The Amount of spermatic cord rotation magnifies the timerelated orchidectomy risk in intravaginal testicular torsion

Degrees of Testicular Atrophy Following Orchidopexy for Testicular Torsion

Introduction Testicular torsion is an urological emergency. It is a time-sensitive condition in which twisting of the spermatic cord and testicular blood supply occurs, causing acute onset severe scrotal pain. The incidence of testicular torsion is highest amongst prepubertal males; however, it can occur at any age. Every hour that passes from the onset of symptoms has been shown to decrease the salvageability rate of the torted testis. Another significant factor that impacts testicular salvage is the degree of torsion. Prompt surgical exploration of the scrotum and orchidopexy, if the testis is salvageable, is the mainstay of treatment. A major sequela following orchidopexy for torsion is the decrease in testicular volume. The aim of this study is to assess testicular volume loss post orchidopexy in patients who presented with testicular torsion, as well as to identify the significance of the degree of rotation and duration of torsion in post-fixation volume loss. Methods This is a retrospective study in which all patients who underwent scrotal exploration for a primary diagnosis of testicular torsion between June 1, 2016, to January 15, 2023, were reviewed. The information obtained included the patients' demographics such as age, duration of symptoms, and laterality. Ultrasound images were reviewed for pre- and postoperative findings which included confirmation of testicular torsion as well as testicular volume measurements. Patients were excluded if they underwent an orchidectomy, had a diagnosis other than testicular torsion once scrotal exploration was done, or did not perform a follow-up scrotal ultrasound. Additionally, patients who underwent an orchidopexy for undescended testis earlier in life were also excluded. For statistical analysis purposes, degrees of testicular torsion and time to surgery were classified into mild, moderate, and severe. Results A total of 109 patient records were reviewed within the specific time frame. Of these, 47 patients were excluded as per the exclusion criteria mentioned previously, which gave us a sample size of 62 patients. Our findings showed that increasing severity of the degree of torsion as well as the time for surgery have statistically significant (p-value <0.05) effects on postoperative testicular volume loss. However, it was noted that time to surgery has a more pronounced effect on the mean volume loss than the degree of torsion. Moreover, the analysis also showed that, on average, with every additional hour from the onset of symptoms to surgery, the approximate volume loss is 0.15 ml. However, once time exceeds the 4.5-hour mark, the mean volume loss is 0.4 ml for each additional hour. Conclusion The current study indicates that earlier surgical intervention and correction of torsion are associated with enhanced preservation of postoperative testicular volume. Both the degree of torsion and time to surgery influence mean volume loss; however, time to surgery has a greater impact on the mean volume loss. These results highlight the importance of early diagnosis and intervention in cases of testicular torsion to minimize the risk of long-term testicular volume loss.

Complete Blood Count Markers and C-Reactive Protein as Predictors of Testicular Viability in the Event of Testicular Torsion in Adults

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.

Outcomes of Surgical Exploration of Acute Scrotal Pain Raising Suspicion of Testicular Torsion

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.

Testicular torsion diagnosis and injury assessment using photoacoustic oxygenation imaging

Testicular torsion (TT) is a medical emergency that requires immediate diagnostic evaluation. Photoacoustic imaging (PAI) has the potential to provide spatially resolved oxygen saturation (sO₂), which can serve as a valuable marker in TT diagnosis. We investigated the potential of PAI as an alternative method for TT diagnosis and testicular injury assessment. We measured sO₂ levels in different degrees of TT models using PAI at various time points. Based on histopathological results, we found that the averaged sO₂ per pixel (sO2®) and reduction of sO2® (rsO₂) in twisted testicles had significant correlations with hypoxic conditions. Both sO2® and rsO₂ exhibited excellent diagnostic abilities in detecting TT and identifying ischemia/hypoxia injury following TT. Furthermore, PAI-measured sO₂ demonstrated favorable diagnostic capabilities in discriminating if the testicle had suffered irreversible injury. In summary, PAI presents a potentially promising novel approach in evaluating TT and warrants further clinical investigation.

Testicular volume and Tanner stage: determinant factors for testicular torsion

Objective

To assess testicular volumes and sexual maturation in patients with testicular torsion.

