Degree of Twisting and Duration of Symptoms are Prognostic Factors of Testis Survival During Episodes of Testicular Torsion
Adam S. Howe, MD1, Vinaya Vasudevan, MD2, Michael Kongnyuy, MD3, Kevin Rychik, BS3, Lisa A. Thomas, MD2, Maria Matuskova, AS4, Steven C. Friedman, MD2, Jordan S. Gitlin, MD1, Edward F. Reda, MD1, Lane S. Palmer, MD5.
1Cohen Children's Medical Center of NY and Winthrop University Hospital, New Hyde Park and Mineola, NY, USA, 2Cohen Children's Medical Center of NY, New Hyde Park, NY, USA, 3Winthrop University Hospital, Mineola, NY, USA, 4LaGuardia Community College, Long Island City, NY, USA, 5Chief, Cohen Children's Medical Center of NY and Winthrop University Hospital, New Hyde Park and Mineola, NY, USA.
INTRODUCTION: Testicular torsion is surgical emergency. Prompt diagnosis and treatment of testicular torsion is essential for testicular viability. At surgical exploration, the spermatic cord is seen twisted a variable number of times around its longitudinal axis. There is scant data regarding the degree of twisting and its association with testis outcomes. The purpose of our study is to explore how the degree of torsion factors into testicular outcome using follow-up data and to derive equations for pain duration and degree of twisting of the spermatic cord in determining clinically prognostic outcome during episodes of testicular torsion. It is hypothesized that the greater number of twists of the spermatic cord would offer more obstruction of the vasculature and thus a lower salvage rate based on immediate intraoperative findings (orchiectomy) along with delayed atrophy of the testicle at follow-up.
MATERIALS & METHODS: We retrospectively reviewed the records of adolescent males who presented with testicular torsion to our institution, looking at duration of pain symptoms, degree of torsion documented in the operative note, and follow-up clinic data for whether testicular atrophy after orchiopexy was present. Sensitivity and specificity of the degree of torsion and duration of symptoms to intervention were calculated using receiver operator characteristics (ROC) analysis, along with multivariate analysis to predict testicular viability. A logistic regression analysis was performed to estimate the probability of death of a torsed testis using these variables and linear probability formulas were generated.
RESULTS: 81 patients with a mean age of 14.3 years met our study criteria, with 55 testes deemed viable and 26 testes were dead. We found a 25.7% atrophy rate after orchiopexy. A cut-off value of 495 degrees of torsion would provide a 53% sensitivity and 80% specificity for predicting testicular death, along with a cutoff of 8.5 hours providing a 73% sensitivity and 80% specificity. Multivariate analysis revealed that only patient age and duration were correlated with the risk of testicular death. Logistic regression analysis determined linear probability formulas of 4 + (3 x time in hours) [Figure A] and 7 + (0.05 x degree of twisting) [Figure B] in calculating the probability of testicular death with strong correlation.
CONCLUSIONS: We were able to derive separate formulas to determine the viability of the torsed testis based on duration of symptoms along with degree of twisting. 15 hours of symptom duration and 860 degrees of torsion gives the testis a 50% probability of death. 25% of testes undergo atrophy after orchiopexy. Further studies are need to accurately characterize the significance of twisting degree in relation to time and prognosis during testicular torsion.
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