Management of Ovarian Torsion
Abstract & Commentary
by Frank W. Ling, MD, Clinical Professor, Dept. of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, is Associate Editor for OB/GYN Clinical Alert.
Dr. Ling reports no financial relationship to this field of study.
Synopsis: Adnexa-sparing laparoscopic procedures for ovarian torsion might predispose to recurrence of torsion.
Source: Pansky M, et al. Torsion of Normal Adnexa in Postmenarchal Women and Risk of Recurrence. Obstet Gynecol.2007;109:355-359.
In this retrospective study, the authors gleaned hospital records to identify cases of adnexal torsion at their hospital in Israel between 2002 and 2006. Sixty-two cases were found appropriate for the study. These were classified as having pathologic adnexa or normal adnexa. The patients were then followed via telephone interview to determine whether or not there was recurrence of adnexal torsion.
Twelve patients were found to have normal adnexa at the time of torsion. Fifty-seven patients were able to provide reliable follow-up information. Of the 11 patients who originally had normal adnexa, 7 had a recurrent episode of torsion (63.3%) while 8.7% (4 of 46) of patients with abnormal adnexa had recurrent torsion. Among the 7 women with recurrent torsion of normal adnexa, 4 were ipsilateral with a mean interval between the events of 2 years.
Of the patients with abnormal adnexa, recurrence was higher if minimal surgery was performed for the first event (detorsion with/without cyst aspiration). There was less likelihood that torsion would recur if resection of the pathology or the entire adnexa had been undertaken.
Commentary
Hmmmmmm. So the pendulum continues to swing back and forth. Historically, adnexal torsion was managed by removal of the adnexa due to a fear of thrombus formation in the ovarian vein, which could lead to a thromboembolic event. Subsequently, due to the minimal risk of thromboembolism, conservation of the adnexa and untwisting of the adnexa became the standard management. These authors now challenge us to reconsider once again, particularly with regard to ovarian fixation, ie, ovariopexy. Hmmm again. What to do? First, it appears that the results here do not warrant returning to the old days of removing adnexa. Conservation of the adnexa in the absence of obvious pathology makes sense. With regards to ovariopexy, the authors acknowledge that neither the literature in general nor their data give us any guidance. There are no data that tell us that ovariopexy would have prevented any of these cases of retorsion.
Although the paper focuses on the postmenarchal patient, the authors do review the arguments for and against fixation of the normal ovaries in that population. Factors in favor of doing so include avoiding the devastating significance of losing the ovary if torsion were to reoccur, whereas negative factors include interference with adnexal blood supply and risk of tubal function. Despite an admitted lack of data, they conclude by suggesting that bilateral ovariopexy in cases of normal adnexal torsion in premenarchal patients is warranted.
Data on postmenarchal patients is even more scarce. I believe that they are objective in their suggestion that surgeons should at least raise the possibility of ovariopexy in patients who have had one adnexal torsion, with the possibility of even doing so bilaterally. So I say again: Hmmmmm.
In this retrospective study, the authors gleaned hospital records to identify cases of adnexal torsion at their hospital in Israel between 2002 and 2006. Sixty-two cases were found appropriate for the study.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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