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Ovarian torsion: to pex or not to pex? case report and review of the literature
J Pediatr Adolesc Gynecol (2003) 16:381–384
Communications in Brief Ovarian Torsion: To Pex or Not To Pex? Case Report and Review of the Literature Naomi S. Crouch, MRCOG, Bright Gyampoh, MB, ChB, Alfred S. Cutner, MD, MRCOG, and Sarah M. Creighton, MD, FRCOG Department of Gynaecology, Elizabeth Garrett Anderson Hospital, University College London Hospital, Huntley Street, London, UK
Abstract. Study objective: We report the case of a 7-yearold girl who underwent laparoscopic ovariopexy for a suspected ovarian torsion after a previous oophorectomy. We consider the role of elective ovariopexy of the contralateral ovary in the case of adnexal torsion. Design: Case study and review of the literature. Result: There was evidence to suggest a very recent adnexal torsion and an unusually long ovarian pedicle, with a possible familial linkage. The patient underwent laparoscopic ovariopexy for the remaining normal ovary, which was found to be loosely twisted at operation. After detorsion, ovariopexy was performed laparoscopically, by suturing the ovary to the back of uterus. There are no other descriptions in the literature of a familial linkage with ovarian torsion. Conclusion: The case presented reminds doctors of the strong possibility of ovarian torsion in young girls presenting with pelvic pain. Laparoscopic ovariopexy for the contralateral ovary should be considered in all women with evidence of torsion, including children and adolescents, as is standard for testicular torsion.
Key Words. Pediatric—Laparoscopy—Ovarian torsion—Ovariopexy—Oophoropexy—Family history Introduction Adnexal torsion in pre-pubertal girls is uncommon. It may mimic acute appendicitis and a delay in diagnosis can be dire, with future fertility repercussions. We describe here a case of a 7-year-old girl with sequential Address reprint requests to: Miss Sarah Creighton, Department of Gynaecology, Elizabeth Garrett Anderson Hospital, University College London Hospital, Huntley Street, London WC1E 6DH. Tel.: 00 44 207 387 9300; E-mail: [email protected] SYNOPSIS: We present the case of a 7-year-old girl who underwent an elective ovariopexy following possible torsion, with a positive family history of torted ovaries.
쑖 2003 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Inc.
ovarian torsion. One ovary was removed at laparotomy, while the second torsion was managed laparoscopically. She had an unusually long ovarian pedicle which was suggested to be the cause of her adnexal torsion. We consider the arguments for prophylactic ovariopexy.
Case Report A 7-year-old girl was admitted to University College London Hospitals (UCLH) in May 2001, with a history of pelvic pain, nausea, and an episode of vomiting. During the preceding month she had experienced similar pains. A tentative diagnosis of ovarian torsion was made although the clinical signs were not classical. One month prior to her admission, she had developed pain in her right iliac fossa, which progressively worsened. She was reviewed in a local hospital with suspected appendicitis and managed conservatively. She improved but the pain recurred a few days later while on holiday in the United Kingdom. She was admitted to hospital and underwent laparotomy for an acute abdomen. She was found to have a normal appendix, but a large hemorrhagic and torted right adnexal mass. The left ovary and tube appeared normal. Appendectomy and right salpingo-oophorectomy was performed. She recovered well. The pathologist reported a mass consisting of ovarian tissue weighing 36.7 g and measured 5 cm at its maximum diameter. No normal ovarian tissue was identified. The histology confirmed a hemorrhagic necrotic ovary in keeping with a history of torsion. During her admission at UCLH the patient was managed conservatively with analgesics and her pelvic pain resolved. There was no subsequent clinical evidence of torsion. Ultrasound scan of her pelvis showed the uterus measured 44 mm in length with AP diameter 1083-3188/03/$22.00 doi:10.1016/j.jpag.2003.09.017
382
Crouch et al: Ovarian Torsion
