- Email: [email protected]
Mesorchial Testicular Torsion: Case Report and a Review of the Literature
Pediatric Case Report Mesorchial Testicular Torsion: Case Report and a Review of the Literature Jennifer L. Chan, Judith M. Knoll, Peter L. Depowski, Richard A. Williams, and Justine M. Schober Testicular torsion can be extravaginal, intravaginal, or mesorchial. Mesorchial torsion is less well defined and has an atypical presentation. Here we present the case of a 13-year-old with severe, intermittent right scrotal pain, erythema, and a large hydrocele. Color Doppler ultrasound examination showed epididymal enlargement and normal flow. Weeks after presentation, serial color Doppler ultrasound examinations showed epididymal enlargement and decreased perfusion. A literature review for testicular torsion etiology and clinical and radiologic findings documents this as the only recorded case of mesorchial testicular torsion with clinical and radiologic findings. Atypical pain, if persistent, requires careful reassessment, radiologic studies, and surgical exploration. UROLOGY 73: 83– 86, 2009. © 2009 Elsevier Inc.
T
esticular torsion is a twisting of the entire spermatic cord or a portion thereof, causing ischemia. Grouped as extravaginal, intravaginal, or mesorchial torsion (Fig. 1),1-3 a variance in mesenteric (mesorchium) attachment can be causative. Narrow attachment allows the testis to fall forward, increasing testicular mobility. Broad mesenteric attachment maintains upright integrity, limiting testicular motion. Pubertal testicular enlargement increases the possibility of torsion. Anomalies in epididymal attachment to the testis and nondescent may also lead to torsion.4,5 Testicular torsion can occur at any age but is most common in adolescence.6 Extravaginal torsion, a perinatal phenomenon occurring when the scrotum is not securely attached to the tunica vaginalis,3,7 is rare.8,9 Intravaginal torsion (65%-80% of torsions) may be associated with bell-clapper deformity, which occurs when tunica vaginalis completely encircles the epididymis, distal spermatic cord, and testis.1,3 Normally the tunica vaginalis attaches to the posterolateral aspect of the scrotal wall and suspends the testes in a vertical position. Horizontal lie creates a greater propensity to torsion.3,6 Typically, the anterior half of the testes is covered by mesothelium, and the posterior surface is loosely adherent to the scrotal wall.10 Anomalies of suspension of the mesothelium occur with narrow-based attachments of the testes.7 Mesorchial torsion is a twist in tissue overlying the vasculature (anteriorly) between the epididymis and parietal tunica vaginalis, associated with abnormality of the membrane and epididymal attachments to the testes.
From the Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania; and Hamot Medical Center, Erie, Pennsylvania Reprint requests: Justine M. Schober, M.D., 333 State St, Suite 201, Erie, PA 16507. E-mail: [email protected] Submitted: May 19, 2008, accepted (with revisions): June 28, 2008
© 2009 Elsevier Inc. All Rights Reserved
Degree of rotation is a good predictor of ischemia. Three main arteries supply the scrotum and its contents (testicular, cremasteric, and deferential). The testicular artery is the primary supply to the testes and epididymis, the cremasteric artery supplies the peritesticular tissues, the deferential artery the vas deferens. Torsion leads to obstruction of venous drainage, followed by vascular engorgement. Obstruction of arterial inflow and ultimately ischemia are a secondary process.1 Vessels in a thin cord are easily compressed, whereas a thicker cord is more resistant to kinking and could preserve blood flow.4 The contents of the spermatic cord include vas deferens and its artery, testicular artery, pampiniform plexus of veins, lymphatic vessels, and sympathetic nerves enclosed in fascial layers. Cremasteric muscle, innervated by the ilioinguinal nerve, encircles the spermatic cord and scrotum and is responsible for the cremasteric reflex. A classic finding in testicular torsion is absence of cremasteric reflex. The testicle of the affected side may be somewhat enlarged and higher when compared with the asymptomatic testicle. Hydrocele may be present, as well as scrotal erythema. The clinical picture of testicular torsion includes unilateral pain with swelling of the testicle. Duration of the pain is variable, lasting hours to days,1,3 intermittent or continuous. The differential diagnosis of scrotal pain includes torsion of appendix testis, epididymitis, and epididymoorchitis. Torsion of the appendix may present with a tender nodule and blue dot on the upper pole of the testicle,11 epididymitis with localized tenderness of the epididymis and a normal testicle. Epididymo-orchitis is characterized by scrotal and testicular pain, tenderness, edema, and erythema.
