青春期精索扭转的诊治分析(附67例报告)

目的:提高精索扭转的早期诊断和治疗水平,减少睾丸丧失。方法:回顾性分析2003年8月~2011年12月收治的67例青春期精索扭转的临床资料:患者年龄13~16岁,平均14.6岁。发病6小时内就诊23例,6~24小时39例,24小时以上5例。本组彩超检查53例;手术治疗63例,非手术治疗4例。并分析其确诊、误诊及睾丸挽救率。结果:首诊确诊率72%(48/67),误诊率28%(19/67)。误诊病种包括附睾-睾丸炎52%(10/19),鞘膜积液16%(3/19),腹股沟疝16%(3/19),输尿管结石11%(2/19),睾丸血肿5%(1/19)。67例中,外科干预63例,均为鞘膜内360°~1 080°扭转,其中发病6小时内手术探查19例,睾丸挽救率84%(16/19);6小时以上手术探查44例,睾丸挽救率23%(10/44),两组间差异有统计学意义(P0.05,两组睾丸中位扭转角度540°)。挽救及健侧睾丸行阴囊肉膜下固定术。切除睾丸病理检查结果为出血坏死性改变。非手术治疗4例中,2例手法复位成功,1例就诊睾丸已萎缩,1例自发缓解。挽救睾丸26例,其中16例随访6~18个月,睾丸萎缩11例。结论:精索扭转误诊率较高,青春期突发阴囊剧痛首先要考虑精索扭转的可能。彩超为一线检查方法。扭转程度及缺血时间是影响睾丸结局的重要因素,及时手术探查可降低睾丸切除率。因此,早期确诊和治疗是避免睾丸丧失的关键。     

Testicular oximetry: a new method for the assessment of tissue perfusion and viability following torsion and detorsion

This study evaluated the use of a polarographic surface PO2 electrode to assess testicular perfusion and viability following torsion and detorsion. Adult male Sprague-Dawley rats were divided into groups and subjected to unilateral testicular torsion and detorsion of varying degrees and durations. Rats subjected to sham torsion or 720 degrees torsion did not show significant decreases in testicular PO2 after 15 minutes, whereas those subjected to 1,080 degrees torsion or spermatic cord ligation uniformly decreased their testicular PO2 to 0 mm Hg within 10 minutes. Testicular PO2 values were similar in rats subjected to 60 minutes of 720 degrees torsion followed by detorsion and those undergoing 15 minutes of 1,080 degrees torsion and detorsion. Rats subjected to breathing 100% oxygen uniformly increased their testicular PO2 to an average of more than twice room-air values. However, rats subjected to 1,080 degrees torsion for 6 hours followed by detorsion did not increase their testicular PO2 when subjected to breathing 100% oxygen, whereas those subjected to 720 degrees torsion for 6 hours followed by detorsion did increase their testicular PO2 when subjected to breathing 100% oxygen. The latter rats did not show microscopic changes associated with acute testicular infarction, whereas the former did.(ABSTRACT TRUNCATED AT 250 WORDS)     

睾丸扭转的诊治(附59例报告)

目的 探讨睾丸扭转的诊治。方法 回顾性分析59例睾丸扭转患者的临床资料。结果 1例为腹腔内恶变隐睾扭转，余58例（59次）发病时中位年龄18．5岁，均无发热，50例次在夜间或剧烈运动后发病。4例手法复位成功。1例手法复位后再次扭转，拒行手术致睾丸萎缩。2例明确睾丸已坏死未手术治疗，患睾逐渐萎缩。接受手术探查的52例中有15例睾 丸存活，其中发病超过24d的1例，不到10h11例。结论 青少年夜间或运动后突发急性睾丸痛应该警惕扭转的可能，必要时紧急手术探查，手法复位可尝试应用。     

