Serious incidents in testicular torsion management in England, 2007-2019: optimizing individual and training factors are the key to improved outcomes.

OBJECTIVES: To establish the healthcare factors that contribute to testicular torsion adverse events (orchidectomies) and 'near misses'. The secondary objective was to identify areas suitable for impactful quality improvement initiatives to be undertaken by National Health Service (NHS) healthcare providers nationally. MATERIALS AND METHODS: This was a retrospective record review and analysis, carried out in four phases. We applied the well-validated London Protocol patient safety incident analysis framework to all eligible serious incidents related to testicular torsion submitted by English NHS Trusts over a 12-year period to the Strategic Executive Information System database. Clinical reviewers established the incident population (Phase 1), were trained and piloted the feasibility of using the London Protocol (Phase 2), applied the protocol and themed the identified contributing factors linked to adverse events (orchidectomies) and near-misses (Phase 3), and reviewed the evidence for improvement interventions (Phase 4). RESULTS: Our search returned 992 serious incidents, of which 732 were eligible for study inclusion and analysis. Of those, 137 resulted in orchidectomies, equivalent to one serious incident resulting in orchidectomy per month, and 595 were near misses. Factors contributing to all incidents were: individual staff/training (38%); team (18%); work environment (16%); task and technology (14%); and institutional context (13%). Subgroup analysis of incidents resulting in orchidectomies vs near misses demonstrated a different pattern of factors, with individual staff/training factors significantly more prominent: individual/training (88%); work environment (8%); and task and technology (1%). No evidenced improvement interventions were found in the literature. CONCLUSION: This is the first study to our knowledge to systematically analyse and classify factors that are associated with loss of a testicle and related near-miss incidents in patients presenting with testicular torsion. In England, a significant number of orchidectomies occur annually as a consequence of healthcare serious incidents. In order to improve outcomes, we propose clinical support to aid the diagnosis of torsion, improved national clinical guidelines, development of specific standard operating procedures and (in the longer term) more exposure of trainees and medical students to urology to improve the testicular salvage rate.

Supporting a Learning System in Pediatric Emergency Pathways: Using Organizational Comparisons, Serious Incidents, and Near-Miss Events to Improve the Diagnosis and Treatment of Testicular Torsion.

BACKGROUND: Scrotal pain is a common presentation to the emergency department requiring prompt investigation and management to identify testicular torsion and increase the opportunity for testicular salvage. Using national data obtained from the NHS Improvement, we aim to identify key suboptimal areas in the acute diagnosis and management of testicular torsion with a view to learning from these and improving outcomes. METHODS: A freedom of information request was made to all 134 hospital groups in England and Wales that manage testicular torsion. Serious incidents experienced by these hospitals were analyzed to see whether those with pediatric emergency departments fared better than those without. In addition, a qualitative thematic analysis of the NHS Improvement National Reporting and Learning System database over a 12-year period (2007-2019) was undertaken, to identify common themes associated with orchidectomies and "near-miss" events in the pediatric population. RESULTS: Three hundred four patient safety incidents were returned and divided into 62 orchidectomies and 242 near-miss events. The most common factor in the orchidectomy group was individual factors (83.9%). Misdiagnosis of symptomatic testicle was not significant when comparing ED to specialist surgeons (odds ratio = 1.46, P = 0.3842). Atypical presentation resulting in orchidectomy was significant when comparing ED with specialists (odds ratio = 6, P = 0.0355). Near-miss events, not leading to orchidectomy, are often due to a wider variety of factors. A Mann-Whitney U test showed that there was no statistical significance in incidents when comparing general ED units caring for all ages with pediatric EDs in terms of incidents ( U = 807.5, z = -1.124, P = 0.261). CONCLUSIONS: There is a need for education in ED about atypical presentation of testicular torsion and examination of scrotum in cases of lower abdominal pain. It is also vital that specialist teams are cognizant of the standard operating procedures relevant to scrotal pain and testicular within the organization and the wider clinical network. Finally, there should be a drive for annual collation of data in urology and ED units with regards to testicular torsion as patient safety incidents may be underreported.

Segmental Testicular Infarction Due to Arterial Atheroma: A Case Report.

