Asynchronous ovarian torsion--the case for prophylactic oophoropexy

How can the risk of ovarian retorsion be reduced?

BACKGROUND

In the current treatment of idiopathic ovarian torsion, the use of oophorectomy has declined in favor of preserving the ovary. This approach brings with it the question of how to reduce the possibility of retorsion of the detorsioned ovary. The aim of this study was to analyze how retorsion can be prevented.

METHODS

Five patients (a 30-day-old Caucasian girl, a 55-day-old Caucasian girl, an 8-year-old Caucasian girl, a 10-year-old Caucasian girl, and a 16-year-old Caucasian girl) who underwent surgery due to non-neoplastic ovarian torsion were retrospectively analyzed for diagnosis and treatment in terms of reducing the possibility of retorsion.

RESULTS

In all patients, a precise diagnosis of idiopathic unilateral ovarian torsion was made during laparotomy, and the patients underwent different procedures. The ovary was found to be autoamputated in one patient, and two patients underwent salpingo-oophorectomies due to adnexal necrosis. The ovaries were detorsioned in the remaining two patients. During the operations, patients were evaluated regarding the prevention of retorsion of the ipsilateral and/or contralateral ovary; cyst drainage, cystectomy, ligament fixation, and/or oophoropexy were performed. The median follow-up period of the patients was 2 years (range 1.5-6 years), and they continue to be followed uneventfully.

CONCLUSIONS

To date, there is no standard approach to protect the ovary from retorsion in patients who undergo surgery due to torsion. The surgical procedure should be tailored on a case-by-case basis.

Asynchronous Bilateral Ovarian Torsion: Three Cases, Three Lessons

Background

Ovarian torsion (OT) is a serious condition, and delay in surgical intervention may result in loss of the ovary. Children and adolescents who have suffered from ovarian torsion may be at risk for asynchronous torsion of the contralateral ovary.

Study objective

Three cases of asynchronous bilateral ovarian torsion were reported to analyse clinical history of three patients, to review the current literature, and to draw a conclusion for future treatment.

Design

Case reports and review of the literature.

Result

When a prepubertal girl presents with an ovarian torsion, several considerations have to be taken in account in order to preserve her future fertility; in particular, the pediatric surgeon/gynecologist has to preserve as much as possible the twisted ovary in addition to considering the fate of the contralateral ovary.

Summary and Conclusions

Pelvic pain in a young girl has always raised the clinical suspect of an ovarian torsion; the possibility of asynchronous bilateral ovarian torsion is rare, but it is described in the literature and has catastrophic consequences; this condition has to be known and treated in the proper way by pediatric surgeons as well as by gynecologists in order to maximize the future fertility of the young patients.

Oophoropexy for ovarian torsion: a new easier technique

Background

Oophoropexy for ovarian torsion is easy to be done by many tools either suturing to the lateral pelvic wall, plication of the ovarian ligament or even fixation to the back of the uterus, but it is little bit difficult to do it for pregnant women with less manipulation.

Objective

We propose that using trocar site closure needle can be easier and faster technique to do this. To assess the feasibility of using the trocar site closure needle to do oophoropexy in ovarian torsion and its possible applicability.

Patients

Seven patients presented with ovarian torsion; four of them were pregnant at 7, 15, 19 and 20 weeks of gestation, two patients with ovarian hyperstimulation in IVF cycles and one adolescent patient with hemorrhagic cyst. They were diagnosed by clinical presentation and ultrasound with Doppler analysis, and confirmed by laparoscopy where they underwent detorsion and fixation of the ovary using the trocar site closure needle.

Results

Follow up of all the cases after one week showed improvement of the symptoms and normal Doppler flow of the target ovary then after three weeks by ultrasonography which revealed normal Doppler flow in the previously torsioned ovary. Two pregnant women underwent cesarean delivery where the operated ovary was observed during the delivery and was normal in shape and freely mobile with no adhesions.