精索扭转37例误诊分析

目的：提高精索扭转诊治水平。方法：对52例精索扭转患者首诊误诊37例(71．2％)的临床诊治资料进行回顾性分析。结果：37例患者中，误诊为急性附睾、睾丸炎30例(81．1％)，睾丸肿瘤3例(8．1％)，泌尿系结石2例(5．4％)，附睾结核及慢性结肠炎各1例(2．7％)。28例行B超检查，21例诊断符合(75．0％)，漏诊3例(10．7％)，误诊为急性附睾、睾丸炎及睾丸占位各2例(7．1％)。22例行彩色多普勒血流显像(CDFI)检查，20例诊断符合(90．9％)，误诊为附睾炎及睾丸占位各1例(4．5％)。2例入院时患侧睾丸已萎缩未手术。35例探查手术，其中26例睾丸切除，病理报告均为睾丸缺血性梗死；余9例保留睾丸并予固定(5例血运完全恢复，4例已不可逆性坏死，家属坚决要求保留)。因为首诊误诊，86．5％(32／37)患者睾丸切除或萎缩。结论：对于阴囊急症患者。尤其是青少年，首诊医生应高度警惕精索扭转可能性，可疑时立即行B超、CDFI检查，尽早手术探查，是降低误诊率、提高诊治水平、挽救睾丸功能的关键。     

精索形态观察在睾丸扭转早期诊治中的意义

目的:提高睾丸扭转早期的诊断和治疗水平。方法:回顾性分析49例睾丸扭转的临床资料及睾丸内血流声像图和精索超声特征。结果:49例睾丸扭转患者,彩色多普勒血流显像出现睾丸血流改变42例,其中血流增加3例,睾丸血流无明显改变7例;二维超声检查发现精索形态异常47例。手术复位固定21例,睾丸存活12例。结论:彩色多普勒超声扫描精索形态与睾丸血流变化对睾丸扭转的早期诊断有重要价值,尽早手术探查有助于挽救存活睾丸。     

Testicular fixation following torsion of the spermatic cord--does it guarantee prevention of recurrent torsion events?

PURPOSE: Patients with history of testicular torsion who have undergone orchiopexy may rarely present with acute scrotum due to recurrent episodes of torsion. Most of the reports in the literature regarding this scenario refer to the era when absorbable sutures were used for testicular fixation. Herein, we review our experience in recent years, focusing upon the surgical technique and sutures' material. MATERIALS AND METHODS: Between 1991 and 2003, 179 patients were operated on at our institute with the clinical diagnosis of unilateral testicular torsion. They ranged in age between neonates to 45 years old (average age 18). In a comprehensive retrospective study we managed to locate 8 patients who experienced recurrent intravaginal testicular torsion following previous fixation performed in our institute. RESULTS: The patients who experienced repeat torsion have initially presented at the mean age of 18.5 years old (range 12 to 30) with unilateral twisted testicle (left 3, right 5). Urgent explorations were generally performed, apart from in 2 cases that underwent spontaneous detorsion which was followed by an elective surgery. Testicular fixation was conducted by suturing of the tunica albuginea to the dartos layer by 2 sutures at each side, using chromic 3-zero in the 3 more early cases, followed by the usage of polyglactin 3-zero stitches in 4 subsequent cases and 3 sutures of polypropylene 4-zero for each testicle, thereafter, in the most recent case. The patients presented with repeat torsion, 0.5 to 23 years subsequently (average 7 years), involving either the ipsilateral testicle in 4 cases or the contralateral gonad in 4. CONCLUSIONS: Recurrent torsion following previous testicular fixation may appear many years following the primary procedure, even in cases in which either polyglactin or, notwithstanding, polypropylene sutures have been applied, in accordance with the common practice used in the last 2 decades. Increased awareness regarding this possibility is imperative for early diagnosis and prevention of testicular loss.     

睾丸扭转的诊断和治疗(附23例报告)

目的总结睾丸扭转的诊治经验。方法23例患者平均年龄24.8岁,发病至确诊时间平均2.4 d(5 h~40 d),10 h以上者占87.0%(20/23)。隐睾扭转4例,行睾丸切除术;阴囊内睾丸扭转19例,其中16例因睾丸坏死予以切除,3例睾丸复位后血供恢复而予保留。结果保存睾丸的3例分别随访18、21和29个月,睾丸萎缩1例,正常2例。20例切除睾丸者随访6个月~5年,彩色多普勒检查示健侧睾丸大小、血供正常。结论睾丸扭转应与睾丸炎及附睾炎鉴别,隐睾扭转应与腹股沟嵌顿疝和急腹症鉴别。彩色多普勒对鉴别诊断有帮助。早期手术探查对降低睾丸切除率有重要意义。     

