Similar But Different: A Comparison of Adnexal Torsion in Pediatric, Adolescent, and Pregnant and Reproductive-Age Women

Comparison of salpingectomy and tubal detorsion procedures after experimental ischemia-reperfusion injury in a rat fallopian tube model: biochemical and histopathological evaluation

OBJECTIVE

To compare salpingectomy and detorsion procedures and investigate the biochemical and histopathological changes in the fallopian tubes in the experimentally isolated fallopian tube torsion model in rats.

DESIGN

Experimental study.

SETTING

Experimental surgery laboratory in a training and research hospital.

ANIMAL(S)

Twenty-seven Sprague-Dawley rats in the reproductive period.

INTERVENTION(S)

Group 1, control group (n = 6); group 2, bilateral total salpingectomy group after 4 hours of tubal ischemia (n = 7); group 3: 4 hours of bilateral tubal ischemia plus 1 week of reperfusion (n = 7); and group 4, 4-hour period of bilateral tubal ischemia plus 30 days of reperfusion (n = 7). A 22-gauge catheter was administered before and after surgery using methylene blue through the uterine horn of the rat to evaluate tubal patency.

MAIN OUTCOME MEASURE(S)

Preoperative and postoperative serum antimüllerian hormone (AMH) levels, histopathological examination of the rat tuba uterine and histopathological damage scores, antioxidant compounds (superoxide dismutase [SOD], catalase, and glutathione peroxidase [GSH-Px]), and oxidative stress end product levels (malondialdehyde [MDA] and 8-hydroxy-2'-deoxyguanosine [8-OHdG]).

RESULT(S)

Although a significant difference was observed in the tissue SOD, GSH-Px, MDA, and 8-OHdG values, no significant difference was observed between the groups in serum samples. The tissue SOD and tissue GSH-Px levels in group 2 significantly decreased, and a significant increase was observed in the tissue MDA and 8-OHdG values in group 2. Among the histopathological parameters, epithelial changes, vascular congestion, and the total fallopian tube mean damage score of 4 showed a significant decrease in group 4. When the methylene blue transitions before and after ischemia-reperfusion injury were compared, the values of the methylene blue transition after ischemia-reperfusion injury in groups 2-4 significantly decreased. When the serum AMH levels were analyzed, the postoperative AMH value in group 2 significantly increased.

CONCLUSION(S)

This study reveals that biochemical and histopathological improvement is observed in the fallopian tube tissues gradually when the detorsion procedure is performed for the necrotized tubal tissue instead of salpingectomy. Although there is restoration of epithelial integrity after reperfusion, tubal passage remains absent.

CLINICAL TRIAL REGISTRATION NUMBER

This study was approved by the Local Ethics Committee for Animal Experiments of the Health Sciences University, Istanbul Hamidiye Medicine Faculty (approval number 27.05.2022-9269). The study followed the ethics standards recommended by the Declaration of Helsinki.

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.

Ovarian Torsion and Its Remediation in a Three-Year-Old Girl

Ovarian torsion is a rare, emergent occurrence seen in the premenarchal population. If detected promptly, ovarian torsion can be treated via detorsion. We present a case of a three-year-old girl whose ovary spontaneously torsed and was corrected via ovarian detorsion. The patient presented with sudden-onset abdominal pain and emesis; a transabdominal ultrasound with Doppler was performed, which led to the diagnosis of ovarian torsion. The patient was directly taken into surgery for correction, after which she quickly recovered and was subsequently discharged. The choice of ovarian detorsion to protect fertility in pediatric patients is supported by this case and by the related literature. The key to safeguarding fertility in these patients lies in rapid detection, which remains a challenge in the pediatric population. By raising widespread awareness of the use of Doppler ultrasound as well as symptom presentation, the protection of fertility in cases of pediatric ovarian torsion can be improved.

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.

Diagnosis and Management of Pediatric Ovarian Torsion in the Emergency Department: Current Insights

Ovarian torsion is defined as twisting of the ovary around an axis consisting of its vascular pedicle, the infundibulopelvic ligament and the tubo-ovarian ligament, and can occur in females of any age. Torsion can be a result of ovarian mass causing asymmetry and subsequent torsion, or can be spontaneous. While ovarian torsion is a surgical emergency, early diagnosis and treatment can preserve ovarian viability even if necrosis is seen operatively. Presentation classically involves sudden onset severe abdominal pain and vomiting but diagnostic delay can follow subtler presentations. Diagnosis is most commonly based on sonographic findings, but advanced imaging such as CT or MRI may be required if sonography is not diagnostic. Treatment is surgical, with ovarian preservation preferred in almost all cases. In this review, I present the most recent evidence on epidemiology, diagnosis, and management of pediatric ovarian torsion, with a focus on point-of-care ultrasound for the emergency care provider.

