Ovarian torsion. Management and ovarian prognosis: a report of 45 cases

doi:10.1016/j.jpedsurg.2008.11.058

Journal of Pediatric Surgery

Volume 44, Issue 9, September 2009, Pages 1759-1765

https://doi.org/10.1016/j.jpedsurg.2008.11.058 Get rights and content

Abstract

Background/Purpose

Ovarian torsion in childhood and adolescence is a rare entity. Traditionally, treatment is oophorectomy. The aim of this study was to evaluate ovarian outcome and to propose a decision-making protocol for suspected ovarian torsion.

Methods

Between January 1986 and December 2007, 45 ovarian torsion cases in 40 girls were operated on. In all the cases, when the ovary was preserved, patients were clinically and ultrasonographically followed up for several months.

Results

Median age was 11 years. Median delay between the first symptoms and surgical procedure was 3 days. There was a statistical difference (P = .0003) between the mean of the largest diameter of twisted normal ovary and the mean of the largest diameter of twisted diseased ovary. Underlying pathology was benign in 22 cases and low-grade malignancy in 2 (one grade II immature teratoma and one steroid cell tumor). Conservative management was performed in 26 cases. At follow-up, 17 ovaries were follicular, 7 being black-bluish during surgery.

Conclusions

Conservative approach after detorsion of black-bluish ovaries is safe and effective in children. Although very unlikely, the fear of missing malignancy must incite to proceed with caution and can lead, when the size of the twisted ovary is greater than 75 mm, to prefer laparotomy to laparoscopy.

Section snippets

Materials and methods

Charts of 40 patients who presented 45 ovarian torsion cases treated from January 1986 to December 2007 in the Department of Pediatric Surgery, Toulouse, France, have been reviewed retrospectively. Neonates with ovarian torsion were excluded. This torsion results usually from complication of a fetal ovarian cyst and has been reported separately [13].

Type and duration of symptoms, diagnostic modality, age at surgery, operative procedures, pathology report, and follow-up have been recorded. When

Results

Median age was 11 years (range, 22 months to 17 years). In 51%, torsion occurred on right ovary (n = 23), and in 49%, torsion occurred on the left one (n = 22).

In almost all cases, 44 of 45 children presented with an abrupt onset of abdominal pain; in 60% of cases, vomiting was synchronous with pain onset. Fever was rare and followed the initial discomfort by several hours. In one case, a calcification disclosed on a plain x-ray study for scoliosis revealed a wandering ovary because of

Discussion

Ovarian torsion in children is rare. Signs and symptoms can mimic many abdominopelvic medical or surgical diseases. The preoperative diagnosis remains a challenge to the pediatric surgeon. This is illustrated by the prolonged delay between the onset of symptoms and surgery found in our series and already stated by others [1], [4], [16]. Abdominal mass effect or calcifications on plain x-ray study could be useful to suggest diagnosis.

Abdominopelvic US scan has been the primary diagnostic

Acknowledgment

The authors thank Thierry Almont (epidemiologist, INSERM EA 3694, PDV Hospital, Toulouse, France) for his statistical analysis.

