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Yığman M, Ekenci BY, Durak HM, Karakoyunlu AN. Predictive factors for manual detorsion success in testicular torsion. Int Urol Nephrol 2024:10.1007/s11255-024-04151-0. [PMID: 38985245 DOI: 10.1007/s11255-024-04151-0] [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: 05/14/2024] [Accepted: 07/07/2024] [Indexed: 07/11/2024]
Abstract
PURPOSE In cases of testicular torsion (TT), prompt diagnosis and treatment are highly associated with organ salvage, and manual detorsion (MD) is a recommended maneuver as a first intervention. In our study, we aimed to investigate the effect of predictive factors of TT in predicting the success of MD. METHODS A retrospective, 2-center study was conducted on patients diagnosed with TT between January 2015 and 2024. Demographic, clinical, ultrasound, and laboratory characteristics at presentation were analyzed. MD was routinely performed as the first intervention in all patients. Predictive parameters were compared in the MD success and failure groups. Univariate and multiple logistic regression analysis was used to identify risk factors for MD failure. RESULTS A total of 94 patients were included in the study. The median age of the patients was 20 (IQR: 12-69) years, and the median symptom duration was 6 (IQR: 4-12) hours. MD confirmed by Doppler ultrasonography was successful in 52 (55.3%) patients and unsuccessful in 42 (44.7%). Age, symptom duration, Testicular Workup for Ischemia and Suspected Torsion (TWIST) score, TWIST risk groups, WBC, neutrophil, monocyte counts, and Monocyte/Eosinophil ratio (MER) were statistically different between the two groups. In multiple logistic regression analysis, the risk factors for failure of MD were found to be being over 18 years of age, the duration of symptoms being longer than 9 h, and MER > 28. CONCLUSION Current urology guidelines suggest that age, symptom duration, and MER are reliable predictors of the success of MD, which is recommended in all cases of TT.
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Affiliation(s)
- Metin Yığman
- Department of Urology, Ankara Etlik Integrated Health Campus, Halil Sezai Erkut Street, Varlik, Etlik, Kecioren, 06170, Ankara, Turkey.
| | - Berk Yasin Ekenci
- Department of Urology, Ankara Etlik Integrated Health Campus, Halil Sezai Erkut Street, Varlik, Etlik, Kecioren, 06170, Ankara, Turkey
| | - Hüseyin Mert Durak
- Department of Urology, Ankara Etlik Integrated Health Campus, Halil Sezai Erkut Street, Varlik, Etlik, Kecioren, 06170, Ankara, Turkey
| | - Ahmet Nihat Karakoyunlu
- Department of Urology, Ankara Etlik Integrated Health Campus, Halil Sezai Erkut Street, Varlik, Etlik, Kecioren, 06170, Ankara, Turkey
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Qi X, Yu J, Ding X, Wang Y, Zhu H. Manual reduction in testicular torsion and subsequent treatment after successful reduction: a series of reports in a single institution. Front Pediatr 2024; 12:1362104. [PMID: 38529050 PMCID: PMC10961435 DOI: 10.3389/fped.2024.1362104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 02/28/2024] [Indexed: 03/27/2024] Open
Abstract
Introduction To explore the factors affecting the success of testicular torsion manual reduction and the safety of subsequent conservative treatment after successful reduction. Methods Clinical data of 66 patients with testicular torsion treated in our emergency department from February 2017 to February 2022 were retrospectively collected. Manual reduction without anesthesia was performed in 19 patients. Patients with successful manual reduction chose different subsequent treatments according to the wishes of themselves and their guardians, including continuing conservative treatment and surgical exploration. Relevant clinical data were collected and analyzed. Results Manual reduction was successful in 11 patients (11/19). Seven of them chose to continue conservative treatment, and four underwent surgical exploration immediately. Among the 7 patients who were treated conservatively, 3 underwent surgical treatment due to scrotal discomfort or testicular torsion at different stages, and the remaining 4 patients showed no recurrence of torsion during follow-up. Compared with other patients, patients with successful manual reduction had the shorter duration of pain (p < 0.05). The time from visiting our hospital to surgery in patients who attempted manual reduction was slightly shorter than those who underwent surgery directly (p > 0.05). The testes of these 11 patients were all successfully preserved. Conclusions The short duration of pain may contribute to the success of manual reduction, and manual reduction did not increase the preparation time before surgery. Due to the unpredictable risk of recurrence, immediate surgical treatment is still recommended, or postponed elective surgical treatment should be offered in the next days or weeks.