Ovarian torsion: diagnosis, surgery, and fertility preservation in the pediatric population

Ovarian torsion is rare in the pediatric population. Delayed diagnosis can significantly impact fertility. The aim of this review is to highlight current knowledge regarding clinical presentation, diagnosis, surgical management, and follow-up in the pediatric population. Whilst the presentation is often very unspecific, most children will present with sudden severe unilateral pelvic pain associated with vomiting. A key diagnostic test is pelvic ultrasonography, which may help demonstrate an asymmetric enlarged ovary with peripherally displaced follicles. In the pediatric population, ovarian torsion may occur in a normal ovary. However, underlying lesions can be found in half of cases. Benign neoplasms (teratomas or cystic lesions) represent the commonest etiology, with the risk of malignancy being less than 2%. Surgical management should be focused on fertility preservation. This is achievable through ovarian detorsion ± ovarian cystectomy ± oophoropexy to avoid recurrence. Follow-up studies demonstrate excellent recovery rates of detorsed ovaries including those with ischemic appearances. What is Known: • Ovarian torsion is a rare diagnosis in the pediatric population. • Aspecific symptoms and differential diagnoses lead to missed or delayed diagnosis increasing the risk of oophoprectomy and further infertility. What is New: • Reviewing the latest knowledge about clinical presentation, diagnostic, surgical management, and follow-up of ovarian torsion in the pediatric population. • Adiponectin was negatively associated with diastolic blood pressure and HOMA-IR, and chemerin was negatively associated with glucose.

Pregnancy outcomes following laparoscopy for suspected adnexal torsion during pregnancy

OBJECTIVE

To evaluate pregnancy outcomes of women with surgically confirmed adnexal torsion (AT) as compared to those in whom AT was ruled out.

METHODS

A retrospective cohort study in a tertiary medical center. All pregnant women who underwent diagnostic laparoscopy due to suspected AT between 3/2011 and 4/2020 were included. We compared maternal, delivery and neonatal outcomes of both groups. We further compared women with confirmed AT to a control group of women who did not undergo laparoscopy during pregnancy.

RESULTS

During the study period, 112 women met the inclusion criteria. AT was confirmed in 93 cases (83.0%). Baseline characteristics did not differ between groups, excluding the rate of previous AT [5.4% in the torsion vs. 26.3% in the no-torsion group, odds ratio (OR) 0.15, 95% confidence interval (CI) 0.04-0.62, p = .004], and nulliparity rate (57.0% in the torsion vs. 31.6% in the no-torsion group, OR 2.41, 95%CI 1.004-8.21, p = .043). Pregnancies conceived by assisted reproductive technology were more common in the AT group compared to the no-AT group (46.2% vs. 10.5%, OR 7.21, 95%CI 1.59-33.45, p = .002). Miscarriage and stillbirth rates, gestational age at delivery, delivery characteristics and neonatal outcomes were favorable and did not differ between groups. Outcomes of pregnancies with confirmed AT did not differ from a control group of women who did not undergo laparoscopy during pregnancy.

CONCLUSION

Pregnancy outcomes among women who underwent laparoscopy for a suspected AT during pregnancy were reassuring, irrespective of the surgical findings and gestational week. Outcomes did not differ when compared to pregnant women who did not undergo laparoscopy.

SYNOPSIS

Maternal, fetal and neonatal outcomes among women who underwent laparoscopy for suspected adnexal torsion during pregnancy are reassuring, irrespective of the surgical findings and gestational week.

Adnexal torsion recurrence-is the adnexal twist degree a risk factor? A retrospective cohort study

OBJECTIVE

To evaluate whether the adnexal twist degree is related to torsion recurrence and whether there is a dose-dependent correlation.

DESIGN

A retrospective cohort study.

SETTING

Single tertiary medical centre.

POPULATION

The study includes non-pregnant patients operated, for the first time, for adnexal torsion, between 2011 and 2018.

