Diagnosis and treatment of cryptorchid testicular torsion in children: A 12-year retrospective study

Development of a nomogram to predict risk factors for orchiectomy after testicular torsion in children

Testicular torsion (TT) in children is a common urological emergency, and timely and accurate management is crucial for prognosis. Orchiectomy is one of the severe complications of this condition, and accurately predicting its risk is of great significance for clinical decision-making. This study aims to develop a nomogram to predict risk factors for orchiectomy after TT in children. This study retrospectively collected clinical data from 327 cases of TT at the Children's Hospital of Fudan University and 141 cases at Anhui Provincial Children's Hospital, which were classified into the training and validation cohorts, respectively. Multivariate logistic regression analysis was performed to identify independent predictors of orchiectomy in TT patients, and a nomogram was constructed. The model's effectiveness in both the training and validation cohorts was evaluated using the area under the receiver operating characteristic curve (AUC), calibration curves, and decision curve analysis (DCA). A total of 468 cases were included, of which 230 (49.15%) ultimately underwent orchiectomy. Duration of symptoms, neutrophil count, eosinophil count, degree of torsion, undescended testis(UDT), Testicular Workup for Ischemia and Suspected Torsion(TWIST) score grading, and ultrasound blood flow signal were identified as independent risk factors for orchiectomy in children with TT and were used to construct the nomogram. The AUCs of the nomogram were 0.93 (95% CI: 0.91-0.96) in the training cohort and 0.86 (95% CI: 0.79-0.92) in the validation cohort. The calibration curves demonstrated good agreement between predicted and observed values, and DCA indicated that the constructed nomogram had a high clinical net benefit. The nomogram developed in this study effectively predicts the risk of orchiectomy after TT in children, providing clinicians with a valuable decision-making tool. Future multicenter clinical studies are needed to optimize and validate the model's effectiveness.

Association of MPV, NLR, PLR and CRP on testicular salvage in testicular torsion: A systematic review and meta-analysis

Testicular torsion, a critical urological emergency caused by twisting of the spermatic cord, poses a risk of ischemia, particularly in children who often struggle to pinpoint symptoms onset. Delay in managing testicular torsion can lead to the need for orchiectomy. The aim of this study was to assess the association between hematologic parameters-mean platelet volume (MPV), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and C-reactive protein (CRP)-and testicular salvage in cases of testicular torsion. Four databases (PubMed, Embase (Ovid), Science Direct, and Scopus) were systematically searched for eligible studies published up to November 4, 2024. The primary outcome was testicular salvage. Sensitivity analysis was performed using leave- one-out plot. Subgroup analysis was performed based on age, country, region, duration to orchiopexy and duration to orchiectomy. Heterogeneity was examined using I 2 statistics, and a random-effect model was applied. Out of 363 studies identified, nine observational studies involving 796 patients were included, with 338 (42.3%) in orchiopexy group. The meta-analysis indicated that MPV value was significantly elevated in orchiectomy group (mean difference (MD): -0.4; 95% confidence interval (95%CI): -0.62-(-0.18); p < 0.01), with higher MPV levels associated with an increased likelihood of orchiectomy (odds ratio (OR): 2.12; 95%CI: 1.35-3.33; p < 0.01). NLR, PLR, and CRP showed no significant association with testicular salvage, as demonstrated by pooled MD and OR analyses (p > 0.05). No significant differences were observed after sensitivity and subgroup analysis (p > 0.05). These findings suggest that elevated MPV levels are associated with non- salvageable testis, requiring orchiectomy highlighting its potential utility in clinical evaluation for testicular torsion.

A Survey of Preoperative, Perioperative, and Postoperative Management Practices for Testicular Torsion in Pediatric Patients among European Surgeons

INTRODUCTION

 Management of testicular torsion varies between specialties resulting in lack of standardization. The aim of this survey was to assess pre-, peri-, and postoperative differences.

METHODS

 An online questionnaire was distributed in 2023 to general and pediatric surgeons, pediatric urologists, and urologists by the Trainees of European Pediatric Surgery.

MAIN RESULTS

 Among 88 respondents (92% tertiary referral hospital), 38% always or usually perform sonography in case of suspected torsion respectively. In addition, 15% always attempt manual detorsion and 44% depending on the clinical presentation. Most surgeons (93%) favor a scrotal approach. Interestingly, pediatric surgeons choose a transscrotal while other specialties opt for a midline incision (p = 0.002). The majority (57%) employ a three-point fixation, while 42% opt for a two-point fixation. In case of necrotic testis, 61% puncture the testis with 52% opting for surgical removal, while 33% perform orchiectomy and 6% leave it in situ. Regarding necrotic or borderline-appearing testis, 54% take a biopsy. Furthermore, 82% perform prophylactic orchidopexy of the contralateral side during the same session. Postoperative antibiotics are always administered by 12%, while 52% do so sometimes. Most perform sonographic (58%) or clinical (57%) follow-up 3 months postoperatively. Notably, pediatric surgeons and urologists perform follow-up more frequently themselves, while general surgeons/urologists recommend follow-up by pediatricians (p = 0.002). In addition, 76% of responders affirm adhering to European Association of Urology guidelines. Unawareness of guidelines and institutional practices are reasons most commonly cited for nonadherence.

