Asynchronous bilateral ovarian torsion

Rate of oophorectomy in pediatric ovarian torsion: risk factors and change over time

PURPOSE

The management of ovarian torsion in pediatric patients has evolved over time. Ovarian salvage is currently recommended given concerns for fertility preservation and the low likelihood of malignancy. Studies have shown that the incidence of oophorectomy is higher amongst pediatric surgeons in comparison to gynecologists. Using a national database, this study examined how the surgical management of ovarian torsion has evolved.

METHODS

Children with a discharge diagnosis of ovarian torsion (ICD-9 code 620.5, ICD-10 code N835X) and procedure codes for oophorectomy (CCS code 119) were identified within the KID database from 2003, 2006, 2009, 2012, 2016, and 2019. Diagnosis of ovarian pathology was based upon ICD-9 and ICD-10 codes at the time of discharge.

RESULTS

A total of 7008 patients, ages 1-20, had a discharge diagnosis of ovarian torsion. Of those patients, 2,597 (37.1%) were diagnosed with an ovarian cyst, 1560 (22.2%) were diagnosed with a benign ovarian neoplasm, and 30 (0.4%) were diagnosed with a malignant neoplasm. There was a decreased risk of oophorectomy in urban-teaching versus rural hospitals (OR: 0.64, p < 0.001). The rate of oophorectomy has decreased overtime. However, patients with benign or malignant neoplasms were more likely to undergo oophorectomy than those without a diagnosis (OR: 2.03, p < 0.001; 4.82, p < 0.001).

CONCLUSION

The rate of oophorectomy amongst children with ovarian torsion has decreased over time. Yet, despite improvements, oophorectomy is common amongst patients with benign ovarian neoplasms and those treated at rural hospitals. Continued education is needed to optimize patient care in all clinical scenarios.

LEVEL OF EVIDENCE

IV.

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.

Postoperative outcomes of ovarian preserving surgery in premenopausal women with adnexal torsion

OBJECTIVE

We aimed to determine whether ovarian-preserving surgery for adnexal torsion helps preserve ovarian function without increasing the risk of postoperative complications.

METHODS

We retrospectively evaluated 71 women who were surgically diagnosed with adnexal torsion between January 2015 and December 2019 at Severance Hospital, Yonsei University College of Medicine (ovarian preservation group, 56; oophorectomy, 15). Serum anti-Müllerian hormone (AMH) levels measured within 6 months before surgery were compared to levels measured 6-24 months after surgery. Surgical findings and postoperative complications were compared between the groups.

RESULTS

There was a borderline significant difference in the decrease in serum AMH levels between the oophorectomy group and ovarian preservation group before and after surgery. There were no significant differences between the groups in terms of fever, infection, or duration of admission. Discoloration of the twisted ovary was found in 27.3% and 33.3% of the patients in the ovarian preservation and oophorectomy groups, respectively. There was no difference in the decrease in serum AMH levels between patients with and those without discoloration.

CONCLUSION

Ovarian-preserving surgery may not increase postoperative complications in patients with adnexal torsion, even if a twisted mass is suspected to be necrotic. Moreover, the ovarian reserve may not be affected by torsion if the ovary is preserved. Conservative ovarian surgery can be safely performed to preserve the reproductive potential of women with adnexal torsion and cystic masses.

Retrospective analysis of patients with surgically proven ovarian torsion, our experience

Aim

To study the patients who were admitted to our hospital with surgically proven ovarian torsion and were operated for the same and to study for whom detorsion was done.

Materials and Methods

A retrospective analysis of the medical records and surgical notes of 150 patients with surgically proven ovarian torsion over a 10-year period between January 2011 and January 2021 was carried out. Surgical notes included details like mode of the surgery (laparotomy or laparoscopy), type of surgery (oophorectomy, detorsion, detorsion with cystectomy), whether fixation was done or not, size of mass/ovary, laterality, appearance of the torted ovary, color of the ovary, and number of twists. Histopathologic reports of the patients who underwent oophorectomy or detorsion with cystectomy were also recorded.

Results

During the 10-year study period, 88 (58.7%) patients had undergone laparotomy and 62 (41.2%) patients had undergone laparoscopy. Detorsion with cystectomy was done in 96 (64%) cases, detorsion alone in 14 (9.3%) cases, and oophorectomy was done in 40 (26.6%) cases. There was no significant difference in terms of increase in postoperative complications.

Conclusion

Laparoscopic detorsion with cystectomy is the most common surgical procedure used for ovarian torsion at King Hussein Medical Center.

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.

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.

An Insidious Cause of Abdominal Pain in a Preschooler Girl: The Asynchronous Bilateral Ovarian Torsion

ABSTRACT

The ovarian torsion (OT) represents one of the most misleading and challenging diagnoses for the pediatrician. Symptoms are often nonspecific, including sudden, piercing localized lower abdominal pain and tenderness associated with a palpable mass and peritoneal signs. Although the adnexal torsion is most frequently unilateral, cases of bilateral synchronous or asynchronous have been recorded; in the latter, the OT involved both ovaries at different settings. We reported the case of a 6-year-old girl who presented an asynchronous bilateral OT.

Adnexal torsion in a pediatric population: Acute presentation with question of chronicity

OBJECTIVES

To establish the frequency of torsion with multiple twists of the adnexa in girls 19 years old and younger surgically diagnosed with torsion.

STUDY DESIGN

A retrospective chart review using an institutional tool to review charts of female patients 19 years old or younger who presented with acute abdominal pain leading to a surgical diagnosis of adnexal torsion.

RESULTS

Of 141 pediatric patients with torsion, 61 (43%) had documentation of multiple twists, with 2 to 12 rotations present. 33% reported acute pain (<24 hrs) whereas most (67%) had pain > 24 h up to 4 weeks without abatement (23%) or experienced discrete episodes with pain resolution between episodes (44%). Even when vascular flow was demonstrated, multiple twists were frequently found (14/36 = 39%). When multiple twists were documented, more patients had an extirpative procedure due to a nonviable appearing ovary than when a single or unstated number of twists twist was found, although the results were not statistically significant (53.5% vs 42.9%, p = 0.098).

