Download Title SYNCHRONOUS BILATERAL OVARIAN TORSION IN A

Title
SYNCHRONOUS BILATERAL OVARIAN TORSION IN A NEONATE,
LAPAROSCOPIC MANAGEMENT
Authors
Murat Alkan1, Ali Elbek2, Cuneyt Evruke3, Ahmet Eray Memec4,
Bülent Aziz Özkan5, Hatice Gülin Sucak6, Ozgur Talat Erkan7
Affiliations
Cukurova University Faculty of Medicine, Department of Pediatric Surgery and Division
of Pediatric Urology1, Department of Obstetrics and Gynecology3, Adana, Turkey
Medline Adana Hospital, Department of Pediatric Surgery2, Obstetrics and Gynecology4,
Pediatrics5, Radiology6 and Anesthesiology7, Adana, Turkey
Corresponding author
Dr. Murat Alkan
Cukurova University Faculty of Medicine
Department of Pediatric Surgery,
Division of Pediatric Urology,
Balcalı, Adana
Turkey
Phone: 00905327402068
Fax: 00903223386428
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Introduction
Asynchronous bilateral ovarian torsion is stated as torsion of each ovary in different time periods.
Synchronous bilateral ovarian torsion is an uncommon entity of which both ovaries twist at the same time
or observed twisted during the surgical intervention. Both situations can be a destructive circumstance
possibly leading to castration. Delay either in diagnosis or operation, ovarian torsion can result loss of
ovarian tissue. We report a case of intrauterine bilateral ovarian torsion in a newborn, which successfully
managed by laparoscopic approach.
Case report
A neonate born at term to a 26 year-old primigravida by elective cesarean delivery was diagnosed with an
intra-abdominal cystic mass at 35th week of pregnancy. A conservative management plan was undertaken
with repeated ultrasonographic evaluations every two weeks. The pregnancy, medical history of the patient
and birth were unremarkable. A female full-term infant of 39+5 week of gestation was delivered with a
birth weight of 4160 gram. Physical examination was unremarkable. Post-delivery ultrasonography
revealed an anechoic uncomplicated cystic mass measuring 5x3.5 cm located in the right pelvis and another
a semi-solid complicated cystic mass was located in the left pelvis with a measure of 5.4x3.8 cm, without
any vascular signal. Both ovaries were not identified. Differential diagnoses were: omental cysts,
mesenteric cysts, intestinal duplications and ovarian torsion. Bilateral unidentified ovaries with bilateral
cystic masses in the pelvis called ‘bilateral ovarian torsion?’ into mind. We asked the parents to perform
laparoscopy in order to preclude the possibility of bilateral torsion of the ovaries. We performed
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laparoscopy after 16 hours of cesarean section.
The initial laparoscopic finding revealed brown round smooth cystic mass with a tiny stalk nearly
amputated from the left fallopian tube in the left pelvis. A loop of intestinal segment also twisted around
this calcified tiny stalk of the mass (Figure 1). We then turned our attention to the right ovary. Right ovary
was twisted with the cystic mass (Figure 2). The cyst nature was uncomplicated. The right ovary was
untwisted 2 times (360 degree) and left in the pelvis after cyst aspiration without excision and ovarian
fixation. Then the left ovary examined and seemed to be nearly amputated from the adnexa. The semisolid
mass was aspirated, and muddy brownish fluid spreaded out to the peritoneal cavity. The tiny calcified
stalk of the cyst leaded obstruction of a segment of small intestine. Calcified stalk separated and the
adhesion with the segment of the intestinal loop released. The brownish ovary with cyst excised via
aspiration. So, left oophorectomy was performed. The right ovary was re-examined. We decided not to
perform oophoropexy or excise the cyst in order to salvage the rest of the ovarian tissue in the patient. The
post-operative period was uneventful and the patient was discharged on the 2 nd post-operative day. Followup with ultrasonographic evaluations showed with a measure of 18 mm, 9 mm and no cyst in the right
ovary in the first, second and third months, respectively.
Discussion:
The differential diagnosis of a cystic abdominal mass discovered by ultrasonography during pre-natal
period derives from the omental cyst, mesenteric cyst, intestinal duplication, urachal cysts, renal cysts and
ovarian cysts 1. Preoperative diagnosis of ovarian torsion is difficult not only in newborns or infants but
also in pre pubertal ages of the children as well. The etiology of the ovarian cysts during pregnancy is
related to the immature hypothalamus-pituitary-ovarian feedback that results gonadal hyperstimulation or
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placental insufficiency with incomplete maturation of the gonadostat 2. In the early pubertal ages,
functional ovarian cysts may be a predisposing cause of ovarian torsion 3. There are few reported patients
of asynchronous bilateral adnexal torsion in children in the literature 4,5. These reports are all about the
asynchronous ovarian torsions that internal between surgeries changes 6 week to 9 years time. Synchronous
bilateral ovarian torsion has been reported with a case of a 26 year-old primigravida with a singleton
pregnancy of 9 weeks gestation due to spontaneous ovarian hyperstimulation syndrome that was
successfully managed by laparoscopic detorsion 6.
When a post-natal radiological evaluation reveals a complicated ovarian cyst, irrespective of the size,
surgical management recommended either by laparoscopy or laparotomy after delivery 7. Uncomplicated
cysts, smaller than 5 cm diameter usually resolve spontaneously while the cysts exceeding 5 cm should be
decompress via aspiration to prevent complications 8.
When we searched the PubMed/Medline databases with the words ‘synchronous’, ‘bilateral ovarian
torsion’, ‘newborn’ or ‘intrauterine’, the result is ‘no items found’. To the best of our knowledge, this is the
first case of bilateral ovarian torsion diagnosed and managed laparoscopically in the neonatal period. This
case highlights the importance of high index of suspicion and early diagnosis of bilateral ovarian torsion in
the newborn that bilateral pelvic cysts detected in the pre-natal and post-natal period.
References:
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Figure Legends:
1.
Figure 1: A loop of intestinal segment twisted around the calcified stalk of the left brownish ovary
2.
Figure 2: Twisted right ovary
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