Same-day discharge protocol for laparoscopic treatment of adnexal disease: management and acceptance.

OBJECTIVE: Develop a 'same-day discharge' setting for laparoscopic treatment of adnexal disease. SETTING: Preventive Gynecology, European Institute of Oncology, Milan, Italy. POPULATION: Two hundred patients undergoing laparoscopic procedures. MATERIAL AND METHODS: Data were retrospectively collected through clinical, surgical and laboratory reports. After discharge patients were contacted by phone and e-mail. MAIN OUTCOME MEASURES: The rate of discharge, adverse events and readmission was measured. The need for adjunctive care provided by our on-call service or by a primary care physician and the acceptability of the same-day discharge protocol were also investigated. RESULTS: One hundred and sixty-five patients out of 200 were discharged on the same day. Of the 35 patients hospitalized, the most frequent causes for overnight admission were: uncontrolled pain, surgical length or complexity of the procedure in nine patients, nausea/vomit in four patients. One hundred and one out of 200 patients answered the mailed questionnaire. None of the discharged patients were readmitted. Eighty-five percent of the answering patients evaluated the length of their hospital stay as adequate or moderately adequate. Ninety-two percent of the patients would recommend the day surgery to other patients. CONCLUSIONS: our experience demonstrates that the same-day discharge protocol for laparoscopic treatment of adnexal disease is safe and acceptable.

Torsion of Functional Adnexal Cysts in Pregnancy: Aspiration and Drainage are Important in Preventing Recurrence.

BACKGROUND: Adnexal torsion in pregnancy is often associated with functional adnexal cysts, especially in pregnancies conceived by ovulation induction (OI) or in-vitro fertilization (IVF). During laparoscopy for adnexal de-torsion, drainage of the functional cysts can be attempted, although this procedure may cause bleeding. OBJECTIVES: To investigate the characteristics of ovarian torsion in pregnancy associated with functional cysts and to compare the rate of torsion recurrence following de-torsion alone versus cyst drainage. METHODS: All cases of surgically diagnosed adnexal torsion occurring during pregnancy between January 2007 and April 2019 in our department were retrospectively analyzed. The cases of torsion associated with presumed functional ovarian cysts were selected. The rate of recurrent torsion during the same pregnancy was compared for de-torsion alone versus de-torsion and cyst aspiration. RESULTS: Of the 113 women who experienced adnexal torsion during pregnancy, 71 (67.0%) of torsion cases were caused by presumed functional ovarian cysts. Among women with torsion of functional ovarian cysts, the rate of torsion recurrence was significantly higher in patients who underwent de-torsion alone (n=28) compared to women who underwent aspiration and drainage of the ovarian cysts (n=43) (14.3% vs. 0, P = 0.021). There were no cases of intra- or post-operative bleeding in the study cohort. CONCLUSIONS: Functional ovarian cysts are the most common adnexal pathology encountered in pregnant women with torsion. Intra-operative cyst aspiration and drainage may reduce the risk of recurrent torsion. Further multi-center studies are required to validate our data prospectively.

Adnexal torsion without neoplastic lesions after laparoscopic hysterectomy: A report of three cases and literature review.

The major risk factor for adnexal torsion is the presence of adnexal neoplasms, and torsion without a neoplastic lesion of the adnexa is rare. We report three cases of right adnexal torsion without neoplastic lesion after laparoscopic hysterectomy. In all three cases, the right adnexas, which did not form adhesions, had undergone torsion. According to several case reports, most cases of adnexal torsion after laparoscopic hysterectomy developed without neoplastic lesion. In fact, adnexal torsion without neoplasm is reported to occur relatively frequently after laparoscopic hysterectomy and more commonly involves the right side. Therefore, at the end of laparoscopic hysterectomy, ovariopexy should be performed to prevent postoperative adnexal torsion.

Adnexal Masses in Adolescents.

Adnexal masses in adolescents, such as functional cysts, are often benign and can usually be managed expectantly since they typically regress on their own. The most common ovarian neoplasm in adolescents is a benign cystic teratoma. Both functional cysts and benign cystic teratomas are associated with ovarian torsion. Of concern, ovarian torsion requires a high level of suspicion when adolescents present with acute abdominal pain, as almost one-half of cases have no associated adnexal masses. The most common malignant adnexal masses in this age group include germ cell tumors, followed by epithelial cell tumors. Finally, ectopic pregnancy and tubo-ovarian abscesses must be considered in the differential diagnosis of adnexal mass, as delays in treatment may seriously affect an adolescent's health and future fertility. Obtaining an accurate history, including a sexual history, requires reviewing this history with the adolescent privately. Management of adnexal mases should prioritize fertility preservation. [Pediatr Ann. 2020;49(4):e183-e187.].

