Ovarian Necrosis Research Articles

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

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

Losartan ameliorates ovarian ischaemia/reperfusion injury in rats: an experimental study

This study aimed to investigate the protective and antioxidant role of losartan in ovarian ischaemia and ischaemia/reperfusion injury in an experimental ovarian torsion model. Thirty adult female rats were used. Rats were separated randomly into five groups; Group 1: sham group (abdominal wall was only opened and closed), Group 2: torsion group with 3-hour ischaemia using atraumatic vascular clips. Group 3: torsion + losartan group with 3-hour ischaemia 30 minutes after the administration of 40 mg/kg of losartan via oral gavage. Group 4: torsion-detorsion group with 3-hour ischaemia and 3-hour reperfusion (vascular clips were removed). Group 5: torsion-detorsion + losartan group with 3-hour ischaemia followed by administration of 40 mg/kg of losartan 30 minutes prior to a 3-hour detorsion/reperfusion. Ovarian tissue damage was scored by histopathological analysis. Ovarian tissue malondialdehyde (MDA) and plasma pentraxin 3 (PTX 3) levels were measured biochemically. In comparison with the sham group, both the torsion and torsion-detorsion groups had significantly higher scores for follicular degeneration, vascular congestion, oedema, haemorrhage, and leukocyte infiltration (p < .05). The aforementioned parameters significantly decreased in the torsion-detorsion + losartan group (p < .01) compared to those in the torsion-detorsion group. MDA and plasma PTX 3 levels were notably higher both in the torsion and torsion-detorsion groups compared with those in the sham group (p < .01). The current experimental ovarian torsion study suggests a protective role for losartan upon ischaemia and ischaemia/reperfusion injury in rat ovaries. Losartan may be a novel agent for decreasing ovarian ischaemia/reperfusion injury in ovaries.Impact statementWhat is already known on this subject? Among gynaecological emergencies, the diagnosis of ovarian torsion is highly difficult. A delayed diagnosis may lead to ovarian necrosis and subsequent loss of ovaries if timely surgical intervention is not performed, which is essential for the fertility and protection of ovarian functions in young patients. However, reperfusion of the ischaemic tissue might leads to more serious damage to the tissue than the damage caused by ischaemia.What the results of this study add? This study found that losartan, an Ang II type 1 receptor blocker which has been currently used for regulation of blood pressure, could be used experimentally to alleviate I/R injury in ovary through improving histological parameters, reducing tissue MDA and plasma PTX3 levels. To date, there is no study regarding the usage of losartan for alleviating I/R on ovary due to torsion.What the implications are of these findings for clinical practice and/or further research? Losartan may be suggested to have therapeutic value in patients with ovarian torsion. Further large clinical studies are necessary to prove the beneficial effect of losartan to prevent I/R injury on human ovaries.

Recurrent Ovarian Torsion in a Premenarchal Girl

A 10-year-old girl presented with a recurrence of left ovarian torsion where she presented with intermittent left sided abdominal pain for 2 days. She had a similar presentation occuring 1 month ago. The patient underwent successful ovarian salvage with laparoscopic left ovary detorsion and bilateral oophoropexy 5 hours after presentation. Tumour markers were not raised. Intraoperative incisional ovarian biopsy showed no evidence of malignancy. Ovarian torsion is a rare gynaecological emergency in children with nonspecific symptoms. Early recognition and surgery are important to prevent ovarian necrosis. The presentation of acute onset unilateral abdominal pain on the background of a similar previous presentation should alert the clinician of this diagnosis. Although ovarian torsions occur more commonly in the presence of adnexal masses more than 5cm in size, it can also occur in normal ovaries especially in the premenarchal age group. Laparoscopic detorsion is the treatment of choice with oophoropexy a feasible option for prevention of a recurrence. Close follow up with ovarian surveillance is required to ensure resolution of ovarian enlargement.

Predicting necrosis in adnexal torsion in women of reproductive age using magnetic resonance imaging.

