What is the recommended treatment for a young male patient presenting with acute onset of severe testicular pain suspected to be testicular torsion?

Open Book Technique for Testicular Torsion

Surgical Approach

The open book technique involves a midline scrotal incision with bilateral scrotal exploration, detorsion of the affected testis, assessment of viability, and bilateral orchiopexy to prevent future torsion on either side. 1

Immediate Surgical Indications

• Surgical exploration and detorsion must occur within 6-8 hours of symptom onset to prevent permanent ischemic damage and testicular loss. 1, 2
• When clinical suspicion for testicular torsion is high, proceed directly to surgical exploration without delaying for imaging studies. 1
• The salvage rate depends critically on the duration of ischemia, with optimal outcomes when surgery occurs within 6 hours. 1, 3, 4

Surgical Technique Components

Incision approach: A midline scrotal incision allows access to both testicles through a single incision, facilitating the "open book" bilateral exploration. 1

Detorsion procedure: After exposing the affected testis, manually untwist the spermatic cord to restore blood flow. 1, 3

Viability assessment: Following detorsion, assess testicular viability by observing color change, tissue turgor, and evidence of reperfusion. 1

Bilateral orchiopexy: Fix both testicles to prevent recurrence, as the bell-clapper deformity (present in 82% of intermittent torsion cases) affects both sides. 1

Critical Surgical Considerations

• The contralateral testis must be fixed during the same operation because the anatomical predisposition (bell-clapper deformity) is bilateral in nature. 1
• No single orchiopexy technique has proven superior in preventing retorsion, though all studied techniques showed 0% ipsilateral retorsion rates in available literature. 5
• Surgical complications are uncommon but may include scrotal abscess (9.1%) and stitch abscess (4.5%). 5

Post-Operative Management

• Bed rest, scrotal elevation, and analgesics should continue until inflammation subsides. 1
• Testicular atrophy rates range from 9.1% to 47.5% even after successful detorsion, depending on ischemia duration. 5
• Follow-up assessment is necessary to monitor for atrophy and long-term complications. 1

Common Pitfalls to Avoid

• Never delay surgery for imaging when clinical suspicion is high - testicular viability is time-dependent, and imaging adds no value when torsion is clinically evident. 1, 4
• Do not rely solely on ultrasound findings, as false-negative Doppler evaluations occur in 30% or more of cases, particularly with partial torsion. 1
• Failing to perform bilateral orchiopexy leaves the contralateral testis at risk for future torsion. 1
• The 6-8 hour window is not absolute - earlier intervention always improves outcomes, and surgery should not be delayed even if this window has passed. 1, 4