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\begin{document}

\title{The Impact of COVID-19 Pandemic on Admission Times, Manual Detorsion
Rates and Outcomes in Testicular Torsion}



\author[1]{Emre Tokuç}%
\author[1]{Ilker Artuk}%
\author[1]{Ridvan Kayar}%
\author[2]{Emrah Özsoy}%
\author[1]{Ramazan Topaktas}%
\author[1]{Yavuz Bastug}%
\author[1]{Mehmet Akyüz}%
\author[1]{Metin Öztürk}%
\affil[1]{University of Health Sciences, Haydarpasa Numune SUAM}%
\affil[2]{Ünye State Hospital}%


\vspace{-1em}



  
  \date{May 17, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
Aim: This study aims to assess the admission times, manual detorsion
rates and outcomes of the testicular torsion cases during COVID-19
pandemic. Methods: A retrospective analysis of the testicular torsion
cases was done through our hospital's electronic archive. Patients with
were distributed into two groups as ``COVID-19 era'' (between 11th of
March 2020 -- March 2021) and ``pre-COVID-19 era'' (between January 2018
and 10th of March 2020). Time between the onset of symptoms and the
moment of detorsion was calculated as the duration of ischemia. Two
groups were compared in terms of ischemia duration, manual detorsion
rates and operational outcomes. Results: No statistically significant
differences was detected between groups in terms of ischemia duration,
manual detorsion rates and surgical procedure type (all
p\textgreater{}0.05). During the COVID-19 pandemic, the number and
percentage of manual detorsions have increased, resulting in a numerical
decrease in orchiectomies. Conclusions: Conditions caused by COVID-19
may prompt urologists to manual detorsion more to set up safer surgical
environment. Moreover, this approach may result in a decrease in
orchiectomy rates by saving time and preserving the vascularity of the
testis. Further studies with larger samples sizes and meta-analyses may
support this concept. Keywords: testicular torsion, COVID-19, manual
detorsion, orchiectomy, emergency%
\end{abstract}%



\sloppy


\textbf{The Impact of COVID-19 Pandemic on Admission Times, Manual
Detorsion Rates and Outcomes in Testicular Torsion}

\textbf{ABSTRACT}

\textbf{Aim:} This study aims to assess the admission times, manual
detorsion rates and outcomes of the testicular torsion cases during
COVID-19 pandemic.

\textbf{Methods:} A retrospective analysis of the testicular torsion
cases was done through our hospital's electronic archive. Patients with
were distributed into two groups as ``COVID-19 era'' (between
11\textsuperscript{th} of March 2020 -- March 2021) and ``pre-COVID-19
era'' (between January 2018 and 10\textsuperscript{th} of March 2020).
Time between the onset of symptoms and the moment of detorsion was
calculated as the duration of ischemia. Two groups were compared in
terms of ischemia duration, manual detorsion rates and operational
outcomes.

\textbf{Results:} No statistically significant differences was detected
between groups in terms of ischemia duration, manual detorsion rates and
surgical procedure type (all p\textgreater{}0.05). During the COVID-19
pandemic, the number and percentage of manual detorsions have increased,
resulting in a numerical decrease in orchiectomies.

\textbf{Conclusions:} Conditions caused by COVID-19 may prompt
urologists to manual detorsion more to set up safer surgical
environment. Moreover, this approach may result in a decrease in
orchiectomy rates by saving time and preserving the vascularity of the
testis. Further studies with larger samples sizes and meta-analyses may
support this concept.

\textbf{Keywords:} testicular torsion, COVID-19, manual detorsion,
orchiectomy, emergency

\textbf{What's Already Known About This Topic?}

Testicular torsion is an organ-threatening pathology in urology practice
in which time has a critical role. Delay in surgical treatment as
detorsion of the torted testicle will lead to an organ loss. Conditions
brought with the COVID-19 pandemic might complicate the admission times,
leading to an undesirable increase in orchiectomies.

\textbf{What Does This Article Add?}

Although the admission times and the outcomes of testicular torsion
cases did not vary during the pandemic, there was an increasing trend to
manual detorsion for overcoming the emergency temporarily. This approach
has led to a numerical decrease in orchiectomies compared with
pre-pandemic era.

