Testicular torsion: A retrospective investigation of predictors of surgical outcomes and of remaining controversies

A nomogram for predicting risk factors of testicular salvage after testicular torsion in children

OBJECTIVES

This study aimed to establish a nomogram for predicting the probability of testicular salvage after testicular torsion in children.

METHODS

We retrospectively collected data of children with testicular torsion who were treated at Shenzhen Children's Hospital between September 2005 and August 2022. Of the training cohort, 113 patients who underwent orchiectomy and five with testicular atrophy after orchiopexy were included in the failed testicular salvage group. Additionally, 37 patients who underwent orchiopexy without postoperative testicular atrophy were included in the successful testicular salvage group. The predictive factors affecting testicular salvage were determined using univariate and multivariate logistic regression analyses; a nomogram was constructed. The nomogram was verified using data from the validation group.

RESULTS

Using multivariate logistic regression analysis, the independent risk factors of testicular salvage after testicular torsion were symptom duration (p = 0.034), intratesticular blood flow (p = 0.003), spermatic cord torsion degree (p = 0.037), and monocyte count (odds ratio: 0.012, p = 0.036). A nomogram was established based on these four risk factors. In the training cohort, the area under the receiver operating characteristic curve was 0.969. The area under the receiver operating characteristic curve of the verification cohort was 0.965, indicating good discrimination ability of the nomogram. Increased symptom duration without intratesticular blood flow increased the monocyte count and spermatic cord torsion degree and decreased the success rate of testicular salvage.

CONCLUSION

This prediction model could obtain the corresponding probability of testicular salvage according to the clinical characteristics of different patients with testicular torsion, providing reference for clinicians and parents.

Atypical Presentation Delays Treatment of Pediatric Testicular Torsion

OBJECTIVE

The aim of the study is to identify patient- and care-related factors associated with time to treatment for acute testicular torsion and the likelihood of testicular loss.

METHODS

Data were retrospectively collected for patients 18 years and younger who had surgery for acute testicular torsion between April 1, 2005, and September 1, 2021. Atypical symptoms and history were defined as having abdominal, leg, or flank pain, dysuria, urinary frequency, local trauma, or not having testicular pain. The primary outcome was testicular loss. The primary process measure was time from emergency department (ED) triage to surgery.

RESULTS

One hundred eleven patients were included in descriptive analysis. The rate of testicular loss was 35%. Forty-one percent of all patients reported atypical symptoms or history. Eighty-four patients had adequate data to calculate time from symptom onset to surgery and time from triage to surgery and were included in analyses of factors affecting risk of testicular loss. Sixty-eight patients had adequate data to evaluate all care-related time points and were included in analyses to determine factors affecting time from ED triage to surgery. On multivariable regression analyses, increased risk of testicular loss was associated with younger age and longer time from symptom onset to ED triage, while longer time from triage to surgery was associated with reporting atypical symptoms or history.The most frequently reported atypical symptom was abdominal pain, in 26% of patients. These patients were more likely to have nausea and/or vomiting and abdominal tenderness but equally likely to report testicular pain and swelling and have testicular findings on examination.

CONCLUSIONS

Patients presenting to the ED with acute testicular torsion reporting atypical symptoms or history experience slower transit from arrival in the ED to operative management and may be at greater risk of testicular loss. Increased awareness of atypical presentations of pediatric acute testicular torsion may improve time to treatment.

Practice Patterns Affecting Delays in Care of Testicular Torsion

OBJECTIVES

To compare impact of day or on-call team, pediatric or adult attending, and patient age on testicular torsion management and outcomes.

METHODS

A retrospective study of patients with testicular torsion between 2012 and 2022 at a single institution was conducted. Variables impacting management time were assessed using univariate analyses.

RESULTS

One hundred and thirty-four patients were included: 49 underwent orchiectomies and 84 underwent orchiopexies. There was no significant difference between efficiency of on-call vs day team regarding time to ultrasound or time to operating room (OR). There were no significant differences between pediatric vs adult attending surgeons for time to surgery, intraoperative length of surgery, or testicular salvage rates. However, when patients were stratified by age greater or younger than 18years, older patients had significantly longer symptom duration (91.9 vs 20.0 minutes, P = .005), time to receive an ultrasound from emergency room registration (152 vs 87 minutes, P < .001), time to OR from emergency room registration (268 vs 185 minutes, P < .001), and time to OR from ultrasound read (187 vs 123 minutes, P = .03). Older patients also had lower rates of testicular salvage approaching significance (orchiectomy rate 48.8% vs 31.5%, P = .057).