CONCLUSIONS

Forty-three percent of girls presenting with symptoms of torsion had multiple twists in the adnexa. Many had provided a history of previous similar episodes of pain and presentation to emergency departments, suggesting possible previous undiagnosed episodes of torsion. Earlier diagnosis may provide a better opportunity for ovarian conservation prior to a recurrent torsion. Further study may reveal whether multiple twists are more likely to result in a nonviable ovary and need for oophorectomy.

Ovarian Preservation and Recurrent Torsion in Children: Both Less Common Than We Thought

PURPOSE

Surgical management of pediatric ovarian torsion includes total oophorectomy (TO) or ovarian preservation surgery (OPS). This study sought to identify factors contributing to surgical management and readmission outcomes for ovarian torsion.

METHODS

The Nationwide Readmission Database from 2010-2014 was used to identify patients < 18 years admitted with ovarian torsion. Patient factors, hospital characteristics, and readmission outcomes were compared by TO and OPS. Standard statistical analysis was performed and results were weighted for national estimates.

RESULTS

There were 6028 patients (age 13 ± 4 years) identified with ovarian torsion who underwent either TO (50%) or OPS (50%). Patients had secondary pathology of ovarian cyst (41%), benign mass (19%), and malignant mass (0.4%). OPS was more common in teaching hospitals (84% vs. 74% TO, P<0.001), patients < 13 years of age (41% vs. 37% TO, P = 0.001), and those from high-income households (51% vs. 41% TO, P<0.001). The overall readmission rate was 4%, with no difference between surgical approach (4.3% OPS vs. 4.4% TO, P = 0.882). Of those readmitted (n = 265), readmission diagnoses were cyst (10%), malignant mass (9%), benign mass (7%), and torsion (5%). The overall rate of recurrent torsion was 0.2%, with no difference between OPS and TO (< 0.3% vs. < 0.2%, P = 0.282).

CONCLUSION

Half of pediatric patients are undergoing TO for ovarian torsion in the U.S. and disparities exist with the utilization of OPS. There is no difference in rate of readmission or recurrent torsion between surgical approaches, and the overall rate of retorsion is lower than previously reported.

Ovarian lesions and tumors in infants and older children

Objectives

Ovarian lesions are rare but frequent in children. Patients could present with abdominal pain, but ovarian lesions could also be incidentally found on ultrasound. Awareness is required in cases with acute, severe lower abdominal pain, as ovarian torsion could be the cause. Other lesions can be cysts or benign or malignant ovarian tumors. Thus, the aim of this paper is to review typical ovarian lesions according to age, imaging and laboratory findings, and surgical management.

Methods

We retrospectively analysed the patient charts of 39 patients aged 10.4 ± 6.1 years (from 3 months to 18 years) with ovarian lesions treated in our institution between 01/2009 and 08/2020. All clinical and pathological findings of infants and children operated on for ovarian lesions were included.

Results

Ovarian lesions in children younger than 2 years of age were typically ovarian cysts, and ovarian tumors were not observed in this age group. In older children over 10 years of age, tumors were more common – with mostly teratoma or other germ cell tumors, followed by epithelial tumors. Moreover, acute or chronic ovarian torsion was observed in all age groups. In general, ovarian tumors were much larger in size than ovarian cysts or twisted ovaries and eventually showed tumor marker expression of AFP or ß-HCG. Simple ovarian cysts or twisted ovaries were smaller in size. Surgery for all ovarian lesions should aim to preserve healthy ovarian tissue by performing partial ovariectomy.

Conclusions

In adolescent girls with acute abdominal pain, immediate laparoscopy should be performed to rule out ovarian torsion. Careful imaging evaluation and the assessment of tumor markers should be performed in painless ovarian lesions to indicate an adequate surgical ovarian-sparing approach.

Adnexal torsion without neoplastic lesions after laparoscopic hysterectomy: A report of three cases and literature review

The major risk factor for adnexal torsion is the presence of adnexal neoplasms, and torsion without a neoplastic lesion of the adnexa is rare. We report three cases of right adnexal torsion without neoplastic lesion after laparoscopic hysterectomy. In all three cases, the right adnexas, which did not form adhesions, had undergone torsion. According to several case reports, most cases of adnexal torsion after laparoscopic hysterectomy developed without neoplastic lesion. In fact, adnexal torsion without neoplasm is reported to occur relatively frequently after laparoscopic hysterectomy and more commonly involves the right side. Therefore, at the end of laparoscopic hysterectomy, ovariopexy should be performed to prevent postoperative adnexal torsion.

Imaging in gynecological disease (20): clinical and ultrasound characteristics of adnexal torsion

OBJECTIVES

To describe the clinical and ultrasound characteristics of adnexal torsion.

METHODS

This was a retrospective study. From the operative records of the eight participating gynecological ultrasound centers, we identified patients with a surgically confirmed diagnosis of adnexal torsion, defined as surgical evidence of ovarian pedicle, paraovarian cyst and/or Fallopian tube twisted on its own axis, who had undergone preoperative ultrasound examination by an experienced examiner, between 2008 and 2018. Only cases with at least two available ultrasound images and/or videoclips (one grayscale and one with Doppler evaluation) were included. Clinical, ultrasound, surgical and histological information was retrieved from each patient's medical record and entered into an Excel file by the principal investigator at each center. In addition, two authors reviewed all available ultrasound images and videoclips of the twisted adnexa, with regard to the presence of four predefined ultrasound features reported to be characteristic of adnexal torsion: (1) ovarian stromal edema with or without peripherally displaced antral follicles, (2) the follicular ring sign, (3) the whirlpool sign and (4) absence of vascularization in the twisted organ.

