Isolated fallopian tube torsion: A systematic review of case reports.

OBJECTIVE: To combine all literature describing cases of isolated fallopian tube torsion in adult non pregnant patients in a systematic manner, to optimize knowledge and practice both for diagnosis and management. STUDY DESIGN: EMBASE and PubMed databases were searched for the terms 'tubal' OR 'fallopian tube' AND 'isolated' AND 'torsion' from the inception of these databases to July 5, 2023. All case reports or case series of adult patients (18 years or older) with isolated fallopian tube torsion were included. Exclusion criteria included: all other study types; cases involving children and adolescents (less than 18 years old); pregnant patients of all trimesters; tubo-ovarian torsion; studies not published in English; duplicates and those not available in text. Following the database search, two authors independently screened the studies and search results were subsequently reported in accordance with PRISMA guidelines. Data was extracted independently by two authors and analysed using Excel. All cases were assessed for bias using a modified version of the tool proposed by Murad et al. RESULTS: 92 unique articles enrolling 131 individual cases were included in this systematic review. Isolated fallopian tube torsion most commonly occurs during reproductive ages between 18 and 45 years. It is uncommon in postmenopausal women. The most common presenting symptoms include unilateral lower abdominal or pelvic pain along the affected side with nausea and vomiting. Risk factors can be intrinsic or extrinsic and can include conditions such as hydrosalpinx, sterilization, pelvic inflammatory disease or cysts. Ultrasound is the optimal imaging modality however Computed Tomography and Magnetic Resonance Imaging can also be used. Imaging in general has low sensitivity, however isolated fallopian tube torsion can be identified with appropriate expertise. The gold standard for isolated fallopian tube torsion management is laparoscopy and detorsion however currently, the most common intervention performed is salpingectomy. CONCLUSIONS: Isolated fallopian tube torsion is a rare but important gynaecological emergency with significant fertility implications. This study summarizes the most common presentations, investigation findings and surgical interventions in patients with isolated fallopian tube torsion. This study also emphasizes the importance of clinicians maintaining a high degree of suspicion and low threshold for early laparoscopic intervention to retain fertility.

Ovarian torsion: A retrospective case series at a tertiary care center emergency department.

Ovarian torsion (OT) is a gynecological emergency that can have diverse clinical presentations makings its diagnosis especially challenging. Few studies exist in the literature describing the clinical presentation as well as the management of OT in the emergency department (ED). This study aims to describe the clinical presentation, physical examination, emergency management, radiographic and intraoperative findings, histopathology reports and the time-to-intervention metrics of OT cases presenting to the emergency room of our tertiary care center. Data was collected by a retrospective chart review of all OT cases that presented to our ED over a period of 1 year. A total of 20 cases were included in the final analysis. The incidence of OT in the ED was 157.4 per 100 000 visits of women in the reproductive age group. All patients were women of reproductive age, with a mean age of 27.3 years. A total of 15 patients (78.9%) presented within 24 hours of symptom onset. The most common presenting symptom was abdominal pain (95%, 19/20) with most localizing to the right lower quadrant (60%, 12/20), followed by nausea and vomiting (90%, 18/20). Almost all patients (95%, 19/20) required opioids for pain management. The majority (80%, 16/20) were diagnosed by ultrasound prior to surgery, whereas (20%, 4/20) went straight to surgery based on a high index of clinical suspicion. Among those who underwent ultrasound, ovarian cyst was present in (75%, 12/16) while (68.9%, 11/16) showed ovarian enlargement and (50%, 8/16) showed abnormal ovarian blood flow. All patients except one patient underwent operative management. Out of the 19 patients who underwent surgery, the majority of patients (94.7%, 18/19) had viable ovaries with the exception of 1 patient (5.3%) who required a salpingo-oophorectomy post ovarian detorsion. A total of 13 cases included histopathologic review of specimens out of which 6 (46.2%) had a mature cystic teratoma. The mean time from door to ultrasonography was 1.4 hours and from door to surgery was 11.4 hours. Our study provides valuable insights into the incidence, clinical presentation, physical examination, emergency management, ultrasonographic and intraoperative findings, histopathology reports as well as the time-to-intervention metrics of OT patients presenting to the ED.

Effect of hyperbaric oxygen treatment on ischaemia-reperfusion injury in rats detorsioned after experimental ovarian torsion.

