Testicular Survival Research Articles

Implementation of a health system intervention to reduce time from presentation to surgical intervention for pediatric testicular torsion

Testicular salvage rates for torsion are time-dependent1. Door to detorsion time has been identified as an independent testicular survival factor2. We describe an initiative to reduce door to incision (DTI) time for pediatric testicular torsion. An institutional multidisciplinary quality improvement initiative with a primary outcome of reducing DTI time for pediatric testicular torsion was developed with multidisciplinary stakeholders. Several process and balancing measures were used as secondary outcomes to help interpret and verify the observed change in DTI time. Interventions were implemented in cycles. Initial interventions standardized assessment of suspected torsion by Emergency Medicine utilizing a validated scoring system. A threshold Testicular Workup for Ischemia and Suspected Torsion (TWIST) score led to parallel notification of essential services for rapid assessment and case prioritization3. Subsequently, bedside ultrasound in the Emergency Department was implemented. Progress was tracked in a live dashboard and analyzed with X-mR process control charts and Nelson rules. These tools are used in quality improvement and process control to demonstrate the significance of changes as they are being implemented, prior to when traditional hypothesis testing would be able to do so. We aimed to increase the proportion of cases with DTI times under 4h from 64% to >90% within one year. We observed 22 torsion cases prior to and 62 following initial implementation. The percentage of cases with DTI times under 4h improved from 64% to 95%. At week 29, a shift identified a significant change on the X chart, with reduction in mean DTI time from 221 to 147min. At the same time, a shift on the mR chart identified reduction in patient-to-patient variation. Mean time from arrival to Urology evaluation decreased from 140 to 56min, mean time from arrival to scrotal ultrasound decreased from 70 to 36min, and mean time from scrotal ultrasound to surgical incision decreased from 128 to 80min. These improvements highlight the two key successes of our project: application of the TWIST score and bedside ultrasound for rapid assessment of suspected testicular torsions, and parallel processing of the evaluation and management. Implementation of a protocol for pediatric testicular torsion increased the proportion of cases with DTI time <4h to 95%, decreased mean DTI time, and decreased variation. Our protocol provides a model to improve timeliness of care in treating pediatric testicular torsion.

Using clinical pathways to identify patient candidates for survivorship in testicular cancer.

492 Background: Dana-Farber Cancer Institute’s (DFCI) Clinical Pathways provide evidence-based decision support for oncologists across a variety of care settings. Data generated by Pathways enable continued cancer care improvement and may also be a tool for identifying patient candidates for survivorship. Here, we explore patients diagnosed with testicular cancer treated with curative intent. Methods: Oncologists at DFCI navigate Clinical Pathways when starting or changing therapies. Each navigation provides discrete clinical data elements about disease (e.g., histology, stage), treatment setting (e.g., line of therapy), and treatment selected. Here, pathway navigation data was used to retrospectively identify patients with testicular cancer who were appropriate for survivorship resources. Eligibility criteria included patients who completed therapy, had not received treatment in 12-24 months since initial therapy navigation, and had a follow-up appointment scheduled. Eligible patients were referred to the testicular cancer survivorship program. Results: Between April 2021 to April 2022, we identified 25 testicular cancer patients treated at DFCI’s primary Longwood campus. Twelve of the 25 patients were identified as eligible for a survivorship referral. Nine of those 12 patients (75%) were successfully identified through the Pathways testicular survival algorithm described above. A Pathways navigation had not been completed by the providers of the 3-remaining survivorship-eligible patients, who were instead identified by EHR treatment plan data. One of the 12 patients screened by the testicular survivorship identification process developed metastatic disease that was not captured by the current algorithm and was then deemed inappropriate for survivorship referral. The remaining 11 patients were contacted and offered survivorship resources. As a reference, the total pathways usage rate between April 2021 to April 2022 for the DFCI genitourinary oncology group was 85% across all GU malignancies, and 74% in testicular cancer. Conclusions: Pathways Navigations can provide robust clinical information about patients, disease, and treatment. This information can be used to identify patients appropriate for survivorship and other clinical resources and trial opportunities in testicular cancer and across other malignancies. The impact of this process requires reliable provider usage of the Clinical Pathways tool.[Table: see text]

