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.

Rate of oophorectomy in pediatric ovarian torsion: risk factors and change over time.

PURPOSE: The management of ovarian torsion in pediatric patients has evolved over time. Ovarian salvage is currently recommended given concerns for fertility preservation and the low likelihood of malignancy. Studies have shown that the incidence of oophorectomy is higher amongst pediatric surgeons in comparison to gynecologists. Using a national database, this study examined how the surgical management of ovarian torsion has evolved. METHODS: Children with a discharge diagnosis of ovarian torsion (ICD-9 code 620.5, ICD-10 code N835X) and procedure codes for oophorectomy (CCS code 119) were identified within the KID database from 2003, 2006, 2009, 2012, 2016, and 2019. Diagnosis of ovarian pathology was based upon ICD-9 and ICD-10 codes at the time of discharge. RESULTS: A total of 7008 patients, ages 1-20, had a discharge diagnosis of ovarian torsion. Of those patients, 2,597 (37.1%) were diagnosed with an ovarian cyst, 1560 (22.2%) were diagnosed with a benign ovarian neoplasm, and 30 (0.4%) were diagnosed with a malignant neoplasm. There was a decreased risk of oophorectomy in urban-teaching versus rural hospitals (OR: 0.64, p < 0.001). The rate of oophorectomy has decreased overtime. However, patients with benign or malignant neoplasms were more likely to undergo oophorectomy than those without a diagnosis (OR: 2.03, p < 0.001; 4.82, p < 0.001). CONCLUSION: The rate of oophorectomy amongst children with ovarian torsion has decreased over time. Yet, despite improvements, oophorectomy is common amongst patients with benign ovarian neoplasms and those treated at rural hospitals. Continued education is needed to optimize patient care in all clinical scenarios. LEVEL OF EVIDENCE: IV.

Rethinking ovary preservation by adnexal torsion reversal in adolescents: a case of delayed diagnosis.

BACKGROUND: This article discusses the management of an adolescent woman with a delayed diagnosis of adnexal torsion (AT) whose ovaries were successfully preserved. CASE PRESENTATION: The patient was a 14-year-old female teen admitted with the chief complaint of lower abdominal pain for 3 days and worsening pain for 2 days. Magnetic resonance imaging suggested a high possibility of torsion in the anterosuperior uterine mass and was accompanied by severe ovarian edema, bleeding, and enlargement. Intraoperatively, the left fallopian tube was characterized by thickening and torsion and appeared blackish purple. The left fallopian tube paraovarian cyst was about 20 cm in size, and the left adnexa was twisted 1080° along the left infundibulopelvic ligament (suspensory ligament of the left ovary). The left ovary appeared blackish purple, with an enlarged diameter of about 10 cm. At the request and with the informed consent of the patient's parents, we preserved the left ovary and removed the left fallopian tube. The results of the endocrine, ultrasound, and tumor marker tests were normal 1 month after surgery. Follicles and blood flow signals seen in ultrasound examinations indirectly proved the successful preservation of the left ovary in the follow-up. CONCLUSIONS: Our attempt to preserve the ovaries in an adolescent with a delayed diagnosis of AT was successful.

Pediatric and adolescent females are at higher risk of adnexal torsion recurrence-A large-scale retrospective study.

AIM: Recurrence of adnexal torsion (rAT) is reported mainly in small series. Normal and small appearing ovaries are associated with an increased risk for rAT. Nevertheless, updated data of larger cohorts is lacking. We aimed to investigate the predictors for rAT in a cohort of women who had surgical intervention for primary adnexal torsion (pAT). METHODS: A retrospective case-control study from a single institution between 2011 and 2020. Women with a primary occurrence of surgically proven adnexal torsion were included. We compared those who had experienced rAT to those who had not. Univariate and multivariate analysis were performed to study independent predictors for rAT. RESULTS: Overall, 358 women were included. Of those, 35 (9.8%) had a rAT. Women who experienced rAT were younger (mean age 26 vs. 30 years, p = 0.01). Women experiencing rAT had smaller mean ovarian cyst diameter in the pAT episode (42 vs. 59 mm. p < 0.001). Performance of laparoscopic detorsion was only associated with rAT (odds ration [OR] 95% confidence interval [CI] 2.13 [1.02-4.42], p = 0.03), while the performance of additional cystectomy was negatively associated with rAT (OR 95% CI 0.10 [0.01-0.79], p = 0.006). Multivariate analysis demonstrated that age ≤15 and smaller cyst diameter at pAT were independently associated with the risk for rAT (aOR 95% CI 5.0 [1.09-23.2] and 1.47 [1.08-2.0], for every 10 mm decrease in cyst diameter, respectively). CONCLUSIONS: Adolescents and pediatric females and women with smaller ovarian cysts at pAT are at higher risk for future recurrence of adnexal torsion.