Is post hysterectomy adnexal torsion a complication of laparoscopic approach? A retrospective cohort study.

OBJECTIVE: To investigate the correlation between the hysterectomy's surgical approach and post hysterectomy adnexal torsion. STUDY DESIGN: Retrospective cohort study of patients with diagnosed adnexal torsion after hysterectomy (abdominal, vaginal and laparoscopic approaches) in a tertiary care medical center from 2007 through 2017 was done. Demographic data, clinical symptoms, type of previous hysterectomy, surgical findings and treatment were retrospectively reviewed from patient records. To calculate the risk of post-hysterectomy adnexal torsion (PHAH) and evaluate its association with type of hysterectomy, we used a national hysterectomy registry that included all hysterectomy done in region of our medical centre. RESULTS: Eight cases of AT after hysterectomy were operated during the study period, seven after laparoscopic and one after vaginal hysterectomy. Torsion occurred a mean of 27.25 ±â€¯16.65 months (range 3-60 months) after surgery. Mean patient age at AT was 45 ±â€¯4.6 years. All patients presented with abdominal pain, five (62.5%) had nausea and vomiting and one had diarrhoea. Laparoscopic findings revealed ovarian torsion in 5 cases, fallopian tube torsion in one and torsion of the adnexa in two cases. The national hysterectomy registry in the geographic region of our hospital summarized 705 patients with laparoscopic hysterectomy with adnexal preservation. The prevalence of post-laparoscopic hysterectomy adnexal torsion was significant high than after other types of hysterectomy (P < 0.05). CONCLUSION: PHAT occurs more frequently after laparoscopic hysterectomy then after other approaches. Measures for prevention of adnexal torsion should be considered during the primary surgery.

Hydrosalpinx in patients with hysterectomy without salpingo-oophorectomy referred for pelvic magnetic resonance imaging.

OBJECTIVE: Women with ovarian-sparing hysterectomy before 2007 are more likely to have retained Fallopian tube remnants which can become fluid-filled, distended masses, potentially mistaken for a cystic adnexal neoplasm on imaging. Here we assess the prevalence and appearance of hydrosalpinx in women with ovarian-sparing hysterectomy prior to 2007 referred for pelvic MRI. METHODS: A total of 3044 consecutive pelvic MRI exams performed over a two-year period (2003-2004) were selected from our radiology database and retrospectively reviewed. Examinations performed on male patients (N = 858), duplicate examinations on the same patient (N = 675) and examinations performed for MR guided biopsy (N = 1) were excluded from the study. From the remaining female pelvic MRI examinations (N = 1510), patients with hysterectomy without oophorectomy were identified. The frequency of hydrosalpinx in this population was then determined visually by two experienced radiologists and kappa analysis was then performed to assess for interobserver agreement. RESULTS: Of the 3044 pelvic MRI examinations, 1510 were performed on females and 76 (5%) of these women had ovarian-sparing hysterectomy. Of these 76 women, 14 patients (18%) had hydrosalpinx (kappa = 0.8) of which 11 were unilateral and 3 bilateral. A total of 9 of the 14 cases positive for hydrosalpinx in patients with ovarian-sparing hysterectomy were referred to MRI for evaluation of cystic adnexal masses detected on other modalities. CONCLUSION: Hydrosalpinx should be considered in the differential diagnosis of cystic adnexal lesions in women with prior hysterectomy and retained ovaries.

Characteristics of the patients with adnexal torsion and outcomes of different surgical procedures: A retrospective study.

There is no uniform standard to assess the viability of the ovary and choose conservative surgery or radical surgery for patients with adnexal torsion. This retrospective study aims to explore the characteristics of patients with adnexal torsion and the outcomes of different surgical procedures.A retrospective analysis of 174 cases diagnosed with adnexal torsion at our hospital between January 2005 and October 2014 was performed. Patients' clinical characteristics, surgical procedures, and postoperative recovery were analyzed.Of the cases, 31 (17.82%) did not have any emergent symptom; adnexal torsion were found during other surgeries. Among all 174 adnexal torsion patients, 14 cases received conservative treatment, including anti-inflammatory treatment, and 8 (58.1%) were pregnant. Of the cases, 160 underwent surgical treatment: 144 (90%) were confirmed to have ovary/ovarian cyst torsion, among whom 26 (18.1%) had their adnexa retained (group A) and 118 (81.9%) underwent adnexectomy (group B). Age, time of torsion, and rounds of torsion in group A were significantly less than in group B. None of the patients with adnexa preservation surgery had any complication, such as abdominal infection or thrombotic diseases.Patients with ovary/ovarian cyst torsion can attempt to preserve the ovaries without serious clinical complications; there were no severe complications such as embolism after the conservative surgeries in this study.

