Surgical Exploration

Manual detorsion

According to the current guidelines of the European Society for Paediatric Urology (ESPU) and the American Association of Pediatric Urologists (AAPU) in some cases of testicular torsion, manually untwisting the spermatic cord may allow reestablishment of vascular flow (Level of evidence: 3; Grade of recommendation: C).

The technique involves manipulating the involved testis so that the anterior surface rotates from medial to lateral. This is termed the "open book" method because the motion resembles opening the cover of a book (for a right testis). However testicular torsion does not always occur in a uniform direction.

When successful, this maneuver almost immediately relieves pain in most patients. Manual detorsion is best performed with the intention of buying time until the surgical team is ready, rather than with the intention of altogether avoiding a surgical procedure.

In actuality, manual detorsion is difficult and rarely used. Application of this maneuver in an emergency department setting in a child with a swollen painful scrotum can be difficult or impossible without anesthesia. Furthermore, the testis may not be fully detorsed or may retorse shortly after the patient leaves the hospital. In addition, knowing which way the testis is torsed a priori is impossible; thus, attempting detorsion may simply worsen the degree of torsion.

Manual detorsion may play a role in decreasing the degree of ischemia when a substantial delay in reaching the operating room is anticipated, but it is not a substitute for exploration and fixation.

When testicular torsion cannot be excluded, exploration is warranted!

Early surgical intervention with detorsion (mean torsion time < 13 hours) was found to preserve fertility. Urgent surgical exploration is mandatory in all cases of testicular torsion within 24 hours of the onset of symptoms.

In those patients with testicular torsion of more than 24 hours, semi-elective exploration is necessary (Level of evidence: 3; Grade of recommendation: C).

Exploration can involve paramedian scrotal incision, transverse incision, or single midline scrotal incision. Some surgeons prefer to explore the acute scrotum through an inguinal incision, based on the theory that this approach offers better control of the high spermatic cord if the exploration reveals an unexpected diagnosis (eg, testis tumor, incarcerated hernia).

It may be difficult to intraoperatively determine whether a testis of marginal viability should be retained or excised. The affected testicle is inspected, detorsed, and placed in a warm sponge. Up to 30 minutes observation is acceptable.

If doubt remains regarding viability, the testis is incised to determine the presence of bleeding. The flow of the tunica may be restored to some extent while the parenchyma remains underperfused. Debate ranges regarding the treatment of marginally viable testicle. If atrophy or hypoplasia ensue, the testicle is removed.

Testicular ischemia disrupts the blood-testis barrier, which may result in autoimmunization against spermatozoa and formation of antisperm antibodies; this may affect sperm produced by both testes.

However, both spermatogenesis and the blood-testis barrier are established after age 10 years; thus, some surgeons always retain the doubtful testis in children younger than 10 years.

There is no common recommendation about the preferred type of fixation and suture material; however, many urologists currently use a Dartos pouch orchiopexy (2-3 sutures are passed through the dartos and tunica albuginea of the testicle). Some surgeons avoid placing sutures directly into the tunica albuginea out of concern for disrupting the blood-testis barrier; instead, they place the sutures into the visceral tunica vaginalis of the mesorchium.

Although torsion of the contralateral testis is extremely rare, many clinicians, fueled by fear of litigation, have become more aggressive with surgical exploration to fix the contralateral side and prevent future torsion. This is an area of considerable controversy!

Notwithstanding according to the current guidelines of the European Society for Paediatric Urology if torsion is confirmed, contralateral orchiopexy is recommended. This should not be done as an elective procedure, but rather immediately following detorsion.

Recurrence after orchiopexy is rare and may occur several years after operation.

Дата добавления: 2014-10-15