FLUORESCENCE
OF TESTICLE
An Indication of Viability of Spermatic Cord After Torsion HENRY C. SCHNEIDER,
JR., M.D.
A. RICHARD
M.D.
LESTER
KENDALL,
KARAFIN,
M.D.
From the Departments of Urology, Temple University School of Medicine and Medical College of Pennsylvania, Philadelphia, Pennsylvania
ABSTRACT - We present an salvaging the testicle at the time administration of 5 to 10 cc. of mined by its fluorescence when
objective measure of testicular viability of operation for torsion of the spermatic sodium$uorescein, the viability of the exposed to a portable long wavelength
The preoperative diagnosis of torsion of the testis has remained an enigma to clinicians. Today most urologists would agree that the sudden onset of testicular swelling and pain in a child under fifteen years of age should be considered either torsion of the spermatic cord or the appendix testis until proved otherwise. Too many reports in the literature demonstrate absence of this high index of suspicion, thus resulting in loss of a testicle at the time of operation or eventual ischemic atrophy. In a large series of 500 cases of torsion reviewed by Barker and Raper,l 90 per cent of the testes were ultimately lost, 80 per cent by immediate orchiectomy, and 10 per cent by subsequent ischemic atrophy. Even with a high index of suspicion and prompt operative exploration, the vital question of testicular viability often arises. Although some urologists advocate simple untwisting and replacement of a testis in the scrotum even if apparently nonviable, many of us choose to perform an orchiectomy if viability cannot be demonstrated. The authors are aware of no prior reports of objective operative measurement of testicular viability, and the surgeon has had to rely on his naked eye and clinical judgment Herein is
UROLOGY
/
JANUARY 19%
/
VOLUME V, NUMBER 1
intended to aid the surgeon in cord. Following the intravenous untwisted testicle can be deterWood ultraviolet light source.
reported an objective measure of testicular viability intended to aid the surgeon in deciding between a primary orchiectomy or orchiopexy. Experiment Part one Seven male mongrel dogs underwent right scrotal exploration under sodium pentothal anesthesia. The testis was freed from any attachments to the scrotal wall and then twisted on its
FIGURE 1. Fhn-escence of testicle as demonstrated under ultraviolet light source following administration of sodium fluorescein. Control study without jluorescence is on right.
133
FIGURE 2. (A) Biopsy of the canine testicle which had been torqued five hours; focal necrosis present but viability demonstrated. CB) Biopsy of the canine testicle which had undergone torsion for sixteen hours, demonstrating infarction.
TABLE I.
uration of Torsion Dog 1 2 3 4 5 6 7
1.5 4 5 5 8 16
23
*T./L. = tuniea dbuginea;
Experiment
one
Fluorescence After Detorsion (T. A.)* (S.T.)* Positive Positive Positive Positive Negative Negative Negative S.T. = seminiferous
Positive Positive Positive Negative Negative Negative Negative
Gross Appearance (Viable) Yes Yes Yes Yes Probable No No
Microscopic Appearance (Viable) Yes Yes Yes Yes NCI No NO
tubule.
spermatic cord for a total 1,080 degrees (3 complete twists) and fixed in this position for a varying period of time. At the end of the designated interval the right testicle was then reexposed as was its contralateral mate. At this time 10 cc. of fluorescein sodium 5 per cent solution (Fluorescite) was injected intravenously. orescein is an aqueous dye used ively by ophthalmologists and is wel.1 tolerated with few side effects. In the human patient nausea, vomiting, and mild syncope are rare occurrences while more severe reactions en noted to occur in only 0.6 per cent of This dye gains rapid access to viable cells and is strongly fluorescent, most readily detected at a wavelength of 3,600 A units, within the range of the ultraviolet spectrum. It is excreted mostly in the urine for by the kidney being present twelve to thirty-six hours after administration and also by the liver after conjugation with glucuronide. Uncfer the ultraviolet light source a bright green fluorescence indicates uptake of the dye (Fig. I), hollowing the intravenous administration of uorescein the still torqued testis and its mate were examined with the ultraviolet light
source. After onset of fluorescence in the contralateral testicle (usually less than five minutes), the previously torqued testicle was then untwisted and again studied with the ultraviolet lamp over a period of five to fifteen minutes. A small biopsy specimen of the seminiferous tubules was obtained, and this specimen was also studied under the ultraviolet lamp. The gross appearance of the testicle was noted, orchiectomy was performed, and the specimen was sent for pathologic study. Results
The contralateral testicle always exhibited fluorescence while there was absolutely no evidence of fluorescence in the testicle which had undergone torsion. Following detorsion., fluorescence was noted to occur in the first 4 animals but to be absent in the 3 animals in whom torsion had been maintained for eight or more hours (Table I). As can be clearly noted, the presence of fluorescence of both the tunica albuginea and the seminiferous tubule biopsy correlated extremely well with both the gross and microscopic appearance of the testicle. Figure 2A is the biopsy of
UROLOGY
/ TANUARY1975
i VOLU.MEV,NUMBERI
FIGURE 3. (A) Biopsy of canine testicle demonstrating some cellular necrosis but viability. (B) Biopsy of canine testicle demonstrating SOW cellular necrosis, but viability confirmed by fluorescence.
