Reduction of Testicular Torsion

Acute testicular torsion is one of the few true urologic surgical emergencies — delay leads to testicular loss and carries clear medicolegal weight. The operative goal is prompt scrotal exploration to detorse the cord, salvage a viable testis with extravaginal fixation (orchidopexy), and fix the contralateral side; a non-viable testis is removed. Diagnosis is clinical — do not delay exploration for imaging if it is not immediately available.

Indications and Differentiation

The first step is to distinguish extravaginal from intravaginal torsion, as the two differ in age, presentation, and surgical aim.

Feature	Extravaginal	Intravaginal
Typical age	Neonates	Adolescent boys
What twists	Cord, testis, and tunica vaginalis as a single unit	Cord and testis only (within the tunica vaginalis)
Presentation	Firm, non-transilluminating scrotal mass with a bluish cast; often painless	Acute onset, moderate-to-severe scrotal pain
Doppler	Usually no signals of vascular return	Highly sensitive for obstructed blood flow
Manual detorsion	Not applicable	May be attempted while awaiting surgery
Surgical aim	Orchiectomy (salvage rarely successful); contralateral orchidopexy at the same sitting is optional and its rationale remains controversial	Emergent exploration with detorsion; orchidopexy if viable

In equivocal cases, examine the cord (with or without a cord block) for displacement of the lower pole of the epididymis away from the lower pole of the testis — the anomaly that permits torsion. If in doubt, order a color Doppler ultrasound, but treatment must not wait on it.

Salvage is time-critical: salvage rates approach 100% within ~6 hours of symptom onset, fall to ~50% by 12 hours, and drop below 10% beyond 24 hours.

Manual Detorsion

While awaiting exploration of a clinically suspected torsion, manual detorsion can restore perfusion and reduce pain — but it is never a substitute for surgery.

• Follow the "opening the book" mantra: rotate the affected testis laterally first.
• If met with resistance, rotate medially instead — ~33% of torsions occur in the opposite (medial) direction.
• Success is marked by sudden pain relief and return of the testis to a normal vertical position low in the scrotum.
• Explore surgically even after apparent success — residual torsion has been reported in up to 32% and threatens viability.

Pre-operative Preparation

• Position: supine, for scrotal exploration and contralateral orchidopexy.
• Anesthesia: general; a caudal block can be placed at the end of the case for postoperative analgesia in a suitable-age patient.
• Prep: external genitalia, groin, and perineum prepped with betadine and draped sterilely.
• Antibiotics: a dose of IV cefazolin at the surgeon's discretion.
• Sutures: 2-0 Vicryl or silk (cord ligation if orchiectomy); 3-0 Vicryl (tunica vaginalis eversion); 4-0 PDS (fixation); 4-0/5-0 absorbable (skin).

Steps — Scrotal Exploration and Detorsion

1. Incision. A median raphe incision gives access to both hemiscrota through a single wound. Alternatively, two short anterolateral incisions (one per hemiscrotum) may better preserve the distribution of scrotal nerves.
2. Reach the tunica vaginalis. Carry the dissection through the dartos fascia onto the tunica vaginalis, approaching the affected side first.
3. Open the tunica vaginalis. Open it sharply at a relatively thin, avascular point. Evacuate any reactive hydrocele fluid.
4. Deliver and detorse. Extrude the ipsilateral testis, inspect the cord for the direction and degree of torsion, and untwist (detorse) the cord.
5. Assess viability (see below) and decide between orchidopexy (viable) and orchiectomy (non-viable).

Assessing Testicular Viability

If the testis remains blue and congested after detorsion, use one of two approaches:

• Warm and wait: wrap the testis in warm saline sponges and proceed to the contralateral orchidopexy first, then reassess colour on the affected side.
• Cut and observe: make a short incision through the tunica albuginea deep into the medulla and watch for 10 minutes. Bleeding from the cut surface — immediate or within 10 minutes — indicates viability and favours orchidopexy. No bleeding means the testis is unlikely to be viable, and orchiectomy is performed.

Orchidopexy (Viable Testis)

1. Trim and tidy. Trim excess tunica vaginalis and obtain hemostasis along the edge with careful fulguration.
2. Optional eversion. Evert the tunica vaginalis edges and approximate them behind the testis with two or three interrupted 3-0 Vicryl sutures to minimise hydrocele formation.
3. Three-point fixation. Tack the tunica albuginea to the dartos in three places — medial, lateral, and inferior — using absorbable suture such as 4-0 PDS. Do not throw the stitches deep into the testicular parenchyma. Alternatively, place all three medially, affixing the testis to the septum.
4. Goal. In either approach, the aim is an extravaginal position to prevent recurrent intravaginal torsion.
5. Contralateral orchidopexy. Perform on the other side using the same technique — the bell-clapper anomaly is typically bilateral. Close the dartos with absorbable suture and the skin with 4-0/5-0 absorbable suture (interrupted or running subcuticular).

Nontunical (dartos pouch) orchidopexy is an alternative driven by evidence that transparenchymal sutures may harm spermatogenesis: braided polyglactin sutures are secured around the circumference of the pouch opening (with a dependent fourth), fixing the testis through the visceral layer of the tunica vaginalis rather than the albuginea. A 29-year series reported favourable outcomes, with atrophy, long-term pain, or malposition in only 14 testes (8 patients) of 1104 orchidopexies.

Orchiectomy (Non-viable Testis)

Divide the cord structures between clamps and ligate with 2-0 Vicryl or silk. In postpubertal patients who have completed testicular growth, and with consent, combined orchiectomy and testicular prosthesis placement can be offered — it gives an orthotopic prosthetic position, an extra tunica vaginalis barrier layer, and avoids a second anesthetic; a series reported no infections or extrusions at a median 4.8-month follow-up.

Postoperative Care and Complications

• Testicular atrophy — close follow-up is needed and parents should be counselled that atrophy is possible despite salvage, especially with prolonged symptom duration or no immediate bleeding on the deep medullary cut. One series reported atrophy in 27% of salvaged (orchidopexy) testes.
• Recurrent torsion — rare but possible even after orchidopexy and even with polyglactin or polypropylene sutures; one series found 4.5% (8/179), recurring on average 7 years later (range 0.5–23).
• Fertility — current evidence suggests acute testicular torsion does not contribute significantly to male-factor infertility.