To identify the diagnostic performance of magnetic resonance (MR) imaging for patients with adnexal torsion and to develop a predictive model for necrosis related to torsion. The institutional ethics committee approved this retrospective study. A total of 56 women with a preoperative pelvic MR scan and a surgical and pathologic diagnosis of adnexal torsion were enrolled from five institutions. Three radiologists reviewed the MR images independently. The kappa value of interrater agreement was assessed. Differences between patients treated with conservative surgery and adnexectomy were evaluated by univariate and multivariate logistic regression analyses. Receiver operating characteristic (ROC) curve analysis was used to assess the ability of the model to predict ovarian necrosis. Fifty-six patients were divided into the conservative surgery group (24/56, 42.9%) or the adnexectomy group (32/56, 57.1%) depending on the surgical outcomes. The radiographic features related to torsion were interpreted by three raters retrospectively with substantial interrater agreement (kappa > 0.60). Older reproductive age and pedicle hemorrhagic infarction were significantly associated with adnexectomy (p < 0.05). At multivariate analysis, pedicle hemorrhagic infarction (odds ratio = 10.476 [95% confidence interval 1.103, 99.504; p = 0.041]) was associated with adnexectomy. Using the predictive model (older reproductive age and pedicle hemorrhagic infarction), a receiver operating characteristic curve was generated with an area under the curve (AUC = 0.870 ± 0.049). The presence of pedicle hemorrhagic infarction and older reproductive age can predict necrosis of adnexal torsion and may be used to guide the optimal treatment strategy. • Pedicle hemorrhagic infarction and older reproductive age are predictors of necrosis in adnexal torsion in patients of reproductive age (AUC = 0.870 ± 0.049). • Cystic wall thickening, enlarged vascular pedicle, tubal thickening, and uterine deviation are associated with a high risk for adnexal torsion, occurring in more than half of the cases in this study. • MR findings are useful for the definitive diagnosis of adnexal torsion and for the prediction of adnexal necrosis.

Premenarchal patients present differently: A twist on the typical patient presenting with ovarian torsion

Background/PurposeThe aim of this study was to characterize differences between pre- and postmenarchal females with ovarian torsion. MethodsA single-center review was conducted of all nonneonatal pediatric patients with ovarian torsion from 2011 to 2018. Clinical data were compared between pre- and postmenarchal patients. ResultsOne hundred and twenty-seven patients were identified, and 25% were premenarchal. Premenarchal patients were more likely to have a delay in diagnosis (38% vs 20%, p = 0.042), develop ovarian necrosis (34% vs 17%, p = 0.036), and present without an associated adnexal mass (44% vs 0%, p < 0.001). All patients without a mass (n = 14) were premenarchal and presented with ovarian asymmetry. Patients without an associated mass underwent oophoropexy in the majority of cases. There were no differences in postoperative complication or recurrence rates between groups. ConclusionPremenarchal females with ovarian torsion can present differently than females postmenarche and often have a delay in diagnosis. Premenarchal females are more likely to undergo torsion without an associated adnexal mass and are at higher risk for ovarian necrosis. Oophoropexy is an appropriate treatment in the absence of an adnexal mass. A high-index of suspicion for ovarian torsion should be maintained for premenarchal females presenting with abdominal pain and an otherwise negative workup. Type of studyRetrospective comparative study. Level of evidenceLevel III.

Ovarian Torsion in a Primipara Female Dog in Brazil

Background: Ovarian torsion is a condition which the ovary and the ovarian pedicle twist around the ovary suspensory ligament. No report regarding this condition was reported. The aim of the report was to describe a case of unilateral ovarian torsion in a 2-year-old primipara Golden Retriever dog.Case: A 2-year-old female primipara Golden Retriever dog weighting was referred to the Veterinary Hospital, for purulent vaginal discharge evaluation. The dog was presenting anorexia, weight loss, and intermittent diarrhea and vomiting. A cesarean section was performed nine months before her presentation and the oestrus cycle was recorded six months after the cesarean section. Discomfort was observed during the palpation of the abdomen and purulent vaginal was observed. Vaginal swab was performed and followed by cytological examination. The ultrasonographic examination was consistent with pyometra. The ovariohysterectomy was performed and were observed torsion of the left ovary. The histopathological examination of the left ovary and uterus were consistent with ovary necrosis and pyometra. Ten days after surgery the vaginal discharge had resolved and the sutures were removed. Six months postoperatively the dog revealed no further abnormalities. Grossly, the left ovary had firm consistency, dark red surface and 8 cm diameter. The histopathology examination findings were consistent with a diagnosis of diffuse necrosis of left ovary due to ovarian torsion, and uterinesuppurative inflammatory process - pyometra.Discussion: Ovarian torsion is uncommon in small animals, but can be observed high incidence in pregnant female dogs than in non-pregnant ones. The 360º an asynchronous ovarian torsion described in the present case is also an unusual condition in primipara female dogs due to the smaller stretching of the ovary suspensory ligament. The ovarian torsionis considerate an emergency condition due to acute abdominal pain. The mild abdominal discomfort observed during the physical examination was associated to pyometra or to ovarian torsion. The histopathological findings as hemorrhage, edema and necrosis were associated to compromised arterial circulation and ovarian torsion in late stage. The size of the pregnant uterus and/or the pyometra has contributed to ovary torsion. The dog of the present report had pyometra and previouscesarean sections; and these conditions may have contributed to ovarian torsion. The condition was incidentally found during the ovariohysterectomy, and the ovarian torsion diagnosis was determinate through histopathological examination. Computed tomography and magnetic resonance image could be used to diagnose, furthermore, they were not conducted due to the high cost. The leukocytosis and red blood cells Rouleaux was associated with ovarian necrosis and pyometra.Ovariohysterectomy was the treatment of choice to pyometra and ovarian torsion, and the surgery was performed without ovarian torsion reversion to minimize the reperfusion lesions. Ovarian torsion is a rare event in dogs, and it was clinically diagnosed during the surgery. To the best of the authors’ knowledge, this is the first report of ovarian torsion associate withpyometra in primipara female dogs in Brazil.Keywords: dog, obstetric, ovary, pyometra complex, endometrium.

