The management of testicular torsion: A survey of Turkish pediatric surgeons and pediatric urologists.

BACKGROUND: This study aimed to evaluate the approaches of pediatric surgeons and pediatric urologists in Türkiye regarding the diagnosis and treatment of testicular torsion (TT) and their adherence to the European Association of Urology (EAU) pediatric urology guideline. METHODS: A survey consisting of 19 questions, accompanied by an annotation describing the objective of the study, was emailed to pediatric surgeons and pediatric urologists in June and July 2023. RESULTS: Of the 95 respondents, 62.1% had over 10 years of experience, and 48.4% treated more than five cases of TT annually. Of the participants, 87.4% stated that scrotal Doppler ultrasonography (US) was always used, and 12.6% stated that US was used in cases of doubtful diagnosis. Concerning treatment, 14.7% reported performing manual detorsion, 70.5% never did, and 14.7% did so only if the operating room was unavailable soon. A total of 92.6% of participants opted for emergency surgery. Among participants who perform manual detorsion, 71.4% perform surgery within 24 hours after successful manual detorsion. Regarding fixation of the contralateral testicle, 14.7% never performed it, and 27.4% did so only when they performed an orchiectomy on the torsion testicle. CONCLUSION: While most participants follow EAU pediatric urology guidelines by performing emergency surgery, the rate of manual detorsion is low. Few participants stated that emergency surgery may not be performed after manual detorsion. While all of the participants performed fixation of the torsion testicle in accordance with the guidelines, the same adherence was not observed in the contralateral testicle.

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.

Contrast-enhanced ultrasound findings in testicular torsion and non-testicular torsion.

PURPOSE: Testicular torsion requires emergency surgery; thus, prompt and correct diagnosis is very important. Ultrasound with color Doppler is usually the first-choice modality for diagnosis; however, skill and experience are required for confident diagnosis. Recently, contrast-enhanced ultrasound for the diagnosis of testicular torsion has been reported, but there have been only a few reports. This study aimed to compare contrast-enhanced ultrasound findings in cases of testicular torsion and non-testicular torsion. METHODS: Patients who underwent contrast-enhanced ultrasound for acute scrotum at our institution between April 2010 and January 2023 were divided into testicular torsion (n = 17) and non-testicular torsion (n = 16) groups. The respective contrast-enhanced ultrasound findings were retrospectively examined and compared. RESULTS: In 16 out of 17 cases of testicular torsion, the parenchyma of the affected testis was not enhanced. In the remaining case, reduced contrast enhancement was observed; however, it was still notably less than that observed on the unaffected testis. On the other hand, in all cases of non-testicular torsion (n = 16), the parenchyma of the affected testis was notably enhanced. CONCLUSION: Contrast-enhanced ultrasound is considered an easy and accurate method for diagnosing testicular torsion.

Role and added value of contrast enhanced ultrasound of the painful scrotum in the emergency setting.

Emergency imaging of the scrotum is part of routine medical practice. Indications include epididymitis/epididymo-orchitis, testicular torsion, trauma, tumors and infarction. Prompt diagnosis and management are needed to ensure optimal patient outcome. Ultrasound (US) is the initial, and often the only, imaging modality for testicular pathologies. Usually, B-mode and color Doppler US are adequate. In challenging cases, contrast-enhanced US (CEUS) facilitates final diagnosis or increases the examiner's confidence by confirming findings on non-enhanced US. This paper elaborates on the examination technique of CEUS for testicular pathologies, thereby showing its added value over baseline US techniques in the emergency setting.

Clinical risk factors for testicular torsion and a warning against falsely reassuring ultrasound scans: a 10-year single-centre experience.

