. RESULTS A total of 54/154 patients had a nonviable testis. Mean of 59.5% cases was classified as category 1, 27.3% cases as category 2, and 13.2% cases as category 3. Testicular necrosis was 12%, 34%, and 92% in each category, respectively. Category 3 classified non-viability with a mean specificity of 99.3% and with a high inter-rater agreement level (Cohen's kappa coefficient of 0.830). Mean positive predictive value of 97% and mean negative predictive value of 74.3%. The mean sensitivity of this test however was low 39.7%. CONCLUSION Ultrasound finding of focal parenchymal echotexture heterogeneous changes is highly specific although not sensitive, for nonviable testis. The presence of this finding reassures non-viability in over 99%.
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Xu Z, Wu J, Ni S, Luo H. The diagnostic value of ultrasound in pediatric testicular torsion with preserved flow. Front Pediatr 2022; 10:1001958. [PMID: 36245726 PMCID: PMC9554414 DOI: 10.3389/fped.2022.1001958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 09/07/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Zhihua Xu
- Department of Ultrasonic Diagnosis, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Junbo Wu
- Department of Children's Ultrasound Imaging, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuangshuang Ni
- Department of Ultrasonic Diagnosis, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hongxia Luo
- Department of Ultrasonic Diagnosis, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
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Hosokawa T, Tanami Y, Sato Y, Ishimaru T, Kawashima H, Oguma E. Role of ultrasound in manual detorsion for testicular torsion. JOURNAL OF CLINICAL ULTRASOUND : JCU 2021; 49:860-869. [PMID: 34240428 DOI: 10.1002/jcu.23039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/03/2021] [Accepted: 06/27/2021] [Indexed: 06/13/2023]
Abstract
PURPOSE Manual detorsion can be performed for testicular torsion before scrotal exploration. Using sonographic findings, this study investigated the need for additional treatments after manual detorsion for testicular torsion. METHODS This study evaluated 13 retrospective cases of testicular torsion subjected to manual detorsion. Manual detorsion was classified as failure or success based on residual spermatic cord twist. The following sonographic findings of the affected testis were compared using the Fisher exact test: whirlpool sign, horizontal or altered lie, and hypoperfusion. RESULTS Manual detorsion failed in five patients. There was a significant difference in the incidence of the whirlpool sign between the two groups (present/absent sign in the failure vs. success groups: 4/1 vs. 0/8, p = 0.007). Horizontal or altered lie and hypoperfusion in the affected testis were not significantly different between groups (5/0 vs. 3/4, p = 0.07, one case excluded, and 5/0 vs. 4/4, p = 0.10, respectively). CONCLUSIONS Ultrasound findings after manual detorsion, particularly, the whirlpool sign, were useful for planning subsequent treatment such as additional manual detorsion or surgical intervention. The testicular axis and the perfusion of the twisted testis may not recover to normal after successful manual detorsion, but if they recover, this procedure could be judged a success.
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Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Tetsuya Ishimaru
- Department of Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Hiroshi Kawashima
- Department of Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
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Bhardwaj R, Chakravarthy S, Misra S. Testicular Torsion: Successful Management of a Late-Diagnosed Case. Cureus 2021; 13:e16845. [PMID: 34522489 PMCID: PMC8424974 DOI: 10.7759/cureus.16845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2021] [Indexed: 11/17/2022] Open
Abstract
Testicular torsion is an emergency. It usually occurs spontaneously, without an apparent cause but has been associated with anatomical, traumatic, and environmental factors. In the case of the acute scrotum, a high degree of clinical suspicion is the most important factor in early diagnosis. Scrotal Doppler helps to confirm the diagnosis of testicular torsion. Prompt recognition and treatment are critical for testicular viability. Surgical intervention, even in late-diagnosed selected cases may yield desirable results. We report a case of a 16-year-old boy who came to the urology outpatient department (OPD) with a history of scrotal pain for approximately 12 hours.
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Hasan O, Mubarak M, Mohamed Jawad Alwedaie S, Baksh H, Alaradi H, Alarayedh A, Alaradi A, Ahmadi A, Jalal A. Ultrasound heterogeneity as an indicator of testicular salvage in testicular torsion: A single center experience. Asian J Urol 2021; 9:57-62. [PMID: 35198397 PMCID: PMC8841272 DOI: 10.1016/j.ajur.2021.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/19/2020] [Accepted: 08/20/2020] [Indexed: 11/28/2022] Open
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Zheng WX, Hou GD, Zhang W, Wei D, Gao XL, Chen MH, Huang LG, Yan F, Zhang G, Yu L, Liu F, Zhang B, Yuan JL. Establishment and internal validation of preoperative nomograms for predicting the possibility of testicular salvage in patients with testicular torsion. Asian J Androl 2021; 23:97-102. [PMID: 32687070 PMCID: PMC7831831 DOI: 10.4103/aja.aja_31_20] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Wan-Xiang Zheng
- Department of Urology, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Guang-Dong Hou
- Department of Urology, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Wei Zhang
- Department of Urology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China
| | - Di Wei
- Department of Urology, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Xue-Lin Gao
- Department of Urology, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Mei-Hong Chen
- Department of Urology, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Lu-Guang Huang
- Information Center, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Fei Yan
- Department of Urology, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Geng Zhang
- Department of Urology, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Lei Yu
- Department of Urology, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Fei Liu
- Department of Urology, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Bo Zhang
- Department of Urology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China
| | - Jian-Lin Yuan
- Department of Urology, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
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Alawamlh OAH, Flannigan R, Hayden R, Goldstein M, Li PS, Lee RK. Testicular Torsion and Spermatogenesis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1288:287-306. [PMID: 34453742 DOI: 10.1007/978-3-030-77779-1_14] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Testicular torsion (TT) is a common urologic emergency that can occur at any age. It is most common in newborns and during puberty. Prompt evaluation and management is required to salvage the testis following an episode of torsion. TT brings about damage to testicular tissue and spermatogenesis through various hypothesized mechanisms; however there is a consensus that the effects of ischemia, ischemia-reperfusion injury, and oxidative stress account for the most destructive effects. Numerous studies have examined the effects of various agents and therapies in limiting the effects of TT on the testis.
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Affiliation(s)
- Omar Al Hussein Alawamlh
- James Buchanan Brady Foundation, Department of Urology, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Ryan Flannigan
- James Buchanan Brady Foundation, Department of Urology, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Russell Hayden
- James Buchanan Brady Foundation, Department of Urology, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Marc Goldstein
- James Buchanan Brady Foundation, Department of Urology, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Philip S Li
- James Buchanan Brady Foundation, Department of Urology, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Richard K Lee
- James Buchanan Brady Foundation, Department of Urology, Weill Cornell Medical College of Cornell University, New York, NY, USA.
