TESTICULAR TORSION – A LIFE THREATENING MEDICAL EMERGENCY?

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common reason for a failed primary orchiopexy is inadequate cranial dissection of the hernia sac and vascular pedicle. In this study, we reviewed preoperative considerations and postoperative outcomes in our re-operative orchiopexy patients. METHODS: Thirty-two patients (35 testes) underwent reoperative orchiopexy between 1992 and 2007. The testicle was palpable in 28 and non-palpable in 4 cases. In most cases, previous incision scar was used for the surgical approach, which could be extended FUDQLDOO\LIQHHGHG7KHWHVWLVZDVLGHQWL¿HGDQGFDUHIXOO\PRELOL]HGZLWK preservation of the adjacent scar tissue in an effort to prevent inadvertent LQMXU\:LWK¿QHGLVVHFWLRQWKHYDVFXODUSHGLFOHZDVGLVVHFWHGFUDQLDOO\ IROORZHGE\VNHOHWRQL]DWLRQRIWKHYHVVHOVDQGWKHYDVGHIHUHQV'DUWRV pouch orchiopexy was completed without any consequence. RESULTS: Orchiectomy was required in 4 cases due to inadvertent injury to the vascular pedicle (n=1), and testicular atrophy Q  ,QFDVHVWKHWHVWLFOHFRXOGQRWEHPRELOL]HGIXUWKHUFDXGDOO\ and it was concluded that primary surgery was performed correctly. 7KH UHPDLQLQJ  WHVWLFOHV FRXOG EH PRELOL]HG FDXGDOO\ ZLWK D ¿QDO scrotal position in 20. Among the 4 non-palpable testicles, 2 could not be found during exploration. The remaining 2 were intraabdominal and were successfully brought to a high-scrotal location. Atrophy was not evident in any case with a follow-up of at least 12 months. &21&/86,216,QRXUH[SHULHQFHD¿QDOVFURWDOSRVLWLRQ could be achieved in 60% of the cases who underwent re-operative orchiopexy. During these highly demanding procedures, inadequate cranial dissection of the vascular pedicle off the peritoneum and the FUHPDVWHULF¿EHUVZDVREVHUYHGWREHWKHSULPDU\FDXVHIRUWKHLQLWLDO failure. We also stress the importance of en-bloc dissection of the testis with the surrounding scar tissue in order to avoid inadvertent injury to the blood supply. Source of Funding: None

410 MALIGNANT POTENTIAL OF THE CRYPTORCHID TESTIS ASSOCIATED WITH BILATERAL OCCURRENCE, PERSISTENT NON-DESCENT, AND ADVANCED AGE AT REPAIR: RESULTS OF A COMPREHENSIVE META-ANALYSIS Kimberly Banks, Ellenie Tuazon, Chester Koh, Roger De Filippo, Andy Chang, Kiros Berhane, Victoria K Cortessis*. Orange, CA, and Los Angeles, CA. INTRODUCTION AND OBJECTIVE: Cryptochidism (CO) is an important risk factor for testis cancer (TC), but the small subset of boys with CO who are likely to develop neoplasm cannot be distinguished in infancy. 0(7+2'66\VWHPDWLFUHYLHZLGHQWL¿HGSXEOLVKHGUHSRUWV RQ WKH &27& DVVRFLDWLRQ DPRQJ FRPSDUDEOH PHQ  H[DPLQHG features of CO postulated to modify the association: anatomic location and number of undescended testes, means and age of CO resolution/ repair. Anatomic data were too sparse for analysis. Remaining factors ZHUHWUHDWHGDVSRWHQWLDOPRGL¿HUVLQIRUPDOPHWDDQD\VHVLPSOHPHQWHG using STATA. RESULTS: Overall, TC was over four times more common among men with reported history of CO (odds ratio (OR)=4.3, 95% CI=3.7-5.0). Regarding laterality, weakest CO-TC association was observed in testes ipsilateral to unlilaterally undescended testes (OR=1.5, 95% CI=0.9-2.5), intermediate in those contralateral to unilaterally undescended testes (OR=5.1, 95% CI=3.4-7.6), and highest in bilaterally undescended testes (OR=7.1, 95% CI=3.5-14.6), trend P=0.03. Regarding means of descent, the association was weakest for testes that descended spontaneously (OR=1.3, 95% CI=0.9-1.8), intermediate for testes repositioned by treatment (OR=4.3, 95% CI=3.2-5.7), and greatest for those remaining undescended (OR=6.2,  &,   EXW GLIIHUHQFHV ZHUH QRW VLJQ¿FDQW WUHQG 3  Among treated testes, the CO-TC assocation was lowest for correction by 9 years (OR=2.7, 95% CI=1.2-6.1), intermediate for correction at 10-14 years (OR=4.5, 95% CI=2.9-6.8), and highest for correction after 14 years of age (OR=6.3, 95% CI=3.3-11.9), trend P=0.02. CONCLUSIONS: This comprehensive meta-analysis suggests that measureable features of CO may indicate malignant potential. However, longitudinal data relating anatomic position of cryptorchid testes to risk of neoplasm are needed. Testes repositioned

