Journal of Pediatric Urology最新文献

Aim: Various laparoscopic approaches have been described for managing intra-abdominal testicles. We aimed to evaluate the outcomes of patients who had laparoscopic single stage vessel sparing (LSSVO) with regards to testicular atrophy, testicular ascent, and with special emphasis on surgical outcomes of a subsequent groin exploration for testicular ascent.

Methods: Retrospective review of patients who had LSSVO at a UK tertiary paediatric surgery centre between 2006 and 2024. We included all patients under 16 years following LSSVO who had complete follow up. We analysed age at operation, laterality, pre-and post-operative description of testicular size, whether tension was present on fixing the testis, and testicular position at follow-up. In addition, we evaluated the outcomes of patients who had recurrent testicular ascent requiring groin-based redo surgery.

Results: 105 patients had LSSVO over the 18 year period. Mean age at operation was 2 years and mean follow up was 19 months. The testis size at time of surgery was subjectively described rather than objectively measured. The scrotal position after surgery and tension was recorded. First post-op follow up was at 6 months. Twenty-six testicles (24 %) had ascended requiring a groin approach for further mobilisation; all were scrotal at 6 months follow up with no testicular atrophy. We found no association between tension at the time of LSSVO, age or associated anomalies with the risk of needing further surgery.

Discussion: Laparoscopic Fowler-Stephen's orchidopexy remains the standard approach for the intra-abdominal testis although vessel division may decrease germ call count. We preferred sparing the testicular vessels, accepting that a second procedure involving inguinal incision may be required. We had no cases of testicular atrophy, in comparison to the up to 25 % rate in the literature for vessel dividing orchidopexy. 24 % of our cohort required a second groin-based operation to bring the testis to a more satisfactory scrotal position, compared to a recurrent ascent rate of 0-14 % in the literature. We accepted this higher recurrence rate as the groin exploration has proven to be technically straightforward, and as there were no cases of subsequent testicular atrophy.

Conclusion: LSSVO, paired with groin exploration for recurrent testicular ascent when needed, achieved a scrotal testis in all patients with no testicular atrophy, whilst preserving the testicular blood supply and avoiding any potential effects on its histology. It has the added benefit over other 2-stage techniques of avoiding both a 2nd stage in 76 % of patients and the need for repeat laparoscopy.

Background: Testicular torsion is a well-documented pediatric urological emergency that poses a time-sensitive risk to the testicle and long-term morbidity. Despite the urgent nature of testicular torsion, few studies have explored the institutional and clinical factors that influence diagnosis and management. To address this gap, we performed qualitative focus group interviews across the National Surgical Quality Improvement Program Pediatric (NSQIPP) Testicular Torsion Collaborative to better understand facilitators and barriers to testicular torsion care.

Methods: Relevant stakeholders involved in testicular torsion care (i.e. emergency department, radiology, urology, peri-operative services, anesthesia, and surgical quality leadership) across the Testicular Torsion Collaborative were invited to participate in focus group interviews led by a moderator and included a note-taker. All focus groups were recorded and transcribed via Zoom™ audio-visual conferencing software. Inductive coding was performed by 3 reviewers using Dedoose (Los Angeles CA). Themes were designated within the Theoretical Domain Framework (TDF) construct for implementation science and determined to be either a facilitator or barrier to testicular torsion care.

Results: Of the 29 invited sites, 10 sites and 47 individuals participated. Thematic saturation was reached for 20 themes, each represented in at least 2 focus group discussions. All elements of the TDF were represented in the discussions. Community education, culture of quality, high standard of care expectations, and leveraging available data were universally seen as facilitators. Long term follow-up and outcomes, manual detorsion care, and competing care demands were universally seen as barriers.

Conclusions: Based on focus groups of stakeholders in all aspects of testicular torsion care, opportunities to improve care include leveraging quality improvement culture and resources (i.e. trained personnel, data). Barriers to care include competing care demands arising from outside transfers and institutional clinical volume. We hope readers can use this data as a framework to improve in testicular torsion care.