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Indicators and outcomes of transfer to tertiary pediatric hospitals for patients with testicular torsion

      Summary

      Introduction

      Testicular torsion threatens testicular viability with increased risk of loss with delayed management. Still, healthy adolescents continue to be transferred from community hospitals to tertiary hospitals for surgical management for torsion even though adult urologists may be available. We sought to determine reasons behind patient transfer and to evaluate whether transfer to tertiary centers for testicular torsion leads to increased rates of testicular loss.

      Materials and methods

      A retrospective chart review was performed for patients presenting to our free-standing pediatric tertiary care facility with surgically confirmed testicular torsion during the 5-year period between January 2011 and January 2016. Data was collected regarding transfer status, patient demographics, time of presentation to our facility, duration of symptoms, patient workup, and surgical outcomes. Patients with perinatal or intermittent torsion were excluded.

      Results

      One-hundred and twenty-five patients met the inclusion criteria. Thirty-six of those were transferred from outside facilities while 89 presented directly to our hospital. A greater proportion of the transferred patients presented during nights or weekends than those presenting directly to our facility (77.8% versus 51.7%, p = 0.009). Eighty-nine patients presented with symptom duration of less than 24 h and had potentially viable testicles. Of those, 23 were transferred and 66 presented directly to our hospital. Differences are shown in the Table. Transferred patients had twice the rate of testicular loss as those not transferred, although the results were not significant (30.4% versus 15.2%, p = 0.129). Patients undergoing ultrasound prior to transfer had prolonged symptom duration and faced higher rates of testicular loss when compared with patients not transferred, although the latter was not significant (mean duration 8.0 versus 4.9 h, p = 0.025, and testicular loss 40.0% versus 15.2%, p = 0.065, respectively). Patients transferred over 30 miles had over 2.5 times the rate of testicular loss than those not transferred (42.8% versus 15.2%, p = 0.029).

      Discussion

      This study is unique in its examination of motivations for transfer of patients presenting with testicular torsion and in its evaluation of the impact of transfer on testicular salvage rates for potentially viable testicles (those with less than 24 h since symptom onset).

      Conclusion

      TableComparison of patients presenting with symptom duration <24 h: transfer status, ultrasound status, and transfer distance
      TransferredNot transferredp-valueUltrasound prior to transferNot transferredp-valueTransferred >30 milesNot transferredp-value
      n = 23n = 66n = 15n = 66n = 14n = 66
      Duration of symptoms, hoursMean 12.8 range 0.4–17.9 SD 4.3Mean 14.1 range 3.6–21.7 SD 3.00.116Mean 8.0 range 3.1–18.2 SD 5.1Mean 4.9 range 0.5–23.3 SD 4.60.025Mean 7.1 range 2.6–18.2 SD 5.1Mean 4.9 range 0.5–23.3 SD 4.60.121
      Testicular loss30.4%15.2%0.12940.0%15.2%0.06542.8%15.2%0.029

      Keywords

      Introduction

      Testicular torsion remains the leading cause of testicular loss in adolescents [

      American Urological Association. Medical Student Curriculum: Acute Scrotum https://www.auanet.org/education/acute-scrotum.cfm. [Accessed 29 November 2016].

