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Outcome Following Detorsion Of Torsed Adnexa

In Children

Article in Journal of Pediatric and Adolescent Gynecology · April 2014

DOI: 10.1016/j.jpag.2014.04.002

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Xiomara M Santos Darrell Cass

Baylor College of Medicine Texas Children's Hospital
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Accepted Manuscript

Outcome Following Detorsion Of Torsed Adnexa In Children

X.M. Santos, MD D. Cass, MD J.E. Dietrich, MD, MSc

PII: S1083-3188(14)00203-4
DOI: 10.1016/j.jpag.2014.04.002
Reference: PEDADO 1712

To appear in: Journal of Pediatric and Adolescent Gynecology

Received Date: 1 November 2013

Revised Date: 31 March 2014
Accepted Date: 17 April 2014

Please cite this article as: Santos X, Cass D, Dietrich J, Outcome Following Detorsion Of Torsed Adnexa
In Children, Journal of Pediatric and Adolescent Gynecology (2014), doi: 10.1016/j.jpag.2014.04.002.

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 ACCEPTED MANUSCRIPT

OUTCOME FOLLOWING DETORSION OF TORSED ADNEXA IN CHILDREN

XM. Santos, MD1, D. Cass, MD2, JE. Dietrich, MD, MSc1
Houston, Texas
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Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology,

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Baylor College of Medicine
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Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of

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Medicine

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Corresponding Author/Reprint Request:
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Xiomara M. Santos, MD

6651 Main Street, Suite F1050

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Houston, Texas 77030

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Office: 832-826-7464
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Fax: 832-825-9349

xmcampos@bcm.edu
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Abstract

Study Objective: To examine the postoperative course and outcomes of young females with

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ovarian torsion treated with detorsion and ovarian preservation. The secondary objective was to

determine which operative findings correlated with higher follicular counts following detorsion.

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Design: Retrospective chart review.

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Setting: Tertiary academic center.

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Participants: 29 females (mean age was 10.3±4.9 years) who underwent surgery for ovarian
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torsion with detorsion and ovarian preservation at our institution between July 2007 and July

2010 and who had follow-up pelvic ultrasound available for review.
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Interventions: None.
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Main Outcome Measures: Surgical findings, postoperative complications, and follicular counts
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on follow-up ultrasound.

Results: Mean duration of abdominal pain on presentation was 77.5±78.8 hours. The detorsed
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ovary was described as “dusky/purple” in 21 cases (72.4%), “normal” in 1 (3.4%), “necrotic” in

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1 (3.4%), and not described in 6 (20.7%). All pubertal patients resumed menstrual function. No
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patients required reoperation for removal of the salvaged ovary. There were no instances of

postoperative fever or concern for ovarian venous thrombosis. Average timing of follow-up US

was 8.1±6.7 months, with 28 patients (96.6%) showing ovarian follicles on the affected side

(mean 4.6 ±1.9 and 4.7±3.3 follicles on the right and left ovary, respectively). No correlation was

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found between the side affected, gross appearance of the torsed ovary or the number of follicles

found on follow-up US.

Conclusions: Detorsion with ovarian preservation is a safe and effective treatment, and should

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be considered the primary treatment for girls with ovarian torsion, even for those with ovaries

that appear necrotic.

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Key words: ovarian torsion, ovarian preservation, outcome following detorsion

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Introduction

Ovarian torsion is most likely to occur in women of reproductive age or younger1. It is usually

associated with the presence of ovarian or tubal cysts, but it has also been observed in normal

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adnexa2-5. When providers are presented with these patients, timely diagnosis and management is

important to prevent loss of ovarian function.

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Traditionally, surgeons performed oophorectomy in children and adolescents if the twisted ovary

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appeared necrotic2,4,6. This was performed due to concerns that the necrotic ovary was unlikely

to be viable in the future, the possibility of ovarian malignancy, development of chronic

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abdominal pain, risk of adhesive bowel obstruction, and concerns for ovarian venous thrombosis
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once the ovary was detorsed2,4,6,7. More recent literature supports a conservative management,

with detorsion and preservation of the adnexa, even if necrotic, as a safe and effective
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approach2,7-12. However, oophorectomy is still performed in a significant number of cases, with

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national data showing rates of oophorectomy in cases of ovarian torsion unchanged from year

2000 (61%) to 2006 (58%)13.

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Not many studies address ovarian function after a torsion episode on adolescent patients and
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none specifically assess follicle counts on follow-up ultrasound as a measure of ovarian function.

The objective of this study was to examine the postoperative course and outcome of young
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females treated with detorsion and ovarian preservation as treatment for ovarian torsion. Our
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secondary objective was to determine which operative findings correlated with higher follicular

counts following detorsion.

