Isolated torsion of fallopian tube with associated torsed paratubal cystadenofibroma: A case report

Cystadenofibromas (CAF) and adenofibromas (AF) are rare benign gynecologic neoplasms of epithelial origin. They can be composed predominantly of solid fibrous tissue, adenofibromas, or contain cystic components, as seen in cystadenofibromas; which can be further classified by their epithelial cell type (serous, mucinous, etc.). They most commonly arise from the ovary; however, CAF/AF associated with the fallopian tube have also been reported. CAF/AF is typically asymptomatic and found incidentally. Like other adnexal and ovarian masses, patients are at increased risk of ovarian/adnexal torsion, with increasing risk with lesion size. Herein, we present the case of a patient with isolated torsion of a fallopian tube with associated torsed paratubal serous cystadenofibroma. To our knowledge, this is the first reported case of isolated torsion of a fallopian tube with associated para-tubal cystadenofibroma.

Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) in gynecological emergencies

Objective

Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is an emerging minimally invasive approach increasingly applied to perform many gynecological procedures. Despite a still limited level of evidence, compared to conventional laparoscopy, vNOTES seems to be associated with reduced blood loss, shorter operative time, less postoperative pain, shorter hospitalization time, better cosmetic results and decreased postoperative morbidity. Although growing evidence supports the effectiveness of vNOTES for elective adnexal surgeries, there is still limited knowledge regarding its feasibility and safety in emergency settings. In the present study, we report our experience performing vNOTES in gynecological emergency cases.

Study design

We prospectively collected and analyzed data from patients who underwent vNOTES for gynecological emergencies between November 2021 and June 2023. Demographic and perioperative characteristics were collected and analyzed.

Results

Seventeen patients were included. Interventions were realized for suspicion of ectopic pregnancy in 7 cases (41.2%), for suspicion of adnexal torsion in 7 cases (41.2%), for post-hysterectomy hemoperitoneum in 2 cases (11.8%), and for uncontrollable uterine bleeding in 1 case (5.9%). Emergency procedures included unilateral salpingectomy (35.3%), ovarian cystectomy (23.5%), ovarian cystotomy (17.6%), adnexal detorsion (11.8%), hemoperitoneum drainage (11.8%), hysterectomy (5.9%), and appendectomy (5.9%). The overall median operative time was 38 [18-72] minutes. The median estimated intraoperative blood loss was 30 [5-150] mL, and no intraoperative complications occurred. Conversion to conventional laparoscopy or laparotomy was never needed. Patients stayed hospitalized for a median time of 30 [4-144] hours after the intervention. The median visual analog scale value for postoperative pain evaluation was 2 [0-5] at 12, 24, and 48 postoperative hours. No complications associated with the procedure occurred.

Conclusions

This study demonstrated the feasibility of performing vNOTES procedures for managing gynecological emergencies such as tubal ectopic pregnancy, adnexal torsion, painful ovarian lesions, post-hysterectomy hemoperitoneum, and uncontrollable uterine bleeding. Associated with data reported in the available literature, our results suggest potential benefits in treating gynecological emergencies by vNOTES over conventional laparoscopy. However, stronger evidence from larger studies is needed to confirm it.

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.

Ovarian torsion due to ovarian hyperstimulation syndrome diagnosed by sonographic whirlpool sign in the first trimester of pregnancy: A case report

Ovarian torsion during pregnancy is a rare condition that needs prompt diagnosis and detorsion in order to preserve ovarian function. Diagnosing ovarian torsion is a difficult procedure especially in pregnant cases since radiation exposure should be avoided. Detecting the whirlpool sign by ultrasonography is a highly useful technique as it is noninvasive, less time-consuming, and radiation-free. Here is a case of ovarian torsion due to ovarian hyperstimulation syndrome diagnosed solely by sonographic features and in which laparoscopic detorsion was promptly performed. A 26-year-old woman in her sixth week of pregnancy visited a tertiary hospital with sudden onset lower abdomen pain. Transvaginal ultrasound detected an 8 cm left ovary and a whirlpool sign between the uterus and left ovary. Ovarian torsion was suspected and laparoscopic surgery was performed. Intraoperatively, an enlarged left ovary was twisted at 540° involving the left fallopian tube. After detorsion, bilateral ovaries were preserved and the postoperative course was uneventful. Ovarian torsion was suspected solely by ultrasonographic features which led to surgical detorsion quickly, resulting in the preservation of bilateral ovaries. Detecting the whirlpool sign when ovarian torsion is suspected is useful, especially in pregnant women.

Combined Utero-Ovarian and Round Ligament Oophoropexy for Recurrent Torsion of Normal Adnexa: A Case Series

STUDY OBJECTIVE

Recurrent torsion of otherwise normal adnexa (not involving adnexal cysts) has been reported in young girls and adolescents. Previous ovarian fixation techniques (oophoropexy), such as plication of the utero-ovarian ligament, appear to have limited efficacy in preventing recurrent torsion. A novel technique combining plication of the utero-ovarian ligament and suturing of the ovary to the round ligament has recently been described. In this study, we describe our short-term experience with the combined utero-ovarian and round ligament oophoropexy technique.

METHODS

Patients who underwent combined oophoropexy as a primary fixation technique or as a secondary fixation technique (ie, after failure of a previous fixation) due to recurrent torsion of otherwise normal adnexa between January 2020 and December 2022 were included in this retrospective cohort study. Follow-up to assess for further torsion events was conducted by telephone interview.

RESULTS

Ten patients underwent combined utero-ovarian and round ligament oophoropexy during the study period. In all cases, at least 2 episodes of torsion of otherwise normal adnexa were surgically diagnosed before oophoropexy (range 2-4). The median patient age at the time of combined oophoropexy was 21.8 years (range 9.1-35.7 years); 3 were premenarchal, and 7 were postmenarchal. After a median follow-up of 19.1 months (range 3.0-29.3 months), only 1 case of recurrent torsion occurred.

CONCLUSION

Combined utero-ovarian and round ligament oophoropexy is novel oophoropexy procedure that may reduce the risk of recurrent torsion. However, longer follow-up is needed to determine its efficacy.

Preservation of ovarian tissue embedded in omentum following torsion and auto-amputation of the left ovary and fallopian tube in a 14-year-old girl: A case report

INTRODUCTION

Autoamputation of the ovary and fallopian tube is a scarce phenomenon particularly in adolescents but could adversely affect fertility by causing ovarian damage and loss of tubal function.

CASE PRESENTATION

A case of autoamputation of the left adnexa as a result of chronic torsion in the setting of an ovarian dermoid cyst in an adolescent girl is presented. The patient had also a large dermoid cyst in the contralateral ovary which was in danger of another torsion and loss of ovarian reserve and tube. Her left fallopian tube was absent and left ovary was embedded in the omentum. She was successfully managed through laparoscopic surgery. Bilateral cystectomy was performed and the ectopic ovarian tissue was saved.

CLINICAL DISCUSSION

Chronic torsion sometimes results in ectopic displacement of the affected ovary. While some patients may be asymptomatic, many of these cases express episodes of acute or chronic abdominopelvic pain. Hence, a prolonged pain or discomfort, even of low intensity, should not be overlooked particularly in younger patients with bilateral ovarian cysts.

CONCLUSION

Ovarian dermoid cysts in adolescents could possibly undergo chronic torsion resulting in autoamputation of the adnexa and ectopic displacement of the ovary. With prompt diagnosis and intervention, ovarian tissue and fertility could be preserved.

Artemisinin reduces acute ovarian ischemia-reperfusion injury in rats

Artemisinin (ARS) is well known as an effective agent in the treatment of malaria through the rapid elimination of Plasmodium falciparum parasites. This study aims to investigate the effect of ARS in treating adnexal torsion, one of the most common gynecological surgical emergencies. ARS was administered intraperitoneally once 30 min before unilateral ovarian torsion in two different doses (10 mg/kg vs. 50 mg/kg). Torsion was maintained for 3 h and then held in the detorted state for 3 h. Bilateral adnexectomy was performed to measure antioxidant enzyme activities and oxidant levels on the ipsilateral ovary and to make histopathological and immunohistochemical analyses on the contralateral ovary. Ischemia-reperfusion (I/R) injury dramatically upregulated the activities of CAT, GST, and MDA levels in the ipsilateral ovary, which were all downregulated by ARS treatment. A significant increase in follicular cell degeneration, congestion, and edema in the contralateral ovary was seen in the I/R group, which was significantly reduced with ARS treatment. Furthermore, I/R injury resulted in a significant increase in apoptosis as shown by the increased levels of BAX and CASP-3, and decreased levels of BCL-2 whereas ARS significantly reduced the impact of the injury. Our data, based on a rat I/R injury model, show that both ipsilateral and contralateral ovaries are protected with ARS pretreatment, and 50 mg/kg ARS treatment demonstrates to be more effective than the 10 mg/kg ARS.

