Spermatic cord torsion: loss of spermatogenesis despite return of blood flow

Testicular torsion in vivo models: Mechanisms and treatments

BACKGROUND

Testicular torsion is a condition in which a testis rotates around its longitudinal axis and twists the spermatic cord. This in turn results in a significant decrease in blood flow and perfusion of testicular tissue. During Testicular torsion, the testicular tissue is affected by ischemia, heat stress, hypoxia, and oxidative and nitrosative stress. The testicular torsion should be considered an emergency condition and surgical intervention (testicular detorsion ) as the sole treatment option in viable cases involves counter-rotation on twisted testes associated, when possible, to orchipexy, in order to avoid recurrence. Possible testicular detorsion side-effects occur due to reperfusion and endothelial cells injury, microcirculation disturbances, and intense germ cells loss.

OBJECTIVES

To discuss testicular torsion surgery-based methods, different time frames for testicular torsion induction, and the associated pathophysiology by emphasizing cellular and molecular events as well as different therapeutic agent applications for testicular torsion.

MATERIALS AND METHODS

We reviewed all original research and epidemiological papers related to testicular torsion condition.

RESULTS

Testicular torsion causes germ cell necrosis, arrested spermatogenesis, and diminished testosterone levels, with consequent infertility. Among different involved pathophysiological impacts, testicular torsion/detorsion-induced ischemia seems to play the key role by leading the tissue toward other series of events in testis. Numerous studies have used adjuvant antioxidants, calcium channel blockers, anti-inflammatory agents, or vasodilating agents in order to decrease these effects.

DISCUSSION AND CONCLUSION

To the best of our knowledge, no previously conducted study examined therapeutical agents' beneficial effects post clinical I/R condition in humans. Different agents targeting different pathophysiological conditions were used to ameliorate the ischemia/reperfusion-induced condition in animal models, however, none of the administrated agents were tested in human cases. Although considering testicular detorsion surgery is still the golden method to reverse the testicular torsion condition and the surgical approach is undeniable, the evaluated agents with beneficial effects, need to be investigated furthermore in clinical conditions. Thus, furthermore clinical studies and case reports are required to approve the animal models proposed agents' beneficial impacts.

The role of taurine in male reproduction: Physiology, pathology and toxicology

Taurine, a sulfur-containing amino acid, has a wide range of biological effects, such as bile salt formation, osmotic regulation, oxidative stress inhibition, immunomodulation and neuromodulation. Taurine has been proved to be synthesized and abundant in male reproductive organs. Recently, accumulating data showed that taurine has a potential protective effect on reproductive function of male animals. In physiology, taurine can promote the endocrine function of the hypothalamus-pituitary-testis (HPT) axis, testicular tissue development, spermatogenesis and maturation, delay the aging of testicular structure and function, maintain the homeostasis of the testicular environment, and enhance sexual ability. In pathology, taurine supplement may be beneficial to alleviate pathological damage of male reproductive system, including oxidative damage of sperm preservation in vitro, testicular reperfusion injury and diabetes -induced reproductive complications. In addition, taurine acts as a protective agent against toxic damage to the male reproductive system by exogenous substances (e.g., therapeutic drugs, environmental pollutants, radiation). Related mechanisms include reduced oxidative stress, increased antioxidant capacity, inhibited inflammation and apoptosis, restored the secretory activity of the HPT axis, reduced chromosomal variation, enhanced sperm mitochondrial energy metabolism, cell membrane stabilization effect, etc. Therefore, this article reviewed the protective effect of taurine on male reproductive function and its detailed mechanism, in order to provide reference for further research and clinical application.

Long-Term Follow-Up after Testicular Torsion: Prospective Evaluation of Endocrine and Exocrine Testicular Function, Fertility, Oxidative Stress and Erectile Function

Background: This study investigates endocrine and exocrine testicular function, oxidative stress (OS) in semen, and erectile function in patients who underwent surgery for suspected testicular torsion (TT). Methods: We evaluated 49 patients over a mean follow-up of 101 months: n = 25 patients treated with surgical exploration, n = 20 patients treated with detorsion, and n = 4 treated with orchiectomy. We performed semen analysis including Male infertility Oxidative System (MyOxSIS) analysis, physical examination, and evaluation of endocrine and erectile function. Results: OS, erectile function and spermiogram categories did not differ significantly between the groups. The interval from the onset of symptoms to surgery differed significantly between groups (p < 0.001). Preservation of the testes was associated with a higher round cell count (p = 0.002) and follicle stimulating hormone (FSH, p = 0.003). OS showed a significant positive correlation with the spermiogram category (0.337; p = 0.022). A negative correlation was observed between OS and age (p = 0.033), sperm concentration (p < 0.001) and total sperm count (p = 0.006). Conclusions: Endocrine, exocrine and erectile function are not significantly affected by TT in the long term. Orchiectomy results in elevated FSH and a lower round cell count compared to preservation of the testis.

Adipose Mesenchymal Stromal Cell-Derived Exosomes Prevent Testicular Torsion Injury via Activating PI3K/AKT and MAPK/ERK1/2 Pathways

Adipose mesenchymal stromal cell-derived exosomes (ADSC-Exos) have shown great potential in the treatment of oxidative stress induced by ischemia-reperfusion injury. However, alleviation of testicular torsion injury by ADSC-Exos has not been reported. Therefore, we investigated the protective effect of ADSC-Exos against testicular torsion-detorsion injury. ADSC-Exos were isolated by ultracentrifugation and injected into torsion-detorsion-affected testes of rats. H&E staining and sperm quality were used to evaluate the therapeutic effects of ADSC-Exos, and tissue oxidative stress was measured by determining MDA and SOD levels. In addition, TUNEL staining and immunohistological analysis (Ki67, Cleaved Caspase-3, IL-6, IL-10, CCR7, and CD163) were used to clarify the effects of ADSC-Exos on spermatogenic cell proliferation, apoptosis, and the inflammatory microenvironment in vivo. Possible signaling pathways were predicted using sequencing technology and bioinformatics analysis. The predicted signaling pathways were validated in vitro by assessing the proliferation (EdU assay), migration (transwell assay and scratch test), and apoptosis (flow cytometry, TUNEL staining, and western blotting) of spermatogenic cells. The results showed that ADSC-Exos alleviated testicular torsion-detorsion injury by attenuating oxidative stress and the inflammatory response. In addition, ADSC-Exos promoted the proliferation and migration of spermatogenic cells and inhibited their apoptosis by activating the PI3K/AKT and MAPK/ERK1/2 signaling pathways.