RESULTS

A total of 315 cases of adnexal torsion were identified. The median age of the patients was 30 (range, 1-88) years. Most patients were premenopausal (284/314; 90.4%) and presented with acute or subacute pelvic pain (305/315; 96.8%). The surgical approach was laparoscopic in 239/312 (76.6%) patients and conservative surgery (untwisting with or without excision of a lesion) was performed in 149/315 (47.3%) cases. According to the original ultrasound reports, the median largest diameter of the twisted organ was 83 (range, 30-349) mm. Free fluid in the pouch of Douglas was detected in 196/275 (71.3%) patients. Ovarian stromal edema with or without peripherally displaced antral follicles was reported in the original ultrasound report in 167/241 (69.3%) patients, the whirlpool sign in 178/226 (78.8%) patients, absent color Doppler signals in the twisted organ in 119/269 (44.2%) patients and the follicular ring sign in 51/134 (38.1%) patients. On retrospective review of images and videoclips, ovarian stromal edema with or without peripherally displaced antral follicles (201/254; 79.1%) and the whirlpool sign (139/153; 90.8%) were the most commonly detected features of adnexal torsion.

CONCLUSION

Most patients with surgically confirmed adnexal torsion are of reproductive age and present with acute or subacute pain. Common ultrasound signs are an enlarged adnexa, the whirlpool sign, ovarian stromal edema with or without peripherally displaced antral follicles and free fluid in the pelvis. The follicular ring sign and absence of Doppler signals in the twisted organ are slightly less common signs. Recognizing ultrasound signs of adnexal torsion is important so that the correct treatment, i.e. surgery without delay, can be offered. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Evaluation of the usefulness of laparoscopy in the diagnosis and treatment of adnexal pathologies in the pediatric population

INTRODUCTION

The current trend in adnexal surgery in children is to minimize the invasiveness of diagnostic and therapeutic procedures, reduce the number of complications and reduce the risk of infertility.

AIM

Evaluation of the usefulness and effectiveness of laparoscopy in diagnostics and treatment of pathological lesions of adnexa in the pediatric population and evaluation of the correlation of imaging with the intraoperative diagnosis during laparoscopy.

MATERIAL AND METHODS

The study included 89 patients aged 0-18 years (mean: 12.62) who underwent an emergency or elective laparoscopic procedure due to the suspicion of adnexa pathology in the imaging tests or in which intraoperative pathology of the adnexa was found without previous suspicion of these changes in the imaging tests. Patients were divided into 2 groups according to the procedure (emergency or elective) and into 4 age groups.

RESULTS

The most frequent postoperative diagnosis was an adnexal cyst and ovarian tumor. The ratio of malignant to benign lesions was 0.087. In 32.58% of patients appendix pathology was found. Coexistence of adnexa and appendix pathology was statistically significantly more frequent in patients undergoing emergency surgery (p = 0.013). There was no correlation between the size of the tumor or ovarian cyst and the occurrence of adnexal torsion, and no correlation between the size of the tumor and the degree of torsion of the adnexa. Three conversions were performed. The average operation time was 63.7 min.

CONCLUSIONS

Laparoscopic diagnosis and treatment of adnexal pathology seems to be safe due to the low percentage of perioperative complications. It shows high sensitivity in recognizing adnexal pathologies and other defects.

Ovarian torsion: developing a machine-learned algorithm for diagnosis

BACKGROUND

Ovarian torsion is a common concern in girls presenting to emergency care with pelvic or abdominal pain. The diagnosis is challenging to make accurately and quickly, relying on a combination of physical exam, history and radiologic evaluation. Failure to establish the diagnosis in a timely fashion can result in irreversible ovarian ischemia with implications for future fertility. Ultrasound is the mainstay of evaluation for ovarian torsion in the pediatric population. However, even with a high index of suspicion, imaging features are not pathognomonic.

OBJECTIVE

We sought to develop an algorithm to aid radiologists in diagnosing ovarian torsion using machine learning from sonographic features and to evaluate the frequency of each sonographic element.

MATERIALS AND METHODS

All pediatric patients treated for ovarian torsion at a quaternary pediatric hospital over an 11-year period were identified by both an internal radiology database and hospital-based International Statistical Classification of Diseases and Related Health Problems (ICD) code review. Inclusion criteria were surgical confirmation of ovarian torsion and available imaging. Patients were excluded if the diagnosis could not be confirmed, no imaging was available for review, the ovary was not identified by imaging, or torsion involved other adnexal structures but spared the ovary. Data collection included: patient age; laterality of torsion; bilateral ovarian volumes; torsed ovarian position, i.e. whether medialized with respect to the mid-uterine line; presence or absence of Doppler signal within the torsed ovary; visualization of peripheral follicles; and presence of a mass or cyst, and free peritoneal fluid. Subsequently, we evaluated a non-torsed control cohort from April 2015 to May 2016. This cohort consisted of sequential girls and young adults presenting to the emergency department with abdominopelvic symptoms concerning for ovarian torsion but who were ultimately diagnosed otherwise. These features were then fed into supervised machine learning systems to identify and develop viable decision algorithms. We divided data into training and validation sets and assessed algorithm performance using sub-sets of the validation set.

RESULTS

We identified 119 torsion-confirmed cases and 331 torsion-absent cases. Of the torsion-confirmed cases, significant imaging differences were evident for girls younger than 1 year; these girls were then excluded from analysis, and 99 pediatric patients older than 1 year were included in our study. Among these 99, all variables demonstrated statistically significant differences between the torsion-confirmed and torsion-absent groups with P-values <0.005. Using any single variable to identify torsion provided only modest detection performance, with areas under the curve (AUC) for medialization, peripheral follicles, and absence of Doppler flow of 0.76±0.16, 0.66±0.14 and 0.82±0.14, respectively. The best decision tree using a combination of variables yielded an AUC of 0.96±0.07 and required knowledge of the presence of intra-ovarian flow, peripheral follicles, the volume of both ovaries, and the presence of cysts or masses.

CONCLUSION

Based on the largest series of pediatric ovarian torsion in the literature to date, we quantified sonographic features and used machine learning to create an algorithm to identify the presence of ovarian torsion - an algorithm that performs better than simple approaches relying on single features. Although complex combinations using multiple-interaction models provide slightly better performance, a clinically pragmatic decision tree can be employed to detect torsion, providing sensitivity levels of 95±14% and specificity of 92±2%.

