Orchiectomy Rate Research Articles

Do healthcare disparities play a role in pediatric testicular torsion? – Analysis of a single large pediatric center

Healthcare disparities have been shown to impact outcomes of various acute pediatric conditions. We sought to examine the impact of race, ethnicity and insurance status on the presentation, management and outcome of testicular torsion. A retrospective review of a prospectively maintained testicular torsion database was performed. Patients ≤18 years of age evaluated in our pediatric institution's emergency room between April 2016-April 2020 with US diagnosed and OR confirmed testicular torsion were included. Basic demographics, timing of presentation, referral rate, time to OR and orchiectomy rate were extracted and compared. P<0.05 was considered statistically significant. A total of 206 patients were included. 114 (56.2%) were Black or African American (Black/AA), 43 were (21.2%) Hispanic/Latino, 22 (10.8%) were Caucasian, and 24 (11.8%) were designated as Other races. Ninety-eight (48.3%) patients had Medicaid, 90 (44.3%) had private insurance, and 15 (7.4%) patients were uninsured. Sixty-eight (33.0%) presented in a delayed fashion (>24h). Compared to the Caucasian patients, Black/AA patients were 2.1 years (95% CI: 0.5, 3.8; P=0.010) older at the time of presentation. When compared to those with Medicaid insurance, uninsured patients had 6.26 times (95% CI: 1.58, 41.88; P=0.021) higher odds to be referred from an outside hospital for management. In those patients presenting acutely (<24h, N=138), there were no significant differences in the odds of orchiectomy for Black/AA or Hispanic/Latino patients when compared to Caucasian patients, however, the odds of orchiectomy in Other races (non-Caucasian, non-Black/AA, non-Hispanic/Latino) was significantly higher (OR: 10.38; 95% CI: 1.13, 246.96; P=0.049). While the mean time in minutes from ED to OR was longer in those with Medicaid insurance (141 vs 125.4 private vs 115 uninsured, p=0.042), this did not impact orchiectomy rate (39.8% vs 40.9% vs 46.7%, p=0.88). We found no differences in the orchiectomy rates by race with the exception of a higher rate in the diverse and heterogeneous Other race (non-Caucasian, non-Black/AA, non-Hispanic/Latino) group. Those uninsured had a higher referral rate highlighting the potential existence of disparities for those uninsured and the need for further investigation.

The incidence of testicular torsion and testicular salvage rate in Korea over 10 years: A nationwide population-based study.

PurposeWe performed a nationwide epidemiological study of testicular torsion using the National Health Insurance System database for the entire male population of Korea.Materials and MethodsAge, sex, socioeconomic status, regional information, and diagnostic codes were retrieved from January 2009 to December 2019. To clearly identify the diagnosis of testicular torsion, patients who had not undergone orchiectomy or orchiopexy were excluded from the study. Multivariable logistic regression models were used to analyze the association between demographic characteristics and testicular loss.ResultsThe overall incidence of testicular torsion in males was 2.02 cases per 100,000 person-years and 6.99 cases per 100,000 person-years in males under 19 years of age. Testicular torsion most commonly occurred either in infancy or adolescence. The total testicular salvage rate was 75.22% and highest in children at 79.91%. The rate of orchiectomy was high in infancy and in the oldest patients. We determined that age distribution was related to the risk of testicular loss.ConclusionsThis study is the first nationwide epidemiological study of testicular torsion, which contains the entire Korean population. Although the testicular salvage rate in Korea was higher compared to other countries, it is necessary to educate males under 19 years of age on the seriousness of acute testicular pain to minimize the possibility of testicular loss.

