Author's Accepted Manuscript

Testicular Torsion Presentation Trends Before and After Pediatric Urology

Subspecialty Certification

Christopher E. Bayne , Patrick T. Gomella , John M. DiBianco , Tanya D. Davis ,

Hans G. Pohl , H.G. Rushton

PII: S0022-5347(16)31409-4
DOI: 10.1016/j.juro.2016.09.090
Reference: JURO 14055

To appear in: The Journal of Urology

Accepted Date: 14 September 2016

Please cite this article as: Bayne CE, Gomella PT, DiBianco JM, Davis TD, Pohl HG, Rushton HG,
Testicular Torsion Presentation Trends Before and After Pediatric Urology Subspecialty Certification,
The Journal of Urology® (2016), doi: 10.1016/j.juro.2016.09.090.

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 ACCEPTED MANUSCRIPT

TESTICULAR TORSION PRESENTATION TRENDS BEFORE AND AFTER

PEDIATRIC UROLOGY SUBSPECIALTY CERTIFICATION

Christopher E. Bayne1, Patrick T. Gomella2, John M. DiBianco2, Tanya D. Davis1, Hans

G. Pohl1, H. G. Rushton1
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Division of Urology, Children’s National Medical Center, Washington, DC, USA

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Department of Urology, The George Washington University, Washington, DC, USA

Abstract word count 247

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Manuscript word count: 2,499

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Running head: Testicular torsion referral patterns

Key words: spermatic cord torsion, referral and consultation, clinical practice patterns,
pediatric urology, certification

Corresponding author:
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Christopher E. Bayne, MD
Children’s National Medical Center
111 Michigan Ave, NW
Washington, DC 20010
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Ph: (757) 639-7773

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ABSTRACT

Purpose

Examine testicular torsion presentation and referral trends at our institution before and

after pediatric urology subspecialty certification.

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Materials and Methods

We reviewed cases of testicular torsion presenting directly to our children’s hospital

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emergency department (ED) (“direct”) and transferred from an outside ED (“referred”)

that underwent detorsion and orchiopexy or orchiectomy between 2005 and 2015.

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Presentations were considered acute (<24 hours) or delayed (≥24 hours) based on time
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from symptom onset. The primary outcomes were case volume and presentation trends

over time. Secondary outcomes were the effect of presenting location and transport
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variables on orchiectomy rate.

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Results

The incidence of testicular torsion increased from 15 cases in 2005 to 32 in 2015. The
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annual incidence of direct cases increased slightly over the study period from 12 to 17

whereas the incidence of referred cases increased from 3 in 2005 to 15 in 2015. The
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proportion of referred acute cases markedly increased from the pre- (4/63, 6.3%) to post-
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certification (42/155, 27.1%) periods (p<0.01). The majority of referred cases (59/83,

71.1%) presented during weekday nights or weekends compared to a minority of direct

cases (59/135, 43.7%; p<0.01). Orchiectomy rates were similar between direct and

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referred cases across all study periods and were not significantly impacted by

presentation location, transport distance, or transport modality (all p>0.05).

Conclusions

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Patients with testicular torsion have been increasingly referred to our institution with the

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majority presenting on weekday nights and weekends. Our data do not support routinely

transferring these patients to dedicated pediatric hospitals.

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INTRODUCTION

The American Board of Urology granted the first subspecialty Certificate of Added

Qualification (CAQ) in pediatric urology in 2008.1 The intent of pediatric urology

certification was to ensure specialized surgeons for high quality patient care. During the

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approval process, there was concern certification would have unintended consequences

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on patients and physicians.2 At our institution we have perceived an increase in testicular

torsion referrals from outside emergency departments (EDs) since pediatric urology

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certification. We sought to analyze testicular torsion presentation trends and outcomes at

our institution before and after the first certifications were issued.

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MATERIALS AND METHODS

After institutional review board approval, we retrospectively reviewed all cases of

testicular torsion presenting to our ED that underwent detorsion and orchiopexy or

orchiectomy from 2005 through 2015. This timeframe was selected as billing logistics

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prohibited identification of cases prior to September 2004, making 2005 the first year

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complete data could be obtained. Cases were identified using Current Procedural

Terminology (CPT) codes 54600 (reduction of torsion of testis, surgical, with or without

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fixation of contralateral testis) and/or 54620 (fixation of contralateral testis). These CPT

codes are uniformly the only codes used at our institution for testicular torsion

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procedures. We used CPT codes and not International Classification of Diseases (ICD)
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codes to exclude diagnoses other than testicular torsion. Cases of perinatal torsion and

elective management of suspected intermittent torsion were excluded.