CONCLUSION

While no significant delays in testicular torsion management were detected between management by on-call vs day team nor pediatric vs adult attending, increased age of patient was associated with delays in definitive surgical management. Greater index of suspicion for testicular torsion diagnosis in adult patients may improve the rate of testicular salvage.

Implementing Point-of-Care Ultrasound for Acute Scrotal Pain in the Pediatric Emergency Department: Screening Testicular Torsion and Patient Flow Analysis

OBJECTIVES

Testicular torsion (TT) is a pediatric surgical emergency that requires prompt treatment. This study investigated the feasibility of point-of-care ultrasound (POCUS) for diagnosing TT in the pediatric emergency department (ED).

METHODS

We retrospectively reviewed the medical records of patients, aged 18 years or younger, who visited a university-affiliated hospital pediatric ED with acute scrotal pain without trauma history and underwent diagnostic ultrasounds between January 2010 and October 2022.

RESULTS

This study included 731 patients (median age: 9 years), Of these, 315 (43%) were in the POCUS-performed group: 188 in the POCUS-only group, and 127 in the POCUS-and-RADUS group. The other 416 patients (56.9%) were in the RADUS-only group. In total, 45 patients (6.2%) were diagnosed with TT (19 in the POCUS-performed group and 26 in the RADUS-only group). The sensitivity, specificity, and positive and negative predictive values of POCUS for diagnosing TT were 94.7%, 92.9%, 46.2%, and 99.6%, respectively. The median time to perform POCUS was shorter than RADUS (23 versus 61 minutes, P < .001). The POCUS-performed group had a shorter ED length of stay than the RADUS-only group (93 versus 170 minutes, P < .001). Among the patients diagnosed with TT, performing POCUS first did not significantly delay the ED process, including time to operation (250 versus 205 minutes, P = .142).

CONCLUSIONS

For patients with acute scrotal pain, evaluation performed by pediatric emergency physicians using POCUS performs well in screening TT, and can decrease length of stay in the ED.

Factors Determining Testicular Torsion and Consequent Orchiectomy in Pediatric Patients Presenting With Scrotal Pain

OBJECTIVE

Factors associated with testicular torsion (TT) and consequent orchiectomy in patients presenting to pediatric emergency departments (PEDs) with scrotal pain (SP) are not well described. We report the factors predicting TT and consequent orchiectomy in children with SP.

METHODS

The data on patients (aged ≤18 years) who presented with SP to PEDs at 4 branches of the Chang Gung Hospital through 10 years were analyzed.

RESULTS

In all, 256 pediatric patients presented with SP. Their mean age was 11.60 ± 4.61 years and 72.7% (n = 186) were aged 10 to 18 years. The pain was left-sided in 54.7% (n = 140) and the interval between SP onset and PED arrival was 22.45 ± 31.27 hours. Overall, 84 (32.8%) patients needed surgery and 72 (28.1%) had TT. Of the patients with TT, 28 (38.9%) patients needed an orchiectomy. After analysis, TT and consequent orchiectomy were associated with a longer interval between SP onset and PED arrival, absent of testicular ultrasonic blood flow, interval between SP onset and surgery of more than 24 hours, and a high degree of TT. None of them experienced recurrent SP symptoms or TT again.

CONCLUSIONS

The rate of TT in patients presenting to PEDs with an SP was 28.1%, and 38.9% of the patients with TT needed an orchiectomy. Early diagnosis and intervention helped to prevent subsequent orchiectomy in pediatric patients with TT.

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.

Impact of seasonal variations on incidence and laterality of testicular torsion

Nowadays, there is confusing evidence in the literature regarding the association between seasonal variations and events of testicular torsion (TT). We attempted to assess the correlation between seasonal variations, including season, ambient temperatures, and humidity levels to onset and laterality of testicular torsion. We conducted a retrospective review of patients diagnosed with testicular torsion and confirmed surgically between January 2009 and December 2019, at Hillel Yaffe Medical Center. Weather data was collected from meteorological observation stations near the hospital. TT incidents were stratified into five temperature categories (< 15 °C, 15-20 °C, 20-25 °C, 25-30 °C, > 30 °C) and into two categories of humidity (≤ 50%, > 50%). Potential associations between TT and seasonal variations were investigated. Of 235 patients diagnosed with TT, 156 (66%) were children and adolescents and 79 (34%) were adults. In both groups, rate of TT incidents increased in winter and fall months. Significant correlation between TT and temperatures below 15 °C was observed in both groups; OR 3.3 [95% IC 1.54-7.07], p = 0.002 in children and adolescents and 3.77 [1.79-7.94], p < 0.001) in adults. The correlation between TT and humidity was non-significant in both groups. Among children and adolescents left-sided TT was observed in most of the cases, with strong correlation to lower temperatures; OR 3.15 [1.34-7.40], p = 0.008. Higher rates of acute TT were observed in patients admitted to the emergency department (ED) during the cold seasons in Israel. Significant association was observed between left-side TT and temperatures below 15 °C in the children and adolescents' group. Our findings suggest that there might be a predilection for TT occurrence in cold weather, particularly left-side laterality among children and adolescents.

