Torsion testis - Operative chat

1. TESTICULAR TORSION
OPERATIVE CHAT
- ABHISHEK PANDEY

2. Introduction
• Testicular Torsion - twisting of spermatic cord that
compromises testicular perfusion
• Acute scrotum with pain & nausea, high-riding testis,
& absent cremasteric reflex
• Bell-clapper deformity
• Surgical emergency

3. Intravaginal vs Extravaginal

4. Manual Detorsion
• Initial attempt – opening the book → rotating the
affected testicle laterally
• If met with resistance → rotating it medially (33%
torsions occur in opposite direction)
• Residual torsion >30% reported
• Exploration & Fixation to be done

5. Preparation – Scrotal Exploration
• Position – Supine
• Part Preparation – Betadine prepping of external
genitalia, groin, and perineum
• Draping
• Prophylactic Antibiotic – Cephazolin (at discretion)
• Caudal block can be done at the end of the case for
postoperative pain control

6. 1: Incision
• Longitudinal incision along
the median raphe
– Access to bilateral
hemiscrotum via single
incision
• Two separate short incisions
in each hemiscrotum
– Less likely to interfere with
scrotal nerve distribution

7. 2: Opening Tunica Vaginalis
• Affected side approached first
• Dissection carried through Dartos
• Tunica vaginalis opened sharply at thin & avascular
point
• Reactive hydrocele evacuated
• Ipsilateral testis extruded to assess viability
• Detorsion of the cord

9. 3: Assessment of Testicular Viability
Two approaches
1. Wrap testicle in warm saline sponge → contralateral
orchiopexy → reassess for color
2. Short incision in tunica albuginea (deep through
medulla) → observe 10 minutes for active bleeding
a) Bleed immediate / within 10 minutes → Orchiopexy
b) No bleed → Orchiectomy

10. 4-A: ORCHIECTOMY
• Divide the cord structures between clamps
• Ligate with 2-0 Vicryl or silk sutures
• Postpubertal males (achieved full testicular growth)
→ Orchiectomy + Testicular Prosthesis placement
Orthotopic prosthetic position
Extra tunica vaginalis barrier layer
Avoidance of another anaesthesia

12. 4-B: ORCHIOPEXY
• Trim excess tunica vaginalis
• Obtain hemostasis along edge
• Evert edges of tunica vaginalis
• Approximate behind testis
(interrupted) → minimize
hydrocele formation

13. Placement of Fixation Sutures
• Goal - Extravaginal fixation to prevent recurrent
intravaginal torsion
• Tack tunica albuginea to dartos in three places
– One each – medially, laterally, & inferiorly
– All medially, affixing to the septum
• Absorbable (4-0 PDS) suture can be used
• Caution – No deep stitches in testicular parenchyma

15. • Contralateral orchiopexy
– same technique
• Dartos closed with
absorbable sutures
• Skin closed with 4-0/5-0
absorbable sutures –
interrupted or running
subcuticular

16. Window Orchiopexy
Edges of T. vaginalis are
sutured to T. albuginea
creating a window at
least 1.5×2cm in size

17. Axial Fixation Technique
Straight needle suture
used to fix bilateral T.
albuginea along long-
axis of testes, through
the median septum

18. Bilateral Transverse Fixation Technique
Through the median
septum in a figure-of-
eight configuration

19. Non-Albuginea breaching Orchiopexy
Mazaris E, Tadtayev S, Shah T, Boustead G. Surgery illustrated--focus on details: A novel
method of scrotal orchidopexy: description of the technique and short-term outcomes. BJU
Int. 2012;110(11):1838-1842. doi:10.1111/j.1464-410X.2012.11605.x

20. Scrotal Pouch Orchiopexy
Redman & Barthold
High transverse scrotal incision
Tunica vaginalis eversion
Scrotal pouch b/w dartos &
External spermatic fascia
Fixation b/w T. vaginalis &
Pouch wall

21. Testicular Faciotomy
Kutikov A, Casale P, White MA, Meyer WA, Chang A, Gosalbez R, Canning DA. Testicular
compartment syndrome: a new approach to conceptualizing and managing testicular
torsion. Urology. 2008 Oct 1;72(4):786-9
Compartment Pressure
Before – 40mmHg
After – 5mmHg

22. Tunica Vaginalis Flap

24. Testicular Prosthesis
• Delayed approach – after complete healing or later in
puberty
• Combined Orchiectomy & Prosthesis exchange
– Orthotopic prosthetic position
– Extra tunica vaginalis barrier layer
– Avoidance of second anesthesia
Bush NC, Bagrodia A. Initial results for combined orchiectomy and prosthesis exchange for
unsalvageable testicular torsion in adolescents: description of intravaginal prosthesis
placement at orchiectomy. J Urol. 2012;188(4 Suppl):1424-1428.

25. Testicular Salvage Rate
Duration of Torsion (hr) Risk of Orchiectomy (%)
0 - 6 5 %
7- 12 20 %
13 - 18 40 %
19 – 24 60 %
> 24 80 %
> 48 90 %

26. Complications
• Immediate complications –
– Pain
– Scrotal Hematoma
– Surgical Site Infection
• Recurrent Torsion –
– Reported even after orchiopexy
– Reported with non-absorbable sutures too
– 4.5% cases, median 7yr after orchiopexy

27. • Delayed Testicular Atrophy –
– <10% Orchiopexy done <12hr after onset of pain
– 40% 12 to 24hr
– 75% >24hr pain
• Fertility Potential –
– 0.5% Infertile men have history of Torsion Testis
– Long term data lacking

28. Thank You

29. A
• A