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Affiliation(s)
- Xiaokang Qi
- Department of Urology, Northern Jiangsu People’s Hospital, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Junjie Yu
- Department of Urology, Northern Jiangsu People’s Hospital, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Xuefei Ding
- Department of Urology, Northern Jiangsu People’s Hospital, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Yehua Wang
- Department of Urology, Northern Jiangsu People’s Hospital, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Haiyan Zhu
- Department of Day Surgery Ward, Northern Jiangsu People’s Hospital, Clinical Medical College, Yangzhou University, Yangzhou, China
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Hsu CT, Chiu PW. Successful Outcome of Manual Testicular Detorsion Using Point-of-Care Ultrasound Guidance: A Clinical Experience. Pediatr Emerg Care 2023; 39:813-815. [PMID: 37665788 DOI: 10.1097/pec.0000000000003048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
ABSTRACT Testicular torsion is a surgical emergency. It obstructs the blood supply to the testes, leading to testicular ischemia and necrosis. It presents with a sudden onset of severe unilateral testicular pain associated with nausea/vomiting, swollen scrotum, and high-riding testicles with an absent cremasteric reflex and negative Prehn sign. Prompt diagnosis of ischemic testicles using ultrasonography is challenging for emergency physicians. Color Doppler ultrasound may reveal a relative decrease or absence of blood flow in the affected testicle. The most specific ultrasonographic feature was the whirlpool sign of the spermatic cord. Manual detorsion should be performed as soon as possible before surgical intervention. However, manual detorsion may fail because of patient discomfort, incomplete torsion, and rotation of the testicle in a less common direction. We report a case demonstrating ultrasound-guided detorsion in a 14-year-old boy with right testicular torsion. The present case highlights the importance of incorporating ultrasound guidance into manual detorsion, which can improve the success rate of the procedure.
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Affiliation(s)
- Chien-Te Hsu
- From the Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Russo T, Cozzi DA, Gaglione G, Ceccanti S. The Role of Manual Detorsion in Pediatric Testicular Torsion During the Global COVID-19 Pandemic: Experience From 2 Centres. Urology 2023; 180:227-234. [PMID: 37150406 PMCID: PMC10162471 DOI: 10.1016/j.urology.2023.04.025] [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: 03/01/2023] [Revised: 04/07/2023] [Accepted: 04/18/2023] [Indexed: 05/09/2023]
Abstract
OBJECTIVE To evaluate the role of emergency manual detorsion as first line management for testicular torsion in the context of the COVID-19 pandemic. METHODS This retrospective observational study includes 90 pediatric patients ≤14 years old with diagnosis of testicular torsion made at 2 tertiary centers between October 2020 and June 2022. Variables examined included age, presentation delay, surgical wait time, number of attempts at manual testicular detorsion, and manual testicular detorsion success. All patients finally underwent surgery, including contralateral testicular fixation. Outcomes included predictors of successful manual detorsion, testicular findings at surgery, and operation time. RESULTS Mean (SD) age at diagnosis was 11.51 (2.64) years. Mean presentation delay was 11.76 (13.79) hours. Detorsion was attempted in 72 (80%) patients, resulting successful in 58 (80.5%). Surgical wait time after successful manual detorsion was 22.85 (16.94) hours. On multivariable analysis, successful manual detorsion was associated with a presentation delay<6 hours (odds ratios [OR] 0.154, 95% confidence intervals (CI) 0.036-0.655, P = 0.01) and absence of scrotal edema (OR 0.171, 95% CI 0.038-0.769, P = 0.02). Vice versa, a heterogeneous echo-texture (OR 0.57, 95% CI 0.007-0.461, P = 0.007) and absent blood flow on Doppler ultrasound scan (OR 0.256, 95% CI 0.067-0.971, P = 0.045) were significantly associated with the likelihood of manual detorsion failure. CONCLUSION In our experience, manual detorsion provided safe and effective emergency treatment for pediatric testicular torsion, especially in absence of edema and when presentation delay is <6 hours. This maneuver should be more widely attempted immediately after diagnosis as temporizing rescue.
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Affiliation(s)
- Tiziana Russo
- Pediatric Surgery Unit, Department of Surgery, AORN Santobono-Pausilipon, Naples, Italy
| | - Denis A Cozzi
- Pediatric Surgery Unit, Azienda Ospedaliero Universitaria Policlinico Umberto I, and Department of Maternal Infantile and Urological Sciences, "Sapienza" University of Rome, Italy.
| | - Giovanni Gaglione
- Pediatric Surgery Unit, Department of Surgery, AORN Santobono-Pausilipon, Naples, Italy
| | - Silvia Ceccanti
- Pediatric Surgery Unit, Azienda Ospedaliero Universitaria Policlinico Umberto I, and Department of Maternal Infantile and Urological Sciences, "Sapienza" University of Rome, Italy
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Zhou M, Zhang L, Zeng J, Lan Y, He F, Gao W, Li J, Wang Q, Guo W, Yuan Z, Zhang J. Visualizing the early-stage testicular torsion by dual-modal photoacoustic and ultrasound imaging. PHOTOACOUSTICS 2023; 31:100523. [PMID: 37362871 PMCID: PMC10285283 DOI: 10.1016/j.pacs.2023.100523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/27/2023] [Accepted: 06/08/2023] [Indexed: 06/28/2023]
Abstract
Delayed treatment of testicular torsion (TT) can lead to permanent loss of reproductive capacity. Photoacoustic imaging (PAI) and ultrasound imaging (USI) was tested for detecting TT at early stage in mice based on PAI-obtained oxygen saturation (sO2), and USI-collected color pixel density (CPD), peak systolic velocity (PSV) and resistance index (RI). For complete TT, both CPD (9.08 % ± 3.084 to almost zero) and sO2 data (70.09 % ± 1.656-59.84 % ± 1.427) showed an significant change 2 h post-torsion. For incomplete TT, sO2 data exhibited a strong time relationship (Mean values: 6 h, 64.83 % ± 1.898; 12 h, 60.67 % ± 3.555; 24 h, 57.85 % ± 3.575; P < 0.05). However, USI-collected CPD, PSV or IR data from the same TT models showed no significant difference. This study indicated that USI and PAI could identify complete TT. Meanwhile, PAI has shown great potential in the diagnosis of incomplete TT within 24 h based on time-related sO2 map.
