Comparison of hyperbaric oxygen and ozone treatment for ischemia/re-perfusion injury in an experimental testicular torsion model.

BACKGROUND: This study aims to compare the effects of medical ozone (MO) therapy and hyperbaric oxygen (HBO) therapy in an experimental testicular torsion model by measuring the oxidant and antioxidant markers and examining the histopathological tissue damage findings. METHODS: Thirty-two Wistar rats are used and are divided into four groups; (1) sham group (SG), (2) only ischemia/reperfusion (I/R) by testicular torsion, (3) HBO administered group, and (4) MO administered group. No torsion was conducted in the SG. In all other groups, rats underwent testicular torsion followed by detorsion to create an I/R model. After I/R, HBO was injected in the HBO group, and in the MO group, intraperitoneal ozone was applied. At the end of 1 week, testicular tissues were obtained for biochemical analyzes and histopathological examinations. Biochemically, malondialdehyde (MDA) levels were measured for oxidant activity, and superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) levels were measured for antioxidant activity. Furthermore, the testicles were evaluated histopathologically. RESULTS: Both HBO and MO have significantly decreased MDA levels, compared with sham and I/R groups, resulting in decreased oxidation effects. The antioxidant GSH-Px levels in the HBO and MO groups were significantly higher than in the sham and I/R groups. In addition, the antioxidant SOD levels in the HBO group were significantly higher than sham, I/R, and MO groups. Therefore, the antioxidant effect of HBO was observed to be superior to MO, specifically considering SOD levels. Histopathologically, there was no significant difference between the groups (p>0.05). CONCLUSION: The study may extrapolate that both HBO and MO are antioxidant agents that can be used in testicular torsion. HBO treatment might improve the cellular antioxidant capacity due to increased antioxidant marker levels more than MO therapy. However, further studies are needed with a larger sample size.

The impact of bone marrow-derived mesenchymal stem cells on experimental testiculartorsion in rats.

BACKGROUND: The aim of this study was to investigate the healing effects of bone marrow-derived mesenchymal stem cells (BMMSCs) on experimental testicular torsion in rats. METHODS: Three groups consisting of 10 Wistar albino rats were created. In Group I, the left testicle was explored and relocated in the scrotum without any attempt to modify it. In Group II, the left testicle underwent torsion for three h and then was detorsed and relocated. In Group III, in addition to torsion and detorsion, BM-MSCs were administered intratesticularly. The rats were sacrificed on the seventh day, and the healing status of the testicles was investigated with histopathological and biochemical analyses. BM-MSC involvement was investigated by immunofluorescence microscopy. Statistical analysis was performed using SPSS 15.0. A p-value < 0.05 was considered statistically significant for all variables. RESULTS: Immunofluorescence microscopy showed that BM-MSCs were located around the Leydig cells in Group III. Under light microscopy, the mean Johnsen Score of Group III was significantly higher than that of Group II (p = 0.035). The interleukin-10 (IL-10) level was significantly higher in Group III compared to Group II (p = 0.003). While the malondialdehyde (MDA) values in Group I (the control group) were lower than in the other groups (p = 0.037), the superoxide dismutase (SOD) values were similar (p = 0.158). Although there was no statistically significant difference between Group II and Group III in terms of MDA, it was lower in Group III. Although the tissue SOD levels were higher in Group III than in Group II, the difference was not statistically significant. DISCUSSION: : This study has demonstrated that BM-MSCs significantly corrected the Johnsen Score and increased anti-inflammatory cytokine levels after testicular torsion. BM-MSCs can be used in testicular torsion as supportive therapy to minimize tissue damage.

Combined melatonin-adipose derived mesenchymal stem cells therapy effectively protected the testis from testicular torsion-induced ischemia-reperfusion injury.

