Prognostic ultrasonographic findings in the epididymis of pediatric patients with testicular torsion
Cagatay E. Afsarlar, MD1, Engin Yilmaz, MD2, Emin Cakmakci, MD3, Daniel J. Ballow, MD2, Emre Demir, MSc4, Chester J. Koh, MD1.
1Department of Surgery, Division of Pediatric Urology, Texas Children’s Hospital & Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA, 2Department of Surgery, Division of Pediatric Urology, Texas Children’s Hospital, Houston, TX, USA, 3Department of Radiology, Dr.Sami Ulus Maternity, Children's Health and Diseases Training and Research Hospital, Ankara, Turkey, 4Department of Biostatistics, Faculty of Medicine, Hitit University, Çorum, Turkey.
BACKGROUND: Although grayscale and Doppler ultrasound (US) findings of the torsed testes are well-established in the literature, less is known about its anatomic partner, the epididymis. The epididymis is well-known to become enlarged based on US findings in pediatric patients with testicular torsion (TT). However, other sonographic morphologic features of the epididymis may provide further clinical information regarding the associated testis. In this study, we hypothesized that the US findings in the epididymis can provide clinical prognostic factors in pediatric patients with TT.
METHODS: We retrospectively reviewed the records of patients with acute TT between July 2009 and May 2016. Patients that had surgery for other acute scrotal diseases, intermittent TT, perinatal TT, or purposely-delayed surgery for late TT were excluded as well as patients with missing scrotal US images. A reviewer who was blinded to the clinical data analyzed the US images (grayscale and color Doppler images), and the sizes, parenchymal characteristics, and vascular flow to the right and left epididymal heads were recorded. Patient demographics, time flow charts, surgical outcomes, and follow-up periods were also analyzed. Epididymis size, the correlation of sizes of the affected and contralateral epididymides, and parenchymal characteristics were analyzed in relation with the length of time of TT prior to surgery(0-6 h, 6-12 h, 12-24 h, 24-48 h, >48 h), twisting degree, and ultimate clinical outcome of the testes. The testes were grouped as either viable or non-viable testes, and their associations with other clinical variables were analyzed. A p value <0.05 was considered statistically significant.
RESULTS: The records of a total of 268 patients with TT were reviewed. Fifty-one patients were excluded from the study (n=14 perinatal TT, n=12 purposely-delayed surgery for late TT, n=25 missing scrotal US images). The final cohort included 217 patients (107 orchiectomy, 110 detorsion). 104 testes (97%) continued to be viable during the follow-up period. Blood flow in the epididymides was absent in 96.2% and decreased in 3.8% in the orchiectomy group, while 27.3% of epididymides had decreased blood flow in the detorsion group (p<0.05). Affected epididymis size and twisting degree were significantly different when length of time of TT was taken into consideration (p<0.05). There was no significant difference between the viable and non-viable testes in terms of epididymis echotexture (p>0.05). However, we identified cystic dilatations of efferent ejaculatory ducts in the torsed epididymides, and grouped the cyst counts as 0-4, 5-10, and ≥11. The numbers of cystic dilatations in the torsed epididymis significantly increased when twisting degrees were taken into consideration (p<0.05). Additionally, non-viable testes had significantly higher number of cysts (48% had ≥11) as compared to the viable testes (p<0.05).
CONCLUSION: US findings in the epididymis may be able to provide clinical prognostic factors in pediatric patients with TT, where a higher number of cystic dilatations in the epididymis appear to be associated with higher rates of non-viability. Prospective studies are necessary to validate these findings.
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