Original Study
Pediatric Ovarian Torsion and its Recurrence: A Multicenter Study

https://doi.org/10.1016/j.jpag.2016.11.008Get rights and content

Abstract

Study Objective

To report results of a retrospective multicentric Italian survey concerning the management of pediatric ovarian torsion (OT) and its recurrence.

Design

Multicenter retrospective cohort study.

Setting

Italian Units of Pediatric Surgery.

Participants

Participants were female aged 1-14 years of age with surgically diagnosed OT between 2004 and 2014.

Interventions

Adnexal detorsion, adnexectomy, mass excision using laparoscopy or laparotomy. Different kinds of oophoropexy (OPY) for OT or recurrence, respectively.

Main Outcome Measures

A total of 124 questionnaires were returned and analyzed to understand the current management of pediatric OT and its recurrence. The questionnaires concerned patient age, presence of menarche, OT site, presence and type of mass, performed procedure, OPY technique adopted, intra- and postoperative complications, recurrence and site, procedure performed for recurrence, OPY technique for recurrence, and 1 year follow-up of detorsed ovaries.

Results

Mean age at surgery was 9.79 ± 3.54 years. Performed procedures were open adnexectomy (52 of 125; 41.6%), laparoscopic adnexectomy (25 of 125; 20%), open detorsion (10 of 125; 8%), and laparoscopic detorsion (38 of 125; 30.4%). Recurrence occurred in 15 of 125 cases (12%) and resulted as significant (P = .012) if associated with a normal ovary at the first episode of torsion. Recurrence occurred only in 1 of 19 cases after OPY (5.2%). Ultrasonographic results of detorsed ovaries were not significant whether an OPY was performed or not (P = 1.00).

Conclusion

Unfortunately, oophorectomy and open technique are still widely adopted even if not advised. Recurrence is not rare and the risk is greater in patients without ovarian masses. OPY does not adversely affect ultrasonographic results at 1 year. When possible OPY should be performed at the first episode of OT.

Introduction

Ovarian torsion (OT) is a rare condition in pediatric patients. Overall, approximately 15% of cases occur during infancy and childhood1 and this percentage is greater if adolescent and teenage patients are included.2

Large series from pediatric centers report an incidence between 0.3 and 3.5 cases per year.1, 3, 4, 5, 6, 7, 8, 9

In pediatric patients the torsion of normal ovaries ranges from 16% to 49% and the remaining percentage is associated with the presence of masses.3, 10, 11, 12

The etiology of OT in the absence of cysts or masses is more obscure. Contributing factors could be the hypermobility caused by an elongated ovarian ligament or a hyperlax mesosalpinx or meso-ovarium.13

In the case of OT, adnexectomy appears largely abandoned for a conservative management also in the case of a necrotic-appearing ovary.14, 15

Indeed, recent literature suggests that standard care for OT is detorsion without removal of the fallopian tube/ovary and excision or aspiration of the cause of the torsion.2

OT recurrence is rarely reported and different surgical techniques to limit ovarian mobility,16, 17, 18, 19, 20 also called oophoropexy (OPY), have been described.

There are concerns that OPY might damage the ovary or distort the relationship between ovary follicles and the fallopian tubes.2

Indeed, alteration of pelvic anatomy during OPY might lead to tubal occlusion and impaired tube-ovary interaction.21 Nevertheless, there is no evidence in the literature that OPY decreases fertility.2

Here we report results of a multicenter Italian survey of a 10-year retrospective study concerning the treatment of OT and its recurrence in children. This report describes the management of 10 different centers in the case of OT and OT recurrence as well as results at 1 year follow-up of the preserved ovaries, to describe the current management of OT.

Section snippets

Materials and Methods

Data collection ranged from January 2004 to January 2014 and was carried out by a questionnaire sent to 10 Italian centers of pediatric surgery. A total of 124 questionnaires were returned and analyzed. The information obtained was: (1) patient age; (2) presence of menarche; (3) site of torsion; (4) presence of mass in the torsed ovary; (5) type of mass; (6) type of procedure performed; (7) associated procedures; (8) if an OPY was performed after the first episode of torsion, the site and the

Results

The mean age at the time of surgery was 9.79 ± 3.54 (range, 2-14) years. Eighty-four of 124 patients were premenarchal (67.7%) and 40 of 124 were postmenarche (32.3%). Torsion involved the right ovary in 82 of 125 cases (66.1%) and left OT was reported in 41 of 125 cases (33%). In 1 of 125 patients the OT was bilateral and synchronous (0.9%).

In 59 of 125 cases (47.2%; 39 right, 20 left) the OT was caused by the presence of a mass; the other 66 of 125 torsed ovaries (52.8%; 44 right, 22 left)

Discussion

OT is an uncommon event in the pediatric age group.22 Approximately half of these cases involves an ovarian mass.3, 10, 11, 12, 23, 24 However, several case series with torsion of normal premenarchal ovaries have been reported in the literature.7, 10, 23

In our multicenter study results confirmed data reported in the literature because in 47.2% of the cases the OT was caused by the presence of a mass and in 52.8% there was a normal ovary.

Eighty-four of 124 patients were in the premenarchal

References (40)

Cited by (27)

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    Salpingectomy is in conflict with the current recommendation for ovarian torsion. Recent trends in conservative management of adnexal torsion by detorsion even in those cases of black and necrotic appearing ovaries [18] do not correlate with an increased patient morbidity [21]. In the case of IFTT, the dilemma to perform salpingectomy or conservative management may not be resolved without a prospective long-term study where long term function of the de-torsed fallopian tube can be examined.

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

    2019, Journal of Pediatric and Adolescent Gynecology
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    The benefits to oophoropexy are controversial. Some have cited fears that ovarian fixation could impair the ovary and compromise the anatomic relationship between the ovarian follicles and oviduct.19,40–42 Although this is a theoretical concern, there are no prospective studies available to assist with decision-making in this situation.

  • Adnexal Torsion

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    Pediatric ovarian torsion accounts for approximately 15% of all cases of ovarian torsion.7–10 Although the actual incidence of AT is unknown, studies have reported between 0.3 and 3.5 cases per year.3,5,11–13 The largest analysis of pediatric ovarian torsion-related hospitalizations in the United States (Kids Inpatient Database) provides an estimated incidence of ovarian torsion of 4.9 per 100,000 female patients aged 1-20 years.14

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The authors indicate no conflicts of interest.

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