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into the scrotum at earlier ages experienced lower rates of malignancy, but published data do not address timepoints of greatest interest (3 months to 2 years of age). It is possible that this pattern arose in part from presence in earlier intervention groups of higher proportions of testes destined to descend spontanously in the absence of intervention, and therefore at inherently lower risk of malignancy. Nonetheless, features of CO addressed in this analysis together with emerging biomarkers may SURYLGHDEDVLVIRUPRUHLQGLYLGXDOL]HGPDQDJHPHQWRI&2 Source of Funding: None

411 DEFINING SALVAGE AFTER TESTICULAR TORSION IMPACTS COUNSELLING AND FOLLOW-UP John H Makari*, John C Pope, Mark C Adams, John W Brock, John C Thomas. Nashville, TN. INTRODUCTION AND OBJECTIVE: Reported rates of testicular salvage following surgical exploration for presumed testicular WRUVLRQYDU\PDUNHGO\LQSDUWGXHWRYDULDEOHGH¿QLWLRQVRI³VDOYDJH´:H VWXGLHGWKHLPSDFWRISUHFLVHGH¿QLWLRQRIWHVWLFXODUVDOYDJH METHODS: We reviewed the records of all pediatric patients who underwent surgical exploration for presumed testicular torsion at our institution between 1998 and 2006 and who had at least one postoperative follow-up visit or testicular sonogram. We excluded patients with alternate GLDJQRVHV RQ H[SORUDWLRQ :H GH¿QHG ³LQWUDRSHUDWLYH VDOYDJH´ DV D YLDEOHWHVWLVZRUWK\RI¿[DWLRQDQG³SRVWRSHUDWLYHVDOYDJH´DVV\PPHWULF testes on postoperative sonogram or exam. We examined presenting FKDUDFWHULVWLFVRSHUDWLYH¿QGLQJVDQGRXWFRPHVRIVXUJLFDOLQWHUYHQWLRQ in patients with intraoperative salvage. RESULTS: 51 boys underwent surgical exploration for presumed testicular torsion. 6 patients were found to have torsed appendages and were excluded from review. Of the remaining 45 SDWLHQWV    XQGHUZHQW RUFKLHFWRP\ IRU D QRQYLDEOH WHVWLFOH 15 (33%) had intraoperative salvage. In patients with intraoperative salvage, mean age was 14.0 y. 4 patients were lost to follow-up, leaving 11 patients with follow-up (mean 131.5 months) after intraoperative salvage. On follow-up, 7 (64%) patients with intraoperative salvage had postoperative salvage (3 by sonogram, 4 by exam) while 4 (36%) had asymmetry or atrophy (1 by sonogram, 3 by exam). Of patients with asymmetry or atrophy, 3 (75%) were surgically explored in less than 6 hours. CONCLUSIONS: Distinguishing intraoperative from postoperative salvage after testicular torsion is important. The impact of testicular asymmetry after testicular torsion on fertility is unclear, but LWVSUHVHQFHLVVLJQL¿FDQWGHVSLWHLQWUDRSHUDWLYHVDOYDJH$GGLWLRQDOO\ intervention prior to six hours does not guarantee postoperative salvage. These data have implications for preoperative counseling about the expectations for surgical intervention and for determining the appropriate interval for postoperative follow-up. Source of Funding: None

412 TESTICULAR TORSION – A LIFE THREATENING MEDICAL EMERGENCY? Michael C Carr*, Thomas F Kolon, Pasquale Casale, Stephen A Zderic, Howard M Snyder, Nicholas Tsarouhas, Douglas A Canning. Philadelphia, PA. INTRODUCTION AND OBJECTIVE: We reviewed the emergency transport records for a major urban pediatric center from September 2005 to August 2007 for those patients deemed to have acute scrotal pathology. METHODS: A total of 146 patients were referred to the emergency department for evaluation of testicular swelling, pain, trauma, testicular torsion or rule out testicular torsion. Most patients were brought to the emergency department by private vehicle (n = 122) but 16 arrived via emergency ground transportation and 8 by rotor-wing. 5(68/76:HDVVHVVHGWKH¿QDOGLDJQRVLVRIWKRVHSDWLHQWV ZKRDUULYHGE\HPHUJHQF\WUDQVSRUWJURXQGDQG¿[HGURWRU DVZHOO as the salvage rate of testicular torsion. Of those patients who arrived by ground transportation, only 2 of 16 patients required urgent surgery with one successful detorsion occurring. For those arriving via air

