Abstract
Background
Testicular torsion is the most frequent cause of irreversible ischemia to the testis. Despite guidelines being available, challenges remain in both diagnosis and management of the disease.
Objective
This study aims to determine the adherence of urologists and residents in urology to the European Association of Urology (EAU) Pediatric Guideline on Testicular torsion.
Study design
Both Dutch and European urologists, and residents in urology filled in a survey on testicular torsion. Information on demographics, diagnostics, and treatment modalities was retrieved from the questionnaire based on the EAU Guideline on Paediatric Urology.
Results
A total of 303 responders participated, of which 214 (71%) were from The Netherlands. Most (61%) responders treated three or more cases of testicular torsion in 2020. Ultrasound was used by 64%, followed by an attempt of manual detorsion by 38% (Summary Fig.). Importantly, 23% preferred not to perform emergency surgery after successful manual detorsion. A Winkelmann procedure was performed by 23%, without fixation of the test is using suture material. A large group of responders (30%) only fixed the contralateral testis by a proven testicular torsion.
Discussion
A feasible adherence to the EAU Guideline on Paediatric Urology in treating testicular torsion was reported using this survey, although not all recommendations are implemented as proposed. The fact that outcomes of the different diagnostic and treatment modalities are lacking might be a limitation in interpreting the results of this survey.
Conclusion
Graphical AbstractPercentage of respondents performing ultrasound, emergency surgery, fixation with suture material or fixation of the contralateral testis.
Keywords
Abbreviations:
EAU (European Association of Urology), OR (Operation Room), FEBU (Fellow of the European Board of Urology), US (Ultrasound), TWIST (Testicular Workup for Ischemia and Suspected Torsion)Introduction
Testicular torsion is a well-known emergency in urological practice. It is commonly diagnosed in paediatric patients with an incidence of 5.9 patients per 100,000 males (age: 1–17 years) [
[1]
]. For patients with an age of 18 years or older the incidence is lower, with 1.3 per 100,000 males. Testicular torsion remains the most frequent cause of irreversible testicular ischemia, but that could be prevented when diagnosis and treatment are performed correctly during a narrow window of opportunity.The European Association of Urology (EAU) Guidelines on Paediatric Urology advises to perform a manual detorsion without anesthesia [
[2]
]. A successful detorsion is defined as immediate pain relief and normal findings at clinical examination. According to the guidelines, scrotal ultrasound (US) examination might be helpful, but should never delay the intervention. Hence, testicular torsion needs prompt surgical intervention (<24 h) and a bilateral orchidopexy is required, even after a successful detorsion. For the type of fixation (i.e., one-point, two-point, or three-point fixation) and suture-material the guidelines provide no recommendations. A guideline for diagnosis and treatment of testicular torsion considering adolescents or adults is lacking, however, the Guideline on Paediatric Urology should sustain in this matter.This study aims to assess the adherence to the EAU guideline on testicular torsion by urologists and residents in urology using a survey. It is hypothesized that due to challenges in diagnosis and management of testicular torsions diagnostic habits and treatment modalities might deviate from the recommendations of the EAU guideline.
