Adnexal Torsion in Adolescents

Rapid abdominal MRI for appendicitis for evaluation of ovarian torsion in children

PURPOSE

Diagnosing adnexal torsion is challenging due to non-specific presentation and ultrasound findings. MRI may provide alternative assessment of adnexal torsion. We evaluated an MRI appendicitis protocol for torsion identification.

METHODS

Retrospective chart and image review was performed for girls with appendicitis MRI exams from 2013 to 2019. Ovarian volumes, stromal T2 signal, and apparent diffusion coefficient (ADC) ratios were tabulated. Ovarian and paratubal cysts' size and location were recorded as well as presence or absence of torsion. Statistical analysis was performed.

RESULTS

Six hundred-fifty cases were included, eight with torsion. Higher ovarian volumes and volume ratios were found with torsion (p < 0.0001 and p < 0.0001, respectively). Ovarian volume ratio less than 4:1 had 99.7% negative predictive value (NPV). Ovarian volume less than 20 mL had 99.8% NPV. Five of six cases with 7 cm or larger adnexal cysts were torsed. T2 signal and ADC ratios overlapped between torsed and untorsed groups. No torsed adnexa appeared normal on MRI.

CONCLUSION

Torsed cases tended to have larger ovaries and higher volume ratios. Adnexal cysts greater than 7 cm diameter were likely to be torsed. No torsion cases had normal adnexae on MRI. Normal appearing adnexae on MRI are very unlikely to be torsed.

Oophorectomy Rates in Pediatric and Adolescent Patients with Adnexal Torsion in US Emergency Departments

OBJECTIVE

To evaluate oophorectomy rates in pediatric and adolescent patients who presented to a US emergency department with adnexal torsion METHODS: This study was a retrospective, cross-sectional analysis utilizing the National Emergency Department Sample data from 2016 to 2018. It included patients younger than 20 years old and of the female sex. International Classification of Diseases Version 10 and ICD 10 Procedure Coding System codes were utilized to define patients with adnexal torsion who underwent adnexal surgery. Descriptive statistics and multivariate logistic regression were utilized to compare oophorectomy rates according to patient demographic characteristics.

RESULTS

There were 263 sampled patients younger than 20 years old who presented to a US emergency department with a diagnosis of adnexal torsion and underwent adnexal surgery. Of them, 177 had an oophorectomy (67.3%); 85 had a minimally invasive surgery (48%). Compared with 10- to 14-year-olds, 15- to 19-year-olds were 2.54 times more likely to have an oophorectomy (95% CI, 1.42-4.71; Table 2).

CONCLUSION

Despite standards for ovarian-sparing surgery since 2016 and data suggestive of safety since the 1990s, oophorectomy rates remain high in pediatric and adolescent patients with torsion who present to US emergency departments for care. Continued efforts should identify barriers to ovarian-sparing surgeries and better quantify specific clinical nuances when oophorectomies are performed.

Oncofertility care for children, adolescents, and young adults at risk for treatment-related fertility loss

As therapy for childhood malignancies becomes more sophisticated and survival has improved, long-term therapy-related sequelae have emerged. Loss of reproductive potential among childhood cancer survivors is one such concern that has become increasingly recognized among patients, families, and healthcare providers. The risk status for infertility based upon therapy received, state of current reproductive technology and outcomes, and an emphasis on adequate referral and counseling for fertility preservation options are reviewed. Contributing factors to infertility are discussed, and options for female and male preservation based upon age and pubertal status are summarized. This article highlights the current state of fertility opportunities for children and adolescents undergoing therapy for cancer. Providers caring for these young patients should be familiar with such options and should routinely initiate evaluations for eligibility of fertility preservation.

The Evaluation, Diagnosis, and Management of Ovarian Cysts, Masses, and Their Complications in Fetuses, Infants, Children, and Adolescents

The majority of abdominal masses in female children derive from the ovaries. Ovarian masses in pediatric populations can vary from simple functional cysts to malignant neoplasms. Their incidence, clinical presentation, and histological distribution vary across age groups. In the assessment of ovarian masses in children, the primary aim is to determine the probability of malignancy, as the treatment approaches for benign and malignant lesions are significantly distinct. The primary imaging tool for evaluating ovarian cysts and masses is ultrasound, which can assess the size, location, and characteristics of masses. Magnetic resonance imaging (MRI) or computed tomography (CT) may be used for further evaluation if ultrasound findings are inconclusive or if malignancy is suspected, especially in older adolescents. Serum markers may be considered in older adolescents to help assess the risk of malignancy, though it is less useful in younger populations due to normal developmental variations. Many functional ovarian cysts, especially those detected in fetuses or infants, often resolve spontaneously without intervention. Surgical intervention is indicated in cases of large cysts that cause symptoms, or if there are concerns for malignancy. Common procedures include primarily ovarian sparing laparoscopy or laparotomy. Complications like torsion, rupture, or hemorrhage may require urgent surgical intervention. Treatment should be performed in specialized centers to avoid unnecessary oophorectomies and ensure the best possible outcome for the patient. This comprehensive review aims to provide an overview of the evaluation, diagnosis, and treatment of ovarian masses in the pediatric population. Emphasis is placed on the particularities of the lesions and their management in relation to age subgroups.

Unexpected acute appendicitis found at laparoscopic surgery for a right ovarian teratoma: A case report

Acute appendicitis and adnexal torsion associated with ovarian tumors are possible causes of acute abdomen in women, yet differentiation remains challenging. Once adnexal torsion is suspected in young women, gynecologists should perform surgery to release the torsion as promptly as possible to preserve future fertility. Herein, we report a case of acute appendicitis that was unexpectedly discovered during laparoscopic surgery initially performed for suspected torsion of a right ovarian teratoma. A 20-year-old nulligravid woman with a history of left ovarian teratoma resection and ulcerative colitis presented with left lower abdominal pain. Non-contrast-enhanced computed tomography showed no findings suggestive of exacerbation of ulcerative colitis, such as bowel wall thickening or worsening ascites, while a mass suspected to be an ovarian teratoma was identified. Gynecologists and an emergency physician specializing in gastroenterology who attended the patient suspected an acute abdomen caused by adnexal torsion or tumor leakage associated with a right ovarian teratoma 5 cm across. However, laparoscopy revealed that the right ovarian teratoma was neither twisted nor ruptured. Instead, the appendix was swollen with yellow turbid ascites, compatible with acute appendicitis. Therefore, laparoscopic excision of the right ovarian teratoma and appendix was performed, and the patient's pain resolved postoperatively. The assumption that the pain was caused by torsion of the right ovarian teratoma was the primary reason for failing to diagnose acute appendicitis. This underscores the importance of evaluating the appendix during gynecologic laparoscopic surgery performed for suspected ovarian torsion.

Clinical utility of ultrasonography in pediatric and adolescent gynecology: retrospective review of 1313 ultrasound examinations

OBJECTIVES

Ultrasound is the first-line imaging modality of the pelvis in the pediatric and adolescent gynecology (PAG) population. Ultrasound findings in pre- and postpubertal PAG patients differ from those in adults. Diagnostic models for adnexal pathology have not been validated in this cohort. The primary aim of this study was to evaluate normative findings and the incidence of pathology in this cohort. The secondary aim was to assess the performance of expert opinion alone, as well as using retrospective application of the International Ovarian Tumor Analysis (IOTA) simple rules (SRs) and benign descriptors (BDs) in those found to have an adnexal mass.

METHODS

This was a retrospective review of pelvic ultrasound examinations performed in patients < 18 years of age from January 2017 to July 2021 in one expert center in the UK. Analysis was performed on three age groups: neonatal (aged < 1 year), premenarchal (aged ≥ 1 year) and postmenarchal. The study was locally approved as an audit (GRM_082). Expert review of images of ovarian masses was performed using retrospective application of the IOTA-SRs and IOTA-BDs.