CASE REPORT A 13-year-old presented with a 48-hour history of right scrotal swelling and pain. Outpatient color Doppler ul0090-4295/09/$34.00 doi:10.1016/j.urology.2008.06.053
83
Figure 1. Classification of types of testicular torsion. (A) Intravaginal torsion; (B) extravaginal torsion; (C) torsion due to long mesorchium. (Reprinted with permission.3)
trasound (CDU) examination demonstrated right hydrocele, enlarged, heterogeneous epididymis, and thickening of the scrotum. The patient was diagnosed with epididymitis and administered amoxicillin. Worsening pain led to re-examination. Significant right epididymal tenderness, small right hydrocele, and intact cremasteric reflex was appreciated. The testes was not elevated. Examination by CDU again demonstrated normal blood flow, edema, and increased vascularity of the epididymis. The patient’s antibiotic was changed to ciprofloxacin, with notable improvement and resolution of tenderness after 10 days. The pain recurred, first testicular, then localizing along the anterior iliac crest and flank. Physical examination noted a larger, firm right scrotum with pronounced erythema. Color Doppler ultrasound demonstrated large right hydrocele, right-sided epididymitis, and orchitis. Diminished vascularity of the right testis, which the radiology department considered secondary to edema and pressure effects from the enlarged epididymis, and noncontrast computed tomography showing enlarged right hemiscrotum with hyperdense material present focally (suggesting calcification or hemorrhage) led to surgical exploration. Clear fluid was drained from the right hydrocele. The right testicle had a mottled cyanotic appearance with an area of acute hemorrhage with cyanotic discoloration between the epididymis and testis. Epididymis and mesorchium were elongated, with dysjunction from the testes. A 180° torsion of the mesorchium, in addition to a twist in the mesorchium overlying the vasculature between the epididymis and testis, were observed. This tissue was gently lifted and incised, and the testis resumed normal coloration. Twisted tissue of the mesorchium seemed to have impinged upon vascular flow. The patient 84
had complete resolution of symptoms postoperatively and no testicular atrophy.
COMMENT In this atypical case of testicular torsion observed over 16 days, serial physical examinations and multiple radiologic studies failed to provide a strong case for the diagnosis of testicular torsion. Atypical presentation and intermittent pain, which stopped during antibiotic treatment, at times localizing to the scrotum but also to the anterior hip and costovertebral angle, were confusing findings. Cremasteric reflex was present throughout. This physical examination lacked the usual findings that direct surgical exploration. Initial ultrasound and computed tomography studies were nonconclusive, with only altered echogenicity of the epididymis, edema, and hydrocele. These nonspecific findings may be associated with trauma, epididymo-orchitis, or testicular torsion.1,2 Radiologic studies may differentiate torsion from nonsurgical conditions. Color Doppler ultrasound and scintigraphy evaluate perfusion and anatomy. Color Doppler ultrasound has a sensitivity of 88.9% and a specificity of 98.8%12 but is technically difficult in infants. It is reliable and reproducible in large multicenter studies.12-14 Scintigraphy, using technetium-99m pertechnetate, has a sensitivity of 100%.15 Segmental ischemia may be found in cases of intermittent torsion.16 Typically, normal flow is present with torsion of appendices testes, normal or increased flow in epididymitis. Decreased radiotracer is noted in ischemic testes, whereas increased perfusion is seen in an inflamed testicle.17 Recognition of slightly diminished vascularity was key to this diagnosis. Doppler spectral analysis showed UROLOGY 73 (1), 2009
crease in testicular weight despite return of blood flow has been shown in an animal model.24
CONCLUSIONS To our knowledge, this is the only recorded case of mesorchial testicular torsion with clinical and radiologic findings detailed. Scrotal pain from torsion may be atypical at presentation; if persistent, careful reassessment, radiologic studies, and surgical exploration may be required. Figure 2. Spectral Doppler image demonstrating decreased arterial velocity compared with left (amplitude from baseline).