Bisphenol S dysregulates thyroid hormone homeostasis; Testicular survival, redox and metabolic status: Ameliorative actions of melatonin

Bisphenol S (BPS) is an incipient threat for reproductive health augmenting societal burden of infertility worldwide. In the present study, we investigated the mechanism of BPS induced testicular dysfunctions and protective actions of melatonin in mice. BPS (150 mg/kg BW) treatment reduced serum T3/T4, testosterone and elevated insulin levels along with adverse effect on thyroid and testicular histoarchitecture. Further, BPS treatment compromised sperm quality, reduced mRNA expression of steroidogenic (StAR/CYP11A1) markers, elevated oxidative load and disrupts metabolic status. However, melatonin (5 mg/kg BW) administration to BPS treated mice showed improved hormonal/histological parameters, enhanced thyroid hormone (TR-α/Dio-2)/melatonin (MT-1) receptor expressions. Further, melatonin treatment modulated the expression of testicular survival/redox (SIRT1/PGC-1α/FOXO-1, Nrf2/HO-1, p-JAK2/p-STAT3), proliferative (PCNA) and metabolic (IR/pAKT/GLUT-1) markers. Furthermore, melatonin treatment enhanced testicular antioxidant status and reduced caspase-3 expression. In conclusion, our results showed that BPS induces endocrine/oxidative and metabolic anomalies while melatonin improved male reproductive health.

Diagnostics of testicular torsion using the TWIST scale (Testicular Workup for Ischemia and Suspected Torsion)

Introduction. Testicular torsion (TT) is the most common pediatric emergency urological pathology. To reduce the duration of the diagnostic stage, systems for assessing the risks of testicular torsion based on anamnesis and clinical symptoms were proposed. In 2013, Barbosa et al. proposed the TWIST system (testicular examination for ischemia and suspected torsion), which became the most well-known and widespread. This system makes it possible to identify groups of patients who do not require scrotal ultrasound, which reduces the number of stages in the diagnosis of TT.Objective. To evaluate the experience of using and diagnostic significance of the TWIST scale based on available data in scientific publications.Materials &amp; methods. Review and analysis of literature data on the use of the TWIST scale.Results. We conducted an analysis of 13 publications, in which the results of using TWIST with statistical analysis were published. In all articles, the final diagnosis was established according to Doppler scrotal ultrasound or intraoperatively. Analysis of publications shows that even in large foreign medical centers there is a problem of emergency scrotal ultrasound, which increases the time of testicular ischemia with ТТ. To use the TWIST scale, only history and physical examination data are needed. Any specialist can use the scale in his practise. The low probability of TT in the low-risk group makes it possible not to perform routine scrotal revision, and, consequently, material and human resources are saved.Conclusion. Literature analysis has shown that the use of the original TWIST scale proposed by J.A. Barbosa, in case of suspected testicular torsion, has sufficient diagnostic accuracy, high sensitivity and specificity of TT detection, which significantly reduces the need for ultrasound, reduces the diagnostic time before surgery, that increases testicular survival.

Open Versus Laparoscopic Gubernaculum-Sparing Second-Stage Fowler-Stephens Orchiopexy for Intra-Abdominal Testis: A Long-Term Study.

