Journal of Pediatric Surgery 54 (2019) 1453–1456

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Journal of Pediatric Surgery

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Pediatric ovarian torsion: Follow- up after preservation of ovarian tissue

Lina Geimanaite a,b,⁎, Kestutis Trainavicius a,b
a
Vilnius University, Faculty of Medicine, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius, Lithuania
b
Children's Hospital, Affiliate of Vilnius University Hospital Santaros Klinikos, Department of Pediatric Surgery, Vilnius, Lithuania

a r t i c l e i n f o a b s t r a c t

Article history: Background: The aim of this study was to evaluate the efficiency of the preservation of ovarian tissue in cases of
Received 19 April 2018 ovarian torsion.
Received in revised form 14 February 2019 Materials and methods: A retrospective study was performed of patients treated at our hospital for ovarian torsion
Accepted 14 February 2019 from January 2007 to December 2017. This research does not include patients with antenatal ovarian torsion and
1 girl with an immature teratoma, in whom the twisted ovary was removed during the initial operation. Follow-
Key words:
up ultrasonography of all patients was performed after 4–6 weeks and again after more than 12 weeks. Volume,
Ovarian torsion
Conservative management
blood flow and folliculogenesis of the ovary were measured and assessed.
Children Results: All 42 ovaries (39 patients) preserved their normal anatomy and folliculogenesis after detorsion. All pa-
Outcomes tients had an enlarged ovary at the time of detorsion. In all cases of ovarian torsion, enlargement of the ovary up
to an average of 58.14 ± 52.86 (17.37–86.83) ml was detected. After 4–6 weeks, all untwisted ovaries decreased
in volume by an average of 9.01 ± 13.69 (2.33–9.30) times, and 59.5% of them became normal in size. In 3 girls,
enlarged ovaries were still observed after 12 weeks. Teratoma was diagnosed for these patients and ovarian spar-
ing operations were performed.
Conclusions: It is safe to perform detorsion regardless of the level of ischemia or volume of the affected ovary. The
follow-up is essential, especially for the further diagnostics of potential pathological structures or tumors; there-
fore, the normalization of blood flow and the volume of the ovary must be monitored.
Type of study: Prognosis retrospective study.
Level of evidence: II
© 2019 Elsevier Inc. All rights reserved.

Ovarian torsion is a rare pediatric surgery emergency. It accounts for 1. Materials and methods
2.7% of all pediatric abdominal pain causes [1]. The traditional treatment
of the twisted ovary is oophorectomy owing to the fear of peritonitis, This retrospective research included all cases of ovarian torsion
thromboembolism and malignancy. Extensive research has shown treated in the Children‘s Hospital, Affiliate of Vilnius University Hospital
that the fear is overestimated — the risk of thromboembolism or leaving Santaros Klinikos, from January 2007 to December 2017. This research
a malignancy is minimal [2,3]. Conservative surgical treatment proved did not include patients with antenatal ovarian torsion and 1 girl with
to be safe and successful [4,5]. The macroscopic appearance of the an immature teratoma, in whom the twisted ovary was removed during
ovary at the time of surgery is not a reliable sign of the viability of ovar- the initial operation. All of the ovarian torsions were managed by
ian tissue. Therefore, an increasing number of researchers in the last performing detorsion. All patients were followed-up by ultrasonogra-
15 years have suggested conservative treatment for ovarian torsion in phy 4–6 weeks and more than 12 weeks after the ovarian sparing oper-
order to preserve fertility [6–8]. Nevertheless, the number of oophorec- ations. Ovary volume, blood flow and folliculogenesis were evaluated.
tomy surgeries remains high, since only up to 86.4% of twisted ovaries Ultrasonography was performed with a full bladder. Ovary volume
are preserved [2,7,9–15]. was calculated with the formula of ellipsoid: V = 0.5233 × length ×
The aim of this study was to evaluate the outcomes of ovarian tor- width × height [16]. Ovarian volume was evaluated and normality con-
sion management and prove the safety and efficiency of conservative cluded according to Cohen H.L. et al. and Garel L. et al. table [30,31]
surgical treatment. (Table 1). In order to evaluate the dynamics of recovery after detorsion,
the volume ratio of the affected and unaffected ovary was calculated
and the volume ratio at surgery and follow-up was compared.
⁎ Corresponding author at: Vilnius University, Faculty of Medicine, Clinic of Gastroen-
terology, Nephrourology and Surgery, Santariskiu Str.7, LT-08406 Vilnius, Lithuania.
Descriptive analysis was performed using mean ± SD (IQR25%–
Tel.: +370 611 44266; fax: +370 527 20283. IQR75%) (SPSS 22.0). The differences between the groups were ana-
E-mail address: lgeimanaite@gmail.com (L. Geimanaite). lyzed with a normality test. The two variables without a normal