The effect of hydrogen sulfide on ischemi̇a /reperfusion injury in an experimental testicular torsion model

INTRODUCTION

Testicular torsion is an acute pediatric surgical emergency requiring rapid diagnosis to prevent the permanent ischaemic damage of the testicles. Hydrogen Sulfide (H2S) have shown to cure tissue damage and has a role in the prevention of I/R damage. We aimed to evaluate the effect of H2S in testicular torsion.

MATERIALS AND METHODS

Eighteen male, Wistar albino rats were divided into 3 groups. The sham group which is applied surgical stress. The ischemia/reperfusion group (I/R) which detorsion performed 1 h later than testicular torsion application. I/R + NaHS treatment group, NaHS solution was injected intraperitoneally for 1 week. On the 7th day of the detorsion all left testes were fixed in Bouin solution and sent to Pathology Department for histopathological examination. All right testes were washed with normal saline, dried in a sterile way and stored in - 80 °C deepfreeze up to the date of biochemical processes. Testicular tissues were obtained for the detection of myeloperoxidase (MPO), malondialdehyde (MDA), AOPP (advanced oxidation protein product) for oxidant markers and ferric reducing antioxidant power (FRAP) levels, superoxide dismutase (SOD),glutathione peroxidase (GSH-Px) activities for antioxidant markers and histopathological exploration.

RESULTS

The effects of NaHs administration on oxidation were evaluated by determination of testicular MPO, MDA and AOPP levels. Increased testicular MPO (58.6%) activity was observed in the I/R group compared to the sham group. Following NaHS treatment, MPO (26.7%) activity was significantly decreased in rats exposed to I/R injury (Figure 1). MDA levels did not alter. Increases in AOPP (20.9%) levels were observed in the I/R group. NaHS treatment resulted in significant decreases in AOPP (25.1%) levels in testes tissues of rats exposed to I/R injury. The effects of NaHS treatment on antioxidant system FRAP, SOD, GSH and GSH-Px activities were evaluated. GSH levels were significantly increased in the IR + NaHS group compared to the I/R group. In histopathological examination degeneration of seminiferous tubules and spermatogenic cells were observed in the I/R group. After NaHS treatment, normal spermatogenic activity with many spermatozoa in the lumen of most seminiferous tubules were observed in the I/R injured rats. According to Johnsen's scoring (JS), the I/R group was significantly decreased compared to the sham group. JS values for the I/R + NaHS group were significantly increased compared to the I/R group.

CONCLUSION

Our study supports that ischemia/reperfusion injury plays an important role in the testicular torsion injury, and it is a pioneer study showing that H₂S may have a potential for therapeutic effect. The limitation of this work is this is an experimental study with limited number of animals. According to the results of our study, hydrogen sulfide treatment has beneficial effects on biochemical and histopathological results of testicular injury in testic torsion.

Relaxin exerts a protective effect during ischemia-reperfusion in the rat model

BACKGROUND

Testicular torsion, which causes ischemia-reperfusion (IR) injury, is a serious urological emergency that can lead to testicular dysfunction, including infertility, primarily among newborn and pubertal males; thus, effective drugs should be administered during or after ischemia.

OBJECTIVES

Using a rat model of testicular IR injury, the present study investigated the protective effects of relaxin (RLN) against oxidative stress, testicular dysfunction, inflammation, histological damage, arrested spermatogenesis, and germ cell apoptosis as well as explored the usefulness of RLN as a potential protective drug for IR injury combined with surgical treatment.

MATERIALS AND METHODS

Male Sprague-Dawley rats were subjected to left testicular ischemia for 2 h, followed by 24 h of reperfusion. They were subsequently divided into three groups: sham, IR, and IR + RLN groups. Porcine RLN (500 ng/h) or saline was infused using an implanted osmotic mini-pump 90 min after inducing ischemia. The RLN dose used herein was that which resulted in serum RLN levels comparable to those in mid-pregnant rats based on previous studies.

RESULTS

Testicular IR increased germ cell apoptosis and histological damage as well as promoted disorganized and arrested spermatogenesis, accompanied by a significant increase in oxidative stress and inflammation. However, RLN administration ameliorated the adverse consequences associated with IR injury by attenuating oxidative stress and mitigating apoptosis and inflammation.

DISCUSSION AND CONCLUSION

The study findings clearly demonstrated that RLN exerts a protective effect against IR-induced testicular injury by attenuating oxidative stress, apoptosis, and inflammation, suggesting that RLN together with surgical treatment is a potentially efficacious approach toward ameliorating testicular dysfunction following testicular torsion.

Combined melatonin-adipose derived mesenchymal stem cells therapy effectively protected the testis from testicular torsion-induced ischemia-reperfusion injury

Background

This study tested the hypothesis that combined melatonin (Mel) and adipose-derived mesenchymal stem cells (ADMSCs) treatment was superior to either one alone on protecting the testis against acute testicular torsion-induced ischemia-reperfusion (TTIR) injury.

