PROGNOSTIC FACTORS FOR ORCHIDECTOMY IN TESTICULAR TORSION PATIENTS AT TERTIARY HOSPITAL

Objective: This study was conducted to analyze the prognostic factors for orchidectomy in testicular torsion patients. Material &Methods: From January 2001 to December 2021, 100 cases of testicular torsion cases were retrospectively collected. Data were described and analyzed based on clinical factors (age, duration of symptoms, scrotal swelling, high-riding testis, Prehn test, cremasteric reflex, leukocytosis, degree of twisting) and non-clinical factors (distance from hospital, duration of travel to hospital, education level and employment status) for each surgical procedure. Then logistic regression analysis was performed. Results: There were 88 testicular torsion patients (88%) underwent orchidectomy and 12 patients (12%) underwent orchidopexy. There was no significant relationship between age, duration of symptoms, scrotal swelling, Prehn test, cremasteric reflex, leukocytosis, distance from hospital, duration of travel to hospital, education level and employment status with orchidectomy (p>0.05). Significant prognostic factors for orchidectomy in testicular torsion patients were high-riding testis (OR = 0.06; 95% CI = 0.01-0.37; p = 0.002) and degree of twisting (OR = 0.04; 95% CI = 0.006-0.24; p = 0.000). Conclusion: High-riding testis and degree of twisting are prognostic factors for orchidectomy in testicular torsion patients.


INTRODUCTION
Testicular torsion or torsion of the spermatic cord is a urological emergency that usually occurs in young men.It is the most common cause of testicular loss in adolescents and neonates.The annual incidence of testicular torsion is 3 -4.5 in 100,000 1 men aged 1 to 25 years.It can occur in men of any age but usually occurs in younger men, with a bimodal incidence in the pediatric population, particularly during the first year of life and between 2 the ages of 13 and 16 years.Delay in surgical management increases the risk of decreased testicular viability and leads to a poor prognosis.The duration of symptoms, intratesticular blood flow, spermatic cord torsion degree, and monocyte counts all predicted effective testicular rescue following testicular torsion.Long-term testicular torsion symptoms, lack of blood flow, significant spermatic cord torsion, increased monocyte count, and decreased testicular rescue success rate.The previous study developed a nomogram based on 3 these independent risk factors.

OBJECTIVE
This study was conducted to analyze the prognostic factors, both clinical and non-clinical for orchidectomy in testicular torsion patients.

MATERIAL &METHODS
From January 2001 to December 2021, 100 cases of testicular torsion that were performed scrotal exploration at my institution were collected retrospectively.Data consisting of clinical factors (age, duration of symptoms, scrotal swelling, highriding testis, Prehn test, cremasteric reflex, leukocytosis, degree of torsion) and non-clinical factors (distance from hospital, duration of travel to hospital, education level and employment status).Complete medical record on patients with testicular torsion undergoing orchidectomy was the inclusion criteria, while the exclusion criteria were incomplete medical record data, and patients who did not perform orchidectomy.
Data were described and analyzed using the Statistical Package for Social Science (SPSS) version 22.Data were presented as sums and percentages for categorical variables and Chi-Square analysis was applied to categorical data.Then multivariate analysis was performed using logistic regression test.The level of significant difference was defined as p<0.05 with a 95% confidence interval.

RESULTS
Data collected from medical record showed the mean age of the patients is 19.87 years.Most of the testicular torsion cases were carried out by scrotal exploration occurs in the age group ≤ 18 years.Of the 100 patients, 12 patients (12%) underwent orchidopexy because testis was still viable, whereas 88 patients (88%) underwent orchidectomy because testis could not be saved.(Table 1).
Then multivariate logistic regression analysis was performed and we found high-riding testis and degree of torsion were correlated with orchidectomy.High-riding testis was significantly associated and increased the likelihood of orchidectomy (OR = 0.06; 95% CI = 0.01-0.37;p = 0.002).The degree of torsion was also significantly associated and increased the likelihood of orchidectomy (OR = 0.04; 95% CI = 0.006 -0.24; p = 0.000) (Table 2).

DISCUSSION
In this study, most cases of testicular torsion occurred in the age ≤ 18 years old with total of 63 patients (63%).There was no significant relationship between age and orchidectomy.The incidence of testicular torsion was estimated to be 1 in 4000 in men younger than 25 years old.1 Based on references, approximately sixty-five percent of cases of testicular torsion was occurred between ages of 12 2,4 and 18 years old.
The average distance from hospital was 29.7 km and the duration of travel to the hospital is 44.9 minutes.Education level varied with college as many as 37 patients (37%) and 88% of patients were not working.In this study, there were no significant relationship between distance from hospital, duration of travel to hospital, education level, and employment status with orchidectomy.In another study, Bayne et al. showed that distance from hospital was statistically significant in multivariate analysis and became the strongest predictors of 5 orchiectomy.The difference of result could be caused by difference in research samples.Bayne et al. study used only boys as sample of the study, while this study covered all ages from children to adults with the range from 5 to 48 years old.
Duration of symptoms was calculated from the onset of symptoms until surgery.We found that 18 patients (18%) presented to the hospital emergency department in less than 6 hours (Table 1).However, duration of symptoms was not High riding testis was significantly associated and increased the likelihood of orchidectomy (Table 2).Patients also had persistent pain that was not relieved by elevating the scrotum.Scrotal swelling was also one of the most common 8 complaints of testicular torsion.In this study, scrotal swelling was found in 79 patients (79%), but scrotal swelling was not associated with orchidectomy.For late cases, it was also found that the cremasteric reflex was absent.The presence of cremasteric reflex 9 did not confirm the absence of testicular torsion.In this study, cremasteric reflex and Prehn test were also not associated with orchidectomy.
Complete blood count test and urinalysis may be performed to rule out infection.Previous reports showed that leukocyte count was 10 significantly greater in testicular torsion patients.However, most studies did not differentiate between [11][12] testicular torsion and epididymo-orchitis.In this study, leukocytosis was not associated with orchidectomy.
Scrotal exploration should be carried out immediately if a testicular torsion was suspected.Scrotal exploration was performed with a para raphe incision.The incision was continued into tunica vaginalis, which may appear dark due to blood serum.It was necessary to evacuate accumulated 39% to 71% in most of the literature.It was found that only high-riding testis and degree of torsion were correlated with orchidectomy.High-riding testis and degree of torsion were significantly associated and increased likelihood of orchidectomy (Table 2).Howe et al. reported that twisting of the spermatic cord more than 360 degrees increased the risk of unsalvageable testicle.The degree of testicular rotation multiplies the role of presentation delay in testicular torsion.A greater degree of testicular rotation indicated a higher risk of 16 ischemia and necrosis due to reduced blood supply.The limitations of this study were its retrospective nature and the limited number of patients.Further multicenter studies with larger sample sizes are needed to confirm these findings.

CONCLUSION
High-riding testis and degree of torsion were prognostic factors for orchidectomy in testicular torsion patients.

Table 1 .
Univariate analysis of prognostic factors for orchidectomy in testicular torsion patients.

Table 2 .
Multivariate analysis of prognostic factors for orchidectomy in testicular torsion patients.