Management Of Testicular Torsion Research Articles

MP02-04 IS THERE A WEEKEND EFFECT IN THE MANAGEMENT OF TESTICULAR TORSION? ANALYSIS OF THE SPARCS DATABASE FOR PEDIATRIC AND ADULT PATIENTS

You have accessJournal of UrologyCME1 Apr 2023MP02-04 IS THERE A WEEKEND EFFECT IN THE MANAGEMENT OF TESTICULAR TORSION? ANALYSIS OF THE SPARCS DATABASE FOR PEDIATRIC AND ADULT PATIENTS Micah Levy, Chih Peng Chin, Evan B. Garden, Krishna T. Ravivarapu, Christopher Connors, Olamide O. Omidele, Hasan Bilal, Jeffrey A. Stock, and Michael A. Palese Micah LevyMicah Levy More articles by this author , Chih Peng ChinChih Peng Chin More articles by this author , Evan B. GardenEvan B. Garden More articles by this author , Krishna T. RavivarapuKrishna T. Ravivarapu More articles by this author , Christopher ConnorsChristopher Connors More articles by this author , Olamide O. OmideleOlamide O. Omidele More articles by this author , Hasan BilalHasan Bilal More articles by this author , Jeffrey A. StockJeffrey A. Stock More articles by this author , and Michael A. PaleseMichael A. Palese More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003213.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The “weekend effect” refers to patients experiencing worse outcomes when presenting to the hospital on the weekend. This phenomenon has been evaluated for several surgical procedures but has yet to be studied in patients with testicular torsion, a condition requiring emergent surgical intervention to preserve testicular function. We evaluated for the presence of a weekend effect in the management of testicular torsion in both a pediatric and adult patients. METHODS: The Statewide Planning and Research Cooperative System, a New York State all payer data reporting system, was queried from 2010-2017. All patients presenting with testicular torsion requiring surgical management were stratified into pediatric (<16 years old) or adult (>17 years old) groups, and then sub-stratified by admission on weekday (WD) or weekend (WE). Patient age, rate of orchiectomy vs. orchiopexy, rate of bilateral orchiopexy, length of stay (LOS), operative time (OPT), total hospital cost (THC), and incidence of evaluation of torsion within 7 days prior to current admission were analyzed. RESULTS: Of 1,445 cases, 807 were pediatric (WD: 600 [74.3%], WE: 207 [25.7%]) and 638 were adult (WD: 464 [72.7%], WE: 174 [27.3%]) with no difference in rate of weekend admission between populations (p=0.487). WE pediatric patients had a greater rate of orchiectomy (WE: 11.6%, WD: 6.7%, p=0.024), and bilateral orchiopexy (WE: 71.0%, WD: 62.7%, p=0.040). They were also older (WE: 11.9, WD: 10.6, p=0.002), had a greater LOS (WE: 0.45, WD: 0.27, p=0.037) and THC (WE: $18,257, WD: $12,460, p=0.016) though these are likely clinically insignificant. There was no difference in OPT or prior torsion evaluations [Table 1A]. The adult cohorts had no significant differences for any analyses [Table 1B]. CONCLUSIONS: On weekends, pediatric patients had a greater rate of orchiectomy and of bilateral orchiopexy, suggesting a possible weekend effect in the pediatric population. This may be due to delays in presenting to the hospital by either the patient or parent. No evidence of a weekend effect was found in the adult population. Patients and parents should continue to be educated on the symptoms of testicular torsion and be encouraged to always seek immediate medical attention to improve the chances for testicular salvage. Source of Funding: NA © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e11 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Micah Levy More articles by this author Chih Peng Chin More articles by this author Evan B. Garden More articles by this author Krishna T. Ravivarapu More articles by this author Christopher Connors More articles by this author Olamide O. Omidele More articles by this author Hasan Bilal More articles by this author Jeffrey A. Stock More articles by this author Michael A. Palese More articles by this author Expand All Advertisement PDF downloadLoading ...