RESULTS

In total, data on 1429 pelvic ultrasound examinations were retrieved, of which 116 were excluded, resulting in the inclusion of 1313 ultrasound images (1145 patients). The median age at the first ultrasound scan was 2 days after birth in the neonatal group (n = 20), 8.8 years in the premenarchal group (n = 124) and 16.1 years in the postmenarchal group (n = 961). The status of menarche was unknown in a further 40 patients. Normative ultrasound findings were in keeping with those in the existing literature. Uterine anomalies were seen in 14 (1.2%) patients. Endometrial pathology was rare, with five cases of gestational trophoblastic disease. The most frequent indication for ultrasound scan for each group were a known medical condition in neonates (n = 11 (55.0%)), suspected precocious puberty in premenarchal girls (n = 38 (30.6%)) and abnormal vaginal bleeding in postmenarchal girls (n = 504 (52.4%)). Polycystic ovarian appearances were described in 150 (15.6%) postmenarchal girls. Adnexal pathology was identified in 102 (8.9%) participants on initial ultrasound: four neonates, three premenarchal and 95 postmenarchal patients. Benign cystadenomas and hemorrhagic cysts were the most common adnexal mass type in all groups. Final outcomes were available for 79/95 masses in the postmenarchal group, none of which were malignant. The IOTA-SRs, IOTA-BDs, expert opinion and standard ultrasound reporting could characterize as benign 96.2%, 87.3%, 98.7% and 77.2% of the masses, respectively, all with a specificity of 100%. Eleven patients underwent 12 surgeries overall (three oophorectomies, six cystectomies and three cyst aspirations), with 11 out of 12 masses classified as benign based on retrospective expert assessment.

CONCLUSIONS

Ultrasound is effective for assessment of the female pelvis in the PAG population. Adnexal masses are common, but few require surgical intervention and most resolve expectantly. The IOTA-BDs and IOTA-SRs maintain their performance in this population. Larger studies are required for the prospective validation of diagnostic models which may aid a fertility-sparing approach to care. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Decreased attenuation difference between non-contrast and portal-venous phases of CT predicts the ultrasonography-unspecified adnexal torsion

OBJECTIVES

To evaluate the value of contrast-enhanced CT in diagnosing ultrasonography-unspecified adnexal torsion (AT).

METHODS

Surgically confirmed patients with painful pelvic masses (n = 165) were retrospectively collected from two institutes. Two senior radiologists independently reviewed the CT images and determined the Hounsfield unit difference between non-contrast vs portal venous phases (ΔHUPV-NC) in both derivation and validation samples. The cutoff value, sensitivity, specificity, predictivity, and reproducibility of the ΔHUPV-NC and other visually assessed CT signs were analyzed and compared using the receiver-operating characteristic curve, multivariable regression, and inter-rater agreement assays, respectively.

RESULTS

Women with twisted (n = 73 [47 ± 19 years]) or untwisted (n = 92 [40 ± 15 years]) adnexal lesions were reviewed. The ΔHUPV-NC ≤ 17.5 HU (AUC: 0.91 [95% CI: 0.86, 0.96]; sensitivity: 95% [95% CI: 87, 98]; and specificity: 88% [95% CI: 80, 94]) was the independent predictor of AT (OR: 137 [95% CI: 39, 481], p < 0.001). After training in ΔHUPV-NC measurement, the agreement between two junior residents and the consensus increased from fair (resident-1: 0.29 [95% CI: 0.17, 0.41]; resident-2: 0.24 [95% CI: 0.1, 0.39]) to substantial (resident-1: 0.75 [95% CI: 0.65, 0.85]; resident-2: 0.72 [95% CI: 0.62, 0.83]). The post-training diagnostic accuracy (both residents: 81% [95% CI: 74, 87]) was higher than the pre-training accuracy (resident-1: 67% [95% CI: 59, 74], p = 0.007; resident-2: 66% [95% CI: 58, 73], p = 0.002).

CONCLUSION

The sign of ΔHUPV-NC ≤ 17.5 HU in contrast-enhanced CT can be used to predict the ultrasonography-unspecified AT.

CRITICAL RELEVANCE STATEMENT

The decreased attenuation difference between non-contrast vs portal venous phases, a quantitative measurement-based CT sign, highlights the value of using contrast-enhanced CT as a second-line imaging approach after an equivocal ultrasonographic examination to diagnose AT in emergency settings.

KEY POINTS

The value of contrast-enhanced CT in diagnosing ultrasonography-unspecified AT is underestimated. The ΔHUPV-NC ≤ 17.5 HU is the only predictor to diagnose the ultrasonography-unspecified AT. Contrast-enhanced CT can be used as a second-line imaging approach after an equivocal ultrasonographic examination.

Sustained Positive Practice Change After Targeted Education in the Management of Ovarian Torsion

BACKGROUND

Failure to perform ovarian conservation surgery (OCS) for patients who present with adnexal torsion was recognized as a practice gap by the American Pediatric Surgical Association (APSA) in 2017. A targeted educational campaign was conducted to promote detorsion and ovarian conservation surgery as the standard of care for ovarian torsion. We evaluated the practice change that has occurred for pediatric and adolescent patients with ovarian torsion from 2012 to 2022.

METHODS

Using the American College of Surgeons (ACS) National Safety and Quality Improvement Project-Pediatrics (NSQIP-P) Participant Use Files from 2012 to 2022, we compared surgical treatment types during the time periods that encompassed the targeted educational period.

RESULTS

A total of 2249 patients (70 %) underwent OCS surgery and 980 (30 %) patients underwent salpingectomy and/or oophorectomy (SO). Patients who were treated with OCS were older (12.4 [SD 3.6] vs. 11.4 [SD 4.8] years, p < 0.01). Patients were more likely to be treated with SO if they were Black (11 vs. 15 %, p < 0.01) or obese (28 vs. 33 %, p < 0.01). From 2012 to 2017, 42 % of patients underwent OCS, compared to 76 % in 2018-2022 (p < 0.01). A mixed effect analysis comparing year-over-year rates of SO across pediatric surgeons and gynecologic surgeons showed a statistically significant difference in rates across specialty and time (p < 0.01), with pediatric surgeons performing fewer SOs.

CONCLUSION

In the treatment of ovarian torsion in pediatric and adolescent patients, we demonstrated successful adoption and sustained implementation of practice improvement coincident with the introduction of a comprehensive educational initiative.

TYPE OF STUDY

Retrospective cohort.

LEVEL OF EVIDENCE

IV.

Laparotomy versus laparoscopy for the treatment of adnexal torsion during pregnancy

BACKGROUND

Adnexal torsion (AT) is a rare emergency complication during pregnancy. Increasing evidence implies that operative laparoscopy for adnexal torsion performed during pregnancy could be safe and feasible. We procured and evaluated the surgical and obstetric outcomes between laparoscopy and laparotomy to determine the optimal approach for treating AT during pregnancy.

METHODS

This was a retrospective study involving telephone questionnaire on adnexal torsion during pregnancy that occurred between July 2012 and July 2023 in the First Affiliated Hospital of Zhengzhou University. The study cohort included 155 pregnant women who underwent laparotomy or laparoscopic surgery. The clinical characteristics, surgical interventions, postoperative pathology and pregnancy outcomes were analyzed.

RESULTS

A total of 102 patients were treated by laparoscopy, and 53 patients were treated by laparotomy. Compared with the laparotomy group, the laparoscopy group had significantly less blood loss (17.5 ml vs. 20.0 ml, p = .004), a lower incidence of delayed incision healing (1.0% vs. 11.3%, p = .011), and a shorter hospital stay (5.0 days vs. 8.0 days, p < .001). There was no significant difference between the two groups in terms of obstetric outcomes, including preterm delivery, miscarriage rate, birth weight, delivery gestation, cesarean delivery rate, or neonatal intensive care unit admission. All the pathological findings were benign except for one case of borderline mucinous cystadenoma. The most common pathological types were luteal cysts in the laparoscopy group and mature teratomas in the laparotomy group.

CONCLUSION

In this retrospective study, compared with laparotomy, laparoscopy yielded successful outcomes, with less surgical bleeding, less delayed wound healing, and shorter hospital stays. Laparoscopy could be a promising approach for diagnosing and treating AT during pregnancy.

