De-torsion without oophoropexy for torsion of normal ovary in children: a report of 10 cases

De-torsion without oophoropexy for torsion of normal ovary in children: a report of 10 cases | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review De-torsion without oophoropexy for torsion of normal ovary in children: a report of 10 cases Fei Duan, Huizhong Niu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6031448/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Study objective Torsion of normal ovary is rare in children. There is no consensus on the optimal method. A preliminary study of the clinical features of normal ovarian torsion and the efficacy and feasibility of de-torsion without oophoropexy in children. Design Retrospective analysis of the clinical data of 10 girls with normal ovarian torsion treated in the Department of General Surgery,Hebei Provincial Children's Hospital from May 2018 to December 2023.According to whether the ovaries have atrophied and disappeared during follow-up,they were categorized into atrophy group(4 cases) and non-atrophy group(5 cases).The age,affected side, nausea and vomiting,fever,onset-operation time,degree of torsion,color of ovary,preoperative and postoperative neutrophil(NE),C-reaction protein(CRP) and white blood cell(WBC) were compared between the two groups.The surgical procedure was laparoscopic de-torsion without oophoropexy.Hematoma removal in 5 cases of severely congested ovaries.Follow up the children for recurrent torsion and recovery of ovarian function. Participants Childrenwith a diagnosis of normal ovarian torsion intraoperatively confirmed and surgically treated in our department. Results There was statistical differences in onset-operation time, color of ovary,preoperative CRP and nausea and vomiting(P0.05). No recurrent torsion after laparoscopic de-torsion without oophoropexy.Normal ovarian morphology and functional recovery in the non-atrophy group. Conclusions High incidence of atrophy after de-torsion of normal ovarian torsion in children.There was no recurrent torsion without oophoropexy.Children with longer onset, darker ovaries and higher preoperative CRP are more likely to develop ovarian atrophy postoperatively, but those with nausea and vomiting are less likely to develop ovarian atrophy. Normal ovarian torsion De-torsion Atrophy Efficacy Children Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Ovarian torsion(OT) includes pathological ovary and normal ovary. Ovarian cyst or masses are the main risk factor for OT. OT without an adnexal mass is thought to be a lengthy utero-ovarian ligament and mesosalpinx that increase the risk of torsion [ 1 ] .A smaller uterus on the long axis has also been considered a risk factor [ 2 ] .Since no mass triggers torsion in these cases, normal ovaries are prone to re-torsion, especially in premenarcheal children [ 3 ] .Various oophoropexy or shortening of the utero-ovarian ligament are usually used to reduce recurrence.However, the incidence of normal ovarian torsion in children is low and there are no standardized treatment criteria.Retrospective analysis of the clinical characteristics of 10 girls with normal ovarian torsion treated in our department.Observe the efficacy and prognosis of laparoscopic ovarian de-torsion without oophoropexy. Material and Methods 1. Research object In this retrospective study, 10 girls were underwent surgical treatment for torsion of normal ovarian in our department from May 2018 to December 2023.Exclude children with pathologic ovaries, including ovarian cysts, ovarian teratomas, and ovarian malignancies.Mean age of girls was 5 years and 8 months(4 months-12 years), all premenarchal children.The surgical procedure was laparoscopic de-torsion without oophoropexy. 2. Observation indicators The cases were categorized into atrophy group and non-atrophy group according to whether or not the ovaries recovered during follow-up.Comparison of age, clinical symptoms (fever, onset-operation time, nausea and vomiting), blood test [CRP, WBC, NE], intraoperative findings (affected side of ovarian torsion, degree of torsion, and color of the ovary) between the two groups.Ultrasound follow-up of children with recurrent OT.Monitoring of ovarian morphology and size and follicular development to assess whether ovarian function has recovered. 