Bilateral intra-uterine testicular torsion in a newborn

Pitfalls and Practical Challenges in Imaging of the Pediatric Scrotum

ABSTRACT

Ultrasound is the modality of choice for evaluation of the pediatric scrotum, as it provides excellent image quality without the use of radiation, need for sedation/anesthesia, or use of contrast material and can be used for serial examination. Ultrasound of the scrotum has proven to be useful for assessment of a wide gamut of congenital, infectious, inflammatory, endocrine, neoplastic, and traumatic abnormalities in pediatric patients of all ages from the tiniest premature infant to a fully grown young adult. This review article presents a varied spectrum of conditions that may affect the pediatric scrotum, what the radiologist needs to know to meet the challenge of limiting the differential diagnosis, and how to avoid pitfalls when imaging the scrotum.

Perspectives in Pediatric Pathology, Chapter 19. Testicular Torsion, Testicular Appendix Torsion, and Other Forms of Testicular Infarction

Among the most frequent specimens at the pediatric surgical pathology bench, orchiectomy performed after testicular torsion deserves significant attention. Multiple implications, including fertility, legal complications, possibility of occult lesion, and others, need to be considered. Furthermore, torsion of testicular and other appendices represents common urological emergencies frequently encountered in surgical pathology. Here we present a review of testicular torsion and infarction, including theories about their pathogenesis and the appropriate handling by the diagnostic pathologist.

Scrotal emergencies

This review describes the clinical, grey-scale and colour Doppler US findings of different conditions that may be the cause of an acute scrotum. The US appearances of testicular torsion, torsion of the appendix testis, epididymoorchitis, incarcerated hernia and idiopathic scrotal oedema are described. Some of the major studies regarding the sensitivity and specificity of US in the diagnosis of these diseases are reviewed. Grey-scale and colour Doppler US demonstrate high accuracy in the aetiological diagnosis of an acute scrotum and can differentiate between diseases that require immediate surgical intervention and those that can be treated conservatively.

Neonatal bilateral testicular torsion: a plea for emergency exploration

PURPOSE

Bilateral testicular torsion is a rare condition. Most authors present single case reports. Therefore, the clinical and surgical aspects of bilateral torsion in a neonate have not been subjected to detailed analysis. We performed a retrospective analysis of our experience in the management of bilateral perinatal torsion as well as a collective review of the medical literature.

MATERIALS AND METHODS

All cases of neonatal testicular torsion managed at our neonatal surgical center during the last 2 decades (1986 to 2005) were reviewed, and 3 cases of bilateral torsion were identified. In addition, 45 neonatal cases of bilateral torsion were found through the literature search. In all cases data regarding clinical presentation, imaging studies, surgical management, intraoperative and pathological findings, and final outcome were analyzed.

RESULTS

Synchronous torsion occurred in 32 of 48 newborns (67%), while asynchronous pathology was reported in 16 (33%), including the 3 presented in this report. All except 1 patient were full-term newborns with normal or above average birth weight. Difficult delivery was noted in 33% of the cases. Despite prompt surgical intervention in 46 infants, the salvage rate was low, with arterial flow confirmed postoperatively in only 3 gonads (3.1%). Four gonads in 3 additional patients were reported to be of normal size on followup.

CONCLUSIONS

Asynchronous torsion is not as rare an event as previously reported, and it may pose a diagnostic challenge. In the majority of these cases torsion of the left testis seems to occur later than torsion of the right testis. The role of imaging studies in newborns with bilateral torsion seems to be limited, especially in cases of asynchronous pathology. Urgent bilateral exploration is strongly advised in all newborns presenting with either unilateral or bilateral torsion. Such policy carries diagnostic, potential therapeutic and prognostic implications.

Spin on perinatal testicular torsion

We describe a recent case of perinatal testicular torsion at our institution. The presentation, management and outcome of perinatal testicular torsion are quite different to testicular torsion in the general paediatric population. The literature describes a variety of management options for perinatal testicular torsion and these are briefly reviewed. In cases of unilateral perinatal testicular torsin, there is controversy over whether surgery to fix the contralateral testis is required, and if so, the appropriate timing for the surgery. A good understanding of the issues unique to perinatal torsion will facilitate appropriate counseling of parents of affected neonates.

Prenatal testicular torsion: Ultrasonographic features, management and histopathological findings

AIM

To highlight the ultrasonographic features of prenatal torsion of the testis in utero (IUTT) at presentation, the neonatal management and the histological findings postorchiectomy or biopsy.

METHODS

Seven newborns underwent emergency exploration for IUTT. All patients underwent a sonography and real-time color Doppler ultrasound study of the scrotum before any surgical procedure. A histological examination was performed in the removed specimens.

