Testicular Torsion. Pediatric Testicular Torsion: Demographics of National Orchiopexy Versus Orchiectomy Rates

Size: px

Start display at page:

Download "Testicular Torsion. Pediatric Testicular Torsion: Demographics of National Orchiopexy Versus Orchiectomy Rates"

Muriel Quinn
6 years ago
Views:

1 Testicular Torsion Pediatric Testicular Torsion: Demographics of National Orchiopexy Versus Orchiectomy Rates Nicholas G. Cost,* Nicol C. Bush, Theodore D. Barber, Rong Huang and Linda A. Baker From the Division of Pediatric Urology and Department of Research (RH), Children s Medical Center and University of Texas Southwestern Medical Center at Dallas, Dallas, Texas Purpose: While the timely diagnosis and management of pediatric torsion can lead to testicular salvage, limited data exist on rates of orchiopexy vs orchiectomy and associated factors. Thus, we examined the Pediatric Health Information System database for torsion outcomes and demographics at American pediatric hospitals. Materials and Methods: Using the Pediatric Health Information System database we performed a 7-year retrospective cohort study in children 1 to 17 years old with a primary ICD-9 diagnosis of torsion, assessing CPT codes for orchiopexy and orchiectomy. Data were analyzed with SPSS, version Results: Of 2,876 patients who underwent surgery for an ICD-9 diagnosis code of testicular torsion 918 (31.9%) underwent orchiectomy at a mean age of 10.7 years and 1,958 (68.1%) underwent orchiopexy at a mean age of 12.6 years (p ). In the age groups 1 to 9, 10 to 13 and 14 years or greater 274 (49.9%), 311 (29.4%) and 333 patients (26.2%), respectively, underwent orchiectomy. A higher orchiectomy rate was seen at age 1 to 9 vs 10 years or greater. Torsion and orchiectomy rates did not vary by season or geographic region. A higher orchiectomy rate was seen in black vs white children (37.6% vs 28.1%) and in patients without vs with private insurance (36.7% vs 27.0%). Multivariate analysis revealed an association of age (p ), race (p ) and insurance status (p 0.001) with orchiectomy. Conclusions: Nationally an average of 32% of the 411 pediatric torsion cases explored annually result in orchiectomy. Identified factors increasing the orchiectomy risk included age 1 to 9 years, black race and lack of private insurance. Efforts should continue to identify modifiable variables that can increase testicular salvage in patients with testicular torsion. Abbreviations and Acronyms NC north central NE northeast NIS Nationwide Inpatient Sample NW northwest PHIS Pediatric Health Information System database SC south central SE southeast SW southwest Study received institutional review board approval. * Correspondence: Department of Urology, University of Texas Southwestern Medical Center at Dallas, J8.148, 5235 Harry Hines Blvd., Dallas, Texas (telephone: ; FAX: ; nicholas. cost@sbcglobal.net). Supported by Grant NIH R01 HD48838 from the National Institutes of Health, Washington, DC. Key Words: testis, spermatic cord torsion, orchiectomy, orchiopexy, demography TESTICULAR torsion is a surgical emergency that is unfortunately common with an incidence of 1/4,000 males younger than 25 years. 1 With prompt recognition appropriate management can lead to testicular salvage via detorsion and orchiopexy. However, barriers to a timely diagnosis can result in testicular loss and orchiectomy. Limited data exist on the rates of orchiopexy vs orchiectomy for torsion management and associated risk factors predisposing a patient to orchiectomy. Previous groups have attempted to link the risk of testicular loss to factors such as age, race, insurance status, season and region of presentation with mixed results and an /11/ /0 Vol. 185, , June 2011 THE JOURNAL OF UROLOGY Printed in U.S.A by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC. DOI: /j.juro