Azoospermia and Sperm Retrieval in Post-Pubertal Testicular Torsion; Benefits and limitations

OBJECTIVES

To assess the risk of azoospermia development and the value of sperm retrieval in post-pubertal testicular torsion (TT).

MATERIALS AND METHODS

This prospective study included patients with post-pubertal TT. Surgical exploration was urgently performed with either orchiopexy or orchiedectomy and contralateral orchiopexy. With the intention of cryopreservation, all cases underwent conventional testicular sperm extraction. Patients were followed-up after 1, 3, and 6 months with semen analysis and hormonal assay (FSH, LH and testosterone). Sperm retrieval rate (SRR), azoospermia rate and changes in hormonal profile were evaluated.

RESULTS

The study included 62 patients with a median (IQR) age of 19 (18-20.7) years and duration of testicular torsion of 32.5 (18.3-48) hours. Testicular salvage was successful in 20 (32.3%) while orchiedectomy was performed on 42 patients. The duration of torsion [OR, 95% CI = 0.75 (0.61-0.93), P = .008] was the independent predictor of testicular salvage. Successful SR was achieved in 58 patients (93.5%); (40 from the affected testis and 18 from the contralateral side). After 6 months, 21 patients (33.8%) developed azoospermia [19 (45.2%) in orchidectomy group and 2 (10%) in orchiopexy group, P = .006]. Abnormal contralateral testis was the independent predictor of azoospermia [OR, 95% CI = 92(8.4-101.5), P < .001]. Azoospermia patients showed a statistically significant increase in FSH and LH and decrease in testosterone level as compared to the non-azoospermia group (P < .001).

CONCLUSION

Azoospermia is not rare in post-pubertal TT patients; therefore, SR at time of intervention seems to be a good option for them to preserve their fertility potentials.

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.

Quality Assessment of YouTube Videos as an Information Source for Testicular Torsion

Background

Testicular torsion is an acute scrotal disease requiring urgent management, and the COVID-19 pandemic has been demonstrated to lead to poor outcomes for this disease. Presently, many people tend to seek health information via YouTube. This study aims to quantitatively assess the quality of English YouTube video content as an information source of testicular torsion.

Methods

In this cross-sectional study, a search was performed with the search term "testicular torsion" on YouTube, and the first 100 videos listed by relevance were selected for our analysis. Duplicate, non-English, videos without audio and surgical videos were excluded. Video features (duration, number of days online, views, likes, comments), source of the video, and author's country were collected. Each video included in the study was assessed using DISCERN and Journal of the American Medical Association (JAMA) Benchmark Criteria. A correlation analysis was performed considering video features, video source, DISCERN scores and JAMA scores.

Results

A total of 66 videos were included and analyzed. The most common video content was general information, including etiology, symptoms, and treatment. The majority of videos were from education and training websites (30%), physicians (23%), and independent users (21%). The mean DISCERN and JAMA scores were 36.56 and 2.68, respectively. According to DISCERN, the quality of video uploaded by physicians was relatively high (P < 0.001), and the quality of video uploaded by independent users was relatively low (P < 0.001). The JAMA score had no relevance to the video source (P = 0.813). The correlation between the video features, DISCERN and JAMA scores was controversial by different assessment methods.

Conclusions

Despite most of the videos on YouTube being uploaded by medical or education-related authors, the overall quality was poor. The misleading, inaccurate and incomplete information may pose a health risk to the viewers, especially during the COVID-19 pandemic. Much effort needs to be undertaken to improve the quality of health-related videos regarding testicular torsion.

Impact of Distance From the Hospital and Patient Transfer on Pediatric Testicular Torsion Outcomes

Background: Testicular torsion is the most common pediatric emergency that requires prompt diagnosis and surgical treatment to prevent testicular loss. Distance from the hospital where the patient will be undergoing treatment for testicular torsion and transfer from an outside facility are factors that may impact whether a testis is salvageable. We sought to determine whether these factors play a role in pediatric testicular torsion outcomes. 

