{"paper_id":"2795484b-4b12-4580-a888-ce28dfd48017","body_text":"THIEME\n43Pictorial Essay\nImaging of Subcutaneous Ovarian Transposition and \nIts Rare Complications—A Pictorial Assay\nThara Pratap 1   K. Chithratara 2 Muhammed Jasim Abdul Jalal 3 Dhanya Jacob 1 A.K. Vishnu 1\n1Department of Radiology, VPS Lakeshore Hospital, Kochi, Kerala, \nIndia\n2Department of Surgical and Gynaec Oncology, VPS Lakeshore \nHospital, Kochi, Kerala, India\n3Department of Internal Medicine and Rheumatology, VPS \nLakeshore Hospital, Kochi, Kerala, India\npublished online\nAugust 5, 2021\nAddress for correspondence Muhammed Jasim Abdul Jalal, \nMBBS, DNB, MNAMS, MRCGP (UK), MRCP (UK), Department of \nInternal Medicine and Rheumatology, VPS Lakeshore Hospital, \nNettoor PO, Maradu, NH 47 Bypass, Kochi 682040, Kerala, India \n(e-mail: jasimabduljalal@yahoo.com).\nOvarian transposition, as the name implies, is transpositioning the ovary from its nor-\nmal anatomical position to another location. This procedure is usually done to preserve \nthe ovarian function. The most common indication of ovarian transposition is early \ncervical cancer in young premenopausal women to preserve fertility. Subcutaneous \novarian transposition can also be done for benign conditions such as adenomyosis and \nsevere endometriosis in young premenopausal women. We discuss our experience \nwith ovarian transposition in 9 cases, normal ultrasound and CT imaging findings in \ntransposed ovaries, and rare complications which occurred in 2 cases.\nAbstract\nDOI https://doi.org/  \n10.1055/s-0041-1731965  \nISSN  2581-9933\n© 2021. Indian Society of Gastrointestinal and Abdominal Radiology.\nThis is an open access article published by Thieme under the terms of the Creative \nCommons Attribution-NonDerivative-NonCommercial-License, permitting copying \nand reproduction so long as the original work is given appropriate credit. Contents \nmay not be used for commercial purposes, or adapted, remixed, transformed or \nbuilt upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).\nThieme Medical and Scientific Publishers Pvt. Ltd. A-12, 2nd Floor, \nSector 2, Noida-201301 UP, India\nIntroduction\nOvarian transposition is a rare procedure where the normal \nfunctioning ovary is repositioned from its normal anatomical \nposition to another location in the peritoneum or retroperi -\ntoneum mostly to the lateral paracolic gutter or anterior to \nthe psoas muscle above the pelvic brim or rarely in the sub -\ncutaneous region in the abdominal wall.\nThis procedure is usually done to preserve the ovarian \nfunction and hence preserve fertility and quality of life in \nyoung premenopausal women, mostly with early malig -\nnancy, who may require radiotherapy. The ovary, if healthy, \ncan be transposed outside the radiation field by a simple \nprocedure. Ovarian transposition can also be done for benign \nconditions like adenomyosis and severe endometriosis in \nyoung premenopausal women for easy ovum retrieval and to \npreserve fertility.\nThe surgical procedure is simple and can be performed \nmostly by laparoscopic method or open surgery. Laparoscopic \nreimplantation is less cumbersome compared with open sur-\ngery. It is done either with definitive surgery or as a sepa-\nrate procedure before radiotherapy. If ovarian transposition \nis done at the time of an extensive surgery, risk of vascular \ncompromise may be higher.1\nEither one or both ovaries can be transposed, though one \novary is enough to preserve the ovarian function. The posi -\ntion of transposed ovaries varies according to the extent of \nthe radiation field planned.