Testicular torsion after laparoscopic appendectomy: salvage by spermatic cord heparin flush and testicular decompression - a case report and literature review.

A 14-year-old male patient was admitted to the hospital with metastatic right lower abdominal pain that had persisted for a duration of five hours. Following admission, a comprehensive examination and preoperative preparation were conducted to exclude contraindications to surgery. The patient underwent laparoscopic appendectomy on the same day of admission. During the procedure, the appendix was observed to be enlarged, with signs of oozing in the local area and the pelvis. No gangrenous perforation of the appendix was identified. Postoperatively, the patient experienced significant relief from the right lower abdominal pain. Postoperative pathology revealed acute simple appendicitis with peripheral inflammation. On the first postoperative day, the patient exhibited a sudden onset of swelling and pain in the right scrotum. Emergency ultrasound imaging revealed an enlarged right testis, though this finding did not exclude the possibility of inflammation. Doppler ultrasound did not reveal any difference in the blood supply of the testes bilaterally. On the second postoperative day (12 h after the onset of symptoms), the right testis exhibited redness and swelling, accompanied by an escalation in pain. Ultrasonography revealed that the spermatic cord was thickened, and the blood flow signal was enhanced. Concurrently, the blood flow signal of the right testis and epididymis was diminished, and the surrounding area appeared dark and flaky. This constellation of findings led to the consideration of the possibility of testicular torsion (Fig.  1 ). The right testis exhibited a twisted inward rotation of 720°, and a conspicuous elevation was observed. The testis and epididymis demonstrated an enlargement in size, and a dark and purple coloration was evident, accompanied by increased tension of testicular tunica albuginea. The spermatic vessels exhibited a twisted configuration, with the proximal spermatic vessels displaying tortuousness and dilatation, accompanied by thrombosis within the vessels. The testis underwent a rotated outward rotation of 720°, followed by a reset, yet the black and purple coloration of the testis remained unchanged. Local warm saline gauze was applied intermittently for 30 min, and no change in the color of the testis was observed (Fig.  2 ). Intraoperatively, it was confirmed that right testicular torsion combined with testicular infarction was a possible occurrence. Fig. 1 A thorough evaluation of the ultrasound results indicates several notable findings. The spermatic cord appears to be thickened, and the blood flow signal appears to be enhanced. However, the blood flow signal of the right testis and epididymis appears to be reduced. Additionally, a dark area of fluid is observed in the surrounding flakes, which suggests the potential for testicular torsion A thorough evaluation of the ultrasound results indicates several notable findings. The spermatic cord appears to be thickened, and the blood flow signal appears to be enhanced. However, the blood flow signal of the right testis and epididymis appears to be reduced. Additionally, a dark area of fluid is observed in the surrounding flakes, which suggests the potential for testicular torsion Fig. 2 Intraoperatively, the right testis was observed to be twisted inward by 720°. The testis and epididymis exhibited enlargement, black and purple discoloration, and increased tension of testicular tunica albuginea. The spermatic vessels were distorted, and the proximal spermatic vessels demonstrated tortuousness and dilatation. No change in testis color was observed following repositioning and heat application Intraoperatively, the right testis was observed to be twisted inward by 720°. The testis and epididymis exhibited enlargement, black and purple discoloration, and increased tension of testicular tunica albuginea. The spermatic vessels were distorted, and the proximal spermatic vessels demonstrated tortuousness and dilatation. No change in testis color was observed following repositioning and heat application A substantial body of clinical evidence has demonstrated the necessity of testicular tissue resection in cases of ischaemic necrotic tissue, with the objective of averting atrophy, infertility, and malignant transformation of the preserved necrotic tissue [ 18 ]. During the surgical procedure, the family was apprised of the circumstances and prognosis, and they vehemently expressed their desire to preserve the right testicular tissue and acknowledged their willingness to assume the associated risks. The surgical approach