Perinatal Testicular Torsion: The Clear Cut, the Controversial and the "Quiet" Scenarios
Tomer Erlich, M.D1, Ali El Ghazzaoui, M.D1, Martha Pokarowski, MPH1, Fardod O'Kelly, M.D, MA2, Armando J. Lorenzo, M.D , MSc1, Darius J. Bagli, MDCM1, Martin A. Koyle, M.D1.
1The Hospital for Sick Children (SickKids), Toronto, ON, Canada, 2Beacon Hospital, Dublin, Ireland.
Background: Perinatal testicular torsion (PTT), occurs in utero and up 30 days postnatally, with testicular loss being the most common outcome. The purpose of this study is to assess clinical evaluation, surgical management decisions, and clinical outcomes in patients with PTT in a quaternary referral hospital over 2 decades, in order to determine testicular salvageability and propose future management options.
Methods: A retrospective, observational cohort study of males born outside the quaternary center with a diagnosis of PTT was carried out (5.2000-7.2020). Data collection included mode of delivery, gestational age, birth weight, clinical presentation, testicular examination at birth, ultrasound (US) results at diagnosis, surgical management and findings, post-operative complications, and follow-up.
Results: 62 patients, including 2 patients with bilateral asynchronous PTT were identified. Median (IQR) gestation age and birth weight were 39 (±1.4) weeks and 3.4 (±0.62) Kg, respectively. 53% were delivered vaginally. Abnormal testicular examination at birth was found in 69% (43/62), while an initial “normal examination” was found in 16% (10/62) of cases. Physical examination revealed abnormal scrotal color in 56%, and a firm testicle in 80% (Table 1). Doppler US was performed in all but 1 patient, who was transported directly to operating room upon arrival. 59 patients underwent surgery, 21 of them within 4 hours, with bilateral exploration in most cases (76% of affected side, 98% of non-affected side). 3 "nubbins" were found, of which 2 were excised. In the last 7 years there have been no peri-operative complications. Prior to this, there were 3 complications, none surgical, that were identified. During a median follow up of 3 months, 63 testicles were removed or found to be non-functional. Compensatory hypertrophy was found in 38% of patients at follow-up.
Conclusion: Given that 3% of our patients presented with asynchronous bilateral PTT, a potentially devastating outcome, and given the safety of anesthesia in a referral pediatric hospital, early bilateral scrotal exploration PTT is recommended. 
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