Spermatic cord torsion: are we looking at the right place?

Spermatic cord torsion: are we looking at the right place? Poster No.: C-0419 Congress: ECR 2011 Type: Scientific Paper Authors: G. del Pozo Garcia, C. Gallego, M. Rasero, M. Castaño, D. Coca, C. Serrano, G. Gonzalez de Orbe; Madrid/ES Keywords: Genital / Reproductive system male, Pediatric, Vascular, Ultrasound-Colour Doppler, Ultrasound, Ultrasound-Power Doppler, Acute, Ischemia / Infarction, Volvulus DOI: 10.1594/ecr2011/C-0419 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 34

Purpose The diagnosis of cord torsion is currently based on the absence of testicular flow as well as in the evaluation of the spermatic vessels at the inguinal canal Recently the whirlpool sing has been described as the most reliable US sign of testicular torsion Our aim is to determine the location of the twisted cord vessels Images for this section: Fig. 1: G. del Pozo; Radiodiagnóstico. Sección de Pediatría, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 2 of 34

Fig. 2: G. del Pozo; Radiodiagnóstico. Sección de Pediatría, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 3 of 34

Fig. 3: G. del Pozo; Radiodiagnóstico. Sección de Pediatría, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 4 of 34

Fig. 4: G. del Pozo; Radiodiagnóstico. Sección de Pediatría, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 5 of 34

Fig. 5: G. del Pozo; Radiodiagnóstico. Sección de Pediatría, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 6 of 34

Methods and Materials 21 cases were evaluated A retrospective analysis of US findings was performed We retrospectively evaluate which areas on US records (testes, paratesticular area, inguinal canal) were depicted US Doppler images features evaluated were: Testicular flow Paratesticular area flow and vessels shape Inguinal canal flow and vessels shape (straight vs. spiral) US Doppler findings are correlated with surgery, pathologic specimens and/or clinical and US evolution Images for this section: Page 7 of 34

Fig. 1: G. del Pozo; Radiodiagnóstico. Sección de Pediatría, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 8 of 34

Fig. 2: G. del Pozo; Radiodiagnóstico. Sección de Pediatría, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 9 of 34

Results In 17 cases the images were just focused on testicular vascularization and in 11 cases the inguinal canal was additionally checked. Dedicated US of spermatic cord and its vascularization was only found in 4 cases. In 2 cases a complete and in 2 cases an incomplete (peak sign) whirlpool sign was depicted in a laterocaudal position to the teste (intravaginal location). Only in one case the testicular flow remained normal. Although vessels appeared straigth at the inguinal canal, demonstrative videos showed a whirlpool sign or spiral twist of the testicular vascular pedicle caudal to the testis Images for this section: Page 10 of 34

Fig. 1: G. del Pozo; Radiodiagnóstico. Sección de Pediatria, Hospital Universitario 12 de Octubre, Madrid, SPAIN Fig. 2: G. del Pozo; Radiodiagnóstico. Sección de Pediatria, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 11 of 34

Fig. 3: G. del Pozo; Radiodiagnóstico. Sección de Pediatria, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 12 of 34

Fig. 4: G. del Pozo; Radiodiagnóstico. Sección de Pediatria, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 13 of 34

Fig. 5: G. del Pozo; Radiodiagnóstico. Sección de Pediatria, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 14 of 34

Fig. 6: G. del Pozo; Radiodiagnóstico. Sección de Pediatria, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 15 of 34

Fig. 7: Case 2:Video G. del Pozo; Radiodiagnóstico. Seción de Pediatria, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 16 of 34

Fig. 8: G. del Pozo; Radiodiagnóstico. Sección de Pediatria, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 17 of 34

Fig. 9: G. del Pozo; Radiodiagnóstico. Sección de Pediatria, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 18 of 34

Fig. 10: G. del Pozo; Radiodiagnóstico. Sección de Pediatria, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 19 of 34