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Cases were coded as “direct” or “referred” based on initial site of presentation.

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Cases presenting directly to our ED were considered direct. Cases were considered
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referred if they were transported from another medical facility with emergency and

general urology services (e.g., a community hospital ED) and transferred to our
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institution for care. Patients transferred to our institution from facilities without

emergency and general urology care (e.g., health maintenance organization clinics, urgent
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care facilities, or pediatrician offices) were considered direct presentations. All cases
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were coded as “acute” (<24 hours) or “delayed” (≥24 hours) presentations based on time

of symptom onset prior to presentation. This dichotomization was felt to be the most

reliable given the varying reports of symptom duration in patient records.

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The primary outcomes examined were change in case volume and presentation

trends over the entire study period as well as the pre- (2005-2008) and post-certification

(2009-2015) periods. Day of the week and time of day of presentations were isolated with

a focus on 12-hour segments of weekday nights and weekends due to the perceived

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increase in referred cases during those times. Mean patient age and weight were

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compared for direct and referred cases. Transportation distance and time were compared

pre- and post-certification.

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Interhospital transportation and its effect on orchiectomy versus detorsion and

orchiopexy rate were calculated as secondary outcomes. Presentation time for direct cases

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was considered check-in time at our ED triage station. For referred cases, true
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presentation time could not be reliably obtained due to inconsistencies in outside ED

records across patients and years. Time of transport initiation, which was consistent
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across all patients, was used as a surrogate presentation time for referred cases. Transport
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time was the time between transport initiation at an outside ED to the time the transport
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arrived at our institution’s ED triage station.

Delayed presentations were omitted from secondary outcome analyses as the

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majority ended in orchiectomy and surgical treatment was often electively delayed when

testicular salvage was no longer possible. Surgical pathology was reviewed in cases of
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orchiectomy to confirm nonviable testicular torsion as the underlying pathology. Due to

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inconsistent follow-up, testicular atrophy for those testes that underwent detorsion and

orchiopexy could not be measured, hence testicular salvage could not be analyzed.

Continuous variables were compared with Student’s t-tests while relationships

between categorical variables were compared using chi-square and Fisher’s exact tests,

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where appropriate. Level of significance was set at a level of p<0.05. All statistical

analyses were performed using the SAS® Statistical Software Package, Version 9.3 (SAS

Institute Inc., Cary, NC).

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RESULTS

Between January 2005 and December 2015, 218 cases of testicular torsion presented to

our ED and were taken to the operating room (OR). Demographic and descriptive

statistics for all cases are shown in Table 1.

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The majority of cases (135/218, 61.9%) were direct presentations. While the

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incidence of direct cases did increase from 12 in 2005 to 17 in 2015, the trend over the

entire study period showed only a slight increase when accounting for annual variance

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(Figure 1). There were similar proportions of direct acute (70/135, 51.9%) and direct

delayed (65/135, 48.1%) presentations over the entire study period with only minor

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differences between the pre- and post-certification periods. (Table 2)
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The incidence of referred testicular torsion at our institution increased from 3 cases

in 2005 to 15 in 2015 with a polynomial trend line noting the increase after 2009 (Table 2
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and Figure 1). This trend was largely due to an increase in the incidence of referred acute
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cases over the entire study period (1 in 2005 compared to 12 in 2015) while the incidence
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of referred delayed cases remained overall stable (2 in 2005 to 3 in 2015). The proportion

of referred acute cases markedly increased from the pre- (4/63, 6.3%) to post-certification
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(42/155, 27.1%) periods (p<0.01).

There was no difference between mean patient age and weight for direct and
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referred presentations over the entire study period or between pre- and post-certification
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periods (all p>0.05). There was a trend toward the referral of smaller patients over time

(mean 62.4 kg before vs 53.0 kg after certification; p=0.2). Mean transport distance and

time were similar for referred patients between pre- and post-certification periods (10.8

air miles and 93.2 mins vs 11.6 air miles and 90.2 mins, respectively; all p>0.05).

