key: cord-0722473-9uvz68p2 authors: Pogorelić, Zenon; Milanović, Karla; Veršić, Ana Bosak; Pasini, Miram; Divković, Dalibor; Pavlović, Oliver; Lučev, Josip; Žufić, Vanja title: Is there an increased incidence of orchiectomy in pediatric patients with acute testicular torsion during COVID-19 pandemic? - A retrospective multicenter study date: 2021-05-01 journal: J Pediatr Urol DOI: 10.1016/j.jpurol.2021.04.017 sha: b64314192dd275c72b3a44d38b5d606ab4ad013a doc_id: 722473 cord_uid: 9uvz68p2 INTRODUCTION: Testicular torsion is a real emergency condition which requires prompt diagnosis and surgical management to prevent testicular loss. During the coronavirus (COVID-19) pandemic, an increased avoidance of the emergency departments for non-COVID-19 illnesses has been reported in the medical literature. OBJECTIVE: The aim of this study was to investigate whether the COVID-19 pandemic caused increased number of orchiectomies in pediatric patients presenting with acute testicular torsion compared to pre-COVID-19 period. STUDY DESIGN: A total number of 119 pediatric patients who underwent surgery for acute testicular torsion from January 2019 to December 2020 were enrolled in retrospective multi-center study from six institutions in Croatia. The patients were divided in two groups. The first group (pre-COVID-19) consisted of the patients who underwent surgery before COVID-19 pandemic (n=68), while the second group (COVID-19) consisted of the patients who underwent surgery during the COVID-19 pandemic (n=51). Main outcomes of the study were orchiectomy rates and time from onset of the symptoms to emergency department presentation. RESULTS: During the COVID-19 pandemic period 43.1% (22/51) of the patients underwent orchiectomy while orchiectomy was performed in 16.2% (11/68) of the patients from the pre-COVID group (p=0.001). Median time from onset of the symptoms to emergency department presentation during COVID-19 pandemic and pre-COVID-19 periods was 14h (IQR 5, 48) and 6h (IQR 3, 22) (p=0.007), respectively. A higher proportion of patients waited over 24 h to present to emergency department during the COVID-19 pandemic compared to the pre-COVID-19 period (47% vs 8.8%, p=0.007). CONCLUSION: During COVID-19 pandemic a significantly higher rates of orchiectomies and increase in delayed presentations for testicular torsion was found. More patient education during pandemic in regards to management of emergency conditions such as testicular torsion is required. During COVID-19 pandemic a significantly higher rates of orchiectomies and increase in delayed presentations for testicular torsion was found. More patient education during pandemic in regards to management of emergency conditions such as testicular torsion is required. Key words: Testicular torsion; Acute scrotum; COVID-19; Pandemic; Urologic emergencies; Children Rates of orchidopexy / orchiectomy between pre-COVID-19 and COVID-19 periods. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% pre-COVID- 19 COVID-19 [VALUE] [VALUE] [VALUE] [VALUE] p=0.001 Orchidopexy Orchiectomy J o u r n a l P r e -p r o o f INTRODUCTION Testicular torsion is a common pediatric emergency which occurs when the testicle rotates around its axis leading to an impaired blood supply and possible irreversible changes and a complete loss of testis [1] . An incidence of testicular torsion is 4.5 in 100,000 males up to 25 years of age [2] . Testicular torsion can occur at any age but usually occurs in newborns and young males who are in puberty or adolescence, between the ages of 13 and 16 years [3] . Testicular torsion is most often presented by sudden onset of pain, swelling and redness of the affected side of the scrotum. The testis is hard and often positioned higher than normal or at an unusual angle [1] [2] [3] . In rare cases testicular torsion may have unusual presentation and lower abdominal pain can be the only presenting symptom [3] [4] [5] . Also an unusual variant of testicular torsion can occur in the setting of cryptorchidism, with testicular torsion in inguinal canal [3, 6] . Prompt diagnosis and surgical management with scrotal exploration and detorsion are important to prevent testicular loss. The likelihood of testicular salvage is timedependent. Many studies reported that a testicle torsed for longer than six to eight hours is outside the timeframe for survival [1] [2] [3] [4] . A recent systematic review of the literature showed that testicular survival time, in the case of testicular torsion, can be much longer than six to eight hours as previously believed. Survival percentages are significant even past 24 hours of