The Role of Manual Detorsion in Pediatric Testicular Torsion During the Global COVID-19 Pandemic: Experience From 2 Centres

Testicular torsion and ultrasound-assisted manual detorsion

Testicular torsion is a medical emergency that requires an immediate and multidisciplinary approach from emergency, surgical, and radiological services. In this article, we discuss the current knowledge and growing value of ultrasound (US) for intravaginal testicular torsion diagnosis and our experience with manual testicular detorsion with US assistance. Testicular torsion requires prompt and accurate diagnosis and quick therapeutic action. Technological advances in US equipment and knowledge of this pathology place the radiologist in an excellent position for its diagnosis and management. During the same medical procedure, the radiologist can both confirm the intravaginal testicular torsion and attempt manual testicular detorsion. US-assisted manual testicular detorsion is a non-invasive, simple, quick, safe, and effective manoeuvre that can rapidly restore testicular blood flow, maximising testicular salvage, relieving the patient's symptoms, and facilitating surgery.

Pediatric High-Risk Conditions

Meningitis, appendicitis, and testicular torsion are among the most common conditions resulting in malpractice litigation in Pediatric Emergency Medicine. With meningitis, most litigation claims involved patients <2 years old. Notably, 25% of patients had no fever and many lacked classic signs of meningitis. For appendicitis, nearly 3/4 of litigated cases claimed delayed/missed diagnosis. A non-diagnostic ultrasound (eg, no appendix visualized) has a negative predictive value of only 86%. Finally, testicular torsion carries a 34-42% testicular loss rate and 10% of patients with torsion only present with isolated abdominal pain. Atypical presentations must be considered and clear return precautions are imperative.

Predictive factors for manual detorsion success in testicular torsion

PURPOSE

In cases of testicular torsion (TT), prompt diagnosis and treatment are highly associated with organ salvage, and manual detorsion (MD) is a recommended maneuver as a first intervention. In our study, we aimed to investigate the effect of predictive factors of TT in predicting the success of MD.

METHODS

A retrospective, 2-center study was conducted on patients diagnosed with TT between January 2015 and 2024. Demographic, clinical, ultrasound, and laboratory characteristics at presentation were analyzed. MD was routinely performed as the first intervention in all patients. Predictive parameters were compared in the MD success and failure groups. Univariate and multiple logistic regression analysis was used to identify risk factors for MD failure.

RESULTS

A total of 94 patients were included in the study. The median age of the patients was 20 (IQR: 12-69) years, and the median symptom duration was 6 (IQR: 4-12) hours. MD confirmed by Doppler ultrasonography was successful in 52 (55.3%) patients and unsuccessful in 42 (44.7%). Age, symptom duration, Testicular Workup for Ischemia and Suspected Torsion (TWIST) score, TWIST risk groups, WBC, neutrophil, monocyte counts, and Monocyte/Eosinophil ratio (MER) were statistically different between the two groups. In multiple logistic regression analysis, the risk factors for failure of MD were found to be being over 18 years of age, the duration of symptoms being longer than 9 h, and MER > 28.

CONCLUSION

Current urology guidelines suggest that age, symptom duration, and MER are reliable predictors of the success of MD, which is recommended in all cases of TT.

Contemporary disparities in progression to orchiopexy for cryptorchidism as reported in the Pediatric Health Information System (PHIS) database

INTRODUCTION

When evaluating the timeliness of orchiopexy for cryptorchidism, health disparities are apparent among Hispanic and African American males and those with public insurance. Since the publication of these data, the COVID-19 pandemic has stressed our healthcare system and significantly affected the provision of pediatric urology care.

OBJECTIVE

We sought to assess if certain groups were disproportionately affected in progression to orchiopexy after the diagnosis of cryptorchidism during and after the pandemic in US freestanding children's hospitals.

STUDY DESIGN

Using the PHIS database, pediatric patients ≤5 years who underwent orchiopexy between January 2018 and December 2022 were retrospectively analyzed. Exclusion criteria included prematurity, retractile testes, and testicular torsion. Primary outcomes were age at orchiopexy and the proportion of individuals undergoing timely orchiopexy for cryptorchidism.