involved spermatic vascular thrombus flushing and decompression by the incision of testicular tunica albuginea (Fig.  3 ). The thrombus was flushed with sodium heparin by pulsatile injection following the puncture of the spermatic vasculature with a venous indwelling needle. Concurrently, the tunica albuginea of the anterior margin of the testis was punctured with a 20-ml syringe needle, resulting in the extrusion of darker-colored blood. However, no sustained blood flow was observed. To enhance the decompression effect, we made multiple incisions in the testicular tunica albuginea, approximately 1 cm in size, to decompress the testis. Concurrently, we performed continuous flushing of the spermatic cord blood vessels with sodium heparin and local hot compresses. Approximately 10 min after the incision of the testicular leucorrhaphy, bright red blood flow was observed continuously, and the color of the testicle became lighter than before. Subsequently, we closed the testicular tunica albuginea incision with absorbable wires, retracted the testes to the scrotum, and fixed both testes. Fig. 3 A testicular tunica albuginea puncture (incision) is performed for the purpose of decompression, and the spermatic cord is subjected to vascular flushing of a thrombus with sodium heparin perfusion A testicular tunica albuginea puncture (incision) is performed for the purpose of decompression, and the spermatic cord is subjected to vascular flushing of a thrombus with sodium heparin perfusion On postoperative day 1, a review of the patient’s ultrasound revealed that the blood supply to the right testis had increased significantly compared to the preoperative state, indicating enhanced blood flow (Fig.  4 ). With regard to the sodium heparin flush of the spermatic cord vessels and decompression by the incision of testicular tunica albuginea, there is a paucity of reported cases. However, relevant studies have demonstrated that following testicular repositioning, the application of wet compresses with warm saline gauze and lidocaine spermatic cord closure is advantageous for restoring testicular blood supply. In order to preserve the testicular tissue, we applied intraoperative spermatic cord vascular heparin sodium irrigation and decompression by the incision of testicular tunica albuginea. This approach is currently indicated by expert guidelines and existing literature. Preservation of necrotic testicular tissue carries risks associated with long-term testicular atrophy and infertility [ 16 ]. We endeavored to preserve testicular tissue subsequent to restoring blood supply to the testicles by employing intraoperative spermatic cord vasovagal heparin sodium irrigation and decompression by the incision of testicular tunica albuginea. The potential for averting these risks and the long-term prognosis remains to be substantiated through long-term follow-up and extensive clinical studies. Fig. 4 Intraoperative visualization of persistent bright red blood flow from the the incision of testicular tunica albuginea and return of normal testicular color was observed. Postoperative ultrasound suggested that the blood supply of the right testis was significantly increased compared with the preoperative period, with increased blood flow Intraoperative visualization of persistent bright red blood flow from the the incision of testicular tunica albuginea and return of normal testicular color was observed. Postoperative ultrasound suggested that the blood supply of the right testis was significantly increased compared with the preoperative period, with increased blood flow Subsequent ultrasonographic evaluation at the 3-month postoperative interval revealed atrophy of the affected testis and compensatory enlargement of the contralateral testis (see Fig.  5 ). Hormonal levels and semen analysis were not assessed due to the patient’s age falling below the age of childbearing. A thorough review of the ultrasound data pertaining to the child’s right testis was conducted (refer to Table  2 ). It was ascertained that the preservation of the ischaemic testis did not impede testicular atrophy in this particular instance, even subsequent to the restoration of blood supply to the testicles. The efficacy of testicular preservation was consistent with the outcomes documented in the extant literature [ 18 ]. However, we conducted a psychological assessment of the children and their families, who expressed a preference for the current outcome over orchiectomy and would make the same decision even if they had to do it again. Assessed in terms of mental health (long-term psychological impact of testicular loss), preservation of the testicle in this case avoided early psychological shock for