Torsion of otherwise healthy ovary Has a worse prognosis than torsion of pathologic ovary in children

INTRODUCTION

To evaluate if torsion of an otherwise healthy ovary (THO) has a different prognosis than torsion with an underlying ovarian mass (TUOM) in children.

MATERIAL AND METHODS

Children with an ovarian torsion who were treated in our department from 1997 to 2016 were studied retrospectively. Patients with prenatal ovarian torsion and isolated oviduct torsion were excluded. Trophicity of the ovary was assessed by ultrasonography at the end of follow-up.

RESULTS

Fifty-four girls were included. Twenty-seven presented a TUOM; the others had a THO. Beside the deleterious effect of late surgical management, another prognostic factor was identified. THO was more prone to an ovarian hypotrophy or atrophy than TUOM (n = 20 vs n = 5, p < 0.01). This was confirmed by logistic regression analysis (OR = 5.08, p = 0.01). To explain this finding, we further compared TUOM and THO. The diagnosis of TUOM was more frequently suspected on US at the first visit (p = 0.005). TUOM also occurred more often after puberty (>12 years, 52.9% vs 11.1%, p < 0.001) than THO.

CONCLUSION

THO is more frequently associated with an ovarian atrophy or hypotrophy than TUOM. A less obvious diagnosis at US and the early occurrence of THO before puberty with a less favorable hormonal climate may explain this finding.

LEVEL OF EVIDENCE

III.

Evaluation of Ovarian Vascularity in Children by Using the "Superb Microvascular Imaging" Ultrasound Technique in Comparison With Conventional Doppler Ultrasound Techniques

OBJECTIVES

The aim of this study was to assess the feasibility of the novel "superb microvascular imaging" (SMI) Doppler ultrasound technique to detect ovarian vascularity in healthy children and to compare it with the conventional Doppler ultrasound techniques.

METHODS

This prospective study included 140 girls, aged 3 to 18 years, for which an abdominal ultrasound study was requested in the pediatrics outpatient clinics for suspicion of nonovarian pathologies. Nineteen individuals were excluded from the study due to incomplete ultrasound scanning. For the remaining 121 cases, gray scale ultrasound evaluation was performed followed by color Doppler imaging, power Doppler imaging, advanced dynamic flow, color SMI, and monochrome SMI to detect the presence and degree of vascularity in the ovaries. Ultrasound scanning was performed for all participants by the same doctor by using curvilinear probe via the suprapubic approach, and the images were independently evaluated by 3 different observers. The images were assessed with regard to the degree of vascularity and the presence of artifacts.

RESULTS

A total of 146 ovaries (42 right, 54 left, and 25 bilateral) were examined by sonography. The mean interrater agreement regarding the detection of vascularity was moderate for the color Doppler imaging, power Doppler imaging, advanced dynamic flow, and monochrome SMI techniques (κ = 0.514-0.551) and substantial for the color SMI technique (κ = 0.636) (P < .001). The techniques were found to be statistically significant for detecting vascularity: monochrome SMI > color SMI > power Doppler imaging > color Doppler imaging > advanced dynamic flow (P < .001).

CONCLUSION

SMI is a promising tool that can detect ovarian vascularity more effectively than the conventional Doppler ultrasound techniques.

No. 341-Diagnosis and Management of Adnexal Torsion in Children, Adolescents, and Adults

OBJECTIVE

To review the evidence and provide recommendations on the diagnosis and management of adnexal torsion in children, adolescents, and women.

OUTCOMES

Elements evaluated include the risk factors, diagnostic accuracy, management options, and outcomes of adnexal torsion.

EVIDENCE

Published literature was retrieved through searches of MEDLINE, Embase, CINAHL, and the Cochrane Library using appropriate controlled vocabulary and key words ("adnexal torsion," "ovarian torsion"). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and new material incorporated in the guideline to December 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The evidence obtained was reviewed and evaluated by the Canadian Paediatric and Adolescent Gynaecology and Obstetrics Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) under the leadership of the principal authors. Recommendations were made according to guidelines developed by the Canadian Task Force on the Periodic Health Examination.

BENEFITS, HARMS AND COSTS

Guideline implementation should assist the practitioner in developing an optimal approach to the diagnosis and management of adnexal torsion while minimizing harm and improving patient outcomes.

VALIDATION

These guidelines have been reviewed and approved by the Gynaecology Committee of the SOGC and approved by the council of the SOGC.

SPONSOR

The Society of Obstetricians and Gynaecologists of Canada SUMMARY STATEMENTS: RECOMMENDATIONS.

Pediatric ovarian torsion: Follow- up after preservation of ovarian tissue

BACKGROUND

The aim of this study was to evaluate the efficiency of the preservation of ovarian tissue in cases of ovarian torsion.

MATERIALS AND METHODS

A retrospective study was performed of patients treated at our hospital for ovarian torsion from January 2007 to December 2017. This research does not include patients with antenatal ovarian torsion and 1 girl with an immature teratoma, in whom the twisted ovary was removed during the initial operation. Follow-up ultrasonography of all patients was performed after 4-6 weeks and again after more than 12 weeks. Volume, blood flow and folliculogenesis of the ovary were measured and assessed.

RESULTS

All 42 ovaries (39 patients) preserved their normal anatomy and folliculogenesis after detorsion. All patients had an enlarged ovary at the time of detorsion. In all cases of ovarian torsion, enlargement of the ovary up to an average of 58.14 ± 52.86 (17.37-86.83) ml was detected. After 4-6 weeks, all untwisted ovaries decreased in volume by an average of 9.01 ± 13.69 (2.33-9.30) times, and 59.5% of them became normal in size. In 3 girls, enlarged ovaries were still observed after 12 weeks. Teratoma was diagnosed for these patients and ovarian sparing operations were performed.