Background:The benefits of performing open versus laparoscopic gubernaculum-sparing second-stage Fowler–Stephens orchiopexy (FSO) remain unclear. We compared the two techniques to answer this question.Methods:We retrospectively studied a cohort of patients who underwent laparoscopic first-stage FSO and open versus laparoscopic gubernaculum-sparing second-stage FSO at our institution between September 2004 and June 2020 (all patients underwent surgery by a single surgeon). We evaluated both procedures based on the incidence of testicular atrophy, testicular ascent, and other complications.Results:The age at initial surgery was 45.7 ± 28.2 months (median, 39). One hundred nine cases were treated with open second-stage gubernaculum-sparing FSO (OFSO), and 96 cases were treated with laparoscopic second-stage gubernaculum-sparing FSO (LFSO). The mean follow-up period was 59.8 months (median, 54; standard deviation, +35). The overall testicular atrophy rate was 1.5%. Atrophy was observed in 2 and 1 patient in the OFSO and LFSO groups, respectively (1.8% versus 1.0%, P > .05). There was no significant difference in the incidence of testicular ascent between both groups (2.8% versus 3.1%). Five and four complications were noted in the OFSO and LFSO groups, respectively (P > .05).Conclusions:Second-stage gubernaculum-sparing FSO achieved high testicular survival rates and satisfactory testicular positions. Neither the open nor laparoscopic approach appeared superior, because the overall testicular survival rates and incidence of testicular ascent and other complications were equivalent between both groups.

Should haematological inflammatory markers be included as an adjuvant in the differential diagnosis of acute scrotal pathologies?

The aim of this study was to determine discriminative role of haematological inflammatories between acute scrotal pathologies and malignancies. In addition, it was aimed to search for a predictive marker of testicular survival in the TT group. Medical data of 141 patients with acute scrotal pathology and 63TTm patients who presented to our clinic between January 2015 and July 2019 were retrospectively reviewed and compared in terms of haematological values and demographic parameters following the inclusion of 92 healthy controls. In the TTm group, NLR was the discriminative parameter with a median of 2.42 (0.25-8.42), whereas discriminative median values of MCV for TT and CRP for EO were 83.65 (56.9-98.16) and 59.5 (2.9-337) respectively. NLR, PLR, MER and RDW values were statistically lower in the control group compared to the patients groups. In TT subgroup analysis, monocyte count, MER and CRP were found to be statistically higher in the orchiectomy group, while multivariate logistic regression analysis performed for testicular viability revealed monocyte count to be the only significant variable (Odds Ratio [95% Confidence Interval]=0.046 (0.006-0.366), p<0.004). While our study demonstrated both diagnostic and discriminative values of haematological parameters, it also showed that monocyte count could predict testicular salvage in TT patients. However, further prospective studies are required.

High platelet distribution width can independently predict testicular survival in testicular torsion among patients with steady-state sickle cell anemia.

This study aimed to evaluate the predictive value of platelet volume indices (PVI), such as mean platelet volume (MPV), platelet distribution width (PDW), and plateletcrit (PCT), as prognostic indicators of testicular viability in torsion patients with steady-state sickle cell anemia (SCA) who underwent surgical exploration. Forty-eight patients with SCA with testicular torsion and 46 male control subjects were enrolled in the study. All patients underwent scrotal color Doppler ultrasonography before surgery, and PVI (MPV, PDW, and PCT) values were measured in all participants. Symptom duration and testicular volume were also recorded. The testicular salvage rate in patients with SCA was 73% after surgery. Analyses showed that MPV, PDW, and PCT values were significantly higher in torsed SCA as compared with controls (p<0.05). Orchiectomy in patients with SCA showed significantly higher MPV, PDW, and PCT values than the orchiopexy group (p<0.05). The MPV values of orchiectomy patients showed a higher significant cut-off of ≥11.5 fL, which is higher than in torsed patients without SCA, as an indicator of testis survival. PDW also demonstrated a higher significant cut-off of ≥12.7 fL for detorsion outcomes in patients with SCA. Symptom duration of less than 7 hours was also significantly correlated with orchiopexy (p≤0.001). Univariate analysis showed that higher MPV, increased PDW, and symptom duration were indicative of the outcome of testicular detorsion in SCA. Multivariable analysis showed that increased PDW and symptom duration are prognostic parameters for testicular viability in SCA. Increased PDW and symptom duration can be used as parameters for predicting testicular detorsion outcomes in patients with steady-state SCA.