Management of testicular torsion by a general surgeon isolated in Africa

RésuméL’apparition d’une douleur scrotale brutale et intense pose plusieurs problèmes quand elle survient chez un homme jeune en Afrique. Parmi les étiologies possibles, la torsion testiculaire est l’urgence chirurgicale à écarter, car au-delà de 6 heures d’évolution le pronostic fonctionnel du testicule est engagé. L’évolution septique vers une fonte purulente, en cas de torsion dépassée, est aussi possible. D’incidence légèrement inférieure à celle des pays occidentaux, la méconnaissance de cette pathologie par les acteurs de santé de proximité, la précarité ou l’isolement sanitaire de certaines populations dans certaines régions sous-médicalisées, contribuent aux retards diagnostique et thérapeutique. Cela conduit souvent à une évolution péjorative, la perte du testicule étant directement corrélée au délai de prise en charge. La torsion testiculaire a ainsi été identifiée comme l’une des principales causes d’infertilité masculine en Afrique. Pourtant, le diagnostic clinique et le traitement chirurgical nécessitent peu de moyens et restent accessibles dans un milieu à faibles ressources ou en conditions précaires. Cet article reprend le tableau clinique de torsion du cordon spermatique et la technique d’orchidopexie.

164 Testicular Torsion: A Race to Beat the Golden Hours

Abstract Introduction Testicular torsion is a condition requiring immediate attention and the golden time period for its management is 6 hours at which rate of salvageability of the testes is 90 percent (NICE). This decreases considerably with passing time. Imaging has minimal value. Method The electronic data of 36 patients from June 2020 to May 2021 were reviewed and analysed. Majority of patients were between the age of 11–20 i.e., 21. We analysed the mode of admission of these patients, the time between the A&amp;E triage and surgical clerking and A&amp;E triage and induction of anaesthesia. Results Majority (70 percent) patients were admitted through Emergency A&amp;E. The time between the A&amp;E triage and surgical clerking was less than 30 minutes for 10 patients while 11 patients had no proper documentation of time. The time between the A&amp;E triage and the induction of anaesthesia was less than 6 hours in 23 patients, and more than 6 hours for 7 of them. 14 underwent Scrotal Exploration and Bilateral orchidopexy and 13 orchidectomies. Out of 13 orchidectomies, 6 had crossed the golden time period at the time of induction. Out of 10 patients booked for USS testis, 8 underwent Orchidectomy and 6 had crossed the golden hour (6 Hours). Conclusions Early presentation, diagnosis and exploration of testicular torsion improves the salvable rate of testes. 6 patients who underwent USS testis passed the golden timeframe which shows that there is a scope for faster and appropriate management of testicular torsion.

123 Supporting A Learning System in Paediatric Emergency Pathways; Using Organisational Comparisons, Serious Incidents and Near Miss Events To Improve The Diagnosis And Treatment Of Testicular Torsion

Abstract Introduction Scrotal pain is a common presentation to the emergency department requiring prompt investigation and management to identify testicular torsion. Using national data we aim to identify key suboptimal areas in the acute diagnosis and management of testicular torsion with a view to improving outcomes. Method A freedom of information request was made to all Trusts in England that manage testicular torsion. Serious Incidents (SI's) were analysed to see if those with Paediatric Emergency Departments fared better than those without. In addition, a qualitative thematic analysis of the NHS England Strategic Executive Information System database from 2007-2019 was undertaken, identifying common themes associated with orchidectomies and ‘near miss’ events in children. Results 304 serious incidents were returned with 62 Orchidectomies and 242 Near Miss Events. Misdiagnosis of symptomatic testicle was not significant when comparing ED to specialists (OR = 1.46, p = 0.3842). Atypical presentation resulting in orchidectomy was significant when comparing ED to specialists (OR = 6, p = 0.0355). Near miss events are due to a variety of factors. There was no statistical significance in incidents when comparing ED's caring for all ages with Paediatric EDs U = 807.5, z = -1.124, p = 0.261. Conclusions There's a need for education in ED about atypical presentation of testicular torsion and examination of scrotum in cases of lower abdominal pain. It's also vital that specialist teams are cognisant of the standard operating procedures relevant to scrotal pain. Finally, there should be a drive for annual audit in Urology and ED units with regards to testicular torsion as SI's may be under-reported.