https://doi.org/10.1016/j.jpedsurg.2019.02.004
0022-3468/© 2019 Elsevier Inc. All rights reserved.
1454 L. Geimanaite, K. Trainavicius / Journal of Pediatric Surgery 54 (2019) 1453–1456

Table 1 This research was approved by the Vilnius Regional Biomedical Re-
Normal ovarian volume (Garel et al [30] and Cohen et al. [31]). search Ethics Committee at Vilnius University Faculty of Medicine and
Age Mean Volume (ml) Standard Deviation the Children's Hospital, an Affiliate of Vilnius University Hospital
1 day to 3 months 1.06 0.96
Santaros Clinics.
4–12 months 1.05 0.67
2 0.67 0.35
3 0.7 0.2 2. Results
4 0.8 0.4
5 0.9 0.02
6 1.2 0.4 From 2007 to 2017, 39 girls were treated for ovarian torsion of 42
7 1.3 0.6 ovaries. All of the ovaries were untwisted and left in the abdominal cav-
8 1.1 0.5 ity. The study included female patients from 0 to 18 years old, with an
9 2.0 0.8 average age of 10.48 ± 5.64 (5.53–15.35) years (Table 2). The average
10 2.2 0.7
time from the onset of pain until surgery was 35.98 ± 32.3
11 2.5 1.3
12 3.8 1.4 (14.13–42.13) h. During the laparoscopy, 32 ovaries were deeply isch-
13 4.2 2.3 aemic (black-bluish in color), while 10 were ischemic (bluish in
color). The volume of the twisted ovary was from 3 to 228 ml, with an
average of 58.14 ± 52.86 (17.37–86.83) ml. The twisted ovary was en-
distribution were analyzed using the Mann Whitney Test. The Wilcoxon larged by 14.28 ± 15.18 (5.44–15.50) times in comparison to the con-
Test was used for the variables measured at different time points. The tralateral ovary. Enlargement of the affected ovary less than 10 times
level of statistical significance was set as a p-value less than 0.05. in comparison to the contralateral ovary was observed in 23 patients,

Table 2
Ovarian volume and ovarian volume ratio.

N age Ovaria At the time of torsion 4–6 weeks after detorsion N12 weeks after detorsion Patology
appearacensce at the of ovary
Torsed Contralateral Ovarian Torsed Contalateral Ovarian Torsed Contalateral Ovarian
time of surgery
ovary ovary volume volume ovary ovary volume volume ovary ovary volume volume
volume ml ml ratio volume ml ml ratio volume ml ml ratio

