Comparative analysis of detorsion alone versus detorsion and tunica albuginea decompression (fasciotomy) with tunica vaginalis flap coverage in the surgical management of prolonged testicular ischemia

Abstract

Purpose: Recent data suggest that testicular torsion may include an element of the compartment syndrome that improves with decompression. In 2009 we instituted tunica albuginea incision with tunica vaginalis flap coverage as an alternative in cases in which the torsed testis continued to appear ischemic after detorsion.

Materials and methods: The medical records of 65 boys who underwent scrotal exploration for testicular torsion between 2000 and 2010 were reviewed. There were 6 patients excluded from study due to lack of followup. Of the remaining 59 patients 31 (52.5%) showed improvement in testicular appearance after detorsion and underwent orchiopexy, whereas 28 (47.5%) did not show evidence of recovery after detorsion. Of these patients 11 underwent tunica albuginea incision with tunica vaginalis flap coverage and 17 underwent orchiectomy. Demographic data, duration of symptoms and rate of testicular salvage were analyzed.

Results: Mean patient age was 11.8 years (detorsion plus orchiopexy), 10.1 years (tunica albuginea incision plus tunica vaginalis flap coverage) and 10.1 years (detorsion plus orchiectomy). Average followup was greater than 6 months in all groups. Mean duration of torsion was 13.4 hours (detorsion plus orchiopexy), 31.2 hours (tunica albuginea incision plus tunica vaginalis flap coverage) and 67.5 hours (detorsion plus orchiectomy). Before tunica albuginea incision with tunica vaginalis flap coverage was offered, the rate of orchiectomy was 35.9% (14 of 39) vs 15% (3 of 20) after this technique was introduced (p <0.05). The rates of testicular salvage were 62.5% (detorsion plus orchiopexy), 54.6% (tunica albuginea incision plus tunica vaginalis flap coverage) and 0% (detorsion plus orchiectomy). Although the numbers are limited, it is likely that without tunica albuginea incision with tunica vaginalis flap coverage 6 of 11 testes would have been removed.

Conclusions: This preliminary experience suggests that tunica albuginea incision with tunica vaginalis flap coverage is a promising option for the management of clinically marginal torsed testes, enhancing salvageability after prolonged ischemia. We recommend considering this maneuver before performing orchiectomy in selected cases of testicular torsion.