CONCLUSIONS

It is safe to perform detorsion regardless of the level of ischemia or volume of the affected ovary. The follow-up is essential, especially for the further diagnostics of potential pathological structures or tumors; therefore, the normalization of blood flow and the volume of the ovary must be monitored.

TYPE OF STUDY

Prognosis retrospective study.

LEVEL OF EVIDENCE

II.

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.

Conservative laparoscopic management of adnexal torsion based on a 17-year follow-up experience

Laparoscopic unwinding of adnexal torsion has been proposed for decades. However, this technique is still controversial regarding the concern of thromboembolic events. We present two cases of conservative laparoscopic management of adnexal torsion. In the first case, a 16-year-old adolescent with serous cystadenoma was successfully managed by untwisting and cystectomy. We followed up this patient for 17 years with regular re-examinations in our hospital. To the best of our knowledge, this is the longest follow-up reported of this condition. In the second case, a 32-year-old infertile woman who received oocyte retrieval 3 days before being admitted to hospital was referred to hospital with right ovarian torsion. We treated her successfully based on our long-term follow-up experience, and she is now asymptomatic and in her 7th month of pregnancy.

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.

Asynchronus bilateral ovarian torsions in girls-systematic review

BACKGROUND

Bilateral ovarian torsions with complete loss of ovaries is devastating. This study analyzed the literature on bilateral ovarian torsions in girls to evaluate surgical options and outcomes.

METHODS

Literature was searched on Pubmed^® (1987-2014) using terms "bilateral", "adnexal", "ovary", "torsion" and "children". Data were collected on age, surgical preference, pathology and outcomes.

RESULTS

Thirteen articles were identified, and 9 met the inclusion criteria (5 case reports, 4 original articles); and analyzed 17 girls (mean age: 8.75 years, range: 1-16). Bilateral oophorectomies (n=4), ipsilateral oophorectomy of severely affected ovary and contralateral oophoropexy (n=10), and detorsion of bilateral ovaries and bilateral oophoropexy (n=3) were performed. One torsion recurrence occurred after two oophoropexies. Laparoscopy and open surgery was done in 2 and 15 girls, respectively. Considering etiology, there were simple tubo-ovarian torsions (n=8), polycystic ovary (n=1), polycystic ovary associated with Down syndrome (n=1) and corpus luteum cyst (n=1). No tumors were reported. Serial ultrasound follow-ups of ipsilateral oophorectomy and contralateral oophoropexy (n=5) confirmed follicular function (n=4) and viability and position of the ovary (n=1).

CONCLUSIONS

Though extremely rare, school age girls present bilateral ovarian torsion. Ipsilateral oophorectomy and contralateral detorsion with oophoropexy has been the preferred approach.

Polycystic ovary syndrome with asynchronous bilateral adnexal torsion in a natural cycle

Cases involving polycystic ovaries (PCOs) with adnexal torsion in a natural cycle without ovulation induction are rare, and no reports of such cases have described asynchronous bilateral adnexal torsion. Here, we report a case of PCO syndrome (PCOS) with asynchronous bilateral adnexal torsion in a natural cycle. The patient was a 37-year-old woman with a history of 2 gravidas 1 para. Her primary complaint was left lower abdominal pain. Ultrasonography and MRI identified multiple uterine myomas occupying the pelvis and the left ovary, with oedematous swelling that had moved ventrally to the uterus. She was diagnosed with adnexal torsion and underwent emergency laparoscopic adnexectomy. Nine months after surgery, she experienced right lower abdominal pain. Ultrasonography revealed suspected right adnexal torsion and she underwent emergency surgery. The right ovary was twisted 540° counterclockwise and swollen to 7 cm in size, with partial polycystic changes. She was histopathologically diagnosed with a PCO, and the final diagnosis, which also considered the endocrine test results, was PCOS. In PCOS, adnexal torsion may occur if the swollen ovary moves because of a hysteromyoma or other cause. Accordingly, torsion should be considered during the follow-up of patients with PCOS.

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

STUDY OBJECTIVE

Ovarian torsion (OT) is uncommon, but can result in loss of reproductive function. Traditionally managed using adnexectomy, torsed adnexae are now being conserved, increasing the potential for recurrent OT. As a result, some experts suggest oophoropexy (OP) to prevent recurrence. We report on a series of 11 patients who underwent OP. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A retrospective case series was conducted from 2004 to 2013 to identify patients younger than the age of 18 years with OT. From this, data for patients with OP were extracted for detailed review.

RESULTS

We identified 97 patients with OT; 6 of 97 (6.2%) had recurrent OT. The rate of recurrence was higher (14.8%, 4/27) in the group with torsion without an adnexal mass. Eleven of 97 patients (11.3%) underwent OP. The mean age of patients with OP was 8.8 years. Nine patients had normal adnexae at initial torsion. Five of 11 had OP during their initial procedure. OP was most commonly performed for long utero-ovarian ligaments (n = 6), recurrence (n = 4), or bilateral OT (n = 2). Eight of 8 patients with follow-up ultrasound imaging after torsion showed at least 1 marker of normal ovarian function. One of 11 patients (9%) had a recurrence of OT of an oophoropexied ovary. There were no complications due to the OP portion of the procedure.

CONCLUSION

In our series of OT, a small percentage of patients underwent prophylactic OP. Recurrence might still occur after OP. It seems reasonable to offer OP to patients at higher risk of recurrent OT although level 1 evidence is lacking. Future research should focus on techniques and long-term outcomes of OP.

Variability in surgical management of benign ovarian neoplasms in children

BACKGROUND/PURPOSE

Although most pediatric ovarian neoplasms are benign and may be treated with ovary-sparing surgery (OSS), consensus is lacking on the optimal surgical approach. We aimed to determine the proportion of pediatric benign ovarian neoplasms managed with OSS and to assess variability in management across hospitals and specialties.

METHODS

Using the Pediatric Health Information System, we studied patients aged 6-21 years treated in 2006-2014 for a benign ovarian neoplasm with oophorectomy or OSS. Inter-hospital variability and predictors of the type of surgery were determined using logistic mixed effects models with random hospital effects.