Management of Adnexal Torsion: A 13-Year Experience in Single Tertiary Center.

PURPOSE: Adnexal torsion constitutes 2.7% of gynecological emergencies, it is more frequently seen in reproductive age. Delay in diagnosis and treatment may lead to loss of the ovary. In this study, we aimed to assess patients who had adnexal torsion and compare laparoscopy with laparotomy in the treatment of these patients and point the most appropriate surgery according to age groups of the patients and comparison of patient characteristics and management between adnexal torsion in postmenopausal and premenopausal patients. MATERIALS AND METHODS: This study was carried out in Necmettin Erbakan University, Meram Medicine Faculty, Department of Obstetrics and Gynecology. The study retrospectively analyzed 380 patients presented to our clinic with abdominal pain between January 2005 and December 2017 and had surgery for adnexal torsion. RESULTS: The study included 380 patients who had surgery for adnexal torsion. A total of 220 patients had laparoscopy and 160 patients had laparotomy. Laparoscopy group consisted of young patients with low parity, whereas laparotomy group consisted of 160 patients of which 92 (57.5%) were in menopause. Teratomas were the most common pathological finding followed by follicular cysts. Fourteen ovarian malignancies and 11 borderline tumors had been reported. Eleven ovarian malignancies had been reported in postmenopausal patients and three in premenopausal patients. CONCLUSION: Laparoscopic surgery is preferred for young patients who want to preserve their fertility, but postmenopausal ovarian masses presenting with torsion should be analyzed with frozen section whenever possible, if not possible or not conclusive, staging surgery is more appropriate especially if there is suspicion of malignancy.

Pelvic Castleman's Disease Presenting as an Adnexal Mass in an Adolescent.

BACKGROUND: Castleman disease (CD) is a rare lymphoproliferative disorder that might present as an adnexal mass. We report a case of pelvic CD in an adolescent girl who presented with abdominal pain. CASE: A 13-year-old girl presented with severe abdominal pain, nausea, and vomiting, and was found to have a solid adnexal mass. Repeat imaging revealed the mass to be retroperitoneal and in the left pelvic side wall. She underwent surgical removal via an open retroperitoneal approach, and pathology revealed CD, hyaline vascular variant subtype. SUMMARY AND CONCLUSION: Pelvic CD should be considered in the differential diagnosis for an adnexal mass in a young woman. Surgical planning is critical because of the possibility of extension and mass effect. Most pelvic CD is unicentric, hyaline vascular variant subtype, and does not recur after surgical removal.

Prolonged Vaginal Bleeding in an Adolescent Secondary to a Foreign Body: Need for a Comprehensive Assessment and Complex Surgery.

BACKGROUND: Heavy, prolonged menstrual bleeding is common in adolescents and results from a variety of etiologies. CASE: A 13-year-old, virginal girl was referred for prolonged, heavy vaginal bleeding despite combined oral contraceptive use and elected management with a levonorgestrel intrauterine device. A preprocedure exam revealed a plastic foreign body embedded in the posterior vaginal fornix, however, attempted removal in the office was unsuccessful. Subsequent computed tomography imaging of the pelvis revealed a vaginal foreign body, complex adnexal mass, and hydroureter. The patient underwent exam under anesthesia and diagnostic laparoscopy, but required conversion to exploratory laparotomy for removal of a foreign body because of vaginal perforation abutting the rectum. SUMMARY AND CONCLUSION: Foreign bodies not easily removed in the outpatient setting should be considered for surgical removal with consideration of preoperative multidisciplinary coordination when imaging reveals intra-abdominal pathology, such as tubo-ovarian abscess and hydroureter.

Para-ovarian adrenal rest tumors: gynecologic manifestations of untreated congenital adrenal hyperplasia.

