Review of a 25-Year Experience in the Management of Ovarian Masses in Neonates, Children and Adolescents: From Laparoscopy to Robotics and Indocyanine Green Fluorescence Technology

Current surgical approach: Extracranial malignant germ cell tumors

Germ cell tumors (GCT) are a complex, heterogeneous collection of tumors that may present in either gonadal or extragonadal sites. They consist of a variety of benign and malignant histologies that can occur at several locations throughout the body. An important component of treatment is surgical resection, and while the key components of resection are site specific, the universal goals of GCT resection include the complete resection of tumor without violating the tumor capsule, while preserving function of surrounding organs, minimizing morbidity, and assessing for regional spread.

The Shared Ovary: A Multidisciplinary Discussion With Pediatric and Adolescent Gynecology

Pediatric and adolescent ovarian lesions are common and are frequently managed by both pediatric surgeons and pediatric and adolescent gynecologists. During the 2023 American Academy of Pediatric Section on Surgery meeting, an educational symposium was delivered focusing on various aspects of management of pediatric and adolescent benign and malignant masses, borderline lesions, and fertility options for children and adolescents undergoing cancer therapies. This article highlights the discussion during this symposium.

Analysis of Various Laparoscopic Pediatric Urology Surgeries: Five-Year Experience of a Single Institution

Background In this study, we aim to report our single-center experience with laparoscopic pediatric urological surgeries. We aim to determine the feasibility of various urological and urogenital laparoscopic procedures and the tricks that increase surgical success. Methodology Data from 98 patients who underwent laparoscopic urological and/or urogenital procedures for diagnostic and therapeutic purposes in our clinic between June 2018 and February 2023 were retrospectively analyzed. All surgeries were performed by the same surgical team. Laparoscopic procedures included orchidopexy, gonadectomy, vaginoplasty, hysterectomy, pyeloplasty, nephrectomy/partial nephrectomy, ureteroneocystostomy, bladder diverticulum excision, renal cyst excision, proximal ureter stone removal, oophorectomy, ovarian detorsion, oophoropexy, and lymph node excision for diagnostic purposes. The surgical planning of the patients was based on the decisions of the pediatric nephrology, pediatric endocrinology, and pediatric oncology departments and the multidisciplinary council. Demographic characteristics of the patients, surgical indications, and intraoperative data, as well as postoperative pathological diagnoses and complications, were recorded. All patients underwent a transperitoneal approach. The duration of the operation was obtained from anesthesia records and defined as the time from the beginning of the surgical incision to the closure of the skin incision. Results Of the patients, 54 were males and 44 were females. The median age was 7.8 years. No complications other than grade 1 according to the Clavien-Dindo classification were observed in our patients. As different types of surgeries were analyzed, the mean operative duration was estimated. Conclusions The laparoscopic method should be performed by surgeons experienced in advanced surgeries in pediatric urology. It is critical to consider the difference in the size of pediatric patients in preparation for laparoscopic surgery to minimize technical and ergonomic problems. We believe that each surgery has its specific tricks and that these should be a part of laparoscopy training. Moreover, developing and sharing this information would be very useful for pediatric urologists.

Robotic-assisted surgery for gynecological indications in children and adolescents: European multicenter report

Robotic-assisted surgery (RAS) is increasingly adopted in the pediatric population. This retrospective multicenter study aimed to report application of RAS for gynecological indications in pediatric patients. The medical records of all girls with gynecological pathology, operated in 4 different institutions over a 3-year period, were retrospectively collected. Robot docking time, total operative time, length of stay (LOS), requirement time of pain medication, complication rate, conversion rate, and pathology were analyzed. Twenty-three girls, with median age of 12.3 years (range 0.6-17.8) and median weight of 47.2 kg (range 9-73), received the following RAS procedures: ovarian cystectomy for ovarian cyst/mass (n = 10), salpingo-oophorectomy for ovarian complex mass (n = 6), bilateral gonadectomy for Turner syndrome SRY + (n = 1), salpingectomy for fallopian tube lesion (n = 1), paratubal cyst excision (n = 1), Gartner cyst excision (n = 1), paravaginal ganglioneuroma resection (n = 1), fistula closure in urogenital sinus (n = 1), and vaginoplasty using ileal flap in cloaca malformation (n = 1). Median operative time was 144.9 min (range 64-360), and median docking time was 17.3 min (range 7-50). Conversion to open or laparoscopy was not necessary in any case. Median LOS was 2.1 days (range 1-7), and median analgesic requirement was 2.2 days (range 1-6). One patient (4.3%) needed redo-surgery for recurrent Gartner cyst (Clavien 3b). This preliminary experience showed that RAS is safe and feasible for surgical treatment of gynecological pathology in pediatric patients, although no conclusive data are available to confirm its superiority over traditional laparoscopy. Randomized, prospective, comparative studies are needed to identify the gold standard approach for such indication.