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Affiliation(s)
- Mengyu Zhou
- School of Biomedical Engineering, Guangzhou Medical University, Guangzhou, Guangdong, China
- Guangdong Engine Research Center of Urinary Continence and Reproductive Medicine, The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan, Guangdong, China
| | - Luting Zhang
- School of Biomedical Engineering, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jianwen Zeng
- Guangdong Engine Research Center of Urinary Continence and Reproductive Medicine, The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan, Guangdong, China
| | - Yintao Lan
- Bioland Laboratory (Guangzhou Regenerative Medicine and Health—Guangdong Laboratory), Guangzhou, Guangdong, China
| | - Fengbing He
- School of Biomedical Engineering, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Weijian Gao
- School of Biomedical Engineering, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jinghang Li
- School of Biomedical Engineering, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Qian Wang
- School of Biomedical Engineering, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Weisheng Guo
- School of Biomedical Engineering, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Zhen Yuan
- Faculty of Health Sciences, University of Macao, Macao, China
| | - Jian Zhang
- School of Biomedical Engineering, Guangzhou Medical University, Guangzhou, Guangdong, China
- Guangdong Engine Research Center of Urinary Continence and Reproductive Medicine, The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan, Guangdong, China
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Ebrahim SH, Alaysreen AA, Yousif YF. Outcomes of Surgical Exploration of Acute Scrotal Pain Raising Suspicion of Testicular Torsion. Cureus 2023; 15:e40098. [PMID: 37425520 PMCID: PMC10328451 DOI: 10.7759/cureus.40098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 07/11/2023] Open
Abstract
Background and objective Testicular torsion (TT) is a surgical emergency, affecting approximately one in every 4000 males under the age of 25 years annually in the United States. In this study, we aimed to determine the outcomes of emergency scrotal surgical exploration of cases that raised suspicion of TT presenting to Salmaniya Medical Complex (SMC), Bahrain's largest secondary and tertiary care center. Methods This was a retrospective cohort study. The data were collected from the hospital's electronic medical record software (I-SEHA). The data included patient age, Doppler ultrasound (DUS) findings prior to any surgical procedure, type of surgical procedure, and the surgical findings of that procedure. Results Of the 198 patients who underwent scrotal exploration, 141 had presented with signs and symptoms suggestive of TT. The mean age of the patients was 22.3 ±9.3 years. Doppler imaging was performed preoperatively on 135 out of 141 (95.7%) patients. After scrotal exploration, 91.4% of the patients were found to have TT. The proportion of patients with salvageable testis was 78.7%. Conclusions The study found that surgical exploration remains the definitive method in the management of acute scrotum in TT patients. Our findings are in line with those from other similar studies and meta-analyses.
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Piotrowska-Gall A, Stępień P, Wolak P. A Survey of Current Practice in Operative Management of Testicular Torsion in Poland. CHILDREN 2023; 10:children10040643. [PMID: 37189892 DOI: 10.3390/children10040643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 03/22/2023] [Accepted: 03/28/2023] [Indexed: 03/31/2023]
Abstract
The primary aim of this study is to evaluate heterogeneity in the current management of testicular torsion (TT). A secondary aim is to investigate incidences of recurrent torsion and the methods used for primary fixation. An online multiple-choice questionnaire comprising 10 questions was distributed to paediatric surgeons and urologists. There were a total of 99 questionnaires distributed to representatives from 39 paediatric surgery and urology departments in Poland. The majority of participants agreed on fixation of the torsed testicle (98%). Use of sutures was reported by 95% of surgeons: absorbable by 48%, non-absorbable by 42%, and 4% using both. There was no consensus on the number of sutures. The contralateral testicle was always fixed by 69%, with 28% fixing it only in case of necrosis and amputation of the torsed testicle, and the remaining 2% never fixing the contralateral side. In case of negative scrotal exploration, 18% of surgeons would still fix the testis. The recurrence of torsion after prior fixation was identified by eight of the participants. The most commonly reported primarily used technique was absorbable sutures. There is a general consensus on the fixation of torsed testicles; however, other aspects remain controversial. Based on the survey and the literature review, the use of non-absorbable sutures rather than absorbable sutures would be advisable.