at the fundus of 10 mm and at the cervix of 6 mm. There was no endometrial thickening. The left ovary measured 23 × 12 × 20 mm (volume 2.8 ml) with numerous follicles. There was no evidence of torsion and an absent right ovary was noted. Hormonal profile performed on her was normal with a follicle stimulatory hormone of 5 mIu/ml, luteinizing hormone of ⬍ 0.1 mIu/ml, and estradiol levels of ⬍ 55 pmol/l. Significantly, her mother also gave a history of having torted an ovary, also at the age of seven. She had an oophorectomy but sequentially torted the contralateral ovary two years later. At laparotomy some ovarian tissue was preserved and an ovariopexy was performed. She subsequently managed to conceive with the salvaged ovary. In view of mother and daughter’s gynecology history and a strong possibility of ovarian torsion accounting for her symptoms, a decision was made for her to undergo elective laparoscopic ovariopexy. Laparoscopic ovariopexy and adhesiolysis was performed. A carbon dioxide pneumoperitoneum was created using a direct entry technique under vision through an umbilical incision. A three-port laparoscopy was performed, with the primary 10-mm port being inserted through the umbilical ring for the 10-mm telescope. Two secondary 5-mm ports were inserted; one at the same level lateral to the rectus sheath on the left side, and the other in the midline in the suprapubic region. Adhesions were noted from the cecum to the right adnexa, and were divided. The left fallopian tube and ovary were normal. However, both had loosely twisted on the utero-ovarian pedicle, which was unusually long. There was no evidence of ischemia and the ovary and tube were untwisted laparoscopically. Ovariopexy was then performed laparoscopically by fixing the ovary to the back of the uterus on the left side, with two sutures, using non-absorbable monofilament polypropylene suture material (Prolene, Ethicon, UK) see figure 1. Post-operative recovery was unremarkable and she was discharged two days later.
Discussion Adnexal torsion is an uncommon cause of acute pelvic pain which may occur in women or prepubertal girls.1 Any delay in diagnosis can result in infarction of the ovary and fallopian tube and necessitate adnexal removal. Torsion is generally unilateral but can involve the contralateral ovary or adnexa. Although rare, the potential remains for sequential torsion, with devastating effects.2 Torsion may occur with normal or enlarged ovaries, and is thought to be more common in pregnancy. However, there are many cases in the literature of torsion of
normal adnexa in prepubescent and adolescent girls.3,4 Torsion of normal adnexa is thought to be due to excessively mobile mesovaria or fallopian tubes, resulting from congenitally long ovarian ligaments. Presumably this is the mechanism that accounted for the torsion in our patient as she was found to have an unusually long ovarian ligament. Both the patient and her mother torted and lost an ovary at the age of 7 years. Her mother sequentially torted her remaining ovary while the patient was found to have a loosely twisted ovary and tube at laparoscopy. It is highly likely that this was the cause of her pain and that she would subsequently have torted and possibly lost her remaining ovary. We have been unable to identify in the literature any other report of familial linkage of adnexal torsion and it would seem logical that the same pathological mechanism would apply to both mother and daughter. The traditional management of a torted ovary has been laparotomy and oophorectomy, with adnexectomy if complicated. Untwisting the adnexa was thought to increase the risk of emboli departing from thrombosed ovarian veins and resulting in pulmonary embolus. However, from the literature, this seems an unlikely endpoint, and simple untwisting does not appear to increase the risk.5 Indeed, pulmonary emboli may occur when the adnexa have not been untwisted prior to removal; thus potential prevention of an embolic event should not be the primary reason for adnexectomy being performed. The ideal management would be laparoscopic untwisting of the torted ovary, or laparoscopic oophorectomy if the ovary was non-viable.6 Some surgeons have advocated shortening of the uteroovarian ligaments as an alternative to ovariopexy, for prophylaxis against ovarian torsion. This has been described as a laparoscopic procedure, although, inevitably, long-term results are not yet available.7,8 Unfortunately the management of ovarian torsion is often complicated by misdiagnosis. The commonest cause of pelvic pain in children is appendicitis and ovarian torsion may only be found at laparotomy. Often such procedures may be carried out late at night, and without initial gynecological input. Even if the diagnosis is correctly suspected, there has been a reluctance to perform laparoscopy in children. However, with the development of new instrumentation appropriate for children, laparoscopic diagnosis and treatment has become well established and should often be the standard surgical intervention.9 Surprisingly, there is no consensus among gynecologists as to the management of the remaining ovary following unilateral torsion. Children who have suffered from ovarian torsion may be at increased risk of repetitive event either of the same ovary (if preserved and not fixed) or the contralateral ovary.2,10 Indeed, with the increasing practice of conservative