Testicular torsion: An assessment of knowledge and referral pattern among health care workers in primary health-care facilities in Auchi, Nigeria

Objectives: Testicular torsion is the twisting of the spermatic cord with attendant loss of the blood supply to the affected testis. It is a common urological emergency and one of the frequent causes of acute scrotum in adolescents and young adults. Prompt diagnosis and immediate surgical intervention are necessary for testicular salvage. Testicular loss is directly linked to delay in presentation, surgery, and the referral patterns at the point of the first contact with health-care providers. The purpose of our study is to assess the knowledge, management methods, and referral pattern among health care workers in the primary health-care facilities in Auchi primary health-care zone, Nigeria. Material and Methods: This was a cross-sectional carried out among primary health care workers in Auchi primary health-care zone between May and October 2020. A structured self-administered questionnaire was given to all the first contact health care workers in this zone. The knowledge, management, and referral pattern of testicular torsion were determined based on responses to the questionnaires. Data were analyzed using SPSS version 21. Results were displayed with frequency distribution tables and charts. Results: Eighty-seven health care workers met the inclusion criteria and were given questionnaires to fill. The mean age of the respondents was 37.74 ± 7.53 years. The majority of the health workers (n = 66, 75.9%) have more than 5 years’ experience with only 12 (13.8%) having a secondary level of education. Most respondents have heard of testicular torsion (n = 77, 88.5%) and know the symptoms (n = 68, 78.2%) but they have a poor knowledge of the age group predominantly affected (n = 36, 41.1%) and testicular survival time following torsion (n= 41, 47.7%). Only about a third (n = 28, 32.2%) had attended to patients with testicular torsion. Of the 28 health workers who had managed patients with testicular torsion, less than half (n = 11, 39.3%) referred almost immediately, while about half treated conservatively (n = 14, 49.9%) keeping the patients under their care for a period of 3–7 days. Conclusion: This study showed that a comprehensive education of all categories of health workers in the primary health-care centers is needed. This is necessary for the early identification and appropriate surgical intervention or prompt referral of patients with testicular torsion to prevent avoidable testicular losses.

Laparoscopic Fowler-Stephens orchidopexy for intra-abdominal cryptorchid testis: a single institution experience.

Fowler-Stephens Laparoscopic Orchiopexy (FSLO) permits the mobilization of Intra-Abdominal Testis (IAT) to the scrotal position after spermatic vessel ligation. We reported our experience of FSLO for IAT. The charts of all boys who underwent a FSLO were retrospectively reviewed. Data were analysed for demographic data, procedure, complications and follow-up results. From January 2008 to June 2016, 160 laparoscopies for Non Palpable Testis (NPT) were performed at a mean age of 3,2 years. 61% of patients had a right NPT, while 6% were bilateral. In 64 cases, an IAT was found: 20 were managed by FSLO with a two-stage procedure in 11 patients. There were no differences in hospitalisations; one patient had a prolonged ileus. Follow-up ranged from 1 to 8 years. Of the 20 patients who underwent FSLO, testicular atrophy developed in three; the remaining testes were in the scrotal position, with normal consistency. FSLO was applied in 31% of IAT. The overall success rate of the technique was 85 %. The percentage of atrophy associated after spermatic vessels interruption appears to provide a good chance of testicular survival.

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.

Door To Detorsion Time Determines Testicular Survival

ObjectiveTo determine the importance of the duration of in-hospital management of patients with testicular torsion for testes survival. The time from onset of symptoms until surgery is a well-known factor determining testicular survival but there is no data regarding the contribution of in-hospital management duration to testicular survival. Unlike the time from onset of symptoms until seeking medical attention, the time from registration to the emergency department (ED) to the time of detorsion—“Door To Detorsion time” (DTD) is dependent on medical providers and should be minimized. Materials and MethodsData was retrieved on all patients who underwent surgery for testicular torsion in 1994-2014 (N = 219). We used multivariable logistic regression analysis to examine independent association between DTD time or duration of symptoms to testicular survival. ResultsMedian DTD time was 135 minutes (range 23-546). Among patients with a viable testis, median DTD time was 107 minutes (range 35-381) compared to 160 minutes (range 23-546) among patients with a nonviable testis (P <.001). Logistic regression models showed that both DTD time (P = .04) and duration of symptoms (P <.001) are independent factors associated with testicular survival.Adjusted odds ratio was 1.0048 for a nonviable testis for every minute of delayed management in the ED (P = .04). Results suggest that every 10 minutes of delay in the ED increases the chance of having a nonviable testis in exploration by 4.8%. ConclusionDTD is an independent factor predicting testicular survival. Institutional efforts should be made to decrease duration of DTD. DTD should be considered as a measure for quality of care.