RESULTS

Sonography of the scrotum revealed enlarged, heterogeneous testes. In all cases the color and power Doppler did not reveal any flow signal on the affected side. Four newborn with unilateral testicular torsion underwent orchiectomy and contralateral orchidopexy. In one neonate after detorsion and with the absence of gangrenous changes and a reassuring biopsy, a twisted testis could be treated conservatively with orchidopexy. In another case, the parents, acknowledging the inviability of the affected testis, gave consent only for a biopsy of the testis. In the neonate with bilateral IUTT, bilateral testicular biopsies were performed. Histology of the removed testes variably showed interstitial red cell extravasion and coagulation or hemorrhagic necrosis. Light microscopy of the preserved testis highlighted surviving seminiferous tubules, with gonocytes, spermatogonia and fetal Sertoli cells.

CONCLUSIONS

An early diagnosis and treatment in IUTT is essential. Surgical exploration should be always performed through the inguinal route. In bilateral IUTT testes should be left to try to assure, as long as possible, a residual Leydig cell function.

A case of bilateral prenatal testicular torsion: Ultrasonographic features, histopathological findings and management

OBJECTIVES

The aim of this study was to demonstrate the ultrasonographic features of prenatal bilateral torsion of the testis, and its histological correlation and management.

PATIENT

A newborn presented at delivery with both testes enlarged, swollen and tender. Prenatal ultrasound (US) showed enlarged, hyperechoic testes. Colour Doppler US examination was performed.

RESULTS

US revealed both testes to be heterogeneous. Colour Doppler US did not reveal any flow signal. On inguinal exploration both testes appeared necrotic. Histology showed recognizable seminiferous tubules and Leydig cells.

CONCLUSION

We believe that both testes should be left in situ after bilateral detorsion even if their macroscopic appearance is necrotic.

[Spermatic cord torsion in the newborn: role of surgical exploration]

Torsion of the spermatic cord is frequent in neonates suffering from acute scrotal distress. A retrospective study was carried out to determine the viability and the outcome of testis treated by surgical exploration.

PATIENTS AND RESULTS

Surgical exploration of 30 neonates presenting acute scrotal distress found: 18 torsions of the spermatic cord, six intrascrotal bleedings or hematoma due to delivery trauma, five tunica vaginalis inflammations and one ischemia without torsion. The torsion occurred in utero in 16 cases and after birth in two cases. The contralateral uninvolved testis was fixed to the scrotum in all cases. The torsion was extravaginal in 17 cases and intravaginal in one case. In all cases of prenatal torsion, there was total necrosis of the testis. One case of postnatal torsion operated on four hours after the beginning of the torsion was saved.

CONCLUSION

Although the viability of the torsioned testis is compromised in cases of prenatal torsion, surgical exploration is necessary to confirm diagnosis and to avoid any contralateral torsion because bilateral torsion exists. Only emergency surgical exploration can save a testis that has undergone post-natal torsion as reported in others series.

Bilateral asynchronous perinatal testicular torsion: a case report

Bilateral perinatal testicular torsion (PTT) is an extremely rare condition. A baby boy at the postnatal 28th hour presented with right scrotal erythema and swelling, and left hydrocele were detected. There were no systemic symptoms. Right hydrocele had been detected during prenatal ultrasonography at the 34th week of gestation. Emergency technetium Tc 99m pertechnetate scintigraphy showed hypoperfusion in both sides suggesting testicular torsion. The patient underwent surgery immediately. Right necrotic testis was removed, left testis was judged as viable, and thus was treated with detorsion. Bilateral PTT in the neonate is a true emergency because of the risk of anorchia. Controversy still exists regarding the treatment of unilateral PTT. Some investigators suggest delayed operation regarding the anesthetic risk imposed on the neonate and the reality that operative salvage of the prenatally torsed testicle is a remote possibility. However, although asynchronous bilateral PTT is rare, the patient with unilateral PTT is at risk of contralateral testicular torsion in the waiting period of delayed operation. Therefore, the authors recommend early surgical intervention.

Intra-uterine testicular torsion: early diagnosis and treatment

OBJECTIVE

To review the incidence and treatment of intra-uterine torsion of the testis which although rare is being recognized with increasing frequency.

PATIENTS AND METHODS

From 1988 to 1997, five newborns (mean birth weight 3.62 kg, range 3.15-4.12) with unilateral torsion of the testis were treated; all underwent emergency exploration. The right testis was affected in three and the left in two boys.

RESULTS

In all except one child, the affected testis was enlarged, firm to hard, tender, the overlying skin dark red and the affected testis higher than the contralateral testis. In one child the right testis was enlarged and higher, but soft to firm, and the overlying skin was oedematous and red. The exploration revealed extravaginal torsion of the testis which was gangrenous in four; in one after detorsion there was haemorrhage and haematoma of the cord and the tunica, and the testis was slightly congested but not gangrenous. This testis was preserved and bilateral orchidopexies performed; at 18 months both testes are palpable and of normal size. In the remaining four children the testes were frankly necrotic; they underwent orchidectomy and contralateral orchidopexy. Histology in all four revealed a totally infarcted testis with extensive haemorrhage and vascular congestion.

CONCLUSION

The early diagnosis and treatment of intra-uterine torsion of the testis is essential.

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.