Large ovarian cyst causing cecal perforation in a newborn infant

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.

Conservative treatment for complex neonatal ovarian cysts: a long-term follow-up analysis

OBJECTIVE

We aimed to investigate safety and effectiveness of a conservative approach for complex neonatal ovarian cysts and its long term impact on fertility.

STUDY DESIGN

Neonates with congenital complex ovarian cysts were conservatively managed and followed from the perinatal period to adolescence. Statistical analysis included Student's t-test, Mann-Whitney U-test, the Kaplan-Meier method, and the receiver operating characteristic curve.

RESULTS

The post-natal progressive dimensional reduction of diagnosed ovarian cyst was statistically significant. The Kaplan-Meier survival curves revealed the probability of persistence of the cyst was up to 5% at the age of 25 months. Long term follow-up revealed both ovaries visible at US in 60% of adolescent patients.

CONCLUSION

Conservative management of asymptomatic complex neonatal ovarian cysts can be safely undertaken. As far as the chances of the ovarian tissue to survive conservative treatment are concerned, the results are not encouraging.

Neonatal ovarian torsion complicated by intestinal obstruction and perforation, and review of the literature

We present a case of neonatal ovarian torsion complicated by bowel obstruction and perforation and review the literature regarding the incidence of bowel obstruction in neonatal ovarian cysts, the presentation, and treatment. A term neonate was prenatally diagnosed with a cystic abdominal mass palpable on physical examination. A postnatal abdominal x-ray showed paucity of gas in the left hemiabdomen with rightward displacement of bowel loops. Exploratory laparotomy on day 2 of life revealed a large cystic mass in the left lower quadrant consistent with a torsed left ovary, an omental band causing strangulation of the bowel mesentery, and a perforation of the distal ileum. Our literature search revealed 19 reported cases of neonatal ovarian cysts resulting in bowel obstruction. Infants may present with a palpable abdominal mass, respiratory distress, as well as signs and symptoms of intestinal obstruction. Two mechanisms exist for bowel obstruction: adhesions caused by a torsed necrotic ovary and mass effect of a large ovarian cyst, often measuring 9 to 10 cm in diameter. Options to treat ovarian cysts include antenatal or postnatal aspiration, laparoscopy, and laparotomy. Cysts less than 4 to 5 cm can be observed, whereas operative intervention is indicated in symptomatic cases and in persistent or enlarging ovarian cysts.

Is the stripping technique a tissue-sparing procedure in large simple ovarian cysts in children?

BACKGROUND

Stripping of the cystic wall is performed by gynecologists to treat large ovarian cysts. Information in the pediatric population is poor. We prospectively evaluated the pathologic specimens of large ovarian cyst to determine whether the stripping technique is a tissue-sparing procedure even in this age.

METHODS

We evaluated 5 patients. Samples were taken from the intermediate part of the cystic wall and from the layer covering the cyst during excision. The presence of ovarian tissue adjacent to the cyst wall, and the morphological features of the surrounding tissue were both evaluated. Pelvic ultrasound follow-up was also performed.

RESULTS

Patients' mean age was 4.5 years (7 days to 12 years). All cysts were removed because all were symptomatic. The mean diameter was 86.6 mm (74-100 mm). Cysts were follicular in 2 cases, serous in other two, and endometriotic in 1 case. Adjacent ovarian tissue was present in 1 of 5 specimens and was approximately 1 to 2 mm in thickness. The layer adjacent to the cystic wall always appeared as normal ovarian tissue. Ultrasound scans at follow-up revealed presence of ovarian tissue.

CONCLUSION

The stripping procedure for large ovarian cyst excision allows to spare the adjacent normal ovarian tissue even in pediatric age because ovarian tissue is rarely excised with the cyst wall during the procedure.

Transumbilical management for neonatal ovarian cysts

BACKGROUND/PURPOSE

Since Tan and Bianchi (Br J Surg. 1986;73:399) reported umbilical incision as an access for pyloromyotomy in infantile hypertrophic pyloric stenosis, many pediatric surgeons have used this approach for a number of other procedures. Because of the long pedicle with good mobility and the frequent intraabdominal position of the neonatal ovarian cyst, we attempted to manage it via the transumbilical route.

