Adnexal torsion in pediatric and adolescent girls

Factors Associated With Isolated Fallopian Tube Torsion in Pediatric Patients

BACKGROUND

Isolated fallopian tube torsion (IFTT) is a rare form of adnexal torsion that is more difficult to diagnose, which may lead to delays in treatment. Our objectives were to identify clinical and radiologic factors associated with surgically-confirmed IFTT and compare them with those of patients without torsion and with adnexal torsion (AT) in a large pediatric population.

METHODS

We conducted a retrospective chart review of all patients who underwent surgery for suspected adnexal torsion from 2016 to 2019. Torsion was determined intraoperatively, with IFFT defined as those with only tubal but no ovarian torsion and AT defined as those with ovarian torsion, with or without involvement of the ipsilateral fallopian tube. Clinical and radiologic variables were compared between patients with IFTT and those without torsion and with AT using descriptive statistics. A previously-described composite score to predict torsion based on the presence of vomiting and adnexal volume (VVCS) was calculated for each patient.

RESULTS

Of 291 patients who underwent surgery for suspected torsion, 168 had confirmed torsion: 33 (19.6%) IFTT and 135 (80.4%) AT. Patients with IFTT were more likely to be younger (12.8 vs. 14.2 years, P = 0.02), premenarchal (29.0% vs. 10.7%, P = 0.009), experience nausea (90.6% vs. 70.9%, P = 0.02) and vomiting (81.3% vs. 32.8%, P < 0.001), have a paratubal cyst on imaging (18.8% vs. 2.5%, P = 0.003), and have larger adnexal volume (143.3 vs. 64.9 ml, P < 0.001) than those without torsion. Higher BMI (26.6 vs. 22.9 kg/m2, P = 0.03), a paratubal cyst on imaging (18.8% vs. 1.5%, P < 0.001), presence of arterial (65.5% vs. 44.1%, P = 0.04) and venous Doppler flow (79.3% vs. 55.9%, P = 0.02), and radiologic impression indicating lack of torsion (37.9% vs. 16.8%, P = 0.04) were more common in IFTT than AT. The accuracy of the VVCS in predicting torsion for the IFFT group was 83.9%.

CONCLUSIONS

IFTT has a similar clinical presentation to AT but with a higher likelihood of a paratubal cyst and preserved Doppler flow on imaging. IFTT should be strongly considered in patients who present with pain, nausea, and vomiting and have an adnexal mass separate from the ovary on imaging, regardless of Doppler flow.

LEVEL OF EVIDENCE

Level II.

TYPE OF STUDY

Prognosis study.

The Role of Neutrophyl-to-Lymphocyte Ratio as a Predictor of Ovarian Torsion in Children: Results of a Multicentric Study

INTRODUCTION

Pediatric ovarian torsion (OT) is an emergency condition that remains challenging to diagnose because of its overall unspecific clinical presentation. The aim of this study was to determine the diagnostic value of clinical, ultrasound, and inflammatory laboratory markers in pediatric OT.

METHODS

We performed a retrospective multicentric case-control study in patients with clinical and ultrasound suspicion of OT, in whom surgical examination was performed between 2016-2022 in seven pediatric hospitals. Patients were divided into two groups according to intraoperative findings: OT group (ovarian torsion), defined as torsion of the ovarian axis at least 360°, and non-OT group (no torsion). Demographics, clinical, ultrasound, and laboratory features at admission were analyzed. The diagnostic yield analysis was performed using logistic regression models, and the results were represented by ROC curves.

RESULTS

We included a total of 110 patients (75 in OT group; 35 in non-OT group), with no demographic or clinical differences between them. OT-group patients had shorter time from symptom onset (8 vs. 12 h; p = 0.023), higher ultrasound median ovarian volume (63 vs. 51 mL; p = 0.013), and a significant increase in inflammatory markers (leukocytes, neutrophils, neutrophil-to-lymphocyte ratio, C-reactive protein) when compared to the non-OT group. In the ROC curve analysis, the neutrophil-to-lymphocyte ratio (NLR) presented the highest AUC (0.918), with maximum sensitivity (92.4%) and specificity (90.1%) at the cut-off point NLR = 2.57.

CONCLUSIONS

NLR can be considered as a useful predictor of pediatric OT in cases with clinical and ultrasound suspicion. Values above 2.57 may help to anticipate urgent surgical treatment in these patients.

Clinicopathological features and surgical procedures of adnexal masses with abdominal pain in pediatric and adolescent patients

PURPOSE

This study investigated the clinicopathological features and surgical procedures of adnexal masses with abdominal pain in pediatric and adolescent patients. Our objective was to better define the clinical presentation of adnexal torsion and to distinguish characteristics of those with torsion and those with an alternate diagnosis.

METHODS

Retrospective cohort study of 212 pediatric and adolescent patients was performed who admitted for abdominal pain and presenting with an adnexal mass between March 2012 to December 2019.Medical records were reviewed for age at operation, including presentation of symptoms and signs; the levels of tumor markers; imaging examinations; pathologic findings; the size of masses; treatment; and outcome. Data management and descriptive analyses were performed using SPSS 26.0.