BACKGROUND: We sought to determine which demographic, clinical and ultrasonography characteristics are predictive of testicular torsion (TT) and to determine factors associated with time to treatment. METHODS: We retrospectively reviewed all medical records of patients (0-17 years) with acute scrotal syndrome (ASS) who were treated in our hospital in Lithuania between 2011 and 2020. We extracted patients' demographic data, in-hospital time intervals, clinical, US and surgical findings. TT was determined at surgery or clinically after manual detorsion. Test characteristics of demographic, clinical and US findings for the diagnosis of TT versus other causes of ASS were determined. We performed a multivariate analysis to identify independent clinical predictors of torsion, and factors associated with surgical delay. RESULTS: A search of medical records yielded 555 cases: 196 (35%) patients with TT and 359 (65%) patients with other ASS causes. Multivariate logistic regression analysis showed that age between 13 and 17 years (OR 8.39; 95% CI 5.12 to 13.76), duration of symptoms <7 hours (OR 3.41; 95% CI 2.03 to 5.72), palpated hard testis (OR 4.65; 95% CI 2.02 to 10.67), scrotal swelling (OR 2.37; 95% CI 1.31 to 4.30), nausea/vomiting (OR 4.37; 95% CI 2.03 to 9.43), abdominal pain (OR 2.38; 95% CI 1.27 to 4.45) were independent clinical predictors of TT. No testicular blood flow in Doppler US had a specificity of 98.2% and a positive predictive value of 94.6%. However, 75 (41.7%) patients with TT had normal testicular blood flow, yielding low sensitivity (58.3%) and negative predictive value of 81.3% for this US finding. In-hospital waiting time for surgery was longer in patients with TT with normal testicular blood flow by USS (195 min) compared with no blood flow (123 min), p<0.01. Higher orchiectomy rates were associated with longer duration of symptoms (p<0.001) and longer waiting time for USS (p=0.029) but not with false-negative US. CONCLUSIONS: Pubertal age, symptoms duration of <7 hours, nausea/vomiting, palpated hard testis, abdominal pain and scrotal swelling are predictive factors for TT. Time lost between symptom onset and seeking medical care, and between arrival and US are associated with the need for orchiectomy. Preserved blood flow in USS does not rule out TT and may contribute to delays to surgery.

Management of acute testicular pain in children: changing trends with improvements in scrotal ultrasonography over 18 years.

Introduction: Doppler scrotal ultrasonography (US) is the modality of choice in diagnosing testicular torsion. We aimed to evaluate the performance of scrotal US in diagnosing testicular torsion over the past 18 years in our institution and determine the factors contributing to the length of wait times for it. Methods: A retrospective review was conducted of boys who presented with acute scrotal pain from 2014 to 2015. US reports, operative findings, final diagnosis and key time points of the patients' journey (time to emergency department consultation, time to admission, time to US and time to operating theatre [OT]) were collected. US performance results were compared with those observed in a historical cohort from 1998 to 2004. Wait times were compared between operated and non-operated patients. Results: Data from 519 boys with a mean age of 9.15 years was collected. Of these, 438 (84.4%) boys had undergone initial scrotal US; of these scrotal US cases, 28 were surgically explored, with 23 confirmed to have torsion. Another five cases were explored without prior US, and all were confirmed to have torsion. Performance analysis of US showed a sensitivity of 100% and a specificity of 98.8%. There was no significant difference between wait times of operated and non-operated patients. Time to US (P < 0.0001, r = 0.96) and time to OT (P < 0.0001, r = 0.64) correlated significantly with the total time from presentation to surgery. Conclusion: There has been an improvement in the diagnostic performance of scrotal US for testicular torsion over the past 18 years. Quality improvement programmes targeted at reducing wait times for patients presenting with acute scrotum should target time to US and time to OT.

Effects of acetylsalicylic acid and ultrasound elastography on testicular torsion in rats.