1 6.2 B 41.2 1.44 28.61 17.82 1.44 12.375 1.45 1.44 1.01
2 9.6 B 78.91 2.02 39.06 34.05 2.02 16.85 2.12 2.02 1.05
3 11.8 B 86.8 3.6 24.11 3.9 3.6 1.08 3.5 3.6 0.97 MT at
first
surgery
4 16.4 B 179 14.6 12.26 15.2 14.6 1.04 15.3 14.6 1.05
5 16 B 158.1 12.6 12.55 15.2 12.6 1.2 13.4 12.6 1.06
6 11 B 80.1 2.2 36.41 10.1 2.2 4.59 2.3 2.2 1.05
7 3.5 B 9.43 1.55 6.08 1.57 1.55 1.01 1.56 1.55 1.01
8 2.6 B 8.04 0.77 10.44 0.88 0.77 1.14 0.78 0.77 1.01
9 4.9 B 6.53 0.9 7.25 1.01 0.9 1.12 0.89 0.9 0.99
10 15.3 B 77.9 12.1 6.43 12.4 12.1 1.02 12.3 12.1 1.02
11 0.21 B 9.61 1.04 9.24 1.05 1.04 1.01 0.48 1.04 0.46
12 7.25 BB 15.47 1.45 10.67 1.56 1.45 1.07
13 16.5 B 25.85 12.7 2.03 12.9 12.7 1.02
14 10.9 BB 9.61 2.65 3.62 3.65 2.65 1.37 11.59 2.64 4.39
15 17.25 BB 22.2 12.6 1.76 12.7 12.6 1.01
16 15.5 B 152.77 19.23 7.94 34.46 19.23 1.79
17 0.17 B 50.76 0.69 73.56 0.72 0.69 1.04 0.7 0.69 1.01
18 14 BB 108.64 13.2 8.23 14.8 12.8 1.15 14.9 12.8 1.16 SC
19 14.5 BB 80 12.8 6.25 13.2 12.8 1.03 13.2 12.8 1.03
20 12 BB 40 18 2.22 26.47 10.77 2.45
21 13.9 B 86.9 9.4 9.24 20.2 9.4 2.14
22 16.5 BB 32 10.79 2.97 22.1 15.5 1.42 19 15.5 1.22 PO
23 17 B 41.03 7.02 5.85 6.64 6.76 0.98 11.27 7.77 1.45
24 15.9 BB 106 8.82 12.02 20.2 8.82 2.29 11.3 8.82 1.26
25 14.9 B 30.25 6.5 4.65 6.7 6.5 1.03
26 15.2 B 25 6.7 3.73 7.2 6.7 1.07
27 8.9 BB 28.2 2.35 12 3.77 5.21 0.72 0.6 1.04 0.6
28 0.15 B 9.4 0.53 17.73 0.6 0.53 1.13 0.12 0.44 0.27
29 5.75 B 3 1.27 2.36 1.28 1.27 1.01 1.29 1.27 1.01
30 0.2 B 6.94 0.47 14.76 0.48 0.47 1.02 0.38 0.47 0.81
31 4.5 B 31.3 2.58 12.13 4.7 2.58 1.82 1.85 1.59 1.46
32 15.5 B 127.85 5.6 22.83 9.8 5.6 1.75 4.4 5.6 0.79 PO
33 12.8 B 3 0.6 5 2.56 1.58 1.62 2.56 1.58 1.62
34 10 B 24.41 3.16 7.72 13.73 3.16 4.34 30.6 3.16 9.71 MT
35 3 B 40.03 0.72 55.59 20.55 0.72 28.54 20.09 0.72 27.9 MT
36 13 B 228 9.28 24.57 85 9.38 9.06 54.55 10.57 5.16
37 14 B 90 10.55 8.53 51.77 10.55 4.9 60.7 9.38 6.47 MT
38 0.8 B 18 0.44 40.9 0.3 0.44 0.68 0.3 0.44 0.68
39 10.5 B 48 8.6 5.58 52.34 8.6 6.08 14.24 5.25 2.71
40 12.5 BB 51.98 6.17 8.42 19.22 6.17 3.11
41 17.9 B 104.26 22.85 4.56 20.48 23.27 0.88 9.94 22.85 0.44
42 11.5 B 65.28 6.52 10.01 16.56 6.71 2.46