Congenital adrenal hyperplasia (CAH) is an inherited disorder of adrenal steroidogenesis often diagnosed in infancy. Gynecologists may encounter adult patients with CAH due to the clinical effects of increased androgens, e.g. hirsutism, clitoromegaly, oligomenorrhea, or, rarely, pelvic masses. This case report reviews the association of para-ovarian adrenal rest tumors with CAH, and the role of gynecologists in their evaluation and treatment. A 23-year-old woman with CAH (21-hydroxyase deficiency) untreated for the past 5 years presented with a pelvic mass and elevated serum testosterone (1433 ng/dL) and plasma ACTH (1117 pg/mL). Intraoperative findings revealed multiple retroperitoneal masses. Final pathology demonstrated adrenal rest tissue. Para-ovarian and ovarian adrenal rest tumors may present as a rare gynecologic manifestation in patients with untreated CAH.

No. 341-Diagnosis and Management of Adnexal Torsion in Children, Adolescents, and Adults.

OBJECTIVE: To review the evidence and provide recommendations on the diagnosis and management of adnexal torsion in children, adolescents, and women. OUTCOMES: Elements evaluated include the risk factors, diagnostic accuracy, management options, and outcomes of adnexal torsion. EVIDENCE: Published literature was retrieved through searches of MEDLINE, Embase, CINAHL, and the Cochrane Library using appropriate controlled vocabulary and key words ("adnexal torsion," "ovarian torsion"). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and new material incorporated in the guideline to December 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The evidence obtained was reviewed and evaluated by the Canadian Paediatric and Adolescent Gynaecology and Obstetrics Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) under the leadership of the principal authors. Recommendations were made according to guidelines developed by the Canadian Task Force on the Periodic Health Examination. BENEFITS, HARMS AND COSTS: Guideline implementation should assist the practitioner in developing an optimal approach to the diagnosis and management of adnexal torsion while minimizing harm and improving patient outcomes. VALIDATION: These guidelines have been reviewed and approved by the Gynaecology Committee of the SOGC and approved by the council of the SOGC. SPONSOR: The Society of Obstetricians and Gynaecologists of Canada SUMMARY STATEMENTS: RECOMMENDATIONS.

Randomized Controlled Trial of Hyalobarrier® Versus No Hyalobarrier® on the Ovulatory Status of Women with Periovarian Adhesions: A Pilot Study.

INTRODUCTION: Periadnexal adhesions are known to contribute to subfertility. The restoration of the tubo-ovarian anatomy is one the key principles in reproductive surgery, and this involves adhesiolysis. However, adhesion formation/reformation is very common after periovarian adhesiolysis. It is not known if the application of Hyalobarrier®, an anti-adhesion gel, around the adnexal region postsurgery influences ovulatory status. The study is a pilot randomized controlled trial (RCT) randomizing women into the application of Hyalobarrier® versus no Hyalobarrier® at the time of laparoscopy, where postsurgical ovulatory status and pregnancy rates were evaluated. METHODS: This was a pilot RCT where women were recruited from the gynecological and subfertility clinic who were deemed to require an operative laparoscopy. If intraoperatively they were found to have periovarian adhesions, they were randomized into having adhesiolysis with and without usage of Hyalobarrier®. Demographic details and intraoperative details including the severity, extent, and the ease of use of Hyalobarrier® were recorded. Prior to the surgery and postoperatively, the participants had their serum hormonal status (day 2 FSH, LH and day 21 progesterone) evaluated. Postoperatively, they underwent a follicular tracking cycle at 3 months. RESULTS: Fifteen women were randomized into use of Hyalobarrier® (study group) and 15 into the no Hyalobarrier® group (control group) between December 2011 and January 2014. There was no difference in the patient characteristics in terms of age, BMI, the number of previous pregnancies, or the extent, site, and severity of adhesions between the two groups. There was no significant difference between the study versus control groups in terms of the hormonal profile (day 2 FSH and day 21 progesterone) before or after surgery. The 3-month postoperative day 10-12 follicular tracking findings and endometrial thickness were similar between the study and control groups. Four women were pregnant in the study group (24%) and one in the control group (7%) cumulatively over 2 years. CONCLUSION: The use of Hyalobarrier® post salpingo-ovariolysis did not influence follicular development as inferred from the results of the day 21 progesterone and folliculogram on day 10-12 3-month postsurgery. TRIAL REGISTRATION: ISRCTN number, ISRCTN1833588. FUNDING: Nordic Pharma.

Utility of human epididymis protein 4 serum marker for the detection of adnexal malignancy: a multicentric prospective study.

