Paediatric testicular torsion in low- and middle-income countries: an OxPLORE scoping study.

BACKGROUND: Literature on paediatric surgical conditions in low- and middle-income countries (LMICs) remains limited. As a common emergency, timely treatment of testicular torsion acts as a benchmark of adequate emergency service delivery in paediatric surgery. This scoping study aims to synthesise all existing literature on paediatric testicular torsion in LMICs. METHODS: A database search was conducted by the OxPLORE global paediatric surgery research group to identify studies containing the terms 'testicular torsion' or 'acute scrotum' originating from LMICs. A thematic analysis was applied to the results of the search and the quality of evidence was appraised for all included articles. RESULTS: This review included 17 studies with 1798 patients. All studies originated from middle-income countries and the majority (76%) had sample sizes smaller than 100 patients. All studies were appraised as providing less than adequate evidence. Included studies identified long delays to treatment and highlighted ongoing debates on the value of scoring systems and Doppler ultrasonography in diagnosing torsion. Major heterogeneity in surgical approaches to treatment of testicular torsion in children was also observed. CONCLUSIONS: Literature on paediatric testicular torsion in LMICs is scarce and heterogeneous. Prospective, multi-centre research on the management of this common paediatric surgical emergency is urgently required.

Clinical characteristics and outcome of children with acute cryptorchid testicular torsion: A single-center, retrospective case series study.

BACKGROUND: Cryptorchidism and testicular torsion (TT) are relatively common conditions in clinical practice; however, sparse information about cryptorchid TT is available in the current literature. METHODS: We retrospectively reviewed the clinical characteristics, treatment modalities, and long-term outcomes of pediatric patients treated for acute cryptorchid TT. RESULTS: We found eight patients with unilateral acute cryptorchid TT with a prevalence of 8.9% (8/90) among all TT cases. The left testis was affected in six patients. The median age of patients at the time of the surgery was 65 months (interquartile range (IQR) 4-136 months). The median duration of symptoms was 16 h (IQR 9-25 h), while the median time to treatment was 60 min (IQR 59-63 min). The most common symptoms were pain (abdominal and inguinal) and inguinal mass with no palpable testis in the ipsilateral hemiscrotum. Preoperative color Doppler ultrasonography revealed absent or decreased testicular blood flow in the affected testes in 7/8 of patients. Various degrees of testicular torsion (median 540°, min 360°, max 1260°) were found during surgery. A necrotic testis that led to orchidectomy was found in 4/8 of patients. The median follow-up period was 42.6 months (IQR 12.5-71.2 months), revealing only one patient with testicular atrophy. The final testicular salvage rate was 35%. CONCLUSIONS: Greater awareness among caregivers and primary care physicians about acute cryptorchid TT is required to improve their timely diagnosis and treatment. A physical examination of the external genitalia and inguinal regions should be mandatory to attain a proper diagnosis and treatment without delay.

The impact of health care on outcomes of suspected testicular torsion: results from the GRAND study.

BACKGROUND: Suspicion of testicular torsion represents a urological emergency, necessitating immediate surgery. Comprehensive data on the current trends and perioperative outcomes regarding surgical exploration are sparse. Therefore, we utilized nationwide data on the prevalence and results of this surgery, aiming to provide evidence on this matter. METHODS: We assessed the GeRmAn Nationwide inpatient Data (GRAND) from 2005 to 2021, provided by the Research Data Center of the Federal Bureau of Statistics. We performed multiple regression analyses to evaluate the perioperative outcomes (length of hospital stay, transfusion, and surgical wound infection) after surgical exploration due to suspected testicular torsion based on both the outcome of surgery (orchiectomy, detorsion with preservation of the testicle, and no testicular torsion) and on the department of operation (urological versus non-urological). RESULTS: A total of 81,899 males underwent surgical exploration due to suspected testicular torsion in Germany from 2005 to 2021. Of them, 11,725 (14%) underwent orchiectomy, 30,765 (38%) detorsion with preservation of the testicle and subsequent orchidopexy, and 39,409 (48%) presented no testicular torsion. Orchiectomy was significantly associated with longer length of hospital stay (day difference of 1.4 days, 95%CI: 1.3-1.4, p < 0.001), higher odds of transfusion (1.8, 95% CI: 1.2-2.6, p = 0.002) and surgical wound infections (1.8, 95%CI: 1.4-2.3, p < 0.001) compared to no testicular torsion. The proportion of patients undergoing orchiectomy was significantly lower in urological departments (14%) versus non-urological departments (16%) and the proportion of patients undergoing preservation of testicle after detorsion was significantly higher in urological departments (38%) versus non-urological departments (37%), p < 0.001. Patients undergoing treatment in a urological department were discharged earlier and presented lower odds of transfusion and surgical wound infection (p < 0.001) compared to patients undergoing treatment in a non-urological department. CONCLUSIONS: Nearly half of patients who underwent surgery for suspected testicular torsion did not have intraoperatively the condition confirmed. Patients treated in urological departments had significantly better perioperative outcomes compared to those treated in non-urological departments. Therefore, we advise to refer patients to urological treatment as early as possible.

