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European Urology Focus Nov 2021Acute testicular torsion is a common urological emergency. Accepted practice is surgical exploration, detorsion, and orchidopexy for a salvageable testis. (Review)
Review
CONTEXT
Acute testicular torsion is a common urological emergency. Accepted practice is surgical exploration, detorsion, and orchidopexy for a salvageable testis.
OBJECTIVE
To critically evaluate the methods of orchidopexy and their outcomes with a view to determining the optimal surgical technique.
EVIDENCE ACQUISITION
This review protocol was published via PROSPERO [CRD42016043165] and conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). EMBASE, MEDLINE, and CENTRAL databases were searched using the following terms: "orchidopexy", "fixation", "exploration", "torsion", "scrotum", and variants. Article screening was performed by two reviewers independently. The primary outcome was retorsion rate of the ipsilateral testis following orchidopexy. Secondary outcomes included testicular atrophy and fertility.
EVIDENCE SYNTHESIS
To our knowledge, this is the first systematic review on this topic. The search yielded 2257 abstracts. Five studies (n = 138 patients) were included. All five techniques differed in incision and/or type of suture and/or point(s) of fixation. Postoperative complications were reported in one study, and included scrotal abscess in 9.1% and stitch abscess in 4.5%. The contralateral testis was fixed in 57.6% of cases. Three studies reported follow-up duration (range 6-31 wk). No study reported any episodes of ipsilateral retorsion. In the studies reporting ipsilateral atrophy rate, this ranged from 9.1% to 47.5%. Fertility outcomes and patient-reported outcome measures were not reported in any studies.
CONCLUSIONS
There is limited evidence in favour of any one surgical technique for acute testicular torsion. During the consent process for scrotal exploration, uncertainties in long-term harms should be discussed. This review highlights the need for an interim consensus on surgical approach until robust studies examining the effects of an operative approach on clinical and fertility outcomes are available.
PATIENT SUMMARY
Twisting of blood supply to the testis, termed testicular torsion, is a urological emergency. Testicular torsion is treated using an operation to untwist the cord that contains the blood vessels. If the testis is still salvageable, surgery can be performed to prevent further torsion. The method that is used to prevent further torsion varies. We reviewed the literature to assess the outcomes of using various surgical techniques to fix the twisting of the testis. Our review shows that there is limited evidence in favour of any one technique.
Topics: Abscess; Atrophy; Humans; Male; Orchiopexy; Spermatic Cord Torsion; Testis
PubMed: 32863201
DOI: 10.1016/j.euf.2020.07.006 -
Sexual Medicine Reviews Apr 2018Post-vasectomy pain syndrome (PVPS) is a challenging problem for the practicing urologist because of its unclear pathophysiology and no clearly established protocol for...
INTRODUCTION
Post-vasectomy pain syndrome (PVPS) is a challenging problem for the practicing urologist because of its unclear pathophysiology and no clearly established protocol for evaluation or treatment. PVPS is defined as at least 3 months of chronic or intermittent scrotal content pain after a vasectomy procedure once other etiologies for the pain have been ruled out.
AIM
To systematically review the current literature on the effectiveness of micro-denervation of the spermatic cord (MDSC) for PVPS.
METHODS
A systematic literature search using PubMed, Scopus, Medline, Embase, and Cochrane databases for all reports pertaining to PVPS using the Medical Subject Heading terms post vasectomy pain syndrome and micro-denervation of spermatic cord through February 2017.
MAIN OUTCOME MEASURES
Scrotal content pain after MDSC for PVPS.
RESULTS
There were nine retrospective studies evaluating MDSC for chronic testicular pain. After omitting repeated series, there were 213 patients who underwent MDSC for chronic orchialgia. Only one study specifically reviewed the outcomes of patients who underwent MDSC for PVPS. In this study, 17 patients underwent MSDC for PVPS, with 13 (76.5%) reporting complete relief of pain at their first follow-up visit. The other four patients had significant improvement in pain and were satisfied with the results. Long-term follow-up data were not available for this study.
CONCLUSION
MDSC remains a valuable approach with high success rates and should be considered for PVPS that is refractory to medical therapy. MDSC appears to have the most success for patients who experience a temporary relief from a cord block and can significantly improve the patient's quality of life and ability to return to daily activities. Tan WP, Levine LA. Micro-Denervation of the Spermatic Cord for Post-Vasectomy Pain Management. Sex Med Rev 2018;6:328-334.
