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Journal of Pediatric Surgery Jul 2018Ovarian torsion in pediatric patients is a rare event and is primarily managed by pediatric general surgeons. Torsion can be treated with detorsion of the ovary or... (Review)
Review
OBJECTIVE
Ovarian torsion in pediatric patients is a rare event and is primarily managed by pediatric general surgeons. Torsion can be treated with detorsion of the ovary or oopherectomy. Oopherectomy is the most common procedure performed by pediatric general surgeons for ovarian torsion. The purpose of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee was to examine evidence from the medical literature and provide recommendations regarding the optimal treatment of ovarian torsion.
METHODS
Using PRISMA guidelines, six questions were addressed by searching Medline, Cochrane, Embase Central and National clearing house databases using relevant search terms. Risks of ovarian detorsion including thromboembolism and malignancy, indications for oophoropexy, benefits of detorsion including recovery of function and subsequent fertility, and recommended surveillance after detorsion were evaluated. Consensus recommendations were derived for each question based on the best available evidence.
RESULTS
Ninety-six studies were included. Risks of ovarian detorsion such as thromboembolism and malignancy were reviewed, demonstrating minimal evidence for unknowingly leaving a malignancy behind in the salvaged ovary and no evidence in the literature of thromboembolic events after detorsion of a torsed ovary. There is no clear evidence supporting the benefit of oophoropexy after a single episode of ovarian torsion. The gross appearance of the ovary does not correlate with long-term ovarian viability or function. Pregnancies have occurred in patients after detorsion of an ovary both spontaneously and with harvested oocytes from previously torsed ovaries. The consensus recommendation for imaging surveillance following ovarian detorsion is an ultrasound at 3months postprocedure but sooner if there is a concern for malignancy.
CONCLUSION
There appears to be overwhelming evidence supporting ovarian detorsion rather than oopherectomy for the management of ovarian torsion in pediatric patients. Ovarian salvage is safe and is the preferred treatment for ovarian torsion. Most salvaged ovaries will maintain viability after detorsion.
TYPE OF STUDY
Systematic review of level 3-4 studies.
LEVEL OF EVIDENCE
3-4.
Topics: Adolescent; Child; Female; Fertility; Humans; Ovarian Cysts; Ovarian Diseases; Ovary; Torsion Abnormality; Ultrasonography
PubMed: 29153467
DOI: 10.1016/j.jpedsurg.2017.10.053 -
Pediatric Emergency Care Apr 2016This study aimed to identify, through systematic literature review, the most reliable clinical, biological, and radiological signs of ovarian torsion in the pediatric... (Review)
Review
OBJECTIVES
This study aimed to identify, through systematic literature review, the most reliable clinical, biological, and radiological signs of ovarian torsion in the pediatric population and to compare their diagnostic value.
METHODS
This is a systematic review of the literature, searching MEDLINE, EMBASE, and Cochrane Databases for articles published between January 1990 and January 2014.
RESULTS
From the 946 references initially identified, 14 retrospective publications fulfilled the inclusion criteria, involving a total of 663 episodes of ovarian torsion. Sudden onset abdominal pain with nausea and/or vomiting is the most frequent symptom of ovarian torsion. It can occur at any age, not only in menarchal or perimenarchal patients. Abdominal tenderness is present in 88.4% of patients, whereas only 24% have a palpable mass. Blood tests are commonly requested (51.4% of cases) but are not diagnostic. Abnormalities on plain abdominal radiograph include masses, calcifications, and ossified images. Ultrasound has a sensitivity for ovarian torsion of 79% and computerized tomographic scan of 42.2%. There is a significant diagnostic delay at 101.8 hours (median).
CONCLUSIONS
Abdominal pain in children and adolescents is difficult to evaluate, and the diagnosis of ovarian torsion remains a challenge. Because of its potential complications, we need effective clinical tools. From our review of the literature, it was not possible to develop a diagnostic algorithm. Further research is needed to improve our practice and shorten the delay to diagnosis. Considering the low incidence of ovarian torsion, a multicenter prospective study would be required.
