Dr. Avantika Gupta is currently working as an Assistant Professor in the Department of Obstetrics and Gynaecology, JIPMER, Puducherry. She did her MBBS from Lady Hardinge Medical College, Delhi, and MS in Obstetrics and Gynaecology from Maulana Azad Medical College, New Delhi. She has completed MRCOG and has been awarded with FOGSI Imaging award and Young Turk award. She has various national and international publications credited her name.
The aim of the study was to analyse risk factors, surgical findings, ovarian salvage rate and histology of ovarian mass. We reviewed 81 cases of surgically proven ovarian torsion retrospectively from June 2014 to June 2019 at a tertiary care referral centre in South India. Demographic, clinical and surgical details of all patients were noted from the medical records. Mean age of the patients was 26 years. Most of the patients were nulliparous and had a pre-existing ovarian mass of size > 5 cm. Ovarian salvage rate was 43.2%. Concomitant cystectomy with detorsion was done in 30 patients without increase in blood loss or complications. Extensive necrosis was present in 78.2% of oophorectomy specimens. Most common histology of ovarian mass in cystectomy specimens was simple ovarian cyst.
Keywords Conservative surgery · Necrosis · Cystectomy · Histology
Ovarian torsion is an uncommon gynaecological emergency. Ovary can twist over its own pedicle leading to obstruction of its blood supply causing ischaemic necrosis. Owing to its non-specific symptoms, lack of a specific diagnostic test and management guidelines, it can cause diagnostic dilemma and delay in management. However, it should be suspected in any woman in reproductive age group with sudden onset abdominal pain especially with known risk factor for ovarian torsion. Imaging can give a clue to diagnosis; however, definite diagnosis is intraoperative. The known risk factors for ovarian torsion are pre-existing ovarian mass especially dermoid, previous torsion, polycystic ovary, previous surgery, tubal sterilization and pregnancy [1–5]. The definite management of ovarian torsion is surgical. Over last 2 decades, there has been a shift from radical to conservative surgery irrespective of the appearance of ovary, delay in diagnosis or number of twists [1, 2, 5, 6]. The aim of the study is to study the risk factors, surgical findings, salvage rate and histology of the ovarian torsion cases at a tertiary care referral centre in South India.
Materials and Methods
This was a retrospective observational study conducted at the women and child hospital attached to Jawaharlal Nehru Institute of Postgraduate Medical Education and Research, a tertiary care referral institute in southern India, over 5 years from June 2014 to June 2019. All women with surgically proven ovarian torsion, defined as partial or complete rotation of the ovarian vascular pedicle, were identified from the surgical records [7]. Isolated fallopian tube or para-ovarian cyst torsion and incidental finding of ovarian torsion in surgeries done for some other indications were excluded from the study. The Institute Ethical Committee approved the study and waived the need for informed consent from participants of this study. Patients were either referred from other hospitals or presented themselves in the Department of Obstetrics and Gynaecology. Data was collected using a predesigned proforma from records of the patients including basic demographics, clinical data, surgical details and pathology reports. The authors were not blinded to the study purpose or to the patient’s final diagnosis and findings. After de-identification, demographic data in the form of age, parity and pre-existing risk of torsion were noted. Emergency department resident’s history, examination and consultant’s notes were reviewed for clinical details such as presenting complaints, duration from onset of symptoms to presentation, duration from presentation to surgery, leucocyte count and ultrasound findings. Surgical details included size of mass/ovary, laterality, colour of the torsed ovary, number of twists and type of surgery performed. Ovarian salvage was defined if all or part of ovary was preserved after detorsion. Finally, histopathology report of the ovary was reviewed for the presence of necrosis or haemorrhage and associated pathology of the mass. Follow-up of the patients till discharge from the hospital was noted. All statistical analysis was performed using STATA 15.0 (Stata Corp, Texas, USA). All categorical variables were expressed as frequencies and percentages. All continuous variables were expressed as median.
During 5-year period from June 2014 to June 2019, a total
of 81 cases of ovarian torsion were operated and included in
the study. The demographic details are presented in Table 1.
Three patients had recurrent ovarian torsion.
