Prenatal Torsion Research Articles

Prenatally Diagnosed Testicular Torsion: A Rare Condition That Causes Dilemma in Management

Background Prenatal testicular torsion (PTT) is exceedingly rare in intrauterine development, often diagnosed at the time of birth and very rarely diagnosed in utero during routine gestational ultrasound. As a result, incidence is unknown, and there exists no consensus regarding the pathophysiology of this phenomenon nor universally recognized algorithms and guidelines regarding its diagnosis and management. Case Presentation. We present the case of an antenatally diagnosed torsion and our subsequent management which included ipsilateral orchiectomy and prophylactic contralateral orchiopexy via a scrotal approach. Conclusion While controversy regarding surgical intervention in patients with unilateral PTT exists due to poor salvage rates—estimated to be less than 1%—the risk of anorchia is higher in affected patients due to limitations in the accuracy of detecting bilateral testicular involvement. Risk of misdiagnosis of bilaterality may lead to lasting sequelae such as infertility and devastating psychological consequences for affected patients, supporting the need for surgical exploration, as was performed in our case.

A case of bilateral perinatal testicular torsion that presented with unilateral torsion; necessity of contralateral testis exploration.

Perinatal testicular torsion is a rare emergency in a neonate that prompts immediate attention. Bilateral testicular torsion is extremely rare. We report a case of bilateral torsion that presented with unilateral scrotal swelling but significant atrophy and dark discoloration of the contralateral testis that was secondary to asynchronous prenatal torsion. There is no consensus about exploration of the contralateral testis when exploring a case with unilateral testicular torsion. Nevertheless, findings in this case report indicate that bilateral exploration is mandatory in each case of perinatal testicular torsion to evaluate the condition of contralateral testis and fix it to prevent development of future torsion that may result in anorchia.

A Survey of the Current Practice Patterns of Contralateral Testis Fixation in Unilateral Testicular Conditions

To query the current contralateral testis fixation (CTF) practice patterns among pediatric urologists in different clinical situations that could result in monorchism. An online survey was sent to members of the Urology Section of the American Academy of Pediatrics. The survey included questions addressing CTF practice patterns in 14 clinical scenarios. Responses were anonymously submitted, blindly reviewed, and analyzed. Among 53 respondents, 62.3% had academic appointments and 73.6% had an exclusive pediatric urology practice. All participants agreed on CTF necessity in testicular torsion beyond the neonatal period. CTF was advocated by 84.9% in prenatal torsion, 96.2% in postnatal torsion, and 94.3% in delayed torsion presentation. Emergent intervention was favored by 64.4% in prenatal and 98% in postnatal torsion. Only 1 participant (1.9%) preferred CTF with a unilateral testicular tumor and 5 (9.4%) in trauma substantiating an orchiectomy. There was less consensus on CTF in torsed undescended testis (79.3% in prepubertal and 81.13% in postpubertal), testicular nubbin in a child (40.4%), palpable atrophic undescended testis (13.2%), and unilateral bell-clapper anomaly (47.2%). In situations other than torsion, lack of strong evidence was the commonest reason not to perform CTF. The majority of responding pediatric urologists currently performs CTF in neonatal torsion. Although there is a general consensus on CTF in testicular torsion outside the neonatal period, CTF remains controversial in other clinical situations, warranting further research. The decision for CTF should involve patients, parents, and treating physicians.

Perinatal testicular torsion - Not an uncommon entity

Perinatal testicular torsion is a rare condition with an incidence of 1 in 7500 live births. 70% are prenatal and 30% postnatal. Postnatal torsion presents as an acute scrotum, whereas prenatal torsion may be usually missed as it is a non-tender hard mass. Management of prenatal torsion is controversial. We are reporting three such case series presenting within a period of 1 year. Prenatal testicular torsion is usually missed as it is asymptomatic and later presents as cryptorchid. Careful postnatal physical examination and documentation is essential, as a missed case can later present as cryptorchid and may lead to medicolegal issues. In torsion in the immediate perinatal period, the testis may be salvaged if promptly operated.

Is Prenatal Testis Torsion Unsalvageable Event?

Is Prenatal Testis Torsion Unsalvageable Event?