BACKGROUND: This study tested the hypothesis that combined melatonin (Mel) and adipose-derived mesenchymal stem cells (ADMSCs) treatment was superior to either one alone on protecting the testis against acute testicular torsion-induced ischemia-reperfusion (TTIR) injury. METHODS AND RESULTS: Male adult SD rats (n = 30) were equally categorized into group 1 (sham-operated control), group 2 [TTIR/by torsion of right/left testis (i.e., ischemia) with rotated 720° counterclockwise for 2 h, then detorsion (i.e., reperfusion) to the original position for 72 h], group 3 (TTIR + Mel/intraperitoneal administration/50 mg/kg at 30 min after ischemia, followed by 20 mg at 3 h and days 1/2/3 after TTIR), group 4 (TTIR + ADMSCs/1.2 × 106 cells/by tail-vein administration at 30 min after ischemia, followed by days 1/2 TTIR), and group 5 (TTIR + Mel + ADMSCs/tail-vein administration). The result showed that the protein expressions of oxidative-stress (NOX-1/NOX-2/oxidized-protein), apoptotic/mitochondrial-damaged (mitochondrial-Bax/cleaved-caspase3/cleaved-PARP/cytosolic-cytochrome C), and fibrotic (TGF-ß/Smad3) biomarkers as well as testicular damage scores were lowest in group 1, highest in group 2, and significantly higher in groups 3/4 than in group 5, but they showed no difference between groups 3/4, whereas the protein expressions of androgen receptor (AR) and vimentin showed an opposite pattern of oxidative stress (all p < 0.0001). The cellular levels of inflammation (MMP-9/MPO/CD68) exhibited an identical pattern, whereas the numbers of Sertoli cells, α-tubulin, AR and vimentin as well as thickness of seminiferous tubule exhibited an opposite pattern of oxidative stress among the groups (all p < 0.0001). CONCLUSION: Mel-ADMSCs effectively protected the testis against TTIR injury.

Men's Health: Scrotal and Testicular Conditions.

Scrotal and testicular conditions include benign masses, infections, testicular torsion, and testicular cancer. Common palpable benign scrotal masses include spermatocele, varicocele, and hydrocele. Most patients with these masses require no treatment. Some varicoceles are associated with impaired fertility, probably due to an increase in scrotal temperature that leads to testicular hyperthermia, oxidative stress, and reduced spermatogenesis. Patients with documented infertility or scrotal pain should be referred to a urology subspecialist for consideration of surgical management. Epididymitis and epididymo-orchitis are caused by infection with Neisseria gonorrhoeae, Chlamydia trachomatis, or enteric bacteria. Antibiotics and supportive measures (eg, scrotal elevation, bed rest) are recommended for management of acute epididymitis. Testicular torsion is a urologic emergency that requires rapid surgical exploration and orchidopexy to reduce the risk of testicular loss due to ischemia. Salvage rates exceed 90% when surgical exploration is performed within 6 hours of symptom onset. Testicular cancer commonly manifests as a painless, incidentally discovered mass in a single testis. Ultrasonography is recommended to confirm the diagnosis. The recommended primary intervention for a suspected malignant testicular tumor is radical inguinal orchiectomy.

Long-term protective effects of the combination of intermittent reperfusion and hypothermia on reperfusion injury in an experimental testicular torsion model.