BB: black-bluish, B: bluish, MT: mature teratoma, PO: polycystic ovary, SC: serous cystadenoma.
 L. Geimanaite, K. Trainavicius / Journal of Pediatric Surgery 54 (2019) 1453–1456 1455

while enlargement of the affected ovary by more than 10 times was ob- 4–6 weeks after detorsion showed a dramatic decrease in volume, in-
served in 19 patients. The average volume ratio of the ovaries with path- crease in blood flow, as well as signs of folliculogenesis in menarcheal
ological structures and nonaffected ovaries was 18.45 ± 14.5 girls and signs of preserved microfollicles in premenarchael girls. There-
(8.28–24.46). The average volume ratio of an ovary without pathologi- fore, we recommend performing follow-up ultrasonography 4–6 weeks
cal structures and nonaffected ovaries was 11.72 ± 15.3 (3.70–12.03). after detorsion of an ovary in all patients. Even if after 4–6 weeks ultra-
There was a statistically significant difference between the group with sonography showed a normal anatomy and follicles (microfollicles) in
pathological structures and the group without pathological structures an affected ovary, we performed further ultrasonographies for research
(p = 0.001). The girls were divided into two groups: premenarcheal purposes.
and menarcheal. Enlargement of the ovary was statistically larger in The scientific literature provides few studies about the follow-up of
the premenarcheal group (p = 0.023). There was no statistically signif- conservative surgical treatment. Parelkar et al. examined the long-
icant difference between the time of disease (p = 0.077) or level of is- term results after the preservation of 13 ovaries in 12 girls with ovarian
chemia (black-bluish, bluish in color) of the ovaries (p = 0.482). torsion, aged 6–12 years [17]. Normal ovarian blood flow and follicular
Detorsion was performed in all cases regardless of the level of ische- structure was observed in 12 ovaries (92%) during ultrasonography
mia or volume of the affected ovary. Detorsion of the ovary was per- 3 months after detorsion of the ovary. In one of the treated patients,
formed laparoscopically in 37 (88.1%) cases. In 5 (11.9%) cases with bilateral ovarian torsion, the left ovary could not be visualized dur-
laparotomy and detorsion were performed. During the operation, ovar- ing the follow up. The authors conclude that detorsion of the twisted
ian cysts were observed in 15 (35.7%) patients, 6 of them in the ovary and the maximal preservation of ovarian tissues are the method
premenarcheal and 9 in the menarcheal group. In 1 patient of choice for the treatment of all pediatric ovarian torsion cases. Oelsner
(premenarcheal), an ovarian teratoma was observed, which was re- et al. studied 102 women and girls after ovarian torsion: folliculogenesis
moved after the ovarian detorsion. In 26 cases, no pathological struc- and macroscopic evaluation of the ovaries was performed with ultraso-
tures were observed. None of the patients required subsequent nography [18]. Overall, 91% of the preserved untwisted ovaries proved
surgery owing to the complications of ovarian detorsion and preserva- to be functional. Walker et al. analyzed 34 pediatric ovarian torsion
tion during the immediate postoperative period. The recurrence of ovar- cases and concluded that, during the long-term follow-up, follicles
ian torsion was seen in 3 patients who underwent a repeated ovarian were observed in 74% of the preserved untwisted ovaries [19]. It was
detorsion and oophoropexy to the womb. concluded that the conservative surgical management of ovarian tor-
All patients underwent ultrasonographic follow-up 4–6 weeks after sion is a safe and successful treatment option [4,5].
detorsion of an ovary. All 42 affected ovaries were visualized, with no at- However, the rate of oophorectomies remains high, since only up to
rophy found. The ovaries were 3.15 ± 5.15 (1.02–2.45) times larger on 86.4% of ovaries are preserved [2,7,9–15]. Spinelli et al. presented a liter-
average than the contralateral ovary. Signs of folliculogenesis were ob- ature review and statistical analysis of pediatric ovarian torsion treat-
served in 33 (78.6%) ovaries (21 in the premenarcheal (microfollicular ment methods from 2000 to 2010 [20]. The research showed that
ovary) and 12 in the menarcheal group), cysts or cyst-like structures conservative surgical tactics have slowly increased in rate from 28 to
were observed in 5 ovaries, and in 2 ovaries there was minimal blood 45%, with the remaining 55% of ovaries undergoing oophorectomy.