\nSubcutaneous transposition was done in our center for \n9 patients from 2014 to 2019 ( ►Table 1). The age group \nJ Gastrointestinal Abdominal Radiol ISGAR 2022;5:43–48\nKeywords\n ► subcutaneous ovarian \ntransposition\n ► ovarian preservation\n ► endometriosis\n ► adenomyosis\n ► fertility\n ► radiotherapy\n ► ovarian \ndysgerminoma\n ► fibroid\nArticle published online: 2021-08-05\n\n44\nSubcutaneous Ovarian Transposition Pratap et al.\nJournal of Gastrointestinal and Abdominal Radiology ISGAR Vol. 5 No. 1/2022 © 2021. Indian Society of Gastrointestinal and Abdominal Radiology\nranged from 23 to 36 years. Out of the 9 cases, 2 were of \nadenomyosis; one of uterine fibroid; one of ovarian dysger-\nminoma; and others of malignancy—cervical, endometrial, \nand ovarian. Of the 9 cases, there were complications only in \n2 cases. We discuss the imaging findings of the normal trans-\nposed ovary as well as the rare complications.\nSurgical Procedure\nThe ovaries and vascular pedicle were dissected from \ntheir ligamentous attachments to the uterus, mesovar-\nium. Adequate length of vascular pedicle was secured and \nimplanted either in the lateral abdominal wall or in the sub-\ncutaneous region.\nThe pedicle was brought out lateral to the cecum on the \nright side and lateral to the sigmoid-descending colon on the \nleft side. Care was taken to ensure that the pedicle was not \ntwisted. Fallopian tube was also removed. Literature search \nshows that to facilitate easy bringing out and positioning of \nthe ovary in the anterior abdominal wall, the fallopian tube \nis not removed in some centres.2 The ovary was extraperito-\nnealized in all the cases.\nAt our center, ovaries were positioned in the deep sub -\ncutaneous plane right or left paramedian infraumbilical \nregion, so that they can be easily assessed on ultrasound scan \n(USS) with a high-resolution probe. This is to facilitate ovum \nretrieval as well as for the early detection of complications.\nNormal imaging findings and shown in ►Figs. 1 –3.\nAll the patients were on regular follow-up with USS. Most \nof the patients were asymptomatic; however, on follow-up \ntwo patients developed complications.\nWe herein highlight the imaging findings of the complica-\ntions of ovarian transposition in two cases.\nTable  1  Summary of 9 patients who underwent subcutaneous ovarian transposition\nID Age, y Year Indication Marital Status Position\nCase 1 35 2017 Adenomyosis with endometriosis Married, \nnulliparous\nSubcutaneous, unilateral \nright\nCase 2 29 2016 Carcinoma endometrium\nFIGO 1a\nUnmarried Subcutaneous, unilateral \nright\nCase 3 33 2018 Adenomyosis with endometriosis Married, com-\npleted family\nSubcutaneous, unilateral \nright\nCase 4 23 2017 Carcinoma ovary with deposits on the sur-\nface of ovary/fallopian tube\nstage 1c\nMarried, \nnulliparous\nSubcutaneous, unilateral \nright\nCase 5 36 2018 Large multiple subserous leiomyomas where \npreoperative diagnosis was spindle cell \nneoplasm\nMarried, com-\npleted family\nSubcutaneous, unilateral \nright\nCase 6 31 2018 Intraepithelial neoplasia; endometrial malig-\nnancy, FIGO stage 0\nMarried, \nnulliparous\nSubcutaneous, unilateral \nright\nCase 7 36 2019 Endometrial adenocarcinoma, FIGO 1a Married, \nnulliparous\nSubcutaneous, unilateral \nright\nCase 8 27 2014 FIGO 1a adenocarcinoma Married \nnulliparous\nSubcutaneous, unilateral \nright\nCase 9 31 2015 Dysgerminoma Married, not \ncompleted \nfamily\nSubcutaneous, unilateral left\nAbbreviation: FIGO, The International Federation of Gynecology and Obstetrics.\nFig. 1  (A--C) High-resolution ultrasound showing normal transposed ovary in the subcutaneous anterior abdominal wall in the right parame -\ndian region showing normal ovarian follicles (arrow).\n\n\n45\nSubcutaneous Ovarian Transposition Pratap et al.