Histological study in contralateral testis of prepubertal children following unilateral testicular torsion

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

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

Testicular torsion: orchiectomy or orchiopexy?

OBJECTIVE

To evaluate the impact on testicular function of the surgical approach used to treat testicular torsion.

PATIENTS AND METHODS

Seventeen males operated on for testicular torsion at a median age of 14 years were investigated. Serum follicle-stimulating hormone (FSH), testosterone and inhibin B as well as testicular volume were measured early (median 36 days) and/or late (median 1.1 years) after operation.

RESULTS

Orchiectomy was performed in six, and testicular detorsion and orchiopexy in 11 patients. The duration of the preoperative symptoms in the detorsion group was 15 h (range 6-168) and in the orchiectomy group 42 h (range 24-96) (P=0.03). Preoperative colour Doppler ultrasonography showed some circulation in 40% of the patients. At 1 month the median serum inhibin B level was significantly higher after preserving surgery (P=0.01). At 1 year postoperatively, the median serum FSH level tended to be lower after testicular preservation (P=0.09). Abnormal inhibin B or FSH values were observed in 35% of the patients.

CONCLUSIONS

Testicular function is often compromised in patients with testicular torsion. Testis-preserving surgery yields better testicular function than orchiectomy in the short term if the testis is not obviously necrotic. Testicular torsion does not necessarily cause the circulation to cease completely, and preserving surgery can also sometimes be attempted after delayed diagnosis.

Effect of angiotensin-converting enzyme inhibition and angiotensin II type 1 receptor blockade on apoptotic changes in contralateral testis following unilateral testicular torsion

OBJECTIVES

In this experimental study, our aim was to determine whether angiotensin-converting enzyme (ACE) inhibition and angiotensin II type 1 (AT1) receptor blockade affect the apoptotic changes in contralateral testis following unilateral testicular torsion (UTT).

METHODS

Study groups consisted of 30 adult male Wistar rats. The rats were randomly separated into five groups. Group 1 was maintained as control without manipulation. Group 2 underwent the sham operation. Torsion was created by rotating the left testis 720 degrees clockwise for 4 h and maintained by fixing the testis to the scrotum in the other groups. Group 3 underwent torsion and detorsion, with saline administration after detorsion. In group 4, the same surgical procedure was done as in the detorsion group, but AT1 receptor blocker (losartan 30 mg/kg) was injected intraperitoneally for 60 min before detorsion. In group 5, the same surgical procedure was done as in the detorsion group, but ACE inhibitor (lisinopril 50 mg/kg) was injected intraperitoneally for 60 min before detorsion. Bilateral testes were removed from each rat 24 h after surgery. Apoptosis was assessed in paraffin-embedded sections stained for TUNEL method. Reticulum staining was performed to evaluate the extracellular changes semiquantitatively. Testicular biopsy score counts were performed on these sections according to Johnsen.

RESULTS

The mean apoptotic scores of group 1, group 2 and group 3 were significantly higher than that of the other groups. There was no difference between the apoptotic scores of groups 1, 2, 4 and 5. Reticulum stain was increased in group 3 as compared to other groups. The mean Johnsen biopsy score of group 3 was significantly lower than that of the other groups.

CONCLUSION

ACE inhibition and AT1 receptor blockade reduced the tubular damage and apoptosis in the contralateral testes after UTT. The beneficial effect of these drugs may arise from inhibition of ischemic process resulting from increased sympathetic activity and elimination of insults subsequent to dysregulation of RAS. These results suggest that ACE inhibitors and AT1 receptor blockers may be of potential value in patients with UTT.

Prenatal testicular torsion: Ultrasonographic features, management and histopathological findings

AIM

To highlight the ultrasonographic features of prenatal torsion of the testis in utero (IUTT) at presentation, the neonatal management and the histological findings postorchiectomy or biopsy.

METHODS

Seven newborns underwent emergency exploration for IUTT. All patients underwent a sonography and real-time color Doppler ultrasound study of the scrotum before any surgical procedure. A histological examination was performed in the removed specimens.