Sex-based Disparities in the Management of Pediatric Gonadal Torsion.

INTRODUCTION: In 2015, the U.S. News and World Report (USNWR) implemented a quality metric to expedite surgery for testicular torsion (TT), but not ovarian torsion (OT). This study examined OR timing among children with suspected TT and OT before and after this metric. METHODS: A single-center retrospective cohort study of children (1-18yr) who underwent surgery for suspected gonadal torsion was performed. Time to OR (TTOR) from hospital presentation to surgery start was calculated. An interrupted time series analysis identified changes in TTOR for suspected TT versus OT after the 2015 USNWR quality metric. RESULTS: Overall, 216 patients presented with TT and 120 with OT. Median TTOR for TT was 147 min (IQR:99-198) versus 462 min (IQR:308-606) for OT. Post-quality metric, children with TT experienced a 27.8 min decrease (95% CI:-51.7,-3.9, p = 0.05) in annual median TTOR. No significant decrease was observed for children with OT (p = 0.22). Children with history of a known ovarian mass (N = 62) experienced a shorter TTOR compared to those without (422 vs 499min; p = 0.04). CONCLUSION: Implementation of a national quality metric for TT expedited surgical care for children with TT, but not children with OT. These findings highlight the need for equitable quality metrics for children presenting with suspected gonadal torsion. LEVEL OF EVIDENCE: III. TYPE OF STUDY: Retrospective Comparative Study, Observational Cohort Study.

Surgical Management of Extravaginal Testicular Torsion in a 16-Year-Old Male: A Case Report.

Extravaginal torsion (EVT) is a rare type of testicular torsion that usually occurs in neonates. The primary type of testicular torsion that occurs in adolescents is intravaginal torsion. In this case report, we describe the first case of EVT reported in a 16-year-old male with a contralateral bell clapper deformity and subsequent surgical management using a tunica vaginalis flap and bilateral orchiopexy. In discussion of this case, we examine possible anatomical causes of EVT and suggestions for appropriate surgical management.

The impact of ultrasound on testicular loss in cases of testicular torsion in children.

PURPOSE: Ultrasound as a diagnostic tool in suspicion of testicular torsion is still highly debated. In this investigation, we aimed to evaluate whether time spent on scrotal ultrasonography had a negative impact on testicular loss. METHODS: Patients' records containing a scrotal ultrasound and/or surgical procedure codes for testicular interventions on suspicion of testicular torsion were examined. Patients aged 0-15 years admitted during 2015-2019 at Copenhagen University Hospital, Rigshospitalet were included. RESULTS: In total, 1566 patients underwent an ultrasound and 142 of these proceeded to surgery while 13 patients proceeded directly to surgery without an ultrasound. The rate of testicular loss with a preceding ultrasound was 23% versus 42% without (p = 0.18). Four cases of testicular torsion were misdiagnosed by ultrasound resulting in a sensitivity of 95.4% and specificity of 95.6%. The mean diagnostic delay from ultrasound examination was 55 ± 39 min, and the mean time from ultrasound to surgery was at 169 ± 76 min versus 171 ± 72 min without ultrasound. CONCLUSION: In a clinical setting, ultrasound provided a reliable tool for the diagnosis of testicular torsion and did not seem to increase the orchiectomy rate.

A nationwide epidemiological study of testicular torsion: Analysis of the Japanese National Database.