\nJournal of Gastrointestinal and Abdominal Radiology ISGAR Vol. 5 No. 1/2022 © 2021. Indian Society of Gastrointestinal and Abdominal Radiology\nCase Report 1\nA 35-year-old woman who did not have any child had grade \n3 endometriosis. She underwent total abdominal hysterec-\ntomy and left oophorectomy with right ovary transposition \nin the subcutaneous region of right iliac fossa. There were \nseveral causes for transposing the ovary rather than retain -\ning it in the abdomen. She had severe endometriosis, with a \npossibility of endometriosis developing in the retained ovary. \nAlso, there were dense peritoneal adhesions which might \npredispose to the development of peritoneal inclusion cyst. It \nwas also considered reassuring that subcutaneous transposi-\ntion would help in the early detection of endometriosis and, \nat the same time, give ease of surgical access if endometriosis \ndevelops.\n►Fig. 4  shows high-resolution ultrasound images of the \ntransposed right ovary in the abdominal wall. The ovary \nappears bulky with prominent follicles.\nThe patient was doing well but presented 3 years later \nwith acute-onset right lower abdominal pain, abdominal \ndistension, and 3 to 4 episodes of bilious vomiting. Contrast-\nenhanced computed tomography  showed normal transposed \nright ovary in the anterior abdominal wall. ►Fig. 5 shows the \nbowel loops were dilated suggestive of subacute intestinal \nobstruction (SAIO) with transition at the distal ileal loop in \nthe right iliac fossa ( ►Fig. 5E, F). There was beaking at the \ntransition zone with twisting of bowel loops around the \ntransposed right ovarian pedicle. Transposed ovary was of \nnormal size, in the anterior abdominal wall.\nWith a diagnosis of SAIO, due to adhesion and twisting \nof ileal loops around the ovarian pedicle, the patient was \ntaken up for surgery, findings were confirmed, the twisting \nwas released, and ovary was conserved. The patient has been \nasymptomatic after that and is on follow-up.\nCase Report 2\nA 29-year-old unmarried woman was evaluated for irreg -\nular bleeding per vaginam and polymenorrhagia, and was \nfound to have an endometrial polyp. Polypectomy was done \nwhich was reported as endometrioid adenocarcinoma grade \nII. Ca 125 (10.4 U/mL) and CEA (0.59 ng/mL) were normal. \nDilatation and curettage showed endometroid adenocarci -\nnoma with areas of complex hyperplasia with atypia. Total \nabdominal hysterectomy was suggested but the patient was \nunwilling for surgery. Initial fluorodeoxyglucose (FDG) posi-\ntron emission tomography (PET) CT did not show evidence of \ndisease in the uterus or abdomen. Hence, hormone-eluting \ndevice (Mirena, Bayer. Whippany, New Jersey) was inserted \nand the patient was kept on follow-up. A year later, she pre-\nsented with heavy irregular bleeding. Repeat FDG PET CT after \na year showed ill-defined FDG-avid hypodense area in the \nFig. 2  (A, B) Contrast-enhanced computed tomography axial scans \nat the level of transposed ovary showing normal-sized ovary in the \nright paramedian subcutaneous fat (arrow) with pedicle contain -\ning ovarian artery and vein (arrowhead).(C ) Three-dimensional \nangiography/(D ) surface-shaded display showing ovarian pedicle \nwith ovarian artery (A ) arising from the lower aorta (B ) supplying the \ntransposed ovary (C ).\nFig. 3  (A,B) Normal transposed ovary in the left paramedian region \non high-resolution ultrasound and axial CT (arrow).\nFig. 4 Case 1: This 35-year-old woman who had not completed her \nfamily presented with severe endometriosis and underwent total \nabdominal hysterectomy and left oophorectomy with right ovar-\nian transposition in the anterior abdominal wall. Transabdominal \n(A) and high-resolution ultrasound scan (B–D) shows mildly bulky \nright ovary with prominent ovarian follicles (arrow).\n\n\n46\nSubcutaneous Ovarian Transposition Pratap et al.