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Göger YE, Özkent MS, Ünlü MZ, Kocaoğlu C, Madenci H, Pişkin MM. Evaluation of parental sociocultural background and education level in response to pediatric testis torsion. J Pediatr Urol 2020; 16:820.e1-820.e6. [PMID: 33077390 DOI: 10.1016/j.jpurol.2020.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/09/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Acute scrotal pain (ASP) remains one of the most common male urologic emergencies in the pediatric age group. The most concerning outcome of testicular torsion (TT) is the need for orchiectomy, which has a negative impact on the child's development in general and on sexual development and psychology in particular. Time is the most important factor in the treatment of TT. Parental awareness of ASP indicating the possibility of TT is a significant factor in children's hospital admission time. Sociocultural background may be an indicator in parental awareness. OBJECTIVE This study sought to determine if parental sociocultural and education level is associated with delayed treatment for TT. STUDY DESIGN This retrospective study evaluated data for patients with scrotal or abdominal pain and TT at two hospitals in Konya, Turkey from 2012 to 2020. Study participants were the parents of the patients treated for TT. Participants were contacted by telephone and asked about their educational background. The study population was divided into 2 groups based on parent characteristics. Group 1 parents had an education level less than high school, had no health insurance, were in need of state aid, and had a low sociocultural background. Group 2 parents had an education level of at least high school or higher and had health insurance. Symptom duration (time between symptom onset and hospital admission) and surgical procedures for the patients were compared between the 2 parent groups. RESULTS Of the 140 patients who received a diagnosis of TT, 77 were in Group 1 and 63 in Group 2. Mean patient age was 12.7 ± 2.7 (5-16) years Median symptom duration was 7 (1-120) hours. Symptom duration was higher in Group 1, but no statistically significant differences were noted between groups (Group 1 duration was 8h vs. Group 2 duration of 6h; p = 0.331). Orchiectomy was performed for 62 (44.3%) patients and testicular-sparing surgery for 78 (55.7%). Orchiectomy rates between groups were statistically significant and higher in Group 1 with 41 (53.2%) versus 21 (33.3%) in Group 2. CONCLUSION Factors such as low sociocultural family background and low parental education level increase the risk of orchiectomy for their children. Awareness of the symptoms of TT may minimize the possibility of testicular loss.
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Affiliation(s)
- Yunus Emre Göger
- Department of Urology, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey.
| | - Mehmet Serkan Özkent
- Department of Urology, Konya Education and Research Hospital, Health Sciences University, Konya, Turkey.
| | - Mahmud Zahid Ünlü
- Department of Urology, Konya Education and Research Hospital, Health Sciences University, Konya, Turkey.
| | - Canan Kocaoğlu
- Department of Pediatric Surgery, Konya Education and Research Hospital, Health Sciences University, Konya, Turkey.
| | - Hasan Madenci
- Department of Pediatric Surgery, Konya Education and Research Hospital, Health Sciences University, Konya, Turkey.
| | - Mehmet Mesut Pişkin
- Department of Urology, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey.
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Liu MY, Gray E, Hahn ME, Shiehmorteza M. Scrotal Ultrasound: Updates on Testicular Microlithiasis, Incidental Non-Palpable Lesions, Varicoceles and Testicular Infarction. CURRENT RADIOLOGY REPORTS 2020. [DOI: 10.1007/s40134-020-00372-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Song SH, Afşarlar ÇE, Xie HW, Hung AJ, Koh CJ. Estimating the time of onset of testicular torsion using ultrasonography in an experimental rat model. Ultrasonography 2020; 39:152-158. [PMID: 32098458 PMCID: PMC7065987 DOI: 10.14366/usg.19055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/04/2020] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
- Sang Hoon Song
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, USA.,Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA.,Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Çağatay E Afşarlar
- Department of Pediatric Surgery, Faculty of Medicine, Hitit University, Corum, Turkey
| | - Hui Wen Xie
- Division of Pediatric Urology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Andrew J Hung
- University of Southern California (USC) Institute of Urology, Keck School of Medicine, USC, Los Angeles, CA, USA
| | - Chester J Koh
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, USA.,Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
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15
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Tian XM, Tan XH, Shi QL, Wen S, Lu P, Liu X, Li XL, He DW, Lin T, Wei GH. Risk Factors for Testicular Atrophy in Children With Testicular Torsion Following Emergent Orchiopexy. Front Pediatr 2020; 8:584796. [PMID: 33262963 PMCID: PMC7686235 DOI: 10.3389/fped.2020.584796] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 10/29/2020] [Indexed: 12/02/2022] Open
Abstract
Objective: To analyze the risk factors for testicular atrophy (TA) in children with testicular torsion (TT) following emergent orchiopexy. Methods: Clinical data of patients with TT undergoing orchiopexy were retrospectively reviewed, including age at surgery, affected side, delayed surgery (12-24 h and more than 24 h), echogenicity of testicular parenchyma on ultrasonography (ETPU), testicular blood flow on Color Doppler ultrasonography (CDUS), surgical findings (intraoperative blood supply, the degree of torsion, and surgical approaches), and follow-up. The primary outcome was the rate of TA after orchiopexy. The secondary outcome was the testicular volume loss (TVL) between the affected testis and the contralateral. Results: A total of 113 patients were enrolled in this study with a median age of 11 years. The median follow-up was 21 months. Patients had a median TVL of 51.02% and 44 (38.94%) of them developed severe TA during follow-up. TA was significantly associated with age at surgery (P < 0.0001), delayed surgery (P = 0.0003), ETPU (P = 0.0001), and intraoperative blood supply (P = 0.0005). Multivariate logistic regression analysis showed that school-age children (OR = 0.069, P < 0.001) and puberty (OR = 0.177, P = 0.007) had a decreased risk of TA compared with preschool children, and that heterogeneous ETPU (OR = 14.489, P = 0.0279) and delayed surgery >24 h (OR = 3.921, P = 0.040) increased the risk of TA. Multivariate analysis demonstrated that ETPU (F = 16.349, P < 0.001) and delayed surgery (F = 6.016, P = 0.003) were independent risk factors for TVL. Conclusions: Age at surgery, delayed surgery, and ETPU may play a crucial role in predicting the TA in children with TT following emergent orchiopexy. Moreover, blood flow measured by CDUS could not predict the outcome properly.