3. Statistical processing Data were analyzed using SPSS 27.0 (IBM, Armonk, NY).Normality test for measurement data using the Shapiro-Wilk test.Categorical data was expressed as proportions (%) and the x² test was applied to compare differences between groups.Normally distributed data were expressed as x±s and analyzed using the independent samples t-test.Non-normally distributed data were expressed as M(Q 1 ,Q 3 ) and analyzed using the independent sample Mann-Whitney U test. A P value of less than 0.05 was considered statistically significant. Results In the past 4.5 years, our department has diagnosed and treated 70 cases of OT in children, with a total of 71 ovaries affected.Normal ovarian torsion totaled 10 cases, accounting for 14.1% of all OT (including pathological OT) during the same period in our department.9 girls were unilateral OT, and 1 child underwent ovarian torsion repositioning with ovarian cyst removal for the right ovary 2 months before the left normal OT. Ultrasound in all the children showed rotation at the root of the ovaries, namely "whirlpool sign" (see Fig.1).Patients were underwent urgent laparoscopy with surgically confirmed OT in the absence of an associated adnexal mass.The procedure was de-torsion with preserving the ovary tissue.The ovaries and fallopian tubes were placed back in their original anatomical position(see Fig.2).Hematoma removal was performed in 5 ovaries with severe hyperemia and edema. Incision of the ovarian cortex at the site of hemodynamic recovery to remove old blood clots and necrotic tissue to prevent re-torsion of the enlarged ovary(see Fig.3).Oophoropexy and utero-ovarian plication were not performed.Average timing of follow-up was 28.4 months (9 months - 43 months).1 case was lost, 4 cases had atrophy of the affected ovaries, and 5 cases had normal ovarian morphology and follicular development after surgery(see Fig.4).There were no complications such as recurrent torsion or abdominal infection during follow-up. There was statistical difference in terms of onset-operation time[5.00 (3.50, 23.75)h vs 0.54(0.48, 1.00)h], color of ovary(4/0 vs 1/4) ,preoperative CRP[(45.61±35.19)mg/L vs (0.74±0.55)mg/L], and nausea and vomiting[1 case (25%) vs 5 cases (100%)].There was no statistical difference in terms of age [(6.08±5.72) vs (5.77±4.19)],affected side (left/right)(3/1 vs 2/3),fever [2 cases(50%) vs 0 cases(0%)],degree of OT,[(675.00±307.41)°vs (756.00±410.46) °], preoperative WBC [(13.13±4.31)×10 9 /L vs (8.30±2.10)×109/L], preoperative NE [(8.08±3.52)×10 9 /L vs (6.34±2.18)×10 9 /L], postoperative WBC[10.75(9.30, 14.00)×10 9 /L vs 5.30(4.95,11.25)×10 9 /L], postoperative NE[(8.73±1.15)×10 9 /L vs (4.94±1.52)×10 9 /L], postoperative CRP [(56.9±48.91)mg/L vs (6.82±7.31)mg/L). (see Tab.1) Intraoperative ovarian color,blue-black in 6 cases and dark red in 4 cases.Of the 6 blue-black cases,4 had ovarian atrophied and disappeared.1 case was lost,and in 1 case,the affected ovary was half the size of the contralateral one with normal follicular development(see Fig.5).In atrophy group, girls all underwent surgery after 24 h of onset.They were 3 d, 5 d, 5 d, and 30 d.Atrophy was detected at follow-up at 4, 5, 10, and 10 months postoperatively.The remaining 6 girls had onset of symptoms within 24 h. Tab 1 Results of univariate analysis of risk factors for OT atrophy Parameter preoperativeWBC (x±s,×10 9 /L) preoperativeNE (x±s,×10 9 /L) preoperativeCRP (x±s,mg/L) postoperativeWBC M(Q 1 ,Q 3 )×10 9 /L postoperativeNE (x±s,×10 9 /L) postoperativeCRP (x±s,mg/L) atrophy group （n=4） 13.13±4.31 8.08±3.52 45.61±35.19 10.75 （9.30, 14.00） 8.73±1.15 56.9±48.91 Non atrophy group （n=5） 8.30±2.10 6.34±2.18 0.74±0.55 5.30（4.95,11.25） 4.94±1.52 6.82±7.31 t/U t=-2.22 t=-0.913 t=-2.903 U=3.000 t=-1.895 t=-2.298 P 0.062 0.392 0.023 0.111 0.100 0.055 Parameter age (x±s,years) affected side （L/R,cases） Fever (case％) nausea and vomiting (cases％) onset-operation time(M(Q 1 ,Q 3 ),days torsion degree (x±s,°) color of ovary (blue-black/dark red,cases) atrophy group （n=4） 6.08±5.72 3(75)/1(25) 2(50) 1(25) 5.00 (3.50, 23.75) 675.00±307.41 4(100)/0(0) non-atrophy group（n=5) 5.77±4.19 2(40)/3(60) 0(0) 5(100) 0.54 (0.48, 1.00) 756.00±410.46 