Background/aim: To investigate the effects of acetylsalicylic acid (ASA) and the use of ultrasound elastography on testicular torsion. Materials and methods: Herein, 6 equal groups of rats were formed (n: 48): control group, sham group, torsion/detorsion (T/D)-1 h group, T/D-1 h + ASA group, T/D-8 h group, and T/D-8 h + ASA group. Testicular torsion was created by rotating the left testis 720° clockwise. At 30 min before torsion, 100 mg/kg of ASA was injected intraperitoneally. Elastography was performed at 8 and 24 h. After orchiectomy, specimens were collected for histopathological evaluation. Results: When comparing the left testicular volume (LV) parameters obtained from the elastography applied at 8 h, significant differences were observed between the following group pairs: the sham and T/D-8 h groups, T/D-1 h and T/D-8 h groups, and T/D-1 h + ASA and T/D-8 h groups (p = 0.004, p = 0.023, and p = 0.026, respectively). The mean LVS (velocity) (stiffness assessment) of the groups was similar at 8 h. When comparing the LV parameters at 24 h, significant differences were found between the T/D-1 h and T/D-8 h groups and between the T/D-8 h and T/D-8 h + ASA groups (p = 0.008 and p = 0.004, respectively). For the LVS mean values at 24 h, significant differences were found between the control and sham groups, sham and T/D-1 h groups, sham and T/D-8 h groups, and sham and T/D-8 h + ASA groups (p = 0.009, p = 0.021, p = 0.027, and p = 0.009, respectively).Histopathological evaluation showed a decrease in the morphological grades and an increase in the mean testicular injury scores in the T/D-1 h + ASA group compared to the T/D-1 h group. The T/D-8 h + ASA group had a higher morphological grade than the T/D-8 h group, whereas their mean testicular injury scores were similar. Conclusion: ASA treatment for testicular torsion was shown to be ineffective. Elastography can be a complementary method to Doppler ultrasonography in the diagnosis of testicular torsion and can guide surgeons in their approach to surgery.

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.

Intraoperative evaluation of testicular vascularization and perfusion in rat testicles with indocyanine green (ICG)/near-infrared (NIR) fluorescent imaging after torsion-detorsion and reperfusion.

INTRODUCTION: The aim of this study was to evaluate testicular perfusion and vascularization with intraoperative ICG/NIR imaging in a testicular ischemia-reperfusion model and to investigate the effects of ICG on testicular tissue. MATERIALS AND METHODS: 24 male rats were divided into four groups. In the ICG group, only ICG was given and images of the testicles were recorded with NIR camera. In the torsion group, the testicles were left in torsion for 4 h. ICG/NIR images were obtained after torsion and detorsion. In the reperfusion group, ICG/NIR images of the testicles were obtained at the 4th hour of reperfusion. After the procedures, testicles were collected and evaluated with histological, immunohistochemical examination and qRT-PCR. RESULTS: There was no histologically negative effect of ICG on testicular tissue. There was no testicular perfusion in the torsion group, but perfusion started after detorsion. At the 4th hour of reperfusion, testicular perfusion continued. TNF-a, IL-6, MCP-1 and caspase-3 immunoreactivity were found to be at low levels in the control and ICG groups, while high in the torsion and reperfusion groups (p < 0.05). In qRT-PCR, TNF-a, IL-6, MCP-1 and caspase-3 expressions were lower in the control and ICG groups, but higher in the torsion and reperfusion groups. CONCLUSION: There was no histologically negative effect of ICG on testicles. The ICG/NIR imaging technique seems to be a feasible method in testicular torsion and may contribute to the surgeon in the intraoperative management of testicular torsion. In testicles that started to be perfused after detorsion, perfusion still continued at the 4th hour of reperfusion. Our next goal is to test whether testicles showing ICG fluorescence in during reperfusion maintain their viability for long term.

Shear wave elastography for the evaluation of testicular salvage after testicular torsion.

