What is the appropriate time to perform surgery for a pediatric patient with testicular torsion, characterized by a tender and edematous cord?

Surgical Timing for Pediatric Testicular Torsion

Surgery must be performed within 6 hours of symptom onset (Option A) to maximize testicular salvage and prevent permanent ischemic damage. 1

Critical Time Window

The 6-8 hour window is the definitive threshold for testicular viability. The American College of Radiology explicitly states that testicular viability may be compromised if not treated promptly within 6-8 hours of symptom onset, and surgical outcomes are significantly better when surgery occurs within this timeframe 1. This represents the critical ischemic threshold before permanent damage occurs.

Evidence-Based Surgical Timing

Optimal Window (<6 hours)

• Immediate surgical exploration and detorsion should be performed within 6-8 hours to prevent permanent ischemic damage 1
• The optimal time frame for treatment is less than 6 hours after symptom onset 2
• Testis-sparing surgery is most valuable for cases with onset time <12 hours, with only a 9.1% orchiectomy rate in this group 3

Declining Salvage Rates Beyond 6 Hours

• At 12-24 hours: orchiectomy rate increases dramatically to 47.4%, with postoperative testicular atrophy occurring in 25% of salvaged testicles 3
• Between 6-12 hours, orchiectomy was required in 17% of patients 4
• Beyond 24 hours: orchiectomy rate reaches 92.4%, with testicular atrophy in 83.3% of attempted salvages 3

Clinical Decision Algorithm

Do not wait for 12 or 24 hours—this is a surgical emergency requiring immediate intervention:

1. Immediate urological consultation upon clinical suspicion 1
2. Surgical exploration as soon as possible, ideally <6 hours from symptom onset 1, 2
3. Intraoperative assessment determines orchiopexy vs. orchiectomy 1
4. Prophylactic contralateral orchiopexy during same procedure 2

Critical Pitfalls to Avoid

• Do not delay surgery waiting for imaging if clinical suspicion is high—the American College of Radiology recommends immediate specialist consultation 1
• Do not use symptom duration as the sole determinant of viability—retrospective analysis shows that duration is not an absolute indicator of testicular damage, with some testicles salvageable even beyond 12 hours 5
• However, statistically, every hour of delay significantly reduces salvage probability, so the 6-hour window remains the evidence-based standard 1, 3

Supporting Evidence on Degree of Torsion

• Complete torsion >450 degrees results in absent arterial and venous flow 1
• Among patients who waited less than the median time to surgery, those requiring orchiectomy had greater degrees of torsion 6
• The combination of time and degree of torsion determines outcome, but time is the modifiable factor 6

The answer is A: 6 hours. Waiting 12 or 24 hours dramatically increases the risk of testicular loss and compromises both immediate surgical outcomes and long-term testicular function 1, 3.