MP55-09 ALBUGINEOTOMY WITH TUNICA VAGINALIS FLAP COVERAGE IN ACUTE TESTICULAR TORSION: A PROSPECTIVE RANDOMIZED STUDY

You have accessJournal of UrologyPediatric Urology V (MP55)1 Sep 2021MP55-09 ALBUGINEOTOMY WITH TUNICA VAGINALIS FLAP COVERAGE IN ACUTE TESTICULAR TORSION: A PROSPECTIVE RANDOMIZED STUDY Rafael Ribeiro Zanotti, Luis Gustavo Morato de Toledo, André Costa Matos, Marcos Broglio, Sergio Paolillo, and Jorge Ricardo Gois e Cunha Rafael Ribeiro ZanottiRafael Ribeiro Zanotti More articles by this author , Luis Gustavo Morato de ToledoLuis Gustavo Morato de Toledo More articles by this author , André Costa MatosAndré Costa Matos More articles by this author , Marcos BroglioMarcos Broglio More articles by this author , Sergio PaolilloSergio Paolillo More articles by this author , and Jorge Ricardo Gois e CunhaJorge Ricardo Gois e Cunha More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002085.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Testicular torsion is the most potential harmful cause of acute scrotal pain. To date, the most significant efforts in terms of testicular rescue rates have been based on early detorsion. Compartment syndrome has been increasingly recognized as important in enhancing the ischemic insult of several organs limited by their natural sheaths, such as the testis. Therefore we evaluate the impact of albugineotomy with reconstruction using a vaginal tunica flap in testicular salvage rate and late viability. METHODS: This study was conducted after institutional approval by local Research Ethics Committee. We randomized testicles that appeared to be ischemic even after detorsion and heating (which traditionally would be treated by orchiectomy), in one group for albugineotomy with tunica vaginalis flap coverage and another group for orchiectomy. Testicles with signs of good perfusion were not randomized, and so treated by orchidopexy. The follow-up was maintained for further analysis of testicular viability. Time from pain to surgery was not a variable that would determine the technique. Doppler sonography was performed at 6 postoperative months to assess the symmetry of blood flow and the volume in relation to the contralateral testis. Viable testes were defined as those with detectable flow and more than 50% of contralateral testis volume. RESULTS: From December 2018 to August 2020, a total of 28 patients were treated. Ten patients were randomized to albugineotomy and 7 to orchiectomy. Eleven patients were not randomized because the affected testicle had good perfusion aspect, so they underwent orchidopexy. The median time between the onset of pain and surgery was 48 hours (4 to 140 hours). This late presentation was mainly caused by the transfer of patients from other centers. Upon arriving at our service, the patient was immediately referred to treatment in the operating room. In the group with good reperfusion after detorsion and heating; and therefore, not randomized, only 22% of the testicles did not suffer atrophy after 6 months. Of those who underwent the technique under study, 25% did not atrophy. CONCLUSIONS: The application of albugineotomy with tunica vaginalis flap resulted in decrease of orchiectomy rates and avoids long-term testicular atrophy in a significant percentage of gonads (25%) that would otherwise be considered for orchiectomy, without causing major complications. We can conclude that albugineotomy allows to increase the intraoperative and long-term testicular preservation rate. Only 22% of testicles considered viable in the intraoperative, non-randomized, did not present atrophy after 6 months. The use of albugineotomy for these patients with late presentation but good perfusion aspect has not yet been studied. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e961-e962 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rafael Ribeiro Zanotti More articles by this author Luis Gustavo Morato de Toledo More articles by this author André Costa Matos More articles by this author Marcos Broglio More articles by this author Sergio Paolillo More articles by this author Jorge Ricardo Gois e Cunha More articles by this author Expand All Advertisement Loading ...

Is there an increased incidence of orchiectomy in pediatric patients with acute testicular torsion during COVID-19 pandemic?–A retrospective multicenter study

IntroductionTesticular torsion is a real emergency condition which requires prompt diagnosis and surgical management to prevent testicular loss. During the coronavirus (COVID-19) pandemic, an increased avoidance of the emergency departments for non-COVID-19 illnesses has been reported in the medical literature.ObjectiveThe aim of this study was to investigate whether the COVID-19 pandemic caused increased number of orchiectomies in pediatric patients presenting with acute testicular torsion compared to pre-COVID-19 period.Study designA total number of 119 pediatric patients who underwent surgery for acute testicular torsion from January 2019 to December 2020 were enrolled in retrospective multi-center study from six institutions in Croatia. The patients were divided in two groups. The first group (pre-COVID-19) consisted of the patients who underwent surgery before COVID-19 pandemic (n = 68), while the second group (COVID-19) consisted of the patients who underwent surgery during the COVID-19 pandemic (n = 51). Main outcomes of the study were orchiectomy rates and time from onset of the symptoms to emergency department presentation.ResultsDuring the COVID-19 pandemic period 43.1% (22/51) of the patients underwent orchiectomy while orchiectomy was performed in 16.2% (11/68) of the patients from the pre-COVID group (p = 0.001). Median time from onset of the symptoms to emergency department presentation during COVID-19 pandemic and pre-COVID-19 periods was 14h (IQR 5, 48) and 6h (IQR 3, 22) (p = 0.007), respectively. A higher proportion of patients waited over 24 h to present to emergency department during the COVID-19 pandemic compared to the pre-COVID-19 period (47% vs 8.8%, p = 0.007).ConclusionDuring COVID-19 pandemic a significantly higher rates of orchiectomies and increase in delayed presentations for testicular torsion was found. More patient education during pandemic in regards to management of emergency conditions such as testicular torsion is required.Summary figureRates of orchidopexy/orchiectomy between pre-COVID-19 and COVID-19 periods.Summary figure

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.