      ,
      • Mansbach J.M.
      • Forbes P.
      • Peters C.
      Testicular torsion and risk factors for orchiectomy.
      ]. Timing from symptom onset to repair is the main factor affecting testicular loss [
      • Bennett S.
      • Nicholson M.S.
      • Little T.M.
      Torsion of the testis: why is the prognosis so poor?.
      ,
      • Yang C.
      • Song B.
      • Tan J.
      • Liu X.
      • Wei G.H.
      Testicular torsion in children: a 20-year retrospective study in a single institution.
      ,
      • Sessions A.E.
      • Rabinowitz R.
      • Hulbert W.C.
      • Goldstein M.M.
      • Mevorach R.A.
      Testicular torsion: direction, degree, duration and disinformation.
      ,
      • Cubillos J.
      • Palmer J.S.
      • Friedman S.C.
      • Freyle J.
      • Lowe F.C.
      • Palmer L.S.
      Familial testicular torsion.
      ]. While patients with torsion may require transfer to tertiary facilities for management because of complex medical conditions or lack of local urologic coverage, transfers of healthy adolescents from hospitals served by board certified urologists also occur. The American Board of Urology (ABU) considers management of testicular torsion to be part of core urologic training and recently stated “the Board does not support the practice of urologists on call deferring routine pediatric care to subspecialty certified colleagues in order to avoid call cases” [
      • Jordan G.H.
      From the desk of Gerald H. Jordan, ABU executive secretary.
      ].
      Transferring patients may be encouraged by the lack of data surrounding transfer rates and testicular loss. Prior studies suggested an association between patient transfer and increased risk of orchiectomy [
      • Zhao L.C.
      • Lautz T.B.
      • Meeks J.J.
      • Maizels M.
      Pediatric testicular torsion epidemiology using a national database: incidence, risk of orchiectomy and possible measures towards improving the quality of care.
      ]; transfer distance and duration of symptoms have been shown to be associated with orchiectomy rate, although transfer status alone was not an independent factor [
      • Even L.
      • Abbo O.
      • Le Mandat A.
      • Lemasson F.
      • Carfagna L.
      • Soler P.
      • et al.
      Testicular torsion in children: factors influencing delayed treatment and orchiectomy rate.
      ]. Still, these studies suffered from inclusion of patients with symptom duration over 24 h (with only remote possibility of salvage) [
      • Friedman A.
      • Ahmed H.
      • Gitlin J.S.
      • Palmer L.S.
      Standardized education and parental awareness are lacking for testicular torsion.
      ], which may have contributed to the negative findings. Given that testicular salvage in torsion is a time-dependent issue and transfer increases the time from presentation to management, it would follow that patients being transferred are at increased risk for testicular loss.
      We sought to determine reasons for transfer of otherwise healthy patients with testicular torsion. We hypothesized that patients are more likely to be transferred when presenting during inconvenient times, that is, at nights and weekends, and that patients are more likely to be transferred if they have public insurance. Moreover, we sought to evaluate whether transfer to a tertiary center for testicular torsion leads to increased rates of testicular loss.

      Methods

      With institutional review board approval, we performed a retrospective review of patients with surgically confirmed testicular torsion presenting to our facility, an urban stand-alone tertiary pediatric hospital, between January 2011 and January 2016. Data collected for each patient included demographic data, information about symptoms and presentation, timing of workup, and testicular viability. We excluded events of perinatal torsion and patients with delayed repairs for intermittent torsion. Because exact information regarding timing of initial presentation to outside facilities was unknown, time of presentation was recorded for arrival to the emergency department at our tertiary care facility. Duration of symptoms was calculated using the difference between patient-reported symptom onset and the time of presentation to our facility.
      Patients were divided into two groups: transferred and not transferred. Patients were classified as being transferred if they were referred to our emergency department (ED) after being initially evaluated at institutions where our urologists do not provide coverage. Patients were considered not to have been transferred if their initial presentation was to our ED or a facility where our urologists are covering staff, such as urgent care facilities owned by our hospital. Patients presenting initially to their primary care providers were also considered not to be transferred, as these patients initially presented to institutions without urology coverage.
      Patients were also classified into two groups according to time of arrival at our ED: daytime or nighttime/weekend. Daytime arrival included patients presenting between 6 am and 6 pm Monday through Friday. Nighttime and weekend arrival included patients who presented during the weekend (Friday at 6 pm to Monday at 6 am) or Monday through Thursday night between 6 pm and 6 am.
      To evaluate testicular viability, we selected the sub-group of patients presenting with duration of symptoms <24 h. Testicles were considered non-viable if they had ischemia requiring orchiectomy at surgery or if there was evidence of severe atrophy at follow-up. Data were compared for patients transferred from outside institutions and those not transferred. Rates of testicular salvage were compared. Transferred patients were further stratified based on distance of transfer from initial presenting institution to our facility and whether an ultrasound was performed prior to transfer. Data were found to be normally distributed. Univariate analysis was performed using Student t test and Fisher's exact tests. Multivariate analysis for predicting testicular loss in patients with symptoms <24 h was performed by logistic regression analysis using variables found to have p-value <0.20 on univariate analysis. A p-value <0.05 was considered to be significant.