Analiza zmian chorobowych przydatków u dziewczynek leczonych operacyjnie

AimTo analyse data of adolescent patients operated on due to adnexal masses at Department of Operative Gynecology and Gynecologic Oncology of Polish Mother's Memorial Hospital. Materials and methodsThe data of patients below 19 years of age operated on between 1993 and 2015 were analysed. We analysed data the age, type of surgical treatment, size and histological type of adnexal masses and complications. Results172 adolescents were operated on; adnexal masses were identified in 141 patients. The average age of patients was 15 years (+/-2.2). Malignant lesions were diagnosed in 6 patients. Two girls had two types of malignant lesions at the same time (gonadoblastoma and dysgerminoma, embryonal carcinoma and dysgerminoma). Benign lesions accounted for 94% of adnexal masses. Mature teratoma (31%) and serous cysts were the most common lesions. Hemorrhagic lesions and mucous cysts represent 13% and 4% of all benign lesions respectively. Oviductus lesions were diagnosed in 13% of all operated patients. Fibrothecoma, adnexal torsion and ovarian necrosis were confirm in 11% of benign masses. The avarege diameter of masses was 9.35cm (+/-5.4cm). Bilateral masses occurred in 3 patients (2%). Lesions of a smaller diameter (5.8cm +/-2.9cm) were removed by laparoscopy while laparotomy was performed to remove bigger lesions (10.35cm +/-5.5 in diameter). In one case re-laparoscopy was needed to coagulate bleeding in the lodge of a removed tumor. Two patients required conversion to laparotomy. In one case an abscess of the fallopian tube and appendicitis were confirmed. In the other patient laparoscopy was abandoned due to the suspicious character of the tumor. ConclusionAdnexal lesions requiring surgical treatment in adolescent are mostly unilateral benign ovarian cysts. The type of surgery (laparoscopy/laparotomy) mainly depends on the size and nature of an adnexal lesion.

Ovarian lesions in 44 rabbits (Oryctolagus cuniculus).

The clinical and pathological records of 44 domestic, female rabbits with an age ranging from 6–124 months (median age: 63.5 month) were assessed retrospectively for ovarian lesions. Included were all rabbits that underwent an ovariohysterectomy with a subsequent pathological examination of the genital tract between March 1997 and June 2016. Pathological examination revealed ovarian lesions in 12 of the 44 rabbits including follicular cysts (n=7), cystic rete ovarii (n=3), widespread ovarian necrosis with dystrophic calcification (n=2), ovarian adenoma (n=1). Clinical examination including radiographs only suggested ovarian disorders in two cases of ovarian necrosis with dystrophic calcification and in two cases of cystic rete ovarii. Clinical significance was only conclusive in a case of cystic rete ovarii.