Figure 3. Operative finding of mesorchial torsion with hemorrhage and inflammation exudate.
a normal low-resistance, high-flow spectral waveform in the nonaffected testis and a high-impedance waveform with decreased diastolic flow in the affected testis (Fig. 2). Surgery for torsion should occur immediately to minimize ischemic damage. Testicular salvage is estimated at 90% if detorsion is within 6 hours of onset but decreases to 50% after 12 hours and 10% after 24 hours.18,19 Orchiectomy may be required if the testicle is necrotic and perfusion not observed. In retrospect the location of mesorchial torsion and surgical findings of hemorrhage and vascular compromise correlate. Upon surgical exploration, an anatomic anomaly with a distinct abnormal membrane was identified as torsed and was lysed to re-establish perfusion. The membrane arises from the visceral tunica vaginalis, extending over the epididymal surface with attachment at the junction between the epididymis and parietal tunica vaginalis (Fig. 3). Orchiopexy is performed on the affected testes if perfusion is re-established and on the contralateral testis as a preventive measure. Ischemia may cause ultrastructural changes in the contralateral testis20 and induce antitesticular or antisperm antibody production.21-23 Loss of spermatogenesis and deUROLOGY 73 (1), 2009
References 1. Lin EP, Bhatt S, Rubens DJ, et al. Testicular torsion: twists and turns. Semin Ultrasound CT MR. 2007;28:317-328. 2. Vijayaraghavan SB. Sonographic differential diagnosis of acute scrotum: real-time whirlpool sign, a key sign of torsion. J Ultrasound Med. 2006;25:563-574. 3. Favorito LA, Cavalcante AG, Costa WS. Anatomic aspects of epididymis and tunica vaginalis in patients with testicular torsion. Int Braz J Urol. 2004;30:420-424. 4. Bentley DF, Ricchiuti DJ, Nasrallah PF, et al. Spermatic cord torsion with preserved testis perfusion: initial anatomical observations. J Urol. 2004;172:2373-2376. 5. Williamson RC. Torsion of the testis and allied conditions. Br J Surg. 1979;63:465-476. 6. Espy PG, Koo HP. Torsion of the testicle. In: Graham SM Jr, Glenn JF, Keane TE, eds. Glenn’s Urologic Surgery. 6th ed. Philadelphia: Lippincott Williams and Wilkins; 2004:513-517. 7. Rajfer J. Congenital anomalies of the testis and scrotum. In: Walsh PC, Retik AB, Vaughan ED Jr, et al, eds. Campbell’s Urology. 7th ed. Philadelphia: W. B. Saunders; 1998:2184-2186. 8. Arena F, Nicòtina PA, Romeo C, et al. Prenatal testicular torsion: ultrasonographic features, management and histopathological findings. Int J Urol. 2006;13:135-141. 9. Chiang MC, Chen HW, Fu RH, et al. Clinical features of testicular torsion and epididymo-orchitis in infants younger than 3 months. J Pediatr Surg. 2007;42:1574-1577. 10. Kelalis PP, King LR, Belman AB. Clinical Pediatric Urology. 2nd ed. Philadelphia: W. B. Saunders; 1985:649-654. 11. Dresner ML. Torsed appendage. Diagnosis and management: blue dot sign. Urology. 1973;1:63-66. 12. Baker LA, Sigman D, Mathews RI, et al. An analysis of clinical outcomes using color Doppler testicular ultrasound for testicular torsion. Pediatrics. 2000;105:604-607. 13. Kalfa N, Veyrac C, Lopez M, et al. Multicenter assessment of ultrasound of the spermatic cord in children with acute scrotum. J Urol. 2007;177:297-301. 14. Gunther P, Schenk JP, Wunsch R, et al. Acute testicular torsion in children: the role of sonography in the diagnostic workup. Eur Radiol. 2006;16:2527-2532. 15. Eshghi M, Silver L, Smith AD. Technetium 99m scan in acute scrotal lesions. Urology. 1987;30:586-593. 16. White WM, Brewer ME, Kim ED. Segmental ischemia of testis secondary to intermittent testicular torsion. Urology. 2006;68:670671. 17. Chen DC, Holder LE, Melloul M. Radionuclide scrotal imaging: further experience with 210 new patients. Part 2: results and discussion. J Nucl Med. 1983;24:841-853. 18. Ringdahl E, Teague L. Testicular torsion. Am Fam Physician. 2006; 74:1739-1743. 19. Davenport M. ABC of general surgery in children. Acute problems of the scrotum. Br Med J. 1996;312:435-437.
