Ultrasonographical features of perinatal testicular torsion: an assessment of interobserver variability among radiologists and pediatric urologists

PURPOSE

To retrospectively compare interpretations of Doppler ultrasound (US) in newborns with confirmed perinatal testicular torsion (PTT) by an experienced faculty (staff) pediatric radiologist (SPR), pediatric radiology fellow (PRF), pediatric urology fellow (PUF) and staff pediatric urologist (SPU).

METHODS

US images of 27 consecutive males with PTT between May 2000 and July 2020 were retrieved. The testicles were classified as affected or non-affected by PTT. We performed a blinded comparison of interpretation by four assessors (SPR, PRF, PUF, SPU), with respect to the US features of PTT. Paired inter-rater agreement was calculated using Cohen's Kappa (κ) and overall agreement was assessed using Fleiss' kappa.

RESULTS

Overall comparison using Fleiss' kappa found fair agreement for most features except testicular echogenicity and echogenic foci at interface for which there was poor agreement. Paired comparisons revealed better agreement between the SPR and PRF compared to the remaining two pairs, suggesting a need for the pediatric urologists (PUF and SPU) to acquaint themselves with testicular ultrasonography as this may have an impact on patient risk stratification and the quality of information given to parents.

CONCLUSION

This study highlights the need for focused training program for pediatric urologists to attain similar agreement as the radiologists, suggesting a need for the pediatric urologists (PUF and SPU) to acquaint themselves with testicular ultrasonography as this may have an impact on patient risk stratification and the quality of information given to parents.

Perinatal testicular torsion: The clear cut, the controversial, and the "quiet" scenarios

BACKGROUND

Perinatal testicular torsion (PTT) is a catastrophic event that occurs in utero or up to 30 days postnatally, with testicular loss being the most common outcome.

OBJECTIVE

To assess clinical evaluation, surgical management and clinical outcomes in patients with PTT in a quaternary referral pediatric center, to determine testicular salvageability and propose future management options.

METHODS

We retrospectively reviewed a cohort of males born outside the quaternary center with a diagnosis of PTT, from May 2000 to July 2020. Data collection included mode of delivery, gestational age, birth weight, testicular examination at birth, clinical presentation, ultrasound results at diagnosis, surgical management and findings, perioperative complications, and follow-up.

RESULTS

62 patients, including 2 patients with bilateral asynchronous PTT, were identified. Median (IQR) gestational age and birth weight were 39 (38-39.4) weeks and 3.4 (3.1-3.72) kg, respectively. Abnormal testicular examination at birth was found in 69% (Table 1). Doppler ultrasound was performed in all but 1 patient. 59 patients underwent surgery, 21 within 4 h, with bilateral exploration in 44 cases. Affected and non-affected testicles were explored in 76% and 98% of cases, respectively. 3 "nubbins" were found, of which 2 were excised. 3 nonsurgical complications were identified. During a median (IQR) follow-up of 3 (3-3) months, 63 testicles were removed or found to be non-functional, with compensatory hypertrophy in 38% of patients.

CONCLUSION

Given that 3% of our patients presented with asynchronous bilateral PTT, as well as the safety of general anesthesia in a referral pediatric hospital, early bilateral scrotal exploration of PTT is recommended.

LEVEL OF EVIDENCE

IV.

Controversies in the management of neonatal testicular torsion: A meta-analysis

OBJECTIVE

This meta-analysis seeks to discern the optimal management strategy in neonatal testicular torsion (NTT).

METHODS

Reviewed all English-language articles published between 2005 and 2015 in Medline/Pubmed that had a defined diagnosis of NTT within the first thirty days of life, and discussed specific surgical and nonsurgical management. Exclusion criteria were non-English literature, case reports, case studies, and failure to clearly describe the management of NTT. Data from 9 studies were analyzed, individually and together as pooled data, using a random effect model with a random intercept to estimate the pooled proportions of interest. Results are presented with 95% confidence interval. All analyses were done in SAS 9.4®.

RESULTS

9 publications met criteria for this analysis with a total of 196 patients. Bilateral testicular torsions (n = 14) were less common as compared to right/left testicular torsion (n = 85/97). Asynchronous NTTs (n = 9) were more common than synchronous NTTs (n = 2). There was a higher incidence of NTT in neonates delivered by vaginal delivery (n = 110) as compared to those delivered by c-section (n = 25). Extravaginal torsion (n = 54) is far more common than intravaginal torsion (n = 2). Full-term neonates (n = 122) have a higher incidence of NTT as compared to preterm neonates (n = 9). A total of 15 testicles were salvaged. Of the salvaged testicles 2 were documented as prenatal, 10 postnatal and 3 were undocumented. A strategy of bilateral exploration allows for salvage of about 7% of ipsilateral testicles and prevent asynchronous torsion in about 4% of neonates.

CONCLUSIONS

Based on our population, between 8-12% of patients would benefit from bilateral exploration at the time of diagnosis. We recommend urgent bilateral exploration with orchiopexy of the contralateral testicle in order to avert anorchia.

TYPE OF STUDY

Systematic review.

LEVEL OF EVIDENCE

Level 5 meta-synthesis (Evidence from systematic reviews of qualitative and descriptive studies).