Discussion
Concerns about the contagiousness and mortalities of COVID-19 has led
most governments take measures like lockdowns, stay-at-home and social
distancing suggestions 6. In hospitals, daily routine
healthcare services were heavily interrupted, either the hospitals were
completely converted into quarantine clinics or admitted reduced number
of patients. There are many studies indicating significant delay in
patients with urgent conditions in emergency departments such as
cardiovascular emergencies 7,8. Also, studies
conducted in pediatric emergency clinics assert the fact that number of
patients has significantly decreased during COVID-19 pandemic and the
main reason for this is the fear of infection and the protectionist
instinct of the families 9,10. In this study, the
aggravated, acute and severe presentation of testicular torsion may be
the reason not having any significant differences between ages and
duration of symptoms between the groups. Similar to this study, Littman
et al. and Nelson et al. found no delay in the time of presentation of
testicular torsion cases during COVID-19 pandemic11,12. On the other hand, a very recent multicenter
study from the Western Pediatric Urology Consortium (WPUC) suggests
significantly longer presentation times of testicular torsion cases
during the pandemic 13.
In testicular torsion, ischemia duration and torsion degree are the most
important factors in preserving the functional features of the testis14. Irreversible damage starts after four to six hours
and affects both the spermatogenesis and the endocrine functions15,16. Also, it has been suggested that unilateral
testicular torsion may harm the spermatogenesis in the contralateral
testis through ischemia-reperfusion metabolites as an early mechanism
and by autoimmune response in latter stages 17. A
study comparing the time to treat and duration of symptoms in respect of
testicular salvage indicates a clear significance in conserving the
testis in the group with duration of symptoms below 24 hours while there
was no significance in time to treat 18. Concerning
all the issues above, immediate intervention is recommended. In regards
to prompt management, manual detorsion has been described by Nash in
1893, has been proposed as urgent procedure reducing the duration of
ischemia of torsioned testis 19. Various studies in
literature suggests that this method may be an alternative to
exploration and surgical detorsion 20-22. On the other
hand, some studies in literature suggest the risk of residual torsion
and subsequent testicular atrophy 23,24. In this
study, although there are no significant differences between groups, the
number of manual detorsions has increased throughout the COVID-19 era.
This result may be interpreted as the self-protective instinct of the
surgeon providing an urgent and temporary management to a testicular
torsion case which is COVID-19 suspicious. All patients with prior
manual detorsion in this study have been confirmed with scrotal Doppler
ultrasound and also operated under elective and COVID-PCR negative
conditions for bilateral orchiopexy.
There were no significant differences between the groups in terms of
surgical approach and orchiectomy rates. Since there were no significant
differences in the admission times of the patients, this result could be
predicted. Both Littman et al. and Nelson et al. showed no significant
alterations in orchiectomy rates of testicular torsion cases during the
pandemic which this study was consistent with 11,12.
Contrarily, in the multicenter study by WPUC, significantly delayed
patients during the pandemic resulted in a non-significant but
numerically higher percentages of orchiectomies 13. In
this study, during the COVID-19 pandemic, the number and percentage of
orchiectomies have decreased numerically but not significantly. The
increase in the number of manual detorsions may have contributed to this
result. In addition to providing a remedy to the patient’s pain and
saving time for the surgeon, the manual detorsion procedure have been
shown to have an organ-preserving aspect. This approach may also be
implemented on daily practice to reduce orchiectomies.
Even though contralateral orchiopexy of the testis is controversial,
there is still evidence in the literature indicating the risk of future
torsions 25. Hence, this approach is recommended to
avoid the possible risk. All patients included in our study underwent
contralateral orchiopexy in direction of the current guidelines and
recommendations.
Emergency surgeries during COVID-19 pandemic are a great risk for the
surgeon and the whole staff in the operating room. Both in urology and
other aspects of surgery, biosecurity measures, recommendations and
guidelines are continuously being reported about this subject3,26,27. Also a report by Parikh et al. shows in order
not to compromise the outcome of testicular torsion, COVID-PCR testing
results cannot be waited and all protective measures should be taken as
if the patient is COVID-19 positive 28.
Although this stands out to be the only study evaluating manual
detorsion rates in testicular torsion during the COVID-19 era, the main
limitation is its retrospective nature. Also, due to the short time
intervals, especially in COVID-19 era which is 9 months in this study,
number of patients is limited to reach definitive, descriptive and
significant results. Randomized, prospective studies with increased
number of participants may end up in statistical significance.
Even though there were no significant differences between pre-COVID-19
era and during the COVID-19 crisis in terms of admission times, the
approach to testicular torsion and surgical outcomes, conditions caused
by COVID-19 may prompt urologists to manual detorsion more to set up
safer surgical environment. Additionally, this approach may result in a
decrease in orchiectomy rates by saving time and preserving the
vascularity of the testis.