A Scoring System Developed by a Machine Learning Algorithm to Better Predict Adnexal Torsion

STUDY OBJECTIVE

To establish a clinically relevant prediction score for the diagnosis of adnexal torsion (AT) in women who were operated on for suspected AT.

DESIGN

A retrospective cohort study conducted between 2014 and 2021.

SETTING

A large tertiary teaching medical center.

PATIENTS

Women who underwent urgent laparoscopy for suspected AT.

INTERVENTIONS

Analyses included univariate and multivariate models combined with the machine learning (ML) Random Forest model, which included all information available about the women and reported the accuracy of the model and the importance of each variable. Based on this model, we created a predictive score and evaluated its accuracy by receiver operating characteristic (ROC) curve.

MEASUREMENTS AND MAIN RESULTS

A total of 503 women were included in our study, 244 (49%) of whom were diagnosed with AT during the surgery, and 44 (8.8%) cases of necrotic ovary were found. Based on the Random Forrest and multivariate models, the most important preoperative clinical predictive variables for AT were vomiting, left-side complaints, and concurrent pregnancy; cervical tenderness and urinary symptoms decreased the likelihood of surgically confirmed AT. The most important sonographic findings that predicted increased risk of surgically confirmed AT were ovarian edema and decreased vascular flow; in contrast, hemorrhagic corpus luteum decreased the likelihood of surgically confirmed AT. The accuracy of the Random Forest model was 71% for the training set and 68% for the testing set, and the area under the curve for the multivariate model was 0.75 (95% confidence interval [CI] 0.69-0.80). Based on these models, we created a predictive score with a total score that ranges from 4 to 12. The area under the curve for this score was 0.72 (95% CI 0.67-0.76), and the best cutoff for the final score was >5, with a sensitivity, specificity, positive predictive value, and negative predictive value of 64%, 73%, 70%, and 67%, respectively.

CONCLUSION

Clinical characteristics and ultrasound findings may be incorporated into the emergency room workup of women with suspected AT. ML in this setting has no diagnostic/predictive advantage over the performance of logistic regression methods. Additional prospective studies are needed to confirm the accuracy of this model.

Hydrosalpinx with adnexal torsion in an adult patient-A case report

Adnexal torsion is a common gynecological emergency and a significant cause of acute pelvic pain in women. Hydrosalpinx-induced torsion of the adnexa is a rare situation and requires prompt and accurate management. Twenty-three years old nulliparous woman admitted in our structure for acute pelvic pain. The ultrasound revealed an enlarged right ovary with an adnexal cystic mass. We suspected the diagnosis of a right adnexal torsion due to cystic ovarian mass. Laparotomy revealed torsion of the right adnexa and a second large mass appearing to be a hydrosalpinx. Diagnosis of adnexal torsion is difficult and is based on a range of arguments obtained by anamnesis, clinical examination, ultrasonography and other investigations. Early diagnosis is important for preserving tubal and ovarian function, given the risk of ovarian necrosis in young women. Laparoscopy is the gold standard for diagnosing and treating adnexal torsion. The treatment can be conservative or radical, consisting of detorsion of the twisted adnexa, with or without adnexectomy.

Scoring system for predicting ovarian necrosis in adnexal torsion using an ultra-short optimized MRI protocol

PURPOSE

To evaluate a MRI scoring system predicting haemorrhagic necrosis in adnexal torsion with intraoperative and/or histopathological correlation using an abbreviated and optimized MRI protocol.

METHODS

This retrospective observational study includes patients with adnexal torsion who underwent Magnetic Resonance Imaging(MRI) and surgery. T2 sequences were evaluated by three observers of varying experience for following findings: Hypo-intensity of ovarian stroma, around the follicle, cyst wall or ovarian capsule and the twisted pedicle. Hypo-intensities in the above and a thick cyst wall were considered as predictors of necrosis. A scoring system was created based on the number of positive findings. MRI was correlated with intraoperative and histopathological findings. Lesions showing haemorrhagic necrosis were considered true positives.

RESULTS

43 women with torsion were included. 74.4% were secondary to a lead point and 25.4% were without one. Hypointensity score of 2 or more had the highest diagnostic accuracy and inter-reader agreement in predicting necrosis (R1-sensitivity: 92%, specificity: 89%, positive predictive value (PPV): 92% and negative predictive value (NPV): 89%, R2-sensitivity: 92%, specificity: 94%, PPV: 96% and NPV: 90% and R3-sensitivity: 92%, specificity: 83%, PPV: 89% and NPV: 89%).

CONCLUSION

In patients with suspected adnexal torsion, optimized MRI using T2 weighted sequences will serve as a rapid and effective single imaging modality for diagnosing adnexal torsion and accurately predicting necrosis thereby triaging the patients for appropriate management.

Recurrent torsion of otherwise normal adnexa: oophoropexy does not prevent recurrence

PURPOSE

Recurrence of adnexal torsion involving otherwise normal adnexa is not rare. Various oophoropexy (ovarian fixation) procedures have been suggested to prevent recurrence; however, long-term information of their efficacy is lacking. The aim of this study was to investigate the recurrence rate of adnexal torsion following oophoropexy.

METHODS

Retrospective cohort study, including all consecutive patients who underwent an oophoropexy procedure for the prevention of recurrent torsion of "normal adnexa" in our department from 2008 to 2019 by shortening of the utero-ovarian ligament.

RESULTS

Nineteen patients (age range 7-35 years) with a mean follow-up of 90.9 ± 57.7 months were identified. Fifteen of them (78.9%) were re-operated for recurrent torsion following an oophoropexy procedure, while four (21.1%) did not experience recurrence. Nine torsion recurrences following an oophoropexy occurred within the first 2 postoperative years. There were no differences in mean age and menarcheal status )pre- or post-menarcheal) at the time of the first torsion event, age at the time of oophoropexy, oophoropexy side, number of adnexal torsion events before oophoropexy, and follow-up duration between those with and those without post-oophoropexy recurrences.

CONCLUSION

Oophoropexy procedure by shortening of the utero-ovarian ligament may not prevent recurrent torsion of otherwise normal adnexa. Further studies to determine whether combined fixation (utero-ovarian and round ligament plication) is more efficacious than isolated utero-ovarian plication for the prevention of recurrent torsion are warranted.

Gangrenous Hydrosalpinx with Isolated Fallopian Tube Torsion in Premenarchal Child

Hydrosalpinx induced torsion of the adnexa in a premenarchal child without sexual experience is a rare situation and immediate intervention is necessary. This report describes a 10-year old premenarchal female without a history of sexual intercourse who presented with left lower abdominal pain. Ultrasound imaging revealed a left adnexa with thick-walled cystic lesion measuring 5.1 × 3.7 × 2.7 cm suggestive of hydrosalpinx or para ovarian cyst. Diagnostic laparoscopic surgery showed ischaemic tubular shaped cystic left hydrosalpinx that was twisted along its own axis at the level of isthmus. Laparoscopic left salpingectomy was performed within 24 h of presentation leaving behind a healthy left ovary. Early diagnosis is important in preventing further complications including severe infection and peritonitis and to prevent complications that might affect fertility.

Rethinking ovary preservation by adnexal torsion reversal in adolescents: a case of delayed diagnosis

Background

This article discusses the management of an adolescent woman with a delayed diagnosis of adnexal torsion (AT) whose ovaries were successfully preserved.

Case presentation

The patient was a 14-year-old female teen admitted with the chief complaint of lower abdominal pain for 3 days and worsening pain for 2 days. Magnetic resonance imaging suggested a high possibility of torsion in the anterosuperior uterine mass and was accompanied by severe ovarian edema, bleeding, and enlargement. Intraoperatively, the left fallopian tube was characterized by thickening and torsion and appeared blackish purple. The left fallopian tube paraovarian cyst was about 20 cm in size, and the left adnexa was twisted 1080° along the left infundibulopelvic ligament (suspensory ligament of the left ovary). The left ovary appeared blackish purple, with an enlarged diameter of about 10 cm. At the request and with the informed consent of the patient’s parents, we preserved the left ovary and removed the left fallopian tube. The results of the endocrine, ultrasound, and tumor marker tests were normal 1 month after surgery. Follicles and blood flow signals seen in ultrasound examinations indirectly proved the successful preservation of the left ovary in the follow-up.