Introduction: This study aimed to investigate whether hyperbaric oxygen treatment (HBOT) could ameliorate ischaemia-reperfusion injury in a rat model of ovarian torsion-detorsion. Methods: Twenty-seven rats were divided among four groups: surgical sham rats (S) (n = 6) underwent identical anaesthesia and surgical incisions to other groups (n = 7 per group) but with no ovary intervention; torsion rats (T) underwent laparotomy, ovarian torsion, relaparotomy and sacrifice after three hours; torsion and detorsion rats (T/DT) underwent laparotomy, ovarian torsion (three hours), relaparotomy and detorsion, and sacrifice after one week; torsion, detorsion, hyperbaric oxygen rats (T/DT/HBOT) underwent laparotomy, ovarian torsion, relaparotomy and detorsion, and sacrifice after one week during which HBOT was provided 21 times (100% oxygen at 600 kPa for 50 min). In all groups blood collection for markers of oxidative stress or related responses, and ovary collection for histology were performed after sacrifice. Results: When the T/DT, and T/DT/HBOT groups were compared, 8-hydroxy-2'-deoxyguanosine (a marker of oxidative damage to DNA) and malondialdehyde (a product of lipid peroxidation) levels were lower in the T/DT/HBOT group. Anti-Mullerian hormone levels were higher in the T/DT/HBOT group compared to the T/DT group. In addition, oedema, vascular occlusion, neutrophilic infiltration and follicular cell damage were less in the T/DT/HBOT group than in the T/DT group. Conclusions: When biochemical and histopathological findings were evaluated together, HBOT appeared reduce ovarian ischaemia / reperfusion injury in this rat model of ovarian torsion-detorsion.

Use of Indocyanine Green to Evaluate Ovarian Perfusion After Laparoscopic Detorsion. A Step-By-Step Demonstration Video.

OBJECTIVE: Demonstrate the usefulness of using indocyanine green after laparoscopic ovarian detorsion to save the ovary. DESIGN: A step-by-step video demonstration of a surgical technique. SETTING: Ovarian torsion is one of the most common gynecological emergencies, mainly affecting patients younger than 20 years of age [1], and causes 2% to 7% of acute abdomens [2]. It is not advisable to routinely perform ovariectomy even with a necrotic ovary appearance [1]. Furthermore only in a small percentage of cases (16%) necrosis has been confirmed histologically [2]. Some studies have demonstrated that using indocyanine green to evaluate ovarian perfusion is inexpensive, low risk, and easily reproducible [3-5]. INTERVENTIONS: A 17-year-old patient was referred to our hospital for acute abdominal pain. Ultrasound revealed ovarian torsion; therefore, the patient underwent surgical treatment. During laparoscopy, the presence of a right ovarian torsion was confirmed. A lesion compatible with a hemorrhagic corpus luteum of 6 cm was present on the ovary affected. Before ovarian detorsion, indocyanine green was administered intravenously at a 0.5 mg/kg dose. The first aspect noted was the total lack of ovarian vascularization; then ovarian detorsion was performed. At this point, using technology of Rubina (KARL STORZ SE & Co. KG, Tuttlingen, Germany), it was possible to highlight the progressive ovarian revascularization. Ovarian reperfusion occurred starting from the ovarian hilum and ending at the periphery. We proceeded with enucleation of the hemorrhagic corpus luteum by stripping technique, with subsequent ovarian reconstruction with continuous 2-0 monofilament suture. Finally, we fixed the ovary to the stump of the right round ligament. The final view highlights good ovarian vascularization. No complications occurred; the patient was discharged on the first postoperative day. A 6-month follow-up ultrasound confirmed the recovery of the vascularization of ovary. CONCLUSION: Using indocyanine green represents a valid option to evaluate ovarian perfusion after detorsion. It could help the surgeon decide to save the ovary and thus allow fertility-sparing surgery in more cases.

Ovarian Torsion and Oophorectomy in Childhood: A Case Report.

BACKGROUND: Ovarian torsion in infants can be asymptomatic or may present with abdominal mass and malnutrition. It is an uncommon and non-specific condition in children. We report a girl who underwent detorsion and ovariopexy for suspected ovarian torsion after a previous oophorectomy. The role of progesterone therapy is determined in reducing the size of adnexal mass. CASE PRESENTATION: The patient was diagnosed with right ovarian torsion and underwent an oophorectomy at one year of age. About 18 months later, she was diagnosed with left ovarian torsion and underwent detorsion with lateral pelvic fixation. Despite the pelvic fixation of the ovary, a continuous increase in the volume of the ovarian tissue was evident during successive ultrasounds. Progesterone therapy was started at five years of age in order to prevent retorsion and preserve the ovarian tissue. In successive follow-ups during the therapy, ovarian volume decreased, and its size (27*18 mm) was restored. CONCLUSION: The presented case reminds doctors of the possibility of ovarian torsion in young girls with pelvic pain. More research is needed on the use of hormonal drugs, such as progesterone, in similar cases.