A systematic review and meta‐analysis on fetal ovarian cysts: impact of size, appearance and prenatal aspiration

The objective of the study is to compare outcomes of ultrasound-guided aspiration of fetal ovarian cysts with conservative management. A systematic review of MEDLINE and Web of Science included studies reporting outcomes (prenatal and postnatal torsion, spontaneous resolution and surgery) of fetuses with ovarian cysts. Subgroup analysis was performed according to cyst diameter at diagnosis and cysts ≥40mm. Ninety-two non-randomised studies reported on 380 cysts (324 observed and 56 aspirated in utero) in 365 fetuses. All studies were case reports or series with high heterogeneity and risk of bias. The overall spontaneous resolution rate of conservatively managed cysts was 46%, yet decreased with increasing cyst size. Risk of prenatal ovarian torsion in conservatively managed cases depended on cyst size and was particularly important in the range 30 to 59mm (15-34%). The rate of prenatal torsion in simple cysts ≥40mm was lower in aspirated than conservatively managed cysts (0% vs 10%, p=0.03). Aspirated cysts had lower rates of postnatal surgery (7%) compared with conservatively managed cysts (49%, p<0.001). Cysts 30 to 59mm were at highest risk of torsion. Simple cysts >40mm had lower rates of torsion when aspirated prenatally. Randomised studies and safety data are needed prior to routine prenatal ovarian cyst aspiration. © 2017 John Wiley & Sons, Ltd.

Testicular torsion – an important consideration in neonatal scrotal swelling

Scrotal swelling in a neonate is rarely caused by testicular torsion, but it is an important differential diagnosis as acute treatment can prevent loss of fertility. The clinical findings differ, depending on whether the torsion has occurred in utero (prenatal) or after birth (postnatal). Postnatal testicular torsion presents with pain, redness, and swelling of the affected testis and requires acute surgical intervention to restore the blood flow and prevent ischemic necrosis. Contrary, prenatal testicular torsion will present with a hard, discolored untender mass that has already atrophied. It is important to quickly distinguish between prenatal versus postnatal cases to enable timely surgery of postnatal torsion, whereas the treatment of prenatal torsion is less urgent. A thorough clinical examination and ultrasonography with Doppler to detect blood flow or the lack of flow are the cornerstones in establishing an early diagnosis.

Ultrasound assessment of perinatal testicular torsion.

The goal of this study was to elucidate the different sonographic features of prenatal and postnatal testicular torsion (TT) using high-frequency colour Doppler ultrasound (HCDU) in an effort to increase diagnostic accuracy. 29 patients (average age, 7.5 days) with perinatal TT were divided into patients with postnatal (acute) TT vs patients with prenatal (chronic) TT and their clinical characteristics, imaging features on HCDU and surgical pathology results were retrospectively analyzed. Significant differences were observed between prenatal and postnatal TT cases with regard to testicular size (p = 0.01) and echogenicity (p = 0.007). All 17 prenatal cases had non-homogeneous testicular parenchymal echo patterns compared with only 9 (64.3%) postnatal TT cases. Five postnatal TT cases presented with homogeneous echo patterns compared with none of the prenatal TT cases. Testicular blood supply was absent in 25 (80.7%) of 31 testes on colour Doppler flow imaging, with the majority occurring in the prenatal TT cases [i.e. 16 (94.1%) cases]. 1 affected testis out of a total 17 testes from 16 patients with prenatal TT was salvaged, with a salvage rate of 1/17 or 0.06%. 7 affected testes out of a total 16 testes from 13 patients with postnatal neonatal TT were salvaged, with a salvage rate of 7/16 or 43.8%. In neonates with acute scrotal symptoms, the possibility of perinatal TT should be considered and HCDU examination should be performed in a timely manner. HCDU examination could aid in testicular salvage by prompting quick surgical intervention. This study underlined the clinical contribution of HCDU in evaluating postnatal (acute) vs prenatal (chronic) TT. The sonographic features of postnatal TT with salvageable testes were compared with prenatal torsion and the relative salvage rates in both cases were discussed.

Fetal diagnosis of testicular torsion: what shall we tell the parents?

The objectives of this study are to present our collective experience with the prenatal diagnosis of testicular torsion and to propose a possible prenatal management scheme. We retrospectively collected and reviewed all medical records of cases that were diagnosed with perinatal testicular torsion in our medical center between the years 2002 and 2013. Prenatal torsion was categorized as torsion diagnosed in utero or on immediate newborn examination. A total of five unilateral prenatal torsions were diagnosed. Two fetuses were diagnosed in the third trimester of pregnancy. In both cases, cesarean section was performed immediately upon diagnosis. One newborn underwent immediate orchiectomy with contralateral orchiopexy. Torsion was confirmed by pathological examination. The other was managed conservatively, just as the three newborns who were diagnosed immediately after birth. On follow-up scan, the affected testicle was found atrophied with lack of blood flow on color Doppler examination. The unaffected contralateral testicle remained within the normal size with good blood flow. Prenatal diagnosis of unilateral testicular torsion is a coincidental rare finding. Because the twisted testicle cannot be salvaged, induced delivery and prompt surgery are not recommended.

