Sex-based Disparities in the Management of Pediatric Gonadal Torsion

INTRODUCTION

In 2015, the U.S. News and World Report (USNWR) implemented a quality metric to expedite surgery for testicular torsion (TT), but not ovarian torsion (OT). This study examined OR timing among children with suspected TT and OT before and after this metric.

METHODS

A single-center retrospective cohort study of children (1-18yr) who underwent surgery for suspected gonadal torsion was performed. Time to OR (TTOR) from hospital presentation to surgery start was calculated. An interrupted time series analysis identified changes in TTOR for suspected TT versus OT after the 2015 USNWR quality metric.

RESULTS

Overall, 216 patients presented with TT and 120 with OT. Median TTOR for TT was 147 min (IQR:99-198) versus 462 min (IQR:308-606) for OT. Post-quality metric, children with TT experienced a 27.8 min decrease (95% CI:-51.7,-3.9, p = 0.05) in annual median TTOR. No significant decrease was observed for children with OT (p = 0.22). Children with history of a known ovarian mass (N = 62) experienced a shorter TTOR compared to those without (422 vs 499min; p = 0.04).

CONCLUSION

Implementation of a national quality metric for TT expedited surgical care for children with TT, but not children with OT. These findings highlight the need for equitable quality metrics for children presenting with suspected gonadal torsion.

LEVEL OF EVIDENCE

III.

TYPE OF STUDY

Retrospective Comparative Study, Observational Cohort Study.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV.

Gynecologic Adnexal Tumors and Tumor-Like Lesions in Children and Adolescents: Experience at a Cancer Center

Introduction. Tumors and tumor-like lesions of the uterine adnexa in children and adolescents are uncommon but may carry devastating consequences. Methods. We conducted an observational retrospective cohort study, to describe patients aged 0 to 19 years diagnosed with tumors and tumor-like lesions of the uterine adnexa at our institution between 2000 and 2018. Results. Eighty-nine patients with 105 adnexal lesions were included. Thirty-seven (42%) patients presented with benign tumors, 13 (15%) with borderline tumors, 25 (28%) with malignant tumors and 14 (16%) with tumor-like lesions. Germ cell tumors (n = 45|43%) were the most frequent, followed by epithelial tumors (n = 30|29%). No significant differences were found in the age distribution of the lesions by malignant potential or histologic group. Most patients (n = 80|90%) were treated primarily with conservative surgery, including cystectomy (n = 25|28%) and unilateral oophorectomy/adnexectomy (n = 54|61%). Thirty-four (38%) underwent surgical staging (partial omentectomy and peritoneal biopsies). Twenty (23%) patients with borderline and malignant tumors were submitted to chemotherapy. Four (5%) patients with borderline or malignant tumors relapsed, one of whom died from disease. Conclusion. Gynecological lesions in children and adolescents encompass a wide range of rare histological tumor subtypes, requiring evaluation by experienced pathologists. Most tumors were diagnosed at early stages, with low relapse and mortality rates. Conservative management, with fertility sparing surgery and limited use of adjuvant chemotherapy, is of utmost importance.

Laparoscopic salvage procedures for adnexal torsion in pediatric and adolescent patients during the COVID-19 pandemic: a retrospective cohort study

BACKGROUND

Early management for adnexal torsion increases likelihood of ovarian/tubal salvage. The Coronavirus disease of 2019 (COVID-19) pandemic poses delays from symptom-onset to intervention. The primary objective was to evaluate rates of ovarian salvage and tubal salvage following ovarian torsion and adnexal torsion during the COVID-19 pandemic in a pediatric and adolescent gynecology population.

METHODS

This was a retrospective quality improvement cohort study of pediatric and adolescent gynecology patients at a single children's hospital who underwent laparoscopy for suspected ovarian torsion/adnexal torsion between March 2020 to March 2021. Descriptive statistics and t-tests were utilized.