Topics: Adult; Denervation; Humans; Male; Microsurgery; Middle Aged; Pain Management; Pain, Postoperative; Spermatic Cord; Vasectomy
PubMed: 28735684
DOI: 10.1016/j.sxmr.2017.06.002 -
Urology Research & Practice Sep 2023Scrotal tumors of nerve origin are extremely rare and occur mostly in the extratesticular tissues of scrotum, such as the spermatic cord and epididymis. A systematic...
Scrotal tumors of nerve origin are extremely rare and occur mostly in the extratesticular tissues of scrotum, such as the spermatic cord and epididymis. A systematic search of the literature in PubMed, Medline, and Google Scholar databases concerning intrascrotal nerve tumors was performed by 2 independent investigators. The systematic search retrieved 45 male adults, with a mean age of included patients at 43.9 ± 18.8 years. The majority of nerve tumors were extra-testicular (86.7%), and only 13.3% originated from the testis. Out of that, 51.1% of neoplasms were histologically proved as schwannomas, 44.4% as neurofibromatosis, and 4.4% as malignant peripheral nerve sheath tumors. The majority of patients presented with atypical symptoms such as scrotal swelling (51.1%), while only 4.4% of patients were asymptomatic. Ultrasonography is the diagnostic modality of choice (97.2%) for the detection of primary lesion, while magnetic resonance imaging and computed tomography comprise supplementary diagnostic tools. Surgical excision of the mass was the preferred type of surgery performed (75.6%), whereas orchiectomy was performed only in 22.2% of patients. Intrascrotal tumors of nerve origin are extremely rare neoplasms that present mainly in middle-aged males. Increased clinical suspicion is required for accurate diagnosis of this rare entity.
PubMed: 37877874
DOI: 10.5152/tud.2023.23050 -
Pediatric Surgery International Feb 2023A systematic review and meta-analysis of the studies evaluating the utility of the Testicular Work-up for Ischemia and Suspected Torsion (TWIST) score in establishing or... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
A systematic review and meta-analysis of the studies evaluating the utility of the Testicular Work-up for Ischemia and Suspected Torsion (TWIST) score in establishing or excluding the diagnosis of testicular torsion (TT) is herewith presented in an attempt to quantify the available evidence.
METHODS
The study protocol was outlined in advance. The review has been conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). The PubMed, PUBMED Central, PMC databases & Scopus followed by Google (Scholar & search engine) were systematically interrogated with the keywords TWIST score, testis and testicular torsion. Fourteen sets of data (n = 1940) from 13 studies were included; data from 7 studies (giving a detailed score-wise break-up) (n = 1285) were dis-integrated and re-integrated to tweak the cut-offs for low and high risk.
RESULTS
For every 4 patients presenting to the Emergency Department (ED) with acute scrotum, one patient will eventually be diagnosed with TT. The mean TWIST score was higher in patients with testicular torsion (5.13 ± 1.53 vs 1.50 ± 1.40 for those without TT). TWIST score can be used to predict testicular torsion at cut-off of 5 with a sensitivity, specificity, PPV, NPV, and accuracy of 0.71 (0.66, 0.75; 95%CI), 0.97 (0.97, 0.98; 95%CI), 90.2%, 91.0%, and 90.9% respectively. While the slider for cut-off was shifted from 4 to 7, there was a rise in specificity and PPV of the test with a corresponding decline in sensitivity, NPV, and accuracy. The sensitivity witnessed a sharp decline from 0.86 (0.81-0.90; 95%CI) @ cut-off 4 to 0.18 (0.14-0.23; 95%CI) @ cut-off 7. The area under the SROC curve for cut-off 5 was more than that for cut-offs 4, 6 & 7. TWIST cut-off of 2 may be used to predict the absence of testicular torsion with a sensitivity, specificity, PPV, NPV, and accuracy of 0.76 (0.74, 0.78; 95%CI), 0.95 (0.93, 0.97; 95%CI), 97.9%, 56.5%, and 80.7%, respectively. While the cut-off is lowered from 3 to 0, there is a corresponding rise in the specificity and PPV, while the sensitivity, NPV, and accuracy are compromised. The sensitivity witnesses a sharp decline from 91 to 35%. The area under the SROC curve for cut-off 2 was more than that for cut-off @ 0, 1 or 3. The sum of sensitivity and specificity of TWIST scoring system to ascertain the diagnosis of TT is more than 1.5 for cut-off values 4 & 5 only. The sum of sensitivity and specificity of TWIST scoring system to confirm the absence of TT is more than 1.5 for cut-off values 3 & 2 only.