Contemporary Trends in Laparoscopy and Ovarian Sparing Surgery for Ovarian Torsion in the Pediatric Population.

PURPOSE: Although total oophorectomy (TO) was historically performed in cases of nonviable-appearing ovaries, considerable evidence has demonstrated equivalent outcomes after ovarian sparing surgery (OSS) as well as long-term fertility preservation benefits. This study sought to compare outcomes of OSS and TO for patients with ovarian torsion. METHODS: Females <21 years old admitted for ovarian torsion were identified from the Nationwide Readmissions Database (2016-2018) and stratified by OSS or TO. Propensity score-matched analysis (PSMA) utilizing >50 covariates (demographics, medical comorbidities, ovarian diagnoses, etc.) was constructed between those receiving TO and OSS. RESULTS: There were 3,161 females (median 15 [12-18] years) with ovarian torsion, and concomitant pathologies included cysts (42%), benign masses (25%), and malignant masses (<1%). Open approaches were more common (52% vs. 48% laparoscopic), and ovarian resection (OSS or TO) was performed in 87% (39% OSS and 48% TO). OSS was more commonly performed with laparoscopic detorsions (60% vs. 40% TO), while TO was more frequent in open operations (59% vs. 41% TO; both p < 0.001). No differences in overall readmissions (7% OSS vs. 8% TO) or readmissions for recurrent torsion (<1% overall) and ovarian masses (<1%) were observed (both groups <1%; p = 0.612). After PSMA, laparoscopy was still utilized less frequently with TO (39% vs. 53%; p < 0.001) despite similar rates of malignant masses. CONCLUSIONS: Overall, these data offer additional support for the current practice guidelines that give preference to OSS as the primary method of treatment for pediatric ovarian torsion in the majority of cases. LEVEL OF EVIDENCE: III. TYPE OF STUDY: Retrospective Comparative Study.

Application of a Composite Score to Predict Adnexal Torsion in Premenarchal and Menarchal Children and Adolescents.

STUDY OBJECTIVE: The study objective was to apply a previously created composite score for the prediction of adnexal torsion in children and adolescents to a larger group of heterogeneous patients to test its validity and to refine this scoring system to more accurately predict adnexal torsion. METHODS: This was a retrospective chart review at a tertiary care children's hospital and its affiliates. Participants were female patients 0-20 years of age who underwent surgery for suspected adnexal torsion from 2016 to 2019. Data were collected from outpatient, emergency department, and inpatient notes, radiographic data, and operative reports. The primary outcome was the accuracy and predictive value of the total composite score (TCS) to identify or exclude adnexal torsion. RESULTS: Of the 291 patients with suspected adnexal torsion who went to the operating room during the study period, 168 (57.8 %) had confirmed adnexal torsion. The accuracy of the TCS, which included presence of vomiting, adnexal volume, and adnexal ratio, in predicting or excluding torsion was 83.6 % for all patients, 92.1 % for premenarchal patients, and 81.3 % for menarchal patients. A variation of the TCS that included only vomiting and adnexal volume had an accuracy of 85.8 %. CONCLUSIONS: Our study demonstrates the accuracy and reproducibility of a previously published composite score to predict adnexal torsion in children and adolescents. It also further refines this score to a potentially more clinically useful tool. Future studies are needed to prospectively evaluate these composite scores and their implementation in clinical settings. LEVEL OF EVIDENCE: III.

Ovarian torsion masquerading as a ureteral stone.