Adnexal Incarceration in a Posterior Pelvic Peritoneal Defect Associated with Ovarian Torsion: A Case Report

Ovarian torsion is one of the gynecological emergencies and surgical intervention is the standard management for ovarian salvage as well as reveals some unexpected anatomical defects that increase the risk of ovarian torsion. We report a case of a 27-year-old single, nulliparous female taken for diagnostic laparoscopy with suspicion of ovarian torsion. Intraoperatively, we found right adnexa torsion (ovary with tube) along with incarceration of the right ovary and tube into the big peritoneal sac, which was located medial to the right uterosacral ligament. Detorsion and careful pulling of the swollen adnexa were done to the outside of the big peritoneal sac using nontraumatic laparoscopic forceps. The left side was normal with normal left adnexa. The patient had a second laparoscopic look with a plan for peritoneal closure of the big peritoneal defect. There are two cases which have previously reported ovarian incarceration, but were not associated with ovarian torsion, and did not involve peritoneal closure unlike our report of ovarian detorsion and peritoneal defect closure. The etiology of this condition is thought to be likely congenital as there were no other visible etiologies like pelvic trauma, previous surgery, pelvic inflammatory disease, or endometriosis. Our clinical assessment suggests that a peritoneal sac can enhance the course of ovarian torsion to involve ischemic changes of the ovary when trapped inside of it, by its prevention of spontaneous detorsion. This condition will result in the compression of the cells between the sac wall and subsequent tissue edema enhancing the ischemic effect.

Factors Associated With Isolated Fallopian Tube Torsion in Pediatric Patients

BACKGROUND

Isolated fallopian tube torsion (IFTT) is a rare form of adnexal torsion that is more difficult to diagnose, which may lead to delays in treatment. Our objectives were to identify clinical and radiologic factors associated with surgically-confirmed IFTT and compare them with those of patients without torsion and with adnexal torsion (AT) in a large pediatric population.

METHODS

We conducted a retrospective chart review of all patients who underwent surgery for suspected adnexal torsion from 2016 to 2019. Torsion was determined intraoperatively, with IFFT defined as those with only tubal but no ovarian torsion and AT defined as those with ovarian torsion, with or without involvement of the ipsilateral fallopian tube. Clinical and radiologic variables were compared between patients with IFTT and those without torsion and with AT using descriptive statistics. A previously-described composite score to predict torsion based on the presence of vomiting and adnexal volume (VVCS) was calculated for each patient.

RESULTS

Of 291 patients who underwent surgery for suspected torsion, 168 had confirmed torsion: 33 (19.6%) IFTT and 135 (80.4%) AT. Patients with IFTT were more likely to be younger (12.8 vs. 14.2 years, P = 0.02), premenarchal (29.0% vs. 10.7%, P = 0.009), experience nausea (90.6% vs. 70.9%, P = 0.02) and vomiting (81.3% vs. 32.8%, P < 0.001), have a paratubal cyst on imaging (18.8% vs. 2.5%, P = 0.003), and have larger adnexal volume (143.3 vs. 64.9 ml, P < 0.001) than those without torsion. Higher BMI (26.6 vs. 22.9 kg/m2, P = 0.03), a paratubal cyst on imaging (18.8% vs. 1.5%, P < 0.001), presence of arterial (65.5% vs. 44.1%, P = 0.04) and venous Doppler flow (79.3% vs. 55.9%, P = 0.02), and radiologic impression indicating lack of torsion (37.9% vs. 16.8%, P = 0.04) were more common in IFTT than AT. The accuracy of the VVCS in predicting torsion for the IFFT group was 83.9%.

CONCLUSIONS

IFTT has a similar clinical presentation to AT but with a higher likelihood of a paratubal cyst and preserved Doppler flow on imaging. IFTT should be strongly considered in patients who present with pain, nausea, and vomiting and have an adnexal mass separate from the ovary on imaging, regardless of Doppler flow.

LEVEL OF EVIDENCE

Level II.

TYPE OF STUDY

Prognosis study.

Sex-based Disparities in the Management of Pediatric Gonadal Torsion

INTRODUCTION

In 2015, the U.S. News and World Report (USNWR) implemented a quality metric to expedite surgery for testicular torsion (TT), but not ovarian torsion (OT). This study examined OR timing among children with suspected TT and OT before and after this metric.

METHODS

A single-center retrospective cohort study of children (1-18yr) who underwent surgery for suspected gonadal torsion was performed. Time to OR (TTOR) from hospital presentation to surgery start was calculated. An interrupted time series analysis identified changes in TTOR for suspected TT versus OT after the 2015 USNWR quality metric.

RESULTS

Overall, 216 patients presented with TT and 120 with OT. Median TTOR for TT was 147 min (IQR:99-198) versus 462 min (IQR:308-606) for OT. Post-quality metric, children with TT experienced a 27.8 min decrease (95% CI:-51.7,-3.9, p = 0.05) in annual median TTOR. No significant decrease was observed for children with OT (p = 0.22). Children with history of a known ovarian mass (N = 62) experienced a shorter TTOR compared to those without (422 vs 499min; p = 0.04).

CONCLUSION

Implementation of a national quality metric for TT expedited surgical care for children with TT, but not children with OT. These findings highlight the need for equitable quality metrics for children presenting with suspected gonadal torsion.

LEVEL OF EVIDENCE

III.

TYPE OF STUDY

Retrospective Comparative Study, Observational Cohort Study.

Ovarian tumors in the pediatric population: An update

Research reveals that 1% of neoplasms in females under 17 years of age are ovarian neoplasms and though usually benign, malignant tumors may occur in the pediatric age group. This review considers various current concepts of these tumors including the epidemiology, risk factors, clinical presentations, diagnosis, differential diagnosis, and treatment options including the need to provide fertility-sparing surgery as well as their potential impacts on the psychological well-being of children and adolescents. We gathered data from the published articles ranging from studies, meta-analyses, retrospective studies, and reviews. We focused on the articles published in English between January 1, 2000, and August 31, 2023. Only a few articles published prior to 2000 were included for historical perspective.

Ovarian Salvage With Prompt Surgical Intervention for Adnexal Torsion: Does Timing Matter?

BACKGROUND

Adnexal torsion requires treatment to limit ischemic injury and tissue loss. Optimal time to surgical intervention has not been established. We compared outcomes of ovarian loss amongst pediatric patients.

METHODS

We conducted a retrospective review of 88 patients with adnexal torsion from March 2014 through April 2021. Rates of ovarian loss were compared for patients who underwent surgery within and beyond 60 minutes from diagnosis.

RESULTS

Most patients underwent surgery more than 60 minutes from the time of diagnosis (83%; median time 116 minutes). Comparing patients with and without ovarian loss, there was no statistically significant difference in time to surgery from time of diagnosis (P = .618). Patients with ovarian loss had a longer duration of symptoms (24 vs 96 hours; P = .017).

CONCLUSIONS

While surgical repair of adnexal torsion may be urgent, this study suggests that duration of symptoms should be considered when assessing a patient's likelihood of ovarian loss.

Clinicopathological features and surgical procedures of adnexal masses with abdominal pain in pediatric and adolescent patients

PURPOSE

This study investigated the clinicopathological features and surgical procedures of adnexal masses with abdominal pain in pediatric and adolescent patients. Our objective was to better define the clinical presentation of adnexal torsion and to distinguish characteristics of those with torsion and those with an alternate diagnosis.

METHODS

Retrospective cohort study of 212 pediatric and adolescent patients was performed who admitted for abdominal pain and presenting with an adnexal mass between March 2012 to December 2019.Medical records were reviewed for age at operation, including presentation of symptoms and signs; the levels of tumor markers; imaging examinations; pathologic findings; the size of masses; treatment; and outcome. Data management and descriptive analyses were performed using SPSS 26.0.