RESULTS

Of 1164 patients with benign ovarian neoplasms, 646 underwent oophorectomy, and 518 underwent OSS. Across hospitals, there was significant variability in the proportion of OSS (range: 21.7-76.6%). In multivariable analysis, patients managed by pediatric surgeons (vs. pediatric and adolescent gynecologists) (OR: 0.27, 95%CI: 0.17-0.43, p<0.001), younger patients (OR: 0.94 per year, 95%CI: 0.90-0.98, p=0.007), and those admitted through the emergency department (OR: 0.76, 95%CI: 0.58-0.99, p=0.04) were less likely to undergo OSS. Inter-hospital variability remained significant after adjusting for relevant patient and hospital characteristics (p<0.001).

CONCLUSIONS

Significant variability exists in management of benign ovarian neoplasms across hospitals and specialties. Collaborative efforts between treating specialists may improve implementation of evidence-based guidelines for OSS.

TYPE OF STUDY

retrospective study LEVEL OF EVIDENCE: III.

Pediatric Ovarian Torsion and its Recurrence: A Multicenter Study

STUDY OBJECTIVE

To report results of a retrospective multicentric Italian survey concerning the management of pediatric ovarian torsion (OT) and its recurrence.

DESIGN

Multicenter retrospective cohort study.

SETTING

Italian Units of Pediatric Surgery.

PARTICIPANTS

Participants were female aged 1-14 years of age with surgically diagnosed OT between 2004 and 2014.

INTERVENTIONS

Adnexal detorsion, adnexectomy, mass excision using laparoscopy or laparotomy. Different kinds of oophoropexy (OPY) for OT or recurrence, respectively.

MAIN OUTCOME MEASURES

A total of 124 questionnaires were returned and analyzed to understand the current management of pediatric OT and its recurrence. The questionnaires concerned patient age, presence of menarche, OT site, presence and type of mass, performed procedure, OPY technique adopted, intra- and postoperative complications, recurrence and site, procedure performed for recurrence, OPY technique for recurrence, and 1 year follow-up of detorsed ovaries.

RESULTS

Mean age at surgery was 9.79 ± 3.54 years. Performed procedures were open adnexectomy (52 of 125; 41.6%), laparoscopic adnexectomy (25 of 125; 20%), open detorsion (10 of 125; 8%), and laparoscopic detorsion (38 of 125; 30.4%). Recurrence occurred in 15 of 125 cases (12%) and resulted as significant (P = .012) if associated with a normal ovary at the first episode of torsion. Recurrence occurred only in 1 of 19 cases after OPY (5.2%). Ultrasonographic results of detorsed ovaries were not significant whether an OPY was performed or not (P = 1.00).

CONCLUSION

Unfortunately, oophorectomy and open technique are still widely adopted even if not advised. Recurrence is not rare and the risk is greater in patients without ovarian masses. OPY does not adversely affect ultrasonographic results at 1 year. When possible OPY should be performed at the first episode of OT.

Evolution in the Management of Pediatric and Adolescent Ovarian Torsion as a Result of Quality Improvement Measures

STUDY OBJECTIVE

The aim of this study was to document the change in ovarian conservation rate after ovarian torsion as a result of continuous quality improvement (CQI) measures, and to determine factors that contribute to this outcome.

DESIGN

A retrospective, uncontrolled before-and-after study.

SETTING

An academic children's hospital.

PARTICIPANTS

Female adolescents younger than 18 years with surgically confirmed ovarian torsion from April 1, 1988 to October 15, 2013; excluding cases from 2003 (intervention period).

INTERVENTIONS

Implementation of CQI measures including educational programs, collaborative care pathways, and quality review with the goal of improving ovarian conservation.

MAIN OUTCOME MEASURES

Demographic characteristics, details on presentation, investigations, consultation, surgical intervention, surgical findings, pathology, postoperative course, and follow-up imaging.

RESULTS

One hundred thirty-nine patients met inclusion criteria (42 pre-CQI cohort and 97 post-CQI cohort). Mean ages were 9.96 and 10.33 years, respectively. Ovarian conservation rates were 47.6% compared with 85.6%, respectively (P < .001). The following factors differed between cohorts: fever (P = .003), ultrasound completed (P = .001), time from first health care provider visit to imaging (P = .025), time from specialist consultation to surgery (P = .002), surgical start time within 1 hour of booking (P < .001), and gynecologist present in operating room (P < .001). A log-binomial regression model showed that gynecology presence in the operating room (relative risk [RR], 2.043) was associated with untwisting. Increasing time from specialist consultation to surgery (RR, 0.986 per hour) was inversely associated with untwisting. Fever at presentation was also inversely associated with untwisting (RR, 0.666).

CONCLUSION

The implementation of CQI measures was associated with a significant increase in ovarian conservation rate.

The effect of metamizole on ischemia/reperfusion injury in the rat ovary: An analysis of biochemistry, molecular gene expression, and histopathology

Objectives:

In this study, we investigated the effect of metamizole on ischemia/reperfusion (I/R) injury an analysis of biochemistry, molecular gene expression, and histopathology in the rat ovary of female albino Wistar rats.

Materials and Methods:

Animals were divided into four groups; control group with induced ischemia-reperfusion (IRC), ischemia-reperfusion +100 mg/kg metamizole sodium (MS) (IRM-100), ischemia-reperfusion +200 mg/kg MS (IRM-200), and healthy group applied sham operation (SG).

Results:

Myeloperoxidase (MPO) activity and gene expression increased significantly in IRC and IRM-100 group rat ovarian tissue compared with the SG group (P < 0.0001). However, MPO activity and gene expression in IRM-200 group ovarian tissue decreased significantly compared with the IRC and IRM-100 groups (P < 0.0001). Histopathologically, pronounced congestion, dilated vessels, hemorrhage, edema, degenerative cells, and neutrophil migration and adhesion to the endothelium were observed in the IRC and IRM-100 group ovarian tissues. A small number of congested dilated vessels, mild congestion, and edema were observed in the IRM-200 group, but no neutrophil migration and adhesion to the endothelium or degenerative cells.