BACKGROUND: Abdominal pain is the most common complaint within the emergency department (ED) and has many varied etiologies. Some of these conditions can be medical emergencies, including ovarian torsion. While representing just 3% of gynecologic emergencies, ovarian torsion should be considered in all females presenting to the ED with abdominal or pelvic complaints. CASE: A 38-year-old G5P5 female with a past medical history significant for ureterolithiasis presented to a freestanding ED with abdominal pain, nausea, and vomiting. She developed sudden onset of right sided abdominal pain radiating to her right flank upon awakening. The initial differential diagnosis was for ureterolithiasis or appendicitis. Her complete blood count (CBC) was normal, and testing for pregnancy, infection, and hematuria was negative. Computed topography (CT) imaging of the abdomen and pelvis revealed a 9 cm adnexal mass, consistent with a possible dermoid cyst. A pelvic ultrasound was ordered which showed a possible ovarian torsion. She was transferred to a tertiary care hospital where she had a laparoscopy with right-sided oophorectomy and salpingectomy performed. DISCUSSION: This patient presented with abdominal pain, nausea, and vomiting and was first suspected to have ureterolithiasis or appendicitis. She was found to have an ovarian torsion with a dermoid cyst, which resulted in the loss of her ovary and fallopian tube. This case demonstrates the importance of including gynecologic emergencies in the differential on all female patients presenting with abdominal pain.

Hospital Volume and Quality of Care for Emergency Gynecologic Care.

OBJECTIVE: To evaluate the association between hospital volume and the quality of gynecologic emergency care for tubal ectopic pregnancies, ovarian torsion, and pelvic inflammatory disease (PID). METHODS: In this cross-sectional analysis, we analyzed patients who presented for emergency care for tubal ectopic pregnancies, ovarian torsion, and PID using the Premier Healthcare Database from 2006 to 2020. We measured the following outcomes: methotrexate use for ectopic pregnancy, ovarian cystectomy for torsion, and guideline-based antibiotic use for PID. For each condition, we measured outlier hospitals that performed the above interventions at below the 10th percentile. Multivariable logistic regression models were used to analyze associations between outlier care and hospital factors such as annualized mean case volume, urban or rural location, teaching status, bed capacity, and geographic region, as well as hospital-level patient population factors, including age, insurance status, and race. RESULTS: A total of 602 hospitals treated patients with tubal ectopic pregnancies, of which 21.9% were outliers, with no cases managed with methotrexate. Of 512 hospitals treating patients with ovarian torsion, 17.4% were outliers, with no cases managed with cystectomy. Of 929 hospitals that treated patients with PID, 9.9% were deemed outliers with low rates of guideline-adherent antibiotic administration. Low-volume hospitals were more likely to be outliers with low rates of use of methotrexate for ectopic pregnancy (6.7% of high-volume hospitals vs 49.7% of low-volume hospitals were outliers; adjusted odds ratio [aOR] 0.13, 95% CI, 0.05-0.31 for high-volume hospitals) and cystectomy for torsion (34.9% of low-volume vs 2.4% of high-volume hospitals were outliers; aOR 0.05, 95% CI, 0.01-0.18 for high-volume hospitals). There was no association between hospital volume and lower rates of guideline-based antibiotic use for PID. CONCLUSION: Higher hospital volume is associated with use of conservative, fertility-preserving treatment of emergency gynecologic conditions, including ectopic pregnancy and ovarian torsion.

Rapid, free-breathing non-contrast MRI for first-line imaging evaluation of ovarian torsion in the emergency department.

BACKGROUND: Transabdominal ultrasound (US) is first-line imaging to evaluate ovaries in girls presenting to the emergency department (ED) with suspected ovarian torsion. Ovaries may be difficult to visualize sonographically; therefore, prompt diagnosis using US alone can be challenging. Rapid MRI as first-line imaging may help streamline patient throughput, especially with increasing MRI availability in the ED. OBJECTIVE: To assess feasibility of rapid MRI for diagnosis of ovarian torsion. MATERIALS AND METHODS: A retrospective, single-center IRB approved study of MRI performed in female pediatric patients presenting with abdominopelvic pain from August 2022 to January 2023. Imaging occurred according to one of three clinical pathways (US-first approach vs MRI-first approach vs US + MRI-second-line approach). A rapid three-sequence free-breathing MRI protocol was utilized. Frequency of ovarian torsion and secondary diagnoses was recorded. Length of MR scan time, time from ED arrival to time of diagnosis, and whether patient had US prior to MR exam were obtained. A historical cohort of patients with US only performed for assessment of ovarian torsion were evaluated for length of the US examination and time from ED arrival to time of diagnosis. Intervals were compared using the uncorrected Fisher's least significant difference and Turkey's multiple comparison tests. RESULTS: A total of 140 MRI exams (mean age 14.6 years) and 248 historical US exams (mean age 13.5 years) were included. Of the patients with MRI, 41 (29%) patients were imaged with US + MRI and 99 (71%) imaged with MRI only; 4% (6/140) MR exams were suspicious for ovarian torsion, with one true positive case (1/6 TP) and 5 false positive cases (5/6 FP); 26.4% (37/140) of exams had secondary diagnoses. Median MRI scan time was 11.4 min (4.4) vs median historical US scan time was 24.1 min (19.7) (P<0.001). Median time from arrival in ED to MRI read was 242 (140). Median time from arrival in ED to US only read was 268 min (148). This was not a statistically significant difference when compared to the MRI only cohort. CONCLUSION: First-line MRI imaging for evaluation of ovarian torsion is a rapid and feasible imaging modality for female patients in the emergent setting.