Conclusion

We propose that this technique is easier, faster and more comfortable especially in ovarian torsion in pregnant women and torsion in hyperstimulated ovaries.

Electronic supplementary material

The online version of this article (doi:10.1186/s10397-017-1001-9) contains supplementary material, which is available to authorized users.

A review of ovary torsion

Ovarian torsion is a rare but emergency condition in women. Early diagnosis is necessary to preserve the function of the ovaries and tubes and prevent severe morbidity. Ovarian torsion refers to complete or partial rotation of the adnexal supporting organ with ischemia. It can affect females of all ages. Ovarian torsion occurs in around 2%-15% of patients who have surgical treatment of adnexal masses. The main risk in ovarian torsion is an ovarian mass. The most common symptom of ovarian torsion is acute onset of pelvic pain, followed by nausea and vomiting. Pelvic ultrasonography can provide information on ovarian cysts. Once ovarian torsion is suspected, surgery or detorsion is the mainstay of diagnosis and treatment.

Ovarian torsion in children: management and outcomes

BACKGROUND

The purpose of this study is to evaluate the clinical symptoms, diagnosis, management, and outcomes in children with ovarian torsion.

METHODS

The charts of 50 patients with 53 cases of ovarian torsion treated between January 1989 and March 2012 were reviewed retrospectively. Long term follow up was available for 20 girls who had their ovaries left in the abdominal cavity after detorsion.

RESULTS

In 22 cases ovaries were removed, and in 31 cases the torsion was relieved and the ovaries left in the abdominal cavity. Twenty-five of the salvaged ovaries were black-bluish and 10 bluish in color. Since 2005, after a change in preferred treatment, all ovaries treated by detorsion were left in the abdominal cavity. The long term results were observed clinically and by ultrasound in 20 girls. Multifollicular ovaries were found in 17 girls. One girl had a normal size paucifollicular ovary, a one-year-old girl had a normal size ovary with microfollicles, and one girl had no ovarian material detectable by ultrasound.

CONCLUSIONS

Long term analysis of the treatment of ovarian torsion revealed that ovaries treated by detorsion and left in the abdominal cavity preserved their normal anatomy and function. Conservative surgical treatment proved to be safe. None of the girls had thromboembolism or peritonitis, and no malignant tumors were found in the operated ovaries.

"Habitual adnexal torsions"--recurrence after two oophoropexies in a prepubertal girl: a case report and review of the literature

BACKGROUND

Recurrent adnexal torsion rarely affects girls. Various surgical techniques for its prevention are available. We describe a case of recurrent asynchronous bilateral torsions in a prepubertal patient.

CASE

An 8-year-old girl first presented with a right adnexal torsion and underwent a laparoscopic untwisting. During the following 3 years, 4 additional laparoscopies were required for treatment of left adnexal torsions. Although undergoing bilateral utero-ovarian ligament plication twice, torsion recurred. After examining the various options, we fixated the left ovary to the sidewall just below the pelvic brim.

SUMMARY AND CONCLUSION

In the absence of clear evidence, treatment should be flexible and dependent on the individual case. Thorough patient education is imperative in order to prevent a delay in diagnosis and treatment of recurrent adnexal torsion.

Laparoscopic exploration in pediatric surgery emergencies

The laparoscopic approach of pediatric surgery emergencies represents a specific preoccupation in hospitals everywhere in the world. Nowadays, when confronted with this pathology, pediatric surgeons are able to apply certain well-defined therapeutic protocols, depending on the technical equipment at their disposal and their laparoscopic expertise and training. We hereby present some of the surgical pediatric emergencies that have been subjected to minimally invasive celioscopic techniques, in the Department of Pediatric Surgery "Maria Sklodowska Curie" Hospital, from August 1999 to July 2007. Out of 83 exploratory laparoscopies, 12 were performed for emergency pathology, other than acute appendicitis (in its various forms, including peritonitis) or acute cholecystitis. However, during the above-mentioned period, the number of therapeutic laparoscopies for emergencies has grown significantly (239 from a total of 663 laparoscopies), reflecting to a large extent the activity of a clinic with an emergency surgery profile. The authors conclude that exploratory laparoscopies in pediatric surgery emergencies are suited for surgical teams with a solid experience in celioscopy and a certain professional maturity, necessary to correctly appreciate the surgical and anesthetic risks involved by each individual case. It is not recommended that inexperienced laparoscopic surgeons embark on the "adventure" of this minimally invasive approach for this type of pathology. Only when the training and learning process is fully and correctly completed, specialists are offered the advantage of continuing a celioscopic exploration by performing a minimally invasive therapeutic procedure, even for a pediatric emergency case.