Methods

A retrospective analysis of consecutively treated patients with testicular torsion between 2016 and 2018. Age, pubic hair staging (Tanner), and by ultrasonography, volume of the unaffected testis (in cubic centimeters) were evaluated either immediately before surgery or at the first postoperative visit. Patients with previous testicular disease, such as cryptorchidism, or with no records of testicular volume were excluded. The analysis included descriptive statistics and Bayesian regression.

Results

We treated 149 patients during the study period, and 141 (94.6%, median age 17.3 years) met the inclusion criteria. Median testicular volume was 13.0cm³ (interquartile range of 10.5-15.2), with similar right and left volumes (12.9cm³versus 13.3cm³; p=0.94). Sixty-five (46.1%) patients were Tanner stage IV, 17 (12.1%) stage III, and 59 (41.8%) stage V.

Conclusion

In this study, we were able to estimate volumes of testicular torsion, which aggregated around late puberty values (13.0cm³ for the whole dataset, 12.2cm³ for patients <25 years), suggesting that testicular hypermobility, due to congenital anatomical abnormalities, remains quiescent until the organ reaches a critical volume, after which torsion becomes possible. These findings provide a tentative explanation for the disease’s age distribution.

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

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.

Should haematological inflammatory markers be included as an adjuvant in the differential diagnosis of acute scrotal pathologies?

The aim of this study was to determine discriminative role of haematological inflammatories between acute scrotal pathologies and malignancies. In addition, it was aimed to search for a predictive marker of testicular survival in the TT group. Medical data of 141 patients with acute scrotal pathology and 63 TTm patients who presented to our clinic between January 2015 and July 2019 were retrospectively reviewed and compared in terms of haematological values and demographic parameters following the inclusion of 92 healthy controls. In the TTm group, NLR was the discriminative parameter with a median of 2.42 (0.25-8.42), whereas discriminative median values of MCV for TT and CRP for EO were 83.65 (56.9-98.16) and 59.5 (2.9-337) respectively. NLR, PLR, MER and RDW values were statistically lower in the control group compared to the patients groups. In TT subgroup analysis, monocyte count, MER and CRP were found to be statistically higher in the orchiectomy group, while multivariate logistic regression analysis performed for testicular viability revealed monocyte count to be the only significant variable (Odds Ratio [95% Confidence Interval] = 0.046 (0.006-0.366), p<0.004). While our study demonstrated both diagnostic and discriminative values of haematological parameters, it also showed that monocyte count could predict testicular salvage in TT patients. However, further prospective studies are required.

Testicular Torsion: Successful Management of a Late-Diagnosed Case

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.

Predictive factors for orchiectomy in adult's spermatic cord torsion: a case-control study

Background

Spermatic cord torsion (SCT) is a surgical emergency. Any delay in diagnosis or treatment may compromise the vital and functional prognosis of the testicle. The orchiectomy rate remains very high in the literature; it can even reach 50 % in certain series. Several factors have been reported in the literature as being significantly correlated with the risk of orchiectomy: duration of symptoms, the number of turns, the younger ages, etc. The objective of this study has been to analyse the predictive factors of orchiectomy in adult SCT in our context.

Results

During the study period, 74 cases of SCT were included. Orchidopexy was performed in 43.2 % (32/74) versus orchiectomy in 56.8 % (42/74) of cases. The patients’ median age was 22 years (interquartile range (IQR) = 18–26.75 years). The duration of symptoms (p = 0.009), the previous medical management (p < 0.001), performing a scrotal ultrasonography (p = 0.004) were statistically significant at univariate analysis. On multivariate analysis only the previous medical management was statistically significant (p = 0.017).

Conclusions

The orchiectomy rate was very high in our cohort. The previous medical management was the only significant predictive factor of orchiectomy on multivariate analysis. Our findings demonstrated that the delay in diagnosis is the determining factor in testicular loss in our context.

Duration of symptoms is the only predictor of testicular salvage following testicular torsion in children: A case-control study

OBJECTIVE

Testicular torsion (TT) is an emergency requiring a prompt diagnosis and surgery to avoid irreversible changes and a complete loss of testis. The present study aimed to identify potential factors that may be predict a testicular salvage after TT in pediatric patients.

