Predictive value of hematological parameters in testicular torsion: retrospective investigation of data from a high-volume tertiary care center

A novel nomogram to predict testicular torsion in children with acute scrotal pain: a single-center retrospective study in western China

Background

Acute scrotal pain (ASP) is the most common urological emergency in pediatrics, and its causes include testicular torsion (TT), testicular appendage torsion, and epididymo-orchitis. Among them, TT requires prompt and accurate diagnosis and urgent surgical exploration to prevent testicular loss. Conservative anti-infective treatment is recommended for epididymo-orchitis, and surgery is considered only when scrotal abscess formation and sepsis occur. Improving the understanding of TT in primary care doctors, early diagnosis, and timely surgical exploration are essential to improve the survival rate of TT and avoid excessive treatment. This study aimed to explore the risk factors for TT in children with ASP and construct a predictive model.

Methods

Clinical data of children who presented with ASP and underwent emergency scrotal exploration surgery were retrospectively analyzed, including general information, physical examination, laboratory tests, and color Doppler ultrasonography (CDU) findings. Based on surgical exploration, the outcomes were categorized as confirmed TT or not.

Results

A total of 283 children were included in this study, among whom 134 had TT. The mean age of all patients was 105±47.9 months, with the majority being of Han ethnicity (87.6%) and residing in urban areas (83%). Most patients had normal C-reactive protein levels and negative results in urine routine white blood cell tests (63.3%). After conducting univariate and multivariate logistic regression analyses, we identified laterality, neutrophil count, mean erythrocyte sedimentation rate, epididymal blood flow signal, testicular parenchymal echogenicity, and testicular blood flow signal as independent risk factors influencing the occurrence of TT in ASP patients.

Conclusions

This study is the report with the largest sample size on the construction of prediction models for ASP in children in southwestern China. The predictive model we developed demonstrated excellent performance and higher accuracy in predicting TT in children compared to the traditional Testicular Workup for Ischemia and Suspected Torsion (TWIST) score. It can assist pediatric surgeons in diagnosing and treating children with ASP.

When should contralateral testicular fixation be performed in postpubertal patients with testicular torsion: A comparative study

OBJECTIVE

In this study, we aimed to describe the timing of contralateral testicular fixation with our ten year results in postpubertal patients with testicular torsion with a patient-based approach.

METHODS

Postpubertal patients diagnosed with testicular torsion in a tertiary hospital between January-2012 and September-2022 were divided into 2 groups according to the "patient-based approach" criteria we adopted in our clinic. Group 1 in whom the contralateral teste was fixed in the same surgical act and group 2 in whom the fixation was deferred. Both groups, were retrospectively examined, statistically analyzed and compared.

RESULTS

A total of 41 patients were included in the study. Among those, 19 (46.3%) were fixed in the same act, and 22 (53.7%) underwent postponed elective contralateral testicular fixation. Early term wound dehiscence was observed in one patient in each group (4.5% Group 1 vs. 5.3% Group 2). In the postoperative period, no contralateral testicular atrophy or torsion was detected in the study groups during 1-year follow-up.

CONCLUSION

There is no algorithm for when contralateral testicular fixation should be performed in postpubertal patients with testicular torsion. Patient-based approaches, in which the clinical characteristics of the patient are prioritized in determining the timing of contralateral testicular fixation, can produce more effective and safe results.

Role of augmenter of liver regeneration on testicular ischemia and ischemia/reperfusion injury: An experimental study

Background

Testicular torsion causes ischemic injury, and torsion causes reperfusion injury.

Aim

Evaluating the role of augmenter of liver regeneration (ALR) in testicular ischemia and ischemia/reperfusion injury.

Materials and Method(s)

Seventy-eight (78) healthy Wistar albino male rats were randomly divided into four groups; control (C) (n = 6), sham (S) (n = 24), torsion (T) (n = 24), and torsion/detorsion (T/D) (n = 24). S, T, and T/D groups were divided into four subgroups (n = 6) as 1st, 2nd, 3rd, and 4th hours. Blood, tissue ALR, and histology analyses were performed between groups and subgroups.