Impact of treatment delays on outcome of acute testicular torsion: a 15-year retrospective study

Introduction Preservation of the testicle is directly associated with the duration of torsion. The aim in this retrospective study was to identify factors that influence pre-and in-hospital times and measure the extent to which these times affect testicle survival. Patients and methods A retrospective review of 116 patients who underwent exploration for testicular torsion between 2000 and 2015. Patients were divided into orchiectomy and salvaged testicle groups. Times in patient management and clinical features were compared with Mann–Whitney, chi-squared, and Fisher exact tests. Multivariate logistical regression was used to identify independent factors associated with orchiectomy. Results The median prehospital time of 48 h (15.4–138 h) in the orchiectomy group was longer than the 2.4 h (1.6 h–5.2h) in the salvaged group. Patients examined by a general practitioner (GP) prior to presenting at hospital had a median prehospital time of 48 h, compared to 3 h for patients not examined before presentation at hospital. In-hospital times between admission and operation room, as well as times between ultrasonography and operation room, were also longer in the orchiectomy group. Previous GP consultation (OR = 27.26, 95% CI 2.32–320.59, p = .009), prehospital time (OR = 1.04, 95% CI 1.01–1.07, p = .003) and nausea (OR = 9.25, 95% IC 1.33–64.52, p = .025) were independent predictive factors associated with orchiectomy. Conclusion Prehospital time was a determining factor in orchiectomy. For each extra hour of prehospital delay, the risk of orchiectomy increased by 4%. The rate of orchiectomy was higher among patients who first consulted a GP.

Impact of hospital transfer on testicular torsion outcomes: A systematic review and meta-analysis

Testicular torsion is an emergent condition requiring prompt treatment. Previous studies have suggested transfer of pediatric testicular torsion cases may be detrimental to patient outcomes. Findings have not reached statistical significance. No study has quantitatively analyzed all literature reporting outcomes for transferred torsion patients. The aim of this study was to elucidate the impact of hospital transfer on pediatric testicular torsion outcomes through a systematic review and meta-analysis. A predefined study protocol registered with PROSPERO was developed according to PRISMA. A comprehensive literature review of articles investigating outcomes for pediatric testicular torsion for transferred and non-transferred (treated "directly" at presentation institution) patients with orchiectomy as the primary outcome was conducted by systematically searching PubMed and Embase. Potential studies were screened against a predefined study protocol. Meta-analysis using a random effects model with transferred status as the "intervention" was performed using Review Manager 5.3. Of 18 eligible studies, 9 retrospective studies comprised of 2564 patients (532 transferred and 2032 direct) were suitable for quantitative analysis. Main analysis showed transfer status does not have a significant effect on torsion outcomes (RR 0.96 [95% CI 0.78-1.17]; I2=44%). Subgroup analysis for torsion patients presenting within 24h of symptom onset shows patients who are transferred to another facility for management are more likely to undergo orchiectomy than those treated at their presenting institution (RR 0.35 [95% CI 0.24-0.51]; I2=4%). In this meta-analysis, hospital transfer does not affect orchiectomy rate in pediatric patients with testicular torsion when pooling data from all presentation timeframes. Subgroup analysis of patients presenting with testicular torsion in an acute setting (<24h of symptom onset) suggests the delay associated with hospital transfer has a deleterious effect on testicular viability.

Predictive factors for orchiectomy in adult\u2019s spermatic cord torsion: a case\u2010control study

BackgroundSpermatic cord torsion (SCT) is a surgical emergency. Any delay in diagnosis or treatment may compromise the vital and functional prognosis of the testicle. The orchiectomy rate remains very high in the literature; it can even reach 50 % in certain series. Several factors have been reported in the literature as being significantly correlated with the risk of orchiectomy: duration of symptoms, the number of turns, the younger ages, etc. The objective of this study has been to analyse the predictive factors of orchiectomy in adult SCT in our context.Results During the study period, 74 cases of SCT were included. Orchidopexy was performed in 43.2 % (32/74) versus orchiectomy in 56.8 % (42/74) of cases. The patients’ median age was 22 years (interquartile range (IQR) = 18–26.75 years). The duration of symptoms (p = 0.009), the previous medical management (p < 0.001), performing a scrotal ultrasonography (p = 0.004) were statistically significant at univariate analysis. On multivariate analysis only the previous medical management was statistically significant (p = 0.017).ConclusionsThe orchiectomy rate was very high in our cohort. The previous medical management was the only significant predictive factor of orchiectomy on multivariate analysis. Our findings demonstrated that the delay in diagnosis is the determining factor in testicular loss in our context.