\textbf{Introduction}

COVID-19 pandemic which outbroke in December 2019 has caused disruption
of both emergency and routine urological healthcare services around the
world \textsuperscript{1,2}. Through this period of worldwide health
crisis, urologists have adapted by trying to take protective measures
while striving not to interrupt their practice \textsuperscript{3}. In
our country, first COVID-19 case has been reported on
11\textsuperscript{th} of March, 2020 and since then; the daily workload
of urologists has dramatically dropped. Although this decrease,
nondeferrable emergent interventions were prioritized and
continued\textsuperscript{4}.

Testicular torsion is an acute urgent scrotal pathology in which time is
of great importance in preserving the testis. Testis, being an
end-organ, is vulnerable to ischemia and the time of ischemia is
directly proportional with the risk of testicular atrophy and
dysfunction \textsuperscript{5}. Early admission is a critical factor to
prevent these negative outcomes which leads to organ loss. Management of
testicular torsion is a race against time even if in normal conditions.
In this extraordinary COVID-19 pandemic which affects every aspect of
clinical practice, approach to cases with testicular torsion becomes
even more crucial.

The aim of our study is to evaluate the admission times, our approach
and orchiectomy rates of patients diagnosed with testicular torsion
during COVID-19 pandemic in our tertiary referral educational urology
clinic.

\textbf{Materials \& Methods}

This study has been approved by the Clinical Studies Ethics Board of
University of Health Sciences, Haydarpasa Numune SUAM (Decision Number:
HNEAH-KAEK 2021/KK/138) and the study was conducted in compliance with
the Declaration of Helsinki. Testicular torsion cases were
retrospectively analyzed through our hospital's electronic archive
system and patients were distributed into 2 groups as ``COVID-19 era''
(between 11\textsuperscript{th} of March 2020 -- March 2021) and
``pre-COVID-19 era'' (between January 2018 and 10\textsuperscript{th} of
March 2020). Ages and laterality of the patients were recorded.
Differential diagnosis of all patients was done with scrotal Doppler
ultrasound. A written informed consent was taken from all patients prior
to procedures. Patients whom manual detorsion were done were recorded
and the vascularity of testis was confirmed with scrotal Doppler
ultrasound after the procedure. The duration of ischemia was calculated
in hours by considering the time between the onset of symptoms and the
moment of detorsion (manual or operational). All perioperative findings
and applied procedures were recorded. All orchiectomy materials were
sent to the pathology department and the results were confirmed as
necrotic tissues.

Since preoperative COVID-19 testing could not be done in patients who
were operated immediately after diagnosis, emergency operations during
pandemic were managed as the operations of COVID-19 positive patients,
with taking preventive measures such as N95 masks and necessary personal
protective equipments. Preoperative PCR (polymerase-chain reaction)
testing was requested to patients whose manual detorsion were
successful. Patients who tested negative for COVID-19 were electively
operated under safer conditions.

Statistical Analysis

Statistical Package for the Social Science (SPSS Inc, Chicago, IL, USA)
version 22.0 was used for the statistical analysis. Differences between
independent groups containing non-parametric variables which are not
normally distributed within were compared with Mann-Whitney U test and
p\textless{}0.05 was considered as statistically significant.

\textbf{Results}

There were 31 testicular torsion cases, 13 while COVID-19 pandemic and
18 in pre-COVID era. The average age of all patients was 19.45\selectlanguage{ngerman}±6.47. The
average age was 18.62±4.48 in COVID-19 group and 20.06±7.66 in
pre-COVID-19 group. There was no significant difference between the
groups in terms of age (p=0.441).

Generally, the average duration of ischemia was 19.03±22.83 hours. The
average time of ischemia was 19.46±31.54 hours during the pandemic and
18.72±14.75 hours before the COVID-19 outbreak. No significant
difference was detected between the groups in terms of ischemia time
(p=0.115).

There was only one case (5.6\%) which manual detorsion was done in the
pre-COVID-19 group. During the pandemic, four (30.8\%) patients
underwent manual detorsion prior to elective surgery. There was no
significant difference between groups in terms of patients underwent
manual detorsion (p=0.242).