Conclusions

Our attempt to preserve the ovaries in an adolescent with a delayed diagnosis of AT was successful.

Healthy adnexal torsion in pregnancy: A case report

•

Adnexal torsion during pregnancy is a rare surgical emergency.

•

The diagnosis of certainty of adnexal torsion can only be made intraoperatively.

•

In the absence of any contraindication, laparoscopy should be the preferred approach.

•

Ovariopexy is proposed by certain authors in order to prevent recurrence.

Adnexal Torsion Due to Borderline Mucinous Tumor of the Gonad in a Prepubertal Girl with Mixed Gonadal Dysgenesis (45,X/46,XY) and a Turner Phenotype

BACKGROUND

Turner syndrome (TS) is a sex chromosome condition characterized by complete or partial loss of the X chromosome. Patients with mixed gonadal dysgenesis (45,X/46,XY) and a Turner phenotype are predisposed to gonadoblastoma with malignant transformation.

CASE

We present the case of a TS patient with 45,X/46,XY with 2 episodes of left adnexal torsion (AT). Biopsies during detorsion showed benign mucinous cystadenoma. Pathology following bilateral gonadectomy revealed a left gonad with mucinous borderline tumor and right gonad with gonadoblastoma, both of which have malignant potential.

SUMMARY AND CONCLUSION

Gonadectomy is recommended in XY gonadal dysgenesis to decrease risk of malignant transformation from gonadoblastoma. Although rare in pediatric patients, ovarian malignancies have been identified among AT cases. To our knowledge, we present the first case of AT due to borderline ovarian mucinous tumor of the ovary and contralateral gonadoblastoma in a patient with mixed gonadal dysgenesis (45,X/46,XY) and a Turner phenotype.

High risk and low prevalence diseases: Ovarian torsion

INTRODUCTION

Ovarian torsion is a rare, frequently misdiagnosed condition that carries with it a high rate of morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of ovarian torsion, including presentation, evaluation, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Ovarian torsion is one of the most common gynecological surgical emergencies and occurs with complete or partial rotation of the ovary along the supporting ligaments, obstructing vascular flow. Several risk factors include the presence of an ovarian mass or cyst. The most common population affected includes reproductive aged women, though cases also occur in premenarchal females, pregnant women, and postmenopausal women. Abdominal or pelvic pain is common but is not always sudden in onset or severe. Nausea and vomiting occur in 70%. Ultrasound can assist with diagnosis, but a normal ultrasound examination cannot exclude the diagnosis. Computed tomography with intravenous contrast can assist with diagnosis. Treatment includes emergent gynecologic consultation for surgical detorsion, along with symptomatic therapy in the ED.

CONCLUSIONS

An understanding of ovarian torsion can assist emergency clinicians in diagnosing and managing this disease.

Risk Factors Associated with Adnexal Torsion after Hysterectomy

STUDY OBJECTIVE

To identify preoperative and intraoperative risk factors for adnexal torsion after hysterectomy, and to estimate the incidence of the disease in the modern-day era of laparoscopic surgery.

DESIGN

Retrospective nested case-control study.

SETTING

Large urban medical system.

PATIENTS

Eighty-nine female patients ages 17 to 51.

INTERVENTIONS

Patients underwent ovarian-sparing hysterectomy.

MEASUREMENTS AND MAIN RESULTS

The estimated incidence of ovarian torsion after hysterectomy was 0.5% (46/8538 ovarian-sparing hysterectomies). The following variables were found to be associated with adnexal torsion after hysterectomy in an adjusted logistic regression: laparoscopic or laparoscopic-assisted approach to hysterectomy vs any other approach (odds ratio [OR], 3.36; 95% confidence interval [CI], 0.86-13.23); younger age at the time of hysterectomy (17-40 years) vs older age (41-51 years) (OR, 3.45; 95% CI, 1.33-8.97); and a gynecologic history significant for endometriosis (OR, 4.07; 95% CI, 1.04-15.88).

CONCLUSION

There is an association between laparoscopic approach to hysterectomy, younger age at time of hysterectomy, and a history of endometriosis with subsequent risk of adnexal torsion. Providers should have a heightened index of suspicion for adnexal torsion after hysterectomy in patients presenting with acute-onset abdominal pain who underwent laparoscopic hysterectomy at a younger age.

The Role of Surgery in Antenatal Ovarian Torsion: Retrospective Evaluation of 28 Cases and Review of the Literature

STUDY OBJECTIVE

Antenatal ovarian torsion (AOT) is rare and requires differentiating from other congenital cystic masses of the abdomen and pelvis in neonates. In this study, it was aimed to evaluate the prenatal characteristics and postnatal outcomes of AOT. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Hospital records of patients (n = 28) with diagnosis of AOT between 2004 and 2020 were reviewed and their prenatal characteristics, postnatal examination, imaging, operative, and histopathological findings were evaluated.

RESULTS

There were 28 patients during the study period. In most of the patients (25/28; 89.3%) AOTs were detected prenatally. All were term babies with a mean birth weight of 3010 ± 466.6 g. Mean maternal age was 25.75 ± 3.65 years. Prenatal history was event-free in all and none had additional anomalies. Physical examination revealed mobile intra-abdominal cystic lesions in 16 (57.1%) patients. AOTs mimicked other pathologies as intestinal duplication cyst or mesenteric cyst (n = 7), complex ovarian cyst (n = 3), mature cystic teratoma (n = 3), simple renal cyst (n = 1), and ectopic kidney (n = 1) in 15 (53.6%) patients in postnatal ultrasonography. Elective laparoscopic surgery was performed in 26 (92.8%) patients. The other 2 patients required emergency open surgery because of acute symptoms. Ovaries were autoamputated in 17 (60.7%) patients. Histopathological examination revealed necrosis and dystrophic calcification in all specimens. There was neoplastic involvement in 2 patients (serous cystadenoma and gonadoblastoma). No complication occurred in the early follow-up period (mean: 73.9 ± 46.8 months).

CONCLUSION

AOTs can be detected easily during the antenatal period. Neoplastic involvement with AOTs is rare but possible. Although AOTs might mimic other cystic pathologies, it should be one of the first diagnoses to be considered, in the presence of a palpable intra-abdominal mass and complex cystic lesion in infant girls. It can be efficiently and safely managed using minimally invasive techniques.

A validated predictive model for adnexal torsion pre-operative diagnosis

PURPOSE

To develop a simple predictive model for pre-operative diagnosis of adnexal torsion (AT).

METHODS

A retrospective cohort study with a retrospective validation, including 669 separate episodes of women who underwent laparoscopy due to a suspected AT between January 2011 and June 2020. We compared the pre-operative characteristics between women with surgically confirmed AT and those without.

RESULTS

The derivation cohort included 615 episodes of suspected AT. AT was surgically confirmed in 445 episodes (72%). The retrospectively collected validation cohort included 54 episodes, with 31 (57.4%) surgically confirmed AT. In a multivariate regression analysis, vomiting, neutrophils to lymphocytes ratio > 3.5 and sonographic finding of enlarged ovary were independently associated with AT [OR 95% CI 2.78 (1.21-6.36), 3.15 (1.42-6.97) and 2.80 (1.33-5.88), respectively]. In the derivation cohort, the PPV for AT diagnosis was 69.7%, 84.5% and 93.1% if 1, 2 and 3 risk factors were present, respectively. Retrospective validation analysis underlined a PPV of 67.6%, 82.6 and 66.6% for 1, 2 and 3 risk factors, respectively.

CONCLUSION

We have developed and validated a simple predictive model for pre-operative diagnosis of AT, based on three parameters. Our model may assist clinicians while evaluating patients with suspected AT and improve pre-operative diagnosis.