Clinical factors and surgical decision-making when managing premenopausal women with adnexal torsion.

PURPOSE: The primary objective of this study is to identify if and which clinical factors may influence surgical decision-making when managing premenopausal women who present emergently with adnexal torsion (AT). METHODS: This retrospective cohort study was conducted at a single tertiary hospital. Medical records for all admissions for AT between 1 January 2010 and 30 June 2020 were reviewed and data regarding patient demographics, history of torsion, and the index admission were collected. Conservative surgery was defined as detorsion only or detorsion with cyst decompression. Interventional surgery was defined as ovarian cystectomy, salpingectomy, oophorectomy or salpingo-oopherectomy. RESULTS: 126 women were included for final analysis. Of the 109 women diagnosed with AT at emergency surgery, 12 were postmenopausal (all had interventional surgery). In the 97 premenopausal women, 50 (52%) underwent conservative surgery. Pregnant women were more likely to undergo conservative surgery than non-pregnant women (Relative Risk [RR] 0.20, 95% confidence interval [CI] 0.5, 0.75, p = 0.001). Women having laparoscopies were also more likely to undergo conservative surgery (RR 0.08, 95% CI 0.01, 0.53, p = 0.001) than if they had laparotomies. Although not reaching statistical significance, women were more likely to undergo laparotomy if they were febrile or if a senior gynecology consultant was involved in their care. History of torsion, age, parity and ovarian size did not alter the risk of interventional surgery. CONCLUSION: This study identified that premenopausal women who presented emergently with AT were significantly more likely to have conservative surgery if they were pregnant or if they underwent laparoscopic surgery.

When is it too late? Ovarian preservation and duration of symptoms in ovarian torsion.

This 10-year retrospective study between 2008 and 2018, aims to investigate the duration of symptoms of ovarian torsion and the subsequent rate of ovarian preservation. Eighty-six women with surgically confirmed ovarian torsion were included. The median duration from the onset of pain symptoms to presentation (26.0 vs 6.0 h, p < .001) and from presentation to surgery (11.0 vs 5.5 h, p = .010) were significantly longer in women who required an oophorectomy compared to women who had conservative surgery. There was no significant difference in symptoms, signs or investigations except ultrasound finding of an enlarged ovary (94.9% vs 76.9%, p = .026). Awareness of the condition among the community and healthcare is crucial and routine investigations should not delay management as positive Doppler flow on ultrasound does not exclude an ovarian torsion.Impact StatementWhat is already known on this subject? Ovarian torsion is a gynaecological emergency and may lead to ovarian necrosis, infection and peritonitis. Early recognition is essential in preserving the ovary, particularly in patients with future fertility aspirations. Currently there is no consensus regarding the time period of ovarian viability after the onset of symptoms.What do the results of this study add? We have demonstrated a significant difference in the duration from the onset of symptoms to surgery. Furthermore, the duration from the onset of symptoms to presentation (26.0 vs 6.0 h, p<.001) and from presentation to surgery (11.0 vs 5.5 h, p=.010) were significantly longer in women who required an oophorectomy compared to women who had conservative surgery. There was no significant difference in symptoms, signs or investigations except ultrasound finding of an enlarged ovary.What are the implications of these findings for clinical practice and/or further research? Women with known ovarian cysts in particular should be educated of the risk of ovarian torsion. Routine investigations should not delay management as it does not exclude an ovarian torsion. Although our study suggests that early presentation and management would reduce the risk of oophorectomy, prospective studies are required to confirm the findings.

