From time to time (as paediatric surgeons), we receive referrals from regional hospitals to explore the testis in older boys. Given the time-critical nature of the condition, patients should benefit from assessment and surgery performed locally (when possible). Inter-hospital transfer may prolong ischaemic time and reduce likelihood of testicular salvage. Bayne et al. undertook a retrospective review of patients (2005-2015) with testicular torsion presenting ‘directly’ to their hospital emergency department or ‘referred’ from an outside institution. The authors perceived an increase in emergent referrals following the introduction of paediatric urology sub-speciality certification (2008). Cases were identified using operative coding. Perinatal torsion and elective management of intermittent torsion were excluded. A total of 218 patients with testicular torsion presented to the ED. The majority (61.9%) were ‘direct’ presentations and only increased slightly over the study period. However, the incidence of referred testicular torsion increased from three cases in 2005 to 15 in 2015. This was mainly due to an increase in ‘referred’ acute cases (pain <24 hours). The proportion of ‘referred’ acute cases increased markedly from the pre-certification period to the post-certification period. The majority of ‘referred’ cases presented during weekday nights or weekends compared to a minority of ‘direct’ cases. Time from symptom onset to presentation was the most significant factor affecting orchiectomy rate (76.7% of delayed cases undergoing orchiectomy vs. 10% of acute cases). Similar numbers of ‘direct’ and ‘referred’ cases underwent orchiectomy. There was a trend towards increased orchiectomy in those transported more than 10 miles. They concluded that, despite the surgical treatment representing a basic procedure in which all urologists are trained, it seemed that cases were being increasingly referred to paediatric urologists. It was also unlikely that the majority of patients benefited from transfer. The editorial commentary also makes interesting reading.

Testicular torsion presentation trends before and after pediatric urology subspeciality certification.
Bayne CE, Gomella PT, DiBianco JM, et al.
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Neil Featherstone

Cambridge University Hospitals NHS Foundation Trust (Addenbrookes Hospital).

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