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.

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.

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.

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.

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.

Cut-off time for surgery and prediction of orchiectomy in spermatic cord torsion: a retrospective multicentric study over 15 years.

PURPOSE: Cut-off time to avoid orchiectomy relies on small series of patients. The objective was to determine the cut-off time to avoid orchiectomy in torsion of the spermatic cord in a large cohort. METHODS: We performed a retrospective multicenter study (TORSAFUF cohort) of patients with suspected spermatic cord torsion between 2005 and 2019. All patients aged > 12 years who were suspected of having a torsion of the spermatic cord in 14 University Hospitals in France were included (n = 2986). Patients for whom data on pain duration were not available (n = 923) or for whom the final diagnosis was not torsion of the spermatic cord (n = 807) were excluded. The primary outcome was orchiectomy. The secondary outcomes were testicular survival time and the prediction of orchiectomy with the duration of pain. RESULTS: 1266 patients were included with an orchiectomy rate of 12% (150 patients). The mean age was 21.5 years old in the salvage group and 23.7 years old in the orchiectomy group (p = 0.01), respectively. The median time from the onset of pain to surgery was 5.5 (IQR = 5) hours in the salvage group and 51.1 (IQR = 70) hours in the orchiectomy group (p < 0.0001). The risk of orchiectomy increased after a time cut-off of 6 h 30. A delay of 15 h 30 in pain duration was found to predict orchiectomy (sensitivity: 0.81; specificity: 0.87). CONCLUSIONS: Pain duration can predict the probability of salvaging the testicles and performing orchiectomy. Rapid intervention should be recommended, regardless of the time elapsed from the onset of pain.

Infarction of Paratesticular Inflammatory Myofibroblastic Tumor Mimicking Testicular Torsion.

This report describes a 14-year-old male with a rare paratesticular inflammatory myofibroblastic tumor that presented atypically with acute unilateral scrotal pain and swelling. This presentation, which raised suspicion for testicular torsion, contrasts with the typical presentation of a slow-growing scrotal mass. Scrotal exploration revealed an infarcted right testis, demonstrating this locally aggressive tumor can undergo vascular invasion and occlude testicular blood supply. Thus, inflammatory myofibroblastic tumor should be considered in the differential diagnosis when evaluating patients with acute scrotal pain suspicious for testicular infarction.

Factors Determining Testicular Torsion and Consequent Orchiectomy in Pediatric Patients Presenting With Scrotal Pain.

OBJECTIVE: Factors associated with testicular torsion (TT) and consequent orchiectomy in patients presenting to pediatric emergency departments (PEDs) with scrotal pain (SP) are not well described. We report the factors predicting TT and consequent orchiectomy in children with SP. METHODS: The data on patients (aged ≤18 years) who presented with SP to PEDs at 4 branches of the Chang Gung Hospital through 10 years were analyzed. RESULTS: In all, 256 pediatric patients presented with SP. Their mean age was 11.60 ± 4.61 years and 72.7% (n = 186) were aged 10 to 18 years. The pain was left-sided in 54.7% (n = 140) and the interval between SP onset and PED arrival was 22.45 ± 31.27 hours. Overall, 84 (32.8%) patients needed surgery and 72 (28.1%) had TT. Of the patients with TT, 28 (38.9%) patients needed an orchiectomy. After analysis, TT and consequent orchiectomy were associated with a longer interval between SP onset and PED arrival, absent of testicular ultrasonic blood flow, interval between SP onset and surgery of more than 24 hours, and a high degree of TT. None of them experienced recurrent SP symptoms or TT again. CONCLUSIONS: The rate of TT in patients presenting to PEDs with an SP was 28.1%, and 38.9% of the patients with TT needed an orchiectomy. Early diagnosis and intervention helped to prevent subsequent orchiectomy in pediatric patients with TT.

Testicular salvageability and its predictors among patients with testicular torsion in a resource limited setting: a multicentre longitudinal study.

