Decompressive fasciotomy in testicular torsion of the spermatic cord in rats

Pathophysiology and management of testicular ischemia/reperfusion injury: Lessons from animal models

Testicular torsion is a urological emergency that involves the twisting of the spermatic cord along its course. Compelling pieces of evidence have implicated oxidative stress-sensitive signaling in pathogenesis of testicular I/R injury. Although, surgical detorsion is the mainstay management; blockade of the pathways involved in the pathogenesis may improve the surgical outcome. Experimental studies using various testicular I/R models have been reported in a bid to explore the mechanisms associated with testicular I/R and evaluate the benefits of potential therapeutic measures; however, most are limited by their shortcomings. Thus, this review was intended to describe the details of the available testicular I/R models as well as their merits and drawbacks, the pathophysiological basis and consequences of testicular I/R, and the pharmacological agents that have being proposed to confer testicular benefits against testicular I/R. This provides an understanding of the pathophysiological events and available models used in studying testicular I/R. In addition, this research provides evidence-based molecules with therapeutic potentials as well as their mechanisms of action in testicular I/R.

Is testicular tissue resection effective in testicular compartment syndrome?

Background

There have been many testicular losses due to testicular compartment syndrome (TCS). Studies are ongoing to lower the pressure within tunica vaginalis during TCS.

Aims

To provide enough space for reperfusion of the testicular tissue and to reduce intratesticular pressure by resecting testicular tissue in the affected testis for treatment of TCS.

Materials and Methods

The study was designed as a prospective randomized animal study. A total of 24 Wistar albino adult rats were randomly divided into three groups. After torsion surgery group 1 underwent detorsion + testicular tissue resection (TTR), while only detorsion was performed in group 2. The control group did not undergo any procedures. At the postoperative 5th day all subjects were sacrificed, and their testes were evaluated in terms of histologic findings, apoptosis, and microangiogenesis. One-way ANOVA and Tukey's test were used for analysis.

Results

According to Johnsen scores, all the groups were statistically different from each other and the damage in group 1 was less than in group 2 (P < 0.05). Factor VIII expressions in surgical groups were significantly higher than in the control group (P < 0.05). However, the surgical groups did not show any significant difference between each other (P > 0.05). Apoptotic cell counts were higher in both surgical groups than in the control group. Also, there was significantly higher apoptotic cell count in group 2 than in group 1 (P < 0.05).

Conclusions

The injury secondary to TCS is lower when TTR is performed. In the cases in which tunica vaginalis graft could not be obtained or in the delayed cases, TTR may be useful.

Epithelial growth factor and decompressive testicular fasciotomy to control ischemia reperfusion injury in rats

PURPOSE

Testicular torsion is an urological emergency and an important cause of male infertility. Recent studies have shown that not only ischemia, but also the restoration of blood flow creates a deleterious situation for the testis. The goal of this work was to evaluate the role of systemic epithelial growth factor application and its association with decompressive fasciotomy in tissue recovery of the testes undergoing the torsion of the spermatic cord.

METHOD

Torsion of the spermatic cord was induced in 40 Wistar pubescent testes for a period of 4 h. At the time of detorsion systemic epithelial growth factor and decompressive fasciotomy were applied as treatment alternatives. After 21 days, the testicles were examined macro and microscopically.

RESULTS

The variables evaluated were weight, testicular volume and the degree of histological alterations by optical microscopy. The rate of healing of testicular torsion showed significant difference between the groups. It was noted that in terms of testicular weight and volume the animals treated with systemic epithelial growth factor resembled the control group and had a better histological classification than the other groups. The mean Johnsen score was significantly higher in the group treated with systemic growth factor and decompressive testicular fasciotomy than in the group without fasciotomy. No significant changes were noted in the contralateral testes.

CONCLUSION

Although decompressive testicular fasciotomy improved spermatogenesis, recovery was limited. Systemic epithelial growth factor administered in combination with decompressive testicular fasciotomy was more effective for spermatogenesis than fasciotomy alone. Administering epithelial growth factor after reperfusion might have the potential to decrease long-term histologic damage after testicular torsion. The combination of decompressive testicular fasciotomy and epithelial growth factor had a synergistic effect on the healing of these testes.