Topics: Abdominal Pain; Adolescent; Child; Child, Preschool; Disease Management; Female; Humans; Infant; Infant, Newborn; Ovarian Diseases; Torsion Abnormality
PubMed: 26855342
DOI: 10.1097/PEC.0000000000000621 -
Journal of Ovarian Research Jan 2023Ovarian absence is an uncommon condition that most frequently presents unilaterally. Several etiologies for the condition have been proposed, including torsion, vascular... (Review)
Review
Ovarian absence is an uncommon condition that most frequently presents unilaterally. Several etiologies for the condition have been proposed, including torsion, vascular accident, and embryological defect. A systematic review was conducted to describe the clinical presentation of ovarian absence, as well as its associations with other congenital anomalies, through a systematic search of Cochrane Library, ClinicalTrials.gov, Google Scholar, Ovid Embase, Ovid Medline, PubMed, Scopus, and Web of Science. Exclusion criteria included cases with suspicion for Differences of Sex Development, lack of surgically-confirmed ovarian absence, and karyotypes other than 46XX. Our search yielded 12,120 citations, of which 79 studies were included. 10 additional studies were found by citation chasing resulting in a total 113 cases including two unpublished cases presented in this review. Abdominal/pelvic pain (30%) and infertility/subfertility (19%) were the most frequent presentations. Ovarian abnormalities were not noted in 28% of cases with pre-operative ovarian imaging results. Approximately 17% of cases had concomitant uterine abnormalities, while 22% had renal abnormalities. Renal abnormalities were more likely in patients with uterine abnormalities (p < 0.005). Torsion or vascular etiology was the most frequently suspected etiology of ovarian absence (52%), followed by indeterminate (27%) and embryologic etiology (21%). Most cases of ovarian absence are likely attributable to torsion or vascular accidents, despite many references to the condition as "agenesis" in the literature. Imaging may fail to correctly diagnose ovarian absence, and diagnostic laparoscopy may be preferable in many cases as genitourinary anatomy and fertility considerations can be assessed during the procedure. Fertility is likely minimally or not affected in women with unilateral ovarian absence.
Topics: Humans; Female; Urogenital Abnormalities; Ovary; Uterus
PubMed: 36642704
DOI: 10.1186/s13048-022-01090-1 -
Archives of Gynecology and Obstetrics Jul 2023Ovarian torsion (OT) in pediatric age is a challenging condition to diagnose and treat. To date, there is still no clear consensus about its management. Our aim was to... (Review)
Review
STUDY OBJECTIVE
Ovarian torsion (OT) in pediatric age is a challenging condition to diagnose and treat. To date, there is still no clear consensus about its management. Our aim was to assess some possible associated factors that can help surgeons in decision-making.
DESIGN
We conducted a retrospective multicentric study of pediatric OT surgically treated between 2010 and 2020 in six Italian and German institutions, comparing our findings with a literature review of the last 10 years (2010-2020).
PARTICIPANTS
Patients aged 0-18 years with a diagnosis of OT intraoperatively confirmed and surgically treated at the involved institutions.
RESULTS
Ninety-seven patients with a mean age at diagnosis of 8.37 years were enrolled in the study. Severe abdominal pain was present in 82 patients (84.5%). Eighty children (82.5%) presented an enlarged ovary with an US diameter > 5 cm and only 32 (40%) of them underwent conservative surgery. A laparoscopic approach was performed in 60 cases (61.9%) although in 15 (15.5%) conversion to open surgery was deemed necessary. A functional cyst was present in 49 patients (50.5%) while 11 children (11.3%) suffered from OT on a normal ovary.
CONCLUSIONS
Our results showed that a post-menarchal age (p = .001), a pre-operative US ovarian size < 5 cm, (p = .001), the presence of severe abdominal pain (p = .002), a laparoscopic approach (p < .001), and the presence of a functional cyst (p = .002) were significantly associated with conservative surgery.