flow, while in another 2 there was no blood flow registered. One Common causes of ovarian torsion are ovarian cysts or solid tumors.
month after detorsion of an ovary, the volume of the ovary decreased Walker et al. found benign solid tumors in 8 (30.8%) of the 26 patients
by an average of 9.01 ± 13.69 (2.33–9.30) times, and in one case by treated for ovarian torsion in their study [19]. No malignant tumors
70.73 times. Ovaries returned to their normal size in 24 (57.14%) pa- were identified. Oltmann et al. studied 114 girls treated for ovarian tor-
tients, while they remained enlarged in 18 (42.86%) cases. sion over a course of 15 years [2]. Only 4 (3.5%) malignant tumors were
Thirty-two patients were followed-up after more than 12 weeks identified. Based on our hospital's 30 year experience, only one patient
after detorsion of an ovary. Folliculogenesis according to the age of the was treated for an immature teratoma in a twisted ovary. We perform
patient (multifollicular or microfollicular ovary) and blood flow was ob- the excision of a functional ovarian cyst in a twisted ovary if ischemia
served in all patients, with no atrophy found. The affected ovary was en- is not deep and if the boundaries of the cyst or tumor are clearly defined.
larged by an average of 2.52 ± 5.05 (0.79–1.40) times in comparison to If signs of deep ischemia are observed during detorsion, only aspiration
the contralateral ovary. In 25 (78.13%) patients, the volume of the ova- of the cyst is performed in order to spare the fragile ovarian tissue, since
ries was normal, while in 7 (21.87%) cases they remained enlarged. the boundaries of the cyst become difficult to identify. Normalization of
Three patients were diagnosed with a teratoma, 2 patients with poly- ovarian size can be followed up by ultrasonography. If the ovary re-
cystic ovaries, and 1 patient with serous cystadenoma, with cyst or mains enlarged and pathological structures are continuously observed
cyst-like structures observed in 5 ovaries. Teratoma was diagnosed in during ultrasonography, a tumor should be suspected. In such case, an
3 patients in whom the enlarged ovaries were still observed after AFP test is done after detorsion [11,13,26]. Three girls in our study
12 weeks (refer to Table 2, Patients 34, 35, 37 to see the enlargement were diagnosed with mature teratomas of the twisted ovaries. Their
volume). As a result, ovarian sparing operations were performed. ovarian volume remained 6.47 to 27.9 times enlarged in comparison
The results of both follow-up examinations were compared — all of to the contralateral ovary. All of them had normal AFP before teratoma
the patients' ovaries statistically significantly decreased in size (after extirpation. Four months after detorsion of an ovary, they underwent
1 month: p b 0.001, and after 3 months: p = 0.009). laparoscopic excision of the teratoma with ovarian tissue preservation.
Teratomas were more common in the younger patient group, even Based on our experience, we recommend a 1–1.5 year follow-up in
though there was no statistically significant difference between girls treated for ovarian torsion.
premenarcheal and menarcheal groups (p = 0.635). The ovaries af- Three girls in our study had asynchronous ovarian torsion.
fected by a teratoma were statistically significantly more enlarged Oophoropexy was performed for all of them. The role of oophoropexy
after 1 and 3 months in comparison with teratoma-free ovaries. in treating ovarian torsion is not clear [21–24]. In the past, most authors
suggested this procedure with some reluctance [9], because of the fear
3. Discussion that ovarian fixation could impair the organ, and that the deformed re-
lation between the ovarian follicles and oviduct would decrease fertility
We present our experience of ovarian sparing surgery and demon- [21,25,26]. In recent years, an increasing number of authors started to
strate 100% functional preservation of ovarian tissue. This was moni- support fixation of the ovary after detorsion [23,27–29]. Walker et al.
tored by follow-up adnexal ultrasonography. We performed suggest fixing the ovary only in asynchronous ovarian torsion and in re-
ultrasonography 2–5 days and 2 weeks after detorsion; however, the re- current ovarian torsion cases [19]. We support this opinion. There are no
sults were inconclusive. Adnexal ultrasonography performed at data in the medical literature about complications related to ovarian
1456 L. Geimanaite, K. Trainavicius / Journal of Pediatric Surgery 54 (2019) 1453–1456