Protective effects of passiflora incarnata on ovarian ischemia/reperfusion damage in rats with ovarian torsion.

BACKGROUND: This study aimed to investigate whether Passiflora Incarnata (PI) has a protective effect against ischemia-reperfu-sion (IR)-induced oxidative and inflammatory ovarian damage. METHODS: The effects of PI on ovarian ischemia-reperfusion injury were investigated in female Wistar albino rats. The animals were randomly divided into three groups: Group 1 (sham), Group 2 (IR), and Group 3 (IR+PI). RESULTS: The mean levels of Malondialdehyde (MDA), Myeloperoxidase (MPO), and Total Oxidant Status (TOS) were higher in the IR group (p=0.025, p<0.001, and p=0.016, respectively). The Total Antioxidant Status (TAS) levels were lower in the IR group (p=0.005). Immunostaining revealed significant differences across the groups for Tumor necrosis factor-alpha (TNF-α): 13.84%, 49.51%, and 22.51% for Groups 1, 2, and 3, respectively (p<0.01). Bax: 10.53%, 46.74%, and 26.46% for Groups 1, 2, and 3, respectively (p<0.01). Annexin V: 12.24%, 44.86%, and 23.28% for Groups 1, 2, and 3, respectively (p<0.01). The mean scores for hemorrhage, inflammation, follicular degeneration, and congestion showed significant variations among the groups, all registering p<0.001. CONCLUSION: Passiflora Incarnata exhibited antioxidant, anti-inflammatory, and anti-apoptotic properties, promoting cell survival, histologically protecting ovarian tissue, and ameliorating IR injury by reducing oxidative stress.

Paraovarian cyst with associated ovarian torsion.

The paraovarian or paratubarian cysts are both situated in the broad ligament between the ovary and fallopian tube. The diagnosis of adnexal torsion is challenging since both symptoms and physical examination are nonspecific. In most cases, the patient presents abdominal pain, followed by nausea and vomiting. Imaging tests, such as ultrasound, are very useful to elucidate the cause of the symptoms in those patients.

Direct bilirubin to lymphocyte ratio can discriminate acute appendicitis and ovarian torsion: a comparative study.

OBJECTIVE: In this study, we aimed to determine whether a patient presenting to the emergency room with abdominal pain and for whom ultrasound access is challenging until an ultrasound is performed, is suffering from ovarian torsion or acute appendicitis. We sought to make this determination based on hematological indices and to investigate the diagnostic value of the direct bilirubin-to-lymphocyte ratio (DLR) in this context. PATIENTS AND METHODS: This study encompasses female patients who presented with abdominal pain to Çam and Sakura Training and Research Hospital between the years 2015 and 2023 and were diagnosed with either acute appendicitis or ovarian torsion. Patients' files were screened retrospectively. Key information, including patients' ages, the onset time of symptoms (duration of symptoms), and laboratory values, was meticulously recorded. The patients were divided into two groups: those with ovarian torsion (Group 1) and those with acute appendicitis (Group 2). RESULTS: The study comprised two distinct patient groups with a total of 159 patients: Group 1 (n=57), representing ovarian torsion, and Group 2 (n=102) representing acute appendicitis. No differences were found in terms of age, symptom duration, White Blood Cell (WBC) Count, Platelet (PLT), CRP (C-reactive protein), and Platelet-to-lymphocyte ratio (PLR) (p>0.05 for each comparison). Direct bilirubin (DB), indirect bilirubin (IB), and total bilirubin (TB) were higher in Group 2 than in Group 1 (p=0.011, p<0.001, p=0.044, respectively). Neutrophil-to-Lymphocyte Ratio (NLR) and Direct Bilirubin-to-Lymphocyte Ratio (DLR) were higher in Group 2 than in Group 1 (p=0.013, p=0.002, respectively). The NLR was analyzed with a cut-off value of 4.1 (AUC: 0.642; sensitivity 82%, specificity 52%). The PLR was analyzed with a cut-off value of 116 (AUC: 0.670; sensitivity 92%, specificity 42%). The DLR was analyzed with a cut-off value of 0.14 (AUC: 0.741; sensitivity 93%, specificity 55%). CONCLUSIONS: This research highlighted the potential of the DLR index in differentiating between ovarian torsion and acute appendicitis, revealing that DLR levels were notably higher in appendicitis patients.

