Spermatic cord torsion in the newborn: role of surgical exploration]

Torsion of the spermatic cord is frequent in neonates suffering from acute scrotal distress. A retrospective study was carried out to determine the viability and the outcome of testis treated by surgical exploration. PATIENTS AND RESULTS: Surgical exploration of 30 neonates presenting acute scrotal distress found: 18 torsions of the spermatic cord, six intrascrotal bleedings or hematoma due to delivery trauma, five tunica vaginalis inflammations and one ischemia without torsion. The torsion occurred in utero in 16 cases and after birth in two cases. The contralateral uninvolved testis was fixed to the scrotum in all cases. The torsion was extravaginal in 17 cases and intravaginal in one case. In all cases of prenatal torsion, there was total necrosis of the testis. One case of postnatal torsion operated on four hours after the beginning of the torsion was saved. CONCLUSION: Although the viability of the torsioned testis is compromised in cases of prenatal torsion, surgical exploration is necessary to confirm diagnosis and to avoid any contralateral torsion because bilateral torsion exists. Only emergency surgical exploration can save a testis that has undergone post-natal torsion as reported in others series.     

Acute scrotum -etiology,clinical presentation and seasonal variation

Objective  The aim of the present study was to evaluate the etiology, history, physical examination findings, and seasonal variation of acute scrotal problems in children. Methods  A retrospective review of all boys, presenting with acute scrotum to the Pediatric Surgery Clinic of the University Hospital Heraklion between January 1989 and December 2006 was performed. Results  A total of 140 boys presented with scrotal pain were included. Overall the commonest cause of acute scrotum was epididymo-orchitis (35%, 95%CI: 27%–43%), followed by torsion of appendages. In contrast the most common cause in boys of preschool age was spermatic cord torsion (P<0.020). All cases of spermatic cord torsion were characterized by severe testicular pain and an absent cremasteric reflex. The interval between pain initiation and presentation to our clinic was 11.4 hours (SD:3.07) when the testis was salvaged by detorsion, and 19.0 hours (SD:6.32) when the testis was removed. The difference between means was statistical significant (p<0.001). The incidence of torsion of appendages (p<0.036) and/or spermatic cord (p<0.047) was increased in winter. Conclusion  The absence of cremasteric reflex in association with testicular tenderness strongly suggests testicular torsion. The low temperatures during winter may account for the increased incidence of the torsion of both the spermatic cord torsion and the appendages.     

Inguinal approach for the management of unilateral non-palpable testis: Is diagnostic laparoscopy necessary?

ObjectiveDuring the last decade laparoscopy has increasingly been advocated as the primary investigative procedure for the management of the non-palpable testis. We reviewed the medical records in a consecutive series of boys with non-palpable testis to examine the contribution of the initial inguinal approach in the management of unilateral non-palpable testis.Materials and methodsAmong the 183 consecutive patients with cryptorchidism from 2003 to 2012, there were 21 patients with unilateral and three with bilateral non-palpable testes. All unilateral patients then underwent inguinal and scrotal exploration through an inguinal incision. For those patients with an intra-abdominal peeping testis, the gonad was placed into the scrotum after meticulous cranial mobilization of the spermatic cord.ResultsPatient age ranged from 11 months to 144 months (mean age: 23 months). Among the 21 unilateral cases, testicular absence or atrophy was confirmed in seven patients with a scrotal nubbin in six, and blind-ending vas and vessels at the external inguinal ring in one patient. Among the remaining 14 patients with sizeable testes, 12 testes were intra-abdominal peeping testes and two testicles were seen within the distal inguinal canal, which may be missed on physical examination owing to patient obesity. The intra-abdominal peeping testicle had the opened processus vaginalis entering the internal ring in which testicle was found. These were fixed into the scrotum successfully by cranial mobilization of spermatic vessel sometimes cutting the internal oblique muscle and by Prentiss and Fowler-Stephen's maneuver. Diagnostic laparoscopy was done on three patients with bilateral cases.ConclusionsGiven the result that most of nubbins are within the scrotum and testes with intra-abdominal peeping testes are fixed down safely into the scrotum, the inguinal approach may suffice for the management of unilateral non-palpable testis. Laparoscopy should be reserved for patients with bilateral non-palpable undescended testes.     

Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys

Background: Diagnosis of testicular torsion in children is challenging, as clinical presentation and findings may overlap with other diagnoses. Objective: To define the clinical and ultrasound criteria that best predict testicular torsion. Materials and methods: The records of children hospitalized for acute scrotum from 1997 to 2002 were reviewed. The clinical and ultrasound findings of children who had a final diagnosis of testicular torsion were compared with those of children who had other diagnoses (torsion of the testicular appendix, epididymitis, and epididymo-orchitis). Results: Forty-one children had testicular torsion; 131 had other diagnoses. Stepwise regression analysis yielded three factors that were significantly associated with testicular torsion: duration of pain 6 h; absent or decreased cremasteric reflex; and diffuse testicular tenderness. When the children were scored by final diagnosis for the presence of these factors (0–3), none of the children with a score of 0 had testicular torsion, whereas 87% with a score of 3 did. The ultrasound finding of decreased or absent testicular flow had a sensitivity of 63% and a specificity of 99%. Eight of ten children with testicular torsion and normal or increased testicular flow had a coiled spermatic cord on ultrasound. Conclusion: We suggest that all children with acute scrotal pain and a clinical score of 3 should undergo testicular exploration, and children with a lower probability of testicular torsion (score 1 or 2) should first undergo diagnostic ultrasound. Because the presence of testicular flow does not exclude torsion, the spermatic cord should be meticulously evaluated in all children with acute scrotum and normal or increased testicular blood flow.     

Critical validation of colour Doppler ultrasound in diagnostics of acute scrotum in children.

Acute scrotum in children is generally a symptom. Several pathologies of the testis, scrotum or groin may cause it, including inflammatory as well as ischaemic processes. Testicular torsion with ischaemia of the testis is an emergency requiring prompt surgical intervention. Even experienced paediatric surgeons and urologists may have difficulties differentiating an ischaemic from an inflammatory aetiology solely on the basis of clinical signs and symptoms. In cases of aetiologic uncertainty, operative exploration has to be performed to rule out ischaemia, which led in the past to a high rate of surgery. More recently, colour Doppler ultrasonography (CDUS) has become an imaging modality for the examination of the acute scrotum with the purpose of detecting ischaemia, thus reducing the need for explorative surgery. In this study we examined the reliability of CDUS, comparing the sonographical diagnoses with both the intraoperative findings and the clinical course. We present here 132 consecutive cases of acute scrotum in children, who were admitted from 01/98 through 10/02 to our hospital. All patients underwent CDUS. Patients with ultrasonographic signs of ischaemia of the testis (group A) and patients with demonstrated perfusion and suspicious or severe clinical symptoms (group B) were operated immediately. Patients with demonstrated perfusion without suspicious or severe symptoms (group C) were treated conservatively. Thirty-eight patients (28.8%) were treated operatively. Eleven cases of testicular torsion in group A (12 pat.) could be confirmed intraoperatively, in one case there was no testicular torsion but a severe inflammation of the testis with torsion of the appendix testis. In group B (26 pat.) operative exploration revealed one case of testicular torsion. In group B two cases of sonographically suspected torsions of the appendix testis also emerged as epididymitis intraoperatively. In the other cases postoperative diagnosis was in agreement with the preoperative CDUS. The clinical course of 94 conservatively treated patients (71.2%) (group C) confirmed in all cases a non-ischaemic aetiology. There was a total of 12 cases (9.1%) where acute scrotum was caused by testicular torsions. This relatively low rate underlines the necessity to differentiate between ischaemic and other aetiologies, thus avoiding operation in many patients. 71.2% of our patients could be treated conservatively. However, it is essential to exclude an ischaemic cause before opting for conservative therapy. Even though CDUS is a very valuable diagnostic tool in this sense, this exclusion cannot be ensured in every case and is highly dependent on the expertise and technique of the investigator. Therefore in cases with any doubts an operative exploration has to be performed to avoid the most dreaded complication in the treatment of acute scrotum.     