Crouch et al: Ovarian Torsion
management of ovarian torsion, it seems likely that the incidence will increase. Ovariopexy has been described in the literature, both at laparotomy and laparoscopically, but this is usually for a salvageable ovary which has already torted, as in the case of our patient’s mother.4,11 In the case of a unilateral torsion where the ovary is non-viable it is essential to consider the future of the single remaining ovary to secure future fertility. It would seem logical to perform ovariopexy either at the time of initial surgery or at a later date. It is likely that ovariopexy would reduce the risk of future torsion, although, as the condition is rare, there are few data to support this. However, the consequences of a second torsion are so dramatic that elective ovariopexy would seem justified. No such uncertainty exists with testicular torsion. The management is uncontroversial and involves prompt surgical exploration of the scrotum. If performed within 6 hours of the onset of pain, it is estimated that up to 90% of testes can be preserved. It is standard practice to fix the contralateral testis to the scrotum at the same time. Clearly, diagnosis is often easier as it is the commonest cause of pain and swelling of the scrotum. However, once the diagnosis is made, contralateral orchidopexy is routine. Reluctance to perform ovariopexy may be a leftover from an era prior to laparoscopy and minimal access surgery. The thought of a repeat laparotomy in a child soon after their first laparotomy for torsion is difficult to justify. It means another major operation and more time off school. The practice of laparoscopic diagnosis and detorsion predates that of laparoscopic ovariopexy. Surgeons may have been reluctant to perform a laparotomy solely for ovariopexy, once the initial torsion had been treated. However, laparoscopic ovariopexy, as performed in this case, is a procedure with a low
Fig. 1. Laparoscopic view of remaining ovary fixed to the uterus.
383
morbidity and allows a quick return to normal activities and schooling. Ideally it would be most sensible to perform the ovariopexy at the same time as the initial laparotomy or laparoscopy. However, these procedures are often performed as an emergency, and possibly without the initial involvement of gynecological services. It also relies on anticipating torsion and discussing the potential procedure and risks with the patient and her parents. There have been no complications following ovariopexy reported in the literature, although in theory fixing the ovary either to the uterus, as in this case, or to the pelvic sidewall may interfere with tubal blood supply or function. There is therefore a possibility that ovariopexy may create mechanical infertility with blockage of the remaining tube requiring invitro fertilization. It is important to consider this, but to balance this against the risk of losing the ovary and therefore requiring more complex fertility treatment with ovum donation. Additionally, there would be the requirement for hormonal induction of puberty and maintenance hormone replacement therapy. The need to discuss all of these complex issues with the patient and parents would justify an interval procedure, rather than ovariopexy being carried out at the initial operation. In the future, with the collection of prospective data, it may be that the risk of tubal damage can be ruled out. However, with present knowledge, the recommendation of an elective ovariopexy of the contralateral normal ovary following adnexal torsion seems fully justifiable, in order to avoid devastating consequences.
Conclusion This is the first report of familial linkage in ovarian torsion, and highlights the problem of sequential torsion. The advent and development of minimal access techniques has converted ovariopexy into a relatively minor procedure which may be carried out in children and adolescents. Orchidopexy of the contralateral normal testes in boys is automatically performed at the time of diagnosis of testicular torsion, and ovariopexy should be considered in the same way. The theoretical possibility of tubal damage should be discussed with the patient and parents. We recommend that elective contralateral ovariopexy should be considered in all children who have undergone ovarian torsion. This may require referral to a unit offering laparoscopy in pediatric gynecology. However, the consequences of not offering ovariopexy are extreme and warrant this approach. In the case presented, a vigilant mother and prompt gynecological intervention have optimized the patient’s future fertility. Other children may not be as fortunate.
