The implementation of code torsion can improve testicular salvage rates: A multi-disciplinary clinical pathway

Introduction Testicular torsion (TT) is a surgical emergency that requires prompt detection and management to prevent testicular loss. This study aimed to assess whether a formal code-torsion pathway modeled after other ischemic events would improve the testicular salvage rates. Methods An Institutional Review Board (IRB)-approved clinical pathway was developed at our institution in January 2022 to assess all acute scrotal pain presenting to the emergency department of an academic tertiary care institution. Risk stratification was based on the Testicular Workup for Ischemia and Suspected Torsion (TWIST) score and the availability of Doppler ultrasonography depending on the time of presentation. A Code Torsion, based on risk assessment, then triggered a chain of events culminating in the expedited transfer of moderate and high-risk patients to the OR with the goal of a door-to-OR time of approximately 60 minutes. Results Our cohort of 45 adult patients with testicular pain or torsion with a mean age of 20.4 years old. A total of 45 patients with testicular pain or torsion were analyzed, with 23 (51.1%) in the pre-implementation group and 22 (48.9%) in the post-implementation group. Mean age was comparable between groups (20.1 years vs. 20.7 years). Time of symptom onset times showed no significant difference. The post-implementation group demonstrated improvements in key time intervals: door-to-examination time decreased from 17.5 (11.7) to 10.0 (7.0) minutes (p = 0.013), door-to-imaging time from 62.7 (54.9) to 23.1 (13.2) minutes (p = 0.002), and door-to-OR time from 207.4 (125.3) to 66.5 (19.8) minutes (p < 0.001). Orchiectomy rates significantly decreased from 52.2% to 13.6% (p = 0.006). Conclusions The implementation of a hospital-wide “Code Torsion” protocol, incorporating the validated TWIST score for risk stratification of acute scrotal pain, significantly improved care efficiency. By streamlining the activation of multiple clinical teams for rapid assessment and transfer to the OR, this protocol reduced door-to-OR times, minimized the duration of testicular ischemia, and improved orchiectomy rates.