CONCLUSION

 Our study reveals significant disparities in the pre-, peri-, and postoperative management of testicular torsion underscoring the need for establishing standardized practices.

Clinical characteristics and management strategies of testicular torsion in children with cryptorchidism: a comprehensive analysis

Background

Cryptorchidism increases the risk of testicular torsion, a condition requiring urgent intervention. However, the atypical presentation in these cases makes diagnosis challenging, necessitating improved clinical awareness and management strategies. This study aims to analyze the clinical characteristics, diagnostic methods, and treatment outcomes of testicular torsion in children with cryptorchidism. The goal is to enhance the understanding of this rare condition and provide valuable insights into its diagnosis and management, based on clinical and surgical findings.

Methods

A retrospective analysis was conducted on the clinical data of 21 children with cryptorchidism who experienced testicular torsion and were treated at Anhui Provincial Children's Hospital from January 2015 to June 2024. Among the 21 patients, five had bilateral cryptorchidism, all of which involved unilateral testicular torsion, with 16 cases on the left side and five on the right side. The median age of the patients was 48 months [interquartile range (IQR): 8.5-117.5 months]. The median onset time, defined as the time interval between the onset of symptoms and surgical intervention, was 24 hours (IQR: 12-72 hours).

Results

All patients underwent surgical exploration. The average surgery time was 60.9 [standard deviation (SD): 25.1] minutes, with an average blood loss of 4.5 (SD: 2.3) mL. The median torsion angle was 540° (IQR: 270°-720°). Intraoperatively, 18 testes were found to have irreversible necrosis and were removed, while three were successfully detorsed and preserved with good blood supply. Postoperative follow-up for an average of 50.4 (SD: 18.3) months showed no atrophy in the surviving testes, and the contralateral fixed testes developed well without recurrent torsion.

Conclusions

Testicular torsion in children with cryptorchidism is rare and often presents with subtle symptoms. Early diagnosis and treatment are crucial. Ultrasound plays a significant role in the diagnosis of testicular torsion in cryptorchidism. The degree of torsion and the time of onset are critical factors for improving testicular survival rates. It is recommended that surgical intervention be performed early in cryptorchid patients older than six months to reduce the risk of testicular torsion.

Decoding Acute Scrotum: Diagnostic Accuracy of Ultrasound in Urgent Clinical Settings

Background Acute scrotum is a medical emergency commonly encountered in clinical practice, particularly in pediatric and adolescent populations. It is characterized by sudden onset of scrotal pain and may involve swelling, redness, or tenderness. The most common etiologies include testicular torsion, epididymo-orchitis, trauma, and, less frequently, tumors. Early and accurate diagnosis is critical, especially in cases of testicular torsion, where timely surgical intervention is required to preserve testicular viability. Ultrasound (US), particularly high-resolution gray-scale imaging combined with color Doppler (CD), has emerged as the primary imaging modality for evaluating acute scrotal conditions due to its accessibility, non-invasiveness, and high diagnostic accuracy. Aims and objectives This study aims to assess the diagnostic accuracy of US in differentiating the causes of acute scrotum, specifically focusing on testicular torsion, epididymo-orchitis, and varicocele. We also evaluate its role in reducing unnecessary surgical explorations and improving clinical decision-making in urgent settings. Materials and methods This retrospective observational study was conducted in a tertiary care center in Puducherry, India. A total of 250 male patients, ranging in age from 10 to 70 years, presented with acute scrotal pain over the 12-month study period. Inclusion criteria included all patients with sudden scrotal pain, regardless of clinical suspicion of underlying pathology. US scans were performed using a 7.5- to 12-MHz linear transducer. Gray-scale imaging was used to evaluate the testes, epididymis, spermatic cord, scrotal wall, and inguinal region, while CD was used to assess vascular flow. Statistical analysis was conducted using SPSS Version 18 (IBM Corp., Armonk, NY). Diagnostic accuracy was calculated based on sensitivity, specificity, positive predictive value, and negative predictive value. Results The most common cause of acute scrotum was inflammatory pathology, including epididymo-orchitis, accounting for 56.4% of cases (141 patients). Varicocele was the second most common cause, diagnosed in 11.6% of patients (29 cases), while hernias and epididymal cysts were found in 8% and 7.6% of cases, respectively. Testicular torsion was diagnosed in 2% of cases (five patients). US demonstrated high diagnostic accuracy for inflammatory pathologies, with sensitivity and specificity reaching 97% and 96%, respectively. The sensitivity for testicular torsion was 62%, reflecting the challenges in diagnosing partial or intermittent torsion, while specificity was high at 99%. US's performance in identifying varicocele was excellent, with a sensitivity of 93% and specificity of 98%. Conclusion US, especially when combined with CD, is an indispensable tool in the emergency evaluation of acute scrotum. It provides high diagnostic accuracy for inflammatory pathologies and varicocele while serving as an effective screening modality for testicular torsion. This study reinforces the role of US in reducing unnecessary surgical explorations, guiding clinical management, and improving patient outcomes in urgent clinical settings.