METHODS

Information regarding the degree of adnexal twist was collected from surgical reports. Recurrence was identified using a computerised database and ascertained via telephone with a response rate of 87.2% (253/290).

MAIN OUTCOME MEASURES

Adnexal torsion recurrence rate.

RESULTS

A total of 182 women who had undergone laparoscopic detorsion met the inclusion criteria. Twenty-two had torsion recurrence (12.1%). Adnexal twist degree in the primary event was associated with a higher recurrence risk: 4.3% of women with twist degree ≤360 (n = 3/70), 14.5% of women with twist degree of 361-720 (n = 9/62) and 20% of women with twist degree >720 (n = 10/50) (P = 0.03). The median twist degree was 540 (interquartile range [IQR] 360-855) and 720 (IQR 675-1080) degrees in the control and study groups, respectively (P = 0.005). Additional possibly associated factors for recurrence were evaluated. Age emerged as a possible risk factor, with a median age of 19 years in the recurrence group (IQR 14-27 years) versus 28.5 (IQR 19-36 years) in the non-recurrence group (P < 0.01). Logistic regression analysis revealed that together with age, adnexal twist degree remained significantly associated with torsion recurrence (odds ratio [OR] 1.98, 95% CI 1.09-3.61; P = 0.02).

CONCLUSION

Adnexal twist degree was found to be positively associated with the risk of torsion recurrence.

TWEETABLE ABSTRACT

Adnexal twist degree was found to be positively associated with the risk of torsion recurrence.

Isolated fallopian tubal torsion: Reproductive age case series

AIM

To present our experiences in isolated fallopian tubal torsion (IFTT) case series, which are difficult to diagnose, in light of the literature.

METHODS

The data of the patients diagnosed with IFTT surgically in our tertiary hospital between 2018 and 2019 were evaluated.

RESULTS

Abdominal lower quadrant pain was present in all nine cases. Abdominal pain was accompanied by nausea in five of the nine cases with vomiting in four of the nine cases. Seven of the patients had pain radiating to the vagina. Only one case of IFTT was diagnosed with transvaginal ultrasonography where left tubal dilation and free fluid in the abdomen was found. Two of the nine cases were operated on with a preoperative diagnosis of IFTT. Seven cases were approached laparoscopically and two cases underwent a laparotomy. During the treatment, two of the nine cases underwent detorsion, while seven of the patients underwent a salpingectomy.

CONCLUSION

IFTT is a very rare condition. Therefore, it is difficult to diagnose as it does not come to mind at first glance. Delay of the operation reduces the chance of preserving the tube.

CT predictive model for torsion angle as a marker for risk of necrosis in patients with adnexal torsion

AIM

To assess the feasibility of preoperative computed tomography (CT) prediction of torsion angle for stratifying the risk of necrosis in patients with adnexal torsion.

MATERIALS AND METHODS

In this multicentre, retrospective study, 72 patients underwent preoperative CT and surgically verified adnexal torsion. Surgeons identified the torsion angle and adnexal necrosis requiring adnexectomy. The twisted angles were compared between conservative surgery group and salpingo-oophorectomy group. Variables included demographic, pathological and CT details. Logistic analysis was used to identify the indicators of twisted angle associated with high-risk necrosis.

RESULTS

The necrosis associated with adnexal torsion treated with adnexectomy was performed more often in patients with a torsion angle of ≥720° (odds ratio [OR]=7, 95% confidence interval [CI]: 1.314-37.295, p=0.023). The enlarged twisted pedicle (OR=14.592, 95% CI: 2.048-103.953, p=0.007) and pedicle haemorrhage (OR=5.612, 95% CI: 1.088-28.941, p=0.039) can predict a torsion angle of ≥720°, and area under the receiver operating characteristic (ROC) curve (AUC=0.758±0.058) was generated with the combined variables.

CONCLUSION

The risk of adnexal necrosis is high in patients with torsion angle of ≥720°. CT findings of enlarged twisted pedicle and pedicle haemorrhage can be used to predict torsion angle of ≥720° and can imply adnexal necrosis indirectly.

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.

