What matters in testicular torsion? Association of hospital transfer, race and socioeconomic factors with testicular outcomes in a single center experience.

Introduction: Testicular torsion is a surgical emergency that is managed with either septopexy-only or tunica vaginalis flap with septopexy if the testis is potentially viable or orchiectomy if not. Minimizing time from ischemia onset to surgery maximizes the likelihood of testicular preservation. While factors such as time from door to OR can be easily targeted, others such as inequalities in access to care are more difficult to address.

Objective: We sought to determine whether patient transfer affects testicular outcomes intraoperatively and in the long-term. Secondary goals included investigating the impact of race and Child Opportunity Index (COI) on testicular torsion outcomes and defining the optimal time cutoff from symptom onset to presentation that predicts salvage.

Methods: We reviewed our prospective testicular torsion database to identify boys who underwent operative intervention for testicular torsion between January 2015 and March 2022. The association of race and COI with testicular salvage, defined as septopexy-only, was evaluated with univariate and multivariate logistic regression controlling for time to presentation, while the association of transfer with salvage was evaluated with univariate and multivariate logistic regression controlling for age, time to presentation, and time to OR. To determine the optimal cutoff for time to presentation to predict testicular salvage, the Youden index was calculated.

Results: Race and COI were not associated with testicular salvage on either univariate or multivariate logistic regression that controlled for time to presentation. Transfer status was not associated with salvage, while age, time from symptoms to presentation, and time from institutional arrival to OR were associated with salvage. The optimal time cutoff to predict salvage using the Youden index was 10.5 hours from symptom onset to presentation and 14.5 hours from symptom onset to detorsion.

Discussion: Time to presentation was the strongest, modifiable risk factor associated with testicular salvage. As it may be difficult for children to accurately communicate their symptoms, diagnosis and prompt management of testicular torsion can be delayed. Improvement in outcomes can be achieved by placing greater efforts into patient, parental, and primary care provider education of the signs and symptoms of testicular torsion.

Conclusions: Race, COI, and transfer status were not found to have a statistically significant effect on testicular salvage outcomes in patients presenting with testicular torsion. Despite the common premise of a 6-hour window until testicular loss, we found that intervention within the acute window of 14.5 hours from symptom onset is still associated with salvage.