Imaging in gynecological disease (20): clinical and ultrasound characteristics of adnexal torsion.

OBJECTIVES: To describe the clinical and ultrasound characteristics of adnexal torsion. METHODS: This was a retrospective study. From the operative records of the eight participating gynecological ultrasound centers, we identified patients with a surgically confirmed diagnosis of adnexal torsion, defined as surgical evidence of ovarian pedicle, paraovarian cyst and/or Fallopian tube twisted on its own axis, who had undergone preoperative ultrasound examination by an experienced examiner, between 2008 and 2018. Only cases with at least two available ultrasound images and/or videoclips (one grayscale and one with Doppler evaluation) were included. Clinical, ultrasound, surgical and histological information was retrieved from each patient's medical record and entered into an Excel file by the principal investigator at each center. In addition, two authors reviewed all available ultrasound images and videoclips of the twisted adnexa, with regard to the presence of four predefined ultrasound features reported to be characteristic of adnexal torsion: (1) ovarian stromal edema with or without peripherally displaced antral follicles, (2) the follicular ring sign, (3) the whirlpool sign and (4) absence of vascularization in the twisted organ. RESULTS: A total of 315 cases of adnexal torsion were identified. The median age of the patients was 30 (range, 1-88) years. Most patients were premenopausal (284/314; 90.4%) and presented with acute or subacute pelvic pain (305/315; 96.8%). The surgical approach was laparoscopic in 239/312 (76.6%) patients and conservative surgery (untwisting with or without excision of a lesion) was performed in 149/315 (47.3%) cases. According to the original ultrasound reports, the median largest diameter of the twisted organ was 83 (range, 30-349) mm. Free fluid in the pouch of Douglas was detected in 196/275 (71.3%) patients. Ovarian stromal edema with or without peripherally displaced antral follicles was reported in the original ultrasound report in 167/241 (69.3%) patients, the whirlpool sign in 178/226 (78.8%) patients, absent color Doppler signals in the twisted organ in 119/269 (44.2%) patients and the follicular ring sign in 51/134 (38.1%) patients. On retrospective review of images and videoclips, ovarian stromal edema with or without peripherally displaced antral follicles (201/254; 79.1%) and the whirlpool sign (139/153; 90.8%) were the most commonly detected features of adnexal torsion. CONCLUSION: Most patients with surgically confirmed adnexal torsion are of reproductive age and present with acute or subacute pain. Common ultrasound signs are an enlarged adnexa, the whirlpool sign, ovarian stromal edema with or without peripherally displaced antral follicles and free fluid in the pelvis. The follicular ring sign and absence of Doppler signals in the twisted organ are slightly less common signs. Recognizing ultrasound signs of adnexal torsion is important so that the correct treatment, i.e. surgery without delay, can be offered. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

CT in the diagnosis of adnexal torsion: a retrospective study.

Ultrasonography (USG) is the first and best modality for diagnosis of the adnexal torsion. But frequently in clinical practice, computed tomography (CT) scan becomes the first acquired modality as adnexal torsion mimics other non-gynaecological conditions. This retrospective study evaluated the diagnostic performance of CT as a modality in adnexal torsion. Thirty cases of surgically proven adnexal torsion with preoperative CT scans were included. Changes in the ovary, fallopian tube, uterine axis and other features were documented and analysed. At least one positive CT sign was seen in all 30 adnexal torsion patients. Twisted pedicle was seen in 100% cases. Peripherally displaced follicles in 57.1%, associated mass in 93.3%, ovarian hyperdensity in 46.4%, hydrosalpinx in 46.7%, change in uterine axis in 43.4% and ascites in 73.3%. CT of the pelvis can diagnose ovarian torsion when the described signs are carefully looked for.Impact statementWhat is already known on this subject? Adnexal torsion is an surgical emergency where delayed diagnosis may reduce the ovarian salvageability rate. USG has been a trusted modality for imaging the adnexa and associated pathologies such as torsion. It is a general assumption that CT is not an apt modality for diagnosis of torsion.What the results of this study add? The results of this study emphasise that CT can be used to diagnose adnexal torsion when the signs described are carefully looked for. A normal appearing ovary on CT can rule out torsion as at least one sign will be positive in such cases.What the implications are of these findings for clinical practice and/or further research? As adnexal torsion clinically mimics non-gynaecological conditions such as ureteric colic, appendicitis, etc. where CT is the initial and only available modality, applying the results of our study can aid in diagnosis of adnexal torsion on CT itself, prompting immediate surgical referral and thereby reducing the delay by not acquiring or confirming by another modality such as USG.