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In 2015, the U.S. News and World Report (USNWR) implemented a quality metric to expedite surgery for testicular torsion (TT), but not ovarian torsion (OT). This study examined OR timing among children with suspected TT and OT before and after this metric.
A single-center retrospective cohort study of children (1–18yr) who underwent surgery for suspected gonadal torsion was performed. Time to OR (TTOR) from hospital presentation to surgery start was calculated. An interrupted time series analysis identified changes in TTOR for suspected TT versus OT after the 2015 USNWR quality metric.
Overall, 216 patients presented with TT and 120 with OT. Median TTOR for TT was 147 min (IQR:99–198) versus 462 min (IQR:308–606) for OT. Post-quality metric, children with TT experienced a 27.8 min decrease (95% CI:-51.7,-3.9, p = 0.05) in annual median TTOR. No significant decrease was observed for children with OT (p = 0.22). Children with history of a known ovarian mass (N = 62) experienced a shorter TTOR compared to those without (422 vs 499min; p = 0.04).
Implementation of a national quality metric for TT expedited surgical care for children with TT, but not children with OT. These findings highlight the need for equitable quality metrics for children presenting with suspected gonadal torsion.
III.
Retrospective Comparative Study, Observational Cohort Study.
Postoperative Ovarian Morphology on Ultrasound after Ovarian Torsion—Effect of Immediate Surgery: A Retrospective Cohort Study
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Our objective was to determine if ovarian surgery at the time of ovarian detorsion is associated with impaired short-term ovarian function as indicated by ovarian morphology on ultrasound when compared with detorsion alone.
Retrospective cohort study
The Hospital for Sick Children, Toronto
Patients ≤ 18 years old with confirmed ovarian torsion from January 1, 2004, to December 31, 2018, with ovarian-sparing surgery.
Data were collected on demographics, procedure, intraoperative findings, and postoperative ultrasound. To determine ovarian function, we compared the morphology on the postoperative ultrasound between those with surgery to the ovary and those without surgery to the ovary at the time of detorsion. We also compared the ovarian volume of affected and contralateral ovaries after detorsion and surgery to the affected ovary.
One hundred and nineteen patients met the inclusion criteria, of whom 67 (56%) had detorsion with surgery to the ovary and 52 (44%) had detorsion alone. There was no statistically significant difference in appearance on the postoperative ultrasound between these groups (P =.446). There was also no statistically significant difference on the postoperative ultrasound of affected and contralateral ovarian volumes after detorsion and surgery to the affected ovary (P = .69). Patients who underwent surgery to the ovary experienced a lower rate of recurrence; however, this did not reach statistical significance, with a P value of 0.080.
Our study demonstrates that surgery, eg cystectomy to the ovary at the time of ovarian detorsion, does not appear to impact ovarian function when compared with detorsion alone, as indicated on postoperative imaging. There was also no difference in volume of the affected and contralateral ovaries in those cases that underwent surgery at the time of initial detorsion. This evidence would support that immediate cystectomy at the time of initial ovarian detorsion is not associated with impaired ovarian function, thus avoiding the need for an interval cystectomy.
Ovarian Preservation and Recurrent Torsion in Children: Both Less Common Than We Thought
2022, Journal of Surgical Research
Surgical management of pediatric ovarian torsion includes total oophorectomy (TO) or ovarian preservation surgery (OPS). This study sought to identify factors contributing to surgical management and readmission outcomes for ovarian torsion.
The Nationwide Readmission Database from 2010-2014 was used to identify patients < 18 years admitted with ovarian torsion. Patient factors, hospital characteristics, and readmission outcomes were compared by TO and OPS. Standard statistical analysis was performed and results were weighted for national estimates.
There were 6028 patients (age 13 ± 4 years) identified with ovarian torsion who underwent either TO (50%) or OPS (50%). Patients had secondary pathology of ovarian cyst (41%), benign mass (19%), and malignant mass (0.4%). OPS was more common in teaching hospitals (84% vs. 74% TO, P<0.001), patients < 13 years of age (41% vs. 37% TO, P = 0.001), and those from high-income households (51% vs. 41% TO, P<0.001). The overall readmission rate was 4%, with no difference between surgical approach (4.3% OPS vs. 4.4% TO, P = 0.882). Of those readmitted (n = 265), readmission diagnoses were cyst (10%), malignant mass (9%), benign mass (7%), and torsion (5%). The overall rate of recurrent torsion was 0.2%, with no difference between OPS and TO (< 0.3% vs. < 0.2%, P = 0.282).
