Ovarian Torsion in Premenarchal Girls

Study ObjectiveTo investigate characteristics that differentiate premenarchal girls with ovarian torsion (OT) from those without OT at the time of surgery.DesignRetrospective chart review of 36 premenarchal girls who underwent 42 surgeries for either OT (n = 33) or a nontorsed ovarian mass (n = 9) from 2006 to 2017.SettingLarge, tertiary care academic institution.ParticipantsWe included patients aged 0-12 years with International Classification of Diseases, Ninth Revision codes for torsion of the ovary, adnexa, ovarian pedicle, or fallopian tube. Controls had International Classification of Diseases, Ninth Revision codes for ovarian mass or cyst, who also underwent surgery and did not have OT.InterventionsRecords were reviewed for patient characteristics including laboratory and imaging studies, surgical intervention, and pathologic diagnosis. Fischer exact test and the nonparametric Mann–Whitney U test were used for statistical analysis.Main Outcome MeasuresCharacteristics predictive of OT in premenarchal girls.ResultsTwenty-nine premenarchal patients were diagnosed with 33 episodes of OT. Nine patients underwent surgery for ovarian masses but did not have OT. All patients with OT reported abdominal pain (compared with 55.6% without OT; P < .001) and most had nausea and/or emesis (81.8% vs 33.3%; P < .009). Ultrasound findings of ovarian enlargement and decreased Doppler flow were significant in the OT group (P < .083, P < .009). There were 2 cases of malignancy in each group.ConclusionPatients with OT had significantly more nausea, emesis, and abdominal pain compared with those without OT. Additionally, 2 of 4 malignancies were found in patients with OT, indicating that malignancy should still be considered with large, complex masses.     

Surgical Management of Benign Adnexal Masses in the Pediatric/Adolescent Population: An 11-Year Review

Study Objective

The purpose of this study was to compare ovarian conservation rates and surgical approach in benign adnexal surgeries performed by surgeons vs gynecologists at a tertiary care institution.

Compensatory Ovarian Hypertrophy after Unilateral Oophorectomy: Evaluation of Ovarian Volumes in Pediatric and Adolescent Populations

Study ObjectiveLimited data exist on the morphologic and physiologic effect on the remaining ovary after unilateral oophorectomy, especially in the pediatric population. Our aim is to evaluate ovarian volumes following unilateral oophorectomy to determine whether compensatory ovarian hypertrophy occurs in the remaining contralateral ovary.DesignThis was a retrospective chart review of ovarian volume measured on ultrasounds that were completed after unilateral oophorectomy. Postoperative ovarian volumes were compared to established radiologic standards.SettingLarge tertiary care academic children's hospital in Atlanta, GA.ParticipantsFemale patients less than 21 years old who underwent unilateral oophorectomy.Main Outcome MeasuresOvarian volumes measured on postoperative ultrasounds.ResultsA total of 93 patients met inclusion criteria for this study. Serial ultrasounds were performed in slightly more than half of the patients (n = 48, 51.6%), totaling 193 postoperative ovarian volumes. The average age of oophorectomy was 10.8 years. Prior to surgery, the majority of patients presented with abdominal pain (n = 51, 54.8%) or pelvic mass (n = 51, 54.8%), and most (n = 77, 82.8%) had benign final pathology. Ovarian volumes were compared to 4 published radiologic ultrasound standards. More than 62.2% of ovarian volumes from girls who had previously had unilateral oophorectomy were larger than age-matched standard ovarian volumes.ConclusionOvarian enlargement occurs in the contralateral ovary following unilateral oophorectomy in the pediatric and adolescent population. This supports the concept of compensatory ovarian hypertrophy. This knowledge provides valuable information for interpretation of radiologic images in young female individuals who have undergone oophorectomy, and can assist with counseling on the risk of adnexal complications due to ovarian hypertrophy after unilateral oophorectomy.     

Rates and Technique for Oophoropexy in Pediatric Ovarian Torsion: A Single-Institution Case Series

Study Objective

Ovarian torsion (OT) is uncommon, but can result in loss of reproductive function. Traditionally managed using adnexectomy, torsed adnexae are now being conserved, increasing the potential for recurrent OT. As a result, some experts suggest oophoropexy (OP) to prevent recurrence. We report on a series of 11 patients who underwent OP.