RESULTS

The median age of the patients was 14.5 ± 3.6 years at the operation. 126 (59.4%, 126/212) patients presented with an abrupt onset of abdominal pain. A total of 82.1% (174/212) of the participants underwent adnexal conservative surgery. 179 (84.5%, 179/212) patients underwent laparoscopic surgery with an average tumor size of 7.7 ± 3.4 cm, while 33 patients ( 15.6%, 33/212) underwent laparotomy. Rupture of mass and ectopic pregnancy accounted for 7.5% (16/212) and 0.9%(2/212), respectively. Torsion was responsible for 36.8% (78/212) of all patients. Among the patients with torsion, the symptom of nausea and vomiting was more common among girls without torsion (P < 0.0001). 88.5% of the girls with torsion had acute onset of abdominal pain, while 92.3% had persistent pain that could not be relieved or occurred repeatedly, which significantly higher than that in the patients without torsion (P < 0.001). 69.2% of patients with torsion had fixed pain sites, compared with 42.2% in patients without torsion (P < 0.001). 88.5% of girls with torsion had an ovarian cyst/mass ≥ 5 cm, compared with 75.0% in girls without torsion (P = 0.038). 66.7% of girls underwent ovary-preserving surgery, compared with 92.2% in patients without torsion. The most common pathologic types were mature teratoma and simple cyst, accounting for 29.4% and 25.6%, respectively. The multivariate analyses confirmed that mass size greater than 5 cm (OR 4.134, 95% CI: 1.349-12.669,P = 0.013), acute onset pain (OR 24.150,95%CI: 8.398-69.444,P = 0.000), persistent or recurrent pain (OR 15.911,95%CI: 6.164-41.075,P = 0.000) were significantly associated with increased risk of torsion.

CONCLUSIONS

Torsion which is a relatively rare event in the pediatric population was not an uncommon condition and responsible for more than one third of all pediatric and adolescent patients presented with adnexal masses and abdominal pain. Pain assessment in children and adolescents is important to distinguish characteristics of those with torsion and those with an alternate diagnosis.Thus, pediatric and adolescent patients particularly with a pelvic mass size greater than 5 cm, acute onset pain, persistent or recurrent pain have a benign cause and not missing the devastating condition that needs emergent attention. Thus, a strategy of earlier and liberal use of Diagnostic Laparoscopy (DL) may improve ovarian salvage.

Contemporary Trends in Laparoscopy and Ovarian Sparing Surgery for Ovarian Torsion in the Pediatric Population

PURPOSE

Although total oophorectomy (TO) was historically performed in cases of nonviable-appearing ovaries, considerable evidence has demonstrated equivalent outcomes after ovarian sparing surgery (OSS) as well as long-term fertility preservation benefits. This study sought to compare outcomes of OSS and TO for patients with ovarian torsion.

METHODS

Females <21 years old admitted for ovarian torsion were identified from the Nationwide Readmissions Database (2016-2018) and stratified by OSS or TO. Propensity score-matched analysis (PSMA) utilizing >50 covariates (demographics, medical comorbidities, ovarian diagnoses, etc.) was constructed between those receiving TO and OSS.

RESULTS

There were 3,161 females (median 15 [12-18] years) with ovarian torsion, and concomitant pathologies included cysts (42%), benign masses (25%), and malignant masses (<1%). Open approaches were more common (52% vs. 48% laparoscopic), and ovarian resection (OSS or TO) was performed in 87% (39% OSS and 48% TO). OSS was more commonly performed with laparoscopic detorsions (60% vs. 40% TO), while TO was more frequent in open operations (59% vs. 41% TO; both p < 0.001). No differences in overall readmissions (7% OSS vs. 8% TO) or readmissions for recurrent torsion (<1% overall) and ovarian masses (<1%) were observed (both groups <1%; p = 0.612). After PSMA, laparoscopy was still utilized less frequently with TO (39% vs. 53%; p < 0.001) despite similar rates of malignant masses.

CONCLUSIONS

Overall, these data offer additional support for the current practice guidelines that give preference to OSS as the primary method of treatment for pediatric ovarian torsion in the majority of cases.

LEVEL OF EVIDENCE

III.

TYPE OF STUDY

Retrospective Comparative Study.

Hospital Volume and Quality of Care for Emergency Gynecologic Care

OBJECTIVE

To evaluate the association between hospital volume and the quality of gynecologic emergency care for tubal ectopic pregnancies, ovarian torsion, and pelvic inflammatory disease (PID).

METHODS

In this cross-sectional analysis, we analyzed patients who presented for emergency care for tubal ectopic pregnancies, ovarian torsion, and PID using the Premier Healthcare Database from 2006 to 2020. We measured the following outcomes: methotrexate use for ectopic pregnancy, ovarian cystectomy for torsion, and guideline-based antibiotic use for PID. For each condition, we measured outlier hospitals that performed the above interventions at below the 10th percentile. Multivariable logistic regression models were used to analyze associations between outlier care and hospital factors such as annualized mean case volume, urban or rural location, teaching status, bed capacity, and geographic region, as well as hospital-level patient population factors, including age, insurance status, and race.

RESULTS

A total of 602 hospitals treated patients with tubal ectopic pregnancies, of which 21.9% were outliers, with no cases managed with methotrexate. Of 512 hospitals treating patients with ovarian torsion, 17.4% were outliers, with no cases managed with cystectomy. Of 929 hospitals that treated patients with PID, 9.9% were deemed outliers with low rates of guideline-adherent antibiotic administration. Low-volume hospitals were more likely to be outliers with low rates of use of methotrexate for ectopic pregnancy (6.7% of high-volume hospitals vs 49.7% of low-volume hospitals were outliers; adjusted odds ratio [aOR] 0.13, 95% CI, 0.05-0.31 for high-volume hospitals) and cystectomy for torsion (34.9% of low-volume vs 2.4% of high-volume hospitals were outliers; aOR 0.05, 95% CI, 0.01-0.18 for high-volume hospitals). There was no association between hospital volume and lower rates of guideline-based antibiotic use for PID.

CONCLUSION

Higher hospital volume is associated with use of conservative, fertility-preserving treatment of emergency gynecologic conditions, including ectopic pregnancy and ovarian torsion.

Laparoscopic salvage procedures for adnexal torsion in pediatric and adolescent patients during the COVID-19 pandemic: a retrospective cohort study

BACKGROUND

Early management for adnexal torsion increases likelihood of ovarian/tubal salvage. The Coronavirus disease of 2019 (COVID-19) pandemic poses delays from symptom-onset to intervention. The primary objective was to evaluate rates of ovarian salvage and tubal salvage following ovarian torsion and adnexal torsion during the COVID-19 pandemic in a pediatric and adolescent gynecology population.

METHODS

This was a retrospective quality improvement cohort study of pediatric and adolescent gynecology patients at a single children's hospital who underwent laparoscopy for suspected ovarian torsion/adnexal torsion between March 2020 to March 2021. Descriptive statistics and t-tests were utilized.

RESULTS

There were 50 suspected adnexal cases in 47 patients. All underwent laparoscopy, revealing 39 adnexal torsion occurrences in 36 patients and 1 patient with recurrent adnexal torsion three times. All underwent pre-operative COVID-19 testing. Mean age was 13.9 ± 2.6 years for adnexal torsion cohort. Menarche was achieved in 88% (n = 44) and 12% (n = 6) were pre-menarchal. The primary outcome was ovarian salvage and tubal salvage rates, which were 97.4% (n = 38) and 89.7% (n = 35), respectively. Secondary outcomes assessed factors contributing to the primary outcome or operative delays. The mean age of menarche was 11.2 years (salvaged) and 12.5 years (non-salvaged) (p = 0.04). There were no differences in mean pain duration or mean COVID-19 testing time between groups. Left, right and bilateral adnexal torsion occurred in 42% (n = 21), 32% (n = 16), and 4% (n = 2) respectively. The most common pathologies were paratubal cyst (n = 17, 34%) and benign ovarian cyst (n = 16, 32%).

CONCLUSIONS

Ovarian salvage and tubal salvage rates were 97.4% and 89.7%, respectively during the time frame studied. These salvage rates during the study period are comparable to previous rates in a pre-COVID cohort at our institution. Institutional and departmental quality and safety initiatives likely contributed to this outcome.

Synchronous Bilateral Torsion of Nonpathological Ovaries in an Adolescent Girl with Unilateral Recurrence

Synchronous bilateral ovarian torsion is rare that too in nonpathological ovaries. To the best of our knowledge, this is the second case of synchronous bilateral ovarian torsion of nonpathological ovaries in adolescents. A 14-year-old girl presented with pain lower abdomen, vomiting, and constipation for the last 10 days. Ultrasonography (USG) suggested bilateral ovarian torsion without any ovarian pathology. Emergency laparoscopy confirmed bilateral ovarian torsion with necrosed-looking ovaries, and detorsion was done. During follow-up period, she had intermittent mild pain abdomen, and on USG, her left ovary returned to normal size, but her right ovary had been bulky throughout without any cyst. At around 10 months, the patient presented with severe abdomen pain. This time only right ovarian torsion was there. Laparoscopic bilateral ovarian detorsion with bilateral ovarian ligament plication was done. Ovarian torsion can be bilateral, even in nonpathological ovaries. Ovarian fixation should be done in these cases to prevent recurrent torsion.

