Let's Do the TWIST

Abstract

Testicular torsion is a frequently encountered urological emergency that presents a time-sensitive risk to the testicle. Prompt diagnosis and treatment are crucial in the management of this condition, as delays may result in testicular loss. Clinical decision tools can aid in the evaluation and timely diagnosis of patients presenting with an acute scrotum where testicular torsion is suspected. One such tool was introduced by Barbosa and colleagues in 2013, the 7-point Testicular Workup for Ischemia and Suspected Torsion (TWIST) score. 1 Patients are stratified into 3 risk groups based on 5 criteria from the history and clinical examinationdlow, intermediate and high riskdwith recommendations for rule-out, further evaluation with ultrasound and surgical exploration, respectively.Within the last several years, there have been a number of studies evaluating the TWIST algorithm. Most studies have employed the Barbosa stratification system without questioning whether the scoring thresholds are appropriate. In this issue of The Journal, Qin and Qu (page 62) performed a systematic review from pertinent prospective and retrospective studies as well as a meta-analysis to determine the diagnostic utility of TWIST and its role in risk stratification of testicular torsion. 2 The authors specifically examined various TWIST cutoff scores to ascertain the ideal risk stratification system for widespread adoption.One can conclude from this well-conducted study that the TWIST algorithm is an accurate risk stratification instrument for testicular torsion. The authors confirmed that the original scoring system proposed by Barbosa had the greatest overall reliability: the AUC was 0.924, the sensitivity for the low-risk group was 98.4% and specificity in the high-risk group was 97.5%. Application of TWIST to high-risk patients may reduce delays in management caused by unnecessary imaging, potentially improving the time to treatment, leading to better outcomes in patients with testicular torsion and reducing costs. This portends particular significance in resource-limited settings, where waiting for imaging may delay diagnosis and result in unfavorable surgical outcomes.