Did COVID-19 Affect Time to Presentation in the Setting of Pediatric Testicular Torsion?

ObjectivesTo determine if boys with acute testicular torsion, a surgical emergency requiring prompt diagnosis and treatment to optimize salvage of the testicle, delayed presentation to a medical facility and experienced an extended duration of symptoms (DoS), and secondarily, a higher rate of orchiectomy, during the coronavirus disease 2019 (COVID-19) pandemic.MethodsSingle-center, descriptive retrospective chart review of boys presenting with acute testicular torsion from March 15, to May 4, 2020 (“during COVID-19” or group 2), as well as for the same time window in the 5-year period from 2015 to 2019 (“pre–COVID-19” or group 1).ResultsA total of 78 boys met inclusion criteria, group 1 (n = 57) and group 2 (n = 21). The mean age was 12.86 ± 2.63 (group 1) and 12.86 ± 2.13 (group 2). Mean DoS before presentation at a medical facility was 23.2 ± 35.0 hours in group 1 compared with 21.3 ± 29.7 hours in group 2 (P < 0.37). When DoS was broken down into acute (<24 hours) versus delayed (≥24 hours), 41 (71.9%) of 57 boys in group 1 and 16 (76.2%) of 21 boys in group 2 presented within less than 24 hours of symptom onset (P < 0.78). There was no difference in rate of orchiectomy between group 1 and group 2 (44.7% vs 25%, P < 0.17), respectively.ConclusionsBoys with acute testicular torsion in our catchment area did not delay presentation to a medical facility from March 15, to May 4, 2020, and did not subsequently undergo a higher rate of orchiectomy.

Evaluation of the effectiveness of vacuum-assisted closure in the treatment of Fournier gangrene

Background and objective: To evaluate the effectiveness of vacuum-assisted closure (VAC) in the treatment of Fournier gangrene (FG). Material and methods: Forty-eight male patients treated for Fournier gangrene were included in the study. The patients were divided into two groups (Group I: conventional dressing, Group II: VAC therapy). Characteristics of the patients, laboratory parameters, number of debridement procedures, daily number of dressings, visual analogue scale (VAS) during dressing, analgesic requirement, colostomy requirement, time from the first debridement to wound closure, wound closure method, length of hospital stay, and mortality rates were compared. Results: Group I comprised 33 patients and Group II comprised 15 patients. The number of dressings, VAS score and daily analgesic requirement were statistically significantly lower in Group II (p &lt; 0.05) than in Group I. The number of debridement procedures, colostomy requirement, orchiectomy rate, time from first debridement to wound closure, length of hospital stay, wound closure method and mortality rate were similar between these two groups (p &gt; 0.05). Conclusion: The clinical results of conventional dressing and VAC therapy were similar for treating FG. VAC therapy is an effective postoperative wound care method that offers less requirement for dressing changes, less pain, less analgesic requirement and more patient satisfaction compared to conventional dressing.

Delaying Urgent Exploration in Neonatal Testicular Torsion May Have Significant Consequences for the Contralateral Testis: A Critical Literature Review

To assess the optimal management strategy for boys with neonatal testicular torsion (NTT) in the first 30 days of life, and to stratify outcomes for prenatal, postnatal, unilateral, synchronous, and asynchronous events METHODS: All articles including case reports published between 1946 and 2020 in Embase/Scopus/Medline/Pubmed and Web of Science that had a defined diagnosis of NTT within the first 30 days of life were reviewed. Data and outcomes were analyzed individually, and together as pooled data, using a random effect model. There was a total of 152 studies representing 1336 patients. Outcome data was available on 974 patients (1121 testes). NTT was unilateral in 829 cases, synchronous bilateral in 80 cases, and asynchronous in 66 cases. There were a total of 1107 orchiectomies, and 229 salvage orchiopexies. A total of 2.5% synchronous NTT underwent successful salvage. A total of 95.7% of prenatal unilateral torsions underwent orchiectomy, compared with 92% postnatal torsions. 11.8% of all NTT events were asynchronous with a median time to second torsion of 1 day (Range 1-8). The contralateral orchiectomy rate in this group was 31.8%, with a 40% atrophy rate following orchiopexy. The number needed to treat to avoid bilateral orchiectomy was 1.6, and the number needed to treat to avoid solitary atrophy was 2.6. NTT is an important condition carrying a significant risk for testicular loss and endocrine insufficiency. Given the potential catastrophic risk of asynchronous extravaginal torsion, we recommend urgent, safe, surgical intervention with both unilateral and bilateral NTT.