Reproductive and Family Building Considerations for Female Patients with Anorectal And Urogenital Malformations

BACKGROUND

Little is known about fertility and pregnancy outcomes in patients with anorectal malformations (ARM), particularly those with long common channel cloaca and cloacal exstrophy who may have impaired fertility. The purpose of this study is to describe pregnancy and offspring data from a cohort of patients with ARM.

METHODS

A retrospective review of female patients with ARM from our database, which includes patients operated on since 1980, was performed as well as a review of the literature. Demographic, operative, and self-reported fertility, obstetric, and offspring data were collected.

RESULTS

There were 37 females identified in our database who reported any pregnancy or having children. There were 59 pregnancies, 48 (81.3%) of which resulted in live birth. The most common mode of delivery was cesarean delivery. There were five patients with long channel cloaca (>3 cm) and one with cloacal exstrophy that reported 11 total pregnancies, eight of which resulted in live birth. Four cloaca patients in which the native vagina was pulled through were able to conceive spontaneously. Three patients with cloacal anomalies required in vitro fertilization to conceive; one was unsuccessful. No patients who underwent bowel partial vaginal replacement became pregnant. Women with ARM face many unique challenges in assisted reproduction, pregnancy, and delivery owing to their anatomy and associated anomalies.

CONCLUSIONS

Women with recto-perineal, recto-vestibular, and cloacas in which the native vagina was pulled through are capable of spontaneous pregnancy. Assisted reproduction, however, may be needed those with more complex anomalies and surgical repairs.

LEVEL OF EVIDENCE

IV.

Preservation of ovarian tissue embedded in omentum following torsion and auto-amputation of the left ovary and fallopian tube in a 14-year-old girl: A case report

INTRODUCTION

Autoamputation of the ovary and fallopian tube is a scarce phenomenon particularly in adolescents but could adversely affect fertility by causing ovarian damage and loss of tubal function.

CASE PRESENTATION

A case of autoamputation of the left adnexa as a result of chronic torsion in the setting of an ovarian dermoid cyst in an adolescent girl is presented. The patient had also a large dermoid cyst in the contralateral ovary which was in danger of another torsion and loss of ovarian reserve and tube. Her left fallopian tube was absent and left ovary was embedded in the omentum. She was successfully managed through laparoscopic surgery. Bilateral cystectomy was performed and the ectopic ovarian tissue was saved.

CLINICAL DISCUSSION

Chronic torsion sometimes results in ectopic displacement of the affected ovary. While some patients may be asymptomatic, many of these cases express episodes of acute or chronic abdominopelvic pain. Hence, a prolonged pain or discomfort, even of low intensity, should not be overlooked particularly in younger patients with bilateral ovarian cysts.

CONCLUSION

Ovarian dermoid cysts in adolescents could possibly undergo chronic torsion resulting in autoamputation of the adnexa and ectopic displacement of the ovary. With prompt diagnosis and intervention, ovarian tissue and fertility could be preserved.

Pregnancy-Associated Ovarian Torsion - a Single-Center Case-Control Study

The etiology of OT is largely unknown. Any predisposition to rotation of the infundibulopelvic ligament and utero-ovarian ligament should be considered a possible etiology. Information with respect to ovarian torsion (OT) among pregnant is underreported and based on small studies. We aim to compare characteristics of confirmed OT to laparoscopies performed for the indication of suspected OT, in which no OT was found among pregnant women. This is a retrospective case-control study. We included pregnant women who underwent laparoscopy for a suspected OT between March 2011 and August 2020. Pregnant women with confirmed OT (torsion group) were compared to those without (no torsion group). There were 169 women with suspected OT. OT was confirmed in 140 (82.8%) women. There was higher proportion of assisted reproductive technology (ART) gestation in the torsion group [76 (54.3%) vs. 5 (17.2%), p < 0.001]. The rate of pregnant approaching evaluation within 8 h of symptoms onset was higher in the torsion group [57 (40.7%) vs. 2 (6.9%), p < 0.001]. The mean visual analogue score (VAS) was higher in the torsion group (8.5 vs. 7.1, p = 0.002). The mean pulse was lower in the torsion group (79 vs. 88 bpm, p < 0.001). From sonographic characteristics examined, the following was higher in the torsion group; mean maximal size of the ovary (70 mm in the torsion group vs. 54 mm in the no torsion group, p = 0.011). In a multivariable logistic regression analysis, number of hours of symptoms was negatively associated with AT [aOR, 95% CI 0.95 (0.91-0.98)] and pulse was negatively associated with OT [aOR, 95% CI 0.78 (0.63-0.95)]. Among the 29 cases in which no OT was found during laparoscopy, the following findings were noted: 16 (55.2%) no abnormality at all, 5 (17.2%) functional ovarian cyst, 2 (6.9%) mature teratoma and 6 cases of peritoneal adhesions (20.7%). The time from pain onset to approaching evaluation and women's pulse should be considered and acknowledged in the evaluation of OT during pregnancy.

Clinical and radiologic factors associated with adnexal torsion in premenarchal and menarchal children and adolescents

BACKGROUND

Adnexal torsion is a gynecologic emergency in children and adolescents but remains a challenging diagnosis, with no consistent clinical or radiologic diagnostic criteria. Our objective was to identify risk factors associated with adnexal torsion in premenarchal and menarchal patients with surgically confirmed torsion compared with those without torsion.

METHODS

We conducted a retrospective chart review of all patients who underwent surgery between January 2016 and December 2019 for possible adnexal torsion. Data on demographics, clinical characteristics, radiologic variables, and operative findings were compared using descriptive statistics. Independent predictors of torsion were then examined in multivariate logistic regression models.

RESULTS

Of the 291 patients who underwent surgery, 168 (57.7%) had torsion. Patients with torsion were younger than those without torsion (11.9 vs. 14.2 years, P < .01). Vomiting was significantly associated with torsion for all patients (P < .001). Large adnexal volume and absent arterial Doppler flow were associated with torsion for the total population and menarchal subgroup. A logistic regression model for the total population that controlled for age and menarchal status found that vomiting (adjusted odds ratio [aOR] 5.92, 95% confidence interval [CI] 2.87-12.22), highest adnexal volume category (aOR 4.92, 95% CI 2.25-10.75), and absent arterial Doppler flow (aOR 2.674, 95% CI 1.28-5.60) were associated with torsion.

CONCLUSIONS

Vomiting, enlarged adnexal volume, and absent arterial Doppler flow were associated with adnexal torsion. However, no single risk factor accurately diagnosed torsion, and multiple factors should be interpreted together.

LEVEL OF EVIDENCE

Study of Diagnostic Test, Level II.

Successful resection of growing teratoma syndrome in the abdominal wall with reconstruction using tensor fascia lata muscle flap: A case report and literature review

While cancer cure is the primary goal, fertility preservation is also a cornerstone of the underlying principle of treatment for ovarian germ cell tumors. Growing teratoma syndrome (GTS) presents with growth of mature teratomas during or after chemotherapy. We report a case of successful treatment of GTS in the anterior abdominal wall involving reconstruction. A 23-year-old woman with a suspected right ovarian mature teratoma with torsion underwent emergency laparoscopically assisted extracorporeal ovarian cystectomy. Histopathological findings revealed a grade 1 immature teratoma. After two months, postoperative α-fetoprotein (AFP) levels increased, and disseminated lesions developed not only in the pelvic cavity but also in the abdominal wound where the tumor had been extracted using an extracorporeal technique at the time of primary surgery. The patient underwent laparoscopic right salpingo-oophorectomy, excision of multiple peritoneal nodules, and biopsy of abdominal wall mass. The left rectus abdominis muscle tumor could not be removed. All of these nodules were diagnosed as metastatic immature teratomas. Although the patient received three cycles of chemotherapy, the residual tumor in the abdominal wall grew remarkably despite post-chemotherapy normalization of AFP levels. Both rectus abdominis muscles involving the residual tumors were removed and reconstructed using a left tensor fascia lata muscle flap. Histopathologically, the residual tumors were identified as mature teratomas with no immature elements, resulting in GTS. The patient got pregnant without the need of fertility treatment and gave birth uneventfully by cesarean section. Thus, reconstruction with a tensor fascia lata muscle flap facilitated complete removal of GTS while preserving fertility.

