Successful salvage of torsion testis by means of intraoperative indocyanine green fluorescence imaging

Application and Evaluation of Indocyanine Green Fluorescence Imaging in Pediatric Testicular Torsion Surgery

OBJECTIVES

To assess the feasibility of ICG-NIRF imaging technology in evaluating testicular blood supply during pediatric testicular torsion surgery and guiding intraoperative surgical decision-making.

METHODS

A retrospective study was performed on patients diagnosed with testicular torsion and treated surgically at our hospital between January and September 2024. ICG-NIRF imaging was utilized intraoperatively to assess testicular blood flow and guide the decision on testicular preservation. The clinical data we collected included age, symptom onset time, rotation of torsion, coloration grade of torsional testis, ICG fluorescence time of torsional testis, fluorescence pattern classification, surgical methods, complications, and histopathology. Torsional testes were classified into six grades based on color. Fluorescence patterns were classified into three types (A, B, and C), and further refined this classification standard and divided type C into C1, C2, and C3. Follow-ups were conducted at 1 and 3 months postoperatively. Grayscale ultrasound assessed testicular volume and echotexture bilaterally, while Color Doppler flow imaging (CDFI) evaluated blood flow.

RESULTS

15 patients were included in this study, with a median age of 12.7 years (range: 4.3-15.1 years). The median symptom onset time was 10 h (range: 0.5-48 h). The median rotation of torsion was 360° (range: 180°-720°). The median ICG fluorescence time of torsional testis was 22.5 s (range: 18-30 s). The median coloration grade of torsional testis was 3 (range: 2-6). Intraoperatively, ICG fluorescence was detected in 10 torsional testes, while 5 showed no fluorescence signal. 7 cases exhibited type A fluorescence, 3 cases type B, and 5 cases type C. ICG fluorescence was observed in the tunica albuginea or parenchyma (Type A & B) in 10 patients following intravenous injection, leading to testicular preservation and fixation. Among the 5 patients with Type C fluorescence, 2 (Type C1) showed no enhancement of the tunica albuginea or parenchyma within 2 min of ICG injection, but fluorescence leakage was observed after incising the tunica albuginea and parenchyma, warranting testicular preservation. The remaining 3 patients showed no ICG enhancement, upon incising the tunica albuginea and parenchyma, bleeding was observed in one case, while 2 did not. However, none of the three cases exhibited fluorescence leakage (Type C2 & C3). Consequently, orchiectomy was performed in all three cases. Histopathological examination confirmed extensive hemorrhage and necrosis of the testicular tissue. Postoperative recovery was uneventful. One-month follow-up revealed uniform testicular echotexture on grayscale ultrasound in 11 of 12 orchiopexy patients, while one patient exhibited uneven echoes. CDFI showed normal intratesticular blood flow in 10 patients, while two exhibited reduced blood flow. At three-month follow-up, 11 of 12 orchiopexy patients had uniform testicular echotexture on grayscale ultrasound. One patient developed an upper pole cyst. CDFI confirmed normal blood flow in all 12 cases. Statistical analysis revealed a significant difference between the preoperative contralateral testicular volume and the torsional testicular volume at one month postoperatively (P = 0.048) and at three months postoperatively (P = 0.002). However, no significant difference was observed between the one-month and three-month postoperative volumes (P = 0.138).

CONCLUSIONS

ICG-NIRF imaging effectively assesses intraoperative testicular perfusion in torsion cases, aids in surgical decision-making regarding testicular preservation, and predicts postoperative outcomes.

Indocyanine green fluorescence imaging as a predictor of long-term testicular atrophy in testicular torsion: a pilot study

PURPOSE

This pilot study evaluated indocyanine green-guided near-infrared fluorescence (ICG-NIRF) imaging of testicular blood flow to predict long-term testicular atrophy after testicular torsion (TT) surgery.

METHODS

The subjects of this retrospective study were patients who underwent surgery for TT at our hospital between December, 2020 and July, 2022. After detorsion, testicular blood flow was evaluated by ICG-NIRF imaging and classified into three categories: fluorescence detected, no fluorescence detected, and fluorescence detected only in the tunica albuginea vessels. Testicular volume was measured by ultrasonography up to 12 months after surgery to evaluate long-term outcomes.

RESULTS

Twelve patients were included in this analysis. We found a 100% correlation between the absence of ICG-NIRF signals and subsequent testicular atrophy. In three patients without an ICG-NIRF signal, the median testis size 12 months postoperatively was significantly smaller (16.5% of the contralateral testis; range 13-20%) than that in six patients with an ICG-NIRF signal (96%; 89-115%) (p = 0.013). Mild atrophy (74.5%; 73-76%) was also observed in the three patients for whom an ICG-NIRF signal was detected only in the tunica albuginea vessels.

CONCLUSIONS

Our pilot study highlights the potential of ICG-NIRF imaging as a prognostic tool for guiding surgical decision-making for patients with TT, by predicting postoperative testicular atrophy.