The value of laparoscopy in the management of non-palpable testis

ObjectTo retrospectively review the value of laparoscopy in the management of impalpable testis.Materials and methodsIn 1993–2006, 182 laparoscopies for impalpable testis were performed for a total of 194 testicular units. Five laparoscopic findings were considered: testicular ectopia, intra-abdominal testis, and cord structures that are blind ending, completely absent (agenesis) or entering the internal inguinal ring.ResultsIn 62 cases an intra-abdominal testis was found; 18 were classified as high and managed by a laparoscopic Fowler–Stephens procedure. Cord structures entering the inguinal ring were observed in 77 patients and 45 underwent an inguinal exploration: a testis was found in 12 cases and in 33 a remnant was excised. In 35 cases, intra-abdominal blind ending vas and vessels were observed and eight showed testicular agenesis. No major surgical complications were recorded. Follow up ranged from 1 to 3 years.ConclusionsOur study confirms the value of laparoscopy in the management of non-palpable testis, providing a definitive diagnosis by the direct view of spermatic bundle and testis. Ninety-three patients were managed by laparoscopy only, and in 44 it was essential for the subsequent surgical approach. When the internal inguinal ring is patent and/or normal spermatic vessels are present an inguinal exploration is mandatory.     

Right testicular necrosis and left vanishing testis in a neonate

We describe a rare case of right testicular necrosis and left vanishing testis in a neonate. The patient presented with a right swollen testis and left non-palpable testis at birth. Exploratory laparotomy was performed at 23 days after birth, and the right testis was extirpated because of extensive necrosis due to torsion of the spermatic cord. Histopathological examination revealed a massively necrotic testicular structure with hypertrophy of Leydig cells. Hypergonadotropinemia was also recognized before operation. On laparoscopy at the age of 5.3 years, a normal left vas deferens and spermatic vessels exiting through the internal inguinal ring were confirmed, although the patient's left testis was not found in the intraperitoneal cavity. An hCG test demonstrated no response of serum testosterone. These findings suggested a diagnosis of left vanishing testis due to testicular regression. We therefore speculated that bilateral asynchronous testicular torsion had occurred prenatally in this patient.     

新生儿睾丸扭转临床特点探讨

目的 探讨新生儿睾丸扭转发生的特点及治疗时机选择.方法 回顾性分析近10年新生儿睾丸扭转患儿可能的致病危险因素、临床特点、超声检查结果、治疗策略、病理结果及术后随访情况.结果 新生儿睾丸扭转共17例,左侧7例,右侧10例;其中剖腹产11例(65%),第二产程延长5例(29%),羊水过少2例(12%);术前体检均发现睾丸增大,多伴有阴囊色泽改变(94%).超声检查均发现患睾体积增大、回声不均或增强、血流信号减小或消失.术中探查打开肉膜组织后均发现精索睾丸扭转并已坏死而行患睾切除,其中14例行对侧睾丸固定术.所有患睾病理活检均提示睾丸坏死,7例(41%)可见钙化灶.所有随诊病例超声检查未发现对侧睾丸异常.结论 新生儿睾丸扭转失睾率极高;当发现阴囊色泽改变、睾丸增大等改变,即应考虑睾丸扭转可能;超声检查敏感性高,可作为首选检查方法;患儿出生过程出现异常可能是新生儿睾丸扭转的诱因.

Abstract：

Objective To investigate the clinical characteristics and management of neonatal testicular torsion. Methods Neonatal testicular torsion were reviewed focusing on the possible risk factors, clinical features, ultrasonic characteristics, management, pathological outcome and follow-up results. Results A total of 17 neonatal testicular torsion (left side 7, right side 10) was diagnosed. 11cases of them were cesarean delivery (65 %). 5 cases were found a prolonged second stage of labor (29%), and 2 cases with oligohydramnios (12%) before birth. All patients presented an enlarged testes. Most of them presented with scrotal discoloration (94%). Ultrasound examination showed enlargment of testicular volum, heterogeneity and lacked of blood flow. The twisted testes and spermatic cord showed necrosis intra-operatively. Orchiectomy was carried out. Orchidopexy on contralateral testis was performed in 14 cases. Pathology of ipsilateral testes showed necrosis, and calcification occurred in 7 cases(41 %). All contralateral testes presented normal Ultrasound image during the followup. Conclusions The rate of testicular necreosis was high in neonatal testicular torsion. Testicular torsion should be suspected when neonatal testis presents scrotal discoloration and enlarged testicular mass. Ultrasound inspection is a sensitive method in diagnosing neonatal testis torsion, and should be recommended. Abnormal labor may lead to the neonatal testis torsion.     