When the operative findings and outcomes are taken into consideration;

In the pre-COVID-19 era, out of 18 patients, six (33.3\%) underwent
surgical detorsion + bilateral testicular orchiopexy because the testis
was viable. In seven patients (38.9\%), necrotic testicular tissue was
observed and orchiectomy + contralateral testicular orchiopexy was
performed. In five patients, only bilateral orchiopexy was done. Four of
these five patients had incomplete/partial torsion in the scrotal
Doppler ultrasound prior to surgery. One patient underwent manual
detorsion which was confirmed with ultrasound, so bilateral orchiopexy
was done electively.

During the COVID-19 pandemic, four out of 13 patients (30.8\%) underwent
surgical detorsion + bilateral testicular orchiopexy, three (23.1\%)
underwent orchiectomy + contralateral testicular orchiopexy and six
(46.2\%) underwent only bilateral orchiopexy. In two patients who
underwent bilateral orchiopexy, incomplete/partial torsion was detected
as preoperative ultrasound finding. In four patients, emergent manual
detorsion was performed and after the negative COVID-PCR test results,
bilateral orchiopexy was done electively.

Concerning the operative outcomes of these patients, there was no
significant difference between two groups in terms of surgical procedure
(p=0.514). (Table 1)

\textbf{Discussion}

Concerns about the contagiousness and mortalities of COVID-19 has led
most governments take measures like lockdowns, stay-at-home and social
distancing suggestions \textsuperscript{6}. In hospitals, daily routine
healthcare services were heavily interrupted, either the hospitals were
completely converted into quarantine clinics or admitted reduced number
of patients. There are many studies indicating significant delay in
patients with urgent conditions in emergency departments such as
cardiovascular emergencies \textsuperscript{7,8}. Also, studies
conducted in pediatric emergency clinics assert the fact that number of
patients has significantly decreased during COVID-19 pandemic and the
main reason for this is the fear of infection and the protectionist
instinct of the families \textsuperscript{9,10}. In this study, the
aggravated, acute and severe presentation of testicular torsion may be
the reason not having any significant differences between ages and
duration of symptoms between the groups. Similar to this study, Littman
et al. and Nelson et al. found no delay in the time of presentation of
testicular torsion cases during COVID-19
pandemic\textsuperscript{11,12}. On the other hand, a very recent
multicenter study from the Western Pediatric Urology Consortium (WPUC)
suggests significantly longer presentation times of testicular torsion
cases during the pandemic \textsuperscript{13}.

In testicular torsion, ischemia duration and torsion degree are the most
important factors in preserving the functional features of the
testis\textsuperscript{14}. Irreversible damage starts after four to six
hours and affects both the spermatogenesis and the endocrine
functions\textsuperscript{15,16}. Also, it has been suggested that
unilateral testicular torsion may harm the spermatogenesis in the
contralateral testis through ischemia-reperfusion metabolites as an
early mechanism and by autoimmune response in latter stages
\textsuperscript{17}. A study comparing the time to treat and duration
of symptoms in respect of testicular salvage indicates a clear
significance in conserving the testis in the group with duration of
symptoms below 24 hours while there was no significance in time to treat
\textsuperscript{18}. Concerning all the issues above, immediate
intervention is recommended. In regards to prompt management, manual
detorsion has been described by Nash in 1893, has been proposed as
urgent procedure reducing the duration of ischemia of torsioned testis
\textsuperscript{19}. Various studies in literature suggests that this
method may be an alternative to exploration and surgical detorsion
\textsuperscript{20-22}. On the other hand, some studies in literature
suggest the risk of residual torsion and subsequent testicular atrophy
\textsuperscript{23,24}. In this study, although there are no
significant differences between groups, the number of manual detorsions
has increased throughout the COVID-19 era. This result may be
interpreted as the self-protective instinct of the surgeon providing an
urgent and temporary management to a testicular torsion case which is
COVID-19 suspicious. All patients with prior manual detorsion in this
study have been confirmed with scrotal Doppler ultrasound and also
operated under elective and COVID-PCR negative conditions for bilateral
orchiopexy.