Laparoscopy for Ovary-Sparing Tumorectomy in Children with Ovarian Tumors: A Clinical Retrospective Analysis

Objective: The aim of this study is to analyze the characteristics of pediatric ovarian tumors (OTs) and evaluate treatment strategies for ovary-sparing tumorectomy (OST). Materials and Methods: Medical records of children from October 2011 to December 2021 were reviewed. Data regarding clinical characteristics, pathological type, and management of OST were analyzed. Results: In total, 61 patients with OTs were screened. The median age was 14.8 ± 3.0 years. The median length and volume of borderline and malignant OTs were larger than those of benign OTs (P < .001 and P = .05, respectively). There was a significant difference in the median OT volume between torsion and nontorsion OTs (P = .04). The overall OST rate was 91.8% (67/73). A total of 53.4% (39/73) lesions were treated with laparoscopic OST. The OT volume was smaller in patients who underwent laparoscopy than in those who underwent laparotomy (P = .04). The probability of intraoperative tumor rupture or spillage was higher during laparoscopy than during laparotomy (P = .02). No significant differences were observed in OT recurrence. Seven patients had borderline and malignant tumors, 3 of whom had stage IA tumors and underwent OST. None of the patients experienced relapse. Conclusions: OT size is a useful reference factor for differential diagnosis and choosing laparoscopic surgery. Intraoperative tumor rupture and spillage of benign tumors during laparoscopy and laparotomy did not seem to be associated with recurrence, and laparoscopic OST was considered safe. Further prospective studies are required to confirm these conclusions.

Diagnostic accuracy of ultrasound signs for detecting adnexal torsion: systematic review and meta-analysis

OBJECTIVE

To evaluate the diagnostic accuracy of different ultrasound signs for diagnosing adnexal torsion, using surgery as the reference standard.

METHODS

This was a systematic review and meta-analysis of studies published between January 1990 and November 2021 evaluating ovarian edema, adnexal mass, ovarian Doppler flow findings, the whirlpool sign and pelvic fluid as ultrasound signs (index tests) for detecting adnexal torsion, using surgical findings as the reference standard. The search for studies was performed in PubMed/MEDLINE, CINAHL, Scopus, The Cochrane Library, ClinicalTrials.gov and Web of Science databases. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool was used to evaluate the quality of the studies. Pooled sensitivity, specificity, and positive and negative likelihood ratios were calculated separately, and the post-test probability of adnexal torsion following a positive or negative test was also determined.

RESULTS

The search identified 1267 citations after excluding duplicates. Eighteen studies were ultimately included in the qualitative and quantitative syntheses. Eight studies (809 patients) analyzed the presence of ovarian edema, eight studies (1044 patients) analyzed the presence of an adnexal mass, 14 studies (1742 patients) analyzed ovarian Doppler flow, six studies (545 patients) analyzed the whirlpool sign and seven studies (981 patients) analyzed the presence of pelvic fluid as ultrasound signs of adnexal torsion. Overall, the quality of most studies was considered to be moderate or good. However, there was a high risk of bias in the patient-selection and index-text domains (with the exception of the whirlpool sign) in a significant proportion of studies. Pooled sensitivity, specificity, and positive and negative likelihood ratios of each ultrasound sign were 58%, 86%, 4.0 and 0.49 for ovarian edema, 69%, 46%, 1.3 and 0.67 for adnexal mass, 65%, 91%, 7.6 and 0.38 for the whirlpool sign, 53%, 95%, 11.0 and 0.49 for ovarian Doppler findings and 55%, 69%, 1.7 and 0.66 for pelvic fluid. Heterogeneity was high for all analyses.

CONCLUSIONS

The presence of an adnexal mass or pelvic fluid have poor diagnostic accuracy as ultrasound signs of adnexal torsion, while the presence of ovarian edema, the whirlpool sign and decreased or absent ovarian Doppler flow have good specificity but moderate sensitivity for detecting adnexal torsion. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Underutilization of laparoscopy for ovarian surgeries in the pediatric population: A nationwide analysis

PURPOSE

Oophorectomy and ovarian detorsion are some of the most frequent operations performed in the female pediatric population. Despite the advent of laparoscopy, many surgeons continue to utilize open surgical approaches in these patients. This study sought to compare nationwide trends and postoperative outcomes in laparoscopic and open ovarian operations in the pediatric population.

METHODS

Females less than 21 years old who underwent ovarian operations (oophorectomy, detorsion, and/or drainage) from 2016 to 2017 were identified from the Nationwide Readmissions Database. Patients were stratified by surgical approach (laparoscopic or open). Hospital characteristics and outcomes were compared using standard statistical tests.

RESULTS

There were 13,202 females (age 17 [14-20] years) who underwent open (59%) or laparoscopic (41%) ovarian operations. The most common indications for surgery were ovarian mass (48%), cyst (36%), and/or torsion (19%) for which oophorectomy (88%), detorsion (26%), and drainage (13%) were performed most frequently. The open approach was utilized more frequently for oophorectomy (95% vs. 77% laparoscopic) and detorsion (33% vs. 16% laparoscopic), both p < 0.001. A greater proportion of laparoscopic procedures were performed at large (67% vs. 61% open), teaching (82% vs. 76% open) hospitals in patients with private insurance (47% vs. 42% open), all p < 0.001. Patients undergoing open procedures had significantly higher index length of stay (LOS) and rates of wound infections. Thirty-day and overall readmission rates, as well as overall readmission costs, were higher in patients who received open surgeries.

CONCLUSIONS

Despite fewer overall complications, decreased cost, fewer readmissions, and shorter LOS, laparoscopic approaches are underutilized for pediatric ovarian procedures.

TYPE OF STUDY

Retrospective Comparative.

LEVEL OF EVIDENCE

Level III.

Added value of gadolinium-based contrast agents for magnetic resonance evaluation of adnexal torsion in girls

PURPOSE

Ultrasound is the first-line imaging modality to evaluate adnexa in girls with clinical suspicion of torsion. Patients with equivocal ultrasound findings can undergo MRI for better delineation of adnexal pathology. Here, we assess the utility of intravenous contrast in MRI evaluation of adnexal torsion in children.

METHODS

Two pediatric radiologists (R1, R2) retrospectively reviewed 198 pelvic MRI exams in 172 girls (median age 15 years). Each MRI was reviewed twice. The first review included pre-contrast images only. A second review, at least 1 month later, included both pre- and post-contrast images. Readers concluded if findings were suspicious for torsion or not. Readers' findings were compared to each other's and to surgical and MRI reports and clinical course.

RESULTS

198 MRI exams yielded 354 evaluable ovaries. Surgical and pathological reports were available for 47 patients. 11 patients had adnexal torsion. Both readers accurately diagnosed acutely torsed ovaries during pre- and post-contrast reviews (n = 4). However, readers disagreed on torsed paraovarian cysts (n = 4) and chronically/intermittently torsed ovaries (n = 3). In 21 non-torsed ovaries that had lesions, one or both readers concluded that there were pre-contrast features of torsion. In this set with ovarian lesions, contrast helped readers to correctly conclude no torsion (R1 = 8, R2 = 6) more commonly than to incorrectly conclude torsion (1 each), improving post-contrast specificity for each reader.

CONCLUSIONS

Post-contrast sequences did not provide additional benefit in evaluating acutely torsed ovaries but helped in excluding torsion in patients with adnexal lesions. Therefore, contrast administration should be individualized, potentially reserved only for those with abnormal ultrasound or pre-contrast images.

Rethinking ovary preservation by adnexal torsion reversal in adolescents: a case of delayed diagnosis

Background

This article discusses the management of an adolescent woman with a delayed diagnosis of adnexal torsion (AT) whose ovaries were successfully preserved.

