Adnexal torsion in adolescents: update and review of the literature

A case of torsioned giant mucinous cystadenoma mimicking mesenteric cyst

Ovarian mucinous cystadenomas are cystic neoplasms lined by mucin-producing epithelial cells. They account for ~15%-20% of ovarian tumors, and in 80% of the cases, they are benign. Intra-abdominal mucinous cystic neoplasms commonly arise from the ovaries but can rarely arise from the mesentery. Here, we report a case of a 49-year-old para II mother who presented with a complaint of progressive abdominal swelling and discomfort of 6 months duration. She had an ill-defined mass around the peri-umbilical and lower abdominal area. Abdominopelvic ultrasound suggested a mesenteric cyst, while computed tomography showed a large, thick-walled cystic lesion of ovarian origin. Determining the tissue of origin of a giant cyst that involves both the mesentery and adnexa is difficult. Torsion of a massive ovarian cyst is a rare gynecologic emergency that involves both diagnostic and management challenges. No matter the diagnostic dilemmas, surgery is the mainstay of treatment.

Protective Effect of Ramipril Against Oxidant and Proinflammatory Cytokine Damage Induced by Ischemia-Reperfusion in Ovarian Tissue in Rats

BACKGROUND

It is known that the increase in oxidants and proinflammatory cytokines, as well as the decrease in antioxidants, play a role in ovarian ischemia-reperfusion (I/R) injury. The antioxidant and anti-inflammatory properties of ramipril have been studied in various diseases. This study aims to investigate the effect of ramipril on I/R-induced ovarian damage in rats.

METHODS

Rats were divided into healthy (HG), sham (SG), ovary I/R (OIR), and ramipril + ovary I/R (ROIR) groups (n = 6/each group). One hour before the surgical procedures, ROIR was given 2 mg/kg ramipril. The lower abdomen of the SG, OIR, and ROIR was surgically opened. Right ovarian tissues of OIR and ROIR were subjected to 2 hours of ischemia and 6 hours of reperfusion. Then, all animals were euthanized, and their right ovaries were removed. Ovarian tissues were examined for oxidants (malondialdehyde), antioxidants (total glutathione, superoxide dismutase, and catalase), and proinflammatory cytokines (nuclear factor kappa-B, tumor necrosis factor-alpha, interleukin 1 beta, and interleukin-6) analysis was performed. Tissues were examined histopathologically.

RESULTS

The ovarian tissue of the OIR, which underwent the I/R procedure, exhibited a significant increase in oxidant and proinflammatory cytokine levels, along with a decrease in antioxidant levels (P < .001). Ramipril suppressed the I/R-induced increase in oxidants and pro-inflammatory cytokines and the decrease in antioxidants (P < .001). Ramipril also attenuated I/R-induced histopathological damage in ovarian tissue (P < .05).

CONCLUSION

Ramipril treatment may be a treatment strategy to protect ovarian tissue against oxidative and inflammatory damage of I/R.

Ovarian Teratomas in Children and Adolescents: Our Own Experience and Review of Literature

Background: Ovarian teratomas are the most common type of ovarian mass during childhood and adolescence. There is no clear guidance for the management of the ovarian teratomas in children and adolescents. It is necessary, however, to understand the feature of these tumours and the indications for operating on them, and to put subjective criteria for the management in elective or emergency presentations. Methods: Medical records of patients between the age of 12 and 20 years old that underwent surgery for ovarian teratomas at the Department of Obstetrics and Gynaecology in University Hospital of Ioannina, between January 2000 and August 2022, were reviewed. A medical database was searched between January 2000 and August 2022 with the following keywords: ovarian teratoma, paediatrics and adolescents. Results: We present the results of forty patients, with a mean age of 11.8 years of age. All patients had surgery, where three out of four underwent oophorectomy and only one out of four underwent ovary-sparing operation; similar results were found in the literature. Conclusion: Ovary-sparing treatment is more common recently compared with the past, such as MIS compared with laparotomy. Better-organised and -planned prospective multi-centre studies are necessary to gain a deeper knowledge of the physiology and prognostic factors of teratomas in children.