RESULTS

The median age of the patients was 14.5 ± 3.6 years at the operation. 126 (59.4%, 126/212) patients presented with an abrupt onset of abdominal pain. A total of 82.1% (174/212) of the participants underwent adnexal conservative surgery. 179 (84.5%, 179/212) patients underwent laparoscopic surgery with an average tumor size of 7.7 ± 3.4 cm, while 33 patients ( 15.6%, 33/212) underwent laparotomy. Rupture of mass and ectopic pregnancy accounted for 7.5% (16/212) and 0.9%(2/212), respectively. Torsion was responsible for 36.8% (78/212) of all patients. Among the patients with torsion, the symptom of nausea and vomiting was more common among girls without torsion (P < 0.0001). 88.5% of the girls with torsion had acute onset of abdominal pain, while 92.3% had persistent pain that could not be relieved or occurred repeatedly, which significantly higher than that in the patients without torsion (P < 0.001). 69.2% of patients with torsion had fixed pain sites, compared with 42.2% in patients without torsion (P < 0.001). 88.5% of girls with torsion had an ovarian cyst/mass ≥ 5 cm, compared with 75.0% in girls without torsion (P = 0.038). 66.7% of girls underwent ovary-preserving surgery, compared with 92.2% in patients without torsion. The most common pathologic types were mature teratoma and simple cyst, accounting for 29.4% and 25.6%, respectively. The multivariate analyses confirmed that mass size greater than 5 cm (OR 4.134, 95% CI: 1.349-12.669,P = 0.013), acute onset pain (OR 24.150,95%CI: 8.398-69.444,P = 0.000), persistent or recurrent pain (OR 15.911,95%CI: 6.164-41.075,P = 0.000) were significantly associated with increased risk of torsion.

CONCLUSIONS

Torsion which is a relatively rare event in the pediatric population was not an uncommon condition and responsible for more than one third of all pediatric and adolescent patients presented with adnexal masses and abdominal pain. Pain assessment in children and adolescents is important to distinguish characteristics of those with torsion and those with an alternate diagnosis.Thus, pediatric and adolescent patients particularly with a pelvic mass size greater than 5 cm, acute onset pain, persistent or recurrent pain have a benign cause and not missing the devastating condition that needs emergent attention. Thus, a strategy of earlier and liberal use of Diagnostic Laparoscopy (DL) may improve ovarian salvage.

Application of a Composite Score to Predict Adnexal Torsion in Premenarchal and Menarchal Children and Adolescents

STUDY OBJECTIVE

The study objective was to apply a previously created composite score for the prediction of adnexal torsion in children and adolescents to a larger group of heterogeneous patients to test its validity and to refine this scoring system to more accurately predict adnexal torsion.

METHODS

This was a retrospective chart review at a tertiary care children's hospital and its affiliates. Participants were female patients 0-20 years of age who underwent surgery for suspected adnexal torsion from 2016 to 2019. Data were collected from outpatient, emergency department, and inpatient notes, radiographic data, and operative reports. The primary outcome was the accuracy and predictive value of the total composite score (TCS) to identify or exclude adnexal torsion.

RESULTS

Of the 291 patients with suspected adnexal torsion who went to the operating room during the study period, 168 (57.8 %) had confirmed adnexal torsion. The accuracy of the TCS, which included presence of vomiting, adnexal volume, and adnexal ratio, in predicting or excluding torsion was 83.6 % for all patients, 92.1 % for premenarchal patients, and 81.3 % for menarchal patients. A variation of the TCS that included only vomiting and adnexal volume had an accuracy of 85.8 %.

CONCLUSIONS

Our study demonstrates the accuracy and reproducibility of a previously published composite score to predict adnexal torsion in children and adolescents. It also further refines this score to a potentially more clinically useful tool. Future studies are needed to prospectively evaluate these composite scores and their implementation in clinical settings.

LEVEL OF EVIDENCE

III.

Intraoperative Utilization of Indocyanine Green (ICG) Dye for the Assessment of Ovarian Perfusion-Case Report and Review of the Literature

The assessment of ovarian perfusion after detorsion is crucial in the surgical management of patients with ovarian torsion. In current routine clinical practice, the surgical decision (preservation of the ovary versus oophorectomy) is based on the subjective impression of the surgeon. Intraoperative indocyanine green (ICG) angiography has been shown to sufficiently reflect tissue perfusion with a potential impact on the surgical procedure. Currently, there are only sparse data available on the utilization of ICG in the surgical treatment of ovarian torsion. Here, we describe the successful intraoperative use of ICG in a 17-year-old female patient with ovarian torsion who underwent ovary-preserving surgery. Further, a systematic literature review was performed. Based on the data available to date, the use of ICG in the surgical treatment of ovarian torsion is feasible and safe. The extent to which this might reduce the necessity for oophorectomy has to be evaluated in further investigations.

Clinical and radiologic factors associated with adnexal torsion in premenarchal and menarchal children and adolescents

BACKGROUND

Adnexal torsion is a gynecologic emergency in children and adolescents but remains a challenging diagnosis, with no consistent clinical or radiologic diagnostic criteria. Our objective was to identify risk factors associated with adnexal torsion in premenarchal and menarchal patients with surgically confirmed torsion compared with those without torsion.