TABLE II.
Dog
Duration of Torsion (Hours)
1 2 3 4 5 6
5 5 8 8 15 15
. Fluorescence_ After Detorsion (T.A.)* (ST.)* Positive Positive Positive Negative Negative Negative
*T.A. = tunica albuginea;
Time Returned to Scrotum (Days)
Gross Appearance (Viable)
3 4 7 3 3 4
Yes Yes Yes Probably no No No
Positive Positive Positive Negative Negative Negative
S.T. = seminiferous
Experiment two Fluorescence (T.A.)” (ST.)* Positive Positive Positive Negative Negative Negative
Positive Positive Positive Negative Negative Negative
Microscopic Appearance (Viable) Yes Yes Yes No No No
tubule.
the testicle of Dog 4 which was torqued for five hours and demonstrated fluorescence under the ultraviolet light source. Focal necrosis was present but viability is demonstrated. Figure 2B represents the biopsy from Dog 6 which had undergone torsion for sixteen hours. No fluorescence occurred, and the biopsy demonstrated infarction of the testicle and nonviability. Part two Six male dogs were subjected to operative production of torsion for varying periods of time as in Part one of this experiment. Following detorsion the presence or absence of fluorescence was again recorded and the testicle returned to the scrotum for periods varying from three to seven days. The testicle was then reexplored, its gross appearance determined and again studied under the ultraviolet light source. As can be seen in Table II, the presence or absence of fluorescence was identical in all testes immediately following detorsion and again after reexploration. Again the excellent correlation between viability
UROLOGY / JANUARY1975 / VOLUMEV, NUMBER1
as determined by histopathologic study as compared with fluorescence is obvious. Figure 3A is the biopsy from Dog 2 demonstrating some cellular necrosis but viability which was confirmed by a positive test for fluorescence. Figure 3B is that of Dog 3 similarly demonstrating some areas of cellular necrosis but over-all viability confirmed by fluorescence. The biopsy of Dog 6 subjected to fifteen hours of torsion with the testicle being returned to the scrotum for four days following detorsion demonstrates infarction of the testis with nonviability and indeed the test result for fluorescence was negative (Fig. 4). Human
Application
Initially 4 patients undergoing bilateral orchiectomy for carcinoma of the prostate were subjected to fluorescein administration. The right spermatic cord was occluded by a vascular clamp, and after fluorescein administration positive fluorescence was noted on the left. Following removal of the clamp the right testicle demonstrated fluorescence under the ultraviolet lamp,
135
FIGURE 4.
Biopsy of canine testicle
demonstrating
infarction.
thus demonstrating that the human testis behaves in the manner described previously for the canine. Subsequently fluorescein has been similarly utilized in 3 patients with clinical torsion of the spermatic cord. One testicle demonstrated no fluorescence after detorsion, and microscopic examination following orchiectomy revealed complete infarction of this testicle which had been ischemic for at least forty-eight hours. Two other testes demonstrated satisfactory fluorescence following detorsion with the gross appear-
136
ance and biopsy demonstrating viability. Many more studies on human subjects will be necessary to determine if a grossly nonviable testis may show fluorescence and later undergo ischemic atrophy. From these preliminary studies it appears that the presence of fluorescence of the tunica albuginea as well as the seminiferous tubules within five to ten minutes following detorsion is indicative of viability. Preservation of tubular architecture is probably indicative of reversibility of the lesion similar to the way Kupffer cells in the liver regenerate following necrosis with preservation of basic hepatic architecture. Thus, it is hoped that the clinical application of testicular Auorescence will detect testicular viability which may be unrecognized by the naked eye and result in an unnecessary orchiectomy. 3401 N. Broad Street Philadelphia, Pennsylvania 19140 (DR. KENDALI,) References F. P.: Torsion of the testis, Br. J. Ural. 36: 35 (1964). 2. STEIN,M. R., and PARKER, C. W. : Reactions following intravenous fluorescein, Am. J. Ophthalmol. 72: 861 (1971). 1. BARKER, K., and RAPER,
UROLOGY
I JANUARY1975
1 VOLUMEV,NU.MBEHl
OF TESTICLE
An Indication of Viability of Spermatic Cord After Torsion HENRY C. SCHNEIDER,
JR., M.D.