Case presentation

The patient was a 14-year-old female teen admitted with the chief complaint of lower abdominal pain for 3 days and worsening pain for 2 days. Magnetic resonance imaging suggested a high possibility of torsion in the anterosuperior uterine mass and was accompanied by severe ovarian edema, bleeding, and enlargement. Intraoperatively, the left fallopian tube was characterized by thickening and torsion and appeared blackish purple. The left fallopian tube paraovarian cyst was about 20 cm in size, and the left adnexa was twisted 1080° along the left infundibulopelvic ligament (suspensory ligament of the left ovary). The left ovary appeared blackish purple, with an enlarged diameter of about 10 cm. At the request and with the informed consent of the patient’s parents, we preserved the left ovary and removed the left fallopian tube. The results of the endocrine, ultrasound, and tumor marker tests were normal 1 month after surgery. Follicles and blood flow signals seen in ultrasound examinations indirectly proved the successful preservation of the left ovary in the follow-up.

Conclusions

Our attempt to preserve the ovaries in an adolescent with a delayed diagnosis of AT was successful.

Ovarian Ligament Plication as a Treatment for Patient with Elongated Ovarian Ligament with Recurrent Abdominal Pain in the Absence of Ovarian Torsion

Elongated ovarian ligament can lead to adnexal torsion. Several cases of ovarian torsion have been reported where the ovarian ligament was elongated, and ovarian detorsion and ovarian ligament plication were done. In our case, a young girl presented with recurrent left lower abdominal pain, especially after exercise, with normal ovaries found on ultrasound. Laparoscopy was performed given recurrent pelvic pain and found elongated left ovarian ligament with normal ovaries. Considering the possibility of recurrent torsion and detorsion of the ovary due to elongated left ovarian ligament, left ovarian ligament plication was done. The patient remained pain-free till 1 year of follow-up. No such case has been reported in the literature where the ovarian ligament plication was performed without torsion. Hence, elongated ovarian ligament could cause recurrent pelvic pain due to possible torsion, and a simple, easy procedure of ovarian ligament plication can help relieve pain.

Cystic Teratoma Resection With Ovarian Preservation in a Pediatric Transgender Male: A Case Report

Ovarian teratomas are germ cell-derived tumors that are classically reported in the literature to occur in cisgender female patients. While this is statistically the most common patient population that they are diagnosed in, they can also occur in transgender men with ovaries who have not undergone a previous oophorectomy. Because of the lack of research and literature regarding this unique patient population, decisions regarding the treatment of these neoplasms are controversial. Here, we report the case of a pediatric transgender male who developed an ovarian teratoma and discuss specific considerations for treating ovarian neoplasms in the transgender population.

Pediatric and Adolescent Gynecologic Emergencies

Diagnosis of gynecologic emergencies in the pediatric and adolescent population requires a high index of suspicion to avoid delayed or incorrect diagnoses. This article aims to dispel common misunderstandings and aid with diagnosis and management of 3 common pediatric and adolescent gynecologic emergencies: adnexal torsion, vulvovaginal lacerations, and nonsexually acquired genital ulcers.

Adnexal torsion: a review of diagnosis and management strategies

PURPOSE OF REVIEW

Adnexal torsion remains a diagnostic challenge heavily reliant on high clinical suspicion, with patient presentation and imaging used as adjuncts to aid in its diagnosis. This review summarizes diagnostic and management techniques of adnexal torsion to assist providers when encountering this surgical emergency.

RECENT FINDINGS

Common findings of adnexal torsion include abdominal pain, nausea, vomiting, and adnexal mass or ovarian enlargement. An elevated neutrophil to lymphocyte ratio may be useful for diagnosis. A 'whirlpool' sign, 'follicular ring' sign, enlarged/edematous ovary, and absent Doppler flow to the ovary are highly suggestive of adnexal torsion. Intraoperative visual diagnosis of ovarian death is highly inaccurate, with only 18-20% of ovaries necrotic on pathological examination. Necrotic appearing ovaries have been shown to have follicular activity on ultrasound one year postoperatively.

SUMMARY

Pelvic ultrasound remains the first-line imaging modality. In patients of reproductive age, we recommend performing detorsion with ovarian conservation, even in cases where the tissue appears necrotic, given poor intraoperative diagnostic rates of tissue death. Retention of ovarian function is also reliant on a timely diagnosis and intervention. We emphasize that the risk of ovarian damage/loss outweigh the risk of a diagnostic laparoscopy in patients of reproductive age.

Postoperative Ovarian Morphology on Ultrasound after Ovarian Torsion-Effect of Immediate Surgery: A Retrospective Cohort Study

STUDY OBJECTIVE

Our objective was to determine if ovarian surgery at the time of ovarian detorsion is associated with impaired short-term ovarian function as indicated by ovarian morphology on ultrasound when compared with detorsion alone.

DESIGN

Retrospective cohort study SETTING: The Hospital for Sick Children, Toronto PARTICIPANTS: Patients ≤ 18 years old with confirmed ovarian torsion from January 1, 2004, to December 31, 2018, with ovarian-sparing surgery.

MAIN OUTCOME MEASURES

Data were collected on demographics, procedure, intraoperative findings, and postoperative ultrasound. To determine ovarian function, we compared the morphology on the postoperative ultrasound between those with surgery to the ovary and those without surgery to the ovary at the time of detorsion. We also compared the ovarian volume of affected and contralateral ovaries after detorsion and surgery to the affected ovary.

RESULTS

One hundred and nineteen patients met the inclusion criteria, of whom 67 (56%) had detorsion with surgery to the ovary and 52 (44%) had detorsion alone. There was no statistically significant difference in appearance on the postoperative ultrasound between these groups (P =.446). There was also no statistically significant difference on the postoperative ultrasound of affected and contralateral ovarian volumes after detorsion and surgery to the affected ovary (P = .69). Patients who underwent surgery to the ovary experienced a lower rate of recurrence; however, this did not reach statistical significance, with a P value of 0.080.

CONCLUSION

Our study demonstrates that surgery, eg cystectomy to the ovary at the time of ovarian detorsion, does not appear to impact ovarian function when compared with detorsion alone, as indicated on postoperative imaging. There was also no difference in volume of the affected and contralateral ovaries in those cases that underwent surgery at the time of initial detorsion. This evidence would support that immediate cystectomy at the time of initial ovarian detorsion is not associated with impaired ovarian function, thus avoiding the need for an interval cystectomy.

Is color Doppler ultrasonography reliable in diagnosing adnexal torsion? A large cohort analysis

INTRODUCTION

Color Doppler ultrasonography (CDU) is widely used to diagnose adnexal torsion (AT). However, its validity remains questionable due to its low sensitivity. Our study aimed to evaluate the accuracy of CDU for the preoperative diagnosis of AT.

MATERIAL AND METHODS

The electronic medical records of patients who were taken to the operating room with the diagnosis of suspected AT were reviewed. Patients having surgically/pathologically-proven AT were compared with patients who were found to have a different pathology at the time of surgery. CDU validity was assessed using a 2 × 2 table and compared with a diagnostic model that consists of the Doppler findings, patient's age, and previous surgical history.

RESULTS

AT was diagnosed correctly in 74.6% of cases. Absent Doppler flow was seen in only 18.6% of cases. Although its specificity and positive predictive value were high, CDU had very low sensitivity and negative predictive value. The combined diagnostic model exceeded CDU alone in terms of diagnostic accuracy.

CONCLUSIONS

The use of CDU alone is not a reliable modality to exclude AT. Absent Doppler flow is a sign of ovarian necrosis. Clinical correlation between CDU findings and the patient's symptoms makes the diagnosis of AT more timely and accurate.

A clinical prediction model for adnexal torsion in pediatric and adolescent population

PURPOSE

To describe the clinical characteristics of children and adolescents that underwent diagnostic laparoscopy for suspected adnexal torsion (AT), and to develop a prediction model for preoperative detection of AT among young women.

METHODS

A retrospective cohort study. We included all girls ≤18 years old with clinically suspected AT who underwent a diagnostic laparoscopy between 3/2011 and 6/2020. We compared patients with AT to those without AT and constructed a prediction model.