Testicular torsion is a severe urological emergency caused by the twisting of the spermatic cord. The nationwide incidence of testicular torsion in Japan has not been previously reported. Accordingly, we aimed to estimate the nationwide incidence of testicular torsion using the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) and examine the orchiectomy rate. This cross-sectional study was based on data from the NDB. We extracted data of patients aged < 21 years with documented testicular torsion and relevant treatment from January 2018 to December 2020. Testicular torsion was identified based on the Japanese standardized disease codes. The national incidence rate between 2018 and 2020 was calculated and assessed according to age and region of origin. Orchiectomy rates were evaluated according to age. The nationwide incidence rates of testicular torsion were 14.46, 15.09, and 15.88 per 100,000 males aged < 21 years in 2018, 2019, and 2020, respectively. The orchiectomy rate was 7.1%. Testicular torsion was most frequently observed during winter. A similar trend was observed nationwide. To the best of our knowledge, this study is the first to report the nationwide incidence of testicular torsion in Japan.

A nomogram for predicting risk factors of testicular salvage after testicular torsion in children.

OBJECTIVES: This study aimed to establish a nomogram for predicting the probability of testicular salvage after testicular torsion in children. METHODS: We retrospectively collected data of children with testicular torsion who were treated at Shenzhen Children's Hospital between September 2005 and August 2022. Of the training cohort, 113 patients who underwent orchiectomy and five with testicular atrophy after orchiopexy were included in the failed testicular salvage group. Additionally, 37 patients who underwent orchiopexy without postoperative testicular atrophy were included in the successful testicular salvage group. The predictive factors affecting testicular salvage were determined using univariate and multivariate logistic regression analyses; a nomogram was constructed. The nomogram was verified using data from the validation group. RESULTS: Using multivariate logistic regression analysis, the independent risk factors of testicular salvage after testicular torsion were symptom duration (p = 0.034), intratesticular blood flow (p = 0.003), spermatic cord torsion degree (p = 0.037), and monocyte count (odds ratio: 0.012, p = 0.036). A nomogram was established based on these four risk factors. In the training cohort, the area under the receiver operating characteristic curve was 0.969. The area under the receiver operating characteristic curve of the verification cohort was 0.965, indicating good discrimination ability of the nomogram. Increased symptom duration without intratesticular blood flow increased the monocyte count and spermatic cord torsion degree and decreased the success rate of testicular salvage. CONCLUSION: This prediction model could obtain the corresponding probability of testicular salvage according to the clinical characteristics of different patients with testicular torsion, providing reference for clinicians and parents.

[A Case of Testicular Torsion of Retractile Testis Requiring Orchidectomy].

We report a case of testicular torsion in an 8-year-old who was referred to our hospital for right groin pain. He was diagnosed with right retractile testis during a 12-month check-up. However, instead of performing orchiopexy, he was placed under observation until the age of 5, after which he did not seek medical attention. Physical examination revealed swelling and tenderness in the right inguinal region and no palpable testis in the right scrotum. Ultrasound and computed tomography revealed right testicular torsion, and emergency surgery was performed. Intraoperative findings revealed a dark and ischemic testis that was twisted at 180°in the right inguinal region. There was no improvement in blood flow even after the testicular torsion was released; therefore, right orchidectomy with left orchiopexy was performed. Although the incidence of testicular torsion is higher in patients with an undescended testis than in those with a normally positioned scrotal position testis, reports of testicular torsion associated with a retractile testis are rare.

Morphometric study applied to testicular and epididymis hydatids torsion.

Twisted testicular appendages had difficult differential diagnosis with testicular torsion. The objective of this paper is to evaluate the number, shape, size and determine the laterality pattern of the testicular and epididymal hydatids and evaluate the correlations between the length and width of the testicular and epididymal hydatids with testicular measurements. We analyzed 60 fixed cadavers and 16 patients with prostate cancer without previous hormonal treatment undergoing bilateral orchiectomy, totalizing 76 units and 152 testicles. In relation to the testicular appendices, we analyzed the following situations: absence of testicular and epididymis appendages, presence of a testicular appendix, presence of epididymis appendix, and presence of testicular and epididymis appendix. We measured the length, width and thickness of the testis and classified the appendages as sessile or pedicled. Chi-square test was used to verify associations between categorical variables. McNemar Test was used to verify differences between the percentages of right and left appendages. Correlations between quantitative measures were evaluated using the Pearson Correlation Coefficient (p < 0.05). In 50 cases (65.78%) we observed the presence of some type of appendices, in 34 cases (44.72%) we observed the presence of testicular appendices and in 19 cases (25%) the presence of epididymal appendices. We observed the presence of pedicled appendices in 39 cases (51.32%), with 25 of the cases (32.89%) of pedicled testicular appendices and 14 of the cases (18.42%) of pedicled epididymal appendages, with a significant association between the occurrence of appendices on the right and left sides (p < 0.001). Testicular hydatids were present in around two thirds of our sample being pedunculated in almost half of the cases with bilateral similarity. There is a significant chance in cases of twisted appendices that the same anatomical characteristics are present on the opposite side, which is a factor that tends to indicate the need for contralateral surgical exploration in cases of torsion, however studies with larger samples are needed to confirm these findings.