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Elifranji M, Abbas T, Leslie B, Vallasciani S, El Kadhi A, Pippi-Salle JL. Orchio-Septopexy: A new technique to cover and fix detorsed testis undergoing fasciotomy of tunica albuginea. Int Braz J Urol 2022; 48:706-711. [PMID: 35373956 PMCID: PMC9306361 DOI: 10.1590/s1677-5538.ibju.2022.0128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose Compartment Syndrome (CS) has been recognized as a potential factor that worsens testicular viability after detorsion, especially in borderline cases of prolonged ischemia. Fasciotomy of the testicular tunica albuginea to relieve the pressure associated with CS has been proposed to accommodate edema after detorsion, embracing the raw fasciotomy area with tunica vaginalis flap (TVF) or graft. Fashioning the TVF can be tedious in cases of severe scrotal edema. Herein we present a technique that facilitates and expedites the procedure, maintaining the fasciotomy area decompressed. Materials and Methods In testicular torsion, where the testis remains with dark coloration and questionable viability after detorsion a longitudinal releasing incision is made in the tunica albuginea (fasciotomy) to decrease compartmental pressure. If signs of parenchymal recovery (bleeding points, better color) are seen an orchio-septopexy is performed, suturing the incised albuginea’s edges to the septum with a running suture, avoiding CS as well as re-torsion. Results Orchio-septopexy was performed in 11 cases with a mean age of 11.9 years (3-17). All cases had clinic follow-up and testicular Doppler US with a mean of 9.5 months (6-24). 6/11 cases (54%) were salvaged, with good vascularity in the Doppler US and maintained more than 50% testicular volume compared to the contralateral side. Conclusion Orchio-septopexy after testicular fasciotomy is a simple and fast technique that can be utilized in cases of prolonged testicular ischemia and questionable viability. More than half of the testes recovered, encouraging us to propose its utilization as well as its validation by other surgeons.
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Affiliation(s)
- Mohammed Elifranji
- Department of Surgery, Division of Pediatric Urology, Sidra Medicine, Doha, Qatar
| | - Tariq Abbas
- Department of Surgery, Division of Pediatric Urology, Sidra Medicine, Doha, Qatar
| | - Bruno Leslie
- Department of Surgery, Division of Pediatric Urology, Sidra Medicine, Doha, Qatar
| | - Santiago Vallasciani
- Department of Surgery, Division of Pediatric Urology, Sidra Medicine, Doha, Qatar
| | - Abderrahman El Kadhi
- Department of Surgery, Division of Pediatric Urology, Sidra Medicine, Doha, Qatar
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Cabral Dias Filho A, Rincon Cintra da Cruz P, Zanettini Riccetto CL. Testicular Torsion Patients Should Be Manually Detorsed at Diagnosis: A Propensity Score Matched Analysis of the Influence of Interhospital Transfer and Surgical Wait Times on Surgical Organ Salvage. Pediatr Emerg Care 2022; 38:e936-e942. [PMID: 34225327 DOI: 10.1097/pec.0000000000002492] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to assess organ salvage in testicular torsion patients submitted to manual detorsion according to interhospital transfer and surgical wait times. METHODS Retrospective analysis of consecutive surgically treated testicular torsion patients between 2012 and 2018. We compared testicular surgical salvage in testicular torsion patients submitted to manual detorsion either at clinical diagnosis (immediate detorsion) or after interhospital transfer from lower level-of-care facilities (delayed detorsion) and estimated the influence of interhospital transfer and surgical wait times on outcomes. Analysis included Bayesian logistic regression after propensity score matching. We excluded patients first examined at off-state and private facilities, with prediagnostic time of more than 24 hours, not initially diagnosed with testicular torsion or not submitted to manual detorsion at any time. RESULTS One hundred sixty-two patients (median age, 15.8 years) fulfilled inclusion criteria. The median prediagnostic, transfer, and surgical wait times were respectively 4.9, 2.4, and 4.3 hours, with 58 patients undergoing immediate and 104 delayed detorsion. Propensity score matching for prediagnostic and surgical wait times paired 58 immediate with 40 delayed detorsion patients, with corresponding surgical salvage rates of 54/58 (93%) and 33/40 (82%). Forty-seven patients (29%) still had torsion at surgery. Transfer time was inversely associated with testicular salvage, with median 13% greater probability of an unfavorable outcome for each hour of transfer time. Similarly, each hour of surgical wait time decreased surgical salvage by 6%. CONCLUSIONS Immediate detorsion led to improved surgical outcomes in testicular torsion patients. Because of residual torsion, surgery for detorsed patients should not be postponed.
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Nene RV, Subramony R, Macias M, Campbell C, Aminlari A. Real-time Point-of-care Ultrasound for the Diagnosis and Treatment of Testicular Torsion. POCUS JOURNAL 2021; 6:70-72. [PMID: 36895665 PMCID: PMC9979951 DOI: 10.24908/pocus.v6i2.15186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background: Testicular torsion is a surgical emergency that needs prompt diagnosis and treatment. Point-of-Care ultrasound (POCUS) can not only establish the diagnosis but also guide the Emergency Physician in evaluating the response to manual detorsion. Case Report: We describe the case of a 13-year-old male who presented with acute scrotal pain. We demonstrate how bedside ultrasound was used to make the diagnosis of testicular torsion, guide the technique for manual detorsion, and confirm adequate return of blood flow. Our case illustrates the ease with which POCUS can be used in real time to diagnose and treat organ-threatening pathology, but more importantly, it shows how real-time POCUS was used to detorse a testicle that was refractory to the standard detorsion technique. Conclusion: The acute scrotum is a time-sensitive presentation and if testicular torsion is present, the diagnosis should be made as soon as possible. Many Emergency Departments do not have 24-hour coverage of ultrasound technicians, which would delay the diagnosis and treatment. Moreover, when manual detorsion is attempted, it often does not work because the testicle may need more than the standard 180 degree medial to lateral rotation. POCUS provides real-time analysis of return of blood flow and can thus guide further rotation, or opposite direction rotation, as needed.
