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 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 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 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 pandemic11,12. 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 13.
In testicular torsion, ischemia duration and torsion degree are the most important factors in preserving the functional features of the testis14. Irreversible damage starts after four to six hours and affects both the spermatogenesis and the endocrine functions15,16. 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 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 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 19. Various studies in literature suggests that this method may be an alternative to exploration and surgical detorsion 20-22. On the other hand, some studies in literature suggest the risk of residual torsion and subsequent testicular atrophy 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 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 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 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 subject3,26,27. 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 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.