METHODS

We conducted a retrospective chart review of all patients who underwent surgery between January 2016 and December 2019 for possible adnexal torsion. Data on demographics, clinical characteristics, radiologic variables, and operative findings were compared using descriptive statistics. Independent predictors of torsion were then examined in multivariate logistic regression models.

RESULTS

Of the 291 patients who underwent surgery, 168 (57.7%) had torsion. Patients with torsion were younger than those without torsion (11.9 vs. 14.2 years, P < .01). Vomiting was significantly associated with torsion for all patients (P < .001). Large adnexal volume and absent arterial Doppler flow were associated with torsion for the total population and menarchal subgroup. A logistic regression model for the total population that controlled for age and menarchal status found that vomiting (adjusted odds ratio [aOR] 5.92, 95% confidence interval [CI] 2.87-12.22), highest adnexal volume category (aOR 4.92, 95% CI 2.25-10.75), and absent arterial Doppler flow (aOR 2.674, 95% CI 1.28-5.60) were associated with torsion.

CONCLUSIONS

Vomiting, enlarged adnexal volume, and absent arterial Doppler flow were associated with adnexal torsion. However, no single risk factor accurately diagnosed torsion, and multiple factors should be interpreted together.

LEVEL OF EVIDENCE

Study of Diagnostic Test, Level II.

Infarcts and ischemia in the abdomen: an imaging perspective with an emphasis on cross-sectional imaging findings

Infarcts and ischemia of abdominal organs may present with acute abdominal pain, and early diagnosis is crucial to prevent morbidity and mortality. Unfortunately, some of these patients present in poor clinical conditions to the emergency department, and imaging specialists are crucial for optimal outcomes. Although the radiological diagnosis of abdominal infarcts is often straightforward, it is vital to use the appropriate imaging modalities and correct imaging techniques for their detection. Additionally, some non-infarct-related abdominal pathologies may mimic infarcts, cause diagnostic confusion, and result in delayed diagnosis or misdiagnosis. In this article, we aimed to outline the general imaging approach, present cross-sectional imaging findings of infarcts and ischemia in several abdominal organs, including but not limited to, liver, spleen, kidneys, adrenals, omentum, and intestinal segments with relevant vascular anatomy, discuss possible differential diagnoses and emphasize important clinical/radiological clues that may assist radiologists in the diagnostic process.

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.

Premenarchal Adolescent Female Ovarian Torsion: A Case of Delayed Diagnosis

Patient: Female, 11-year-old

Final Diagnosis: Ovarian

Symptoms: Abdomenal • pain

Medication: —

Clinical Procedure: —

Specialty: Surgery

Adnexal Torsion: Review of Radiologic Appearances

Adnexal torsion is the twisting of the ovary, and often of the fallopian tube, on its ligamental supports, resulting in vascular compromise and ovarian infarction. The definitive management is surgical detorsion, and prompt diagnosis facilitates preservation of the ovary, which is particularly important because this condition predominantly affects premenopausal women. The majority of patients present with severe acute pain, vomiting, and a surgical abdomen, and the diagnosis is often made clinically with corroborative US. However, the symptoms of adnexal torsion can be variable and nonspecific, making an early diagnosis challenging unless this condition is clinically suspected. When adnexal torsion is not clinically suspected, CT or MRI may be performed. Imaging has an important role in identifying adnexal torsion and accelerating definitive treatment, particularly in cases in which the diagnosis is not an early consideration. Several imaging features are characteristic of adnexal torsion and can be seen to varying degrees across different modalities: a massive, edematous ovary migrated to the midline; peripherally displaced ovarian follicles resembling a string of pearls; a benign ovarian lesion acting as a lead mass; surrounding inflammatory change or free fluid; and the uterus pulled toward the side of the affected ovary. Hemorrhage and absence of internal flow or enhancement are suggestive of ovarian infarction. Pertinent conditions to consider in the differential diagnosis are a ruptured hemorrhagic ovarian cyst, massive ovarian edema, ovarian hyperstimulation, and a degenerating leiomyoma. Online supplemental material is available for this article. ^©RSNA, 2021.

The role of laparoscopy in paediatric and adolescent gynaecology

Paediatric and adolescent gynaecology is a narrow field of medicine dealing with the diagnosis of and treatment of gynaecological diseases from the neonatal period to sexual maturity. The current trend in surgical gynaecology in the paediatric population is to minimise the degree of invasiveness of diagnostic and therapeutic procedures. This contributes to reducing the number of complications and the risk of infertility. Laparoscopic procedures are a challenge for paediatric surgeons and gynaecologists, not only because of the age of treated patients, and anatomical and physiological differences between different age groups but also because of the complexity of the pathology, the differentiation of cancer tumours, and the presence of congenital developmental defects.

Abdominal Pain in a Young Female Adolescent: Point-of-Care Ultrasound Added Value

An adolescent female patient presented to the emergency department with diffuse, severe lower abdominal pain and vomiting. The initial suspected diagnosis was appendicitis. Point-of-care ultrasound did not visualize the appendix but demonstrated a suspected left ovarian torsion, which was confirmed by radiology-performed ultrasound. The clinical presentation, in combination with images obtained via point-of-care ultrasound, helped to expedite gynecology consultation and immediate surgery.