Half of pediatric patients are undergoing TO for ovarian torsion in the U.S. and disparities exist with the utilization of OPS. There is no difference in rate of readmission or recurrent torsion between surgical approaches, and the overall rate of retorsion is lower than previously reported.
Clinical and Computed Tomographic Features of Ovarian Lesions in Infants, Children, and Adolescents: A Series of 222 Cases
2021, Journal of Pediatric and Adolescent Gynecology
To investigate the clinical and computed tomography (CT) characteristics of ovarian lesions in infants, children, and adolescents.
A retrospective analysis of the clinical and CT data was performed in 222 patients who were 20 years or younger with ovarian lesions. Patients’ age, medical history, symptoms, tumor marker levels, and CT imaging findings were recorded.
None.
Identification of the clinical and CT features of ovarian lesions in infants, children, and adolescents.
A total of 136 patients had abdominal pain, and 73 patients had palpable abdominal mass. The β-HCG was elevated in 4 and AFP was elevated in 16 of the 222 cases. A total of 235 lesions were found in 222 cases, including 75 non-neoplastic and 160 neoplastic lesions. Ovarian cyst exhibited homogeneous low density. The torsion of a normal-sized ovary demonstrated mild or no enhancement. The torsion associated with an ovarian mass demonstrated a thickened, hyperdense wall. Mature teratoma presented as a cystic mass, with bulk fat and coarse calcification. Immature teratoma appeared as a solid mass with foci of fat and fine calcification. Yolk sac tumor was shown as cystic–solid mass with intense enhancement of solid component. Wall and septation of benign epithelial tumors were relatively uniform in thickness; mural nodule was detected in borderline tumor; and malignant epithelial tumor was predominantly a solid mass with intense enhancement.
Ovarian cyst is the most common non-neoplastic lesion. Torsion of a normal-sized ovary was the second most common non-neoplastic lesion, almost always causing abdominal pain. Germ cell tumor has the highest incidence among neoplastic lesions. Fat and calcification are highly specific for germ cell tumor. The elevation of AFP and HCG levels in serum indicates germ cell tumor. Ovarian epithelial tumor is usually large, benign, and predominantly cystic. The combination of clinical and imaging features is helpful for correct diagnosis.
Ovarian masses in children and adolescents: Analysis on 146 patients
2021, Journal of Gynecology Obstetrics and Human Reproduction
Ovarian masses in pediatric population are the most common genital neoplasms, and these masses are often benign. The purpose of this study is to evaluate the pediatric ovarian masses operated in our hospital.
The records of patients, under the age of 18 who were operated in our hospital due to ovarian mass between 2012 and 2018 were reviewed retrospectively. Clinical findings, operational procedures, histopathologies, tumor markers and radiological images were evaluated.
During the study, 146 patients (5 patients were bilateral) were evaluated. The average age of the study patients was 14.01 ± 4.02 years. 107 of the study patients were benign, 37 were malignant and 2 were borderline. The most common symptom in benign masses was tenderness in lower abdominal (75.7 %). 124 of the patients (86.1 %) were in post-menarche period. 34 of the patients had ovarian torsion. Open surgery was conducted on 79.5 % (116/146) of the patients, and laparoscopic surgery was conducted on 20.5 % (30/146). The rate of oophorectomy was 24.6 % (36/146) throughout the operations. The most frequently conducted surgical procedure was cyst excision in benign masses and oophorectomy in malignant masses. In neoplastic masses, the ratio of pelvic mass palpation; and in non-neoplastic masses, lower abdominal tenderness was more apparent. The rate of ovarian torsion was 23.6 % (25/107) in benign masses and 24.3 % (9/37) in malignant masses.
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The long-term protective effect of hypothermia and gradual detorsion on ovarian tissue in adnexal torsion/detorsion model in rats
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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.
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.
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.
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.

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Original articleOvarian torsion. Management and ovarian prognosis: a report of 45 cases

Abstract

Background/Purpose

Methods

Results

Conclusions

Section snippets

Materials and methods

Results

Discussion

Acknowledgment

J Pediatr Surg

Am J Surg

J Pediatr Surg

J Pediatr Surg

Lancet

Fertil Steril

Am J Obstet Gynecol

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Fertil Steril

Original article
Ovarian torsion. Management and ovarian prognosis: a report of 45 cases