INTRODUCTION: Testicular torsion refers to ischemia of the testicle due to twisting or rotation of the vessels supplying the testes. It is a urologic emergency requiring a high index of clinical suspicion and prompt surgical intervention with management aimed at avoiding testicular loss and resulting infertility. This paper gives an update on the current situation regarding this topic in low-income settings. The aim of this study was to determine testicular salvageability and its predictors amongst patients with testicular torsion at two tertiary African hospitals. METHODS: This was a hospital-based multicentre longitudinal study at two tertiary hospitals in western Uganda. Patients with acute scrotum were enrolled and evaluated for testicular torsion. Those with confirmed testicular torsion underwent surgery and salvageability was reported as the primary outcome. Predictors for testicular salvageability were determined using backward binary logistic regression in SPSS version 22. RESULTS: During the study period, 232 patients with acute scrotum were enrolled. The mean age was 35.3 (SD = 20.4) years. Forty-one (17.7%) patients had testicular torsion. Only 16 (39.0%) of patients with torsion had viable testes that were salvageable. Orchiectomy was performed on 25 patients (61.0%). At multivariate analysis, a patient who presented after 48 h from the onset of symptoms was 34.833 times more likely to have orchiectomy compared to one who presented within 12 h [AOR = 34.833, (95% CI = 5.020-60.711), P < 0.001]. CONCLUSION: In this study, the testicular salvage rate was low. The only predictor of salvageability was the time from the onset of symptoms to presentation. All males should be sensitized about the clinical features of testicular torsion to ensure early presentation to increase salvage rates.

Granulomatosis with poliangiitis mimicking testicular torsion.

Granulomatosis with polyangiitis (GPA) is an autoimmune vasculitis which rarely affects the lower genitourinary tract. We share the case of a 53-year-old man who presented with a retroperitoneal mass and thereafter developed a left multiseptated hydrocele that conditioned a testicular infarction. The pathology report of the orchidectomy was consistent with GPA.

Unjumbling the TWIST score for testicular torsion: systematic review and meta-analysis.

OBJECTIVE: A systematic review and meta-analysis of the studies evaluating the utility of the Testicular Work-up for Ischemia and Suspected Torsion (TWIST) score in establishing or excluding the diagnosis of testicular torsion (TT) is herewith presented in an attempt to quantify the available evidence. METHODS: The study protocol was outlined in advance. The review has been conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). The PubMed, PUBMED Central, PMC databases & Scopus followed by Google (Scholar & search engine) were systematically interrogated with the keywords TWIST score, testis and testicular torsion. Fourteen sets of data (n = 1940) from 13 studies were included; data from 7 studies (giving a detailed score-wise break-up) (n = 1285) were dis-integrated and re-integrated to tweak the cut-offs for low and high risk. RESULTS: For every 4 patients presenting to the Emergency Department (ED) with acute scrotum, one patient will eventually be diagnosed with TT. The mean TWIST score was higher in patients with testicular torsion (5.13 ± 1.53 vs 1.50 ± 1.40 for those without TT). TWIST score can be used to predict testicular torsion at cut-off of 5 with a sensitivity, specificity, PPV, NPV, and accuracy of 0.71 (0.66, 0.75; 95%CI), 0.97 (0.97, 0.98; 95%CI), 90.2%, 91.0%, and 90.9% respectively. While the slider for cut-off was shifted from 4 to 7, there was a rise in specificity and PPV of the test with a corresponding decline in sensitivity, NPV, and accuracy. The sensitivity witnessed a sharp decline from 0.86 (0.81-0.90; 95%CI) @ cut-off 4 to 0.18 (0.14-0.23; 95%CI) @ cut-off 7. The area under the SROC curve for cut-off 5 was more than that for cut-offs 4, 6 & 7. TWIST cut-off of 2 may be used to predict the absence of testicular torsion with a sensitivity, specificity, PPV, NPV, and accuracy of 0.76 (0.74, 0.78; 95%CI), 0.95 (0.93, 0.97; 95%CI), 97.9%, 56.5%, and 80.7%, respectively. While the cut-off is lowered from 3 to 0, there is a corresponding rise in the specificity and PPV, while the sensitivity, NPV, and accuracy are compromised. The sensitivity witnesses a sharp decline from 91 to 35%. The area under the SROC curve for cut-off 2 was more than that for cut-off @ 0, 1 or 3. The sum of sensitivity and specificity of TWIST scoring system to ascertain the diagnosis of TT is more than 1.5 for cut-off values 4 & 5 only. The sum of sensitivity and specificity of TWIST scoring system to confirm the absence of TT is more than 1.5 for cut-off values 3 & 2 only. CONCLUSION: TWIST is a relatively simple, flexible, and objective tool which may be swiftly administered even by the para-medical personnel in the ED. The overlapping clinical presentation of diseases originating from the same organ may prevent TWIST from absolutely establishing or refuting the diagnosis of TT in all the patients with acute scrotum. The proposed cut-offs are a trade-off between sensitivity and specificity. Yet, the TWIST scoring system is immensely helpful in the clinical decision-making process and saves time-lag associated with investigations in a significant majority of patients.

