What is the appropriate time to perform surgery for a male patient of reproductive age with suspected testicular torsion, presenting with a tender and edematous spermatic cord?

Surgical Timing for Suspected Testicular Torsion

Surgery must be performed within 6 hours of symptom onset to maximize testicular salvage, making option A (within 6 hours) the correct answer. 1

Critical Time Window

The American College of Radiology establishes that surgical exploration and detorsion must occur within 6-8 hours of symptom onset to prevent permanent ischemic damage and testicular loss. 1 This represents the critical threshold where testicular viability begins to decline precipitously.

Testicular Salvage Rates by Time Interval

The evidence demonstrates a clear time-dependent relationship with outcomes:

• 0-6 hours: 97.2% salvage rate, with 100% salvage documented when detorsion performed within this window 2, 3
• 7-12 hours: 79.3% salvage rate, dropping to only 50% when symptoms exceed 6 hours 2, 3
• 13-24 hours: 42.5-61.3% salvage rate 3
• Beyond 24 hours: 18.1% salvage rate 3

Three-quarters of patients operated within 6 hours from symptom onset had testicular torsion, and all testicles were saved when detorsion was performed within this timeframe. 2

Clinical Decision Algorithm

When a patient presents with tender, edematous spermatic cord and suspected testicular torsion:

1. Immediate urological consultation - Do not delay for imaging if clinical suspicion is high 1

2. Proceed directly to surgical exploration within 6 hours - The American College of Radiology emphasizes that surgical outcomes are significantly better when surgery occurs within this window, and imaging should never delay surgical exploration when clinical suspicion is high 1

3. Accept that imaging has limitations - Color Doppler ultrasound sensitivity ranges only 69-96.8%, with false-negative rates up to 30%, particularly with partial torsion 1

Critical Pitfalls to Avoid

Do not wait for imaging confirmation if clinical presentation is consistent with torsion. 1 The physical examination findings of tender, edematous spermatic cord in the appropriate clinical context (acute onset severe pain, high-riding testicle, absent cremasteric reflex) warrant immediate surgical exploration. 4

Do not be falsely reassured by the 12-hour or 24-hour windows mentioned in some literature. 1 While some testicular salvage is possible beyond 6 hours, the salvage rate drops dramatically from 97.2% to 79.3% after 6 hours, and fertility outcomes worsen significantly. 3

The American College of Radiology specifically states that any delay in surgical intervention increases the risk of testicular loss and compromises salvage rates. 1

Why Not 12 or 24 Hours?

While the American College of Radiology mentions that "surgical outcomes are better when surgery occurs within 12 hours," 1 this represents an outer limit, not an optimal target. The dramatic decline in salvage rates after 6 hours (from 97.2% to 79.3%) makes the 6-hour window the appropriate clinical target. 2, 3

The correct answer is A: Within 6 hours. 1, 2