them. However, it is not possible to predict the long-term prognosis and psychological impact. Of course, the patient was informed of the importance of close follow-up, especially in the context of reproductive needs. Fig. 5 At the 3-month postoperative review, the affected testis was atrophied and the healthy testis was compensatorily enlarged. Ultrasound suggested that blood flow around the right testicular tissue could be explored At the 3-month postoperative review, the affected testis was atrophied and the healthy testis was compensatorily enlarged. Ultrasound suggested that blood flow around the right testicular tissue could be explored Table 2 The table presents the results of the testicular ultrasound follow-up Inspection time Testicular size (contralateral) (cm) Blood flow Testicular tissue echogenicity Epididymis At the onset of symptoms 4.2*2.9*2.8(4.0*2.5*2.1) nothing out of the ordinary Uneven, patchy strong echoes visible nothing out of the ordinary preoperative ultrasound 4.2*3.0*3.0(4.0*2.5*2.1) minimize Uneven, patchy strong echoes visible Thickening, uneven echogenicity, decreased blood flow Postoperative day 1 4.3*3.2*2.7(4.0*2.4*2.2) Decrease, increase from pre-op Uneven (better than before), scattered streaks of blood flow signal Thickened, uneven echogenicity, increased blood flow. 3 months after surgery 1.9*1.3*1.1(4.3*2.9*2.1) Visible around the testicles Disorganized, patchy strong echoes Unreported The table presents the results of the testicular ultrasound follow-up

Testicular torsion is a prevalent scrotal emergency in adolescents, characterized by the twisting and torsion of the spermatic cord due to anatomical abnormalities or increased mobility, resulting in obstruction of the blood supply to the testis [ 1 ]. Testicular torsion has been documented to account for 13–54% of acute scrotal disorders in children, with an incidence of 1/4000 per year in males under 25 years of age. The age peaks for the occurrence of testicular torsion occur in the neonatal period and adolescence, respectively, at the age of 12–18 years, which accounts for 65% of the cases [ 2 ]. Testicular torsion can be classified into intratesticular and extratesticular types. The intratesticular type is more prevalent and occurs mainly in adolescents, while the extratesticular type occurs almost exclusively in the foetus or neonate [ 3 ]. Testicular torsion is an emergency situation; therefore, a thorough understanding, early diagnosis, and prompt treatment of testicular torsion are essential. The etiology of testicular torsion has not been fully elucidated, and current research suggests anatomical abnormalities [ 4 ]. The core mechanism of testicular torsion is an anatomical defect that results in poor fixation of the testis, allowing it to move excessively within the scrotum. The main anatomical anomalies include: Bell-Clapper deformity, abnormal testicular taping, and abnormally high attachment of the sheath lumen, which causes the testis to hang from the end of the spermatic cord and move freely in a “pendulum” fashion. This abnormality has been observed in approximately 90% of patients with testicular torsion, predominantly in a bilateral manner (12%), though unilateral onset is also prevalent. Exertion of strenuous physical activity or abrupt alterations in posture have been identified as the primary triggers for torsion. Additionally, testicular rotation may be initiated by the contraction of the levator muscle during exercise (e.g., kicking, jumping) or vagal arousal during sleep [ 5 ]. Approximately 40% of cases are associated with strenuous exercise, torsion during sleep accounts for 25%, and trauma-induced testicular torsion accounts for 5–10% of cases. It has also been reported in the literature that cold environments cause reflex contraction of the levator muscle, which increases the risk of testicular torsion [ 6 ]. Furthermore, testicular torsion can be secondary to torsion of the testicular adnexa, testicular tumors or cysts, cryptorchidism, and epididymitis of the testis [ 7 ]. It is now believed that pendulum deformity is the core anatomical basis of testicular torsion, while triggers such as strenuous exercise, temperature changes, inflammation, and stress trigger torsion through levator muscle activity [ 4 ]. There are also some cases of testicular torsion that may have no obvious trigger. Testicular torsion is characterized by a sudden onset of scrotal pain, often occurring during sleep or after strenuous exercise. The pain manifests initially as a vague sensation and subsequently transitions into a severe, persistent or intermittent pain. Some patients may also experience concomitant pain in the lower abdomen or groin area, accompanied