Rates and Technique for Oophoropexy in Pediatric Ovarian Torsion: A Single-Institution Case Series

Combined Utero-Ovarian and Round Ligament Oophoropexy for Recurrent Torsion of Normal Adnexa: A Case Series

STUDY OBJECTIVE

Recurrent torsion of otherwise normal adnexa (not involving adnexal cysts) has been reported in young girls and adolescents. Previous ovarian fixation techniques (oophoropexy), such as plication of the utero-ovarian ligament, appear to have limited efficacy in preventing recurrent torsion. A novel technique combining plication of the utero-ovarian ligament and suturing of the ovary to the round ligament has recently been described. In this study, we describe our short-term experience with the combined utero-ovarian and round ligament oophoropexy technique.

METHODS

Patients who underwent combined oophoropexy as a primary fixation technique or as a secondary fixation technique (ie, after failure of a previous fixation) due to recurrent torsion of otherwise normal adnexa between January 2020 and December 2022 were included in this retrospective cohort study. Follow-up to assess for further torsion events was conducted by telephone interview.

RESULTS

Ten patients underwent combined utero-ovarian and round ligament oophoropexy during the study period. In all cases, at least 2 episodes of torsion of otherwise normal adnexa were surgically diagnosed before oophoropexy (range 2-4). The median patient age at the time of combined oophoropexy was 21.8 years (range 9.1-35.7 years); 3 were premenarchal, and 7 were postmenarchal. After a median follow-up of 19.1 months (range 3.0-29.3 months), only 1 case of recurrent torsion occurred.

CONCLUSION

Combined utero-ovarian and round ligament oophoropexy is novel oophoropexy procedure that may reduce the risk of recurrent torsion. However, longer follow-up is needed to determine its efficacy.

Recurrent torsion of otherwise normal adnexa: oophoropexy does not prevent recurrence

PURPOSE

Recurrence of adnexal torsion involving otherwise normal adnexa is not rare. Various oophoropexy (ovarian fixation) procedures have been suggested to prevent recurrence; however, long-term information of their efficacy is lacking. The aim of this study was to investigate the recurrence rate of adnexal torsion following oophoropexy.

METHODS

Retrospective cohort study, including all consecutive patients who underwent an oophoropexy procedure for the prevention of recurrent torsion of "normal adnexa" in our department from 2008 to 2019 by shortening of the utero-ovarian ligament.

RESULTS

Nineteen patients (age range 7-35 years) with a mean follow-up of 90.9 ± 57.7 months were identified. Fifteen of them (78.9%) were re-operated for recurrent torsion following an oophoropexy procedure, while four (21.1%) did not experience recurrence. Nine torsion recurrences following an oophoropexy occurred within the first 2 postoperative years. There were no differences in mean age and menarcheal status )pre- or post-menarcheal) at the time of the first torsion event, age at the time of oophoropexy, oophoropexy side, number of adnexal torsion events before oophoropexy, and follow-up duration between those with and those without post-oophoropexy recurrences.

CONCLUSION

Oophoropexy procedure by shortening of the utero-ovarian ligament may not prevent recurrent torsion of otherwise normal adnexa. Further studies to determine whether combined fixation (utero-ovarian and round ligament plication) is more efficacious than isolated utero-ovarian plication for the prevention of recurrent torsion are warranted.

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.

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.

Oophorectomy for ovarian torsion - should this be abandoned?

BACKGROUND

Management of ovarian torsion ranges from de-torsion to oophorectomy and is dependent on various factors. Oophorectomy can have significant implications for fertility and general health, thus requiring careful consideration.

AIMS

We evaluate the management of ovarian torsion at a tertiary hospital over a ten-year period and identify the predictors of oophorectomy in ovarian torsion cases.

MATERIALS AND METHODS

Inpatient notes of patients who underwent surgical management for acute ovarian torsion at a tertiary hospital in Victoria, Australia, were reviewed, from January 2008 to June 2018. We reported the incidence and predictors of oophorectomy and ovarian ischaemia and current practices in oophoropexy.

RESULTS

Our analysis included 159 patients. The incidence of oophorectomy was 47%. After confounders were adjusted, increasing age was the only significant predictor for oophorectomy. The adjusted odds ratio of having an oophorectomy based on age alone was 1.10 for each year increase in age between the ages of 15 and 68 (P = 0.001, 95% confidence interval 1.04-1.16). Of those with oophorectomy, 57% had ischaemia confirmed histologically. There were no significant predictors for ischaemia.

CONCLUSION

The incidence of oophorectomy in this audit is comparable to reported incidences in current literature. However, with increasing evidence to support ongoing ovarian function even in cases where ischaemia is histologically confirmed, this incidence could be lowered. Age was the only variable that was found to have a significant effect on the incidence of oophorectomy.

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.