torsion [7] . Additionally, time from onset of J o u r n a l P r e -p r o o f symptoms to the operating room is an independent predictor of testicular survival [1, 2, 7] . During the coronavirus (COVID-19) pandemic, an increased avoidance of the emergency departments for non-COVID-19 illnesses has been reported in the medical literature [8] [9] [10] [11] [12] . Pediatric patients do not commonly experience medical conditions with a high risk of mortality but delay in diagnosis can lead to a significant increase in morbidity, prolonged hospitalization, increased financial expense and mortality [12] . For example, during the first wave of a COVID-19 pandemic, a significantly higher rate of perforated appendicitis was recorded in children, compared to the same period one year before pandemic (39% vs. 13%) [11] . pandemic may also contribute to delays in presentation of patients with testicular torsion to emergency departments and may significantly increase a number of testicular loss. The aim of this multicenter retrospective study was to investigate whether the COVID-19 pandemic caused increased number of orchiectomies in pediatric patients presenting with acute testicular torsion. Our hypothesis was that delays in presentation to the emergency department, as well as the rates of orchiectomy, were increased during the COVID-19 pandemic period. J o u r n a l P r e -p r o o f A total of 119 pediatric patients who underwent emergency scrotal exploration for acute testicular torsion and met the inclusion criteria, between January 2019 and December 2020, were enrolled in the study. The patients were divided in two groups. The primary outcome of the study was orchiectomy rate. The secondary outcome was time from onset of the symptoms to emergency department presentation. For each patient; medical history, demographic data (age, weight, height, body mass index), dwelling, distance from the hospital, side of torsion, duration of symptoms, presenting symptoms, preoperative ultrasound, intraoperative findings (degree of torsion) and outcomes of treatment (detorsion and fixation or orchiectomy) and recurrences were recorded in the study protocol. The surgery was performed in the emergency settings after a clinical examination and ultrasound examination of the scrotum, which depended on the judgment of the operating surgeon. Description of the surgical procedure and algorithm of treatment are available in our previously published study [2] . Postoperatively, the patients received pain medication and were observed in department of pediatric surgery at the included centers. The patients were followed up postoperatively for detection of late complications. The SPSS 24.0 software (IBM Corp, Armonk, NY) was used to analyze the data. Median and interquartile range (IQR) or mean and standard deviation (SD) were used for quantitative or an ordinal variables. To describe a distribution of a categorical variables absolute and relative frequencies were used. The significance of differences in quantitative variables between the study groups was assessed by the ttest for independent samples, or by its alternative -nonparametric test (Mann-Whitney U test). The chi-square test was used to assess differences in distribution of categorical data. When the frequency of events in a certain cell was low, Fisher exact test was used instead. All the tests were two-sided and the significance level of 0.05 was used. During study period, a total number of 119 patients underwent surgery because of acute testicular torsion. During the selected pre-COVID- 19 Table 3 shows comparison of the main outcomes between the centers enrolled in study. Between pre-COVID-19 and COVID-19 cohorts, in all centers increased percentage of orchiectomies (except in one center) and longer mean time from onset of the symptoms to emergency department presentation was found. The results of this study clearly demonstrated significantly higher number of orchiectomies during the COVID-19 pandemic compared with pre-COVID-19 period. pandemic period has been noted by the medical community and published in several reports [8] [9] [10] [11] [12] [13] . Several recent studies of acute appendicitis during COVID-19 pandemic clearly showed that staying at home due to public health safety orders negatively impacted children who developed appendicitis. During the COVID-19 pandemic increased rate of perforated appendicitis in pediatric patients, compared to pre-COVID-19 period, was reported in several published studies [11, [13] [14] [15] . Also, the patients with perforated appendicitis had an increased rate of complications and length of