Effect of ethyl pyruvate on oxidative state and endoplasmic reticulum stress in a rat model of testicular torsion

We investigated the effects of ethyl pyruvate (EP) on oxidative and endoplasmic reticulum (ER) stress due to experimental testicular ischemia-reperfusion (I-R). Eighteen rats were divided into a control group, a torsion-detorsion (T-D) group and an EP group. For pretreatment of the EP group, 50 mg/kg EP was given intraperitoneally (i.p.) 30 min before detorsion. Tissue 4-hydroxynonenal (4-HNE) and 78-kDa glucose-regulated protein (GRP78) levels were determined using enzyme-linked immunosorbent assay (ELISA) kits. Tissue total oxidant status (TOS) and total antioxidant status were determined using colorimetric methods. Histology of the tissues was evaluated using hematoxylin and eosin staining. In the T-D group, tissue 4-HNE, GRP78, TOS and oxidative stress index levels were significantly higher than for the control group. The increases were reduced significantly by EP pretreatment. Our findings suggest that EP can inhibit I-R induced testicular injury by suppressing oxidative and ER stress. EP may be a useful adjunctive treatment for surgical repair in humans.

Protective Effects of Matricaria chamomilla Extract on Torsion/ Detorsion-Induced Tissue Damage and Oxidative Stress in Adult Rat Testis

Background

There is some evidence indicating that Matricaria chamomile (MC) had protective effects on ischemia- reperfusion. In the present study, a rat model was used to investigate the effect of hydroalcoholic extract of MC on torsion/detorsion-induced testis tissue damage.

Materials and Methods

In this experimental study, 28 male Wistar rats were randomly divided into 4 groups as follows: G1, Sham operated; G2, testicular torsion/detorsion (T/D); G3, rats with testicular torsion/detorsion that received 300 mg/kg of MC extracts 30 minutes before detorsion (T/DMC); and G4, healthy rats that received 300 mg/kg of MC extracts (MC). Also, the reperfusion period was 24 hours. After blood sampling, the oxidative stress marker [e.g. superoxide dismutase (SOD) levels], blood levels of testosterone, and anti-oxidant enzyme levels [e.g. glutathione peroxidase (GPx)] were assessed by ELISA methods. Serum activity of malondialdehyde (MDA) was evaluated by spectrophotometry. Another assessment was carried out by histomorphometry, 24-hour post-procedure. The histological parameters investigated by Johnson’s scores (JS), also the seminiferous tubule diameter (STD) and the height of the germinal epithelium (HE) measured using the linear eyepiece grids using light microscopy.

Results

Histological features significantly differed between sham and the other groups. The levels of SOD, GPx, and testosterone hormone were significantly decreased in T/D group as compared to sham group, while these parameters increased in T/DMC group as compared to T/D group. During ischemia, the MDA levels increased; however, treatment with MC extract decreased the MDA levels in G3 and G4 groups.

Conclusion

Results of the present study demonstrated that MC can protect the testis tissue against torsion/detorsion- induced damages by suppressing superoxide production.

Epididymo-orchitis causing testicular infarction: a serious complication of a common disorder

One of the most common differentials for the acute scrotum is an epididymo-orchitis (EO), which can mimic the presentation of testicular torsion. We present a case of a 37-year-old man presented to the Emergency department with a 3-day history of progressive left testicular pain. A Doppler ultrasound was done which revealed increased flow to the left testicle with no evidence of testicular torsion and he was discharged. He was re-admitted with worsening pain and a repeat scan showed that the penile arterial diastolic flow had reversed, indicating testicular infarction. This was confirmed at exploration and an orchidectomy was performed. EO causing severe complications is an uncommon manifestation of a common disorder. Features suggesting a lack of response to antibiotics include sepsis, pronounced scrotal oedema, severe testicular pain and scrotal wall inflammation. The presence of a positive urine culture has also been highlighted as a poor prognostic factor.

Effect of vitamin C on tissue damage and oxidative stress following tunica vaginalis flap coverage after testicular torsion

AIM OF THE STUDY

The aim was to investigate the protective effect of vitamin C on tissue damage and oxidative stress following tunica albuginea incision with tunica vaginalis flap coverage for testicular torsion.

MATERIALS AND METHODS

Adult male Wistar rats were randomly divided into two experimental groups. The first group experienced 5h of testicular torsion followed by treatment with vitamin C alone, with tunica vaginalis flap coverage alone, and with both vitamin C and tunica vaginalis flap coverage along with a control group subjected to a sham procedure. The second group experienced 9h of testicular torsion followed by the same treatment options as described for the 5h group. The oxidative stress and testosterone levels were measured 24h posttreatment. The Johnsen score, diameter of the seminiferous tubules, and thickness of the seminiferous tubule epithelium were recorded 30days following the treatment.