Atypical Presentation Delays Treatment of Pediatric Testicular Torsion.

OBJECTIVE: The aim of the study is to identify patient- and care-related factors associated with time to treatment for acute testicular torsion and the likelihood of testicular loss. METHODS: Data were retrospectively collected for patients 18 years and younger who had surgery for acute testicular torsion between April 1, 2005, and September 1, 2021. Atypical symptoms and history were defined as having abdominal, leg, or flank pain, dysuria, urinary frequency, local trauma, or not having testicular pain. The primary outcome was testicular loss. The primary process measure was time from emergency department (ED) triage to surgery. RESULTS: One hundred eleven patients were included in descriptive analysis. The rate of testicular loss was 35%. Forty-one percent of all patients reported atypical symptoms or history. Eighty-four patients had adequate data to calculate time from symptom onset to surgery and time from triage to surgery and were included in analyses of factors affecting risk of testicular loss. Sixty-eight patients had adequate data to evaluate all care-related time points and were included in analyses to determine factors affecting time from ED triage to surgery. On multivariable regression analyses, increased risk of testicular loss was associated with younger age and longer time from symptom onset to ED triage, while longer time from triage to surgery was associated with reporting atypical symptoms or history.The most frequently reported atypical symptom was abdominal pain, in 26% of patients. These patients were more likely to have nausea and/or vomiting and abdominal tenderness but equally likely to report testicular pain and swelling and have testicular findings on examination. CONCLUSIONS: Patients presenting to the ED with acute testicular torsion reporting atypical symptoms or history experience slower transit from arrival in the ED to operative management and may be at greater risk of testicular loss. Increased awareness of atypical presentations of pediatric acute testicular torsion may improve time to treatment.

Practice Patterns Affecting Delays in Care of Testicular Torsion.

OBJECTIVES: To compare impact of day or on-call team, pediatric or adult attending, and patient age on testicular torsion management and outcomes. METHODS: A retrospective study of patients with testicular torsion between 2012 and 2022 at a single institution was conducted. Variables impacting management time were assessed using univariate analyses. RESULTS: One hundred and thirty-four patients were included: 49 underwent orchiectomies and 84 underwent orchiopexies. There was no significant difference between efficiency of on-call vs day team regarding time to ultrasound or time to operating room (OR). There were no significant differences between pediatric vs adult attending surgeons for time to surgery, intraoperative length of surgery, or testicular salvage rates. However, when patients were stratified by age greater or younger than 18years, older patients had significantly longer symptom duration (91.9 vs 20.0 minutes, P = .005), time to receive an ultrasound from emergency room registration (152 vs 87 minutes, P < .001), time to OR from emergency room registration (268 vs 185 minutes, P < .001), and time to OR from ultrasound read (187 vs 123 minutes, P = .03). Older patients also had lower rates of testicular salvage approaching significance (orchiectomy rate 48.8% vs 31.5%, P = .057). CONCLUSION: While no significant delays in testicular torsion management were detected between management by on-call vs day team nor pediatric vs adult attending, increased age of patient was associated with delays in definitive surgical management. Greater index of suspicion for testicular torsion diagnosis in adult patients may improve the rate of testicular salvage.

Contrast-enhanced ultrasonographic findings in torsion of the appendix testis or epididymis in children: a case series.

PURPOSE: Torsion of the appendix testis or epididymis is a cause of acute scrotum in children. Ultrasonography with color Doppler is the first-choice modality for diagnosis. However, this method requires skill and experience to make a diagnosis with confidence. Recently, contrast-enhanced ultrasonography for diagnosis in various fields has been reported. However, to our knowledge, there has been no report of this method being used to diagnose torsion of the appendix testis or epididymis. The purpose of this study was to retrospectively examine contrast-enhanced ultrasonographic findings in torsion of the appendix testis or epididymis. METHODS: Patients who underwent contrast-enhanced ultrasonography for torsion of the appendix testis or epididymis at our institution between April 2010 and April 2023 were enrolled in this study (n = 12). Contrast-enhanced ultrasonography findings of the affected appendage and the testis parenchyma were examined retrospectively. RESULTS: The parenchyma of the testes was notably enhanced in all the cases. However, 9 of the 12 cases showed that the appendage with torsion was not enhanced at all. In the remaining three cases, only slight enhancement was seen. Nevertheless, it was notably less than that of the parenchyma of the testis. CONCLUSION: Our findings indicated that contrast-enhanced ultrasonography may be an easy and reliable method for diagnosing torsion of the appendix testis or epididymis.