Fig. 11: G. del Pozo; Radiodiagnóstico. Sección de Pediatria, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 20 of 34

Fig. 12: G. del Pozo; Radiodiagnóstico. Sección de Pediatria, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 21 of 34

Fig. 13: G. del Pozo; Radiodiagnostico. Seccion de Pediatria, Hospital 12 de octubre, Madrid, SPAIN Page 22 of 34

Fig. 14: G. del Pozo; Radiodiagnostico. Seccion de Pediatria, Hospital 12 de octubre, Madrid, SPAIN Page 23 of 34

Fig. 15: G. del Pozo; Radiodiagnóstico. Sección de Pediatria, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 24 of 34

Fig. 16: G. del Pozo; Radiodiagnóstico. Sección de Pediatria, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 25 of 34

Fig. 17: G. del Pozo; Radiodiagnóstico. Sección de Pediatria, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 26 of 34

Fig. 18: The possibility the twisted pedicle being located inferior to the testis was mentioned by Baud (2), but neither the drawings nor the posterior literature of the issue paid attention to this point. G. del Pozo; Radiodiagnóstico. Sección de Pediatría, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 27 of 34

Fig. 19: The time of evolution is not the only variable that defines the outcome and necrosis of the testis. There are ischemic testes that recover flow, even after 6-24 h of evolution. The partial arrest of the flow probably linked with a longer vascular pedicle (cord) is presumably the cause. The number of turns necessaries to arrest the flow probably depend on the length of the cord. Acutest presentations as well as torsion/ detorsion phenomena play also a role. G. del Pozo; Radiodiagnóstico. Sección de Pediatria, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 28 of 34

Fig. 20: G. del Pozo; Radiodiagnóstico. Sección de Pediatria, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 29 of 34

Conclusion In our series the spiral twist of the testicular vascular pedicle (TVP) was found laterocaudal to the testis. The vessels at the inguinal canal showed a normal position (intravaginal torsion) A detailed study of the testicular vascular pedicle (TVP) in the paratesticular area, particularly caudal to the testis might increase the detection of the whirlpool sign and make the diagnosis of testicular torsion before ischemic changes are established Images for this section: Fig. 1: G. del Pozo; Radiodiagnóstico. Sección de Pediatría, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 30 of 34

References 1.Maroto A, Serres X, Torrent N et al (1992) Sonographic appearance of torsion knot in spermatic cord torsion. AJR 159:1029/1030 2.Baud C, Veyrac C, Couture A, Ferran JL (1998) Spiral twist of the spermatic cord: a reliable sign of testicular torsion. Pediatr Radiol 28:950-954 3.Arce JD, Cortes M, Vargas JC (2002) Sonographic diagnosis of acute spermatic cord torsion. Rotation of the cord: a key to the diagnosis. Pediatr Radiol 32:485-91 4.Aso C, Enriquez G, Fite M, Toran N, Piro C, Piqueras J, Lucaya J (2005) Gray-scale and color Doppler sonography of scrotal disorders in children : an update. Radiographics 25:1197-1214 5.Vijayaraghavan SB (2006) Sonographic Differential Diagnosis of Acute Scrotum: realtime Whirlpool Sign, akey sign of torsion. Journal of Ultrasound in Medicine 25 (5): 563 6.Baldisserotto M. Scrotal emergencies (2009) Pediatr Radiol 39:516-521 Images for this section: Page 31 of 34

Fig. 1: G. del Pozo; Radiodiagnóstico. Seción de Pediatria, Hospital Universitario 12 de Octubre, Madrid, SPAIN Page 32 of 34

Fig. 2: G. del Pozo; Radiodiagnostico. Seccion de Pediatria, Hospital 12 de octubre, Madrid, SPAIN Page 33 of 34

Personal Information Gloria del Pozo MD PhD Profesor Asociado Universidad Complutense de Madrid Departamento de Radiodiagnóstico Sección de Pediatría Hospital Universitario 12 de Octubre Madrid, SPAIN Page 34 of 34