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 and laparoscopy in the paediatric and adolescent population

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

Effect of Surgical Specialty on Management of Adnexal Masses in Children and Adolescents: An 8-Year Single-Center Review

STUDY OBJECTIVE

Children with adnexal masses might be managed by pediatric surgeons, urologists or gynecologists, with the potential for different management strategies between specialties. In this study we compared ovarian conservation rates and surgical approach for adnexal masses in children and adolescents managed either by pediatric surgeons/urologists or gynecologists at a tertiary care institution.

DESIGN

Retrospective cohort review.

SETTING

Tertiary pediatric and adult university hospital.

PARTICIPANTS

Patients younger than 18 years of age with an adnexal mass managed surgically with removal of histologically confirmed ovarian or fallopian tube tissue from 2008 to 2015.

INTERVENTIONS

Laparoscopic or open procedure for adnexal mass.

MAIN OUTCOME MEASURES

The primary outcome was rate of ovarian conservation relative to surgical specialty. The secondary outcome was surgical approach relative to surgical specialty.

RESULTS

Forty-eight patients underwent surgery for adnexal masses; 26 (54%) under pediatric surgery/urology and 22 (46%) under gynecology care. Laparoscopy was performed in 5 (19%) pediatric and 19 (86%) gynecology cases (P = .000006). Of 24 patients older than 12 years of age with a benign tumor, 10 (42%) underwent procedures resulting in loss of an ovary with or without fallopian tube; 8 of these (80%) were under pediatric care. Of the remaining 14 (58%) who underwent ovarian conserving surgery, 12 (80%) were under gynecology care (P = .0027).

CONCLUSION

Patients with a benign tumor were significantly more likely to undergo ovary-preserving surgery under gynecology care than under pediatric surgery/urology care. A multidisciplinary team approach involving gynecology and pediatric surgical specialties would be valuable in assessing the merits of ablative or conservative surgery in each case.

Cross-sectional imaging of acute gynaecologic disorders: CT and MRI findings with differential diagnosis-part I: corpus luteum and haemorrhagic ovarian cysts, genital causes of haemoperitoneum and adnexal torsion

Acute gynaecologic disorders are commonly encountered in daily clinical practice of emergency departments (ED) and predominantly occur in reproductive-age women. Since clinical presentation may be nonspecific and physical findings are often inconclusive, imaging is required for a timely and accurate diagnosis. Although ultrasound is the ideal non-invasive first-line technique, nowadays multidetector computed tomography (CT) is extensively used in the ED, particularly when a non-gynaecologic disorder is suspected and differential diagnosis from gastrointestinal and urologic diseases is needed. As a result, CT often provides the first diagnosis of female genital emergencies. If clinical conditions and scanner availability permit, magnetic resonance imaging (MRI) is superior to CT for further characterisation of gynaecologic abnormalities, due to the excellent soft-tissue contrast, intrinsic multiplanar capabilities and lack of ionising radiation.

The purpose of this pictorial review is to provide radiologists with a thorough familiarity with gynaecologic emergencies by illustrating their cross-sectional imaging appearances. The present first section will review the CT and MRI findings of corpus luteum and haemorrhagic ovarian cysts, gynaecologic haemoperitoneum (from either ruptured corpus luteum or ectopic pregnancy) and adnexal torsion, with an emphasis on differential diagnosis. Additionally, comprehensive and time-efficient MRI acquisition protocols are provided.

Premenarchal patients present differently: A twist on the typical patient presenting with ovarian torsion

BACKGROUND/PURPOSE

The aim of this study was to characterize differences between pre- and postmenarchal females with ovarian torsion.

METHODS

A single-center review was conducted of all nonneonatal pediatric patients with ovarian torsion from 2011 to 2018. Clinical data were compared between pre- and postmenarchal patients.

RESULTS

One hundred and twenty-seven patients were identified, and 25% were premenarchal. Premenarchal patients were more likely to have a delay in diagnosis (38% vs 20%, p = 0.042), develop ovarian necrosis (34% vs 17%, p = 0.036), and present without an associated adnexal mass (44% vs 0%, p < 0.001). All patients without a mass (n = 14) were premenarchal and presented with ovarian asymmetry. Patients without an associated mass underwent oophoropexy in the majority of cases. There were no differences in postoperative complication or recurrence rates between groups.

CONCLUSION

Premenarchal females with ovarian torsion can present differently than females postmenarche and often have a delay in diagnosis. Premenarchal females are more likely to undergo torsion without an associated adnexal mass and are at higher risk for ovarian necrosis. Oophoropexy is an appropriate treatment in the absence of an adnexal mass. A high-index of suspicion for ovarian torsion should be maintained for premenarchal females presenting with abdominal pain and an otherwise negative workup.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Twist and shout: magnetic resonance imaging findings in ovarian torsion

Adnexal torsion is characterized by partial or complete rotation of the suspensory ligament of the ovary and its corresponding vascular pedicle, resulting in vascular impairment that can culminate in hemorrhagic infarction, as well as necrosis of the ovary and fallopian tube. Because there are myriad causes of acute pelvic pain, the differential diagnosis of ovarian torsion is often challenging. Consequently, radiologists should be familiar with the main imaging findings. In this regard, there are typical signs of ovarian torsion on magnetic resonance imaging, including increased ovarian volume with stromal edema and peripheral distribution of the ovarian follicles, as well as thickening of the fallopian tube, an adnexal mass (causal factor) that shifts toward the midline, and the classic, pathognomonic “whirlpool sign”. The objective of this essay was to review and illustrate the various magnetic resonance imaging findings in ovarian torsion.

