ABSTRACT
Purpose
To estimate statewide presentation delay, misdiagnosis rate, inter-hospital transfer times and testicular salvage for testicular torsion patients treated in our state’s public health system.
Patients and Methods
Case series of consecutive testicular torsion patients treated in our state’s public health system between 2012-2018. Predictors included presentation delay (time from symptoms to first medical assessment), facilitie’s level-of-care (primary, secondary, tertiary), first diagnosis (torsion, epididymitis, other), Doppler-enhanced ultrasound request (Doppler-US) and inter-hospital transfer times, with surgical organ salvage as the main response. We used Bayesian regression to estimate the effect of first examining facilitie’s level-of-care, first diagnosis, and Doppler-US on transfer time.
Results
505 patients were included, most (298, 59%) with presentation delay >6 hours. Misdiagnosis at first examining facility raised transfer time from median 2.8 to 23.4 (epididymitis) and 37.9 hours (other) and lowered testicular salvage rates from 60.3% (torsion) to 10.7% (epididymitis) and 18.3% (other). Doppler-US had negligible effects on transfer time once controlling for misdiagnosis in the regression model. Although organ salvage in patients presenting before 6 hours at the tertiary facility was high (94.6%, and about 20% lower for those presenting at lower levels-of-care), the overall salvage rate was more modest (46%).
Conclusion
Our low overall testicular salvage rates originated from a large proportion of late presentations combined with long transfer times caused by frequent misdiagnoses. Our results indicate that efforts to improve salvage rates should aim at enhancing population-wide disease awareness and continuously updating physicians working at primary and secondary levels-of-care about scrotal emergencies.
Spermatic Cord Torsion; Diagnosis; Surgical Procedures, Operative
INTRODUCTION
Intravaginal testicular torsion (henceforth testicular torsion) occurs when the testis rotates upon its axis inside the tunica vaginalis, twisting the spermatic cord or mesorchium ( 11. Chan JL, Knoll JM, Depowski PL, Williams RA, Schober JM. Mesorchial testicular torsion: case report and a review of the literature. Urology. 2009;73:83-6. , 22. Favorito LA, Cavalcante AG, Costa WS. Anatomic aspects of epididymis and tunica vaginalis in patients with testicular torsion. Int Braz J Urol. 2004;30:420-4. ) interrupting its blood supply. Left untreated, the almost universal outcome is testicular hemorrhagic infarction. The disease is a frequent cause of organ loss by either orchidectomy or atrophy, especially in emerging countries ( 33. Baruga E, Guyton Munabi I. Case series on testicular torsion: an educational emergency for sub-Saharan Africa. Pan Afr Med J. 2013;14:18. , 44. Ugwumba FO, Okoh AD, Echetabu KN. Acute and intermittent testicular torsion: Analysis of presentation, management, and outcome in South East, Nigeria. Niger J Clin Pract. 2016;19:407-10. ).
Since irreversible ischemic injury swiftly follows testicular torsion, supplemental imaging studies are not required after clinical diagnosis. One must admit, however, the possibility of diagnostic uncertainty, mainly acute epididymitis and torsion of testicular appendages ( 33. Baruga E, Guyton Munabi I. Case series on testicular torsion: an educational emergency for sub-Saharan Africa. Pan Afr Med J. 2013;14:18. , 55. Ciftci AO, Senocak ME, Tanyel FC, Büyükpamukçu N. Clinical predictors for differential diagnosis of acute scrotum. Eur J Pediatr Surg. 2004;14:333-8. ). In these situations, imaging studies, usually Doppler-Enhanced Testicular Ultrasonography (Doppler-US), may be useful ( 66. Moschouris H, Stamatiou K, Lampropoulou E, Kalikis D, Matsaidonis D. Imaging of the acute scrotum: is there a place for contrast-enhanced ultrasonography? Int Braz J Urol. 2009;35:692-702. , 77. Yagil Y, Naroditsky I, Milhem J, Leiba R, Leiderman M, Badaan S, et al. Role of Doppler ultrasonography in the triage of acute scrotum in the emergency department. J Ultrasound Med. 2010;29:11-21. ). In hierarchical health care systems such as the one we have in Brazil ( 88. Nicoletti RHA, Conselho Nacional de Secretários de Saúde (Brazil), Programa de Informação e Apoio Técnico às Equipes Gestoras Estaduais do SUS (Brazil). Assistência De Média E Alta Complexidade No SUS. Brasília: CONASS; 2007. Available at. < http://www.rebrats.saude.gov.br/>
http://www.rebrats.saude.gov.br/...
