Chapter 1 of 3 · Surgical Management
Preservation strategy
Ovarian preservation in torsion: shifting from oophorectomy to conservative management
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Ovarian torsion is most common in teenage girls and is being seen as an urgent rather than emergent situation when aiming to preserve the ovary.
The old teaching was 'if it's black, you take it out,' but learning from GYN colleagues shows many black-colored ovaries have viable follicles and ovarian preservation should be the goal.
Ability to preserve the ovary depends on mass size, cyst size (less than or greater than 10 cm), presence or absence of torsion versus pain from cyst size alone, and whether the approach is laparoscopic.
Microscopically, ovarian tissue looks very different than in the gross setting when a surgeon is examining the ovary.
The ability to preserve ovarian function in black-colored torsed ovaries is related to age; in pediatric patients there should be aggressive attempts to preserve the ovary, but in older adults there are fewer active follicles making preservation less likely.
Even preserving just a thin layer of abnormal ovary will preserve enough follicles for function.
The present recommendation is detorsion without complete oophorectomy.
Tumor markers should be sent off before going to the OR, even though results won't be available in time.
If ultrasound shows good blood flow, the case can be done the next day with a tissue-preserving surgical approach.
Good blood flow on ultrasound means absolutely nothing in determining whether torsion is present.
Ultrasound cannot be trusted to determine whether there is good blood flow in suspected ovarian torsion.
Ultrasound sensitivity and specificity for ovarian torsion is in the 50-60% range.
Whether ultrasound shows blood flow or not should be given little weight; if the child is in significant pain, surgery should be done right away.
In torsion secondary to long ligaments where the ovary is swollen, detorsion can be performed and then ultrasound follow-up in a few weeks rather than trying to dissect out the ovary.
A patient who was not pexied after initial torsion returned with torsion on the contralateral ovary, creating a situation with one mostly removed ovary and a second torsion.
Ultrasound findings are dependent on the pressure the sonographer is using and how much the bladder is filled.
One approach is to pexy if there is no cyst to deal with; if there is something to deal with (a cyst), no pexy is performed; if a normal ovary was twisted, then pexy is done.
One surgeon used to routinely pexy but does not do that anymore.
When there is a long ligament, the ligament can be foreshortened.
One technique is to tag the two ovaries together posterior behind the uterus, which is where they naturally lie.
When ovaries are tucked up underneath posterior to the uterus, it would be hard for a loop of bowel to get down there.
Tacking both ovaries together behind the uterus addresses both ovaries simultaneously and may prevent contralateral torsion.
Ovaries are tacked behind the uterus in the setting of Hodgkin's or malignancy where the pelvis will be radiated, but in torsion cases they are pulled in a little bit but not all the way behind the uterus.
Bilateral oophoropexy (including the contralateral side) is performed by at least one surgeon.
For oophoropexy, the ovary is pexied to the pelvic side wall.
Solid component, size greater than 10 centimeters, positive tumor markers, and calcifications are key factors in deciding whether to drain, detorse, or remove an ovarian mass.
In specimens where oophorectomy was performed because the surgeon judged the ovary dead, 76% had normal ovarian tissue, only 13% had no ovarian tissue, and only 11% were completely necrotic.
Most papers report pain in girls as a consequence of doing oophoropexy with ovarian sparing, which is usually short-lived and resolves in a week or so.
In the specimens from studies Andrea pointed out, most cases were not taken urgently to the operating room and still had viable tissue.
Pediatric radiologists, including presidents of their national organization, say ultrasound does not help in the setting of suspected ovarian torsion.
If an ovary is twisted, just because there's blood flow doesn't mean it's not twisted; it may mean at that point in time it's not so tight so blood flow is getting through, but a minute later it could be tight again, so ultrasound doesn't tell you anything about torsion, only about blood flow at that moment.
Placing ovaries posterior behind the uterus rather than laterally may be better for fertility reasons according to a reproductive endocrinologist, and bowel can get through if placed laterally.