Methods
This survey utilized an online, self-administered survey distributed among urologists and residents in urology (hereafter referred to as responders) in the Netherlands and 21 other countries (Supplementary Table 1). An email describing the purpose and significance of the survey was sent with a link to ‘Survey Planet’ in February 2020 and repeated in July 2020. Responders were recruited via the Dutch Urological Association (Nederlandse Vereniging voor Urologie), and European professional networks. The Dutch Urological Association send a link of the questionnaire by email to all members comprising urologists (n = 410) and urologists in training (n = 95). Residents not in training are no member of this association and they had to receive the questionnaire via urologists or residents in training working in their institution. The professional networks consisted of urologists known to the auteurs as former colleagues, work within the EAU or collaborations between institutes. The questionnaire included 18, mostly closed-ended questions, about demographics (country, number of treatment testicular torsion, age, and type of institution), diagnosis (use of ultrasound), and treatment (manual detorsion, emergency surgery, surgical techniques, and use of materials). The questionnaire was developed de novo with the Guideline on Pediatric Urology used as guideline [
[2]
]. Pretesting of the questionnaire was done by urologists from the Franciscus Gasthuis & Vlietland Hospital (community training hospital) in Rotterdam. No sensibility testing of the questionnaire was performed. See all questions in Table 1. Responders were not compensated for participation. The questions were pseudo-anonymous, as participants had the option to fill in their email addresses in case of questions or remarks, although this was not mandatory. The following case was presented as a guideline for the questionnaire: A 14-year-old boy, otherwise fit and healthy, suddenly developed acute severe pain in the right side of the scrotum 2 h ago, shortly before breakfast. On examination in the emergency room, you find a painful, high and transverse testis on the right side with an absent cremaster reflex. There are no abnormalities on the left side. The patient's last meal was last night. What are your actions? A comparison between Dutch and European responders was performed as sub-analyses and can be found in the supplementary.Table 1Questions of the survey on diagnosis and management of testicular torsion.
| Questions |
|---|
Do you perform a scrotal ultrasound?
|
Who performs the scrotal ultrasound?
|
Do you (attempt to) do a manual detorsion?
|
When do you consider manual detorsion to be successful?
|
Do you perform emergency surgery?
|
After a successful detorsion in the emergency room, when do you perform surgery (orchidopexy)?
|
Which incision would you choose?
|
Do you open the tunica vaginalis during the procedure?
|
Which suture material do you use to fixate the testis?
|
To what structure do you fixate the testis?
|
How do you fixate the testis?
|
How many stitches do you use to fixate a single testis?
|
Do you fixate the healthy, contralateral left testiscle?
|
In 2020 I personally treated…?
|
What is your age?
|
In what kind of institution do you work mainly?
|
I am…?
|
Results
Demographics
A total of 303 responders took the survey, of which 214 (71%) were from The Netherlands. The age of the responders was over 40 years in 59%, 81% were clinically active as urologists and 17% were residents in urology (Table 2). Of the responders, 40% was working in a community training hospital. Most (60%) treated three or more cases of testicular torsions in 2020. Considering the Dutch cohort, 175 of the 214 (79%) were active urologists. Based on the known number of 410 urologists and 95 residents in training in the Netherlands, a response rate of 42% was achieved. As there was no information on characteristics of non-responders, no comparison was possible with the characteristics of the responders.
Table 2Response of the questionnaire considering demographic, diagnostic and treatment characteristics (N = 303).
| Characteristics | n (%) |
|---|---|
| Demographic characteristics | |
| Role responder | |
| Urologist | 188 (62) |
| Resident (in training) | 51 (17) |
| Retired | 5 (1.7) |
| Paediatric urologist | 5 (1.7) |
| Clinical andrologist | 7 (1.7) |
| FEBU | 47 (15) |
| Institution | |
| Academic hospital | 78 (26) |
| Community training hospital | 120 (40) |
| Community not-training hospital | 89 (29) |
| Private hospital | 16 (5.3) |
| Age (years) | |
| Under 30 | 11 (3.6) |
| 30–39 | 112 (37) |
| 40–49 | 97 (32) |
| 50–59 | 56 (18) |
| Over 60 | 27 (8.9) |