Optimal Predictor of Gonadal Viability in Testicular Torsion: Time to Treat Versus Duration of Symptoms

BackgroundWe hypothesize that in testicular torsion, the duration of symptoms (DoS) better correlates with predicting testicular viability than minimizing the “time-to-treat” (TtT) after presentation to a medical facility. Materials and methodsMedical records of male pediatric patients treated for suspected diagnosis of testicular torsion in the emergency department (ED) from January 1, 2016, to December 31, 2018, were retrospectively evaluated. Forty-one patients met inclusion criteria. Statistical analysis compared testicular viability based on TtT, DoS, and site of initial presentation. ResultsTesticular salvage rates for patients presenting directly to our ED was 56.3% with an average TtT of 2.5 h versus 77.8% and 1.96 h, respectively, for transferred patients. Overall testicular survival was not statistically impacted by the difference in TtT. Comparing DoS, an 84% testicular salvage rate (DoS < 24 h) versus a 15.4% salvage rate (DoS > 24 h) was shown in patients presenting directly to our ED (P ≤ 0.0001). Within the total population (n = 41), a significant difference was also shown (P ≤ 0.0001) when comparing overall testicular salvage rates in patients presenting with <24 h versus >24 h total DoS (84% versus 25%). ConclusionsThese data reveal that an alternative predictor of testicular salvage rates is a DoS < 24 h. This is a meaningful metric when providing accurate preoperating counseling to parents and may be a better focus of quality improvement efforts surrounding this topic.

Can haematologic parameters be used to predict testicular viability in testicular torsion?

The purpose of this study was to evaluate the predictive value of haematologic parameters for testicular survival in torsion. Children with testicular torsion (TT) treated in Beijing Children's Hospital from January 2006 to December 2018 were enrolled in this study. Patient data collected in this study included age, symptom duration, preoperative preparation time, cryptorchidism testicular torsion or not, spermatic cord torsion degree, orchiectomy/orchiopexy, testicular volume 3months after operation by ultrasound in orchiopexy patients and haematologic parameters. The orchiopexy group comprised of 54 patients with a mean age of 135.6±43.73months,andthe orchiectomy group included 58 patients with a mean age of 119.36±60.82months.The multivariate analysis showed that symptom duration (Odds Ratio=1.11, p<0.001), spermatic cord torsion degree (Odds Ratio=1.006, p=0.002) and mean platelet volume (MPV; Odds Ratio=3.697, p=0.044) were significant predictors of orchiectomy. The cut-off value for MPV during window time for orchiectomy was 10.55fl (10-9 L) and provided a sensitivity of 47.8% and a specificity of 92.6%. This study found that symptom duration, spermatic cord torsion degree and MPV could be indicators of testicular viability in testicular torsion. MPV can provide valuable information before operation which can guide doctors and family members of the patients to select the appropriate treatment.

816 - Testicular atrophy after orchiopexy for congenital undescended testis: Outcomes of testicular survival by different primary locations and ages at orchiopexy

816 - Testicular atrophy after orchiopexy for congenital undescended testis: Outcomes of testicular survival by different primary locations and ages at orchiopexy

The dangers of hurling-genital injuries arising in the modern game.