CONCLUSION
TWIST is a relatively simple, flexible, and objective tool which may be swiftly administered even by the para-medical personnel in the ED. The overlapping clinical presentation of diseases originating from the same organ may prevent TWIST from absolutely establishing or refuting the diagnosis of TT in all the patients with acute scrotum. The proposed cut-offs are a trade-off between sensitivity and specificity. Yet, the TWIST scoring system is immensely helpful in the clinical decision-making process and saves time-lag associated with investigations in a significant majority of patients.
Topics: Male; Humans; Spermatic Cord Torsion; Testis; Scrotum; Sensitivity and Specificity; Emergency Service, Hospital; Retrospective Studies
PubMed: 36811717
DOI: 10.1007/s00383-023-05401-5 -
Clinical Anatomy (New York, N.Y.) May 2017The technique of triggering the cremasteric reflex and its respective signaling pathway is not described uniformly throughout the literature. As this reflex is a useful... (Review)
Review
The technique of triggering the cremasteric reflex and its respective signaling pathway is not described uniformly throughout the literature. As this reflex is a useful sign in diagnosing testicular torsion, orchitis, varicocele, and undescended testis, it seems desirable to identify and define the correct mechanism. Our aim was to investigate how the cremasteric reflex and its signaling pathway are described in the current literature and how the variability of the innervation of the inguinal region could affect the frequency of this reflex. Thirty-five original articles and 18 current textbooks were included after searching PubMed (MEDLINE) and Scopus for the terms "cremaster muscle," "cremasteric reflex," and "genitofemoral nerve" and after applying all exclusion criteria. This systematic review was performed according to the PRISMA Statement Rules. Eliciting the cremasteric reflex was defined either as "rubbing of the upper inner thigh" or "rubbing of the skin under the inguinal ligament." Four different afferent pathways among studies and three different pathways among textbooks were described and the frequency of an intact reflex ranged between 42.7 and 92.5% in newborns and between 61.7 and 100% in boys between 24 months and 12 years. Owing to the huge differences among the studies investigated and the lack of convincing results, it is not possible to define the correct way to elicit the cremasteric reflex. Four hypotheses about the afferent pathway are proposed on the basis of the literature. Further studies should be performed, concentrating on the afferent pathway(s) with respect to the individual innervation of the inguinal region. Clin. Anat. 30:498-507, 2017. © 2017 Wiley Periodicals, Inc.
Topics: Electromyography; Humans; Lumbosacral Plexus; Male; Reflex; Spermatic Cord Torsion; Testis
PubMed: 28295651
DOI: 10.1002/ca.22875 -
European Urology Mar 2019The benefits and harms of intervention (surgical or radiological) versus observation in children and adolescents with varicocele are controversial. (Meta-Analysis)
Meta-Analysis
Treatment of Varicocele in Children and Adolescents: A Systematic Review and Meta-analysis from the European Association of Urology/European Society for Paediatric Urology Guidelines Panel.
CONTEXT
The benefits and harms of intervention (surgical or radiological) versus observation in children and adolescents with varicocele are controversial.
OBJECTIVE
To systematically evaluate the evidence regarding the short- and long-term outcomes of varicocele treatment in children and adolescents.
EVIDENCE ACQUISITION
A systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. A priori protocol was registered to PROSPERO (CRD42018084871), and a literature search was performed for all relevant publications published from January 1980 until June 2017. Randomized controlled trials (RCTs), nonrandomized comparative studies (NRSs), and single-arm case series including a minimum of 50 participants were eligible for inclusion.
EVIDENCE SYNTHESIS
Of 1550 articles identified, 98 articles including 16 130 patients (7-21 yr old) were eligible for inclusion (12 RCTs, 47 NRSs, and 39 case series). Varicocele treatment improved testicular volume (mean difference 1.52ml, 95% confidence interval [CI] 0.73-2.31) and increased total sperm concentration (mean difference 25.54, 95% CI 12.84-38.25) when compared with observation. Open surgery and laparoscopy may have similar treatment success. A significant decrease in hydrocele formation was observed in lymphatic sparing versus non-lymphatic sparing surgery (p=0.02). Our findings are limited by the heterogeneity of the published data, and a lack of long-term outcomes demonstrating sperm parameters and paternity rates.