by nausea, vomiting, or fever. Patients may also present with non-specific symptoms such as fever or lower urinary tract symptoms [ 8 ]. It is noteworthy that cryptorchid torsion is a distinct type of testicular torsion, with a prevalence ranging from 21 to 53 times higher in children with cryptorchid testes. Its clinical manifestations include scrotal emptiness, atypical abdominal pain, and a palpable mass in the inguinal region, often accompanied by fever, nausea, vomiting, and other symptoms. A differential diagnosis is often necessary to rule out other potential pathologies, including inguinal incarcerated hernia, acute inguinal lymphadenitis, intestinal obstruction, and appendicitis, among others [ 9 ]. Testicular torsion is also occasionally observed in conjunction with positive inguinal palpation, elevated, transverse, or oblique testicular position, thickening of the spermatic cord, and tenderness [ 6 ]. The diagnosis of testicular torsion is primarily determined by a comprehensive evaluation of the patient’s symptoms, a physical examination, blood tests, and ultrasonography [ 10 ]. Medical professionals meticulously examine the position, morphology, and tenderness of the testis through palpation and other investigative procedures. Ultrasound imaging plays a pivotal role in the diagnosis of testicular torsion, as it can reveal abnormalities such as testicular enlargement and reduced or absent blood flow signals. The utilization of ultrasound Doppler examination has the potential to diminish the necessity for patients experiencing acute scrotal discomfort to undergo scrotal exploration procedures [ 11 ]. Nevertheless, the diagnostic accuracy of ultrasound Doppler examination for testicular torsion is contingent on the expertise of the operator and can be more challenging to interpret in prepubertal patients. In the early stages of testicular torsion and in patients with incomplete or intermittent testicular torsion, ultrasound Doppler examination can also show arterial blood flow and misdirect the diagnosis [ 12 ]. The point is that the detection of persistent arterial flow does not completely exclude the possibility of testicular torsion either. In instances where there is a discrepancy in the intensity of arterial flow between the two testes, a meticulous differential diagnosis is imperative. TWIST holds considerable clinical value in the diagnosis of testicular torsion, with the potential to expedite the diagnostic process [ 13 ]. Its utilization in conjunction with ultrasonography in medical institutions equipped with the necessary resources is recommended (Table  1 ). Table 1 Presents the TWIST scoring system for evaluating the risk of testicular torsion Clinic signs Score Ulcera testicular. 2 Hardening of the testicles 2 Loss of the testicular reflex 1 Nausea or vomiting 1 The testicles are located in a high position 1 Totals 5 Ps: In the event that the total score is ≤ 2, the likelihood of testicular torsion is considered low, and the diagnosis can be safely excluded. If the total score is 3–4, the risk is considered intermediate, necessitating further scrotal ultrasonography to ascertain the diagnosis. Conversely, if the total score is ≥ 5, the risk is classified as high, and direct surgical exploration is indicated Presents the TWIST scoring system for evaluating the risk of testicular torsion Ps: In the event that the total score is ≤ 2, the likelihood of testicular torsion is considered low, and the diagnosis can be safely excluded. If the total score is 3–4, the risk is considered intermediate, necessitating further scrotal ultrasonography to ascertain the diagnosis. Conversely, if the total score is ≥ 5, the risk is classified as high, and direct surgical exploration is indicated Testicular torsion can be treated by manipulative repositioning, which involves rotating the torsioned testis laterally without increasing pain or significant resistance. The successful restoration of testicular torsion is defined as immediate relief of all discomfort after restoration and a normal physical examination finding of the testis [ 14 ]. At this point, ultrasound Doppler examination can assist in confirmation. Immediate bilateral testicular fixation is recommended to prevent recurrence of testicular torsion after successful manoeuvre. Prompt surgical exploration is required if manipulation fails. During surgical exploration, regardless of whether the affected testis is fixed or removed, the contralateral testis should be fixed at the same time. Recurrent testicular torsion after testicular fixation is quite rare (4.5%) and may occur several years later [ 15 ]. There is no consensus on the mode of testicular fixation and suture material. Most