Phenotypic and clinical aspects of Mayer-Rokitansky-Küster-Hauser syndrome in a Chinese population: an analysis of 594 patients.

OBJECTIVE: To analyze the phenotypic and clinical aspects of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. DESIGN: Cross-sectional study. SETTING: University hospital. PATIENT(S): Five hundred and ninety-four patients with MRKH syndrome. INTERVENTION(S): Clinical examination, abdominal or perineal/rectal ultrasound, magnetic resonance imaging, hormonal profile, karyotype, and laparoscopy. MAIN OUTCOME MEASURE(S): Clinicopathologic data, VCUAM (vagina cervix uterus adnex-associated malformation) classification, types with cycle phase, and karyotype. RESULT(S): We identified associated malformations in 43 out of 594 (7.2%) cases of MRKH. The 594 patients could be grouped into hormone phases: 53.7% follicular, 35.2% luteal, and 11.1% ovulatory. The major karyotype of MRKH patients was 46,XX; abnormal karyotypes were found in two cases. CONCLUSION(S): A lower proportion of associated malformations were found when compared with those provided in the current literature. Renal anomalies were the most frequent associated malformations, and most of the patients presented with a normal karyotype. Given the large cohort of this study, the lower malformation rates might be related to geographic or referral patterns, so further investigation is warranted.

[Pediatric gynecological operations based on 40 years' experience]. / Gyermek-nogyógyászati mutétek 40 év tapasztalatai alapján.

The author analyzes more than 40 years of his own experience concerning the outcome of pediatric gynecology patients who underwent surgery in the Department of Gynecology and Obstetrics, Debrecen University in Hungary. Traditional surgical interventions were performed, and, some new methods elaborated by the author. The age of patients who underwent surgery ranged from infancy to 18 years. The objective of this publication is to describe general principles to support the work of those who are currently active in this area or have chosen the area for their future activity. Types of surgical interventions, conditions of proper management and insitutional background, together with requirements of qualified personnel and diagnostic performance are analyzed. Possible sources of errors and their prevention are pointed out. Different procedures are discussed in separate groups. The author's own procedure modifications based on the original procedure elaborated by Vecchietti for treatment of vaginal aplasia are described. Concluding from results of more than 60 successful modified Vecchietti procedures the author recommends his own procedure.

Is unilateral uterine adnexa absence a congenital developmental abnormality or posteriority? Summary of 39 cases and literature review.

PURPOSE: Unilateral uterine adnexa absence with a normal uterus is extremely rare but meaningful in clinical. To date, this rare malformation is still not well understood. Here, we present a new case and systematically summarize 38 historical cases to make this rare anomaly be understood better by clinicians. METHOD: The Chinese and English language medical literature were searched for all cases reported to date, and 39 were identified. All 39 cases were assessed for age, menstrual history, reproductive history, pelvic adhesions, other organ abnormalities, and mode of diagnosis. RESULTS: Patient age ranged from 6 days to 46 years. Menstrual history included normal (n = 27), irregular (n = 4), or unknown (n = 7). Childbearing history included pregnancy (n = 21), no history of pregnancy (n = 3), and primary infertility (n = 7). The absence of uterine adnexa involved either the left (n = 17) or right (n = 22) structures, showing a right adnexa preferential bias (22/39). CONCLUSIONS: The unilateral absence of uterine adnexa may be a congenital anomaly of reproductive organs; it does not significantly affect fertility or childbearing and is usually not diagnosed until adulthood.