Detorsion of Twisted (Gangrenous) Ovarian Cyst Followed by Complete Disappearance of the Cyst-A Case Report of Innovative Outcome

Adnexal torsion in the pediatric and adolescent population is a rare gynecological disease with an incidence of 2.7%. They are categorized by different clinical presentations and by the need to establish a suitable type and timing of treatment in order to prevent problems, such as ovarian necrosis after torsion and infertility. Ovarian torsion denotes a real surgical emergency. Quick diagnosis is crucial for ovarian salvage, and high clinical notion is imperative in this respect. Confounding the diagnosis in overall are more usually come across abdominal complaints in the Emergency Department (ED) such as constipation, diarrhea, and urinary tract infections and more common surgical emergencies such as appendicitis. Until a decade ago,the standard recommended treatment for ovarian torsion was removal of the gangrenous ovary without detorsion. However, conservative management for preservation of ovarian function should be undertaken because most females with adnexal torsion are adolescent girls and of childbearing age. A 10-year-old obese girl presented with a 3-days history of right iliac fossa pain. She was operated for acute appendicitis; however, intraoperatively found gangrenous twisted right ovarian cyst measuring 10x6 cm. Detorsion was done and noted the right fallopian tube appeared to be viable within few minutes however the right ovarian cyst remained the same. The postoperative period was uneventful. The same gangrenous ovary was monitored through repeated ultrasound examinations during follow-up visits and found that cyst was gradually decreasing in size and finally disappeared within 3 months. Detorsion of twisted ovarian cyst (conservative management) leads to complete disappearance and ovary not only be saved but also operative morbidity of interval cystectomy was avoided. Key words: Cyst, Detorsion, Gangrenous, Ovarian, Twisted.

CT prediction of the degree of ovarian torsion.

Torsion angle determines the incidence of necrosis among patients with ovarian torsion. The purpose of this study was to evaluate the association between torsion angle and findings on CT scan. We retrospectively reviewed CT scan findings obtained less than 36h before surgery for 31 patients with ovarian torsion. Ovarian torsion angles measured intraoperatively ranged from 90° to 1260°. Ovaries with torsion angles less than 360° rarely develop necrosis. Patients were divided into two groups according to torsion angle:<360° (Group A) and≥360° (Group B). A lesion corresponding to an enlarged fallopian tube and mesovarium containing dilated veins between the uterus and twisted ovary is referred to as a "mass-like swelling". A mass-like swelling occurred more often in Group B (p<0.05) and had the highest correlation with torsion angles≥360°. A mass-like swelling lacking enhancement or a high-density area was significantly different between the groups (p<0.05) and was also indicative of torsion angles≥360°. A mass-like swelling alone or with a high-density area or lack of enhancement suggests an ovarian torsion angle≥360°. The presence of these findings predict ovarian necrosis and may allow ovary-sparing treatment.

Presentation, Diagnosis, and Treatment of Ovarian Torsion in Premenarchal Girls

Study ObjectiveTo describe the clinical characteristics and treatment of ovarian torsion in premenarchal girls with surgically verified ovarian torsion. Design and ParticipantsA retrospective cohort study design was used. The medical charts of all premenarchal girls with surgically verified ovarian torsion treated in a university-affiliated tertiary medical center from 1997 to 2012 were reviewed for clinical, treatment, and outcome data. ResultsThirty-two premenarchal girls were identified. Their median age was 9 years. There were 7 recurrences during the study period (17.9%), for a total of 39 cases. The main presenting symptoms were abdominal pain (92.3%) and nausea and vomiting (84.6%). Physical examination revealed abdominal tenderness in 25 cases (64.1%). Abdominal ultrasound, performed in 31 patients (38 cases), yielded pathologic findings in 28 (73.7%), mainly an enlarged ovary (11 cases, 28.9%). Doppler flow studies were abnormal in 15 cases. In 26 cases (68.4%), the tentative preoperative working diagnosis was ovarian torsion. Laparoscopy was performed in 26 cases, laparotomy in 10, and laparoscopy converted to laparotomy in 3 cases. Conservative management, mainly with additional cyst drainage or cystectomy, was used in 37 cases (95.2%) with oophoropexy in 5 cases. Two patients required oophorectomy because of a suspected neoplasm and severe ovarian necrosis. Pathologic examination demonstrated 5 simple cysts, 1 necrotic ovary, and 1 mature cystic teratoma. ConclusionsOvarian torsion in premenarchal girls is associated with nonspecific signs and symptoms. Abdominal ultrasound and Doppler imaging may assist in the diagnosis. Laparoscopy with conservative management is preferred. Owing to the high recurrence rate, oophoropexy may be considered.