Variation in Oophorectomy Rates for Children with Ovarian Torsion across US Children's Hospitals.

In this multicenter study of 1783 children diagnosed with ovarian torsion from 2012 to 2017, 402 children (22.5%) underwent oophorectomy. The odds of oophorectomy were higher in children under 11 years of age, children with public insurance, and children with complex chronic conditions. Future efforts should target a preservation-first approach.

Factors Associated with Torsion in Pediatric Patients with Ovarian Masses.

BACKGROUND: Management of ovarian torsion has evolved toward ovarian preservation regardless of ovarian appearance during surgery. However, patients with torsion and an ovarian neoplasm undergo a disproportionately high rate of oophorectomy. Our objectives were to identify factors associated with ovarian torsion among females with an ovarian mass and to determine if torsion is associated with malignancy. METHODS: A retrospective review of females aged 2-21 y who underwent an operation for an ovarian cyst or neoplasm between 2010 and 2016 at 10 children's hospitals was performed. Multivariate logistic regression was used to assess factors associated with torsion. Imaging data were assessed for sensitivity, specificity, and predictive value in identifying ovarian torsion. RESULTS: Of 814 girls with an ovarian neoplasm, 180 (22%) had torsion. In risk-adjusted analyses, patients with a younger age, mass size >5 cm, abdominal pain, and vomiting had an increased likelihood of torsion (P < 0.01 for all). Patients with a mass >5 cm had two times the odds of torsion (odds ratio: 2.1; confidence interval: 1.2, 3.6). Imaging was not reliable at identifying torsion (sensitivity 34%, positive predictive value 49%) or excluding torsion (specificity 72%, negative predictive value 87%). The rates of malignancy were lower in those with an ovarian mass and torsion than those without torsion (10% versus 17%, P = 0.01). Among the 180 girls with torsion and a mass, 48% underwent oophorectomy of which 14% (n = 12) had a malignancy. CONCLUSIONS: In females with an ovarian neoplasm, torsion is not associated with an increased risk of malignancy and ovarian preservation should be considered.

CT predictive model for torsion angle as a marker for risk of necrosis in patients with adnexal torsion.

AIM: To assess the feasibility of preoperative computed tomography (CT) prediction of torsion angle for stratifying the risk of necrosis in patients with adnexal torsion. MATERIALS AND METHODS: In this multicentre, retrospective study, 72 patients underwent preoperative CT and surgically verified adnexal torsion. Surgeons identified the torsion angle and adnexal necrosis requiring adnexectomy. The twisted angles were compared between conservative surgery group and salpingo-oophorectomy group. Variables included demographic, pathological and CT details. Logistic analysis was used to identify the indicators of twisted angle associated with high-risk necrosis. RESULTS: The necrosis associated with adnexal torsion treated with adnexectomy was performed more often in patients with a torsion angle of ≥720° (odds ratio [OR]=7, 95% confidence interval [CI]: 1.314-37.295, p=0.023). The enlarged twisted pedicle (OR=14.592, 95% CI: 2.048-103.953, p=0.007) and pedicle haemorrhage (OR=5.612, 95% CI: 1.088-28.941, p=0.039) can predict a torsion angle of ≥720°, and area under the receiver operating characteristic (ROC) curve (AUC=0.758±0.058) was generated with the combined variables. CONCLUSION: The risk of adnexal necrosis is high in patients with torsion angle of ≥720°. CT findings of enlarged twisted pedicle and pedicle haemorrhage can be used to predict torsion angle of ≥720° and can imply adnexal necrosis indirectly.

Ovarian torsion: can we save the ovary?