Risk of epithelial ovarian cancer in asymptomatic women with ultrasound-detected ovarian masses: a prospective cohort study within the UK collaborative trial of ovarian cancer screening (UKCTOCS).

OBJECTIVE: To estimate the risk of primary epithelial ovarian cancer (EOC) and slow growing borderline or Type I and aggressive Type II EOC in postmenopausal women with adnexal abnormalities on ultrasound. METHODS: This was a prospective cohort study in the ultrasound group of the UK Collaborative Trial of Ovarian Cancer Screening of postmenopausal women with ultrasound-detected abnormal adnexal (unilocular, multilocular, unilocular solid and multilocular solid, solid) morphology on their first scan. Women were followed up through the national cancer registries and by postal questionnaires. Absolute risks of EOC and borderline, Type I and Type II EOC within 3 years of initial scan were calculated. RESULTS: Of 48 053 women who underwent ultrasound examination and had complete scan data, 4367 (9.1% (95% CI, 8.8-9.3%)) had abnormal adnexal morphology. Median follow-up was 7.09 (25(th) -75(th) centiles, 6.03-7.92) years. Forty-seven (32 borderline or Type I, 15 Type II) were diagnosed with EOC. The overall absolute risk of EOC associated with abnormal adnexal morphology was 1.08% (95% CI, 0.79-1.43%); for borderline and Type I it was 0.73% (95% CI, 0.5-1.03%); and for Type II it was 0.34% (95% CI, 0.33-0.79%). In the subgroup (n = 741) with solid elements (unilocular solid, multilocular solid and solid) overall absolute risk was 4.45% (95% CI, 3.08-6.20%), for borderline and Type I it was 3.1% (95% CI, 1.9-4.6%) and for Type II it was 1.3% (95% CI, 0.6-2.4%). 11 982 women had both ovaries visualized and normal annual scans throughout the 3-year follow-up period. In this group, no borderline or Type I and eight Type II cancers were diagnosed. CONCLUSION: Asymptomatic postmenopausal women with ultrasound-detected adnexal abnormalities with solid elements have a 1 in 22 risk for EOC. Despite the higher prevalence of Type II EOC, the risk of borderline or Type I cancer in women with ultrasound abnormalities seems to be higher than does the risk of Type II cancer. This has important immediate implications for patients with incidental adnexal findings as well as for any future ultrasound-based screening.

The utility of ultrasound and magnetic resonance imaging versus surgery for the characterization of müllerian anomalies in the pediatric and adolescent population.

STUDY OBJECTIVE: To evaluate the utility of transabdominal ultrasound and magnetic resonance imaging in the evaluation of American Society for Reproductive Medicine (†)(ASRM)-classified müllerian anomalies compared to surgical findings in the pediatric and adolescent population. DESIGN: Retrospective chart review. SETTING: Tertiary academic center. PARTICIPANTS: Thirty-eight patients with müllerian anomalies seen in our pediatric and adolescent gynecology clinic were identified both on the basis of ICD-9 codes and having magnetic resonance imaging at Texas Children's Hospital between 2004 and 2009. INTERVENTIONS: None. MAIN OUTCOMES MEASURE: Correlation among transabdominal ultrasound and magnetic resonance imaging findings with surgical findings. RESULTS: Mean age was 12.2 (± 4.1) years. Twenty-eight patients underwent magnetic resonance imaging and required surgical intervention, and 88.5% demonstrated correlative consistency with surgical findings. Twenty-two patients underwent ultrasound, magnetic resonance imaging, and surgery, which revealed consistency among ultrasound and surgical findings (59.1%) and consistency among magnetic resonance imaging and surgical findings (90.9%). In ASRM diagnoses evaluated by magnetic resonance imaging, surgical findings correlated in 92% (Pearson 0.89). Overall, 55.2% of patients had a renal malformation. CONCLUSIONS: Magnetic resonance imaging is the gold standard imaging modality for müllerian anomalies and is an effective technique for noninvasive evaluation and accurate classification of the type of anomaly in the pediatric and adolescent population. Magnetic resonance imaging should be considered as an adjunct to transabdominal ultrasound to evaluate müllerian anomalies.