Real-world management of testicular torsion: Level of adherence to the EAU Pediatric Urology guidelines.

BACKGROUND: Testicular torsion is the most frequent cause of irreversible ischemia to the testis. Despite guidelines being available, challenges remain in both diagnosis and management of the disease. OBJECTIVE: This study aims to determine the adherence of urologists and residents in urology to the European Association of Urology (EAU) Pediatric Guideline on Testicular torsion. STUDY DESIGN: Both Dutch and European urologists, and residents in urology filled in a survey on testicular torsion. Information on demographics, diagnostics, and treatment modalities was retrieved from the questionnaire based on the EAU Guideline on Paediatric Urology. RESULTS: A total of 303 responders participated, of which 214 (71%) were from The Netherlands. Most (61%) responders treated three or more cases of testicular torsion in 2020. Ultrasound was used by 64%, followed by an attempt of manual detorsion by 38% (Summary Fig.). Importantly, 23% preferred not to perform emergency surgery after successful manual detorsion. A Winkelmann procedure was performed by 23%, without fixation of the test is using suture material. A large group of responders (30%) only fixed the contralateral testis by a proven testicular torsion. DISCUSSION: A feasible adherence to the EAU Guideline on Paediatric Urology in treating testicular torsion was reported using this survey, although not all recommendations are implemented as proposed. The fact that outcomes of the different diagnostic and treatment modalities are lacking might be a limitation in interpreting the results of this survey. CONCLUSION: Majority of the responders followed the EAU Guideline on Paediatric Urology in the diagnosis and treatment of testicular torsion. Ultrasound might contribute to diagnosing testicular torsion as long as this does not cause any delay for surgical exploration. Surprisingly, many urologists do not perform a surgical fixation of the testis after detorsion. Since a wide range of techniques and materials is used in case of surgical fixation, the guideline may provide in preferences for a unified policy among urologists.

Pediatric Testicular Cavernous Hemangioma With Acute Onset Mimicking Testicular Torsion: Case Report and Review of the Literature.

Testicular cavernous hemangioma is a rare benign vascular tumor that typically occurs in childhood and adolescence. The clinical presentation may be variable and lead to diagnostic difficulties. We report an atypical presentation of intratesticular cavernous hemangioma with acute onset mimicking testicular torsion in a teenager. Inadvertent minor scrotal injury may have probably triggered the rupture of the hemangioma, leading to hemorrhage and infarction of the testicle. Although ultrasonography findings and serum tumor markers may be helpful in differential diagnosis, surgical exploration, and pathology examination are essential for definitive diagnosis.

Perinatal Testicular Torsion in Northern Ireland: A Nationwide 10-Year Review.

INTRODUCTION: Perinatal or neonatal testicular torsion (PTT) is defined as testicular torsion within the first 30 days of life. PTT is a rare event, and bilateral PTT is even rarer. However, recent articles have advocated emergency bilateral exploration to exclude the catastrophic possibility of asymptomatic contralateral testicular torsion leading to anorchia. The aim of this study is to evaluate PTT in Northern Ireland (NI) using a nationwide population-based retrospective observational study. METHODS: All boys in NI who underwent emergency scrotal exploration within their first 30 days of life for possible testicular torsion over a 10-year period (January 2010-December 2019 inclusive) were included. Intraoperative findings primarily evaluated included diagnosis and presence of synchronous or asynchronous (metachronous) contralateral testicular torsion. Secondary outcomes included correlation between intraoperative findings and any preoperative ultrasound scan (USS), and scrotal examination findings during postoperative outpatient follow-up. RESULTS: A total of 19 patients who underwent emergency scrotal exploration in the study period were included. An intraoperative finding confirming the diagnosis of PTT was reported in 14 (73.7%) patients. The incidence of PTT was calculated as 11.3 per 100,000 per male live births in NI, with bilateral PTT accounting for two patients (14.2% of all PTTs), divided equally between synchronous and asynchronous PTTs. Of two affected testes where preservation was felt appropriate intraoperatively, only one was still palpable at follow-up, producing a testicular salvage rate after PTT of only 7.1%. Testicular findings on preoperative USS were confirmed intraoperatively in five out of six patients, producing a concordance rate of 83.3%. CONCLUSION: This is the first nationwide population-based study to calculate more accurately the incidence of PTT, and bilateral synchronous and asynchronous bilateral PTTs, all of which seem to be significantly higher than previously estimated. However, in keeping with previous reports, this study confirms the poor salvage rate of testes undergoing perinatal torsion, and suboptimal concordance between preoperative USS findings and intraoperative diagnosis.