RESULTS

There were 50 suspected adnexal cases in 47 patients. All underwent laparoscopy, revealing 39 adnexal torsion occurrences in 36 patients and 1 patient with recurrent adnexal torsion three times. All underwent pre-operative COVID-19 testing. Mean age was 13.9 ± 2.6 years for adnexal torsion cohort. Menarche was achieved in 88% (n = 44) and 12% (n = 6) were pre-menarchal. The primary outcome was ovarian salvage and tubal salvage rates, which were 97.4% (n = 38) and 89.7% (n = 35), respectively. Secondary outcomes assessed factors contributing to the primary outcome or operative delays. The mean age of menarche was 11.2 years (salvaged) and 12.5 years (non-salvaged) (p = 0.04). There were no differences in mean pain duration or mean COVID-19 testing time between groups. Left, right and bilateral adnexal torsion occurred in 42% (n = 21), 32% (n = 16), and 4% (n = 2) respectively. The most common pathologies were paratubal cyst (n = 17, 34%) and benign ovarian cyst (n = 16, 32%).

CONCLUSIONS

Ovarian salvage and tubal salvage rates were 97.4% and 89.7%, respectively during the time frame studied. These salvage rates during the study period are comparable to previous rates in a pre-COVID cohort at our institution. Institutional and departmental quality and safety initiatives likely contributed to this outcome.

NASPAG Pediatric and Adolescent Gynecology Surgery Compensation Survey

INTRODUCTION

Over the last decade, the field of pediatric and adolescent gynecology (PAG) has rapidly expanded on the basis of a need for this specialized training to care for children and adolescents with gynecologic concerns. There are 18 PAG fellowship programs within the United States and Canada. Since 2017, which marked the beginning of the American Board of Obstetrics and Gynecology (ABOG) Focused Practice Examination in PAG and PAG Maintenance of Certification program, there has been a growing recognition of this specialty, given the unique population served. However, there is a paucity of information related to compensation in PAG. As the field has grown and more PAG fellow graduates are sought by children's hospitals throughout the United States and Canada, there is an urgent need to ensure that salary is equitable for these specialty PAG providers given the unique skills acquired during fellowship training, beyond that of obstetrics and gynecology (OBGYN) residency. This initial survey aimed to focus on compensation for PAG surgeons in the United States.

OBJECTIVES

To survey NASPAG PAG surgeons in the United States about current benefits, practice metrics, and compensation METHODS: A 15-question anonymous survey was sent to PAG surgeons in the United States in February 2022, with 3 reminders sent by email to engage voluntary participation. The survey aimed to understand practice characteristics, current compensation, and relative value unit (RVU) benchmarks. Descriptive statistics were utilized. Compensation means and quartiles were calculated in U.S. dollars for the following categories: assistant professor, associate professor, and full professor. The compensation mean was also calculated for private/hybrid and instructor categories.

RESULTS

Among 255 eligible members, 88 completed the survey, for a participation rate of 34.5%. Sixty-three point six percent reported having completed a PAG fellowship, whereas one-third reported specializing in this area with no fellowship available at the time. Three-fourths reported having achieved ABOG Focused Practice PAG certification. Most providers were academic (75%) and working full time (82.9%). Among academicians, most were assistant professors (48%) and on the non-tenure track (50.6%). RVU benchmarks varied, with 40.2% reporting OBGYN generalist targets and only 18.3% reporting PAG-specific targets, despite most physicians practicing only PAG (62.5%) and less than 30% practicing PAG plus some adult OBGYN. Salary support varied, with 57% employed by a hospital. Incentives were common, with most receiving a bonus at the end of the year (52.9%). As expected, full professors reported higher mean compensation ($345k) as compared with less senior colleagues ($248k and $302k for assistant and associate professors, respectively). Private practice/hybrid practitioners reported compensation ($251k) similar to that of assistant professors ($248k). Only 2 instructor-level physicians completed the survey. The mean number for this level is skewed and is not a reliable predictor for this academic level. Quartiles could not be calculated for this category.