Comparison of different diagnostic procedures for the staging of malformations associated with Mayer-Rokitansky-Küster-Hauser syndrome.

OBJECTIVE: To compare different diagnostic procedures for staging malformations associated with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. DESIGN: Retrospective two-center cohort study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENT(S): One hundred and thirty-eight women with MRKH. INTERVENTION(S): Clinical examinations, abdominal or perineal/rectal ultrasound, magnetic resonance imaging (MRI), and laparoscopy. MAIN OUTCOME MEASURE(S): Agreement between the results obtained with the other methods and the results obtained with the reference methods for correct staging of malformations, presented as kappa values (κ). RESULT(S): The VCUAM (vagina cervix uterus adnex-associated malformation) classification system was used to classify genital malformations in 138 women with MRKH. The reference methods for examining the individual organs were: vagina-clinical examination; cervix/uterus and adnexa-laparoscopy; and urinary tract malformations-MRI. The values obtained were as follows. Vagina was κ 0.74 for MRI versus clinical examination; ultrasound and laparoscopy did not allow adequate description of vaginal malformations. Cervical findings were rarely detailed with any of the imaging methods. Uterus was κ 0.93 for MRI versus laparoscopy, and κ 0.83 for ultrasound. For adnexa, only laparoscopy was able to describe the morphology adequately. The urinary tract was κ 0.87 for ultrasound versus MRI. CONCLUSION(S): For the correct staging of malformations associated with MRKH, MRI or a combination of clinical examination and ultrasound are equivalent. However, none of the imaging methods adequately describes adnexal morphology.

Utilidad de la ultrasonografía en el diagnóstico de la torsión anexial (TA): revisión / Usefulness of ultrasonography in the diagnosis of adnexal torsion: review

Adnexal torsion is a gynecological emergency caused by the twisting of the ovary on its pedicle, causing lymphatic and venous stasis later in the evolution ischemia and necrosis when left untreated. There is no specific clinical sign or manifestation, nor any sensitive biochemical marker available for diagnosing adnexal torsion or ischemia. The best imaging tool in the diagnosis of torsion is the gynecologic ultrasound. The purpose of this review is to gather the ultrasound signs (coiling, whirlpool, ovary size, Doppler, etc.) found to make the diagnosis of this pathology easier.

La torsión anexial es una emergencia ginecológica causada por la torsión del ovario sobre el pedículo, lo que lleva a estasia linfática y venosa, más tarde en la evolución isquemia y necrosis, cuando no es tradada. No hay signos ni manifestaciones específicas, no hay marcadores bioquímicos para el diagnóstico de torsión anexial o isquemia. La mejor herramienta, en cuanto a exámenes de imágenes, es la ecografía ginecológica. El propósito de esta revisión es recolectar los hallazgos ecográficos (enbobinado, remolino, tamaño ovárico, Doppler, etc.) encontrados en la torsión para hacer más fácil el diagnóstico de esta patología.

An incidental finding of unicornuate uterus with unilateral ovarian agenesis during cesarean delivery.

INTRODUCTION: The association of müllerian anomalies with concomitant gonadal development abnormalities is very rare. The literature revealed only a few cases of unicornuate uterus with unilateral ovarian agenesis. The pathophysiology of this rare combination is not clear. CASE REPORT: A 31-year-old primiparous woman at 38 weeks' gestation admitted to our labor room due to painful uterine contractions. An emergency cesarean section was performed and a 3,100-g healthy male infant was delivered. At cesarean delivery, she was found to have unicornuate uterus with no evidence of a rudimentary horn and the absence of a left (unilateral) ovary. The right fallopian tube, round ligament, and ovary were all normal. The left fallopian tube, round ligament, and ovary were all absent. Intraabdominal exploration, intravenous pyelography, postoperative abdominal and transvaginal ultrasonography were failed to reveal additional gynecologic, renal and urinary tract anomalies. CONCLUSION: To our best knowledge this case is unique since the incidental diagnosis of unicornuate uterus with ipsilateral ovary was made during cesarean delivery.

