Laparoscopic Treatment of Testicular Torsion in a Puppy
A 6 mo old male puppy was presented as an emergency for an acute onset of lethargy, ptyalism, and vomiting. On physical examination, the dog was painful on abdominal palpation. A torsed intra-abdominal testis was diagnosed via abdominal ultrasonography and radiography. Laparoscopy was used to identify and remove the torsed testis. The dog recovered uneventfully and was described as doing well by the owners at the 6 mo follow-up telephone contact. This is the first report of an abdominal testicular torsion treated with laparoscopy.
Introduction
Torsion of retained intra-abdominal testes is uncommon in younger dogs and more commonly occurs in older animals due to neoplasia.1 Complications of intra-abdominal testes include infertility due to atrophy of the testicular epithelium, an increased risk of testicular neoplasia, and risk of testicular torsion.1 Traditional treatment of testicular torsion in dogs includes surgical removal of the retained testis via a midline laparotomy.2,3 Reports exist detailing canine laparoscopic removal of cryptorchid testes.5 Specifically, laparoscopy offers at least two advantages over traditional cryptorchidectomy surgery. First, the ability to rapidly explore the inguinal ring allows the observer to determine if the testes have exited the abdominal cavity. Secondly, laparoscopy offers excellent visibility of the structures of interest with minimal trauma to vital structures.4 No reports currently exist in the veterinary literature of minimally invasive approaches to treat canine intra-abdominal torsed testes. The purpose of this report is to provide the first documentation of the use of laparoscopy for testicular torsion in a dog.
Case Report
A 6 mo old, male, English setter weighing 18.7 kg was presented to the emergency service with an 8 hr history of lethargy, ptyalism, vomiting, and abdominal pain. The owners noted the dog was painful when touched in the abdominal area. Physical examination revealed that the puppy was lethargic, had significant ptyalism, a tense abdomen, and one descended testis. The body condition score was 5 out of 9; and temperature, pulse, and respiration were all within normal limits (37.8°C 150 beats/min, and 30 breaths/min). Mucous membranes were pink with a capillary refill time of <2 sec. Although painful, the dog did not exhibit signs of either hypovolemic or cardiovascular shock. A complete blood count and serum biochemical profile were unremarkable. Abdominal radiographs demonstrated a round, soft-tissue opacity measuring 5 cm in diameter in the left caudal abdomen caudal to the left kidney with a well-defined caudolateral margin. Visualization of the peritoneal serosal margins was decreased in the midabdomen (Figures 1A, B).
Citation: Journal of the American Animal Hospital Association 51, 2; 10.5326/JAAHA-MS-6055
The dog was hospitalized and treated for pain overnight, enabling the clients to make a financial decision about further therapy. IV crystalloid fluids (120 mL/kg/day), buprenorphinea (0.01 mg/kg IV q 8 hr), famotidineb (0.5 mg/kg IV q 12 hr), and ondansetronc (0.1 mg/kg IV q 12 hr) were administered. Overnight, three additional episodes of vomiting occurred.
The following day, the clients elected to pursue further diagnostics and treatment. An abdominal ultrasound revealed a 2 cm × 4 cm mass caudal to the left kidney and a small amount of anechoic peritoneal effusion (Figures 2A, B). The cranial portion of the mass appeared as a well-defined spherical hyperechoic structure with a peripheral hypoechoic rim. Caudally, the mass was bordered by a region of more complex echogenicity and with anechoic tubules that were devoid of signal on color Doppler evaluation. The mass was suspected to be the torsed pedicle. The remainder of the abdomen was unremarkable.
Citation: Journal of the American Animal Hospital Association 51, 2; 10.5326/JAAHA-MS-6055
With torsion of a retained testis the primary differential diagnosis, laparoscopic exploration of the abdomen was performed with the animal under general anesthesia. A 10 mm portd was placed at the umbilicus and two 5 mm ports were placed in the caudal abdomen in standard triangulation for caudal abdominal procedures (Figure 3). Visual exploration revealed a small amount of intra-abdominal hemorrhage and a dark purple mass caudal to the left kidney (Figure 4). The mass was elevated using Babcock forceps and the ductus deferens was identified, twisted about the vascular pedicle going to the mass. A harmonic scalpele was used to coagulate any remaining blood supply and transect the ductus deferens and vascular pedicle. The testis was removed through the 10 mm port site. Following inspection to ensure complete hemostasis, the ports were removed and the incisions were closed routinely with absorbable sutures. The descended testis was removed through a prescrotal incision.
Citation: Journal of the American Animal Hospital Association 51, 2; 10.5326/JAAHA-MS-6055
Citation: Journal of the American Animal Hospital Association 51, 2; 10.5326/JAAHA-MS-6055
Histopathological findings were consistent with torsion of the spermatic cord with no evidence of neoplasia. The dog recovered uneventfully from surgery and was administered hydromorphonef (0.05 mg/kg intramuscularly) and tramadolg (5mg/kg per os) overnight and discharged the following day with an Elizabethan collar and instructions to limit activity for 10 days. Follow-up phone calls to the owner were performed at 14 days and 6 mo postoperatively. The owner reported the dog was doing well with no health problems.