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Heat maps illustrate the presentation time of day and day of the week for all direct

and referred presentations from 2005 to 2015 (Figure 2). The majority of referred cases

(59/83, 71.1%) presented during weekday nights or weekends compared to a minority of

direct cases (59/135, 43.7%; p<0.01). This pattern was consistent across the pre- and

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post-certification periods (Figure 3).

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For all referred cases, time from symptom onset to presentation was the most

significant factor affecting orchiectomy rate, with 33/43 (76.7%) of delayed cases

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undergoing orchiectomy compared to just 4/40 (10%) of acute presentations (p<0.01).

Accordingly, secondary analyses were only calculated for acute presentations. Over the

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study period, 19/70 (27.1%) direct cases underwent orchiectomy compared to 10/46
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(21.7%) of referred cases (p=0.51). There was a slight trend toward increased

orchiectomy rate among patients transported longer distances, with 6/19 (31.6%) of
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patients transported >10 miles from an outside ED to our institution undergoing

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orchiectomy compared to 4/27 (14.8%) of patients transferred <10 miles (p=0.2).

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Transport modality did not significantly affect orchiectomy rate. Two of 18 referred

patients transported by air underwent orchiectomy (11.1%) compared to 3/11 (27.3%)

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and 5/17 (29.4%) of patients transported by private vehicle and ambulance, respectively

(p=0.39). This trend was still statistically insignificant when considering orchiectomy
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rates among patients transported by air versus combined ground modalities (2/18, 11.1%
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vs 8/28, 28.6%, p=0.27).

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DISCUSSION

The practice of pediatric urology began in the 1960s and evolved over the next 50 years

until the first subspecialty certificates in pediatric urology were issued in 2008.1 The

ABMS issued 291 subspecialty certificates in pediatric urology between 2008 and 2013.3

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Initial efforts to achieve subspecialty certification in pediatric urology were met with

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concerns that certification would adversely impact or restrict the practice of the general

urologist.4 However, as stated in the ABMS handbook, there is no requirement for a

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diplomat in a recognized specialty to hold a special certification in a subspecialty of that

field to be considered qualified to include aspects of that subspecialty within a specialty

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practice.5 In reality, a reverse scenario may be an unintended consequence of
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certification: routine “pediatric urology” problems, previously treated by general

urologists, are being referred to pediatric urologists at an increasing rate.

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At our institution, we have noted an increase in the incidence of testicular torsion

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since pediatric urology certification. The incidence of referred cases rose slowly after
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2009 with a sharper increase after 2013. The primary driver of this trend is the increase in

patients referred from outside institutions in the acute presentation setting. The majority
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of patients referred to our institution presented at outside hospitals during nights and

weekends.
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Given the overall stability of direct testicular torsion cases presenting to our ED
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over the past 11 years, it is unlikely the observed increase in referred cases is reflective of

an increase in the incidence in testicular torsion or other acute scrotum diagnoses in our

institution’s catchment area. Furthermore, no hospital acquisitions or closures in our

Washington, DC Metro Area have directly affected the referral of pediatric patients to our

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institution. In fact, there are freestanding, expanding children’s hospitals in Northern

Virginia and Baltimore, Maryland 12.5 and 34.2 air miles from our institution,

respectively, which we suspect may be dampening the incidence of referred cases to our

institution. Despite the fact that surgical treatment of testicular torsion represents a basic

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procedure in which all urologists are trained, it appears these cases are being increasingly

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referred to pediatric urologists when geographically available. Data from a retrospective

review of the Nationwide Emergency Department Sample database supports this theory.6

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Lodwick et al. reported the transfer rate of patients ≤21 years-old with testicular torsion

from one emergency room to another hospital increased from 23.6% in 2006 to 38.8% in

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2012, with the greatest increase in transfer between 2009 and 2010.
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Pediatric urology subspecialty certification may not entirely account for the

increasing referral rates of patients with testicular torsion. Our institution experienced an
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increase in referred cases of testicular torsion after 2009 and a significantly increased
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proportion of referred acute cases in the post-certification period, but the largest increase
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in referred cases was not seen until after 2012. It is unclear if the fact that we found no

difference in the age, weight, transportation metrics, or daily presentation patterns of

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referred patients before and after certification has significance as an increase in referral

incidence may not necessarily change these parameters. Other factors, such as an overall
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increase in community emergency room and general urology case volume, could drive
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testicular torsion patient referrals to dedicated pediatric facilities, but in this case we

would have expected to see a similar increase in direct presentations of acute torsion to

our ED.