INTRODUCTION: There are many significantfactors in testicular injury which determine the prognosis in testicular torsion. Reperfusion injury following detorsion also has a significant effect on testicular injury.This study was planned considering that with the implementation of intermittent reperfusion and hypothermia, reperfusion injury can be reduced, and such an application might have a positive effect on testicular tissue in the long term. MATERIALS AND METHODS: Forty adult male rats were divided into five groups as follows: Sham(Sh)(n = 8), Torsion(T)(n = 8), Intermittent reperfusion(IR)(n = 8), Hypothermia(H)(n = 8), and Intermittent reperfusion+hypothermia(IR+H)(n = 8). Except forGroup Sh, the left testicle was taken out of the scrotum in all groups, rotated three times counterclockwise, fixed back in the scrotum, and left for four hours.After four hours, and just before reperfusion, the testicle's detorsion was performed while holding the vascular structures in the proximal part of the torsed segment with an atraumatic vessel clamp, and thus, not allowing reperfusion in Groups T, IR, H, and IR+H. In Group T, the clamp was released immediately. In Group H, an ice-bag cooling was performed around the testis, and the clamp was released when the tissue temperature was reached and kept constant at 4 °C. In Group IR, the clamp was released, allowing reperfusion of five seconds, followed by reclamping, providing an ischemic status for ten seconds; this procedure was repeated ten times. In Group H+IR,an ice-bag cooling was performed around the testis, and the clamp was released when the tissue temperature was reached and kept constant at 4 °C. Then, reperfusion was applied for 5 s, followed by 10 s ischemia with reclamping. This procedure was repeated ten times.Tissue blood flow was provided for60 days of reperfusion in all groups. After 60 days, both testicles were excised under anesthesia in all living rats, and samples ofthe left testicle werereserved for biochemical and pathological examinations. At the end of the procedure, all animals were sacrificed by a high dose of anesthesia. RESULTS: It was biochemically and histopathologically determined that the tissues were preserved in the experimental groups compared to Group T, which was statistically significant (p < 0.05).However, no experimental group's superiority over each other was determined both biochemically and histopathologically (p > 0.05). CONCLUSION: Our long-term experimental study revealed that all methods were protective in testicular torsion. The authors believe that these methods can be applied in clinical practice because of their ease of application and no additional cost. On the other hand, the results of our study should further be supported by other experimental studies.

The theoretical method and clinical application of testicular torsion.

INTRODUCTION: This study aims to explore the theoretical method and clinical application of manipulation reduction for testicular torsion. METHODS: A total of 28 patients with testicular torsion were recruited from the Emergency Surgery Department of Beijing Children's Hospital affiliated to Capital Medical University from July 2016 to July 2018. Among these patients, 22 patients (age: 10.80 ± 3.50 years old) were treated with manual reduction using the elastic retraction method and push-and-turn method. Observation indexes included dramatically alleviated or completely disappeared pain without general anesthesia; the spermatic cord being smooth and unknotted; the restoration of the suffered testis to normal anatomical position under ultrasonography monitoring; blood flow signals increased in the affected testis and epididymis, which was regarded as the main sign of a successful reduction. RESULTS: Among the 22 cases who received manual reduction, 19 patients were successfully treated (left side: n = 11, right side: n = 8) with a total success rate of 86.36%. The other three cases showed either incomplete (n = 2) or failed (n = 1) reposition. Among the 19 patients who were successfully treated by manual reduction, 2 of them did not undergo prophylactic orchiopexy, and no abnormalities were found during the follow-up. CONCLUSION: The reduction of testicular torsion using the elastic retraction method and push-and-turn method may improve the success rate of the manual reduction of testicular torsion, especially for incomplete testicular torsion. Furthermore, manual reduction may help increase the rate of testicular salvage in a timely manner before emergency surgery. Hence, this skill should be extended to primary hospitals to reduce the possibility of testectomy caused by testicular torsion.

An unusual presentation of testicular torsion in children: a single - centre retrospective study.

INTRODUCTION: The aim of this study was to investigate demographic and clinical characteristics and outcomes of the treatments of the patients with an unusual presentation of the testicular torsion (TT) and to clarify their peculiarities. MATERIAL AND METHODS: From January 1999 until December 2017, the case records of 149 patients who underwent surgery for TT were retrospectively reviewed. Out of that number, 25 patients were identified with unusual presentation of an acute scrotum (14 patients who presented with an abdominal pain only, and 11 who presented with testicular torsion in inguinal canal). RESULTS: The median age of all children with TT at the time of surgery was 14 years. The duration of the symptoms varied substantially and ranged from 1 hour to 120 hours with a median of 6 hours, with only 63 (42.3%) out of the 149 patients staying below the golden 6 hours. Only 2/11 (18.2%) children of the inguinal group and 5/14 (35.71%) children of the abdominal group presented within 6 hours. In the group with inguinal TT the median age was 13 years with the median duration of symptoms of 24 hours. The symptoms were mostly abdominal pain (90.9%), followed by groin pain (45.5%) and nausea (45.5%). In 6 out of 11 children, the first physical examination did not include a genital examination. In the group with abdominal pain, the a median age was 13 years, with median duration of symptoms of 17 hours. The symptoms were limited, besides the abdominal pain, to groin pain (42.8%) and nausea (50%). In 9 out of 14 children, the first physical examination did not include a genital examination. The rate of orchidectomy in the inguinal TT group was 54.5%, while in the abdominal group 57.1%. CONCLUSION: Testicular torsion, particulary in regard to torsion in the inguinal canal or presenting dominantly with abdominal pain can be easily misdiagnosed, but needs to be recognized on time, to salvage the affected testicle. The complete physical examination, including the genital examination, needs to be performed in each male patient presenting with lower abdominal or groin pain.

