Manual detorsion and orchiectomy risk in testicular torsion: an updated systematic review and attempt-based meta-analysis.

BACKGROUND

Testicular torsion requires urgent restoration of blood flow. Manual detorsion (MD) may reduce ischemic time before surgery, but evidence is observational and vulnerable to treatment-selection bias.

METHODS

We searched PubMed, Embase, Web of Science, and the Cochrane Library through April 30, 2026. The primary outcome was orchiectomy comparing attempted MD with no MD attempt, irrespective of technical success. Random-effects odds ratios were pooled using Paule-Mandel estimation and Hartung-Knapp inference. Risk of bias and certainty were assessed using ROBINS-I and GRADE.

RESULTS

Eight retrospective comparative studies involving 844 patients were included. Orchiectomy occurred in 17/406 patients (4.2%) after attempted MD and 127/438 (29.0%) without MD attempt. Attempted MD was associated with lower orchiectomy odds (OR 0.13, 95% CI 0.07-0.24; P < 0.001; I²=0%). All studies had serious overall risk of bias, mainly from confounding by indication, and certainty was low. No study directly compared ultrasound-assisted with non-guided MD. Shorter symptom duration was most consistently associated with technical success.

CONCLUSIONS

Attempted MD was associated with lower orchiectomy odds, but causality is unproven. MD may be used as an adjunct if it does not delay urgent exploration and fixation.