A multicenter review of undescended testis torsion: A plea for early management

Torsion of an undescended testis (UT) is a surgical emergency, difficult to diagnose, whose prognosis depends on a quick management. To evaluate the management and outcome of these patients. We retrospectively analyzed all cases of UT torsion operated in nine French hospitals between 1997 and 2017. We divided patients in two groups: patients referred less than 6h after the onset of symptoms (group A) or more than 6h (group B). We collected 60 cases (17 in group A and 43 in group B). Median age was 2.2 years [IQR=0.7-7.8] (2.3y in group A and 2y in group B, p=0.76). Eleven patients (10 in group B) had neurological disorders (p=0.15). The main reason for absence of UT treatment was the absence of surgical consultation in a normal delay (n=44, 73%). Symptoms were pain (n=58, 97%), inguinal mass (n=55, 92%) and vomiting (n=16, 27%). An inguinal mass with no palpable testis in the ipsilateral hemiscrotum was seen in 55 patients (92%). An ultrasound scan performed in 27 patients led to the diagnosis in 16 patients (59%). At surgery, an orchiectomy was performed in 4 patients (23%) of group A and 24 patients (56%) of group B (p=0.04). After a median follow-up of 11 months [IQR=4-23], 11 patients of group A (65%) and 7 patients of group B (16%) had a clinically normal testis (p=0.03). The salvage rate among patients with conservative treatment was 85% for group A and 37% for group B (p=0.01). Our study reveals that although UT torsion is an emergency, 72% of patients are referred more than 6h after the onset of symptoms. We mostly found classic clinical presentation of UT torsion: a painful inguinal mass with an empty ipsilateral scrotum. Ultrasound was performed in half cases, and even if the result was not significant, it still seemed to be associated with a higher rate of orchiectomy especially in group B because of the delay in care. However, when ultrasound was realized early, it led to diagnosis in all cases. This dilemma poses the problem of the role of imaging in diagnostic management. Early clinical diagnosis in front of a painful inguinal mass with an empty scrotum is essential to improve the salvage rate of testis in UT torsion. Early management of UT should have avoided 68% of testis loss.

Timing and outcomes of testicular torsion during the COVID-19 crisis

BackgroundDuring the COVID-19 crisis, there has been widespread reporting that non-COVID-19-related medical care has been delayed, even for emergent conditions. Testicular torsion is an emergent condition with higher risk of testicular loss with longer ischemic times. We sought to investigate whether patients with testicular torsion had longer time from symptom onset to initial presentation, longer total ischemic time, and higher rate of orchiectomy during the pandemic.Materials and methodsUsing billing data, we identified all patients age >1yo seen in our hospital from 1/1/2018 through 5/31/2020 who underwent emergent scrotal exploration for confirmed testicular torsion, comparing the COVID-19 crisis (3/1/2020–5/31/20) to the pre-COVID-19 period (1/1/2018–2/29/20). The primary outcome was time from symptom onset to initial presentation and secondary outcomes were ischemic time (time from symptom onset to entry of the OR) and orchiectomy rate. Parameters were compared with Mann–Whitney U and Fisher's exact tests; Poisson regression compared rates of torsion.ResultsOf 94 total cases, 77 occurred during the pre-COVID-19 period and 17 during the COVID-19 crisis. Median time from symptom onset to initial presentation was not significantly different (2.4 h [IQR 1.1 h–38.9] during COVID-19 vs. 5.6 h [IQR 1.6–16.9] during pre-COVID-19 period, p = 0.476). Time to presentation was >12 h in 5/17 patients (29%) during COVID-19 and 24/77 patients (31%) during pre-COVID-19 period (p = 1.00). Median ischemic time during COVID-19 was 7.5 h (IQR 4.7 h–45.5 h) compared to 9.4 h (IQR 5.4 h–22.5 h) during pre-COVID-19 period (p = 0.694). Incidence of orchiectomy in our center was 29% (5/17) during COVID-19 and 17% (13/77) during pre-COVID-19 period (p = 0.397). About half of patients were seen initially at outside facilities prior to arrival (47% [8/17] during COVID-19 vs. 49% [38/77] during pre-COVID-19 period, p = 1.00). The number of torsion case presentations per week to our facility increased from 0.7 cases/week in the pre-COVID-19 period to 1.3 cases/week during COVID-19 (p = 0.015); when comparing only the March 1 to May 31 calendar period, there were 0.6 cases/week during the pre-COVID-19 period and 1.3 cases/week during COVID-19 (p = 0.021).ConclusionTime to presentation, ischemic times, and orchiectomy rates for testicular torsion at our center were not significantly different during the COVID-19 period compared to the preceding 2 year period. The number of torsion case per week presenting to our facility increased significantly.Summary Table 1Comparison of patients, timing, and testicular outcomes among patients with testicular torsion before and during COVID-19 crisis.Summary Table 1OverallPre-COVIDCOVIDp-valuen947717Age, years (median [IQR]{range})14.38 [12.70, 15.87] {1.3–19.7}14.22 [12.64, 15.83]{1.3–19.7}15.24 [14.21, 16.01]{4.2–17.4}0.2950Time from symptom onset to presentation, hours (median [IQR]{range})5.38 [1.49, 18.38]{0.7, 148.0}5.58 [1.60, 16.85]{0.7, 81.3}2.40 [1.12, 38.92]{0.9, 148.0}0.4760Time from symptom onset to presentation > 6 h, n (%)43 (45.7)35 (45.5)8 (47.1)1.0000Time from symptom onset to presentation > 12 h, n (%)29 (30.9)24 (31.2)5 (29.4)1.0000Ischemic time, hours (Time from symptom onset to OR) (median [IQR]{range})9.19 [5.32, 26.02]{2.7, 152.2}9.40 [5.42, 22.52]{2.7, 86.3}7.52 [4.67, 45.45]{2.7, 152.2}0.6940Orchiectomy, n (%)18 (19.1)13 (16.9)5 (29.4)0.3970Presentation at OSH, n (%)46 (48.9)38 (49.4)8 (47.1)1.0000

