Long-term effects of the testicular torsion on the spermatogenesis of the contralateral testis and the preventive value of the twisted testis orchiepididymectomy

Testicular torsion in vivo models: Mechanisms and treatments

BACKGROUND

Testicular torsion is a condition in which a testis rotates around its longitudinal axis and twists the spermatic cord. This in turn results in a significant decrease in blood flow and perfusion of testicular tissue. During Testicular torsion, the testicular tissue is affected by ischemia, heat stress, hypoxia, and oxidative and nitrosative stress. The testicular torsion should be considered an emergency condition and surgical intervention (testicular detorsion ) as the sole treatment option in viable cases involves counter-rotation on twisted testes associated, when possible, to orchipexy, in order to avoid recurrence. Possible testicular detorsion side-effects occur due to reperfusion and endothelial cells injury, microcirculation disturbances, and intense germ cells loss.

OBJECTIVES

To discuss testicular torsion surgery-based methods, different time frames for testicular torsion induction, and the associated pathophysiology by emphasizing cellular and molecular events as well as different therapeutic agent applications for testicular torsion.

MATERIALS AND METHODS

We reviewed all original research and epidemiological papers related to testicular torsion condition.

RESULTS

Testicular torsion causes germ cell necrosis, arrested spermatogenesis, and diminished testosterone levels, with consequent infertility. Among different involved pathophysiological impacts, testicular torsion/detorsion-induced ischemia seems to play the key role by leading the tissue toward other series of events in testis. Numerous studies have used adjuvant antioxidants, calcium channel blockers, anti-inflammatory agents, or vasodilating agents in order to decrease these effects.

DISCUSSION AND CONCLUSION

To the best of our knowledge, no previously conducted study examined therapeutical agents' beneficial effects post clinical I/R condition in humans. Different agents targeting different pathophysiological conditions were used to ameliorate the ischemia/reperfusion-induced condition in animal models, however, none of the administrated agents were tested in human cases. Although considering testicular detorsion surgery is still the golden method to reverse the testicular torsion condition and the surgical approach is undeniable, the evaluated agents with beneficial effects, need to be investigated furthermore in clinical conditions. Thus, furthermore clinical studies and case reports are required to approve the animal models proposed agents' beneficial impacts.

Shear wave elastography for the evaluation of testicular salvage after testicular torsion

The aim of this study was to assess the utility of shear wave elastography in the follow-up of testicular detorsion, evaluate long-term outcomes, and explore its relationship with parameters such as tissue stiffness values, pain duration, and torsion type. Elastography examinations were independently performed by two radiologists to evaluate patients who presented to our hospital for follow-up after being diagnosed with testicular torsion and age-matched controls. Inter-observer variability of the mean testicular tissue elasticity was excellent (Intraclass correlation coefficient: 0.939, p < 0.001). Median time between testicular detorsion and follow-up ultrasound examination was 18 months (range, 11-36 months). Torsion side, torsion degree, and pain duration were recorded, and testicular volumes were calculated. The study population comprised 24 patients (48 testes) with a mean age of 21.1 ± 7.8 years. The mean testicular volume was measured as 12.3 ± 5.4 ml for the testicular salvage group, 13.9 ± 3.8 ml for the contralateral testes, and 13.7 ± 2.7 ml for the control group (p = 0.553). The mean testicular speed mode values were higher in the testicular salvage group (1.34 ± 1.21 m/s) compared with the contralateral testes group (1.00 ± 0.08 m/s), and the control group (1.01 ± 0.06 m/s), however there was no statistically significant difference between the three groups (p = 0.861). While testicular atrophy was detected in three patients, an intraparenchymal wedge-shaped focal hypoechoic area developed after torsion in a further three patients. The elastography examination for focal hypoechoic areas revealed an increase or decrease in tissue stiffness compared to the normal parenchyma. The tissue stiffness values of the testicular salvage group were higher in complete torsion compared to incomplete torsion. The elastography method contributes to other imaging methods in distinguishing focal lesion areas that can be seen after testicular torsion from malignant conditions. Elastography presents as a feasible and practical complementary modality for the follow-up of testicular salvage after torsion.

Long-term effects of orchiopexy and orchiectomy on the testes of rats with testicular torsion

INTRODUCTION

Ischemia/reperfusion injury occurs after testicular torsion, levels of free oxygen radicals and inflammatory cytokines are increased in both the torsional and contralateral testis, leading to testicular injury.

OBJECTIVE

The present study investigated whether orchiopexy or orchiectomy after testicular torsion was superior in terms of fertility potential in the long term.

STUDY DESIGN

Following 720°, 4 h left testicular torsion, orchiectomy or orchiopexy was performed on 84 rats, which were then sacrificed and evaluated for testicular function at day 1, at 3 months and 6 months (n = 14 per group). An additional 14 rats were in the control group.