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

INTRODUCTION

The aetiology and management of ovarian pathology in children differs between antenatal and postnatal lesions. However, all lesions may present acutely due to adnexal torsion. In this setting, opportunities to preserve fertility with ovary-sparing surgery (OSS) may be missed. Some studies suggest that pediatric and adolescent gynaecology (PAG) input in care is associated with OSS.

METHODS

A retrospective cohort study of children undergoing surgery for ovarian pathology at a tertiary pediatric surgery centre over an 8-year period (2011-2018). Patient factors, lesion characteristics and PAG involvement were examined for association with OSS using multivariate logistic regression.

RESULTS

Thirty-five patients with ovarian pathology managed surgically were included. Ten were infants with lesions detected antenatally; all were managed by pediatric surgeons (PS) alone at median age 2 weeks (1 day-25 weeks). Twenty-five patients presented postnatally at median age 11 (0.75-15) years. In total, there were 16 cases of adnexal torsion, each managed primarily by PS. Twelve underwent oophorectomy and six (50%) of these cases had viable ovarian tissue on histology. Furthermore, two infants with large simple cysts were similarly managed by unnecessary oophorectomy based on histology. Overall rate of OSS was 46% and PAG involvement was the only factor associated with ovarian salvage.

CONCLUSION

Differences in surgical management between PAGs and PS may be attributable to the different patient populations they serve. We recommend improving the knowledge of PS trainees in OSS approaches for adnexal torsion and large benign lesions.

Compensatory Ovarian Hypertrophy after Unilateral Oophorectomy: Evaluation of Ovarian Volumes in Pediatric and Adolescent Populations

STUDY OBJECTIVE

Limited data exist on the morphologic and physiologic effect on the remaining ovary after unilateral oophorectomy, especially in the pediatric population. Our aim is to evaluate ovarian volumes following unilateral oophorectomy to determine whether compensatory ovarian hypertrophy occurs in the remaining contralateral ovary.

DESIGN

This was a retrospective chart review of ovarian volume measured on ultrasounds that were completed after unilateral oophorectomy. Postoperative ovarian volumes were compared to established radiologic standards.

SETTING

Large tertiary care academic children's hospital in Atlanta, GA.

PARTICIPANTS

Female patients less than 21 years old who underwent unilateral oophorectomy.

MAIN OUTCOME MEASURES

Ovarian volumes measured on postoperative ultrasounds.

RESULTS

A total of 93 patients met inclusion criteria for this study. Serial ultrasounds were performed in slightly more than half of the patients (n = 48, 51.6%), totaling 193 postoperative ovarian volumes. The average age of oophorectomy was 10.8 years. Prior to surgery, the majority of patients presented with abdominal pain (n = 51, 54.8%) or pelvic mass (n = 51, 54.8%), and most (n = 77, 82.8%) had benign final pathology. Ovarian volumes were compared to 4 published radiologic ultrasound standards. More than 62.2% of ovarian volumes from girls who had previously had unilateral oophorectomy were larger than age-matched standard ovarian volumes.

CONCLUSION

Ovarian enlargement occurs in the contralateral ovary following unilateral oophorectomy in the pediatric and adolescent population. This supports the concept of compensatory ovarian hypertrophy. This knowledge provides valuable information for interpretation of radiologic images in young female individuals who have undergone oophorectomy, and can assist with counseling on the risk of adnexal complications due to ovarian hypertrophy after unilateral oophorectomy.

Management of Adnexal Torsion in the Pediatric and Adolescent Population at Western Australia's Single Tertiary Children's Hospital over the Last 10 Years: Retrospective Study

OBJECTIVE

To review our institutional data regarding the management of adnexal torsion (AT) and assess the ovarian conservation rates.

DESIGN

Retrospective study.

SETTING

Tertiary children's hospital.

PATIENTS

Pediatric and adolescent patients with surgically diagnosed AT. Participants (n = 54, mean age 9.80 ± 3.95 years) were identified between June 2010 and May 2019.

INTERVENTIONS

Surgical management of AT.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was to determine the ovarian conservation rates in AT cases. The secondary outcomes were to determine the incidence of AT to total emergency department (ED) presentations, decision to operation theater (OT) time in AT cases, return to OT, histopathology, and follow-up with ultrasound to determine ovarian function. Data were collected on demographic and clinical characteristics. Continuous data were compared with t tests or Kruskal-Wallis tests; categoric data were compared with chi-square tests. A total of 52 (96.29%) patients had ovarian conservation, and 53 (98.14%) had laparoscopic management. The incidence rate for AT cases to total ED presentations for the last 10 years was 9.9 per 100 000, which was based on a Poisson distribution. Presentations to an ED for AT cases have trended upward since 2010. Decision to OT time was statistically significantly shorter in cases with preoperative suspicion of AT than those with intraoperative diagnosis of AT (p = .000). A total of 7 (12.96%) patients returned to OT for suspicion of recurrent torsion. Of these, 5 (9.26%) had confirmed repeat AT. The presence of fever, pain duration, severity of pain, and severity of torsion did not correlate with the follow-up ultrasound findings of ovarian activity.