Management of undescended testis

PURPOSE OF REVIEW

Describe why this review is timely and relevant.Undescended testis, or cryptorchidism, is a common diagnosis encountered by pediatricians that requires timely collaboration with pediatric surgical specialists to optimize outcomes for these patients. As this topic continues to be heavily researched, it is imperative to understand current recommendations and emerging management options including new surgical techniques, as well as common pitfalls in care highlighted in the literature.

RECENT FINDINGS

Describe the main themes in the literature covered by the article.This review primarily examines current practice in management including delays in surgical referral, with unnecessary imaging being a key factor that delays time to surgery. This review briefly discusses the diagnosis of undescended testis and the various surgical techniques used including the more recently proposed laparoscopic staged traction orchiopexy (Shehata technique). The ineffectiveness of hormonal therapy is also addressed.

SUMMARY

describe the implications of the findings for clinical practice or research.This review emphasizes prompt evaluation and diagnosis of undescended testis to facilitate appropriately timed surgical intervention, which plays a major role in outcomes for these patients. Identifying patients at risk of delayed referral is an area of focus for improvement, along with better resource utilization with fewer imaging. Familiarization of surgical options can also facilitate better patient education and provider understanding of risks/benefits.

A 7-year-old with extravaginal torsion of an undescended testicle in the left inguinal region: The first case report from Syria

The incidence of undescended testicles torsion in a 7-year-old is rare, making it a clinically unusual occurrence. Emphasizing the importance of thorough urogenital assessments in children, particularly in underserved communities, is critical to prevent serious complications like testicular gangrene.

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.

Comparison of clinical features and outcomes between two age groups of cryptorchidism testicular torsion in children: a retrospective study in single center

Objective

The purpose of this study was to compare the clinical characteristics and outcomes of children with cryptorchidism testicular torsion between the younger age group and the older age group.

Methods

We collected the clinical data of children with cryptorchidism complicated with testicular torsion in our hospital from January 1, 2013 to January 1, 2023. The patients were divided into two groups: the younger age group (1month∼4 years old, n = 7) and the older age group (4∼18 years old, n = 7). The differences of clinical manifestations and surgical results between the two groups were compared.

Results

A total of 14 patients with unilateral cryptorchidism testicular torsion were included in this study, including 9 on the left side and 5 on the right side. The main clinical manifestations were pain /swelling of groin. The rate of crying in the younger age group was significantly higher than those in the older age group [(5,71.4%) vs. (0,0.0%), P < 0.05]. The median duration of symptoms of the younger group was less than the older group [42(7,96) h vs. 70(24, 96) h, P > 0.05]. The ipsilateral testicular salvage rate in the younger age group was 14.3% (1/7), which was lower than the older age group 57.1% [(4/7), P > 0.05]. The degree of testicular torsion in younger age group was more severe than the older age group [720(360, 1,080)° vs. 360(270, 360)°, P > 0.05].

Conclusions

The overall salvage rate of cryptorchidism testicular torsion is low. Although the duration of symptoms in the older age group was longer, the salvage rate of the older age group seemed to be higher than that in the younger age group. In addition, physical and imaging examination of the reproductive system should be carried out in time to identify the children with cryptorchidism testicular torsion in the early stage.

Atypical symptoms of testicular torsion in a 7-year-old child: A case report

RATIONALE

Testicular torsion accounting for 25% of acute scrotal disease, is an acute surgical condition. Atypical presentations of testicular torsion may lead delay diagnosis.

PATIENT CONCERNS

A 7-year-old boy was admitted to the pediatric emergency department with continuous and progressive left scrotal pain for 2 days, associated symptoms and signs included left scrotal swelling and erythema. The pain started 4 days ago as left lower abdominal pain which then migrated to the left scrotum.

DIAGNOSES

Physical examination showed left scrotum skin redness, swelling, local heat, tenderness, high-riding testis, absence of the left side cremasteric reflex and a negative Prehn's sign. Subsequent point of care ultrasound of scrotum revealed increased volume of the left testicle, inhomogeneous hypo-echoic left testis, and no detectable flow in the left testis. Left testicular torsion was diagnosed.

INTERVENTIONS

Surgical examination confirmed testicular torsion showing 720° counterclockwise rotation of the spermatic cord with ischemic changes in the left testis and epididymis.

OUTCOMES

The patient was stabilized and discharged after left orchiectomy, right orchiopexy and antibiotic therapy.

LESSONS

Symptoms of testicular torsion may be atypical, especially in prepubertal age. Detailed history, physical examination, point of care ultrasound usage and timely urologist consultation and intervention are important for prompt rescue to prevent testicular loss, testicular atrophy, and eventual impairment of fertility.