CONCLUSION

This is the first survey addressing compensation in the field of PAG in the United States. There is an ongoing need to collect this information to prepare PAG fellow graduates for the job market. Additional surveys, including an understanding of the compensation landscape in Canada, are needed in the future to address specific questions related to compensation for those who have less than 50% clinical time.

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.

Characteristics and Risk Factors for Ischemic Ovary Torsion in Children

Identifying ischemic ovary as a complication of ovary torsion (OT) is a significant challenge in children. This study identified risk factors for ischemic OT among pediatric OT patients to prevent delayed treatment. This retrospective study included pediatric inpatients who underwent operation for OT over 20 years. We employed multivariable logistic regression to find the risk factors associated with ischemic OT. Among the 118 patients included in this study, 78 (66.1%) had ischemic OT. Patients with ischemic OT tended to be younger; had more frequent vomiting; and had elevated White blood cell (WBC), C-Reactive protein (CRP), and segments in comparison with non-ischemic OT patients. Multivariable regression showed increased odds of ischemic ovary torsion, associated with higher WBC (12.3 × 10³/mm³ vs. 8.7 × 10³/mm³, p < 0.001), CRP (50.4 mg/L vs. 8.4 mg/L, p < 0.001), and vomiting (55.1% vs. 25%, p = 0.002) than in non-ischemic patients. A receiver-operating characteristic (ROC) analysis indicated that patients with vomiting, leukocytosis, or CRP ≧ 40 mg/L were more likely to have ischemic OT (sensitivity, 92%; specificity, 54%; PPV, 79.6; NPV, 78.9%). Ischemic OT is common among pediatric OT patients. The presence of potential risk factors of vomiting, leukocytosis, and CRP more significant than 40 mg/L may assist clinicians in ensuring an expedited surgical treatment.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Variation in Oophorectomy Rates for Children with Ovarian Torsion across US Children's Hospitals

In this multicenter study of 1783 children diagnosed with ovarian torsion from 2012 to 2017, 402 children (22.5%) underwent oophorectomy. The odds of oophorectomy were higher in children under 11 years of age, children with public insurance, and children with complex chronic conditions. Future efforts should target a preservation-first approach.

Factors Associated with Torsion in Pediatric Patients with Ovarian Masses

BACKGROUND

Management of ovarian torsion has evolved toward ovarian preservation regardless of ovarian appearance during surgery. However, patients with torsion and an ovarian neoplasm undergo a disproportionately high rate of oophorectomy. Our objectives were to identify factors associated with ovarian torsion among females with an ovarian mass and to determine if torsion is associated with malignancy.

METHODS

A retrospective review of females aged 2-21 y who underwent an operation for an ovarian cyst or neoplasm between 2010 and 2016 at 10 children's hospitals was performed. Multivariate logistic regression was used to assess factors associated with torsion. Imaging data were assessed for sensitivity, specificity, and predictive value in identifying ovarian torsion.

RESULTS

Of 814 girls with an ovarian neoplasm, 180 (22%) had torsion. In risk-adjusted analyses, patients with a younger age, mass size >5 cm, abdominal pain, and vomiting had an increased likelihood of torsion (P < 0.01 for all). Patients with a mass >5 cm had two times the odds of torsion (odds ratio: 2.1; confidence interval: 1.2, 3.6). Imaging was not reliable at identifying torsion (sensitivity 34%, positive predictive value 49%) or excluding torsion (specificity 72%, negative predictive value 87%). The rates of malignancy were lower in those with an ovarian mass and torsion than those without torsion (10% versus 17%, P = 0.01). Among the 180 girls with torsion and a mass, 48% underwent oophorectomy of which 14% (n = 12) had a malignancy.

CONCLUSIONS

In females with an ovarian neoplasm, torsion is not associated with an increased risk of malignancy and ovarian preservation should be considered.