), where patients with scrotal emergencies are often first examined by general practitioners at primary or secondary level-of-care facilities, then referred to tertiary facilities for treatment, this not only requires the first examining physician to perceive the case as an emergency, but also that referral is not deferred for supplemental diagnostic testing. Thus, in the ideal situation - where patients rapidly seek medical attention, and are promptly examined by a competent diagnostician with immediate access to expert diagnostic imaging and referral protocols - one should observe low orchidectomy rates ( 99. Cattolica EV, Karol JB, Rankin KN, Klein RS. High testicular salvage rate in torsion of the spermatic cord. J Urol. 1982;128:66-8. ), which, unfortunately, have not been our experience ( 1010. Dias Filho AC, Alves JR, Buson Filho H, Oliveira PG de. The Amount of Spermatic Cord Rotation Magnifies the Time-Related Orchidectomy Risk in Intravaginal Testicular Torsion. Int Braz J Urol. 2016; 42: 1210-9. ).
While the time interval between symptoms and first medical assessment, i.e. presentation delay, rests upon the patient’s awareness of the disease and medical care availability ( 1111. Ubee SS, Hopkinson V, Srirangam SJ. Parental perception of acute scrotal pain in children. Ann R Coll Surg Engl. 2014;96:618-20.
12. Friedman AA, Ahmed H, Gitlin J, Palmer LS. Lack of Parental Awareness in Testicular Torsion. J Urol. 2016; 195: e582. - 1313. Yap LC, Keenan R, Khan J, Cozman C, Dowling C, Cullen I, et al. Parental awareness of testicular torsion amongst Irish parents. World J Urol. 2018;36:1485-1488. ), delays from this first assessment until evaluation at the treating institution have been associated with the first examining physician’s clinical diagnosis and subsequent action, such as imaging studies orders and inter-hospital patient referral and transfer ( 1414. Preece J, Ching C, Yackey K, Jayanthi V, McLeod D, Alpert S, et al. Indicators and outcomes of transfer to tertiary pediatric hospitals for patients with testicular torsion. J Pediatr Urol. 2017;13:388.e1-388.e6.
15. Ramachandra P, Palazzi KL, Holmes NM, Marietti S. Factors influencing rate of testicular salvage in acute testicular torsion at a tertiary pediatric center. West J Emerg Med. 2015;16:190-4. - 1616. Bayne CE, Gomella PT, DiBianco JM, Davis TD, Pohl HG, Rushton HG. Testicular Torsion Presentation Trends before and after Pediatric Urology Subspecialty Certification. J Urol. 2017;197:507-15. ). This information, however, comes from economically advanced countries, and although one may postulate that similar associations should also be observed in emerging countries, region-specific data is necessary to ascertain not only the existence but also the magnitude of these associations.
Since our tertiary unit is the referral center for testicular torsion patients within the public health network of our state - which grants database access for each patient’s entire medical history within the network, with time-stamps for each medical assessment - we may begin to fill this void in the urological literature. In this study, we set a two-fold goal. Firstly, to evaluate the relative roles of presentation delay and inter-hospital transfer time on testicular salvage; and secondly, to investigate the influence of the patient’s first clinical diagnosis and Doppler-US request on inter-hospital transfer time, especially on those examined shortly after symptoms, where expedient treatment is most decisive.