studies state [ 16 ] that necrotic testicular tissue needs to be removed. The two most significant factors influencing testicular survival are the duration between the onset and resolution of testicular torsion, and the extent of testicular torsion. In cases of testicular torsion exceeding 360° within a span of 4 h, there is a high probability of severe testicular atrophy. Conversely, when testicular torsion reaches 360° and persists for more than 24 h, the atrophy of all testes is pronounced [ 17 ]. Despite prompt and appropriate testicular repositioning and immobilization, up to half of patients may still develop testicular atrophy. Further intervention, such as removal of the testis, is required if testicular atrophy is found to exceed 50% during follow-up [ 18 ]. Testicular torsion is an emergency medical condition that requires early diagnosis and prompt treatment. The risk of testicular torsion can be mitigated and the prognosis of patients can be enhanced by understanding the etiology, clinical presentation, diagnostic methods and therapeutic measures, as well as by taking appropriate preventive measures [ 15 ]. Parents and physicians should pay close attention to the testicular health of adolescents to ensure timely medical attention and effective treatment. This will prevent testicular loss and its subsequent impact on adolescent mental health. This paper presents a case of testicular torsion that occurred after appendectomy in a 14-year-old male patient. Emergency exploration of the testis revealed infarction and difficulty in restoring blood supply. As the family insisted on preserving the testicular tissue, we attempted to flush the thrombus against the spermatic cord vessels with sodium heparin and decompression by the incision of testicular tunica albuginea to restore the testicular blood supply as much as possible before preserving the testicular tissue. The patient was followed up and reviewed in the literature.

This case of testicular torsion occurred on day 1 post appendicitis, which is a relatively rare occurrence. A review of the admission examination and preoperative surveillance revealed no evidence of testicular erythema/tenderness or other relevant findings. The occurrence of testicular torsion in this case may be related to the contraction of the testicular raising muscles caused by appendicitis or painful stimulation of the surgical incision. The presence of testicular torsion secondary to local inflammatory stimuli in the right lower abdomen due to the effects of local inflammation cannot be ruled out, and testicular inflammation has also been documented as a high risk factor for testicular torsion [ 7 ]. It is important to note that the occurrence of testicular torsion in this case was identified subsequent to laparoscopic appendectomy, which does not exclude the possibility of testicular torsion being caused by preoperative disinfection of the perineum. Prolonged bed rest during the perioperative period may also be a significant risk factor for testicular torsion. In this case, when the child presented with right testicular pain, there was no obvious local redness or swelling. The tenderness was not obvious, the position of the testicle was normal, there was no uplift, and the texture of the testicle did not appear to be obviously hardened. Immediate ultrasound suggests the possibility of inflammation. However, it cannot be ruled out that torsion may occur in the early stage of torsion, when the blood supply of the testis is not affected by the ultrasound. The success rate of testicular torsion repair is contingent upon the timing of the procedure. When performed within 4–6 h of diagnosis, the success rate is 90%. However, if the procedure is performed after 12 h, the success rate declines to 50%. After 24 h, the success rate is only 10%. The onset of testicular necrosis occurs in 7 days in cases of 90° torsion, 3–4 days in cases of 180° torsion, 12–24 h in cases of 360° torsion, and 2 h in cases of 720° torsion [ 19 ]. The result might have been different if surgical exploration had been performed when the child first exhibited symptoms. However, it is challenging for clinicians to accurately and efficiently diagnose and identify testicular torsion, a process that often relies on the examination by an experienced physician and the recognition of ultrasound images [ 12 ]. Ultrasound is the imaging modality of choice for the diagnosis of testicular torsion. In cases where the diagnosis is difficult to establish due to a lack of experience, it is recommended that specialists participate in the ultrasound procedure and collaborate with the imaging physician to identify the appropriate imaging data. This may include comparing