Utility of indocyanine green fluorescent dye in emergency general surgery: a review of the contemporary literature

For decades, indocyanine green (ICG) has been available for medical and surgical use. The indications for ICG use in surgery have expanded where guided surgery directed by fluorescence and near-infrared fluorescent imaging offers numerous advantages. Recently, surgeons have reported using ICG operative navigation in the emergency setting, with fluorescent cholangiography being the most common procedure. The utility of ICG also involves real-time perfusion assessment, such as ischemic organs and limbs. The rising use of ICG in surgery can be explained by the ICG's rapid technological evolution, accuracy, ease of use, and great potential to guide precision surgical diagnosis and management. The review aims to summarize the current literature on the uses of ICG in emergency general surgery. It provides a comprehensive and practical summary of the use of ICG, including indication, route of administration, and dosages. To simplify the application of ICG, we subdivided its use into anatomical mapping and perfusion assessment. Anatomical mapping includes the biliary tree, ureters, and bowel. Perfusion assessment includes bowel, pancreas, skin and soft tissue, and gonads. This review provides a reference to emergency general surgeons to aid in implementing ICG in the emergency setting for more enhanced and safer patient care.

Evaluation of testicular blood flow during testicular torsion surgery in children using the indocyanine green-guided near-infrared fluorescence imaging technique

Objective

This study investigates the feasibility of the indocyanine green-guided near-infrared fluorescence (ICG-NIRF) imaging technique in evaluating testicular blood flow during testicular torsion (TT) surgery in pediatric cases.

Methods

We retrospectively analyzed the eight pediatric patients with TT who underwent surgery in our hospital between February and July 2023. The intraoperative two-step method of ICG-NIRF imaging and testicular incision was used to evaluate the testicular blood flow, followed by a selection of different surgical methods. The removed testes were pathologically examined after surgery, and all patients were followed up 1 month after surgery to evaluate testicular blood flow using gray-scale ultrasound and color Doppler flow imaging (CDFI).

Results

Eight pediatric TT patients aged 1-16 years, with a median age of 11.5 years, were enrolled. Time from the onset ranged from 4 to 72 h (mean 26.13 ± 25.09 h). A total of eight testes were twisted, including four on the left side and four on the right side. The twisting direction of the testes was clockwise in four cases and counterclockwise in four cases. The rotation of torsion was 180°-1,080° (mean 472.5° ± 396°). There was no statistically significant difference in the imaging time between the four patients with testicular blood vessel imaging on both the torsional and normal sides (P > 0.05). The postoperative recovery was uneventful, with no complications during the follow-up period of 1 month. The postoperative histopathological results of three patients who underwent orchiectomy showed extensive hemorrhage, degeneration, and necrosis of the testicular tissue. Among the five patients who underwent orchiopexy, a gray-scale ultrasound and CDFI examinations showed uniform internal echo of the testes and normal blood flow signals in four patients. One patient with no testicular blood vessel imaging on the torsional side showed uneven internal echo of the testis and no blood flow signals.

Conclusion

ICG-NIRF imaging is a feasible method to evaluate testicular blood flow during TT surgery. Testicular blood vessel imaging within 5 minutes after ICG injection might be the basis for testicular retention during TT surgery.

Criteria for Preserving Grossly Ischemic Torsed Testicles Using Indocyanine Green Fluorescence Imaging: A Single-Center Case Series

Testicular torsion (TT) is a surgical emergency requiring early diagnosis and surgical intervention to avoid testicular loss. We report 3 pediatric TT cases with testicular salvage to visualize the blood flow by indocyanine green fluorescence imaging (ICG-FI) on the tunica albuginea of the testis. ICG-FI could not confirm blood flow in the testicular parenchyma; however, it could be detected in postoperative ultrasonography. Blood visualization of the tunica albuginea by ICG-FI may have potential criteria for testicular salvage. Long-term follow-up investigations after testicular salvage are needed to conclude the ICG-FI efficacy for TT.

Use of intraoperative indocyanine green fluorescence in determining testicular viability in testicular torsion patients in rural settings: A case report

INTRODUCTION AND IMPORTANCE

Testicular torsion (TT) is the result of spermatic cord twisting which can lead to significant ischemia, making it a time-sensitive surgical emergency. General surgeons in rural centers may lack the resources to adequately evaluate the viability of the affected testicle. Indocyanine green fluorescence (IGF) has been increasingly used to assess vascular perfusion in general surgery cases. In this case report, we show the use of IGF in a rural setting to assess testicular viability in TT.

CASE PRESENTATION

A 17-year-old male was transferred to our rural regional hospital emergency department for sudden and persistent right scrotal pain. The onset of symptoms was approximately 52 h at presentation. TT was diagnosed with a doppler ultrasound by a radiologist. Urgent detorsion surgery was performed. Intraoperative assessment of viability was unclear after the usual means and IGF helped confirm the absence of testicle vascularization and the need for orchiectomy.

CLINICAL DISCUSSION

General surgeons in rural communities are called to manage TT with limited resources and experience. IGF is widely used in general surgery and urology. Animal studies and two case reports show potential benefits of IGF in TT. In our patient, IGF was useful to confirm without a doubt that the right testicle was ischemic and non-viable.

CONCLUSION

In a rural setting with limited access to radiology and distant urology coverage, IGF is an excellent resource to determine intraoperative blood flow in TT with uncertain viability.