Materials and Methods: We identified males aged 1-18 years with testicular torsion between January 1, 2015 and December 31, 2020. The patients’ distance from our hospital and whether they were transferred from an outlying hospital were a particular focus. 

Results: The number of miles from our hospital and transfer from an outlying hospital were not significantly different between boys who underwent an orchiectomy versus an orchiopexy (p=0.258 and p=0.574, respectively). The number of miles from our hospital was negatively correlated to age at surgery (rho=-0.22, p=0.01). Significantly (p<0.001) more transfers were seen in patients who lived far (>22.1 miles) from our hospital (32/69 (46%)) versus near our hospital (10/68 (15%)). For every mile boys lived from our hospital, there was no difference (adjusted odds ratio (OR)=0.98 (0.96, 1.00), p=0.10) in the likelihood of receiving an orchiectomy versus an orchiopexy when adjusting for age, symptom duration, and degrees of torsion.

Conclusions: Our study determined that neither distance from our hospital nor transfer from an outlying hospital affected the orchiectomy rate. An expedited medical evaluation and surgery offer the best prognosis for salvaging the testes. 

Impact of treatment delays on outcome of acute testicular torsion: a 15-year retrospective study

INTRODUCTION

Preservation of the testicle is directly associated with the duration of torsion. The aim in this retrospective study was to identify factors that influence pre-and in-hospital times and measure the extent to which these times affect testicle survival.

PATIENTS AND METHODS

A retrospective review of 116 patients who underwent exploration for testicular torsion between 2000 and 2015. Patients were divided into orchiectomy and salvaged testicle groups. Times in patient management and clinical features were compared with Mann-Whitney, chi-squared, and Fisher exact tests. Multivariate logistical regression was used to identify independent factors associated with orchiectomy.

RESULTS

The median prehospital time of 48 h (15.4-138 h) in the orchiectomy group was longer than the 2.4 h (1.6 h-5.2h) in the salvaged group. Patients examined by a general practitioner (GP) prior to presenting at hospital had a median prehospital time of 48 h, compared to 3 h for patients not examined before presentation at hospital. In-hospital times between admission and operation room, as well as times between ultrasonography and operation room, were also longer in the orchiectomy group. Previous GP consultation (OR = 27.26, 95% CI 2.32-320.59, p = .009), prehospital time (OR = 1.04, 95% CI 1.01-1.07, p = .003) and nausea (OR = 9.25, 95% IC 1.33-64.52, p = .025) were independent predictive factors associated with orchiectomy.

CONCLUSION

Prehospital time was a determining factor in orchiectomy. For each extra hour of prehospital delay, the risk of orchiectomy increased by 4%. The rate of orchiectomy was higher among patients who first consulted a GP.

Testicular torsions in veterinary medicine

The purpose of this review is to provide a comprehensive comparison of spermatic cord torsion in domestic animals. Spermatic cord torsion leads to occlusion of testicular blood flow resulting in ischemia and tissue hypoxia. Spermatic cord torsion has been reported in all domestic mammals but dogs and horses are overrepresented. Abdominal pain (colic), anorexia, vomiting, lameness, and stiff gait are the most common clinical signs reported. The condition may be asymptomatic in cases of a low degree of spermatic cord torsion. In dogs, spermatic cord torsion is most commonly reported in undescended testes, which in some cases are neoplastic. However, in horses, spermatic cord torsion occurs more commonly in scrotal testes. Surgical treatment for spermatic cord torsion depends upon the degree and duration of torsion. If the affected testis is located within the scrotum and determined to still be viable, detorsion with orchidopexy can be performed. Orchiopexy of the unaffected scrotal testis is also recommended in stallions. If the affected testis cannot be salvaged, unilateral or bilateral orchidectomy is recommended. In all cases of spermatic cord torsion of an undescended testis, orchidectomy is recommended. Veterinarians should be aware of the clinical signs and treatment options for spermatic cord torsion in domestic mammals.

Leech therapy (Hirudo medicinalis) attenuates testicular damages induced by testicular ischemia/reperfusion in an animal model

BACKGROUND

Testicular torsion/detorsion triggers tissue ischemia/reperfusion, leading to reactive oxygen species overgeneration and apoptosis. The saliva of leeches is full of anti-inflammatory, anticoagulants, antioxidants, and antimicrobial agents. Therefore, this study aimed to assess the protective mechanism of leech therapy on testicular ischemia/reperfusion damage.