Ovarian torsion in the pediatric population: predictive factors for ovarian-sparing surgery-an international retrospective multicenter study and a systematic review

STUDY OBJECTIVE

Ovarian torsion (OT) in pediatric age is a challenging condition to diagnose and treat. To date, there is still no clear consensus about its management. Our aim was to assess some possible associated factors that can help surgeons in decision-making.

DESIGN

We conducted a retrospective multicentric study of pediatric OT surgically treated between 2010 and 2020 in six Italian and German institutions, comparing our findings with a literature review of the last 10 years (2010-2020).

PARTICIPANTS

Patients aged 0-18 years with a diagnosis of OT intraoperatively confirmed and surgically treated at the involved institutions.

RESULTS

Ninety-seven patients with a mean age at diagnosis of 8.37 years were enrolled in the study. Severe abdominal pain was present in 82 patients (84.5%). Eighty children (82.5%) presented an enlarged ovary with an US diameter > 5 cm and only 32 (40%) of them underwent conservative surgery. A laparoscopic approach was performed in 60 cases (61.9%) although in 15 (15.5%) conversion to open surgery was deemed necessary. A functional cyst was present in 49 patients (50.5%) while 11 children (11.3%) suffered from OT on a normal ovary.

CONCLUSIONS

Our results showed that a post-menarchal age (p = .001), a pre-operative US ovarian size < 5 cm, (p = .001), the presence of severe abdominal pain (p = .002), a laparoscopic approach (p < .001), and the presence of a functional cyst (p = .002) were significantly associated with conservative surgery.

Appearances Are Deceptive: Two Case Reports in Teenagers on the Conservative Laparoscopic Surgery for Adnexal Torsion with Apparent Infarction

Introduction. Torsion of the ovary, tube, or both is estimated to be responsible for 2-7% of all gynaecological emergencies. Oophorectomy is commonly performed for adnexal torsion with a possible negative impact on fertility in women of reproductive age. Case Presentations. We report two cases of teenage girls presented with adnexal torsion describing their laparoscopy features. Detorsion without additional surgical intervention could save their ovaries. Discussion. Detorsion is a more conservative surgical approach that should be considered in all younger women with ovarian torsion.

High risk and low prevalence diseases: Ovarian torsion

INTRODUCTION

Ovarian torsion is a rare, frequently misdiagnosed condition that carries with it a high rate of morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of ovarian torsion, including presentation, evaluation, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Ovarian torsion is one of the most common gynecological surgical emergencies and occurs with complete or partial rotation of the ovary along the supporting ligaments, obstructing vascular flow. Several risk factors include the presence of an ovarian mass or cyst. The most common population affected includes reproductive aged women, though cases also occur in premenarchal females, pregnant women, and postmenopausal women. Abdominal or pelvic pain is common but is not always sudden in onset or severe. Nausea and vomiting occur in 70%. Ultrasound can assist with diagnosis, but a normal ultrasound examination cannot exclude the diagnosis. Computed tomography with intravenous contrast can assist with diagnosis. Treatment includes emergent gynecologic consultation for surgical detorsion, along with symptomatic therapy in the ED.

CONCLUSIONS

An understanding of ovarian torsion can assist emergency clinicians in diagnosing and managing this disease.

A validated predictive model for adnexal torsion pre-operative diagnosis

PURPOSE

To develop a simple predictive model for pre-operative diagnosis of adnexal torsion (AT).

METHODS

A retrospective cohort study with a retrospective validation, including 669 separate episodes of women who underwent laparoscopy due to a suspected AT between January 2011 and June 2020. We compared the pre-operative characteristics between women with surgically confirmed AT and those without.

RESULTS

The derivation cohort included 615 episodes of suspected AT. AT was surgically confirmed in 445 episodes (72%). The retrospectively collected validation cohort included 54 episodes, with 31 (57.4%) surgically confirmed AT. In a multivariate regression analysis, vomiting, neutrophils to lymphocytes ratio > 3.5 and sonographic finding of enlarged ovary were independently associated with AT [OR 95% CI 2.78 (1.21-6.36), 3.15 (1.42-6.97) and 2.80 (1.33-5.88), respectively]. In the derivation cohort, the PPV for AT diagnosis was 69.7%, 84.5% and 93.1% if 1, 2 and 3 risk factors were present, respectively. Retrospective validation analysis underlined a PPV of 67.6%, 82.6 and 66.6% for 1, 2 and 3 risk factors, respectively.