Results

The increase in plasma ALR values at the 3rd and 4th hours compared to the 1st hour in the T group were significant (P < 0.01, P < 0.001, respectively). In the T/D group, a significant increase was observed in plasma ALR values at the 3rd and 4th hours compared to the 1st hour (P < 0.05, P < 0.001, respectively). Plasma ALR values at the 1st, 2nd, 3rd, and 4th hours were higher in the T and T/D groups than in the C group (P < 0.001, P < 0.05, respectively). Plasma ALR values were higher in the T group at the 1st, 2nd, 3rd, and 4th hours than in the S group (P < 0.05). A significant increase was observed in tissue ALR at the 3rd and 4th hours than at the 1st hour in the T group (P < 0.05, P < 0.001, respectively). A significant increase was observed in tissue ALR at the 3rd and 4th hours than in the 1st hour in the T/D group (P < 0.05, P < 0.001, respectively).

Discussion

ALR in plasma and testicular tissue has a potential role in the early diagnosis of testicular torsion and in predicting the prognosis of T and T/D.

The role of neutrophil-to-lymphocyte ratio as a predictor of testicular torsion in children

INTRODUCTION

Doppler ultrasound constitutes the gold standard for the diagnosis of testicular torsion (TT), although sometimes the spermatic cord twisting and absence of testicular flow are difficult to visualize. To date, no laboratory markers have been shown to be useful for preoperative TT diagnosis.

OBJECTIVE

Our aim is to analyze the role of the neutrophil-to-lymphocyte ratio (NLR) as a predictor of pediatric TT.

STUDY DESIGN

A retrospective single-center case-control study was performed in patients with ultrasound suspicion of TT, in whom surgical testicular examination was performed between 2016 and 2020. Patients were divided into two groups according to the intraoperative findings: TT group (testicular torsion), defined as spermatic cord twisting on itself around its longitudinal axis at least 360°, and non-TT group (no torsion). Demographics, clinical, ultrasound and laboratory features at admission were analyzed. Sensitivity and specificity were determined by the area under the curve (AUC) represented on the receiver operating characteristic (ROC) curves.

RESULTS

A total of 159 patients were included (117 TT group; 42 non-TT group), with no demographic or clinical differences. TT group patients presented significantly shorter median time since symptoms onset (4 vs. 8 h; p < 0.012). Laboratory inflammatory test were significantly higher in TT group: Leukocytes (10,900 × 10³/μl vs. 7,980 × 10³/μl; p < 0.001), neutrophils (8,050 × 10³/μl vs. 3,350 × 10³/μl; p < 0.001) and NLR (4.6 vs. 1.1; p < 0.001). In ROC curve analysis, NLR presented the highest AUC (0.903), significantly higher than all other laboratory and ultrasound parameters. NLR of 2.3 was the cut-off point with maximum sensitivity (86.9%) and specificity (94.8%).

DISCUSSION

This is, to the best of our knowledge, the first study to analyze the usefulness of NLR in predicting the diagnosis of TT in patients with clinical and ultrasound suspicion. The limitations are mainly derived from being a single-center retrospective study. For this reason, multicenter studies with a higher number of patients and prospective design may be useful to minimize these biases. The sample size of our study, although not large, has allowed us to identify significant differences between the distinct parameters analyzed as predictors of TT. However, the absence of other similar studies in pediatric patients has hindered the comparison of our results.

CONCLUSION

NLR should be considered as a predictor of pediatric TT in cases with nuclear ultrasound suspicion that may help to anticipate the urgent surgical treatment in these patients.

The lymphocyte-to-monocyte ratio may distinguish complicated from non-complicated pediatric appendicitis: A retrospective study and literature review

BACKGROUND

To date, no parameter with satisfactory accuracy exists for the diagnosis of appendicitis. This retrospective study describes the discriminatory value of preoperative hematologic factors associated with complicated and non-complicated pediatric appendicitis.