Discussion
Based on this case, laparoscopy provided excellent visualization for confirmation of the diagnosis and removal of an abdominally retained testis with minimal postoperative morbidity. Laparoscopy has been used to remove cryptorchid testes in dogs.4,5 However, this is the first application of laparoscopic surgery to remove a torsed abdominal testis in a dog. Only two case reports of laparoscopic management of testicular torsion in humans were found in the literature.6,7 Laparoscopy is frequently used for pediatric patients with nonpalpable testes to aid in diagnosis to confirm the location of the retained testis and to differentiate them from so-called vanishing testes, where there is a blind-ending spermatic cord and vessels.8
Complications of intra-abdominal testes include infertility due to atrophy of the testicular epithelium, an increased risk of testicular neoplasia, and risk of testicular torsion.1 Until recently, testicular torsion was thought to be a consequence of neoplastic transformation of the retained testes.1 However, a recent report by Hecht et al. describes a 6 mo old boxer puppy with an intra-abdominal testicular torsion withoutevidence of neoplasia.1 In humans, intra-abdominal testicular torsion is more commonly associated with neoplasia as well, although reports of nonneoplastic cases have been published.9
Ultrasonography has been shown to have a sensitivity of 96.6% for detecting abdominally located testes.10 A 100% positive predictive value was found for all testes with use of ultrasonography in both abdominal and inguinal regions. There are limited reports of the sonographic appearance of torsion of nonneoplastic retained testes in the veterinary literature. Echogenicity relative to fat may range from hypoechoic (with a prominent mediastinum testis) to hyperechoic and complex.1,11,12 An experimental study performed on dogs suggests that the sonographic appearance of the parenchyma varies with chronicity of torsion.13 Within 60 min of torsion, the testis becomes enlarged and hypoechoic secondary to venous congestion. Following the acute phase, echogenicity becomes more complex as normal testicular architecture is lost.14 Chronic testicular torsion (>10 days) typically results in a small hypoechoic testis. This case is somewhat unusual in that the parenchyma of the affected testis was hyperechoic to a degree that obscured visualization of the mediastinum testis, an important anatomic landmark.
Hyperechogenicity of the testicular parenchyma has been reported with acute testicular torsion in both a human and a dog; however, the cause or significance of this finding is unknown.1,15 The size and echogenicity, along with the acute clinical presentation in this dog, indicate that this was not a chronic torsion.
Treatment of choice for abdominally retained testes is surgical removal.2,3 Laparoscopy offers several advantages over traditional laparotomy. When compared to open ovariectomy, increased activity postoperatively, similar surgical times, and similar complication rates were documented in dogs undergoing laparoscopic ovariectomy.16 Laparoscopic ovariohysterectomies in dogs were found to be less painful than their open counterparts when performed with a harmonic scalpel.17 Visualization of important structures, such as the spermatic cord, may be better appreciated with the magnification provided by the laparoscopic view. One study of second-look procedures following laparoscopic urological procedures in children suggested a lower incidence of postoperative adhesion formation.18
There are disadvantages associated with laparoscopy and its use. When an experienced surgical team is not available, veterinarians may be reluctant to perform those procedures. Because of the high technical demands of proper set up of the equipment, it can be more difficult to perform laparoscopic procedures whether on an emergent basis or not. In the authors' experience, few veterinary procedures are performed laparoscopically in an emergency situation. For an inexperienced veterinary surgeon, increased surgical times may be observed with a less invasive approach. With experience, laparoscopic ovariectomy can be performed in about the same time as an open approach. In addition, utilizing and maintaining laparoscopy equipment can be costly. The transfer of those costs to clients may not be either feasible or acceptable in all cases.
In this case, the owners consented to a laparoscopic approach because of the teaching value provided in confirming a diagnosis through enhancing the visualization of the retained testis and in demonstrating the quick recovery with minimally invasive surgery. Each case represents an opportunity for learning, and laparoscopic training is one way less-experienced surgeons can begin to incorporate the techniques into everyday practice.
Conclusion
This report describes a 6 mo old puppy with an acute presentation due to an intra-abdominal torsed testis that was successfully treated via a laparoscopic approach. Laparoscopy offers a safe and effective means of abdominal exploration and, in this case, a simple surgical procedure for ligating and extracting a torsed testis. This approach should be considered, even in an emergent situation, because of excellent visualization and minimal postoperative morbidity.
A: Lateral abdominal radiograph demonstrating reduction in serosal margin visualization and presence of a round soft-tissue opaque mass ventral to the fifth lumbar veterbra (arrows). B: Ventrodorsal abdominal radiograph demonstrating a round soft-tissue opacity mass in the left caudal abdomen (arrows).
A: Conventional grayscale ultrasound of the retained left testis revealing enlarged size and hyperechoic parenchyma. B: Color Doppler ultrasound demonstrating lack of perfusion in the affected testis.
Illustration of port placement used to remove a torsed intra-abdominal testis.
Photograph of the retained testis immediately after laparoscopic removal.
Contributor Notes