      Results

      During the study period, 152 patients with torsion were treated, 19 of whom had perinatal torsion and were excluded. Of the remaining 133 patients, three patients elected for delayed orchiopexy for testicular torsion with spontaneous detorsion by the time of evaluation at our institution and were also excluded. Timing of symptom onset was unknown for four patients and one patient was initially diagnosed with epididymitis prior to being diagnosed with torsion later because of ongoing pain; these patients were excluded. Of the 125 remaining patients, mean age was 13.4 (range 4 months–21.7 years, standard deviation 3.8 years). Four patients were adults (age ≥18 years) at the time of evaluation; all of whom presented initially to our ED. Mean time from symptom onset to evaluation in our ER was 21.4 h (range 0.5–184.5 h; standard deviation 32.1 h).
      Thirty-six patients were classified as transferred. Of the 89 patients not transferred, 58 presented directly to our ED, 26 presented to an urgent care facility within our hospital system, and five were referred from their primary care provider. Results of the two groups are presented in Table 1. There was no difference between the groups with regards to age (mean 13.1 years for those transferred versus 13.5 years for those not transferred; p = 0.625). Duration of symptoms in the transferred group was 28.0 h compared with 18.7 h for those not transferred (p = 0.144). While 51.7% of patients not transferred presented to our facility during inconvenient hours (nights/weekends), 77.8% of transferred patients presented during nights/weekends (p = 0.009). There was no difference in rates of public insurance between patients transferred to our institution and those not transferred (33.3% versus 42.7%, respectively, p = 0.421).
      Table 1Comparison of patients by transfer status.
      TransferredNot transferredp-valueOR
      n = 36n = 8995% CI
      Age, yearsMean 13.1 range 0.4–17.9 SD 4.1Mean 13.5 range 3.0–21.7 SD 3.60.625
      Duration of symptoms, hoursMean 28.0 range 1.9–107.6 SD 33.1Mean 18.7 range 0.5–184.9 SD 31.40.144
      Night or weekend presentation to our facility77.8%51.7%0.0093.27 (1.35–7.96)
      Night or weekend symptom onset58.3%40.4%0.0782.06 (0.94–4.55)
      Public insurance33.3%42.7%0.4210.67 (0.30–1.51)
      When evaluating rates of testicular loss for the 125 included patients, 45 required orchiectomy at the time of exploration, while two who underwent orchiopexy demonstrated severe atrophy upon follow-up, resulting in a 37.6% overall rate of testicular loss. There was no difference in rates of testicular loss for patients with public versus private insurance (34.0% versus 40.0%, respectively, p = 0.573).
      Eighty-nine patients had symptom duration <24 h at the time of presentation to our facility. Mean patient age for these patients was 13.8 years (range 4 months–21.7 years, standard deviation 3.4 years). Mean duration of symptoms was 5.4 h (range 0.5–23.3, standard deviation 5.0 h) Twenty-three patients were transferred to our facility. Table 2 examines patients with symptom duration <24 h, comparing transferred with those not transferred. There was no significant difference in patient age between those transferred and those not transferred (mean 12.8 versus 14.1 years, respectively, p = 0.116). Mean duration of symptoms from symptom onset to evaluation in our facility for those transferred to and those presenting directly to our facility were 6.7 h and 4.9 h, respectively (p = 0.107). Of the transferred patients, 30.4% experienced testicular loss, compared with 15.2% of patients presenting directly to our facility (p = 0.129, OR 2.56, 95% CI 0.80–7.47).