MP55-02 TRENDS IN TESTICULAR SALVAGE RATE FOR TESTICULAR TORSION: COMPARISON OF THE PRE- AND POST- QUALITY METRIC ERAS

INTRODUCTION AND OBJECTIVE:Management of testicular torsion is predicated on prompt intervention with the goal of testicular salvage by limiting ischemia time. On June 15, 2015, US News & World Rep...

Just the facts: assessment and management of testicular torsion in the emergency department.

Just the facts: assessment and management of testicular torsion in the emergency department.

Access to emergency paediatric surgery for testicular torsion or intestinal volvulus in New Zealand: A system perspective.

The risk of organ loss is increased in children with testicular torsion or intestinal volvulus if surgical management is not expedient. The current retrospective study aims to review the time-course from first symptom to 'knife to skin' in these conditions, to determine where delays occur and facilitate a systems approach to better manage these children. One hundred consecutive paediatric cases of scrotal exploration for presumed testicular torsion, and 100 neonatal cases presenting with possible malrotation/volvulus were analysed to evaluate the exact time-course of events from admission to surgery. (i) Scrotal exploration: the median time from onset of symptoms to presentation was 12 h (interquartile range (IQR): 5-48 h). In children over 5 years of age, 36% (33/93) were transferred from an external district service area. (ii) Malrotation/volvulus: the median duration of symptoms prior to arrival/assessment was 12 h (IQR: 4-24 h). The median cumulative in-hospital time was over 6 h (368 min, IQR: 247-634 min). Time to presentation contributes significantly to testicular ischaemic time. This delay to timely surgical intervention is multi-factorial, and must be addressed at a public health level. Support and training in the management of testicular torsion should be provided to all adult surgeons/trainees that may care for these children. In general, this condition is best managed at the presenting hospital whenever appropriate expertise is available. Novel pathways that streamline care may improve efficiency at an institutional level. Addressing issues of access to specialised neonatal surgery is more vexed on account of the tyranny of distance, and the pre-requisite level of surgical expertise required.

Improving testicular examinations on paediatric patients in the emergency department: A quality improvement study to improve early diagnosis of testicular torsion

ObjectiveMale paediatric patients presenting with abdominal and/or testicular pain are common in the emergency department. As a time-sensitive diagnosis, the importance of early recognition, referral, and definitive management is critical. Missed or delayed diagnoses and management of testicular torsion can result in significant long-term sequelae including impaired fertility and psychological burden. In this quality improvement study, we utilised educational posters aiming to improve awareness of testicular torsion as a differential for abdominal pain and therefore, improve the quality of testicular examinations performed in the emergency department. MethodsObservational pre- and post-intervention study was conducted at a tertiary hospital emergency department. A pre-interventional retrospective review of the electronic medical records was conducted. All male patients under 16-years-old presenting with “abdominal pain” or “testicular problem” were included. We assessed the rate of testicular examination and the quality of the examination based on four domains: Cremasteric reflex, lie, swelling, and hardness. Educational posters targeting both patients and clinicians were placed around the emergency department. Subsequent review of the electronic medical records post-intervention was performed assessing the same domains. ResultsA total of 235 presentations were analysed with 124 in the pre-intervention group and 111 in the post-intervention group. Overall rate of documented testicular examinations increased by 14% (p=0.032). The quality of testicular examinations also improved from an average of 0.85 domains documented to 2.29 post-intervention (p<0.001). Subgroup analysis found doctors in training had a greater improvement in both rate and quality of documented testicular examination. ConclusionOur study demonstrated the value of continuing education in promoting awareness of testicular torsion in the emergency department. We found a clear improvement in the quality of clinical documentation of a time-sensitive condition which may infer a decreased risk of missed and delayed diagnosis of testicular torsion.

