Testicular torsion in adults: which news?

Abstract

We read with pleasure the article written by Dang et al.1 and the authors should be noted for the large case series reported. Testicular torsion is one of the causes of acute scrotum, in all age groups. Even in adults, testicular torsion is difficult to diagnose, so it is necessary to perform a surgical exploration. Some diseases such as testicular cancer must be considered when treating a patient with testicular torsion. Radiological investigations sometimes help us in the diagnosis, but surgery is always necessary to exclude testicular damage. A long-term follow-up is always necessary to evaluate testicular function and viability. It is clear that organizing a multicenter study, even if retrospectively, is always difficult and complex. The data reported are interesting, especially on some clinical aspects, thus highlighting how the diagnosis and treatment of testicular torsion are also in adults sometimes difficult and not always correct. The clinical approach is similar to what is done in the pediatric age, but some differences are evident. For example, the time of onset and the time used for the diagnosis seem to be reduced compared to the pediatric age, perhaps because the adult goes alone to the hospital and knows how to evaluate their symptoms. In spite of this, the absolute percentage of torsions (50%), if corrected excluding 30% of procedures without cause and 10% associated with tumor, is clearly higher than that in the previous age (pediatric and adolescent age). Interesting is also the side localization, which confirms a predisposition for the right side. Based on the study results, if we must analyze and find some uncertain aspects, we can highlight that some data which currently seem to be fundamental in pediatric age for the therapeutic approach, are not reported. In fact, metachronous torsions are not described, and therefore, the simultaneous treatment of the contralateral side is not suggested.2 Moreover, although they reported ultrasound and Doppler data, they do not report data concerning the ultrasound appearance of the testicular parenchyma, so we cannot have data to correlate with testicular viability at the time of surgery and during follow-up. Also inherent to follow-up, the authors reported a follow-up of 30 days, and this may be incorrect on the assessment of testicular viability. How many testes have become atrophic some months after surgery? The long-term outcome is therefore crucial because the ultrasonographic appearance, vitality at surgery, and long-term testicular quality are key elements in predicting any problems with fertility or gonadal function. Very interesting are the data regarding the presence of testicular cancer since it is practically nonexistent in pediatric age.3 These data are important, especially for those surgeons that work with adolescents and young adults. If we have to find some limits, we can specify that the surgical approach is always secondary to the experience of the surgeon who may or may not use ultrasound and other diagnostic methods. In this case, in a multicenter study without having decided beforehand the criteria to treat acute scrotum, what tests to do and when to perform a surgical approach, data collected can be difficult to interpret. However, in the conclusions that are to be shared, surgical exploration should always be performed in case of doubt; and although the percentage of operations without diagnosis may be high, it is correct not to waste time waiting for radiological investigations that may not help in the clinical decision. In our opinion, it remains fundamental that future research should be based on long-term follow-up of these patients, with clinical and radiological controls to be defined, certainly for many months, perhaps adding laboratory tests and analysis of seminal fluid in those patients seeking paternity. Many experiences in fact report that in the long term, testicles left in place after torsion, have altered function. It is therefore essential that research proposes new diagnostic and therapeutic treatments after surgical procedures to ensure better testicular vascularization and vitality of the testis.4 COMPETING INTERESTS Both authors declare no competing interests.