Laparoscopic detorsion of twisted ovary

An 18-year-old female presented with a 6-day history of lower abdominal pain. Transabdominal ultrasonography revealed a right adnexal cyst measuring 9 cm. Laparoscopic examination demonstrated a 10-cm right paratubal cyst and a 5-cm right ovarian torsion with gangrenous discoloration. After removal of the right paratubal cyst, untwisting of the right ovary was performed. The postoperative period was uneventful. During follow-up, ultrasonography revealed restoration of right ovarian size with follicular growth. Arterial and venous blood flows were seen on Doppler examination. The right ovary appeared to be completely viable through a second-look laparoscopic examination. A twisted ovary may be completely restored with conservative management.

Asynchronous bilateral adnexal torsion in a 13-year-old adolescent: our experience of a rare case with review of the literature

Adnexal torsion is a serious condition and delay in surgical intervention may result in loss of the tube and/or ovary. Children and adolescents who have suffered from uterine adnexal torsion may be at risk for asynchronous torsion of the contralateral uterine adnexa. We report the case of sequential bilateral torsion of uterine adnexa in a 13-year-old girl, resulting in right and subsequently left salpingo-oophorectomy because of gross evidence of total necrosis in both uterine adnexa. After the castration the patient was started on hormone replacement therapy. Families of children who suffered from ovarian torsion and unilateral ovarian loss should be educated about the risk of the contralateral ovary for future torsion and should be encouraged to seek immediate medical help with the recurrence of abdominal pain.

Ovarian torsion

Ovarian torsion is a rare problem in the pediatric age group that must be included in the differential diagnosis of any girl with abdominal pain or a pelvic or abdominal mass. Clinical presentation is nonspecific, and diagnosis is based on a high index of suspicion. Ultrasound scan remains the most useful investigation, but blood flow on Doppler examination does not exclude ovarian torsion. Current recommendations of treatment strongly support ovary conservation, and macroscopic appearance of the ovary is not a reliable indicator of the degree of necrosis and potential for ovary recovery. For children with ovarian torsion, laparoscopic detorsion should be performed with strong consideration of oophoropexy. An underlying ovary lesion such as mature teratoma or functional cyst is found in most cases; however, the risk of cancer in these patients is extremely low. If there is concern of a mass or underlying pathology, then follow-up ultrasound, resolution of edema and interval laparoscopic treatment may be required.

Paratubal and tubal abnormalities

The fallopian tubes are the essential genital ducts that convey the female sex cells for fertilization. They are differentiated and detectable early in fetal life. There are numerous paratubal and tubal abnormalities that can occur at any point in the female life. Some of these are rare but may initiate significant morbidity and/or manifest as life-threatening clinical problems. A comprehensive understanding of symptoms, diagnosis, optimal imaging modalities, and medical and surgical management is vital to identify the best treatment option. The clinical entities described in this article include torsion, hydatids of Morgagni, paraovarian cysts, infections including tuboovarian abscess/pyosalpinx and salpingitis isthmic nodosa, ectopic pregnancy, tumors, and genetic disorders.

Long-term results of conservative management of adnexal torsion in children

BACKGROUND/PURPOSE

Adnexal torsion is a condition that may result in serious morbidity including adnexal removal. However, conservative management with preserving the torsed adnexa is not justified, and long-term outcomes remain unclear.