The effect of protocatechuic acid on ovarian histopathology and reserve in rat ovarian torsion model.

OBJECTIVES: The aim of the study is to investigate the effects of Protocatechuic Acid (PCA), which is an antioxidant, anti-inflammatory and anti-apoptotic agent, on ovarian tissue and ovarian reserve against ischemia-reperfusion (IR) injury in a rat ovarian torsion model. BACKGROUND: Reactive oxygen radicals cause histopathological changes in the ovarian tissue during the reperfusion phase. PCA may have protective effects on ovarian tissue and reserve due to its antioxidant and antiapoptotic properties. METHODS: A total of 24 Wistar adult female rats were divided into 3 groups as the control (sham operation, n = 8), IR (Ischemia-Reperfusion, n = 8), and IR+PCA (Ischemia-Reperfusion + 80 mg/kg protocatechuic acid, n = 8). The IR and IR + PCA groups underwent 3 hours of ischemia followed by 3 hours of ovarian reperfusion. Protocatechuic acid (80 mg/kg) was administered to the IR+PCA group 30 minutes before reperfusion. After reperfusion, the ovaries were removed for histopathological and biochemical examination. RESULTS: Histopathological score and TUNEL+ cell count were significantly lower and AMH expression level was significantly higher in the IR+PCA group when compared to the IR group (p <0.05). However, in the comparison of the follicle counts, there was no statistically significant difference between all groups. Due to the increase in antioxidant activity, the MDA levels were found to be significantly lower in the IR+PCA group compared to the IR group (p < 0.05). CONCLUSION: Protocatechuic acid may be an effective antioxidant in protecting ovarian tissue and follicle reserve against IR injury of the ovary (Tab. 1, Fig. 4, Ref. 36).

Ovarian cyst torsion in a pre-menopausal woman causing intestinal obstruction: a case report.

Intestinal obstruction due to adnexal torsion is a rare complication that can be occurred during torsion of an ovarian cyst. A premenopausal woman presented to the emergency department with complaints of abdominal distension, abdominal pain, and obstipation for 2 days. An abdominal radiograph showed signs of large bowel partial obstruction. Hence admission to the surgical department was ordered. Due to deterioration of the patient, a gynaecological evaluation took place. Ultrasonography demonstrated a large ovarian cyst, which was also confirmed by an abdominal computed tomography scan and thus immediate laparotomy was decided. Abdominal hysterectomy with bilateral salpingo-oophorectomy was performed due to torsion of a giant ovarian cyst, which caused intestinal obstruction by compression. The post-operative course of the patient was uneventful. Ovarian torsion should not be eliminated from differential diagnosis when it comes to female patients with clinical presentation relevant to small and/or large bowel obstruction.

Synchronous bilateral ovarian torsion followed by recurrent unilateral torsion in a patient undergoing fertility treatment: A case report and literature review.

BACKGROUND: Ovarian torsion (OT) is a gynaecological emergency and requires prompt recognition and treatment in order to prevent the loss of ovarian function. Patients who are undergoing fertility treatment are at an increased risk of developing OT. OBJECTIVE: The diagnosis of OT in patients undergoing fertility treatment can be challenging as they often present with abdominal pain and other non-specific symptoms. We highlight the importance of early diagnosis of suspected torsion and performed a literature review on cases of bilateral OT to review its presentation, investigation, and subsequent management. CASE REPORT: A 32-year-old nulliparous woman who was undergoing controlled ovarian stimulation presented with lower abdominal pain and was initially managed as ovarian hyperstimulation syndrome (OHSS). Her pain did not subside following conservative management and she proceeded to have a laparoscopy which demonstrated synchronous bilateral ovarian torsion (SBOT), both ovaries were detorted. Eight months later, she was preparing for her frozen embryo transfer (FET) cycle, patient again presented with significant right sided abdominal pain and was found to have a recurrent torsion of the right ovary which was again detorted successfully. CONCLUSIONS: Clinicians should have a low-threshold to investigate and rule out OT in patients who present with lower abdominal pain, especially in those with additional risk factors for torsion. Patients with confirmed torsion can be successfully managed with detorsion of the ovaries. Further research is needed to determine the best management option for patients with recurrent torsion episodes.