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Affiliation(s)
- Xiao-Mao Tian
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Medical University, Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, China
| | - Xiao-Hui Tan
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Qin-Lin Shi
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Medical University, Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, China
| | - Sheng Wen
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Peng Lu
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xing Liu
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Medical University, Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, China
| | - Xu-Liang Li
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Da-Wei He
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Medical University, Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, China
| | - Tao Lin
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Medical University, Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, China
| | - Guang-Hui Wei
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Medical University, Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, China
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16
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Afsarlar CE, Cakmakci E, Demir E, Guney G, Komut E, Elizondo R, Seth A, Koh CJ. Novel prognostic grayscale ultrasonographic findings in the testis from a comprehensive analysis of pediatric patients with testicular torsion. J Pediatr Urol 2019; 15:480.e1-480.e7. [PMID: 31495779 DOI: 10.1016/j.jpurol.2019.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 08/01/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Although grayscale and Doppler ultrasound (US) findings of testicular torsion (TT) have previously been described in the literature, other US findings may provide more prognostic information to families. OBJECTIVE The authors hypothesized that a comprehensive analysis of US findings of TT that focused on time-dependent changes would lead to additional ultrasonographic morphologic findings and clinically relevant prognostic information. STUDY DESIGN The authors reviewed the records of pediatric patients with acute TT from 2010 to 2017. The sizes and parenchymal characteristics of the torsed and contralateral testes on US were analyzed in relation to the time duration from the onset of scrotal pain to the time of surgery (0-6 h, 6-12 h, 12-24 h, 24-48 h, and >48 h), torsion degree, and clinical outcomes of the testes. RESULTS Patient demographics, time intervals, and US measurements of the torsed and contralateral testes showed significant differences with respect to testicular viability (Summary Table). The mean volume ratios of torsed to contralateral testis showed significant differences between the 0-6 h and the 12-24 h time groups as well as the 6-12 h and the 12-24 h time groups (P = 0.003 and P = 0.035, respectively), as well as significant differences between the viable and non-viable testes (P = 0.005). Regarding testicular heterogeneity, two novel grayscale sonographic findings were noted: (1) multiple hypoechoic lines that were termed 'testicular fragmentation' and (2) hyperechoic patches that were termed 'testicular patching'. The presence of these two findings were significantly increased as TT time duration increased (P < 0.001), and these findings were significantly associated with testicular non-viability (P < 0.001). Torsion degree was also noted to be significantly higher in the non-viable testes (P < 0.001). Presence of hydrocele or scrotal edema also showed significant differences between the TT time groups (P < 0.001). DISCUSSION The results of this study demonstrated ultrasonographic findings related to time dependent changes in TT and provided prognostic information regarding testicular viability. CONCLUSIONS Specific US grayscale findings in torsed testes (testicular fragmentation and testicular patching) were identified that provide prognostic information regarding time duration of testicular torsion and testicular viability. Testicular fragmentation and testicular patching significantly increased as TT time increased, with increasing risk for testicular non-viability.
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Affiliation(s)
- Cagatay E Afsarlar
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, USA; Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA; Department of Pediatric Surgery, Faculty of Medicine, Hitit University, Çorum, Turkey
| | - Emin Cakmakci
- Department of Radiology, Dr.Sami Ulus Maternity, Children's Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Emre Demir
- Department of Biostatistics, Faculty of Medicine, Hitit University, Çorum, Turkey
| | - Guven Guney
- Department of Pathology, Faculty of Medicine, Hitit University, Çorum, Turkey
| | - Erdal Komut
- Department of Radiology, Faculty of Medicine, Hitit University, Çorum, Turkey
| | - Rodolfo Elizondo
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, USA; Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
| | - Abhishek Seth
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, USA; Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
| | - Chester J Koh
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, USA; Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA.
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17
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Abbas TO, Abdelkareem M, Alhadi A, Kini V, Chandra P, Al-Ansari A, Ali M. Suspected testicular torsion in children: diagnostic dilemma and recommendation for a lower threshold for initiation of surgical exploration. Res Rep Urol 2018; 10:241-249. [PMID: 30584529 PMCID: PMC6287511 DOI: 10.2147/rru.s186112] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Testicular torsion (TT) represents a clinical challenge that needs emergency surgical assessment. It is common to have negative scrotal exploration due to confounding symptoms and signs which makes it sometimes difficult to differentiate from similar surgical emergencies that do not warrant surgery. At the same time, several occasions of misdiagnoses or late interventions occur with devastating effects. We aim at delineating the significance of the different clinical, laboratory, and radiological variables in the detection of TT. Methods We retrospectively reviewed the charts of 52 patients who were surgically explored with a preoperative working diagnosis of suspected TT in our center over the period from 2011 to 2015. All the patients were examined by pediatric surgeons in the emergency room and had undergone ultrasound imaging of the testes. The ultrasound images were retrospectively reviewed by a pediatric radiologist who was blinded to the intraoperative findings. Univariate and multivariate and logistic regression analyses were performed. Results Of the studied group of patients, the majority (84.6%) had TT upon surgical exploration. The most frequently presented symptom was pain (80.8%), and only a minority (11.5%) presented with vomiting. Radiological findings with the highest sensitivity were heterogeneous echogenicity in favor of TT and enlarged epididymis indicating that TT is unlikely. However, the predictability of TT by any of the assessed clinical and imaging factors was statistically insignificant. Conclusion It is important to gather all relevant data from clinical, laboratory, and imaging sources when assessing pediatric patients with suspected TT given the inaccuracy of each single one of them if used alone. Keeping this in mind, Doppler ultrasound has a significant role to aid in the accuracy of the diagnosis and hence the appropriate decision-making thereafter. However, we found no single clinical or imaging sign that is sensitive enough to prove or rule out TT. Therefore, surgical exploration should take place in a timely manner. Moreover, further research is necessary to construct scoring systems where different predictors collectively have higher reliability.
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Affiliation(s)
- Tariq O Abbas
- Department of Pediatric Surgery, Hamad General Hospital, Doha, Qatar, .,College of Medicine, Qatar University, Doha, Qatar, .,Weill Cornell Medical College-Qatar, Doha, Qatar,
| | | | | | | | - Prem Chandra
- Medical Research Center, Hamad Medical Corporation, Doha, Qatar
| | | | - Mansour Ali
- Department of Pediatric Surgery, Hamad General Hospital, Doha, Qatar,
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18
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Abbas TO, Ali M. Bilateral Neonatal Testicular Torsion; Hidden Surgical Nightmare. Front Pediatr 2018; 6:318. [PMID: 30525011 PMCID: PMC6256121 DOI: 10.3389/fped.2018.00318] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 10/05/2018] [Indexed: 11/13/2022] Open
Abstract
Perinatal testicular torsion is a relatively rare event that remains unidentified in many situations and managed only after an avoidable delay of time. Its current management approaches include watchful observation, delayed contralateral orchiopexy, and emergent contralateral orchiopexy. On the other hand, bilateral torsion is now being more frequently reported. However, the assessment of the contralateral testis through physical examination and imaging can be inaccurate in cases of perinatal torsion. We report a case of prenatal testicular torsion with incidentally discovered metachronous contralateral extravaginal testicular torsion. Therefore, immediate surgical intervention is recommended both when uni- or bilateral testicular torsion is suspected. Whenever possible, affected testes should be preserved as some endocrine function may be retained.