| Number of testicular torsions treated (last year)? | |
| 0 cases | 29 (9.6) |
| 1-2 cases | 90 (30) |
| 3-5 cases | 130 (42) |
| 5 or more cases | 54 (18) |
| Diagnostic characteristics | |
| Scrotal ultrasound? | |
| Yes | 196 (64) |
| Only with doubts | 96 (32) |
| No, never | 11 (3.6) |
| Who performs the scrotal ultrasound? | |
| Myself | 49 (16) |
| A radiologist | 140 (46) |
| Me, pending availability radiologist | 68 (22) |
| Only with own doubts: radiologist | 35 (12) |
| Ultrasound is never indicated | 11 (3.6) |
| Treatment characteristics | |
| Manual detorsion? | |
| Yes, with anesthetics | 3 (1.0) |
| Yes, without anesthetics | 108 (37) |
| Pending availability immediate OR | 77 (25) |
| No, never | 115 (37) |
| Successful manual detorsion? | |
| When pain is gone | 86 (28) |
| If ultrasound shows Doppler signal(s) | 92 (30) |
| Same position of testes | 10 (3.3) |
| I never attempt manual detorsion | 115 (39) |
| Treatment characteristics | |
| Emergency surgery? | |
| Yes, always | 164 (54) |
| Yes, even after successful detorsion | 68 (23) |
| No, preferably not | 71 (23) |
| Timing of surgery? | |
| No detorsion, immediate OR | 115 (38) |
| OR as soon as possible after detorsion | 76 (25) |
| Within 24 h | 15 (5.0) |
| Within 72 h | 12 (4.0) |
| Only in case of recurrence | 5 (1.7) |
| First available occasion regular planning | 80 (26) |
| Placement of incision? | |
| Medial in the raphe | 229 (76) |
| Lateral, perpendicular to raphe | 66 (22) |
| Inguinal plus scrotal | 4 (1.3) |
| Inguinal only | 4 (1.3) |
| Opening tunica vaginalis? | |
| Yes, with Winkelmann fixation | 181 (59) |
| Yes, but without Winkelmann fixation | 108 (36) |
| No, I usually don't | 14 (4.6) |
| Suture material? | |
| Just detorsion, no fixation | 71 (23) |
| Soluble monofilament | 32 (11) |
| Insoluble monofilament | 42 (14) |
| Soluble braided suture | 146 (48) |
| Insoluble braided suture | 12 (4.0) |
| Structure for fixation? | |
| Tunica vaginalis | 59 (20) |
| Tunica dartos | 173 (57) |
| I do not fixate the testis | 71 (23) |
| Type of fixation? | |
| Big bite through tunica albuginea | 28 (9.2) |
| Superficial bite through tunica albuginea | 155 (51) |
| Suture through surrounding structures | 49 (16) |
| I do not fixate the testis | 71 (24) |
| Number of stitches? | |
| I do not fixate the testis | 71 (24) |
| 1-point fixation | 22 (7.3) |
| 2-point fixation | 95 (31) |
| 3-point fixation | 115 (38) |
| Fixation of contralateral, healthy testis? | |
| Yes, always | 195 (64) |
| Only after a proven torsion | 89 (30) |
| No, never | 19 (6.3) |
FEBU = Fellow of the European Board of Urology; OR = Operation Room
Diagnosis
Ultrasound was reported to be performed in 64% of the cases, and in 46% of the cases, this was done by a radiologist. In 22%, it was only performed by the responder if the radiologist was not available immediately. Only 3.6% of the responders reported that ultrasound was never indicated for testicular torsion.
Treatment
Manual detorsion was in any case performed by 38% of the responders (97% without anesthesia) versus 37% of the responders who do never attempt a manual detorsion. When a manual detorsion was performed, it was considered to be successful when the pain settled and/or US showed Doppler signals. Considering surgery, 77% of responders regard testicular torsion as an emergency and will perform surgery immediately, even after successful detorsion. Importantly, 23% of the responders prefer not to perform emergency surgery. In this context, 26% will only perform surgery on the first available occasion on the regular planned operating schedule. When surgery is performed, majority perform a medial incision in the raphe of the scrotum (76%). A Winkelmann fixation, fixation of the edges of the opened tunica vaginalis behind the spermatic cord, was performed in 59% of the cases after opening the tunica vaginalis. A soluble braided suture was used for the fixation in 48%, and in 69% of the cases, the testis was fixed with a 2 or 3-point fixation. Surprisingly, 23% of the responders indicated that they never fix the testes and will only perform detorsion plus the Winkelmann procedure during surgery. Most of the responders will eventually also fixate the contralateral testis, but 30% only perform this when there was indeed a proven torsion of the ipsilateral testis. A comparison between Dutch responders and European responders as a sub-analysis can be found in Supplementary Table 2. The most remarkable differences were found in the timing of surgery and fixation of the testis where European urologists seem more inclined to perform an emergency operation and fixate the testis more often with suture material.