METHODS

18 adult male rats were randomly divided into three groups: 1-Sham-operated group (SO). 2-Torsion/detorsion (T.D) group: two hours of testicular torsion with two hours of testicular detorsion was performed. 3-Torsion/detorsion + Leech therapy (TDL) group. Sperm parameters (motility, vitality, morphology, and concentration), oxidative stress biomarkers (MDA, CAT, GPx, and TAC), histopathological factors (Mean seminiferous tubular diameter, Germinal epithelial cell thickness, Testicular capsule thickness, Johnson's score, and Cosentino's score), and immunohistochemical markers for apoptosis detection (Bax, Bcl-2, and Caspase-3) were measured.

RESULTS

There was a significant difference for all sperm parameters in the T. D group compared to the sham group. Leech therapy significantly increased progressive motility and normal morphology and reduced non-progressive motility. In the TDL group, MDA concentration significantly reduced, and levels of GPx, TAC, and CAT remarkably increased. All evaluated histopathological parameters in the TDL group significantly increased compared to the T. D group except for the testicular capsule thickness. T. D notably increased the expression of Bax and Caspase-3, while the treatment group slowed the rate of apoptosis compared to the control group. Bcl-2 expression in the T. D group was significantly lower than that in the sham group. Leech therapy increased the Bcl-2 expression.

CONCLUSION

Leech therapy attenuates damages to testicular tissue following torsion/detorsion due to its antioxidant, anti-inflammatory, and anti-apoptotic effects. Hence, it can be considered as an effective remedy for testicular ischemia/reperfusion.

Serious incidents in testicular torsion management in England, 2007-2019: optimizing individual and training factors are the key to improved outcomes

OBJECTIVES

To establish the healthcare factors that contribute to testicular torsion adverse events (orchidectomies) and 'near misses'. The secondary objective was to identify areas suitable for impactful quality improvement initiatives to be undertaken by National Health Service (NHS) healthcare providers nationally.

MATERIALS AND METHODS

This was a retrospective record review and analysis, carried out in four phases. We applied the well-validated London Protocol patient safety incident analysis framework to all eligible serious incidents related to testicular torsion submitted by English NHS Trusts over a 12-year period to the Strategic Executive Information System database. Clinical reviewers established the incident population (Phase 1), were trained and piloted the feasibility of using the London Protocol (Phase 2), applied the protocol and themed the identified contributing factors linked to adverse events (orchidectomies) and near-misses (Phase 3), and reviewed the evidence for improvement interventions (Phase 4).

RESULTS

Our search returned 992 serious incidents, of which 732 were eligible for study inclusion and analysis. Of those, 137 resulted in orchidectomies, equivalent to one serious incident resulting in orchidectomy per month, and 595 were near misses. Factors contributing to all incidents were: individual staff/training (38%); team (18%); work environment (16%); task and technology (14%); and institutional context (13%). Subgroup analysis of incidents resulting in orchidectomies vs near misses demonstrated a different pattern of factors, with individual staff/training factors significantly more prominent: individual/training (88%); work environment (8%); and task and technology (1%). No evidenced improvement interventions were found in the literature.

CONCLUSION

This is the first study to our knowledge to systematically analyse and classify factors that are associated with loss of a testicle and related near-miss incidents in patients presenting with testicular torsion. In England, a significant number of orchidectomies occur annually as a consequence of healthcare serious incidents. In order to improve outcomes, we propose clinical support to aid the diagnosis of torsion, improved national clinical guidelines, development of specific standard operating procedures and (in the longer term) more exposure of trainees and medical students to urology to improve the testicular salvage rate.

Establishment and internal validation of preoperative nomograms for predicting the possibility of testicular salvage in patients with testicular torsion

This study aimed to establish nomograms to preoperatively predict the possibility of testicular salvage (TS) in patients with testicular torsion. The clinical data of 204 patients with testicular torsion diagnosed at Xijing Hospital and Tangdu Hospital (Xi'an, China) between August 2008 and November 2019 were retrospectively analyzed. Univariate and multivariate logistic regression analyses were used to determine the independent predictors of TS. Based on multivariate regression coefficients, nomograms to predict possibility of TS were established. The predictive ability of the nomograms was internally validated by receiver operating characteristic (ROC) curves and calibration plots. The duration of symptoms ranged from 2 h to 1 month, with a median of 3.5 days. Thirty (14.7%) patients underwent surgical reduction and contralateral orchiopexy, while the remaining 174 (85.3%) underwent orchiectomy and contralateral orchiopexy. Finally, long symptom duration was an independent risk predictor for TS, while visible intratesticular blood flow and homogeneous testicular echotexture under color Doppler ultrasound were independent protective predictors. Internal validation showed that the nomograms, which were established by integrating these three predictive factors, had good discrimination ability in predicting the possibility of TS (areas under the ROC curves were 0.851 and 0.828, respectively). The calibration plots showed good agreement between the nomogram-predicted possibility of TS and the actual situation. In conclusion, this brief preoperative prediction tool will help clinicians to quickly determine the urgency of surgical exploration.

