Recurrent Ovarian Torsion Following Oophoropexy

Introduction

Ovarian torsion is a gynecologic emergency that can have severe sequelae and, thus, when this occurs, it is treated surgically.

Case

Results

Following the final laparotomy and oophoropexy of the right ovary to the posterior uterine wall, the patient is free of complaints and symptoms.

Discussion

Ovarian torsion is characterized by the twisting of the ovary around its supporting ligaments, causing blood-flow obstruction, which may result in edema, ischemia, and eventual necrosis. It is a surgical emergency, which may result in infertility or even peritonitis if untreated, and has an incidence of 2.5%–7.4% in patients undergoing surgery for pelvic pain. ¹ Presentation commonly includes acute or intermittent abdominal pain, nausea and vomiting, and possible fever.^2,3 Torsion occurs more frequently during the reproductive age and occurs mainly on the right side. It is thought that torsion occurs with unusually long ligaments or in the presence of increased adnexal mass such as occurs with cysts, pregnancy, ovarian hyperstimulation, and polycystic ovaries.^1,2 Although diagnosis may be made clinically and with serum markers and imaging, laparoscopy provides the only definitive diagnosis.^1–3

In this article, a fifth occurrence of ovarian torsion, after oophoropexy for the three previous occurrences, has been described. Whereas oophorectomy was traditionally the standard treatment following torsion, conservative treatment with detorsion has now become the practice of choice although it may predispose patients to recurrent ipsilateral or contralateral torsion.^4,5 Recurrence rates range from 2 to 11%. ⁶ Oophoropexy constitutes a variety of procedures aimed at securing the ovary in a fixed position in order to prevent future recurrences. These procedures include plication of the utero-ovarian ligament, fixation of the ovary to the pelvic sidewall, plication of the utero-ovarian ligament to the round ligament, and fixation of the ovary to the uterine serosa.^4,6 Although many researchers recommend oophoropexy following torsion, there is some debate concerning whether or not to perform oophoropexy on the contralateral ovary. Some researchers propose a procedure on the contralateral ovary for any woman with an episode of torsion,^7–9 whereas other researchers suggest this procedure only in the case of asynchronous bilateral torsion.^4,6 There are concerns regarding possible ovarian and fallopian-tube dysfunction and infertility, and long-term studies will be necessary to determine the safety and the efficacy of these procedures. ¹⁰ Recurrence of torsion may be the result of incomplete removal of a lesion that caused the occurrence. Whereas some researchers recommend only cyst aspiration to prevent recurrence, ¹⁰ others maintain that complete resection of cysts is necessary. ¹¹ The use of oral contraception may reduce recurrent torsion caused by functional cysts, as this treatment decreases incidence of corpus luteum and follicular cysts, ¹⁰ although it is to be noted that this patient was on oral contraception prior to some episodes.

Various oophoropexy procedures,^4,12–14 as well as utero-ovarian ligament shortening,^15,16 have been used in the past for women with recurrent torsion, and although rarely reported, torsion can occur following oophoropexy. ⁴

The majority of articles describing surgical techniques in recurrent ovarian torsion deal with adolescent patients. ¹⁷ It is in these patients specifically that conservative treatment should be encouraged. Oophoropexy procedures have been described in order to prevent future events in patients after unilateral oophorectomy. ¹¹ Although the patient presented here had two viable ovaries, given her youg age, oophorectomy was not advocated. A more-invasive approach was used in the hope of maintaining the function of both ovaries.

This report is the first to describe recurrent episodes of torsion following multiple oophoropexy surgeries, and suggests that a strong index of suspicion must be maintained for ovarian torsion even when prior surgeries have been undertaken to prevent it.

Conclusions

Ovarian torsion must be kept in mind in any case of a woman presenting with lower abdominal pain, as it is an emergency that may have severe consequences. This report and one other described previously demonstrate that oophoropexy is not a fail-proof procedure in the prevention of recurrent torsion. Although torsion did recur following oophoropexy in this patient, it is an important procedure and should be considered in all patients who present with ovarian torsion. Future studies will need to be performed in order to evaluate the effectiveness of oophoropexy fully for the prevention of recurrent torsion.