hospital stay [13] . In the available literature, only two studies investigated whether the COVID-19 pandemic caused increased number of orchiectomies and delays in presentation to emergency department in pediatric patients suffering from acute testicular torsion. Contrary to our results Nelson et al. in their study found that time from onset of symptoms to emergency department presentation, ischemic times, and orchiectomy rates for testicular torsion at their center were not significantly different during the COVID-19 pandemic period compared to pre-COVID period [16] . Although in their town dramatic drop in urgent presentations for stroke, heart attack and cancer during the COVID-19 was noticed. They explained this finding with the fact that the nature of this condition, the severity and acuity of symptoms associated with J o u r n a l P r e -p r o o f testicular torsion and visible swelling, make this condition difficult to ignore [16] . Littman et al. in their study also did not found delay presentation to a medical facility or a higher rate of orchiectomy during the COVID-19 pandemic [17] . We are of the opinion that this results are due exclusively to the small number of patients with testicular torsion in COVID-19 pandemic (n=17 and n=21), as well as the fact that patients from only one center were included in the study. Six centers with a significantly higher number of patients (n=119) participated in our study. group from only March through May of 2020 while our study continued by the end of the year. Comparing the patients from each center separately, clearly showed that no significant difference between the groups in some of the centers was recorded, mostly in the centers with small sample size while in centers with larger number of patients' included significant difference was found. Baseline rate of orchiectomies for testicular torsion is already high and varies between 20 -35% [1] . The rate of orchiectomies in a large study from USA was 34% while in our previous study was 28% [2, 18] . Regardless to the pandemic, some children have delayed presentation to the emergency departments for acute testicular torsion. Recent study reported that 13% of children with torsion may delay informing their parents, mostly due to shame and fear. Also the children with autism spectrum disorders are at higher risk of delayed presentation [19] . As we know that most of the testicles would be saved if surgery is performed within 6 -8 hours from the onset of Duration of symptoms is the only predictor of testicular salvage following testicular torsion in children: A case-control study Management of acute scrotum in children: a 25-year single center experience on 558 pediatric patients An unusual presentation of testicular torsion in children: a single -centre retrospective study Do not forget to include testicular torsion in differential diagnosis of lower acute abdominal pain in young males Abdominal pain in teenagers: Beware of testicular torsion Testicular torsion in the inguinal canal in children A systematic review of testicle survival time after a torsion event Experience of a surgeon at the emergency department during COVID-19 pandemic Emergency surgery in COVID-19 outbreak: Has anything changed? Single center experience Potential indirect effects of the COVID-19 pandemic on use of emergency departments for acute lifethreatening conditions -United States Rate of pediatric appendiceal perforation at a Children's hospital during the COVID-19 pandemic compared with the previous year Delayed access or provision of care in Italy resulting from fear of COVID-19 Delayed presentation and sub-optimal outcomes of pediatric patients with acute appendicitis during the COVID-19 pandemic Influence of the coronavirus 2 (SARS-Cov-2) pandemic on acute appendicitis Timing and outcomes of testicular torsion during the COVID-19 crisis Did COVID-19 affect time to presentation in the setting of pediatric testicular torsion? Testicular torsion and risk factors for orchiectomy Factors associated with delayed presentation and misdiagnosis of testicular torsion: A case-control study Time delays in presentation and treatment of acute scrotal pain in a provincial hospital improved our findings, but in this moment we cannot plan that because we do not know whether the pandemic will continue. During COVID-19 pandemic a significantly higher rates of orchiectomies and increase in delayed presentations for testicular torsion was found. More patient education during pandemic in regards to management of emergency conditions such as testicular torsion is required. None declared. None declared.