Adnexal torsion caused by tuberculous pyosalpinx: An uncommon case report of urogenital tuberculosis

Background

According to the World Health Organization, TB is a global public health problem and it remains in 2020 the deadliest infectious disease in the world, ahead of Covid19 (Global Tuberculosis Report 2020, 2020). Morocco is an endemic area with more than 30,000 new cases of all forms of tuberculosis each year (Plan stratégique national 2018-2021 de lutte antituberculeuse, 2018). UGTB is the second most frequent localization after lymph node involvement and is responsible for 30 to 40% of all extrapulmonary cases.

Case presentation

We hereby present the uncommon case of a 27-year-old virgin woman with unremarkable medical and surgical histories, who presented at the emergency department for left-sided pelvic pain of acute installation. An exploratory laparotomy using a Pfannenstiel incision, demonstrated a peritoneal effusion of low abundance with a twisted left ovary and a huge pyosalpinx. Detorsion was then carefully performed, with improvement in color of the ovary and decrease in edema within 10 min. Histopathological study of the Fallopian tube biopsy revealed granulomatous abscessificated salpingitis with genital tuberculosis. Thus, the patient received her anti-tuberculosis treatment with a course of 6 months of 2HRZE/4HR.

Conclusions

In view of the resurgence of cases of tuberculosis of all forms, the importance of prevention and screening should not be underestimated, especially in endemic areas. In fact, only BCG at birth and the correct treatment of any primary tuberculosis infection, whatever its location, will make it possible to reduce the consequences of this affection and avoid the tragedy of the home without children.

Ovarian Torsion in Adolescents with and without ovarian mass: A Cross-sectional Study

STUDY OBJECTIVE

The aim of this study was to compare the characteristics of adolescents with and without adnexal mass who were diagnosed with ovarian torsion (OT).

DESIGN

Retrospective cross-sectional study.

SETTING

Gynecology Department at Tepecik Education and Reseach Hospital, Izmir, Turkey.

PARTICIPANTS

Adolescent girls who received surgery for OT between March 2012 and October 2020 in our institution.

INTERVENTIONS AND MAIN OUTCOME MEASURES

The patients were divided into 2 groups according to the presence or absence of an ovarian mass and compared. Demographic and clinical characteristics, imaging findings, surgery, and pathology reports of the patients were obtained. Differences in initial symptoms, ultrasound findings, the diagnostic process, and the degree of torsion in patients with and without ovarian mass.

RESULTS

Seventy-six patients were diagnosed with OT. Of the 76 patients, 41/76 (53.9%) had an ovarian mass (OTwM), and 35/76 (46.1%) had no pathology (OTnP). The admission to surgery interval was longer in the OTnP group (P = .03). Ultrasound findings of ovarian edema and the appearance of free fluid were significant in the OTnP group (P = .001). The largest dimension of the nontorsion ovary in the OTnP group was greater than in the OTwM group (P = .03). In addition, it was found that torsion more than 360° was more common in the OTnP group than in the OTwM group (24/35, 68.5% vs 41/18, 43.9%; P = .03).

CONCLUSION

In symptomatic adolescents without an ovarian mass, the presence of follicle peripheralization suggesting ovarian edema on ultrasound and the presence of free fluid in the abdomen are important in terms of suspicion of torsion for clinicians. In addition, the degree of torsion was increased in these patients.

When is it too late? Ovarian preservation and duration of symptoms in ovarian torsion

This 10-year retrospective study between 2008 and 2018, aims to investigate the duration of symptoms of ovarian torsion and the subsequent rate of ovarian preservation. Eighty-six women with surgically confirmed ovarian torsion were included. The median duration from the onset of pain symptoms to presentation (26.0 vs 6.0 h, p < .001) and from presentation to surgery (11.0 vs 5.5 h, p = .010) were significantly longer in women who required an oophorectomy compared to women who had conservative surgery. There was no significant difference in symptoms, signs or investigations except ultrasound finding of an enlarged ovary (94.9% vs 76.9%, p = .026). Awareness of the condition among the community and healthcare is crucial and routine investigations should not delay management as positive Doppler flow on ultrasound does not exclude an ovarian torsion.Impact StatementWhat is already known on this subject? Ovarian torsion is a gynaecological emergency and may lead to ovarian necrosis, infection and peritonitis. Early recognition is essential in preserving the ovary, particularly in patients with future fertility aspirations. Currently there is no consensus regarding the time period of ovarian viability after the onset of symptoms.What do the results of this study add? We have demonstrated a significant difference in the duration from the onset of symptoms to surgery. Furthermore, the duration from the onset of symptoms to presentation (26.0 vs 6.0 h, p<.001) and from presentation to surgery (11.0 vs 5.5 h, p=.010) were significantly longer in women who required an oophorectomy compared to women who had conservative surgery. There was no significant difference in symptoms, signs or investigations except ultrasound finding of an enlarged ovary.What are the implications of these findings for clinical practice and/or further research? Women with known ovarian cysts in particular should be educated of the risk of ovarian torsion. Routine investigations should not delay management as it does not exclude an ovarian torsion. Although our study suggests that early presentation and management would reduce the risk of oophorectomy, prospective studies are required to confirm the findings.

Isolated Fallopian Tube Torsion: An Underdiagnosed Entity with Debatable Management

STUDY OBJECTIVE

To study features of isolated fallopian tube torsion (IFTT) to promote early diagnosis of this entity and describe options for management.

DESIGN

Retrospective cohort study from October 2017 through October 2020.

SETTING

Tertiary care hospital.

PATIENTS

All patients with surgically confirmed adnexal torsion or IFTT during the study period.

INTERVENTIONS

All of the patients underwent gynecological examination, imaging, and laparoscopy.

MEASUREMENTS AND MAIN RESULTS

During this 3-year period, 64 patients underwent laparoscopy owing to confirmed torsion, of which 55 had adnexal torsion, and 9 had IFTT. Patients with IFTT tended to be younger (21.2 years ± 8.2 vs 29.1 years ± 11.9, p = .06) and had more fever on admission (p = .007). On ultrasound examination, isolated hydrosalpinx was demonstrated only in patients with IFTT (p <.001). During surgery, more para-ovarian cysts were observed in patients with IFTT (44.4% vs 10.9%, p = .01), whereas patients with adnexal torsion had more ovarian cysts (52.7% vs 0%, p = .003). The most common procedure was detorsion in both groups. Most patients that underwent detorsion of the tube had a normal ultrasound scan on follow-up examination.

CONCLUSION

IFTT is probably underdiagnosed. Its clinical presentation is more equivocal than adnexal torsion, and ovaries are usually of normal size on ultrasonography. Hydrosalpinx or para-ovarian cysts should raise suspicion toward IFTT. Detorsion of the tube is probably a valid management option, although further research with long-term follow-up analyzing tubal patency is necessary to define the optimal management for this condition.

Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio Might Predict Pediatric Ovarian Torsion: A Single-Institution Experience and Review of the Literature

STUDY OBJECTIVE

To determine clinical and laboratory characteristics of ovarian torsion (OT; n = 28) compared with a non-OT control (OC; n = 64) group.

DESIGN

Retrospective single-center review performed between January 2006 and December 2016.

SETTING

Academic department of pediatric surgery.

PARTICIPANTS AND INTERVENTIONS

Postoperative diagnosis of pediatric ovarian pathology (International Classification of Diseases, 10th Revision code N83) in 88 patients who underwent 92 surgeries for suspected OT, aged from 3 days to 17.8 years.

MAIN OUTCOME MEASURES

Predictive value for OT according to biometric, procedural, and laboratory parameters at the time of admission.

RESULTS

Compared with OC, OT in patients aged older than 1 year was associated with elevated values regarding white blood cell count, neutrophils, neutrophil to lymphocyte ratio (NLR; all P < .001), platelet to lymphocyte ratio (PLR; P = .003), platelets (P = .011), and a trend toward raised C-reactive protein (P = .054), whereas lymphocytes and lymphocyte to C-reactive protein ratio (both P < .001) were decreased. Using receiver operating characteristic analysis for differentiating OC from OT, besides lymphocytes and NLR (both area under the curve > 0.9), PLR elicited strongest discriminatory accuracy (area under the curve = 0.946 ± 0.037; P < .001; sensitivity 82%; specificity 90%). At binary logistic regression analysis PLR (P = .018) was independently predictive of OT. OT was suspected on ultrasound imaging in 15/18 (83%), showed a right-sided dominance in 13/18 (72%), and was associated with younger age (P = .003). No differences regarding laboratory or procedural parameters in patients aged younger than 1 year were discerned.

