A Displaced Mass in the Abdomen, Torsioned Ovary Cyst

Ovarian cysts are one of the most common pathologies in the infancy period. Approximately 15% of intraabdominal masses seen in this period are genital origined and one-third of these masses are ovarian cysts. The incidence of ovarian cysts has been reported as 1 in 2500 live births. The most common complications in ovarian cysts are torsion and bleeding. Fetal ovarian cysts usually regress spontaneously in complicated cysts; laparoscopic or open surgery can be applied. A female infant with a diagnosis of intraabdominal cystic mass, suspicion of duodenal atresia, and mesenteric cyst made based on a prenatal ultrasonographic imaging was hospitalized in the neonatal intensive care unit for examination and treatment. The abdominal ultrasonography revealed a cystic lesion in the lower left quadrant. The patient was evaluated with abdominal CT for detailed evaluation 1 day later and revealed a cystic lesion in the right upper quadrant. The displacement of the cystic mass conducted the differential diagnosis in favor of mesenteric cyst and ovarian torsion. Laparoscopic surgery was performed for examination and treatment. It was observed that the left ovary was torsioned and displaced. Ovarian cysts are the most frequently observed masses among prenatal cystic masses in female fetuses. It should be kept in mind that cystic masses detected in the prenatal period may often be ovarian cysts and that these cysts can be displaced in the abdomen while torsion, and a treatment plan should be determined according to the clinical findings of the patient.

The Role of Surgery in Antenatal Ovarian Torsion: Retrospective Evaluation of 28 Cases and Review of the Literature

STUDY OBJECTIVE

Antenatal ovarian torsion (AOT) is rare and requires differentiating from other congenital cystic masses of the abdomen and pelvis in neonates. In this study, it was aimed to evaluate the prenatal characteristics and postnatal outcomes of AOT. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Hospital records of patients (n = 28) with diagnosis of AOT between 2004 and 2020 were reviewed and their prenatal characteristics, postnatal examination, imaging, operative, and histopathological findings were evaluated.

RESULTS

There were 28 patients during the study period. In most of the patients (25/28; 89.3%) AOTs were detected prenatally. All were term babies with a mean birth weight of 3010 ± 466.6 g. Mean maternal age was 25.75 ± 3.65 years. Prenatal history was event-free in all and none had additional anomalies. Physical examination revealed mobile intra-abdominal cystic lesions in 16 (57.1%) patients. AOTs mimicked other pathologies as intestinal duplication cyst or mesenteric cyst (n = 7), complex ovarian cyst (n = 3), mature cystic teratoma (n = 3), simple renal cyst (n = 1), and ectopic kidney (n = 1) in 15 (53.6%) patients in postnatal ultrasonography. Elective laparoscopic surgery was performed in 26 (92.8%) patients. The other 2 patients required emergency open surgery because of acute symptoms. Ovaries were autoamputated in 17 (60.7%) patients. Histopathological examination revealed necrosis and dystrophic calcification in all specimens. There was neoplastic involvement in 2 patients (serous cystadenoma and gonadoblastoma). No complication occurred in the early follow-up period (mean: 73.9 ± 46.8 months).

CONCLUSION

AOTs can be detected easily during the antenatal period. Neoplastic involvement with AOTs is rare but possible. Although AOTs might mimic other cystic pathologies, it should be one of the first diagnoses to be considered, in the presence of a palpable intra-abdominal mass and complex cystic lesion in infant girls. It can be efficiently and safely managed using minimally invasive techniques.

A retrospective multicenter study of the natural history of fetal ovarian cysts

AIM

We investigated the natural history of fetal ovarian cysts to estimate the risk of torsion according to size.

METHODS

Cases were identified from 1/1/2000 until 1/1/2015. Data were collected pre- and postnatally on cyst size and sonographic features until an outcome of surgery, torsion, or resolution. Fisher's exact test for categorical data and logistic regression for continuous data were used to test the significance of size on torsion; P value <0.05 was considered significant.

RESULTS

37 patients with unilateral ovarian cysts were included. 12 (32%) resolved spontaneously prenatally, 14 (38%) resolved spontaneously postnatally, 5 (14%) underwent surgery postnatally and 6 (16%) cases underwent torsion. Rate of torsion increased with size from 0% (n=0) in cysts ≤20mm to 33% (n=2) in cysts >50mm; however, the overall trend failed to reach statistical significance (P=0.1). Cysts of 0-40mm had a significantly higher rate of spontaneous resolution (90% vs. 44% in >40mm, P=0.003), but the rate of torsion was not significantly different (10% in 0-40mm vs. 25% in >40mm, P=0.26). The median time to postnatal resolution was 10 (5-27) weeks in those treated conservatively.

CONCLUSION

Cysts >40mm are significantly less likely to resolve spontaneously; however torsion showed no significant correlation with cyst size. No complications were observed in cysts <20mm.

LEVEL OF EVIDENCE

IV, case series with no comparison group.

Recurrent fetal complex ovarian cysts with rupture followed by simple cyst in the neonatal period with no adverse sequelae

Fetal ovarian cysts are the most frequent type of abdominal tumors in female fetuses with prenatal detection rate of more than 30%. The etiology of fetal ovarian cysts is unclear, but hormonal stimulation as well as presence of maternal diabetes, hypothyroidism, Rh iso-immune hemolytic disease and toxemia has been generally considered responsible for the disease. Complications of fetal ovarian cysts include compression of other viscera, cyst rupture, hemorrhage and, most frequently, ovarian torsion with consequent loss of the ovary. Management is controversial with several options described in the literature, including watchful expectancy, antenatal aspiration of simple cysts to prevent torsion and ovarian loss and finally, resection of all complex cysts in the neonatal period. To date, no case report has described recurrent complex cysts with rupture in the fetal period and recurrence of simple cyst in neonatal period. By presenting this case, we wanted to show that surgical intervention in case of prenatally diagnosed fetal ovarian cyst should be considered postnatally and only in symptomatic or complicated cases.