PATIENTS AND METHODS
Patient identification and variable recovery
After Institutional Board Review, all consecutive patients surgically diagnosed with testicular torsion in our tertiary facility between January 2012 and January 2018 were retrospectively identified from our unit’s data repository and were initially included in the study’s database. We retrieved each patient’s complete medical file - including assessments made outside our unit - for variable recovery. Since we did not have access to the time-stamps of patients first examined at private facilities or outside state borders, these were excluded from further analysis.
Continuous predictors included patient’s age in years, and the following time intervals: presentation delay, defined as the time between symptom’s onset and first examination, and transfer time, defined as the time between first examination and assessment at the tertiary facility. The arithmetic sum of these sub-intervals was named treatment delay. Categorical predictors included: The level-of-care of the facility where the patient was first examined (first examining facility), as defined by the Brazilian Health Authority ( 88. Nicoletti RHA, Conselho Nacional de Secretários de Saúde (Brazil), Programa de Informação e Apoio Técnico às Equipes Gestoras Estaduais do SUS (Brazil). Assistência De Média E Alta Complexidade No SUS. Brasília: CONASS; 2007. Available at. < http://www.rebrats.saude.gov.br/>
http://www.rebrats.saude.gov.br/...
): primary, secondary or tertiary; first diagnosis, defined as the clinical diagnosis recorded by the first examining physician: testicular torsion (torsion), acute epididymitis (epididymitis), neither torsion nor epididymitis (other); and whether Doppler-US was requested at the first examining facility, regardless of the actual performance of the study. Response variables were surgical outcome (whether or not the testicle was surgically salvaged) and transfer time, the latter with level-of-care, first diagnosis, and Doppler-US request as predictors.
Univariate and bivariate analysis
Continuous variables were summarized by their medians and interquartile range (IQR), and categorical variables by their frequencies. Differences between continuous variables were assessed with Kruskal-Wallis´ (KW) and Dunn’s tests, and we evaluated differences between categorical variables with Pearson’s Chi-Square (Chi-Square) or Fisher’s Exact (Fisher) tests, with statistical significance set at <0.05.
Linear regression
Bayesian hierarchical linear regression models were implemented using level-of-care, first diagnosis, and Doppler-US as predictors and transfer time as the response variable. The posterior distributions of the parameters were graphically presented and summarized by their medians and 0.95 Highest Posterior Density intervals (HPDI).
Statistical software
Computations took place within the R language statistical environment ( 1717. R Core Team. R: A Language and Environment for Statistical Computing [Internet]. R Foundation for Statistical Computing; 2018. Available at. <https://cran.r-project.org/>
https://cran.r-project.org/...
), supplemented by the rjags ( 1818. Plummer M. rjags: Bayesian Graphical Models using MCMC [Internet]. 2016. Available at. <https://CRAN.R-project.org/package=rjags>
https://CRAN.R-project.org/package=rjags...
) package.
Reporting Guideline
In this report we followed the Preferred Reporting of CasE Series in Surgery (PROCESS) ( 1919. Agha RA, Fowler AJ, Rajmohan S, Barai I, Orgill DP; PROCESS Group. Preferred reporting of case series in surgery; the PROCESS guidelines. Int J Surg. 2016;36(Pt A):319-323. , 2020. Agha RA, Borrelli MR, Farwana R, Koshy K, Fowler AJ, Orgill DP; PROCESS Group. The PROCESS 2018 statement: Updating Consensus Preferred Reporting Of CasE Series in Surgery (PROCESS) guidelines. Int J Surg. 2018;60:279-282. ) guidelines.
RESULTS
Data recovery and first examining facility
Six-hundred and three patients were treated for testicular torsion during the study period. We excluded 72 (11.9%) patients examined in private institutions and 26 (4.3%) patients examined outside state boundaries from our analysis. Most remaining 505 patients (median age 16.1 years, IQR 14.2-18.9) were first examined at secondary facilities (301, 59.6%; Figure-1 ). There were no missing data on recovered variables.