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Affiliation(s)
- Tariq O. Abbas
- Weill Cornell Medicine- Qatar, Ar-Rayyan, Qatar
- Pediatric Surgery, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, Qatar University, Doha, Qatar
| | - Mansour Ali
- Pediatric Surgery, Hamad Medical Corporation, Doha, Qatar
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19
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Grimsby GM, Schlomer BJ, Menon VS, Ostrov L, Keays M, Sheth KR, Villanueva C, Granberg C, Dajusta D, Hill M, Sanchez E, Harrison CB, Jacobs MA, Burgu B, Hennes H, Baker LA. Prospective Evaluation of Predictors of Testis Atrophy After Surgery for Testis Torsion in Children. Urology 2018; 116:150-155. [PMID: 29572055 DOI: 10.1016/j.urology.2018.03.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 02/25/2018] [Accepted: 03/05/2018] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Gwen M Grimsby
- Division of Pediatric Urology, Phoenix Children's Hospital, Phoenix, AZ
| | - Bruce J Schlomer
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Division of Pediatric Urology, Children's Health, Dallas, TX
| | - Vani S Menon
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Division of Pediatric Urology, Children's Health, Dallas, TX
| | - Lauren Ostrov
- Division of Pediatric Urology, Children's Health, Dallas, TX
| | - Melise Keays
- Division of Pediatric Urology, Children's Hospital of East Ontario, Ottawa, Ontario, Canada
| | - Kunj R Sheth
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Carlos Villanueva
- Division of Pediatric Urology, Children's Hospital & Medical Center, Omaha, NE
| | | | - Daniel Dajusta
- Division of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH
| | - Martinez Hill
- Division of Pediatric Urology, Children's Health, Dallas, TX
| | - Emma Sanchez
- Division of Pediatric Urology, Children's Health, Dallas, TX
| | - Clanton B Harrison
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Division of Pediatric Urology, Children's Health, Dallas, TX
| | - Micah A Jacobs
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Division of Pediatric Urology, Children's Health, Dallas, TX
| | - Berk Burgu
- Department of Urology, Ankara Üniversitesi Tıp Fakültesi, Ankara, Turkey
| | - Halim Hennes
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Division of Pediatric Urology, Children's Health, Dallas, TX
| | - Linda A Baker
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Division of Pediatric Urology, Children's Health, Dallas, TX.
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20
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Bandarkar AN, Blask AR. Testicular torsion with preserved flow: key sonographic features and value-added approach to diagnosis. Pediatr Radiol 2018; 48:735-744. [PMID: 29468365 PMCID: PMC5895684 DOI: 10.1007/s00247-018-4093-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/02/2018] [Accepted: 01/19/2018] [Indexed: 11/30/2022]
Abstract
Testicular sonography has contributed greatly to the preoperative diagnosis of testicular torsion in the pediatric patient and is the mainstay for evaluation of acute scrotal pain. Despite its high sensitivity and specificity, both false-negative and false-positive findings occur. Presence of documented Doppler flow within the testis might be a dissuading factor for surgical exploration with resultant testicular loss in the false-negative cases. Our goal is to illustrate key sonographic features in the spectrum of testicular torsion with preserved testicular flow, and to describe how to differentiate testicular torsion from epididymitis in order to avoid the under-diagnosis of testicular torsion. We simplify the anatomy of the bell clapper testis. We also describe our sonographic protocol for testicular torsion and share valuable tips from our approach to challenging cases.
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Affiliation(s)
- Anjum N. Bandarkar
- Department of Radiology, Mid-Atlantic Permanente Medical Group, 1890 Metro Center Drive, Reston, VA 20190 USA
| | - Anna R. Blask
- Department of Radiology, Children’s National Health System, Washington, DC USA
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21
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Pathological effect of arterial ischaemia and venous congestion on rat testes. Sci Rep 2017; 7:5422. [PMID: 28710488 PMCID: PMC5511218 DOI: 10.1038/s41598-017-05880-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 06/05/2017] [Indexed: 11/08/2022] Open
Abstract
Many studies on various organs have concluded that venous congestion (VC) causes severe organ dysfunction with elevation of oxidative stress relative to that of arterial ischaemia (AI). However, a comparison of the pathological effects of AI and VC on the testes has not been conducted. In this study, models of AI and VC and their reperfusion in rat testes, respectively, were developed and analysed. Testicular arteries or veins were interrupted for 6 h, re-perfused and kept for 4 weeks; the effects on the testes were then evaluated. Severe spermatogenic disturbances were observed at 4 weeks after reperfusion in AI but not in VC. At 6 h after blood flow interruption, oxidative stress was significantly increased and germ cells were severely damaged in AI compared with those in VC. RT-PCR analyses revealed that haem oxygenase-1, which exhibits anti-oxidative effects, and vascular endothelial growth factor-A, which exhibits vasculogenic effects, were significantly increased in VC but not in AI. Surprisingly, the results of our experiment in rat testes differed from those of experiments in previous studies performed in other organs. Oxidative stress in testes was more easily elevated by AI than it was by VC, explainable by the different experimental conditions.
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22
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Kitami M. Ultrasonography of pediatric urogenital emergencies: review of classic and new techniques. Ultrasonography 2017; 36:222-238. [PMID: 28494525 PMCID: PMC5494863 DOI: 10.14366/usg.17011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/18/2017] [Accepted: 03/30/2017] [Indexed: 12/28/2022] Open
Abstract
Urogenital emergencies are fairly common in the pediatric population, and a timely and correct diagnosis is necessary to avoid possible future infertility. In this field, ultrasonography is essential, as it has the advantages of being radiation-free and readily accessible. In particular, a high-frequency transducer allows precise evaluation of the morphology and vascularity of the scrotum, which is on the surface of the body. Beyond conventional techniques, new advanced imaging techniques have been developed, including elastography and contrast-enhanced ultrasonography. However, several pitfalls remain in the diagnosis of urogenital diseases using ultrasonography. Thus, accurate knowledge and sufficient experience with the technique are essential for making a correct diagnosis. This review provides an overview of pediatric urogenital emergency pathologies and recent ultrasonography techniques.
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Affiliation(s)
- Masahiro Kitami
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
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23
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Samson P, Hartman C, Palmerola R, Rahman Z, Siev M, Palmer LS, Ghorayeb SR. Ultrasonographic Assessment of Testicular Viability Using Heterogeneity Levels in Torsed Testicles. J Urol 2017; 197:925-930. [DOI: 10.1016/j.juro.2016.09.112] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Patrick Samson
- Division of Pediatric Urology. Cohen Children’s Medical Center of New York, Hofstra-Northwell School of Medicine, Hempstead, New York
| | - Christopher Hartman
- Division of Pediatric Urology. Cohen Children’s Medical Center of New York, Hofstra-Northwell School of Medicine, Hempstead, New York
| | - Ricardo Palmerola
- Division of Pediatric Urology. Cohen Children’s Medical Center of New York, Hofstra-Northwell School of Medicine, Hempstead, New York
| | - Zara Rahman
- School of Engineering and Applied Sciences, Ultrasound Research Laboratory, Hofstra University, Hempstead, New York
| | - Michael Siev
- Division of Pediatric Urology. Cohen Children’s Medical Center of New York, Hofstra-Northwell School of Medicine, Hempstead, New York
| | - Lane S. Palmer
- Division of Pediatric Urology. Cohen Children’s Medical Center of New York, Hofstra-Northwell School of Medicine, Hempstead, New York
| | - Sleiman R. Ghorayeb
- Departments of Radiology and Molecular Medicine, Hofstra-Northwell School of Medicine, Hempstead, New York
- School of Engineering and Applied Sciences, Ultrasound Research Laboratory, Hofstra University, Hempstead, New York
- Center for Immunology and Inflammation, Feinstein Institute for Medical Research, Northwell Health, Manhasset, New York
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24
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Weatherspoon K, Polansky S, Catanzano T. Ultrasound Emergencies of the Male Pelvis. Semin Ultrasound CT MR 2017; 38:327-344. [PMID: 28865524 DOI: 10.1053/j.sult.2017.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Male pelvic emergencies are uncommon, and symptoms typically include scrotal pain, scrotal enlargement, or a palpable scrotal mass or all of these. Ultrasound is often the first-line modality for evaluation of male pelvic emergencies, which may be stratified into vascular, infectious, or traumatic causes. Entities such as testicular torsion, Fournier gangrene, and testicular dislocation are surgical emergencies and should not be missed or misdiagnosed, as this may cause a significant delay in urgently necessary treatment. Radiologists need to be familiar with the role of imaging as well as the key characteristic imaging findings of these injuries to direct the appropriate management.