There were no significant differences between the groups in terms of
surgical approach and orchiectomy rates. Since there were no significant
differences in the admission times of the patients, this result could be
predicted. Both Littman et al. and Nelson et al. showed no significant
alterations in orchiectomy rates of testicular torsion cases during the
pandemic which this study was consistent with \textsuperscript{11,12}.
Contrarily, in the multicenter study by WPUC, significantly delayed
patients during the pandemic resulted in a non-significant but
numerically higher percentages of orchiectomies \textsuperscript{13}. In
this study, during the COVID-19 pandemic, the number and percentage of
orchiectomies have decreased numerically but not significantly. The
increase in the number of manual detorsions may have contributed to this
result. In addition to providing a remedy to the patient's pain and
saving time for the surgeon, the manual detorsion procedure have been
shown to have an organ-preserving aspect. This approach may also be
implemented on daily practice to reduce orchiectomies.

Even though contralateral orchiopexy of the testis is controversial,
there is still evidence in the literature indicating the risk of future
torsions \textsuperscript{25}. Hence, this approach is recommended to
avoid the possible risk. All patients included in our study underwent
contralateral orchiopexy in direction of the current guidelines and
recommendations.

Emergency surgeries during COVID-19 pandemic are a great risk for the
surgeon and the whole staff in the operating room. Both in urology and
other aspects of surgery, biosecurity measures, recommendations and
guidelines are continuously being reported about this
subject\textsuperscript{3,26,27}. Also a report by Parikh et al. shows
in order not to compromise the outcome of testicular torsion, COVID-PCR
testing results cannot be waited and all protective measures should be
taken as if the patient is COVID-19 positive \textsuperscript{28}.

Although this stands out to be the only study evaluating manual
detorsion rates in testicular torsion during the COVID-19 era, the main
limitation is its retrospective nature. Also, due to the short time
intervals, especially in COVID-19 era which is 9 months in this study,
number of patients is limited to reach definitive, descriptive and
significant results. Randomized, prospective studies with increased
number of participants may end up in statistical significance.

Even though there were no significant differences between pre-COVID-19
era and during the COVID-19 crisis in terms of admission times, the
approach to testicular torsion and surgical outcomes, conditions caused
by COVID-19 may prompt urologists to manual detorsion more to set up
safer surgical environment. Additionally, this approach may result in a
decrease in orchiectomy rates by saving time and preserving the
vascularity of the testis.

\textbf{References}

1. Chung HS, Lee DE, Kim JK, Yeo IH, Kim C, Park J, et al. Revised
Triage and Surveillance Protocols for Temporary Emergency Department
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2. Rocco B, Sighinolfi MC, Sandri M, Altieri V, Amenta M, Annino F, et
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3. Amparore D, Campi R, Checcucci E, Sessa F, Pecoraro A, Minervini A,
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4. Bozkurt O, Sen V, Irer B, Sagnak L, Onal B, Tanidir Y, et al.
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5. Jacobsen FM, Rudlang TM, Fode M, Ostergren PB, Sonksen J, Ohl DA, et
al. The Impact of Testicular Torsion on Testicular Function. World J
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6. Hale T, Petherick A, Phillips T, Webster S. Variation in government
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7. Pines JM, Zocchi MS, Black BS, Celedon P, Carlson JN, Moghtaderi A,
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8. Range G, Hakim R, Beygui F, Angoulvant D, Marcollet P, Godin M, et
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9. Walker DM, Tolentino VR. COVID-19: the effects on the practice of
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10. Dopfer C, Wetzke M, Zychlinsky Scharff A, Mueller F, Dressler F,
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11. Littman AR, Janssen KM, Tong L, Wu H, Wang MD, Blum E, et al. Did
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12. Nelson CP, Kurtz MP, Logvinenko T, Venna A, McNamara ER. Timing and
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13. Holzman SA, Ahn JJ, Baker Z, Chuang KW, Copp HL, Davidson J, et al.
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14. Feng S, Yang H, Lou Y, Ru W, Wang A, Liu W. Clinical Characteristics
of Testicular Torsion and Identification of Predictors of Testicular
Salvage in Children: A Retrospective Study in a Single Institution.
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15. Arap MA, Vicentini FC, Cocuzza M, Hallak J, Athayde K, Lucon AM, et
al. Late hormonal levels, semen parameters, and presence of antisperm
antibodies in patients treated for testicular torsion. J Androl
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16. Romeo C, Impellizzeri P, Arrigo T, Antonuccio P, Valenzise M,
Mirabelli S, et al. Late hormonal function after testicular torsion.
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17. Xia Z, Hu J, Han L, Xia Q, Shao F, Lin X. Effect of unilateral
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18. Morin OA, Carr MG, Holcombe JM, Bhattacharya SD. Optimal Predictor
of Gonadal Viability in Testicular Torsion: Time to Treat Versus
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19. Nash WG. Acute torsion of spermatic cord: reduction: immediate
relief. The British Medical Journal 1893:742-3.