384
Crouch et al: Ovarian Torsion
References 1. Nichols DH, Julian PJ: Torsion of the adnexa. Clin Obstet Gynecol 1985; 28:373 2. Ozcan C, Celik A, Ozok G, et al: Adnexal torsion in children may have a catastrophic sequel: asynchronous bilateral torsion. J Pediatr Surg 2002; 37:1617 3. Prasad M, Bone CDM, Arafat Q: Torsion of a normal adnexum in an adolescent. J Obstet Gynaecol 2002; 22:454 4. Kienstra A, Ward MA: Third place winner: Three year old female with intermittent ovarian torsion. J Emerg Med 2002; 23:375 5. McGovern PG, Noah R, Koenigsberg R, et al: Adnexal torsion and pulmonary embolism: case report and review of the literature. Obstet Gynecol Surv 1999; 54:601 6. Rody A, Jackisch C, Klockenbusch W, et al: The conservative management of adnexal torsion - a case report and
7.
8.
9.
10.
11.
review of the literature. Eur J Obstet Gynecol Reprod Biol 2002; 101:83 Germain M, Rarick T, Robins E: Management of intermittent ovarian torsion by laparoscopic oophoropexy. Obstet Gynecol 1996; 88:715 Nagel TC, Sebastian J, Malo JW: Oophoropexy to prevent sequential or recurrent torsion. J Am Assoc Gynecol Laparosc 1997; 4:495 Ure BM, Bax NMA, van der Zee DC: Laparoscopy in infants and children: A prospective study on feasibility and the impact on routine surgery. J Pediatr Surg 2000; 35:1170 Grunewald B, Keating J, Brown S: Asynchronous ovarian torsion - the case for prophylactic oophoropexy. Postgrad Med J 1993; 69:318 Righi RV, McComb PF, Fluker MR: Laparoscopic oophoropexy for recurrent adnexal torsion. Hum Reprod 1995; 10:3136
Communications in Brief Ovarian Torsion: To Pex or Not To Pex? Case Report and Review of the Literature Naomi S. Crouch, MRCOG, Bright Gyampoh, MB, ChB, Alfred S. Cutner, MD, MRCOG, and Sarah M. Creighton, MD, FRCOG Department of Gynaecology, Elizabeth Garrett Anderson Hospital, University College London Hospital, Huntley Street, London, UK
Abstract. Study objective: We report the case of a 7-yearold girl who underwent laparoscopic ovariopexy for a suspected ovarian torsion after a previous oophorectomy. We consider the role of elective ovariopexy of the contralateral ovary in the case of adnexal torsion. Design: Case study and review of the literature. Result: There was evidence to suggest a very recent adnexal torsion and an unusually long ovarian pedicle, with a possible familial linkage. The patient underwent laparoscopic ovariopexy for the remaining normal ovary, which was found to be loosely twisted at operation. After detorsion, ovariopexy was performed laparoscopically, by suturing the ovary to the back of uterus. There are no other descriptions in the literature of a familial linkage with ovarian torsion. Conclusion: The case presented reminds doctors of the strong possibility of ovarian torsion in young girls presenting with pelvic pain. Laparoscopic ovariopexy for the contralateral ovary should be considered in all women with evidence of torsion, including children and adolescents, as is standard for testicular torsion.
Key Words. Pediatric—Laparoscopy—Ovarian torsion—Ovariopexy—Oophoropexy—Family history Introduction Adnexal torsion in pre-pubertal girls is uncommon. It may mimic acute appendicitis and a delay in diagnosis can be dire, with future fertility repercussions. We describe here a case of a 7-year-old girl with sequential Address reprint requests to: Miss Sarah Creighton, Department of Gynaecology, Elizabeth Garrett Anderson Hospital, University College London Hospital, Huntley Street, London WC1E 6DH. Tel.: 00 44 207 387 9300; E-mail: [email protected] SYNOPSIS: We present the case of a 7-year-old girl who underwent an elective ovariopexy following possible torsion, with a positive family history of torted ovaries.