METHODS

Clinical and laboratory data were obtained from 294 children diagnosed with appendicitis on admission and treated at our tertiary-level pediatric hospital from 2015 to 2017; they were divided into three groups: control group (n = 118), histologically proven complicated (n = 120), and non-complicated (n = 56) appendicitis.

RESULTS

Complicated appendicitis was associated with male preponderance and elevated neutrophil and monocyte levels (all p < 0.001). Non-complicated appendicitis was associated with elevated eosinophil levels (p = 0.023), and unaltered lymphocyte levels (p = 0.30). Compared to non-complicated disease, the lymphocyte-to-monocyte ratio (LMR) was decreased in complicated appendicitis (p = 0.003) but unaltered in the control group (p = 0.38). In the discrimination analysis, LMR had high accuracy (AUC 0.73 ± 0.05; p < 0.001; odds ratio (OR) (95% confidence interval (CI)) 6.0 (2.4-15.3)) and was the only parameter independently associated with complicated appendicitis on regression analysis (OR (95% CI), 0.544 (0.359-0.825); p = 0.004).

CONCLUSION

We identified LMR as a novel potential marker for the differentiation of complicated from non-complicated pediatric appendicitis. This has implications on the treatment approach, either surgical in complicated disease or conservative in non-complicated disease.

Should haematological inflammatory markers be included as an adjuvant in the differential diagnosis of acute scrotal pathologies?

The aim of this study was to determine discriminative role of haematological inflammatories between acute scrotal pathologies and malignancies. In addition, it was aimed to search for a predictive marker of testicular survival in the TT group. Medical data of 141 patients with acute scrotal pathology and 63 TTm patients who presented to our clinic between January 2015 and July 2019 were retrospectively reviewed and compared in terms of haematological values and demographic parameters following the inclusion of 92 healthy controls. In the TTm group, NLR was the discriminative parameter with a median of 2.42 (0.25-8.42), whereas discriminative median values of MCV for TT and CRP for EO were 83.65 (56.9-98.16) and 59.5 (2.9-337) respectively. NLR, PLR, MER and RDW values were statistically lower in the control group compared to the patients groups. In TT subgroup analysis, monocyte count, MER and CRP were found to be statistically higher in the orchiectomy group, while multivariate logistic regression analysis performed for testicular viability revealed monocyte count to be the only significant variable (Odds Ratio [95% Confidence Interval] = 0.046 (0.006-0.366), p<0.004). While our study demonstrated both diagnostic and discriminative values of haematological parameters, it also showed that monocyte count could predict testicular salvage in TT patients. However, further prospective studies are required.

Clinical Predictors of Testicular Torsion in Patients with Acute Scrotum; a Cross-Sectional Study

INTRODUCTION

Testicular torsion is an important and critical issue in patients with acute scrotum referring to emergency department (ED). Early detection is very important to save the testicles. This study aimed to determine the diagnostic accuracy of clinical variables in predicting the presence of testicular torsion.

METHODS

This prospective cross-sectional study was done using the information of patients hospitalized from September 2015 to September 2020, with complaint of acute scrotum (ICD 10 code: N50.8), referring to ED for evaluation of the clinical predictors of testicular torsions, which were confirmed by surgery.

RESULTS

81 patients with the mean age of 20.07 ± 9.64 (3- 45) years were studied. After surgical exploration, 70 patients (86.4%) had testicular torsion. Patients with torsion had lower age (p < 0.0001), lower time from symptom to ED visit (p < 0.0001), sudden onset pain (p = 0.003), left side pain (p < 0.0001), and lower white blood cell (WBC) count (p = 0.001). The frequency of dysuria (p = 0.032), diarrhea/vomiting (p = 0.005), and fever (p = 0.002) was significantly lower in patients with torsion. The cremasteric reflex was absent in 57 (81.4%) cases who suffered from testicular torsion (p = 0.001). Based on the results of binary logistic regression analysis, age (B = -0.175, SE = 0.45; p < 0.0001) was the sole independent predictor of testicular torsion. The highest area under the receiver operating characteristics (ROC) curve in predicting the presence of torsion belonged to lower age [91.0 (95%CI: 83.2 - 98.7)], pain in left testis [0.931 (95%CI: 0.828-0.987)], and lower WBC count [0.805 (95%CI: 0.684-0.926)], respectively.