\nJournal of Gastrointestinal and Abdominal Radiology ISGAR Vol. 5 No. 1/2022 © 2021. Indian Society of Gastrointestinal and Abdominal Radiology\nendometrium, suspicious of recurrence. She underwent mod-\nified radical hysterectomy with left salpingo-oophorectomy \n+ right salpingectomy + right ovarian transposition. Ovarian \ntransposition was done to preserve fertility.\nThe final histopathology was endometrioid type—grade II \ntumor ~5.5 cm × 1.5 cm × 1 cm in size, infiltration involv -\ning less than half of myometrium with no lymphovascular \nemboli. Right and left parametrium and paracervical tis -\nsue and bilateral pelvic lymph nodes were free of tumor. \nThere was no distant dissemination. Endometrial carcinoma \nwas staged as 1a (FIGO [The International Federation of \nGynecology and Obstetrics] staging). The patient was on con-\nservative management.\nHowever, 2 years later, she presented with pain and \nenlargement at the site of transposed right ovary. Repeat FDG \nPET CT (►Fig. 6A, B) showed mildly enlarged transposed ovary \n(4.1 cm × 2.2 cm) with PET uptake (SUV) maximum 9.1 in \nthe solid area, along with few enlarged mediastinal, prevas -\ncular, and external iliac nodes suspicious of recurrence. \nThe patient denied biopsy. The size of ovary was gradually \nincreasing in size. Another FDG PET CT (►Fig. 7A, B) was done \na year later and showed further enlargement in the size of \nthe transposed ovary with solid-cystic appearance (84 mm × \n80 mm × 86 mm), with FDG uptake and SUV of 19.7. PET scan \nalso showed avid lung nodules and para-aortic nodes with \nother pelvic deposits, suggesting progression. Axial images \n(►Fig. 7C, D) at the level of renal hilum, showing FDG-avid \npara-aortic nodes (arrow). Axial images ( ►Fig. 7E, F) at the \nlevel of pelvis, showing other peritoneal and abdominal wall \ndeposits.\nTrucut biopsy and histopathology from the transposed \novary was consistent with adenocarcinoma. The disease had \ndisseminated by this time and hence she was started on che-\nmotherapy with taxol and carboplatin.\nDiscussion\nIn young premenopausal patients with early malignancy \nwhere the ovaries are normal and can be preserved, ovarian \ntransposition is an option to preserve the ovarian function. \nThe ovaries are transposed outside the radiation field mainly \nto minimize the chance of ovarian failure.\nOvarian irradiation accelerates the natural process of fol -\nlicular atresia, leading to premature menopause. 3 Complete \novarian failure has been known to occur after radiation doses \nin the region of 20 Gy in women younger than 40 years and \nafter 6 Gy in older women. Ovarian transposition is 44 to 85% \neffective in preserving ovarian function.4\nLiterature search shows that ovarian transposition is \nmostly done for early cervical cancers; few cases have been \ndone for vaginal cancer and nongynecological causes like rec-\ntal cancers, sarcoma, and lymphoma which require pelvic irra-\ndiation. The most common indication of ovarian transposition \nis early cervical cancer in young premenopausal women.\nGuo et al performed ovarian transposition in 34 patients \nfrom August 1989 to December 2000. Apart from malignant \nFig. 5 (A, B) Case 1: After 3 years, the patient presented with abdom -\ninal pain and underwent contrast-enhanced computed tomography \n(CECT). Axial CECT shows dilated proximal and mid small bowel \nloops (arrow). The transposed ovary appears normal in size and is \nseen in the anterior abdominal wall right paramedian region (arrow -\nhead). (C, D) Sagittal and coronal CECT shows the normal-appearing \ntransposed ovary (arrow) in the subcutaneous fat with the pedicle \n(arrowhead). (E, F) Axial and coronal CECT scan of the same patient \nshowing dilated small bowel loops (arrowhead) with transition at the \nRIF region (arrow) with collapsed small bowel loops distally. Case 2: \nA 29-year-old unmarried woman with endometrial carcinoma FIGO \n(The International Federation of Gynecology and Obstetrics) stage \n1b, underwent total abdominal hysterectomy, left salpingo-oopho -\nrectomy, and right ovarian transposition. After 2 years, she presented \nwith abdominal pain at the site of transposed ovary and hence PET CT \nwas done. Axial FDG PET scan was performed. CT, computed tomog -\nraphy; FDG, fluorodeoxyglucose; PET, positron emission tomography.\nFig. 6  (A) Transposed right ovary in the anterior abdominal wall \nwith follicle (arrow) and PET uptake with SUV of 9.1 in the solid area \n(arrowhead). The patient had denied biopsy. (B ) Case 2: The lesion \nwas gradually increasing in size. After a year, a repeat FDG PET CT \nwas done. .\n\n\n47\nSubcutaneous Ovarian Transposition Pratap et al.\nJournal of Gastrointestinal and Abdominal Radiology ISGAR Vol. 5 No. 1/2022 © 2021. Indian Society of Gastrointestinal and Abdominal Radiology\nlesions, 12 patients had stage III to IV endometriosis, 4 had \nmyoma of uterus, and 1 had dysfunctional uterine bleed-\ning.5 The short-term and long-term endocrine function of \nthe translocated ovary remained normal in benign as well as \nmalignant lesions.\nOvarian exteriorization was first described by Kovasev in \nthe setting of carcinoma. This has been successfully done in \n27 patients with no major complications and this may be the \npreferred option if ovarian preservation is planned.6\nThe advantages of subcutaneous implantation are early \ndetection of complications, easy surgical access to cyst \nremoval, and facilitation of in vitro fertilization. The first-ever \nreported case of ovarian hyperstimulation and percutaneous \naspiration of oocytes from a transpositioned right ovary is \nfrom India. Global literature survey has shown published \ncase reports of transabdominal aspiration for retrieval but \nnone using percutaneous technique, resulting in a successful \npregnancy.2\nComplications described in transposed ovary are ovarian \ncysts, ovarian edema, ovarian torsion, peritoneal inclusion \ncysts, and, rarely, ovarian failure and metastasis.\nThere are very few reported cases of ovarian torsion after \ntransposition. Enlargement of the ovary from ovarian stimu-\nlation and an elongated vascular pedicle were thought to be \ncontributing factors in these cases.6 Extensive ovarian mobi-\nlization can also predispose to torsion. 7 Peritoneal inclusion \ncysts can form because of postoperative adhesions, seen with \nlateral transposition of ovaries.\nThe risk of malignancy is rare, approximately 2% in the \ntransposed ovary, more in adenocarcinoma and in tumors \ninvolving the uterine body with lymphovascular invasion. \nSutton et al reported that incidence is 0.5% in squamous \ncell carcinoma, compared with 1.6% for adenocarcinoma. 1 \nHowever, it is uncommon in early stage cervical cancers.\nSystematic review of 24 cases by Gubbala et al in 2014, \nwith lateral ovarian transposition, shows that there is fairly \ngood preservation of ovarian function, with only an accept-\nable risk of ovarian cysts and low risk of metastasis in trans-\nposed ovaries.1\nConclusion\nThe main purpose of ovarian transposition is to preserve \nfertility in those with early cancer or benign conditions like \nsevere refractory endometriosis. Subcutaneous implantation \ncompared with the lateral transposition highlighted here \nprovides easy surgical access to remove the ovary in case of \nany complication.