A. RICHARD
M.D.
LESTER
KENDALL,
KARAFIN,
M.D.
From the Departments of Urology, Temple University School of Medicine and Medical College of Pennsylvania, Philadelphia, Pennsylvania
ABSTRACT - We present an salvaging the testicle at the time administration of 5 to 10 cc. of mined by its fluorescence when
objective measure of testicular viability of operation for torsion of the spermatic sodium$uorescein, the viability of the exposed to a portable long wavelength
The preoperative diagnosis of torsion of the testis has remained an enigma to clinicians. Today most urologists would agree that the sudden onset of testicular swelling and pain in a child under fifteen years of age should be considered either torsion of the spermatic cord or the appendix testis until proved otherwise. Too many reports in the literature demonstrate absence of this high index of suspicion, thus resulting in loss of a testicle at the time of operation or eventual ischemic atrophy. In a large series of 500 cases of torsion reviewed by Barker and Raper,l 90 per cent of the testes were ultimately lost, 80 per cent by immediate orchiectomy, and 10 per cent by subsequent ischemic atrophy. Even with a high index of suspicion and prompt operative exploration, the vital question of testicular viability often arises. Although some urologists advocate simple untwisting and replacement of a testis in the scrotum even if apparently nonviable, many of us choose to perform an orchiectomy if viability cannot be demonstrated. The authors are aware of no prior reports of objective operative measurement of testicular viability, and the surgeon has had to rely on his naked eye and clinical judgment Herein is
UROLOGY
/
JANUARY 19%
/
VOLUME V, NUMBER 1
intended to aid the surgeon in cord. Following the intravenous untwisted testicle can be deterWood ultraviolet light source.
reported an objective measure of testicular viability intended to aid the surgeon in deciding between a primary orchiectomy or orchiopexy. Experiment Part one Seven male mongrel dogs underwent right scrotal exploration under sodium pentothal anesthesia. The testis was freed from any attachments to the scrotal wall and then twisted on its
FIGURE 1. Fhn-escence of testicle as demonstrated under ultraviolet light source following administration of sodium fluorescein. Control study without jluorescence is on right.
133
FIGURE 2. (A) Biopsy of the canine testicle which had been torqued five hours; focal necrosis present but viability demonstrated. CB) Biopsy of the canine testicle which had undergone torsion for sixteen hours, demonstrating infarction.
TABLE I.
uration of Torsion Dog 1 2 3 4 5 6 7
1.5 4 5 5 8 16
23
*T./L. = tuniea dbuginea;
Experiment
one
Fluorescence After Detorsion (T. A.)* (S.T.)* Positive Positive Positive Positive Negative Negative Negative S.T. = seminiferous
Positive Positive Positive Negative Negative Negative Negative
Gross Appearance (Viable) Yes Yes Yes Yes Probable No No
Microscopic Appearance (Viable) Yes Yes Yes Yes NCI No NO
tubule.
spermatic cord for a total 1,080 degrees (3 complete twists) and fixed in this position for a varying period of time. At the end of the designated interval the right testicle was then reexposed as was its contralateral mate. At this time 10 cc. of fluorescein sodium 5 per cent solution (Fluorescite) was injected intravenously. orescein is an aqueous dye used ively by ophthalmologists and is wel.1 tolerated with few side effects. In the human patient nausea, vomiting, and mild syncope are rare occurrences while more severe reactions en noted to occur in only 0.6 per cent of This dye gains rapid access to viable cells and is strongly fluorescent, most readily detected at a wavelength of 3,600 A units, within the range of the ultraviolet spectrum. It is excreted mostly in the urine for by the kidney being present twelve to thirty-six hours after administration and also by the liver after conjugation with glucuronide. Uncfer the ultraviolet light source a bright green fluorescence indicates uptake of the dye (Fig. I), hollowing the intravenous administration of uorescein the still torqued testis and its mate were examined with the ultraviolet light
source. After onset of fluorescence in the contralateral testicle (usually less than five minutes), the previously torqued testicle was then untwisted and again studied with the ultraviolet lamp over a period of five to fifteen minutes. A small biopsy specimen of the seminiferous tubules was obtained, and this specimen was also studied under the ultraviolet lamp. The gross appearance of the testicle was noted, orchiectomy was performed, and the specimen was sent for pathologic study. Results
The contralateral testicle always exhibited fluorescence while there was absolutely no evidence of fluorescence in the testicle which had undergone torsion. Following detorsion., fluorescence was noted to occur in the first 4 animals but to be absent in the 3 animals in whom torsion had been maintained for eight or more hours (Table I). As can be clearly noted, the presence of fluorescence of both the tunica albuginea and the seminiferous tubule biopsy correlated extremely well with both the gross and microscopic appearance of the testicle. Figure 2A is the biopsy of
UROLOGY
/ TANUARY1975
i VOLU.MEV,NUMBERI
FIGURE 3. (A) Biopsy of canine testicle demonstrating some cellular necrosis but viability. (B) Biopsy of canine testicle demonstrating SOW cellular necrosis, but viability confirmed by fluorescence.