Effects of platelet-rich plasma on spermatogenesis and hormone production in an experimental testicular torsion model

BACKGROUND

Platelet-rich plasma is a biological instrument rich in growth factors and cytokines.

OBJECTIVES

The aim of this study was to investigate the effect of platelet-rich plasma on spermatogenesis and hormone production in an experimental testicular torsion model.

MATERIALS AND METHODS

The rats were randomly divided into three groups, including six rats in each group as follows: the first group as the sham group; the second group as the ischemia/reperfusion + Saline group and the third group as the ischemia/reperfusion + platelet-rich plasma group. The left testicles of the ischemia/reperfusion + Saline and ischemia/reperfusion + platelet-rich plasma group were kept in four-hour torsion. Then, the left testicles of ischemia/reperfusion + Saline and ischemia/reperfusion + platelet-rich plasma groups were detorsioned, and intra-testicular 1 cc saline (ischemia/reperfusion + Saline) and 1 cc platelet-rich plasma (ischemia/reperfusion + platelet-rich plasma) were injected. At one month, blood samples were taken from all groups for hormonal evaluation and left orchiectomy was performed.

RESULTS

The mean follicle-stimulating hormone level of ischemia/reperfusion + Saline group was significantly higher than ischemia/reperfusion + platelet-rich plasma group (7.78 ± 0.23 vs 6.18 ± 0.28 nmol/l, respectively, P = .004). The mean LH level of ischemia/reperfusion + platelet-rich plasma group was significantly lower than ischemia/reperfusion + Saline group (3.63 ± 0.28 vs 5.68 ± 0.21 nmol/l, respectively, P = .004). The mean total testosterone level of ischemia/reperfusion + platelet-rich plasma group was significantly higher than ischemia/reperfusion + Saline group (8.05 ± 0.24 vs 5.78 ± 0.23 nmol/l, respectively, P = .004). The mean Johnsen scores of ischemia/reperfusion + platelet-rich plasma group were significantly higher than ischemia/reperfusion + Saline group (5.85 ± 0.58 vs 3.93 ± 0.65, respectively, P = .004). The mean Johnsen score of the sham group was significantly higher than ischemia/reperfusion + platelet-rich plasma and ischemia/reperfusion + Saline groups (P = .003 and P = .003, respectively).

DISCUSSION AND CONCLUSION

The platelet-rich plasma has beneficial effects on spermatogenesis and reproductive hormone production in testicular torsion. It is easily accessible and applicable. In the future, intra-testicular platelet-rich plasma injection may be used in testicular torsion after detorsion. However, further experimental and large-scale prospective clinical studies are needed to establish a definitive conclusion on this topic.

Effect of unilateral testicular torsion at different ages on male fertility

Objective

To investigate the effect of early-life unilateral testicular torsion on adult male fertility.

Methods

Clinical information was collected for 122 patients who had experienced unilateral testicular torsion at a median age of 15.5 years. The recent pregnancy rate and time to pregnancy experienced by the patients’ female partners were assessed by structured interviews. Data were analyzed by the chi-squared test and Student’s t-test.

Results

Seventy-two patients with testicular torsion met the criteria for inclusion in our analyses; 49 had undergone orchiectomy, while 23 had undergone surgical repositioning/orchiopexy. The pregnancy rate and median time to pregnancy were 83.67% (41/49) and 1.6 years, respectively, in the orchiectomy group, whereas they were 91.30% (21/23) and 0.75 years, respectively, in the repositioning/orchiopexy group. The recent pregnancy rate was higher in patients with torsion in childhood than in patients with torsion in adolescence; it was lowest in patients with torsion in adulthood. Surgical repositioning/orchiopexy yielded a significantly better recent pregnancy rate among the three groups, based on age at the time of torsion, and a shorter time to pregnancy than orchiectomy in patients with torsion in adolescence.

Conclusion

Onset of unilateral testicular torsion early in life has a negligible effect on adult male fertility.