RESULTS

The Johnsen score, diameter of the seminiferous tubules, and thickness of the seminiferous tubule epithelium significantly increased in the 5h testicular torsion group receiving treatment with vitamin C and tunica vaginalis flap coverage compared with the group receiving tunica vaginalis flap alone. The level of testosterone decreased significantly in all groups except for the 5h testicular torsion group receiving treatment with vitamin C and tunica vaginalis flap coverage. The MDA level also decreased in the group receiving treatment with vitamin C and tunica vaginalis flap coverage compared with the group receiving tunica vaginalis flap coverage alone.

CONCLUSIONS

The results showed that the histological parameters and testosterone levels improved with the administration of vitamin C before tunica vaginalis flap coverage in the group experiencing 5h of torsion. This may be a result of the antioxidant effect of vitamin C. No advantage was observed for the 9h group, possibly because the dosage of vitamin C was inadequate.

Morphological and microcirculatory evaluation of the rat testis after detorsion with or without a capsular release with a tunica vaginalis flap

Testicular torsion may lead to serious ischemia, and the viability depends on the duration of torsion and the effect of ischemia-reperfusion. Testicular decompression and tunica vaginalis flap application technique were introduced in 2008 by Kutikov et al. We aimed to examine the impact of this method on the testicular microcirculation and hemorheological parameters in a rat model. Six adult rats underwent bilateral scrotal exploration. Intravaginal torsion of the testis was created by 720° rotation on both sides for 2 h. After detorsion, the right testes underwent tunica albuginea incision and tunica vaginalis flap application. Testicular microcirculation was monitored and hematological parameters, erythrocyte deformability, and aggregation were determined. Measurements were performed before and after torsion, directly after detorsion, on the 1^st–2^nd and 8^th postoperative day. After the last sampling, testicles were removed to determine their volume for histological examinations. The microcirculatory parameters demonstrated slight differences between testicles. Apical zone of the left (nondecompressed) testicles had elevated compared to the middle zone (P < 0.05). On the 2^nd and 8^th day, the microcirculation of the testes normalized but not equally. The erythrocyte aggregation and deformability decreased by the 8^th day. Both testicles underwent atrophy and epithelial necrosis, but the volume of the decompressed ones was lower (1.07 ± 0.08 vs 1.25 ± 0.31). Histologically, there was no significant difference in epithelial damage score between decompressed and nondecompressed testes. In conclusion, 2-h ischemia led to alteration in testicular microcirculation, reduction in volume, changes in hemorheological parameters and serious epithelial necrosis both in decompressed and nondecompressed testicles without remarkable differences.

Protective effect of tunica albuginea incision with tunica vaginalis flap coverage on tissue damage and oxidative stress following testicular torsion: Role of duration of ischemia

OBJECTIVE

This experimental study used a rat model to investigate the effect of a tunica albuginea incision with tunica vaginalis flap coverage on tissue damage and oxidative stress caused by testicular torsion and its relationship with the duration of ischemia.

MATERIALS AND METHODS

The test animals were divided into the following groups: G1, sham procedure; G2, testicular torsion for 1, 5, or 9 h followed by detorsion; G3, testicular torsion for 1, 5, or 9 h followed by detorsion using flap technique. Testicular torsion was induced by 720° counterclockwise rotation of the left testis. After the period of torsion, the flap technique was employed for detorsion. The oxidative stress and testosterone levels were measured at 24 h post procedure. Further assessment was carried out by histomorphometry at 30 days post procedure. The histological parameters included the Johnsen score, diameter of the seminiferous tubules, and thickness of seminiferous tubule epithelium.

RESULTS

The histological parameters in the G2 group showed a significant change in relationship with the duration of ischemia. In the G3 group, flap coverage improved the histological parameters only for the 9-hour torsion subjects. The levels of testosterone, glutathione peroxidase (GPX), and superoxide dismutase significantly decreased in all subgroups of G2 and G3, and the malondialdehyde level increased as the duration of ischemia increased. Flap coverage decreased the malondialdehyde level only in the 9-hour torsion subjects.

CONCLUSIONS

Flap coverage reduced tissue damage as the duration of ischemia increased. The findings of the rat model suggested that a tunica albuginea incision with tunica vaginalis flap might have provided a protective effect in long-term ischemia.