Discussion
In this survey of the real-world management of testicular torsion, we found that the majority of responders follow the EAU Guideline of Paediatric Urology. Most of the responders stated that an emergency operation for testicular torsion is indicated, even after a successful detorsion. When an orchidopexy is performed, a majority will also fix the contralateral testis, as recommended by the Guideline.
The majority of the responders (64%) use ultrasound for the diagnosis of testicular torsion which is equal to the proportion of 60% of pediatric urologist in Saudi Arabia who filled in a survey on testicular torsion [
[3]
]. In the past, testicular torsion was a purely clinical diagnosis based on patient's history and clinical examination. However, with the current widespread availability of high-end ultrasound (US), to our opinion, this could help in the diagnosis of testicular torsion. In 2006, Gunther et al. already showed the importance of high-end Doppler ultrasound in diagnosing and differentiating testicular torsion in 61 boys with an acute scrotum [[4]
]. All 15 suspected testicular torsions by using ultrasound were surgically proven. While all 33 boys with normal Doppler signals were conservatively treated and showed normal perfusion during the following two years of follow-up. Testicular ultrasound performed by a radiologist was recommended since presentation on sonography can be subtle and misleading and arterial flow might be preserved or even increased [[5]
]. However, US should never delay diagnosis and treatment. The ‘Testicular Workup for Ischemia and Suspected Torsion (TWIST)’-score, with a positive predictive value of 94% and a negative predictive value of 100%, might help in the decision on waiting for the availability of a radiologist or immediate surgery [[6]
]. By calculating the TWIST-score, patients are classified into low-, intermediate- and high-risk groups. Low-risk patients do not need examination by US and another diagnosis should be devised. For high-risk patients' surgical exploration is indicated without the need for US.As described by Sessions et al., 20% of patients (11 of 54) showed residual torsion during exploration after reported pain relief following manual detorsion [
[7]
]. And in case salvage surgery is performed 7–12 h after testicular torsion, almost 20% of the testis will be atrophic as shown by a meta-analysis in 1635 boys [[8]
]. After 19–24 h, even more than 50% of the testis will be irreversibly damaged. Therefore, prompt surgical treatment is recommended by the EAU Guideline, although almost a quarter of the responders stated that they prefer not to perform emergency surgery with possible a higher patients’ risk of losing a testis. Although not supported by literature, it may be explained by the tendence that a successful detorsion in the ER is considered an adequate treatment and that an official orchiopexy can be performed in the following week during daytime. Hence, the essence of emergency surgery should definitely be brought to the attention of urologists and residents in training, as the chance of saving a testis depends on the timing of surgery. To achieve more awareness of this important step in treating testicular torsion, more education and attention to the guideline is needed. As recommended, surgery includes orchidopexy of the ipsilateral and contralateral testis and/or removal of an atrophic testis. That bilateral orchidopexy should be performed was already an universal agreement in 2002 following a survey filled in by 33 urologist from the North West region of England on treatment of testicular torsion [[9]
]. This was also confirmed by Almaramhy et al., as 95% of the pediatric urologist stated to fixated both testes in case of a proven testicular torsion [[3]
]. However, within the present study, 23% of responders do not fix the testis at all during surgery. The reason for this outcome is not clear since there is no literature supporting this method, although this probably has to do with the assumption that the use of sutures during fixation of the testis might influence fertility. A study by Arap et al., however, showed no difference in sperm count or motility after orchidopexy versus healthy patients [[10]
]. For patients with bilateral orchidopexy or orchiectomy and fixation of the ipsilateral testis, a pregnancy rate of more than 90% was described by Gielchinsky et al. [[11]
].Considering the technique and material used for incision and fixation, there are no recommendations in the Guideline resulting in a variation of used techniques and materials in this study. Hence, this has not been changed as compared to the variations already showed by Pearce et al. in 2002 in the North West of England [
[9]