Presentation delay, first examining facility and first diagnosis
Median presentation delay was 8.7 hours (IQR 3.9-53.4), with significant differences between primary (median 5.2 hours, IQR 2.4-32.3) and secondary facilities (median 8.4 hours, IQR 3.4-52.1; P=0.025), and between primary or secondary versus tertiary facilities (median 10.1 hours, IQR 5.7-64.2; P=0.004 and 0.008, respectively; Dunn’s; Figure-2 ).
Presentation delay (log10 transformed) according to the first examining facilitie’s level-of-care.
Most patients were first diagnosed with torsion (345, 68.3%). Fifty-six (11.1%) were first diagnosed with epididymitis and 104 (20.6%) received another first diagnosis. Torsion was more often first diagnosed at the tertiary facility (123/133, 92.5%), compared to primary (44/71, 62%) and secondary facilities (178/301, 59.1%; P <0.001, Chi-Square; Table-1 ).
Doppler-US at first examining facility by first diagnosis and presentation delay
Doppler-US was requested for 126 patients (25%), more often in primary (17/71, 23.9%) and secondary facilities (103/301, 34.2%) than in the tertiary facility (6/133, 4.5%; P <0.001, Chi-Square). Doppler-US was less frequently requested when the first diagnosis was torsion (49/345, 14.2%; compared to epididymitis: 24/56, 42.9%; or other: 53/104, 51%; P <0.001, Chi-Square).
Globally, Doppler-US requests were associated with longer presentation delays (median 24.3 hours, IQR 5.8-74.2 versus median 7.6 hours, IQR 3.6-33.8; P <0.001, KW), a pattern reproduced at primary (median 27.3 hours, IQR 6.0-62.7 versus median 3.6 hours, IQR 2.1-15.0; P=0.006) and secondary level-of-care facilities (median 22.8 hours, IQR 5.8-71.9 versus 6.0 hours, IQR 2.9-25.6; P <0.001, KW). Longer - but not statistically significant-presentation delays were also associated with Doppler-US requests at the tertiary level (median 65.9 hours, IQR 9.3-126.8, versus 10.1 hours, IQR 5.7-61.9; P=0.128, KW).
Transfer time by first examining facility, first diagnosis, and Doppler-US
Transfer time was similar between primary and secondary facilities (median 5.7 hours, IQR 2.7-21.7 and 4.8 hours, IQR 2.1-22.5, respectively; P=0.276, KW). Transfer times diverged, however, considering first diagnosis: Median transfer time for patients diagnosed with torsion was 2.8 hours (IQR 1.8-5.7), compared to 37.9 hours (IQR 6.7-133.4; P <0.001, Dunn’s test) for epididymitis and 23.4 hours (IQR 5.9-69.7; P <0.001, Dunn’s test) for other diagnoses. Transfer time was longer when Doppler-US was requested, rising from median 3.5 hours (IQR 1.9-11.1), when not requested, to 10.5 hours (IQR 4.2-53.8), when requested (P <0.001, KW).
Testicular salvage by first examining facility, first diagnosis, and Doppler-US request
The testis was surgically salvaged in 233 patients (46.1%). Although salvage rates were similar across levels-of-care (primary: 30/71, 42.3%; secondary: 132/301, 43.9%; tertiary: 71/133, 53.4%; P=0.152, Chi-Square), rates differed regarding patient’s subsets presenting before 6 and 3 hours: In the former time frame, 35/37 (94.6%) patients first examined at the tertiary facility had their organs salvaged, compared to 24/39 (61.5%) first examined at primary and 100/131 (76.3%) first examined at secondary facilities (P=0.002, Chi-Square). Similar differences were observed in the subset of patients with presentation delay <3 hours, where all 11 patients first examined at the tertiary facility had their organs salvaged, contrasting with 18/25 (72%) and 50/65 (76.5%) in those first seen at primary and secondary facilities (P <0.001, Chi-Square).