Topics: Female; Child; Humans; Retrospective Studies; Ovarian Torsion; Torsion Abnormality; Ovarian Diseases; Abdominal Pain; Cysts; Multicenter Studies as Topic
PubMed: 35751675
DOI: 10.1007/s00404-022-06522-3 -
Journal of Obstetrics and Gynaecology :... Jul 2013Ovarian torsion may have significant fertility implications. Interleukin-6 is a pro-inflammatory cytokine, which may act as a helpful diagnostic test. Our objective was... (Meta-Analysis)
Meta-Analysis Review
Ovarian torsion may have significant fertility implications. Interleukin-6 is a pro-inflammatory cytokine, which may act as a helpful diagnostic test. Our objective was to investigate the accuracy of serum interleukin-6 in the diagnosis of ovarian torsion in women with ultrasonographic evidence of an ovarian cyst. An electronic search of published data, unpublished dissertations, theses and conference proceedings was performed. The systematic review involved observational studies. The studies had to provide data to construct 2 × 2 tables. A modified QUADAS tool was used to assess the quality of studies. Sensitivity, specificity, positive and negative predictive value, likelihood ratios and diagnostic odds ratios were calculated. Three studies were identified. Two were included in the meta-analysis. The prevalence of torsion was 30% (21/70). The pooled sensitivity was 85.1% and the pooled specificity was 84.1%. Although further cohort studies would be required, there may be a role for interleukin-6 in the diagnosis of ovarian torsion.
Topics: Female; Humans; Interleukin-6; Ischemia; Ovarian Cysts; Ovary; Predictive Value of Tests; Torsion Abnormality
PubMed: 23815191
DOI: 10.3109/01443615.2013.788622 -
Journal of Clinical Ultrasound : JCU Sep 2021In this review, we investigated the diagnostic value of the sonographic "whirlpool sign" in identifying ovarian torsion. This was done by performing a search in PubMed,... (Meta-Analysis)
Meta-Analysis Review
In this review, we investigated the diagnostic value of the sonographic "whirlpool sign" in identifying ovarian torsion. This was done by performing a search in PubMed, Scopus, Embase, Web of Science, CINAHL, and Google scholar. Additional search for the grey literature was made in EThOS.bl.uk, explore.bl.uk, opengrey.eu, greylit.org, and clinicaltrials.org. A total of eight studies were included in this meta-analysis. Sensitivity and specificity of whirlpool sign were extracted from the studies and computed into the Metadisc statistical software for pooled analysis. The whirlpool sign showed a high sensitivity and specificity for the diagnosis of ovarian torsion.
Topics: Female; Humans; Ovarian Torsion; Sensitivity and Specificity; Torsion Abnormality; Ultrasonography
PubMed: 34021602
DOI: 10.1002/jcu.23021 -
Ultrasound in Obstetrics & Gynecology :... Mar 2023To evaluate the diagnostic accuracy of different ultrasound signs for diagnosing adnexal torsion, using surgery as the reference standard. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To evaluate the diagnostic accuracy of different ultrasound signs for diagnosing adnexal torsion, using surgery as the reference standard.
METHODS
This was a systematic review and meta-analysis of studies published between January 1990 and November 2021 evaluating ovarian edema, adnexal mass, ovarian Doppler flow findings, the whirlpool sign and pelvic fluid as ultrasound signs (index tests) for detecting adnexal torsion, using surgical findings as the reference standard. The search for studies was performed in PubMed/MEDLINE, CINAHL, Scopus, The Cochrane Library, ClinicalTrials.gov and Web of Science databases. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool was used to evaluate the quality of the studies. Pooled sensitivity, specificity, and positive and negative likelihood ratios were calculated separately, and the post-test probability of adnexal torsion following a positive or negative test was also determined.
