Contralateral testicular torsion after previous unilateral orchiopexy for undescended testis

Is Routine Excision of Dysplastic Testicular Remnants/Nubbins Associated with Nonpalpable Testis Necessary? Is Routine Fixation of Contralateral Solitary Testis Indicated? A Survey on the Prevalent Practice among Indian Pediatric Surgeons

Background and Aims

Dysplastic nubbin also referred to as testicular regression syndrome (TRS) is found in 5% of cases of the Non palpable testis (NPT). There is no consensus on the excision of the above and fixation of the contralateral solitary testis. We aimed to survey the prevalent practice of the same among members of the Indian Association of Pediatric Surgeons (IAPS).

Methods

A structured questionnaire was sent through group e-mail and social media platforms to IAPS members to identify their practices in management.

Results

A total of 132 surgeons responded to the questionnaire. Excision of intra-abdominal and inguinoscrotal TRS remnants was practiced by 84% (95% confidence interval [CI] 77%-89%) and 82% (95% CI 74%-87%). Fixation of contralateral solitary testis was practiced by 62% (95% CI 53%-70%) in the above scenario. Among the respondents, 30% reported encountering torsion of solitary testis during their career and this experience was a significant factor (P = 0.01) in deciding contralateral orchidopexy. Scrotal infection/necrosis was not encountered by a majority (72%) and it was not a deterrent factor in preventing contralateral orchidopexy (P = 0.68).

Conclusions

The majority of pediatric surgeons favored the removal of intra-abdominal/inguinoscrotal TRS remnants identified during laparoscopy for NPT. A majority favored sutureless fixation of the contralateral solitary testis.

Recurrent testicular torsion post orchidopexy - an occult emergency: a systematic review

Background

Recurrent Testicular Torsion (RTT) is a rarely reported event after previous testicular torsion (TT) repair. Both conditions have similar signs and symptoms. Various techniques have been attempted to reduce the incidence of retorsion. This review assesses the presentation, diagnosis, risk factors, management and outcomes associated with RTT.

Methods

After PROSPERO Registration (CRD42021258997), a systematic search of PubMed, Google Scholar, Embase, Scopus, Web of Science, Cochrane Database of Systematic Reviews, Global Index Medicus and Cumulative Index to Nursing and Allied Health Literature (CIANHL) was performed using specific search terms. Study metadata including patient demographics, orchidopexy techniques, RTT rates and RTT timing were extracted.

Results

Twenty‐six articles, comprising 12 case series and 14 case reports, with a total of 46 patients were included. Overall, the median (IQR) age of the pooled cohort was 18 (15–26) years, the median (IQR) time to presentation was 6 (3–36) hours from the onset of testicular pain. The most common presenting features were testicular pain (100%), testicular swelling (60.9%) and a high riding testicle (34.8%). The left testicle was most commonly affected (63.0%), RTT was on the ipsilateral side in relation to the primary episode of TT in 52.2% of cases, the median (IQR) interval between torsion and retorsion events was 4 (1.3–10.0) years, non‐absorbable sutures were the most common suture material used during orchidopexy after RTT (88.9%).

Conclusion

RTT is a rare presentation to the Emergency Department. Even with a prior history of TT, RTT should be considered in patients presenting with classic symptoms.

Suspected Testicular Torsion: A Survey of Clinical Practice in North West England

Several aspects of the management of suspected testicular torsion are controversial. A questionnaire was mailed to all 33 consultant urologists in the North West region of England to elicit their policies for routine clinical management. 29 of 33 questionnaires were returned (2 incomplete).

As regards radiological investigation, 4 consultants always request ultrasound examination; the others do not favour routine imaging. When the diagnosis of testicular torsion is confirmed at operation, all consultants would perform bilateral testicular fixation, although with considerable variations in technique; most use Vicryl sutures (66%) and three-point fixation (57%). One-third would do an ipsilateral orchidopexy if there was no clear evidence of testicular torsion at operation.

The variation revealed by this survey prompted an attempt to formulate a protocol for management. A review of the published work indicates that, in cases of proven testicular torsion, treatment should include bilateral fixation with delayed-absorption or nonabsorbable sutures; fixation should be at three points. When torsion is not found at operation, there is no evidence of benefit from orchidopexy.

EFFECTS OF TESTICULAR FIXATION ON OXIDATIVE STRESS-RELATED PARAMETERS IN PREPUBERTAL RAT TESTIS

The goal of orchiopexy is to provide adequate scrotal fixation to prevent recurrent torsion of the testis and the spermatic cord or ascent of the testis, to be achieved with minimal trauma to the testis. Forty-two prepubertal male Sprague-Dawley rats were equally distributed into 6 groups (1 SHAM + 5 Operation). In operational groups, two lateral sutures were placed near the upper and lower pole of the testis passing through the tunica albuginea with 4-zero polyglactin suture in the transverse axis of the testis. At the 1st-3rd-7th-15th and 30th postoperative days, bilateral orchiectomy was performed, then malondialdehyde (MDA), nitrite, superoxide dismutase (SOD) and glutathion peroxidase (GPx) values were measured in testicular tissue homogenates. MDA and nitrite levels increased, while GPx and SOD levels diminished, statistically significant in both ipsilateral and contralateral testicular tissue homogenates. Prepubertal testicular fixation causes overproduction of the lipid peroxidation end product and free radicals while heavy consuming anti-oxidant reserve systems in both ipsilateral and contralateral testicular tissue. These results clearly reveal the extent of the testicular deterioration due to suture fixation technique.

Suspected testicular torsion: a survey of clinical practice in North West England

Several aspects of the management of suspected testicular torsion are controversial. A questionnaire was mailed to all 33 consultant urologists in the North West region of England to elicit their policies for routine clinical management. 29 of 33 questionnaires were returned (2 incomplete). As regards radiological investigation, 4 consultants always request ultrasound examination; the others do not favour routine imaging. When the diagnosis of testicular torsion is confirmed at operation, all consultants would perform bilateral testicular fixation, although with considerable variations in technique; most use Vicryl sutures (66%) and three-point fixation (57%). One-third would do an ipsilateral orchidopexy if there was no clear evidence of testicular torsion at operation. The variation revealed by this survey prompted an attempt to formulate a protocol for management. A review of the published work indicates that, in cases of proven testicular torsion, treatment should include bilateral fixation with delayed-absorption or non-absorbable sutures; fixation should be at three points. When torsion is not found at operation, there is no evidence of benefit from orchidopexy.

Assessment of acute scrotal symptoms and findings. A clinician's dilemma

Diagnosis of testis torsion relies on the clinical wisdom of the examining physician, supplemented with timely imaging techniques by color Doppler examination or scintigraphy. A knowledge of the pathophysiology of acute scrotal conditions can help to eliminate diagnostic errors but the literature demonstrates that errors can occur even with sophisticated testing. Data from the literature suggests that manual detorsion of the testis can successfully relieve ischemia until surgical correction can eliminate the possibility of testis torsion. Surgical therapy has progressively improved and can save the germinal function of the testis.