Neonatal testicular torsion: Doppler flow and contralateral fixation need careful interpretation

Neonatal testicular torsion remains one of the most difficult diagnostic and management dilemmas in pediatric urology, and a new commentary from clinicians at Habib Hospital Thameur in Tunis, Tunisia, published in Frontiers in Urology, argues that two pillars of current practice deserve sharper scrutiny: the interpretation of Doppler ultrasonography findings and the routine performance of contralateral orchidopexy. Writing as a commentary on a single-center 14-year experience with neonatal testicular torsion, the authors do not dispute the value of that surgical series. Instead, they caution that the statistics it generated can easily be over-read, and that the consequences of over-reading them may be delayed operations or a false sense of security about the unaffected testis.

The first caution concerns a striking figure from the original study: Doppler flow was absent in 28 of 29 unilaterally affected testes, a rate of 96.55 percent. On its face, that number looks like powerful evidence that Doppler ultrasonography is an almost perfect detector of neonatal torsion. The commentary urges a more careful reading.

Because the cohort was surgically confirmed and consisted predominantly of non-viable testes, the data demonstrate an association between absent Doppler flow and established ischemia. They cannot establish the diagnostic sensitivity of Doppler ultrasonography for early neonatal testicular torsion, a fundamentally different question. More consequential for bedside decision-making is the converse point: preserved Doppler flow does not necessarily exclude torsion in the neonatal period.

The commentary highlights reported cases of asynchronous perinatal torsion in which apparently preserved preoperative Doppler flow preceded the diagnosis of torsion at surgical exploration. The practical implication, the authors argue, is that Doppler ultrasonography should remain an adjunct to clinical assessment rather than a prerequisite for exploration. The second major caution addresses contralateral orchidopexy, the practice of surgically fixing the healthy opposite testis to protect it against a future torsion.

In the original series, 23 of the 29 patients with unilateral torsion underwent contralateral fixation, and no patient subsequently developed a torsion on the fixed side. That sounds reassuring, but the commentary stresses that the absence of contralateral torsion during follow-up should not be interpreted as evidence of preventive efficacy. Without a comparable group of unfixed patients, there is no way to assess whether fixation actually reduced the risk, because the baseline risk of a metachronous contralateral event in this population is not established by the study design.

A protective effect may exist, but this dataset cannot demonstrate it. The uncertainty is not merely academic. Contemporary practice remains strikingly heterogeneous, and the commentary points to a recent national analysis of pediatric testicular torsion that documented substantial variation in the use of contralateral fixation while highlighting the limited evidence supporting the practice.

In other words, surgeons are making different decisions about operating on the healthy side, and the literature available to guide them is thin. For a condition as rare as neonatal testicular torsion, no single center will ever accumulate enough cases to settle the question on its own, which is one reason the commentary closes with a call for multicenter registries. Timing adds a further layer of complexity to both diagnosis and prevention.

The authors emphasize that age at diagnosis does not necessarily indicate when the torsion occurred, and this distinction may be crucial for understanding the possibility of salvage. Supporting this framing, a large literature review encompassing 1,336 patients demonstrated the very high rate of testicular loss associated with neonatal testicular torsion while also identifying asynchronous torsion as an important concern for the contralateral testis, reinforcing why the question of protecting the healthy side persists even as outcomes for the affected side remain poor. Within the original series, the few viable testes shared a telling feature: they were low-degree torsions in which perfusion was restored after detorsion.

The commentary reads this observation as a hint that salvage may depend not simply on the interval between diagnosis and surgery, but on recognizing a recent or atypical torsion before irreversible ischemia develops. None of these considerations diminish the contribution of the 14-year single-center experience. The commentary's purpose is to define the limits of what those observations can prove, so that the findings inform rather than mislead future practice.

Prompt clinical recognition, avoidance of unnecessary diagnostic delay, appropriate use of Doppler ultrasonography, and careful consideration of contralateral protection remain the central elements of management. Because neonatal testicular torsion is rare, the authors propose multicenter registries that incorporate the presumed timing of torsion, standardized Doppler findings, the degree of torsion found at exploration, treatment delay, and long-term testicular outcomes. Until those data exist, the commentary's message to clinicians is a disciplined one: treat a reassuring Doppler signal with skepticism in the neonatal scrotum, and treat an uneventful follow-up after contralateral fixation as an observation, not a proof.

Subject of Research: Diagnostic interpretation of Doppler ultrasonography and the preventive value of contralateral orchidopexy in neonatal testicular torsion

Article Title: Commentary: Neonatal testicular torsion: refining the role of Doppler and contralateral orchidopexy

Article References: Saadi, C., Laarif, S., Daib, A., & Hellal, Y. (2026). Commentary: Neonatal testicular torsion: refining the role of Doppler and contralateral orchidopexy. Frontiers in Urology, 6, 2004112. https://doi.org/10.3389/fruro.2026.2004112

Image Credits: AI Generated

DOI: 10.3389/fruro.2026.2004112

Keywords: neonatal testicular torsion, Doppler ultrasonography, contralateral orchidopexy, perinatal torsion, pediatric urology, testicular salvage, asynchronous torsion, testicular ischemia, orchidopexy, scrotal exploration, multicenter registries, diagnostic sensitivity