RESULTS
The search identified 1267 citations after excluding duplicates. Eighteen studies were ultimately included in the qualitative and quantitative syntheses. Eight studies (809 patients) analyzed the presence of ovarian edema, eight studies (1044 patients) analyzed the presence of an adnexal mass, 14 studies (1742 patients) analyzed ovarian Doppler flow, six studies (545 patients) analyzed the whirlpool sign and seven studies (981 patients) analyzed the presence of pelvic fluid as ultrasound signs of adnexal torsion. Overall, the quality of most studies was considered to be moderate or good. However, there was a high risk of bias in the patient-selection and index-text domains (with the exception of the whirlpool sign) in a significant proportion of studies. Pooled sensitivity, specificity, and positive and negative likelihood ratios of each ultrasound sign were 58%, 86%, 4.0 and 0.49 for ovarian edema, 69%, 46%, 1.3 and 0.67 for adnexal mass, 65%, 91%, 7.6 and 0.38 for the whirlpool sign, 53%, 95%, 11.0 and 0.49 for ovarian Doppler findings and 55%, 69%, 1.7 and 0.66 for pelvic fluid. Heterogeneity was high for all analyses.
CONCLUSIONS
The presence of an adnexal mass or pelvic fluid have poor diagnostic accuracy as ultrasound signs of adnexal torsion, while the presence of ovarian edema, the whirlpool sign and decreased or absent ovarian Doppler flow have good specificity but moderate sensitivity for detecting adnexal torsion. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
Topics: Female; Pregnancy; Humans; Ovarian Torsion; Torsion Abnormality; Adnexal Diseases; Ovarian Diseases; Edema
PubMed: 35751902
DOI: 10.1002/uog.24976 -
Prenatal Diagnosis Oct 2017The objective of the study is to compare outcomes of ultrasound-guided aspiration of fetal ovarian cysts with conservative management. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The objective of the study is to compare outcomes of ultrasound-guided aspiration of fetal ovarian cysts with conservative management.
METHOD
A systematic review of MEDLINE and Web of Science included studies reporting outcomes (prenatal and postnatal torsion, spontaneous resolution and surgery) of fetuses with ovarian cysts. Subgroup analysis was performed according to cyst diameter at diagnosis and cysts ≥40 mm.
RESULTS
Ninety-two non-randomised studies reported on 380 cysts (324 observed and 56 aspirated in utero) in 365 fetuses. All studies were case reports or series with high heterogeneity and risk of bias. The overall spontaneous resolution rate of conservatively managed cysts was 46%, yet decreased with increasing cyst size. Risk of prenatal ovarian torsion in conservatively managed cases depended on cyst size and was particularly important in the range 30 to 59 mm (15-34%). The rate of prenatal torsion in simple cysts ≥40 mm was lower in aspirated than conservatively managed cysts (0% vs 10%, p = 0.03). Aspirated cysts had lower rates of postnatal surgery (7%) compared with conservatively managed cysts (49%, p < 0.001).
CONCLUSION
Cysts 30 to 59 mm were at highest risk of torsion. Simple cysts >40 mm had lower rates of torsion when aspirated prenatally. Randomised studies and safety data are needed prior to routine prenatal ovarian cyst aspiration. © 2017 John Wiley & Sons, Ltd.
Topics: Female; Fetal Diseases; Humans; MEDLINE; Ovarian Cysts; Ovarian Diseases; Pregnancy; Risk Factors; Suction; Torsion Abnormality; Treatment Outcome; Ultrasonography, Prenatal
PubMed: 28886226
DOI: 10.1002/pd.5143 -
Ultrasound in Obstetrics & Gynecology :... Jul 2017To explore the outcome of fetuses with a prenatal diagnosis of ovarian cyst. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To explore the outcome of fetuses with a prenatal diagnosis of ovarian cyst.
METHODS
The electronic databases MEDLINE and EMBASE were searched using keywords and word variants for 'ovarian cysts', 'ultrasound' and 'outcome'. The following outcomes in fetuses with a prenatal diagnosis of ovarian cyst were explored: resolution of the cyst, change of ultrasound pattern of the cyst, occurrence of ovarian torsion and intracystic hemorrhage, need for postnatal surgery, need for oophorectomy, accuracy of prenatal ultrasound examination in correctly identifying ovarian cyst, type of ovarian cyst at histopathological analysis and intrauterine treatment. Meta-analyses using individual data random-effects logistic regression and meta-analyses of proportions were performed. Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale.