The current state of surgical practice for neonatal torsion: A survey of pediatric urologists

ObjectiveThe evaluation and treatment of perinatal testicular torsion is controversial. We performed a survey to assess practice patterns among pediatric urologists regarding treatment of perinatal torsion. MethodsAn internet survey was administered to members of two pediatric urology societies. Cases of prenatal, postnatal and bilateral prenatal torsion were outlined. Respondents were asked about use of ultrasound, timing of surgery, incision, and management of the contralateral testicle. A case with a non-palpable testicle and blind ending vessels was also presented. ResultsWe had 121 respondents. In a neonate with prenatal torsion, 34% percent would operate immediately, 26% urgently within 72 h, 28% electively and 12% would not explore; 93% would perform a contralateral orchiopexy. In a neonate with postnatal torsion, 93% would operate immediately, 5% urgently, 1% electively and 1% would not explore; 96% would perform a contralateral orchiopexy. In both cases, 75% would use a scrotal incision and 25% would use an inguinal incision. When presented with bilateral prenatal torsion, 90% would operate immediately, 1% urgently, 2% electively and 7% would not operate. In the case of a non-palpable testicle with blind ending vessels 28% would perform a contralateral orchiopexy, 12% would explore the ipsilateral canal for a “nubbin”, 56% would perform no intervention and 4% would perform some other form of management. ConclusionWe documented variability of timing for intervention of prenatal torsion and confirmed that most view postnatal torsion as a surgical emergency. Most perform a contralateral orchiopexy for prenatal torsion despite the fact that most cases are extravaginal. The surgical approach via a scrotal incision appears to be preferred at this time.

Histological Examination of Solitary Contralateral Descended Testis in Congenital Absence of Testis

Congenital absence of the testis is believed to be secondary to prenatal torsion, differing from the isolated undescended testis. We determined whether congenital absence of the testis is associated with abnormal histology in the solitary contralateral descended testis. A total of 239 boys with a primary diagnosis of unilateral absent testis underwent orchiectomy and testis biopsy. Germ cell counts were compared between solitary contralateral descended testes and contralateral descended testes in a randomly selected, age matched cohort of patients with unilateral undescended testes. Subanalyses evaluating hypertrophic testes and hypertrophic prepubertal testes between the study groups were performed. The solitary contralateral descended testis group exhibited a significantly greater volume (p <0.001) and a significantly greater germ cell count (p = 0.001). In the hypertrophied testes there was a greater gonocyte count (p = 0.02), greater percentage of gonocytes (p = 0.02), greater primary spermatocyte count (p = 0.04) and greater percentage of primary spermatocytes (p = 0.03). No significant differences in adult dark spermatogonia or Leydig cells were detected. Primary spermatocytes did not differ significantly in prepubertal patients. The solitary contralateral descended testis exhibits increased volume, increased germ cell proliferation and dissimilar maturation patterns compared to the contralateral descended testis in unilateral cryptorchidism. These findings support prenatal torsion rather than endocrinopathy as the etiology for the congenitally absent testis. In the postpubertal solitary contralateral descended testis more germ cell maturation is seen and primary spermatocytes account for the increased total germ cell count. Patients with a solitary testis are likely not at additional risk for infertility.

Testicular torsion: Potential pitfalls in its diagnosis and management

Torsion of the testis is a surgical emergency. Within the paediatric population, peaks in incidence occur in the perinatal and adolescent age groups. There exist traps that can make torsion of the testis a difficult diagnosis to make and once made a tricky condition to manage, in some instances. It is becoming clear that perinatal torsion should serve as an umbrella term for what is increasingly being regarded as two separate entities: prenatal and post-natal torsion. Evidence suggests that the management for each of these may be different. While management of testicular torsion in the adolescent is universally agreed upon, the diagnosis can sometimes be difficult to make. This notwithstanding, early diagnosis is imperative for ensuring the best possible outcome.

Incomplete Prenatal Torsion of the Testicle—A Successful Salvage

The role of emergent intervention in prenatal testicular torsion is controversial. We report a case of successful testicular salvage of incomplete prenatal torsion. A 1-day-old male infant presented with a bluish-hued scrotum at birth. Testicular ultrasonography demonstrated right testicular torsion with minimal peripheral blood flow. Scrotal exploration was performed, confirming extravaginal torsion; both testes underwent orchiopexy. Subsequent imaging demonstrated normal bilateral testes with good vascular flow. Although intervention of prenatal torsion has been debated, the present case represents prenatal torsion saved by intervention. We propose the presence of any blood flow suggests incomplete torsion and the potential for salvage.

