Incomplete prenatal torsion of the testicle--a successful salvage

The role of emergent intervention in prenatal testicular torsion is controversial. We report a case of successful testicular salvage of incomplete prenatal torsion. A 1-day-old male infant presented with a bluish-hued scrotum at birth. Testicular ultrasonography demonstrated right testicular torsion with minimal peripheral blood flow. Scrotal exploration was performed, confirming extravaginal torsion; both testes underwent orchiopexy. Subsequent imaging demonstrated normal bilateral testes with good vascular flow. Although intervention of prenatal torsion has been debated, the present case represents prenatal torsion saved by intervention. We propose the presence of any blood flow suggests incomplete torsion and the potential for salvage.     

A case of testicular torsion in a neonate]

A case of testicular torsion in a neonate is reported. A two-day-old boy with an abnormal hard mass in the right scrotum was referred to us. Right testicular torsion was suspected and operation was performed at 13 days after birth. During the operation extra-vaginal torsion of the right spermatic cord was revealed. The right testis appeared extensively necrotic, and right orchiectomy was selected. Histological examination revealed massively coagulo-necrotic testicular structure. To our knowledge, this is the 56th case of testicular torsion in a neonate reported in Japan. We discussed the onset, laterality, form, direction, angle and treatment of the torsion.     

Bilateral testicular torsion in a pre-term neonate

Bilateral testicular torsion in the neonate, although uncommon, is being reported with increasing frequency. Most previously reported cases have been full term, average to above average weight infants born with nonviable testes. We report a case of bilateral neonatal testicular torsion in a 32-week newborn in whom testicular viability may have been preserved by pre-term birth.     

The effect of unilateral experimental testicular torsion on spermatogenesis and fertility

Significant subfertility exists in patients following unilateral testicular torsion, implying bilateral testicular disease. Immunological activation has been detected after experimental torsion and the present study sought to demonstrate immunologically mediated effects on contralateral spermatogenesis following experimental torsion, as well as quantifying ipsilateral damage. Early and late effects of torsion on bilateral spermatogenesis were studied at 1 and 6 months in 10 groups each containing 20 rats. Gross and histological examination, direct immunofluorescence tests, vas deferens counts and copulation studies were performed. Severe ipsilateral damage was noted, even after brief torsion periods. No contralateral testicular effects, immunological or otherwise, were observed. Ipsilateral damage after torsion may have been underestimated. There is no damage to contralateral testicular exocrine function following unilateral experimental torsion.     

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.     

睾丸扭转误诊后导致男性不育及勃起功能障碍(英文)

睾丸扭转在25岁以下的男性中其发病率约为1/4 000,其高发人群为新生儿和进入青春期的青少年。睾丸扭转的误诊率为4%,非同期的双侧睾丸扭转被误诊的发病率没有报导。本文报道1例由于双侧睾丸扭转误诊后导致的睾丸功能衰竭、性腺功能低下及勃起功能障碍。患者在睾丸扭转10年后才因不育和勃起功能障碍就诊,精液分析检查为无精症,血清中的睾酮水平降低到去势的水平(0.14 nmol/L)。其不育为永久性,其勃起功能经睾酮替代和使用西地那非后得以恢复。     

Bell-Clapper综合征

目的：加强对Ｂｅｌｌ－Ｃｌａｐｐｅｒ综合征的认识，以及早诊断与手术，减少睾丸扭转坏死的发生率。方法：对４例间歇性睾丸疼痛及３例睾丸扭转坏死或萎缩病例的临床资料进行回顾性分析。结果：７例解剖上均有Ｂｅｌｌ－Ｃｌａｐｐｅｒ。对４例间歇性睾丸疼痛患者作了双侧睾丸探查及固定，３例睾丸坏死或萎缩者作了病睾切除及对侧睾丸固定术。     

Perinatal testicular torsion: preoperative radiological findings and the argument for urgent surgical exploration