The significance of measuring the time course of serum malondialdehyde concentration in patients with torsion of the testis

PURPOSE: We determined the time course of malondialdehyde, a measure of free radical damage, in patients undergoing standard surgical treatment for testicular torsion. MATERIALS AND METHODS: Patients presenting with testicular torsion were studied prospectively. Blood samples were obtained after administering general anesthesia but before surgical incision, and 10 minutes, 30 minutes and 24 hours after detorsion. Orchiopexy was performed in patients with viable testes (group 1) and orchiectomy was performed in those with nonviable testes (group 2). Further blood samples were obtained 1 and 3 months after surgery. Similar blood samples were taken from controls, including patients younger than 40 years undergoing other operations involving manipulation of the testis, such as hydrocelectomy or orchiopexy (group 3). The level of malondialdehyde in each serum sample was determined by the thiobarbituric acid reaction. RESULTS: A total of 65 patients were studied, including 56 with testicular torsion and 9 controls (group 3). Of the 56 patients 11 (19.6%) with testicular torsion underwent ipsilateral orchiectomy and contralateral orchiopexy (group 2). The remaining 45 patients (80.4%) underwent bilateral orchiopexy (group 1). However serum malondialdehyde was estimated in only 34 of the 56 patients with torsion. Mean malondialdehyde at 0, 10 and 30 minutes, 24 hours, and 3 and 6 months was 3.3, 3.69, 3.69, 2.9, 2.65 and 2.39 nmol./ml. on the 24 group 1 patients, 3.53, 4.56, 3.87, 2.87, 2.82 and 2.64 nmol./ml. in the 10 group 2 patients, and 3.6, 3.08, 3.18, 2.95, 2.88 and 2.65 nmol./ml. in the 9 group 3 controls, respectively. The highest serum malondialdehyde was at 10 minutes after detorsion in groups 1 and 2. There was a statistically significant difference in malondialdehyde between groups 1 and 2 compared with group 3 at 10 minutes (p <0.04). Serum malondialdehyde returned to baseline at 24 hours in all patients. CONCLUSIONS: The results of this study indicate that testicular torsion and its treatment with detorsion is an example of ischemia-reperfusion injury, producing measurable changes in malondialdehyde in humans. Thus, serum malondialdehyde could be used to determine the extent of injury.     

精索扭转的诊断和治疗(附14例报告)

目的：探讨精索扭转的诊断和治疗方法。方法：结合文献复习，回顾性总结14例精索扭转的临床资料。结果：8例术前彩色多普勒超声检查（CDS）诊断并经手术证实，符合率100％。经手术探查，4例行手术复位，固定，睾丸获救，10例行患侧睾丸切除术，所有病例均行对侧探查，固定。结论：CDS是诊断急性精索扭转的首选方法，治疗上应尽快手术探查，复位并做预防性固定。     

睾丸扭转误诊113例分析

目的 :提高睾丸扭转 (精索扭转 )诊治水平。　方法 :回顾分析 1994～ 2 0 0 4年总计 113例睾丸扭转误诊的临床资料。　结果 :首诊误诊率 84 .3%。误诊为急性附睾、睾丸炎 81例 (71.7% ) ;鞘膜积液 10例 (8.8% ) ;急性肠炎 7例 (6 .2 % ) ;泌尿系结石 5例 (4.4 % ) ;腹股沟疝 5例 (4.4 % ) ;睾丸肿瘤 3例 (2 .7% ) ;附睾结核 2例 (1.8% )。发病至误诊时间 2h～ 2个月 ,平均 6 .3d。手法复位成功 3例 ;92例行手术探查 ,睾丸、附睾切除 6 4例 ,睾丸萎缩 2 6例 ,总计睾丸毁损率 79.6 %。　结论 :提高首诊医生对睾丸扭转的诊治水平是减少误诊的关键 ,诊断流程采用病史、体征、彩超 3者结合 ,治疗的最佳方法是积极开展阴囊急诊的手术探查。     