Segmental testicular infarction is an uncommon condition, of which the majority of cases are idiopathic. Cases associated with atherosclerotic disease are extremely rare, with only two other cases reported in the literature to our knowledge. We report the case of a 71-year-old man who presented with left testicular pain and a mass. Ultrasound imaging confirmed an upper pole left testicular mass, and he subsequently underwent radical inguinal orchidectomy for presumed testicular malignancy. Histological analysis revealed a segmental testicular infarction related to arterial atheroma. Segmental testicular infarction can mimic other pathologies, such as testicular torsion or cancer, resulting in misdiagnosis and potentially unnecessary surgery. Increased awareness of the risk factors and clinical features may help clinicians identify and appropriately manage this uncommon pathology.

The management of testicular torsion in the UK: How can we do better? A national quantitative and qualitative analysis of the factors affecting successful testicular salvage.

BACKGROUND: Testicular torsion is a surgical emergency, requiring time-critical surgery to avoid potential organ loss. This study collates national data on paediatric testicular torsion, offering a comprehensive insight into the current standard of care in England for paediatric patients with suspected testicular torsion. METHODS: National data collection using Freedom of Information requests. Of 134 acute secondary care NHS trusts in England that treat paediatric patients, responses were received from 121 trusts - representing 140 hospitals - providing a picture of the current standard of care in England. FINDINGS: Less than two thirds of hospitals have a paediatric A&E department. One third of hospitals use inter-hospital transfer for paediatric patients with suspected torsion, with variable age restrictions. Mean transfer distance was 19·4 miles (range 2·2 to 61·6 miles). No statistically significant relationship between transfer arrangements and the number of non-viable testicle incidents was found (P = 0·15, ns). There was no correlation demonstrated nationally between size of population served and number of scrotal explorations completed (Pearson's r = 0·20 (CI -0·0·8-0·46), p = 0·16, ns). Qualitative thematic content analysis of serious incident reports identified common themes leading to missed diagnosis and delayed time to theatre: Education and Training, Communication, Transfer Complications, On-site Resources and Cross-site Working. INTERPRETATION: We found variability in resource provision across England, as well as the number of explorations, and the number of unviable testicles found at exploration nationally. We received variable and incomplete data on emergency scrotal explorations and subsequent orchidectomies, very low levels of local audit and limited disclosure of incident reports. A mandatory national audit would allow more comprehensive data collection to accurately identify trends and make informed recommendations. To improve outcomes, we recommend continued education of ED and surgical teams, with mandatory testicular examination for young males presenting with abdominal pain. Whilst streamlining inpatient services is important, the time lost between symptom onset and seeking medical attention is crucial, and raising awareness in the community for young boys and parents may be imperative to improve rates of testicular salvage.

Reno-duodenal fistula as a complication of longstanding renal tract calculus.

We present a rare case detailing the investigations and subsequent treatment of a lady who presented with a reno-duodenal fistula and perinephric abscess as a complication of staghorn calculus and recurrent upper urinary tract infections. Treatment involved antibiotics, nephrostomy, endoscopic closure of the fistula tract with clips, radiological drain insertion and, ultimately, nephrectomy with primary omental patch closure of the duodenal defect. We discuss the incidence of fistula tract formation as a complication of staghorn calculi, as well as investigations and management strategies employed in the literature to treat such complications, which span from conservative treatment to nephrectomy and closure of the intestinal defect. We illustrate the post-operative complications such patients are prone to and discuss these in context of the case. Whilst such cases are rare clinicians should be vigilant for complications associated with chronic inflammatory processes occurring in the urinary tract and investigate accordingly.

Skin lesions caused by Mycobacterium marinumin a patient with occupational exposure.

Mycobacterium marinum infections are associated with specific occupational risk factors and often have a delay to diagnosis. We present the case of a young tropical fish whole-sale worker presenting with skin lesions on the hand.

A rare case of localised oral amyloid of the labial mucosa.

Amyloidosis is often a systemic process, and localised oral amyloidosis is rare. We present the case of a young woman with amyloid deposition in the labial mucosa of her lower lip. Systemic involvement was excluded by comprehensive assessment at the UK Amyloidosis Centre. Of 40 previously reported cases of localised oral amyloidosis we found only one that was limited to the labial mucosa.