Approach Considerations
Testicular torsion is a surgical emergency, and all efforts should be aimed at bringing the patient to the operating room as quickly as possible within the limits of surgical and anesthetic safety. Outcomes directly depend on the duration of ischemia; thus, time is of the essence. [3] Time wasted attempting to arrange for imaging studies, laboratory testing, or other diagnostic procedures results in lost testicular tissue.
Ongoing controversy surrounds the issue of exploration versus observation for perinatal torsion. This condition is uncommon enough that few centers see enough cases to merit any prospective studies, and medicolegal issues likely drive much of the decision-making in this area. [51, 52]
Various experimental studies in animal models have investigated ways of minimizing the testicular injury associated with ischemia-reperfusion injury. Agents as varied as superoxide dismutase, catalase, calcium-channel blockers, oxypurinol, and allopurinol have been used. Other agents used include melatonin, [53] zinc aspartate, [54] and dehydroepiandrosterone. [55] Unfortunately, none of these models has yet generated adequate evidence to justify trials in humans.
Manual Detorsion
In some cases of testicular torsion, manually untwisting the spermatic cord may allow reestablishment of vascular flow. The technique involves manipulating the involved testis so that the anterior surface rotates from medial to lateral. This is termed the open book method because the motion resembles opening the cover of a book (for a right testis).
When successful, this maneuver almost immediately relieves pain in most patients. Manual detorsion is best performed with the intention of buying time until the surgical team is ready, rather than with the intention of avoiding a surgical procedure altogether. [56]
Reports of this procedure have suggested that it is highly effective, in that it allows the acute emergency to be converted into an elective surgical procedure, with a quoted salvage rate of 100%. [7] Cornel et al reported that no testicular atrophy was detected after performing a manual detorsion. [57] Siu Uribe et al found that manual detorsion and elective orchidopexy appeared to be efficient and reliable in children with testicular torsion. [58]
In actuality, manual detorsion is difficult and is not commonly used. Application of this maneuver in an emergency department setting in a child with a swollen painful scrotum can be difficult or impossible without anesthesia. Furthermore, the testis may not be fully detorsed or may retorse shortly after the patient leaves the hospital. In addition, knowing which way the testis is torsed a priori is impossible; thus, attempting detorsion may simply worsen the degree of torsion.
Surgical Exploration
The goals of surgical exploration are as follows:
-
Confirmation of the diagnosis of torsion
-
Detorsion of the involved testis
-
Assessment of the viability of the involved testis
-
Removal of the involved testis (if it is nonviable) or fixation (if it is viable)
-
Fixation of the contralateral testis, when appropriate
Because of the concern regarding the possibility of asynchronous testicular torsion, contralateral exploration and fixation is widely performed. [59, 60, 61]
The argument against surgical exploration includes the low probability of salvage in the setting of old torsion (>24-48 hours). However, proponents of surgery argue that in view of the medicolegal implications, exploration must be performed to prove the diagnosis, to salvage the testis (if possible), and to perform a concurrent contralateral orchidopexy. Indeed, surgeons rarely experience medicolegal consequences for a negative exploration finding in the setting of acute scrotum, whereas lawsuits for failure to explore are routine. [62]
Indications for surgery
In the neonate with acute scrotum at birth or a few days afterward, surgical recommendations are controversial. Although most authorities recommend exploration of the ipsilateral side and fixation of the contralateral testis, some have suggested that observation is acceptable because of the negligible salvage rate of the ischemic testis and the low incidence of contralateral torsion. The risk of anesthesia in children younger than 1 year may also factor into decision-making process.
In the prepubertal boy with acute scrotum, exploration with salvage of the ipsilateral testis is recommended, if possible. If testicular torsion is confirmed, contralateral orchiopexy is recommended. Differential diagnoses to consider include torsed appendix epididymis ("blue-dot" sign) and epididymitis. If a clear-cut blue-dot sign is identified and confirmed with Doppler ultrasonography (US), a nonsurgical approach is justified.
In the adolescent with acute scrotum, exploration with salvage of the ipsilateral testis is recommended, if possible. If torsion is confirmed, contralateral orchiopexy is recommended. If the testis has not been salvaged, ipsilateral orchiectomy is usually performed.
Operative details
Exploration can be performed via a paramedian scrotal incision, a transverse incision, or a single midline scrotal incision. Some surgeons prefer to explore the acute scrotum through an inguinal incision, theorizing that this approach offers better control of the high spermatic cord if the exploration reveals an unexpected diagnosis (eg, testis tumor).
It may be difficult to determine intraoperatively whether a testis of marginal viability should be retained or excised. Although retaining a marginal testis may appear to carry no negative consequences, long-term concerns about the immunologic consequences of the infarcted testis have been raised. Testicular ischemia disrupts the blood-testis barrier, which may result in autoimmunization against spermatozoa and formation of antisperm antibodies; this may affect sperm produced by both testes.
However, both spermatogenesis and the blood-testis barrier are established after age 10 years; thus, some surgeons always retain the doubtful testis in children younger than 10 years. [5]
Arda et al recommended that the testis be incised at exploration to look for bleeding as a measure of viability. Bleeding was graded as follows [63] :
-
Grade I - Immediate bleeding
-
Grade II - Bleeding after 10 minutes
-
Grade III - No bleeding after 10 minutes
Excision of the testis was recommended for grade III.
Once the testis has been detorsed and the decision is made to preserve it, the tunica vaginalis is everted, as in a Jaboulay procedure; two or three sutures are passed through the dartos and tunica albuginea of the testicle. Some surgeons avoid placing sutures directly into the tunica albuginea, out of concern about possible disruption of the blood-testis barrier; instead, they place the sutures into the visceral tunica vaginalis of the mesorchium. [64]
Kuntze et al reported that absorbable sutures predispose to recurrent torsion after orchiopexy; thus, nonabsorbable sutures are recommended for securing the testis. [65]
Window orchidopexy has been performed to ensure better fixation of the testis and thus avoid recurrent torsion, on the principle that creating a window in the tunica vaginalis makes a broad area of dense adhesion during healing, which results in better apposition. [66] Sutureless fixation in a dartos pouch has been reported for neonatal orchiopexy [67] in performing a contralateral exploration.
Complications
As many as half of patients with testicular torsion who undergo salvage surgery may develop testicular atrophy, even when the testis was intraoperatively assessed as viable. [68] Pain lasting longer than 12-24 hours and heterogeneous echogenicity on US are predictive. [68, 69]
Long-Term Monitoring
Although long-term observation to monitor for testicular atrophy would be helpful in patients with testicular torsion, in actuality, many of these patients (particularly the adolescents) do not return for follow-up. In patients who do return, annual scrotal US during the 2-3 years after surgery can be used to document testicular volume and growth.
Recurrent torsion following an orchiopexy is possible (though rare) and may occur several years after the initial fixation of the testis. Thus, patients and parents should be forewarned about this risk and should promptly seek medical care if testicular pain occurs, even after an orchiopexy has been performed. [34]
-
Perinatal testicular torsion.
-
Intravaginal testicular torsion with ischemia in adolescent boy.
-
Torsion of undescended testis.
-
Torsion of testis, with cord twist clearly demonstrated.
-
Torsion of appendix testis.