Conclusions:

At 200 mg/kg dose metamizole prevented ovarian injury induced with I/R. This data show that metamizole can be used in the ovarian I/R injury treatment.

Oxidative Stress during Ovarian Torsion in Pediatric and Adolescent Patients: Changing The Perspective of The Disease

Among the different causes of gynecological acute pelvic pain, ovarian torsion represents a surgical emergency. It is a rare case in the pediatric/adolescent aged group that must be included in the differential diagnosis of any girl with abdominal pain or pelvic/abdominal mass. Current recommendations suggest that laparoscopic detorsion should be performed in order to preserve the integrity of the ovaries and fertility, although oophoropexy may be considered in case of severe necrosis. Nevertheless, maintaining the circulation of the ovary after detorsion deteriorates the tissue injury and leads to a pathologic process called ischaemia/reperfusion (I/R) injury, which is characterized by oxidative stress. During the detorsion process, an excess amount of molecular oxygen is supplied to the tissues, and reactive species of oxygen (ROS) such as superoxide radical (O₂^-), hydrogen peroxide (H₂O₂), hydroxyl radical (OH•), as well as reactive nitrogen species (RNS) are produced in excess. ROS, RNS and their toxic products cause DNA damage and lipid peroxidation in the cellular and mitochondrial membranes, leading to cell death. In spite of attention on this topic, currently there is no shared and clear evidence about the use of anti-inflammatory and antioxidant agents to prevent I/R damage after laparoscopic ovarian detorsion. Considering this element, future research should aim to develop shared protocols for the clinical use (route of application, dosage and time of application) of antioxidants after laparoscopic management of this condition.

Recurrent Ipsilateral Ovarian Torsion: Case Report and Literature Review

BACKGROUND

Recurrent ipsilateral ovarian torsion at pediatric age is a rare event. Different surgical techniques for its prevention are available. We present a case of recurrent ipsilateral ovarian torsion in a prepubertal girl and we reviewed the literature about the management of this condition.

CASE

A 6-year-old girl presented with right ovarian torsion and underwent a laparoscopic untwisting. Nine months later an ipsilateral recurrence occurred. Laparoscopic untwisting and right-sided oophoropexy with plication to the round ligament was performed.

SUMMARY AND CONCLUSION

In addition to our presented case, four cases of recurrent ipsilateral ovarian torsion in pediatric patients were identified in the literature. The few available reports in the pediatric literature show different management techniques. A long-term study is necessary to define the most effective treatment.

Presentation, Diagnosis, and Treatment of Ovarian Torsion in Premenarchal Girls

STUDY OBJECTIVE

To describe the clinical characteristics and treatment of ovarian torsion in premenarchal girls with surgically verified ovarian torsion.

DESIGN AND PARTICIPANTS

A retrospective cohort study design was used. The medical charts of all premenarchal girls with surgically verified ovarian torsion treated in a university-affiliated tertiary medical center from 1997 to 2012 were reviewed for clinical, treatment, and outcome data.

RESULTS

Thirty-two premenarchal girls were identified. Their median age was 9 years. There were 7 recurrences during the study period (17.9%), for a total of 39 cases. The main presenting symptoms were abdominal pain (92.3%) and nausea and vomiting (84.6%). Physical examination revealed abdominal tenderness in 25 cases (64.1%). Abdominal ultrasound, performed in 31 patients (38 cases), yielded pathologic findings in 28 (73.7%), mainly an enlarged ovary (11 cases, 28.9%). Doppler flow studies were abnormal in 15 cases. In 26 cases (68.4%), the tentative preoperative working diagnosis was ovarian torsion. Laparoscopy was performed in 26 cases, laparotomy in 10, and laparoscopy converted to laparotomy in 3 cases. Conservative management, mainly with additional cyst drainage or cystectomy, was used in 37 cases (95.2%) with oophoropexy in 5 cases. Two patients required oophorectomy because of a suspected neoplasm and severe ovarian necrosis. Pathologic examination demonstrated 5 simple cysts, 1 necrotic ovary, and 1 mature cystic teratoma.

CONCLUSIONS

Ovarian torsion in premenarchal girls is associated with nonspecific signs and symptoms. Abdominal ultrasound and Doppler imaging may assist in the diagnosis. Laparoscopy with conservative management is preferred. Owing to the high recurrence rate, oophoropexy may be considered.

A normal ovary in an abnormal location: A case of torsion

The clinical and radiologic diagnosis of adnexal torsion is challenging. The patient's history, physical examination, and laboratory evaluation may overlap significantly with other causes of abdominal pain. Ultrasound is the most common radiologic tool to assess for torsion, and the imaging findings can be equally equivocal. We present a case of adnexal torsion in an 18-year-old emergency room patient with abdominal pain, diagnosed by ultrasound based solely on an abnormal medial position of the ovary-a finding that has been only rarely mentioned in the literature, and never in isolation.

Laparoscopic uteroovarian ligament truncation and uterosacral oophoropexy for idiopathic recurrent ovarian torsion: case report and review of literature

Background

Unilateral recurrent ovarian torsion in adults is unusual following treatment of common underlying risk factors (e.g. benign cysts). Subtle anatomic etiologies, such as an elongated uteroovarian ligament and robust ovarian volume, are commonly underappreciated and may contribute to idiopathic recurrent unilateral torsion in adults. As seen in this case, combined surgical procedures may be required to prevent recurrence.

Case

28 year old nulligravid woman with seven episodes of right ovarian torsion (without adnexal pathology)—six of those within 18 months—refractory to a series of previous surgical interventions. Laparoscopic uteroovarian ligament truncation with interval uterosacral ligament oophoropexy was employed. Ovarian torsion has not occurred in 45 months.

Conclusion

Uteroovarian ligament truncation and uterosacral ligament oophoropexy is a feasible and effective combined surgical approach for the prevention of recurrent idiopathic ovarian torsion in adults without obvious risk factors.