Clinical state of the paediatric acute scrotum in south-eastern Victoria.

BACKGROUND: Acute scrotal pain is a common paediatric surgical presentation. Delays in treatment can result in testicular loss from torsion. It is unclear where delays occur. We aimed to investigate presentations with an acute scrotum to identify any potential areas of delay. METHODS: We conducted a prospective study (April 2017-November 2018) of paediatric patients (<18 years) presenting with acute scrotal pain. Data collected included: patient demographics, history/examination findings, mode of presentation, clinical timeline details and outcomes. RESULTS: A total of 107 acute scrotum presentations were identified: 58 (54.2%) testicular appendage torsion, 23 (21.5%) testicular torsion, 6 (5.6%) epididymo-orchidits and 20 (18.7%) other diagnoses. Median age at presentation was 11 years (4 months-16 years). Fifty-seven (53.3%) underwent emergency surgery, of whom 23 (40.4%) had testicular torsion, with 2 requiring orchidectomy. Median time from onset of symptoms to seeking medical opinion was 5.5 (0-135) h. Once assessed by a medical professional, the route to paediatric surgical review via general practitioner (GP) and local emergency department (ED) to paediatric ED was 4.84 (1.67-24.5) h; via GP to paediatric ED was 2.58 (0.75-25.5) h; via local ED to paediatric ED was 2.25 (1-7.75) h; and directly to paediatric ED was 0.45 (0-1.42) h. CONCLUSION: Delays in assessment and treatment of acute scrotal pain occur from the time parents are aware of symptoms to seeking medical opinion. Education to increase awareness may reduce time delays. GPs should refer patients directly to a paediatric ED. Local EDs should manage paediatric cases as per the local surgeons' skill base.

Does the source of referral affect outcomes for paediatric testicular torsion?

INTRODUCTION: This single centre study retrospectively analysed the intraoperative findings relative to source of referral for emergency scrotal explorations performed in a tertiary level paediatric surgery department. METHODS: All patients who underwent emergency scrotal exploration under the care of paediatric surgeons in our unit between April 2008 and April 2016 were identified. Clinical data were obtained from contemporaneous records. RESULTS: Over the 8-year study period, 662 boys underwent emergency scrotal exploration: 6 (1%) were internal referrals, 294 (44%) attended our emergency department (ED) directly, 271 (41%) were referred from primary care and 91 (14%) were transferred from other hospitals. Excluding procedures in neonates, testicular torsion was present in 100 cases (15%). Testicular detorsion with bilateral 3-point testicular fixation was performed in 66 (66%) and orchidectomy with contralateral fixation in 34 (34%) where the torted testis was non-viable intraoperatively. The orchidectomy rate in the presence of torsion was 23% in ED referrals (12/52), 43% in primary care referrals (12/28) and 50% for transfers (10/20). The difference in rates between ED referrals and patients transferred from other hospitals was significant (p=0.026). There was no significant difference in median age between any of the groups (p=0.10). CONCLUSIONS: Boys undergoing emergency scrotal exploration had a higher orchidectomy rate when transferred from other hospitals to our unit. This difference was statistically significant when compared with boys presenting directly to our ED. This supports advice from The Royal College of Surgeons of England for undertaking paediatric scrotal explorations in the presenting hospital when safe to do so rather than delaying the care of these patients by transferring them to a tertiary paediatric surgical unit.