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Despite the increase referrals, testicular torsion outcomes at our institution

remained unchanged. Over 70% of patients with acute presentations of testicular torsion

underwent detorsion and orchiopexy regardless of study period, site of initial presentation

or transport modality. These data raise a key question: Should cases of testicular torsion

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be treated at the hospital of initial presentation or referred to a dedicated pediatric

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facility?

Previous studies regarding the effect of hospital transfer on torsion outcomes have

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yielded mixed results. Bayne et al. reported a single center retrospective review of 97

patients in which distance from the hospital and transfer time led a trend toward risk of

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orchiectomy, yet the authors did not limit their analysis to acute presentations, and the
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study was underpowered to report a statistically significant difference.7 Yiee et al.

reported hospital transfer did not influence orchiectomy rates in a retrospective review of
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a California cohort including 2,794 cases of testicular torsion, but exclusion of ED data
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from the study likely overrepresented neonatal testicular torsion outcomes.8,9

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It is unlikely that the majority of referred patients in our study benefitted from

transfer. Time from ED to incision in the OR was faster for referred cases than direct
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cases (data not shown), but this reflects the fact that the majority of children referred to

our institution arrived with a complete workup and diagnosis. That less than a third of
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referred patients underwent a repeat sonogram supports this theory. In addition, advance
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notice to the pediatric urology team that a testicular torsion patient was being transferred

likely affected (i.e., shortened) their time from ED triage to OR incision compared to

patients presenting directly to our ED. Since we could not fully capture the time patients

spent at during evaluation at outside institutions, it is distinctly possible that patients

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referred to our institution may have experienced improved testicular detorsion and

orchiopexy rates if they had been definitively treated at their presenting hospital. It is

worth mention that the pediatric cases referred to our institution over the study period

were an average 11.8 years-old and 55.2 kg. Based on age, physical size, and physiology,

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the surgical and anesthetic management of these patients is similar to that of young adults

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who might present with testicular torsion to community hospitals and could have been

provided by a general anesthesiologist and urologist.

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Our data found no effect of interhospital transportation modality on orchiectomy

rates. Without clear benefit, the cost of transporting children with testicular torsion to a

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pediatric hospital is a concern. For acute referrals, air transport may be justifiable at times
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of extreme traffic congestion or long distances, which we were unable to evaluate given

our area and referral radius. In general, air and ground ambulance transport are costly
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methods of transport and unlikely to make a significant impact in care outcomes in cases
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of delayed presentation.
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It is important to note our data should not be interpreted to support the routine

transfer of adolescent patients with testicular torsion to a dedicated pediatric hospital. We

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could not fully capture time elapse at outside hospitals (i.e., patients could not be fully

risk stratified) and it is well documented that the chance of testicular salvage is time
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sensitive and decreased by delay in treatment. Furthermore, patients referred to our

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institution may have benefited from a shorter transfer time from hospitals in a relatively

small referral radius not representative of other regions of the country. Therefore,

orchiectomy rates for our referred patients, which were similar to direct patients, likely

represent the “best case scenario.”

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Strengths of our study relative to others testicular torsion series include its larger

size, longer study period, and delineation of acute and delayed presentations.7,8,10-14

Retrospective review and an inability to account for the time spent at outside institutions

are notable limitations. The lack of long-term follow-up in the majority of patients limit

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our ability to ascertain testicular atrophy rates following testicular detorsion and

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orchiopexy, thus our data cannot predict functional outcomes. Additionally, though all

referring facilities during our study period have on-call emergency urology coverage,

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documentation of urologist involvement in the decision to refer a patient to our institution

was inconsistently available in the medical records. It is possible some patients were

referred without urologist input.