Evaluation of parental sociocultural background and education level in response to pediatric testis torsion

Acute scrotal pain (ASP) remains one of the most common male urologic emergencies in the pediatric age group. The most concerning outcome of testicular torsion (TT) is the need for orchiectomy, which has a negative impact on the child's development in general and on sexual development and psychology in particular. Time is the most important factor in the treatment of TT. Parental awareness of ASP indicating the possibility of TT is a significant factor in children's hospital admission time. Sociocultural background may be an indicator in parental awareness. This study sought to determine if parental sociocultural and education level is associated with delayed treatment for TT. This retrospective study evaluated data for patients with scrotal or abdominal pain and TT at two hospitals in Konya, Turkey from 2012 to 2020. Study participants were the parents of the patients treated for TT. Participants were contacted by telephone and asked about their educational background. The study population was divided into 2 groups based on parent characteristics. Group 1 parents had an education level less than high school, had no health insurance, were in need of state aid, and had a low sociocultural background. Group 2 parents had an education level of at least high school or higher and had health insurance. Symptom duration (time between symptom onset and hospital admission) and surgical procedures for the patients were compared between the 2 parent groups. Of the 140 patients who received a diagnosis of TT, 77 were in Group 1 and 63 in Group 2. Mean patient age was 12.7±2.7 (5-16) years Median symptom duration was 7 (1-120) hours. Symptom duration was higher in Group 1, but no statistically significant differences were noted between groups (Group 1 duration was 8h vs. Group 2 duration of 6h; p=0.331). Orchiectomy was performed for 62 (44.3%) patients and testicular-sparing surgery for 78 (55.7%). Orchiectomy rates between groups were statistically significant and higher in Group 1 with 41 (53.2%) versus 21 (33.3%) in Group 2. Factors such as low sociocultural family background and low parental education level increase the risk of orchiectomy for their children. Awareness of the symptoms of TT may minimize the possibility of testicular loss.

Testicular torsion: epidemiological risk factors for orchiectomy in pediatric and adult patients.

Testicular torsion is a known cause of morbidity in pediatric patients, but the burden in the adult population is poorly understood. We sought to determine the incidence of testicular torsion and risk factors for orchiectomy in a population encompassing all ages. A cohort analysis of 1625 males undergoing surgery for torsion was performed using the 2011 and 2012 Healthcare Cost and Utilization Project Nationwide Emergency Departments Sample. Patient and hospital factors were examined for association with orchiectomy vs. testicular salvage. The estimated yearly incidence of testicular torsion was 5.9 per 100,000 males ages 1-17 years and 1.3 per 100,000 males ≥18 years. Among those undergoing surgical intervention, orchiectomy was performed in 33.6%. The risk of orchiectomy was highest in patients 1-11 years of age and patients over 50 years of age (46.0% and 69.7% of patients, respectively). Orchiectomy was also associated with public insurance (Medicaid/Medicare) or self-pay as primary payer. While testicular torsion is less common in the adult population, the rate of orchiectomy is high. Those with disadvantaged payer status are also at increased risk for testicular loss.