85
20. Savas C, Ozogul C, Karaoz E, et al. Ischemia, whether from ligation or torsion, causes ultrastructural changes on the contralateral testis. Scand J Urol Nephrol. 2002;36:302-306. 21. Pentyala S, Lee J, Yalamanchili P, et al. Testicular torsion: a review. J Low Genit Tract Dis. 2001;5:38-47. 22. Arap MA, Vicentini FC, Cocuzza M, et al. Late hormonal levels, semen parameters, and presence of antisperm antibodies in
86
patients treated for testicular torsion. J Androl. 2007;28: 528-532. 23. Kos¸ar A, Küpeli B, Alçigir G, et al. Immunologic aspect of testicular torsion: detection of antisperm antibodies in contralateral testicle. Eur Urol. 1999;36:640-644. 24. Turner TT, Brown KJ. Spermatic cord torsion: loss of spermatogenesis despite return of blood flow. Biol Reprod. 1993;49:401-407.
UROLOGY 73 (1), 2009
T
esticular torsion is a twisting of the entire spermatic cord or a portion thereof, causing ischemia. Grouped as extravaginal, intravaginal, or mesorchial torsion (Fig. 1),1-3 a variance in mesenteric (mesorchium) attachment can be causative. Narrow attachment allows the testis to fall forward, increasing testicular mobility. Broad mesenteric attachment maintains upright integrity, limiting testicular motion. Pubertal testicular enlargement increases the possibility of torsion. Anomalies in epididymal attachment to the testis and nondescent may also lead to torsion.4,5 Testicular torsion can occur at any age but is most common in adolescence.6 Extravaginal torsion, a perinatal phenomenon occurring when the scrotum is not securely attached to the tunica vaginalis,3,7 is rare.8,9 Intravaginal torsion (65%-80% of torsions) may be associated with bell-clapper deformity, which occurs when tunica vaginalis completely encircles the epididymis, distal spermatic cord, and testis.1,3 Normally the tunica vaginalis attaches to the posterolateral aspect of the scrotal wall and suspends the testes in a vertical position. Horizontal lie creates a greater propensity to torsion.3,6 Typically, the anterior half of the testes is covered by mesothelium, and the posterior surface is loosely adherent to the scrotal wall.10 Anomalies of suspension of the mesothelium occur with narrow-based attachments of the testes.7 Mesorchial torsion is a twist in tissue overlying the vasculature (anteriorly) between the epididymis and parietal tunica vaginalis, associated with abnormality of the membrane and epididymal attachments to the testes.
From the Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania; and Hamot Medical Center, Erie, Pennsylvania Reprint requests: Justine M. Schober, M.D., 333 State St, Suite 201, Erie, PA 16507. E-mail: [email protected] Submitted: May 19, 2008, accepted (with revisions): June 28, 2008
© 2009 Elsevier Inc. All Rights Reserved
Degree of rotation is a good predictor of ischemia. Three main arteries supply the scrotum and its contents (testicular, cremasteric, and deferential). The testicular artery is the primary supply to the testes and epididymis, the cremasteric artery supplies the peritesticular tissues, the deferential artery the vas deferens. Torsion leads to obstruction of venous drainage, followed by vascular engorgement. Obstruction of arterial inflow and ultimately ischemia are a secondary process.1 Vessels in a thin cord are easily compressed, whereas a thicker cord is more resistant to kinking and could preserve blood flow.4 The contents of the spermatic cord include vas deferens and its artery, testicular artery, pampiniform plexus of veins, lymphatic vessels, and sympathetic nerves enclosed in fascial layers. Cremasteric muscle, innervated by the ilioinguinal nerve, encircles the spermatic cord and scrotum and is responsible for the cremasteric reflex. A classic finding in testicular torsion is absence of cremasteric reflex. The testicle of the affected side may be somewhat enlarged and higher when compared with the asymptomatic testicle. Hydrocele may be present, as well as scrotal erythema. The clinical picture of testicular torsion includes unilateral pain with swelling of the testicle. Duration of the pain is variable, lasting hours to days,1,3 intermittent or continuous. The differential diagnosis of scrotal pain includes torsion of appendix testis, epididymitis, and epididymoorchitis. Torsion of the appendix may present with a tender nodule and blue dot on the upper pole of the testicle,11 epididymitis with localized tenderness of the epididymis and a normal testicle. Epididymo-orchitis is characterized by scrotal and testicular pain, tenderness, edema, and erythema.