Re-presentations and recurrent events following initial management of the acute paediatric scrotum: a 5-year review.

BACKGROUND: Previous reviews report relatively low rates of post-operative complications for acute scrotal exploration. The aim of this study was to evaluate the re-presentation to hospital in boys with previous acute scrotal pathology, reviewing contralateral symptoms, post-operative complications, testicular torsion following fixation and failure of conservative management of testicular appendage (TA) torsion. METHODS: All boys under 16 years presenting to our unit with an acute scrotum from January 2008 to December 2012 (5-year period) were identified. A retrospective review of clinical records was performed. RESULTS: A total of 683 boys presented over this 5-year period, with an overall re-presentation rate of 10%. Seventeen (25%) re-presentations were metachronous. Post-operative complication rate was 2.2%. Testicular torsion rate following orchiopexy was 0.3% (1/292). Thirty-three percent of those managed conservatively for TA torsion returned with ongoing pain; 80% underwent scrotal exploration on return. Eight boys returned following excision of a torted TA with contralateral torted TA confirmed, accounting for 2.6% (8/308) of boys with a torted TA at first presentation. This gives a number-needed-to-treat of 39 for bilateral scrotal exploration and prophylactic excision of contralateral non-torted TA, to prevent one boy from returning to hospital with a metachronous presentation. CONCLUSION: Further prolonged follow-up is needed to adequately assess recurrence rates of testicular torsion following orchiopexy to validate routine orchiopexy. Post-operative complication rates equal that of the return rate for a contralateral torted TA; this needs to be considered in proceeding to bilateral scrotal exploration on finding a torted TA at initial presentation.

The protective effect of low-energy shock wave on testicular ischemia-reperfusion injury is mediated by the PI3K/AKT/NRF2 pathway.

AIMS: Testicular ischemia-reperfusion (IR) injury is the primary pathophysiological consequence of testicular torsion. Low-energy shock wave (LESW) is an effective treatment for certain diseases. The present study investigated whether LESW could improve on testicular IR injury in rats and examined the involved mechanism. MAIN METHODS: Testicular reperfusion was induced in rats after 1-h ischemia. The first LESW treatment was performed 30 min prior to testicular reperfusion, and then every other day for another 3 applications. LY294002 was applied to investigate the involved mechanism. Testicular morphological changes and malonaldehyde (MDA) level were respectively assessed by hematoxylin-eosin staining. Western blot and thiobarbituric acid method. Western blot, real-time quantitative PCR and immunohistochemistry were performed to assess the apoptosis, the activation of phosphatidylinositol-4,5-bisphosphate 3-kinase/protein kinase B (PI3K/AKT) pathway the nuclear factor erythroid 2-related factor 2 (NRF2) and vascular endothelial growth factor A (VEGF-A) level in the testis of rats. KEY FINDINGS: LESW improved testicular IR injury in rats. Moreover, LESW upregulated the phosphorylation levels of AKT and glycogen synthase kinase 3ß (GSK-3ß). Also, it upregulated the levels of nuclear NRF2, heme oxygenase 1 (HO-1) and NAD(P)H quinone dehydrogenase 1 (NQO-1) in these rats. Nevertheless, LY294002 blocked these protective effects. LESW also upregulated VEGF-A level in rats with testicular IR injury. SIGNIFICANCE: This study demonstrated that LESW could ameliorate testicular IR injury in rats, which might be attributed to the activation of PI3K/AKT/NRF2 pathway. These findings suggested the potential of LESW in the treatment of testicular torsion.

Urologic Emergencies.

Urologic emergencies can involve the kidneys, ureters, bladder, urethra, penis, scrotum, or testicles. History and physical examination are essential to diagnosis, whereas imaging is increasingly used to confirm diagnoses. Acute urinary retention should be relieved with Foley placement. Penile emergencies include paraphimosis, which can be treated by foreskin reduction, whereas penile fracture and priapism require urologic intervention. Fournier gangrene and testicular torsion are scrotal emergencies requiring emergent surgery. Nephrolithiasis, although painful, is not an emergency unless there is concern for concomitant urinary tract infection, both ureters are obstructed by stones, or there is an obstructing stone in a solitary kidney.