Female Nonobstetric Genitourinary Emergencies

The emergency medicine provider sees a broad range of pathology involving the female genitourinary system on a daily basis. Must-not-miss diagnoses include pelvic inflammatory disease and ovarian torsion, because these diagnoses can have severe complications and affect future fertility. Although most patients with abnormal uterine bleeding are hemodynamically stable, it can present as a life-threatening emergency and providers should be adept managing severe hemorrhage. Bartholin gland cysts are common complaints that often require procedural intervention. This article discusses these diagnoses and appropriate evaluation and management in the emergency department.

Adnexal Torsion in Pregnancy Managed by Laparoscopy Is Associated with Favorable Obstetric Outcomes

STUDY OBJECTIVE

Most cases of adnexal torsion in pregnancy are currently managed by laparoscopy, which may be associated with increased risks for spontaneous abortion and preterm delivery. We sought to evaluate the obstetric outcomes of these women, with emphasis on their live birth rate and gestational age at delivery.

DESIGN

Retrospective cohort study and telephone questionnaire.

SETTING

University-affiliated obstetrics and gynecology department.

PATIENTS

All pregnant women who underwent laparoscopy for adnexal torsion between 2007 and 2017. Their obstetric outcomes were obtained by retrospective review of medical records and a telephone questionnaire.

INTERVENTIONS

Laparoscopy for adnexal detorsion, with or without cyst drainage or cystectomy.

MEASUREMENTS AND MAIN RESULTS

The study cohort included 94 women. Most torsion cases (71, 75.5%) were diagnosed in the first trimester of pregnancy, whereas 21 (22.3%) cases and 2 (2.1%) cases were diagnosed in the second and third trimesters, respectively. Conception was achieved by in vitro fertilization or by ovulation induction in 45 (47.9%) cases. The information on pregnancy outcomes was available for 93 women. Of those, live birth was reported for 86 (92.5%) pregnancies, while 6 (6.5%) women had a spontaneous abortion, and 1 woman experienced an intrauterine fetal death. Five cases of spontaneous abortion were diagnosed in the first trimester, all within 3 weeks of surgery. Preterm delivery before 37 gestational weeks was reported for 18 (19.4%) pregnancies and was significantly associated with twin pregnancy (p = .002) and with conception following in vitro fertilization and ovulation induction (p = .03). On logistic regression analysis, preterm delivery was only associated with twin vs singleton gestation (odds ratio, 6.7; 95% confidence interval, 1.3-34.8; p = .02).

CONCLUSION

The obstetric outcomes of pregnant women who underwent laparoscopy for adnexal torsion are generally favorable. However, there is a risk for preterm delivery, which is primarily associated with multiple gestations.

Clinical and sonographic predictors of adnexal torsion in pediatric and adolescent patients

OBJECTIVE

To investigate the accuracy of torsion diagnosis in the pediatric and adolescent population.

METHODS

This retrospective study included 87 patients <18years who presented with acute pelvic pain and were operated for suspected adnexal torsion from January 2009 to September 2016.

RESULTS

Adnexal torsion was found in 53 of 87 (60.9%) cases operated for suspected torsion. The rate of accurate torsion diagnosis was significantly higher among pre-menarchal (21/21, 100%) compared with post-menarchal girls (32/66, 48.5%) (p<0.001). Patients with torsion were more likely to report nausea or vomiting (73.6% compared with 32.3%, p<0.001) and had higher rates of peritoneal irritation signs on exam (15.1% compared with 0.0%, p=0.02). On the pre-operative ultrasound, patients with torsion were characterized by higher rates of enlarged ovary showing signs of edema (49.1% compared with 8.8%, p<0.001) and free pelvic fluid (45.3% compared with 17.6%, p<0.001). In post-menarchal girls without adnexal torsion, the leading diagnosis was hemorrhagic corpus luteum cyst (found in 18/33, 78.3%) cases.

CONCLUSIONS

Various clinical and ultrasound findings may point to the correct diagnosis of torsion in the pediatric and adolescent population. However, none of the clinical and ultrasound characteristics are sufficient to confirm or disprove the pre-operative diagnosis, and young patients with the clinical suspicion of adnexal torsion should undergo laparoscopy.

LEVEL OF EVIDENCE

Level II.

TYPE OF STUDY

Clinical retrospective study.

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.

Adnexal Torsion during Pregnancy: Outcomes after Surgical Intervention-A Retrospective Case-Control Study

STUDY OBJECTIVE

To investigate the pregnancy and neonatal outcomes of surgical treatment for adnexal torsion (AT) during pregnancy.