Most patients first diagnosed with torsion had their organs salvaged (208/345, 60.3%), in contrast with those first diagnosed with epididymitis (6/56, 10.7%) or other (19/104, 18.3%; P <0.001, Chi-Square). Salvage rates for 160 patients first diagnosed with torsion and presentation delay <6 hours were 73.3%, 90.3% and 94.3% for those respectively seen at primary, secondary and tertiary facilities. In the subset of patients first diagnosed with testicular torsion with presentation delay <3 hours, Doppler-US was associated with significantly lower salvage rates: 28/126 (22.2%) organs were salvaged when Doppler-US was requested, compared to 205/378 (54.2%, P <0.001, Chi-Square) when it was not requested.
Bayesian regression of transfer time by Doppler-US and first diagnosis
Models were implemented for the whole dataset and patient’s subsets with presentation delay <6 and <3 hours, with 300.000 to 400.000 posterior distribution samples generated for each model. Testicular torsion misdiagnosis increased overall median transfer times by 53.2 hours (HPDI 46.1-60.3, Table-2 , Figure-3 ), an effect also observed in the <6 hours (median increase 43.5 hours) and in the <3 hours (median increase 40.2 hours) subsets. Doppler-US requests had negligible effects on transfer time once controlling for misdiagnosis.
Distribution of transfer times according to facilities´ level of care (1ary=primary, 2ary=secondary), first diagnosis (dx=torsion, dx=not torsion) and Doppler-US request computed from the Bayesian linear regression model. Horizontal axis, transfer time in hours; vertical axis, probability.
DISCUSSION
In this study, clinical misdiagnosis of testicular torsion at first examination, at either primary or secondary level-of-care facilities, was associated with large increases in inter-hospital transfer time. These long transfer times combined with even longer presentation delays to yield lowed an overall testicular salvage rate (46.1%). The highest salvage rates were observed among patients first examined at the tertiary facility shortly after symptoms.
Most of our patients (59%) were first examined after 6 hours of symptom’s onset. Presentation delay has been reported as the leading cause of organ loss in testicular torsion ( 2121. Nevo A, Mano R, Sivan B, Ben-Meir D. Missed Torsion of the Spermatic Cord: A Common yet Underreported Event. Urology. 2017;102:202-206. ), having been associated with low patient and parental awareness both of the disease and of its limited time frame for treatment. British researchers ( 1111. Ubee SS, Hopkinson V, Srirangam SJ. Parental perception of acute scrotal pain in children. Ann R Coll Surg Engl. 2014;96:618-20. ) found that only 30% of their patients sought medical attention within 6 hours of symptoms (46% presented after 12 hours), and 2/3 of those were incognizant that the disease could cause organ loss. Similarly, American investigators ( 1212. Friedman AA, Ahmed H, Gitlin J, Palmer LS. Lack of Parental Awareness in Testicular Torsion. J Urol. 2016; 195: e582. ) reported that only 1/3 of 479 parents surveyed in a Pediatric Urology clinic had some knowledge about the disease, and an Irish study ( 1313. Yap LC, Keenan R, Khan J, Cozman C, Dowling C, Cullen I, et al. Parental awareness of testicular torsion amongst Irish parents. World J Urol. 2018;36:1485-1488. ) uncovered that although 56% of parents knew about the disease, just 1/3 were aware of the time frame available for treatment.
Even if the patient rapidly seeks medical attention, the organ can still be lost if the first examining physician does not contemplate the diagnosis of testicular torsion. In our series, misdiagnosis was second only to presentation delay in determining the organ’s prognosis-especially in patients presenting before 6 hours of symptoms-by increasing median transfer time by more than a day on average. This influence of patient’s first diagnosis on transfer time remained even after accounting for Doppler-US in the regression model. Since the request for supplemental imaging studies must chronologically follow the patient’s first examination and initial diagnosis, this finding suggests that Doppler-US mainly acted as a mediator of the effects of first diagnosis on the outcome.