CONCLUSION

Blood count indices such as PLR, NLR, and lymphocyte to C-reactive protein ratio might be helpful in identification of inflammatory processes as induced by ischemia in OT. Together with ultrasound and clinical features, these parameters constitute potential predictors of OT in girls aged older than 1 year.

Isolated tubal twist: A case series of a rare event occurring at different times in reproductive life

•

Isolated fallopian tube torsion is a rare but potentially serious event occurring at different times in reproductive life.

•

This diagnosis is often overlooked before surgery.

•

It should be evoked in front acute pelvic pain in patients with history of hydrosalpinx or paratubal cyst.

•

Conservative management must be privileged especially in woman of childbearing age and in a pediatric population.

Introduction and importance

Isolated fallopian tube torsion (IFTT) is a rare but potentially serious cause of pelvic pain in women. Despite being a surgical emergency, this diagnosis is often overlooked before surgery. To raise awareness of this diagnosis among clinicians, we describe here five cases, which occurred at different times in reproductive life.

Cases presentation

We present five cases of isolated fallopian tube torsion at different ages (13–54 years). It often manifests with sudden onset of acute pelvic pain in four cases and chronic pelvic pain in one case.

At admission, patients were suspected of adnexal torsion (3 cases), genital infection (1 case), and renal pain (1 case). CT-scan showed IFTT in only one patient. Laparoscopic surgical management, performed by experienced surgeons, consisted of salpingectomy in 4 cases and conservative treatment in one case. The latter was complicated with hydrosalpinx 6 years later. All patients were followed in outpatient clinic at least one time after surgery and had favorable outcomes.

Clinical discussion

Given the rarity of the pathology and the lack of pathognomonic imaging, IFTT is rarely diagnosed before surgery. Its etiology is still unknown but hydrosalpinx following an infectious process seems to be a major risk factor.

Conclusion

Increasing awareness of this rare entity is advocated, especially in woman of reproductive age. Torsion should be evoked in front acute pelvic pain in patients with hydrosalpinx or paratubal cyst. Conservative management must be privileged especially in women of childbearing age and in pediatric population.

Is color Doppler ultrasonography reliable in diagnosing adnexal torsion? A large cohort analysis

INTRODUCTION

Color Doppler ultrasonography (CDU) is widely used to diagnose adnexal torsion (AT). However, its validity remains questionable due to its low sensitivity. Our study aimed to evaluate the accuracy of CDU for the preoperative diagnosis of AT.

MATERIAL AND METHODS

The electronic medical records of patients who were taken to the operating room with the diagnosis of suspected AT were reviewed. Patients having surgically/pathologically-proven AT were compared with patients who were found to have a different pathology at the time of surgery. CDU validity was assessed using a 2 × 2 table and compared with a diagnostic model that consists of the Doppler findings, patient's age, and previous surgical history.

RESULTS

AT was diagnosed correctly in 74.6% of cases. Absent Doppler flow was seen in only 18.6% of cases. Although its specificity and positive predictive value were high, CDU had very low sensitivity and negative predictive value. The combined diagnostic model exceeded CDU alone in terms of diagnostic accuracy.

CONCLUSIONS

The use of CDU alone is not a reliable modality to exclude AT. Absent Doppler flow is a sign of ovarian necrosis. Clinical correlation between CDU findings and the patient's symptoms makes the diagnosis of AT more timely and accurate.

The effect of folate on ischemia/reperfusion injury in a rat adnexal torsion model

PURPOSE

The ischemia/reperfusion (I/R) injury of ovaries in adnexal torsion may have inadvertent consequences. Many agents have been studied in terms of their ability to prevent reperfusion damage to ovaries in suspected cases. In this study, folic acid, known to have antioxidative properties, was investigated to determine whether it played a role in the prevention of I/R damage in a rat ovarian torsion model.

METHODS

In this experimental study, 40 female adult Wistar-Albino rats were randomly divided into five groups as control, ischemia, I/R, Fol2 (2 mg/kg folic acid), and Fol4 (4 mg/kg folic acid). In the Fol2 and Fol4 groups, folic acid was intraperitonelly administered 30 min before reperfusion. Blood samples were obtained from the tails of each rat at the second hour of reperfusion.

RESULTS

The total oxidant status (TOS), total antioxidant status, cystatin C and folic acid levels of the five groups were investigated. Folic acid in 2 mg/kg dose could moderately increase the serum folic acid concentration (15.75-19.95 ng/ml, p < 0.05), reduce the level of cystatin C (0.18-0.12 μg/L, p < 0.05), and had a tendency to improve the oxidative stress injury (OSI: 76.05-33.06, p > 0.05), although there was no statistical difference in TOS levels (p = 0.07). Folic acid in 4 mg/kg dose, could significantly increase the serum folic acid concentration (15.75-37.65 ng/ml). However, it did not significantly reduce the level of cystatin C (0.18-0.19 μg/L, p > 0.05), and did not improve oxidative stress injury (76.05-130.58, p > 0.05).

CONCLUSION

Folic acid in 2 mg/kg dose might improve the ovarian I/R injury though this was not statistically significant. Further studies are required to reach a definitive conclusion about the protective effect of folic acid in I/R injury.

Management of Adnexal Torsion in the Pediatric and Adolescent Population at Western Australia's Single Tertiary Children's Hospital over the Last 10 Years: Retrospective Study

OBJECTIVE

To review our institutional data regarding the management of adnexal torsion (AT) and assess the ovarian conservation rates.

DESIGN

Retrospective study.

SETTING

Tertiary children's hospital.

PATIENTS

Pediatric and adolescent patients with surgically diagnosed AT. Participants (n = 54, mean age 9.80 ± 3.95 years) were identified between June 2010 and May 2019.

INTERVENTIONS

Surgical management of AT.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was to determine the ovarian conservation rates in AT cases. The secondary outcomes were to determine the incidence of AT to total emergency department (ED) presentations, decision to operation theater (OT) time in AT cases, return to OT, histopathology, and follow-up with ultrasound to determine ovarian function. Data were collected on demographic and clinical characteristics. Continuous data were compared with t tests or Kruskal-Wallis tests; categoric data were compared with chi-square tests. A total of 52 (96.29%) patients had ovarian conservation, and 53 (98.14%) had laparoscopic management. The incidence rate for AT cases to total ED presentations for the last 10 years was 9.9 per 100 000, which was based on a Poisson distribution. Presentations to an ED for AT cases have trended upward since 2010. Decision to OT time was statistically significantly shorter in cases with preoperative suspicion of AT than those with intraoperative diagnosis of AT (p = .000). A total of 7 (12.96%) patients returned to OT for suspicion of recurrent torsion. Of these, 5 (9.26%) had confirmed repeat AT. The presence of fever, pain duration, severity of pain, and severity of torsion did not correlate with the follow-up ultrasound findings of ovarian activity.

CONCLUSION

The findings from our study suggest that high ovarian conservation rates are achievable in AT cases. A high index of suspicion is required to prevent a delay in surgery.

Maternal and perinatal outcomes following laparoscopy for suspected adnexal torsion during pregnancy: a multicenter cohort study

PURPOSE

To investigate the association of maternal and perinatal outcomes with the surgical diagnosis of adnexal torsion in a retrospective cohort of women operated for suspected torsion during pregnancy.

STUDY DESIGN

This is a multicenter retrospective study and telephone questionnaire of urgent laparoscopies that occurred during pregnancy for suspected torsion between 2004 and 2019 in three tertiary medical centers. Pregnancy outcomes of women with the surgical diagnosis were compared with those whose laparoscopy was negative for adnexal torsion. Multivariable regression modeling was applied to control for possible confounders ((adjusted odds ratios (aOR) ± 95% confidence intervals (CI)].

RESULTS

The study cohort included 186 women. Adnexal torsion was surgically found in 129/186 (69.4%) cases. The torsion group was characterized by higher rate of nulliparity, fertility treatments and multiple gestations as well as lower rates of previous cesarean delivery. Live birth was reported for 171 (91.9%) pregnancies, and the miscarriage rate was significantly higher in the non-torsion group. Women with torsion were more likely to be hospitalizes due to preterm labor; however, rates of preterm delivery were comparable between the groups (10.8% vs. 10.9%, p = 0.99). Logistic regression analysis had demonstrated that the performance of laparoscopy prior to 8 weeks of gestation was the only independent factor associated with miscarriage (8.23, 2.01-33.67).

