Neonatal Testicular Torsion - When To Explore?
Joshua Rae, MBChB, MRCS, Kirti Rathod, Mbbs, Ms, Mch, Frcs,, Khalid Elmalik, Mbchb, Frcs, Dch, Haitham Dagash, Mbchb, Frcs, Ashok Rajimwale, Mbbs, Ms, Mch, Dnb, Frcs, Feapu.
Leicester Royal Infirmary, Leicester, United Kingdom.
Background/ aim:
Neonatal testicular torsion (NTT) accounts for approximately 12% of childhood testicular torsion; however salvage rates vary widely from 4-100%. NTT with sequential contralateral torsion may occur in the absence of clinical signs. We report 5 cases of asynchronous bilateral NTT who underwent emergency exploration at our institution. We advocate emergency exploration in order not only to preserve the contralateral side but potentially the affected side too.
Material and Methods:
Retrospective records review of 5 neonates presenting with acute scrotum were reviewed. Age at diagnosis, clinical and operative findings and long term follow up outcome is presented.
Results:
Between 2010 and 2015 we treated 5 cases of bilateral asynchronous NTT at The Leicester Royal Infirmary. Two neonates presented to us within 24 hours post discharge from the hospital with left testicular swelling and the contralateral testes were thought to be normal. Within 4 hours of presentation, the left side was explored to confirm extravaginal torsion and nonviable testes which were excised. However, on contralateral exploration we found that the right 'normal' testes were also necrotic probably from pre-natal torsion.
Two other neonatal cases with left and right testicular swelling respectively on day 2 of life underwent emergency surgery in the middle of night 2 hours after the diagnosis only to find nonviable testes. The contralateral testes were also found to have 720 degrees of extra vaginal torsion. These testes were put back in sub dartos pouch after detorsion and warm packs. On follow up at 1 year these testes were found to be atrophic.
The remaining neonate who presented few hours after birth with unilateral testicular swelling was explored detorted and fixed in the sub dartos pouch. The contralateral testis was also found to have 540 degrees of extra vaginal torsion, which was detorted and fixed. This child has both testes well and surviving at 1 year follow up.
Four of five cases with bilateral atrophic testis/ orchidectomy are waiting for testosterone replacement therapy at the time of puberty. One 3 year old child has had testicular prosthesis inserted and a 6 year old child is waiting for the testicular prosthesis insertion.
Conclusion:
Neonatal torsion should be considered as a surgical emergency as contralateral torsion is more common than previously perceived. Delayed management can potentially render these children anorchic.
Discussion -
Early asynchronous bilateral NTT is rare and can present with only unilateral signs. The reported salvage rate for bilateral NTT vary widely however, more recent papers are more optimistic, citing much higher success rate. Although in our series of 5 cases of bilateral asynchronous NTT, testes could be salvaged only in 1 case despite emergent exploration, however it highlights the 'soft' or absent clinical signs of contralateral testicular torsion. We therefore, recommend that 'wait-and-see' approach is inappropriate in NTT. The delayed diagnosis and the choice of an incorrect therapeutic approach can compromise the position of healthcare professionals, in terms of skill, prudence and diligence.
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