Conservative surgery for ovarian torsion in young women: perioperative complications and national trends

OBJECTIVE

To analyse populational trends and perioperative complications following conservative surgery versus oophorectomy in women <50 years of age with ovarian torsion.

DESIGN

Population-based retrospective observational study.

SETTING

Nationwide Inpatient Sample in the USA (2001-2015).

POPULATION

In all, 89 177 ovarian torsions including 20 597 (23.1%) conservative surgeries and 68 580 (76.9%) oophorectomies.

METHODS

(1) Trend analysis to assess utilisation of conservative surgery over time, (2) multivariable binary logistic regression to identify independent factors associated with conservative surgery and (3) inverse probability of treatment weighting with a generalised estimating equation to analyze perioperative complications.

MAIN OUTCOME MEASURES

Trends, characteristics and complications related to conservative surgery.

RESULTS

Performance of conservative surgery increased from 18.9 to 25.1% between 2001 and 2015 (32.8% relative increase, P = 0.001) but decreased steadily after age 15, and sharply declined after age 35 (P < 0.001). On multivariable analysis, younger age exhibited the largest effect size for conservative surgery among the independent factors (adjusted odds ratios 3.39-7.96, P < 0.001). In the weighted model, conservative surgery was associated with an approximately 30% decreased risk of perioperative complications overall (10.0% versus 13.6%, odds ratio 0.73, 95% confidence interval 0.62-0.85, P < 0.001) and was not associated with venous thromboembolism (0.2 versus 0.3%, P = 0.457) or sepsis (0.4 versus 0.3%, P = 0.638).

CONCLUSION

There has been an increasing utilisation of conservative surgery for ovarian torsion in the USA in recent years. Our study suggests that conservative surgery for ovarian torsion may not be associated with increased perioperative complications.

TWEETABLE ABSTRACT

Conservative surgery for ovarian torsion may not be associated with increased perioperative complications.

Ovarian Torsion in a Pediatric Patient: The Importance of Repeat Imaging

A previously healthy 10-year-old girl presented to the emergency department with a 1-day history of abdominal pain. She was afebrile with an elevated white blood cell count and a negative pelvic ultrasound. The pain resolved while in hospital, and the patient was discharged home. The patient returned 10 days later, and the pain now migrated from the left flank to the subumbilical region. The patient now had an elevated white blood cell count and C-reactive protein. On pelvic ultrasound, the patient had a large midline mass and a normal right ovary. The patient was taken to the operating room where she was found to have a torted and necrotic left ovary and fallopian tube, which were removed. There are few instances where pediatric ovarian torsion presents as intermittent episodes of abdominal pain. Emergency physicians should always have a high index of suspicion for ovarian torsion in any case of abdominal/pelvic pain in young girls with previous negative imaging.

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.

Disparities in pediatric gonadal torsion: Does gender, race and insurance status affect outcomes?

PURPOSE

Ovarian and testicular torsions are emergencies requiring prompt surgical treatment to preserve gonadal function. However, diagnosis in females is often delayed owing to nonspecific symptoms. We sought to assess disparities in management and outcomes between males and females with torsion.

METHODS

The National Inpatient Sample was queried for pediatric patients with "emergent", "urgent", or "trauma center" admission and ICD-9 codes for ovarian torsion and testicular torsion. Demographic data, operative procedure, gonadal loss, length of stay (LOS), total charges (TC), and mortality were recorded.

