Adnexal torsion in girls: Predictors and methods for surgical treatment. Case reports and review

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Abstract

Modern diagnostic and treatment methods make it possible to establish a preoperative diagnosis of uterine torsion and provide surgical assistance. Thus, the causes of this disease and the scope of surgical treatment must be investigated. This study reports the cases of 20 patients aged 3–17 years with uterine torsion who were treated at the St. Vladimir Children’s City Clinical Hospital between 2017 and 2023. Ultrasonography is a mandatory preoperative screening diagnostic method. All patients underwent laparoscopic surgery. During the postoperative period, magnetic resonance imaging was performed to confirm the diagnosis. Increased ovarian size due to cysts (7), paramesonephric cysts (4), and fixed lateroflexion (6) were identified as predictors of torsion. In 3 (15%) patients, the cause of torsion was unknown. Paramesonephric cysts were resected, and two adnexectomies were performed. After detorsion, 12 (60%) patients underwent fixation of the appendages. A literature search was conducted using PubMed, Scopus, eLibrary, and RSCI. A total of 47 articles were analyzed, 58 articles were reviewed, and 39 on the problems of determining predictors of uterine torsion in children and methods of surgical correction were selected. Based on the data obtained, the main disease predictors were clarified. A change in the angle of the uterus (lateroflexion) was found to cause the atypical location of the ovaries, which in turn can lead to torsion of the changed or unchanged appendage. Suggestions have been made regarding the connection between connective tissue dysplasia and uterine lateroflexion in the development of adnexal torsion in childhood. The results confirmed the complexity of the radiological diagnosis of lateroflexion. The scope of the surgical intervention for acute torsion of the uterine appendages was dependent on the etiology of the torsion and the degree of ischemia of the appendage. Various options for detorsion with unilateral and bilateral oophoropexy and without fixation of the injured appendage have been proposed. Removal of uncomplicated paramesonephric formations of the uterine appendages identified during diagnostic laparoscopy is a simple procedure and helps prevent torsion. Thus, puncture of accidentally detected ovarian cysts in patients who have not been examined for tumor markers is deemed inappropriate.

About the authors

Dmitry V. Donskoy

Russian Medical Academy of Continuous Professional Education; Children’s State Hospital of St. Vladimir

Author for correspondence.
Email: dvdonskoy@gmail.com
ORCID iD: 0000-0001-5076-2378
SPIN-code: 8584-8933

MD, Cand. Sci. (Medicine)

Russian Federation, Moscow; Moscow

Sergey A. Korovin

Russian Medical Academy of Continuous Professional Education

Email: korovinsa@mail.ru
ORCID iD: 0000-0002-8030-9926
SPIN-code: 2091-6381

MD, Dr. Sci. (Medicine)

Russian Federation, Moscow

Alexey V. Vilesov

Children’s State Hospital of St. Vladimir

Email: vilesov.alexej@yandex.ru
ORCID iD: 0009-0001-4545-9590
SPIN-code: 2081-3871
Russian Federation, Moscow

Roman А. Akhmatov

Russian Medical Academy of Continuous Professional Education; Children’s State Hospital of St. Vladimir

Email: Romaahmatov@yandex.ru
ORCID iD: 0000-0002-5415-0499
SPIN-code: 9024-8324
Russian Federation, Moscow; Moscow

Kadidiatou D. Sangare

Russian Medical Academy of Continuous Professional Education

Email: tanti_sangare@yahoo.fr
ORCID iD: 0000-0003-2395-5777
Russian Federation, Moscow

Olga A. Alimova

Children’s State Hospital of St. Vladimir

Email: dr.olga_andreevna@mail.ru
ORCID iD: 0009-0007-0679-885X
Russian Federation, Moscow

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2. Fig. 1. Adnexal torsion with transient lateroflexion of the uterus: a — adnexal torsion on the right; classical transient right-sided uterine lateroflexia caused by the mass effect; and b — condition after detorsion. The uterus is in a central position

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3. Fig. 2. Adnexal torsion with left-sided lateroflexion of the uterus: a — adnexal torsion on the left; b — the condition after detorsion; and the yellow line means conditional; c — the layout of the torsioned adnexal (arrow)

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4. Fig. 3. Adnexal torsion on the left: a — torsion of the “healthy” adnexa on the left. The arrow indicates the torsioned left ovary; b — right-sided uterine lateroflexia; the yellow line indicates the conditional central axis; and c — scheme of the formation of a free space in the pelvis (arrow)

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5. Fig. 4. Adnexal torsion on the right: a — the left ovary above the uterus (arrow); b — state after detorsion. The left ovary maintains its position. The right adnexa in the free abdominal cavity (arrow)

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6. Fig. 5. Adnexal torsion on the left. Condition after detorsion. Left-sided lateroflexion of the uterus. The arrow indicates a left-sided inguinal hernia

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7. Fig. 6. Endoscopic view during revision of the pelvic organs. The arrow points to the left-sided lateroflexion of the uterus

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8. Fig. 7. Magnetic resonance tomography of the lower abdominal cavity. The uterus is in the anteflexio and retroversio position, with clear boundaries. The body is tilted to the left (arrow). The right ovary at the entrance to the pelvis (oval)

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