The aim of this study was to assess the utility of shear wave elastography in the follow-up of testicular detorsion, evaluate long-term outcomes, and explore its relationship with parameters such as tissue stiffness values, pain duration, and torsion type. Elastography examinations were independently performed by two radiologists to evaluate patients who presented to our hospital for follow-up after being diagnosed with testicular torsion and age-matched controls. Inter-observer variability of the mean testicular tissue elasticity was excellent (Intraclass correlation coefficient: 0.939, p < 0.001). Median time between testicular detorsion and follow-up ultrasound examination was 18 months (range, 11-36 months). Torsion side, torsion degree, and pain duration were recorded, and testicular volumes were calculated. The study population comprised 24 patients (48 testes) with a mean age of 21.1 ± 7.8 years. The mean testicular volume was measured as 12.3 ± 5.4 ml for the testicular salvage group, 13.9 ± 3.8 ml for the contralateral testes, and 13.7 ± 2.7 ml for the control group (p = 0.553). The mean testicular speed mode values were higher in the testicular salvage group (1.34 ± 1.21 m/s) compared with the contralateral testes group (1.00 ± 0.08 m/s), and the control group (1.01 ± 0.06 m/s), however there was no statistically significant difference between the three groups (p = 0.861). While testicular atrophy was detected in three patients, an intraparenchymal wedge-shaped focal hypoechoic area developed after torsion in a further three patients. The elastography examination for focal hypoechoic areas revealed an increase or decrease in tissue stiffness compared to the normal parenchyma. The tissue stiffness values of the testicular salvage group were higher in complete torsion compared to incomplete torsion. The elastography method contributes to other imaging methods in distinguishing focal lesion areas that can be seen after testicular torsion from malignant conditions. Elastography presents as a feasible and practical complementary modality for the follow-up of testicular salvage after torsion.

Testicular salvage: using machine learning algorithm to develop a predictive model in testicular torsion.

PURPOSE: To compare the models developed with a classical statistics method and a machine learning model to predict the possibility of orchiectomy using preoperative parameters in patients who were admitted with testicular torsion. MATERIALS AND METHODS: Patients who underwent scrotal exploration due to testicular torsion between the years 2000 and 2020 were retrospectively reviewed. Demographic data, features of admission time, and other preoperative clinical findings were recorded. Cox Regression Analysis as a classical statistics method and Random Forest as a Machine Learning algorithm was used to create a prediction model. RESULTS: Among patients, 215 (71.6%) were performed orchidopexy and 85 (28.3%) were performed orchiectomy. The multivariate analysis revealed that monocyte count, symptom duration, and the number of previous Doppler ultrasonography were predictive of orchiectomy. Classical Cox regression analysis had an area under the curve (AUC) 0.937 with a sensitivity and specificity of 88 and 87%. The AUC for the Random Forest model was 0.95 with a sensitivity and specificity of 92 and 89%. CONCLUSION: The ML model outperformed the conventional statistical regression model in the prediction of orchiectomy. The ML methods are cheap, and their powers increase with increasing data input; we believe that their clinical use will increase over time.

Computed tomography of testicular torsion in a juvenile dog with unilateral cryptorchidism.

A 14-week-old male unilaterally cryptorchid Clumber spaniel was presented for acute lethargy. Physical examination revealed abdominal pain, and a single testis was palpated in the scrotum. Abdominal ultrasound and computed tomography (CT) revealed a poorly vascularized, ovoid structure immediately caudal to the left kidney with scant regional peritoneal effusion. Left intra-abdominal testicular torsion was confirmed at surgery, and routine cryptorchidectomy was performed. The patient recovered uneventfully from anesthesia and surgery. Key clinical message: The most common CT characteristics of testicular torsion were present in this case and correlated well with sonographic findings to allow for rapid, accurate diagnosis and surgical planning of unilateral, non-neoplastic, intra-abdominal cryptorchid testicular torsion in a juvenile dog. Contrast enhanced CT facilitated accurate localization of the undescended testis and evaluation of testicular perfusion and may be a useful alternative to ultrasound for diagnosing testicular torsion, especially in indeterminate cases.

Tomodensitométrie d'une torsion testiculaire chez un chien juvénile atteint de cryptorchidie unilatérale. Un épagneul Clumber avec une cryptorchidie unilatérale âgé de 14 semaines a été présenté pour une léthargie aiguë. L'examen physique a révélé des douleurs abdominales et un seul testicule a été palpé dans le scrotum. L'échographie abdominale et la tomodensitométrie ont révélé une structure ovoïde mal vascularisée immédiatement caudale au rein gauche avec peu d'épanchement péritonéal régional. Une torsion testiculaire intra-abdominale gauche a été confirmée lors de la chirurgie et une cryptorchidectomie de routine a été réalisée. Le patient s'est remis sans incident de l'anesthésie et de la chirurgie.Message clinique clé:Les caractéristiques tomodensitométriques les plus courantes de la torsion testiculaire étaient présentes dans ce cas et bien corrélées avec les résultats échographiques pour permettre un diagnostic rapide et précis et une planification chirurgicale de la torsion testiculaire avec cryptorchidie unilatérale, non néoplasique et intra-abdominale chez un chien juvénile. La tomodensitométrie avec contraste a facilité la localisation précise du testicule non descendu et l'évaluation de la perfusion testiculaire et peut être une alternative utile à l'échographie pour diagnostiquer la torsion testiculaire, en particulier dans les cas indéterminés.(Traduit par Dr Serge Messier).