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Affiliation(s)
- Kimberly Weatherspoon
- Department of Radiology, Radiology resident Baystate Medical Center, University of Massachusetts, Springfield, MA.
| | - Stanley Polansky
- Department of Radiology, Assistant Professor Baystate Medical Center, University of Massachusetts, Springfield, MA
| | - Tara Catanzano
- Department of Radiology, Program Director Radiology Residency Program, Baystate Medical Center, University of Massachusetts, Springfield, MA
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Gandhi J, Dagur G, Sheynkin YR, Smith NL, Khan SA. Testicular compartment syndrome: an overview of pathophysiology, etiology, evaluation, and management. Transl Androl Urol 2016; 5:927-934. [PMID: 28078225 PMCID: PMC5182235 DOI: 10.21037/tau.2016.11.05] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Testicular compartment syndrome (TCS) refers to the impairment of microcirculation in the testicle due to either increased venous resistance or extraluminal compression, which leads to hypoxia. TCS releases oxidants through hypoxia and ischemia/reperfusion injury (IRI). The pathophysiology, etiology, evaluation, and management of TCS are reviewed. Based on the properties of TCS, specific causes, e.g., varicocele, hydrocele, orchitis, cryptorchidism, and scrotal hernia, are suggested and categorized. The oxidant-induced stress from TCS may explain the correlations between these causes and infertility. A chief shortcoming of current imaging modalities is that they detect TCS late after it has progressed to impair the macrocirculation of the testicle. We propose frequent sequential periodic power Doppler ultrasonography to monitoring for earlier detection. Intraoperatively, TCS can be diagnosed by the dull purple appearance of a hypoxic testicle and by tissue pressures above 30 mmHg. When compartment pressure is low, the underlying etiology must be promptly treated. During acute presentation, an incision of the resilient tunica albuginea may be necessary. A great challenge of treating TCS is restoring microcirculation while minimizing IRI; concomitant antioxidant therapy secondary to treatment may be effective and harmless at the least. Because testicular oxidant stress is common in infertility and since TCS can cause such a stress, TCS may be a larger factor in infertility than currently suspected.
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Affiliation(s)
- Jason Gandhi
- Department of Physiology and Biophysics, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Gautam Dagur
- Department of Physiology and Biophysics, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Yefim R Sheynkin
- Department of Urology, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | | | - Sardar Ali Khan
- Department of Physiology and Biophysics, Stony Brook University School of Medicine, Stony Brook, NY, USA;; Department of Urology, Stony Brook University School of Medicine, Stony Brook, NY, USA
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Ufuk F, Herek D, Herek Ö, Akbulut M. Role of diffusion weighted magnetic resonance imaging in a rat model of testicular torsion. Br J Radiol 2016; 89:20160585. [PMID: 27690538 DOI: 10.1259/bjr.20160585] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The purpose of this study was to investigate the usefulness of diffusion-weighted imaging (DWI) in the detection of different degrees of testicular torsion (TT) at the 8th hour and testicular salvageability at the 24th hour of torsion. METHODS 31 rats were randomly classified into 4 groups. In Group 1 (sham-control group), the left testicle was kept outside and replaced. Left testicles were kept outside and twisted 360° in Group 2, 720° in Group 3 and 1080° in Group 4. Later, DWI was performed at 8th and 24th hours. After DWI, bilateral radical orchiectomy and histopathological examination were performed. Apparent diffusion coefficient (ADC) maps were obtained with b-factors of 0 and 800 s mm-2. Comparisons of ADC values and damage in testicles were performed with Kruskal-Wallis test. RESULTS Sensitivity of DWI in the diagnosis of TT was 12.5% for 360° torsion, 100% for 720° torsion and 1080° torsion at the 8th hour of torsion. Mean ADC values of the left testicles increased significantly at the 24th hour of torsion in Groups 3 and 4. All testicles in Groups 3 and 4 were observed to be irrecoverable on histopathological examination. CONCLUSION Increased ADC values in the affected testicle may represent irreversible tissue damage. So, immediate surgery is not required at this stage, which may reduce morbidity and mortality caused by immediate surgery and anaesthesia. Advances in knowledge: TT can be diagnosed easily by DWI without administrating any contrast material. DWI findings in the affected testicle may represent testicular salvageability.
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Affiliation(s)
- Furkan Ufuk
- 1 Department of Radiology, Sandikli State Hospital, Afyonkarahisar, Turkey
| | - Duygu Herek
- 2 Department of Diagnostic Radiology, University of Pamukkale, Denizli, Turkey
| | - Özkan Herek
- 3 Department of Pediatric Surgery, University of Pamukkale, Denizli, Turkey
| | - Metin Akbulut
- 4 Department of Pathology, University of Pamukkale, Denizli, Turkey
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Fenton LZ, Karakas SP, Baskin L, Campbell JB. Sonography of pediatric blunt scrotal trauma: what the pediatric urologist wants to know. Pediatr Radiol 2016; 46:1049-58. [PMID: 27112160 DOI: 10.1007/s00247-016-3600-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 02/02/2016] [Accepted: 02/25/2016] [Indexed: 11/28/2022]
Abstract
Pediatric blunt scrotal trauma is most often the consequence of sports injury and presents a diagnostic challenge because swelling and pain make a scrotal physical exam difficult. US with color flow and duplex Doppler is the first-line imaging modality with the goal of accurate and timely diagnosis of injury requiring surgery to preserve fertility and hormonal function. US imaging findings following blunt scrotal trauma include hydrocele, hematocele, testicular hematoma, testicular fracture, testicular rupture, compromised perfusion/testicular torsion and testicular dislocation. Importantly, several of these findings may coexist. Our goal is to present the pertinent intrascrotal anatomy, US imaging findings for each testicular injury, and contemporary management for each, with emphasis on what our pediatric urology colleagues need to know for optimal patient care.