The Effect of Controlled Reperfusion in the Prevention of Infertility Caused by Ischemia Induced in the Contralateral Ovary in Rats with Unilateral Ovariectomy

BACKGROUND/AIMS

To investigate the effectiveness of controlled reperfusion (CR) on ovarian tissue malondialdehyde, total glutathione and 8-hydroxyguanine levels and infertility rates in a rat model of induced ischemia-reperfusion (I/R) injury with unilateral oophorectomy.

METHODS

A total of 135 adult female albino Wistar rats were divided into 9 groups (n = 15 for each group): unilateral ovariectomy + ovarian I/R (OIR), unilateral ovariectomy alone (OEG), a sham operation group (SG), and unilateral ovariectomy + CR performed at different intervals (the clips were released 10 times for 10, 8, 6, 4, 2 or 1 s and closed again 10 times for 10, 8, 6, 4, 2 or 1 s; OCR-1-6, respectively). Five rats from each group were sacrificed, and their ovaries were removed.

RESULTS

Higher ovarian tissue malondialdehyde and 8-hydroxyguanine levels and lower ovarian tissue total glutathione levels were found in the OIR group compared with the SG, OEG and OCR-4-6 groups. The number of rats giving birth during the study period was found to be similar among the SG (n = 8), OEG (n = 8) and OCR-6 (n = 7) groups.

CONCLUSION

These results suggest that sterility and ovarian oxidative stress caused by I/R injury decreases in parallel to the shortening of CR duration.

Update on the management of ovarian torsion in children and adolescents

BACKGROUND

Ovarian torsion is commonly seen in young girls. Unfortunately it is often misdiagnosed because of its non-specific symptoms and lack of diagnostic modalities. This article focuses on the diagnostic challenge and also the changes in the management of ovarian torsion.

DATA SOURCES

We reviewed original reports on the management of ovarian torsion in young girls published from 1984 till 2014. A literature search was conducted by electronic scanning of five electronic database: MEDLINE, EMBASE, SCI, SSCI and CINAHL. In addition, relevant papers and review articles were hand-searched. The search was limited to English language and human studies. The search was conducted by combining the textwords "ovarian torsion", "adnexal torsion", "adolescents" and "oophoropexy".

RESULTS

There are no specific symptoms that can be identified as a pathognomonic feature of ovarian torsion. Ultrasound is a useful diagnostic tool, but it is not always reliable in absence of an enlarged ovary. Laparoscopic detorsion is recognized as the mainstay of treatment regardless the condition of the ovaries. Reports have shown favorable ovarian function after detorsion. The role of oopheropexy remains controversial.

CONCLUSIONS

Clinicians should be aware of ovarian torsion in girls presenting with abdominal pain. A timely management in this young population can help preserve their ovaries and fertility.

Asynchronous bilateral ovarian torsion. A case report and mini review

BACKGROUND

Adnexal torsion is a serious condition and delay in surgical intervention may result in loss of ovary. Children and adolescents who have suffered from uterine adnexal torsion may be at risk for asynchronous torsion of the contralateral adnexa.

CASE

We report the case of asynchronous bilateral ovarian torsion in a 9-year-old girl, resulting in right and subsequently left salpingo-oophorectomy.

CONCLUSION

The diagnosis of ovarian torsion often is delayed. When ovarian torsion is suspected, laparoscopy should be performed without delay, and conservative management should be strongly considered to prevent surgical castration. Oophoropexy of the ipsilateral and contralateral ovary should be considered to prevent a recurrent torsion.

Should the ovary always be conserved in torsion? A tertiary care institute experience

AIM

The aim of this study was to analyze our experience in conserving ovarian tissue in cases of ovarian torsion, irrespective of grade of necrosis at exploration.

MATERIALS AND METHODS

All children with a diagnosis of ovarian torsion admitted to our hospital from January 2009 to January 2013 were included. Patients with underlying ovarian pathology were excluded.

RESULTS

There were 13 torsions in 12 children (one bilateral). All underwent detorsion with or without evacuation of hematoma. Follow-up ultrasonography (USG) with color Doppler was done for all 13 ovaries, which showed an ovary with good vascularity and follicular development in 12 ovaries (92%). In 76% (10 of 13) of cases, intraoperatively, the ovary was judged to be moderately to severely ischemic/necrotic. Yet, follow-up sonograms showed the ovary with follicular development in all cases except one (7%). There were no major complications in our series.

CONCLUSION

Simple detorsion, instead of traditionally advocated oophorectomy, was not accompanied by an increase in morbidity. On follow-up, almost all patients studied had functioning ovarian tissue despite the grave ischemia observed intraoperatively. Detorsion should be the procedure of choice for all cases of simple ovarian torsion in children.

Predictors of ovarian malignancy in children: overcoming clinical barriers of ovarian preservation

BACKGROUND/PURPOSE

Ovarian preservation is desirable in girls with benign ovarian masses. We aimed to 1) identify clinical predictors of malignant ovarian masses, 2) investigate how often ovarian tissue is present to preserve in benign masses, and 3) identify factors associated with successful ovarian preservation.

METHODS

Retrospective analysis (1997-2012) of girls age 1-18years with an ovarian mass managed operatively. Data on presenting symptoms, imaging, biochemical markers, treatment, outcome, and pathology were extracted.

RESULTS

We identified 150 patients. Large mass size, solid components, and elevated tumor markers (AFP, βHCG, and/or LDH) were significantly predictive of malignancy. All masses <10cm, predominantly cystic, and with negative tumor markers were benign. Masses with all three of these characteristics would decrease a 20% malignancy pretest probability to a posttest probability of 0.25%. Benign masses managed by oophorectomy contained normal ovarian tissue in 76% of the specimens. For benign masses, successful ovarian preservation was significantly associated with size <10cm, predominantly cystic, laparoscopy, and absence of torsion or calcifications.

CONCLUSION

Ovarian masses that are <10cm, primarily cystic, and have negative tumor markers are most likely benign. Viable ovarian tissue is frequently present in benign masses, so significant efforts should be made for ovarian preservation.

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.