the blood supply of the testes bilaterally and examining whether the spermatic cord vessels are twisted. Early diagnosis and early repositioning can reduce the occurrence of testicular necrosis [ 20 ]. TWIST has been shown to have a high clinical predictive value for the diagnosis of testicular torsion and can expedite the diagnostic process. TWIST can be utilized in conjunction with ultrasonography in medical institutions where available. With the advancement of artificial intelligence (AI), the development of AI-assisted diagnosis holds great potential to enhance the specificity and sensitivity of imaging examinations, thereby facilitating more efficient and sensitive detection of testicular torsion [ 21 ]. During surgical exploration, following testicular repositioning, the application of wet compresses of warm saline gauze and lidocaine spermatic cord closure can be initiated. The recovery of testicular blood supply can then be observed, facilitating the decision regarding the necessity of testicular fixation or orchiectomy [ 22 ]. In the event that the testicular blood supply is restored following twisting and repositioning, accompanied by a reddish hue and adequate vascular pulsation of the spermatic cord, the testis can be preserved. Conversely, if the restoration of blood supply to the testis is deemed unsatisfactory, the “three-level scoring system” proposed by Arda et al. [ 23 ] (Table  3 ) is recommended for evaluation. It is imperative to observe the recovery of blood supply to the testis for a minimum of 10 min prior to the removal of the testis. Methodology: The testicular tunica albuginea was incised deep to the testicular medulla, and the time of arterial blood leakage from the trauma was observed. Table 3 The “three-stage evaluation system” proposed by Arda et al Rating scale Time after scrotal incision when blood is visible Suggestion Class I Arterial bleeding immediately after incision Preservation of testicles Class II Arterial hemorrhage begins within 10 min of incision Preservation of testicles Class III No arterial hemorrhage 10 min after incision Removal of testicles The “three-stage evaluation system” proposed by Arda et al Clinical guidelines stipulate that in the event of persistent black/cyanosis in the testis following intraoperative complete testicular repositioning, warm saline gauze and lidocaine spermatic cord closure, restoration of the blood supply is rendered unfeasible, and testicular necrosis and atrophy are inevitable. Consequently, orchiectomy is imperative [ 18 ]. Prior to testis removal, it is strongly recommended that the patient’s family be apprised once more of the exploration and obtain consent. Following the occurrence of necrosis and the subsequent removal of a testicular torsion, it is imperative to explore and fix the contralateral testis [ 24 ]. The rate of testicular resection in the treatment of testicular torsion typically ranges from 39 to 71%, while the rate of testicular resection in patients with misdiagnosis or missed diagnosis approaches 100% [ 25 ]. The timely repositioning of the testis is paramount to the restoration of blood supply, and local hot compresses have been shown to dilate local blood vessels, thereby facilitating the recovery of local blood supply [ 26 ]. In this case, the testis exhibited signs of black/cyanosis even after complete repositioning for 30 min, and restoration of the blood supply was unsuccessful. Consequently, necrosis or atrophy of the testis was inevitable. Following comprehensive communication with the family, they expressed a desire to preserve the testicular tissue. Consequently, we made multiple incisions to decompress the testis. Concurrently, we initiated continuous flushing of the spermatic cord blood vessels with sodium heparin and local hot compresses on the testis. After approximately 10 min, bright red blood began to emerge from the testicular tunica albuginea incision. Intraoperative thrombus flushing of the spermatic cord vessels may be an effective means of reversing testicular infarction and improving blood supply. The incision of testicular tunica albuginea not only reduced testicular pressure, but also observed the recovery of testicular blood supply. Testicular necrosis should be excised during surgery to prevent infection, atrophy and other complications. Due to the mutual blood flow between the two testes, if necrosis occurs in one side of the testis, if it is not removed in a timely fashion, it may affect the opposite testis, resulting in impaired function, which may affect semen production and quality [ 16 ]. The necrotic testis will continue to irritate the surrounding normal tissues and may induce infection. If the infection is not