A MINIMALLY INVASIVE METHOD

IN DIAGNOSING TESTICULAR TORSION:

THE INITIAL EXPERIENCE OF
SCROTOSCOPE
Huamao Ye, MD,* Zhiyong Liu, MD,* Haifeng Wang, MD,* Yifan Chang, MD,* Xu Gao,
MD,Chuanliang Xu, MD, Jianguo Hou, MD, and Yinghao Sun, MD

JOURNAL OF ENDOUROLOGY
Volume 30, Number 6, June 2016

Agung Adhitya
INTRODUCTION

 testicular torsion 1840 by Delasiuave

 under 25 years 1 : 4000 male

 delay in diagnosis  loss testicular circulation

 exploration is gold standard  diagnosis &

treatment
 overlap symptoms epididymo-orchitis  risk
traumatic surgery for children  cloud treated
conservatively  very high.
INTRODUCTION

 Doppler ultrasound & scoring system

 alternative ways
 noninvasive examination
 minimally invasive surgery

 Purpose  minimally invasive with high

sensitivity and specificity in diagnosing
testicular torsion
PATIENTS AND METHODS: PATIENT AND
PREOPERATIVE EXAMINATIONS
 February 2010 - June 2013
 14 patients

 aged 12 - 24 years

 acute onset of scrotum pain

 the urological center of Changhai Hospital

 No predisposing factors or fever

 longest time to admission 10 hours

PATIENT AND PREOPERATIVE EXAMINATIONS

 hemiscrotum mildly - moderately congested

and swollen
 ipsilateral testis and epididymis were not
palpable
 urine + blood tests + USG color Doppler

 blood flow decreased 7 cases and normal 7

cases
PATIENTS AND METHODS: SURGICAL
PROCEDURE
 sign informed consent
 10F pediatric cystoscope for scrotoscope

 General anesthesia + supine position

 8 mm incision  1/3 laterally and inferiorly to

the hemiscrotum
SURGICAL PROCEDURE

 dissection scrotal skin + dartos muscle

 insert the sheath to parietal layer tunica vaginalis

 scope introduced to the sheath

 purse-string suture / Allis clamps at incision edge

 Scrotoscope  testis + epididymis + torsion of

spermatic cord
 saline irrigation for adequate space + clear
surgical vision.
RESULTS

 Scrotoscopy 14 patients
 Torsioned testis 5 cases

 Epidymitis 9 cases
RESULTS
RESULTS
RESULTS
RESULTS

 4 of 5 cases rotated by 360⁰ viable

 1 of 5 cases 540⁰ still nonviable

 9 cases epididymis edema & congestion

 drainage hemiscrotum 24 hours postop + 7 day

antibiotics
RESULTS

 Average time scrotoscopy 29.4 (range 21–45)

minutes
 5 cases scrotal incision

 pain measured NRS

 USG Doppler follow-up

 No bleeding of scrotum, testicular atrophy, or

relapse
 14 patients followed 2 years
DISCUSSION
 Testicular torsion, epididymo-orchitis, and
torsion of the testicular appendix  most
common
 different management & outcomes 
distinguish
 MRI and nuclear scintigraphy  high detection
rate  costly, not universally available, time
consuming and may miss optimal time for
surgery
DISCUSSION

 Doppler USG
 excellent imaging anatomical
 perfusion

 high availability

 short duration

 low costs

 hight false negative rate and high operator

dependency  specificity 71.4%.
DISCUSSION

 Scrotoscopy  use of endoscopy in diagnosis

and treatment  described by Gerris & Shafik
 Gerris and colleagues  scrotoscopy
evaluation of infertile patients
 Shafik  diagnosis testis masses, testicular
biopsies in infertile, venography, and
vasography
DISCUSSION

 Shafik  suitable endoscope  distended tunica

vaginalis 40-60mL saline  18F scrotoscope
 scrotal layer swelling  cannot be well distended
 hydrodistention  damage ipsilateral testis.
 7F semirigid ureteroscope 
 easy insertion
 easier to navigate and

 observe better in limited space

 long shaft  difficult to operate precisely.

DISCUSSION
 Yin and colleagues
 adult cystoscopy
 easy to operate
 more damage
 pediatric cystoscope
 easier navigation
 more precise manipulation
 space for scrotoscopy  hydropressure distend
cavity  small incision  purse string suture /
pair of Allis clamps  adequate irrigation pressure
DISCUSSION

 The key point scrotoscopic  distinguish

normal or abnormal testis and epididymis
 1st scrotal anatomy

 2nd testis color

 3RD retracted cavity

DISCUSSION

 scrotoscopy vs scrotal exploration

 Emergency time  substituting general
anesthesia with local anesthesia
 Future studies  larger sample  validate this
technique
 Younger child with communicating hernia 
contraindication
CONCLUSIONS

 Scrotoscopy  safe and efficacious

 confirming diagnosis with minimally invasive

 reducing surgical trauma and acquiring timely

intervention
CRITICAL APPRAISAL

 Population
 14 patients
 aged 12 - 24 years

 acute onset of scrotum pain

 Intervention
 urine+ blood tests + USG color Doppler
 Scrotoscopy

 Scrotal exploration
CRITICAL APPRAISAL

 Comparasion
 scrotoscopy vs diagnostic scrotal exploration
 Outcome
 NRS 1-3
 No bleeding of scrotum, testicular atrophy, or
relapse
 Clearly distinguish tosion and inflamation