Testicular tissue bleeding as an indicator of gonadal salvageability in testicular torsion surgery

Objective To investigate the reliability of using bleeding from the cut sur face of testicular tissue during surgery for testicular torsion to assess t esticular viability, compared with the duration of symptoms and preoperativ e findings on testicular Doppler ultrasonography (DUS). Patients and methods The study comprised 19 children with testicular torsio n who underwent surgery; all underwent DUS before surgery. During surgery t he tunica vaginalis of the affected gonad was incised and a deep incision m ade through the medulla after obtaining a wedge biopsy for histological exa mination, After waiting up to 10 min to assess any fresh arterial bleeding from the cut surface, the patients were categorized using three grades; gra de I (sufficient bleeding, i.e. bleeding or oozing when the biopsy was obta ined); grade II (insufficient bleeding, no bleeding immediately after the i ncision but starting within 10 min); and grade In: (no bleeding within 10 m in). The final surgical decision on whether to save the testis was made acc ording to the grade of testicular tissue bleeding; grade I and II testes we re saved and grade III testes were removed, The biopsies were histopatholog ically examined and classified as haemorrhagic, necrotic or indeterminate. The patients were followed up at 15 days and at 1, 3, 6 and 12 months, with the affected testis examined using DUS. At the end of the study, the sensi tivity and specificity of the duration of symptoms, characteristics of bloo d flow on DUS and grading of testicular tissue bleeding at surgery were cal culated for predicting testis viability, using the histopathological diagno sis as the reference standard. Results The sensitivity, specificity, positive and negative predictive valu es were respectively 100%, 90%, 90% and 100% for a duration of symptoms of >10 h, 78%, 80%, 78% and 80% for DUS findings, and 100%, 78%, 83% and 100% for testicular tissue bleeding in predicting gonad viability after torsion, respectively. Conclusion Although the 10 h limit for the duration of symptoms seems a mor e accurate predictor of the fate of a twisted testis than were the other va riables, testicular tissue bleeding may also be a good indicator of gonadal viability during surgery. The surgeon should wait up to 10 min after incis ing the testicular tissue deep to the medulla before deciding the type of s urgery. In cases where bleeding from the cut surface is sufficient or insuf ficient (according to the proposed grading system), orchidopexy is the trea tment of choice. The salvaged testes should be assessed during follow-up, e specially in those who had had insufficient bleeding at surgery and/or a du ration of symptoms >10 h,to assess for any delayed damage to the untwisted testis. If no bleeding is seen during surgery the best option is to remove the affected testis.