Acute scrotum and testicular torsion in children: a retrospective study in a single institution

INTRODUCTION

Testicular torsion (TT), as per the reported incidences in children and preadolescents, is an emergency medical condition that requires prompt surgical treatment. In cases of TT, early and accurate diagnosis of acute scrotum (AS) is important to preserve testicular fertility. In this study, the authors aimed to determine the incidence, clinical examination, etiology, clinical predictors, and treatment of patients with AS and TT.

MATERIAL AND METHODS

The authors retrospectively reviewed all children (age, ≤15 years) with AS who visited their hospital between January 2012 and June 2019. Data on age and diagnosis, clinical findings, mode of treatment, and blood examination results were collected.

RESULTS

The authors examined 165 children aged between 0 days and 15 years (mean age, 9.4 years). Final diagnosis identified 72 patients with torsion of the appendix testis, 44 patients with epididymitis, and 38 patients with TT. Testes were salvaged in 23 of the 38 patients with TT (60.5%). Statistically significant variables revealed that the risk factors of TT were age (older than 12 years), white blood cell (WBC) count (>12,000 cells/mm³), and laterality (left side). The level of C-reactive protein (CRP), duration of symptoms, and degree of torsion were significantly higher in the non-salvageable testis group than in the salvageable testis group. Furthermore, the significant predictive factor for non-salvageable testis was the level of CRP >1.0 mg/dl.

CONCLUSION

The study results indicates that age, WBC count, and laterality are key factors to distinguish TT from AS. Salvageability largely depended on the duration of symptoms and the degree of TT. The salvage rate of the testis can be improved by educating pediatricians, parents, patients, and medical staff about the early diagnosis and treatment of torsion.

A comparison of clinical outcomes of acute testicular torsion between prepubertal and postpubertal males

SHORT INTRODUCTION/BACKGROUND

Surgical intervention for acute testicular torsion can require either orchiopexy or orchiectomy. The decision of which surgery to perform is dependant on the amount of time that the testicle experienced ischemia and the viability of the testicle after reperfusion.

OBJECTIVE

It is hypothesized that (1) there is a difference in orchiectomy and orchiopexy rates between prepubertal and postpubertal males with acute testicular torsion and (2) presenting symptoms may vary between the two age groups as prepubertal males may present with atypical symptoms, which could result in delayed presentation and diagnosis.

STUDY DESIGN

A retrospective chart review was conducted on pediatric patients who were diagnosed with acute testicular torsion between June 2010 and August 2017. Demographic and clinical characteristics were extracted: age, ethnicity, referral pattern, primary insurance status, symptoms at presentation, prior history of ipsilateral testicular pain or intermittent torsion, recent trauma to genitalia, duration of symptoms (hours), gradual vs. acute onset of symptoms, time/weekday/season at presentation, and time interval from arrival at the study institution to surgical intervention (minutes). Patients were categorized into two groups: prepubertal group (age 1-12 years) and postpubertal group (age 13-18 years). Statistical analyses were performed using R, version 3.3.1.

RESULTS

Ninety-one patients were included in the study. The overall orchiectomy rate was 30.8%. More prepubertal males underwent orchiectomy than postpubertal males (42.4% vs. 24.1%, respectively). Prepubertal males were more likely to present with abdominal pain than postpubertal males (27.3% vs. 10.3%, respectively). Those who underwent orchiectomy were more likely to present with longer duration of symptoms, testicular swelling, and abdominal pain than those who underwent orchiopexy. The risk of orchiectomy decreased by 14% per 1-year increase in age (odds ratio [OR]: 0.86, 95% confidence interval [CI]: 0.94-1.00, p = .009). A steady decline in the proportion of patients undergoing orchiectomy was seen from 1 to 12 years of age.

DISCUSSION

This study found that prepubertal males are at higher risk for orchiectomy than postpubertal males. The risk of orchiectomy decreases by 14-16% per 1-year increase in age. Prepubertal males are more likely to present with atypical symptoms and delayed presentation and diagnosis, leading to delayed surgical intervention. It is important for providers to perform a genital examination in prepubertal males who present with abdominal pain to rule out acute testicular torsion. Patients presenting with longer duration of symptoms, testicular swelling, and abdominal pain are at higher risk for orchiectomy. No correlation was found between orchiectomy rate and ethnicity, referral status, primary insurance status, and time/weekday/season at presentation.

CONCLUSION

Among patients presenting to a tertiary pediatric hospital with acute testicular torsion, prepubertal males (younger than 12 years) are at higher risk for orchiectomy than postpubertal males. Prepubertal males are more likely to present with atypical symptoms which results in delayed presentation and diagnosis, leading to delayed in surgical intervention.