DESIGN

A retrospective case-control study (Canadian Task Force classification II-2).

SETTING

A tertiary care academic medical center.

MEASUREMENTS AND MAIN RESULTS

The study group included all parturients who underwent surgery for suspected AT during pregnancy from January 2005 to January 2017. The control group included parturients with an uneventful pregnancy matched by maternal age, parity, multiple gestation, and pregnancy complications. The primary outcome was gestational age at delivery. Secondary outcomes were perinatal outcomes and intraoperative and immediate postoperative complications. Among 85 study group patients with suspected AT, 78 (91.7%) underwent laparoscopy and 7 (8.3%) laparotomy. Torsion was diagnosed in 84 patients (98.8%). The gestational age at delivery was similar between the study and control groups (38.7 ± 1.5 vs 38.6 ± 1.6 weeks, respectively; p = .908) as was preterm labor (5.8% in both groups, p = 1.00). There was no significant difference between the study and control groups in pregnancy and neonatal outcomes, including Apgar scores, mean cord blood pH (7.25 ± 0.1 and 7.26 ± 0.08, respectively), and birth weight (3040 ± 473 g and 3115 ± 584 g, respectively). In the study group, the mean gestational age at surgery was 11.2 ± 6 weeks (range, 4-34 weeks). The average operative time was 40.2 ± 22 minutes. In the postoperative follow-up, 3 (3.5%) patients had a first trimester miscarriage. A previous cesarean delivery was a risk factor for ovarian torsion during pregnancy (p = .012).

CONCLUSION

Adnexal detorsion with or without additional surgical procedures during pregnancy did not affect the gestational age at delivery and did not appear to increase fetal or maternal complication rates.

Spectrums and Outcomes of Adnexal Torsion at Different Ages

OBJECTIVES

To investigate the role of ultrasound in the preoperative diagnosis of adnexal torsion and describe its histological spectrum and outcomes at different ages.

METHODS

This study comprised a retrospective investigation of a data set that included 195 female patients with clinically suspected adnexal torsion between January 2010 and July 2015. Each patient received a detailed pelvic ultrasound examination by an experienced ultrasound examiner, and a definitive diagnosis was achieved via surgery. The accuracy of an ultrasonic diagnosis of adnexal torsion was assessed. The patients were divided into three groups: female children and adolescents, fertile women, and postmenopausal women. The size, type, histological spectrum, and outcome of adnexal torsion in the different groups were also described.

RESULTS

The sensitivity, specificity, and accuracy of ultrasound were 0.84, 0.77, and 0.81, respectively. There were significant differences in the presence of ultrasonic hallmarks among the true positive, false positive, and false negative cases of adnexal torsion. Ovarian torsion was identified in 94 cases, and isolated tubal torsion was identified in 15 cases. The most common histologic diagnoses of the pediatric group and the other two groups were a normal ovary and teratoma, respectively. The most common histologic diagnoses in the cases of isolated tubal torsion were mesosalpinx cyst and oviduct inflammation.

CONCLUSIONS

Ultrasonography plays an important role in the preoperative diagnosis of adnexal torsion. Despite ovarian involvement in most of the cases, isolated oviduct torsion was not uncommon. The spectrum of histological diagnoses varied among the age groups.

Autoamputation of an ovarian mature cystic teratoma: a case report and a review of the literature

Background

Torsion is known to be the most frequent complication of ovarian teratomas. Torsion of the adnexa usually manifests with severe abdominal pain and is treated as an acute surgical emergency. However, it may be asymptomatic. Autoamputation of an ovary, along with other adnexal structures, due to previous torsion is extremely rare.

Case presentation

A parasitic ovarian teratoma that underwent torsion, autoamputation, and reimplantation was found incidentally during laparoendoscopic single-site surgery (LESS). The amputated tumor was located in the omentum of the right upper abdomen of a patient with concomitant torsion of a left ovarian teratoma. The right ovary and tube were absent even though she had no surgical history. This finding could be interpreted as an autoamputation of the adnexa due to torsion of a previous ovarian cyst arising from the right ovary. We removed all masses by LESS.

Conclusions

Although both ultrasonography and computed tomography were performed preoperatively in our patient, the correct diagnosis of autoamputation and exact localization of the teratoma were extremely difficult. Physicians should consider the possibility of an autoamputated ovarian cyst even if preoperative radiography shows no calcification.