To assess the proportion of penoscrotal injuries arising from the sport of hurling and to assess work-up and management of each injury. Using Hospital In-Patient Enquiry data, all penoscrotal injuries occurring over a 10-year period between 2007 and 2017 were identified and assessed. Chart review, imaging reports, operative notes and discharge summaries were used to identify the aetiology of each injury and those occurring due to hurling were selected for analysis. Investigations and management of each case were reviewed. Seventy patients presented to our institution over a 10-year period with penoscrotal injuries and, of these, ten patients (14%) presented with injuries arising due to blunt scrotal trauma whilst playing hurling. The average age of these patients was 24.3years, and the right testicle was injured six times, compared with the left testicle twice and isolated scrotal injuries twice also. One hundred percent of patients underwent diagnostic ultrasonography with Doppler flow assessment with 90% (n = 9) having positive findings. Three patients (33%) required operative management with only one patient (10%) requiring an orchidectomy. There were no delayed or interval procedures. Hurling is a physical sport with a notable proportion of blunt scrotal trauma arising due to the sport. Prompt physical examination and diagnostic ultrasonography are essential in investigations of injuries, and surgical exploration should be considered in all cases with concerns of testicular survival. Groin protection should be recommended to all players and in particular to those at high risk such as single testis or prior injury.

Laparoscopic Orchiopexy for the Nonpalpable Testis : 3 Years Experience

We evaluated the safety and efficacy of laparoscopic orchiopexy to manage a nonpalpable intra-abdominal testis and studied the outcomes. We report our 3 years experience.Patients and methods Laparoscopic Orchiopexy was performed on 28 children (32 testicular units) for non-palpable intra-abdominal testis between 2010 and 2012. We retrospectively reviewed the medical records. The mean age was 3.4 years (range, 2.5 -11 years). Of the 28 patients, 18 (64.28 %) were on the right, 6 (21.44%) were on the left and 4 (14.28%) of bilateral. The mean follow-up period was 14.8 months (range, 3-36 months). Testicular viability and orchiopexed positioning were evaluated within 1 month and beyond 3 months.Results Thirty one testes were descended successfully by laparoscopy. The average operative time was 41.5 ± 3.8 min. Primary laparoscopic orchiopexy done in 26 testes.Three of unilateral and 2 of bilateral testicular units underwent one -stage Fowler-Stephens Orchiopexy. One patient needs laparoscopic orchiectomy. At follow-up (mean 14.8 months), one testis atrophied and need orchiectomy. Testicular survival rate was 96.77% (30/31) and all of the testes maintained an adequate size. Twenty six (86.66%) are in an acceptable scrotal position and 4 testes (13.33%) are mid to high in the scrotum without atrophy. There was no recurrent inguinal hernia.Conclusions Laparoscopic orchiopexy is successful for a nonpalpable intra-abdominal testis with a high testicular survival rate. The low incidence of complications and high success rate underscore the feasibility of this procedure. It is our procedure of choice for the treatment of nonpalpable testis.TAJ 2011; 24(2): 70-75

Laparoscopic one-stage Fowler-Stephens orchiopexy preserving gubernaculum.

To assess gubernaculum-sparing laparoscopic one-stage Fowler-Stephens orchiopexy (FSO), in the management of high intrapelvic testis. Medical reports of boys who underwent laparoscopic one-stage FSO were retrospectively reviewed. High intrapelvic testis was defined as testis ≥3 cm away from ipsilateral internal ring. Testes were evaluated on physical examination at 3rd, 6th and 18th months after surgery. Children were evaluated as for their demographic data, operative findings, interventional details and outcomes. Seven patients met inclusion criteria of the study. Six of 7 testis were small and had abnormal appearance, compared with the contralateral testis. Average distance of the testes from the internal ring was 4.2±1.1 cm (3 to 6). Average age at surgery was 6.1±4.2 years (2 to 12). Average follow-up period was 14±5.8 months (8 to 20), and 5 testis (71.4%) were considered to be normal in volume and scrotal location. Two testes were relatively atrophic and underwent orchiectomy. Our preliminary results shows a good testicular survival rate for one-stage laparoscopic FSO. Sparing collateral vasculature of the gubernaculum is important.

Manual Detorsion of Testicular Torsion - A Primary Care Intervention Procedure. Case Reports.