Methods and results

Male adult SD rats (n = 30) were equally categorized into group 1 (sham-operated control), group 2 [TTIR/by torsion of right/left testis (i.e., ischemia) with rotated 720° counterclockwise for 2 h, then detorsion (i.e., reperfusion) to the original position for 72 h], group 3 (TTIR + Mel/intraperitoneal administration/50 mg/kg at 30 min after ischemia, followed by 20 mg at 3 h and days 1/2/3 after TTIR), group 4 (TTIR + ADMSCs/1.2 × 10⁶ cells/by tail-vein administration at 30 min after ischemia, followed by days 1/2 TTIR), and group 5 (TTIR + Mel + ADMSCs/tail-vein administration). The result showed that the protein expressions of oxidative-stress (NOX-1/NOX-2/oxidized-protein), apoptotic/mitochondrial-damaged (mitochondrial-Bax/cleaved-caspase3/cleaved-PARP/cytosolic-cytochrome C), and fibrotic (TGF-ß/Smad3) biomarkers as well as testicular damage scores were lowest in group 1, highest in group 2, and significantly higher in groups 3/4 than in group 5, but they showed no difference between groups 3/4, whereas the protein expressions of androgen receptor (AR) and vimentin showed an opposite pattern of oxidative stress (all p < 0.0001). The cellular levels of inflammation (MMP-9/MPO/CD68) exhibited an identical pattern, whereas the numbers of Sertoli cells, α-tubulin, AR and vimentin as well as thickness of seminiferous tubule exhibited an opposite pattern of oxidative stress among the groups (all p < 0.0001).

Conclusion

Mel-ADMSCs effectively protected the testis against TTIR injury.

Pentoxifylline improves the survival of spermatogenic cells via oxidative stress suppression and upregulation of PI3K/AKT pathway in mouse model of testicular torsion-detorsion

Testicular torsion-detorsion results in enhanced formation of free radicals which contribute to the pathophysiology of testicular tissue damage. Recent reports have identified protective role of pentoxifylline (PTX) against free radicals. Thus, we determined the protective effect of pentoxifylline against testicular damage in mouse model of testicular torsion-detorsion.

Twenty (6 weeks old) male mice were divided into 4 groups of 5 animals each namely: Control (sham operated group), T1 (Torsion-detosion + single dose 100 mg/kg PTX, T2 (torsion-detorsion + 20 mg/kg PTX for 2 weeks and T/D (torsion-detorsion only). Animals in T1, T2 and T/D groups underwent 2 h of testicular torsion with the left testes rotated 720° (clockwisely) followed by 30 min of detorsion. After detorsion, drug administration was done intraperitoneally. The left testes of all the animals were excised on the 35th day after torsion-detortion for histopathological and biochemical assay. Histomorphological analysis of the seminiferous tubules showed that there were significant increase (P < 0.01 or 0.05) in the mean seminiferous tubule diameter, Johnson score and germ cells of animals in Control and T1 compared to T2 and T/D with no significant difference (P > 0.05) in testes weight, sertoli, leydig and myoid cells in all groups. IHC results showed significant increase (P < 0.01 or 0.05) in id4 and scp3 protein markers in Control, T1 and T2 compared to T/D. Oxidative stress analysis revealed that Pentoxifylline significantly increased (P < 0.01 or 0.05) the level of SOD, catalase, mRNA expression of akt and pi3k genes but significantly suppress (P < 0.01 or 0.05) MDA and Caspase-3 level in Control, T1 and T2 compared to T/D. Pentoxifylline could be used as an adjunct therapy to surgery in the treatment of torsion-detorsion related testicular injury, However, Further studies are needed to evaluate the effects of pentoxifylline on testicular torsion.

Diffusion tensor imaging in evaluating testicular injury after unilateral testicular torsion and detorsion in rat model: A preliminary study

Diffusion tensor imaging (DTI) is a functional magnetic resonance sequence based on the movement of water molecules. This study attempted to investigate the feasibility of DTI in evaluating testicular injury after testicular torsion and detorsion. Seventy-two rats were randomly divided into the sham group, torsion group and detorsion group. The left testis in the sham group was brought out through a scrotal incision for 1 hr, and that of the torsion group was twisted 720^o clockwise for 1 hr and fixed to the scrotum, while the detorsion group was restored after being twisted 720° for 1 hr. Rats were further divided into four subgroups according to the set time, then performed DTI and histology analysis. The mean diffusion of the torsion and detorsion groups increased within 24 hr (p <.01), while it in the detorsion-1-week-group was lower than that in the detorsion-24-hr-group (p <.05). The fraction anisotropy of both experimental groups decreased in the acute phase (p <.01), while that of the detorsion-1-week-group increased (p <.01). Cosentino score in both experimental groups showed an increasing trend (p <.05). Besides, the spermatogenic ability of the detorsion-1-week-group decreased (p <.05). In conclusion, DTI was able to evaluate the injury after testicular torsion and detorsion.

Testicular Torsion and Spermatogenesis

Testicular torsion (TT) is a common urologic emergency that can occur at any age. It is most common in newborns and during puberty. Prompt evaluation and management is required to salvage the testis following an episode of torsion. TT brings about damage to testicular tissue and spermatogenesis through various hypothesized mechanisms; however there is a consensus that the effects of ischemia, ischemia-reperfusion injury, and oxidative stress account for the most destructive effects. Numerous studies have examined the effects of various agents and therapies in limiting the effects of TT on the testis.

Estimating the time of onset of testicular torsion using ultrasonography in an experimental rat model

Purpose

We aimed to document the time of onset of ultrasonographic and histologic changes in the testes of a rat model following testicular torsion.