2 2460 TESTICULAR TORSION DEMOGRAPHICS OF ORCHIOPEXY VERSUS ORCHIECTOMY inability to define risk factors. 2 5 For example, a recent study using a national database to investigate this issue showed that age greater than 10 years was a risk factor for orchiectomy 3 while another study showed that younger patients were more likely to undergo orchiectomy. 2 Using PHIS we identified demographic factors predisposing patients to testicular torsion and subsequent orchiectomy or orchiopexy. MATERIALS AND METHODS Patient Population Using institutional review board approved methods we performed a retrospective cohort study between 2003 and PHIS was queried for visits with a primary ICD-9 code diagnosis of testicular torsion (608.2). CPT codes were then assessed for orchiopexy or testicular torsion reduction (54600, 54620, 54640, and 54800) and orchiectomy (54520). Patients 1 to 17 years old were included in analysis but we excluded infants younger than 1 year since this study did not focus on neonatal torsion. Data Source PHIS consists of data contributed by 42 nonprofit, freestanding pediatric hospitals. The primary ICD-9 code is designated in PHIS as the diagnosis that led to presentation to the facility. Study Design We extracted data on patients who met our study criteria, including hospital admission and discharge dates, admission site, race, age and insurance status. These variables were selected since they were previously linked to testicular torsion and the risk of orchiectomy or orchiopexy, and were extractable from PHIS. 2 4 The study end point was orchiopexy vs orchiectomy. Age was categorized as prepubertal (9 years or less), pubertal (10 to 13 years) and postpubertal (14 years or greater) based on a prior study of the rate of orchiectomy for torsion 3 and existing data on puberty timing. 6 Each case was assigned to a season of presentation, including winter, spring, summer or fall. Insurance status was categorized as private insurance vs governmental aid or nonfunded. Presentation site was assigned to regions, including NE, NC, NW, SE, SC and SW. PHIS comprises 7 hospitals (16.7%) in the NE, 12 (28.6%) in the NC, 3 (7.1%) in the NW, 11 (26.2%) in the SE, 5 (11.9%) in the SC and 4 (9.5%) in the SW region. Data Analysis Using these demographic factors we compared children who underwent orchiopexy vs orchiectomy for testicular torsion. Using SPSS, version 17.0 all data were compared by nonparametric statistical analysis with the Mann- Whitney test for continuous variables and the chi-square test for categorical variables to calculate the OR. After univariate analysis any statistically significant variable was added to multivariate Cox regression analysis to calculate the adjusted OR. In all analyses p 0.05 or a 95% CI not crossing 1.0 was considered significant. RESULTS We identified 2,876 unique patients diagnosed with torsion in the 7-year study period, that is 411 cases annually. Mean age was 11.9 years, including 1 to 9, 10 to 13 and 14 years or greater in 549 (19.1%), 1,059 (36.8%) and 1,268 patients (44.1%), respectively. Of patients who underwent exploration orchiectomy was done in 918 (31.9%) at a mean age of 10.7 years and orchiopexy was done in 1,958 (68.1%) at a mean age of 12.6 years, demonstrating a significant difference for younger age in those with orchiectomy (p ). To investigate this further we analyzed each age group. Of those 1 to 9 years old 274 (49.9%) underwent orchiectomy vs 311 (29.4%) 10 to 13 years old and 333 (26.2%) 14 years or older, demonstrating a higher orchiectomy rate in patients 1 to 9 vs 10 years or older (OR 2.6, 95% CI , see figure). Thus, children 1 to 9 years old represented 19.1% of those with torsion overall but 29.8% of those with orchiectomy for torsion in our cohort. We investigated the role of seasonal variation. Of the patients 792 (27.5%), 827 (28.8%), 616 (21.4%) and 641 (22.3%) presented in the winter, spring, summer and fall, respectively (p 0.05). A total of 264 (33.3%), 265 (32.0%), 180 (29.2%) and 209 cases (32.6%) were managed by orchiectomy, respectively (p 0.05). When assessing for regional variation, 381 (13.2%), 743 (25.8%), 55 (1.9%), 881 (30.6%), 553 (19.2%) and 263 patients (9.1%) presented with testicular torsion in the NE, NC, NW, SE, SC and SW regions, respectively (p 0.05). Of these cases 138 (36.2%), 218 (29.3%), 22 (40.0%), 261 (29.6%), 186 (33.6%) and 93 (35.4%) were managed by orchiectomy, respectively (p 0.05). The racial distribution was 1,671 patients (58.2%) identified as white, 872 (30.3%) identified as black and 333 (11.5%) identified as other or with unavailable racial/ethnic information. At surgery a higher rate of orchiectomy was seen in black than in white patients (37.6% vs 28.1%, OR 1.55, 95% CI ). When assessing insurance status, 2,193 children (76.3%) had data available, including 1,063 with private insurance while 1,130 had no coverage, were self-payors or had government assistance. We found a higher orchiectomy rate in patients who had no coverage, were self-payors or had government assistance than in those with private insurance (36.7% vs 27.0%, OR 1.57, 95% CI ). After identifying on univariate analysis the statistically significant risks as age 1 to 9 vs 10 years or greater, nonprivate vs private insurance and black vs white race we performed Cox regression multivariate analysis in the 1,939 patients (67.4%) with complete PHIS data. A significant association was