CASE REPORT A 13-year-old presented with a 48-hour history of right scrotal swelling and pain. Outpatient color Doppler ul0090-4295/09/$34.00 doi:10.1016/j.urology.2008.06.053
83
Figure 1. Classification of types of testicular torsion. (A) Intravaginal torsion; (B) extravaginal torsion; (C) torsion due to long mesorchium. (Reprinted with permission.3)
trasound (CDU) examination demonstrated right hydrocele, enlarged, heterogeneous epididymis, and thickening of the scrotum. The patient was diagnosed with epididymitis and administered amoxicillin. Worsening pain led to re-examination. Significant right epididymal tenderness, small right hydrocele, and intact cremasteric reflex was appreciated. The testes was not elevated. Examination by CDU again demonstrated normal blood flow, edema, and increased vascularity of the epididymis. The patient’s antibiotic was changed to ciprofloxacin, with notable improvement and resolution of tenderness after 10 days. The pain recurred, first testicular, then localizing along the anterior iliac crest and flank. Physical examination noted a larger, firm right scrotum with pronounced erythema. Color Doppler ultrasound demonstrated large right hydrocele, right-sided epididymitis, and orchitis. Diminished vascularity of the right testis, which the radiology department considered secondary to edema and pressure effects from the enlarged epididymis, and noncontrast computed tomography showing enlarged right hemiscrotum with hyperdense material present focally (suggesting calcification or hemorrhage) led to surgical exploration. Clear fluid was drained from the right hydrocele. The right testicle had a mottled cyanotic appearance with an area of acute hemorrhage with cyanotic discoloration between the epididymis and testis. Epididymis and mesorchium were elongated, with dysjunction from the testes. A 180° torsion of the mesorchium, in addition to a twist in the mesorchium overlying the vasculature between the epididymis and testis, were observed. This tissue was gently lifted and incised, and the testis resumed normal coloration. Twisted tissue of the mesorchium seemed to have impinged upon vascular flow. The patient 84
had complete resolution of symptoms postoperatively and no testicular atrophy.
COMMENT In this atypical case of testicular torsion observed over 16 days, serial physical examinations and multiple radiologic studies failed to provide a strong case for the diagnosis of testicular torsion. Atypical presentation and intermittent pain, which stopped during antibiotic treatment, at times localizing to the scrotum but also to the anterior hip and costovertebral angle, were confusing findings. Cremasteric reflex was present throughout. This physical examination lacked the usual findings that direct surgical exploration. Initial ultrasound and computed tomography studies were nonconclusive, with only altered echogenicity of the epididymis, edema, and hydrocele. These nonspecific findings may be associated with trauma, epididymo-orchitis, or testicular torsion.1,2 Radiologic studies may differentiate torsion from nonsurgical conditions. Color Doppler ultrasound and scintigraphy evaluate perfusion and anatomy. Color Doppler ultrasound has a sensitivity of 88.9% and a specificity of 98.8%12 but is technically difficult in infants. It is reliable and reproducible in large multicenter studies.12-14 Scintigraphy, using technetium-99m pertechnetate, has a sensitivity of 100%.15 Segmental ischemia may be found in cases of intermittent torsion.16 Typically, normal flow is present with torsion of appendices testes, normal or increased flow in epididymitis. Decreased radiotracer is noted in ischemic testes, whereas increased perfusion is seen in an inflamed testicle.17 Recognition of slightly diminished vascularity was key to this diagnosis. Doppler spectral analysis showed UROLOGY 73 (1), 2009
crease in testicular weight despite return of blood flow has been shown in an animal model.24
CONCLUSIONS To our knowledge, this is the only recorded case of mesorchial testicular torsion with clinical and radiologic findings detailed. Scrotal pain from torsion may be atypical at presentation; if persistent, careful reassessment, radiologic studies, and surgical exploration may be required. Figure 2. Spectral Doppler image demonstrating decreased arterial velocity compared with left (amplitude from baseline).
Figure 3. Operative finding of mesorchial torsion with hemorrhage and inflammation exudate.