Clinical analysis of laparoscopic surgery for ovarian masses under different conditions during the second trimester

Background Laparoscopic surgery in pregnant women has become increasingly more common; however, the safety of laparoscopy in this population has been widely debated in emergent situations and big size at bigger pregnant weeks. This study was to determine the characteristics of laparoscopic surgery for adnexal masses in different conditions during the second trimester of pregnancy. Methods Between April 2002 and December 2011, 24 patients with suspected ovary cyst during the second trimester underwent laparoscopic surgery at the Peking Union Medical College Hospital retrospectively. Clinical data were collected retrospectively and patient's outcomes were analyzed. Results The incidence of laparoscopic surgery for ovarian cysts during pregnancy was 0.12% of all laparoscopic gynecological surgeries performed at the hospital. No patients required conversion. There were 9 (37.5%) patients whose gestational age was no less than 16 weeks, and 15 patients whose gestational age was less than 16 weeks; no difference was noted in the operation time between the two groups (P &gt;0.05). Emergency surgery due to abdominal pain was performed in 4 (16.7%) patients, 2 (8.3%) of whom underwent simple salpingo-oophorectomy because of ovarian necrosis. The other patients underwent enucleation of the ovarian cyst. There were no severe complications. Twenty (83.3%) pregnant women delivered healthy term infants and 4 (16.7%) cases were lost to follow up. Conclusion Laparoscopic surgery for ovary masses is a safe and feasible procedure for the treatment of ovary cyst in different conditions during the second trimester, even if gestational age reaching 16-19 weeks or in emergency.

Case Report: Ovarian Torsion in Pregnancy – Diagnosis and Management

BackgroundOvarian torsion (OT) is one of the most common gynecologic surgical emergencies. All age groups can be affected, but ovarian stimulation, as found during early pregnancy or infertility treatment, is a major risk factor. ObjectiveDiagnosing OT in early pregnancy can be challenging. Patients frequently present with abdominal pain and non-specific symptoms. Missed diagnosis of OT could lead not only to ovarian necrosis and sepsis, but also threaten the pregnancy. The objective of this article is to present a case of OT in early pregnancy and to review its epidemiology, diagnosis, and treatment. Case ReportA 30-year-old woman at 10 weeks gestational age presented to the Emergency Department (ED) with 2 h duration of abdominal pain, nausea, and vomiting. The patient was not on ovarian stimulation treatments. A bedside ED ultrasound showed an enlarged edematous right ovary with a large cyst, but without flow on color Doppler. Immediate obstetric consultation was initiated. Eventual radiology ultrasound showed decreased but present flow in the right ovary. The patient underwent emergent laparoscopic surgery, during which the necrotic right ovary was removed. She was placed on progesterone therapy upon hospital discharge and eventually delivered a healthy term infant. ConclusionsOvarian torsion in pregnancy is increasing in frequency due to the growing prevalence of ovarian stimulation treatment. Although diagnostic ultrasound is a frequently used imaging tool in patients with suspected OT, the mere presence of blood flow on Doppler ultrasonography of the adnexa has a poor negative predictive value. A high clinical suspicion and early laparoscopic management correlate with favorable maternal and fetal outcomes.

Ovarian torsion—A course for severe abdominal pain in children

Ovarian torsion is a rare, albeit important cause of abdominal pain as it may lead to ovarian necrosis if not resolved. Although it has been described in all ages, it is very rare in young children. The primary symptom is abdominal pain, and due to the abundance hereof in a pediatric setting and the significant overlap in the clinical manifestations between ovarian torsion and more common entities such as appendicitis, a high level of suspicion needs to be maintained. We report the case of a young girl with a history of severe abdominal pain. A primary hospitalization at the age of 1? years resolved quickly and spontaneously without any imaging. At the age of 2 years and 10 months, she was once again hospitalized for severe abdominal pain. A CT scan shoved a large dermoid cyst and possible torsion of the ovary. An exploratory laparotomy confirmed the diagnosis and oophorectomy was performed. Histopathological examination of the cyst demonstrated a 5 × 5 × 6 cm mature cystic teratoma without malignancy. This case illustrates how a high level of suspicion for ovarian torsion needs to be maintained, even in otherwise healthy children.