METHODS

All patients were treated under intubation general anesthesia. Semicircular infraumbilical incision was made, and the abdomen was entered through a transverse fascial incision. The partially collapsed cyst after aspiration was exteriorized through the incision for cystectomy, partial deroofing, or adnexectomy.

RESULTS

From May 2000 to December 2006, 6 female newborns with ovarian cysts were treated via the transumbilical route. There were no complications from surgery. The operation time and duration of hospital stay were short. The cosmetic appearance after the procedure was good.

CONCLUSIONS

The initial result suggests that transumbilical management for neonatal ovarian cysts may be a good alternative procedure when laparoscopic equipment is unavailable or experienced technique is lacking.

Is Conservative Management of Prenatal and Neonatal Ovarian Cysts Justifiable?

OBJECTIVES

To evaluate conservative management of fetal and neonatal ovarian cysts.

METHODS

We followed the progress of 11 fetal and 2 neonatal ovarian cysts.

RESULTS

Ten fetal cysts were simple at recognition, but 8 silently became complex by birth, with ovarian loss in 6/11 cases (54%). In 2 cases where large simple cysts presented for the first time at birth, serious complications occurred, resulting in the death of 1 newborn.

CONCLUSIONS

If a fetal ovarian cyst is already complex before birth it can be managed conservatively, albeit with loss of the ipsilateral ovary in the majority of cases. As simple fetal ovarian cysts frequently become complex before birth, intervention may be justifiable to preserve the ovary. But any intervention also has the potential for complications, and may be ineffective. Intervention also requires accurate differentiation of ovarian cysts from other abdominal cysts.

Neonatal Ovarian Cysts: Management with Reference to Magnetic Resonance Imaging

OBJECTIVE

Ultrasound (US) has been used as a tool to determine the indication for surgery for neonatal ovarian cysts. The purpose of this study was to investigate whether magnetic resonance imaging (MRI) contributes to optimal management.

METHODS

Between 1993 and 2001, US and MRI studies were simultaneously performed on 13 consecutive infants younger than 2 months of age with ovarian cysts. The US Patterns were classified as complex or simple. Signal intensity (SI) of the cysts on MRI was compared with that of the liver on T1-weighted images (T1WI) and with urine on T2-weighted images (T2WI). We assumed that high SI on T1WI and iso or low SI on T2WI indicated complications.

RESULTS

There were 10 complex and three simple cysts on US. Of the 10 complex cysts, two had no complications at surgery or resolved spontaneously. These two cysts showed low SI on T1WI. Eight complex cysts showed high SI on T1WI and all were haemorrhagic. The US diagnosis corresponded to the MRI findings in three simple cysts. The sensitivity of US for haemorrhage was 80%, and that of MRI was 100%.

CONCLUSIONS

We found that MRI was a more reliable diagnostic modality than US for diagnosing neonatal ovarian cysts.

Ovarian masses in the newborn

Prenatal sonography uncovers many fetal ovarian masses that previously would have gone unrecognized. This challenges clinicians to learn the natural history of these asymptomatic lesions so as to provide the best care postnatally. Spontaneous resolution of simple ovarian cysts is expected by about 6 months of age, which is attributed to predicted changes in the postnatal hormonal milieu. After birth, levels of human chorionic gonadotropin (HCG) and estrogen plummet. Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) rise until about 3 months of age and then fall as the "gonadostat" matures. Although symptomatic cysts demand intervention, simple asymptomatic cysts less than 5 cm in diameter should be left alone but reassessed sonographically. If simple cysts are larger than 5 cm in diameter the risk of torsion may be significant, and intervention often is advocated. However, the risk of torsion versus the likelihood of resolution is not well established. The therapeutic goal for a clinician managing a newborn with a simple ovarian cyst is to maximize ovarian salvage. Aspiration alone may be a reasonable option. The laparascopic approach to the neonatal ovarian cyst provides a view of both ovaries and allows aspiration, unroofing, cystectomy, or ovariectomy. The sonographically complex cyst usually represents adnexal torsion but could be a neoplasm and warrants intervention because the morbidity from untreated neonatal adnexal torsion can be significant beyond loss of the ovary (eg, hemorrhage, peritonitis, intestinal obstruction, or a wandering tumor).