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Affiliation(s)
- Rahul V Nene
- Department of Emergency Medicine, University of California San Diego, CA
| | - Rachna Subramony
- Department of Emergency Medicine, University of California San Diego, CA
| | - Michael Macias
- Department of Emergency Medicine, University of California San Diego, CA
| | - Colleen Campbell
- Department of Emergency Medicine, University of California San Diego, CA
| | - Amir Aminlari
- Department of Emergency Medicine, University of California San Diego, CA
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Vasconcelos-Castro S, Flor-de-Lima B, Campos JM, Soares-Oliveira M. Manual detorsion in testicular torsion: 5 years of experience at a single center. J Pediatr Surg 2020; 55:2728-2731. [PMID: 32169343 DOI: 10.1016/j.jpedsurg.2020.02.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 01/25/2020] [Accepted: 02/19/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Testicular torsion is one of the most common causes of acute scrotum in pediatric age. The present study aimed to evaluate the role of preoperative manual detorsion in the management of testicular torsion. METHODS Retrospective data analysis of pediatric patients treated for acute testicular torsion at a tertiary center over the last 5 years. Manual detorsion was attempted by surgeon's preference. Successful manual detorsion was defined as complete pain resolution with a normal color Doppler ultrasound. All patients underwent surgical exploration. Patient data analyzed included: age, pain duration, site of onset, attempt of manual detorsion, pain relief after manual detorsion, color Doppler ultrasound results, surgical findings and outcome. RESULTS One hundred twenty-two patients were included. Manual detorsion was attempted in 48% (58/122) cases. Manual detorsion was successful in 26% (15/58) patients. In the unsuccessful, residual cord torsion was found at surgery in 27.5% (16/58); in the remaining 27, there was no cord torsion at surgery. Five patients (5/15) with successful manual detorsion underwent elective orchiopexy. Gonadal loss after manual detorsion (9%, 5/58) occurred after unsuccessful manual detorsion, all submitted to emergency surgery. CONCLUSIONS Testicular torsion warrants prompt detorsion. Manual detorsion is simple, immediately available, and maximizes testis salvage. A successful maneuver permits nonemergency orchiopexy. An algorithm for the management of testicular torsion that includes an attempt of manual detorsion prior to surgery is proposed. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Sofia Vasconcelos-Castro
- Department of Pediatric Surgery, Centro Hospitalar Universitário São João, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal.
| | - Beatriz Flor-de-Lima
- Department of Radiology, Centro Hospitalar Universitário São João, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
| | - José Miguel Campos
- Department of Pediatric Surgery, Centro Hospitalar Universitário São João, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Miguel Soares-Oliveira
- Department of Pediatric Surgery, Centro Hospitalar Universitário São João, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal; Faculty of Medicine, Universidade do Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
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Dias AC, Maroccolo MVO, Ribeiro HDP, Riccetto CLZ. Presentation delay, misdiagnosis, inter-hospital transfer times and surgical outcomes in testicular torsion: analysis of statewide case series from central Brazil. Int Braz J Urol 2020; 46:972-981. [PMID: 32758303 PMCID: PMC7527113 DOI: 10.1590/s1677-5538.ibju.2019.0660] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 12/02/2019] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To estimate statewide presentation delay, misdiagnosis rate, inter-hospital transfer times and testicular salvage for testicular torsion patients treated in our state's public health system. PATIENTS AND METHODS Case series of consecutive testicular torsion patients treated in our state's public health system between 2012-2018. Predictors included presentation delay (time from symptoms to first medical assessment), facilitie's level-of-care (primary, secondary, tertiary), first diagnosis (torsion, epididymitis, other), Doppler-enhanced ultrasound request (Doppler-US) and inter-hospital transfer times, with surgical organ salvage as the main response. We used Bayesian regression to estimate the effect of first examining facilitie's level-of-care, first diagnosis, and Doppler-US on transfer time. RESULTS 505 patients were included, most (298, 59%) with presentation delay >6 hours. Misdiagnosis at first examining facility raised transfer time from median 2.8 to 23.4 (epididymitis) and 37.9 hours (other) and lowered testicular salvage rates from 60.3% (torsion) to 10.7% (epididymitis) and 18.3% (other). Doppler-US had negligible effects on transfer time once controlling for misdiagnosis in the regression model. Although organ salvage in patients presenting before 6 hours at the tertiary facility was high (94.6%, and about 20% lower for those presenting at lower levels-of-care), the overall salvage rate was more modest (46%). CONCLUSION Our low overall testicular salvage rates originated from a large proportion of late presentations combined with long transfer times caused by frequent misdiagnoses. Our results indicate that efforts to improve salvage rates should aim at enhancing population-wide disease awareness and continuously updating physicians working at primary and secondary levels-of-care about scrotal emergencies.