쑖 2003 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Inc.
ovarian torsion. One ovary was removed at laparotomy, while the second torsion was managed laparoscopically. She had an unusually long ovarian pedicle which was suggested to be the cause of her adnexal torsion. We consider the arguments for prophylactic ovariopexy.
Case Report A 7-year-old girl was admitted to University College London Hospitals (UCLH) in May 2001, with a history of pelvic pain, nausea, and an episode of vomiting. During the preceding month she had experienced similar pains. A tentative diagnosis of ovarian torsion was made although the clinical signs were not classical. One month prior to her admission, she had developed pain in her right iliac fossa, which progressively worsened. She was reviewed in a local hospital with suspected appendicitis and managed conservatively. She improved but the pain recurred a few days later while on holiday in the United Kingdom. She was admitted to hospital and underwent laparotomy for an acute abdomen. She was found to have a normal appendix, but a large hemorrhagic and torted right adnexal mass. The left ovary and tube appeared normal. Appendectomy and right salpingo-oophorectomy was performed. She recovered well. The pathologist reported a mass consisting of ovarian tissue weighing 36.7 g and measured 5 cm at its maximum diameter. No normal ovarian tissue was identified. The histology confirmed a hemorrhagic necrotic ovary in keeping with a history of torsion. During her admission at UCLH the patient was managed conservatively with analgesics and her pelvic pain resolved. There was no subsequent clinical evidence of torsion. Ultrasound scan of her pelvis showed the uterus measured 44 mm in length with AP diameter 1083-3188/03/$22.00 doi:10.1016/j.jpag.2003.09.017
382
Crouch et al: Ovarian Torsion
at the fundus of 10 mm and at the cervix of 6 mm. There was no endometrial thickening. The left ovary measured 23 × 12 × 20 mm (volume 2.8 ml) with numerous follicles. There was no evidence of torsion and an absent right ovary was noted. Hormonal profile performed on her was normal with a follicle stimulatory hormone of 5 mIu/ml, luteinizing hormone of ⬍ 0.1 mIu/ml, and estradiol levels of ⬍ 55 pmol/l. Significantly, her mother also gave a history of having torted an ovary, also at the age of seven. She had an oophorectomy but sequentially torted the contralateral ovary two years later. At laparotomy some ovarian tissue was preserved and an ovariopexy was performed. She subsequently managed to conceive with the salvaged ovary. In view of mother and daughter’s gynecology history and a strong possibility of ovarian torsion accounting for her symptoms, a decision was made for her to undergo elective laparoscopic ovariopexy. Laparoscopic ovariopexy and adhesiolysis was performed. A carbon dioxide pneumoperitoneum was created using a direct entry technique under vision through an umbilical incision. A three-port laparoscopy was performed, with the primary 10-mm port being inserted through the umbilical ring for the 10-mm telescope. Two secondary 5-mm ports were inserted; one at the same level lateral to the rectus sheath on the left side, and the other in the midline in the suprapubic region. Adhesions were noted from the cecum to the right adnexa, and were divided. The left fallopian tube and ovary were normal. However, both had loosely twisted on the utero-ovarian pedicle, which was unusually long. There was no evidence of ischemia and the ovary and tube were untwisted laparoscopically. Ovariopexy was then performed laparoscopically by fixing the ovary to the back of the uterus on the left side, with two sutures, using non-absorbable monofilament polypropylene suture material (Prolene, Ethicon, UK) see figure 1. Post-operative recovery was unremarkable and she was discharged two days later.