METHODS

Consecutive medical records of all children ≤16 years old with surgically confirmed TT over a period of five years (2011-2016) were collected. Patients were divided into 2 groups according to testicular viability and the type of treatment: Orchidectomy and orchidopexy. The differences between the two groups and potential predictors of testicular salvage were analyzed.

RESULTS

Thirty-one boys with TT met the inclusion criteria and were included in the study. The mean age was 13.6 years (range, 10 days - 15.8 years). Testicular salvage was possible in 18 (58.1%) patients. The duration of symptoms and a lesser degree of torsion indicated a testicular salvage in children and adolescents with testicular torsion, but in multivariate analysis only duration of symptoms (time to surgical detorsion) was significantly associated with the risk of non-salvage. At follow-up, testicular atrophy affected 73.3% of the patients treated with orchidopexy.

CONCLUSION

Duration of symptoms is the only predictor of successful testicular salvage following testicular torsion in children. It is associated with a substantial risk of testicular loss and atrophy.

Presentation delay, misdiagnosis, inter-hospital transfer times and surgical outcomes in testicular torsion: analysis of statewide case series from central Brazil

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.

A systematic review and meta-analysis revealing realistic outcomes following paediatric torsion of testes

INTRODUCTION

Reported testicular loss rates following paediatric testicular torsion often reflect the surgical decision-making process, rather than long-term survival of the testes.

OBJECTIVES

We aim to perform systematic analysis and meta-analysis to investigate testicular salvage rates and to assess predictors of long-term viability.

STUDY DESIGN

Systematic review according to PRISMA guidelines was performed to investigate immediate and long-term (>12 months) testicular loss rates following torsion in the paediatric population. Literature search and study inclusion were performed by two investigators. A study quality score was derived and attributed to each study. Predictors of testicular loss were described. Proportions meta-analysis was performed with random effects modelling, and testing for heterogeneity.

RESULTS

Twelve studies were includedm, 6 reporting early orchidectomy rates, and 6 reporting long-term outcomes. Study quality was generally low.

DISCUSSION

The mean early testicular loss rate was 39%, whereas meta-analysis revealed late loss to approach 50%. Predictors of outcomes include prehospital symptom duration, location of presentation, transfer to a tertiary centre, social affluence and use of ultrasound prior to diagnosis or transfer.

CONCLUSIONS

This study has shown a considerable late testicular loss rate, which must be relayed to families even after testicular salvage. Delay in time to presentation is consistently found to predict poor outcomes.

Direction of Rotation in Testicular Torsion and Identification of Predictors of Testicular Salvage

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.

Immediate and delayed effects of atmospheric temperature in the incidence of testicular torsion

INTRODUCTION

Ongoing controversy surrounds the role of atmospheric temperature in the incidence of intravaginal testicular torsion (iTT). This debate may be attributed to inadequate research methodology. As environmental risk factors have been successfully investigated with distributed lag non-linear model regression (DLNM), we applied this methodology to investigate the association between daily mean atmospheric temperatures (Tmean) and daily incidences of intravaginal testicular torsion (iTT) in our region.

STUDY DESIGN

We analyzed time series consisting of the daily incidences of surgically confirmed iTT according to Tmean, in a circumscribed region in central Brazil from 2012 to 2015, with non-parametric tests, unadjusted and seasonally and long-term trend adjusted time series regression, as well as with DLNM.

RESULTS

We recovered 218 cases of iTT in 1125 days of study. Most patients were teenagers (median 15.8 years, interquartile range 14.1-18.5 years). Within the 188 days with events, a single event was recorded on 161 days, two events were recorded on 24 days, and three events were recorded on 3 days. Tmean was lower in days with iTT compared with days without iTT (median 21.4 °C vs. 20.9 °C, p = 0.0002). We found decreasing magnitude and uncertainty of the direction of the effect of Tmean as a risk factor for iTT as the time series regression model was adjusted for seasonal and long-term trends. DLNM indicated a more complex exposure-response relation, with a proportional increase in risk when Tmean fell below 19.4 °C at the day of exposure (for 18.0 °C, RR 4.35) and a protective effect, for similar temperatures, after 1-2 and 7-12 days of exposure (RR 0.44 and 0.78, respectively).