Management of testicular torsion in the ER: lessons learned from medical professional liability claims

ObjectiveTo evaluate emergency care for testicular torsion (TT) in medical professional liability (MPL) claims. MethodsClaims related to TT from 2000 to 2018 were located. The assistance provided and the association with MPL were analyzed. ResultsEighty complaints were identified, testicular pain was reported in 83.75% of first consultations, with a mean evolution time of 15.5 h. The mean time to diagnosis was 7.98 days. The first consultation was at the hospital in 75.1% of cases, but an ultrasound was performed only in 7.5%. When TT diagnosis was performed, 97.3% had undergone ancillary tests. The MPL was significantly associated with non-criminal proceedings and with less than 6 h of symptoms’ evolution, and, within this subgroup, without undergoing an ultrasound scan. ConclusionsLate consultations, wrong diagnosis and late diagnosis are claimed. When MPL are claimed by means of non-criminal law, the existence of responsibility is frequently considered, even more in those cases when the consultation took place before 6 h of evolution with no ancillary tests having been performed.

A multicenter study of acute testicular torsion in the time of COVID-19

BackgroundTesticular torsion is a surgical emergency, and time to detorsion is imperative for testicular salvage. During the COVID-19 pandemic, patients may delay emergency care due to stay-at-home orders and concern of COVID-19 exposure.ObjectiveTo assess whether emergency presentation for testicular torsion was delayed during the COVID-19 pandemic, and whether the rate of orchiectomy increased compared to a retrospective period.Study designPatients were prospectively enrolled in a multicenter study from seven institutions in the United States and Canada. Inclusion criteria were patients two months to 18 years of age with acute testicular torsion from March through July 2020. The retrospective group included patients from January 2019 through February 2020. Statistical analysis was performed using Kruskal–Wallis tests, Chi-square tests, and logistic regression.ResultsA total of 221 patients were included: 84 patients in the COVID-19 cohort and 137 in the retrospective cohort. Median times from symptom onset to emergency department presentation during COVID-19 compared to the retrospective period were 17.9 h (IQR 5.5–48.0) and 7.5 h (IQR 4.0–28.0) respectively (p = 0.04). In the COVID-19 cohort, 42% of patients underwent orchiectomy compared to 29% of pre-pandemic controls (p = 0.06). During COVID-19, 46% of patients endorsed delay in presentation compared to 33% in the retrospective group (p = 0.04).DiscussionWe found a significantly longer time from testicular torsion symptom onset to presentation during the pandemic and a higher proportion of patients reported delaying care. Strengths of the study include the number of included patients and the multicenter prospective design during the pandemic. Limitations include a retrospective pre-pandemic comparison group.ConclusionsIn a large multicenter study we found a significantly longer time from testicular torsion symptom onset to presentation during the pandemic and a significantly higher proportion of patients reported delaying care. Based on the findings of this study, more patient education is needed on the management of testicular torsion during a pandemic.

Accurate Estimation of the Duration of Testicular Ischemia Using Creatine Chemical Exchange Saturation Transfer (CrCEST) Imaging.

In the management of testicular torsion, estimating the duration of testicular ischemia is essential for deciding on an appropriate surgical treatment, but there are currently limited evaluation methods. To perform testicular creatine chemical exchange saturation transfer (CrCEST) imaging and to evaluate its ability to accurately estimate the duration of testicular ischemia. Prospective. C57BL/6 control mice (n = 6) and testicular ischemia models induced by clamping the spermatic cord (n = 14). Eight of testicular ischemia models were serially imaged at two or three timepoints and a total of 26 images of ischemic testis were obtained. The ischemic duration ranged from 6-42 hours. 11.7T vertical-bore MRI/segment fast low-angle shot acquisition for CEST. CrCEST imaging was performed and the magnetization transfer ratio for the CrCEST effect (MTRCr** ) was calculated in control mice and testicular ischemia models. Correlation analysis between the duration of testicular ischemia and MTRCr** decline was performed. Paired t-test, and Pearson's correlation analysis. In control mice, the CrCEST effect in testes was significantly more than five times higher than that in skeletal muscle. MTRCr** did not differ significantly between the right and left testes (8.6 ± 0.8 vs. 8.3 ± 0.6, P = 0.96). In testicular ischemia models, MTRCr** of ischemic testes was significantly lower than that of controls (4 ± 2 vs. 8.9 ± 0.6, P < 0.001). Correlation analysis revealed a strong linear correlation between MTRCr** decline and the duration of ischemia (r = 0.96, P < 0.001). A decreased CrCEST effect in ischemic testes correlated well with ischemic duration. Testicular CrCEST imaging was useful for accurately estimating the duration of testicular ischemia. 2 TECHNICAL EFFICACY STAGE: 2.