Testicular volume loss in the long-term follow-up after surgical detorsion of the testis.

AIM: The aim of this study is to evaluate sonographic testicular volume of patients who underwent surgical detorsion due to testicular torsion and to reveal the frequency of long-term testicular volume loss and the factors affecting it. METHOD: The files of patients who underwent surgical detorsion due to unilateral testicular torsion in our hospital between 2011 and 2019 were reviewed retrospectively. Age at the time of detorsion surgery, time from the onset of pain to surgery, degree of torsion, and ultrasonographic testicular volumes before detorsion were noted. Afterward, patients with at least 6 months of follow-up were contacted by phone and testicular volumes were measured by scrotal ultrasonography (US). The sonographic formula Length × Width × Height × 0.72 was used to determine testicular volumes. RESULTS: There were 97 patients who underwent surgical detorsion within the given time frame. However, 43 of these patients accepted to be involved in the study and a follow-up scrotal US was performed. The mean age at the time of detorsion was 13.6 ± 5.6 years, whereas it was 16.7 ± 6.2 years at the time of the follow-up visit. The median time from the onset of pain to surgery was 4 h (range 1-36 h). In the preoperative US, the mean volume of the affected testis was 10.8 ± 5.6 mm3, while the mean contralateral testis volume was 10.2 ± 5.4 mm3 (p = 0.134). The median follow-up time in our study was 24 months (range 6-96 months). In the control US, the mean volume of the affected testis was 9.5 ± 7.1 mm3, while the mean volume of the contralateral testis was 14.4 ± 9 mm3 (p = 0.001). The affected testicular volumes decreased in 23 patients (range 1.1-100%), there was no change in testicular volumes in two patients, and there was an increase in testicular volumes in 18 patients (range 3.8-100%). In the ROC analysis, risk of testicular volume loss can be predicted with 87.5% sensitivity and 83.9% specificity when the time from the onset of pain to surgery exceeds 5.5 h (AUC = 0.904). CONCLUSION: Our results indicated that if the time from the onset of pain to surgery exceeds 5.5 h, the testicular volume loss may be expected in the long term. Thus, patients and parents should be informed accordingly.

Testicular volume and Tanner stage: determinant factors for testicular torsion.

OBJECTIVE: To assess testicular volumes and sexual maturation in patients with testicular torsion. METHODS: A retrospective analysis of consecutively treated patients with testicular torsion between 2016 and 2018. Age, pubic hair staging (Tanner), and by ultrasonography, volume of the unaffected testis (in cubic centimeters) were evaluated either immediately before surgery or at the first postoperative visit. Patients with previous testicular disease, such as cryptorchidism, or with no records of testicular volume were excluded. The analysis included descriptive statistics and Bayesian regression. RESULTS: We treated 149 patients during the study period, and 141 (94.6%, median age 17.3 years) met the inclusion criteria. Median testicular volume was 13.0cm3 (interquartile range of 10.5-15.2), with similar right and left volumes (12.9cm3versus 13.3cm3; p=0.94). Sixty-five (46.1%) patients were Tanner stage IV, 17 (12.1%) stage III, and 59 (41.8%) stage V. CONCLUSION: In this study, we were able to estimate volumes of testicular torsion, which aggregated around late puberty values (13.0cm3 for the whole dataset, 12.2cm3 for patients <25 years), suggesting that testicular hypermobility, due to congenital anatomical abnormalities, remains quiescent until the organ reaches a critical volume, after which torsion becomes possible. These findings provide a tentative explanation for the disease's age distribution.