The operative findings, type of surgery performed and the
histopathology of the specimens are presented in Tables 2
and 3. All patients presented with abdominal pain, 65
patients presented with acute onset colicky pain, while 16 had intermittent pain over more than 48 h. All the patients
had a tender pelvic mass. 60% experienced nausea or vomiting
along with abdominal pain. Low-grade fever was present
in only two patients. Median time from onset of symptoms
to presentation was 24 h (12–120 h). The main cause of
delayed presentation was lack of specific symptoms, intermittent
nature of pain, misdiagnosis as acute appendicitis or
acute pelvic inflammatory disease. Median time from admission
to surgery was 12 h (6–48 h), most common cause of
delay in surgery being non-availability of operation theatre
in emergency hours and nil per oral status of the patients.
Leucocytosis, i.e. leucocyte count more than 15,000/dL, was
present in only 14 patients. Ultrasonogram showed cyst with
thickened walls and echogenic contents in 59 patients and
complex ovarian mass in 13 patients, while nine patients
had associated enlarged oedematous ovary and peripherally
arranged follicles. Free fluid was present in 15 patients. Doppler
was documented in only 16 patients: blood flow was
present in two patients, indeterminate in three and absent in
11 patients. CT scan of abdomen was done in four patients
where diagnosis was not clear.
During the 5-year study period, there was a shift from
radical to conservative surgery, the latter being done more
commonly in the last 2 years. Conservative surgery was performed
based on surgeon’s discretion for colour of ovary
and return of circulation after detorsion. The average blood
loss in concomitant cystectomy along with detorsion was
80 cc (50–150 cc), and none of these patients had venous
thromboembolism. Three out of 46 patients in whom ovary
was removed showed no evidence of necrosis on pathology
report, and in five patients, necrosis was present only in
few areas of ovary. Reasons for oophorectomy in these eight
patients were postmenopausal status (n = 1), no return of
colour after detorsion (n = 5) and absence of plane between
mass and normal ovary (n = 2). Simple cyst was the commonest
pathology followed by dermoid cyst and serous cystadenoma.
There was no malignancy in any of the patients.
Recurrent torsion was present in three cases in the present
study. The interval between two events was 2–4 years, and
the opposite side was involved in all three patients. In these
patients, detorsion with ovarian cystectomy was done along
with oophoropexy. The latter was done by plication of ovarian
ligament to round ligament or back of uterus in these
patients. One patient was a 23-year-old girl who had recurrent
ovarian torsion on opposite side and ovary was blackish
in colour. The other ovary was already absent owing to
previous radical surgery. Hence, detorsion and cystectomy
were performed despite the blackish appearance of ovary.
She presented with secondary amenorrhoea after surgery,
and ovaries were not visualized on ultrasound. Her serum
FSH was raised to 65.2 IU/L, and she was started on hormone
replacement therapy thereafter.
Out of a total 81 surgically proven cases of ovarian torsion,
35 had conservative surgery, whereas 46 had oophorectomy.
Since ours is a tertiary care referral centre for many hospitals,
on an average 1–2 cases of ovarian torsion are referred
every month.
The most common risk factors for ovarian torsion in our
study were an associated ovarian mass (88.8%), ovarian cyst
of size > 5 cm (92.7%) and nulliparity (42%). 71% patients and 97.3% had ovarian mass in a studies by Balci et al. [3]
and Resapu et al. [5], respectively. Pregnancy was also a significant
risk factor in previous studies: 8% were pregnant in
study by Balci et al., whereas 35% patients were pregnant in
study by Resapu et al. [3, 5]. The low rates of ovarian torsion
associated with pregnancy, i.e. three out of 81 patients in this
study, can be explained by the fact that most of the ovarian
cysts except functional cysts are operated during pregnancy
in our institute, considering it as a risk factor for torsion.
Some patients in our study had PCOS which is a known
risk factor for torsion, especially in adolescents [1]. In some
studies, tubal sterilization and ovulation induction are also
described as risk factors for adnexal torsion [4, 8]. Ovarian
cyst of size > 5 cm has also been described as a known risk
factor in most of the studies [2, 9, 10]. The commonest presenting
symptom in our study was acute onset colicky pain
on the one side of abdomen followed by nausea and vomiting.
The clinical suspicion of adnexal torsion should be very
high in any young patient with an ovarian mass presenting
with acute abdominal pain along with nausea or vomiting,
as the latter is associated in up to 85% of the patients [11].
The commonest ultrasound finding in our study was enlarged
ovary along with concomitant cyst showing thickened walls
and echogenic contents due to haemorrhage and necrosis.