TESTICULAR TORSION DEMOGRAPHICS OF ORCHIOPEXY VERSUS ORCHIECTOMY 2461 Effect of age on orchiectomy vs orchiopexy for testicular torsion in American pediatric hospitals from 2003 to 2009 found of age

3 TESTICULAR TORSION DEMOGRAPHICS OF ORCHIOPEXY VERSUS ORCHIECTOMY 2461 Effect of age on orchiectomy vs orchiopexy for testicular torsion in American pediatric hospitals from 2003 to 2009 found of age (p ), race (p ) and insurance status (p 0.001) with orchiectomy. The adjusted OR in patients 1 to 9 years vs 10 years or older for orchiectomy was 2.75 (95% CI ), the adjusted OR in black vs white patients was 1.66 (95% CI ) and the adjusted OR in those without vs with private insurance was 1.42 (95% CI ). DISCUSSION The clinical outcome of testicular torsion depends on delivery of the appropriate diagnosis in timely fashion. If the testicle can be detorsed within 6 hours, as many as 90% of patients experience testicular salvage but this incidence decreases to less than 10% after 24 hours. 7,8 The importance of this issue centers around the association between testicular loss, and decreased hormonal function, fertility and sperm count. 9,10 Due to this morbidity torsion is a sensitive, litigious topic. Thus, we identified demographic factors related to detorsion and orchiopexy vs torsion induced testicular loss and orchiectomy. To our knowledge this is the largest population to be studied on this topic and the first series to show a significant correlation of race and insurance status with an increased risk of orchiectomy due to torsion. Recently Mansbach et al reviewed medical records from the 1998 Healthcare Cost and Utilization Project NIS. 3 They evaluated age, race, insurance status and regional variation in 436 patients 1 to 25 years old. After grouping the population into ages 1 to 9, 10 to 17 and 18 to 25 years they found an increasing risk of testicular loss and orchiectomy starting at age 10 years. When examining only patients 17 years or younger, children 1 to 9 years old represented 13.5% of those with torsion but only 8.2% of those who underwent orchiectomy for torsion. Using similar age groups in our PHIS based study we found that the torsion incidence distribution corresponded to the known age pattern of testicular torsion. 1 3 Age was related to the risk of orchiectomy and children 1 to 9 years old represented 19.1% of those with torsion overall but 49.9% underwent orchiectomy, representing 29.8% of orchiectomies for torsion in patients 1 to 17 years old, placing this age group at increased risk for orchiectomy. In the group 10 to 17 years old the orchiectomy rates were similar at 27.7% and 33.2% in PHIS and the NIS database, respectively. Unlike in our study, Mansbach et al found no correlation between orchiectomy and race or insurance status. 3 They observed a trend toward an increased rate of testicular loss in patients self-identified as black and in those with less income and nonprivate insurance but these trends did not attain statistical significance on univariate or multivariate analysis. This may have been due to their smaller patient cohort since when analyzing our larger data set, we found a correlation of orchiectomy with race and insurance status. Several factors may account for the differing results in the NIS vs PHIS analyses. Since NIS is an inpatient cross-sectional database only while PHIS includes inpatient and some outpatient encounters, PHIS may better represent testicular torsion man-

