Background: Acute testicular torsion is a surgical emergency. Time from onset of pain is a critical determinant of ability to salvage the testicle. While studies have focused on orchiectomy as an end-point, data on longer term atrophy for salvaged testicles are scarce. Our working hypothesis is that under 8 hours of testicular pain will be associated with low rates of testicular atrophy.
Methods: Retrospective chart review of all pubertal patients (age >10 years) diagnosed with testicular torsion using billing codes over a 9-year study period (2015-2023) was performed. Data on demographics, duration of pain, clinical context, times of presentation to either an outside facility or one of our system Emergency Departments, time to surgical detorsion, findings at surgery, and all follow-up findings were collected. Testicular atrophy at follow-up was defined as at-least 50% decrease in testicular volume compared to the contralateral side, either on physical exam or scrotal ultrasound (when performed). Patients underwent surgical intervention by one of seven fellowship trained pediatric urologists over the study period. Prepubertal patients (aged <=10) and patients undergoing surgery for intermittent torsion were excluded.
Results: A total of 774 pubertal patients were diagnosed with acute testicular torsion during the study period. 337 (43.5%) presented to an outside hospital prior to transfer to our center. Median (interquartile range [IQR]) age at presentation was 14 years (13-15.75), and ipsilateral (50% Left/50% right) testicular pain was the most common symptom. Median (IQR) time from onset of pain to surgery was 11.9 hours (5.7-56.1). Overall, 228 patients (29.5%) underwent ipsilateral orchiectomy. Orchiectomy rates varied markedly by surgeon with 12-24 hours of pain (ranging from 6% to 40%; average 22%) and 24-48 hours of pain (7% to 100%; average 41%). For patients undergoing orchidopexy (n=531), urology follow-up visits were completed by 330 patients (62%). Over a median (IQR) follow-up of 99 (45-154) days, 98 (17.9%) of salvaged testicles underwent atrophy. Testicle loss (defined as orchiectomy or atrophy) was increasingly likely with greater duration of pain (Figure 1). Even with less than 8 hours of pain, atrophy was seen in 22% of boys with at-least 6-month follow-up (total n=115).
Conclusions: Within a single academic center, we noted a wide variation in orchiectomy rates for testicular torsion, especially for prolonged duration of pain (>12 hours). This likely reflects differences in intraoperative appearance of testicle on detorsion, and impact of surgeon training and preferences. Further, we saw high rates of testicular atrophy (>20%), even with limited duration of pain (<8 hours), underscoring the need for longer term monitoring, and lack of a safe “cut-off time” to perform surgical detorsion. Lastly, we posit using a combined “testicle loss rate” (defined as orchiectomy OR atrophy) as end point for testicular torsion, given the significant subjectivity in decision for performing orchiectomy. These data can be used to optimize patient and family counseling regarding testicular torsion.