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Affiliation(s)
- Aderivaldo Cabral Dias
- Unidade de Urologia do Hospital de Base do Distrito Federal, Brasília, DF, Brasil
- Disciplina de Urologia, Departamento de Cirurgia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas - UNICAMP, Campinas, SP, Brasil
| | - Marcus Vinicius Osorio Maroccolo
- Unidade de Urologia do Hospital de Base do Distrito Federal, Brasília, DF, Brasil
- Departamento de Cirurgia, Hospital da Criança José de Alencar, Brasília, DF, Brasil
| | | | - Cassio Luis Zanettini Riccetto
- Disciplina de Urologia, Departamento de Cirurgia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas - UNICAMP, Campinas, SP, Brasil
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Vasconcelos-Castro S, Soares-Oliveira M. Abdominal pain in teenagers: Beware of testicular torsion. J Pediatr Surg 2020; 55:1933-1935. [PMID: 31515114 DOI: 10.1016/j.jpedsurg.2019.08.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 08/19/2019] [Accepted: 08/20/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND/PURPOSE Testicular torsion (TT) remains an important cause of testicular loss. Subtle presentations, such as abdominal pain, may be responsible for late diagnosis and increased testicular loss. This study assesses the influence of pain onset location over testicular outcome. METHODS Data of children 17 years and younger submitted to surgical treatment for TT by our department from January 2017 to December 2018 were collected. Demographics, clinical presentation and outcome were reviewed. RESULTS 73 patients (median age of 15.3 years old) were included in the study. 22% (16/73) patients presented with abdominal pain. When compared to patients with initial testicular pain, patients with abdominal pain showed a significant delay in TT diagnosis/treatment (median pain duration of 36 h vs 5 h) and a significantly higher rate of testicular loss [81% (13/16) vs 4% (2/57), p < 0.001]. The majority of testicular losses (68%, 13/19) occurred in patients with abdominal pain. In patients with abdominal pain, TT was initially overlooked in 69% (11/16) of cases, resulting in 81% (9/11) gonadal loss; none of these 11 patients were initially evaluated by a surgeon. All patients with testicular pain were evaluated in order to exclude TT. CONCLUSIONS Abdominal pain is a frequent presentation of TT, being an important cause of delayed diagnosis/treatment and associated higher testicular loss rate. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Sofia Vasconcelos-Castro
- Department of Pediatric Surgery, Centro Hospitalar Universitário São João, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal.
| | - Miguel Soares-Oliveira
- Department of Pediatric Surgery, Centro Hospitalar Universitário São João, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
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Hong H, Cai W, Wu J, Wu X, Lin L, Li T, Zhu Q, Gao Y, Ye L, Wei Y, Yang J. Scrotoscopy and traditional open surgery shows a high degree of consistency in the diagnosis of testicular torsion: An initial report. Medicine (Baltimore) 2020; 99:e21545. [PMID: 32756211 PMCID: PMC7402747 DOI: 10.1097/md.0000000000021545] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Traditional open surgery (OS) is usually necessary when testicular torsion (TT) cannot be excluded by scrotal ultrasound. Scrotoscopy has been used as a minimally invasive technique to diagnose or treat scrotal diseases, and it may also play a role in diagnosing TT.A retrospective analysis was performed for patients with TT to evaluate the consistency of scrotoscopy and OS in the diagnosis of TT. In the cases where preoperational Color Doppler ultrasonography was performed, scrotoscopy, open surgery, and confirmed TT were included for future analysis.A total of 43 patients were studied. Twisted testes were retained in 11 cases (25.59%), and the remaining 32 patients (74.41%) underwent orchiectomy. There were significant differences in the diagnostic value between the grading of scrotoscopy and ultrasound, as well as between ultrasound grading and blood supply grading (BSG) (both P < .05). However, no significant difference was observed between the grading of scrotoscopy and BSG in traditional OS (P > .05), but a high degree of consistency existed between scrotoscopy grading and BSG in traditional OS (Kappa = 0.733, P ≤ .001).Our limited data indicate that the diagnosis of testicular torsion by scrotoscopy is highly consistent with that of traditional surgical exploration. Therefore, further studies are necessary to confirm its application value in the future. Scrotoscopy may have potential application value for the patients whom testicular torsion are insufficiently diagnosed but cannot be excluded.