RESULTS

Sonography of the scrotum revealed enlarged, heterogeneous testes. In all cases the color and power Doppler did not reveal any flow signal on the affected side. Four newborn with unilateral testicular torsion underwent orchiectomy and contralateral orchidopexy. In one neonate after detorsion and with the absence of gangrenous changes and a reassuring biopsy, a twisted testis could be treated conservatively with orchidopexy. In another case, the parents, acknowledging the inviability of the affected testis, gave consent only for a biopsy of the testis. In the neonate with bilateral IUTT, bilateral testicular biopsies were performed. Histology of the removed testes variably showed interstitial red cell extravasion and coagulation or hemorrhagic necrosis. Light microscopy of the preserved testis highlighted surviving seminiferous tubules, with gonocytes, spermatogonia and fetal Sertoli cells.

CONCLUSIONS

An early diagnosis and treatment in IUTT is essential. Surgical exploration should be always performed through the inguinal route. In bilateral IUTT testes should be left to try to assure, as long as possible, a residual Leydig cell function.

[Spermatic cord torsion in the newborn: role of surgical exploration]

Torsion of the spermatic cord is frequent in neonates suffering from acute scrotal distress. A retrospective study was carried out to determine the viability and the outcome of testis treated by surgical exploration.

PATIENTS AND RESULTS

Surgical exploration of 30 neonates presenting acute scrotal distress found: 18 torsions of the spermatic cord, six intrascrotal bleedings or hematoma due to delivery trauma, five tunica vaginalis inflammations and one ischemia without torsion. The torsion occurred in utero in 16 cases and after birth in two cases. The contralateral uninvolved testis was fixed to the scrotum in all cases. The torsion was extravaginal in 17 cases and intravaginal in one case. In all cases of prenatal torsion, there was total necrosis of the testis. One case of postnatal torsion operated on four hours after the beginning of the torsion was saved.

CONCLUSION

Although the viability of the torsioned testis is compromised in cases of prenatal torsion, surgical exploration is necessary to confirm diagnosis and to avoid any contralateral torsion because bilateral torsion exists. Only emergency surgical exploration can save a testis that has undergone post-natal torsion as reported in others series.

The protective effects of nitric oxide on the contralateral testis in prepubertal rats with unilateral testicular torsion

OBJECTIVE

To investigate histological changes in the contralateral testis of rats with unilateral testicular torsion and the protective effects of nitric oxide (NO) on possible damage.

MATERIAL AND METHODS

Twenty-eight prepubertal male Sprague-Dawley rats were divided into four equal groups. Group 1 underwent a sham operation of the right testis under general anaesthesia. Group 2 underwent a similar operation but the right testis was rotated 720 degrees clockwise for 6 h, maintained by fixing the testis to the scrotum, and saline infused during the procedure. Group 3 underwent similar torsion but L-arginine methyl ester (a precursor of NO) was infused during the procedure. In Group 4, NG-nitro-L-arginine-methyl ester, a NO synthase inhibitor, was infused separately during the administration of L-arginine methyl ester and torsion. All the left (untwisted) testes were removed from rats 21 days after surgery and evaluated histologically, assessing seminiferous tubule diameter, loss of sperm and spermatids, loss of germ cell layers, disarray of germ cell layers, rupture of tubules, Leydig cell proliferation and reaction in the ruptured tubules, and oedema.

RESULTS

There was a significant difference in the indicators of histological damage between groups 2 and 4 and groups 1 and 3, except for the Leydig cell reaction in the ruptured tubules and oedema. The damage was significantly less in group 3 than in groups 2 and 4.

CONCLUSION

These results suggest that long-term histopathological changes in the contralateral testes are important after unilateral testicular torsion and that NO has a protective effect on the contralateral testis.

The effect of vitamin E on ipsilateral and contralateral testis following unilateral testicular torsion in rats

An experimental study was conducted to investigate the role of lipid peroxidation in ipsilateral and contralateral testicular reperfusion injury following unilateral testicular torsion (TT) and the effect of vitamin E in the management of this injury. Fifty adult male Sprague-Dawley rats were divided into five equal groups. Bilateral orchiectomy was performed immediately in group 1, and 3 h after unilateral TT in group 2. In group 3, both testes were harvested 3 h after a sham operation. In groups 4 and 5, unilateral TT, detorsion after 3 h and bilateral orchiectomy after 6 h were performed. Vitamin E was given before detorsion in group 4 and after detorsion in group 5. The levels of malondialdehyde (MDA) were measured as an index of lipid peroxidation in all testes. There were no significant differences between right and left testes within groups or between right or left testicular MDA values in different groups. The results suggest that lipid peroxidation does not play an important role in ipsilateral and contralateral testicular injury following unilateral TT and that vitamin E given before or after detorsion of testes is not useful in preventing testicular reperfusion injury.