fixation, but fixing may theoretically disturb the blood flow and the [8] Guthrie BD, Adler MD, Powell EC. Incidence and trends of pediatric ovarian torsion
hospitalizations in the United States, 2000–2006. Pediatrics 2010;125(3):532–8.
function of the oviduct. Thus, in every case, the possibility of the loss [9] Kokoska ER, Keller MS, Weber TR. Acute ovarian torsion in children. Am J Surg 2000;
of ovaries or impairment of their function owing to oophoropexy must 180(6):462–5.
be discussed with both the patient and their parents [27]. Future fertility [10] Piper HG, Oltmann SC, Xu L, et al. Ovarian torsion: diagnosis of inclusion mandates
earlier intervention. J Pediatr Surg 2012;47(11):2071–6.
testing of girls after oophoropexy is required. [11] Beaunoyer M, Chapdelaine J, Bouchard S, et al. Asynchronous bilateral ovarian tor-
The introduction of conservative surgical management of ovarian sion. J Pediatr Surg 2004;39(5):746–9.
torsion in our clinical practice has led to the conclusion that ovarian tis- [12] Anders JF, Powell EC. Urgency of evaluation and outcome of acute ovarian torsion in
pediatric patients. Arch Pediatr Adolesc Med 2005;159(6):532–5.
sue should be spared in all ovarian torsion cases. Given a low malig- [13] Rousseau V, Massicot R, Darwish AA, et al. Emergency management and conserva-
nancy rate in pediatric ovarian torsion, and the excellent regeneration tive surgery of ovarian torsion in children: a report of 40 cases. J Pediatr Adolesc
of ovarian function after detorsion, we recommend detorsion (and fixa- Gynecol 2008;21(4):201–6.
[14] Campbell BT, Austin DM, Kahn O, et al. Current trends in the surgical treatment of
tion in subsequent torsion cases) of ovaries instead of oophorectomy.
pediatric ovarian torsion: we can do better. J Pediatr Surg 2015;50(8):1374–7.
Our study is limited by the individual institutional experience. Al- [15] Tsafrir Z, Azem F, Hasson J, et al. Risk factors, symptoms, and treatment of ovarian
though we have the data about cases of ovarian torsion from last torsion in children: the twelve-year experience of one center. JMIG 2012;19(1):
30 years, we do not have information about the fertility of the patients 29–33.
[16] Salardi S, Orsini LF, Cacciari E, et al. Pelvic ultrasonography in premenarcheal girls:
with detorsed ovaries. In our hospital the long-term follow-up after relation to puberty and sex hormone concentrations. Arch Dis Child 1985;60(2):
detorsion in girls has been taking place already for 10 years. Such 120–5.
follow-up studies in adulthood are highly desirable. [17] Parelkar SV, Mundada D, Sanghvi BV, et al. Should the ovary always be conserved in
torsion? A tertiary care institute experience. J Pediatr Surg 2014;49(3):465–8.
[18] Oelsner G, Cohen SB, Soriano D, et al. Minimal surgery for the twisted ischaemic ad-
4. Conclusion nexa can preserve ovarian function. Hum Reprod 2003;18(12):2599–602.
[19] Walker SK, Lal DR, Boyd KR, et al. Management of pediatric ovarian torsion: evidence
of follicular development after ovarian preservation. Surgery 2018;163(3):547–52.
