Is fixation of the contralateral testis justified after successful detorsion and fixation of the ipsilateral testis?

Every day in the working environment we witness the questioning of whether or not the contralateral testis should be fixed after ipsilateral testicular torsion. EAU (European Association of Urology) Guidelines on Pediatric Urology are interpreted differently by pediatric urologists probably for several reasons. In one sentence, the guidelines explicitly state “Bilateral orchiopexy is still required after successful detorsion”, in the second “During exploration, fixation of the contralateral testis is also performed. It is a good clinical practice to also perform fixation of the contralateral testis in prenatal and neonatal torsion, although there is no literature to support this, and to remove an atrophied testicle.” Furthermore, in the subsection “Unanswered questions” they clearly state that “Although testicular torsion is a common problem, the mechanism of neonatal and prenatal torsion is still not exactly known, as well as whether fixation of the contralateral testicle in these cases is really necessary”, while in the table of recommendations, they state that the strength of the recommendation is weak [1]. As a result of the above, we really need to ask ourselves if a fixation of the contralateral testicle is really necessary after ipsilateral testicular torsion. There are surgeons who, after any surgically confirmed testicular torsion, fix the contralateral testicle, as well as surgeons who, if they do not macroscopically verify significant damage to the ipsilateral testicle after its detorsion, do not fix the contralateral testicle, considering it unnecessary.

There is no doubt that contralateral testicular fixation is necessary if an ipsilateral orchidectomy has been performed, but what about cases where detorsion has been successful with ipsilateral testicular vitality clearly observed? It is a well-known fact that every torsion is not uniform. The torsion itself can be from 180° to more, it can last shorter or longer, and it can be intermittent. As a result, the consequences for the ipsilateral testicle, and thus for the contralateral testicle, are not the same, as confirmed by a number of studies. Although the etiology of testicular torsion has not been clarified to this day, proponents of fixation of the contralateral testicle claim that “bell clapper deformity” is often present on both sides, so fixation of the contralateral testicle should be done prophylactically. Studies have clearly indicated the problem of a precise anatomical definition of this condition and the fact that the “bell clapper deformity” is not always present on both sides. In a systematic review, Taghavi et al. came to the following data; based on autopsy studies the rate of bell-clapper deformity in scrotal testis varied from 4.9% to 16%; with bilaterality in 66–100%. In cases of acute intravaginal torsion, bilaterality was noted in 54–100%. The most disparate results were in cases of testicular regression syndrome where contralateral bell-clapper deformity was noted in 0–87% of cases [2]. Following the above, is it ethical and scientifically based to fix every healthy contralateral testis if we have a clearly saved ipsilateral testis? Furthermore, what are the chances that if you have a “bell clapper deformity” you will experience torsion? How many boys have this deformity without ever developing torsion? There are a lot of unanswered questions.

On the other hand, most pediatric urologists who opt for contralateral testicular fixation, despite the saved ipsilateral testicle, perform fixation by transfixation through the testicular parenchyma. The inflammation caused by the needle and suture penetration has been suggested to be one of the possible causes of subfertility after parenchymal transfixation of the testicles. Testicular transfixation in rats led to important morphologic modifications in the ipsilateral and contralateral organs [3] [4]. Following the above, apart from the fact that it has been proven that anti-sperm antibodies and vasoconstriction affect the contralateral testicle due to ipsilateral torsion, is it necessary to fix it with stitches and further damage it? In a systematic review and meta-analysis, Anand et al., who dealt with the issue of transparenchymal anchoring suture during orchidopexy in children with cryptorchidism, it was observed, although not statistically significant, that the frequency of testicular atrophy was higher among children in whom transparenchymal anchoring suture was used [5]. It is also a well-known fact that despite fixation, retorsion can occur if absorbable sutures were used or fixation was performed in one point [6]. A systematic review regarding the optimal surgical technique for testicular fixation concluded that there is limited evidence in favor of any surgical technique for acute testicular torsion. It is interesting to note that the contralateral testicle was fixed in 57.6% of cases [7]. In addition, Duquesne et al. concluded that immediate contralateral orchiopexy should not be performed systematically, because immediate contralateral orchiopexy was associated with an increased postoperative complication rate, with a particular increase in hematoma, and delayed wound healing [8]. In what indications contralateral testicle fixation should be performed, it may become clearer with the development of diagnostic methods [9].

Following the opinion of Arnbjörnsson and Kullendorff from almost 40 years ago [10], and the studies conducted so far, there is no solid evidence that it is necessary to fix the contralateral testicle after successful surgical detorsion and fixation of the ipsilateral testicle.

Publikationsverlauf

Eingereicht: 14. Februar 2023

Angenommen nach Revision: 03. April 2023

Artikel online veröffentlicht:
04. August 2023

• References

• 1 European Association of Urology. EAU Guidelines on Paediatric Urology. 2022 . https://d56bochluxqnz.cloudfront.net/documents/full-guideline/EAU-Guidelines-on-Paediatric-Urology-2022.pdf
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