A BURST-BAUS consensus document for best practice in the conduct of scrotal exploration for suspected testicular torsion: the Finding consensus for orchIdopeXy In Torsion (FIX-IT) study

Abstract

Objectives: To produce a best practice consensus guideline for the conduct of scrotal exploration for suspected testicular torsion using formal consensus methodology.

Materials and methods: A panel of 16 expert urologists, representing adult, paediatric, general, and andrological urology used the RAND/UCLA Appropriateness Consensus Methodology to score a 184 statement pre-meeting questionnaire on the conduct of scrotal exploration for suspected testicular torsion. The collated responses were presented at a face-to-face online meeting and each item was rescored anonymously after a group discussion, facilitated by an independent chair with expertise in consensus methodology. Items were scored for agreement and consensus and the items scored with consensus were used to derive a set of best practice guidelines.

Results: Statements scored as with consensus increased from Round 1 (122/184, 66.3%) to Round 2 (149/200, 74.5%). Recommendations were generated in ten categories: consent, assessment under anaesthetic, initial incision, intraoperative decision making, fixation, medical photography, closure, operation note, logistics and follow-up after scrotal exploration. Our statements assume that the decision to operate has already been made. Key recommendations in the consent process included the discussion of the possibility of orchidectomy and the possibility of subsequent infection of the affected testis or wound requiring antibiotic therapy. If after the examination under anaesthesia, the index of suspicion of testicular torsion is lower than previously thought, then the surgeon should still proceed to scrotal exploration as planned. A flow chart guiding decision making dependent on intraoperative findings has been designed. If no torsion is present on exploration and the bell clapper deformity is absent, the testis should not be fixed. When fixing a testis using sutures, 3 or 4-point is acceptable and non-absorbable sutures are preferred.

Conclusions: We have produced consensus recommendations to inform best practice in the conduct of scrotal exploration for suspected testicular torsion.

Keywords: Fixation; Orchidopexy; Scrotal exploration; Surgical Technique; Testicular Torsion.

Fig. 1

Visual representation of possible scrotal incisions. Following Round 2, it was agreed that both cranio‐caudal median raphe and transverse incisions (over the testis of concern) are acceptable, but it is uncertain which is preferred. It was uncertain as to whether a cranio‐caudal paramedian incision is acceptable. [Colour figure can be viewed at wileyonlinelibrary.com]

Fig. 2

Flow chart for recommended decision making intra‐operatively, based on appearance of symptomatic testis. [Colour figure can be viewed at wileyonlinelibrary.com]

Fig. 3

Visual illustration of a normal testis vs a testis with a bell clapper deformity. In the bell clapper deformity, the tunica vaginalis (denoted by the purple line) does not attach normally to the epididymis to create a ‘mesentery’, thereby making it more prone to torsion. [Colour figure can be viewed at wileyonlinelibrary.com]

Fig. 4

Visual illustration of a sutureless fixation of the right testis within a Dartos pouch. [Colour figure can be viewed at wileyonlinelibrary.com]

Fig. 5

Visual illustration of a three‐point suture fixation of the right testis. [Colour figure can be viewed at wileyonlinelibrary.com]