Acute scrotum — Etiology and management

Objective: Acute scrotal pain is a common urological emergency. Urgent exploration is the standard means of management, since no investigation can confidently exclude torsion of testis from the differential diagnosis.Methods: A review of all boys presenting with acute scrotal pain who underwent emergency scrotal exploration between January 1983 and March 2003 was performed.Results: 195 boys were included in this study. They were divided into 3 groups: group 1–73 with epididymo-orchitis, group 2–63 with torsion of testicular appendages and group 3–57 with spermatic cord torsion. The patients in group 2 were older than group 1, also patients in group 1 were older than group 3. During neonatal period the most common pathology was spermatic cord torsion, whereas in prepubertal period torsion of appendages was more common. In all boys, mean duration of pain at presentation was 2.11 days. Epididymo-orchitis was diagnosed in 37% of patients, with torsion of the appendages being the next most common entity. Testicular torsion was diagnosed in 29% of patients. In the group with testicular torsion salvage rate of testis was 37% because of late admission. The perioperative morbidity and mortality was not seen in any of the groups.Conclusion: We believe that any boy with acute scrotal pain and any suspicion of testicular torsion in physical examination must be applied routine surgical exploration.     

Sonographic diagnosis of acute spermatic cord torsion. Rotation of the cord: a key to the diagnosis

BACKGROUND: Although the primary abnormality in testicular torsion is at the spermatic cord, imaging studies up to now have mostly been oriented to evaluation of the testicle itself, with emphasis on color Doppler ultrasonography (US). However, findings can be inaccurate when there is incomplete interruption of testicular flow. Indirect findings, such as morphological changes in the testis alone, are not reliable for the diagnosis since they become evident late in the disease. OBJECTIVE: To call to attention to the fact that sonographic visualization of the spermatic cord can be the key for diagnosis in those patients with acute scrotal pain as a result of testicular torsion, particularly when color Doppler US shows that intratesticular flow is present within the affected testis. PATIENTS AND METHODS: Six patients who presented clinically with acute scrotal pain and had spermatic cord torsion, proven at surgery. All patients were initially studied with color Doppler US, and intratesticular flow was detected in all of them. Patients who showed structural abnormalities on gray-scale US and/or absence of intratesticular vascular flow in the affected testis were not included. In addition to a conventional study, the spermatic cord was examined. RESULTS: The spermatic cord was shown to be rotated on the symptomatic side in all patients. Local morphological and vascular flow changes, distal and at the site of the torsion, were found and registered. CONCLUSIONS: The finding of a rotated spermatic cord could be a highly reliable and direct sign for the diagnosis of a testicular torsion, and this is especially important when vascular flow is present within the affected testis on color Doppler US examination. Examination of the spermatic cord should be added to evaluation of the testis in patients with suspected testicular torsion to enhance sensitivity of the examination.     

Scrotal Exploration for Testicular Torsion and Testicular Appendage Torsion: Emergency and Reality

Background:

Scrotal exploration is considered the procedure of choice for acute scrotum.

Objectives:

We evaluated the importance of early diagnosis and testicular salvage on the therapeutic outcomes of patients with pediatric testicular torsion (TT) and testicular appendage torsion (TAT) in our geographic area.

Patients and Methods:

We performed a retrospective database analysis of patients who underwent emergency surgery for TT or TAT between January 1996 and June 2009. Patient history, physical examination findings, laboratory test results, color Doppler sonography (CDS) results, and surgical findings were reviewed.

Results:

A total of 65 cases were included in our analysis. Forty-two cases were followed up for at least 3 months. Testicular tenderness was identified as the major clinical manifestation of TT, while only a few patients with TAT presented with swelling. CDS was an important diagnostic modality. The orchiectomy rate was 71% in the TT group.

Conclusions:

Cases of acute scrotum require attention in our area. Early diagnosis and scrotal exploration could salvage the testis or preserve normal function without the need for surgery.     