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transportation, two patients had successful detorsion and salvage, two required orchiectomy for torsion and one for a shattered testis. The remaining three patients had intermittent torsion which was dealt with via bilateral orchidopexies within twelve hours of arrival. CONCLUSIONS: We are beginning to identify a trend in which patients are told that urologic care is unavailable at outside institutions which then necessitates emergency transportation to the pediatric center. Precious time has been lost while waiting for transportation and an increased risk to both transport team and patient occurs due to the inability of the outside hospital to assume the care of this child. Source of Funding: None

413 SCREENING FOR A GENETIC BASIS FOR TESTICULAR TORSION: THE INSULIN-3 (INSL3) AND LGR8 GENES Yi Wang*, Maggy Fina, Shaohua Zhang, Ronald Taussig, Linda A Baker. Dallas, TX. INTRODUCTION AND OBJECTIVE: The mechanism and molecular basis of testicular torsion is poorly understood. Rare reports of familial torsion possibly suggest a genetic basis. The testis hormone INSL3 and its receptor, LGR8, are key mediators in murine and human testicular descent. Our Insl3 mutant mice have spontaneous testicular torsion and vanished testes. In our human mutation screening, we observed monorchia in 2 of 6 cryptorchids with LGR8 mutations. To date, no one has screened for mutations in INSL3 or LGR8 in patients ZLWKWHVWLFXODUWRUVLRQZHVRXJKWWRDVVHVVDJHQHWLFEDVLVRIWHVWLFXODU torsion. METHODS: From acute or intermittent torsion patients (n=36), genomic DNA was screened for mutations in human INSL3 and LGR8. 105 cryptorchid males and the NCBI dbSNP database VHUYHGDVFRQWUROV7KHPXWDQWSURWHLQVFRQWDLQLQJLGHQWL¿HGPLVVHQVH mutations were functionally tested via mutant receptor transfection into HEK293 cells, and subsequent assessment of cAMP production after stimulation with INSL3. RESULTS: Eleven newborn torsion specimens (mean age GD\V ZHUHREWDLQHGIURPXQLODWHUDO5/ DQGELODWHUDOFDVHV Of the 11, 3 of 7 queried have positive family history (+FHx) of torsion. 25 peripubertal torsion specimens (mean age 8.6 yrs) were obtained IURPXQLODWHUDO5/ DQGELODWHUDOFDVHV2IWKHVHRI queried have +FHx of torsion. No nonsynonymous mutations were found in INSL3. In addition to 3 known silent polymorphisms (A87A, ((DQG// DQGWKHIXQFWLRQDOO\LQVLJQL¿FDQWPLVVHQVH,9 PXWDWLRQLQWKH/*5JHQHZHGHWHFWHGDQRYHOKHWHUR]\JRXV65 mutation in a unilateral neonatal torsion patient with +FHx of torsion and cryptorchidism which was absent in controls. Testing showed the mutant T222P, S314R, R532G, and I604V LGR8 receptors stimulate cAMP same as wild type receptor, with equal dose response curves. CONCLUSIONS: A novel missense mutation in the LGR8 JHQHZDVLGHQWL¿HGLQIDPLOLDOQHZERUQWRUVLRQKRZHYHUPXWDQWSURWHLQ testing did not reveal functional disturbance. Thus mutations in Insl3 and LGR8 are not common in testicular torsion patients. Source of Funding: NIH R01 HD48838 (Baker, LA).

414 INGUINAL HERNIAS IN PREMATURE INFANTS: IS THERE MORBIDITY ASSOCIATED WITH DELAYED REPAIR? Dena L Walsh*, John C Pope, Mark C Adams, John W Brock, John C Thomas. Nashville, TN. INTRODUCTION AND OBJECTIVE: Inguinal hernias occur in approximately 25% of premature infants. Surgical correction is the standard of care. Controversy exists concerning immediate versus delayed repair in terms of increased morbidity. We reviewed our experience with premature infant hernias to address this issue. METHODS: A retrospective review of premature infants (gestational age < 36 weeks) who had undergone inguinal hernia repair was performed at our institution between February 2002 and May 2007. We recorded estimated gestational age at birth, age at initial diagnosis at the time of consultation, time from diagnosis to repair, adverse events, and intra-or postoperative complications.