Perinatal testicular torsion is an infrequent event, the management of which has been controversial. Occurrence is rare, estimated at 1 in 7500 newborns (Kaplan, G. W., Silber, I.: Neonatal torsion--to pex or not? In: Urologic surgery in neonates and young infants. Edited by King, L.R. Philadelphia: W.B. Saunders Co., 1988; Chapter 20, pp. 386-395). The frequency of bilateral perinatal torsion is up to 22% (J Urol. 2005;174:1579). Here, we describe two cases of bilateral asynchronous perinatal torsion, in which the only presenting abnormality on exam after birth was a unilateral scrotal mass. These cases illustrate that contralateral perinatal torsion may be present even when physical exam findings suggest unilateral involvement.     

Bell-C1apper畸形与睾丸扭转

通过7例Bell-Clapper畸形病例的总结和文献复习,提高对间歇性睾丸扭转的认识,及早诊断及手术,减少睾丸扭转坏死的发生率。对4例间歇性睾丸扭转病例及3例睾丸扭转坏死或萎缩病例的解剖与治疗的回顾作出Bell-Clapper畸形与睾丸扭转的关系分析。结果发现7例病人解剖上均有Bell-Clapper畸形,4例间歇性睾丸疼痛病人行了双侧睾丸探查和固定,3例睾丸坏死和萎缩病例行病睾切除及对侧睾丸固定术。作者提示,对间歇性睾丸疼痛的病人应提高警惕,在睾丸未发生扭转坏死之前及时行双睾探查,及时固定,防患于未然。     

Perinatal testicular torsion: The clear cut,the controversial,and the "quiet" scenarios

BackgroundPerinatal testicular torsion (PTT) is a catastrophic event that occurs in utero or up to 30 days postnatally, with testicular loss being the most common outcome.ObjectiveTo assess clinical evaluation, surgical management and clinical outcomes in patients with PTT in a quaternary referral pediatric center, to determine testicular salvageability and propose future management options.MethodsWe retrospectively reviewed a cohort of males born outside the quaternary center with a diagnosis of PTT, from May 2000 to July 2020. Data collection included mode of delivery, gestational age, birth weight, testicular examination at birth, clinical presentation, ultrasound results at diagnosis, surgical management and findings, perioperative complications, and follow-up.Results62 patients, including 2 patients with bilateral asynchronous PTT, were identified. Median (IQR) gestational age and birth weight were 39 (38–39.4) weeks and 3.4 (3.1–3.72) kg, respectively. Abnormal testicular examination at birth was found in 69% (Table 1). Doppler ultrasound was performed in all but 1 patient. 59 patients underwent surgery, 21 within 4 h, with bilateral exploration in 44 cases. Affected and non-affected testicles were explored in 76% and 98% of cases, respectively. 3 "nubbins" were found, of which 2 were excised. 3 nonsurgical complications were identified. During a median (IQR) follow-up of 3 (3–3) months, 63 testicles were removed or found to be non-functional, with compensatory hypertrophy in 38% of patients.ConclusionGiven that 3% of our patients presented with asynchronous bilateral PTT, as well as the safety of general anesthesia in a referral pediatric hospital, early bilateral scrotal exploration of PTT is recommended.Level of evidenceIV     

双侧精索扭转6例诊治体会

目的:探讨精索扭转的诊断和治疗方法。方法:回顾性分析6例双侧精索扭转患者的诊断和治疗经验。结果:6例患者均为双侧发病。1例双侧睾丸同时扭转,5例双侧睾丸相继扭转;2例行单侧睾丸切除,其余扭转睾丸行复位固定。结论:精索扭转需早期诊断并及时手术探查行复位固定,患侧复位固定同时可行健侧固定,如不行健侧固定必须严密监测随访。手法复位可作为有益尝试。     

The protective effect of darbepoetin alfa on experimental testicular torsion and detorsion injury