Neonatal testicular torsion

Twenty-six cases of neonatal torsion of spermatic cord were studied and compared to 171 cases reported in the literature. In a few cases, the torsion was antenatal and this may explain some absent testes. Diagnosis is sometimes difficult to make; symptoms were comparable to those in other disorders: peritoneo-vaginal tunnel, testicular inflammation or testicular tumor. In these cases, surgery can make the exact diagnosis although it cannot save the testis even if it is performed early.     

The “atrophic” testicular remnant

Remnants of testicular tissue at the end of a diminutive spermatic cord are the end result of testicular infarction from torsion of the testis or spermatic cord, occurring either in utero or unrecognized in the neonatal period. Idiopathic testicular artery thrombosis is another possibility. The majority of 20 specimens examined microscopically showed fibrosis, hemosiderin deposits, and calcification. Fixation of the opposite testis is recommended for these patients.     

儿童睾丸附件扭转的保守治疗指征

目的探讨儿童睾丸附件扭转保守治疗的指征。方法回顾性总结分析1993～1997年底的25例急性阴囊疼痛患儿的诊疗情况,结合文献提出鉴别诊断及选择疗法的依据,将其应用于1998年以后收治的26例患儿中,进一步探讨诊断和治疗指征。结果回顾性总结表明睾丸扭转症状重,就诊早,就诊时间多在发病24h之内。附件扭转疼痛轻,就诊晚,多有48h以上的病史,两者比较,差异有显著性意义(P＜0.05)。1998年后治疗的26例中,5例就诊时疼痛时间短于48h,1例在睾丸上极摸到疼痛性结节,诊断睾丸附件扭转,行保守治疗;4例行急症手术,证实1例睾丸扭转、3例附件扭转。21例就诊时疼痛已48h以上,19例症状轻,彩色多普勒检查,睾丸血流正常,行保守治疗,治疗过程中均可摸到大小不等的触痛性结节,诊断睾丸附件扭转。2例睾丸扭转坏死而行睾丸切除。结论睾丸附件扭转是一种自限性疾病。扪到其特有体征,即阴囊内触疼性结节者;阴囊痛持续48h以上,彩色多普勒检查,睾丸血流正常者,可行保守治疗。睾丸扭转是外科急症,应急症手术。彩色多普勒超声检查对鉴别诊断有重要意义。     

有腹股沟区手术史的隐睾患儿诊疗分析

目的探讨腹股沟区手术后隐睾的原因、预防措施及手术方法。方法回顾性分析2006年6月至2011年3月作者收治的13例（14侧）腹股沟区手术后再次行隐睾手术患儿的临床资料,其中隐睾手术后8例,腹股沟斜疝手术后4例,鞘膜积液手术后1例。均再次行睾丸下降固定术,手术前后超声测量睾丸容积。结果13例（14侧）患儿睾丸均降入阴囊内,术中见瘢痕粘连明显。术后12例（13侧）获随访2个月至4年,睾丸无回缩,彩超提示13侧睾丸位置、血流正常,睾丸容积4侧较术前缩小5％一15％,1侧与术前相当,8侧较术前增大。结论导致腹股沟区手术后隐睾的原因为隐睾合并斜疝或鞘膜积液时只处理了后者,或单纯行斜疝或鞘膜积液手术时操作不当使睾丸上移,或隐睾手术中未充分游离精索,未达到无张力下降,以致睾丸上缩。腹股沟区手术后隐睾应适时手术,再次手术要仔细分离腹股沟粘连,并注重腹膜后精索的游离。     

Testicular torsion following torsion of a hydatid of Morgagni

The acute scrotum is one of the commonest surgical emergencies in pediatric practice. Early diagnosis, prompt treatment, and preventive measures are important to avoid testicular infarction. Occurrence of torsion has been previously reported following orchidopexy for undescended testis and for previous torsion of the testis. We report a case of intravaginal torsion of the testis in a patient who had previously undergone exploration and excision of a torted hydatid of Morgagni without formal orchidopexy. As exploration of the scrotum does not confer protection against subsequent torsion, orchidopexy should be routinely performed in patients who are found to have high investment of the tunica vaginalis or separation of the epididymis and testis on scrotal exploration for any reason. Correspondence to: E. J. Guiney     

Colour Doppler ultrasonography replacing surgical exploration for acute scrotum: myth or reality?