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Affiliation(s)
- Huaishan Hong
- Shengli Clinical Medical College of Fujian Medical University
- Department of Urology, Fujian Provincial Hospital South Branch
| | - Wanghai Cai
- Shengli Clinical Medical College of Fujian Medical University
- Department of Urology, Fujian Provincial Hospital, Fuzhou
| | - Jinfeng Wu
- Shengli Clinical Medical College of Fujian Medical University
- Department of Urology, Fujian Provincial Hospital, Fuzhou
| | - Xiang Wu
- Shengli Clinical Medical College of Fujian Medical University
- Department of Urology, Fujian Provincial Hospital, Fuzhou
| | - Le Lin
- Shengli Clinical Medical College of Fujian Medical University
- Department of Urology, Fujian Provincial Hospital, Fuzhou
| | - Tao Li
- Shengli Clinical Medical College of Fujian Medical University
- Department of Urology, Fujian Provincial Hospital, Fuzhou
| | - Qingguo Zhu
- Shengli Clinical Medical College of Fujian Medical University
- Department of Urology, Fujian Provincial Hospital, Fuzhou
| | - Yunliang Gao
- Department of Urology, the Second Xiangya Hospital, Central South University, Changsha, China
| | - Liefu Ye
- Shengli Clinical Medical College of Fujian Medical University
- Department of Urology, Fujian Provincial Hospital, Fuzhou
| | - Yongbao Wei
- Shengli Clinical Medical College of Fujian Medical University
- Department of Urology, Fujian Provincial Hospital, Fuzhou
| | - Jinrui Yang
- Department of Urology, the Second Xiangya Hospital, Central South University, Changsha, China
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Friedman N, Pancer Z, Savic R, Tseng F, Lee MS, Mclean L, Bagli DJ, Tessaro MO. Accuracy of point-of-care ultrasound by pediatric emergency physicians for testicular torsion. J Pediatr Urol 2019; 15:608.e1-608.e6. [PMID: 31455581 DOI: 10.1016/j.jpurol.2019.07.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/05/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Acute scrotum is a common presentation to the pediatric emergency department, and ultrasound is frequently used to narrow the differential diagnosis. Point-of-care ultrasound (POCUS) is increasingly used by urologists and emergency physicians and could potentially be used to detect pediatric testicular torsion. OBJECTIVES This study aimed to determine the accuracy of POCUS by pediatric emergency physicians in diagnosing testicular torsion and the agreement between point-of-care ultrasound and final diagnosis for other causes of acute scrotum. STUDY DESIGN A chart review of patients presenting to the study emergency department who received POCUS by a pediatric emergency physician, as well as radiology department ultrasound and/or surgery, was performed. Charts were reviewed for POCUS diagnoses, final diagnoses, and imaging time metrics. RESULTS A total of 120 patients met study criteria, with 12 cases of testicular torsion. The diagnostic accuracy of POCUS for testicular torsion is described in the summary table. For all causes of acute scrotum, point-of-care ultrasound agreed with final diagnosis in 70% (95% confidence interval [CI] 62-78%) of cases, and more experienced point-of-care ultrasound users displayed higher agreement with final diagnosis. Point-of-care ultrasound results were generated a median of 73 min (Q1 = 51, Q3 = 112) before radiology department ultrasound results. DISCUSSION Scrotal POCUS performed by pediatric emergency physicians appears to be an accurate tool to detect testicular torsion in children with acute scrotum and saves time compared with radiology ultrasound. The study results may not be generalizable to hospitals without a multidisciplinary POCUS system for quality assurance and image sharing. Future work on POCUS for acute scrotum should investigate its impact on patient outcomes, cost-effectiveness, and family satisfaction. CONCLUSION Point-of-care ultrasound by pediatric emergency physicians is accurate for detecting testicular torsion in children with acute scrotum and could expedite diagnosis of this time-sensitive condition.
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Affiliation(s)
- N Friedman
- Emergency Point-of-Care Ultrasound Program, Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada.
| | - Z Pancer
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - R Savic
- Emergency Point-of-Care Ultrasound Program, Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - F Tseng
- Emergency Point-of-Care Ultrasound Program, Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - M S Lee
- Emergency Point-of-Care Ultrasound Program, Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - L Mclean
- Emergency Point-of-Care Ultrasound Program, Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - D J Bagli
- Division of Urology, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - M O Tessaro
- Emergency Point-of-Care Ultrasound Program, Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada
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Osumah TS, Jimbo M, Granberg CF, Gargollo PC. Frontiers in pediatric testicular torsion: An integrated review of prevailing trends and management outcomes. J Pediatr Urol 2018; 14:394-401. [PMID: 30087037 DOI: 10.1016/j.jpurol.2018.07.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 07/13/2018] [Indexed: 12/12/2022]
Abstract
Testicular torsion remains the most frequent cause of testicular ischemia, especially in adolescents and young adults. Timely diagnosis and intervention are keys to saving the affected testicle. This review presents current trends in the diagnosis and treatment of torsion, potential pitfalls and consequent outcomes. Additionally, other salient issues surrounding testicular torsion are also discussed, including: pathogenesis of injury, legal ramifications, fertility outcomes, novel management techniques, and recent advances in diagnostic technology.
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Affiliation(s)
- T S Osumah
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | - M Jimbo
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | - C F Granberg
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | - P C Gargollo
- Department of Urology, Mayo Clinic, Rochester, MN, USA.