Neonatal bilateral testicular torsion: a plea for emergency exploration

PURPOSE: Bilateral testicular torsion is a rare condition. Most authors present single case reports. Therefore, the clinical and surgical aspects of bilateral torsion in a neonate have not been subjected to detailed analysis. We performed a retrospective analysis of our experience in the management of bilateral perinatal torsion as well as a collective review of the medical literature. MATERIALS AND METHODS: All cases of neonatal testicular torsion managed at our neonatal surgical center during the last 2 decades (1986 to 2005) were reviewed, and 3 cases of bilateral torsion were identified. In addition, 45 neonatal cases of bilateral torsion were found through the literature search. In all cases data regarding clinical presentation, imaging studies, surgical management, intraoperative and pathological findings, and final outcome were analyzed. RESULTS: Synchronous torsion occurred in 32 of 48 newborns (67%), while asynchronous pathology was reported in 16 (33%), including the 3 presented in this report. All except 1 patient were full-term newborns with normal or above average birth weight. Difficult delivery was noted in 33% of the cases. Despite prompt surgical intervention in 46 infants, the salvage rate was low, with arterial flow confirmed postoperatively in only 3 gonads (3.1%). Four gonads in 3 additional patients were reported to be of normal size on followup. CONCLUSIONS: Asynchronous torsion is not as rare an event as previously reported, and it may pose a diagnostic challenge. In the majority of these cases torsion of the left testis seems to occur later than torsion of the right testis. The role of imaging studies in newborns with bilateral torsion seems to be limited, especially in cases of asynchronous pathology. Urgent bilateral exploration is strongly advised in all newborns presenting with either unilateral or bilateral torsion. Such policy carries diagnostic, potential therapeutic and prognostic implications.     

Gonadal dysfunction after testicular torsion: luteinizing hormone and follicle-stimulating hormone response to gonadotropin releasing hormone

We studied 14 postpubertal patients at an average of 33 months after treatment for testicular torsion. Of these patients 11 had been treated by detorsion and 3 by orchiectomy. Five normal male volunteers of the approximate age of the study group served as controls. The patients treated by detorsion were subdivided into 3 groups based on the degree of atrophy of the detorsed testicle: group 1--no testicular atrophy (5), group 2--25 per cent testicular atrophy (2) and group 3--greater than 90 per cent testicular atrophy (4). Mean duration of torsion was greatest in the orchiectomy group (161 hours) compared to 6, 16 and 29 hours for groups 1, 2 and 3, respectively. The serum luteinizing hormone and follicle-stimulating hormone response to an intravenous bolus of 100 mcg. synthetic gonadotropin releasing hormone was measured in all patients. All groups had a greater mean follicle-stimulating hormone response to gonadotropin releasing hormone stimulation than controls (p less than 0.05). Patients who underwent orchiectomy had the greatest follicle-stimulating hormone response to gonadotropin releasing hormone stimulation. Mean luteinizing hormone response to gonadotropin releasing hormone stimulation was normal in patients without atrophy (group 1) but it was greater than controls in patients who had atrophy (groups 2 and 3) or who underwent orchiectomy (p less than 0.05). Several conclusions could be made from our study. All patient groups treated for torsion had evidence of testicular dysfunction. Patients who underwent orchiectomy displayed more testicular dysfunction than patients who had atrophy after detorsion. Testicular dysfunction after torsion is more likely to involve spermatogenic before Leydig cell function.     

The effects of N-acetylcysteine on antioxidant enzyme activities in experimental testicular torsion

Testicular torsion is a serious problem in male children and, if not treated at the right time, can lead to subfertility and infertility. The main reason for testicular damage is ischemia-reperfusion injury. A number of chemical substances have been used to protect testes against ischemia-reperfusion injury in experimental animals. The possible protective effect of N-acetylcysteine on testicular tissue after testicular detorsion was examined in the current study. Twenty-four rats were divided into four groups: sham operation, torsion, detorsion, and NAC + detorsion groups (n = 6 for each group). Excluding sham operation group, the rats were subjected to unilateral torsion (720-degree rotation in clockwise direction). After torsion (5 h) and detorsion (2 h), unilateral orchidectomy was performed. Malondialdehyde levels and superoxide dismutase, catalase, glutathione peroxidase, and glutathione reductase activities were determined in testicular tissue. Administration of N-acetylcysteine caused a decrease in malondialdehyde levels and an increase in glutathione peroxidase levels compared to detorsion group. The results suggest that N-acetylcysteine may be a potential protective agent for preventing the negative biochemical changes related to oxidative stress in testicular injury caused by testis torsion.     

