How is three‑point fixation of the contralateral testis performed after detorsion of a torsed testis?

Three-Point Fixation Technique for Contralateral Testis After Testicular Torsion

The contralateral testis should be fixed using non-absorbable suture material (such as polypropylene 3-0 or 4-0) with three separate points of fixation, attaching the tunica albuginea to the dartos muscle at the superior pole, mid-portion, and inferior pole of the testis. 1

Surgical Technique

Suture Material Selection

• Use only non-absorbable sutures (polypropylene or similar permanent material) rather than absorbable sutures like chromic gut or polyglactin 1, 2
• Recommended suture size: 3-0 or 4-0 polypropylene 2
• Absorbable sutures have been associated with recurrent torsion events, even when polyglactin (Vicryl) was used 2, 3

Three-Point Fixation Method

The standard three-point fixation involves:

1. Superior pole fixation: Place first suture through tunica albuginea at upper pole, securing to dartos muscle 1
2. Mid-testicular fixation: Place second suture at the mid-portion of the testis to dartos 1
3. Inferior pole fixation: Place third suture at lower pole, anchoring tunica albuginea to dartos 1

Each suture should penetrate the tunica albuginea (the fibrous covering of the testis) and be secured to the dartos muscle layer of the scrotum 1

Enhanced Four-Point Fixation Alternative

Some surgeons advocate for four-point fixation as a more reliable method to prevent recurrence 4:

• This involves placing sutures at four equidistant points around the testis
• The additional fixation point may provide superior prevention of rotation 4

Critical Surgical Principles

Contralateral Exploration is Mandatory

• 95% of pediatric surgeons routinely fix the contralateral testis during the same operation 3
• The contralateral testis has the same anatomical predisposition (bell-clapper deformity) and is at risk for asynchronous torsion 5
• Failure to fix the contralateral side leaves the patient at significant risk 1

Additional Surgical Considerations

• Eversion of the tunica vaginalis may be performed in combination with suture fixation, though suture fixation alone is the primary method 3
• Excision of the appendix testis is performed routinely by 85% of surgeons to prevent future torsion of the appendage 3
• Some surgeons create a dartos pouch in addition to suture fixation, though this is not universally practiced 3

Common Pitfalls and How to Avoid Them

Inadequate Fixation Leading to Recurrence

• Recurrent torsion can occur even years after fixation (reported range: 0.5 to 23 years post-operatively) 2
• The most common cause of recurrence is improper or inadequate fixation 4
• Using only two points of fixation instead of three increases recurrence risk 1

Suture Material Errors

• Never use absorbable sutures - chromic gut and polyglactin have both been associated with recurrent torsion 1, 2, 3
• Even polypropylene sutures have rarely been associated with recurrence, emphasizing the importance of proper technique 2

Transseptal Fixation Should Be Avoided

• Transseptal fixation (fixing both testes together through the median raphe) has been associated with recurrent torsion 1
• Each testis should be fixed independently to its ipsilateral dartos muscle 1

Timing of Contralateral Fixation

The contralateral testis should be fixed during the same surgical session as the detorsion of the affected testis 3, 5:

• 95% of surgeons perform contralateral fixation at the time of initial surgery 3
• Delaying fixation exposes the patient to unnecessary risk of contralateral torsion 5
• In postpubertal patients, a patient-based approach may occasionally defer fixation, but this is not standard practice 6

Awareness of Recurrence Risk

Despite proper fixation with non-absorbable sutures and appropriate technique:

• Recurrent torsion remains possible, though rare 2
• 17% of surveyed pediatric surgeons have operated on a previously fixed testis that subsequently torsed 3
• Patients and families should be counseled that fixation significantly reduces but does not completely eliminate torsion risk 2
• Any acute scrotal pain in a patient with previous orchiopexy should be evaluated urgently, as recurrence is possible 1, 2