The six-hour rule for testis fixation in testicular torsion: is it history?

Abstract

Objectives: To explore the historical and recent evidence behind the urological rule that operative management within six hours of pain onset in testicular torsion is necessary for organ salvage To use this information to guide those involved in related medico-legal cases Methods: Focused search of the PubMed database. Translation from German to English of the sentinel work of Hellner from 1933. Results: Hellner’s canine studies showed that complete ischaemia of the testis beyond six hours resulted in necrosis and then atrophy. He also showed that the degree of torsion was a key determinant of outcome with organ salvage possible at up to 24 hours when the twist was less than 3600. Recent clinical series support these findings and suggest a success rate of ≥98% when exploration is performed within six hours. Testicular salvage may be as good as 89% when surgery is delayed to 12 hours. Related medico-legal cases may consider whether the operative delay was causative in testicular loss, and where liability may lie for any such delay. Specific literature in this area is sparse. Conclusion: Hellner’s work explains the basis of the six hour rule and its application remains valid in today’s clinical practice. Surgical exploration is indicated out to 24 hours, however, given that testes can still be saved and that the degree of torsion cannot be gleaned pre-operatively. Medico-legally, we believe that an operative delay of up to 8 hours is probably safe when considering the causation of testicular loss, but more data are needed. Liability is more complex in that many factors can contribute to the delay and may be beyond the control of the doctor or hospital.