The most consistent finding in the literature appears to be
enlargement and oedema of ovarian tissue and haemorrhagic
appearance of the concomitant cyst [1]. Whirlpool sign in
the twisted pedicle on colour Doppler is also a specific sign
of ovarian torsion [12].
Laparoscopic surgery is preferred over laparotomy for
ovarian torsion owing to quicker recovery and better cosmesis.
However, less number of laparoscopic surgeries were
performed in this study due to non-availability of facilities
for laparoscopy in emergency hours in our setup. Over last
2 decades, the approach for management of ovarian torsion
has shifted from radical surgery to laparoscopic intervention.
The gross appearance of haemorrhagic adnexa does
not imply that it is non-viable. Even if the ovary appears
ischaemic or haemorrhagic, one need not wait for the signs
of recovery and should proceed with conservative surgery
because blackish appearance is not an indicator of degree of
ischaemia and ovarian function recovers most of the times
after detorsion [6, 11, 13–15]. In the present study, more
number of conservative surgeries were done in last 2 years
of the study period. In five patients in whom ovary appeared
blackish in colour and there was no change in colour upon
detorsion, necrosis was absent or minimal on histopathology
of the ovarian specimen. Performing a conservative surgery
would have saved the ovarian function in these five patients.
Ovarian salvage rate in this study was 43.2%. The comparison
of ovarian salvage rates in adults in previous studies
is shown in Table 4. Delayed presentation after 24 h and
misdiagnosis due to non-specific symptoms were the main reasons for the delay in surgery. The likelihood of preserving
ovarian function with conservative surgery decreases over
time, especially after 48 h [16].
Reasons for the delay in surgery. The likelihood of preserving
ovarian function with conservative surgery decreases over
time, especially after 48 h [16].
Concomitant cystectomy with detorsion was done in 30
patients, to avoid recurrence. There is a theoretical risk of
bleeding due to friable nature of the ovary due to oedema
and congestion, and early elective cystectomy has been
described after an interval of 2–3 weeks for oedema and
congestion to resolve [1]. But in our study, the average blood
loss was 80 cc (50–150 cc) where cystectomy was done after
detorsion and none of these patients had venous thromboembolism
in postoperative period. Hence, a concomitant ovarian
cystectomy is advisable with detorsion without risk of
increased intraoperative bleeding. Cyst aspiration is another
option in case of extensive oedema and congestion; however,
the chances of recurrence of the cyst and torsion will
be higher in such cases. Hence, such patients need close
follow-up.
There were three cases of recurrent torsion in this study.
Ovarian salvageability can be difficult in cases where radical
surgery has been performed previously and there is delay in
diagnosis second time. One of our patients had premature
ovarian failure owing to recurrent surgeries for ovarian torsion
and had to be put on hormone replacement therapy.
Ovarian suppression with hormones can be good option
in such patients after first surgery. Another option to avoid
recurrence is oophoropexy, which was done in three patients
with recurrent torsion in our study. Whether to perform
oophoropexy with detorsion is not clear and lacks long-term
follow-up. Due to non-availability of systematic studies on
its role, presently its role is not very clear. However, in cases
of recurrent torsion, it has shown to reduce the recurrence
rate effectively [17]. Large studies are needed to advocate
its role during primary surgery.
Most common histology in this study was simple ovarian
cyst followed by dermoid cyst. In previous studies, most
common histology of the ovarian mass was dermoid cyst
or haemorrhagic cyst [2, 3, 5]. There was no case of malignancy
in our study. The incidence of ovarian torsion with
ovarian malignancy was < 2% in reported case series [10,18]. However, when malignancy is suspected like in postmenopausal
women, oophorectomy should be done. Whenever
oophorectomy is performed, specimen must always
be sent for histopathology to rule out rare possibility of
malignancy.
This study has certain limitations. Route of the surgery
was determined largely by the non-availability of laparoscopy
in emergency hours. However, laparoscopy is preferred
over laparotomy owing to quicker recovery and better cosmesis.
Conservative surgery was decided by the surgeon
subjectively on the basis of gross appearance of the ovary
and return of colour on detorsion. We did not attempt to follow
patients undergoing conservative surgery for the functioning
of ovary.
Conflict of interest There is no conflict of interest amongst authors.
Ethical Approval Ethical approval was taken from the Institutional Ethics
Committee.
Informed Consent Waiver of informed consent was requested.