Discussion Adnexal torsion is an uncommon cause of acute pelvic pain which may occur in women or prepubertal girls.1 Any delay in diagnosis can result in infarction of the ovary and fallopian tube and necessitate adnexal removal. Torsion is generally unilateral but can involve the contralateral ovary or adnexa. Although rare, the potential remains for sequential torsion, with devastating effects.2 Torsion may occur with normal or enlarged ovaries, and is thought to be more common in pregnancy. However, there are many cases in the literature of torsion of
normal adnexa in prepubescent and adolescent girls.3,4 Torsion of normal adnexa is thought to be due to excessively mobile mesovaria or fallopian tubes, resulting from congenitally long ovarian ligaments. Presumably this is the mechanism that accounted for the torsion in our patient as she was found to have an unusually long ovarian ligament. Both the patient and her mother torted and lost an ovary at the age of 7 years. Her mother sequentially torted her remaining ovary while the patient was found to have a loosely twisted ovary and tube at laparoscopy. It is highly likely that this was the cause of her pain and that she would subsequently have torted and possibly lost her remaining ovary. We have been unable to identify in the literature any other report of familial linkage of adnexal torsion and it would seem logical that the same pathological mechanism would apply to both mother and daughter. The traditional management of a torted ovary has been laparotomy and oophorectomy, with adnexectomy if complicated. Untwisting the adnexa was thought to increase the risk of emboli departing from thrombosed ovarian veins and resulting in pulmonary embolus. However, from the literature, this seems an unlikely endpoint, and simple untwisting does not appear to increase the risk.5 Indeed, pulmonary emboli may occur when the adnexa have not been untwisted prior to removal; thus potential prevention of an embolic event should not be the primary reason for adnexectomy being performed. The ideal management would be laparoscopic untwisting of the torted ovary, or laparoscopic oophorectomy if the ovary was non-viable.6 Some surgeons have advocated shortening of the uteroovarian ligaments as an alternative to ovariopexy, for prophylaxis against ovarian torsion. This has been described as a laparoscopic procedure, although, inevitably, long-term results are not yet available.7,8 Unfortunately the management of ovarian torsion is often complicated by misdiagnosis. The commonest cause of pelvic pain in children is appendicitis and ovarian torsion may only be found at laparotomy. Often such procedures may be carried out late at night, and without initial gynecological input. Even if the diagnosis is correctly suspected, there has been a reluctance to perform laparoscopy in children. However, with the development of new instrumentation appropriate for children, laparoscopic diagnosis and treatment has become well established and should often be the standard surgical intervention.9 Surprisingly, there is no consensus among gynecologists as to the management of the remaining ovary following unilateral torsion. Children who have suffered from ovarian torsion may be at increased risk of repetitive event either of the same ovary (if preserved and not fixed) or the contralateral ovary.2,10 Indeed, with the increasing practice of conservative
Crouch et al: Ovarian Torsion
management of ovarian torsion, it seems likely that the incidence will increase. Ovariopexy has been described in the literature, both at laparotomy and laparoscopically, but this is usually for a salvageable ovary which has already torted, as in the case of our patient’s mother.4,11 In the case of a unilateral torsion where the ovary is non-viable it is essential to consider the future of the single remaining ovary to secure future fertility. It would seem logical to perform ovariopexy either at the time of initial surgery or at a later date. It is likely that ovariopexy would reduce the risk of future torsion, although, as the condition is rare, there are few data to support this. However, the consequences of a second torsion are so dramatic that elective ovariopexy would seem justified. No such uncertainty exists with testicular torsion. The management is uncontroversial and involves prompt surgical exploration of the scrotum. If performed within 6 hours of the onset of pain, it is estimated that up to 90% of testes can be preserved. It is standard practice to fix the contralateral testis to the scrotum at the same time. Clearly, diagnosis is often easier as it is the commonest cause of pain and swelling of the scrotum. However, once the diagnosis is made, contralateral orchidopexy is routine. Reluctance to perform ovariopexy may be a leftover from an era prior to laparoscopy and minimal access surgery. The thought of a repeat laparotomy in a child soon after their first laparotomy for torsion is difficult to justify. It means another major operation and more time off school. The practice of laparoscopic diagnosis and detorsion predates that of laparoscopic ovariopexy. Surgeons may have been reluctant to perform a laparotomy solely for ovariopexy, once the initial torsion had been treated. However, laparoscopic ovariopexy, as performed in this case, is a procedure with a low
Fig. 1. Laparoscopic view of remaining ovary fixed to the uterus.