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CONCLUSIONS

Our institution has experienced an increase in the incidence of testicular torsion since

pediatric urology certification. The increased incidence is primarily due to a marked rise

in the number referred acute cases to our ED from outside institutions with emergency

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and general urology services. Neither presentation location or interhospital transportation

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modality had a statistically significant impact on orchiectomy rate. Further investigations

into testicular atrophy rates after detorsion and orchiopexy and cost of interhospital

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transfer is needed to justify routinely delaying definitive care with transfer to dedicated

pediatric facilities.

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ACKNOWLEDGEMENT

The authors thank Bruce M. Sprague for his help acquiring data for this study.

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DISCLOSURES

The authors report no conflicts of interest.

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REFERENCES

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2. Husmann DA, Routh JC, Hagerty JA, et al: Evaluation of the United States pediatric
urology workforce and fellowships: a series of surveys performed in 2006-2010. J Pediatr
Urol 2011; 7: 446–453.

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3. 2013-2014 ABMS Board Certification Report. American Board of Medical Specialties.
abms.org. Available at:

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http://www.abms.org/media/84770/2013_2014_abmscertreport.pdf, accessed August 15,
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4. Rushton HG: Subspecialty certification in pediatric urology. J. Urol. 2005; 173: 1845–

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1846.

5. Annual Report & Reference Handbook. worldcat.org. Available at:

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http://www.worldcat.org/title/annual-report-reference-handbook/oclc/6887353, accessed
November 9, 2015.
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6. Lodwick DL, Cooper JN, Minneci PC, et al: Factors affecting pediatric patient transfer in
testicular torsion. J. Surg. Res. 2016; 203: 40–46.
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7. Bayne AP, Madden-Fuentes RJ, Jones EA, et al: Factors associated with delayed
treatment of acute testicular torsion-do demographics or interhospital transfer matter? J.
Urol. 2010; 184: 1743–1747.
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8. Yiee JH, Chang L, Kaplan A, et al: Patterns of care in testicular torsion: influence of
hospital transfer on testicular outcomes. J Pediatr Urol 2013; 9: 713–720.
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9. Kim S: Commentary to 'Patterns of care in testicular torsion: influence of hospital transfer

on testicular outcomes'. J Pediatr Urol 2013; 9: 720.
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10. Ramachandra P, Palazzi KL, Holmes NM, et al: Factors influencing rate of testicular
salvage in acute testicular torsion at a tertiary pediatric center. West J Emerg Med 2015;
16: 190–194.
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11. Boettcher M, Bergholz R, Krebs TF, et al: Clinical predictors of testicular torsion in
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children. Urology 2012; 79: 670–674.

12. Zhao LC, Lautz TB, Meeks JJ, et al: Pediatric testicular torsion epidemiology using a
national database: incidence, risk of orchiectomy and possible measures toward improving
the quality of care. J. Urol. 2011; 186: 2009–2013.

13. Cost NG, Bush NC, Barber TD, et al: Pediatric testicular torsion: demographics of
national orchiopexy versus orchiectomy rates. J. Urol. 2011; 185: 2459–2463.

14. Mansbach JM, Forbes P and Peters C: Testicular torsion and risk factors for orchiectomy.

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Arch Pediatr Adolesc Med 2005; 159: 1167–1171.

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Table 1. Demographic and descriptive statistics for patients presenting with testicular torsion from 2005 to 2015

Entire study period Pre-certification Post-certification

(2005-2015) (2005-2008) (2009-2015) p
Total direct cases 135 45 90

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Mean age (±SD; yerars) 12.5* (0-19) ±4.2 12.3 (0-18) ±4.8 12.6 (0-19) ±4.0 0.67

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Mean weight (range, ±SD; kg) 58.5† (7.9-169.5) ±25.4 59.1 (8.8-142) ±27.4 58.3 (7.9-169.5) ±24.4 0.86
Race (n) AA 89, L 23, O 12, C 10, A 1 — —

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Total referred cases 83 18 65

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Mean age (range, ±SD; years) 11.8* (0-17) ±3.8 12.4 (3-16) ±3.1 11.7 (0-17) ±4.0 0.43

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Mean weight (range, ±SD; kg) 55.0† (4-128) ±23.0 62.4* (15-128) ±25.0 53.0* (4-110) ±22.0 0.16
Race (n) AA 52, O 13, L 8, C 8, A 2 — —