A comparison of clinical outcomes of acute testicular torsion between prepubertal and postpubertal males

Surgical intervention for acute testicular torsion can require either orchiopexy or orchiectomy. The decision of which surgery to perform is dependant on the amount of time that the testicle experienced ischemia and the viability of the testicle after reperfusion. It is hypothesized that (1) there is a difference in orchiectomy and orchiopexy rates between prepubertal and postpubertal males with acute testicular torsion and (2) presenting symptoms may vary between the two age groups as prepubertal males may present with atypical symptoms, which could result in delayed presentation and diagnosis. A retrospective chart review was conducted on pediatric patients who were diagnosed with acute testicular torsion between June 2010 and August 2017. Demographic and clinical characteristics were extracted: age, ethnicity, referral pattern, primary insurance status, symptoms at presentation, prior history of ipsilateral testicular pain or intermittent torsion, recent trauma to genitalia, duration of symptoms (hours), gradual vs. acute onset of symptoms, time/weekday/season at presentation, and time interval from arrival at the study institution to surgical intervention (minutes). Patients were categorized into two groups: prepubertal group (age 1-12 years) and postpubertal group (age 13-18 years). Statistical analyses were performed using R, version 3.3.1. Ninety-one patients were included in the study. The overall orchiectomy rate was 30.8%. More prepubertal males underwent orchiectomy than postpubertal males (42.4% vs. 24.1%, respectively). Prepubertal males were more likely to present with abdominal pain than postpubertal males (27.3% vs. 10.3%, respectively). Those who underwent orchiectomy were more likely to present with longer duration of symptoms, testicular swelling, and abdominal pain than those who underwent orchiopexy. The risk of orchiectomy decreased by 14% per 1-year increase in age (odds ratio [OR]: 0.86, 95% confidence interval [CI]: 0.94-1.00, p = .009). A steady decline in the proportion of patients undergoing orchiectomy was seen from 1 to 12 years of age. This study found that prepubertal males are at higher risk for orchiectomy than postpubertal males. The risk of orchiectomy decreases by 14-16% per 1-year increase in age. Prepubertal males are more likely to present with atypical symptoms and delayed presentation and diagnosis, leading to delayed surgical intervention. It is important for providers to perform a genital examination in prepubertal males who present with abdominal pain to rule out acute testicular torsion. Patients presenting with longer duration of symptoms, testicular swelling, and abdominal pain are at higher risk for orchiectomy. No correlation was found between orchiectomy rate and ethnicity, referral status, primary insurance status, and time/weekday/season at presentation. Among patients presenting to a tertiary pediatric hospital with acute testicular torsion, prepubertal males (younger than 12 years) are at higher risk for orchiectomy than postpubertal males. Prepubertal males are more likely to present with atypical symptoms which results in delayed presentation and diagnosis, leading to delayed in surgical intervention.

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.

Pediatric testicular torsion: does patient transfer affect time to intervention or surgical outcomes at a rural tertiary care center?

BackgroundTesticular torsion (TT) is a urologic emergency that requires prompt surgical intervention. In rural Appalachia, patients are often transferred from surrounding communities due to lack of urologic care. We hypothesized that those transferred would have delayed intervention and higher rates of orchiectomy when compared to those who presented directly to our hospital.MethodsWe performed a retrospective review of patient charts with an ICD-9 diagnosis of TT from 2008 to 2016. Patients met inclusion criteria if diagnosis was confirmed by operative exploration. We compared rate of testicular loss and time until surgical intervention between groups.ResultsTwenty-three patients met inclusion criteria (12 transferred, 11 direct). Patient demographics did not significantly differ between groups. Transferred patients had a higher orchiectomy rate (33% v 22%,p = 0.41) although this was not statistically significant. Time to surgery from symptom onset was significantly longer in those transferred (12.9 h) compared to those not transferred (6.9 h, p = 0.02). Distance of transfer was not correlated with time of delay (r2 = 0.063).ConclusionsTransferred patients with TT have numerically higher rates of orchiectomy which may reach significance in an appropriately powered study, and relative delays in surgical intervention. This study highlights the need for improved access to urologic care in rural areas.