      Table 2Comparison of patients with symptom duration <24 h by transfer status.
      TransferredNot transferredp-valueOR
      n = 23n = 6695% CI
      Age (years)Mean 12.8 range 0.4–17.9 SD 4.3Mean 14.1 range 3.6–21.7 SD 3.00.116
      Duration of symptoms (hours)Mean 6.7 range 1.9–18.2 SD 4.5Mean 4.9 range 0.5–23.3 SD 4.60.107
      Testicular loss30.4%15.2%0.1292.45 (0.80–7.47)
      Fifteen (65.2%) of the patients transferred with <24 h of symptoms had ultrasounds suggesting torsion prior to transfer (see Table 3). These patients had longer times between symptom onset and presentation to our facility when compared with those transferred without prior ultrasounds (8.0 versus 4.4 h, p = 0.074) and significantly longer times than those not transferred (8.0 versus 5.0 h, p = 0.025). Ultrasound prior to transfer resulted in increased odds of testicular loss when compared with patients not transferred (OR 3.73, 95% CI 1.09–12.81).
      Table 3Comparison of patients with symptom duration <24 h by status of ultrasound and transfer status.
      Ultrasound prior to transferNo ultrasound prior to transferp-valueOR 95% CIUltrasound prior to transferNot transferredp-valueOR 95% CI
      n = 15n = 8n = 15n = 66
      Age, yearsMean 12.8 range 0.4–17.9 SD 5.0Mean 12.8 range 7.0–16.7 SD 2.90.987Mean 12.8 range 0.4–17.9 SD 5.0Mean 14.1 range 3.6–21.7 SD 3.00.188
      Duration of symptoms (hours)Mean 8.0 range 3.1–18.2 SD 5.1Mean 4.4 range 1.9–8.1 SD 2.00.074Mean 8.0 range 3.1–18.2 SD 5.1Mean 4.9 range 0.5–23.3 SD 4.60.025
      Testicular loss40.0%12.5%0.3454.67 (0.45–48.26)40.0%15.2%0.0653.73 (1.09–12.81)
      Fourteen patients were transferred distances >30 miles (see Table 4). The greatest distance was 100 miles. In an analysis of these patients, patients transferred from distances >30 miles were significantly younger than those not transferred (11.9 versus 14.1 years, p = 0.027). Patients transferred from distances >30 miles had testicular loss rates of 42.9% compared with 11.1% in those transferred <30 miles (p = 0.176). Patients transferred >30 miles had increased rates of testicular loss when compared with those not transferred (42.9% versus 15.2%, p = 0.029), with transfer >30 miles increasing the odds of testicular loss by four times (OR 4.2, 95% CI 1.19–14.72).
      Table 4Comparison of patients with symptom duration <24 h by transfer distance and transfer status.
      Transferred >30 milesTransferred <30 milesp-valueOR 95% CITransferred >30 milesNot transferredp-valueOR 95% CI
      n = 14n = 9n = 14n = 66
      Age, yearsMean 11.9 range 0.4–17.6 SD 4.8Mean 14.3 range 7.2–17.9 SD 3.00.192Mean 11.9 range 0.4–17.6 SD 4.8Mean 14.1 range 3.6–21.7 SD 3.00.027
      Duration of symptoms, hoursMean 7.1 range 2.6–18.2 SD 5.1Mean 6.2 range 1.9–12.4 SD 3.70.679Mean 7.1 range 2.6–18.2 SD 5.1Mean 4.9 range 0.5–23.3 SD 4.60.121
      Testicular loss42.8%11.1%0.1766.00 (0.58–61.85)42.8%15.2%0.0294.20 (1.19–14.72)
      On multivariate analysis of risk factors for testicular loss in patients with symptom duration <24 h, only symptom duration demonstrated significance (p = 0.002, OR 1.25, 95% CI 1.08–1.43).