RESULTS

Follicle stimulating hormone (FSH), luteinizing hormone (LH), and testosterone levels were significantly lower in the orchiopexy group than the orchiectomy and control groups after 3 months. However, there were no significant differences in hormone parameters among the three groups after 6 months. The hormone levels, Johnsen score, seminiferous tubule diameter, and inducible nitric oxide synthase (iNOS) expression at 3 and 6 months were not significantly different between the orchiectomy group and controls. Histopathological analyses at 3 and 6 months indicated significant decreases in Johnsen score and seminiferous tubule diameter in the ipsilateral testis in the orchiopexy group. At 3 months, the level of iNOS expression in the contralateral testis was significantly lower in the orchiopexy group than in other groups. At 6 months, however, it was not significantly different between the orchiopexy and control groups. There were no significant differences in iNOS expression at 3 or 6 months in the orchiectomy group compared to controls.

DISCUSSION

The ipsilateral testis in the orchiopexy group began to atrophy at 3 months, and the degree of atrophy became more evident at 6 months. The level of iNOS expression was low in the bilateral testis at 3 months in the orchiopexy group, and sperm in the contralateral testis were not yet functionally healthy. The level of iNOS expression in the ipsilateral testis decreased further at 6 months in the orchiopexy group, while that in the contralateral testis returned to the normal level.

CONCLUSION

Testicular functions were restored faster after orchiectomy compared to orchiopexy following testicular torsion. However, follow-up of the rats for 6 months demonstrated that orchiopexy or orchiectomy procedures conducted on the testicular torsion had no effect on future fertility potential after 4 h of torsion.

Morphological Characteristics of the Sperm of the Peregrine Falcon (Falco peregrinus) during the Reproductive Season

The morphological characteristics of different sperm cells (normal, abnormal, and immature) in the peregrine falcon during the reproductive season were analysed. We also classified the main sperm defects found in semen. Semen samples were collected from mature peregrine falcons via cloacal massage and stained with Diff-Quik stain. The percentages of normal, abnormal, and immature sperm cells were determined by bright-field optical microscopy. The number of normal spermatozoa were greater at the initial stage and subsequently decreased during the middle and later stages of the reproductive season (p < 0.01). In contrast, the percentage of abnormal spermatozoa increased significantly in the middle and end stages of the reproductive season (p < 0.05), whereas the proportion of immature spermatozoa remained stable during the study. Head defects represented the greatest proportion of morphological abnormalities, followed by the defects in the tail and midpiece regions. A small percentage of multiple defects and cytoplasmic droplets were also observed in the falcon spermatozoa. The findings of this study might be important for the development of future conservation protocols for falcon sperm.

Cross-link between mitochondrial-dependent apoptosis and cell cycle checkpoint proteins after experimental torsion and detorsion in rats

The current study assessed the cross-link between mitochondria-related apoptosis and cell cycle machinery systems during ischemia and reperfusion in a rat model of testicular torsion and detorsion. The Wistar male rats were divided into control, 1 h, 2 h, 4 h and 8 h testicular torsion-induced, and 1 h, 2 h, 4 h and 8 h testicular detorsion-induced groups. The Johnson's score was analyzed. The mRNA and protein contents of Bcl-2, Bax, Caspase-3, Cyclin D1, Cdk4, P21 and P53 were investigated by sqRT-PCR and immunohistochemical staining, respectively. The apoptosis index was analyzed by TUNEL staining. The mRNA levels of bax, p53, p21 and cyclin D1 were increased, and the mRNA levels of bcl-2 and cdk4 were decreased in torsion and reperfusion-induced groups, time-dependently. The caspase-3 mRNA was increased in torsion-induced and diminished in detorsion-induced groups. A time-dependent reduction in Bcl-2⁺, Caspase-3⁺, Cyclin D1⁺, Cdk4⁺ and P53⁺ and increment in P21⁺ cells distribution per mm² of tissue were revealed after torsion and detorsion. The apoptosis index was increased after torsion and decreased after detorsion. In conclusion, torsion-induced severe DNA damage stimulates the cyclin D1, p53 and p21 mRNA expression while more than 8 h is needed to reveal them as protein content in testicular tissue. About detorsion, decreased Cyclin D1 and Cdk4 proteins and the P53-induced transcriptional effect on p21 expression, stimulates the p21 bind to cdk4 and consequent failure in Cyclin D1/Cdk4 complex formation. This situation in association with apoptotic genes results in spermatogenesis failure.