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Materials and Methods

A retrospective chart review was performed after IRB approval was obtained. We reviewed the

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charts of all pediatric and adolescent females who underwent surgery for ovarian torsion at our

institution between July of 2007 and July 2010 on the basis of ICD-9 codes and identified those

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who had detorsion with ovarian preservation. We included those who had at least one

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postoperative pelvic ultrasound at our institution. We excluded patients that underwent surgery

with removal of the ovary, patients who did not have a postoperative ultrasound available for

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review and patients in whom the follow up ultrasound was performed at the time of a new
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torsion episode.
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Information recorded included demographics, pain on presentation, surgical findings,

postoperative complications, menstrual history and findings on postoperative ultrasound,

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including follicular counts to which the ultrasound reader was blinded as to the side of torsion
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occurrence. Data analysis included descriptive statistics and student’s t test (SAS 9.0).

Results
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There were 45 cases of ovarian torsion during the study period. Three patients underwent
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oophorectomy and were excluded from analysis. Follow-up pelvic ultrasound was not available
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for 10 patients. Follow-up ultrasound was performed at the time of a new torsion episode for 2

patients, one of whom had 2 retorsion episodes, and these cases were excluded from analysis.

Twenty-nine patients met inclusion criteria. Mean age for the group was 10.3±4.9 years.

Thirteen patients were premenarchal. Mean age at menarche was 11.1±0.79 years for the 16

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postmenarchal patients. Duration of pain at the time of presentation ranged between 6 hours to

14 days (77.5±78.8 hours). Ovarian torsion was present on the right side in 17 patients (58.6%)

and left sided in 12 patients (41.4%). All patients underwent detorsion of the ovary with or

without additional procedures (Table 1). Oophoropexy was performed bilaterally in one patient

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and unilaterally on 6 patients.

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The appearance of the detorsed ovary was described as dusky/purple in 21 cases (72.4%), normal

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in one case (3.4%), necrotic in one case (3.4%) and the appearance was not described in 6 cases

(20.7%). Additional adnexal findings, including final pathology were also noted (Table 2).

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Average follow up was 13.9±10.1 months. None of the patients required reoperation for removal
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of the salvaged ovary. There were no instances of postoperative fever, no episodes or concern for

ovarian venous thrombosis, and none of the cases were associated with malignancy. Three of the
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perimenarchal patients experienced menarche in the months following surgery; the rest remained
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premenarchal by the time of the first follow-up visit. Information regarding menstrual function
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was available for 12 of the postmenarchal patients; all resumed normal menstrual function

following the initial torsion episode.

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The mean follow-up time for ultrasound was 8.1±6.7 months. Twenty-eight patients (96.6%)

showed ovarian follicles on the affected side, with a mean of 4.6 ±1.9 follicles on the right ovary
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and 4.7±3.3 follicles on the left ovary. There was no correlation between side affected by torsion
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or gross appearance of the torsed ovary and the number of follicles found on follow up

ultrasound.

Discussion

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Recent literature advocates for preservation of the adnexa in cases of adnexal torsion2,7-12.

However, reported rates of oophorectomy performed at the time of ovarian torsion remains

significant. Studies focusing on children and adolescents report oophorectomy being performed

in 30-61% of ovarian torsion cases7,10,13-15.

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The most common postoperative complication reported after conservative management in

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ovarian torsion cases is transient temperature elevation, reported in 12-21% cases2,8,9. Concern

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for missing a malignancy has been reported as one of the reasons for removal of the ovary, and

the malignancy rate in cases presenting with torsion have been reported as high as 1.8-4% in

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children and adolescents7,13. Oophorectomy for this indication should be reserved for thoses few
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cases where the gross appearance of the ovary is concerning for a malignant tumor. Preoperative

measurements of serum alpha fetoprotein and beta human chorionic gonadotropin are helpful to
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screen for ovarian malignancies in pediatric patients, though the assays for these values may take

some time to return from the laboratory12. Another commonly cited concern of leaving a
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necrotic ovary in place is the occurrence of ovarian venous thrombosis after detorsion. In the
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largest review evaluating this association, the incidence of pulmonary embolism (PE) after

ovarian torsion was 0.2% among 981 cases of young and adult women, with 2 documented PE’s
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occurring in patients treated with removal of adnexa and no cases of PE in patients that were
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managed conservatively. It is important to note that no other evaluation of thrombophilias was

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undertaken, therefore it is unknown if these 2 cases were predisposed to thrombosis based on

other underlying medical conditions16. All the patients in our study underwent detorsion of

adnexa without any reported postoperative complications, and no cases were associated with

malignancy.

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Prior studies evaluating the long term follow-up of patients with ovarian torsion, managed

conservatively, have shown rates of follicular function as high as 91-95%7-9,17. In our study

96.6% of patients had follicles on the affected ovary based on follow up ultrasound, consistent

with prior publications. In addition, the average number of follicles did not differ between the

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affected and unaffected ovary.