a normal low-resistance, high-flow spectral waveform in the nonaffected testis and a high-impedance waveform with decreased diastolic flow in the affected testis (Fig. 2). Surgery for torsion should occur immediately to minimize ischemic damage. Testicular salvage is estimated at 90% if detorsion is within 6 hours of onset but decreases to 50% after 12 hours and 10% after 24 hours.18,19 Orchiectomy may be required if the testicle is necrotic and perfusion not observed. In retrospect the location of mesorchial torsion and surgical findings of hemorrhage and vascular compromise correlate. Upon surgical exploration, an anatomic anomaly with a distinct abnormal membrane was identified as torsed and was lysed to re-establish perfusion. The membrane arises from the visceral tunica vaginalis, extending over the epididymal surface with attachment at the junction between the epididymis and parietal tunica vaginalis (Fig. 3). Orchiopexy is performed on the affected testes if perfusion is re-established and on the contralateral testis as a preventive measure. Ischemia may cause ultrastructural changes in the contralateral testis20 and induce antitesticular or antisperm antibody production.21-23 Loss of spermatogenesis and deUROLOGY 73 (1), 2009
References 1. Lin EP, Bhatt S, Rubens DJ, et al. Testicular torsion: twists and turns. Semin Ultrasound CT MR. 2007;28:317-328. 2. Vijayaraghavan SB. Sonographic differential diagnosis of acute scrotum: real-time whirlpool sign, a key sign of torsion. J Ultrasound Med. 2006;25:563-574. 3. Favorito LA, Cavalcante AG, Costa WS. Anatomic aspects of epididymis and tunica vaginalis in patients with testicular torsion. Int Braz J Urol. 2004;30:420-424. 4. Bentley DF, Ricchiuti DJ, Nasrallah PF, et al. Spermatic cord torsion with preserved testis perfusion: initial anatomical observations. J Urol. 2004;172:2373-2376. 5. Williamson RC. Torsion of the testis and allied conditions. Br J Surg. 1979;63:465-476. 6. Espy PG, Koo HP. Torsion of the testicle. In: Graham SM Jr, Glenn JF, Keane TE, eds. Glenn’s Urologic Surgery. 6th ed. Philadelphia: Lippincott Williams and Wilkins; 2004:513-517. 7. Rajfer J. Congenital anomalies of the testis and scrotum. In: Walsh PC, Retik AB, Vaughan ED Jr, et al, eds. Campbell’s Urology. 7th ed. Philadelphia: W. B. Saunders; 1998:2184-2186. 8. Arena F, Nicòtina PA, Romeo C, et al. Prenatal testicular torsion: ultrasonographic features, management and histopathological findings. Int J Urol. 2006;13:135-141. 9. Chiang MC, Chen HW, Fu RH, et al. Clinical features of testicular torsion and epididymo-orchitis in infants younger than 3 months. J Pediatr Surg. 2007;42:1574-1577. 10. Kelalis PP, King LR, Belman AB. Clinical Pediatric Urology. 2nd ed. Philadelphia: W. B. Saunders; 1985:649-654. 11. Dresner ML. Torsed appendage. Diagnosis and management: blue dot sign. Urology. 1973;1:63-66. 12. Baker LA, Sigman D, Mathews RI, et al. An analysis of clinical outcomes using color Doppler testicular ultrasound for testicular torsion. Pediatrics. 2000;105:604-607. 13. Kalfa N, Veyrac C, Lopez M, et al. Multicenter assessment of ultrasound of the spermatic cord in children with acute scrotum. J Urol. 2007;177:297-301. 14. Gunther P, Schenk JP, Wunsch R, et al. Acute testicular torsion in children: the role of sonography in the diagnostic workup. Eur Radiol. 2006;16:2527-2532. 15. Eshghi M, Silver L, Smith AD. Technetium 99m scan in acute scrotal lesions. Urology. 1987;30:586-593. 16. White WM, Brewer ME, Kim ED. Segmental ischemia of testis secondary to intermittent testicular torsion. Urology. 2006;68:670671. 17. Chen DC, Holder LE, Melloul M. Radionuclide scrotal imaging: further experience with 210 new patients. Part 2: results and discussion. J Nucl Med. 1983;24:841-853. 18. Ringdahl E, Teague L. Testicular torsion. Am Fam Physician. 2006; 74:1739-1743. 19. Davenport M. ABC of general surgery in children. Acute problems of the scrotum. Br Med J. 1996;312:435-437.
85
20. Savas C, Ozogul C, Karaoz E, et al. Ischemia, whether from ligation or torsion, causes ultrastructural changes on the contralateral testis. Scand J Urol Nephrol. 2002;36:302-306. 21. Pentyala S, Lee J, Yalamanchili P, et al. Testicular torsion: a review. J Low Genit Tract Dis. 2001;5:38-47. 22. Arap MA, Vicentini FC, Cocuzza M, et al. Late hormonal levels, semen parameters, and presence of antisperm antibodies in
86
patients treated for testicular torsion. J Androl. 2007;28: 528-532. 23. Kos¸ar A, Küpeli B, Alçigir G, et al. Immunologic aspect of testicular torsion: detection of antisperm antibodies in contralateral testicle. Eur Urol. 1999;36:640-644. 24. Turner TT, Brown KJ. Spermatic cord torsion: loss of spermatogenesis despite return of blood flow. Biol Reprod. 1993;49:401-407.
UROLOGY 73 (1), 2009