383
morbidity and allows a quick return to normal activities and schooling. Ideally it would be most sensible to perform the ovariopexy at the same time as the initial laparotomy or laparoscopy. However, these procedures are often performed as an emergency, and possibly without the initial involvement of gynecological services. It also relies on anticipating torsion and discussing the potential procedure and risks with the patient and her parents. There have been no complications following ovariopexy reported in the literature, although in theory fixing the ovary either to the uterus, as in this case, or to the pelvic sidewall may interfere with tubal blood supply or function. There is therefore a possibility that ovariopexy may create mechanical infertility with blockage of the remaining tube requiring invitro fertilization. It is important to consider this, but to balance this against the risk of losing the ovary and therefore requiring more complex fertility treatment with ovum donation. Additionally, there would be the requirement for hormonal induction of puberty and maintenance hormone replacement therapy. The need to discuss all of these complex issues with the patient and parents would justify an interval procedure, rather than ovariopexy being carried out at the initial operation. In the future, with the collection of prospective data, it may be that the risk of tubal damage can be ruled out. However, with present knowledge, the recommendation of an elective ovariopexy of the contralateral normal ovary following adnexal torsion seems fully justifiable, in order to avoid devastating consequences.
Conclusion This is the first report of familial linkage in ovarian torsion, and highlights the problem of sequential torsion. The advent and development of minimal access techniques has converted ovariopexy into a relatively minor procedure which may be carried out in children and adolescents. Orchidopexy of the contralateral normal testes in boys is automatically performed at the time of diagnosis of testicular torsion, and ovariopexy should be considered in the same way. The theoretical possibility of tubal damage should be discussed with the patient and parents. We recommend that elective contralateral ovariopexy should be considered in all children who have undergone ovarian torsion. This may require referral to a unit offering laparoscopy in pediatric gynecology. However, the consequences of not offering ovariopexy are extreme and warrant this approach. In the case presented, a vigilant mother and prompt gynecological intervention have optimized the patient’s future fertility. Other children may not be as fortunate.
384
Crouch et al: Ovarian Torsion
References 1. Nichols DH, Julian PJ: Torsion of the adnexa. Clin Obstet Gynecol 1985; 28:373 2. Ozcan C, Celik A, Ozok G, et al: Adnexal torsion in children may have a catastrophic sequel: asynchronous bilateral torsion. J Pediatr Surg 2002; 37:1617 3. Prasad M, Bone CDM, Arafat Q: Torsion of a normal adnexum in an adolescent. J Obstet Gynaecol 2002; 22:454 4. Kienstra A, Ward MA: Third place winner: Three year old female with intermittent ovarian torsion. J Emerg Med 2002; 23:375 5. McGovern PG, Noah R, Koenigsberg R, et al: Adnexal torsion and pulmonary embolism: case report and review of the literature. Obstet Gynecol Surv 1999; 54:601 6. Rody A, Jackisch C, Klockenbusch W, et al: The conservative management of adnexal torsion - a case report and
7.
8.
9.
10.
11.
review of the literature. Eur J Obstet Gynecol Reprod Biol 2002; 101:83 Germain M, Rarick T, Robins E: Management of intermittent ovarian torsion by laparoscopic oophoropexy. Obstet Gynecol 1996; 88:715 Nagel TC, Sebastian J, Malo JW: Oophoropexy to prevent sequential or recurrent torsion. J Am Assoc Gynecol Laparosc 1997; 4:495 Ure BM, Bax NMA, van der Zee DC: Laparoscopy in infants and children: A prospective study on feasibility and the impact on routine surgery. J Pediatr Surg 2000; 35:1170 Grunewald B, Keating J, Brown S: Asynchronous ovarian torsion - the case for prophylactic oophoropexy. Postgrad Med J 1993; 69:318 Righi RV, McComb PF, Fluker MR: Laparoscopic oophoropexy for recurrent adnexal torsion. Hum Reprod 1995; 10:3136