TABLE II.
Dog
Duration of Torsion (Hours)
1 2 3 4 5 6
5 5 8 8 15 15
. Fluorescence_ After Detorsion (T.A.)* (ST.)* Positive Positive Positive Negative Negative Negative
*T.A. = tunica albuginea;
Time Returned to Scrotum (Days)
Gross Appearance (Viable)
3 4 7 3 3 4
Yes Yes Yes Probably no No No
Positive Positive Positive Negative Negative Negative
S.T. = seminiferous
Experiment two Fluorescence (T.A.)” (ST.)* Positive Positive Positive Negative Negative Negative
Positive Positive Positive Negative Negative Negative
Microscopic Appearance (Viable) Yes Yes Yes No No No
tubule.
the testicle of Dog 4 which was torqued for five hours and demonstrated fluorescence under the ultraviolet light source. Focal necrosis was present but viability is demonstrated. Figure 2B represents the biopsy from Dog 6 which had undergone torsion for sixteen hours. No fluorescence occurred, and the biopsy demonstrated infarction of the testicle and nonviability. Part two Six male dogs were subjected to operative production of torsion for varying periods of time as in Part one of this experiment. Following detorsion the presence or absence of fluorescence was again recorded and the testicle returned to the scrotum for periods varying from three to seven days. The testicle was then reexplored, its gross appearance determined and again studied under the ultraviolet light source. As can be seen in Table II, the presence or absence of fluorescence was identical in all testes immediately following detorsion and again after reexploration. Again the excellent correlation between viability
UROLOGY / JANUARY1975 / VOLUMEV, NUMBER1
as determined by histopathologic study as compared with fluorescence is obvious. Figure 3A is the biopsy from Dog 2 demonstrating some cellular necrosis but viability which was confirmed by a positive test for fluorescence. Figure 3B is that of Dog 3 similarly demonstrating some areas of cellular necrosis but over-all viability confirmed by fluorescence. The biopsy of Dog 6 subjected to fifteen hours of torsion with the testicle being returned to the scrotum for four days following detorsion demonstrates infarction of the testis with nonviability and indeed the test result for fluorescence was negative (Fig. 4). Human
Application
Initially 4 patients undergoing bilateral orchiectomy for carcinoma of the prostate were subjected to fluorescein administration. The right spermatic cord was occluded by a vascular clamp, and after fluorescein administration positive fluorescence was noted on the left. Following removal of the clamp the right testicle demonstrated fluorescence under the ultraviolet lamp,
135
FIGURE 4.
Biopsy of canine testicle
demonstrating
infarction.
thus demonstrating that the human testis behaves in the manner described previously for the canine. Subsequently fluorescein has been similarly utilized in 3 patients with clinical torsion of the spermatic cord. One testicle demonstrated no fluorescence after detorsion, and microscopic examination following orchiectomy revealed complete infarction of this testicle which had been ischemic for at least forty-eight hours. Two other testes demonstrated satisfactory fluorescence following detorsion with the gross appear-
136
ance and biopsy demonstrating viability. Many more studies on human subjects will be necessary to determine if a grossly nonviable testis may show fluorescence and later undergo ischemic atrophy. From these preliminary studies it appears that the presence of fluorescence of the tunica albuginea as well as the seminiferous tubules within five to ten minutes following detorsion is indicative of viability. Preservation of tubular architecture is probably indicative of reversibility of the lesion similar to the way Kupffer cells in the liver regenerate following necrosis with preservation of basic hepatic architecture. Thus, it is hoped that the clinical application of testicular Auorescence will detect testicular viability which may be unrecognized by the naked eye and result in an unnecessary orchiectomy. 3401 N. Broad Street Philadelphia, Pennsylvania 19140 (DR. KENDALI,) References F. P.: Torsion of the testis, Br. J. Ural. 36: 35 (1964). 2. STEIN,M. R., and PARKER, C. W. : Reactions following intravenous fluorescein, Am. J. Ophthalmol. 72: 861 (1971). 1. BARKER, K., and RAPER,
UROLOGY
I JANUARY1975
1 VOLUMEV,NU.MBEHl