Difficulties with the differential diagnosis of acute testicular disease could be addressed by the dissemination of a predictive tool such as the Testicular Workup for Ischemia and Suspected Torsion (TWIST) score ( 2222. Barbosa JA, Tiseo BC, Barayan GA, Rosman BM, Torricelli FC, Passerotti CC, et al. Development and initial validation of a scoring system to diagnose testicular torsion in children. J Urol. 2013;189:1859-64. Erratum in: J Urol. 2014;192:619. , 2323. Barbosa JA, Denes FT, Nguyen HT. Testicular Torsion-Can We Improve the Management of Acute Scrotum? J Urol. 2016;195:1650-1. ), which attributes points to medical history and physical examination findings (testicular swelling=2, hardened testicle=2, cremasteric reflex absent=1, nausea/vomiting=1 and high-riding testis=1), with scores ≤2 representing low risk, 3-4 intermediate and >4 high risk for testicular torsion. Patients with high scores should be promptly operated, those with low scores should be followed, and further investigation would only be warranted for patients with intermediate scores ( 2424. Manohar CS, Gupta A, Keshavamurthy R, Shivalingaiah M, Sharanbasappa BR, Singh VK. Evaluation of Testicular Workup for Ischemia and Suspected Torsion score in patients presenting with acute scrotum. Urol Ann. 2018;10:20-23. ). Furthermore, the score has high positive and negative predictive values even when used by non-physicians ( 2525. Sheth KR, Keays M, Grimsby GM, Granberg CF, Menon VS, DaJusta DG, et al. Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score. J Urol. 2016;195:1870-6. ).
Inter-hospital transfer may further delay treatment, with repercussions on salvage rates. In our study, even patients with presentation delay <3 hours and correctly diagnosed at primary or secondary facilities had salvage rates 10% lower than those first presenting at the tertiary facility. These findings agree with Bayne’s ( 2626. Bayne AP, Madden-Fuentes RJ, Jones EA, Cisek LJ, Gonzales ET Jr, Reavis KM, et al. Factors associated with delayed treatment of acute testicular torsion-do demographics or interhospital transfer matter? J Urol. 2010;184(4 Suppl):1743-7. ), that reported a positive association between inter-hospital transfer and orchidectomy, especially in boys with presentation delay <24 hours. Likewise, Preece and associates ( 1414. Preece J, Ching C, Yackey K, Jayanthi V, McLeod D, Alpert S, et al. Indicators and outcomes of transfer to tertiary pediatric hospitals for patients with testicular torsion. J Pediatr Urol. 2017;13:388.e1-388.e6. ) found that patients transferred within 24 hours of symptoms to their tertiary hospital had twice the probability of testicular loss (30%, versus 15% for those first seen at their tertiary hospital). Although investigators from California ( 1515. Ramachandra P, Palazzi KL, Holmes NM, Marietti S. Factors influencing rate of testicular salvage in acute testicular torsion at a tertiary pediatric center. West J Emerg Med. 2015;16:190-4. ) described comparable salvage rates between patients transferred or examined at their tertiary hospital, the mean time from symptoms to operating room between them differed by only 83 minutes.
Our results show that there is much to improve in the care of our testicular torsion patients. Despite addressing the main cause of organ loss-long presentation delay-attempts to instruct the public about testicular torsion can be complex and expensive to implement, likely requiring large-scale information campaigns. Alternatively, educational efforts aimed at the medical community to increase knowledge about the disease and to improve its diagnosis could be less costly and produce faster results, as envisioned by Friedman and associates ( 2727. Friedman AA, Palmer LS, Maizels M, Bittman ME, Avarello JT. Pediatric acute scrotal pain: A guide to patient assessment and triage. J Pediatr Urol. 2016;12:72-5. ). These authors developed a Computer-Enhanced Visual Learning tool (accessible from the CEVL tab at www.jpurol.com) that reviews genital male anatomy and differential diagnosis of scrotal emergencies, supplemented with a testicular torsion likelihood calculator that uses as inputs easily obtainable clinical data (but not the TWIST score).
