Urol Radiol 12:50-52 (1990)
Urologic Radiology © Springer-VedagNewYork Inc. 1990
Torsion of an Intraabdominal Testis Tumor Presenting as an Acute Abdomen Ronald G. Frank, Perry S. Gerard, l Jude T. Barbera, Kris Lindsay, and Gilbert J. Wise Department of Urology, Coney Island Hospital, Brooklyn; and Departments of Urology and ~Radiology, Maimonides Medical Center, Brooklyn, New York, USA
Torsion of an intraabdominal testicular tumor is a rare preoperative diagnosis. An increased diagnostic yield is dependent on an expedient and comprehensive preoperative evaluation. This consists of a detailed past surgical history, a thorough physical examination, and close inspection of the preoperative abdominal films. An illustrated case report is presented. Abstract.
Key words: Torsion -- Testicle -- Ecotopic testis -- Intraabdominal testis -- Testicular torsion.
Case Report A 24-year-old white male presented to the emergency room surgical service with complaints of acute right lower quadrant abdominal pain accompanied by bouts of vomiting. The patient gave a history of a scrotal genitourinary procedure 6 years earlier with "removal" of the right testicle. On physical examination, the patient was found to be afebrile and normotensive. The findings on abdominal exam revealed localized right lower quadrant guarding with rebound and no palpable masses. The right testicle was absent from the scrotal sac. Laboratory studies included a serum white blood cell count of 14,300, and serum blood urea nitrogen and creatinine which were within normal limits. The initial inspection of the kidney ureter bladder (KUB) abdominal film was read by the emergency room physicians as unremarkable for acute pathology.
Address reprint requests to: Ronald G. Frank, M.D., Department of Urology, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, New York 11219, USA
The presumptive diagnosis was acute appendicitis and the patient was taken to the operating room for an exploratory laparotomy. Upon entering the peritoneal cavity via a Rockey-Davis incision, hemorrhagic intraabdominal fluid was noted. After evacuation of this fluid a large midline mass was identified. The incision was extended across the midline and further inspection of the mass revealed a large intraabdominal testis. At this point, an intraoperative urologic consultation was obtained. The fight testicle was torted 360 ° on its pedicle and found to be hemorrhagic and necrotic (Fig. 1). The spermatic cord was clamped and the mass was removed by performing a high ligation of the cord structures. No lymphadenopathy was appreciated. The pathologic specimen measured 13 × 10 × 10 cm and weighed 460 g (Fig. 2). The final pathology was consistent with an abdominal cryptorchid testis with hemorrhagic infarction and evidence of pure classical seminoma without extension to the capsule or epididymis. In the postoperative period, further staging with computerized tomography of the chest and abdomen failed to reveal significant lymphadenopathy. The serum obtained intraoperatively for B human chorionic gonadotropin (~-HCG) was negative. The patient was lost to any further follow-up with either the urology or oncology service.
Discussion
Only rarely is the diagnosis of torsion of an intraabdominal testis tumor recognized in the preoperative setting. The clinical presentation suggests an acute abdomen, and the majority of patients undergo exploratory celiotomy only to reveal this elusive pathologic entity. The first case reported in the literature was by Gerster in 1897 [1]. Subsequently, sporadic small clusters of cases have appeared in the literature [1, 2]. The importance of early identification of an intraabdominal testis is well known because of the
R.G. Frank et al.: Torsion of an Intraabdominal Testis Tumor
51
Fig. 1. Operative findings showing hemorrhagic infarction of the testicular tumor. Fig. 2. Bivalved specimen demonstrates the gross appearance of the seminoma. Fig. 3. Plain film of the abdomen demonstrates a large soft tissue mass in the pelvis with compression of the bladder.
associated higher incidence o f developing a germ cell t u m o r [1-3]. The intraabdominal testis often presents as a torsion, with an estimated 13 times more likely chance o f undergoing torsion c o m p a r e d to the normally descended testis [4]. In our case report, we can only speculate that our patient had previously undergone a limited and incomplete exploration for a right undescended testis. This serves to illustrate the importance o f performing a diligent search for an impalpable testis. The failure to identify a testis, vas or blind-ending spermatic vessels in the inguinal canal or retroperitoneum, mandates intraabdominal exploration [5]. Supplemental diagnostic studies including venography [6], selective gonadal arteriography [7], sonography [8], computerized t o m o g r a p h y [9], and magnetic resonance imaging [10] o f the a b d o m e n m a y aid in the early localization o f an impalpable testis. Newer recent studies have confirmed the effectiveness o f laparoscopy as an alternate modality in the identification o f a unilateral nonpalpable testis [11].