RESULTS

Overall, 120 children and adolescents with suspected AT were included in the study. Of those, AT was identified in 83 (69.2%). In a multivariate analysis, the following risk factors were independently associated with AT and included in the prediction model: absence of right lower quadrant tenderness upon examination [adjusted odds ratio (aOR) (95% Confidence interval (CI)) 3.23 (1.23-8.47), p = 0.017], platelets level >240 K [aOR (95% CI) 3.15 (1.19-8.36), p = 0.021], and neutrophils level >5.4 [aOR (95% CI) 2.71 (1.02-7.52), p = 0.046]. The rate of AT was 12.5% in cases without risk factors for AT, 56.7% with one, 68.8% with two, and 94.1% with three risk factors present, respectively.

CONCLUSIONS

We have identified preoperative indicators independently associated with surgically confirmed AT in a large cohort of young women. Level of evidence- III.

Ovarian Torsion: Presentation and Management in a Pediatric Patient

Background. Adnexal torsion is the fifth most common gynecologic emergency accounting for approximately 20 to 30% of ovarian surgeries in pediatric patients. Case. The patient is a ten-year-old female who presented to the emergency room for severe left lower quadrant abdominal pain. On presentation, she was hemodynamically stable with an acute abdomen. A transabdominal ultrasound showed a predominantly anechoic structure measuring up to 5.6 cm without definitive Doppler flow, concerning for a large cyst causing ovarian torsion. Gynecology was consulted, and the patient underwent a diagnostic laparoscopy, aspiration of the left ovarian cyst, and left ovarian detorsion. Pathology results were consistent with benign cystic contents. Conclusion. Appropriate diagnosis and timely surgical gynecological intervention allowed this pediatric patient to salvage and preserve ovarian function.

Adnexal Torsion Predictive Tool Maintains Applicability in a Heterogeneous Pediatric Population

STUDY OBJECTIVE

A previously published scoring system showed promise in identifying adnexal torsion in adolescents. However, published patients were homogeneously Caucasian/White. We sought to assess whether this scoring system was generalizable to a more diverse population that is predominantly African American and overweight.

DESIGN

Retrospective chart review.

SETTING

Tertiary academic hospital.

PARTICIPANTS

Female patients 0-21 years of age undergoing surgery for suspected ovarian torsion from 2010 to 2019.

INTERVENTIONS

Records were reviewed for patients, including laboratory studies, imaging, surgery, and pathology. Significance was determined for clinical and imaging findings, and retrospective composite scores were calculated for each participant as suggested by the scoring system.

MAIN OUTCOME MEASURES

Determination of whether the previously published composite score was predictive of pediatric adnexal torsion in our population.

RESULTS

A total of 57 cases of suspected torsion were included. Approximately 60% of patients were African American, 10% Hispanic, and 30% Caucasian/White. The average body mass index (BMI) across ethnicities was 29. Our findings significantly correlated with previously published predictors for all components. The presence of nausea/vomiting, leukocytosis, ovarian volume and ratio were found to be significant. The post hoc calculated composite score was applied to our cohort, and more than 90% of confirmed torsion would have been identified.

CONCLUSION

Our study suggests that a previously published composite score assessing torsion can successfully be used to predict torsion in a more diverse setting than the original study population, potentially accelerating surgical management of patients with the condition.

Pediatric and adolescent gynecology through a global lens

Girls and adolescents, aged 0-19 years make up almost 30% of the world's female population yet their specific healthcare needs often slip between the gaps of pediatrics and adult women's health. Pediatric and adolescent gynecology is the clinical field that endeavors to address the reproductive health needs of this age group. The environment and psychosocial well-being, social determinants of health, have direct bearing on reproductive health, affecting menstrual cycles, menstrual hygiene, and risks for unintended pregnancy and sexually transmitted infections. This narrative review will highlight common gynecologic conditions of adolescents, especially where diagnosis and management are distinct from adult women. It will also present preventive health strategies to improve reproductive health through vaccination, improved access to hygiene supplies and contraception.

Prediction score for recurrent adnexal torsion in women with a previous adnexal torsion

OBJECTIVE

To develop a risk score for preoperative prediction of recurrent adnexal torsion (rAT) among women with a history of previous adnexal torsion (AT).

METHODS

A retrospective cohort study. We included women with a history of AT, presenting with suspected rAT who underwent diagnostic laparoscopy between March 2011 and March 2020. We compared women with rAT to those without. We constructed a prediction score and validated it in a prospectively collected cohort between April 2020 and June 2020.

RESULTS

One hundred and fifteen women composed the study cohort. Recurrent AT was confirmed laparoscopically in 86 (74.8%) cases. A risk score for rAT was developed, based on three associated factors: enlarged ovary, no previous oophoropexy and current IVF treatment. In the construction cohort, the rate of torsion was 44.4%, 67.9%, 82.9% and 100% if none, one, two, or three risk factors were present, respectively. In the prospective validation of the risk score, the prediction of one and two risk factors was 60.0% and 100% respectively.

CONCLUSION

Enlarged ovary is independently associated with preoperative rAT diagnosis. Coupled with information regarding the previous surgical approach in previous AT and current IVF use, these factors could be used to efficiently predict rAT among women with a previous AT.

The effect of folate on ischemia/reperfusion injury in a rat adnexal torsion model

PURPOSE

The ischemia/reperfusion (I/R) injury of ovaries in adnexal torsion may have inadvertent consequences. Many agents have been studied in terms of their ability to prevent reperfusion damage to ovaries in suspected cases. In this study, folic acid, known to have antioxidative properties, was investigated to determine whether it played a role in the prevention of I/R damage in a rat ovarian torsion model.

METHODS

In this experimental study, 40 female adult Wistar-Albino rats were randomly divided into five groups as control, ischemia, I/R, Fol2 (2 mg/kg folic acid), and Fol4 (4 mg/kg folic acid). In the Fol2 and Fol4 groups, folic acid was intraperitonelly administered 30 min before reperfusion. Blood samples were obtained from the tails of each rat at the second hour of reperfusion.

RESULTS

The total oxidant status (TOS), total antioxidant status, cystatin C and folic acid levels of the five groups were investigated. Folic acid in 2 mg/kg dose could moderately increase the serum folic acid concentration (15.75-19.95 ng/ml, p < 0.05), reduce the level of cystatin C (0.18-0.12 μg/L, p < 0.05), and had a tendency to improve the oxidative stress injury (OSI: 76.05-33.06, p > 0.05), although there was no statistical difference in TOS levels (p = 0.07). Folic acid in 4 mg/kg dose, could significantly increase the serum folic acid concentration (15.75-37.65 ng/ml). However, it did not significantly reduce the level of cystatin C (0.18-0.19 μg/L, p > 0.05), and did not improve oxidative stress injury (76.05-130.58, p > 0.05).

CONCLUSION

Folic acid in 2 mg/kg dose might improve the ovarian I/R injury though this was not statistically significant. Further studies are required to reach a definitive conclusion about the protective effect of folic acid in I/R injury.

Variations in the management of adolescent adnexal torsion at a single institution and the creation of a unified care pathway

PURPOSE

Adnexal torsion is a gynecologic emergency, requiring intervention for tissue preservation. At our institution, torsion is managed by pediatric surgeons or gynecologists. We evaluated differences between specialties to streamline evaluation for children with gynecological emergencies, develop a clinical pathway, and prevent care delays.

METHODS

A retrospective review of adolescents undergoing intervention for adnexal torsion from 2004-2018 was performed. Differences in time to intervention, operation duration, the procedure performed, and length of stay (LOS) between the specialties were analyzed.

RESULTS

Eighty-six patients underwent 94 operations for presumed adnexal torsion with 87 positive cases. Pediatric surgeons performed 60 operations and 34 cases were performed by gynecologists. Preservation of fertility was the goal in both cohorts and the rate of oophoropexy, cystectomy, and oophorectomy were similar between the cohorts (p = 0.14, p = 1.0, p = 0.39, respectively). There was no difference in intra-operative time (p = 0.69). LOS was shorter in the gynecology cohort (median 1 day [1-2] vs. 2 days [2-3], p > 0.001).

CONCLUSIONS

Adnexal torsion is a time-sensitive diagnosis requiring prompt intervention for ovarian or fallopian tube preservation. A multidisciplinary institutional care pathway should be developed and implemented.