Point-of-care influences orchiectomy rates in pediatric patients with testicular torsion

The objective of this study was to determine whether point-of-care (community hospitals vs. tertiary centers) or treatment-delaying variables (transfer, emergency room [ER] throughput, and distance traveled) affect orchiectomy rates in minors with testicular torsion (TT) using a national database. This was a retrospective cohort study using prospectively collected data by the Canadian Institute of Health Information (CIHI) between 2010 and 2015. All Canadian male patients in the CIHI database aged <18 years with TT based on International Classification of Diseases (ICD) codes were included, except for those residing in Quebec. Variables collected were age, type of treating institution (community small/medium, community large, or tertiary/academic), transfer for definitive treatment, road distance traveled, and ER throughput. The outcome was testicular loss based on intervention codes for orchiectomy/orchidopexy. Univariable and multivariable analyses were performed using logistic regression. A total of 1713 minors with TT were included. Overall orchiectomy rate was 28%. Most patients (52%) were treated at tertiary hospitals. Small/medium community hospitals depicted the lowest odds of orchiectomy on univariable and multivariable analyses (odds ratio [OR]=0.54, confidence interval [CI]: 0.37-0.79, p<0.001); academic hospitals were also associated with a lower odds of orchiectomy than large community ones. Transfer and distance traveled were not associated with the outcome. Age >12 and ER throughput less than 1h were significantly associated with lower orchiectomy rates. In a subgroup analysis of patients aged <12 years (n=278), transfer was the only factor associated with increased risk of orchiectomy (OR=2.41 , CI: 1.09-5.33; p=0.03). This study showed that small and medium community hospitals had the lowest orchiectomy rates in minors with TT in Canada (Figure). However, on multivariable analysis, they performed similarly to tertiary/academic hospitals, with both being superior to large community hospitals. Transfer and distance traveled did not affect orchiectomy rates. Emergency room throughput had a statistically significant association with orchiectomy rates in every analysis and based on the study data would constitute the best target for policies aimed at reducing orchiectomy rates for TT in minors. The main limitation of this study is the inability to evaluate long-term testicular viability of patients not undergoing orchiectomy (i.e., true testicular salvage). Type of hospital treating facility (point-of-care) affects orchiectomy rates in minors with TT. Small/medium community hospitals depict the lowest orchiectomy rates in Canada. Transfer to another facility for definitive care and distance traveled did not affect orchiectomy rates, except in a subgroup analysis of prepubertal boys. Longer ER throughput and prepubertal age were consistently associated with loss of the testicle.

Do repeat ultrasounds affect orchiectomy rate in patients with testicular torsion treated at a pediatric institution?

Testicular torsion is a urological emergency;as the testicular salvage rate decreases with time, prompt intervention is required to restore the blood flow. Interhospital transfers and ultrasound examinations, while clinically essential to proper treatment and diagnosis, may adversely affect outcomes by delaying surgical intervention. Patients transferred to another institution for treatment of testicular torsion may experience a further time delay by undergoing two ultrasound examinations: one at the initial admitting institution and one at the receiving institution. To the knowledge of the authors, no study has yet explored the time delays and outcomes associated with these repeat ultrasounds. The objective was to investigate the impact of repeat ultrasound imaging on time to treatment and patient outcomes in patients with testicular torsion. A retrospective chart review of 133 patients, aged 0-20 years, treated at the authors' institution for testicular torsion was conducted. Neonate patients and patients who did not receive ultrasound were excluded. Demographic and clinical variables were collected from the electronic medical record. Pearson Chi-squared and t-tests were used for univariate comparisons, and multivariate logistic regression analysis was performed to measure the relationships between variables. Forty-nine percent of patients were primary patients, and 51% were transfer patients. Fifty-two percent of transfer patients received repeat ultrasounds. In comparison to salvaged patients, those who underwent orchiectomy experienced a greater delay between presentation at the institution and surgical intervention (229min vs 177min, p=0.048). The transfer status does not appear to be related to the outcome, i.e. orchiectomy versus salvage. Patients who underwent orchiectomy were more likely than salvaged patients to have received repeat ultrasounds (p=0.008). Repeat ultrasound patients had three times the likelihood of orchiectomy of single ultrasound patients. In a subset analysis of transfer patients, repeat ultrasound patients were more likely than single ultrasound patients to receive an orchiectomy (p=0.03). In agreement with previous studies, patients who underwent orchiectomy were found to experience greater treatment delays and trend toward transfer. Specifically, repeat ultrasound and time between presentation and intervention appear to influence patient outcomes. The effect of repeat ultrasound on outcomes appears to be independent of the transfer status. The study was limited by its retrospective nature and small sample size. The analysis suggests that efforts to prevent repeat ultrasounds and minimize the time between presentation and intervention would improve patient outcomes. It is proposed that standardized clinical decision-making procedures, such as the TWIST scoring system, be incorporated into hospital protocols.