A New Technique of Oophoropexy: Folding and Fixating of Utero-Ovarian Ligament to Round Ligament in a Patient with Reccurrent Ovarian Torsion

Introduction

Most cases of ovarian torsion occur in the reproductive age and many are related to ovarian and paraovarian masses. If it occurs without any subtle anatomic etiology or ovarian and paraovarian masses, recurrence of ovarian torsion is more likely. Recurrent left ovarian torsion is much less common than recurrent right ovarian torsion. The authors describe a rare case with their new ovarian fixation technique.

Case and Method

A 21-year-old female patient with polycystic ovarian syndrome had a 7th recurrence of left ovarian torsion. Although ovarian fixation was performed in addition to detorsion at the 5th and the 6th laparoscopic surgeries, it had failed. Due to recurrence ovarian torsion after ovarian fixation, the authors performed a different technique:folding the utero-ovarian ligament which folded on itself. The distal part of the utero-ovarian ligament with the ovary was both fixed to the proximal part of the round ligament which was adjacent to the uterus.

Conclusion

Although a wide range of oophoropexy methods have been described in the literature, the best method remains a matter for debate. This technique can be performed even when the ovarian tissue is necrotic. Because of this, we think that this technique is useful and effective technique.

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.

A Case-Control Study of Sonographic Maximum Ovarian Diameter as a Predictor of Ovarian Torsion in Emergency Department Females With Pelvic Pain

BACKGROUND

Color and power Doppler ultrasound are commonly used in the evaluation of ovarian torsion but are unreliable. Because normal-sized ovaries are unlikely to cause torsion, maximum ovarian diameter (MOD) could theoretically be used as a screening test in the ED. Identification of MOD values below which torsion is unlikely would be of benefit to providers interpreting radiology department or point-of-care pelvic ultrasound.

OBJECTIVES

The objective was to determine if sonographic MOD can be used as a screening tool to rule out torsion in selected patients.

METHODS

Via a retrospective case-control study spanning a 14-year period, we examined the ultrasound characteristics of patients with torsion and age-matched controls, all presenting to the emergency department with lower abdominal pain and receiving a radiology department pelvic ultrasound for "rule-out torsion." Standardized data collection forms were utilized. Distributions of MOD were compared and sensitivity, specificity, and likelihood ratios were calculated for multiple cutoffs.

RESULTS

We identified 92 cases of surgically confirmed ovarian torsion and selected 92 age-matched controls. In postmenarchal patients the sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 3- and 5-cm MODs were 100% (96%-100%), 30% (20%-41%), 1.4 (1.3-1.7), and 0 and 91% (83%-97%), 92% (83%-97%), 11.2 (5.5-22.9), and 0.09 (0.04-0.19), respectively. The 5-cm MOD, however, excluded an additional 52 of 84 (62%) postmenarchal patients.

CONCLUSIONS

A threshold MOD of 5 cm on pelvic ultrasound may be useful to rule out ovarian torsion in postmenarchal females presenting with lower abdominal and pelvic pain.

Adnexal Torsion in Children and Adolescents: A Retrospective Review of 245 Cases at a Single Institution

STUDY OBJECTIVE

Adnexal torsion (AT) requires urgent surgical intervention to preserve ovarian function. Historically, treatment for AT was oophorectomy because of concerns related to leaving a nonviable ischemic ovary. No published studies support these theoretical concerns and current literature supports conservative management. The aim of this study was to review the institutional outcomes for AT cases, including salvage rates and complications. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: This study was approved by the institutional review board at Baylor College of Medicine. A retrospective chart review on cases of AT from 2007 to 2016 at a single Children's hospital was performed on the basis of International Classification of Diseases, 10th revision and Current Procedural Terminology codes. A standardized chart review form was used in data extraction. Statistical analysis was performed using SAS version 9.4 (SAS Institute).

RESULTS

Chart review identified 245 torsion cases in 237 patients. The mean age was 12.4 ± 3.29 years. Of the participants, 230 (94%) underwent minimally invasive laparoscopy with ovarian preservation in 233 (95%) of the cases. There were no complications due to detorsion of the affected adnexa. Intraoperatively, the right adnexa was affected in 134 (55%) cases and a lesion was noted in 193 (79%) cases, most commonly paratubal cysts and mature teratomas. The malignancy rate was low, noted only in 4/245 patients at (1.2%). Pediatric gynecology performed most of the cases (n = 214; 87%).

CONCLUSION

The findings of our study continue to support the conservative management of patients with AT.