OBJECTIVE: The purpose of this study is to evaluate the correlation between visually appearing ovarian necrosis and necrosis in histopathology in patients with ovarian torsion; and to identify predictive factors of ovarian necrosis. METHODS: This is a retrospective study. All women admitted to the hospital with a diagnosis of suspected ovarian torsion from January 2014 to December 2018 were recruited. Forty-two patients with a confirmed diagnosis of ovarian torsion were finally included. Correlation analysis was done between visual judgement of ovarian necrosis and necrosis in histopathology. Chi-square was performed to analyze dependence between time from pain onset to surgery, ovarian size in ultrasound, Doppler flow, and histopathological analysis. RESULTS: Thirty-one ovaries were visually judged as necrotic. Only five of them (16%) had histopathologically confirmed necrosis, 20 (64.5%) had hemorrhage or congestion, and 6 (19%) had normal ovarian tissue, p = 0.349. Development of ovarian necrosis showed to be dependent on time from onset of pain to surgery. All patients with necrotic ovaries in histopathology underwent surgery after 24 h of pain onset, while there was no necrosis in those who had surgery before 24 h. (p = < 0.05). There was no relationship between ovarian size measured by ultrasound and necrosis (p = 0.265), as well as color flow in ultrasound and necrosis (p = 0.388). CONCLUSION: Visual assessment of ovarian necrosis intraoperatively is not a good predictor of real necrosis in histopathology. To preserve the ovary, surgical management should not be delayed.

Variations in the management of adolescent adnexal torsion at a single institution and the creation of a unified care pathway.

PURPOSE: Adnexal torsion is a gynecologic emergency, requiring intervention for tissue preservation. At our institution, torsion is managed by pediatric surgeons or gynecologists. We evaluated differences between specialties to streamline evaluation for children with gynecological emergencies, develop a clinical pathway, and prevent care delays. METHODS: A retrospective review of adolescents undergoing intervention for adnexal torsion from 2004-2018 was performed. Differences in time to intervention, operation duration, the procedure performed, and length of stay (LOS) between the specialties were analyzed. RESULTS: Eighty-six patients underwent 94 operations for presumed adnexal torsion with 87 positive cases. Pediatric surgeons performed 60 operations and 34 cases were performed by gynecologists. Preservation of fertility was the goal in both cohorts and the rate of oophoropexy, cystectomy, and oophorectomy were similar between the cohorts (p = 0.14, p = 1.0, p = 0.39, respectively). There was no difference in intra-operative time (p = 0.69). LOS was shorter in the gynecology cohort (median 1 day [1-2] vs. 2 days [2-3], p > 0.001). CONCLUSIONS: Adnexal torsion is a time-sensitive diagnosis requiring prompt intervention for ovarian or fallopian tube preservation. A multidisciplinary institutional care pathway should be developed and implemented.

Elevated aspartate aminotransferase and alanine aminotransferase in the torsion of ovarian mature cystic teratoma: normalised after operation for torsion.

The aim of the study was to report the elevated liver function test levels in torsion of ovarian mature cystic teratoma (MCT). A retrospective review was performed of 116 patients with MCT who underwent surgery in our hospital between 2010 and 2017. Eleven of 116 patients were with torsion of MCT. Of the 11 torsion of MCT cases, 6 of those showed abnormal elevated levels of aspartate transaminase (AST)/alanine aminotransferase (ALT). After operation, AST/ALT levels recovered to normal ranges. Elevated liver function levels require attention to complications associated with anaesthesia and emergency operation. However, the current report shows that emergency surgery should not be delayed to assess other causes of elevated liver function tests.Impact statementWhat is already known on this subject? Abnormal liver function tests require attention to complications associated with emergency surgery.What do the results of this study add: Our study shows that some patients with torsion of MCT returned to normal levels of AST/ALT after surgery without any medications to improve liver function.What are the implications of these findings for clinical practice and/or further research? This study would offer that in some cases with torsion of MCT, emergency surgery should not be delayed and the assessment of other possible causes of these elevations postponed to postoperative period. Additional studies are required to assess the correlation between elevated AST/ALT levels and torsion of MCT.

Clinical characteristics, treatment and outcomes of adnexal torsion in pregnant women: a retrospective study.

