What are the chances of saving the testicle in a 2-month-old with perinatal testicular torsion?

Chances of Saving the Testicle in a 2-Month-Old with Perinatal Testicular Torsion

The chances of saving a testicle in a 2-month-old with perinatal testicular torsion are extremely low, with salvage rates of approximately 40% at best when immediate surgical intervention occurs, and much lower when the torsion has been present for some time. 1

Understanding Perinatal Testicular Torsion

• Perinatal testicular torsion (PTT) is primarily caused by an extravaginal twisting of the spermatic cord that often occurs prenatally or perinatally, compromising blood flow to the testicle 2
• PTT is relatively uncommon, accounting for approximately 10% of all testicular torsion cases in children 2
• The incidence is estimated at 6.1 per 100,000 live births, though the true incidence is likely higher due to underdiagnosis 3

Diagnostic Considerations

• Ultrasound is the primary diagnostic tool for PTT, with findings typically showing:
  • Heterogeneous echotexture and possible calcifications in prenatal torsion
  • An enlarged, hypoechoic or heterogeneous testicle
  • The "whirlpool sign" (spiral twist of the spermatic cord) which is the most specific ultrasound sign of torsion 2
• Physical examination may reveal scrotal erythema, swelling, and possible hydrocele 4
• Doppler ultrasound should be performed promptly but should not delay surgical intervention 5

Factors Affecting Salvageability

• Time is the most critical factor in testicular salvage:
  • Surgical exploration within 6-8 hours of symptom onset is essential to prevent testicular loss in cases of acute torsion 2, 6
  • At 2 months of age, the torsion has likely been present since birth or before, significantly reducing salvage chances
• The degree of torsion and duration of ischemia directly impact salvage rates 2
• In one study of neonates under 30 days with extravaginal testicular torsion, only 40% of testes were salvageable even with immediate surgical intervention 1

Management Approach

• Immediate surgical exploration is recommended when testicular torsion is suspected in an infant 2, 7
• Non-operative maneuvers to detorse the testicle are not recommended in PTT 3
• Bilateral scrotal exploration is recommended due to the risk of asynchronous bilateral torsion (reported in approximately 3% of cases) 5
• Even when the affected testicle cannot be saved, contralateral orchiopexy is essential to prevent future torsion of the remaining testicle 7, 5

Outcomes and Follow-up

• Most cases of PTT result in testicular loss, with one study showing 63 out of 64 affected testicles were either removed or found to be non-functional 5
• Compensatory hypertrophy of the remaining testicle was observed in 38% of patients 5
• When a testicle is salvaged, follow-up examination at 6 months is important to assess viability and growth 1
• Even when the testicle appears nonviable, some endocrine function may be retained, suggesting preservation when possible 7

Pitfalls and Caveats

• Delaying surgery in hopes of spontaneous resolution is not recommended as it significantly reduces any chance of salvage 7
• PTT can be asymptomatic and missed on initial newborn examination 3
• The risk of asynchronous bilateral torsion, though rare, must be considered as it could lead to anorchia 4
• Ultrasound findings may not always correlate with actual testicular viability - one study found a potentially viable testis by pathology despite ultrasonography showing no flow 1