BACKGROUND: The decision of orchiopexy or orchiectomy in patients with testicular torsion is subjective and often biased by the time since the pain onset and the surgeon’s judgment of the return of testicular blood flow after detorsion. We present our initial experience using Indocyanine Green fluorescence imaging (ICG-FI) to objectively support the often-perplexing clinical decision of sparing or removing the ischemic testicle in patients with testicular torsion. METHODS: Six adolescents underwent surgical exploration for testicular torsion at a single institution between September 2023 and April 2024. The primary surgeon made an initial decision of orchiopexy or orchiectomy after the ischemic testicle was detorsed and wrapped in warm towels for a minimum of 10 minutes. Then, ICG was intravenously administered. After 30 seconds, testicular blood flow was examined using near-infrared fluorescence imaging, using the contralateral testis as a reference. The clinical decision of orchiopexy or orchiectomy was revisited according to fluorescence imaging findings.
RESULTS: The average patient age at surgery was 13.3 (12-16) years. Preoperative duplex ultrasound confirmed absent or reduced blood flow to the affected testis in all 6 patients. The median duration (range) between symptom onset and surgery was 10.5 (6-20) hours. Testicular torsion was confirmed on surgical exploration in all patients with the degree of torsion ranging from 180-720°. Overall, 5 patients had orchiopexy and one had an orchiectomy of the affected testicle. Contralateral orchiopexy was done in all patients. Based on clinical judgment, the operating surgeon initially decided on orchiopexy in 4 patients and orchiectomy in two. ICG-FI findings supported the clinical decision of orchiopexy in all 4 patients and orchiectomy in one patient. In the remaining patient, the initial decision of orchiectomy was changed to orchiopexy after ICG-FI demonstrated preserved testicular blood flow. In that patient, 3-month follow-up ultrasound demonstrated reduced testicular volume (42% the size of the contralateral testis), but normal testicular blood flow. Follow-up ultrasound was available for 3 other patients treated with orchiopexy and it demonstrated maintained testicular blood flow with no evidence of testicular atrophy in any of them. CONCLUSIONS: Indocyanine green fluorescence imaging can be a valuable objective tool to support intraoperative clinical decision-making in patients with testicular torsion.