In retrospect, a "second l o o k " at the preoperative plain film o f the a b d o m e n (Fig. 3) d e m o n strates a soft tissue mass in the pelvis with extrinsic impression on the superior aspect o f the bladder with its superior b o r d e r extending into the abdomen. Clearly, this coincides with the size o f the mass found intraoperatively. H a d the diagnosis been considered preoperatively after viewing the plain film o f the abdomen, sonography or computerized tomography would be the next modality to help confirm the diagnosis. In summary, the presentation o f an acute abd o m e n with a previous history o f inguinal/scrotal surgery and an absent testis on physical examination should alert the clinician to this diagnosis.
References 1. Riegler HC: Torsion of intra-abdominal testis. Surg Clin North Am 52:371, 1972 2. Garber HE, Kauffer GI: Torsion of an intra-abdominal testicular seminoma. J Urol 98:684, 1968
52 3. Cox L, Donald JC, Machin GA, Popkin JS, Zacks D: Intraabdominal testis with yolk sac tumor in a 2-year-old child. J Pediatr Surg 23:775, 1988 4. Ein SH: Torsion of an undescended intraabdominal benign testicular teratoma. J Pediatr Surg 22:799, 1987 5. Levitt SB, Kogan SJ, Engel RM, Weiss RM, Martin DC, Ehrlich RM: The impalpable testis: a rational approach to management. J Urol 120:515, 1978 6. Diamond AB, Meng CH, KodroffM, Goldman SM: Testicular venography in the nonpalpable testis. A JR 129:71, 1977 7. Vitale PJ, Khademi M, Seebode JJ: Selective gonadal angiography for testicular localization in patients with cryptorchism. Surg Forum 25:538, 1974
R.G. Frank et al.: Torsion of an Intraabdominal Testis Tumor 8. Weiss RM, Carter AR, Rosenfield AT: High resolution realtime ultrasonography in the localization of the undescended testis. J Urol 135:936, 1986 9. Green R Jr: Computerized axial tomography vs spermatic venography in localization of the cryptorchid testes. Urology 26:513, 1985 10. Landa JM, Gylys-Morin V, Mattrey RF, Krous HF, Kaplan GW, Packer MG: Magnetic resonance imaging of the cryptorchid testis. Eur J Pediatr 146[suppl 2]:S 16, 1987 11. Naslund MJ, Gearhart JP, Jeffs RD: Laparoscopy: its selected use in patients with unilateral nonpalpable testis after human chorionic gonadotrophin stimulation. J Urol 142: 108, 1989
Urologic Radiology © Springer-VedagNewYork Inc. 1990
Torsion of an Intraabdominal Testis Tumor Presenting as an Acute Abdomen Ronald G. Frank, Perry S. Gerard, l Jude T. Barbera, Kris Lindsay, and Gilbert J. Wise Department of Urology, Coney Island Hospital, Brooklyn; and Departments of Urology and ~Radiology, Maimonides Medical Center, Brooklyn, New York, USA
Torsion of an intraabdominal testicular tumor is a rare preoperative diagnosis. An increased diagnostic yield is dependent on an expedient and comprehensive preoperative evaluation. This consists of a detailed past surgical history, a thorough physical examination, and close inspection of the preoperative abdominal films. An illustrated case report is presented. Abstract.
Key words: Torsion -- Testicle -- Ecotopic testis -- Intraabdominal testis -- Testicular torsion.
Case Report A 24-year-old white male presented to the emergency room surgical service with complaints of acute right lower quadrant abdominal pain accompanied by bouts of vomiting. The patient gave a history of a scrotal genitourinary procedure 6 years earlier with "removal" of the right testicle. On physical examination, the patient was found to be afebrile and normotensive. The findings on abdominal exam revealed localized right lower quadrant guarding with rebound and no palpable masses. The right testicle was absent from the scrotal sac. Laboratory studies included a serum white blood cell count of 14,300, and serum blood urea nitrogen and creatinine which were within normal limits. The initial inspection of the kidney ureter bladder (KUB) abdominal film was read by the emergency room physicians as unremarkable for acute pathology.
Address reprint requests to: Ronald G. Frank, M.D., Department of Urology, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, New York 11219, USA
The presumptive diagnosis was acute appendicitis and the patient was taken to the operating room for an exploratory laparotomy. Upon entering the peritoneal cavity via a Rockey-Davis incision, hemorrhagic intraabdominal fluid was noted. After evacuation of this fluid a large midline mass was identified. The incision was extended across the midline and further inspection of the mass revealed a large intraabdominal testis. At this point, an intraoperative urologic consultation was obtained. The fight testicle was torted 360 ° on its pedicle and found to be hemorrhagic and necrotic (Fig. 1). The spermatic cord was clamped and the mass was removed by performing a high ligation of the cord structures. No lymphadenopathy was appreciated. The pathologic specimen measured 13 × 10 × 10 cm and weighed 460 g (Fig. 2). The final pathology was consistent with an abdominal cryptorchid testis with hemorrhagic infarction and evidence of pure classical seminoma without extension to the capsule or epididymis. In the postoperative period, further staging with computerized tomography of the chest and abdomen failed to reveal significant lymphadenopathy. The serum obtained intraoperatively for B human chorionic gonadotropin (~-HCG) was negative. The patient was lost to any further follow-up with either the urology or oncology service.