Point-of-care influences orchiectomy rates in pediatric patients with testicular torsion

OBJECTIVES

The objective of this study was to determine whether point-of-care (community hospitals vs. tertiary centers) or treatment-delaying variables (transfer, emergency room [ER] throughput, and distance traveled) affect orchiectomy rates in minors with testicular torsion (TT) using a national database.

STUDY DESIGN

This was a retrospective cohort study using prospectively collected data by the Canadian Institute of Health Information (CIHI) between 2010 and 2015. All Canadian male patients in the CIHI database aged <18 years with TT based on International Classification of Diseases (ICD) codes were included, except for those residing in Quebec. Variables collected were age, type of treating institution (community small/medium, community large, or tertiary/academic), transfer for definitive treatment, road distance traveled, and ER throughput. The outcome was testicular loss based on intervention codes for orchiectomy/orchidopexy. Univariable and multivariable analyses were performed using logistic regression.

RESULTS

A total of 1713 minors with TT were included. Overall orchiectomy rate was 28%. Most patients (52%) were treated at tertiary hospitals. Small/medium community hospitals depicted the lowest odds of orchiectomy on univariable and multivariable analyses (odds ratio [OR] = 0.54, confidence interval [CI]: 0.37-0.79, p < 0.001); academic hospitals were also associated with a lower odds of orchiectomy than large community ones. Transfer and distance traveled were not associated with the outcome. Age >12 and ER throughput less than 1 h were significantly associated with lower orchiectomy rates. In a subgroup analysis of patients aged <12 years (n = 278), transfer was the only factor associated with increased risk of orchiectomy (OR = 2.41 , CI: 1.09-5.33; p = 0.03).

DISCUSSION

This study showed that small and medium community hospitals had the lowest orchiectomy rates in minors with TT in Canada (Figure). However, on multivariable analysis, they performed similarly to tertiary/academic hospitals, with both being superior to large community hospitals. Transfer and distance traveled did not affect orchiectomy rates. Emergency room throughput had a statistically significant association with orchiectomy rates in every analysis and based on the study data would constitute the best target for policies aimed at reducing orchiectomy rates for TT in minors. The main limitation of this study is the inability to evaluate long-term testicular viability of patients not undergoing orchiectomy (i.e., true testicular salvage).

CONCLUSIONS

Type of hospital treating facility (point-of-care) affects orchiectomy rates in minors with TT. Small/medium community hospitals depict the lowest orchiectomy rates in Canada. Transfer to another facility for definitive care and distance traveled did not affect orchiectomy rates, except in a subgroup analysis of prepubertal boys. Longer ER throughput and prepubertal age were consistently associated with loss of the testicle.

The Impact of Testicular Torsion on Testicular Function

Torsion of the spermatic cord is a urological emergency that must be treated with acute surgery. Possible long-term effects of torsion on testicular function are controversial. This review aims to address the impact of testicular torsion (TT) on the endocrine- and exocrine-function of the testis, including possible negative effects of torsion on the function of the contralateral testis. Testis tissue survival after TT is dependent on the degree and duration of TT. TT has been demonstrated to cause long-term decrease in sperm motility and reduce overall sperm counts. Reduced semen quality might be caused by ischemic damage and reperfusion injury. In contrast, most studies find endocrine parameters to be unaffected after torsion, although few report minor alterations in levels of gonadotropins and testosterone. Contralateral damage after unilateral TT has been suggested by histological abnormalities in the contralateral testis after orchiectomy of the torsed testis. The evidence is, however, limited as most human studies are small case-series. Theories as to what causes contralateral damage mainly derive from animal studies making it difficult to interpret the results in a human context. Large long-term follow-up studies are needed to clearly uncover changes in testicular function after TT and to determine the clinical impact of such changes.

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.

Concurrent testicular torsion and acute incarcerated inguinal hernia in an adolescent boy

Testicular torsion and acute incarcerated inguinal hernia are both common surgical emergencies in the paediatric population. We present the unusual case of a 16-year-old adolescent boy who presented with both of these conditions concurrently. He had a history of a right inguinal hernia, but ultrasound confirmed a testicular torsion and we employed manual detorsion in the emergency department prior to taking him to the operating room. We successfully salvaged the testicle in addition to performing inguinal hernia reduction and repair. The goal of this report is to emphasise the importance of maintaining a broad differential and early utilisation of ultrasound in the patient with acute groin pain.