CONCLUSIONS
Moderate evidence exists on the benefits of varicocele treatment in children and adolescents in terms of testicular volume and sperm concentration. Current evidence does not demonstrate superiority of any of the surgical/interventional techniques regarding treatment success. Long-term outcomes including paternity and fertility still remain unknown.
PATIENT SUMMARY
In this paper, we review benefits and harms of varicocele treatment in children and adolescents. We found moderate evidence that varicocele treatment results in improvement of testicular volume and sperm concentration. Lymphatic sparing surgery decreases hydrocele formation. Paternity and fertility outcomes are not clear.
Topics: Adolescent; Age of Onset; Child; Embolization, Therapeutic; Evidence-Based Medicine; Fertility; Humans; Laparoscopy; Male; Risk Factors; Sperm Count; Spermatic Cord; Treatment Outcome; Urologic Surgical Procedures, Male; Varicocele; Young Adult
PubMed: 30316583
DOI: 10.1016/j.eururo.2018.09.042 -
Pediatric Surgery International Oct 2011Neonatal testicular torsion (NTT) is rare and reported salvage rates vary widely both in their cited frequency and plausibility. The timing and necessity of surgery is... (Review)
Review
Neonatal testicular torsion (NTT) is rare and reported salvage rates vary widely both in their cited frequency and plausibility. The timing and necessity of surgery is controversial with different centers arguing for the conservative management of all cases while others argue for prompt exploration for all. Confusion also reigns over the need to fix the contralateral testis. In order to clarify the issue the authors reviewed the literature and found 18 case series of NTT, containing 268 operated cases suitable for analysis. This paper reviews the literature on NTT specifically regarding salvage rates and timing/necessity of surgery. Its primary aim is to produce an overall salvage rate in the operated group. Overall salvage rate was 8.96%, 24 testes. When operation is specified as an emergency, salvage may be as high as 21.7%. While salvage of a testis torted at birth is rare, it is reported. Early asynchronous torsion is also rare but reported. Worryingly, bilateral torsion can present with unilateral signs.Given these findings, we would suggest early surgery with fixation of the contralateral side.
Topics: Delivery, Obstetric; Female; Humans; Infant, Newborn; Male; Orchiopexy; Pregnancy; Spermatic Cord Torsion; Treatment Outcome
PubMed: 21739126
DOI: 10.1007/s00383-011-2945-x -
Journal of Pediatric Urology Dec 2018Reported testicular loss rates following paediatric testicular torsion often reflect the surgical decision-making process, rather than long-term survival of the testes. (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Reported testicular loss rates following paediatric testicular torsion often reflect the surgical decision-making process, rather than long-term survival of the testes.
OBJECTIVES
We aim to perform systematic analysis and meta-analysis to investigate testicular salvage rates and to assess predictors of long-term viability.
STUDY DESIGN
Systematic review according to PRISMA guidelines was performed to investigate immediate and long-term (>12 months) testicular loss rates following torsion in the paediatric population. Literature search and study inclusion were performed by two investigators. A study quality score was derived and attributed to each study. Predictors of testicular loss were described. Proportions meta-analysis was performed with random effects modelling, and testing for heterogeneity.
RESULTS
Twelve studies were includedm, 6 reporting early orchidectomy rates, and 6 reporting long-term outcomes. Study quality was generally low.
DISCUSSION
The mean early testicular loss rate was 39%, whereas meta-analysis revealed late loss to approach 50%. Predictors of outcomes include prehospital symptom duration, location of presentation, transfer to a tertiary centre, social affluence and use of ultrasound prior to diagnosis or transfer.
CONCLUSIONS
This study has shown a considerable late testicular loss rate, which must be relayed to families even after testicular salvage. Delay in time to presentation is consistently found to predict poor outcomes.
Topics: Child; Humans; Male; Orchiectomy; Spermatic Cord Torsion; Time Factors; Tissue Survival; Treatment Outcome
PubMed: 30404723
DOI: 10.1016/j.jpurol.2018.09.017 -
The Cochrane Database of Systematic... 2001A varicocele is an, almost exclusively left-sided, varicosity of the pampiniform plexus of the spermatic cord, forming a tangle of distended blood vessels in the... (Review)
Review
BACKGROUND
A varicocele is an, almost exclusively left-sided, varicosity of the pampiniform plexus of the spermatic cord, forming a tangle of distended blood vessels in the scrotum. Although the concept that varicocele causes male subfertility and therefore varicocelectomy cures male subfertility has been around for almost fifty years now, the mechanisms by which varicocele would affect fertility have not yet been satisfactorily explained, and neither have the mechanisms by which varicocelectomy would resolve subfertility. Furthermore, it has been questioned whether a causal relation exists at all between the distension of the pampiniform plexus and impairment of fertility.