CONCLUSION

Pregnancy outcomes following the diagnosis of adnexal torsion throughout gestation were overall favorable. Laparoscopic procedure during early stages of pregnancy was associated with higher rates of miscarriage, regardless of the surgical diagnosis of adnexal torsion.

Clinical characteristics, treatment and outcomes of adnexal torsion in pregnant women: a retrospective study

Background

Adnexal torsion during pregnancy is a gynecological emergency. Delayed diagnosis and treatment can cause ovarian necrosis and fetal loss. This study assessed the clinical characteristics, treatment and outcomes of adnexal torsion in pregnant women.

Methods

A retrospective study was conducted at a tertiary center between January 2008 and January 2018. Eighty-two pregnant women with surgically confirmed adnexal torsion were included. The clinical characteristics, ultrasound data, surgical interventions and pregnancy outcomes were analyzed.

Results

The median age of the patients was 28 (range, 18–38) years. The median gestational age was 11 (range, 6–31) weeks: 53 (64.6%) were in the first trimester, 21 (25.6%) were in the second trimester, and 8 (9.8%) were in the third trimester. The most common symptoms and signs were sudden pelvic pain (100%) and adnexal or pelvic masses (97.6%), followed by nausea and vomiting (61%). The Doppler blood flow signal disappeared in 62.5% of the patients. Sixty-three (76.8%) patients underwent laparoscopy, and 29 (24.2%) underwent laparotomy. The median gestational age in patients undergoing laparotomy was higher than that in those undergoing laparoscopy (26 weeks vs 10 weeks, p < 0.001). Fifty-three (64.6%) patients underwent conservative surgery, with 48 detorsions and cystectomies, 2 detorsions and cyst fenestrations, 1 detorsion only and 2 salpingectomies only. Twenty-nine (25.4%) patients underwent unilateral salpingo-oophorectomy. There were no cases of postoperative thrombosis, spontaneous abortion or recurrence during the same pregnancy. Seven patients underwent simultaneous artificial abortion. One patient experienced intrauterine fetal death, and 74 patients had live births.

Conclusion

Surgical intervention was required as soon as possible. Laparoscopic conservative surgery is safe and may be appropriate to preserve ovarian function.

The long-term protective effect of hypothermia and gradual detorsion on ovarian tissue in adnexal torsion/detorsion model in rats

INTRODUCTION

Ischemia in ovarian torsion and subsequent reperfusion has significant effects on fertility in the long term. The most important reason for these changes is thought to be a reperfusion injury rather than ischemia. We aimed to evaluate whether the reperfusion injury following ovarian detorsion could be reduced by hypothermia and intermittent reperfusion.

MATERIALS AND METHODS

Forty adult female rats were divided into five groups as follows: Sham (Sh) (n = 8), torsion detorsion (control TD) (n = 8), progressive reperfusion "gradual detorsion" (GD) (n = 8), hypothermia (H) (n = 8) and the progressive reperfusion + hypothermia (GD + H) (n = 8). In all rats, except for the Sh group, the left ovary was rotated counter clockwise 1080° and fixed to the abdominal wall by three 5-0 non-absorbable sutures followed by the closure of the laparotomy. After 30 h, reperfusion was achieved following the detorsion of the ovaries. In both the control TD and H groups, the torsed ovaries were detorsed. H group, however, was subjected to hypothermia with ice packs 30 min before and during the detorsion. Tissue temperature was kept constant at 4 °C, controlled by a digital thermometer. In the GD group, the torsed ovary and pedicle were detorsed by 360°, followed by a 5 min pause. This procedure was repeated twice until a complete detorsion was achieved. GD + H group underwent hypothermia with ice packs 30 min before the procedure and the torsed ovary and pedicle were detorsed by 360°. After a 5 min pause, we repeated this process twice to provide full detorsion. The tissue temperature was constantly held at 4 °C. In the hypothermia groups, we applied hypothermia for an additional 30 min after detorsion and then left the rats at normal body temperature during reperfusion. We followed the rats in all groups for 60 days. Then we excised the left ovaries of all rats through laparotomy and spared some of the ovaries for biochemical and pathological examination. Intracardiac blood was taken at the end of the procedure and it was sent to the biochemical laboratory to assess oxidative stress markers. Finally, all the animals were sacrificed with high-dose of anesthesia.

RESULTS

Evaluation of the results revealed that oxidative stress markers were significantly lower, and antioxidant parameters were higher in the experimental groups compared with the control TD group (p < 0.05). Histopathologically, we found that tissues were preserved in GD, H, GD + H groups (p < 0.05). When we compared the groups among each other, both biochemical and histopathological values in GD + H group showed that the tissue was preserved from oxidative damage, albeit the difference did not reach a level of significance.

DISCUSSION

Several studies have shown that both hypothermia and intermittent reperfusion protect tissue from IR damage in the early period. However, as far as we know there is no study on long-term outcomes of both practices. Our study showed that both hypothermia and intermittent reperfusion alone protect tissue from IR damage in the long term. However, it did not show the superiority of the combination of both methods compared to that of individual application. The advantages of these methods lie in their easy application and cost-effectiveness. We believe that our study will serve as a base for future studies on the subject.

Giant paratubal cyst presenting as adnexal torsion: A case report

Background

Paraovarian/paratubal cysts constitute about 10% of adnexal masses and are usually small and asymptomatic. A huge paratubal cyst complicated by adnexal torsion is a rare cause of acute low abdominal pain.

Case Report

We report the case of an obese 31-year-old nulliparous woman who presented with a large pelvic cyst causing ovarian torsion. The size of the mass (~25 cm) caused pain, and obesity led to explorative laparotomy, which showed a huge central abdominal-pelvic cyst arising from the right adnexa. Cystectomy was technically impossible, so all the adnexa was removed. Pathologic diagnosis revealed a papillary serous cystadenoma with torsion of all structures.

Conclusion

A giant paratubal cystadenoma is a rare condition and management is challenging. If there are clinical and imaging signs of torsion, it should be approached like any other adnexal mass and surgery should be urgent in order to avoid irremediable compromise of ovarian function.

•

Paraovarian/paratubal cysts constitute about 10% of adnexal masses, and are usually small and asymptomatic.

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A huge paratubal cyst complicated by adnexal torsion is a rare cause of acute low abdominal pain.

•

Suspected adnexal torsions require prompt surgical treatment in order to avoid compromises of ovarian function.

Dermoid cysts causing adnexal torsion: What are the risk factors?

OBJECTIVE

Dermoid cysts (benign mature cystic teratoma) are a relatively common cause of adnexal torsion. We aimed to identify the clinical and surgical characteristics associated with adnexal torsion involving dermoid cysts.

STUDY DESIGN

Retrospective review of all cases of ovarian dermoid cysts (as diagnosed by pathology evaluation) operated in our department between 2008-2019. We collected information on demographic characteristics, clinical presentation, and surgical findings and compared those parameters among women with and without adnexal torsion.

RESULTS

The study cohort included 231 patients who were operated for ovarian dermoid cysts. Of these, the surgery was performed urgently for suspected adnexal torsion in 77 (33.3%) cases, while adnexal torsion was surgically diagnosed in 51 (22.1%) cases. Diagnosis of torsion was significantly associated with younger mean age (28.8 ± 14.4 years in torsion cases versus 34.5 ± 14.8 years in non-torsion cases, p = 0.01), but not with the mean cyst diameter (81.9 ± 26.3 mm in the torsion group versus 74.7 ± 35.9 mm in the non-torsion group, p = 0.1). Regarding cyst size, torsion was found in women with cyst diameter ≤ 55 mm (9 cases, 17.7% of torsion cases), 60-90 mm (30 cases, 58.8%), and ≥ 100 mm (12 cases, 23.5%) (p = 0.1 for comparison between all groups and p = 0.05 for comparison between the small diameter group versus the intermediate/large diameter groups). Although abdominal pain was reported in most women with and without torsion, patients with adnexal torsion were significantly more likely to present with nausea and/or vomiting (24 cases [47.1%], versus 14 cases [7.8%], respectively, p < 0.001).

CONCLUSION

Torsion of dermoid cysts is associated with younger age, but not with the mean cyst's diameter. Surgical removal of dermoid cysts should be considered in pre-menarchal girls, adolescents and young women to prevent adnexal torsion.