1(20)/4(80) t/U/χ2 t=0.096 U=0.000 t=-0.326 P 0.926 0.357 0.167 0.048 0.016 0.754 0.04 WBC: white blood cell count; NE: neutrophil; CRP: C-reaction protein Discussion De-torsion of normal ovary without oophoropexy in children had no recurrent torsion in follow up.Ovarian atrophy had prolonged onset, darker ovaries and higher preoperative CRP than non-atrophic children, but had a lower incidence of nausea and vomiting.All women with acute abdomen should consider the possibility of OT.Prolonged OT may result in the loss of ovarian function, so early diagnosis and prompt treatment are crucial.OT is more secondary to pathologic ovaries, such as cysts or tumors.Torsion of normal ovary is rare,but more common in children than in adults,as many as 15%-50༅ [ 4 ] . One recent study reported about 11.3༅ [ 5 ] . The rate of diagnostic delay in patients without a mass is almost three times as often as those with a mass [ 6 ] .In our team, 4 out of 10 children with normal ovarian torsion gradually atrophied and disappeared during follow-up, up to 40%. A number of theories have been proposed to explain the torsion of normal ovary, including congenitally long ovarian ligament or abnormal laxity of the pelvic ligaments leading to increased ovarian activity [ 4 ] . Moreover, larger-than-normal-sized ovaries are a risk factor for torsion [ 7 ] .OT is most often seen on the right side, probably because the sigmoid colon in the left iliac fossa reduces adnexal motility [ 8 ] .However, 60% of the girls in our center are on the left side, which may be because of the small number of cases.The diagnosis of OT without mass is relatively difficult and the most common diagnostic method remains ultrasound.Ovarian asymmetry is a measure of reference.Ultrasound measurement of ovarian volume ratio (OVR) > 2.5 is a predictor of OT in children without an adnexal mass, and OVR does not change with age [ 9 ] .Our sonographers usually measure two ovarian diameters instead of three.So the ovarian volume could not be calculated, but the ultrasound clearly showed "whirlpool sign" at the root of the ovary.The follicular development is detected at follow-up to assess the recovery of ovarian function, as the blood supply to the ovaries allows for follicles alive.The presence of follicles is a surrogate indicator of fertility, and of course successful ovulation and fertilization are the gold standard for assessing ovarian function [ 10 ] . A study found the degree of OT, nausea and vomiting, fever, time from onset to operation, WBC, CRP, and NE are risk factors for predicting OT necrosis [ 11 ] .Ovarian necrosis depends mainly on the time from onset to surgery. It has been shown that patients with histopathologically necrotic ovaries had pain episodes more often than 24 h, but not all patients who undergo surgery after 24 h have necrotic ovaries [ 12 ] .Some physicians, especially internists, have a insufficient knowledge of pediatric OT, leading to delayed diagnosis.A child in our center was seen twice in the emergency internal medicine department of our hospital for abdominal pain, but the doctor did not consider ovarian disease and no ultrasound examination of the adnexa was performed.Five days later, the girl's abdominal pain was not relieved,and examination at our department revealed OT.The left torsion ovary had atrophied and disappeared at the 5-month postoperative follow-up.In this study,ovarian atrophy is more likely to occur in children with prolonged onset, darker ovaries and higher preoperative CRP, but less likely to occur with nausea and vomiting.This may be due to the longer duration of illness or chronic torsion in the atrophy group, with less obvious gastrointestinal symptoms.As one study found, girls with severe abdominal pain were more likely to retain ovaries than those with mild abdominal pain.It may be because severe abdominal pain can be noticed early [ 4 ] .Intraoperative visual assessment of ovarian necrosis is not a good predictor of true necrosis in histopathology [ 12 ] .Laparoscopic ovarian preservation is superior to adnexectomy in both adults and children, even if the ovary has a blue-black appearance [ 6 ] .Ovaries with a blue-black appearance may still be able to regain function after detorsion, but the chances are not good.Although