]. Within this study, most of the responders perform a medial incision of the scrotum and fix with a 2- or 3-point fixation, subsequent to a Winkelmann fixation of the tunica vaginalis. A systematic review in 2020 by Moore et al. highlighted the absence of quality data analyzing the effect of different surgical techniques on outcomes, such as re-torsions and fertility [[12]
]. Although, predominantly short-term outcomes were presented (6–31 weeks, up to 15 years), a re-torsion of the contra- and ipsilateral testis was not described, whatever surgical approach was used. By analyzing case reports on re-torsions after fixation, Sells et al. described a higher incidence of recurrences when absorbable sutures were used, although this might come from the higher number of cases using this material [[13]
]. Considering fixation of the contralateral side there is also a lack of quality data. However, 78% of pubertal boys diagnosed with testicular torsion appeared to have a ‘Bell Clapper deformity’ of the contralateral testis; indicating the need for fixation of this testis [[14]
].Some important differences were observed between the Dutch responders and those from abroad. One-third of the Dutch responders preferred to perform surgery on the first occasion in the regular planned list, whereas European responders preferably performed an emergency operation. As the Dutch guideline advises surgical exploration within 6 h, this might be the explanation for this difference [
[15]
]. A Winkelmann fixation was actually performed more often by the Dutch responders compared to their European colleagues. The most remarkable difference, however, concerned fixation of the testis. Of the Dutch responders, 32% do not fix the testes using suture material vs. only 2.4% of the responders abroad (p < 0.001). This is even more surprising, as the Dutch guideline on testicular torsion also recommends to fixate the ipsi- and contralateral testis. Age and institution showed not to be associated with the decision to fixate or not to fixate the testes. As performing an emergency operation and fixation of the testes are the two cornerstones of treating testicular torsion, this is an important confirmation that, especially within the Netherlands, a higher level of consciousness is needed of the available guidelines.A limitation of the current survey is that the questions are possibly answered in the context of this single clinical case. For every individual clinical case, there are nuances and differences. This might have influenced the answers given by the responders. Another limitation is the fact that for the Dutch invitations, a national database by the Dutch Urology Association was used. For the ‘European’ responders, this was done by a professional network; mostly urologists actively involved within the EAU. Hence, this might explain why the European responders do follow the EAU guidelines more strictly compared to the Dutch responders. The fact that these networks were used to invite respondents for this survey, might have resulted in a response bias. With the assumption that every urologist or resident in training uses and is aware of the EAU guideline in clinical practice, this survey is based on this guideline. Off course, some residents might not even be aware of this guideline or use a national guideline. We do believe that the impact of this group is small, as the EAU guideline is not unique for treatment of testicular torsion and most national protocols in Europa are based on the EAU guideline. Also, information is lacking on the outcome of the different treatment modalities, used materials and timing of surgery. Another limitation is the distribution of responders, 71% were Dutch. Therefore, a balanced comparison between Dutch and European responders was not possible.
Conclusion
Acute testicular torsion is one of the most dramatic urological emergencies for both the patient and his family. When presented in the emergency room, the majority of the responders of this survey appear to follow the EAU Guideline. Even after a successful manual detorsion, an emergency orchidopexy of both testes is usually performed. Surprisingly, during scrotal exploration, many urologists do not perform a surgical fixation after detorsion. The reason for that remains unclear, but might implicate that more awareness of the guideline is needed. This survey showed a wide range of used surgical techniques. For a unified policy, the guideline may provide preferred techniques and materials, which are currently lacking on this subject. Finally, with the widespread availability of ultrasound, to our opinion, this modality could increasingly contribute in diagnosing testicular torsion.
Funding
This research did not receive any specific grant form funding agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interest
None.
