Division of Urology, Children's Hospital of Philadelphia, Philadelphia, USA.
The George Washington University School of Medicine and Health Sciences, Washington, USA.
J Pediatr Urol. 2018 Aug;14(4):329.e1-329.e7. doi: 10.1016/j.jpurol.2018.01.010. Epub 2018 Feb 6.
In testicular torsion, ischemia time from pain onset impacts testicular salvage. A tunica albuginea fasciotomy to relieve compartment pressure followed by a tunica vaginalis flap (TVF) may enhance salvage.
To define the optimal window of ischemia time during which TVF may be most beneficial to avoid orchiectomy.
A retrospective cohort study of males presenting with testicular torsion at a single tertiary-care institution from January, 2003 to March, 2017. Ischemia time was defined as duration of pain from onset to surgery. Because TVF would be an option to orchiectomy, and it was found that ischemia time was longer in testicles that underwent orchiectomy, matching was performed. Cases of torsion treated with TVF were matched 1:1 with cases treated with orchiectomy on age at surgery, and ischemia time. Outcomes included postoperative viability, defined as palpable testicular tissue with normal consistency, and atrophy, defined as palpable decrease in size relative to contralateral testicle. Sensitivity analyses were performed restricting to the subgroups with postoperative ultrasound, >6 months' follow-up, and additionally matching for degrees of twist.
A total of 182 patients met eligibility criteria, of whom 49, 36, and 97 underwent orchiectomy, TVF, and septopexy alone, respectively. Median follow-up was 2.7 months; 26% of patients had postoperative ultrasound (61% of TVF group). In the orchiectomy, TVF, and septopexy groups, respectively, median ischemia times were 51, 11, and 8 h, postoperative viability rates were 0, 86, and 95%, and postoperative atrophy rates were 0, 68, and 24%. After matching, 32 patients with TVF were matched to 32 patients who underwent orchiectomy. In the TVF group, postoperative viability occurred in 95% (19/20) vs 67% (8/12) of patients with ischemia times ≤24 and >24 h, respectively. Atrophy occurred in 67% (12/18) vs 83% (10/12) of these same respective patients. Sensitivity analysis by ultrasound and longer follow-up found similar viability results, although atrophy rates were higher. Additional matching for degrees of twist showed lower viability and higher atrophy rates for increasing ischemia times.
Patients who presented with testicular torsion with ischemia times ≤24 h and who were being considered for orchiectomy may have benefitted most from TVF, albeit at high risk of atrophy. However, for ischemia times >24 h, TVF may still have preserved testicular viability in two-thirds of cases. A limitation was short follow-up.
A TVF was a valid alternative to orchiectomy for torsed testicles, albeit with high testicular atrophy rates.
在睾丸扭转中，从疼痛发作开始的缺血时间会影响睾丸的保存。切开白膜以缓解间隔压力，然后行鞘膜翻转术（TVF）可能会提高保存率。
确定 TVF 最有益于避免睾丸切除术的最佳缺血时间窗口。
这是一项回顾性队列研究，纳入了 2003 年 1 月至 2017 年 3 月期间在一家三级医疗中心就诊的睾丸扭转男性患者。缺血时间定义为从发病到手术的疼痛持续时间。因为 TVF 可以作为睾丸切除术的选择，而且已经发现缺血时间在进行睾丸切除术的睾丸中更长，所以进行了匹配。TVF 治疗的病例与接受睾丸切除术的病例在手术时的年龄和缺血时间上进行 1:1 匹配。结果包括术后存活，定义为可触及具有正常质地的睾丸组织；以及萎缩，定义为与对侧睾丸相比可触及的体积减小。进行了敏感性分析，将研究对象限制为具有术后超声、>6 个月随访和进一步按扭转程度匹配的亚组。
共有 182 名患者符合入选标准，其中 49 名、36 名和 97 名分别接受了睾丸切除术、TVF 和单纯鞘膜固定术。中位随访时间为 2.7 个月；61%的 TVF 组患者进行了术后超声检查。在睾丸切除术、TVF 和鞘膜固定术组中，中位缺血时间分别为 51、11 和 8 小时，术后存活率分别为 0、86 和 95%，术后萎缩率分别为 0、68 和 24%。匹配后，32 名 TVF 患者与 32 名接受睾丸切除术的患者相匹配。在 TVF 组中，缺血时间≤24 小时和>24 小时的患者中，分别有 95%（19/20）和 67%（8/12）的患者出现术后存活。在这些相同的患者中，分别有 67%（12/18）和 83%（10/12）的患者出现萎缩。通过超声和更长随访时间进行的敏感性分析发现了相似的存活率结果，尽管萎缩率更高。进一步按扭转程度进行匹配显示，随着缺血时间的增加，存活能力降低，萎缩率升高。
对于缺血时间≤24 小时且正在考虑进行睾丸切除术的睾丸扭转患者，TVF 可能是一种有效的睾丸切除术替代方法，但存在高萎缩风险。然而，对于缺血时间>24 小时的患者，TVF 仍可使三分之二的病例保留睾丸活力。局限性在于随访时间较短。
TVF 是扭转睾丸的一种有效替代睾丸切除术的方法，但睾丸萎缩率较高。