CONCLUSION

The findings from our study suggest that high ovarian conservation rates are achievable in AT cases. A high index of suspicion is required to prevent a delay in surgery.

Ovarian torsion and laparoscopy in the paediatric and adolescent population

A 9-year-old girl attended the emergency department with right-sided abdominal pain and vomiting. Due to history and following examination, an ultrasound was requested which demonstrated a large complex midline mass. The most likely diagnosis was ovarian torsion, for which the patient underwent laparoscopy, detorsion and ovarian cystectomy. Histology revealed a mature cystic teratoma. Although less common than in the adult population, it is important to consider ovarian torsion in children and adolescents. Presentation is usually with pain accompanied by vomiting and fever, although these symptoms are not always present. Current management is organ-sparing, with laparoscopy±cystectomy. We discuss the adaptations for this procedure with regard to the paediatric and adolescent population. Differences in the anatomy and physiology must lead to consideration for alterations in surgical technique and positioning to ensure the safest and best quality care for these young patients.

Does ischemia reperfusion affect fecundability in a rat model?

BACKGROUND

Adnexal torsion constitutes 2.7% of all gynecological emergencies. Because normal follicular growth has been demonstrated after examination of surgical specimens retrieved from oophorectomies, organ-sparing strategy has gained more popularity irrespective of the appearance of the ovary. However, the functionality of the remaining follicles has not been known. The aim of the study was to evaluate the effect of ischemia-reperfusion on fecundability in a rat model with adnexal torsion.

METHODS

A total of 30 female adult Wistar albino rats were assessed. In the first laparotomy, right ovaries were twisted for 8 (Group I, n = 10) or 24 (Group II, n = 10) hours. Second laparotomy was performed to untwist the torsion side and oophorectomy to the other side. In the control group (Group III, n = 10), left ovaries were removed and right ovaries were kept without any intervention. After 30 days from the last operation, female rats were mated for 10 days and euthanized 4 days later. Fecundability was calculated using beta-human chorionic gonadotropin (hCG) levels for detection of pregnancy rates.

RESULTS

The mean beta-hCG values in control, 8-hour, and 24-hour groups between pregnant rats were 19.8 ± 26.02, 11.7 ± 0.17, and 22.97 ± 11.87 mIU/mL, respectively. Whereas two out of 10 rats (20%) conceived in the 8-hour group, three out of 10 rats (30%) got pregnant in the 24-hour group. In total, whereas five out of the 20 rats got pregnant in the experimental groups, in the control group, seven out of 10 subjects conceived (25% vs 70 %, p = 0.018).

CONCLUSION

Although there was a statistical difference between experimental and control groups, statistical significance was not reached among 8-hour and 24-hour torsion subgroups. In this context, patients with torsion but treated with detorsion should be further investigated for their fecundability potency and be informed accordingly.

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.

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.

Ovarian torsion in pediatric and adolescent patients: A systematic review

OBJECTIVE

Ovarian torsion in pediatric patients is a rare event and is primarily managed by pediatric general surgeons. Torsion can be treated with detorsion of the ovary or oopherectomy. Oopherectomy is the most common procedure performed by pediatric general surgeons for ovarian torsion. The purpose of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee was to examine evidence from the medical literature and provide recommendations regarding the optimal treatment of ovarian torsion.

METHODS

Using PRISMA guidelines, six questions were addressed by searching Medline, Cochrane, Embase Central and National clearing house databases using relevant search terms. Risks of ovarian detorsion including thromboembolism and malignancy, indications for oophoropexy, benefits of detorsion including recovery of function and subsequent fertility, and recommended surveillance after detorsion were evaluated. Consensus recommendations were derived for each question based on the best available evidence.

RESULTS

Ninety-six studies were included. Risks of ovarian detorsion such as thromboembolism and malignancy were reviewed, demonstrating minimal evidence for unknowingly leaving a malignancy behind in the salvaged ovary and no evidence in the literature of thromboembolic events after detorsion of a torsed ovary. There is no clear evidence supporting the benefit of oophoropexy after a single episode of ovarian torsion. The gross appearance of the ovary does not correlate with long-term ovarian viability or function. Pregnancies have occurred in patients after detorsion of an ovary both spontaneously and with harvested oocytes from previously torsed ovaries. The consensus recommendation for imaging surveillance following ovarian detorsion is an ultrasound at 3months postprocedure but sooner if there is a concern for malignancy.

CONCLUSION

There appears to be overwhelming evidence supporting ovarian detorsion rather than oopherectomy for the management of ovarian torsion in pediatric patients. Ovarian salvage is safe and is the preferred treatment for ovarian torsion. Most salvaged ovaries will maintain viability after detorsion.

TYPE OF STUDY

Systematic review of level 3-4 studies.

LEVEL OF EVIDENCE

3-4.