Analysis of factors associated with delayed diagnosis and treatment of testicular torsion in 1005 cases from Chongqing city, China: a cross-sectional study.

This study aimed to investigate the clinical and social factors of delayed treatment for testicular torsion (TT) and to explore the risk factors of testicular excision in China. The clinical data of 1005 patients with TT who were admitted to 48 medical institutions in Chongqing city (China) from January 2012 to December 2021 were retrospectively analyzed. It was revealed that the misdiagnosis rates of non-senior (junior and middle) grade doctors and senior doctors were 25.1% and 9.6%, respectively. The proportion of TT patients who received timely treatment (within 6 h after onset of symptoms) was 23.8%. The results of the multivariable logistic regression analysis indicated that absent cremasteric reflex was a protective factor for delayed surgery of more than 6 h from onset of symptoms to surgery. Misdiagnosis, consultation with a non-urologist as the first consultant doctor, absence blood flow in color Doppler ultrasound, negative high-riding testis findings, the presence of fever, and non-manual detorsion were identified as risk factors associated with delayed surgery (more than 6 h from the onset of symptoms) for TT. Furthermore, misdiagnosis, non-urologist first-consultant doctor, absent blood flow in DUS, non-manual detorsion, fever, degree of cord twisting > 180, and the initial diagnosis in tertiary hospitals were risk factors for orchidectomy. Having TT on the right side, and the presence of nausea and vomiting were identified as protective factors for orchidectomy. Technical training in the diagnosis and treatment of TT should be extended to primary hospitals and doctors to significantly improve their accuracy in managing this condition.

MORPHOLOGICAL AND IMMUNOHISTOCHEMICAL CHANGES IN THE GONADS OF CHILDREN 2-6 HOURS AFTER ACUTE UNILATERAL TESTICULAR TORSION.

OBJECTIVE: The aim: To determine the morphological and immunohistochemical changes in the testes 2-6 hours after the onset of clinical symptoms of acute unilateral testicular torsion. PATIENTS AND METHODS: Materials and methods: A morphological and immunohistochemical study was conducted on biopsy samples of testicular tissues taken 2-6 hours after the onset of clinical symptoms of acute unilateral testicular torsion during detorsion and orchiopexy surgery in 27 adolescent patients. RESULTS: Results: In cases of incomplete torsion (180-360°) and a disease duration of up to 2 hours, the seminiferous tubules maintained their normal structure. The convoluted seminiferous tubules showed minor damage during 4 hours of ischemia caused by testicular torsion of 360-450°, which was characterized by mild damage. Glycogen and neutral glycoproteins were preserved in the cytoplasm of spermatogonia, primary spermatocytes, and Sertoli cells, indicating that their intracellular metabolism was relatively preserved. The ischemia that lasted for 4 hours with testicular torsion of 450-720° was characterized by a moderate degree of gonadal damage. However, there was pronounced expression of vimentin and calretinin, and the presence of glycogen and neutral glycoproteins indicated functional activity of the gonads. A six-hour ischemia period with a 360-450° testicular torsion demonstrated 100% gonadal viability, with 50% of the seminiferous tubules preserved and 35% with minor damage. Severe damage to the spermatogenic epithelium was observed in 15% of seminiferous tubules, characterized by dystrophy of spermatogenic epithelial cells with signs of karyopyknosis, karyorrhexis, vacuolization, hyperchromasia of cytoplasmic organelles, shedding of individual cells into the lumen of tubules, and focal necrosis. CONCLUSION: Conclusions: 1. The degree of torsion and duration of symptoms are prognostic factors for testicular salvage in torsion episodes. Ischemia lasting up to 6 hours is characterized by a moderate degree of gonadal damage, and detorsion of the testicle performed within 6 hours from the onset of pathology allows for preservation of the testicle in 100% of cases. 2. Histological examination of the susceptibility of different cell types to ischemia reveals that Sertoli cells and spermatogonia are the most resistant, while spermatocytes and spermatids are more susceptible and prone to degeneration.