METHODS

The records of 14 girls with ovarian torsion whose adnexal structures were preserved after detorsion were reviewed to evaluate the long-term results of conservative management. Data including age, previous history, duration of complaints, surgical findings and type of intervention, color Doppler ultrasound findings performed in the early and late postoperative periods, and final outcomes were collected.

RESULTS

Mean age of patients was 11.5 +/- 2.8 (range 6 to 15) years. Time interval between the onset of pain to surgery was 46.78 +/- 35.5 (range 12 to 126) hours. Seven patients had a benign solitary cyst as an underlying cause for adnexal torsion. The intervention performed by open surgery in 9 and by laparoscopy in 5 patients included detorsion, simple cyst aspiration, unroofing and/or cystectomy in 7 patients with ovarian cysts, and oophoropexy in 9 of 14 patients. Follow-up ranged from 3 to 66 (mean 21.9 +/- 20.1) months. Thirteen patients resumed normal size and folliculogenesis, whereas in 1 patient, the involved ovary atrophied. No recurrence or contralateral adnexal torsion was observed on follow-up.

CONCLUSIONS

Conservative management with untwisting the ovary and pexing both retained detorsed and contralateral ovaries especially in idiopathic torsions should be considered in cases of ovarian torsion in children.

Adnexal torsion in very young girls: diagnostic pitfalls

OBJECTIVE

Evaluation of cases of young girls diagnosed with adnexal torsion.

STUDY DESIGN

Retrospective cohort study of 39 girls born between January 1980 and January 2000 who presented with acute abdominal pain and/or the diagnosis adnexal torsion in the Groene Hart Hospital. Seven patients, aged 6-13 years, with adnexal torsion were further evaluated.

RESULTS

In three patients, it was possible to save the adnexa. Only the time relapse between the onset of complaints and the surgical intervention correlated with the presence of microscopic necrosis in the ovary. Bluish-black appearance of an ovary did not correlate with the presence of microscopic necrosis.

CONCLUSIONS

Early recognition and treatment are essential to minimise the risk of decreased fertility after adnexal torsion in young girls. We therefore advocate prompt diagnostic laparoscopy and detorsion of the adnexa. In case a cyst is present, it should not be resected, but checked on a regular basis using ultrasound.

Ovarian torsion: to pex or not to pex? Case report and review of the literature

STUDY OBJECTIVE

We report the case of a 7-year-old girl who underwent laparoscopic ovariopexy for a suspected ovarian torsion after a previous oophorectomy. We consider the role of elective ovariopexy of the contralateral ovary in the case of adnexal torsion.

DESIGN

Case study and review of the literature.

RESULT

There was evidence to suggest a very recent adnexal torsion and an unusually long ovarian pedicle, with a possible familial linkage. The patient underwent laparoscopic ovariopexy for the remaining normal ovary, which was found to be loosely twisted at operation. After detorsion, ovariopexy was performed laparoscopically, by suturing the ovary to the back of uterus. There are no other descriptions in the literature of a familial linkage with ovarian torsion.

CONCLUSION

The case presented reminds doctors of the strong possibility of ovarian torsion in young girls presenting with pelvic pain. Laparoscopic ovariopexy for the contralateral ovary should be considered in all women with evidence of torsion, including children and adolescents, as is standard for testicular torsion.

Adnexal torsion in children may have a catastrophic sequel: asynchronous bilateral torsion

BACKGROUND/PURPOSE

Adnexal torsion is a serious condition that frequently may result in ovarian removal, and there always is a risk of castration if the contralateral ovary undergo torsion as well. In this study, the authors present their experience with adnexal torsion in 15 children and describe a catastrophic event, asynchronous bilateral adnexal torsion, with review of the literature.

METHODS

Between November 1993 and November 2000, 15 children under 15 years of age who had undergone operation because of torsion of uterine adnexal structures were evaluated. Two illustrative cases with asynchronous bilateral adnexal torsion are presented.