Protective Effects of Hypericum perforatum and Quercetin in a Rat Model of Ischemia/Reperfusion Injury of Testes.

PURPOSE: This study aimed to compare the protective effects of Hypericum perforatum (Hp) and quercetin, a flavonoid, against ischemia/reperfusion (I/R) injury in rat testes. MATERIALS AND METHODS: This study included 28 male Wistar albino rats that were divided into four groups. Except for the sham group, torsion was created by rotating both testes at an angle of 720 degrees clockwise for 2 hours. The Hp and quercetin groups received 25 mg/kg Hp and quercetin intraperitoneally 30 minutes before detorsion, respectively. Orchiectomy was performed for the measurement of markers of oxidative stress and histopathological examination. RESULTS: In the Hp and quercetin groups, malondialdehyde (MDA) and nitric oxide (NO) levels and total oxidant capacity were significantly lower, the glutathione level and total antioxidant status were significantly higher, and Johnsen's testis biopsy scores were significantly higher than in the torsion/detorsion group (p ˂ 0.001). The markers of oxidative injury were significantly lower (p ˂ 0.001) and total antioxidant status was significantly higher (p ˂ 0.001), except for glutathione (p = 0.62) in the Hp group than in the quercetin group. Johnsen's score between Hp and quercetin groups was not significantly different (p = 0.80). CONCLUSION: Both Hp and quercetin have protective effects against I/R injury of the testes, but the protective effect of Hp was found to be stronger than that of quercetin.

Improving Organ Salvage in Testicular Torsion: Comparative Study of Patients Undergoing vs Not Undergoing Preoperative Manual Detorsion.

PURPOSE: We compared surgical outcomes between patients undergoing and those not undergoing preoperative manual detorsion for intravaginal testicular torsion. MATERIALS AND METHODS: We retrospectively analyzed consecutive patients treated surgically for testicular torsion who were examined within 24 hours of symptoms at our emergency department between January 2012 and September 2015. Explanatory variables were age, presentation delay (time between symptoms and urological examination), surgical wait time (time from examination to surgery), and whether manual detorsion was attempted and, if attempted, was declared successful. End points were surgical outcome (orchiopexy, orchiectomy) and testicular rotation at surgery. Statistical analysis included nonparametric tests and logistic regression. Statistical significance and confidence intervals were set at p <0.05 and 0.95, respectively. RESULTS: Detorsion was attempted in 76 of 133 cases (57.1%) and was successful in 72 (95.1%). Patient age (median 15.6 vs 17.4 years, p = 0.115), presentation delay (6.6 vs 6.3 hours, p = 1.0) and surgical wait time (3.5 vs 3.2 hours, p = 0.412) were comparable between patients who underwent manual detorsion attempt and those who did not. Testicular rotation was less among successfully detorsed patients. Orchiectomy was performed in 2 of 72 successfully detorsed patients (2.8%), compared to 15 of 61 patients (24.6%) in whom detorsion was not attempted or was unsuccessful (OR 11.23, p = 0.0002). Logistic regression indicated that surgical wait time (OR 0.95, p = 0.002) and successful detorsion (OR 17.38, p = 0.001) were independently associated with orchiopexy. CONCLUSIONS: Preoperative manual detorsion was associated with improved surgical salvage in patients with testicular torsion.

Malpractice Litigation and Testicular Torsion: A Legal Database Review.