AIM: Testicular torsion is a serious urological emergency, usually involving newborns, children, and adolescents which can lead to subfertility and infertility. Prevention of testicular damage caused by torsion is still a clinical and experimental problem. So far many chemicals and drugs have been investigated for decreasing ischemia/reperfusion (I/R) injury in experimental animals. The possible protective effect of darbepoetin alfa, a novel erythropoietic protein, on testicular tissue after I/R injury was examined in this study. METHODS: Thirty rats were divided into three groups: sham operation, torsion/detorsion, and torsion/detorsion plus darbepoetin alfa groups. After torsion (2 hours) and detorsion (4 hours), bilateral orchiectomy was performed. Malondialdehyde, nitric oxide and glutathione levels were determined in testicular tissue. RESULTS: Administration of darbepoetin alfa caused a decrease of malondialdehyde and nitric oxide levels and an increase in glutathione levels compared with the torsion/detorsion group. In addition, histological injury scores were significantly decreased in the treatment group more than the torsion/detorsion group. CONCLUSION: The results suggest that darbepoetin alfa may be a potential protective agent for preventing testicular injury caused by testis torsion.     

Testicular torsion: which suture should be used?

We report a case of left testicular torsion four months after a similar homolateral case in which we did detorsion and bilateral fixation of both testicles. The antecedent orchiopexy was accomplished using 3-0 silk and transseptal fixation of the contralateral testicle. A history of bilateral orchiopexy should nor interfere with diagnosing torsion in the acute scrotum. We recommend the use of nonabsorbable suture material joining the testis to the dartos muscle in 3 locations and the contralateral hemiscrotum must be explored.     

Simultaneous bilateral testicular torsion in the adolescent

A rare case of simultaneous bilateral testicular torsion in a 12-year-old boy is reported. Although an acute scrotal emergency of unilateral testicular torsion is not uncommon, bilateral testicular torsion, synchronous or asynchronous, is rare.     

Intra-uterine testicular torsion: early diagnosis and treatment.

OBJECTIVE: To review the incidence and treatment of intra-uterine torsion of the testis which although rare is being recognized with increasing frequency. PATIENTS AND METHODS: From 1988 to 1997, five newborns (mean birth weight 3.62 kg, range 3.15-4.12) with unilateral torsion of the testis were treated; all underwent emergency exploration. The right testis was affected in three and the left in two boys. RESULTS: In all except one child, the affected testis was enlarged, firm to hard, tender, the overlying skin dark red and the affected testis higher than the contralateral testis. In one child the right testis was enlarged and higher, but soft to firm, and the overlying skin was oedematous and red. The exploration revealed extravaginal torsion of the testis which was gangrenous in four; in one after detorsion there was haemorrhage and haematoma of the cord and the tunica, and the testis was slightly congested but not gangrenous. This testis was preserved and bilateral orchidopexies performed; at 18 months both testes are palpable and of normal size. In the remaining four children the testes were frankly necrotic; they underwent orchidectomy and contralateral orchidopexy. Histology in all four revealed a totally infarcted testis with extensive haemorrhage and vascular congestion. CONCLUSION: The early diagnosis and treatment of intra-uterine torsion of the testis is essential.     

Torsion of the testis and allied conditions.

In 15 years at Bristol there have been 293 cases of torsion of the testis, 55 cases of torsion of a testicular appendage and 5 cases of testicular ischaemia due to other causes. The risk of a male developing torsion of the testis or its appendix by the age of 25 is about 1 in 160. Both conditions occurred primarily in adolescents, but among prepubertal boys torsion of an appendage was as common as torsion of a normally descended testis. There was a slight left-sided preponderance in testicular torsion, more marked in torsion of the appendages; the incidence of bilateral torsion was 2-0 and 1-8 per cent respectively. The clinical features and differential diagnosis of the two conditions are compared. Torsion of a testicular appendage is the most commonly misdiagnosed scrotal lesion, the preoperative diagnosis being correct in only 11 per cent of cases compared with 90 per cent for torsion of the testis. Twenty-one cases of recurrent torsion underwent prophylactic bilateral orchidopexy. There were 20 cases of torsion of undescended testes, with a salvage rate of only 20 per cent. The overall testicular survival rate was 55-3 per cent. Viability depends upon the possibility of spontaneous reduction, the preoperative delay after the onset of symptoms, the degree of torsion of the cord and the length of follow-up in doubtful cases. Urgent scrotal exploration is advised in every case of acute testicular pain unless there is overwhelming evidence of epididymoorchitis. Exploration of the opposite side is mandatory in torsion of the testis and advisable in torsion of an appendage.     