Methods

Twenty-five Sprague-Dawley rats were divided into four groups. All animals underwent preoperative Doppler ultrasonography. Groups 1, 2, and 3 underwent unilateral surgical torsion of the testis lasting for 72, 24, and 6 hours, respectively. Group 4 underwent a sham operation. The animals were followed with Doppler ultrasonography at 6, 24, 48, and 72 hours postoperatively. Histologic examinations were performed at the designated final time point for each group.

Results

After torsion, enlargement of the epididymal head and thickening of the spermatic cord over time were noted. Based on the ultrasonographic dimensions, the ratio of the epididymal volume increased with time following torsion (p=0.002). The torsed testes had an average weight gain of 0.27 g at 6 hours compared to the control testes, but an average weight loss of 0.22 g at 72 hours (P=0.006). Changes in testicular echotexture were noted as soon as 6 hours after torsion, but there was no consistent pattern of echotexture change thereafter. Histologically, viable tubules were seen 6 hours after torsion, while extensive hemorrhagic necrosis was found at 72 hours.

Conclusion

In evaluating testicular torsion, the enlargement ratio of the epididymis and thickening of the spermatic cord on Doppler ultrasonography may be useful for determining the urgency of immediate surgery. Changes in testicular echotexture may not be a reliable indicator of the time of onset.

Protective effect of dipeptidyl peptidase-4 inhibitors in testicular torsion/detorsion in rats: a possible role of HIF-1α and nitric oxide

Spermatic cord torsion is a serious and common urologic emergency. It requires early diagnosis for prevention of subfertility and testicular necrosis. Vildagliptin and sitagliptin are anti-diabetic drugs of the dipeptidyl peptidase-4 (DPP-4) inhibitors that have a protective role against cerebral ischemic stroke and cardiac ischemia reperfusion. This study aimed to investigate the role and mechanism of action of vildagliptin and sitagliptin in a model of testicular ischemia/reperfusion injury by testicular torsion/detorsion (T/D). Testicular T/D was done and vildagliptin and sitagliptin were administered either alone or in combination with nitric oxide synthase (NOS) inhibitor. Serum total cholesterol and testosterone were measured, while in testicular tissue testosterone, malondialdehyde (MDA) level, total antioxidant capacity (TAC), nitric oxide level, caspase-3, superoxide dismutase (SOD), hypoxia-inducible factor-1α (HIF-1α), tumor necrosis factor-α (TNF-α) and endothelial NOS (eNOS), and inducible NOS (iNOS) and neuronal NOS (nNOS) were measured. Histopathology of testicular tissue was done. Vildagliptin and sitagliptin increased serum testosterone, expression, and activity of SOD and testicular TAC. It also reduced total serum cholesterol, testicular MDA, caspase-3, HIF-1α, TNF-α, and expression of eNOS, iNOS, and nNOS. Vildagliptin and sitagliptin also improved histopathological picture of testicular tissue. NOS inhibitor produced similar result to DDP-4 inhibitors; however, its co-administration augmented the effect of vildagliptin and sitagliptin on these parameters. DPP-4 inhibitors, vildagliptin, and sitagliptin were protective against testicular T/D-induced injury mostly by anti-oxidative stress, and anti-apoptotic and anti-inflammatory actions that was augmented by NOS inhibition with a possible role for HIF-1α expression.

Effects of L-carnitine and betamethasone on ischemia-reperfusion injuries and sperm parameters following testicular torsion in a rat model

Testicular torsion is a consequence of spermatic cord twisting which causes progressive damage to the structure of the testis and reduces sperm quality and usually results in infertility. In the present study, with the assumption of the protective effects of L-carnitine and betamethasone against ischemia-reperfusion (IR) injuries, their effects on twisted testicles were evaluated and compared. Twenty Wistar rats were randomly divided into four groups and used in this study. Except for the Sham (S) group, testicular IR was induced surgically in three other groups, including Control (C), Betamethasone (BM), and L-carnitine (LC) groups. Betamethasone and L-carnitine were injected before detorsion in the BM and LC groups, respectively. After twelve hours of reperfusion, the testicles were detached, and prepared for sperm parameters evaluation such as sperm count, motility, viability, morphology, and chromatin quality, and histopathologic evaluations, including mean seminiferous tubular diameter (MSTD), germinal epithelial cell thickness (GECT), and Johnsen's mean testicular biopsy scoring (MTBS). The MSTD, GECT, and healthy sperms in the C group were significantly lower than the other groups, while the BM and LC groups were significantly different from others in MTBS. The number of sperms and sperm motility in the BM group was significantly higher than the C group. Sperm viability in the BM and LC groups were significantly higher than the C group. The results of this study showed that both L-carnitine and betamethasone similarly can be effective in treating testicular IR injuries.

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.

Protective Effects of Uncultured Adipose-Derived Stromal Vascular Fraction on Testicular Injury Induced by Torsion-Detorsion in Rats

Torsion‐detorsion (T/D)‐induced testicular injury may lead to male subfertility and even infertility. Stem cell therapy provides an alternative to attenuate testicular injury and promote spermatogenesis. Adipose‐derived stromal vascular fraction (SVF) can be acquired conveniently without in vitro expansion, which may avoid the potential risks of microbial contamination, xenogenic nutritional sources, etc., during cell culture. In this study, we investigate the protective effects of autologous uncultured SVF on testicular injury and spermatogenesis in a rat model of T/D. Animals were randomly divided into sham, T/D+ phosphate‐buffered saline, and T/D + SVF groups (18 rats in each group). SVF was isolated, labeled with lipophilic fluorochrome chloromethylbenzamido dialkylcarbocyanine, and transplanted into T/D testis by local injection. At 3, 7, 14, and 28 days F surgery, testicular tissue and serum samples were harvested for histopathological, immunohistochemical, Western blot, and enzyme‐linked immunosorbent assays. Histopathological findings demonstrated severe injury in the testis with decreased Johnsen's score led by T/D, while uncultured SVF reduced testicular injury and elevated the decreased score. Injected SVF cells were mainly integrated into interstitial region and seminiferous tubules, enhanced the secretion of basic fibroblast growth factor and stem cell factor in the testis, contributed to the declining level of malondialdehyde and restoration of hormonal homeostasis, and then reduced the injury of Leydig cells and germ cells, as well as promoting spermatogenesis. Our findings demonstrated that autologous uncultured SVF could protect the testis from testicular ischemia‐reperfusion injury and promote spermatogenesis, which provide significant clinical implications for the prevention of infertility induced by testicular T/D. stem cells translational medicine2019;8:383–391