The effects of CoQ10 supplement on matrix metalloproteinases, oxidative DNA damage and pro-inflammatory cytokines in testicular ischaemia/reperfusion injury in rats

We aimed to study the effect of coenzyme Q10 on pro-inflammatory cytokine, matrix metalloproteinase, oxidative DNA damage, caspase 3 and caspase 8 in ischaemia/reperfusion injury led to by testicular torsion/detorsion. Our research is a controlled experimental animal research using rats. This study was conducted with fifty-six adult male Albino Wistar rats. Interleucine-1β, 2, 6, 10, tumour necrosis factor-α, matrix metalloproteinase-2, 3, 9, 13, tissue inhibitor matrix metalloproteinase-1, 2, malondialdehyde and leucocyte 8-hydroxy-2-deoxy guanosine/10⁶ deoxyguanosine was detected in serum and tissue samples. In addition, immunohistochemical analysis of caspase 2 and caspase 8 was performed. In testicular I/R injury, especially 24 hr after detorsion, oxidative damage pro-inflammatory cytokines and matrix metalloproteinases were increased. At the coenzyme Q10 group, a meaningful decrease was observed in these parameters. In addition, a decrease in the expression of caspase3 and caspase 8 was viewed in coenzyme Q10-treated groups. The coenzyme Q10 has beneficial effects on oxidative damage, pro-inflammatory cytokine levels, remodelling of extracellular matrix and apoptosis in testicular I/R injury.

Epithelial growth factor and decompressive testicular fasciotomy to control ischemia reperfusion injury in rats

PURPOSE

Testicular torsion is an urological emergency and an important cause of male infertility. Recent studies have shown that not only ischemia, but also the restoration of blood flow creates a deleterious situation for the testis. The goal of this work was to evaluate the role of systemic epithelial growth factor application and its association with decompressive fasciotomy in tissue recovery of the testes undergoing the torsion of the spermatic cord.

METHOD

Torsion of the spermatic cord was induced in 40 Wistar pubescent testes for a period of 4 h. At the time of detorsion systemic epithelial growth factor and decompressive fasciotomy were applied as treatment alternatives. After 21 days, the testicles were examined macro and microscopically.

RESULTS

The variables evaluated were weight, testicular volume and the degree of histological alterations by optical microscopy. The rate of healing of testicular torsion showed significant difference between the groups. It was noted that in terms of testicular weight and volume the animals treated with systemic epithelial growth factor resembled the control group and had a better histological classification than the other groups. The mean Johnsen score was significantly higher in the group treated with systemic growth factor and decompressive testicular fasciotomy than in the group without fasciotomy. No significant changes were noted in the contralateral testes.

CONCLUSION

Although decompressive testicular fasciotomy improved spermatogenesis, recovery was limited. Systemic epithelial growth factor administered in combination with decompressive testicular fasciotomy was more effective for spermatogenesis than fasciotomy alone. Administering epithelial growth factor after reperfusion might have the potential to decrease long-term histologic damage after testicular torsion. The combination of decompressive testicular fasciotomy and epithelial growth factor had a synergistic effect on the healing of these testes.

Clinical evaluation of testicular torsion presenting with acute abdominal pain in young males

Objective

To evaluate the features of testicular torsion presenting with acute abdominal pain and to raise awareness of testicular torsion with specific symptoms.

Methods

From October 2005 to June 2016, nine patients with testicular torsion who presented with isolated acute abdominal pain rather than scrotal pain as their primary symptom were retrospectively reviewed. Data, including the age of patients, season at admission, initial medical history, external genital examination, emergency ultrasound findings, operative findings, duration of abdominal pain, complications, and follow-up results, were collected.

Results

The average age of patients was 14 years (range 10–17 years). Seven patients whose genitals were not initially examined externally were misdiagnosed as having ordinary abdominal diseases. Surgical exploration revealed that all the involved testes necrotized, and orchidectomy was performed. In the other two patients, scrotal and testicular abnormalities were detected immediately on admission, and emergency surgical exploration determined that the involved testis remained vital, so orchiopexy was performed. The mean duration from symptom onset to diagnosis was 4 h (3–5 h) in the orchiopexy group and 37 h (18–72 h) in the orchidectomy group. Six patients were psychologically affected during postoperative follow-up. Neither recurrence of testicular torsion nor testicular atrophy was recorded.

Conclusion

Acute abdominal pain can be the initial and sole symptom of testicular torsion in young males. Physicians should pay close attention to the specific clinical presentation of testicular torsion.

Stereological and morphological analysis of the effects of aging on spermatogenesis in rat testis 1

PURPOSE

To quantify, through stereological and morphometric analysis, spermatogenesis in rats undergoing the natural aging process.

