Archive for category: Letters to the Editor

Clinical and sonographic features predict testicular torsion in children: a prospective study


We read the recent publication on clinical and sonographic features predicting testicular torsion in children with great interest [1]. Boettcher et al. identified a variety of clinical predictors, such as short pain duration, nausea or vomiting, abnormal ipsilateral cremasteric reflex, scrotal skin changes and high position of the testicle, as being associated with an increased likelihood of testiscular torsion. They showed that a clinical scoring system based on these clinical factors would have identified all cases of testicular torsion and would have reduced the negative exploration rate by 55%, and concluded that a reliable torsion diagnosis could not be obtained based on ultrasonography alone.

The authors are to be congratulated for their study, because they have identified important clinical variables for predicting testicular torsion and developed a simple and quick scoring system that will reduce the number of patients with acute scrotum undergoing scrotal exploration. We know that colour Doppler sonography (CDS) is the imaging method of choice for the evaluation of acute scrotum, with 63.6–100% sensitivity and 97–100% specificity [2,3]; however, it can show a misleading arterial flow in the early phases of torsion [3]. Furthermore, this imaging technique is operator-dependent and can be difficult to perform in prepubertal children. Other imaging methods, such as scintigraphy and dynamic MRI of the scrotum, provide a sensitivity and specificity similar to that of CDS [3], but these techniques are time-consuming and may also delay diagnosis. Differential diagnosis of testiscular torsion, therefore, remains a clinical diagnosis, and clinical variables such as short duration of pain, nausea and vomiting, high position of testis, skin changes and abnormal ipsilateral cremasteric reflex, deserve to play a more important role in surgical decision-making [4,5].

We believe that CDS, if performed correctly with modern equipment, is an important examination device for the assessment of children with acute scrotum; however, information from CDS should be supported by clinical findings and a physical examination of the patients. A clinical scoring system combined with CDS would be helpful for patient evaluation and to avoid unnecessary scrotal explorations.

Mustafa Resorlu, Yusuf Ziya Tan*, Fatma Uysal, Murat Tolga Gulpinar, Gurhan Adam and Huseyin Ozdemir
Departments of Radiology, *Nuclear Medicine and  Urology, Faculty of Medicine, Canakkale Onsekiz Mart University, Canakkale, Turkey  

  1. Boettcher M, Krebs T, Bergholz R, Wenke K, Aronson D. Clinical and sonographic features predict testicular torsion in children: a prospective study. BJU Int 2013 [Epub ahead of print], doi:10.1111/bju.12229.
  2. Kalfa N, Veyrac C, Lopez M et al. Multicenter assessment of ultrasound of the spermatic cord in children with acute scrotum. J Urol 2007; 177: 297-301.
  3. Tekgül S, Riedmiller H, Dogan HS et al. EAU Guidelines on paediatric urology p17, 2013. Available at:
  4. Ciftci AO, Senocak ME, Tanyel FC et al. Clinical predictors for differential diagnosis of acute scrotum. Eur J Pediatr Surg 2004; 14: 333-8.
  5. Beni-Israel T, Goldman M, Bar Chaim S, Kozer E. Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med 2010; 28: 786-9.

To treat or not to treat: is the way forward clearer in low-risk prostate cancer?


I read with interest the above “Comment” by Dr Gnanapragasam in the August issue of the Journal [1]. While I applaud his efforts at suggesting improvements to the criteria by which a decision is made to manage a patient with prostate cancer on an active surveillance program I feel he distracts from the clear, simple and important message of the PIVOT trial [2]. That message is that if, using the D’Amico criteria [3], a patient is classified as being in a low risk prostate cancer group then prostate-cancer mortality will not be significantly lower if that patient has a radical prostatectomy compared to that patient being on an active surveillance program. The D’Amico criteria may need updating or improvement but that does not change the basic and clinically important message of the PIVOT trial.

Derek J Byrne MD FRCSI
Consultant Urological Surgeon, NHS Tayside
[email protected]

  1. Gnanapragasam VJ. To treat or not to treat: is the way forward clearer in low-risk prostate cancer. BJUI 2013; 112: 285-287.
  2. Wilt TJ, Brawer MK, Jones KM et al. Prostate Cancer Intervention versus Observation Trial (PIVOT) Study Group.  Radical prostatectomy versus observation for localized prostate cancer. N Engl J Med 2012; 367: 203-13.
  3. D’Amico AV, Whittingham R, Malkowicz SB et al. Biochemical outcome after radical prostatectomy, external beam radiotherapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA 1998; 280: 969-74.
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