Factors Associated with Testicular Salvage in Boys with Testicular Torsion
Katherine M. Fischer, MD1, Curran Uppaluri, MD2, Connie Tan, B.A.1, Sameer Mittal, MD, MSc1, Christopher Long, MD1, Dana Weiss, MD1, Gregory Tasian, MD, MSCE1, Aseem Shukla, MD1, Arun Srinivasan, MD1, Mark Zaontz, MD1, Stephen Zderic, MD1, Summer Kaplan, MD1, Jane Lavelle, MD1, Jason Van Batavia, MD1, Thomas Kolon, MD1.
1Children's Hospital of Philadelphia, Philadelphia, PA, USA, 2Einstein Healthcare Network, Philadelphia, PA, USA.
Background: Testicular torsion is a common urologic emergency, and it is widely accepted that minimizing the time from onset of ischemia to surgery maximizes the likelihood of testicular preservation. It is believed that the likelihood of salvage is highest in the first six hours and rapidly declines thereafter. Many institutions including our own have quality improvement initiatives aimed at accomplishing this. While some factors such as time from door to OR can be targeted, others such as inequalities in access to care are more difficult. The Child Opportunity Index (COI) is a measure that uses 29 neighborhood-level indications across three domains (education, health and environment, social and economic) to assign a rank from 1 (very low) to 5 (very high) to neighborhoods. We hypothesized that non-white race and lower COI would be associated with decreased testicular salvage rates. We sought to investigate the association of these factors with testicular torsion outcomes at our institution and secondarily to define the optimum time cutoff from symptom onset to presentation that predicts salvage.
Methods: We reviewed our prospective testicular torsion database to identify boys who underwent operative intervention for testicular torsion between 1/2015-3/2022. Patients less than 1 year of age were excluded as neonatal testicular torsion was felt to represent a different clinical entity. Records were reviewed to determine procedure performed, demographic information and time to presentation. Testicular salvage was defined as performing septopexy only as opposed to either tunica vaginalis (TV) flap or orchiectomy. The COI was calculated for each patient using their home address. The association of race and COI with testicular salvage was evaluated with univariate and multivariate logistic regression controlling for time to presentation. To determine the optimal cutoff for time to presentation to predict testicular salvage, the Youden index was calculated.
Results: Overall, 358 boys were included, of which 188 (52.5%) underwent testicular preservation with septopexy only. Of the other 170 patients, 65 (38.2%) underwent TV flap and 105 (61.8%) orchiectomy. There was no difference in race or COI quintile between groups, however, time from symptom onset to presentation was significant different with median 3.5 vs. 24 hours (p<0.001) (Table 1). Race and COI were not associated with testicular salvage on either univariate or multivariate logistic regression that controlled for time to presentation. The optimum time cutoff to predict testicular salvage using the Youden index was 10.5 hours (Figure 1).
Conclusions: Neither race nor COI were associated with testicular torsion outcomes, with time to presentation being the strongest, modifiable risk factor associated with non-salvage in our patients. This suggests that efforts should be aimed at decreasing the time it takes patients to present for care perhaps via patient, parent, and primary care provider education.
| Septopexy | TV Flap or Orchiectomy | p-value | ||
| 188 | 170 | |||
| Age at Surgery (years), median (IQR) | 14.30 (12.94, 15.81) | 13.93 (12.18, 15.00) | 0.019 | |
| Race | White | 73 (38.8%) | 53 (31.2%) | 0.24 |
| Black | 75 (39.9%) | 83 (48.8%) | ||
| Asian | 8 (4.3%) | 3 (1.8%) | ||
| Indian | 2 (1.1%) | 1 (0.6%) | ||
| Other | 29 (15.4%) | 30 (17.6%) | ||
| Unknown | 1 (0.5%) | 0 (0.0%) | ||
| COI (Quintiles) | 1 | 69 (36.7%) | 71 (41.8%) | 0.44 |
| 2 | 28 (14.9%) | 32 (18.8%) | ||
| 3 | 20 (10.6%) | 15 (8.8%) | ||
| 4 | 37 (19.7%) | 23 (13.5%) | ||
| 5 | 34 (18.1%) | 29 (17.1%) | ||
| Laterality | Left | 93 (49.5%) | 109 (64.1%) | 0.006 |
| Right | 95 (50.5%) | 61 (35.9%) | ||
| Procedure Performed | Septopexy | 188 (100.0%) | 0 (0.0%) | <0.001 |
| Orchiectomy | 0 (0.0%) | 105 (61.8%) | ||
| TV Flap | 0 (0.0%) | 65 (38.2%) | ||
| Time from Symptom Onset to Presentation (hours), median (IQR) | 3.5 (1.5, 7.75) | 24 (5, 72) | <0.001 | |
| Time from Hospital Arrival to OR (mins), median (IQR) | 146 (96, 200.5) | 134 (86, 191) | 0.061 |
Table 1. Patient characteristics
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