Salvage of Bilateral Asynchronous Perinatal Testicular Torsion

Current management strategies for prenatal torsion include observation alone, delayed contralateral orchiopexy and emergent contralateral orchiopexy. Bilateral torsion is now being reported with more frequency and approximately a third of these patients have asynchronous torsion. We highlight the role of scrotal exploration in neonates diagnosed with bilateral asynchronous testicular torsion. We reviewed the clinical experience from 2000 to present of 2 senior pediatric urologists to identify cases of bilateral perinatal testicular torsion. Asynchronous torsion was identified by the varying physical findings of each testicle at exploration. A literature review was done to evaluate the evolving management of perinatal testicular torsion. Six cases of bilateral perinatal torsion were identified since 2000. In 3 of the 6 cases extravaginal torsion of the contralateral testis was incidentally identified at surgical exploration. All 3 testes had normal Doppler flow before exploration. Testicular salvage was not successful in the 2 patients with bilaterally absent blood flow on newborn ultrasound. The 3 cases of incidentally diagnosed contralateral torsion and 1 of preoperatively diagnosed contralateral torsion were successfully salvaged. Thus, 4 of 6 patients with bilateral torsion were left with 1 viable testis. Physical examination findings and radiography can be inaccurate to assess the contralateral testis in males born with prenatal torsion. We have adopted the strategy of emergent surgical exploration in cases of prenatal torsion. Using this approach anorchia was minimized in patients with bilateral asynchronous torsion.

Neonatal Torsion: A 14-Year Experience and Proposed Algorithm for Management

Management of neonatal torsion is controversial, since the likelihood of testicular salvage and metachronous contralateral torsion must be weighed against the risk of neonatal anesthesia. We reviewed a large series of such cases and stratified neonatal torsion based on time of presentation to determine the potential for testicular salvage. To our knowledge this is the largest series of its kind in the literature. All cases of neonatal torsion were classified as either prenatal (noted at the time of delivery) or postnatal (noted after birth and before age 1 month). The charts of all patients were reviewed and data were collected on demographic information, pregnancy and birth history, laterality, physical examination findings, radiological imaging, intraoperative findings, anesthetic morbidities, perioperative complications and pathological diagnoses. Followup data were also collected for patients who underwent detorsion and orchiopexy. A total of 16 neonatal torsions (right side 8, left side 6, bilateral 1) were diagnosed in 15 patients at our institution between 1993 and 2007. A total of 13 torsions (81%) were prenatal and 3 (19%) were postnatal. All 13 prenatal torsions (100%) resulted in infarction (right 7, left 4, bilateral 2) confirmed by pathological examination. All patients underwent testicular exploration via an inguinal approach. A total of 11 cases were managed by orchiectomy at an average of 7.6 days (range 0 to 37) following birth. One of the bilaterally torsed testes showed infarction and necrosis on biopsy, and was detorsed and fixed in place. A second prenatally torsed testis was detorsed and pexed but atrophied on followup. Among the 3 postnatal torsions 1 (33%) was deemed viable on exploration and, therefore, salvaged. Of the 10 prenatal torsions with known prenatal history 5 (50%) were associated with at least 1 significant prenatal complication. Nine of the 10 patients with prenatal torsion (90%) were delivered vaginally, and 1 by cesarean section after prolonged failure of descent. Complicated pregnancies and vaginal deliveries seem to predispose patients to testicular torsion. Contrary to previous series, neonatal torsions do not appear to favor one side or the other. Prenatal torsions are never salvageable, and, therefore, do not warrant emergent intervention. Postnatal torsions are sometimes salvaged, and a judicious approach to surgical exploration should be taken.

Prenatal testicular torsion: Ultrasonographic features, management and histopathological findings

To highlight the ultrasonographic features of prenatal torsion of the testis in utero (IUTT) at presentation, the neonatal management and the histological findings postorchiectomy or biopsy. Seven newborns underwent emergency exploration for IUTT. All patients underwent a sonography and real-time color Doppler ultrasound study of the scrotum before any surgical procedure. A histological examination was performed in the removed specimens. Sonography of the scrotum revealed enlarged, heterogeneous testes. In all cases the color and power Doppler did not reveal any flow signal on the affected side. Four newborn with unilateral testicular torsion underwent orchiectomy and contralateral orchidopexy. In one neonate after detorsion and with the absence of gangrenous changes and a reassuring biopsy, a twisted testis could be treated conservatively with orchidopexy. In another case, the parents, acknowledging the inviability of the affected testis, gave consent only for a biopsy of the testis. In the neonate with bilateral IUTT, bilateral testicular biopsies were performed. Histology of the removed testes variably showed interstitial red cell extravasion and coagulation or hemorrhagic necrosis. Light microscopy of the preserved testis highlighted surviving seminiferous tubules, with gonocytes, spermatogonia and fetal Sertoli cells. An early diagnosis and treatment in IUTT is essential. Surgical exploration should be always performed through the inguinal route. In bilateral IUTT testes should be left to try to assure, as long as possible, a residual Leydig cell function.