4 2462 TESTICULAR TORSION DEMOGRAPHICS OF ORCHIOPEXY VERSUS ORCHIECTOMY agement patterns. NIS is composed of community hospitals, which pediatric patients tend to be referred to tertiary pediatric hospitals. Thus, they lack an appropriate representation of the pediatric population. Comparatively PHIS is composed of tertiary, mostly academic pediatric hospitals. This may more comprehensively report the pediatric experience but also may bias the study toward more aggressive management, and higher rates of attempted detorsion and orchiopexy. Also, the age of the individual with torsion may affect the likelihood of inpatient vs outpatient management, impacting the completeness of reporting. Previously 2 single center studies retrospectively compared variations in the rate of orchiectomy for torsion in children vs adults with mixed results. Barada et al reviewed the records of 30 patients and noted that children (age 18 years or less) were more likely to undergo orchiectomy than adults (age greater than 18 years) (44% vs 8%). 2 Adults had significantly shorter time to presentation than children (4.25 vs hours, p 0.001). They surmised that younger patients delay reporting symptoms to parents or guardians and, thus, have a decreased window of opportunity for testicular salvage. In contrast, after reviewing the records of 44 patients Cummings et al determined that adults (age 21 years or greater) were more likely to undergo orchiectomy than children (age less than 21 years) (59% vs 29.7%). 4 While they found no difference in time to presentation between the groups, they observed that increasing time to presentation led to an increasing orchiectomy rate. They attributed increased testicular loss in the adult group to more severe torsion in a higher percent with an increased degree of spermatic cord twisting. While we could not extract data from PHIS on the timing of presentation, our analysis agrees with that of Barada et al in that younger patients were more likely to be treated with orchiectomy than older children. However, as we assessed the impact of age, our study differed since it included only children 1 to 17 years old. Without adults with torsion we cannot directly compare our analysis and conclusions to those of Cummings 4 or Barada 2 et al. The role of regional and seasonal variation in testicular torsion was previously reported. 5,11 13 These studies showed an increasing torsion incidence in colder weather. Some groups suggested that this is due to a more hyperactive cremasteric reflex in colder weather since clinically it is well known that the testis ascends in response to a cold environment. These findings were noted in various regions and climates around the world. However, the strongest and most specific data come from the series by Srinivasan et al, who correlated the torsion risk to atmospheric temperature and humidity, thereby removing any regional variability. 5 While these environmental findings are notable, in our cohort we did not determine any relationship between torsion incidence or management and the season or region of presentation. In regard to the correlation between race and insurance status with the orchiectomy rate we believe that this is related to delayed presentation. Whether this is due to barriers to care for lower socioeconomic groups or to mistrust of the medical system in some ethnic communities it is impossible to refute that these factors affect patient outcomes. 14,15 This is not a unique finding since others observed a relationship between insurance status and race with the risk of a ruptured appendicitis. 16,17 Appendicitis provides a scenario similar to that of testicular torsion. It is an acute surgical emergency in which delayed diagnosis or management may lead to morbidity such as rupture. Comparatively in torsion cases delay can lead to orchiectomy and testicular loss. We recognize that the best method to investigate this relationship between barriers to care and torsion management would be to prospectively interview patients and families as they present. Important data to analyze would be symptom onset, time to presentation, and decisions on when and where to present. It could be specifically determined whether there were any reasons why care may or may not have been delayed. A major limitation to our study is that PHIS does not always contain the specific data of interest on each patient or even on the general study population. Even for our 5 included variables only twothirds of our original population had all 5 data points available, which could have impacted on our multivariate analysis. This clearly impacted our statistical conclusions but, given the limited data available, we have presented it as completely as possible. PHIS was originally designed to only include inpatient data. However, it evolved to include outpatient and ambulatory surgery center data, although these outpatient data have not been uniformly added at all participating facilities. Torsion is routinely evaluated and treated on an outpatient basis, Thus, we recognize that our conclusions are limited by the composition and collection methods of PHIS. Also, we could not study a number of potentially important factors impacting torsion and outcome simply because they were not extractable from PHIS. These factors include but are not limited to distance from presentation site to hospital, number of previous hospitals visited before evaluation at the PHIS based facility, emergency room delays, imaging delays, time of initial presentation, time until surgery, and overall duration and type of symptoms. This study was limited by the inability to review

