Acute testicular torsion is one of the few true pediatric urologic surgical emergencies. If the diagnosis of acute testicular torsion is delayed, it can lead to late treatment and subsequent testicular loss. Therefore, testicular torsion is significant from both a clinical and medicolegal perspective.
The first step is to differentiate extravaginal and intravaginal torsion. In extravaginal torsion, which typically occurs in neonates, the spermatic cord, the testis, and the tunica vaginalis twist together as a unit. The neonate presents with a firm, nontransilluminating scrotal mass with a bluish cast. It is often painless. Doppler ultrasonography usually shows no signals of vascular return. Manual detorsion is not applicable. Because surgical salvage is rarely successful, the testis should be removed. Contralateral orchiopexy can be performed at the time of orchiectomy; however, the evidence-based rationale remains controversial.
In contrast, intravaginal torsion more commonly occurs in adolescent boys, and only the spermatic cord and the testis rotate. The onset is acute, usually associated with scrotal pain that is moderate to severe. Treat it as an emergency. In equivocal cases, perform a clinical examination, with or without blocking the cord, and look for the displacement of the lower pole of the epididymis away from the lower pole of the testis (the anomaly that permits torsion). If in doubt, order a color Doppler ultrasound examination, which is highly sensitive for obstructed blood flow, but do not delay treatment if these studies are not immediately available.
While awaiting surgical exploration for a clinically suspected case of testicular torsion, manual detorsion can be attempted to restore perfusion and decrease pain, but it is not as a substitution for surgery. Initial attempt at manual detorsion should follow the mantra of “opening the book” by rotating the affected testicle laterally. If this maneuver is met with resistance, then try rotating the affected testicle medially because 33% of the time, testicular torsion occurs in the opposite direction. Successful manual detorsion is typically marked by sudden relief of scrotal pain and return of the testicle into its normal vertical position in the low scrotum. Even after manual detorsion is deemed successful, surgical exploration remains necessary because residual torsion had been reportedly to be as high as 32% and poses a threat to testicular viability.
Intraoperative Surgical Techniques
Scrotal exploration for suspected testicular torsion and contralateral orchiopexy is performed with the patient in the supine position. A caudal block can be done at the end of the case for postoperative pain control if the patient is of a suitable age. In the supine position, the patient’s external genitalia, groin, and perineum are prepped with betadine and draped in the usual sterile fashion. A dose of intravenous antibiotic, usually cefazolin, can be given at the surgeon’s discretion.
An incision along the median raphe of the scrotum allows access to bilateral hemiscrotum via a single incision. Alternatively, two separate short incisions can be made, one in each hemiscrotum, in an anterolateral location. Proponents of the latter approach believe such incisions are less likely to interfere with the distribution of scrotal nerves.
After the skin incision has been made, the dissection is then carried through the dartos fascia and onto the tunica vaginalis. The affected side is approached first. The next step is to open the tunica vaginalis sharply at a location that is relatively thin and avascular ( Fig. 115.1 ). At this point, if there is reactive hydrocele fluid, it can be evacuated. The ipsilateral testis is extruded for examination of viability, and the spermatic cord is examined for the direction and degrees of torsion. Detorsion, or untwisting of the cord, is performed if necessary.
Assessment of Testicular Viability
If the testicle still appears blue and congested after detorsion of the cord is completed, one approach is to wrap the testicle in warm saline sponges and proceed to contralateral orchiopexy before reassessing the affected side for color. Another approach is to make a short incision in the tunica albuginea but deep through the medulla and then observe for 10 minutes for signs of active bleeding. When bleeding from the cut surface is immediate or starts within 10 minutes, orchiopexy is the treatment of choice. On the other hand, if no bleeding is observed during surgery, then the testis is unlikely to be viable, and orchiectomy can be performed.
If the affected testis is deemed nonviable, then proceed with orchiectomy by dividing the cord structures between clamps and ligating with 2-0 Vicryl or silk sutures. For postpubertal male patients who have already achieved full testicular growth, if permission has been obtained, combined orchiectomy and testicular prosthesis placement can provide the advantages of orthotopic prosthetic position, extra tunica vaginalis barrier layer, and avoidance of a second anesthetic event. After a median of follow-up period of 4.8 months, this combined procedure was not found to have infectious complications or extrusions. If the affected testis is deemed viable, then proceed with orchiopexy as described in the next section.
If the affected testis is deemed viable, trim excess tunica vaginalis and obtain hemostasis along the edge with careful fulguration. As an optional step, the edges of tunica vaginalis can be everted and approximated behind the testis, using two or three interrupted 3-0 Vicryl sutures, in an effort to minimize hydrocele formation ( Fig. 115.2 ). The next step involves placement of fixation sutures that tack the tunica albuginea to the dartos layer in three places, one medially, one laterally, and one inferiorly. Tacking sutures can be absorbable, such as 4-0 polydioxanone (PDS), and care should be taken not to throw the stitches deep into the testicular parenchyma. All three fixation sutures, alternatively, can be placed medially, affixing the testicle to the septum ( Fig. 115.3 ). In either approach, the goal is to place the testicle in an extravaginal position to prevent recurrent intravaginal torsion.