During the course of scrotal exploration for torsion testis in a prepubertal pubertal child what would be the advice if the testis is not frankly gangrenous and is very dark and congested and also not regaining its native color after detorsion (remove or retain it?). What is role of decompression and tunica vaginalis flap of this testis?
Figueroa V, Pippi Salle JL, Braga LH, Romao R, Koyle MA, Bägli DJ, Lorenzo AJ. Comparative analysis of detorsion alone versus detorsion and tunica albuginea decompression (fasciotomy) with tunica vaginalis flap coverage in the surgical management of prolonged testicular ischemia.J Urol. 2012 Oct;188(4 Suppl):1417-22. doi: 10.1016/j.juro.2012.02.017. Epub 2012 Aug 17.
If all methods to test viability are exhausted and the surgeon is not convinced of viability of the testis. It should be removed.
After all the viability options are exhausted , the surgeon may take the call of retaining the testis according to his experience. A strict immediate follow up with clinical and doppler usg is must to see the viability of the testis. If the testis has got doubtful viability then it will atrophy on its own and only a nubbing may have to be removed later on. The consent of the parents is a must for this kind of procedure where a doubtful viability testis is left.
I agree with Dr. Govindarajan that whilst orchidectomy may be the most 'convenient' thing, the age of the patient is important with regard to viability in cases of uncertainty. Giving an 8 year-old a chance is more appropriate than for a 38 year-old who is married and has a family.
Perhaps you should re-read what I wrote, Dr. Zakaria. I said that I agreed with Dr. Govindarajan re. giving a young testis a GREATER chance.
There are numerous factors/ confounding factors in medicine; one size does NOT fit all. There is a place for aggressive intervention, but equally, knee-jerk reactions are sometimes to the detriment of a patient. So, as Dr. Kothari said, strict sequential follow-up MAY be an appropriate course.
Of course gangrene is undesirable - everybody knows that. However, you should remember that there are many cases where males have had a single slowly withering testis (i.e. one that atrophies) into a non-functioning nubbin. This does NOT make the male sterile, NOR does every male that has a dying testicle then automatically die of gangrene-related complications.
I didn't say that you mentioned sterility, Dr. Zakaria! Anyway, it looks as if we are in agreement after all - this is certainly an interesting question, and the lack of unequivocal evidence leaves the decision in the hands (/ experience!) of the attending surgeon.
'As a young boy of 8 years it is important to be sure of the viability and if not the remove to avoid other health related problems in future. The attending surgeon can do more investigation and take a decision
Leave it behind. It might survive. I have not seen these becoming infected. I would not decompress.
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