RESULTS

Over the study period 3140 patients ≤5 years old underwent orchiopexy for cryptorchidism. Non-Hispanic Blacks and Hispanics were significantly less likely to have timely orchiopexy and underwent orchiopexy 2.13 and 3.60 months later compared to whites (p < 0.01). As compared to pre-COVID-19, during the pandemic the proportion of patients who had timely surgery was higher and the median age was significantly lower (p = 0.01 and p < 0.01, respectively) in white patients only. Over the study period, patients with public insurance were less likely to have timely orchiopexy and underwent orchiopexy 2.94 months later (p < 0.01) than patients with private insurance. Compared to during the pandemic, post-pandemic a significantly lower proportion of publicly insured patients have since undergone timely orchiopexy (p = 0.04). Patients in the West were less likely to have timely orchiopexy and had a higher age at time of orchiopexy (p < 0.01) than other regions. However, in the West during the pandemic, the proportion of children who had timely surgery was higher compared to pre-and post-COVID-19 (p < 0.01).

DISCUSSION

Overall, regardless of insurance status, race, or location, a significant proportion of patients did not undergo timely orchiopexy. During the pandemic white patients had a lower median age and an increased proportion underwent timely orchiopexy, despite the number of orchiopexies remaining constant. Disparities in the post-COVID-19 era have been further exacerbated for publicly insured patients, who a significantly lower proportion of have since undergone timely orchiopexy. Specific efforts are required across the United States to increase timely orchiopexy for all boys.

CONCLUSIONS

Progression to timely orchiopexy remains low for all boys in the era surrounding COVID-19; certain groups appear to be more adversely affected.

The management of testicular torsion: A survey of Turkish pediatric surgeons and pediatric urologists

BACKGROUND

This study aimed to evaluate the approaches of pediatric surgeons and pediatric urologists in Türkiye regarding the diagnosis and treatment of testicular torsion (TT) and their adherence to the European Association of Urology (EAU) pediatric urology guideline.

METHODS

A survey consisting of 19 questions, accompanied by an annotation describing the objective of the study, was emailed to pediatric surgeons and pediatric urologists in June and July 2023.

RESULTS

Of the 95 respondents, 62.1% had over 10 years of experience, and 48.4% treated more than five cases of TT annually. Of the participants, 87.4% stated that scrotal Doppler ultrasonography (US) was always used, and 12.6% stated that US was used in cases of doubtful diagnosis. Concerning treatment, 14.7% reported performing manual detorsion, 70.5% never did, and 14.7% did so only if the operating room was unavailable soon. A total of 92.6% of participants opted for emergency surgery. Among participants who perform manual detorsion, 71.4% perform surgery within 24 hours after successful manual detorsion. Regarding fixation of the contralateral testicle, 14.7% never performed it, and 27.4% did so only when they performed an orchiectomy on the torsion testicle.

CONCLUSION

While most participants follow EAU pediatric urology guidelines by performing emergency surgery, the rate of manual detorsion is low. Few participants stated that emergency surgery may not be performed after manual detorsion. While all of the participants performed fixation of the torsion testicle in accordance with the guidelines, the same adherence was not observed in the contralateral testicle.

Manual detorsion in pediatric testicular torsion: A narrative review of the literature

Manual detorsion is infrequently performed in pediatric emergency medicine, particularly in centers with urology coverage. In no other emergency condition does an emergency physician not take immediate action to alleviate pain and damage, even if definitive care is close by. A small number of case reports exist in which pediatric emergency physicians have performed manual detorsion. This review the literature presents the case for routine manual detorsion prior to definitive orchiopexy.

Successful manual detorsion of testicular torsion in an elderly patient: A case report

INTRODUCTION

Testicular torsions in elderly individuals are rare occurrences that are often managed surgically.

CASE PRESENTATION

We present the first reported case of a successful manual detorsion in a 70-year-old male patient, resulting in clinical and radiological improvement.

CLINICAL DISCUSSION

In this case report we discuss the role of manual detorsion alone in elderly without the need for surgery.

CONCLUSION

Observation of our patient for 24 h post-detorsion ensured stability before discharge.