Sublethal dietary effects of microcystin producing Microcystis on threadfin shad, Dorosoma petenense

The presence of the toxic cyanobacterium Microcystis in the upper San Francisco Estuary (SFE) since 1999 is a potential but unquantified threat to the health and survival of aquatic organisms such as fish and zooplankton. The microcystins (MCs) predominantly in the LR-form (MC-LR) produced by Microcystis is hepatotoxic and a potential threat to the fishery. Concurrently, in the SFE significant declines in pelagic fish, known as the Pelagic Organism Decline (POD), has been recognized by state and federal agencies since 2000. In 2005, the presence of the toxic algal bloom, Microcystis has been hypothesized as a link to the POD by the Interagency Ecology Program Management Team. This study aims to characterize the toxic effects of Microcystis in one of the POD species, threadfin shad (Dorosoma petenense) by exposure to diets containing Microcystis harvested from the SFE. The diets contained Microcystis with 4.4 (D5) and 10.0 (D10) μg g−1 MC-LR that was fed to threadfin shad for 57 days. The treatments were compared to the control diet, 0 μg g−1 MC-LR (D0). Results showed that ingested Microcystis was localized in the gut by in situ hybridization and MCs were localized in the tissues of the gut, kidney and liver. Condition factor (CF) and liver and gonadal lesions were sensitive to MC exposure. There was a significant inverse relationship between CF and MC-LR with exposed fish exhibiting severe cachexia. Liver lesions of sinusoidal congestion and glycogen depletion significantly increased with increasing MC-LR concentrations, indicating hemorrhaging in the liver and poor nutritional status, respectively. In females, there was a significant increase in severe ovarian necrosis with increasing MC-LR concentration, indicating loss of reproductive potential. The results indicate that MC-LR from Microcystis significantly impairs the health and reproductive potential of threadfin shad has a potential negative effect on populations in the SFE.

Operative findings in antenatal abdominal masses of unknown etiology in females

BackgroundPerinatal findings of abdominal masses pose a diagnostic challenge to clinicians. This study presents the operative findings of patients who underwent exploration for perinatally identified abdominal masses of unknown etiology. MethodsRetrospective review of all patients with abdominal masses of unknown etiology identified in the antenatal period was conducted from January 1, 2000 to July 1, 2010. Patient demographics were collected. Preoperative radiographic studies, operative findings, and pathologic evaluation were reviewed. ResultsThere were 17 patients identified within the study period. The median age was 30d at the time of operation (range 0–287d). The median height was 51cm (range 45–77cm), and the median weight was 4.0kg (range 2.6–10.4kg). All patients were asymptomatic. After birth, ultrasound identified abdominal masses in 14 patients, and computed tomography scan was used in four patients where one patient had both an ultrasound and a computed tomography scan. Mass resection was performed using laparoscopy in 15 patients, whereas two patients underwent open resection. At the time of surgery, 11 patients were diagnosed with ovarian cysts, four patients with ovarian torsion with an associated cyst, and two patients with an enteric duplication cyst. On final pathology, eight patients had benign ovarian cysts, seven patients had hemorrhagic ovarian necrosis, and two patients had duplication cysts. ConclusionFemales with antenatally identified abdominal masses of unknown etiology appear to be benign in nature. In this series, a benign ovarian cyst is the most common diagnosis, and these lesions can be approached laparoscopically.

When to operate on ovarian cysts in children?

Ovarian cysts are rare conditions in the pediatric age group. They are characterized by different clinical presentations and by the need to establish adequate type and timing of treatment in order to prevent complications, such as ovarian necrosis after torsion and infertility. The diagnostic approach should differentiate benign occasional findings, such as follicular cysts, from neoplastic lesions, and functional cysts which can occur either isolated or in the context of McCune-Albright syndrome. Our aim was to review all the patients affected by ovarian pathologies seen in our department in the past 5 years, in order to establish a protocol for the correct management of these conditions. In the past 5 years we studied 133 patients diagnosed with ovarian lesion. We subdivided the patients into three groups according to age: group A (age <6 months: 66 cases); group B (pre-pubertal patients, age 7 months to 10 years: 10 cases); and group C (pubertal patients, age 11-14 years: 57 cases). We collected historical and clinical data and assigned specific cut-off values in order to perform statistical analysis (Fisher's exact test) comparing the three groups. Ultrasound examination proved to be indispensable in the early detection of ovarian lesions and for identifying the correct treatment. Cyst size, and moreover appearance with ultrasound, were important considerations when selecting the most appropriate therapeutic approach. The larger lesions were found in group B, giving symptoms that required hospitalization (pelvic pain, nausea and vomiting) and leading to increased incidence of postoperative complications. Laparoscopic surgery appeared to be safe and effective for the treatment of ovarian pathologies. The management of ovarian lesions in children must be based on a minimally invasive approach, based on the patient's age and ultrasound findings. Treatment should be conservative, with ovariectomy undertaken only when essential. In adolescents, only cysts larger than 6 cm that do not resolve with estro-progestinic therapy within 6 months should be surgically approached; in infants, any signs of cyst complications must be addressed surgically.