5 TESTICULAR TORSION DEMOGRAPHICS OF ORCHIOPEXY VERSUS ORCHIECTOMY 2463 patient charts to determine the accuracy of diagnosis codes. For example, it is unclear why, how or when the diagnosis of torsion was established, making it impossible to exclude confounding alternate diagnoses, such as appendix testis torsion or epididymitis, that may have been initially miscoded. However, since there is a separate ICD-9 code for these entities, miscoding errors should be minimal. In addition to the study weaknesses of an inability to control for all confounding factors or for missing data, this was a retrospective study looking at 1 time point, which prohibited asking specific post hoc questions. Since we could only assess whether these patients underwent surgical detorsion and orchiopexy vs orchiectomy, we do not know the final outcome of the rate of testicular loss vs salvage after detorsion due to the lack of followup. Thus, the next step is to prospectively assess this topic to answer any unresolved questions with specific data collection, including long-term followup of testicular preservation. CONCLUSIONS Nationally an average of 32% of the 411 pediatric torsion cases explored annually result in orchiectomy. Identified factors that increase the orchiectomy risk included age 1 to 9 years, black race and lack of private insurance. Efforts should continue to identify modifiable variables that can increase testicular salvage in testicular torsion cases. ACKNOWLEDGMENTS Hospitals contributing to PHIS are affiliated with Child Health Corp. of America ( Data are collected and maintained at Solucient L. L. C. ( REFERENCES 1. Cuckow PM and Frank JD: Torsion of the testis. BJU Int 2000; 86: Barada JH, Weingarten JL and Cromie WJ: Testicular salvage and age-related delay in the presentation of testicular torsion. J Urol 1989; 142: Mansbach JM, Forbes P and Peters C: Testicular torsion and risk factors for orchiectomy. Arch Pediatr Adolesc Med 2005; 159: Cummings JM, Boullier JA, Sekhon D et al: Adult testicular torsion. J Urol 2002; 167: Srinivasan AK, Freyle J, Gitlin JS et al: Climatic conditions and the risk of testicular torsion in adolescent males. J Urol 2007; 178: Euling SY, Herman-Giddens ME, Lee PA et al: Examination of US puberty-timing data from 1940 to 1994 for secular trends: panel findings. Pediatrics, suppl., 2008; 121: S Davenport M: ABC of general surgery in children. Acute problems of the scrotum. BMJ 1996; 312: Tryfonas G, Violaki A, Tsikopoulos G et al: Late postoperative results in males treated for testicular torsion during childhood. J Pediatr Surg 1994; 29: Ferreira U, Netto Júnior NR, Esteves SC et al: Comparative study of the fertility potential of men with only one testis. Scand J Urol Nephrol 1991; 25: Romeo C, Impellizzeri P, Arrigo T et al: Late hormonal function after testicular torsion. J Pediatr Surg 2010; 45: Shukla RB, Kelly DG, Daly L et al: Association of cold weather with testicular torsion. Br Med J (Clin Res Ed) 1982; 285: Mabogunje OA: Testicular torsion and low relative humidity in a tropical country. Br Med J (Clin Res Ed) 1986; 292: Williams CR, Heaven KJ and Joseph DB: Testicular torsion: is there a seasonal predilection for occurrence? Urology 2003; 61: Goff DC Jr., Feldman HA, McGovern PG et al: Prehospital delay in patients hospitalized with heart attack symptoms in the United States: the REACT trial. Rapid Early Action for Coronary Treatment (REACT) Study Group. Am Heart J 1999; 138: Weissman JS, Stern R, Fielding SL et al: Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med 1991; 114: Braveman P, Schaaf VM, Egerter S et al: Insurance-related differences in the risk of ruptured appendix. N Engl J Med 1994; 331: Guagliardo MF, Teach SJ, Huang ZJ et al: Racial and ethnic disparities in pediatric appendicitis rupture rate. Acad Emerg Med 2003; 10: 1218.

TESTICULAR TORSION IS A

TESTICULAR TORSION IS A ARTICLE Testicular Torsion and Risk Factors for Orchiectomy Jonathan M. Mansbach, MD; Peter Forbes, MA; Craig Peters, MD Objective: To determine risk factors for testicular loss due to testicular torsion.