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The Effect of Transfer on Surgical Outcomes for Pediatric Patients with Testicular Torsion
Curran Uppaluri, MD, Katherine Fischer, MD, Connie Tan, BA, Jane M. Lavelle, MD, Summer L. Kaplan, MD, Sameer Mittal, MD, Jason Van Batavia, MD, Christopher J. Long, MD, Dana A. Weiss, MD, Gregory E. Tasian, MD, Arun K. Srinivasan, MD, Aseem R. Shukla, MD, Mark R. Zaontz, MD, Stephen A. Zderic, MD, Thomas F. Kolon, MD.
Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Background:Testicular torsion is a surgical emergency that is managed after detorsion with either septopexy alone or tunica vaginalis (TV) flap with septopexy if the testis is viable or orchiectomy if not. While significant efforts have been made to decrease the time from patient presentation to definitive surgical management, little is known about whether the time and delay inherent with patient transfer to another institution affects testicular outcomes both intraoperatively and in the long-term. We hypothesized that patient transfer would be associated with decreased rates of testicular salvage.
Methods:We reviewed our prospective institutional testicular torsion database to identify boys who underwent surgery for testicular torsion between January 2015 and March 2022. Pediatric patients younger than 1 year were excluded to ensure patients with neonatal testicular torsion were not included. Records were reviewed to determine procedure performed, demographic information, transfer status, follow-up rates and outcomes, and times to: presentation, transfer, and OR. Patients were divided into two categories: those who presented to the institution initially with symptoms (i.e. index group) versus those that presented to the institution as a transfer from an outside facility (i.e. transfer group). Testicular salvage was defined as performing septopexy only versus either TV flap or orchiectomy. The association of transfer with testicular salvage was evaluated with univariate and multivariate logistic regression controlling for age, time to presentation, and time to OR.
Results:We identified 358 patients that met inclusion criteria. Of those, 193 (53.9%) patients were index presentations, while 165 (46.1%) patients were transfer presentations. There was no difference in procedure performed between groups (Table 1). The median transfer time to our institution was 90 minutes (IQR=90-120). Transfer status and transfer time were not associated with testicular salvage on univariate regression, while age (OR=0.90, 95%CI=0.850-0.963; p<0.001), time from symptoms to presentation (OR=1.03, 95%CI=1.02-1.04; p< 0.001), and time from institutional arrival to OR (OR=0.998, 95%CI=0.996-0.999; p=0.042) were associated with salvage. On multivariate regression, age (OR=0.90, 95%CI=0.84-0.96; p =0.007), time to presentation (OR=1.03, 95%CI=1.02-1.04;p<0.001), and time to OR (OR=0.99, 95%CI=0.990-0.997; p=0.002) were associated with salvage while transfer status was not. Follow-up rates were lower for the septopexy cohort (64.4%) compared to the TV flap (73.8%) and orchiectomy (78.1%) cohorts (p=0.038) (Table 2). Testicular atrophy on follow-up was greater in the TV flap cohort at 51.1% versus 9.8% for the septopexy cohort (p<0.001).
Conclusions:Transfer of a patient with testicular torsion from an outside facility was interestingly not associated with decreased testicular salvage rates. Age, time from symptom onset to presentation, and time to OR were the only significant variables associated with rates of septopexy versus TV flap or orchiectomy. Given the increased rates of testicular atrophy with TV flaps, establishment of standardized long-term follow-up would be invaluable for this cohort.

Table 1. Patient characteristics by group based on presentation
Index PresentationTransfer Presentationp-value
193165
Age at Surgery (years), median (IQR)14.09 (12.32, 15.66)14.13 (12.86, 15.5)0.51
RaceWhite54 (28.0%)72 (43.6%)<0.001
Black103 (53.4%)55 (33.3%)
Asian7 (3.6%)4 (2.4%)
Indian0 (0.0%)3 (1.8%)
Other29 (15.0%)30 (18.2%)
Unknown0 (0.0%)1 (0.6%)
LateralityLeft106 (54.9%)96 (58.2%)0.59
Right87 (45.1%)69 (41.8%)
Torsion at Time of Exploration161 (83.4%)136 (82.4%)0.89
Procedure PerformedSeptopexy99 (51.3%)89 (53.9%)0.41
Orchiectomy62 (32.1%)43 (26.1%)
TV Flap32 (16.6%)33 (20.0%)
Time from Symptom Onset to Presentation (hours), median (IQR)10 (3.5, 36)4 (2, 33)0.002
Time from Institutional Arrival to OR (mins), median (IQR)180 (143, 216)91 (69, 129)<0.001

Table 2. Follow-up outcomes by group based on surgical management
Septopexy Orchiectomy TV Flap p-value
18810565
Post-Op Complications 7 (3.7%)4 (3.8%)1 (1.5%)0.79
Clavien Grade I6 (86%)2 (50%)1 (100%)0.62
II1 (14%)2 (50%)0 (0%)
Post-Op Follow-Up 121 (64.4%)82 (78.1%)48 (73.8%)0.038
Ipsilateral Testicular Atrophy 12 (9.8%)24 (51.1%)<0.001
Atrophy on Exam 10 (5.3%)22 (33.8%)<0.001
Atrophy on SCRUS 5 (2.7%)19 (29.2%)<0.001


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