Transfer of Patients With Testicular Torsion Associated With Worse Outcomes

Columbus, OH — September 2017

In what appears to be the first study of its kind, physician-researchers at Nationwide Children’s Hospital have found that transferring pediatric patients with testicular torsion may have a negative impact on testicular salvage rates.

This makes sense, because transfer would delay definitive management of this time-sensitive condition, says Daniel DaJusta, MDpediatric urologist at Nationwide Children’s and senior author of the study. Previous investigations, however, have not reached that conclusion — perhaps in part because they included patients whose window for salvage had passed.

The recent study, published in the Journal of Pediatric Urology, only considered patients who presented less than 24 hours after symptom onset, or still within the window. Authors found a 30.4 percent rate of testicular loss in those who were transferred to Nationwide Children’s over five years, and a 15.2 percent loss rate for those who presented to the hospital directly, so were not transferred.

Beyond those findings, the study reported that the large majority of patients were transferred at night or on the weekends. In contrast, there was almost no difference in the number of patients who presented directly to the hospital during weekdays vs. weekends and nights.

One possible suggestion of the data is that urologists at outside hospitals will treat patients with testicular torsion during regular working hours but will transfer if the patient presents at an inconvenient time. This study helps show that is a poor strategy, says Dr. DaJusta, who is also a clinical assistant professor of Urology at The Ohio State College of Medicine.

“When patients were transferred to us, it is certainly possible that the presenting hospital had no urology coverage, and so had to transfer,” he says. “But the best thing for the patient is to be taken to the operating room quickly. Adult urologists are trained in the management of torsion. If there is urology coverage at the presenting hospital, the patient probably should be treated at that hospital.”

Patients transferred more than 30 miles had 2.5 times the rate of testicular loss of patients who were not transferred. Patients who underwent ultrasound before transfer had a higher loss rate than patients who did not have an ultrasound.

If a patient is going to be transferred anyway, the initial institution should not perform an ultrasound, which further delays management, says Dr. DaJusta. The Testicular Workup for Ischemia and Suspected Torsion (TWIST) score has been shown to help properly triage many patients without ultrasound.

“If you can decrease the time before management, it’s better for the patient. That’s what we should all try to do,” Dr. DaJusta says.

Preece J, Ching C, Yackey K, Jayanthi V, McLeod D, Alpert S, DaJusta D. Indicators and outcomes of transfer to tertiary pediatric hospitals for patients with testicular torsion. Journal of Pediatric Urology. 2017 May 18. [Epub ahead of print]

Sheth KR, Keays M, Grimsby GM, Granberg CF, Menon VS, DaJusta DG, Ostrov L, Hill M, Sanchez E, Kuppermann D, Harrison CB, Jacobs MA, Huang R, Burgu B, Hennes H, Schlomer BJ, Baker LA.  Diagnosing testicular torsion before urological consultation and imaging: validation of the TWIST score. The Journal of Urology.  2016 Jun; 195(6): 1870-6.