Pediatric Ovarian Torsion and its Recurrence: A Multicenter Study

Study Objective

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

Management of Large Pediatric and Adolescent Ovarian Neoplasms with a Leak-Proof Extracorporeal Drainage Technique: Our Experience Using a Hybrid Minimally Invasive Approach

Study ObjectiveIn a pediatric setting, laparoscopic management of large cystic ovarian neoplasms with low malignancy probability is not suitable, because of the mass size; nevertheless, an effort should be made to be as minimally invasive as possible, without violating the principles of oncologic surgery. We describe our experience in managing these neoplasms with leak-proof extracorporeal drainage through mini laparotomy, followed by cyst excision or oophorectomy.DesignCase series study, describing interventions and outcomes.SettingDepartment of pediatric surgery in a tertiary pediatric and adult university hospital.ParticipantsPediatric patients affected by large cystic ovarian mass.InterventionsHybrid minimally invasive approach using leak-proof extracorporeal drainage.Main Outcome MeasuresData on demographic characteristics, tumor marker values, and imaging findings were collected and analyzed. Outcome of surgical technique was evaluated and reported.ResultsBetween 2011 and 2018, 17 patients (mean age, 10.2 years; range, 2-14 years) affected by large cystic ovarian mass, were eligible for this technique. All patients had negative preoperative tumor markers. Of the seventeen subjects, 13/17 girls (76%) underwent pelvic magnetic resonance imaging. No sign of lymphadenopathy or metastasis was found. Surgery was successful in all patients, with ovarian preservation in 5/17 cases (29.4%). Mean surgical time was 98 minutes; no intra-abdominal leakage of neoplasm content or postoperative complications occurred. Mature cystic teratoma was the most frequent histopathological diagnosis (71%).ConclusionAfter a thorough patient selection, the management of large cystic ovarian neoplasms with leak-proof extracorporeal drainage performed through a mini laparotomy is a feasible and safe approach, with excellent cosmetic results. When achievable, ovarian-sparing surgery has to be considered.     

Asynchronous Bilateral Ovarian Torsion. A Case Report and Mini Review

BackgroundAdnexal torsion is a serious condition and delay in surgical intervention may result in loss of ovary. Children and adolescents who have suffered from uterine adnexal torsion may be at risk for asynchronous torsion of the contralateral adnexa.CaseWe report the case of asynchronous bilateral ovarian torsion in a 9-year-old girl, resulting in right and subsequently left salpingo-oophorectomy.ConclusionThe diagnosis of ovarian torsion often is delayed. When ovarian torsion is suspected, laparoscopy should be performed without delay, and conservative management should be strongly considered to prevent surgical castration. Oophoropexy of the ipsilateral and contralateral ovary should be considered to prevent a recurrent torsion.     

Management of Large Ovarian Neoplasms in Pediatric and Adolescent Females

The overwhelming majority of ovarian cysts in pediatric and adolescent girls are physiologic; however, large simple and complex ovarian lesions often require surgical intervention due to the increased risk of neoplasia. In this review article, we discuss the preoperative evaluation and intraoperative management of large ovarian neoplasms. We review the current literature regarding long term ovarian function and fertility, rates of recurrence and residual disease, and novel surgical approaches. Managing large ovarian neoplasms in the pediatric and adolescent population requires careful preoperative and intraoperative care to optimally resect neoplasia while maximizing fertility and minimizing pain.     

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

Study ObjectiveTo determine clinical and laboratory characteristics of ovarian torsion (OT; n = 28) compared with a non-OT control (OC; n = 64) group.DesignRetrospective single-center review performed between January 2006 and December 2016.SettingAcademic department of pediatric surgery.Participants and InterventionsPostoperative 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 MeasuresPredictive value for OT according to biometric, procedural, and laboratory parameters at the time of admission.ResultsCompared 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.ConclusionBlood 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.     

Borderline Ovarian Tumor in the Pediatric and Adolescent Population: A Case Series and Literature Review

Study Objective

To determine the diagnosis, management, and outcome for children and adolescents with borderline ovarian tumor (BOT), and to provide a review of the literature on BOT in children and adolescents.

Isolated Torsion of Accessory Fallopian Tube in a Young Adolescent

BackgroundAccessory fallopian tube is a rare anatomical variation, which might rarely cause gynecological complications such as infertility, ectopic pregnancy, cystic swelling, and pyosalpinx. It is usually diagnosed by surgeons during diagnostic laparoscopy for other purposes. We present a rare case of isolated accessory tube torsion in a young adolescent.CaseA 16-year-old virgin teen presented with a 24-hour history of aggravating right lower-quadrant abdominal pain and nausea without vomiting or fever. On examination she had right lower quadrant abdominal tenderness with no peritoneal signs. On pelvic ultrasound a right corpus luteum cyst was suspected, but right adnexal torsion could not be ruled out. On laparoscopy, torsion of the right accessory tube was diagnosed. Because of its ischemic and bluish appearance it was removed. The postoperative course was uneventful. Pathology confirmed the diagnosis.Summary and ConclusionTorsion of an accessory fallopian tube is rare. An English literature search showed that the current case is the third reported overall and the first in a young adolescent. Because of the rarity of this congenital variation, and the low suspicion index for its existence, the diagnosis of accessory tube is often missed. Preventive removal of such findings should be considered but weighed against its possible surgical complications.     