      Discussion

      Testicular torsion remains a concern because of its relatively high incidence of 1/4000 males under the age of 25 [
      • Gaither T.W.
      • Copp H.L.
      State appellant cases for testicular torsion: case review from 1985 to 2015. 2016.
      ]. Zhao et al. outlined the three keys to salvage as “early presentation, correct diagnosis and prompt treatment” [
      • Zhao L.C.
      • Lautz T.B.
      • Meeks J.J.
      • Maizels M.
      Pediatric testicular torsion epidemiology using a national database: incidence, risk of orchiectomy and possible measures towards improving the quality of care.
      ]. The first step may be limited because of a lack of patient or parental knowledge of torsion [
      • Friedman A.
      • Ahmed H.
      • Gitlin J.S.
      • Palmer L.S.
      Standardized education and parental awareness are lacking for testicular torsion.
      ], while numerous studies have evaluated history, exam, and imaging in diagnosing torsion [
      • Sheth K.R.
      • Keays M.
      • Grimsby G.M.
      • Granberg C.F.
      • Menon V.S.
      • DaJusta D.G.
      • et al.
      Diagnosing testicular torsion before urological consultation and imaging: validation of the TWIST score.
      ,
      • Baker L.A.
      • Sigman D.
      • Matthews R.I.
      • Benson J.
      • Docimo S.G.
      An analysis of clinical outcomes using color Doppler testicular ultrasound for testicular torsion.
      ]. Timing of treatment can have physical ramifications for the patient because of potential testicular loss [
      • Bennett S.
      • Nicholson M.S.
      • Little T.M.
      Torsion of the testis: why is the prognosis so poor?.
      ,
      • Yang C.
      • Song B.
      • Tan J.
      • Liu X.
      • Wei G.H.
      Testicular torsion in children: a 20-year retrospective study in a single institution.
      ,
      • Sessions A.E.
      • Rabinowitz R.
      • Hulbert W.C.
      • Goldstein M.M.
      • Mevorach R.A.
      Testicular torsion: direction, degree, duration and disinformation.
      ] and medical-legal ramifications for the provider [
      • Gaither T.W.
      • Copp H.L.
      State appellant cases for testicular torsion: case review from 1985 to 2015. 2016.
      ]. Our study focuses on this third step by evaluating treatment delays because of transfer.
      When comparing patients transferred to our ED with those not transferred, there was no difference with regards to age. Interestingly, four adult patients presented directly to our ED and were managed by our pediatric urologists. There were no adult patients transferred to our ED. Not surprisingly, we saw increased time between symptom onset and arrival in our ED for patients transferred to our facility compared with those not transferred (28.0 versus 18.7 h), although this did not reach statistical significance. We found that transferred patients were 1.5 times more likely to present during nights/weekends than those not transferred (77.8% versus 51.7%, p = 0.009). If outside facilities transferred all pediatric patients to our facility, rates of night/weekend presentation should be similar between the transferred and the not transferred groups. Our data suggest that outside providers may selectively transfer pediatric patients presenting during nights/weekends, typically inconvenient times. Conversely, our hospital provides tertiary coverage to a large geographic area which includes many rural communities. Hospitals in such areas may lack urology night/weekend urology coverage, necessitating transfer. We found no difference between rates of public insurance in those transferred and those not transferred (33.3% versus 42.7%, p = 0.421), suggesting that transfer decisions are not made based on patient insurance status.
      Our most important findings relate to testicular loss. Our overall testicular loss rate of 37.6% is consistent with previously published literature [
      • Sheth K.R.
      • Keays M.
      • Grimsby G.M.
      • Granberg C.F.
      • Menon V.S.
      • DaJusta D.G.
      • et al.
      Diagnosing testicular torsion before urological consultation and imaging: validation of the TWIST score.
      ,
      • Cost N.G.
      • Bush N.C.
      • Barber T.D.
      • Huang R.
      • Baker L.A.
      Pediatric testicular torsion: demographics of national orchiopexy versus orchiectomy rates.
      ]. Interestingly, while other studies have shown increased rates of testicular loss in patients with public insurance [
      • Zhao L.C.
      • Lautz T.B.
      • Meeks J.J.
      • Maizels M.
      Pediatric testicular torsion epidemiology using a national database: incidence, risk of orchiectomy and possible measures towards improving the quality of care.
      ], we found no difference in rates of testicular loss based on insurance status.
      We stratified patients based on duration of symptoms, as we know those with symptoms >24 h have little chance of testicular salvage [
      • Friedman A.
      • Ahmed H.
      • Gitlin J.S.
      • Palmer L.S.
      Standardized education and parental awareness are lacking for testicular torsion.
      ]. For patients with <24 h duration of symptoms, those transferred were younger and had longer duration of symptoms than those not transferred, although neither was statistically significant. Although not significant, the rate of testicular loss in the transferred group was double that of those not transferred (30.4% versus 15.2%), suggestive of a real difference and future studies with more patients may demonstrate statistical significance.
      Patients are often transferred with ultrasounds at outside facilities suggestive of torsion. We found that 68.1% of patients transferred to our facility had one such ultrasound prior to transfer, resulting in significantly longer durations of symptoms in transferred patients compared with those not transferred and further delaying intervention. Furthermore, we saw increased odds of testicular loss in patients undergoing ultrasound prior to transfer compared with those not transferred (OR 3.73, 95% CI 1.09–12.81), demonstrating the clinical outcome resultant from this delay in definitive management.