Added value of MRI for the diagnosis of adnexal torsion in children and adolescents after inconclusive ultrasound examination

PURPOSE

The purpose of this study was to assess the performance of magnetic resonance imaging (MRI) in children and adolescents with suspected adnexal torsion (AT) after inconclusive initial ultrasound examination.

MATERIALS AND METHODS

Twenty-eight girls with a mean age of 12±4 (SD) years (range: 1 month to 18years) were included. All had clinically suspected AT and inconclusive initial ultrasound findings followed by pelvic MRI as a second-line imaging modality. The final diagnosis was obtained by surgery or follow-up. Two radiologists blinded to the clinical, ultrasound and surgical data, retrospectively and independently reviewed MRI examinations. Clinical and MRI features associated with AT were searched for using univariate analyses.

RESULT

Among the 28 patients, 10/28 patients (36%) had AT and 22/28 (79%) had an ovarian or tubal mass. AT was associated with an age<13years (OR: 10.7; 95% CI: 1.3-148.2) (P=0.022) and a whirlpool sign at MRI (OR: 61.0; median unbiased estimate, 7.2) (P<0.0001). When a mass was present, the best quantitative MRI criteria for AT were mass volume and ovary-corrected volume≥30cm³ (κ=0.72 and 0.61, respectively), mass axis length≥5cm (κ=0.90), and mass surface area≥14 cm² (κ=0.58), with moderate to almost perfect interobserver agreement. The overall sensitivity, specificity and accuracy of MRI for the diagnosis of AT were 100% (10/10; 95% CI: 69-100), 94% (17/18; 95% CI: 73-100) and 96% (27/28; 95% CI: 82-100) respectively, with perfect interobserver agreement (κ=1).

CONCLUSION

In pediatric patients with suspected AT and inconclusive initial ultrasound examination, a strategy including MRI as a second-line imaging modality should be considered if MRI does not delay a potential surgery.

Laparoscopic Detorsion and Fertility Preservation in Twisted Ischemic Adnexa - A Single-Center Prospective Study

Objective:

This study aimed to analyze our experience about the salvageability of ovary in cases of adnexal torsion by laparoscopy, irrespective of the grade of necrosis and number of twists, and to assess the subsequent ovarian viability.

Materials and Methods:

This is a prospective study conducted in a tertiary care laparoscopic institute. All the cohorts of intraoperative diagnosis of adnexal torsion were included irrespective of the age group from January 2015 to January 2018 over the period of 3 years after obtaining approval from the institute's human ethics committee. Their demographic details and clinical and operative findings were entered after obtaining an informed written consent. All patients underwent laparoscopy except those with a suspicious diagnosis of malignancy. Postoperatively, ovarian viability was assessed by ultrasound Doppler in terms of vascularity and follicular development at 1, 6, and 12 months.

Results:

A total of 84 patients were included in the study. Acute abdominal pain (71.4%) was the main presenting symptom in all age groups. The total number of cases of adnexal torsion was 69. Adnexal torsion was mainly diagnosed in young and adolescent girls. Out of 46 attempted detorsion, 45 ovaries were preserved (97.8%). Most of the pathologies were benign. All the preserved ovaries were showing follicles and vascularity during ultrasound follow-up.

Conclusion:

Laparoscopic detorsion of the ovary is the best treatment modality irrespective of the grade of ischemia. Ovarian structure and follicles were preserved following detorsion in all the cases, even in gravely ischemic ovaries.

Adnexal torsion in the third trimester of pregnancy: a case report and diagnostic value of MR imaging

BACKGROUND

The torsion of normal adnexa is rare during pregnancy, especially in the third trimester. Nonspecific symptoms and signs as well as the limitations of ultrasound (US) make the diagnosis difficult, resulting in the loss of adnexa and fetal compromise. The magnetic resonance imaging (MRI) features of the torsion of normal adnexa are not classically described during pregnancy and only reported in a few cases. We find some different MRI features of the torsion of normal adnexa in late pregnancy and its diagnosis and treatment values are discussed in our report.

CASE PRESENTATION

A 27-year-old woman at 31 + 5 weeks' gestation presented to the emergency department with a three-day history of the left lower abdominal pain. US discovered a mass of 87 × 61 mm in the left abdomen, but did not show whether the mass originated from the left ovary or the uterus. MRI showed the left ovary was increased in size to 82 × 42 × 85 mm with peripheral follicles. On fat-suppressed T2-weighted images, the signal intensity of the lesion was significantly decreased compared with the right ovary. The adjacent fallopian tube was found to be thickened. The radiologists diagnosed ovary infarction secondary to adnexal torsion. With the provisional diagnosis of adnexal torsion, the patient was taken to surgery. The left adnexal torsion was found during surgery. There was extensive hemorrhage and necrosis, so a left salpingo-oophorectomy was performed. The histopathology confirmed an extensively hemorrhagic fallopian tube and ovary with partial necrosis.

CONCLUSION

We believe MRI is helpful where US is indeterminate in diagnosis of the torsion of normal adnexa in advanced pregnancy. We found that aside from hyperintensity on fat-saturated T1-weighted images, the low signal intensity on T2-weighted images can also reflect adnexal hemorrhage in conjunction with the torsion of normal adnexa.

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.

Comparison of subsequent pregnancy outcomes after surgery for adnexal masses performed in the first and second trimester of pregnancy

OBJECTIVE

To determine whether surgery for adnexal masses in the first trimester of pregnancy affects subsequent pregnancy outcomes compared to surgery in the second trimester.

METHODS

Data were retrospectively reviewed from women who underwent adnexal mass surgery before 26 weeks of gestation at a university hospital between July 2008 and June 2018. Women who underwent surgery in the first trimester were classified as group 1 (n=78) and those in the second trimester were classified as group 2 (n=48). Information on clinical characteristics and pregnancy outcomes was obtained from medical records and follow-up interviews and compared between two groups.

RESULTS

There were no differences in age, parity, mass size, laparoscopy, and operation time between the two groups. A total of 98 cases were confirmed as ovarian torsion, including 72 cases in group 1 and 26 cases in group 2. Accordingly, adnexectomy was performed more often in group 1 (P=0.002). No significant differences concerning the rate of abortion, preterm birth, or cesarean delivery were found.

CONCLUSION

Surgery for adnexal masses performed in the first trimester is almost as safe as that in the second trimester. Surgery should be performed for women with a complex adnexal mass in the first trimester to avoid unfavorable complications.

Emergent complication of assisted reproductive technology: Clinical analysis of 17 pregnant women with adnexal torsion

BACKGROUND

The purpose of this study was to evaluate the clinical symptoms, surgical management, and outcomes of pregnant women with adnexal torsion due to assisted reproductive technology.

METHODS

It was a retrospective study that include 17 pregnant women with adnexal torsion, in which the maternal age, type of fertilization, gestational age, clinical symptoms, ultrasonic findings, side affected by the disease, surgical method, and pregnancy outcomes were evaluated.

RESULTS

A total of 17 patients with adnexal torsion were included in this study, of which 8 patients conceived by in vitro fertilization-embryo transfer (IVF-ET), 1 by artificial insemination (AIH), and the other 8 conceived naturally after ovulation induction. About 14 were reported to have occurred in the first trimester of pregnancy, 1 case in the second trimester, and the other 2 in the third trimester. Clinical symptoms were abdominal pain with or without nausea and vomiting. 14 cases occurred in the right adnexa and the other 3 in the left. 5 of the patients underwent laparoscopy, and the other 12 underwent laparotomy. 8 cases were of full- term delivery, 6 twins gave birth prematurely, and 3 patients had inevitable abortion.

CONCLUSIONS

Adnexal torsion is an acute onset of lower abdominal pain in women, which seldom occurs during pregnancy. However, because of the wide application of assisted reproductive technology (ART), its incidence has increased. Early diagnosis and treatment can lead to better results.

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

STUDY OBJECTIVE

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

DESIGN

Retrospective cohort study and telephone questionnaire.

SETTING

University-affiliated obstetrics and gynecology department.

PATIENTS

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

INTERVENTIONS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSION

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

Peripheral hypervascularity of the corpus luteum with ovarian edema (CLOE) may decrease false positive diagnoses of ovarian torsion

INTRODUCTION

In patients with pelvic pain, corpus luteum with associated ovarian edema (CLOE) may be mistaken for ovarian torsion on ultrasound or CECT.