Fertility preserving management of ovarian torsion.

OBJECTIVE: To analyze characteristics of acute and chronic ovarian torsion, review treatment recommendations, and present possible surgical techniques for fertility preservation in young women. DESIGN: Literature review and demonstration of perioperative management of ovarian torsion using radiologic images and intraoperative video footage. Ovarian torsion is mostly mentioned in context of gynecologic emergencies, where acute ovarian torsion with arterial obstruction leads to ovarian ischemia and necrosis. However, ovarian torsion can also occur as a partial or intermittent torsion with venous and lymphatic obstruction, followed by ovarian swelling. In both cases, surgical management of ovarian torsion commonly includes oophorectomy, although leading guidelines recommend preservation of the ovary. We here aimed to raise awareness for the clinical features of ovarian torsion and demonstrate adequate perioperative management, thereby avoiding surgical overtreatment in young women. SETTING: Medical University of Vienna, Department of Obstetrics and Gynecology. PATIENT(S): We present a case of acute ovarian torsion with a consequently ischemic ovary as well as a case of chronic ovarian torsion with related massive ovarian edema. The patients included in this video gave consent for publication of the video and posting of the video online, including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, etc.), and other applicable sites. INTERVENTION(S): Laparoscopic management with detorsion of the torquated ovaries, cystectomy on an ischemic ovary and oophoropexy to the pelvic side wall and utero-ovarian ligament to prevent recurrence. MAIN OUTCOME MEASURES: Postoperative relief of pain and normalization of ovarian size and morphology on ultrasound imaging. RESULTS: The current cases show successful conservative surgical management of ovarian torsion, hence preserving hormonal function and fertility in young women. CONCLUSION: Although it is recommended to preserve fertility in young women affected by ovarian torsion, surgical overtreatment by means of oophorectomy is still common in clinical routine. Increasing awareness for the clinical characteristics of acute and chronic ovarian torsion, as well as for the importance of preservation of the ovary, is crucial. We therefore believe that ovarian torsion and its surgical management deserve increased attention in the future.

Contribution of contrast-enhanced ultrasound in the diagnosis of adnexal torsion (AGATA): protocol for a prospective comparative study.

INTRODUCTION: Adnexal torsion is a surgical emergency and its prognosis depends on the time elapsed prior to treatment. The diagnosis relies on pelvic ultrasound in which sensitivity remains low and may lead to misdiagnosis.The primary objective is to evaluate the diagnostic performance of contrast-enhanced ultrasound for the diagnosis of adnexal torsion in women with suspected adnexal torsion. The secondary objectives are: (1) to describe the perfusion parameters of the ovaries by contrast-enhanced ultrasound, (2) to compare diagnostic performance of contrast ultrasound with bidimensional (2D) Doppler for the detection of adnexal torsion, (3) to describe the perfusion parameters of the ovarian as a function of the degree of adnexal torsion, (4) to compare perfusion parameters before and after ovarian detorsion and (5) to describe perfusion parameters of the ovarian by using MicroVascular Flow technique. METHODS AND ANALYSIS: This is a monocentric, prospective comparative, non-randomised, open and interventional study. We hypothesise to include 30 women: 20 positive cases compared with 10 control cases. Women are informed and recruited in the emergency ward, over a period of 36 months.The primary endpoint is the signal intensity measurement to assess sensitivity, specificity, positive and negative predictive values of contrast-enhanced ultrasound for detection of adnexal torsion in women with suspected adnexal torsion. The presence or absence of adnexal torsion is confirmed during the surgical intervention. ETHICS AND DISSEMINATION: The study was approved by the French Ethics Committee, the CPP (Comité de Protection des Personnes) OUEST I on 3 July 2020 with reference number 2020T1-16. The results of this study will be published in a peer-reviewed journal and will be presented at relevant conferences. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov registry (NCT04522219); EudraCT registry (2020-000993-27).