Background: Traditionally, every patient with an acute scrotum needed surgical exploration for definitive exclusion of testicular torsion. Objective: In this study, we aimed to evaluate the improved accuracy in clinical diagnosis with colour Doppler Ultrasonography (US) added to normal clinical assessment. Materials and methods: We retrospectively reviewed 626 patients, who presented with acute scrotal pain between January 1998 and June 2004. Following history and physical examination, the patients either proceeded directly to surgery or underwent US examination. If clinical suspicion of testicular torsion persisted after US, the patients would still undergo scrotal exploration. Results: Of the 294 patients who had routine scrotal exploration without preliminary US, only 23 (7.8%) were found to have testicular torsion. Amongst the 332 cases that had initial US, 9 (2.7%) patients revealed testicular torsion that was confirmed at subsequent surgery. The remaining 323 patients had initial negative US, but 29 were explored eventually on clinical indications. Of these, 4 (1.2% of 323) cases were diagnosed intra-operatively as testicular torsion. None of the remaining 294 patients who were managed conservatively proved to have testicular torsion after a minimum follow-up of 2 weeks. For testicular torsion, US yielded a sensitivity of 69.2% (95% confidence interval =38.9–89.5), specificity of 100% (95% CI=98.5–100), positive predictive value of 100% and negative predictive value of 97.5%. Conclusions: US has proven to decrease the number of emergency scrotal explorations, length of hospital stay and hence reduce the cost of management of acute scrotum.     

Colour Doppler imaging — a new method to differentiate torsion of the spermatic cord and epididymo-orchitis

A newborn boy with torsion of the spermatic cord and an 8-year-old boy with epididymitis were investigated by colour Doppler imaging (CDI). Due to torsion of the spermatic cord, no blood flow could be observed within the testis and the epididymis. In epididymitis blood flow was markedly increased. CDI seems to be useful for differentiating between the two disorders.     

Torsion of the spermatic cord after orchiopexy

The cases of spermatic cord torsion reported here show that this condition may occur even some time after fixation. Three men, aged 22, 30 and 35 years, visited the urologist with complaints of an acute scrotum following earlier orchiopexy for spermatic cord torsion. Different techniques are employed to fixate the testicles after spermatic cord torsion. These cases confirm that Jaboulay's bottleneck procedure is the method of choice for bilateral fixation in patients presenting with this condition.     

Division of the genitofemoral nerve and late orchiectomy: effects on the contralateral testis in ipsilateral testicular torsion

Unilateral torsion of the spermatic cord has been demonstrated to damage the contralateral testis; however, the pathogenesis has not yet been examined in detail. The purpose of this study was to evaluate the influence of unilateral torsion on the contralateral testis in rats by performing ipsilateral division of the genitofemoral nerve (GFN) and/or late orchiectomy. Male 25-day-old, prepubertal Wistar albino rats were divided into five groups: (1) sham operation; (2) unilateral testicular torsion; (3) simultaneous unilateral testicular torsion and ipsilateral GFN division; (4) unilateral testicular torsion and orchiectomy on the 4th day after torsion; and (5) simultaneous unilateral testicular torsion and GFN ipsilateral division, and orchiectomy on the 4th day after torsion. Torsions performed were 720°, all on the right testes. On day 55 after torsion, which represents the early postpubertal period of the rat, the contralateral testes were removed. Tubular biopsy score (TBS) was calculated, and seminiferous tubular diameters (STD) were measured. Student's t-test was used for statistical analysis. There was no contralateral testicular damage in the control group, but in all of the study groups destructive changes were found in the left gonad after torsion of the right testicle. The mean TBS of the study groups was higher than that of the control group. STD values were lower in the study groups, but the differences were not statistically significant between groups. In prepubertal rats, unilateral torsion causes histologically measurable changes in the contralateral testis. Ipsilateral division of the GFN and late orchiectomy did not cause any significant alterations in terms of contralateral damage. Further investigations are needed to determine the role of the GFN in testicular torsion.