BACKGROUND: The litigious nature of the American medical environment is a major concern for physicians, with an estimated annual cost of $10 billion. OBJECTIVE: The purpose of this study is to identify causes of litigation in cases of testicular torsion and what factors contribute to verdicts or settlements resulting in indemnity payments. METHODS: Publicly available jury verdict reports were retrieved from the Westlaw legal database (Thomson Reuters, New York, NY). In order to identify pertinent cases, we used the search terms "medical malpractice" and "testicular torsion" with date ranging from 2000 to 2013. Jury verdicts, depositions, and narrative summaries were evaluated for their medical basis, alleged malpractice, findings, and indemnity payment(s) (if any). RESULTS: Fifty-two cases were identified that were relevant to this study. Fifty-one percent of relevant cases were found in favor of the defendant physician, with the remaining 49% involving an indemnity payment (13% of which were settled). The most commonly sued medical providers were emergency physicians (48% of defendants), with urologists being second most common and making up 23% of the defendant pool. Emergency physicians were significantly more likely to make indemnity payments than urologists. CONCLUSION: Testicular torsion is a delicate condition and requires expertise in evaluation and treatment. When emergency physicians choose not to consult an urologist for possible torsion, they leave themselves open to litigation risk. When an urologist is involved in torsion litigation, they are rarely unsuccessful in their defense. Finally, ultrasound is no guarantee for success against litigation.

Local injection of mesenchymal stem cells protects testicular torsion-induced germ cell injury.

INTRODUCTION: Testicular torsion is a urological emergency and infertility is a common complication due to ischemic injury. Surgical reduction and orchiopexy is indicated, but to date there is no effective method for restoration of spermatogenesis. The effects of mesenchymal stem cells (MSCs) on acute tissue injury have been demonstrated, and the abilities of paracrine support, differentiation and immune-modulation may benefit to testicular torsion-induced infertility. We investigate the therapeutic efficacy and the mechanisms of MSCs in testicular torsion-induced germ cell injury when injected locally. METHODS: Six to eight-week-old Sprague-Dawley rats received surgical 720 degree torsion for 3 hours, followed by detorsion on the left testis. 20 µl of phosphate-buffered saline (PBS) without or with 3 x 10(4) MSCs from human orbital fat tissues (OFSCs) were given for 10 rats, respectively, via local injection into the left testis 30 minutes before detorsion. 20 µl of PBS injection for 6 rats with surgical exposure without torsion served as sham control. Histopathology with Johnsen's score analysis, Western blot analysis for superoxide dismutase 2, Bax, Caspase-3, human insulin growth factor-1 and human stem cell factor, malondialdehyde (MDA) assay in testis and plasma, hormones level including testosterone, follicle-stimulating hormone (FSH) and luteinizing hormone (LH) by ELISA Kits, terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay and fluorescence staining for P450, Sox-9 and VASA were performed. RESULTS: Animals were sacrificed and bilateral orchiectomy was performed 7 days after torsion-detorsion. Local injections of OFSCs prevented torsion-induced infertility judging from Johnsen's score. TUNEL assay and Western blot analysis on caspase 3 and Bax demonstrated that OFSCs prevented ischemic/reperfusion induced intrinsic apoptosis. MDA assay revealed that OFSCs significantly reduced the oxidative stress in the damaged testicular tissues. After the OFSC injection, serum testosterone secretion was increased, while the elevation of FSH triggered by testicular injury was balanced. OFSCs also produced stem cell factor in the damaged testis. Immunofluorescence staining revealed that most transplanted cells surrounded the Leydig cells. Some of transplanted cells differentiated into p450 expressing cells within 7 days. CONCLUSIONS: Local injection of allogenic MSCs before surgical detorsion is a simple, clinical friendly procedure to rescue torsion-induced infertility.

Hyperbaric oxygen treatment for unilateral testicular torsion in a child.

Torsion of the testis is a urological emergency most commonly occurring in adolescent boys. Hyperbaric oxygen treatment (HBOT) has been shown to alleviate reperfusion injury in experimental ischaemia of the testis. We report a 13-year-old boy who had prolonged right testicular ischaemia. Despite surgery, the colour of the testis remained poor. He underwent a post-operative course of 10 HBOT over 8 days, with restoration of blood flow on colour Doppler and reduction of oedema. At four-month followup, the testis appeared normal on ultrasonography. To the best of our knowledge, this is the first published case of torsion of the testis treated with HBOT.