RESULTS

Fourteen cases were associated with additional adnexal pathology, whereas in 1 case the torsion was of normal uterine adnexa. Sonographic studies improved the preoperative diagnosis. Hemorrhagic necrosis of the adnexa secondary to the torsion was found in all cases except 3 and necessitated adnexal resection. In only 3 cases preservation of the adnexa was possible. Asynchronous adnexal torsion occurred in 2 patients in the time course. Both were treated by laparotomy and adnexal untwisting and fixation by permanent multiple interrupted sutures. In their final evaluation at 40 and 8 months after the operation, they were found to have good ovarian function.

CONCLUSION

Considering the risk of subsequent contralateral torsion and its impact on future fertility, the authors believe that conservative management (untwisting the ovary and pexing, both retained detorsed and contralateral, ovaries) should be considered in cases of ovarian torsion in children.

Maximizing ovarian salvage when treating idiopathic adnexal torsion

Idiopathic adnexal torsion threatens ovarian function. The best ways to maximize ovarian salvage have not been stressed widely. The authors describe 2 girls who illustrate the benefit of untwisting the torsion, limiting resection and performing bilateral gonadopexy to prevent both ipsilateral recurrence and contralateral occurrence.

Ovarian surgery in premenarchal girls

STUDY OBJECTIVE

This study was undertaken to assess the indications, procedures, and pathology in premenarchal girls undergoing ovarian surgery.

DESIGN

Retrospective chart review.

SETTING

University of Michigan Medical Center 1980-1996.

PARTICIPANTS

Premenarchal girls, who underwent ovarian surgery.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

All available charts (n = 52) had information extracted concerning age at time of surgery, presenting symptoms, preoperative and postoperative diagnosis, procedure, and pathology report.

RESULTS

Of the 52 patients, 50% were less than 1 year old, 31% were between 1 and 8 years old, and 19% were between 8 and 12 years old. Presenting complaints in 31 patients included structural and or endocrinologic abnormalities, and the other 21 patients presented with abdominal or systemic complaints. The most common preoperative diagnosis was an abdominal/pelvic mass (n = 24). The postoperative diagnoses revealed 18 torsions and 16 ovarian masses without torsion, 8 chromosomal abnormalities, 5 hernias, and 5 malignancies. Procedures included 37 salpingo-oophorectomies (28 unilateral and 9 bilateral), 7 oophorectomies, and 7 cystectomies. One patient underwent a staging procedure. Pathology reports confirmed hemorrhagic infarctions (n = 19), dysgenic gonads (n = 8), simple cysts (n = 7), teratomas (n = 6), theca lutein cysts (n = 4), fibroma (n = 1), stromal tumor (n = 1), mucinous cystadenoma (n = 1), granulosa cell tumor (n = 1), uterine neuroblastoma (n = 1), mixed germ cell neoplasm (n = 1), metastatic Wilms' tumor (n = 1), and gonadoblastoma (n = 1).

CONCLUSIONS

Torsion was the most common diagnosis in our study group and was usually unsuspected. Premenarchal ovarian surgery usually included removal of the entire ovary. However, because malignancies are uncommon in this population (9.6%), a cystectomy should be considered when appropriate and technically feasible.

Oophoropexy to prevent sequential or recurrent torsion

Laparoscopic oophoropexy may prevent recurrent (repeat torsion of the same ovary) or sequential (subsequent torsion of the contralateral ovary) ovarian torsion. Two adolescent girls with sequential ovarian torsion underwent laparoscopic plication of utero-ovarian ligaments. Neither patient has had recurrence in the 6. 5 and 2 years, respectively, since surgery. Sequential ovarian torsion has been described,1-8 and in almost every instance the authors raised the question of whether or not oophoropexy should have been done at the time of the initial episode of torsion. In virtually every instance the second ovary was removed and the patient rendered menopausal. In two patients with sequential ovarian torsion the ovary was saved and oophoropexy performed laparoscopically in an effort to prevent recurrence.