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Grand Rounds
GYN #2 Oophoropexy in Adnexal Torsion with Dr. Lesley Breech
With Dr. Lesley Breech · hosted by Dr. Em Gootee
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
In many cases of adnexal torsion, the finding is a big edematous fallopian tube rather than an actual cyst.
In a five year old, you wouldn't really find a paraovarian or wolfian duct cyst, as those present really after puberty.
In little girls after untwisting, there is a large edematous ovary and it's really hard to find any place to put it, and it could retorse right away.
In a teenager, there is space, and you could leave a large edematous ovary in the pelvis to let the edema come down.
There is no definitive time frame for ovarian torsion, unlike testes that only have a very short lifespan.
The ovary is more resilient than testes and it rebounds.
Oophoropexy is not recommended at the time of detorsion in prepubertal girls.
Recurrent torsion constitutes about 10 to 15% of all cases of torsion in the pediatric population.
Torsion is more common on the right side because there's no sigmoid colon to protect it from twisting.
The American College of Obstetricians and Gynecologists does not recommend doing oophoropexy for every patient who has a torsion in teenagers.
Good communication between the fallopian tube and ovary is important so that when ovulation is happening, the tube gets the eggs and brings it down to meet the sperm.
If doing an oophoropexy and placing the ovary in a safe place, you might unfortunately interrupt good communication with the fallopian tube and ovary.
Providers could iatrogenically introduce some degree of impairment in fertility if not oophoropexying in the right site.
About 30% of oophoropexies end up failing.
Utero-ovarian ligament shortening is one of the oophoropexy approaches that fails more commonly than other approaches.
At the time of actual torsion, the ovaries can look horrible, very edematous and hemorrhagic in nature.
After a torsion, it's not the time to do the oophoropexy; it's an interval procedure when you have fabulous looking ovaries because the ovary has healed well.
Gynecologists use a three-point fixation for stabilization: the uterosacral ligament, the pelvic sidewall, and shortening the uteroovarian ligament.
In prepubertal girls, it can take much longer for edema to regress and come down.
We often don't re-image for as long as about two to three months so that edema is completely resolved.
Follow-up ultrasound should always be done after detorsion.
About 46% of patients won't have any real persistent mass or lesion in the ovary after detorsion.
Some patients may have a longer utero ovarian ligament or longer infundibulopelvic ligament as anatomic differences that predispose them to torsion.
Literature suggests that if you have a very hemorrhagic edematous ovary, you can damage the ovary more by doing cystectomy then, than waiting to do it later.
When intervening acutely during the time of a torsion, we can damage the ovary, and the goal is for follicular survival to preserve future fertility.