Adnexal Torsion

Adnexal torsion is an uncommon gynecologic disorder caused by the partial or complete rotation of the ovary and/or the fallopian tube on its vascular support. Delay in treatment can impact fertility adversely. The objective of this report is to provide clinical recommendations based on the latest evidence. Specifically we discuss epidemiology, clinical presentation, diagnostic approach and management of adnexal torsion in adolescents.

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.

['Conservative' organ-sparing approach for ovarian torsion in children]

AIM

To improve the outcomes in children with ovarian torsion.

MATERIAL AND METHODS

Three clinical observations of patients with ovarian torsion are presented. Duration of the disease was 3-4 days. All children underwent organ-sparing surgery including untwisting followed by ovariopexy.

RESULTS

All children were examined in early and late postoperative period (up to 5 years) after organ-sparing procedures. Ultrasonic picture of the ovaries including structure and dimensions corresponded to age, the follicles were determined.

CONCLUSION

'Conservative' approach allows to preserve anatomical structure and potential for reproductive function.

Surgical considerations and challenges in the pediatric and adolescent gynecologic patient

It is important for practitioners to recognize that there are special considerations when performing gynecologic surgery in a pediatric or adolescent patient. A provider must be familiar with differences in anatomy, physiology, surgical technique, and psychosocial concerns. This can be challenging for a provider who does not routinely operate on patients in this population. A minimally invasive surgical approach is preferred in the pediatric and adolescent patient whenever possible. While a good command of laparoscopy in the adult patient is certainly a useful skill when operating on pediatric and adolescent patients, there are technical adaptations and challenges to consider. This chapter reviews the pre-operative preparation, operative technique and challenges, and post-operative care of the surgical pediatric and adolescent gynecologic patient.

Ovarian torsion in children: Development of a predictive score

The aim of this study was to identify clinical signs and symptoms of ovarian torsion (OT) in children and to develop a simple predictive score.A chart review of patients with acute adnexal pathologies treated at the University Children's Hospital Basel, Switzerland, between March 2006 and June 2015 was performed. Medical records were screened for demographic and clinical data. These included clinical symptoms, laboratory studies, imaging, and type of treatment. The diagnosis OT was defined as intraoperative visualization of the torsed ovary around its pedicle at least 360 degrees. Variables predictive for OT were identified and the following score for the likelihood of having OT was developed: age (points = number of years) minus 3 points (if vomitus = "yes") and plus 1 point (if "pain duration >12 hours").A total of 80 patients with acute adnexal pathologies were identified. OT was recorded in 17 (21%) cases and ovarian cysts (OC) only in 63 (79%) cases. Patients who presented with OT were significantly younger than patients with OC only (P = .001). Correspondingly, 11 (65%) of the patients with OT had no menarche compared to 3 (5%) patients with OC only (P = .001). Vomiting (P = .001), a shorter pain duration (P = .01), and an elevated C-reactive protein (CRP) (P = .01) were observed significantly more often in patients with OT. The sensitivity of a positive OT score was 0.81 and increased to 1.00 if restricted to girls between 2 to 12 years of age.The presence of vomiting, short duration of abdominal pain, and elevated CRP level have a predictive value for the diagnosis of OT. In these patients, an exploratory laparoscopy should be conducted without delay. The presented OT score appears to be a helpful tool in diagnosing OT in children.

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.

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.

Ovarian Torsion in the Normal Ovary: A Diagnostic Challenge in Postmenarchal Adolescent Girls in the Emergency Department

Background

Ovarian torsion can be seen in the otherwise-normal ovary and is a challenging issue in the emergency department. The aims were (1) to evaluate and compare the surgically verified ovarian torsion cases in otherwise-normal ovaries and ovaries including a mass or cyst and (2) to investigate whether the normal-appearing ovaries on ultrasound examination affected the diagnosis of ovarian torsion or not.

Material/Methods

A retrospective cohort study design was used. The medical records of all postmenarchal adolescent girls with surgically verified ovarian torsion treated in a university hospital from 2010 to 2016 were reviewed.

Results

Twenty-nine post-menarchal girls were identified. The subjects were divided into two groups. Eight girls (group 1) had ovarian torsion in a normal ovary, and twenty-one girls (group 2) had ovarian torsion including a mass or cyst. The median ages of group 1 and 2 were 13 and 14 years, respectively. Abdominal pain was the main presenting symptom for all cases in both groups. Doppler flow studies were abnormal in 6/9 (66.6%) in group 1 and 12/21 (57.1%) in group 2. The time from first admission to the operation was statistically longer in group 1 than in group 2 (34.5±24.3 hours vs. 19.5±9.2 hours, respectively; p=0.001). The longitudinal axis of uterine size was significantly shorter in group 1 than in group 2 (34.3±2.9 mm vs. 47.6±4.5 mm, respectively; p=0.001).

Conclusions

Ovarian torsion in adolescent girls can be seen within the otherwise-normal ovary. The normal-appearing ovaries on ultrasound in the emergency department may lead to delay in the diagnosis of ovarian torsion in adolescent girls.

