Society For Pediatric Urology

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Novel Prognostic Grayscale Ultrasonographic Findings in the Testis From a Comprehensive Analysis of Pediatric Patients with Testicular Torsion
Cagatay E. Afsarlar, MD1, Emin Cakmakci, MD2, Emre Demir, MSc3, Guven Guney, MD4, Erdal Komut, MD2, Rodolfo A. Elizondo, MD1, Abhishek Seth, MD1, 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 Radiology, Faculty of Medicine, Hitit University, Corum, Turkey, 3Department of Biostatistics, Faculty of Medicine, Hitit University, Corum, Turkey, 4Department of Pathology, Faculty of Medicine, Hitit University, Corum, Turkey.

BACKGROUND: Although grayscale and Doppler ultrasound (US) findings of testicular torsion (TT) have previously been described in the literature, we hypothesized that a comprehensive analysis of US findings of TT that focused on time dependent changes would lead to novel ultrasonographic morphologic findings and clinically relevant prognostic information.
METHODS: We reviewed the records of pediatric patients with acute TT from 2010 - 2017. Patients that had surgery for other acute scrotal diseases, intermittent TT, perinatal TT, missed TT, patients with insufficient scrotal US images or absent contralateral testis were excluded. A reviewer blinded to the clinical data analyzed the US images, and measured the size, parenchymal characteristics, and vascular flow of the testes. Patient demographics, time flow charts, surgical outcomes, and follow-up periods were also analyzed. The sizes and parenchymal characteristics of the torsed and contralateral testes were analyzed in relation to the time duration of scrotal pain prior to surgery (0-6 hours, 6-12 hours, 12-24 hours, 24-48 hours, and >48 hours), twisting degree, and clinical outcomes of the testes.
RESULTS: Of the 266 pediatric patients with TT during this time period, 223 patient had complete records for this study. 43 patients were excluded from the study based on the exclusion criteria (3 intermittent torsion, 11 perinatal TT, 4 missed TT, 24 insufficient US images, 1 absent contralateral testis). The mean age of the cohort patients was 12.2 ± 4.2 years (12 days - 18.3 years). Of the 223 patients, 115 underwent detorsion / fixation and 108 underwent orchiectomy, in addition to contralateral fixation. Finally 108 testes (93.9%) were noted to be viable during the follow-up period (5.9 ± 10.4 months). Preoperative vascular flow to the testes was absent in 85.7% and decreased in 14.3%. The mean volume ratios of torsed to contralateral testis showed significant differences between the 0-6 hours and the 12-24 hours time groups as well as the 6-12 hours and the 12-24 hours time groups (p=0.003 and p=0.035, respectively), as well as significant differences between the viable and non-viable testes (p=0.005). Regarding testicular heterogeneity, two novel grayscale sonographic findings were noted: 1) multiple hypoechoic lines that are called “testicular fragmentation”, and 2) hyperechoic patches called “testicular patching”. The presence of these two findings were significantly increased as torsion time increased (p<0.001), and these findings were significantly associated with testicular non-viability (p<0.001). Twisting degree was also noted to be significantly higher in the non-viable testes (p<0.001), however no significant association between twisting degree and “testicular fragmentation” or “testicular patching” (p>0.05) was noted. Presence of hydrocele or scrotal edema also showed significant differences between the time groups (p<0.001).
CONCLUSIONS: Novel specific grayscale findings in torsed testes were identified that provide prognostic information regarding the timing of onset of testicular torsion and testicular viability.

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