In our series, only patients that presented at the tertiary facility shortly after symptoms had salvage rates >90%, which we attribute to our experience with this disease. Yet, we could not help wondering about the possibility of reproducing these results at the secondary level-of-care, as testicular torsion’s diagnosis is eminently clinical and its surgical treatment is not complex. Matter-of-fact, it was often performed by general surgeons before the consolidation of urologic specialty ( 2828. Thorek M. Torsion of the spermatic cord: report of two cases with review of literature. Ann Surg. 1925;81:1142-9. ). Patients could also benefit from manual detorsion at the emergency setting, a time-tested maneuver ( 2929. Burkitt R. Torsion of Spermatic Cord: A Plea for Manipulative Reduction. Br Med J. 1956;2(4988):345. , 3030. Dias Filho AC, Oliveira Rodrigues R, Riccetto CL, Oliveira PG. Improving Organ Salvage in Testicular Torsion: Comparative Study of Patients Undergoing vs Not Undergoing Preoperative Manual Detorsion. J Urol. 2017;197(3 Pt 1):811-817. ) within reach of any physician. Already in the 1960s, Dr. Sparks, a medical officer working in the small English town of Rugby, demonstrated that this disease could be successfully treated at a lower level-of-care ( 3131. Sparks JP. Torsion of the testis. Ann R Coll Surg Engl. 1971;49:77-91. ). Dr. Sparks combined diagnostic shrewdness, ample use of manual detorsion and timely surgical exploration to salvage all but one testicle of his 15 testicular torsion patients-a commendable 93.4% salvage rate.
This study has many limitations. The main one, shared by all retrospective studies, is selection bias, since our database contained only surgically treated testicular torsion patients and did not provide means to identify those clinically treated for other acute scrotal diseases. Selection bias was manifested in the overall low proportion of Doppler-US requests, especially at the tertiary facility, where patients were first assessed by a team attentive to the recommendation to waive supplemental studies after testicular torsion was clinically diagnosed. Recall bias regarding presentation delay should also be considered, since information about symptom’s onset is patient/parent-provided, with inherent uncertainty that increases with time. Lastly, since our data comes from the smallest Brazilian state with the highest per capita income, further endowed with a structured public health network, we advise caution in generalizing our results.
CONCLUSIONS
In this large statewide case series, we observed that most testicular torsion patients first presented, after considerable delay, at primary or secondary level-of-care facilities, where they were often clinically misdiagnosed. Misdiagnosis led to the increase in inter-hospital transfer time, and the cumulative effect of these extended presentation delays and transfer times led to a low overall organ salvage rate.
This study provides relevant and previously unavailable contemporary information to apprise our medical - especially urological - communities to the real-world state-of-affairs of testicular torsion assessment and treatment at our public health care system. We hope that this study motivates other investigators to replicate our initiative, in order to provide a wider view of the current situation of testicular torsion care and determine where we should act to improve testicular torsion outcomes.
ACKNOWLEDGEMENT
Prof. Anna Maria Bouchardet Grebot revised the text for grammatical correctness.
ABBREVIATIONS
- Doppler-US Doppler-enhanced ultrasonography
- IQR Interquartile ratio
- HPDI Highest posterior density interval
- PROCESS Preferred Reporting of CasE Series in Surgery
REFERENCES
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1Chan JL, Knoll JM, Depowski PL, Williams RA, Schober JM. Mesorchial testicular torsion: case report and a review of the literature. Urology. 2009;73:83-6.
-
2Favorito LA, Cavalcante AG, Costa WS. Anatomic aspects of epididymis and tunica vaginalis in patients with testicular torsion. Int Braz J Urol. 2004;30:420-4.
-
3Baruga E, Guyton Munabi I. Case series on testicular torsion: an educational emergency for sub-Saharan Africa. Pan Afr Med J. 2013;14:18.
-
4Ugwumba FO, Okoh AD, Echetabu KN. Acute and intermittent testicular torsion: Analysis of presentation, management, and outcome in South East, Nigeria. Niger J Clin Pract. 2016;19:407-10.
-
5Ciftci AO, Senocak ME, Tanyel FC, Büyükpamukçu N. Clinical predictors for differential diagnosis of acute scrotum. Eur J Pediatr Surg. 2004;14:333-8.