Leukemia and male infertility: past, present, and future

Spermatogenesis is the process of the proliferation and differentiation of spermatogonial stem cells (SSCs) to generate sperm. Leukemia patients show impairment in some of the endocrine hormones that are involved in spermatogenesis. They also show a decrease in semen parameters before and after thawing of cryopreserved samples compared to a control. The mechanisms behind these effects have not yet been described. This review summarizes the effect of leukemia on semen parameters from adult patients and highlights feasible suggested mechanisms that may affect impairment of spermatogenesis in these patients. We suggest the possible involvement of leukemia in disturbing hormones involved in spermatogenesis, and the imbalance in testicular paracrine/autocrine factors involved in the formation of SSC niches that control their proliferation and differentiation. Understanding the mechanisms of leukemia in the impairment of spermatogenesis may lead to the development of novel therapeutic strategies mainly for prepubertal boys who do not yet produce sperm.

Testicular torsion and reperfusion: evidences for biochemical and molecular alterations

This study was done in order to determine the molecular and biochemical alterations following testicular torsion (TT) and torsion-reperfusion (TR). For this purpose, 54 male Wistar rats were divided into five groups as control group (n = 6) and experimental group subjected to 1, 2, 4, and 8 h unilateral left torsion induction (n = 12 in each group). After induction of TT, testicular samples were collected from each group (n = 6), and the other six rats of each group underwent the same period of reperfusion after TT and then were sampled. Histological changes, the mRNA and protein expression of heat shock protein-70 (Hsp70), and caspase-3 were examined using reverse transcriptase-PCR (RT-PCR) and immunohistochemistry, respectively. Testicular total antioxidant capacity (TAC), glutathione peroxidase (GSH-px), and malondialdehyde (MDA) levels were evaluated. The mRNA damage and DNA fragmentation were assessed. The TT and TR significantly reduced differentiation and spermiogenesis indices (p < 0.05). The TT- and TR-induced groups exhibited a severe reduction in Hsp70 expression as well as remarkable enhancement in caspase-3 expression. The TAC and GSH-px levels were decreased and the MDA content was increased in TT- and TR-induced groups. Finally, the TT and TR enhanced mRNA damage and DNA fragmentation. The TT- and TR-induced damaging oxidative stress, diminished Hsp70 expression, and enhanced caspase-3 mRNA and protein levels result in apoptosis following 1, 2, and 4 h. Whereas, following 8 h, TT and TR initiate the necrosis by inducing energy depletion as well as severe mRNA damage.

Diffusion-Weighted Imaging and Color Doppler Ultrasound in Evaluation of Partial Testicular Torsion in Rat Model

Background

To evaluate the utility of histogram analysis of apparent diffusion coefficient (ADC) in the diagnosis of incomplete testicular torsion.

Material/Methods

Fourteen Wistar albino rats were randomly allocated into two groups. In group 1 (control), left testicles were kept outside for 45 seconds and then replaced, whereas left testicles were twisted by 360° in group 2. Four hours later, DWI was performed. After that, magnetic resonance imaging (MRI) and testicular color Doppler ultrasound (CDU) were performed by two radiologists who looked for the presence or absence of blood flow. ADC measurements were carried out by two radiologists who were blinded to each other's measurements. After CDU, testes were surgically removed and a pathological examination was performed after four hours of torsion. Comparisons of minimum, mean, and maximum ADC values in testicles were performed with the Wilcoxon test. P value of 0.05 or less was considered as statistically significant. Inter-observer agreement was also analyzed.

Results

In the torsion group, minimum ADC values for left testicles were significantly lower than for the control group (p<0.05), regardless of the observer. Inter-observer agreement for measurements of ADCmin and ADCmax values was substantial, with an ICC score of 0.751 and 0.774, respectively (95% CI). Inter-observer agreement for the measurement of ADCmean value was excellent, with an ICC score of 0.844 (95% CI). The pathological examination revealed mild interstitial edema and closely packed seminiferous tubules in the left testes, indicating reversible damage in the torsion group.

Conclusions

On the pathological examination, all left testes in the torsion group were recoverable after four hours of torsion. Minimum ADC values can be used as an auxiliary method in the diagnosis of partial testicular torsion. Comparing minimum ADC values between the affected and non-affected testicles can be a useful tool in the early diagnosis of incomplete testicular torsion.

Protective effects of polydatin on experimental testicular torsion and detorsion injury in rats

Oxidative stress plays a critical role in the process of testicular torsion and detorsion (T/D). The purpose of the present study was to investigate the protective effect of polydatin (PD) on testicular T/D injury. Rats were randomly divided into three groups, a sham group, a group subjected to 2 h torsion followed by 24 h detorsion and a group subjected to T/D and injected i.p. with 20 mg kg−1 PD 30 min before detorsion. Unilateral orchiectomy was performed after 24 h of reperfusion. Half the testes were prepared for histological examination by haematoxylin–eosin staining and the terminal deoxyribonucleotidyl transferase-mediated dUTP–digoxigenin nick end-labelling (TUNEL) technique. In the remaining tissues, levels of malondialdehyde (MDA), catalase (CAT), glutathione peroxidase (GPx) and superoxide dismutase (SOD) were determined, as was the expression of several apoptosis-related proteins. Compared with the T/D group, PD pretreatment significantly ameliorated the morphological damage, lowered the Cosentino histological score and increased the mean number of germ cell layers and Johnsen’s testicular biopsy score. In addition, PD treatment markedly decreased MDA levels and upregulated CAT, GPx and SOD activity. Furthermore, PD decreased T/D-induced germ cell-specific apoptosis, attenuated the activation of caspase-3, caspase-8, caspase-9 and poly(ADP-ribose) polymerase and increased the Bcl-2/Bax ratio. The findings indicate that PD has a protective effect against testicular T/D injuries, especially at the histological, antioxidative stress and antiapoptotic levels.