      Transfer distance also impacts management of torsion. Increased distances require additional time to transfer. We found that patients transferred long distances (>30 miles) had 2.5 times the rate of testicular loss than those presenting directly to our hospital (42.8% versus 15.2%, p = 0.029, OR 4.20, 95% CI 1.19, 14.72). Interestingly, our patients transferred over 30 miles were younger than those presenting directly to our facility (11.9 versus 14.1 years, p = 0.027.) While we are limited by not having full knowledge of the reasoning for transfer, some patients may be transferred for reasons of patient safety. Notably, one patient transferred more than 30 miles was 4 months of age at the time of transfer; community anesthesiologists and urologists are likely not comfortable with a patient this age. If excluding this patient, there is no significant difference in age for the groups (12.7 years for those transferred versus 14.1 years, p = 0.152). While there is a surgical and anesthetic challenge in operating on a 4-month-old, the difference between management of a healthy adolescent and a healthy adult is minimal. Community facilities should manage these patients with torsion locally considering the increased risk of testicular loss associated with transfers over longer distances.
      Our multivariate analysis revealed significance for increased testicular loss with increased duration between symptom onset and repair, reinforcing previous studies [
      • Bennett S.
      • Nicholson M.S.
      • Little T.M.
      Torsion of the testis: why is the prognosis so poor?.
      ,
      • Yang C.
      • Song B.
      • Tan J.
      • Liu X.
      • Wei G.H.
      Testicular torsion in children: a 20-year retrospective study in a single institution.
      ,
      • Sessions A.E.
      • Rabinowitz R.
      • Hulbert W.C.
      • Goldstein M.M.
      • Mevorach R.A.
      Testicular torsion: direction, degree, duration and disinformation.
      ,
      • Cubillos J.
      • Palmer J.S.
      • Friedman S.C.
      • Freyle J.
      • Lowe F.C.
      • Palmer L.S.
      Familial testicular torsion.
      ].
      Our study has limitations because of its design. As with any retrospective review, we have incomplete data. This is especially problematic regarding duration of symptoms, which may demonstrate recall bias from the patients, and regarding lack of precise data for presentation at external facilities for patients being transferred. Furthermore, our experience is that of a single tertiary institution, and patterns of transfer for testicular torsion have been shown to differ throughout the USA [
      • Lodwick D.L.
      • Cooper J.N.
      • Minneci P.C.
      • Deans K.J.
      • McLeod D.
      Factors affecting pediatric patient transfer in testicular torsion.
      ]. As a result, our results are not necessarily generalizable. Future studies with multi-institutional involvement representing facilities in different geographic locations may provide added insight regarding the decision-making process regarding transfer and provide more generalizable results regarding the outcomes of transfer for testicular torsion. Long-term patient follow-up of these patients could further support data regarding detrimental hormonal and fertility outcomes in patients with torsion [
      • Arap M.A.
      • Vicentini F.C.
      • Cocuzza M.
      • Hallak J.
      • Athayde K.
      • Lucon A.M.
      • et al.
      Late hormonal levels, semen parameters, and presence of antisperm antibodies in patients treated for testicular torsion.
      ,
      • Romeo C.
      • Impellizieri P.
      • Arrigo T.
      • Antonuccio P.
      • Valenzise M.
      • Mirabelli S.
      • et al.
      Late hormonal function after testicular torsion.
      ] or concerns over body image in patients undergoing orchiectomy [
      • Skoogh J.
      • Steineck G.
      • Cavallin-Stahl E.
      • Wilderang U.
      • Hakansson U.K.
      • Johansson B.
      • et al.
      Feelings of loss and uneasiness or shame after removal of a testicle by orchiectomy: a population-based long-term follow-up of testicular cancer survivors.
      ]. In the meantime, patients transferred long distances for management of testicular torsion are at increased risk of testicular loss. Emergency medicine physicians and urologists in the community need to be educated about this risk. Pediatric urologists can provide outreach to facilities known to transfer these patients. Establishing collegial relationships with leadership within emergency medicine and urology departments at these hospitals may begin to rectify this problem.

      Conclusion

      Our study confirms that patients with testicular torsion are more likely to be transferred to tertiary pediatric facilities for management of testicular torsion during inconvenient times (nights and weekends). Transferred patients with symptom duration less than 24 h had increased rates of testicular loss compared with those not transferred, although these findings were not statistically significant. Ultrasound performed prior to transfer led to increased symptoms duration and a trend towards higher rates of testicular loss. There was over a 2.5 times increased rate of testicular loss in patients transferred over 30 miles when compared with patients not transferred. Transferring patients for management of testicular torsion delays definitive management and threatens testicular viability, especially in those transferred greater distances; urologists at the facilities of initial presentation should correct torsion when able, as per the recommendations of the ABU [
      • Jordan G.H.
      From the desk of Gerald H. Jordan, ABU executive secretary.
      ].

      Conflict of interest

      None.

      Funding

      None.

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