Testicular Torsion in the Emergency Room: A Review of Detection and Management Strategies.

Testicular torsion is a challenging and time-sensitive diagnosis that is encountered frequently in daily practice, especially in the emergency room. A thorough history, the presence of a painful and swollen testis and testicular ultrasonography plays a vital role in the prompt diagnosis of testicular torsion. Prompt diagnosis is essential to prevent complications of testicular torsion which include testicular infarction, necrosis, and sub/infertility. This can be challenging as there are various other conditions that may mimic the presentation of testicular torsion. Since testicular torsion is an extremely time-sensitive diagnosis, it may also be a subject of many medicolegal challenges. This review article serves as a guide for clinicians involved with the diagnosis and management of testicular torsion. We review and discuss detection and management strategies based on their validity, statistical significance, and effectiveness in enabling prompt diagnosis and management of testicular torsion. Medicolegal implications of testicular torsion are also highlighted.

Management of Testicular Torsion and a Contralateral Testicular Mass Presenting Synchronously

Testicular masses found in prepubertal males are often benign in nature. This has led to an increase in the use of testis-sparing surgery. Testicular torsion is considered a urologic emergency that requires immediate surgical intervention. Based off literature review, it is rare for these unique entities to present synchronously in a single patient. This report demonstrates that in the pediatric population it is possible to safely treat a suspected benign testicular mass with testis sparing mass enucleation if it presents synchronously with testicular torsion in the contralateral testis.

The management of testicular torsion in the UK: How can we do better? A national quantitative and qualitative analysis of the factors affecting successful testicular salvage

Testicular torsion is a surgical emergency, requiring time-critical surgery to avoid potential organ loss. This study collates national data on paediatric testicular torsion, offering a comprehensive insight into the current standard of care in England for paediatric patients with suspected testicular torsion. National data collection using Freedom of Information requests. Of 134 acute secondary care NHS trusts in England that treat paediatric patients, responses were received from 121 trusts - representing 140 hospitals - providing a picture of the current standard of care in England. Less than two thirds of hospitals have a paediatric A&E department. One third of hospitals use inter-hospital transfer for paediatric patients with suspected torsion, with variable age restrictions. Mean transfer distance was 19·4 miles (range 2·2 to 61·6 miles). No statistically significant relationship between transfer arrangements and the number of non-viable testicle incidents was found (P=0·15, ns). There was no correlation demonstrated nationally between size of population served and number of scrotal explorations completed (Pearson's r=0·20 (CI -0·0·8-0·46), p=0·16, ns). Qualitative thematic content analysis of serious incident reports identified common themes leading to missed diagnosis and delayed time to theatre: Education and Training, Communication, Transfer Complications, On-site Resources and Cross-site Working. We found variability in resource provision across England, as well as the number of explorations, and the number of unviable testicles found at exploration nationally. We received variable and incomplete data on emergency scrotal explorations and subsequent orchidectomies, very low levels of local audit and limited disclosure of incident reports. A mandatory national audit would allow more comprehensive data collection to accurately identify trends and make informed recommendations. To improve outcomes, we recommend continued education of ED and surgical teams, with mandatory testicular examination for young males presenting with abdominal pain. Whilst streamlining inpatient services is important, the time lost between symptom onset and seeking medical attention is crucial, and raising awareness in the community for young boys and parents may be imperative to improve rates of testicular salvage.