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Affiliation(s)
- Laura Z Fenton
- Department of Pediatric Radiology, Children's Hospital Colorado, affiliated with the University of Colorado School of Medicine, 13123 East 16th Ave., B125, Aurora, CO, 80045, USA.
| | - S Pinar Karakas
- Department of Radiology, UCSF Benioff Children's Hospital, Oakland, CA, USA
| | - Laurence Baskin
- Department of Pediatric Urology, UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Jeffrey B Campbell
- Department of Pediatric Urology, Children's Hospital Colorado, affiliated with the University of Colorado School of Medicine, Aurora, CO, USA
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Rouzrokh M, Mirshemirani A, Khaleghnejad-Tabari A. Outcomes of Second Look Exploration in Testicular Torsion of Children. IRANIAN JOURNAL OF PEDIATRICS 2015; 25:e528. [PMID: 26396707 PMCID: PMC4575805 DOI: 10.5812/ijp.528] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 12/25/2014] [Indexed: 11/29/2022]
Abstract
Background: Testicular torsion (TT), or twisting of the testicle resulting in a strangulation of the blood supply, occurs in men whose tissue surrounding the testicle is not well attached to the scrotum. It is important to emphasize that testicular torsion is a medical emergency. Objectives: The aim of this study is to evaluate the second look exploration and outcomes in TT. Patients and Methods: Seventy boys out of 124 patients underwent early exploration and 48 hours later second look exploration due to TT. All patients were checked with preoperative color-doppler ultrasonography (CDU) and intraoperative bleeding test. Data included age at admission, side of pathology, relation of TT with season of year, duration of preoperative history, degree of testicular torsion, CDU findings, and degree of bleeding; results of second look exploration, follow-up, and outcomes were analyzed. Results: Totally 70 patients were included in this study within five years, of which mean age was 28.6 ± 32.9 months (range 1 to 144), 48% of our patients had nausea and vomiting. Preoperative CDU showed absent/weak flow in 50 (71%) cases. Winter showed most frequently (44%) referred cases of testicular torsion. Orchidopexy was performed in 44 (63%) and orchidectomy in 26 (37%) cases after second look exploration. Mean follow-up duration was 3.1 ± 1.4 years. 4 (9%) cases in orchidopexy group developed testicular atrophy during follow-up, all four cases had a history of longer than 12 hours and grade II testicular bleeding test intra-operatively. Other orchidopexy patients salvaged. 26 patients, who were in grade III, underwent orchidectomy in second look exploration. Conclusions: TT requires emergency attention. The ischemia time of the testis is traditionally after 6 hours, and imaging or other diagnostic modality should not be a cause of delay. Early surgical exploration is modality of choice, and second look exploration after 48 hours can be more effective and salvageable in these patients.
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Affiliation(s)
- Mohsen Rouzrokh
- Pediatric Surgery Research Center, Shahid Beheshti University of Medial Sciences, Tehran, IR Iran
| | - Alireza Mirshemirani
- Pediatric Surgery Research Center, Shahid Beheshti University of Medial Sciences, Tehran, IR Iran
- Corresponding author: Alireza Mirshemirani, Pediatric Surgery Research Center, Shahid Beheshti University of Medial Sciences, Tehran, IR Iran. Tel/Fax: +98-2122924488, E-mail:
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Yu Y, Zhang F, An Q, Wang L, Li C, Xu Z. Scrotal Exploration for Testicular Torsion and Testicular Appendage Torsion: Emergency and Reality. IRANIAN JOURNAL OF PEDIATRICS 2015. [PMID: 26199690 PMCID: PMC4505972 DOI: 10.5812/ijp.248] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Scrotal exploration is considered the procedure of choice for acute scrotum. OBJECTIVES We evaluated the importance of early diagnosis and testicular salvage on the therapeutic outcomes of patients with pediatric testicular torsion (TT) and testicular appendage torsion (TAT) in our geographic area. PATIENTS AND METHODS We performed a retrospective database analysis of patients who underwent emergency surgery for TT or TAT between January 1996 and June 2009. Patient history, physical examination findings, laboratory test results, color Doppler sonography (CDS) results, and surgical findings were reviewed. RESULTS A total of 65 cases were included in our analysis. Forty-two cases were followed up for at least 3 months. Testicular tenderness was identified as the major clinical manifestation of TT, while only a few patients with TAT presented with swelling. CDS was an important diagnostic modality. The orchiectomy rate was 71% in the TT group. CONCLUSIONS Cases of acute scrotum require attention in our area. Early diagnosis and scrotal exploration could salvage the testis or preserve normal function without the need for surgery.
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Affiliation(s)
- You Yu
- Department of Pediatric Surgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Feng Zhang
- Department of Radiation Oncology, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Qun An
- Department of Pediatric Surgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Long Wang
- Department of Pediatric Surgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Chao Li
- Department of Pediatric Surgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Zhilin Xu
- Department of Pediatric Surgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
- Corresponding author: Zhilin Xu, Department of Pediatric Surgery, First Affiliated Hospital of Harbin Medical University, Harbin 150001, China. Tel: +86-45185555139, Fax: +86-45153670428, E-mail:
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Ubee SS, Hopkinson V, Srirangam SJ. Parental perception of acute scrotal pain in children. Ann R Coll Surg Engl 2015; 96:618-20. [PMID: 25350187 DOI: 10.1308/003588414x14055925058878] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Acute scrotal pain (ASP) remains one of the more common urological emergencies in the paediatric age group. Acute testicular torsion is the only true urological emergency, where delay in presentation or management can lead to loss of the affected testicle. Since prompt presentation, diagnosis and treatment are critical for testicular salvage, multiple patient and hospital specific factors may influence orchidectomy rates. Parental awareness of the sequelae of ASP may be a significant factor in delayed presentation of children to hospital. We examine the awareness among parents of the implications of ASP in this snapshot study. METHODS A prospective study was planned, and all boys between the ages of 2 and 16 years presenting to the unit with ASP and undergoing emergency scrotal exploration were considered for inclusion in the study. The accompanying parents/guardians of all these boys were asked to complete a questionnaire assessing their awareness of ASP and its potential consequences. RESULTS Over a period of 26 months (July 2010 to September 2012), 76 boys were eligible for the study. The response rate was 81.6%. Only a third (30%) presented to hospital within six hours of onset of pain and just under a quarter (22%) of the cohort attended the emergency department directly. Parents overwhelmingly (96%) felt that there ought to be increased public awareness of the condition. The majority of parents questioned (n=41, 66%) did not fully appreciate the implications of ASP. CONCLUSIONS This is a first snapshot study demonstrating the apparent lack of awareness among parents about the implications of ASP, which could influence the rate of testicular salvage.