BACKGROUND: Adnexal torsion during pregnancy is a gynecological emergency. Delayed diagnosis and treatment can cause ovarian necrosis and fetal loss. This study assessed the clinical characteristics, treatment and outcomes of adnexal torsion in pregnant women. METHODS: A retrospective study was conducted at a tertiary center between January 2008 and January 2018. Eighty-two pregnant women with surgically confirmed adnexal torsion were included. The clinical characteristics, ultrasound data, surgical interventions and pregnancy outcomes were analyzed. RESULTS: The median age of the patients was 28 (range, 18-38) years. The median gestational age was 11 (range, 6-31) weeks: 53 (64.6%) were in the first trimester, 21 (25.6%) were in the second trimester, and 8 (9.8%) were in the third trimester. The most common symptoms and signs were sudden pelvic pain (100%) and adnexal or pelvic masses (97.6%), followed by nausea and vomiting (61%). The Doppler blood flow signal disappeared in 62.5% of the patients. Sixty-three (76.8%) patients underwent laparoscopy, and 29 (24.2%) underwent laparotomy. The median gestational age in patients undergoing laparotomy was higher than that in those undergoing laparoscopy (26 weeks vs 10 weeks, p < 0.001). Fifty-three (64.6%) patients underwent conservative surgery, with 48 detorsions and cystectomies, 2 detorsions and cyst fenestrations, 1 detorsion only and 2 salpingectomies only. Twenty-nine (25.4%) patients underwent unilateral salpingo-oophorectomy. There were no cases of postoperative thrombosis, spontaneous abortion or recurrence during the same pregnancy. Seven patients underwent simultaneous artificial abortion. One patient experienced intrauterine fetal death, and 74 patients had live births. CONCLUSION: Surgical intervention was required as soon as possible. Laparoscopic conservative surgery is safe and may be appropriate to preserve ovarian function.

Adnexal Torsion in Pregnancy Managed by Laparoscopy Is Associated with Favorable Obstetric Outcomes.

STUDY OBJECTIVE: Most cases of adnexal torsion in pregnancy are currently managed by laparoscopy, which may be associated with increased risks for spontaneous abortion and preterm delivery. We sought to evaluate the obstetric outcomes of these women, with emphasis on their live birth rate and gestational age at delivery. DESIGN: Retrospective cohort study and telephone questionnaire. SETTING: University-affiliated obstetrics and gynecology department. PATIENTS: All pregnant women who underwent laparoscopy for adnexal torsion between 2007 and 2017. Their obstetric outcomes were obtained by retrospective review of medical records and a telephone questionnaire. INTERVENTIONS: Laparoscopy for adnexal detorsion, with or without cyst drainage or cystectomy. MEASUREMENTS AND MAIN RESULTS: The study cohort included 94 women. Most torsion cases (71, 75.5%) were diagnosed in the first trimester of pregnancy, whereas 21 (22.3%) cases and 2 (2.1%) cases were diagnosed in the second and third trimesters, respectively. Conception was achieved by in vitro fertilization or by ovulation induction in 45 (47.9%) cases. The information on pregnancy outcomes was available for 93 women. Of those, live birth was reported for 86 (92.5%) pregnancies, while 6 (6.5%) women had a spontaneous abortion, and 1 woman experienced an intrauterine fetal death. Five cases of spontaneous abortion were diagnosed in the first trimester, all within 3 weeks of surgery. Preterm delivery before 37 gestational weeks was reported for 18 (19.4%) pregnancies and was significantly associated with twin pregnancy (p = .002) and with conception following in vitro fertilization and ovulation induction (p = .03). On logistic regression analysis, preterm delivery was only associated with twin vs singleton gestation (odds ratio, 6.7; 95% confidence interval, 1.3-34.8; p = .02). CONCLUSION: The obstetric outcomes of pregnant women who underwent laparoscopy for adnexal torsion are generally favorable. However, there is a risk for preterm delivery, which is primarily associated with multiple gestations.

Ovarian size as a risk factor for recurrent adnexal torsion: Smaller is not better.