Sonographic findings of prenatal torsion of ovarian lymphangioma

Ovarian cysts are primarily of follicular origin, and ovarian lymphangioma is an extremely rare lesion. Most ovarian cysts demonstrated on prenatal sonograms are asymptomatic and resolve antenatally. We report a case of ovarian torsion in utero secondary to an ovarian lymphangioma in which sonographic examination revealed a changing pattern of the cystic ovarian mass from an anechoic to echogenic appearance.

Prenatal testicular torsion: diagnosis and natural course. An ultrasonographic study

The aim of this study was to demonstrate the ultrasonographic features of prenatal torsion of the testis at presentation and during follow-up, with histological correlation post-orchidectomy. Between January 1985 and December 1999, 13 neonates with antenatal torsion of the testis were examined postnatally, at presentation and during follow-up, with high-resolution ultrasonography, including colour Doppler ultrasonography. Bilateral testis volume was evaluated [lengthxwidthxdepthx(pi/6)]. Ultrasonographic findings were correlated with histological findings (n=8) and findings at surgery. Moreover, in 1 patient the affected testis was postoperatively examined with ultrasonography in vitro. These findings were correlated with preoperative ultrasonography and corresponding histological slices. All patients (n=13) presented with a painless congenital scrotal mass. On the affected side no flow was found with colour Doppler ultrasonography. Testis volume on the affected and normal side showed mean values of 2.1 and 0.5 cc, respectively. On ultrasonography all patients showed scrotal swelling and a heterogeneous testis with hypoechoic central areas (necrosis). The tunica albuginea was thickened in all patients, with focal (n=2) or rim-like (n=11) hyperechoic reflections (calcifications) at the transitional zone between testis and tunica albuginea. In 9 patients follow-up ultrasonography showed progressive testis atrophy on the affected side. In 10 patients a contralateral hydrocele was found. Prenatal torsion shows a characteristic ultrasonographic pattern. In newborns with a scrotal mass, these ultrasonographic findings should suggest this diagnosis and delay in immediate surgery and/or oncological work-up may be appropriate.

Prenatal testicular torsion: sonographic appearance in the newborn infant

The prenatal diagnosis of spermatic cord torsion is often really difficult and the diagnosis is usually retrospective. Herein, we report a case of a male newborn baby who presented at delivery with an enlarged, swollen and tender scrotum. US showed an enlarged right testis, with dishomogeneous texture, fluid collection between the testis and the tunica vaginalis and large hydrocele. Differential diagnosis included hydrocele complicated by infection or hemorrhage, testicular tumor or postnatal testicular torsion. Color and power Doppler did not reveal any flow signal, and the diagnosis of antenatal torsion with initial necrosis was made. The role of color Doppler US is emphasized in directing the patient to emergency surgical exploration, when testicular salvage may be possible. Delayed surgical treatment can be proposed, when the diagnosis of antenatal torsion has a high degree of certainty. However, the Doppler examination of a newborn baby's testis is a very difficult challenge even for an experienced radiologist.

Torsion du cordon spermatique chez le nouveau-né : que faut-il attendre de l'exploration chirurgicale ?

Torsion of the spermatic cord is frequent in neonates suffering from acute scrotal distress. A retrospective study was carried out to determine the viability and the outcome of testis treated by surgical exploration. Patients and results. – Surgical exploration of 30 neonates presenting acute scrotal distress found: 18 torsions of the spermatic cord, six intrascrotal bleedings or hematoma due to delivery trauma, five tunica vaginalis inflammations and one ischemia without torsion. The torsion occurred in utero in 16 cases and after birth in two cases. The contralateral uninvolved testis was fixed to the scrotum in all cases. The torsion was extravaginal in 17 cases and intravaginal in one case. In all cases of prenatal torsion, there was total necrosis of the testis. One case of postnatal torsion operated on four hours after the beginning of the torsion was saved. Conclusion. – Although the viability of the torsioned testis is compromised in cases of prenatal torsion, surgical exploration is necessary to confirm diagnosis and to avoid any contralateral torsion because bilateral torsion exists. Only emergency surgical exploration can save a testis that has undergone post-natal torsion as reported in others series.