黄芪注射液对大鼠扭转复位后睾丸组织的保护作用

目的:探讨黄芪注射液对雄性Wistar大鼠扭转复位后睾丸的保护作用。方法:30只大鼠随机分为假手术组(A组)、睾丸扭转复位组(B组)、黄芪注射液治疗组(C组),每组10只,Turner法建立单侧睾丸扭转复位模型,原位缺口末端标记法检测各组睾丸组织中生殖细胞凋亡,化学比色法测定超氧化物歧化酶(SOD)和丙二醛(MDA)含量。结果:黄芪注射液治疗组与睾丸扭转复位组比较,SOD含量明显升高,MDA含量明显降低,生精细胞凋亡指数明显降低。睾丸扭转复位组、黄芪注射液治疗组与假手术对照组比较,SOD含量明显降低,MDA含量明显升高,生精细胞凋亡指数明显升高。结论:黄芪注射液可减少大鼠睾丸扭转复位后睾丸组织的双侧睾丸生殖细胞凋亡,对扭转复位后睾丸生殖细胞有保护作用。其机理可能与提高抗氧化酶活性及减少氧自由基的产生从而减轻大鼠睾丸扭转复位后的缺血再灌注损伤有关。     

Sertoli cell tumor in a prepubertal boy mimicking testicular torsion

A 9-year-old boy presented with left, intermittent testicular pain that was present for 3 days. On physical examination, left testis was grossly enlarged and firm but mildly tender. Serum alpha-fetoprotein and beta-human chorionic gonadotropin levels were within normal range. Color doppler ultrasonography which was performed to rule out testicular torsion revealed an intratesticular mass located at the upper pole of left testis and left radical orchiectomy was performed. The histopathological diagnosis was Sertoli cell tumor.     

单侧睾丸扭转对生殖细胞凋亡及黄芪保护作用的实验研究

目的观察大鼠单侧睾丸扭转／复位后患侧和对侧睾丸生精细胞凋亡情况,探讨单侧睾丸扭转／复位后生殖能力下降的机制以及黄芪注射液对其再灌注损伤的保护作用。方法将40只健康雄性Wistar大鼠分为4组,分别为假手术对照组（A组）,睾丸扭转／复位组（B组）,睾丸扭转／复位＋单次腹腔内注射黄芪注射液组（C组）及扭转／复位十连续腹腔内注射黄芪注射液组（D组）,每组10只。按Turner法建立睾丸扭转／复位模型,所有大鼠均在同等条件下喂养至术后7d处死,切取双侧睾丸后检测凋亡指数。结果扭转侧睾丸生殖细胞凋亡指数（AI）A组（5．82±1．21）与B组（36．18±8．40）、C组（20．39±3．57）、D组（11．61±5．12）相比差异有显著性（P〈0．05）,B组明显高于C组及D组（P〈0．05）,C组与D组相比差异有显著性（P〈0．05）;B组对侧睾丸（12．95±3．06）与C组（9．45±1．71）、D组（7．56±1．06）两组对侧睾丸AI相比差异有显著性（P〈0．05）,C、D两组对侧睾丸AI差异有显著性（P〈0．05）。结论单侧睾丸扭转可致患侧和对侧睾丸生精细胞凋亡明显增加,黄芪注射液可明显减少双侧睾丸生殖细胞凋亡,连续应用黄芪注射液优于单次应用。     

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.