Is an emergent orchiectomy (surgical removal of a testicle) appropriate for testicular torsion?

Emergent Orchiectomy for Testicular Torsion

Emergent orchiectomy is appropriate for testicular torsion only when the testicle is clearly non-viable after detorsion, as salvage procedures should be attempted first in cases where viability is questionable. 1

Diagnosis and Management Algorithm

Initial Assessment

• Sudden-onset testicular pain
• High-riding testicle
• Absent cremasteric reflex
• Ultrasound with Doppler showing decreased or absent blood flow

Surgical Management

1. Immediate surgical exploration is the standard of care
2. Detorsion and assessment of testicular viability
3. Decision pathway:
   • If testicle appears viable after detorsion → orchiopexy
   • If testicle appears marginally viable → consider tunica albuginea decompression with tunica vaginalis flap coverage 2
   • If testicle is clearly non-viable (black/necrotic) → orchiectomy

Evidence for Salvage Attempts

Research shows that tunica albuginea incision with tunica vaginalis flap coverage can enhance salvageability after prolonged ischemia. In one study, this technique reduced orchiectomy rates from 35.9% to 15% 2. The procedure appears to address the compartment syndrome element of testicular torsion by decompressing the testicle.

Histopathological analysis of orchidectomy specimens has revealed that approximately 6% of removed testes had only low-grade injury that might have been salvageable 3. This suggests that appropriate intraoperative steps to check for reperfusion should be undertaken prior to proceeding with orchiectomy.

Factors Affecting Outcomes

Several factors influence the likelihood of testicular salvage:

• Duration of symptoms: The mean duration of torsion in cases requiring orchiectomy is significantly longer (67.5 hours) compared to successful orchiopexy cases (13.4 hours) 2
• Degree of torsion: Greater degrees of torsion correlate with higher orchiectomy rates, even among patients who present early 4
• Wait time to surgery: Longer wait times strongly correlate with orchiectomy rates 4

Common Pitfalls and Caveats

• Avoid premature decision for orchiectomy: After detorsion, allow adequate time (10-15 minutes) to assess for reperfusion before deciding on orchiectomy
• Consider salvage techniques: For marginally viable testes, tunica albuginea decompression should be considered before proceeding to orchiectomy 2
• Contralateral orchiopexy: Always perform contralateral orchiopexy as the bell clapper deformity is often bilateral
• Post-operative monitoring: Even salvaged testes may develop ischemic orchitis or atrophy, requiring follow-up

Long-term Considerations

• Testicular atrophy rates after salvage range from 9.1% to 47.5% 5
• Limited evidence exists regarding fertility outcomes after testicular torsion 5
• Patients should be counseled about the potential for decreased fertility even with successful salvage

In conclusion, while emergent orchiectomy is appropriate for clearly non-viable testes after testicular torsion, every effort should be made to salvage the testicle through detorsion and, if necessary, decompression techniques before proceeding to orchiectomy.