Treatment

Manual detorsion of testicular torsion was first described by Nash [24]. Van der Poel later reported a 25-year-old physician suffering recurrent testicular torsion who managed himself manual testicular detorsion successfully [91]. Adequate intravenous sedation or spermatic cord block may be necessary. The torsed testis usually twists from the medial to lateral side. This procedure is probably possible in early salvageable cases only [1, 16].

The aim of the surgical intervention is to restore the blood flow to the testis as soon as possible after the onset of symptoms. Once the diagnosis has been established, during exploration, the clinician faces the dilemma of whether to remove a testicle whose viability seems questionable and, in the absence of objective criteria, can only rely upon their own empirical experience. This decision is usually taken during surgical exploration, and the problem resides in the fact that no objective criteria exist to assess testicular viability [55]. Thus, surgery for torsion should occur immediately to minimize I/R injury and oxidative stress. Testicular salvage is estimated at 90% if detorsion occurs less than 6 h from the onset of symptoms, but it decreases to 50% after 12 h and to less than 10% after 24 h. Orchidectomy may be required if the testicle is necrotic, nonviable and perfusion not observed. Orchidopexy is performed on the affected testes and the contralateral testis (as a preventive measure) if the testes are found to be viable and perfusion is reestablished. Orchidopexy involves suturing the tunica albuginea to the dartos muscle using nonabsorbable sutures. Fixation may be one-, two-, three-, or four-points [16, 31, 54, 87, 92-96],

Based on experimental animal models, the mode of surgery plays an important role in the respect of the fate of the contralateral testis. However, clinical studies' data comparing testicular function after orchidectomy and detorsion and orchi-dopexy are still uncertain [87]. It has been suggested that, after a prolonged period of torsion, preserving surgery of the affected testis is even more harmful to the contralateral testis when compared to orchidectomy of affected testis [7]. On the other hand, in another study, Cimador et al. [55] speculated that as for the diagnosis and therapy of testicular torsion, there is no one history, physical, laboratory, or radiological finding that might predict testicular salvageability which can only be determined at surgical exploration.

Anderson et al. [97] evaluated 16 patients with regard to semen quality, endocrine parameters, and the presence or absence of semen antisperm antibodies. Nine testicular torsion patients were treated with detorsion and bilateral orchidopexy and seven were treated with ipsilateral orchidectomy and contralateral orchidopexy. Their study demonstrated that testicular injury (changes in semen quality and/or serum FSH, luteinizing hormone and testosterone) was occurred in the bilateral testis, regardless of treatment modality. However, with early intervention by detorsion and testicular salvage, subsequent semen quality remained within normal limits. Late surgical intervention, even with removal of the necrotic testis, resulted in significant impairment of semen quality.

Ichikawa et al. [98] evaluated 24 patients following spermatic cord torsion for semen quality and endocrine parameters after spermatic cord torsion. Of patients, 12 were treated with bilateral orchiodopexy, and 12 were treated with ipsilateral orchidectomy and contralateral orchidopexy. The average sperm density and the average total sperm count in the orchidectomy group were significantly lower than those in the orchidopexy group. The mean serum FSH level in the orchidectomy group was significantly higher than that in the orchidopexy group. These results suggested a significant decrease in testicular function in the orchidectomy group. All the patients in the orchidopexy group demonstrated a normal semen quality and endocrine parameters during follow-up. Four of the eight patients in the orchidec-tomy group whose duration of follow-up was more than 2 years still demonstrated oligozoospermia. The average age at operation of these four patients with abnormal semen quality was significantly higher than that of the other four patients with normal semen quality, whereas no significant difference in duration of torsion preceding surgical therapy was observed between these two groups. These findings suggested that subsequent semen quality remained within normal limits with early surgical treatment by bilateral orchidopexy. Ipsilateral orchidectomy was occurred less damage of the contralateral testis in the younger generation than in the older generation.

Arap et al. [57] analyzed the records of 24 patients who underwent surgical treatment (group I: orchidectomy + contralateral orchidopexy and group II: detor-sion+bilateral orchidopexy) for testicular torsion. All patients were assessed by semen analysis, endocrine profile (levels of follicle-stimulating hormone FSH, luteinizing hormone, and testosterone), and seminal antisperm antibody levels. Median ischemia time in group 1 (48 h) was significantly higher than in group II (7 h). The investigators reported that patients treated for testicular torsion show mainly morphologic semen abnormalities and endocrine profiles within the normal range. Testicular fate did not have any correlation with the formation of antisperm antibodies. In addition, no significant correlation was found between antisperm antibody levels and age at torsion, ischemia time, seminal parameters, or surgical treatment type. Patients treated with orchidectomy presented better motility and morphology compared with the detorsion group. These results demonstrated that the maintenance of a severely ischemic testicle may impair seminal parameters; thus, the best procedure is to remove the affected testis.

In the other retrospective study, Taskinen et al. [87] investigated 17 patients operated on for testicular torsion. Testicular volume, serum FSH, testosterone, and inhibin B levels were measured early (median 36 days) and/or late (median 1.1 years) after operation. One third of patients with testicular torsion were found to have a reduced fertility potential according to serum FSH and inhibin B levels. It seems that the fertility prognosis is better after testis preservation than after orchi-dectomy if the testis is not obviously necrotic. Surprisingly, the onset of symptoms does not necessarily cause complete testicular atrophy and sometimes the testis can survive despite a long history of symptoms. In addition, preserving surgery can also sometimes be attempted after delayed diagnosis.

Shafik et al. [99] applied to transcutaneous electro-orchidogram in eight patients with testicular torsion. Slow waves were absent during torsion and after detorsion in seven patients. Semen analysis was done 1, 3, and 6 months after detorsion. Slow waves and semen normalized in one patient 6 months after detorsion, but semen analysis was not performed in the acute stage of the disease as the patients could not tolerate this test. Authors suggested that the electro-orchidogram might be an investigative tool in the diagnosis and follow-up testicular torsion, thus further investigations are needed to determine long-term effects of this tools.

Baker et al. [100] reported a case of missed bilateral testicular torsion with resulting primary testicular failure and hypogonadism with erectile dysfunction. The patient was seen for infertility and erectile dysfunction 10 years after the testicular torsion, semen analysis revealed azoospermia, serum total testosterone was at the castration level, and his infertility was irreversible. His erectile dysfunction was managed successfully with testosterone replacement and sildenafil therapy.

In another study, 25 patients were reexamined 1-12 years after the surgery. Age of torsion, duration of symptoms, and operative findings were reevaluated. It has been speculated that results of testicular atrophy correlated with duration of symptoms and operative findings. In all patients of surgical detorsion in which torsion lasted more than 24 h and testicular viability was questionable, subsequent atrophy was rule [101].

Moreover, it has been reported that hypothermia induced by the application of ice packs probably delays the production of oxygen-free radicals and conserves cellular energy sources and decrease oxygen consumption following testicular torsion/detorsion in rats, which in turn can inhibit lipid peroxidation and increase the survivability of the torsional testis [ 15, 102-107]. Another similar surgical approach to decrease reperfusion injury is ischemic pre- and postconditioning, which is a variation of controlled reperfusion. It is a simple method that provides a new tool to protect testes against I/R injury [108-113]. Nevertheless, Taneli et al. [114] didn't find effective mesh bioprosthesis. Woodruff et al. [115] suggested that the use of cryopreservation must always be offered to these patients regardless of the situation, even after surgery and possibly if patient becomes anorchic.

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