AIM: To investigate characteristics and risk factors for recurrent adnexal torsion (AT). METHODS: Retrospective cohort study in a university-affiliated medical center included 320 Women with AT verified by laparoscopy, from January 2005 through January 2017. Demographic data, clinical symptoms, surgical findings and treatment were retrospectively reviewed from patient records. Data from primary and secondary AT of patients in the recurrent torsion group was compared to those with single torsion, to evaluate risk factors for recurrent AT. RESULTS: Two hundred and sixty seven (83.4%) patients had a single event of AT and 53 (16.5%) had recurrent AT. Patients with recurrent torsion had significantly fewer previous non-gynecologic surgeries (4.3% and 9.8% of the study groups vs 32.2% of the control group, P = 0.001 for both). Ovarian size was significantly smaller in the recurrent torsion groups (47.5 mm and 48.3 mm vs 63.9 mm, P = 0.045 and P = 0.012, respectively). Polycystic ovary was significantly more common in the recurrent AT group (P = 0.028 and P = 0.005), with risk ratio 4.4 (95% confidence interval, 1.66 to 11.63). Ovaries without any specific findings were also more common among recurrent AT cases (P = 0.001 for both groups). Logistic regression analysis demonstrated that smaller ovarian size is an independent risk factor for recurrent AT. CONCLUSION: Recurrent torsion correlated with fewer previous surgeries, small ovarian mass, polycystic ovaries and ovaries without specific findings, which might indicate that additional pathophysiological factors contribute to the recurrent event. Ovarian fixation might be recommended in patients with primary torsion of normal or polycystic ovaries.

Maternal and perinatal outcomes following laparoscopy for suspected adnexal torsion during pregnancy: a multicenter cohort study.

PURPOSE: To investigate the association of maternal and perinatal outcomes with the surgical diagnosis of adnexal torsion in a retrospective cohort of women operated for suspected torsion during pregnancy. STUDY DESIGN: This is a multicenter retrospective study and telephone questionnaire of urgent laparoscopies that occurred during pregnancy for suspected torsion between 2004 and 2019 in three tertiary medical centers. Pregnancy outcomes of women with the surgical diagnosis were compared with those whose laparoscopy was negative for adnexal torsion. Multivariable regression modeling was applied to control for possible confounders ((adjusted odds ratios (aOR) ± 95% confidence intervals (CI)]. RESULTS: The study cohort included 186 women. Adnexal torsion was surgically found in 129/186 (69.4%) cases. The torsion group was characterized by higher rate of nulliparity, fertility treatments and multiple gestations as well as lower rates of previous cesarean delivery. Live birth was reported for 171 (91.9%) pregnancies, and the miscarriage rate was significantly higher in the non-torsion group. Women with torsion were more likely to be hospitalizes due to preterm labor; however, rates of preterm delivery were comparable between the groups (10.8% vs. 10.9%, p = 0.99). Logistic regression analysis had demonstrated that the performance of laparoscopy prior to 8 weeks of gestation was the only independent factor associated with miscarriage (8.23, 2.01-33.67). CONCLUSION: Pregnancy outcomes following the diagnosis of adnexal torsion throughout gestation were overall favorable. Laparoscopic procedure during early stages of pregnancy was associated with higher rates of miscarriage, regardless of the surgical diagnosis of adnexal torsion.

Abdominal Pain in a Young Female Adolescent: Point-of-Care Ultrasound Added Value.

An adolescent female patient presented to the emergency department with diffuse, severe lower abdominal pain and vomiting. The initial suspected diagnosis was appendicitis. Point-of-care ultrasound did not visualize the appendix but demonstrated a suspected left ovarian torsion, which was confirmed by radiology-performed ultrasound. The clinical presentation, in combination with images obtained via point-of-care ultrasound, helped to expedite gynecology consultation and immediate surgery.

A case report of ovarian torsion following ovarian transposition for cervical cancer.

We describe a case report of ovarian torsion after ovarian transposition in a young woman with cervical cancer. Ovarian transposition is a well-established surgical procedure in young women undergoing hysterectomy for pelvic malignancies who may go on to receive radiation therapy. Transposing the ovaries further from the targeted field lowers the radiation dose to the exquisitely radiosensitive ovaries. Torsion is not a commonly acknowledged complication following ovarian transplantation; however, we feel that clinicians and radiologists should include torsion in their differential for women with flank or abdominal pain and a history of ovarian transposition.