Value of ultrasound and magnetic resonance imaging combined with tumor markers in the diagnosis of ovarian tumors

BACKGROUND

Compare the diagnostic performance of ultrasound (US), magnetic resonance imaging (MRI), and serum tumor markers alone or in combination for detecting ovarian tumors.

AIM

To investigate the diagnostic value of US, MRI combined with tumor markers in ovarian tumors.

METHODS

The data of 110 patients with ovarian tumors, confirmed by surgery and pathology, were collected in our hospital from February 2018 to May 2023. The dataset included 60 cases of benign tumors and 50 cases of malignant tumors. Prior to surgery, all patients underwent preoperative US and MRI examinations, as well as serum tumor marker tests [carbohydrate antigen 125 (CA125), human epididymis protein 4 (HE4)]. The aim of the study was to compare the diagnostic performance of these three methods individually and in combination for ovarian tumors.

RESULTS

This study found statistically significant differences in the ultrasonic imaging characteristics between benign and malignant tumors. These differences include echo characteristics, presence or absence of a capsule, blood flow resistance index, clear tumor shape, and blood flow signal display rate (P < 0.05). The apparent diffusion coefficient values of the solid and cystic parts in benign tumors were found to be higher compared to malignant tumors (P < 0.05). Additionally, the time-intensity curve image features of benign and malignant tumors showed significant statistical differences (P < 0.05). The levels of serum CA125 and HE4 in benign tumors were lower than those in malignant tumors (P < 0.05). The combined use of US, MRI, and tumor markers in the diagnosis of ovarian tumors demonstrates higher accuracy, sensitivity, and specificity compared to using each method individually (P < 0.05).

CONCLUSION

US, MRI, and tumor markers each have their own advantages and disadvantages when it comes to diagnosing ovarian tumors. However, by combining these three methods, we can significantly enhance the accuracy of ovarian tumor diagnosis, enabling early detection and identification of the tumor’s nature, and providing valuable guidance for clinical treatment.

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.

Ovarian Masses in Children and Adolescents: A Review of the Literature with Emphasis on the Diagnostic Approach

Most abdominal masses in the pediatric population derive from the ovaries. Ovarian masses can occur in all ages, although their incidence, clinical presentation and histological distribution vary among different age groups. Children and adolescents may develop non-neoplastic ovarian lesions, such as functional cysts, endometrioma, torsion, abscess and lymphangioma as well as neoplasms, which are divided into germ cell, epithelial, sex-cord stromal and miscellaneous tumors. Germ cell tumors account for the majority of ovarian neoplasms in the pediatric population, while adults most frequently present with epithelial tumors. Mature teratoma is the most common ovarian neoplasm in children and adolescents, whereas dysgerminoma constitutes the most frequent ovarian malignancy. Clinical manifestations generally include abdominal pain, palpable mass, nausea/vomiting and endocrine alterations, such as menstrual abnormalities, precocious puberty and virilization. During the investigation of pediatric ovarian masses, the most important objective is to evaluate the likelihood of malignancy since the management of benign and malignant lesions is fundamentally different. The presence of solid components, large size and heterogenous appearance on transabdominal ultrasonography, magnetic resonance imaging and computed tomography indicate an increased risk of malignancy. Useful tumor markers that raise concern for ovarian cancer in children and adolescents include alpha-fetoprotein, lactate dehydrogenase, beta subunit of human chorionic gonadotropin, cancer antigen 125 and inhibin. However, their serum levels can neither confirm nor exclude malignancy. Management of pediatric ovarian masses needs to be curative and, when feasible, function-preserving and minimally invasive. Children and adolescents with an ovarian mass should be treated in specialized centers to avoid unnecessary oophorectomies and ensure the best possible outcome.