The aim of this study was to assess the usefulness of the human epididymis protein 4 (HE4) serum biomarker in predicting malignant disease in a clinical setting in comparison with other diagnostic tools, such as serum CA125 and ROMA score. A multicentric prospective observational study was carried out between January 2010 and December 2011 in four European centres (Italy, Portugal, Latvia and Spain). Data from 981 healthy controls and patients diagnosed with adnexal pathology were collected. Data on the ROMA index, CA124 and HE4 tumour markers were analysed. The receiver-operator characteristics curve and the area under the curve were analysed to discriminate between malignant and nonmalignant disease. Predictive values were also calculated. In total, 642 (65.4%) patients presented with a pelvic mass, with 324 (33%) of them being diagnosed with malignant disease. Sensitivity for HE4 was 64.1%; specificity was 95.7%; and positive predictive value was 88.1%, with a 4.3% false-positive rate. On comparing malignant disease versus nonmalignant/healthy patients, there was a significant difference (P<0.001) in the area under the curve. The receiver-operator characteristic for CA125 was 0.79 [95% confidence interval (CI): 0.76-0.83], for HE4 was 0.89 (95% CI: 0.87-0.91) and for ROMA was 0.71 (95% CI: 0.68-0.75). The HE4 serum marker showed similar sensitivity, but better specificity, than CA125 and can improve the detection of malignant pathology in women diagnosed with adnexal pathology.

Laparoscopic Treatment of Mixed Malignant Ovarian Germ Cell Tumor in a 16-Year-Old Female Adolescent.

BACKGROUND: Malignant ovarian germ cell tumors are rare entities, although they account for a large proportion of ovarian masses in young women. These tumors have traditionally been removed via laparotomy, because of their large size and solid nature. The use of laparoscopy for treatment of adnexal masses in adolescents has been heavily debated and poorly studied to date. CASE: A 16-year-old female patient presented with abdominal pain and an 11-cm adnexal mass on ultrasound. An emergent laparoscopic salpingo-oophorectomy was performed without complication. Pathology revealed a mixed malignant ovarian germ cell tumor. SUMMARY AND CONCLUSION: Laparoscopic fertility-sparing surgery offers many benefits over laparotomy, and should be considered in cases of young women with large adnexal masses, even if potential for malignancy exists.

Recto-vaginal septum cystadenocarcinoma: a case report and review of the literature.

BACKGROUND: Carcinoma of the recto-vaginal septum is a quite rare location and related to peritoneal and primary ovarian carcinomas. There are only few reports in the literature with a very poor prognosis. CASE PRESENTATION: Here we report the case of a 63 years old woman with past medical history of left oophorectomy presenting with a pelvic pain. The magnetic resonance imaging (MRI) demonstrated a 10 cm mass located in the recto-vaginal septum. A block resection was performed allowing the retrieval of a 10 cm solid tumor of the recto-vaginal septum. Peritoneal biopsies and the right ovary were normal the final diagnosis was cystadenocarcinoma of the recto-vaginal septum. The patient received adjuvant chemotherapy and displays no sign of recurrence 36 months after diagnosis. CONCLUSION: The management of recto-vaginal septum carcinoma with en bloc resection should be performed to avoid peritoneal spread and improve prognosis.

Outcome of conservative laparoscopic surgery for adnexal torsion through one-stage or two-stage operation.

AIM: We investigated the outcome on ovarian appearance and occurrence of adhesion after conservative laparoscopic surgery for adnexal torsion during reproductive age. MATERIAL AND METHODS: From April 2009 to September 2012, we treated patients with clinically suspected adnexal torsion who desired future pregnancy. We performed conservative surgery, such as cystectomy or detorsion at one-stage operation, but switched to salpingo-oophorectomy in complicated cases. We evaluated adnexal condition and pattern of adhesion by careful assessment with two-stage laparoscopy or second-look laparoscopy after first surgery. RESULTS: Mean age of patients was 25 ± 8 years. Among 37 patients with suspected adnexal torsion, 18 (49%) had adnexal torsion at first surgery. Conservative treatment was carried out in 14 of 18 cases. We obtained informed consent for second-look laparoscopy or two-stage operation in six of these 14 cases. Among these six patients, two cases were treated with only detorsion by one-stage operation and cystectomy was performed in the other four cases at first operation. At subsequent surgery, the ovary appeared normal in six cases with occurrence of mild to moderate adhesion around the adnexal lesion. Of note, two cases with para-ovarian cyst had torsion that showed complete tubal occlusions and associated severe adhesions. No major complications (peritonitis, thrombotic emboli) were observed after conservative laparoscopic surgery. CONCLUSION: Conservative laparoscopic surgery is a safe procedure to preserve ovarian function in women with adnexal torsion. Careful attention and measures should be considered during follow-up management with the fact in mind that adhesion is a common occurrence and even tubal occlusion may occur in some cases.