Ethical approval
Approval for this study was not required.
Appendix A. Supplementary data
The following is the Supplementary data to this article:
- Multimedia component 1
References
- Testicular torsion: epidemiological risk factors for orchiectomy in pediatric and adult patients.Int J Impot Res. 2021; 33: 184-190
- EAU Guideline on Pediatric Urology presented at the EAU Annual Congress Amsterdam 2022. ISBN 978-94-92671-16-5..European Association of Urology Guidelines Office. 2022;
- Surgical practice among pediatric surgeons and pediatric urologists in the Kingdom of Saudi Arabia for the management of suspected testicular torsion.Saudi Med J. 2018; 39: 1232-1237
- Acute testicular torsion in children: the role of sonography in the diagnostic workup.Eur Radiol. 2006; 16: 2527-2532
- Testicular torsion with preserved flow: key sonographic features and value-added approach to diagnosis.Pediatr Radiol. 2018; 48: 735-744
- Diagnosing testicular torsion before urological consultation and imaging: validation of the TWIST score.J Urol. 2016; 195: 1870-1876
- Testicular torsion: direction, degree, duration and disinformation.J Urol. 2003; 169: 663-665
- Testicular function after torsion of the spermatic cord.BJU Int. 2003; 92: 200-203
- Suspected testicular torsion: a survey of clinical practice in North West England.J R Soc Med. 2002; 95: 247-249
- Late hormonal levels, semen parameters, and presence of antisperm antibodies in patients treated for testicular torsion.J Androl. 2007; 28: 528-532
- Pregnancy rates after testicular torsion.J Urol. 2016; 196: 852-855
- Orchidopexy for testicular torsion: a systematic review of surgical technique.Eur Urol Focus. 2021; 7: 1493-1503
- Recurrent torsion after previous testicular fixation.ANZ J Surg. 2002; 72: 46-48
- The prevalence of bell clapper anomaly in the solitary testis in cases of prior perinatal torsion.J Urol. 2014; 191: 1573-1577
- Urologische Diagnostiek en Therapie; torsio testis.Nederlandse Vereniging voor Urologie, 2015
Article info
Publication history
Published online: September 23, 2022
Accepted:
September 20,
2022
Received in revised form:
September 5,
2022
Received:
May 19,
2022
Publication stage
In Press Journal Pre-ProofIdentification
Copyright
© 2022 The Author(s). Published by Elsevier Ltd on behalf of Journal of Pediatric Urology Company.
User license
Creative Commons Attribution – NonCommercial – NoDerivs (CC BY-NC-ND 4.0) | How you can reuse 
Elsevier's open access license policy
Creative Commons Attribution – NonCommercial – NoDerivs (CC BY-NC-ND 4.0)
Permitted
For non-commercial purposes:
- Read, print & download
- Redistribute or republish the final article
- Text & data mine
- Translate the article (private use only, not for distribution)
- Reuse portions or extracts from the article in other works
Not Permitted
- Sell or re-use for commercial purposes
- Distribute translations or adaptations of the article
Elsevier's open access license policy
ScienceDirect
Access this article on ScienceDirectLinked Article
- Comment on: “Real-world management of testicular torsion: Level of adherence to the EAU Paediatric Urology guidelines.”Journal of Pediatric Urology
- PreviewThis survey study reports on the “real-world” management of testicular torsion with respect to the recommendations published in the EAU Paediatric Urology guidelines [1]. The greatest number of respondents were from The Netherlands (71%) and thus, most of the results reflect Dutch practice patterns. Or, more accurately, it reflects the practice patterns that are immediately recalled upon filling out the survey, since 82% report treating fewer than 5 cases in the past year. Although the authors found that most responders adhere to EAU guidelines, a sizable proportion (23%) do not pursue emergency surgery, nor do they perform fixation of the testis, despite the published and accessible recommendations of the panel.
- Full-Text
- Preview
00387-4&id=fx1.jpg){kind=link}