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Our study is one of the largest ones evaluating long term follow up of children and adolescents

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with ovarian torsion managed conservatively. Most of the limitations of this study are related to

its retrospective nature and potential for interpretation bias based on limited information due to

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differences in charting in some cases. In our study, ovarian function was only measured by the
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presence of functional follicles on ultrasound, for which we did not have an age-matched control

group for comparison. Another limitation is the possible impact of oophoropexy on the
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outcomes. However, outcomes were similar for all patients in terms of presence of follicles

except for one patient for which follicles were not seen on follow up ultrasound.
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Despite our limitations, all patients had good outcomes. The benefits of preserving the adnexa,

knowing that most ovaries will demonstrate follicles in the future, outweigh any theoretical risks
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of leaving a detorsed ovary in place as this study points out that no thromboses, fever or

reoperation occurred following detorsion. Detorsion alone, with cystectomy when indicated, is
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a safe and effective treatment. Preservation of the adnexa should be considered the primary
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treatment for young females with ovarian torsion, even for those with ovaries that appear

necrotic.

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References

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2. Rody A, Jackisch C, Klockenbusch W, Coenen-Worch V, Schneider HP. The conservative

management of adnexal torsion: a case-report and review of the literature. Eur J Obstet Gynecol

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Reprod Biol 2002;101:83-86.

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3.Meyer JS, Harmon CM, Harty MP, Markowitz RI, Hubbard AM, Bellah RD. Ovarian torsion:

clinical and imaging presentation in children. J Pediatr Surg 1995;30:1433-1436.

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4. Kokoska ER, Keller MS, Weber TR. Acute ovarian torsion in children. Am J Surg.
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2000;180:462-465.

5. Oltmann SC, Fischer A, Barber R, Huang R, Hicks B, Garcia N. Cannot exclude torsion- a 15-
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year review. J Pediatr Surg 2009;44(6):1212-1217.

6. Spigland N, Ducharme JC, Yazbeck S. Adnexal torsion in children. J Pediatr Surg. 1989
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Oct;24(10):974-6
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7. Galinier P, Carfagna L, Delsol M. et al. Ovarian torsion. Management and ovarian prognosis:

a report of 45 cases. J Pediatr Surg. 2009; 44: 1759-1765

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8. Oelsner G, Bider D, Goldenberg M, Admon D, Mashiach S. Long-term follow-up of the

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twisted ischemic adnexa managed by detorsion. Fertil Steril. 1993 Dec;60(6):976-9

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9. Celik A, Orkan E, Aldemir H, et. al. Long-term results of conservative management of

adnexal torsion in children. J Pediatr Surg. 2005;40:704-708

10. Aziz D, Davis V, Allen L, Langer JC. Ovarian torsion in children: is oophorectomy

necessary? J Pediatr Surg. 2004 May;39(5):750-753

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11. Cass DL, Hawkins E, Brandt ML, et al. Surgery for ovarian masses in infants, children, and

adolescents: 102 consecutive patients treated in a 15-year period. J Pediatr Surg. 2001 May;

36(5): 693-99

12. Cass Dl. Ovarian Torsion. Semin Pediatr Surg 2005 14:86-92

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13. Guthrie BD, Adler MD, Powell EC. Incidence and trends of pediatric ovarian torsion

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hospitalizations in the United States, 2000-2006. Pediatrics. 2010 Mar;125(3);532-538

14. Rossi BV, Ference EH, Zurakowski D et. al. The clinical presentation and surgical

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management of adnexal torsion in the pediatric and adolescent population. J Pediatr Adolesc

Gynecol. 2012 Apr;25(2):109-13

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15. Rousseau V, Massicot R, Darwish AA, et al. Emergency management and conservative
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surgery of ovarian torsion in children: a report of 40 cases. J Pediatr Adolesce Gynecol. 2008

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16. McGovern PG, Noah R, Koenigsberg R, Little AB. Adnexal torsion and pulmonary
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embolism: case report and review of the literature. Obstet Gynecol Surv. 1999 Sep;54(9):601-8
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17. Oelsner G, Cohen SB, Soriano D, Admon D, Mashiach S, Carp H. Minimal surgery for the

twisted adnexa can preserve ovarian function. Hum Reprod. 2003 Dec;18(12):2599-602
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Table 1. Primary Surgical Procedure in Addition to Detorsion of Adnexa

Procedure No. (%)

N=29

Laparoscopy 26 (89.7%)

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Ovarian cystectomy 12 (41.4%)

Paratubal cystectomy 5 (17.2%)

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Paraovarian cystectomy 4 (13.8%)

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Debulking/Decompression of Ovary 3 (10.3%)

Drainage/Aspiration of Ovarian Cyst 2 (6.9%)

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Laparotomy with ovarian cystectomy 2 (6.9%)
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Reduction of right ovary through inguinal hernia 1 (3.4%)
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Table 2. Adnexal Pathology

Adnexal Finding No. (%)

N=29

Ovarian Cyst 14 (48.3%)

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Functional 9 (31%)

Dermoid Cyst 4 (13.8%)

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Benign Mucinous Cystadenoma 1 (3.4%)

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Paratubal Cyst 5 (17.2%)

Paraovarian Cyst 4 (13.8%)

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No Adnexal Pathology 6 (20.7%)
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