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Journal of Pediatric Surgery Case Reports

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Testicular torsion after previous surgical fixation

Sina Koochakzadeha, Kelly Johnsonb, Mark A. Richa,b,c, Hubert S. Swanaa,b,c,∗
a
University of Central Florida College of Medicine, 6850 Lake Nona Blvd, Orlando, FL 32827, United States
b
University of South Florida Morsani College of Medicine, 12901 Bruce B. Down Blvd., Tampa, FL 33612, United States
c
Arnold Palmer Hospital for Children Urology Center, 1725 Cook Ave., Orlando, FL 32806, United States

A R T I C LE I N FO A B S T R A C T

Keywords: Recurrent testicular torsion after previous surgical fixation is uncommon. We present the case of a 13-year-old
Orhchidopexy male with a previous history of left testicular torsion requiring left orchiectomy and right fixation that presented
Torsion to the emergency room with testicular torsion in the remaining testis. We discuss management and review the
Re-torsion literature.

1. Introduction
Testicular torsion is a urologic emergency with potentially devas-
tating consequences if a there is a delay in diagnosis. After surgical
exploration, reduction of torsion and restoration of blood flow, bilateral
testicular fixation is performed to prevent recurrent torsion. Testicular
torsion can still occur in testicles that have undergone previous fixation.
restoration blood flow (Video 1). The previous sutures were removed.
The testicle was fixed at four points with 4-0 non-absorbable sutures
from the tunica albuginea through the muscle of the scrotal septum
(Fig. 3).
Supplementary video related to this article can be found at https://
doi.org/10.1016/j.epsc.2019.101225.
The patient recovered without complication.

1.1. Case report 2. Discussion

A 13 year-old boy presented to the emergency room with a sudden
onset of severe right scrotal pain. There was no history of trauma. His
physical exam revealed a swollen, tender high-riding right testicle.
Scrotal ultrasonography demonstrated absence of testicular blood flow
in a solitary right testicle. One year prior to this admission the patient
underwent left orchiectomy and right orchidopexy for left testicular
torsion. Review of the post-operative notes revealed a Bell clapper de-
formity and a clockwise torsion of almost 900°. Four-point fixation of
the right testicle using 4-0 prolene sutures to the dartos had been
previously performed.
Despite the history of previous right orchidopexy, the decision was
made to proceed with emergent scrotal exploration due to the high
suspicion for testicular torsion. Surgery was performed through a
midline raphe incision and revealed right intravaginal testicular tor-
sion. The testicle had twisted 360°. The previously placed Prolene
fixation sutures were intact and remained attached to the tunica albu-
ginea but had pulled though the dartos layer. One of the remaining
sutures acted as a point of fixation and axis of rotation allowing torsion
to occur (Fig. 1 and Fig. 2).
The testicle was untwisted and Doppler ultrasound confirmed
Torsion of a previously fixed testicle is a rare occurrence after
previous fixation [1–4]. Failure to consider this possibility may lead to
delay in diagnosis and testicular loss. Sells and colleagues [5] reviewed
20 cases of recurrent testicular torsion after fixation. They were able to
identify the suture material that was used in 17 of the cases. Zastrow
and Sotelino [6] analyzed 23 publications that included 40 patients
with acute testicular torsion after an orchidopexy. The patients ranged
in age from 10 to 39 years and presented 3 months to 20 years after
initial orchidopexy. Both studies demonstrated a higher incidence of
recurrent torsion after the use of absorbable sutures versus non-ab-
sorbable suture materials. They felt, however, that because absorbable
sutures were more commonly utilized that it was not possible to attri-
bute recurrent torsion based on absorbable vs non-absorbable suture
type. In our case permanent suture material was used but the sutures
had pulled out of the dartos layer. It is possible that a larger “bite” of
dartos during initial orchidopexy may have been necessary and that the
issue was one of technique.
Sells et al. [5] also reviewed animal studies that placed the tunica
albuginea directly against the dartos layer in an attempt to achieve
better adhesion and fixation of testis. Sells et al. described a technique

∗
Corresponding author. Arnold Palmer Hospital for Children Urology Center, 1725 Cook Ave., Orlando, FL 32806, United States.
E-mail address: Hubert.Swana@OrlandoHealth.com (H.S. Swana).

https://doi.org/10.1016/j.epsc.2019.101225
Received 27 April 2019; Accepted 11 May 2019

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S. Koochakzadeh, et al.

Fig. 3. 4-point fixation of right testis form tunica albuginea through muscle of
scrotal septum.

they reviewed [6]. They concluded that regardless of suture material or

surgical technique, torsion of a previously fixed testis was still possible
especially if the testicle had an abnormal orientation. To the authors'
knowledge, no study has definitively compared outcomes using dif-
ferent testicular fixation techniques. It is currently recommended that
permanent sutures be used for testicular fixation to prevent torsion [9].

3. Conclusion

Recurrent testicular torsion after previous fixation is a rare possi-

bility that must be considered when patients present with signs and
Figs. 1. 360° torsion of the right testis.
symptoms suspicious for torsion. Previous fixation of the testicle, re-
gardless of technique or material used, does not rule out the diagnosis
of re-torsion in male presenting with acute scrotal pain.

3.1. Patient consent

Any personal information that could lead to the identification of the

patient has been removed. Consent for treatment at our institution as
well as consent to the use of anonymized photographs for scholarly
publications was obtained.

Funding

No funding or grant support.

Authorship

All authors attest that they meet the current ICMJE criteria for au-
thorship.

Fig. 2. Remaining suture acting as point of fixation and axis of rotation for the Conflict of interest
right testis.
The following authors have no financial disclosures: SK, KJ, HS, and
MR.
using absorbable sutures to fix the tunica albuginea to the dartos layer
with complete eversion of the tunica vaginalis [5]. In 1993, Lent and
Appendix A. Supplementary data
Stephani [7] proposed everting the tunica vaginalis without direct su-
turing of the testis or fixation. They described a series of 35 patients
Supplementary data to this article can be found online at https://
treated with this technique that had no recurrent torsion with a mean
doi.org/10.1016/j.epsc.2019.101225.
follow up period of 6.5 years. In a follow up study in 2013, Lent and
Viegas described a series of 53 patients that responded a questionnaire
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For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
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For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.