Adnexal masses in infancy and childhood.

The presentation of adnexal masses in childhood differs from that in adult women. Children may present with poorly localized symptoms or precocious puberty. Ovarian cysts occur throughout development; ovarian tumors are less frequent but occur in all age groups. Congenital malformations may present with signs or symptoms of an adnexal mass. Occasionally adnexal findings may suggest the presence of an underlying syndrome. Assessment of the patient's developmental, hormonal, and pubertal status is necessary to ensure an accurate diagnosis. Treatment options must consider risks to ovarian function and future fertility.

Accessory uterine appendage may be a new Müllerian malformation.

OBJECTIVE: To describe a case of an accessory uterine structure. DESIGN: Case report. SETTING: University affiliated, community-based hospital. PATIENT(S): A 35-year-old woman who presented for laparoscopic tubal sterilization. INTERVENTION(S): Laparoscopy, tubal sterilization, dye test, and excision of accessory uterine structure. MAIN OUTCOME MEASURE(S): Laparoscopic findings and resection of the anomaly. RESULT(S): Laparoscopy showed a hollow uterine appendage that communicated with the uterine cavity. This was completely excised. CONCLUSION(S): We report a rare case of a uterine anomaly that is inconsistent with the traditional classification system, and we offer a possible mechanism for its formation.

[Classification and surgery for uterovaginal anomalies]. / Klasyfikacja oraz leczenie operacyjne anomalii rozwojowych narzadu rodnego.

Maldevelopment of the müllerian ducts occurs in a variety of forms, and each anomaly is distinctive. Nevertheless, some generalizations can be made. A comprehensive preoperative evaluation of patients with suspected uterovaginal malformations is essential, but a clear understanding of the particular anomaly may not be established until the time of surgical correction. It is essential to exclude other then anatomical causes of procreative misfortunes before making the decision dealing with surgical correction of a given uterovaginal anomaly.

Spontaneously acquired, unilateral absence of the adnexa. A case report.

A free-floating, calcified cyst was found in the peritoneal cavity in association with unilateral absence of the adnexa. The evidence was that it was due to torsion and separation of the adnexa from their supporting structures. This phenomenon may be a cause of congenital absence of the ovary.

Absence of a vagina and right sided adnexa uteri in the Waardenburg syndrome: a possible clue to the embryological defect.

An 18 year old single Jewish woman with the Waardenburg syndrome and absence of a vagina and right sided adnexa uteri is reported. Other congenital malformations associated with the Waardenburg syndrome are mentioned and it is postulated that they may be the result of an altered invasion of neurones or altered neurones in certain organ systems early in embryogenesis.

Internal herniation through the broad ligament. Case report.

Two cases of internal herniation through a defect in the broad ligament of the uterus are described. This rare condition should be borne in mind when a middle-aged woman presents with colicky lower abdominal pain. The etiology is unknown, but both congenital and acquired origins have been proposed.

Defects of the broad ligament of the uterus.

A case of intestinal obstruction resulting from passage of the entire small bowel and cecum and its mesentery through a fenestration in the broad ligament of the uterus is presented. A review of the literature reveals that broad ligament defects may occur in multiple locations, which may be responsible for intestinal obstruction. A simple classification of broad ligament defects is proposed. Type 1 defects occur caudal to the round ligament of the uterus. Type 2 defects occur above the round ligament. Type 3 defects occur between the round ligament and the remainder of the broad ligament, through the meso-ligamentum teres.