Recurrent Testicular Torsion After Prior Surgical Fixation: A Two-Case Series and Technical Insight into Orchidopexy Failure

1. Introduction

Testicular torsion is a time-sensitive surgical emergency that most commonly affects adolescent males, with a peak incidence between 12 and 25 years of age. Surgical detorsion and bilateral orchidopexy remain the standard treatment to avoid testicular loss and prevent contralateral torsion [1,2]. Orchidopexy is considered definitive, with recurrence after fixation being exceptionally rare [3,4,5]. The recent literature has increasingly highlighted the importance of surgical technique in orchidopexy, with a particular focus on the suture material, number of fixation points, and orientation, although high-level evidence and standardized recommendations regarding the optimal fixation technique are still lacking, particularly with respect to the suture configuration and prevention of rotational mobility [6,7,8]. We report two cases of recurrent torsion in previously pexied testicles, raising concern regarding technique-dependent failure.

Both patients provided written consent for the reporting of their cases and the use of intraoperative photographs.

2. Case Presentation

Case 1: A 16-year-old male presented to our hospital in May 2020 with acute left scrotal pain. He reported having experienced right-sided testicular torsion in September 2019, which was surgically managed with bilateral orchidopexy at an outside institution. Operative details of the initial procedure, including the number and placement of sutures, were unavailable at the time. On presentation in May 2020, surgical exploration confirmed left-sided torsion despite visible and two intact lateral sutures from the previous pexy. The findings were documented photographically, and the images demonstrate intact suture placement (Figure 1 and Figure 2). Repeat orchidopexy was performed with reinforced three-point fixation. Testicular perfusion was preserved.

Case 2: A 19-year-old male experienced right-sided torsion in March 2000 and underwent detorsion with contralateral (left-sided) orchidopexy in our hospital. No complications were reported, and follow-up was uneventful. In May 2025, now aged 44, he again presented with left scrotal pain, which had been persisting for three days. An ultrasound of the left testis indicated the absence of blood perfusion, and acute surgical exploration of the testis revealed left-sided torsion with the testis rotated 360 degrees, despite a prior orchidopexy. Interestingly, the left testicle was pexied at two longitudinal points, likely allowing axial rotation. Detorsion was successful, and a new fixation with two-point lateral sutures was performed. The old sutures were still visible, indicating that suture failure was not the cause but rather inadequate anchoring. Intraoperative findings also revealed scarred sites of previous fixation (Figure 3 and Figure 4). Remarkably, despite the pain persisting for three days, the testicle reperfused successfully after detorsion, which is unusual and highlights the potential for salvage even after delayed presentation.

3. Discussion

Recurrent torsion despite prior orchidopexy is exceptionally rare but is has been documented in the literature. It is more likely attributable to the insufficient restriction of testicular mobility due to suboptimal fixation techniques the rather than failure of the suture material itself. A recent systematic review by van Welie et al. identified 46 cases of recurrent torsion post-fixation [7]. Our two cases contribute additional clinical details and support the notion that surgical fixation does not universally prevent recurrence. Technical factors, including the number of suture points, orientation, and suture material, appear to play a critical role. In both cases, failure occurred not due to suture resorption or breakage but due to the insufficient restriction of rotational mobility. The second case is particularly instructive, demonstrating how longitudinally oriented fixation fails to address the pathophysiology of torsion, which typically involves clockwise rotation around the vertical axis of the spermatic cord.

Notably, the occurrence of torsion in a 44-year-old patient is extremely rare. Testicular torsion is predominantly a condition of adolescents and young adults, and its presentation in a middle-aged male more than two decades after the initial fixation further underscores the uniqueness and clinical relevance of this case. It also highlights the importance of maintaining a high index of suspicion even in patients who fall outside the typical age range.

Current guidelines offer little standardization regarding suture placement, number, or technique. Neither the European Association of Urology (EAU) nor the American Urological Association (AUA) guidelines provide explicit recommendations on the choice of suture material or specific fixation technique. However, a consensus document from the British Association of Urological Surgeons (BAUS) and the British Urology Researchers in Surgical Training (BURST) favors the use of non-absorbable sutures and multi-point fixation—preferably three- or four-point fixation—to minimize the risk of recurrence, although robust comparative data remain limited [9]. These cases underscore the need for enhanced surgical awareness and possibly revised technical standards in orchidopexy procedures. We suggest that fixation should not be limited to the longitudinal axis but should also include sutures placed in the transverse axis, thereby restricting axial rotation more effectively and enhancing stability.

4. Conclusions

Recurrent torsion after orchidopexy, although exceedingly rare, can occur and is likely related to suboptimal surgical techniques. These cases reinforce the importance of meticulous multi-point fixation during orchidopexy. A higher degree of suspicion is warranted in patients with prior orchidopexy who present with scrotal pain. Due to the rarity of testicular torsion after prior orchidopexy, the development of prospective studies is likely to be extremely difficult, if not impossible. As such, case reports and retrospective cohort studies play a crucial role in raising awareness among surgeons and patients about the potential for re-torsion and in guiding clinical decision-making. These forms of evidence are essential for informing conclusions regarding the most appropriate surgical techniques for orchidopexy. To reduce the risk of recurrence, future research efforts and surgical guidelines should explicitly address technical aspects of testicular fixation and promote standardized, evidence-based approaches. The main limitation of this paper is its descriptive nature and the small number of cases inherent to case reports.

5. Patents