CONCLUSION

We have developed and validated a simple predictive model for pre-operative diagnosis of AT, based on three parameters. Our model may assist clinicians while evaluating patients with suspected AT and improve pre-operative diagnosis.

Surgical management of ovarian teratomas in childhood: a multicentric study on 110 cases and a literature review

AIM OF THE STUDY

To compare a multicentric surgical experience on ovarian teratomas in childhood with the current management trends.

DESIGN

A retrospective multicentric pediatric ovarian teratomas surgically treated between January 2000 and August 2020 at four Italian institutions. PubMed database was used to search for Reviews and Systematic Reviews published between January 2010 and August 2020: 15 manuscripts reported 3633 ovarian neoplasms in pediatric age, 1219 (33,5%) of which were ovarian teratomas.

RESULTS

A hundred-ten patients with a mean age at diagnosis of 11.8 years were enrolled. Mature cystic teratomas accounted for the 90% of the masses. At surgery, 78 were oophorectomies and 32 were ovary sparing surgeries. Laparoscopy occurred in 16.3% of the surgeries.As regarding the current management trends, the mean age at diagnosis was 11.9 years and 80.5% of the cases were represented by mature teratomas. Of 430 procedures, 331 were oophorectomies while 99 were ovary sparing surgeries and laparoscopy was performed in 23.8% of cases.

CONCLUSIONS

Ovary-sparing surgery with laparoscopic approach is increasingly offered as standard treatment for benign masses that fit the criteria for mature teratomas, in the attempt to achieve the best compromise between the preservation of fertility and the prevention of recurrences. Awareness should be raised among pediatric surgeons to reduce unnecessary radical surgery.

Diagnostic dilemma of isolated fallopian tube torsion

Paratubal cysts are fluid-filled sacs that grow adjacent to the fallopian tube which can rarely result in torsion. Isolated fallopian tube torsion (IFTT) is a gynaecological emergency that warrants urgent laparoscopic detorsion to salvage the affected tube. IFTT has a proclivity to affect adolescents between the ages of 12 and 15 years and is rarely seen in premenarchal or perimenopausal women. Due to a lack of pathognomonical features, IFTT is difficult to diagnose. Adnexal torsion, including IFTT is a surgical diagnosis and no clinical or imaging criteria is sufficient to diagnose IFTT. Urgent laparoscopy and detorsion are required for preservation of the affected fallopian tube. However, given the diagnostic ambiguity, IFTT diagnosis is often delayed. IFTT should be included in the differential diagnoses for adolescent patients with acute abdomen when imaging demonstrates a normal appendix and ovaries. We report a 15-year-old girl with a 4-day history of abdominopelvic pain and bilateral paratubal cysts resulting in right IFTT.

Can contrast enhanced ultrasound (CEUS) be useful in the diagnosis of ovarian torsion in pediatric females? A preliminary monocentric experience

PURPOSE

To describe contrast enhanced ultrasound (CEUS) characteristics of ovarian torsion in pediatric females, assessing the potential diagnostic advantages of method as well as its limitations.

MATERIALS AND METHODS

A retrospective study design was used. Between January 2018 and December 2020 we analyzed all pediatric females who underwent explorative surgery with a suspected diagnosis of ovarian torsion, and who were previously evaluated by conventional ultrasound (US), color-Doppler ultrasound (CDUS) and CEUS.

RESULTS

We examined twenty pediatric females with a median age of 12 years. US identified 9/20 ovarian complex masses against 13/20 by CEUS. At US abdominal free fluid was shown in 13/20 patients and in 18/20 cases with CEUS. In our case series the evaluation of contrast enhancement at CEUS in the detection of ovarian torsions revealed a sensitivity of 94.1%, a specificity of 100% and an overall accuracy of 95%.

CONCLUSION

Although there is a known ultrasound semeiotics suggestive of ovarian torsion, it is not always possible to obtain a diagnosis of certainty with conventional US even with CDUS. The study reports that complementation with CEUS showed excellent agreement with surgery obtaining a diagnosis in almost all the pediatric females examined.