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Chu DI, Gupta K, Kawal T, Van Batavia JP, Bowen DK, Zaontz MR, Kolon TF, Weiss DA, Zderic SA, Canning DA. Tunica vaginalis flap for salvaging testicular torsion: A matched cohort analysis. J Pediatr Urol 2018; 14:329.e1-329.e7. [PMID: 29454628 PMCID: PMC6078825 DOI: 10.1016/j.jpurol.2018.01.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 01/17/2018] [Indexed: 10/18/2022]
Abstract
INTRODUCTION In testicular torsion, ischemia time from pain onset impacts testicular salvage. A tunica albuginea fasciotomy to relieve compartment pressure followed by a tunica vaginalis flap (TVF) may enhance salvage. OBJECTIVE To define the optimal window of ischemia time during which TVF may be most beneficial to avoid orchiectomy. STUDY DESIGN A retrospective cohort study of males presenting with testicular torsion at a single tertiary-care institution from January, 2003 to March, 2017. Ischemia time was defined as duration of pain from onset to surgery. Because TVF would be an option to orchiectomy, and it was found that ischemia time was longer in testicles that underwent orchiectomy, matching was performed. Cases of torsion treated with TVF were matched 1:1 with cases treated with orchiectomy on age at surgery, and ischemia time. Outcomes included postoperative viability, defined as palpable testicular tissue with normal consistency, and atrophy, defined as palpable decrease in size relative to contralateral testicle. Sensitivity analyses were performed restricting to the subgroups with postoperative ultrasound, >6 months' follow-up, and additionally matching for degrees of twist. RESULTS A total of 182 patients met eligibility criteria, of whom 49, 36, and 97 underwent orchiectomy, TVF, and septopexy alone, respectively. Median follow-up was 2.7 months; 26% of patients had postoperative ultrasound (61% of TVF group). In the orchiectomy, TVF, and septopexy groups, respectively, median ischemia times were 51, 11, and 8 h, postoperative viability rates were 0, 86, and 95%, and postoperative atrophy rates were 0, 68, and 24%. After matching, 32 patients with TVF were matched to 32 patients who underwent orchiectomy. In the TVF group, postoperative viability occurred in 95% (19/20) vs 67% (8/12) of patients with ischemia times ≤24 and >24 h, respectively. Atrophy occurred in 67% (12/18) vs 83% (10/12) of these same respective patients. Sensitivity analysis by ultrasound and longer follow-up found similar viability results, although atrophy rates were higher. Additional matching for degrees of twist showed lower viability and higher atrophy rates for increasing ischemia times. DISCUSSION Patients who presented with testicular torsion with ischemia times ≤24 h and who were being considered for orchiectomy may have benefitted most from TVF, albeit at high risk of atrophy. However, for ischemia times >24 h, TVF may still have preserved testicular viability in two-thirds of cases. A limitation was short follow-up. CONCLUSION A TVF was a valid alternative to orchiectomy for torsed testicles, albeit with high testicular atrophy rates.
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Affiliation(s)
- D I Chu
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, USA.
| | - K Gupta
- The George Washington University School of Medicine and Health Sciences, Washington, USA
| | - T Kawal
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - J P Van Batavia
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - D K Bowen
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - M R Zaontz
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - T F Kolon
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - D A Weiss
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - S A Zderic
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - D A Canning
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, USA
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Direction of Rotation in Testicular Torsion and Identification of Predictors of Testicular Salvage. Urology 2018; 114:163-166. [PMID: 29203186 DOI: 10.1016/j.urology.2017.11.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 11/15/2017] [Accepted: 11/21/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To identify the rate at which testicular torsion occurs in a lateral direction and identify any predictors of direction of testicular rotation and orchiectomy. MATERIALS AND METHODS We performed a retrospective review of 104 cases of emergent scrotal exploration performed for testicular torsion by 3 pediatric urologists from 2003 to 2017. Patients with neonatal torsion, negative scrotal exploration, or exploration for presumed intermittent testicular torsion were excluded. Univariable logistic regression was performed to assess if any factors predicted direction of testicular rotation. Univariable and multivariable logistic regression was used to identify predictors of testicular salvage. RESULTS Of 104 cases of acute testicular torsion, information regarding the direction of testicular rotation was available in 81 patients. Lateral testicular rotation occurred in 38 cases (46%). No factors were found to be predictive of direction of torsion. Orchiectomy for testicular nonviability was performed in 50 of 104 cases (48%). On univariable analysis, younger age (p = .002), absence of gastrointestinal symptoms (P = .02), time to exploration (P < .001), testicular size differential on ultrasound (p = .002), absence of hydrocele (P = .01), abnormal ultrasound echotexture (P < .001), and degree of torsion (P = .04) were associated with orchiectomy. With the exception of absence of gastrointestinal symptoms, all predictors of orchiectomy remained statistically significant on multivariable analysis. CONCLUSION Testicular rotation occurs in a lateral direction in 46% of cases. Lateral manual detorsion should be performed only with awareness of the potential for increasing the degree of testicular rotation. New independent predictors of testicular salvage were identified.
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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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20
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Wan J. This Month in Pediatric Urology. J Urol 2017. [DOI: 10.1016/j.juro.2016.12.026] [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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