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Low success rate of salvage surgery for testicular torsion in newborns

Rie Jensen, Mark Ellebæk, Lars Rasmussen & Niels Qvist,

1. jan. 2015
10 min.

Faktaboks

Fakta

Testicular torsion in newborns is a rare condition which often results in a non-functioning testis on the affected side despite early surgical intervention. Bilateral torsion occurs in 5-10% of the cases [1-6] and may cause a need for lifetime hormonal replacement.

The treatment of neonatal testicular torsion is controversial, and the prognosis for preservation of testis
viability differs in the literature. Urgent surgical exploration has been recommended [7], but a more conservative approach has been advocated because very few testes saved and because of the potential risk of anaesthesia in neonates [1, 8, 9]. Experimental studies in animals have shown that spermatogenesis is damaged after 4-6 hours and hormonal function after 10-12 hours of ischaemia. On this basis, it is often concluded that pre-natal torsion of the testis is a non-salvageable event [1, 2, 9]. Clinical reports on the salvage rate of post-natal torsion ranges from 0 % to 40%. When the testis is considered non-viable, orchidectomy is often recommended because of an up to 10% risk of later malignancy in persisting germ cells [10-12].

The objective of this study was to retrospectively review our institutional results for surgery for testicular torsion in the neonatal period with a special focus on salvage surgery in relation to clinical presentation and age.

METHODS

Patient records for all children aged up to 30 days operated for testicular torsion at our hospital during the past 20 years were reviewed retrospectively. The following information was obtained: symptoms, objective findings, ultrasonography findings, age at which testicular pathology was first suspected, age at time of operation, doctor or parent delay, operative strategy and pathology
reports.

Trial registration: not relevant.

RESULTS

Thirteen patients (15 affected testis) were identified and included in the study. Emergency surgery (within six hours after symptom presentation) was performed in eight cases (61.5%), and delayed surgery (> 24 hours) in five cases (38.5%). Delayed surgery was most often due to doctor’s delay. No parent delay was described, but there was no information on the cause of delay in two cases. Patient characteristics appear from Table 1. Two cases of bilateral affection were seen. Salvation of the affected testis was successful in two of the 15 affected testes, 12 non-viable testis or remnants were removed, and one fibrotic testis was left in situ. Contralateral orchidopexy was performed in three of the 11 cases with unilateral affection. Pathology reports were available in ten of the 12 orchidectomy cases (case 1-10), and they all showed testicular infarction with calcifications, fibrosis and no viable testicular tissue. Two cases with fibrosis only were considered vanished testis (case 1 and 7).

Preoperative ultrasonography was performed in five of the 13 patients, and in only one case it was conclusive showing testicular torsion with no Doppler-signal (case 10); otherwise, the ultrasonography was inconclusive.

DISCUSSION

The results from the present study confirm the low rate of salvage of the affected testis found in previous
studies [1, 2, 4-6, 13].

Neonatal testicular torsion can be divided into two sub-groups: pre-natal torsion recognised as a fibrous scrotal swelling at delivery and post-natal torsion occurring within the first 30 days of life. The post-natal torsion is clinically similar to that seen later in life with inguinoscrotal swelling and skin discoloration, whereas scrotal tenderness or pain often is difficult to assess [2, 3].

Based on operative findings and pathology reports, we considered that prenatal torsion occurred in at least eight of our cases, which presented with clinical findings within the first day of life. Testis was saved on no cases in this group. Salvation of the testis was possible in only two cases, which presented at two and 19 days of age. Although symptoms like pain are difficult to assess in newborns, it has been claimed that that lack of pain indicates unsalvageable testis [1, 8]. However, in one of our patients with a salvageable testis, no signs of pain or distress were reported in the record.

Urgent surgery was performed in eight cases in our study, and delayed surgery in the remaining cases. A survey among paediatric urologists in the US revealed that only 31% of the respondents would operate immediately in case of pre-natal torsion, and no surgery was recommended by 12% of the surgeons [14]. Almost all surgeons (96%) would operate immediately in cases presenting in the post-natal period. Similar results were obtained from a survey among UK paediatric surgeons and urologists, but only 10% of the surgeons had ever found a viable testis [15]. The policy of “wait and see” has been challenged by others because surgery is the only possible way to save viable testicular testes even in cases with severe ischaemia [16].

Use of ultrasonography with colour Doppler to diagnose testicular torsion is controversial [2, 4, 6, 8, 17]. Even in the hands of a skilled investigator, the specificity and sensitivity is poor and should not delay surgical exploration. In our series, only one out of five cases with preoperative ultrasonography conclusively showed testicular torsion.

Histologically, pre-natal testicular torsion can present either as a fibrotic and non-functioning testicular remnant or as a fibrotic lump without visible testicular tissue, the so-called vanished testis. The vanished testis is hardly the result of underlying endocrine pathology as most of the boys have a normal male karyotype and a normal number of Leydig and germ cells in the contralateral testis [18, 19]. The theory that vanished testis is caused by torsion is further supported by the fact that haemosiderin-laden macrophages are present in most removed specimens, which is consistent with haemorrhagic infarction [5, 10, 11, 18]. It is generally accepted that a necrotic or fibrous testicular remnant (Figure 1) should be removed to prevent infection, avoid risk of later malignancy and minimise the risk of antibodies against testicular tissue.

Contralateral orchidopexy is another important and controversial subject. It has been shown that up to 85% of boys born with monochordism, most likely as a result of vanish testis, have contralateral gubernaculum deformities, possibly increasing the risk of later torsion [20]. Thus, most authors recommend contralateral testicular fixation. Others have been chary of contralateral orchidopexy due to the risk of complication which is seen in up to 18% of the cases [1]. Intrauterine torsion is extravaginal, whereas torsion later in life most often is intravaginal [5]. Therefore, the general recommendation of contralateral fixation is probably not applicable to neonates. Torsion during the observation period (1-19 years) occurred in none of our seven patients with no contralateral testis fixation, To our knowledge, the true risk of testicular torsion later in life is unknown.

The limitations of the present study are the retrospective design and the limited study size, even if this is one of the largest series published. Testicular torsion in the first month of life is a rare condition, and randomised prospective studies are not likely to be conducted ever. Although no firm conclusions can be drawn from this or other published studies, the present results confirm that there seems to be no advantage from early
intervention in the new-born male presenting with a firm testicular mass, scrotal swelling or discoloration within the first day of life.

Urgent surgery is recommended in cases that present with symptoms after birth, but the chance of saving the testis remains poor. Contra-lateral testicular fixation is controversial and carries a significant risk of complications.

CONCLUSION

Testicular torsion is seldom within the first 30 days of life and it is associated with a poor testicular outcome, especially among those presenting within the first day of life. It is not possible to conclude which surgical strategy is the best, but the risk of contralateral testicular fixation should be considered as there is no knowledge on the risk of developing torsion later in life. The parents should be counselled on the merits of the various strategies including the outcome expectations.

Correspondence: Rie Jensen, Kirurgisk Afdeling, Odense Universitetshospital, Sdr. Boulevard 29, 5000 Odense C, Denmark. E-mail: rijen08@gmail.com

Accepted: 24 November 2014

Conflicts of interest:Disclosure forms provided by the authors are available with the full text of this article at www.danmedj.dk

Referencer

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