Intratesticular pressure after testicular torsion as a predictor of subsequent spermatogenesis: a rat model

What’s known on the subject? and What does the study add? Testicular torsion results in atrophy rates of more than 25% despite prompt surgical management, and there is no reliable intraoperative critieria to judge the viability of the testis, except the testicular appearance after scrotal incision. We demonstrated that less reduction of ITP after detorsion correlated with worse subsequent spermatogenesis. This result suggests that ITP can be the index to determine removal of the affected testis during surgery.

OBJECTIVE

? To assess the correlation between intratesticular pressure (ITP) after testicular torsion and subsequent testicular function using a rat model and to show that ITP at surgery is a useful predictor of future spermatogenesis.

MATERIALS AND METHODS

? Fourteen rats were divided into a torsion group (n= 7) and a control group with sham operation (n= 7). ? Torsion was created by 720° rotation of the left testis in a counter‐clockwise direction. ? Using a handheld compartment monitor, the ITP of the torsed testes was measured three times: before torsion (pre‐torsion), just before torsion repair (pre‐detorsion) and 5 min after torsion repair (post‐detorsion). ? We evaluated the correlation between ITP and testicular weight, epididymal sperm count or pathological findings, such as the seminiferous tubule diameter (STD) and the modified Johnsen’s score, 4 weeks after surgery.

RESULTS

? Mean (se) pre‐torsion, pre‐detorsion and post‐detorsion ITP values in the torsion group were 5.9 (2.5), 19.7 (10.7) and 8.2 (4.8) cm H₂O, respectively. ? The ITP in torsed testes significantly increased after torsion (P < 0.01) and decreased after detorsion (P < 0.01). ? Strong correlations were observed between the reduction of ITP after detorsion and testicular weight (r= 0.87, P < 0.05), epididymal sperm count (r= 0.94, P < 0.05), STD (r= 0.87, P < 0.05) or the Johnsen’s score (r= 0.99, P < 0.001).

CONCLUSION

? A smaller reduction in ITP after detorsion can be a risk factor for subsequent disturbance of spermatogenesis, suggesting that ITP can be an index for determining whether the affected testis should be removed after testicular torsion.     

Adult testicular torsion

PURPOSE: Testicular torsion in adulthood is thought to be relatively unusual. We compared a series of men 21 years old or older with testicular torsion with a concurrent series of younger patients with torsion. MATERIALS AND METHODS: We reviewed the medical records of patients admitted with testicular torsion in a 9-year period to hospitals affiliated with our institution. Data included patient demographics, history, physical findings, radiographic results if any, operative findings and outcome (testicular salvage versus loss). RESULTS: The charts of 48 patients were evaluated. Excluded from study was a neonate with torsion and 3 males who underwent delayed surgery for presumed missed torsion. Of the remaining 44 patients we compared 17 who were 21 years old or older (range 21 to 34) with 27 younger than 21 (range 8 to 20). The salvage rate differed in the 2 age groups with 70.3% of testes salvaged in the younger group versus only 41% in the older group. A factor affecting salvage in each group was time to presentation. In the older age group patients in whom the testis was lost had a significantly higher mean delay in presentation than those in whom it was salvaged (102 versus 11 hours). A similar pattern was noted in the younger group with a mean time to presentation of 108 and 6.5 hours in those with testicular loss and salvage, respectively. Mean time between presentation and operation was 7.1 hours in the older and 4.8 in the younger group, which was not statistically different. A significant difference was noted in the degree of spermatic cord twisting. The cord was twisted a mean of 585 degrees in the adults versus 431 in the younger group. CONCLUSIONS: Testicular torsion in adults was more common in our series than expected. Salvage of the affected testis was better in younger patients, presumably due to less twisting of the cord.     

