Testicular loss in adolescents with torsion increases in those transferred from community to tertiary hospitals
Janae Preece, M.D., Christina Ching, M.D., Katelyn Yackey, M.D., Venkata R. Jayanthi, M.D., Seth Alpert, M.D., Daniel DaJusta, M.D..
Nationwide Children's Hospital, Columbus, OH, USA.
Testicular torsion is the leading cause of testicular loss in adolescents. Timing from symptom onset to surgical repair is the main factor affecting testicular loss. Patients may be transferred to tertiary centers in order to receive care from pediatric urologists though local urologists may be available. We sought to evaluate whether long distance transfers for testicular torsion lead to increased rates of testicular loss.
We performed a retrospective review of patients with testicular torsion presenting to our hospital between January 2011 and January 2016. Testicular torsion was confirmed by surgical exploration. We excluded patients whose duration of symptoms was unclear, those with intermittent torsion, and events of perinatal torsion. To examine only patients with potential testicular viability, we excluded those with duration of symptoms >24 hours at the time of presentation.
During the study period, 152 patients with torsion were treated, 19 of whom had perinatal torsion. Of the remaining patients, 88 met inclusion criteria. Mean patient age was 14.1 years; average duration of symptoms was 5.4 hours, and testicular loss rate was 19.3%. Twenty-two patients were transferred from an outside hospital. There was no significant difference in patient age between those transferred and those not transferred, however, there was a trend for those transferred to be younger (mean 12.8 versus 14.0, p=0.13). There was a non-significant trend toward increased time from symptom onset to evaluation in the tertiary care facility for transferred patients (mean 6.9 hours versus 5.0 hours, p=0.09). There was a trend for increased testicular loss in transferred patients (31.8% versus 15.1%, p=0.11). Patients transferred from distances over 30 miles had an increased rate of testicular loss when compared with patients not transferred (46.1% versus 15.1% p=0.02) and those transferred less than 30 miles (46.1% versus 11.1%, p=0.09). Fifteen of the transferred patients had ultrasounds suggestive of torsion prior to transfer. These patients were found to have longer times between symptom onset and presentation to our facility when compared to those without ultrasounds prior transfer (mean 8.0 hours versus 4.5 hours, p=0.10) or those presenting directly to our facility (mean 8.0 versus 5.0 hours, p=0.03). These patients also had increased rates of testicular loss compared with those not undergoing ultrasound prior to transfer (40.0% versus 14.3%, p=0.35) and those not transferred (40.0% versus 15.1%, p=0.07).
For our patients with testicular torsion, transferred patients had more than twice the rate of testicular loss compared to those not transferred, though these findings were not statistically significant. There was an increased rate of testicular loss in patients transferred over 30 miles when compared with patients not transferred and patients transferred less than 30 miles. Ultrasound at community facilities prior to transfer led to increased durations of symptoms and higher rates of testicular loss. Patients with testicular torsion should be treated at the facility of initial presentation if a urologist is available as transferring these patients likely places them at increased risk of testicular loss.
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