Management of Isolated Tubal Torsion in a Premenarchal Adolescent Female with Prior Oophoropexy: A Case Report and Review of the Literature

BackgroundIsolated tubal torsion in a premenarchal adolescent girl is a rare phenomenon. Preoperative diagnosis remains a challenge.CaseA 14-year-old premenarchal girl, with a history of bilateral ovarian torsion treated by laparoscopic detorsion and oophoropexy two years prior, presented to the emergency room with lower abdominal pain accompanied by nausea and vomiting. Pelvic ultrasound demonstrated an enlarged left adnexa. Diagnostic laparoscopy revealed an isolated left tubal torsion. Surgical evidence of previous bilateral plication of the utero-ovarian ligaments was confirmed. Untwisting of the left fallopian tube immediately restored the vascular supply. Subsequently, her symptoms resolved.Summary and ConclusionClinicians should consider torsion of the fallopian tube in the differential diagnosis of lower abdominal pain in all female patients. Prompt laparoscopic intervention is essential. Oophoropexy, while usually efficacious, may not prevent recurrence.     

The Recurrence Rate of Ovarian Dermoid Cysts in Pediatric and Adolescent Girls

Study ObjectiveTo assess the rate of recurrence of ovarian dermoid cysts in pediatric and adolescent girls at the Hospital for Sick Children.DesignA retrospective chart review of all dermoid cysts surgically managed at the hospital for Sick Children from January 2003 to June 2012.SettingThe Hospital for Sick Children, Toronto, Canada.Participants66 adolescent and pediatric patients <18 years old treated with ovarian cystectomy of their dermoid cysts by either laparoscopy (n = 40) or laparotomy (n = 26).Main Outcome MeasuresTotal dermoid cyst recurrence, recurrence after laparoscopy versus laparotomy, follow-up imaging completed and ultrasonographic identification of other ovarian cysts in follow-up. Data was assessed with Fisher exact test where appropriate (P < .05).ResultsThe mean age of patients at time of surgery was 12.9 years (range 2.5-18.1). 25/66 (38%) of patients received no follow-up, 6/66 (9%) were followed by a single ultrasonography and 35/66 (53%) were followed with annual ultrasonography for up to 5 years. 35 patients completed their initial ultrasonography where 19/35 (54%) patients had new ovarian cysts diagnosed including: 6 functional/hemorrhagic, 3 dermoid, and 10 unspecified cysts. All new dermoids were suspected at first follow-up ultrasonography (6/35), but 3 required a second follow-up ultrasonography for confirmation. Overall, 7/66 (11%) patients had recurrent or persistent dermoid cysts of which 2 (3%) required repeat surgery. There was no significant impact on the type of surgery and dermoid recurrence.ConclusionThe incidence of recurrent dermoid cysts in a pediatric and adolescent population following ovarian cystectomy is 10.6% where only 3% will recur and require further surgical management.     

Early Polycystic Ovary Syndrome as a Possible Etiology of Unexplained Premenarcheal Ovarian Torsion

Study ObjectiveTo study evidence of polycystic ovary syndrome (PCOS) in premenarcheal adolescents with unexplained ovarian torsion.DesignRetrospective observational case series.SettingTertiary university clinical centerParticipantsSix premenarcheal adolescents and six adults with acute ovarian torsionInterventionA chart review.Main Outcome MeasuresContralateral ovarian size, operative findings, ovarian pathology, hormone testingResultsFive of the six premenarcheal cases had no pathologic explanation for their ovarian torsion. In four of the cases, size measurements of the contralateral ovary were noted to be larger than the criterion of their respective age group. Three of the four cases had either an ovarian volume (28.5 cm³) or an area (16.0 cm² and 57.6 cm²) that was above the size criterion for a polycystic ovary (volume >10 cm³ or area > 5.5 cm²). Pathology of a wedge biopsy of one of the contralateral ovaries suggested evidence of polycystic ovary. Finally, hormone testing available in three of the cases revealed elevated testosterone levels in two. Among the adults, half of the cases had a pathologic explanation for ovarian torsion. One out of the five cases had a contralateral ovary that was significantly enlarged and this was noted in a woman with a diagnosis of PCOS. The remaining two cases had extensive necrosis of the torsed ovary and no other diagnosis was made.ConclusionWe propose that premenarcheal girls presenting with ovarian torsion, without obvious ovarian pathology, be screened for ultrasound and biochemical evidence of PCOS. In those with evidence of PCOS, treatment with oral contraceptives should be considered taking into account the age and pubertal development, to decrease ovarian volume.     

