GYN #2 Oophoropexy in Adnexal Torsion with Dr. Lesley Breech

Globalcast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hi everyone. I'm Emgody, Research Fellow at Cincinnati Children's Hospital Medical Center. Today, we have a guest from Pediatric Gynecology Department here at Cincinnati Children's, Dr. Leslie Breach. And we will discuss the role of Oophoropexy in Adnexal torsion with a case scenario. So, the patient is five years old. The ultrasound shows a large cystic mass in the right pelvis. And again, no blood flow to the right ovary. In the operating room, you find an ovarian torsion with a dark purple ovary. How would you manage this patient? In this case, and in many cases, the finding is actually a big, edematous fallopian tube. Many times, it's not actually not even an actual cyst that is sitting there. In a five year old, you wouldn't really find a paraovarian or wolfian duct cyst, as those present really after puberty. In this case, they're saying there was a separate cystic mass. What I'm going to suggest to you is just untwisting. The problem is in little girls after you untwist it, you have this large edematous ovary and it's really hard to find any place to put it. And sometimes you try to just tuck it into the pelvis, but oh, it could retorse right away. On the other hand, in a teenager, there is space, and you could leave a large edematous ovary in the pelvis to let the edema come down. So, we detorse the adnexa, ovary and tube, because there's no definitive time frame, unlike testes that only have a very short lifespan. The ovary is more resilient and it rebounds, so we would recommend preserving any potential fertility in the future. If you had a prepubertal girl and she had a torsion, and you thought the ovary was big and swollen, would you do an oophoropexy? We would not recommend doing an oophoropexy at the time of detorsion. Recurrent torsion constitutes about 10 to 15% of all cases of torsion in the pediatric population. More common on the right, because of course, there's no sigmoid colon to protect it from twisting. And for teenagers, the American College of Obstetricians and Gynecologists does not recommend doing oophoropexy for every patient who has a torsion. We want the fallopian tube and the ovary to be in great communication. So when ovulation is happening, the tube is right there. It gets the eggs and brings it right down the fallopian tube to meet the sperm. So, if you're doing an oophoropexy and you're trying to place your ovary safely, you might put it in a safe place, but then unfortunately, interrupt good communication with the fallopian tube and ovary. So, we as providers could iatrogenically introduce some degree of impairment in fertility if we're not oophoropexying in the right site. Next, Dr. Breach would like to talk about techniques because unfortunately, about 30% of oophoropexies end up failing. Actually, utero-ovarian ligament shortening, which is one of the opportunities for oophoropexy, is really the one of the ones that fails more commonly than other approaches. So again, when doing this, we want to be sure that we ourselves are not iatrogenically inducing more impairment to fertility. Here you see these little remnants of suture. Both of these ovaries had previously been pexied and this patient had multiple torsions on both sides. Now, the ovaries actually look pretty good, right? This is an interval procedure. At the time of actual torsion, the ovaries can actually look horrible. They can be very edematous, they can look hemorrhagic in nature. So after a torsion, it's really not the time that we want to do the oophoropexy. It's really an interval procedure when you have fabulous looking ovaries because the ovary has healed well. When gynecologists are fixing it, they're looking for sort of stabilization. That's why they go down to the uterosacral ligament. And the pelvic sidewall, as well as shortening the uteroovarian ligament, works like a three-point fixation. If we do have a fairly edematous ovary and like we've seen in some of those younger patients, and we don't really have a good place to kind of secure it, we um give some good precautions when patients are going home, minimizing activity, letting that edema come down. And our packing nurses have been really excellent at giving those good discharge instructions. However, in this case, Dr. Breach might give additional discharge instructions that are coming more directly to the parents. This can't be like trampolining, gymnastics, there are other things like that. In prepubertal girls, it can really take much longer for that edema to regress and really come down. So we often don't re-image for as long as about two to three months so that edema is completely resolved. After you detorse something, do you think you should get any ultrasounds after, or do you think you just cured it and you're done? We would always want to do a follow up ultrasound. Maybe about 46% of patients that really won't have any real persistent mass or lesion in the ovary. It might just be that they had a longer utero ovarian ligament, maybe they had a longer infundibulopelvic ligament. It might be a real just difference in their own anatomy that predispose them. There is some literature that suggests if you have a very hemorrhagic edematous ovary, you can damage the ovary more by doing your cystectomy then, than waiting to do it later. So, when intervening acutely during the time of a torsion, we can damage the ovary, and our goal is for follicular survival. So that really helps preserve future fertility. So in most cases, if you have an ugly looking ovary, we're just going to ask for people to detorse it, untwist it, put it to a safe place and try to re-image the patient down the line. In conclusion, in managing pediatric ovarian torsion, prioritize detorsing the ovary to preserve future fertility, given its resilience compared to other tissues like testes. Avoid oophoropexy in prepubertal patients due to the risk of recurrent torsion and potential fertility impairment. Post-torsion, carefully monitor for edema reduction and reevaluate for underlying conditions with follow-up imaging. Emphasize postoperative care to minimize activities that could exacerbate recovery, especially in prepubertal girls, where edema resolution may take longer. Thank you for watching this video. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Globalcast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.