New insights into perinatal testicular torsion

Abstract

Perinatal testicular torsion is a relatively rare event that remains unrecognized in many patients or is suspected and treated accordingly only after an avoidable loss of time. The authors report their own experience with several patients, some of them quite atypical but instructive. Missed bilateral torsion is an issue, as are partial torsion, possible antenatal signs, and late presentation. These data are discussed together with the existing literature and may help shed new light on the natural course of testicular torsion and its treatment. The most important conclusion is that a much higher index of suspicion based on clinical findings is needed for timely detection of perinatal torsion. It is the authors' opinion that immediate surgery is mandatory not only in suspected bilateral torsions but also in cases of possible unilateral torsions. There is no place for a more fatalistic "wait-and-see" approach. Whenever possible, even necrotic testes should not be removed during surgery because some endocrine function may be retained.

Fig. 1

Normal situation as opposed to intravaginal torsion of cord structures and extravaginal testicular torsion where tunica vaginalis (and investing outer layers) are also involved

Fig. 2

Clear demonstration of the point of torsion in the spermatic cord: Cremasteric tissues, internal spermatic fascia, and tunica vaginalis all seem involved. The testis is still covered by tunica vaginalis

Fig. 3

A testicular remnant found during scrotal exploration for cryptorchidism, when several years have elapsed after PTT. Note the highest point of torsion, proximal to which (atrophic) vas and vessels can again be identified

Fig. 4

Typical laparoscopic image at the age of 5 of the internal inguinal rings in a patient with left-sided PTT. The black arrow indicates the vas crossing the iliac vessels and then ending blindly close to the closed internal inguinal ring (R), the level to which the torsion of the cord was transmitted. The white arrow shows the atrophic testicular vessels or their fibrotic remnants running toward the internal inguinal ring. Normal contralateral situation

Fig. 5

Scrotal appearance in asynchronous bilateral PTT as described in patient 5. Marked inflammation on the right side with the more recent torsion, only hardening of the left testis on palpation. Clinical underestimation of the severity is possible

Fig. 6

Appearance of both testes in patient 5 immediately after opening the scrotum: The hemorrhagic and necrotic right testis after opening of the tunica vaginalis is demonstrated. Avascular left testis, tunica vaginalis still intact but strongly adherent to the testis. Normal vascularity and no clear torsion of both spermatic cords