Ginkgo Biloba Ameliorates Subfertility Induced by Testicular Ischemia/Reperfusion Injury in Adult Wistar Rats: A Possible New Mitochondrial Mechanism

Testicular torsion, a surgical emergency, could affect the endocrine and exocrine testicular functions. This study demonstrates histopathological and physiological effects of testicular ischemia/perfusion (I/R) injury and the possible protective effects of Ginkgo biloba treatment. Fifty adult male Wistar rats, 180–200 gm, were randomly divided into sham-operated, Gingko biloba supplemented, ischemia only, I/R, and Gingko biloba treated I/R groups. Overnight fasted rats were anaesthetized by Pentobarbital; I/R was performed by left testis 720° rotation in I/R and treated I/R groups. Orchiectomy was performed for histopathological studies and detection of mitochondrial NAD⁺. Determination of free testosterone, FSH, TNF-α, and IL1-β in plasma was performed. Plasma-free testosterone was significantly decreased, while plasma FSH, TNF-α, IL-1β, and testicular mitochondrial NAD⁺ were significantly increased in I/R group compared to control group. These parameters were reversed in Gingko biloba treated I/R group compared to I/R group. I/R caused marked testicular damage and increased APAF-1 in the apoptotic cells which were reversed by Ginkgo biloba treatment. It could be concluded that I/R caused subfertility induced by apoptosis and oxidative stress manifested by the elevated testicular mitochondrial NAD⁺, which is considered a new possible mechanism. Also, testicular injury could be reduced by Gingko biloba administration alone.

Role of diffusion weighted magnetic resonance imaging in a rat model of testicular torsion

OBJECTIVE

The purpose of this study was to investigate the usefulness of diffusion-weighted imaging (DWI) in the detection of different degrees of testicular torsion (TT) at the 8th hour and testicular salvageability at the 24th hour of torsion.

METHODS

31 rats were randomly classified into 4 groups. In Group 1 (sham-control group), the left testicle was kept outside and replaced. Left testicles were kept outside and twisted 360° in Group 2, 720° in Group 3 and 1080° in Group 4. Later, DWI was performed at 8th and 24th hours. After DWI, bilateral radical orchiectomy and histopathological examination were performed. Apparent diffusion coefficient (ADC) maps were obtained with b-factors of 0 and 800 s mm^-2. Comparisons of ADC values and damage in testicles were performed with Kruskal-Wallis test.

RESULTS

Sensitivity of DWI in the diagnosis of TT was 12.5% for 360° torsion, 100% for 720° torsion and 1080° torsion at the 8th hour of torsion. Mean ADC values of the left testicles increased significantly at the 24th hour of torsion in Groups 3 and 4. All testicles in Groups 3 and 4 were observed to be irrecoverable on histopathological examination.

CONCLUSION

Increased ADC values in the affected testicle may represent irreversible tissue damage. So, immediate surgery is not required at this stage, which may reduce morbidity and mortality caused by immediate surgery and anaesthesia. Advances in knowledge: TT can be diagnosed easily by DWI without administrating any contrast material. DWI findings in the affected testicle may represent testicular salvageability.

Protective effect of pterostilbene on testicular ischemia/reperfusion injury in rats

PURPOSE

To evaluate protective effect of pterostilbene against testicular ischemia/reperfusion (I/R) injury, which results in increased formation of oxidative stress, leading to testicular apoptosis and impaired spermatogenesis.

METHODS

Thirty two pubertal male Sprague-Dawley rats weighing 180-220g were selected and randomly divided into the following four groups: group A (normal control group), group B (sham-operated group), group C (induced I/R injury group), group D (induced I/R injury group receiving pterostilbene treatment). Johnsen's scores and mean seminiferous tubule diameters were evaluated for histopathologic assessment; germinal cell apoptosis was evaluated by the transferase dUTP nick end labeling (TUNEL) assay and immunohistochemistry for caspases. Malondialdehyde (MDA) levels were assessed as an indicator of oxidative stress and total antioxidant capacity (TAC) was measured.

RESULTS

Germ cell apoptosis and MDA level significantly increased whereas TAC significantly decreased in group C; moreover, abnormal morphology and impaired spermatogenesis were observed in group C. In contrast, treatment with pterostilbene inhibited lipid peroxidation and apoptosis induced by ROS and restored the antioxidant capacity in group D.

CONCLUSIONS

These results show that treatment with pterostilbene may be a promising therapy for testicular I/R injury.

An experimental study on effects of pyrrolidine dithiocarbamate on ischemia-reperfusion injury in testis

INTRODUCTION

The aim of this experimental study was to investigate the histopathological and biochemical effects of pyrrolidine dithiocarbamate, an antioxidant and inhibitor of NF-kβ, on ischemiareperfusion injury in rats.