Losartan ameliorates ovarian ischaemia/reperfusion injury in rats: an experimental study.

This study aimed to investigate the protective and antioxidant role of losartan in ovarian ischaemia and ischaemia/reperfusion injury in an experimental ovarian torsion model. Thirty adult female rats were used. Rats were separated randomly into five groups; Group 1: sham group (abdominal wall was only opened and closed), Group 2: torsion group with 3-hour ischaemia using atraumatic vascular clips. Group 3: torsion + losartan group with 3-hour ischaemia 30 minutes after the administration of 40 mg/kg of losartan via oral gavage. Group 4: torsion-detorsion group with 3-hour ischaemia and 3-hour reperfusion (vascular clips were removed). Group 5: torsion-detorsion + losartan group with 3-hour ischaemia followed by administration of 40 mg/kg of losartan 30 minutes prior to a 3-hour detorsion/reperfusion. Ovarian tissue damage was scored by histopathological analysis. Ovarian tissue malondialdehyde (MDA) and plasma pentraxin 3 (PTX 3) levels were measured biochemically. In comparison with the sham group, both the torsion and torsion-detorsion groups had significantly higher scores for follicular degeneration, vascular congestion, oedema, haemorrhage, and leukocyte infiltration (p < .05). The aforementioned parameters significantly decreased in the torsion-detorsion + losartan group (p < .01) compared to those in the torsion-detorsion group. MDA and plasma PTX 3 levels were notably higher both in the torsion and torsion-detorsion groups compared with those in the sham group (p < .01). The current experimental ovarian torsion study suggests a protective role for losartan upon ischaemia and ischaemia/reperfusion injury in rat ovaries. Losartan may be a novel agent for decreasing ovarian ischaemia/reperfusion injury in ovaries.Impact statementWhat is already known on this subject? Among gynaecological emergencies, the diagnosis of ovarian torsion is highly difficult. A delayed diagnosis may lead to ovarian necrosis and subsequent loss of ovaries if timely surgical intervention is not performed, which is essential for the fertility and protection of ovarian functions in young patients. However, reperfusion of the ischaemic tissue might leads to more serious damage to the tissue than the damage caused by ischaemia.What the results of this study add? This study found that losartan, an Ang II type 1 receptor blocker which has been currently used for regulation of blood pressure, could be used experimentally to alleviate I/R injury in ovary through improving histological parameters, reducing tissue MDA and plasma PTX3 levels. To date, there is no study regarding the usage of losartan for alleviating I/R on ovary due to torsion.What the implications are of these findings for clinical practice and/or further research? Losartan may be suggested to have therapeutic value in patients with ovarian torsion. Further large clinical studies are necessary to prove the beneficial effect of losartan to prevent I/R injury on human ovaries.

Effect of metformin and detorsion treatment on serum anti-Müllerian hormonelevels and ovarian histopathology in a rat ovarian torsion model

Background/aim: Adnexal torsion is a common gynaecological emergency, and considered to be a problem mostly in reproductive-age women. To evaluatethe effect of metformin and detorsion treatment on reducing ovarian reserve in an ovarian torsion model. Materials and methods: Twenty-four nonpregnant, Wistar Hannover rats were included in the study. Animals were divided into 3 groups: the control group, the detorsion only group, and the metformin + detorsion group. The first group received only laparotomy. In the second group, ovaries were fixed to the abdominal wall after performing 360° ovarian torsion, followed by detorsion after a 3-h period of ischemia. The third group underwent the same torsion and detorsion procedures as the second group, and received 50 mg/kg metformin by gavage for 14 days. Ovarian damage scores, follicle counts, and AMH levels were evaluated. Results: The total damage score was significantly increased in the detorsion only group compared to the metformin+detorsion and control groups. Pre-operative/post-operative AMH decreases were statistically significant in negative direction in the detorsion only group when compared to the metformin+detorsion and control groups (P = 0.001). Conclusion: Metformin+detorsion treatment may be effective in protecting the ovarian reserve after ovarian torsion.