Ovarian cysts in the pediatric population

With the widespread availability and use of pelvic sonography, the rate at which ovarian cysts are detected in the pediatric population has increased, and such cysts are an important problem encountered in pediatric surgical practice. Rational management should take into account key factors such as symptoms, patient age, menarchal status, cysts size, and character, as well as associated medical conditions. The purpose of this review is to discuss the incidence and pathophysiology of ovarian cysts in children. A management strategy is presented based on the above-mentioned key factors.

Surgical indications in antenatally diagnosed ovarian cysts

The antenatal diagnosis of ovarian cysts poses a therapeutic dilemma because the natural history of these lesions is not well known. A retrospective review from 1980 to 1989 showed 29 ovarian cysts in 27 patients diagnosed by prenatal ultrasonography performed between 28 and 36 weeks of gestation. Nineteen cysts were initially observed. Eleven cysts resolved (diameter less than 2 cm), three are decreasing, three were lost to follow-up, and two underwent resection. Eight patients underwent surgical exploration immediately following birth. The diagnosis of benign ovarian cyst was confirmed histologically in all cases. A review of the literature showed an additional 230 cases of antenatally diagnosed ovarian cysts. Simple cysts of the ovary tend to resolve spontaneously and, therefore, may be treated conservatively. Serial ultrasonography allows accurate diagnosis and long-term assessment of ovarian cysts in the neonate and may prevent unnecessary oophorectomy. Patients with cysts larger than 4 cm may be candidates for percutaneous aspiration, or should undergo removal of the cyst because of a significant risk of torsion. Complex cystic masses, symptomatic ovarian cysts, and cysts that do not resolve should be removed.

Surgical treatment of ovarian tumors in childhood

From 1971 to 1988, 45 girls aged 1 week to 17 years were treated for a total of 46 solid and cystic tumors of the ovaries. Pathohistological examination revealed epithelial tumors in eight cases, a tumor originating from the ovarian stroma in one case, germinal tumors in 17 cases, 15 functional ovarian cysts, and five paraovarian cysts. The stroma tumor and four of the 17 germinal tumors were malignant. Surgical treatment for solid tumors consisted generally of a unilateral salpingo-oophorectomy, but in operations for cystic tumors as well, vital ovarian tissue could only rarely be preserved. Functional ovarian cysts were excised if they were larger than 5 cm. Subsequent to excision of malignant tumors, chemotherapy with cisplatin, vincristine and bleomycin was performed. On follow-up, all patients with benign lesions were well. One of the girls with malignancies died and another is undergoing chemotherapy for tumor recurrence in the contralateral ovary.

Neonatal ovarian cysts: therapeutic dilemma

Seven cases of neonatal ovarian cysts that presented over the past seven years were studied. Complications included torsion and rupture and usually occurred in cysts more than 5 cm in diameter. Surgical removal, either oophorectomy or cystectomy, was the treatment of choice. Because even cystectomy results in loss of normal ovarian tissue, and because spontaneous regression of cysts less than 5 cm in diameter can occur, a more conservative approach is now proposed. Regular ultrasonography alone is recommended if the cysts are less than 5 cm in diameter, and aspiration of the cysts followed by regular ultrasonographs if the cysts are more than 5 cm in diameter. Operation should be reserved for recurrent cysts or for those with complications. Cysts diagnosed antenatally may be aspirated in utero if there are signs of thoracic compression.

Neonatal ovarian torsion: report of three cases and review of the literature

Ovarian cysts are common incidental findings in term infants and, if unusually large, may result in dystocia, torsion, or rupture. Torsion and infarction of a normal ovary tend to occur in older childhood. During a 4-month period, 3 cases of neonatal ovarian torsion were observed after antenatal ultrasonography had detected fetal pelvico-abdominal cystic lesions. The three infants were explored between 4 and 16 days of age. Ovarian torsion was right-sided in all 3, and 1 ovary had been autoamputated. The resected specimens were nontense, thin-walled cysts, filled with hemorrhagic fluid, that measured between 4.5 and 8 cm in diameter. Microscopically, focal calcification and widespread necrosis precluded recognition of underlying histologic landmarks. Neonatal ovarian cysts or cystic ovaries greater than 4 cm in diameter should be excised, even if asymptomatic, because they are prone to, or have undergone, torsion.