Missed opportunities for ovarian salvage in children: an 8-year review of surgically managed ovarian lesions at a tertiary pediatric surgery centre

European Paediatric Surgeons' Association Consensus Statement on the Management of Neonatal Ovarian Simple Cysts

INTRODUCTION

 Neonatal ovarian simple cyst management from the pediatric surgical aspect is unclear on cyst size, follow-up, and preferred surgical approach. Therefore, this topic was selected for the 2022 Consensus Session meeting of the European Paediatric Surgeons' Association (EUPSA).

METHODS

 The literature was reviewed on a predefined set of questions relating to the management of the neonatal ovarian simple cysts by a panel of 7 EUPSA members, on current evidence-based opinion and practice outlined. Each question (1) outcomes of fetal interventions in neonates after birth and consensus on size/timing of intervention, (2) consensus on the type of interventions, and (3) complications in neonatal ovarian cysts and follow-up recommendations in nonoperated/operated cysts, was presented with available evidence to congress session participants. The management approach was agreed by participants and comments were accounted to formulate the consensus statement.

RESULTS

 There is still limited data on potential benefits and complications of prenatal ultrasound-guided aspiration; however, neonates after such procedures should be followed for 6 months. Neonates with simple ovarian cysts larger than 4 cm should be offered surgical interventions within the 2 weeks of life with complete laparoscopic cyst aspiration and fenestration with bipolar instruments being the preferred approach. Ultrasound follow-up after surgical intervention after 3 months and with the conservative approach after every 3 to 4 months until 1 year.

CONCLUSION

 A peer-reviewed consensus statement for the management of neonatal ovarian simple cyst was formulated based on current evidence and peer practice. The EUPSA recognizes that the statement can be useful for pediatric surgeons in decision making for this pathology.

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.

Minimally invasive adnexa-sparing surgery for benign ovarian and paratubal masses in children

BACKGROUND

The precision of minimally invasive surgery (MIS) to resect benign ovarian and paratubal masses while preserving adnexa in children is unclear. This study evaluated the integrity of laparoscopy to spare adnexa while resecting benign pathologies in children.

METHODS

The institutional pathology database was queried to identify patients aged 18 years and younger having any ovarian or tubal lesion resected at a comprehensive children's hospital between 2006 and 2021. Adnexa-sparing surgery was defined as preserving both the ovary and tube from which the lesion was resected. Postoperative ultrasounds were reviewed to document ovarian follicles, blood flow, volumes, and lesion recurrence.

RESULTS

Adnexal preservation was implemented in 168 of 328 pathological resections. MIS approach was used in 149 cases. Median age was 13.4 [11.0-15.3]. Among sparing surgeries, MIS associated with benign pathology, shorter operative time (median minutes: 78 MIS [59-111.5]; 130 open [92.8-149.8]; 174 MIS-to-open [132.8-199.5]; p = 0.010), and reduced hospital stay (median days: 1 MIS (Lindfors, 1971; Lovvorn III et al., 1998) [1-2]; 2 open [2-2.9], 2 MIS-to-open [1-3.3]; p = 0.001). Postoperative ovarian volume ipsilateral to the MIS procedure (median, 7.6 ml [4.3-12.1]) was relatively smaller than the contralateral ovary (median, 9.1 ml [5.5-15.0]). Blood flow was documented to the ovary in 70/94 (74.4%) of patients after MIS adnexal-sparing surgery. Distinct follicles were detected in 48/74 (64.8%) of post-menarchal patients after MIS adnexal-sparing surgery. Five ovarian cysts recurred.

CONCLUSIONS

MIS preserves adnexa reliably, with postoperative ovarian follicles and blood flow detected in most patients, and maintains ∼80% of contralateral volume, while achieving definitive tumor resection.

LEVEL OF EVIDENCE

III.

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.