Discussion
Only rarely is the diagnosis of torsion of an intraabdominal testis tumor recognized in the preoperative setting. The clinical presentation suggests an acute abdomen, and the majority of patients undergo exploratory celiotomy only to reveal this elusive pathologic entity. The first case reported in the literature was by Gerster in 1897 [1]. Subsequently, sporadic small clusters of cases have appeared in the literature [1, 2]. The importance of early identification of an intraabdominal testis is well known because of the
R.G. Frank et al.: Torsion of an Intraabdominal Testis Tumor
51
Fig. 1. Operative findings showing hemorrhagic infarction of the testicular tumor. Fig. 2. Bivalved specimen demonstrates the gross appearance of the seminoma. Fig. 3. Plain film of the abdomen demonstrates a large soft tissue mass in the pelvis with compression of the bladder.
associated higher incidence o f developing a germ cell t u m o r [1-3]. The intraabdominal testis often presents as a torsion, with an estimated 13 times more likely chance o f undergoing torsion c o m p a r e d to the normally descended testis [4]. In our case report, we can only speculate that our patient had previously undergone a limited and incomplete exploration for a right undescended testis. This serves to illustrate the importance o f performing a diligent search for an impalpable testis. The failure to identify a testis, vas or blind-ending spermatic vessels in the inguinal canal or retroperitoneum, mandates intraabdominal exploration [5]. Supplemental diagnostic studies including venography [6], selective gonadal arteriography [7], sonography [8], computerized t o m o g r a p h y [9], and magnetic resonance imaging [10] o f the a b d o m e n m a y aid in the early localization o f an impalpable testis. Newer recent studies have confirmed the effectiveness o f laparoscopy as an alternate modality in the identification o f a unilateral nonpalpable testis [11].
In retrospect, a "second l o o k " at the preoperative plain film o f the a b d o m e n (Fig. 3) d e m o n strates a soft tissue mass in the pelvis with extrinsic impression on the superior aspect o f the bladder with its superior b o r d e r extending into the abdomen. Clearly, this coincides with the size o f the mass found intraoperatively. H a d the diagnosis been considered preoperatively after viewing the plain film o f the abdomen, sonography or computerized tomography would be the next modality to help confirm the diagnosis. In summary, the presentation o f an acute abd o m e n with a previous history o f inguinal/scrotal surgery and an absent testis on physical examination should alert the clinician to this diagnosis.
References 1. Riegler HC: Torsion of intra-abdominal testis. Surg Clin North Am 52:371, 1972 2. Garber HE, Kauffer GI: Torsion of an intra-abdominal testicular seminoma. J Urol 98:684, 1968
52 3. Cox L, Donald JC, Machin GA, Popkin JS, Zacks D: Intraabdominal testis with yolk sac tumor in a 2-year-old child. J Pediatr Surg 23:775, 1988 4. Ein SH: Torsion of an undescended intraabdominal benign testicular teratoma. J Pediatr Surg 22:799, 1987 5. Levitt SB, Kogan SJ, Engel RM, Weiss RM, Martin DC, Ehrlich RM: The impalpable testis: a rational approach to management. J Urol 120:515, 1978 6. Diamond AB, Meng CH, KodroffM, Goldman SM: Testicular venography in the nonpalpable testis. A JR 129:71, 1977 7. Vitale PJ, Khademi M, Seebode JJ: Selective gonadal angiography for testicular localization in patients with cryptorchism. Surg Forum 25:538, 1974
R.G. Frank et al.: Torsion of an Intraabdominal Testis Tumor 8. Weiss RM, Carter AR, Rosenfield AT: High resolution realtime ultrasonography in the localization of the undescended testis. J Urol 135:936, 1986 9. Green R Jr: Computerized axial tomography vs spermatic venography in localization of the cryptorchid testes. Urology 26:513, 1985 10. Landa JM, Gylys-Morin V, Mattrey RF, Krous HF, Kaplan GW, Packer MG: Magnetic resonance imaging of the cryptorchid testis. Eur J Pediatr 146[suppl 2]:S 16, 1987 11. Naslund MJ, Gearhart JP, Jeffs RD: Laparoscopy: its selected use in patients with unilateral nonpalpable testis after human chorionic gonadotrophin stimulation. J Urol 142: 108, 1989