CONCLUSION

It seems that clinical variables are not accurate enough to be considered as the sole predictor of testicular torsion and they should be used with caution and in combination with other available screening tools like Doppler ultrasonography in this regard.

High platelet distribution width can independently predict testicular survival in testicular torsion among patients with steady-state sickle cell anemia

Objective

This study aimed to evaluate the predictive value of platelet volume indices (PVI), such as mean platelet volume (MPV), platelet distribution width (PDW), and plateletcrit (PCT), as prognostic indicators of testicular viability in torsion patients with steady-state sickle cell anemia (SCA) who underwent surgical exploration.

Methods

Forty-eight patients with SCA with testicular torsion and 46 male control subjects were enrolled in the study. All patients underwent scrotal color Doppler ultrasonography before surgery, and PVI (MPV, PDW, and PCT) values were measured in all participants. Symptom duration and testicular volume were also recorded.

Results

The testicular salvage rate in patients with SCA was 73% after surgery. Analyses showed that MPV, PDW, and PCT values were significantly higher in torsed SCA as compared with controls (p<0.05). Orchiectomy in patients with SCA showed significantly higher MPV, PDW, and PCT values than the orchiopexy group (p<0.05). The MPV values of orchiectomy patients showed a higher significant cut-off of ≥11.5 fL, which is higher than in torsed patients without SCA, as an indicator of testis survival. PDW also demonstrated a higher significant cut-off of ≥12.7 fL for detorsion outcomes in patients with SCA. Symptom duration of less than 7 hours was also significantly correlated with orchiopexy (p≤0.001). Univariate analysis showed that higher MPV, increased PDW, and symptom duration were indicative of the outcome of testicular detorsion in SCA. Multivariable analysis showed that increased PDW and symptom duration are prognostic parameters for testicular viability in SCA.

Conclusion

Increased PDW and symptom duration can be used as parameters for predicting testicular detorsion outcomes in patients with steady-state SCA.

Predictive value of hematological parameters in testicular salvage: A 12-year retrospective review

PURPOSE

This study aimed to evaluate the predictive value of preoperative hematological parameters for testicular salvage in patients with testicular torsion.

METHODS

Clinical data of patients with testicular torsion treated at Shenzhen Children's Hospital from January 2010 to December 2021 were analyzed retrospectively. The data collected included age, symptom duration, degree of spermatic cord torsion, the surgical approach adopted, hematological parameters, and ultrasound results during postoperative follow-up.

RESULTS

The study participants were classified into three groups as follows: the successful testicular salvage group (n = 43), failed testicular salvage group (n = 124), and control group (n = 100). Univariate analysis showed that testicular salvage was related to patient age, duration of symptoms, spermatic cord torsion degree, white blood cell count, lymphocyte count, monocyte count, platelet-lymphocyte ratio, and neutrophil-lymphocyte ratio. However, multivariate analysis revealed that symptom duration (OR = 0.948, P < 0.001), degree of spermatic cord torsion (OR = 0.994, P < 0.001), and monocyte count (OR = 0.020, P = 0.011) were independent risk factors for testicular torsion salvage. The monocyte count in the failed salvage group was significantly higher than in the successful salvage and control groups (P < 0.01).

CONCLUSION

Monocyte count is an independent predictor of testicular salvage. Therefore, clinicians can predict the success rate of testicular salvage in patients with testicular torsion based on the monocyte count.

Testicular torsion in adults: Demographics and 30-day outcomes after orchiopexy or orchiectomy

Background:

Most often studied in the pediatric population, testicular torsion also affects the adult male population. Little data exists on demographics, patient risk factors, and associated outcomes for the surgical management of testicular torsion. This study sought to describe differences in demographics and outcomes for those patients requiring orchiopexy or orchiectomy.