effectively controlled, repeated irritation may even lead to cancer, posing a serious threat to the patient’s life and health [ 26 ]. Furthermore, it may result in persistent pain and discomfort, thereby significantly impacting the patient’s quality of life. However, the assessment of such risks is only feasible in cases of definitive testicular necrosis. We endeavoured to preserve the testicular tissue following the restoration of blood supply to the testis. Upon conducting a follow-up ultrasound at the 3-month postoperative stage, we observed that atrophy had occurred in the testis. However, we were able to detect the blood supply surrounding the diseased testicular tissue by ultrasound. The child and family were informed that postoperative atrophy of more than 50% was a recommendation for further intervention, such as removal of the testis. The family and the child accepted the present outcome and expressed their willingness to follow the patient closely for further intervention if any abnormality was detected. Although we were able to avoid a psychological shock for the child and family, we were unable to change the outcome of testicular atrophy. We will continue to follow this case to observe the testicular atrophy and fertility. In this regard, we have reviewed the literature to consider whether further postoperative measures, including anticoagulation and local physiotherapy, could have prevented these risks. The long-term prognosis is still unknown and needs to be verified in long-term follow-up and in large clinical studies. As a vital component of the male reproductive system, the testes are frequently associated with gender identity and self-esteem [ 27 ]. Consequently, some men may experience diminished self-esteem following testicular removal. They may develop a dissatisfaction with their body image and even develop low self-esteem. Moreover, testicular loss may act as a catalyst for anxiety and depression in men. Pain from surgery, uncertainty during recovery, and worries about postoperative life may add to men’s psychological burden [ 28 ]. After testicular resection, men need to face a series of physical and psychological changes, which may have some impact on their daily life and work. Preservation of the testis may reduce such psychological shock, and of course, alternative options for testicular loss, such as testicular prosthesis implantation, have also been reported [ 29 ]. The primary objective of postoperative follow-up is to meticulously monitor the recovery process of the testis, encompassing parameters such as testicular volume, texture, and blood flow. It is also vital to detect and manage complications in a timely manner. It is generally recommended that the first follow-up visit is performed around three months postoperatively, as testicular function has usually recovered by this time, allowing a more accurate assessment of the surgical outcome. Follow-up visits before this time may not provide sufficient clinical value [ 17 ]. The follow-up interval should be decided by the clinician on a patient-by-patient basis. If significant atrophy of the affected testis (e.g., A greater than 50% reduction in comparison to the contralateral testis is identified during the subsequent follow-up. The necessity for further treatment or surgical intervention may be indicated in such cases [ 18 ]. In the present case, intraoperative testicular necrosis was identified. Following restoration of the blood supply to the testis, attempts were made to preserve the testicular tissue. Atrophy of the testis was detected during the follow-up ultrasound at 3 months postoperatively. The family and the child expressed reluctance to remove the diseased testis and indicated acceptance of the current outcome and close follow-up, with further interventions to be considered once abnormalities were detected. The case will be continued to observe testicular atrophy and fertility. A number of questions must be posed for further consideration: could additional postoperative measures have altered the outcome, including the initiation of early postoperative anticoagulation and local physiotherapy with the aim of preventing or reducing atrophy? How does the preservation of a partially atrophied testis prevent future fertility complications? Furthermore, how should risks be assessed during follow-up, including testicular atrophy, hormone levels, infertility, and even malignancy? Finally, are there long-term mental health effects that require validation through continued long-term follow-up and large clinical studies? These are questions that require further investigation through the validation of relevant cases, their subsequent summarisation, and timely dissemination.