RESULTS

There were 2254 unweighted encounters. The average age was 11.56±5.30years for males and 12.55±3.72years for females (p<0.001). Among males, 90% underwent surgery (p<0.001), of which 40% required orchiectomy. Conversely, 73% of females had surgery (p<0.001), of which 78% had oophorectomy. Subsequent analysis with only patients who underwent surgery showed that insurance status (p=0.012), race (p<0.001), and U.S. region (p<0.001) were significantly different between males and females. Gender specific analyses showed that hospital control, hospital location/teaching status, and treatment year were also significant. As such, these six factors in addition to age and gender were used for propensity score matching (PSM). PSM produced two gender cohorts of 755 encounters each. Females had longer LOS (2.44±1.84days vs. 1.28±2.27days for males, p<0.001) and had higher TC ($20,058.44±13,420.82) compared to males ($12,386.58±12,793.34), p<0.001. Logistic regression revealed that males (OR 0.163 [0.130-0.206]) and older patients (age OR 0.924 [0.903-0.946]) were less likely to undergo gonadal loss. Compared to those with private insurance, those with Medicare/Medicaid were more likely to have gonadal loss (1.401 [1.101-1.783]).

CONCLUSION

Disparities exist in the management of torsion based on gender. Overall, females had higher charges, had longer hospitalization, and were more likely to have gonadal loss despite current data supporting gonadal preservation for nearly all cases of ovarian torsion.

CLINICAL STUDY

Level III Evidence.

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.

Predictors of Oophorectomy in Girls Hospitalized in Texas With Ovarian Torsion

OBJECTIVES

Inconsistent results have been reported by authors of studies of the management of pediatric patients with ovarian torsion (OT). Our objective was to identify predictors of oophorectomy in girls hospitalized throughout Texas with OT.

METHODS

The Texas Public Use Data File (years 2013-2014) was queried for the records of girls under the age of 18 years who had a principal or secondary discharge diagnosis of OT (International Classification of Diseases, Ninth Revision, Clinical Modification code 620.5). Adjusted odds ratios were estimated from a logistic regression model by using Firth's bias-reducing penalized likelihood. Variables for inclusion in the final model were identified by using a directed acyclic graph.

RESULTS

A sample of 158 girls was identified with an overall risk of oophorectomy during the hospital stay of 41.1% (65 out of 158). After adjusting for the patient's age, health insurance status, and the presence of an ovarian cyst, girls who were treated at a nonteaching hospital were more than twice as likely to undergo oophorectomy than girls who were treated at a teaching hospital (odds ratio = 2.22; 95% confidence interval: 1.05-4.69).

CONCLUSIONS

Our analysis of a statewide database revealed that girls with OT who presented at nonteaching hospitals were significantly more likely to undergo oophorectomy compared with girls who presented at teaching hospitals.

Asynchronus bilateral ovarian torsions in girls-systematic review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Rate of Oophorectomy for Benign Indications in a Children's Hospital: Influence of a Gynecologist

STUDY OBJECTIVE

To compare the rates of oophorectomy performed by pediatric surgeons for benign indications before and after the addition of a gynecologist to the surgical staff of a children's hospital. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We used a retrospective chart review of patients ages 5-21 years who underwent surgical management by pediatric surgeons for benign adnexal indications at a tertiary care children's hospital. Patient characteristics and clinical outcomes were recorded. Rates of oophorectomy for patients managed before the addition of a gynecologist (1998-2004) were compared with those managed after a gynecologist joined the surgical staff (2005-2013). Logistic regression analysis was conducted to compare the likelihood of oophorectomy before and after the addition of a gynecologist to the surgical staff.

RESULTS

One hundred sixty-five cases were included in the final analysis. Pediatric surgeons were 8 times more likely to perform an oophorectomy for benign indications before the addition of a gynecologist to the surgical staff (odds ratio, 8.3; 95% confidence interval, 3.76-18.16). Oophorectomy was performed in 45% (25/56) of cases from 1998 to 2004 compared with 11% (12/109) of cases from 2005 to 2013. Younger age (P = .009), ischemic-appearing adnexa (P < .0001), presence of torsion (P = .017), and mature teratoma (P = .041) were associated with higher likelihood of oophorectomy.

CONCLUSION

There was a higher rate of ovarian preservation for benign indications performed by pediatric surgeons after the addition of a gynecologist to the surgical staff. Younger patients, those with a mature teratoma, and ovarian torsion continue to be at higher risk for oophorectomy.