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Affiliation(s)
- S S Ubee
- Royal Wolverhampton NHS Trust, UK
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31
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DaJusta DG, Granberg CF, Villanueva C, Baker LA. Contemporary review of testicular torsion: new concepts, emerging technologies and potential therapeutics. J Pediatr Urol 2013; 9:723-30. [PMID: 23044376 PMCID: PMC3566290 DOI: 10.1016/j.jpurol.2012.08.012] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Accepted: 08/25/2012] [Indexed: 12/25/2022]
Abstract
Testicular torsion is one of the few emergencies in pediatric urology which requires an accurate and timely diagnosis in order to avoid testis loss. It is not an uncommon event affecting a young male population. In fact, testicular torsion is more common than testicular tumors for this same age group, yet testicular torsion has not been given the public attention it deserves as a male health risk. In this review we highlight the new information published over the past four years regarding testicular torsion. We will discuss a variety of topics associated with torsion including: medical legal issues, etiology and genetics, imaging diagnostics, innovative surgical techniques, management controversies, fertility, and new drug therapies.
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Affiliation(s)
- Daniel G DaJusta
- Children's Medical Center, University of Texas Southwestern Medical School, Dallas, TX, USA
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32
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van Heurn LWE, Pakarinen MP, Wester T. Contemporary management of abdominal surgical emergencies in infants and children. Br J Surg 2013; 101:e24-33. [PMID: 24338775 DOI: 10.1002/bjs.9335] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Acute abdominal complaints in children are common presentations in the emergency department. The aetiology, presentation, diagnosis and management often differ from those in adults. METHODS This review was based on expert paediatric surgical experience confirmed by evidence from the literature obtained by searching PubMed and the Cochrane Library. Keywords used were the combinations of 'abdominal emergencies', 'acute abdomen' and the disorders 'acute appendicitis', 'intussusception', 'volvulus', 'Meckel's diverticulum', 'incarcerated inguinal hernia', 'testicular torsion' and 'ovarian torsion' with 'children'. Information was included from reviews, randomized clinical trials, meta-analyses, and prospective and retrospective cohort studies. RESULTS Presentation and symptoms of abdominal emergencies, especially in young children, vary widely, which renders recognition of the underlying disorder and treatment challenging. Critically targeted imaging techniques are becoming increasingly important in obtaining the correct diagnosis without unnecessary delay. Minimally invasive techniques have become the method of choice for the diagnosis and treatment of many abdominal emergencies in children. CONCLUSION Knowledge of abdominal disorders in childhood, their specific presentation, diagnosis and treatment facilitates management of children with acute abdomen in emergency departments. Imaging and minimally invasive techniques are becoming increasingly important in the diagnosis of acute abdomen in children. Urgent operation remains the cornerstone of therapy for most acute abdominal disorders.
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Affiliation(s)
- L W E van Heurn
- Departments of Paediatric Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
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Abstract
The current opinion on spermatic cord torsion is discussed in this review, with special attention to natural history, value of diagnostic tools, evidence for surgical management, outcome and management of atypical forms of torsion.
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Affiliation(s)
- Marcel Drlík
- Department of Urology, General Teaching Hospital and 1st Medical School of Charles University, Ke Karlovu 6, 128 08 Praha 2, Czech Republic.
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35
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Retrospective Review of Diagnosis and Treatment in Children Presenting to the Pediatric Department With Acute Scrotum. AJR Am J Roentgenol 2013; 200:W444-9. [DOI: 10.2214/ajr.12.10036] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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36
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Hebert SC, Chong WK, Deurdulian C. Essentials of scrotal ultrasound: A review of frequently encountered abnormalities. APPLIED RADIOLOGY 2012. [DOI: 10.37549/ar1932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Günther P, Rübben I. The acute scrotum in childhood and adolescence. DEUTSCHES ARZTEBLATT INTERNATIONAL 2012; 109:449-57; quiz 458. [PMID: 22787516 DOI: 10.3238/arztebl.2012.0449] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Accepted: 03/28/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND The acute scrotum in childhood or adolescence is a medical emergency. Inadequate evaluation and delays in diagnosis and treatment can result in irreversible harm, up to and including loss of a testis. Various diseases can produce this clinical picture. The testis is ischemic in only about 20% of cases. METHODS This review is based on a selective literature search, the existing clinical guideline, and the authors' experience. RESULTS The clinical approach to the acute scrotum must begin with a standardized, rapidly performed diagnostic evaluation. Dopper ultrasonography currently plays a central role. Its main use is to demonstrate the central arterial blood supply and venous drainage of the testis. The resistance index of the testicular vessels should also be determined. CONCLUSION Physical examination and properly performed Doppler ultrasonography enable adequate evaluation of the acute scrotum in childhood and adolescence. In the rare cases of diagnostic uncertainty, immediate surgical exposure of the testis remains the treatment of choice.
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Affiliation(s)
- Patrick Günther
- Sektion Kinderchirurgie, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany.
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Singhal A, Agarwal A, Metuge J, Olsavsky T. Neonatal testicular torsion with an unusual sonographic feature. JOURNAL OF CLINICAL ULTRASOUND : JCU 2012; 40:243-246. [PMID: 22287067 DOI: 10.1002/jcu.21889] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Accepted: 12/14/2011] [Indexed: 05/31/2023]
Abstract
Neonatal testicular torsion is a rare entity, the exact etiology of which is not elucidated. Imaging is performed using color Doppler ultrasound and scintigraphic studies with typically diminished testicular flow on the side with torsion. We present a case of testicular torsion in a newborn with increased testicular vascularity demonstrated by ultrasound and suggesting a torsion-detorsion sequence. Management of patients with torsion involves assessing the risks of neonatal surgery versus the possibility of finding viable testicular tissue at surgical exploration.
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Affiliation(s)
- Aparna Singhal
- Department of Radiology, St. Vincent's Medical Center, Bridgeport, Connecticut, USA
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Srinivasan A, Cinman N, Feber KM, Gitlin J, Palmer LS. History and physical examination findings predictive of testicular torsion: an attempt to promote clinical diagnosis by house staff. J Pediatr Urol 2011; 7:470-4. [PMID: 21454130 DOI: 10.1016/j.jpurol.2010.12.010] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 12/11/2010] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To standardize the history and physical examination of boys who present with acute scrotum and identify parameters that best predict testicular torsion. MATERIALS AND METHODS Over a 5-month period, a standardized history and physical examination form with 22 items was used for all boys presenting with scrotal pain. Management decisions for radiological evaluation and surgical intervention were based on the results. Data were statistically analyzed in correlation with the eventual diagnosis. RESULTS Of the 79 boys evaluated, 8 (10.1%) had testicular torsion. On univariate analysis, age, worsening pain, nausea/vomiting, severe pain at rest, absence of ipsilateral cremaster reflex, abnormal testicular position and scrotal skin changes were statistically predictive of torsion. After multivariate analysis and adjusting for confounding effect of other co-existing variables, absence of ipsilateral cremaster reflex (P < 0.001), nausea/vomiting (P < 0.05) and scrotal skin changes (P < 0.001) were the only consistent predictive factors of testicular torsion. CONCLUSION An accurate history and physical examination of boys with acute scrotum should be primary in deciding upon further radiographic or surgical evaluation. While several forces have led to less consistent overnight resident staffing, consistent and reliable clinical evaluation of the acute scrotum using a standardized approach should reduce error, improve patient care and potentially reduce health care costs.
