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Three Part Question

In [patients diagnosed with testicular torsion] does [anaesthesia] lead to a [reduced risk of testicular ischaemia-reperfusion complications]?

Search Strategy

Databases" Medline (2003-2022), Embase (2014-2022), Cochrane

Search terms: ("Testicular Torsion" OR "Spermatic Cord Torsion" OR "twisted testis").mp AND ("anaesthesia" OR "anaesthetics" OR "anesthesia" OR "anesthetics" OR "anaesthetic" OR "anesthetic").mp.
AND (“ischaemia-reperfusion” OR “ischemia-reperfusion” OR “reperfusion injury”).mp

Search Outcome

The search on Medline found 23 papers. The search on Embase found 3 papers. The search on Cochrane did not find any papers.

After duplications were removed, 23 papers remained; of these, six were relevant to the three-part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Jafarova et al. January 2022 Turkey	24 rats, split into three groups.		Propofol and etomidate decreased germ cell damage and Leydig cell loss. Propofol reduces the level of necrosis in the ischaemic testis. Protective mechanisms associated with etomidate are not fully understood.		Animal study (no humans). No long-term effects were investigated.
Urt Filho et al. February 2012 Brazil	30 rats split into 3 groups.		Unilateral torsion caused significant damage to ipsilateral testes compared to contralateral testes. The difference between the testes was less significant in those who were given propofol. Propofol protected the testes from ischaemic damage in TT.		Animal study (no humans). No long-term effects were investigated.
Taskara et al. September 2011 Turkey	24 rats, split into four groups.		Those who underwent torsion-detorsion (+/-propofol) had markedly smaller testicular weights after 30 days (p-value 0.0017). There was no significant improvement in spermatogenesis in those who had torsion-detorsion with propofol compared to those without (p-value 0.1797).		Animal study (no humans). Immediate effects of ischaemia-reperfusion injury weren’t measured.
Yagmurdur et al March 2008 Turkey	40 rats, split into four groups.		Propofol reduced the amount of testicular nitric oxide compared to thiopental in detorsion. This suggests reduced germ cell apoptosis with propofol. Thiopental had no protective effect for testicular ischaemia-reperfusion injury.		Animal study (no humans). No control for torsion-detorsion without treatment.
Yagmurdur et al November 2006 Turkey	40 rats, split into four groups.		Nitric oxide and malondialdehyde were increased in detorsion – by a lesser extent with propofol (p-values 0.004 and 0.003) than with thiopental (both p-values 0.001). Thiopental showed a greater level of histopathological testicular injury, compared to propofol. No contralateral testicular damage was detected in any group.		Animal study (no humans). No control for torsion-detorsion without treatment.
Unsal et al. December 2004 Turkey	35 rats, split into five groups		Torsion-detorsion caused a larger increase in malondialdehyde than torsion alone (p-value 0.002). Torsion-detorsion with propofol had significantly lower malondialdehyde levels compared to torsion-detorsion without propofol (p-value 0.004). Xanthine oxidase was higher in torsion, compared to torsion-detorsion (p-value 0.002). Propofol significantly reduced catalase activity following detorsion (p-value 0.002). Propofol reduced germ cell damage following detorsion.		Animal study (no humans). Long-term effects not investigated (testes harvested after 2-hours)

Comment(s)

All papers identified were animal studies conducted on rats, thus the evidence is inconclusive for humans. Due to the delicate nature of TT and infertility, it is unlikely for research to be conducted on human subjects, however, further investigations should be conducted using animal studies as a basis. The effect of propofol is considered in all six papers. Propofol is a “highly lipid-soluble anaesthetic” (yagmurdur et al, 2006) which exhibits “potent antioxidant activity” (Taskara et al, 2011). Five papers concluded that propofol reduced germ-cell damage, Leydig-cell loss, and necrosis within the affected testis. The paper by Taskara et al. found propofol to cause no significant improvement in spermatogenesis, however, they did not find propofol to hinder it either. No paper concluded that propofol negatively impacted the contralateral testis, thus the overall impact of propofol on ischaemia-reperfusion injury is beneficial. Thiopental and etomidate were also explored in these papers. Jafarova et al found etomidate to have fewer, but similar, effects on ischaemia-reperfusion injuries as propofol, however, the exact mechanism is not fully understood. Further research should be completed to determine whether etomidate’s effect is more significant than propofol, and thus whether it should be recommended instead of propofol. Both studies by Yagmurdur et al. investigated thiopental, and concluded thiopental has a less protective effect than propofol.

Clinical Bottom Line

Propofol should be administered before detorsion procedures (either manual or surgical), to minimise complications associated with ischaemia-reperfusion.

References

1. Jafarova et al. The effects of etomidate on testicular ischemia reperfusion injury in ipsilateral and contralateral testes of rats
2. Urt Filho et al. Propofol effects on the morphology of rat testes subjected to testicular ischemia-reperfusion
3. Taskara et al. Does propofol prevent testicular ischemia-reperfusion injury due to torsion in the long term
4. Yagmurdur et al Propofol reduces nitric oxide-induced apoptosis in testicular ischemia-reperfusion injury by downregulating the expression of inducible nitric oxide synthase
5. Yagmurdur et al The preventive effects of thiopental and propofol on testicular ischemia-reperfusion injury
6. Unsal et al. Propofol attenuates reperfusion injury after testicular torsion and detorsion