title: Parenchymal echo texture predicts testicular salvage after torsion: potential impact on the need for emergent exploration.
abstract: OBJECTIVE
  In the setting of signs and symptoms of testicular torsion the absence of diastolic flow and/or color flow on Doppler ultrasound has traditionally prompted emergent scrotal exploration. This practice emanates largely from the difficulty on ultrasound of distinguishing salvageable torsed testes from those that are not salvageable. We identified ultrasound findings predictive of testicular viability or the lack thereof.
  
  
  METHODS
  We retrospectively reviewed the charts of all boys who underwent scrotal exploration for signs and symptoms of torsion during a 4-year period. In those who underwent preoperative Doppler ultrasound of the scrotum ultrasound findings were reviewed, as were the operative dictations. In patients who underwent orchiectomy the pathology reports were also reviewed. In patients in whom the torsed testis appeared viable and who underwent orchiopexy followup data were reviewed when available. Emergency room charts were also reviewed to ascertain, when documented, the duration of pain before presentation to the emergency room and the interval between ultrasound and operating room.
  
  
  RESULTS
  During this period 55 boys underwent exploration after preoperative scrotal Doppler ultrasound revealed absent diastolic flow and/or color flow Doppler in the symptomatic testis. Assessment of parenchymal echogenicity revealed heterogeneity in 37 testes (67%), of which none were deemed viable at exploration. Orchiectomy was performed in 34 of 37 cases. Pathological examination revealed necrosis in all 34 cases, a finding consistent with late torsion. The remaining 3 testes underwent orchiopexy by parental directive despite nonviability, as confirmed by biopsy and subsequent atrophy. Thus, heterogeneity on preoperative ultrasound was universally predictive of organ loss (chi-square p <0.001). Of the 18 symptomatic testes (33%) demonstrating homogeneity and isoechogenicity on ultrasound 16 (89%) were deemed viable at exploration. Boys in whom the torsed testicle was nonviable on exploration experienced an average of 27.5 hours of pain preoperatively (range 5 to 72), whereas boys in whom the torsed testis was salvaged experienced an average of 20.5 hours of pain (range 2 to 96) (p = 0.073). The nonviable group underwent surgery an average of 49 minutes after ultrasound, whereas the viable group underwent surgery 52 minutes after ultrasound (p = 0.92). None of the 55 patients experienced any surgical or anesthetic complications and no pathological condition was noted intraoperatively in the contralateral asymptomatic testis.
  
  
  CONCLUSIONS
  In the setting of Doppler proven testicular torsion heterogeneous parenchymal echo texture indicates late torsion and testicular nonviability. Therefore, the case may not require emergent scrotal exploration. On the other hand, homogeneous echo texture portends extremely well for testicular viability. Thus, such testes should be explored emergently.
authors: Division of Pediatric Urology, Schneider Children's Hospital, North Shore-Long Island Jewish Health System, Long Island, New York, USA.
authors: Jonathan D
authors: JD
authors: Kaye
authors: Edan Y
authors: EY
authors: Shapiro
authors: Selwyn B
authors: SB
authors: Levitt
authors: Steven C
authors: SC
authors: Friedman
authors: Jordan
authors: J
authors: Gitlin
authors: Jaime
authors: J
authors: Freyle
authors: Lane S
authors: LS
authors: Palmer
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D004638:Emergency Treatment; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009919:Orchiectomy; D012189:Retrospective Studies; D013086:Spermatic Cord Torsion / Q000000981:diagnostic imaging*; D013737:Testis / Q000000981:diagnostic imaging*; D018608:Ultrasonography, Doppler