Fallopian Tube Torsion as a Cause of Acute Pelvic Pain in Adolescent Females

Purpose. Torsion of the fallopian tube, involving hydatids of Morgagni, though a rare cause of acute pelvic pain in young girls, can pose significant risks to future fertility. Tubal torsion may present as a diagnostic dilemma since the ovary itself usually appears normal on ultrasound. Thus, surgical intervention may be delayed which can lead to worsening necrosis and result in the need for resection of the affected tube. Methods. We reviewed two cases of fallopian tube torsion associated with hydatids of Morgagni in adolescent females. Results. The patients were premenarchal in both cases, aged 10 and 13 years. Both presented with acute clinical signs of ovarian torsion but ultrasound showed the ovary itself to be normal with an adjacent cystic structure. In both cases, the fallopian tube was detorsioned laparoscopically and preserved. The associated cyst was excised in one case and marsupialized in the other. Conclusions. We propose that prompt recognition and operative management of this relatively uncommon source of pelvic pain may prevent unnecessary tubal resection and improve long-term fertility in this population.

Is It Ovarian Torsion? A Systematic Literature Review and Evaluation of Prediction Signs

OBJECTIVES

This study aimed to identify, through systematic literature review, the most reliable clinical, biological, and radiological signs of ovarian torsion in the pediatric population and to compare their diagnostic value.

METHODS

This is a systematic review of the literature, searching MEDLINE, EMBASE, and Cochrane Databases for articles published between January 1990 and January 2014.

RESULTS

From the 946 references initially identified, 14 retrospective publications fulfilled the inclusion criteria, involving a total of 663 episodes of ovarian torsion. Sudden onset abdominal pain with nausea and/or vomiting is the most frequent symptom of ovarian torsion. It can occur at any age, not only in menarchal or perimenarchal patients. Abdominal tenderness is present in 88.4% of patients, whereas only 24% have a palpable mass. Blood tests are commonly requested (51.4% of cases) but are not diagnostic. Abnormalities on plain abdominal radiograph include masses, calcifications, and ossified images. Ultrasound has a sensitivity for ovarian torsion of 79% and computerized tomographic scan of 42.2%. There is a significant diagnostic delay at 101.8 hours (median).

CONCLUSIONS

Abdominal pain in children and adolescents is difficult to evaluate, and the diagnosis of ovarian torsion remains a challenge. Because of its potential complications, we need effective clinical tools. From our review of the literature, it was not possible to develop a diagnostic algorithm. Further research is needed to improve our practice and shorten the delay to diagnosis. Considering the low incidence of ovarian torsion, a multicenter prospective study would be required.

Pediatric incidental appendectomy: a systematic review

Incidental appendectomy is the removal of the vermiform appendix accompanying another operation, without evidence of acute appendicitis. It is generally performed to eliminate the risk of future appendicitis. The risks and benefits of incidental appendectomy during various operations in children have been debated for over a century, but need to be revisited in light of innovations in medical practice, including minimally invasive surgery, improved imaging techniques, and use of the appendix as a tubular conduit for reconstruction. A detailed review was undertaken of the techniques, pathology, risks of appendectomy, utility of the appendix, and incidental appendectomy in the treatment of specific pediatric medical conditions. A comprehensive literature search was performed, and retrieved results were reviewed for relevance to the topic. The decision to perform a pediatric incidental appendectomy relies on informed consideration of the individual patient's co-morbid conditions, the indication for the initial operation, the future utility of the appendix, and the risk of future appendiceal pathology. The discussion includes a variety of situations and comorbid conditions that may influence a surgeon's decision to perform incidental appendectomy.

High risk of recurrent torsion in premenarchal girls with torsion of normal adnexa

OBJECTIVE

To compare adnexal torsion characteristics and torsion recurrence rates in a pre- and postmenarchal pediatric and adolescent population.

DESIGN

Retrospective cohort study.

SETTING

University-affiliated medical center.

PATIENT(S)

Females <18 years old with surgically diagnosed adnexal torsion.

INTERVENTION(S)

Adnexal detorsion, cystectomy, salpingectomy, or salpingo-oophorectomy by laparoscopy or laparotomy. Oophoropexy using the utero-ovarian ligament plication technique was performed in cases of recurrent torsion of normal adnexa.

MAIN OUTCOME MEASURE(S)

The clinical presentation, laboratory and ultrasound characteristics, surgical findings, surgical procedures, pathologic diagnosis, and torsion recurrence rates were analyzed and compared between pre- and postmenarchal patients.

RESULT(S)

Twenty premenarchal and 24 postmenarchal patients were identified. The clinical presentation, laboratory findings, and ultrasound characteristics were similar between the two groups, except for a higher prevalence of paraovarian cysts on preoperative ultrasound in the postmenarchal compared with in the premenarchal group (20.8% vs. 0%). For the whole cohort, torsion of normal adnexa constituted 25.0% (11/44) of cases, while torsion of "pathologic" adnexa constituted 75.0% (33/44) of torsion cases. Torsion recurrence was significantly more common among girls whose first torsion episode occurred in the premenarchal period compared with in postmenarche (35% vs. 4.2%). On multivariate logistic regression analysis, torsion recurrence was significantly associated with premenarchal status (odds ratio [OR] = 12.7; 95% confidence interval [CI], 1.1-152.0) and with torsion involving normal adnexa (OR = 19.1; 95% CI, 2.3-154.5).