20. Demirbas A, Demir DO, Ersoy E, Kabar M, Ozcan S, Karagoz MA, et al.
Should manual detorsion be a routine part of treatment in testicular
torsion? BMC Urol 2017;17:84.

21. Dias Filho AC, Oliveira Rodrigues R, Riccetto CL, Oliveira PG.
Improving Organ Salvage in Testicular Torsion: Comparative Study of
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22. Siu Uribe A, Garrido Perez JI, Vazquez Rueda F, Ibarra Rodrigue MR,
Murcia Pascual FJ, Ramnarine Sanchez SD, et al. {[}Manual detorsion and
elective orchiopexy as an alternative treatment for acute testicular
torsion in children{]}. Cir Pediatr 2019;32:17-21.

23. Sessions AE, Rabinowitz R, Hulbert WC, Goldstein MM, Mevorach RA.
Testicular torsion: direction, degree, duration and disinformation. The
Journal of urology 2003;169:663-5.

24. Gunes M, Umul M, Altok M. Atypical Testicular Torsion: We Must be
Cautious in the Course of Manual Detorsion. Pediatr Emerg Care
2016;32:691-2.

25. Moore SL, Chebbout R, Cumberbatch M, Bondad J, Forster L, Hendry J,
et al. Orchidopexy for Testicular Torsion: A Systematic Review of
Surgical Technique. Eur Urol Focus 2020.

26. Coimbra R, Edwards S, Kurihara H, Bass GA, Balogh ZJ, Tilsed J, et
al. European Society of Trauma and Emergency Surgery (ESTES)
recommendations for trauma and emergency surgery preparation during
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27. de la Reza MT, Autran-Gomez AM, Tardio GU, Bolanos JA, Rivero JCG.
Emergency Surgery in Urology during the COVID-19 Pandemic. International
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2020;46:201-6.

28. Parikh M, Fiadjoe J, Black S. Emergency surgery during the COVID-19
pandemic. Paediatr Anaesth 2020;30:728-9.

\textbf{Tables}

\textbf{Table 1} : Characteristics and results of testicular torsion
cases\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
\textbf{pre-COVID-19 era}\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
\textbf{COVID-19 era}\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
\textbf{Total}\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
\textbf{p}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Number of Patients}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
18\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
13\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
31\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Age (years)}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
20.06\selectlanguage{ngerman}±7,66\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
18.62\selectlanguage{ngerman}±4.48\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
19.45\selectlanguage{ngerman}±6.47\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.441\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Laterality (Right / Left)}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
13/5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4/9\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
17/14\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Duration of Ischemia (hours)}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
18.72\selectlanguage{ngerman}±14.75\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
19.46\selectlanguage{ngerman}±31.54\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
19.03\selectlanguage{ngerman}±22.83\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.115\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Manual Detorsion (n) (\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1 (5.6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4 (30.8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
5 (16.1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.242\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{Orchiectomy +} \textbf{Contralateral Orchiopexy (n) (\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
7 (38.9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
3 (23.1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
10 (32.3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
0.514\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{Detorsion +} \textbf{Bilateral Orchiopexy (n) (\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
6 (33.3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
4 (30.8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
10 (32.3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{Bilateral Orchiopexy (n) (\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
5 (27.8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
6 (46.2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
11 (35.5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Hosted file}

\verb`Table 1.docx`  available at \url{https://authorea.com/users/313370/articles/536199-the-impact-of-covid-19-pandemic-on-admission-times-manual-detorsion-rates-and-outcomes-in-testicular-torsion}

\selectlanguage{english}
\FloatBarrier
\end{document}