Clinical indices and histological changes over time in ovarian torsion related to ovarian tumors

In some emergency surgeries for ovarian torsion, the ovary cannot be conserved because of necrosis. Ovarian necrosis and the time from the onset of symptoms to surgery are likely to be directly correlated. In this study, we retrospectively evaluated the clinical indices from the time of onset of acute abdomen to surgery at our hospital, in patients with tumor-related ovarian torsion. Among cases diagnosed preoperatively with benign ovarian tumors between 1995 and 2010, there were 54 patients who developed acute abdomen that was surgically diagnosed as ovarian torsion. For evaluation, these patients were divided into two groups according to the time from the onset of acute abdomen to surgical intervention as follows: <10 and ≥10 h. C-reactive protein (CRP) levels, leukocyte counts, body temperature, tumor size, and degree of torsion were compared between the two patient groups. Ovarian status based on postoperative histopathology was classified as necrotic, congestive, or normal, and was also evaluated. The mean CRP level was significantly higher in the ≥10-h patient group than in the patients undergoing surgery in <10 h. No differences were observed between the two groups for leukocyte counts, body temperature, tumor size, and mean degree of torsion. Ovarian necrosis was only observed only in patients undergoing surgery at ≥10 h. When tumor-related ovarian torsion is suspected, surgery should be performed within 10 h after the onset of acute abdomen to conserve ovarian function.

Ovarian Torsion Caused by Teratoma Masquerading as Perforated Appendicitis in a 5-Year-Old Girl

Ovarian torsion is a well-known but poorly recognized disease. Although ovarian torsion is the most common complication of ovarian tumors in children, it is an uncommon cause of abdominal pain in pediatric patients. Ovaries can be only salvaged by prompt diagnosis and timely surgical intervention. Acute ovarian torsion without appropriate treatment may result in loss of ovarian function, tissue necrosis, and death. The objective of this article is to present a case of pediatric ovarian torsion and describe the difficulty of distinguishing it from perforated appendicitis in the emergency department (ED). We report a 5-year-old girl who presented to the ED with nausea, tenderness over the right lower guardant of her abdomen, fever, and anorexia. She was initially diagnosed with appendicitis based on physical examination and abdominal computed tomography scan and was sent to the operating room for surgical exploration. The definite diagnosis of the patient was acute ovarian torsion complicated with cystic teratoma. Primary clinicians in the ED should pay more attention to acute ovarian torsion in young children because it is difficult to diagnose in time to salvage the gynecological function when the clinical presentations masquerade as perforated appendicitis.

Predictive Factors for Ovarian Necrosis in Torsion of Ovarian Tumor

Most cases of ovarian torsion require emergency surgery; the ovary has become necrotic and cannot be conserved. Preoperative determination of the ovarian necrosis extent is difficult but it may increase the likelihood of the ovary conservation. In this study, we retrospectively evaluated the findings in ovarian torsion among patients with ovarian tumors who underwent emergency surgery at a single hospital for possible preoperative indicators of ovarian viability. We thus evaluated 77 patients who were intraoperatively diagnosed with torsion of ovarian tumor between 1995 and 2010. These patients were classified into three groups depending on the postoperative histopathological findings: necrotic, congestive, and normal. Preoperative C-reactive protein (CRP) level, leukocyte count, and body temperature, along with tumor size, degree of torsion, time from the onset of abdominal pain to surgery, and incidence of acute abdomen were compared among the three groups. The sensitivity, specificity, and positive and negative predictive values of the preoperative serum CRP levels for ovarian necrosis were calculated. The CRP level, degree of torsion, and time from the onset of abdominal pain to surgery were significantly higher in the necrotic group than in the normal group. The sensitivity and specificity of the CRP level for necrosis were 35% and 83%, respectively, and positive and negative predictive values were 38% and 82% respectively. The potential for ovary conservation in suspected ovarian torsion should be greater if the tumor is non-malignant, the time from the onset of abdominal pain to operation is short, and the CRP level is < 0.3 mg/dl.