CONCLUSION(S)

Recurrent torsion is common in patients whose first torsion episode occurred in the premenarchal period and involved otherwise normal adnexa. Ovarian fixation procedures may be considered in patients at risk for torsion recurrence.

Factors Affecting Adnexal Torsion Direction: A Retrospective Cohort Study

AIMS

To investigate a trend for adnexal torsion direction and factors that may be associated with direction.

METHODS

We retrospectively reviewed the medical files of all women who underwent exploratory laparoscopy for suspected ovarian torsion in our center from August 2010 to December 2012.

RESULTS

Fifty-five women had laparoscopically proven torsion. Medial rotation, defined as clockwise rotation of the left adnexa or counterclockwise rotation of the right adnexa, with the proximal (lateral) segment of the infundibulopelvic ligament serving as the referral point was noted in most cases (n = 47, 85.5%). There was no statistically significant difference between the medial and lateral rotation groups. However, the proportion of pregnant women and mean parity were significantly higher in the lateral compared to the medial rotation group: 62.5 vs. 19.1%, p = 0.009 and 1.1 ± 1.2 vs. 0.1 ± 0.4, p < 0.001. Medial torsion was present in 64.3% of pregnant women vs. 92.7% of nonpregnant women, p = 0.009.

CONCLUSION

The direction of ovarian or adnexal torsion is usually medially rotated, opposite to the psoas muscles and the great blood vessels on the same side. However, surgeons should be aware of an increased rate of lateral rotation among pregnant women.

Ovarian Torsion in a Teenage Girl with Genitourinary Anomaly

We present the clinical presentation, sonography, CT, and MR imaging as well as correlative intra-operative and gross pathological findings of ovarian torsion in a 14-year-old girl. Our findings are discussed in the context of prior imaging studies performed for the evaluation of ovarian torsion. Ovarian torsion is not an uncommon cause of acute abdominal pain in children and teenage girls. Diagnosis of this entity can be difficult based on clinical presentation or on imaging appearance alone.

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.

National Trends in the Surgical Treatment of Ovarian Torsion in Children: An Analysis of 2041 Pediatric Patients Utilizing the Nationwide Inpatient Sample

The aim of this study was to evaluate the national trends in surgical management of ovarian torsion (OT) in children. The Nationwide Inpatient Sample was queried from 1998 to 2011 for females less than 18 years of age with OT. Patients were stratified into three treatment groups: oophorectomy (OO), oophoropexy, or release of torsion (RT) alone. There were 2041 patients with OT, of which 1598 (78%) underwent OO, 126 (6%) oophoropexy, and 317 (15%) RT. RT significantly increased from 1998 to 2011 (9% vs 25%; P < 0.05). At nonteaching hospitals, there were higher rates of OO (89.3% vs 79.5%; P < 0.05) and lower rates of RT (10.7% vs 20.5%; P < 0.05) compared with teaching hospitals. RT was performed at a higher rate in Northeast United States compared with the South (22.7% vs 14.2%; P < 0.05). Girls presenting at nonteaching hospitals and the South had increased odds of undergoing OO compared with those presenting at teaching hospitals and the Northeast ( P < 0.05). Although ovarian conservation for OT in children is more often performed in the Northeast United States and at teaching hospitals, this large population-based study demonstrates OO remains the most common surgical management for OT in the United States.

Laparoscopic Outcomes for Pelvic Pathology in Children and Adolescents among Patients Presenting to the Pediatric and Adolescent Gynecology Service

STUDY OBJECTIVE

The aim of this study was to evaluate surgical indications, outcomes, and common pelvic pathologies presenting to the Pediatric and Adolescent Gynecology service in premenarcheal (PMF) and menarcheal females (MF) undergoing laparoscopic surgery.

DESIGN

A retrospective chart review.

SETTING

An academic children's hospital.

PARTICIPANTS

Females under 21 years of age, excluding pregnant patients, who underwent laparoscopic surgery for a gynecologic indication presenting to the Pediatric and Adolescent Gynecology service at a single children's hospital between July 2007 and January 2012, identified by CPT codes.

MAIN OUTCOME MEASURES

Pertinent patient demographics, indication for surgery, anesthesia time, estimated blood loss, surgical instruments used, intra-operative findings, surgical pathology, complications, length of stay, and concerns at follow-up appointment. Descriptive statistics and chi-square analyses of data were performed using SAS 9.3.

RESULTS

Of 158 cases meeting inclusion criteria, 33 patients were PMF (mean age 8.6 ± 3.2 years) and 125 patients were MF (mean age 14.7 ± 2.3 years). Acute abdominal pain was the most common surgical indication in both groups, but was significantly more likely to be the surgical indication in the PMF group (62.7% vs. 52.8%, P = .006). Adnexal torsion was more likely to be present in the PMF group than in the MF group (66.7% vs. 27.2%, P < .0001). No complications were reported in the PMF group. Two minor complications were reported in the MF group.

CONCLUSION

Minimally invasive surgical techniques represent a safe and well-tolerated method for treating a wide variety of pelvic pathology in both younger children and older adolescent females. For physicians evaluating premenarcheal females with acute-onset abdominal pain, adnexal torsion should be prominent among the differential diagnoses.