METHODS

This was a multi-reader, blinded, retrospective review performed at a single academic center from 2012 to 2018. Cases of CLOE that were misdiagnosed as torsion and cases of ovarian torsion without a lead-point mass were analyzed. Evaluated ultrasound features included presence of a corpus luteum, ovarian and corpus luteum volume, Color Doppler vascularity of the corpus luteum rim compared to that of the ovarian stroma, peripheral follicular displacement, twisted vascular pedicle, and free fluid. Evaluated CT features included presence of a corpus luteum, ovarian and corpus luteum volume, corpus luteum rim enhancement, twisted vascular pedicle, and free fluid.

RESULTS

39 cases of CLOE and 30 cases of ovarian torsion without lead-point mass were reviewed. A corpus luteum was present in 56.7% of torsed ovaries. In CLOE cases, peripheral hypervascularity of the corpus luteum (manifested as enhancement at CECT or flow signal at Doppler US) was present in 67.7% (21/31) of cases on ultrasound, and in 95.7% (22/23) of cases on CT. No peripheral hypervascularity of the corpus luteum was seen in cases of torsion (p < 0.001). Torsed ovaries were significantly larger than CLOE cases. Other findings were not significantly different between the two groups.

CONCLUSION

Increased blood flow in the periphery of a corpus luteum on color Doppler ultrasound or on CECT is a strong negative predictor for ovarian torsion.

Non-visualization of the ovaries on pediatric transabdominal ultrasound with a non-distended bladder: Can adnexal torsion be excluded?

BACKGROUND

The pediatric reproductive organs are optimally imaged with a full bladder. The filling of the bladder, however, often leads to significant delay in diagnosis and can subject the patient to invasive bladder catheterization. As the key imaging feature in ovarian torsion is unilateral ovarian enlargement, we suspected that a torsed ovary is large enough to be visualized even if the bladder is not well distended.

OBJECTIVE

The purpose of this study was to retrospectively investigate if clinically suspected adnexal torsion can be excluded based on non-visualization of the ovaries on transabdominal ultrasound (US) with a non-distended bladder in pediatric patients.

MATERIALS AND METHODS

This retrospective study comprised 349 girls (1-19 years old) between Jan. 1, 2013, and July 30, 2018. Three hundred and forty-one of the girls were referred to transabdominal US to assess for adnexal torsion and/or appendicitis, and the ovaries were initially not visualized on US. Their bladders were subsequently filled and rescanned with a distended bladder showing the ovaries. Ovarian volumes and time between US scans were documented. The ratio of the volume of the larger ovary to the smaller one was calculated. Nine girls had surgically proven adnexal torsion and a preoperative transabdominal US with a non-distended bladder. There was an overlap of one girl between the two groups. The negative predictive value (NPV), positive predictive value (PPV), and sensitivity and specificity for exclusion of adnexal torsion based on non-visualization of the ovaries on US with a non-distended bladder were calculated.

RESULTS

One of the girls (1/341) who had a US study done with a non-distended bladder in which the ovaries were not visualized had a positive diagnosis of adnexal torsion. In eight of the nine girls who had surgically proven adnexal torsion, the torted ovary was identified with a non-distended bladder. The NPV and PPV for exclusion of adnexal torsion with a non-distended bladder was 1.0 and 0.8, respectively. The specificity and sensitivity were 99.4% and 88.9%, respectively. The mean and median time difference between the initial scan and the scan after bladder filling was 105.1 min (standard deviation [SD] -65.8) and 89.0 min (interquartile range [IQR]- 59.0, 130.5), respectively.

CONCLUSION

Non-visualization of the ovaries with a non-distended bladder on transabdominal US study can help exclude clinically suspected adnexal torsion, alleviating the need for bladder filling and prolonging the wait time in the emergency department. Inclusion of non-visualization of the ovaries as one of the features in a predictive score for adnexal torsion should be considered.

Isolated torsion of the fallopian tube in a 16-year-old girl: A case report and review of the literature

Torsion of the fallopian tube is when the tube twists on the axis created between the infundibulopelvic ligament and the utero-ovarian ligament. It most commonly presents with appendicitis-like symptoms, such as abdominal pain, nausea and vomiting. Because of its rarity and non-specific symptoms, it is usually misdiagnosed initially, which delays therapy, at the expense of the preservation of fertility. This case report of a 16-year-old girl who had never had sexual intercourse presents an example of the misdiagnosis of fallopian tube torsion. The definitive diagnosis was based on laparoscopy. We summarize our experience and provide our conclusions after reviewing the literature.

Corpus luteum with ovarian stromal edema is associated with pelvic pain and confusion for ovarian torsion

PURPOSE

To distinguish the corpus luteum with adjacent ovarian stromal edema as an entity associated with pelvic pain, with confounding ultrasound features that may lead to false-positive diagnosis of ovarian torsion.

METHODS

This is a blinded, retrospective study of 243 corpora lutea on transvaginal ultrasound. Imaging parameters included ovarian and corpus luteum volumes, central cystic space within the corpus luteum, vascularity around the corpus luteum, peripherally displaced follicles, and complex free fluid. Residual volume (ovarian volume minus corpus luteum volume) was used as a surrogate for ovarian stromal edema. Clinical parameters included age, pregnancy, and location/acuity of pain if present. Concern for ovarian torsion in radiology reports was documented.

RESULTS

51.0% (124/243) of patients presented with pain. Multivariate regression analysis of factors significantly associated with pain (including age, p = 0.001; larger corpus luteum volume, p = 0.002; larger residual volume, p < 0.001; complex free fluid, p = 0.002; and peripherally displaced follicles, p < 0.001) left only increased residual volume as significantly associated with pain [OR 1.02-1.16; p = 0.01]. False-positive concern for ovarian torsion on ultrasound was present in 12.9% (16/124) of patients with pain, associated with enlarged ovaries (p < 0.001) and peripherally displaced follicles (p < 0.001). High correlation between location of pain and side of the corpus luteum was demonstrated in patients with pain < 14 days duration (p < 0.001).

CONCLUSION

Corpus luteum with ovarian stromal edema is associated with pelvic pain and can mimic ovarian torsion on ultrasound. Further research should explore diagnostically useful differences between cases of ovarian torsion and cases of ovarian edema related to corpora lutea.

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level II.

TYPE OF STUDY

Clinical retrospective study.

Diagnostic value of neutrophil to lymphocyte ratio in differentiation of ruptured ovarian cysts and adnexal torsion

Objective

Ovarian cyst rupture and adnexal torsion (AT) differential diagnosis is important for early surgical intervention of AT for preserving ovarian function. The aim of this study was to evaluate the diagnostic value of preoperative the neutrophil-to-lymphocyte ratio (NLR) in patients with adnexal torsion and ovarian cyst rupture.

Materials and Methods

Data of 80 patients who underwent surgery between 2012 and 2017 for ovarian cyst rupture, adnexal torsion, and unruptured ovarian cyst were analyzed. Patients were categorized as adnexal torsion (n=35), ovarian cyst rupture (n=20), unruptured ovarian cyst (n=25) groups. Preoperative NLR were compared among the three groups of the patients.

Results

The adnexal torsion group had a median NLR of 8.0 (range, 4.0-14.1), the ovarian cyst rupture group had a median of NLR 7.5 (range, 3.7-11.5), and median NLR of the unruptured ovarian cyst group was 2.2 (range,1.8-2.7). The NLR was found to have a difference that reached statistical significance among the three groups (p<0.001). When the groups were individually compared, there was no significant difference between the ovarian cyst rupture and adnexal torsion groups (p=0.372), but there was a significant difference between the unruptured ovarian cyst and adnexal torsion groups (p<0.001).

Conclusion

NLR may be useful in the differential diagnosis of unruptured ovarian cyst from adnexal torsion, but it has no diagnostic value for the differentiation of ovarian cyst rupture and adnexal torsion.

Auto-amputated adnexa in a young woman: Multimodal imaging to rule in a pelvic rolling stone

We report the case of a 26-year-old woman with a right auto-amputated adnexa and a free-floating mass in the pouch of Douglas using multimodal imaging studies including ultrasonography, computed tomography, and magnetic resonance imaging. The absence of an ovary and the evidence of an amorphous and potentially calcified mass, with no connection to the genital tract - in particular when it is found to be mobile - are the key imaging findings. Prospective diagnosis of adnexal auto-amputation could assist surgeons in patient management with a curative laparoscopy in symptomatic women, or potentially expectant management in young women who are asymptomatic or have unrelated symptoms.