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

STUDY OBJECTIVE

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

DESIGN

A retrospective, uncontrolled before-and-after study.

SETTING

An academic children's hospital.

PARTICIPANTS

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

INTERVENTIONS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Lower airway disease and pituitary surgery: Is there an association with postoperative cerebrospinal fluid leak?

OBJECTIVES/HYPOTHESIS

To explore the relationship between lower airway disease and postoperative cerebrospinal fluid (CSF) rhinorrhea among patients undergoing pituitary surgery STUDY DESIGN: Retrospective review.

METHODS

A retrospective review of the Healthcare Cost and Utilization Project's 2013 National Inpatient Sample was conducted to characterize the hospital stay and surgical outcomes of patients undergoing pituitary surgery. Patients with lower airway disease (including chronic obstructive pulmonary disease and asthma) were compared to a disease-free population identifying demographics and complications over-represented in the lower airway group.

RESULTS

The majority of hypophysectomies (92.1%) were performed via a transsphenoidal approach. Among transsphenoidal patients, individuals with asthma (92.8% of the lower airway disease cohort) harbored a greater postoperative CSF leak rate (4.7% vs. 2.7%, P = .022), and were more likely to develop postoperative diabetes insipidus (6.2% vs. 4.1%, P = .024) and neurological complications (13.0% vs. 9.6%, P = .010) when compared to a lower airway disease-free cohort. Patients with CSF rhinorrhea had longer lengths of stay (7.8 days vs. 4.5 days, P < .001) and higher discharge costs ($148,309 vs. $76,246, P < .001). A binary logistic regression model identified having asthma (P = .042), being female (P = .011), and having gastroesophageal reflux disease (P = .006) as independent predictors of postoperative CSF rhinorrhea.

CONCLUSIONS

Several patient comorbidities including asthma are associated with a greater risk of postoperative CSF rhinorrhea. Perioperative lower airway assessment and disease control may potentially decrease one's risk of this complication, although further inquiry is urgently needed to identify optimal preventive strategies.

LEVEL OF EVIDENCE

2c. Laryngoscope, 127:1543-1550, 2017.

Pediatric Adnexal Torsion: Not Just a Postmenarchal Problem

BACKGROUND

Pediatric adnexal torsion is rare, can be challenging to recognize, and may result in ovarian loss.

OBJECTIVE

We sought to identify and compare the defining characteristics of adnexal torsion in premenarchal and postmenarchal girls.

METHODS

A retrospective cohort study was performed at a tertiary care children's hospital, including patients diagnosed postnatally with adnexal (ovarian or tubal) torsion between 1997 and 2013. Proportions were compared using relative risk regression.

RESULTS

Adnexal torsion was found in 59 premenarchal and 43 postmenarchal girls. Abdominal pain was the most common chief complaint (54%). History included reports of pain (96%), vomiting (67%), and fever (19%). Excluding 12 patients with isolated tubal torsion and 19 with a teratoma, there were no statistically significant differences in ovarian loss in premenarchal vs. postmenarchal girls (47% and 25% respectively; relative risk [RR] = 1.8 [95% confidence interval {CI} 0.9-3.8]), left- vs. right-sided torsion (47% and 32%; RR = 1.5 [95% CI 0.8-2.7]), pain duration ≤ 2 days vs. > 2 days (31% and 41%; RR = 0.8 [95% CI 0.4-1.5]; n = 64) and severe pain vs. mild to moderate (38% and 33%; RR = 1.1 [95% CI 0.7-1.5]; n = 56).

CONCLUSIONS

The diagnosis of pediatric adnexal torsion is difficult and often delayed. Pain and tenderness may not be isolated to a unilateral lower quadrant. Although traditionally considered a postmenarchal problem, in a pediatric academic emergency department adnexal torsion occurred with similar frequency in premenarchal and postmenarchal girls. The potential for organ salvage means that adnexal torsion should be considered in all females presenting with acute abdominal pain regardless of age or menstrual history.

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.