Characteristics and management of testicular torsion in patients admitted to the Urology Department at Chris Hani Baragwanath Academic Hospital

BackgroundThe study was carried out to determine the trend of referrals with testicular torsion; the pre-surgery duration of symptoms; the rate of orchidectomy; as well as the seasonality and the age-related laterality of testicular torsion.MethodsThis was a retrospective study conducted at Chris Hani Baragwanath Academic Hospital using patients’ records from 2006 to 2018 from which data were obtained and analyzed.ResultsA total of 308 patients with testicular torsion were included in this study; the mean age was 17.2 ± 4.12 (10–33) years. The median (IQR) time from onset to hospital was 47 h, and 194/308 (63%) underwent orchidectomy. Although the orchidectomy rate was higher (95%) in those who had surgery beyond 72 h, 3.6% had reperfusion after detorsion in theater followed by orchidopexy. In the 112 patients who underwent a bilateral orchidopexy, the time from onset of symptoms to surgery was significantly shorter at a median (IQR) of 13 (9–26) h, compared to 144 (40–264) h in the 194 patients who had an orchidectomy (p < 0.0001). The odds of presenting with a right -sided testicular torsion increases by 6% (p = 0.047) for every 1-year increase in age.ConclusionThis study shows that there is a significant association between the pre-surgery duration of symptoms and the testicular salvage rate. Testicular salvage is possible beyond 72 h from the onset of symptoms, although the salvage rate reduces from 75% within 24 h to 3.6% beyond 72 h. In addition, it also shows that older patients tend to present with right-sided torsion.

Correlation of ultrasonography and surgical outcome in patients with testicular torsion.

IntroductionTesticular torsion is a surgical emergency that is caused by twisting of the spermatic cord and its content. This condition causes irreversible changes after 6 hours. Early recognition and management of testicular torsion is important for testicular salvage and preservation of fertility.MethodsThis is a retrospective study done on all patients who presented with acute scrotal pain from January 2013 to December 2017. The data collected included the patient's age, symptoms, the time duration between the onset, ultrasound, and surgery, ultrasound findings with Doppler and the surgical intervention. Statistical analysis was performed using SPSS 25.0. Data are presented as mean (SD) values. Differences between groups and predictive values were calculated using Chi-square, t-test and Mann-Whitney U-test and are expressed by value with 95% CI.ResultsThe total number of patients who presented with acute scrotal pain were 88. Testicular torsion was diagnosed in 55 (62.50%) of the patients, 17 (19.32%) had epididymis-orchitis, 5 (5.68%) had torsion of appendage/cyst, and 11 (12.50%) had normal testis. Ultrasound has a sensitivity and specificity of 88.24% and 68.40% respectively. It is a good tool to detect testicular torsion but it is operator dependent. Positive predictive value was 83.33% and negative predictive value was 76.47%. When ultrasound is combined with clinical findings the rate of negative exploration is reduced by 10%.ConclusionGood medical history, appropriate clinical evaluation and performing an ultrasound of the scrotum are important in testicular torsion. US evaluation in cases presented after 24 hours does not change the outcome.

Management of testicular torsion

ObjectiveThis study aimed to summarize clinical manifestations, and physical examination, laboratory examination, and ultrasound results of children with testicular torsion <360°.MethodsWe performed a retrospective study of children who were diagnosed with testicular torsion <360° between October 2007 and October 2017.ResultsThere were 11 (19.2%) patients with testicular torsion of 90°, 33 (58.0%) with 180°, and 13 (22.8%) with 270°. The median age of onset was 5.7 years (range, 1–14 years) and the median duration of symptoms was 4.2 days (range, 0.5–5 days). Ultrasound showed low blood flow in 46 (80.8%) patients. The testis was retained in 41 (72.0%) patients and resected in 16 (28.0%). The testes appeared necrotic at 2 to 3 days after onset for patients with 270° torsion, appeared necrotic at 3 to 4 days after onset for those with 180° torsion, and were not necrotic at 4 to 5 days after onset for those with 90° torsion. The duration of symptoms in children decreased as the torsion angle increased.ConclusionChildren with testicular torsion <360° are relatively young, while the duration of symptoms is relatively long. A high postoperative testicular survival rate is one of the clinical features in this study.