\nThe transposed ovaries can be stimulated to produce fol -\nlicles and ovum and can later be retrieved under ultrasound \nguidance from the new sites, be it paracolic gutter or anterior \nabdominal wall. In vitro fertilization and embryo transfer can \nbe done into a surrogate uterus, allowing a patient to have \nher own biological child in cases of early malignancy.\nLaparoscopic ovarian transposition is a simple, safe, effec-\ntive, and a forgotten procedure for young premenopausal \npatients receiving radiotherapy. 4 This novel technique can \nbe safely done in properly selected cases to preserve fer-\ntility and, hence, should be encouraged. The complications \nhighlighted here are very rare and should not defer one from \nchoosing the procedure.\nEthical Approval\nWritten informed consent was obtained from the patient \nfor publication of this case report and any accompanying \nimages.\nAuthors’ Contributions\nT.P. was involved with analysis and interpretation of data \nfor the work, revising it critically for important intellec -\ntual content, and giving final approval of the version to \nbe published. C.K. was involved with analysis and inter-\npretation of data for the work, revising it critically for \nimportant intellectual content, and giving final approval \nof the version to be published. M.J.A.J. was involved with \nsubstantial contributions to the design of the work, anal -\nysis and interpretation of data for the work, drafting the \nwork, and revising it critically for important intellectual \nFig. 7  (A, B) After 1 year—enlargement in the size of ovary (84 mm \n× 80 mm × 86 mm), with complex cystic appearance (arrow) and \nincreased PET uptake with SUV 19.7 (arrowhead). (C, D) In addition \nthere were retroperitoneal nodes. Axial CECT at the level of renal \nhilum shows FDG-avid para-aortic nodes (arrow) suggesting met-\nastatic lymph nodes. (E, F) Axial PET CT at the level of pelvis also \nshowed other peritoneal (arrowhead) and abdominal wall deposits \n(arrow), suggesting disseminating disease. CECT, contrast-enhanced \ncomputed tomography; CT, computed tomography; FDG, fluorode -\noxyglucose; PET, positron emission tomography.\n\n\n48\nSubcutaneous Ovarian Transposition Pratap et al.\nJournal of Gastrointestinal and Abdominal Radiology ISGAR Vol. 5 No. 1/2022 © 2021. Indian Society of Gastrointestinal and Abdominal Radiology\ncontent. D.C. and V.A.K. were involved with analysis and \ninterpretation of data for the work.\nFunding\nNone.\nConflict of Interest\nNone declared.\nReferences\n1 Gubbala K, Laios A, Gallos I, Pathiraja P, Haldar K, Ind T. \nOutcomes of ovarian transposition in gynaecological cancers; a \nsystematic review and meta-analysis. J Ovarian Res 2014;7:69\n2 Selvaraj P, Selvaraj K, Gangadharan C, Annigeri V,  \nSrinivasan K, Sivakumar M. India’s first successful surrogate \nbirth after percutaneous oocyte retrieval following modified \nradical hysterectomy and right ovarian transposition to the \nanterior abdominal wall. J Hum Reprod Sci 2019;12(3):262–266\n3 Welsh LC. Impact of pelvic radiotherapy on the female geni -\ntal tract and fertility preservation measures. World J Obstet \nGynecol 2014;3(2):45–53\n4 Winarto H, Febia E, Purwoto G, Nuranna L. The need for \nlaparoscopic ovarian transposition in young patients with \ncervical cancer undergoing radiotherapy. Int J Reprod \nMed 2013;2013:173568\n5 Guo Y, Shen W, Jiang Y, Liu W, Li X. Application of ovar-\nian transposition during hysterectomy. Chin Med J \n(Engl 2003;116(5):688–691\n6 Simstein R, Merenich W, Graber J, Ferrell M. A case report of \novarian torsion following ovarian transposition for cervical \ncancer. Emerg Radiol 2020;27(5):569–572\n7 Gómez-Hidalgo NR, Darin MC, Dalton H, et al. Ovarian tor-\nsion after laparoscopic ovarian transposition in patients with \ngynecologic cancer: a report of two cases. J Minim Invasive \nGynecol 2015;22(4):687–690","source_license":"CC0","license_restricted":false}