METHODS

A total of 21 male Wistar-Albino rats were randomly distributed into three groups as sham group (Group 1), ischemia-reperfusion (I/R) group (Group 2) and I/R with pyrrolidine dithiocarbamate (PDTC) group (Group 3). Left testicles of rats in Groups 2 and 3 underwent testicular torsion of 720° for four hours and 100 mg/kg of PDTC was administered intraperitoneally prior to detorsion in Group 3. An hour after detorsion process, left orchiectomies were performed and 5 ml of intracardiac blood samples were drawn from rats in all three groups. Histopathological examination of testis tissues performed and measurement of superoxide dismutase (SOD) and malondialdehyde (MDA) levels in blood samples were taken.

RESULTS

Elevated levels of MDA and decreased SOD activity, together with decreased Johnson tubular biopsy scores consistent with I/R injury were observed in Group 2 (p<0.05). Group 1 and Group 3 were similar in terms of MDA levels, SOD activity, and Johnson scores (p>0.05).

CONCLUSIONS

Our results indicated that PDTC may have beneficial effects for alleviation of I/R injury in testicular tissue in rats. Understanding the underlying mechanisms and exploration of its diagnostic and therapeutic potential requires further randomized, controlled trials on a larger scale.

The efficiency of Poly(ADP-Ribose) Polymerase (PARP) cleavage on detection of apoptosis in an experimental model of testicular torsion

The aim of this study was to evaluate the histopathological and apoptotic changes occurring in the rat ipsilateral and contralateral testes, after experimental spermatic cord torsion, and to explore and the role of poly(ADP-ribose) polymerase (PARP) cleavage in testicular torsion-detorsion injury. A total of 37 Wistar albino rats were subjected to 720° unilateral spermatic cord torsion for 1, 2 and 4 h, followed by 4-h reperfusion, or else to a sham operation (control group). Histology of the testicle was evaluated using haematoxylin-eosin (H&E) staining and Johnsen's scoring system. Germ cell apoptosis was evaluated via active caspase-3 immunostaining, and PARP expression levels were evaluated via Western blotting. The mean Johnsen's tubular biopsy scores (JTBS) of the ipsilateral testicles were lower for all torsion groups than for the controls (P < 0.05), but the JTBS of the contralateral testicles were only lower in the 4-h torsion group (P < 0.05). The mean apoptosis score (AS) of the ipsilateral and contralateral testicles was significantly higher in the torsion groups than in the sham group. AS increased correlatively with torsion time, in both testicles. The effect of testicular torsion on PARP cleavage was time dependent, with the highest effect observed after 4 h of testicular torsion (P < 0.05). Testicular torsion caused time-dependent histological changes, apoptosis and increases in PARP cleavage. Our results suggest that testicular torsion-detorsion injury caused cell damage and germ cell apoptosis that apparently involved cleavage of PARP. Increased PARP cleavage could, in turn, lead to enhanced apoptosis.

Microcirculatory effects of selective endothelin-A receptor antagonism in testicular torsion

PURPOSE

Testicular torsion without timely intervention causes incurable damage to the testis. We examined the causative role of microcirculatory injury in torsion induced testicular damage with particular regard to endothelin-A receptor activation.

MATERIALS AND METHODS

The microcirculatory consequences of testicular torsion were assessed in the presence or absence of endothelin-A receptor antagonism in rats. Microcirculatory perfusion changes (red blood cell velocity and pulsatile flow pattern alterations) were examined by an orthogonal polarization spectral imaging technique. Microcirculatory inflammatory alterations were assessed by fluorescence intravital video microscopy after 60-minute torsion followed by 240-minute reperfusion. As a specific endothelin-A receptor inhibitor, the antisense homology box derived peptide ETR-p1/fl was applied 10 minutes before reperfusion. Tissue accumulation of leukocytes was estimated by myeloperoxidase activity in tissue biopsies taken at the end of the 4-hour reperfusion period. In further experiments testicular weight as a marker of permanent damage was evaluated 45 days after torsion.

RESULTS

The physiological pulsatile flow pattern ceased in the initial phase of reperfusion while leukocyte-endothelial interactions increased throughout the examined reperfusion period. Endothelin-A receptor antagonism caused earlier return of pulsatile flow and recovery of red blood cell velocity, and alleviated microcirculatory inflammatory reactions and atrophy.

CONCLUSIONS

Results suggest a pathophysiological role of endothelin-A receptor activation in the pathogenesis of testicular torsion. This effect is related to deterioration in testicular perfusion and activation of microcirculatory inflammatory reactions.

Mechanisms of testicular torsion and potential protective agents

Testicular torsion is a urological emergency most commonly seen in adolescence, involving a decrease in blood flow in the testis resulting from torsion of the spermatic cord that can result in gonad injury or even loss if not treated in time. Testicular ischaemia-reperfusion injury represents the principle pathophysiology of testicular torsion, with ischaemia caused by twisting of the spermatic cord, and reperfusion on its subsequent release. Many cellular and molecular mechanisms are involved in ischaemia-reperfusion injury following testicular torsion. Studies have investigated the use of pharmacological agents as supportive therapy to surgical repair in order to prevent the adverse effects of testicular torsion. Numerous substances have been proposed as important in the prevention of post-ischaemia-reperfusion testicular injury. A range of chemicals and drugs has been successfully tested in animal models for the purpose of mitigating the dangerous effects of ischaemia-reperfusion in testis torsion.

Desferrioxamine effectively attenuates testicular tissue at the end of 3 h of ischemia but not in an equal period of reperfusion

OBJECTIVE

To investigate the effect of desferrioxamine (DFX) on ipsilateral and contralateral testis damage caused by experimental testis torsion and detorsion.

MATERIALS AND METHODS

Forty rats were divided into five groups (n = 8): control, torsion (T), torsion + desferrioxamine (T + DFX), torsion/detorsion (T/D), and torsion/detorsion + desferrioxamine (T/D + DFX). The right testes of the rats were subjected to torsion and detorsion for 3 h each. Thirty minutes before the application of torsion and detorsion, DFX (100 mg/kg) was administered intramuscularly. Blood samples and testicular tissues were examined using specific biochemical and histopathological methods.

