Background: Time from onset of testicular torsion (TT) to detorsion is critical to testicular salvage in TT cases. Anything that delays the time to surgical intervention reduces the chance of testicular salvage.1 Research evaluating the impact of transfer time on salvage rates in pediatric TT is limited. A review of studies in the UK led to the Royal College of Surgeons of England (RCSE) determination that TT cases should be managed at the presenting hospital when at all possible.2 In the UK, this legally binds both general surgeons and urologists to surgically manage TT regardless of pediatric subspecialty certification.3-6 In the US, non-pediatric urologists/surgeons frequently transfer all pediatric TT cases regardless of age and health status. The main objectives of this study are to examine transfer time's effect on TT outcomes and compare TT outcomes for direct and transfer patients to a single tertiary free-standing children’s hospital to determine if there is evidence to support the European standard of care for TT in children/adolescents in the US.
Methods: Male patients <18 years of age at the time of surgical treatment for TT at Nemours Children’s Health (NCH) from 2020 to 2024 were included in this IRB approved retrospective chart review. After exclusions (neonatal/perinatal torsions), 82 cases of both direct presenting and transfer patients were identified. We evaluated age, time (symptom onset to referring ED, symptom onset to surgery, transfer initiation to NCH ED, NCH ED to OR), transport method, NCH repeat ultrasound (US), US results, surgical outcome, follow up, distance in miles, comorbidities, and TWIST score. Surgical outcome is based on testicular viability thus a negative outcome (NO) includes testicular removal, atrophy, or infection.
Results Our data shows TT cases transferred have higher incidences of NO than those presenting directly to NCH. Transfers had 36.2% NO's while direct admissions had 25.7% NO's. The data also shows that longer transfer times resulted in higher percentage of NO. Short transfers (<1 hour) had 9.1%, medium transfers (1 to 1.75 hours) had 33.3%, and long transfers (>1.75 hours) had 66.7% NO. For specific NO’s transfers and direct patients had similar removal and infection rates, while transfers had much higher atrophy rates (Fig 1).
Conclusions: Time from onset of testicular torsion to detorsion is critical for testicular salvage. In the UK, attention to expeditious surgical intervention is reflected in the expectation that all surgeons treat TT and avoid routine transfer. Our data supports the notion that increases in transfer time increase chances of NO for pediatric TT. The data comparing transfers to direct cases indicates that transfer patients are at a higher risk for loss of testicular viability. We believe our data supports the need for larger, collaborative studies to evaluate the impact of transfer on TT outcomes to determine if educational efforts are needed to support changes in the current management of pediatric TT in the US.