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5(68/76)LIW\HLJKWFKLOGUHQZHUHLGHQWL¿HGDQGLQFOXGHG in this study. The male to female ratio was 28:1 (56 males/2 females). Mean gestational age (GA) at birth was 30.4 weeks (range 23 weeks - 36 weeks). Mean GA age at initial urologic consult and diagnosis was 42 weeks (range 36 weeks -53 weeks). Mean GA age at surgical correction was 45 weeks (range 38 weeks - 65 weeks). Mean time from urology consult/diagnosis to repair was 26 days (range 0 - 164 days). Unilateral KHUQLDVZHUHLGHQWL¿HGLQIRXUSDWLHQWV DQGELODWHUDOLQ¿IW\IRXU patients (93%). Ten patients had adverse events while waiting for repair, LQFOXGLQJLQFDUFHUDWLRQLQRQH DQGDQ(5RURI¿FHYLVLWWRUHGXFH the hernia in nine (15.5%). There were two (2/58, 3.4%) postoperative pulmonary complications including respiratory distress and prolonged intubation. Recurrence of the hernia was seen in one patient (1.7%) who required further surgical treatment. There was no incidence of bowel perforation or gangrenous bowel. CONCLUSIONS: Delaying repair did not seem to be associated with major morbidity, as true incarceration occurred in one SDWLHQW$OVR DQRWKHU EHQH¿W WR GHOD\LQJ VXUJHU\ PD\ EH PLQLPL]LQJ SRVWRSHUDWLYHUHVSLUDWRU\SUREOHPVDOWKRXJKWKLVLVGLI¿FXOWWRSURYHZLWK a retrospective study. The most common problem encountered during the waiting period was elective reduction of the hernia. Therefore, daily inspection of the hernia by nursing staff or parents along with education on reduction and potential signs of incarceration are necessary to make delaying the repair safe and feasible. Source of Funding: None

415 SURGICAL TREATMENT OF VARICOCELE IN CHILDREN BY THE OPEN AND LAPAROSCOPIC PALOMO TECHNIQUE. A METANALYSIS Ubirajara Barroso*, Dennysson M Andrade, Hugo Novaes, Jose M Netto, Juarez Andrade. Salvador, Brazil, and Juiz de Fora, Brazil. INTRODUCTION AND OBJECTIVE: The aim of this study is to evaluate the surgical results of the treatment of varicocele in children E\RSHQDQGODSDURVFRSLFDVZHOODVWKHFODVVLFDQGPRGL¿HG3DORPR technique by means of a systematic review of the literature. METHODS: A systematic review of the literature was performed based on an English literature search using the MEDLINE® database between 1970 and 2006. The key words used were varicocele and children. All articles that were related to treatment of varicocele in children and adolescents with Palomo technique were selected. The exclusion criteria was age higher than 18 years and articles in which the type of treatment and the outcome were not clear. Palomo technique was GH¿QHGDVDKLJKOLJDWLRQRIWKHYHVVHOVSUR[LPDOWRWKHLQWHUQDOLQJXLQDO RUL¿FH:KHQDOOWHVWLFXODUYHLQVDQGDUWHU\ZHUHOLJDWHGWKHVXUJHU\ZDV FDOOHG&ODVVLF3DORPR&3 DQGPRGL¿HG3DORPR03 ZKHQWKHDUWHU\ was spared. Of 264 papers evaluated 47 were selected. There were only SURVSHFWLYHFDVHVHULHVDQGUDQGRPL]HGFOLQLFDOWULDO RESULTS: 2054 patients were included in the analisis, 1437 and 617 patients were treated by the open and the laparocopic Palomo technique, respectively. When we compared CP with MP the rate of hydrocele and varicocele recurrence was 7.8% vs. 3.2% (P<0.001) DQG  YV  S   UHVSHFWLYHO\ :KHQ ZH DQDO\]HG RQO\ patients who undergone MP, laparoscopic technique had a lower rate of varicocele recurrence 3.8% vs. 10% (P=0.026) than open surgery. The rate of hydrocele in the laparoscopic CP and CP open surgery was 7.1% vs. 11.4% (p=0.146), respectively. The rate of hydrocele in the prospective studies was 23.8% compared to 5.2% in the retrospective VHULHV7KH UDQJH RI WHVWLFXODU FDWFK XS ZDV ]HUR WR  PHDQ RI 71.5% and 58% in the CP and MP groups, respectively) CONCLUSIONS: This metanalysis demonstrates that a high rate of hydrocele should be expected in the classic Palomo technique. The rate of testicular catch up after surgery is only reasonable. Source of Funding: None