Timely Management of Testicular Torsion: A Collaborative QI Approach

Background Testicular torsion is a surgical emergency requiring timely operative care (ideally within 240 minutes) to achieve optimal testicular salvage and functional outcome. At our institution, approximately 14% patients had a delay in operative management (92 patients, January 2014 - November 2016, with a mean of 164 minutes and range of 48-565 minutes). Objective To increase the percentage of patients arriving to the operating room (OR) within 240 minutes from time of emergency department (ED) arrival from 86% to 95% in 18 …

Implementation of the accelerated care of torsion pathway: a quality improvement initiative for testicular torsion

Timely diagnosis and management of testicular torsion is of paramount importance. Furthermore, time to surgical intervention is a benchmark for the quality of care provided by pediatric urologists included in US News and World Report (USNWR) methodology. We sought to optimize management of acute testicular torsion at a single institution by decreasing time from presentation to definitive management through the creation and implementation of a clinical care pathway (accelerated care of torsionor ACT) for acute testicular torsion in a 2-year period. Multidisciplinary process mapping involving the emergency department (ED), radiology, anesthesiology, peri-operative services, and operating room (OR) teams resulted in development of the ACT pathway with the goal of achieving surgical intervention within 4h of arrival at our institution. The accelerated care of torsion pathway was implemented in April 2016. Thirty-eight consecutive acute torsion cases were then prospectively evaluated from April 2016 to April 2018. For process measures, we recorded triage to OR times and mode of presentation. For outcome measures, we examined orchiectomy rates. We retrospectively reviewed 97 cases of acute torsion from 2004 to 2016 as a control. Time from ED triage to OR start decreased from a median 196min (interquartile range [IQR] 137-249min) to 127min (IQR 100-148min; P<0.0001) for all cases of acute torsion. In the control group, 72% of cases met the USNWR criteria for acute treatment of torsion. After ACT implementation, 100% of cases reached the OR within the 240min time frame. Orchiectomy rates were performed in 24% of control cases vs 30% after ACT implementation (P=NS). Survival curve analysis demonstrated no significant difference in probability of testis salvage before or after implementation of the ACT pathway. In agreement with similar studies, despite a significant reduction in triage to OR times, the orchiectomy rate approached 30%. This outcome did not significantly improve after implementation of the ACT pathway. Overall ischemia time was a more important determinant of testis salvage. Study limitations include limited patient follow-up to assess testis atrophy. The multidisciplinary creation and implementation of a clinical pathway for the care of acute testis torsion has significantly decreased the time from ED to OR in our institution. However, overall orchiectomy rate was not significantly affected.

The applied value of medical history, physical examination, colour-Doppler ultrasonography and testis scintigraphy in the differential diagnosis of acute scrotum.

Acute scrotum, especially testicular torsion, is a common surgical emergency. A delay in diagnosis or management may lead to permanent testicular ischaemic damage. Thus, it is particularly important to differentiate testicular torsion from other acute scrotum conditions as soon as possible. Our study has retrospectively investigated 358 patients with acute scrotum admitted to our hospital from the year 2007 to 2016. We have collected a thorough history and clinical data and drew the conclusion by comparing clinical features of different acute scrotum cases, medical history, imaging and surgical findings. Therefore, we propose an innovative "Testicular Torsion (TT) Green Channel" concept. Through the combination of a comprehensive medical history, physical examination and auxiliary colour-Doppler ultrasonography, the diagnosis of testicular torsion is definite in most circumstances. Testis scintigraphy is a novel and complementary diagnostic modality that can reduce the negative exploration rate in ambiguous and certain cases. The TT Green Channel is a new concept in the management of testicular torsion.