Pearls and Pitfalls of Pediatric Scrotal Imaging.

Ultrasonography (US) is the primary imaging modality for the evaluation of pediatric scrotal disease. The ability to obtain exceptional anatomical detail and testicular perfusion information without ionizing radiation makes it the essential tool for evaluating scrotal pain and palpable masses. Challenges arise in both the performance and interpretation of scrotal US in the child. Optimizing imaging parameters and recognizing key differentiating US features help minimize misinterpretations that can lead to poor patient outcomes. Key pearls and pitfalls in pediatric scrotal ultrasound methods and diagnoses are reviewed. Knowledge of what is normal for the various ages of childhood from neonate through adolescence is necessary for accurate US analysis. Imaging evaluation of key causes of the acute painful scrotum including testicular appendage torsion, epididymitis, and testicular torsion are discussed. Sonographic features for the diagnosis of benign and malignant scrotal masses, microlithiasis, and cryptorchidism are reviewed.

A rare case of acute scrotum in a 12-year old boy: torsion of a paradidymal cystic appendage (organ of Giraldes).

Acute scrotum from testicular and epididymal cyst is relatively uncommon, whereas torsion of a cystic paradidymis is exceedingly rare. In this paper, we present the case of a healthy 12-year-old male patient admitted in our emergency room for acute scrotum, in whom diagnosis of torsion of a cystic paradidymis was suggested at color-Doppler US. Surgical exploration after ultrasound examination revealed a cystic paradidymis (Giraldes' organ) (PC) torsion. Immunohistochemical investigations were also performed after cyst excision to confirm the diagnosis. In our experience this is a very rare condition and appears to be only the third case reported in literature and the only one with pre-operative ultrasound (US) images demonstrating the presence of the cyst and its twisted pedicle.

The Use of Doppler Ultrasound for Suspected Testicular Torsion: Lessons Learned from a 15-Year Multicentre Retrospective Study of 2922 Patients.

BACKGROUND: Use of Doppler ultrasonography (DUS) for patients with suspected testicular torsion (TT) is highly controversial and remains debated, as it can delay surgery and its performance may vary. OBJECTIVE: To assess the role, impact, safety, and performance of DUS in the management of patients with suspected TT before scrotal exploration. DESIGN, SETTING, AND PARTICIPANTS: The TORSAFUF cohort retrospectively included patients older than 12 yr who underwent surgery for suspected TT in 14 academic hospitals between 2005 and 2019. Perioperative data and surgical and DUS reports were collected. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Clinical factors influencing DUS utilisation were analysed using multivariate logistic regression. The orchidectomy rate and delay to surgery were compared by group with and without DUS receipt using one-to-one propensity score (PS) matching to assess imaging safety. For the group with preoperative imaging, DUS performance was evaluated using a contingency table. RESULTS AND LIMITATIONS: Overall, 2922 patients were included, of whom 956 (32.7%) underwent DUS before surgery. DUS was more likely to be performed in older patients (odds ratio [OR] 1.1, 95% confidence interval [CI] 1.1-1.2), those who experienced progressive onset of pain (OR 1.5, 95% CI 1.1-2), and patients who presented at the emergency department more than 6 h after their first scrotal symptoms (OR 2.3, 95% CI 1.9-2.8). After PS matching, DUS receipt was not significantly associated with orchidectomy but the delay to surgery was 1 h longer. DUS demonstrated strong sensitivity of 85.2% (95% CI 82.1-88.3%) and specificity of 52.7% (95% CI 48.8-56.6%). The performance was better for younger patients and for those with time since onset of pain of >6 h. CONCLUSIONS: In this large retrospective study, DUS before surgery was safe, feasible, and useful in selected cases with suspected TT, but it should not delay or replace surgery in cases with a strong clinical suspicion. PATIENT SUMMARY: We analysed the performance and safety of an ultrasound scan of the scrotum before surgery for patients with a suspected twisted testicle (TT). This scan before surgery was not associated with a higher risk of negative outcomes but was only moderate in accurately diagnosing TT. Surgery to correct TT should not be delayed.