Materials and methods:

An analysis of the American College of Surgeons National Surgical Quality Improvement Program database (2015–2018) was performed, capturing patients with a postoperative diagnosis of testicular torsion. Patients were stratified into 2 groups if they received orchiopexy or orchiectomy. Demographics, perioperative variables, surgeon specialty, and outcomes were analyzed.

Results:

A total of 769 patients undergoing surgical treatment of testicular torsion were captured. Most of these patients were White (46.81%) and young adults (28.33 ± 12.04 years) and 28.8% required orchiectomy. Those undergoing orchiectomy were more likely to be older, have more comorbidities, and have a systemic inflammatory response syndrome. Mean operative time was longer in the orchiectomy group (48 ± 23 vs. 44 ± 20 minutes, p < 0.0124). There were no deaths at 30 days. Length of stay and rate of superficial wound infection were higher in the orchiectomy group and discharge to home was more likely in the orchiopexy group.

Conclusions:

Adult testicular torsion should be considered in an acute scrotum differential. Adult patients requiring orchiectomy for testicular torsion are more likely to have confounding medical conditions compared to those undergoing orchiopexy. Clinically, rates of complications between the 2 procedures are small, making the decision to perform orchiopexy or orchiectomy based on the scenario.

The value of hematological inflammatory parameters in the differential diagnosis of testicular torsion and epididymorchitis

OBJECTIVE

Aim of this study is to investigate the effectiveness of mean platelet volume (MPV), neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) values, that can easily be obtained with complete blood count (CBC), in the diagnostic differentiation of testicular torsion and epididymorchitis.

METHOD

Data of patients, who admitted to the urology or emergency departments, diagnosed with acute scrotum, between 2008-2017, were reviewed and retrospectively extracted. Basic characteristics (age, etc.) of patients and blood test results were retrieved. Inflammatory markers such as MPV, NLR and PLR were compared between groups.

RESULT

After determining inclusion/exclusion criteria, a total of 111 patients were divided as testicular torsion, epididymorchitis and control group, including 37 patients each. Mean age of groups were 19.27±6.93, 26.27±6.23 and 23.24±8.49 years, respectively. Statistical significance was found in epididymorchitis and testicular torsion groups compared to the control group according to NLR (P<0.01). PLR showed a statistically significant relationship only with the epididymorchitis group and control group (P=0.46). However, according to MPV values, no statistically significance was found between the groups. Additionally, ROC analyse was performed to evaluate predictive cut-off values of NLR and PLR for the diagnostic differentiation of both groups.

CONCLUSION

Inflammatory markers, obtained from routinely performed low-cost CBC, might be used as adjuvant parameters to differentiate acute scrotal pathologies like testicular torsion and epididymorchitis.

Comprehensive examination of haematological parameters of patients operated due to testicular torsion

We aimed to investigate the pre-operative predictive role of haematological parameters in patients with testicular torsion. The medical records of patients operated between January 2016 and November 2018 were retrospectively analysed. The demographic characteristics and complete blood count of the patients were recorded. We divided the patients who operated with testicular torsion into two groups: detorsion (Group 1) and orchiectomy (Group 2). A control group (Group 3) was created from healthy volunteers. All haematological parameters and other demographic data were compared between three groups. A total of 144 participants were included; Group 1, Group 2 and Group 3; 61, 27 and 56 respectively. The duration of symptoms and monocyte counts were found statistically significantly higher in patients undergoing orchiectomy than detorsion (p < .01). We found a significant difference in terms of neutrophil, lymphocyte, monocyte counts and neutrophil-lymphocyte ratio between patients with testicular torsion and controls. We also found that the monocytes count and symptom duration differed significantly between the detorsion group and the orchiectomy group. It is obvious that there is contradictory information according to the studies in the literature. We can say that the duration of symptoms and the number of monocytes are predictors of testicular viability.