Effect of Surgical Specialty on Management of Adnexal Masses in Children and Adolescents: An 8-Year Single-Center Review

Study ObjectiveChildren 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.DesignRetrospective cohort review.SettingTertiary pediatric and adult university hospital.ParticipantsPatients 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.InterventionsLaparoscopic or open procedure for adnexal mass.Main Outcome MeasuresThe primary outcome was rate of ovarian conservation relative to surgical specialty. The secondary outcome was surgical approach relative to surgical specialty.ResultsForty-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).ConclusionPatients 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.     

Ovarian conservation in adnexal torsion-a report of six cases

Adnexal torsion is an uncommon but important cause of emergency admission to the gynaecologist. Treatment of adnexal torsion has traditionally involved surgical excision of the affected structure, usually via laparotomy. A more conservative surgical approach of untwisting the torsion has been widely reported in paediatric cases. Despite reports of the successful treatment of torsion with this approach in the adult population, many UK surgeons remain reluctant to attempt ovarian conserving surgery, particularly via the laparoscopic route.We report six cases of conservative surgery for adnexal torsion. After initial success via laparotomy, the subsequent five cases were managed laparoscopically. We discuss the advantages and disadvantages of this management approach.     

Vulval Pain in Pediatric and Adolescent Patients

Study ObjectiveTo describe the experience of a tertiary pediatric and adolescent gynecology service that provides care to children and adolescents who present with vulval pain. Their presentation, associated symptoms, and management is described.DesignA retrospective analysis of all girls younger than 18 years of age who presented to the gynecology clinic of our tertiary referral Children’s Hospital between Jan 2010 and July 2016. Electronic medical records were reviewed and parameters recorded using a standardized data sheet.SettingGynecology clinic of a tertiary referral children’s hospital and private rooms of our director of gynecology.ParticipantsYoung women younger than 18 years who presented with symptoms suggestive of vulvodynia.Interventions and Main Outcome MeasuresPresenting symptoms, characteristics of associated features, treatment options, and treatment outcomes.ResultsForty-seven patients with a mean age of 11 years (range, 3-18 years) were identified. At the time of diagnosis 31/47 (65.9%) were premenarchal. Many presented with a symptom other than pain alone. In particular, 35/47 (74.4%) presented with coexisting or previous urinary symptoms. Of patients examined, most had positive cotton tip examination findings (16/17 (94.1%) and 11/13 (84.6%) for pre- and postmenarchal, respectively) with clinical inspection otherwise unremarkable.ConclusionChildren and adolescents with vulval pain have varied presentations. Many of the pre- and postmenarchal patients had coexisting urinary tract symptomatology at the time of diagnosis. This review of patients seen over 5.5 years at a pediatric tertiary referral center provides information on the presenting symptoms, examination features, and response to clinical management.     

The Relationship between Intraoperative Rupture and Recurrence of Pediatric Ovarian Neoplasms: Preliminary Observations

Study ObjectiveWe investigated whether rupture increased the recurrence rate of pediatric ovarian neoplasms.Design20-year single-institution retrospective study.SettingTertiary, free-standing, university children's hospital.ParticipantsAll girls with ovarian neoplasms treated during between 1991 and 2011.Main Outcome MeasureTumor recurrence.ResultsFifty-nine tumors in 53 patients were managed, including 51/59 (86%) benign and 8/59 (14%) malignant. Laparotomy was employed in 44/59 (75%), laparoscopy in 8/59 (14%), and laparoscopy converted to laparotomy in 7/59 (12%). Total and partial oophorectomy (cystectomy) was used for 15/51 (29%) and 36/51 (71%) of benign tumors, respectively. All malignant tumors underwent total oophorectomy. Accidental rupture or intentional tumor puncture occurred in 26/56 cases (46%), 23/51 benign and 3/5 malignant. Rupture was associated with increasing cyst size on univariate and multivariate analyses (p = 0.002 and p = 0.004, respectively). There were 5 recurrences (9%) in 4 patients, including 4 benign (3 mature teratomas, 1 mucinous cystadenoma), and 1 malignant yolk sac tumor. Recurrence occurred in 2/30 (7%) without rupture and 3/26 (12%) with rupture, p = 0.66. Follow-up was available for 50/53 patients (94%), with a median of 23.8 months [range 0.2-189 months]. All recurrences were salvaged by surgery.ConclusionsIn this limited study, intra-operative rupture did not increase the recurrence rate or worsen the prognosis of pediatric ovarian neoplasms.     

Effect of Pregnancy on the Management and Outcomes of Ovarian Torsion: A Population-Based Matched Cohort Study

Study Objective

To compare the treatment and surgical outcomes of ovarian torsion in pregnant and nonpregnant women.