Isolated Tubal Torsion: A Rare Cause of Acute Pelvic/Abdominal Pain among Adolescent Females

Tubal torsion usually occurs as a part of adnexal torsion that affects an ovary and the adjacent tube; however, isolated tubal torsion is an extremely rare condition. Usually, it presents as acute pelvic/abdominal pain but could also exhibit milder intermittent pain alternating with periods of relief (subacute). This condition has seldom been diagnosed preoperative and commonly results in tubal damage due to delayed management. We hereby, report the findings of two cases managed recently at our center. In both cases, the diagnosis was delayed 2–3 days and was only made intraoperative when the tubes could not be salvaged due to extensive necrosis. The extent of tubal damage is predominantly dependent on the duration of vascular insult; hence, the urgency for affecting early diagnosis and intervention to restore blood supply and preserve tubal integrity and function. We advocate the liberal and early use of laparoscopy in patients presenting with subacute unexplained pelvic/abdominal pain.

Ozone therapy: a potential therapeutic adjunct for improving female reproductive health

Ozone is emerging as a new adjunct therapeutic agent for female infertility. We here present a review of the literature, to date, pertaining to the effect of ozone therapy on tubal, ovarian, endometrial, and vaginal factors that could potentially affect female fertility. It also presents data pertaining to the relationship of ozone therapy on pelvic adhesion formation. Most data were performed on animals and very few human studies existed in the literature. Results suggested that ozone therapy could have beneficial effect on tubal occlusion, could protect from endometritis and vaginitis, might protect ovaries from ischemia and oocyte loss and finally might lead to less formation of pelvic adhesions. There is a critical need for human studies pertaining to ozone therapy, especially using safe methods of administration, such as transdermally or intravaginally, on female fertility.

Surgically treated ovarian lesions in preadolescent girls

INTRODUCTION

The purpose of this study was to investigate the epidemiology and characteristics of surgically treated ovarian lesions in preadolescent girls.

MATERIAL AND METHODS

This was a retrospective cohort study including all 0- to 11-year-old girls operated at a single center from 1999 to 2016 for ovarian cysts, neoplasms or torsions. Patient charts were reviewed for symptoms, preoperative radiological imaging, operative details and histopathology.

RESULTS

We identified 78 girls, resulting in a population-based incidence of 4.2/100 000. Infants (n = 44) presented with benign cysts (42/44, 95%, one bilateral), a benign neoplasm (1/44, 2%) and a torsion without other pathology (1/44, 2%). Torsion was found in 25/29 (86%) ovaries with complex cysts and in 3/15 (21%) ovaries with simple cysts in preoperative imaging (P < 0.001). Most infants were symptomless. Lesions in 1- to 11-year-old girls (n = 34) included benign neoplasms (n = 21/34, 62%), malignant neoplasms (n = 5/34, 15%), a cyst with torsion (n = 1/34, 3%) and torsions without other pathology (n = 7/34, 21%). Torsion was more common in benign (17/21, 81%) than in malignant neoplasms (1/5, 20%) (P < 0.020). Ovarian diameter did not differ between ovaries with or without torsion (P = 0.238) or between benign and malignant neoplasms (P = 0.293). The duration of symptoms in lesions with or without torsion was similar.

CONCLUSIONS

The majority of surgically treated ovarian lesions in preadolescent are benign lesions with torsion. Surgery should be ovary-preserving and performed without delay.

Ischemia modified albumin in experimental ovarian torsion with and without controlled reperfusion

Purpose: Ovarian torsion, being a gynecological emergency, requires to be rapidly diagnosed and treated with minimal consequences on ovarian function after the removal of torsion. As ischemia modified albumin (IMA) is considered a good biomarker in diverse ischemic diseases, the aim of our study was to determine the effect of different ovarian torsion/detorsion models on serum and ovarian homogenates levels of IMA in an experimental study.

Methods: IMA was measured in the serum and ovarian homogenates of 7 groups of female rats (10 animals in each group): 1 - control (no intervention); 2 - sham (only laparotomy); 3 - ischemia group: 3 hours ovarian torsion (OT); 4 - 3 hours OT (ischemia), 1 hour simple reperfusion; 5 - 3 hours ischemia, 1 hour controlled reperfusion that was assured during the first two minutes by opening and closing the clips on the ovarian pedicles in 10 seconds intervals, followed by simple reperfusion; 6 - 3 hours ischemia, 24 hours simple reperfusion; 7 - 3 hours OT, 24 hours controlled reperfusion. The results were analyzed by Welch’s ANOVA and Spearman correlation.