METHODS

Seventy-two male Wistar rats were divided into 6 equal groups according to age at the time of killing: 3, 6, 9, 12, 18, and 24 months. All the rats were subjected orchiectomy and collection of testicular parenchymal fragments for histological and morphometric analysis. The numerical density of spermatids was calculated using a stereological study, and morphometric analysis was conducted to measure the height of the germinal epithelium and the area of the seminiferous tubules.

RESULTS

We found that the 18 and 24 months groups showed a significant reduction in the number of round spermatids. However, the height of the germinal epithelium was not significantly different between the groups. The area of seminiferous tubules was also significantly reduced in the elderly rats compared to that in the young ones.

CONCLUSION

Aging of rats showed a significant reduction in the number of round spermatids and the area of the seminiferous tubules, more pronounced in the rats at 18 and 24 months of life.

Protective effects of persian honey, Apis Mellifera Meda Skorikov on side effects of chemotherapy and ischemia/reperfusion induced testicular injury

Introduction The aim of the present study was to survey the protective effect of pretreatment with Persian honey on amelioration of side effects of chemotherapy and ischemia/reperfusion induced testicular injury. Materials and methods Forty adult's male wistar rats were divided into four groups of ischemia-reperfusion (IR), honey + ischemia-reperfusion (HIR), Busulfan (B) and Busulfan intraperitoneally+ honey (BH). The seminiferous tubules were rated for their modified spermatogenesis index (SI) by Johnsons score. Detection of single- and double-stranded DNA breaks at the early stages of apoptosis was performed using the in-situ cell death detection kit. Total serum concentration of Follicle-stimulating hormone (FSH) , Luteinizing hormone (LH) and testosterone was measured using ELISA. All data were expressed as mean ± SD and significance was set at p≤0.05. Results Honey improved SI in the HIR and BH groups and serum levels of FSH and LH in the BH and HIR groups (p<0.001). Also, serum levels of testosterone were significantly higher in BH and HIR groups. But, apoptotic cells in IR and B groups significantly increased (p<0.001), while in HIR and BH groups, the number of apoptotic cells decreased and the positive cells of TUNEL (TdT-mediated dUTP-X nick end labelling) staining were detected in spermatocytes and spermatid. Discussion Pretreatment with honey protect testis against chemotherapy and testicular IR injury, increase FSH and LH and testosterone and decrease the cellular damage and apoptosis. Honey can decrease the side effects of chemotherapy on reproductive system and prevent sterility.

Testicular torsion and reperfusion: evidences for biochemical and molecular alterations

This study was done in order to determine the molecular and biochemical alterations following testicular torsion (TT) and torsion-reperfusion (TR). For this purpose, 54 male Wistar rats were divided into five groups as control group (n = 6) and experimental group subjected to 1, 2, 4, and 8 h unilateral left torsion induction (n = 12 in each group). After induction of TT, testicular samples were collected from each group (n = 6), and the other six rats of each group underwent the same period of reperfusion after TT and then were sampled. Histological changes, the mRNA and protein expression of heat shock protein-70 (Hsp70), and caspase-3 were examined using reverse transcriptase-PCR (RT-PCR) and immunohistochemistry, respectively. Testicular total antioxidant capacity (TAC), glutathione peroxidase (GSH-px), and malondialdehyde (MDA) levels were evaluated. The mRNA damage and DNA fragmentation were assessed. The TT and TR significantly reduced differentiation and spermiogenesis indices (p < 0.05). The TT- and TR-induced groups exhibited a severe reduction in Hsp70 expression as well as remarkable enhancement in caspase-3 expression. The TAC and GSH-px levels were decreased and the MDA content was increased in TT- and TR-induced groups. Finally, the TT and TR enhanced mRNA damage and DNA fragmentation. The TT- and TR-induced damaging oxidative stress, diminished Hsp70 expression, and enhanced caspase-3 mRNA and protein levels result in apoptosis following 1, 2, and 4 h. Whereas, following 8 h, TT and TR initiate the necrosis by inducing energy depletion as well as severe mRNA damage.

Role of diffusion weighted magnetic resonance imaging in a rat model of testicular torsion

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.

Hypoxia and spermatogenesis

This review mainly focuses on our understanding of spermatogenesis in physiological and pathological hypoxic condition. Real hypoxia is closely related to vascular changes and an increase in testicular temperature. Both induce a reduction in sperm count and can be related to the increase in germ cell apoptosis. On the other hand, change in the temperature, and oxygen levels in the microenvironment have influence on spermatogonial stem cell function and differentiation. The initial connection between hypoxia and a factor critical for stem cell maintenance is alteration in Oct-4 expression, and these data may be a useful strategy for modulating stem cell function. Unilateral testicular ischemia-induced cell death can be accompanied by an increase in germ cell apoptosis in the contralateral testis. The injury of contralateral testis following unilateral testicular damage is controversial, and it can contribute to the reduction in fertility.