RESULTS

Ipsilateral and contralateral testis tissue glutathione levels in the T group decreased compared with the control and T + DFX groups. Plasma glutathione peroxidase activity in the T, T/D, and T/D + DFX groups was lower than in the control group. Plasma catalase activity in the T and T/D groups decreased compared with the control group. Ipsilateral mean seminiferous tubule diameter of the T group was lower than that of the T + DFX group. The ipsilateral mean testis biopsy scores in the T and T/D groups were lower than in the control group.

CONCLUSION

The administration of DFX prior to torsion may be useful only for preventing ischemic damage in ipsilateral and contralateral testes.

Protective effects of lipoxin A4 in testis injury following testicular torsion and detorsion in rats

Purpose. To investigate the protective effects of lipoxin A4 (LXA4) in rat testis injury following testicular torsion/detorsion. Methods. A rat testicular torsion model has been established as described. Rats were randomly divided into 6 groups: sham group, torsion group, torsion/detorsion (T/D) group, and T/D plus LXA4-pretreated groups (3 subgroups). Rats in LXA4-pretreated groups received LXA4 injection (0.1, 1.0, and 10 μg/kg body weight in LXA4-pretreated subgroups 1–3, resp.) at a single dose 1 h before detorsion. Biochemical analysis, apoptosis assessment, and morphologic evaluation were carried out after orchiectomies. Results. GPx and SOD levels significantly increased and MDA levels significantly reduced in LXA4-pretreated groups compared to T/D group. LXA4 also reverted IL-2 and TNF-α to basal levels and improved the expression of IL-4 and IL-10 in LXA4-pretreated groups. Moreover, the expression of NF-κB was downregulated in LXA4-pretreated groups. LXA4 treatment also showed an improved testicular morphology and decreased apoptosis in testes. Conclusion. Lipoxin A4 protects rats against testes injury after torsion/detorsion via modulation of cytokines, oxidative stress, and NF-κB activity.

Does gradual detorsion protect the ovary against ischemia-reperfusion injury in rats?

AIM

Adnexal torsion is an infrequent and serious gynecologic surgical emergency. Adnexal torsion may result from pre-existing tubal or ovarian pathology or hyperstimulation of the ovary during ovulation. Early diagnosis and emergency surgical treatment (detorsion) are important to preserve fertility and to prevent peritonitis or loss of the adnexa. However, during reperfusion, tissue damage is more severe than during ischemia because of oxygen-derived radicals. The present study aimed to investigate the protective effect of gradual detorsion on adnexal torsion.

MATERIALS AND METHODS

Twenty-one adult female rats were divided into three groups as sham-operated (Sh group, n = 7); torsion + detorsion (TD group, n = 7); and torsion + gradual detorsion (TGD group, n = 7). A midline laparotomy was performed under anesthesia. In the TD and TGD groups, the left adnexa along with tubal and ovarian vessels were twisted three times in a clockwise direction and fixed to the abdominal wall. After 30 h, detorsion was performed on the mesenteries of both TD and TGD groups. In the TGD group, however, detorsion was performed gradually: the ovarian mesentery was detorsioned 360°, followed by a 5-min pause, then a repeat of the cycle until full detorsion was achieved. Rats were killed 1 week later. Left ovaries were removed and evaluated histopathologically.

RESULTS

The histopathological mean grade was significantly higher in the TD than in the TGD group (p < 0.05).

CONCLUSION

Gradual detorsion can reduce reperfusion injury in a rat model of ovarian torsion. This method is easily applicable and may be a useful method for human patients with ovarian torsion.

The effects of glutathione on malondialdehyde expression and seminiferous tubule damage in experimental testicular torsion-detorsion in Wistar rats

INTRODUCTION

Testicular damage caused by ischemia reperfusion injury can be determined by malondialdehyde (MDA) expression and grading of the histopathological damage to seminiferous tubules. The aim of this study was to investigate the effect of Tationil Glutathione administration on testicular damage following experimental torsion and detorsion.

METHODS

Eighteen Wistar albino rats, 5.5-6 months old and weighing 250-300 g, were divided into three equal groups. In the first group (T), torsion was created by rotating the left testis 720° in a clockwise direction and maintained for 4 h. In the T/D group, after 4 h of torsion, detorsion was performed and maintained for 3 h. In the T/D-GLUT group, we injected 25 mg iv gluthatione before performing detorsion (onset time of agent is ±5 min).

RESULTS

The lowest malondialdehyde (MDA) expression was observed in the T/D-GLUT rats (P < 0.05). Grading of the histopathological damage to seminiferous tubules showed the damage to be worst in T/D and least in T/D-GLUT rats (P < 0.05).

CONCLUSION

Tationil Glutathione inhibits formation of reactive oxygen species in testicular tissue during ischemia and reperfusion injury caused by experimental torsion and detorsion in Wistar rats.

Compartment syndrome of the testicle: a case report and review of the literature

In this case report we describe a patient presenting with symptoms of right sided testicular torsion who, upon surgical exploration, was noted to no longer have a torsion of the spermatic cord but persisted in having an ischaemic testicle refractory to reperfusion. A testicular compartment syndrome was suspected and the patient underwent fasciotomy of the tunica albuginea, leading to full reperfusion and good clinical outcome at three weeks and 10 months. This case raises the question of the value of performing such fasciotomies in patients who would otherwise undergo orchidectomy. Following a review of the literature, we feel the technique may well have a place in the management of torsion, pending further study.

Databases searched were Medline, Embase, Cochrane, Trip and NHS Evidence. Search criteria included ‘compartment’, ‘testicle’, ‘testicular’, ‘syndrome’, ‘compartment syndrome’ and testis’ and combinations of these key words.