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US not performed at presenting ED 2/83 (2.4) — 2/65 (3.1)
US repeated at CNMC 24/81 (29.6) 4/18 (22.2) 20/63 (31.7)

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Private vehicle (n [%]) TE 24 [28.9] 4 [22.2] 20 [30.8]
Ambulance (n [%]) 36 [43.4] 12 [66.7] 24 [36.9]
Helicopter (n [%]) 23 [27.7] 2 [11.1] 21 [32.3]
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Mean air distance (range, ±SD; miles) 11.5 (5.1-45.3) ±8.1 10.8 (5.1-16.4) ±4.1 11.6 (5.1-45.3) ±8.9 0.71
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Mean transport time (range, ±SD; mins) 90.8 (12-198) ±39.3 93.2 (35-181) ±43.2 90.2 (12-198) ±38.2 0.78
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Total case laterality [%] Left 133/218 [61] — —

Legend: SD=standard deviation; AA=African American; L=Latino; O=other/non-specified; C=Caucasian; A=Asian; US=ultrasound (scrotal);
CNMC=Children’s National Medical Center
*p=0.24; †p=0.41

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Table 2. Incidence of testicular torsion from 2005 to 2015

Presentation 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Total
Direct

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Acute 4 7 5 7 4 6 5 7 7 7 11 70
Delayed 8 4 4 6 5 9 7 7 7 2 6 65

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Total 12 11 9 13 9 15 12 14 14 9 17 135

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Referral
Acute 1 1 0 2 3 4 2 3 10 8 12 46

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Delayed 2 4 5 3 1 2 3 3 7 4 3 37

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Total 3 5 5 5 4 6 5 6 17 12 15 83

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Total 15 16 14 18 13 21 17 20 31 21 32 218

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Figure 1. Testicular torsion incidence trends from 2005 to 2015 with polynomial trend lines


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Delayed referred Acute referred Total referred Total direct

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15

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Number of testicular torsion cases

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Figure 2. Heat map of total A) direct and B) referred testicular torsion presentations from 2005 to 2015

A) Direct presentations
7a 8a 9a 10a 11a 12p 1p 2p 3p 4p 5p 6p 7p 8p 9p 10p 11p 12a 1a 2a 3a 4a 5a 6a

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Mon

Tue

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Thur

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Sat 44%

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B) Referred presentations
7a 8a 9a 10a 11a 12p 1p 2p 3p 4p 5p 6p 7p 8p 9p 10p 11p 12a 1a 2a 3a 4a 5a 6a

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Mon TE
Tue
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Wed

Thur
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Fri
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Sat 71%
Sun

Legend: Boxed area shows weekdays from 7:00 pm to 7:00 am and

n=0 n=1 n=2 n=3 n=4
weekends with percentage of presentations during that time

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Figure 3. Heat map of A) direct and B) referred torsion presentations before pediatric urology subspecialty certification
(2005-2008). C) Direct and D) referred presentations after certification (2009-2015)

A) Direct presentations before certification (2005-2008)

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Mon

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Sat 44%

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B) Referred presentations before certification (2005-2008)

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7a 8a 9a 10a 11a 12p 1p 2p 3p 4p 5p 6p 7p 8p 9p 10p 11p 12a 1a 2a 3a 4a 5a 6a

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C) Direct presentations after certification (2009-2015)

7a 8a 9a 10a 11a 12p 1p 2p 3p 4p 5p 6p 7p 8p 9p 10p 11p 12a 1a 2a 3a 4a 5a 6a

Mon

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Thur

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Sat 44%

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D) Referred presentations after certification (2009-2015)

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7a 8a 9a 10a 11a 12p 1p 2p 3p 4p 5p 6p 7p 8p 9p 10p 11p 12a 1a 2a 3a 4a 5a 6a

Mon

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Thur
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Sat 71%
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Legend: Boxed area shows weekdays from 7:00 pm to 7:00 am and

n=0 n=1 n=2 n=3
weekends with percentage of presentations during that time
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KEY OF DEFINITIONS FOR ABBREVIATIONS

ED = emergency department

OR = operating room

PT
RI
U SC
AN
M
D
TE
C EP
AC