OBJECTIVES
To evaluate the effect of varicocele treatment on pregnancy rate in subfertile couples.
SEARCH STRATEGY
Relevant trials were identified in the Cochrane Menstrual Disorders and Subfertility Group's specialised register of controlled trials. A MEDLINE search, using the group's search strategy, was performed for the period 1966-2000. Also, hand searching was performed of 22 specialist journals in the field from their first issue till 2000. Cross references and references from review articles were checked.
SELECTION CRITERIA
RCTs were included if they were relevant to the clinical question posed, if they reported pregnancy rates as an outcome measure, and if they reported data in treated (surgical ligation or radiological embolization of the internal spermatic vein) and untreated groups.
DATA COLLECTION AND ANALYSIS
Six studies met the inclusion criteria for this review. One (Nieschlag 1995/1998) was an extension of a previously published study (Nieschlag 1995/1998), which left five studies for analysis (Nilsson 1979; Breznik 1993; Madgar 1995; Yamamoto 1996; Nieschlag 1995/1998). The results of a WHO megatrial are awaited but as yet are unavailable. The WHO data will be added if and when they will have become available. All five only included men from couples with subfertility problems, one (Madgar 1995) excluded men with sperm counts <5 mill/mL, three (Nilsson 1979; Breznik 1993; Yamamoto 1996) also included men with normal semen analysis. One study (Yamamoto 1996) specifically addressed only men with subclinical varicoceles as diagnosed by thermography. Potentially relevant trials were screened independently by two authors (JE and JC). Any differences of opinion were resolved by consensus meeting (none occurred for this review). Studies were excluded from meta-analysis if they made comparisons other than those specified above.
MAIN RESULTS
One trial (Madgar 1995) reported a statistically significant improvement in pregnancy rate following high ligation of the left spermatic vein. None of the other four studies showed individually a significant effect on pregnancy rates of varicocele treatment over no-treatment (Nilsson 1979; Breznik 1993; Yamamoto 1996), or over counseling only (Nieschlag 1995/1998). The combined RR (Relative Risk; random effects method) of the five studies is 1.06 (95%CI 0.57-1.94), the Peto OR (Odds Ratio) is 1.15 (95%CI 0.73-1.83).
REVIEWER'S CONCLUSIONS
Insufficient evidence exists that treatment of varicocele in men from couples with otherwise unexplained subfertility does improve the couple's spontaneous pregnancy chances.
Topics: Embolization, Therapeutic; Female; Humans; Infertility, Male; Male; Outcome Assessment, Health Care; Pregnancy; Randomized Controlled Trials as Topic; Varicocele
PubMed: 11279693
DOI: 10.1002/14651858.CD000479 -
APMIS : Acta Pathologica,... Mar 2018Primary extratesticular seminomas exceptionally occur in the epididymis or in the paratesticular region/spermatic cord. Some old papers included poor histological... (Review)
Review
Primary extratesticular seminomas exceptionally occur in the epididymis or in the paratesticular region/spermatic cord. Some old papers included poor histological description or insufficient photographic documentation, reducing the number of faithful cases: an up-to-date systematic review is lacking. We report the 4th primary seminoma of the paratesticular region/spermatic cord in a 35-year-old man, including the first echographic description. We provide review of the literature and etiopathogenetic discussion. Ultrasound examination showed a right paratesticular, solid, heterogeneous mass (iso-hypoechoic with hyperechoic striae; peri- and intra-lesional vascular signals) with no testicular involvement: the paratesticular origin was confirmed by pathological examination. Despite careful gross examination and extensive sampling, the 6.5-cm extratesticular tumor revealed only one microscopic focus with minimal invasion (<2 mm) of the atrophic testicular parenchyma. Intratubular germ cell neoplasia or morphologic features of a regressed testicular tumor (fibrosis/scar, necrosis, hyalinization, calcification, inflammation) were not found. Primary seminomas of the paratesticular region/spermatic cord occurred at an older mean age and presented as bigger lesions if compared to the 9 primary epididymal seminomas reported in literature. Clinical-pathological correlation and accurate sampling are mandatory for a correct diagnosis.
Topics: Adult; Epididymis; Humans; Male; Seminoma; Spermatic Cord; Testicular Neoplasms; Ultrasonography
PubMed: 29411910
DOI: 10.1111/apm.12806