RESULTS
Thirty-four studies (954 fetuses) were included. In 53.8% (95% CI, 46.0-61.5%) of cases for which resolution of the cyst was evaluated (784 fetuses), the cyst regressed either during pregnancy or after birth. The likelihood of resolution was significantly lower in complex vs simple cysts (odds ratio (OR), 0.15 (95% CI, 0.10-0.23)) and in cysts measuring ≥ 40 mm vs < 40 mm (OR, 0.03 (95% CI, 0.01-0.06)). Change in ultrasound pattern of the cyst was associated with an increased risk of ovarian loss (surgical removal or autoamputation) (pooled proportion, 57.7% (95% CI, 42.9-71.8%)). The risk of ovarian torsion was significantly higher for cysts measuring ≥ 40 mm compared with < 40 mm (OR, 30.8 (95% CI, 8.6-110.0)). The likelihood of having postnatal surgery was higher in patients with cysts ≥ 40 mm compared with < 40 mm (OR, 64.4 (95% CI, 23.6-175.0)) and in complex compared with simple cysts, irrespective of cyst size (OR, 14.6 (95% CI, 8.5-24.8)). In cases undergoing prenatal aspiration of the cyst, rate of recurrence was 37.9% (95% CI, 14.8-64.3%), ovarian torsion and intracystic hemorrhage were diagnosed after birth in 10.8% (95% CI, 4.4-19.7%) and 12.8% (95% CI, 3.8-26.0%), respectively, and 21.8% (95% CI, 0.9-40.0%) had surgery after birth.
CONCLUSION
Size and ultrasound appearance are the major determinants of perinatal outcome in fetuses with ovarian cysts. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
Topics: Female; Humans; Ovarian Cysts; Predictive Value of Tests; Pregnancy; Ultrasonography, Prenatal
PubMed: 27325566
DOI: 10.1002/uog.16002 -
World Journal of Pediatrics : WJP Oct 2017Bilateral ovarian torsions with complete loss of ovaries is devastating. This study analyzed the literature on bilateral ovarian torsions in girls to evaluate surgical... (Review)
Review
BACKGROUND
Bilateral ovarian torsions with complete loss of ovaries is devastating. This study analyzed the literature on bilateral ovarian torsions in girls to evaluate surgical options and outcomes.
METHODS
Literature was searched on Pubmed (1987-2014) using terms "bilateral", "adnexal", "ovary", "torsion" and "children". Data were collected on age, surgical preference, pathology and outcomes.
RESULTS
Thirteen articles were identified, and 9 met the inclusion criteria (5 case reports, 4 original articles); and analyzed 17 girls (mean age: 8.75 years, range: 1-16). Bilateral oophorectomies (n=4), ipsilateral oophorectomy of severely affected ovary and contralateral oophoropexy (n=10), and detorsion of bilateral ovaries and bilateral oophoropexy (n=3) were performed. One torsion recurrence occurred after two oophoropexies. Laparoscopy and open surgery was done in 2 and 15 girls, respectively. Considering etiology, there were simple tubo-ovarian torsions (n=8), polycystic ovary (n=1), polycystic ovary associated with Down syndrome (n=1) and corpus luteum cyst (n=1). No tumors were reported. Serial ultrasound follow-ups of ipsilateral oophorectomy and contralateral oophoropexy (n=5) confirmed follicular function (n=4) and viability and position of the ovary (n=1).
CONCLUSIONS
Though extremely rare, school age girls present bilateral ovarian torsion. Ipsilateral oophorectomy and contralateral detorsion with oophoropexy has been the preferred approach.
Topics: Adolescent; Algorithms; Child; Child, Preschool; Female; Humans; Infant; Ovarian Diseases; Torsion Abnormality
PubMed: 28646432
DOI: 10.1007/s12519-017-0052-3