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BJOG : An International Journal of... Jan 2021Adnexal torsion (AT), a serious gynaecological emergency, often presents with non-specific symptoms leading to delayed diagnosis. (Meta-Analysis)
Meta-Analysis
BACKGROUND
Adnexal torsion (AT), a serious gynaecological emergency, often presents with non-specific symptoms leading to delayed diagnosis.
OBJECTIVE
To compare the test accuracy of ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) to diagnose AT.
SEARCH STRATEGY
We searched EMBASE, MEDLINE and Cochrane CENTRAL until December 2019.
SELECTION CRITERIA
Studies reporting on the accuracy of any imaging modality (Index Test) in female patients (paediatric and adult) suspected of AT compared with surgical diagnosis and/or standard clinical/radiological follow-up period until resolution of symptoms (Reference Standard).
DATA COLLECTION AND ANALYSIS
We assessed study quality using QUADAS-2. We conducted test accuracy meta-analysis using a univariate model or a hierarchical model.
MAIN RESULTS
We screened 3836 citations, included 18 studies (1654 women, 665 cases), and included 15 in the meta-analyses. Ultrasound pooled sensitivity (n = 12, 1187 women) was 0.79 (95% CI 0.63-0.92) and specificity was 0.76 (95% CI 0.54-0.93), with negative and positive likelihood ratios of 0.29 (95% CI 0.13-0.66) and 4.35 (95% CI 2.03-9.32), respectively. Using Doppler with ultrasound (n = 7, 845 women) yielded similar sensitivity (0.80, 95% CI 0.67-0.93) and specificity (0.88, 95% CI 0.72-1.00). For MRI (n = 3, 99 women), the pooled sensitivity was 0.81 (95% CI 0.63-0.91) and specificity was 0.91 (95% CI 0.80-0.96). A meta-analysis for CT was not possible with two case-control studies and one cohort study (n = 3, 232 women). Its sensitivity range was 0.74-0.95 and specificity was 0.80-0.90.
CONCLUSIONS
Ultrasound has good performance as a first-line diagnostic test for suspected AT. Magnetic resonance imaging could offer improved specificity to investigate complex ovarian morphology, but more evidence is needed.
TWEETABLE ABSTRACT
To investigate adnexal torsion, ultrasound is a good first-line diagnostic test with a pooled sensitivity of 0.79 and specificity of 0.76.
Topics: Female; Humans; Magnetic Resonance Imaging; Ovarian Torsion; Sensitivity and Specificity; Tomography, X-Ray Computed; Ultrasonography
PubMed: 32570294
DOI: 10.1111/1471-0528.16371 -
Cureus Dec 2019The role of preoperative CA 19-9 levels in patients with ovarian mature cystic teratoma (MCT) and the association of elevated levels of the biomarker with patients' and... (Review)
Review
The role of preoperative CA 19-9 levels in patients with ovarian mature cystic teratoma (MCT) and the association of elevated levels of the biomarker with patients' and tumor characteristics were evaluated. Four electronic databases were searched for articles published up to September 2019. Trials that evaluated the significance of elevated CA 19-9 in patients with ovarian MCTs and publications with > 20 patients were considered eligible for inclusion. Seven studies that included 995 patients with an ovarian MCT who were evaluated with elevated (n = 364) or normal (n = 631) CA 19-9 levels were included. Mean tumor size was significantly increased in patients with elevated CA 19-9 levels (p = 0.038). The rate of ovarian torsion was significantly increased in the elevated CA 19-9 group (p = 0.04). The present study highlights the importance of CA 19-9 as a marker in the diagnosis of MCT, and a meta-analysis supports that it could raise a high degree of clinical suspicion of early recognition of torsion and early surgical management due to complications related to increased size. Nonetheless, the diagnostic value of CA 19-9 is still limited and CA 19-9 can still serve only as a supplementary diagnostic tool in patients with MCTs.
PubMed: 31938630
DOI: 10.7759/cureus.6342 -
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 -
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 -
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 -
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 -
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 -
Current Opinion in Obstetrics &... Oct 2015Adnexal torsion is a surgical emergency, which requires immediate recognition and prompt treatment. This article aims to systematically illustrate the most relevant... (Review)
Review
PURPOSE OF REVIEW
Adnexal torsion is a surgical emergency, which requires immediate recognition and prompt treatment. This article aims to systematically illustrate the most relevant approach to follow in cases of suspected adnexal torsion in adolescents. We based our evaluation of the role of clinical features, laboratory tests, and imaging on recent literature, till we consider the most appropriate surgical treatment.
RECENT FINDINGS
The literature describes the conservative treatment for adnexal torsion, consisting of detorsion, as the best surgical approach to guarantee the future reproductive capacity of patients. Recent experimental studies have focused on the consequences of detorsion, which may cause ischemia-reperfusion damage and have speculated about the role of different drugs for its avoidance.
SUMMARY
A systematic review of physiopathology, clinical picture, and imaging of adnexal torsion is certainly useful to identify as soon as possible this emergency condition. An early identification and an adequate treatment are indispensable in order to achieve a proper outcome for the patient. The choice of the appropriate surgical approach can be challenging and should be made on the basis of an accurate evaluation of the ovarian lesion. Therefore, it would be useful to perform an intraoperative frozen section analysis in selected cases.
Topics: Abdominal Pain; Adnexa Uteri; Adnexal Diseases; Adolescent; Early Diagnosis; Female; Fertility Preservation; Humans; Laparoscopy; Practice Guidelines as Topic; Torsion Abnormality
PubMed: 26204167
DOI: 10.1097/GCO.0000000000000197 -
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