-
6Moschouris H, Stamatiou K, Lampropoulou E, Kalikis D, Matsaidonis D. Imaging of the acute scrotum: is there a place for contrast-enhanced ultrasonography? Int Braz J Urol. 2009;35:692-702.
-
7Yagil Y, Naroditsky I, Milhem J, Leiba R, Leiderman M, Badaan S, et al. Role of Doppler ultrasonography in the triage of acute scrotum in the emergency department. J Ultrasound Med. 2010;29:11-21.
-
8Nicoletti RHA, Conselho Nacional de Secretários de Saúde (Brazil), Programa de Informação e Apoio Técnico às Equipes Gestoras Estaduais do SUS (Brazil). Assistência De Média E Alta Complexidade No SUS. Brasília: CONASS; 2007. Available at. < http://www.rebrats.saude.gov.br/>
» http://www.rebrats.saude.gov.br/ -
9Cattolica EV, Karol JB, Rankin KN, Klein RS. High testicular salvage rate in torsion of the spermatic cord. J Urol. 1982;128:66-8.
-
10Dias Filho AC, Alves JR, Buson Filho H, Oliveira PG de. The Amount of Spermatic Cord Rotation Magnifies the Time-Related Orchidectomy Risk in Intravaginal Testicular Torsion. Int Braz J Urol. 2016; 42: 1210-9.
-
11Ubee SS, Hopkinson V, Srirangam SJ. Parental perception of acute scrotal pain in children. Ann R Coll Surg Engl. 2014;96:618-20.
-
12Friedman AA, Ahmed H, Gitlin J, Palmer LS. Lack of Parental Awareness in Testicular Torsion. J Urol. 2016; 195: e582.
-
13Yap LC, Keenan R, Khan J, Cozman C, Dowling C, Cullen I, et al. Parental awareness of testicular torsion amongst Irish parents. World J Urol. 2018;36:1485-1488.
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14Preece J, Ching C, Yackey K, Jayanthi V, McLeod D, Alpert S, et al. Indicators and outcomes of transfer to tertiary pediatric hospitals for patients with testicular torsion. J Pediatr Urol. 2017;13:388.e1-388.e6.
-
15Ramachandra P, Palazzi KL, Holmes NM, Marietti S. Factors influencing rate of testicular salvage in acute testicular torsion at a tertiary pediatric center. West J Emerg Med. 2015;16:190-4.
-
16Bayne CE, Gomella PT, DiBianco JM, Davis TD, Pohl HG, Rushton HG. Testicular Torsion Presentation Trends before and after Pediatric Urology Subspecialty Certification. J Urol. 2017;197:507-15.
-
17R Core Team. R: A Language and Environment for Statistical Computing [Internet]. R Foundation for Statistical Computing; 2018. Available at. <https://cran.r-project.org/>
» https://cran.r-project.org/ -
18Plummer M. rjags: Bayesian Graphical Models using MCMC [Internet]. 2016. Available at. <https://CRAN.R-project.org/package=rjags>
» https://CRAN.R-project.org/package=rjags -
19Agha RA, Fowler AJ, Rajmohan S, Barai I, Orgill DP; PROCESS Group. Preferred reporting of case series in surgery; the PROCESS guidelines. Int J Surg. 2016;36(Pt A):319-323.
-
20Agha RA, Borrelli MR, Farwana R, Koshy K, Fowler AJ, Orgill DP; PROCESS Group. The PROCESS 2018 statement: Updating Consensus Preferred Reporting Of CasE Series in Surgery (PROCESS) guidelines. Int J Surg. 2018;60:279-282.
-
21Nevo A, Mano R, Sivan B, Ben-Meir D. Missed Torsion of the Spermatic Cord: A Common yet Underreported Event. Urology. 2017;102:202-206.
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Publication Dates
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Publication in this collection
11 Sept 2020 -
Date of issue
Nov-Dec 2020
History
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Received
19 Oct 2019 -
Accepted
02 Dec 2019 -
Published
20 Apr 2020