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Affiliation(s)
- Arun Srinivasan
- Division of Pediatric Urology, Cohen Children's Medical Center of New York, North Shore-Long Island Jewish Health System, Long Island, Lake Success, NY 11042, USA
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Cokkinos DD, Antypa E, Tserotas P, Kratimenou E, Kyratzi E, Deligiannis I, Kachrimanis G, Piperopoulos PN. Emergency Ultrasound of the Scrotum: A Review of the Commonest Pathologic Conditions. Curr Probl Diagn Radiol 2011; 40:1-14. [DOI: 10.1067/j.cpradiol.2009.07.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Ralahy FM, Rambel H, Rakototiana FA, Rabenasolo M, Rantomalala Y, Andriamanarivo L. [A case of extravaginal twisting of spermatic cord]. Arch Pediatr 2010; 17:1448-50. [PMID: 20801007 DOI: 10.1016/j.arcped.2010.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Revised: 03/26/2009] [Accepted: 07/11/2010] [Indexed: 11/25/2022]
Abstract
Extravaginal twisting of the spermatic cord is rare and its management is still open to debate. We report the case in a 12-day-old boy with right testicular pain evolving since birth. Scrototomy revealed a complete twist of the extravaginal spermatic cord. The testis was already necrotic and the intervention consisted in orchidectomy and orchidopexy. Twisting of the extravaginal cord remains a surgical emergency, which allows contralateral orchydopexy.
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Affiliation(s)
- F M Ralahy
- Service de chirurgie pédiatrique, CHU Joseph Andrianavalona, Antananarivo, Madagascar.
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Bayne AP, Madden-Fuentes RJ, Jones EA, Cisek LJ, Gonzales ET, Reavis KM, Roth DR, Hsieh MH. Factors associated with delayed treatment of acute testicular torsion-do demographics or interhospital transfer matter? J Urol 2010; 184:1743-7. [PMID: 20728168 DOI: 10.1016/j.juro.2010.03.073] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2009] [Indexed: 11/27/2022]
Abstract
PURPOSE Testicular torsion is a true urological emergency. We determined whether a delay in treatment due to hospital transfer or socioeconomic factors would impact the orchiectomy rate in children with this condition. MATERIALS AND METHODS We retrospectively evaluated the records of boys seen at a single institution emergency department who proceeded to surgery for a diagnosis of acute testicular torsion from 2003 to 2008. Charts were reviewed for transfer status, symptom duration, race, insurance presence or absence and distance from the hospital. Orchiectomy specimens were evaluated for histological confirmation of nonviability. RESULTS We reviewed 97 records. The orchiectomy rate in patients who were vs were not transferred to the emergency department was 47.8% vs 68.9%, respectively (p = 0.07). Symptom duration was greater in the orchiectomy group with a mean difference of 47.9 hours (p <0.01). The mean transfer delay was 1 hour 15 minutes longer in the orchiectomy group (p = 0.01). Boys who underwent orchiectomy were 2.2 years younger than those who avoided orchiectomy (p = 0.01). Multivariate analysis showed that symptom duration and distance from the hospital were the strongest predictors of orchiectomy. CONCLUSIONS Data suggest that torsion is a time dependent event and factors that delay time to treatment lead to poorer outcomes. These factors include distance from the hospital and the time delay associated with hospital transfer.
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Affiliation(s)
- Aaron P Bayne
- Scott Department of Urology, Baylor College of Medicine, Houston, Texas, USA.
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Testicular torsion: sonomorphological appearance as a predictor for testicular viability and outcome in neonates and children. Pediatr Surg Int 2010; 26:281-6. [PMID: 19921212 DOI: 10.1007/s00383-009-2534-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/29/2009] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Testicular torsion in children is found both in neonates [perinatal testicular torsion (PTT), <30th day of life] and in older children [testicular torsion (TT)]. Prediction of testicular viability is essential for deciding whether to perform emergency exploration surgery. The aim of the present study, therefore, was to investigate the sonomorphological parameters as predictors for testicular viability. MATERIALS AND METHODS All our cases of sonographically diagnosed and surgically confirmed testicular torsion (n = 25) in a 7.5-year period were reviewed. We evaluated the overall group and two subgroups, PTT (n = 9) and TT (n = 16), and assessed the following sonomorphological parameters: normal echogenicity (homogeneous), diffuse hyper-/hypoechogenicity (homogeneous) and focal hyper-/hypoechogenicity (heterogeneous). These findings were correlated with the testicular recovery rate. RESULTS In both groups, we found the highest recovery rates in testes with normal, homogeneous echogenicity and a zero recovery rate in testes with heterogeneous echogenicity (p = 0.0117). CONCLUSIONS By using the sonomorpohological criteria presented here, testicular viability can be appraised in all age groups to help determine the prognosis for testicular outcome. In PTT, a nonperfused, homogeneously appearing testis represents the initial phase of torsion. Only for this type is there hope for salvage. In addition to the intraoperative appearance, a testis that is preoperatively heterogeneous in appearance can support the decision for orchiectomy.
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46
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Reis LO. Fundamentos de la práctica diaria de la urología y la medicina basada en la evidencia. Actas Urol Esp 2009. [DOI: 10.1016/s0210-4806(09)73180-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Eifinger F, Ahrens U, Wille S, Roth B, Engelmann U. Neonatal testicular infarction--possibly due to compression of the umbilical cord? Urology 2009; 75:1482-4. [PMID: 19854480 DOI: 10.1016/j.urology.2009.07.1270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2009] [Revised: 07/25/2009] [Accepted: 07/31/2009] [Indexed: 11/15/2022]
Abstract
Neonatal testicular infarction is a rare occurrence. We report on a newborn infant with bilateral testicular infarction. At birth, the uncut umbilical cord ran taut between the thighs making a complete loop around the genitals, compressing the testes. At the age of 6 hours, because of increasing agitation and the beginnings of scrotal discoloration, the infant was operated on, showing a bilateral testicular infarction potentially induced by strangulation of the twisted umbilical cord. Here, we discuss the clinical findings of neonatal testicular infarction and give advice as to the management of this serious complication with regard to the available published data.
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Affiliation(s)
- Frank Eifinger
- Department of Neonatology, University Childrens' Hospital, and Department of Urology, University of Cologne, Kerpener Strasse, Cologne, Germany.
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Hugo Nogueira V, Vila F, Osório L, Cavadas V, Teves F, Sabel F, Oliveira M, Branco F, La Fuente Carvalho JM, Marcelo F. Torção do cordão espermático: aspectos de diagnóstico e terapêutica. Rev Int Androl 2009. [DOI: 10.1016/s1698-031x(09)70259-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Ellati RT, Kavoussi PK, Turner TT, Lysiak JJ. Twist and Shout: A Clinical and Experimental Review of Testicular Torsion. Korean J Urol 2009. [DOI: 10.4111/kju.2009.50.12.1159] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Riyad T. Ellati
- Department of Urology, University of Virginia Health System, USA
| | | | - Terry T. Turner
- Department of Urology, University of Virginia Health System, USA
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