DISCUSSION

The association between lower Tmean and higher incidences of iTT at first observed with conventional non-parametric tests and unadjusted time series regression disappeared with adjusted time series regression models, reproducing the conflicting results of the literature. In contrast, DLNM revealed both a proportional effect of Tmean with decreasing temperatures and a delayed decrease in risk, suggesting a harvesting effect, seen when the pool of susceptible patients is depleted at exposure leading to a subsequent decrease in the incidence of the disease.

CONCLUSION

According to DLMN, exposures to lower Tmean were associated with immediate greater risk and delayed reduction in risk for iTT. This pattern, indicating a harvesting effect, strongly argues that low temperatures do constitute a risk factor for iTT.

Parental awareness of testicular torsion amongst Irish parents

PURPOSE

Testicular torsion is the most concerning underlying cause of acute scrotal pain that can lead to loss of the affected testicle. Whether a torted testicle can be salvaged surgically is directly affected by prompt presentation and diagnosis. This study aims to evaluate the awareness of testicular torsion amongst Irish parents and evaluate their response to a potential torsion.

METHODS

An anonymous questionnaire was distributed to parents attending general paediatric clinics and an acute paediatric unit in two paediatric tertiary referral centres. SPSS statistical analysis software was used to perform multivariant analysis of the data.

RESULTS

There were 242 completed surveys. Fifty-six percent of responders had an awareness of torsion. In the event of an episode of severe testicular pain parents who were aware of testicular torsion were 4 times more likely to present immediately than those who had no awareness of torsion (OR 4.2, 95% CI 1.4-12.2, P < 0.01), and those who identified correctly the critical timeframe were 3 times more likely to present immediately than those who did not (OR 3.0, 95% CI 0.85-10.8, P = 0.08). Of those parents with boys only 11% had discussed what to do in the event of acute scrotal pain.

CONCLUSIONS

Education of this topic to the general Irish population and in particular to parents and young males is not established. Both knowledge of testicular torsion and awareness of the urgency in presentation are factors that determine parents promptness in seeking medical attention for their child in the setting of acute scrotal pain.

Degree of twisting and duration of symptoms are prognostic factors of testis salvage during episodes of testicular torsion

Background

Testicular torsion is surgical emergency. Prompt diagnosis and treatment of testicular torsion is essential for testicular viability. At surgical exploration, the spermatic cord is seen twisted a variable number of times around its longitudinal axis. There is scant data regarding the degree of twisting and its association with testis outcomes. The purpose of our study is to explore how the degree of torsion factors into testicular outcome using follow-up data.

Methods

We retrospectively reviewed the records of adolescent males who presented with testicular torsion to our institution, looking at duration of pain symptoms, degree of torsion documented in the operative note, procedure performed (orchiopexy versus orchiectomy), and follow-up clinic data for whether testicular atrophy after orchiopexy was present. A non-salvageable testis was defined as orchiectomy or atrophy. Receiver operator characteristics (ROC), multivariate, and logistic regression analyses were performed to determine the probability of a non-salvageable torsed testis based on time and degree of twisting.

Results

Eighty-one patients met our study criteria, with 55 testes deemed viable and 26 non-salvageable. We found a 25.7% atrophy rate after orchiopexy. Cut-off values of 8.5 h and 495 degrees of torsion would provide sensitivities of 73% and 53%, respectively, with specificity of 80% for both. Only duration and age were correlated with the risk of non-salvage on multivariate analysis. Logistic regression generated linear probability formulas of 4 + (3 ¡Á hours) and 7 + (0.05 ¡Á degrees) in calculating the probability of non-salvage with strong correlation.

Conclusions

We were able to derive separate formulas to determine the viability of the torsed testis based on symptom duration and degrees of twisting. Fifteen h of symptoms and 860 degrees of torsion gives testes a 50% salvage rate. Interestingly, we also found that about 1 out of every 4 testes undergoes atrophy after orchiopexy.