Results: Ischemia increases the IMA in both serum and ovarian homogenates compared to control and sham groups. The controlled reperfusion groups had a statistically significant lower IMA in serum compared to simple reperfusion groups. IMA was found to be higher in the ovarian homogenates of simple reperfusion compared to controlled reperfusion groups.

Conclusion: Our results suggest that controlled reperfusion prevent the processes that increase the IMA in ovarian torsion.

Adnexal Torsion

Adnexal torsion is an uncommon gynecologic disorder caused by the partial or complete rotation of the ovary and/or the fallopian tube on its vascular support. Delay in treatment can impact fertility adversely. The objective of this report is to provide clinical recommendations based on the latest evidence. Specifically we discuss epidemiology, clinical presentation, diagnostic approach and management of adnexal torsion in adolescents.

Ovarian masses in pediatric patients: a multicenter study of 98 surgical cases in Tunisia

Ovarian masses requiring surgical intervention are uncommon in the pediatric population. Our aim is to report results of a multicentric Tunisian study concerning the clinical practice and the management of pediatric ovarian masses and to identify the factors that are associated with ovarian preservation. Between January 2000 and December 2015, 98 pediatric patients (<14 years) were surgically treated for ovarian masses at the five pediatric surgery departments in Tunisia. Ninety-eight patients were included in this study. The mean age of the patients at time of surgery was 8.46 ± 4.87 years. Sixty-three ovarian masses (64.3%) were non-neoplastic lesions, 24 (24.5%) were benign tumors, and 11 (11.2%) were malignant neoplasms. Conservative surgery (ovarian-preserving surgery) was successfully performed in 72.4% of the benign lesions, whereas only three patients (27.3%) with malignant tumors underwent ovary-sparing tumor resection (p < .001). The mean diameter of the tumors in the patients who underwent oophorectomy was significantly larger than that in the patients who underwent conservative surgery (7.8 ± 3.9 cm vs. 5.7 ± 2.9 cm, respectively, p = .001). In our study, the risk factors for oophorectomy were a malignant pathology and large tumor size. In accordance with the Gynecologic Cancer Intergroup consensus, we recommend that surgical management of ovarian masses in children should be based on ovarian-preserving surgery.

Developmental Programming of Ovarian Functions and Dysfunctions

The pathophysiological mechanisms underlying the origin of several ovarian pathologies remain unclear. In addition to the genetic basis, developmental insults are gaining attention as a basis for the origin of these pathologies. Such early insults include maternal over or under nutrition, stress, and exposure to environmental chemicals. This chapter reviews the development and physiological function of the ovary, the known ovarian pathologies, the developmental check points of ovarian differentiation impacted by developmental insults, the role played by steroidal and metabolic factors as mediaries, the epigenetic mechanisms via which these mediaries induce their effects, and the knowledge gaps for targeting future studies to ultimately aid in the development of improved treatments.

Update on the surgical management of ovarian neoplasms in children and adolescents: analysis on 32 cases

This study analyzes updated clinical, diagnostic, and surgical directions for the treatment of ovarian neoplasms in children and adolescents, comparing them with a retrospective analysis of 32 cases treated in two Pediatric Surgery University Institutions. From January 2005 to December 2015, 32 pediatric patients were surgically treated for 32 ovarian tumors: 28 (87.5%) benign and 4 (12.5%) malignant neoplastic lesions. Median age at surgery was 11.2 years (12.8 years in patients with benign neoplasms, 7.25 years in patients with malignant ones). All patients with malignant and 25% of patients with benign ovarian lesions had elevated serum level of tumors markers. The surgical approach was laparotomic in 62.5% and laparoscopic in 37.5%; 81.2% surgeries were performed in elective surgery and 18.8% in emergency. Intraoperative frozen section analysis was performed in 18.75% of patients. The most frequent surgery (96.8%) was unilateral oophorectomy. After a median follow-up of 76 months (range 6-132 months), 31/32 patients are alive and disease-free. In case of malignant tumors, fertility-sparing surgery with accurate staging must be performed. Laparoscopic multiport is the gold standard approach for benign pediatric ovarian neoplasms, but the use of laparoscopy in full respect of oncological principles also for early stage malignant tumors is currently increased.