小儿急性睾丸扭转(附19例报告)

目的 探讨小儿急性睾丸扭转的诊治方法。方法 回顾分析19例5d至13岁小儿急性睾丸扭转的发病、治疗和预后等临床资料。结果 左侧睾丸扭转15例，右侧扭转4例；发病至就诊时间3h-4d；19例均接受手术治疗。17例为鞘膜内扭转，其中14个睾丸已坏死，行睾丸切除术；睾丸存活，5个，行睾丸固定术。2例为鞘膜外扭转，睾丸均已坏死，行睾丸切除术。结论 睾丸扭转是常见小儿阴囊急症，及早手术是避免睾丸坏死的关键。     

The effect of poly (adenosine diphosphate-ribose) polymerase inhibitors on biochemical changes in testicular ischemia-reperfusion injury

PURPOSE: Poly (adenosine diphosphate [ADP]-ribose) polymerase inhibitors have been used successfully to decrease ischemia-reperfusion injury in several organ systems. We evaluated the efficacy of poly (ADP-ribose) polymerase inhibitors on biochemical changes in testicular ischemia-reperfusion injury. MATERIALS AND METHODS: Adult male Wistar rats were divided into 9 groups of 6 each. One group served to determine baseline values of biochemical parameters, 1 that underwent sham operation served as a control, 1 underwent 2 hours of testicular torsion and 4 hours of detorsion, 2 received pretreatment with vehicle (saline or dimethyl sulfoxide) before detorsion and 4 received pretreatment with the poly (ADP-ribose) polymerase inhibitor nicotinamide, 3-aminobenzamide, 1,5-dihydroxyisoquinoline or 4-amino-1,8-naphthalimide before detorsion. Lipid peroxidation products, nitric oxide content and myeloperoxidase activity, an indicator of neutrophil accumulation, were assessed in testicular and renal tissues. RESULTS: Testicular torsion-detorsion caused a significant increase in lipid peroxidation products, nitric oxide content and myeloperoxidase activity in ipsilateral testes (p <0.01) but not in the contralateral testes or kidneys. Animals treated with poly (ADP-ribose) polymerase inhibitors had a significant decrease in these biochemical parameters compared with vehicle treated animals (p <0.01). CONCLUSIONS: These data emphasize that poly (ADP-ribose) polymerase may have a role in testicular damage caused by ischemia-reperfusion and the inhibition of poly (ADP-ribose) polymerase may be a novel approach to therapy for ischemia-reperfusion injury of the testis.     

睾丸扭转18例报告

目的 总结睾丸扭转的诊治体会。方法 报告18例睾丸扭转的临床诊治资料。结果 5例扭转时间短或不全扭转才经手术复位后保留了睾丸。13例（70％）坏死睾丸予以切除。结论 彩色多普勒超声成像是诊断急性睾丸扭转的可靠方法,治疗上主张作预防性睾丸固定,以免扭转复发或再发。     

Preoperative manual detorsion of the torsed spermatic cord

During a 10-year period 35 of 104 patients with torsion of the spermatic cord had preoperative manual detorsion. The detorsion was performed at the initial physical examination, most commonly without analgesia or sedation. In 34 evaluable patients all of the testes were salvaged without any evidence of atrophy. One patient whose testis appeared viable at operation was not available for followup. Recurrence was prevented by subsequent orchiopexy. The elapsed time between urological consultation and surgery ranged from 1 hour 40 minutes to 2 months. Six patients underwent an elective operation. Torsion did not recur between the time of manual detorsion and orchiopexy. Preoperative manual detorsion should be attempted at the initial physical examination because, if successful, the relief of testicular ischemia converts an acute urological emergency into an urgent or elective surgical procedure. More important, 100 per cent of the testes are salvaged.     

Manual derotation of the twisted spermatic cord

OBJECTIVE: To re-emphasize the safety and efficacy of manual derotation in the management of the twisted spermatic cord. PATIENTS AND METHODS: Seventeen patients (mean age 15 years, range 13-28) with acute unilateral torsion of the spermatic cord, initially treated by manual detorsion, were reviewed; all 17 patients were seen by one consulting urologist (H.F.M.K.). RESULTS: In 14 of the 17 patients the attempt resulted in successful manual derotation, i. e. the immediate relief of all symptoms and normal findings at physical examination. No testicular atrophy was detected during the follow-up (mean 22 months, range 9-72). CONCLUSIONS: These results reinforce the efficacy and safety of manual derotation with subsequent elective bilateral orchidopexy as the primary treatment for the twisted spermatic cord.