Testicular torsion is one of the known acute urological emergencies that require prompt intervention. Salvage of the testis is only possible if derotation is performed within 6 hours of onset of symptoms. The objective of this paper is to report successful manual detorsion of the testes of patients with testicular torsion. Three cases with testicular torsion requiring emergency scrotal exploration underwent manual detorsion after sedation while waiting to be taken to theatre. Case 1, a 15 year old male diagnosed with right sided testicular torsion. Case 2, a 28 year old male with right testicular torsion. Case 3, a 15 year old male who presented with a 6 hour history of left testicular torsion. Attempting manual detortion in patients with acute testicular torsion can salvage the testis against loss. Key Words : testicular torsion, manual detorsion, testicular survival, orchidopexy.

How do they get here: Does the method of transportation impact salvage for patients with testicular torsion?

A growing number of patients are arriving at our tertiary care center for evaluation of possible testicular torsion using ambulance or helicopter transport. In many cases the parents arrive by car before the patient arrives. Are these advanced methods of medical transport worth the expense and risk in the case of suspected testicular torsion? We evaluated the total number of patients presenting to our emergency room for suspected testicular torsion to see if the means of transport affected testicular survival. Retrospective. As shown below in the table, the means of transport did not impact on testicular salvage. It is understandable that many patients with scrotal pain seek treatment closer to home because of their pediatrician's recommendation and/or family preference. However once evaluated many patients are transferred because of a lack of urologists willing to evaluate and treat the pediatric patients in community settings or because of a lack of anesthesia support. These patients are often transported by ambulance or helicopter. Our data would suggest that there is no improvement in the testicular salvage rate seen with these more advanced means of medical transportation compared with transfer by private car even when we restrict the analysis to patients traveling from over 40 miles away. We suspect that important time is lost while waiting to make such transfer arrangements. Furthermore transfer by ambulance or helicopter is more expensive and these costs are often passed on to families. Transfer by helicopter is also riskier. While an argument can be made in favor of medical transport over long distances or long driving times, this data suggests that many of these transfers could be accomplished by car with no effect on testicular salvage rates. The rate of testicular salvage was not affected by the means of transport to our tertiary facility. Only 4 patients would have required advanced of medical transport if this were limited to those facilities over 100 miles or 1.5 hours driving time away. This would achieve a substantial cost savings with no measurable change in outcome.

Standardized process to improve patient flow from the Emergency Room to the Operating Room for pediatric patients with testicular torsion

Testicular torsion (TT) remains one of the most common urological emergencies. The length of time from onset of symptoms to detorsion and degree of spermatic cord twisting are usually the most important factors for testicular damage. Therefore early presentation, accurate diagnosis, and prompt treatment are important factors for optimizing the testicular salvage rate. While delay in seeking medical attention is a common cause of testicular loss in pediatric patients with testicular torsion, delays in diagnosis and treatment can be preventable causes of testicular loss. In this study, we aimed to develop a standardized process to improve the patient flow from the Emergency Room (ER) to Operating Room (OR) for TT patients in an academic children's hospital. Thirty consecutive pediatric patients with acute testicular torsion between November 2013 and July 2014 served as the control group. A scrotal pain checklist was implemented in July 2014, and 30 consecutive patients from July 2014 until April 2015 served as the study group. Perioperative parameters including times, ultrasound (US) findings, and surgical results were reviewed. The mean ages of the control group and the study group were similar (12.3±4.9 years and 11.5±5 years, respectively) (p=0.575). ER arrival to OR time, triage completion to OR time, and scrotal US to OR time were significantly decreased in the study group (p<0.001) (Table). Although triage time and ER arrival to scrotal US times were decreased in the study group, the differences were not significant (p=0.071, p=0.112, respectively). Utilizing scoring tools during the triage of patients with scrotal pain can help identify high-risk patients earlier and prevent unnecessary use of resources in an ER serving a large pediatric population. Limitations of this pilot study include the limited number of patients and the potential for the Hawthorne effect (staff awareness of the study). Additionally, we did not examine scrotal pain checklist scores for other acute scrotal diseases. This study focused on a quality improvement process for TT patients, in order to reduce ER to OR times. A standardized process with use of a scrotal pain checklist and prompt communication between the ER, Urology, and Radiology teams led to significantly reduced times from the ER to the OR. Standardized processes for pediatric patients with testicular torsion may help to improve testicular survival rates.