The results of this research led to the conclusion that it is safe to per- [20] Spinelli C, Buti I, Pucci V, et al. Adnexal torsion in children and adolescents: new
form detorsion, regardless of the level of ischemia or volume of the trends to conservative surgical approach — our experience and review of literature.
Gynecol Endocrinol 2013;29(1):54–8.
torsed ovary. However, follow-up is essential, especially with regard
[21] Breech LL, Hillard PJ. Adnexal torsion in pediatric and adolescent girls. Curr Opin
to the normalization of blood flow and the volume of the ovary, for fur- Obstet Gynecol 2005;17(5):483–9.
ther diagnostics of potential pathological structures or tumors. [22] Oltmann SC, Fischer A, Barber R, et al. Cannot exclude torsion — a 15-year review. J
Pediatr Surg 2009;44(6):1212–6.
[23] Celik A, Ergun O, Aldemir H, et al. Long-term results of conservative management of
References adnexal torsion in children. J Pediatr Surg 2005;40(4):704–8.
[24] Oelsner G, Shashar D. Adnexal torsion. Clin Obstet Gynecol 2006;49(3):459–63.
[1] Hibbard LT. Adnexal torsion. Am J Obstet Gynecol 1985;152(4):456–61. [25] Cass DL. Ovarian torsion. Semin Pediatr Surg 2005;14(2):86–92.
[2] Oltmann SC, Fischer A, Barber R, et al. Pediatric ovarian malignancy presenting as [26] Cass DL, Hawkins E, Brandt ML, et al. Surgery for ovarian masses in infants, children,
ovarian torsion: incidence and relevance. J Pediatr Surg 2010;45(1):135–9. and adolescents: 102 consecutive patients treated in a 15-year period. J Pediatr Surg
[3] McGovern PG, Noah R, Koenigsberg R, et al. Adnexal torsion and pulmonary embo- 2001;36(5):693–9.
lism: case report and review of the literature. Obstet Gynecol Surv 1999;54(9): [27] Crouch NS, Gyampoh B, Cutner AS, et al. Ovarian torsion: to pex or not to pex? Case
601–8. report and review of the literature. J Pediatr Adolesc Gynecol 2003;16(6):381–4.
[4] Aziz D, Davis V, Allen L, et al. Ovarian torsion in children: is oophorectomy neces- [28] Ozcan C, Celik A, Ozok G, et al. Adnexal torsion in children may have a catastrophic
sary? J Pediatr Surg 2004;39(5):750–3. sequel: asynchronous bilateral torsion. J Pediatr Surg 2002;37(11):1617–20.
[5] Dolgin SE, Lublin M, Shlasko E. Maximizing ovarian salvage when treating idiopathic [29] Mordehai J, Mares AJ, Barki Y, et al. Torsion of uterine adnexa in neonates and chil-
adnexaltorsion. J Pediatr Surg 2000;35(4):624–6. dren: a report of 20 cases. J Pediatr Surg 1991;26(10):1195–9.
[6] Galinier P, Carfagna L, Delsol M, et al. Ovarian torsion. Management and ovarian [30] Garel L, Dubois J, Grignon A, et al. US of the pediatric female pelvis: a clinical per-
prognosis: a report of 45 cases. J Pediatr Surg 2009;44(9):1759–65. spective. Radiographics 2001;21(6):1393–407.
[7] Rossi BV, Ference EH, Zurakowski D, et al. The clinical presentation and surgical [31] Cohen HL, Shapiro MA, Mandel FS, et al. Normal ovaries in neonates and infants: a
Management of Adnexal Torsion in the pediatric and adolescent population. J sonographic study of 77 patients 1 day to 24 months old. Am J Roentgenol 1993;
Pediatr Adolesc Gynecol 2012;25(2):109–13. 160:583–6.