there is now a consensus to preserve ovarian tissue, some medical center surgeons still perform adnexectomy based on the color of the ovary.The ovaries that appear blue-black are more likely to atrophy and disappear during follow-up.Although intraoperative ovarian color cannot represent the pathological examination, it can guide the surgeons to inform the condition to relatives in advance.If the ovaries shrink and disappear, it can increase the acceptance of girls and relatives. There is still controversy over its surgical strategy,what is not in dispute is that the adnexal structures should be preserved regardless of the ovarian appearance.Surgeons should not remove a torsed ovary unless oophorectomy is unavoidable, as in the case of severe necrotic ovary falls off [ 7 ] .Normal adnexal torsion in premenarchal girls is more likely to recur and therefore ovarian fixation is recommended for such patients [ 3 ] .Various oophoropexy have been proposed, including suturing of the ovary to the round ligament,lateral pelvic wall,dorsal uterus,or sacral ligament, and utero-ovarian ligament folding to shorten the ligament [ 13 ] .A novel oophorectomy procedure combining utero-ovarian ligament folding and suturing of the ovary to round ligament has recently been described [ 14 ] . Oophoropexy is also controversial.It may reduces fertility due to alterations in anatomy between the ovary and fallopian tube and interference with fallopian tube blood supply by sutures [ 15 ] .Moreover, there is still a certain recurrence rate after oophoropexy, and the ovarian tissue is edematous and fragile at the time of the first torsion episode, which affects effective suturing [ 16 ] .Recurrent torsion after oophoropexy was as high as 30% in a single-center study and the failure was associated with a long time to onset [ 17 ] . Recently,19 girls who underwent oophoropexy with shortening of the utero-ovarian ligament were followed up for a mean of 90.9 months, and recurrent torsion occurred in 15 cases(78.9%) [ 16 ] . Conclusion The recurrent torsion of normal ovary in children is not as high as previously reported, but with a high proportion of atrophy.Even if the chance of blue-black ovarian recovery is very small, the ovarian tissue should be preserved to provide fertility. Even the ovaries shrink and disappear, there's no adverse effect on the girls.Laparoscopic ovarian de-torsion without oophoropexy is feasible and no recurrent torsion occurred.Follicular development was detected and ovarian function was recovered in follow-up.This surgical method preserves the original anatomical position of the ovary relative to the fallopian tube, and the operation technique is simple.For the congested and edematous ovaries for which our team performed hematoma removal,there are no clear numerical criteria, and the assessment is based on the surgeon's experience.The number of cases in our center is small and more casese follow-up are needed to confirm its efficacy.In addition, many relatives expressed doubts or even refused to be screened for adnexal ultrasound in children. This article also hopes that more medical professionals and relatives will become aware of normal ovarian torsion in children. Declarations Author contributions K Xing:data collection, project development; ZG Zhang: project development, data management; YQ Dong: data collection and analysis; Hui Ren:The frst draft of the manuscript writing; JL G:project development and data analysis; Fei Duan:manuscript editing; HZ Niu:Manuscript revision and analysis. All of the co-authors participated in fnalizing the article and approved the final version of the article. Funding The authors declare that no funds, grants, or other support was received during the preparation of this manuscript. Conflict of interest The authors declare they have no competing interests. Ethical approval This study was performed in line with the principles of the Declaration of Helsinki.Approval was granted by the Medical Research Ethics Committee of Hebei Children's Hospital (202407-37) Consent to participate Informed consent was obtained from all guardians of the children included in the study. References Breech LL, Hillard PJA. 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Hartman SJ,Prieto JM,NaheedyJH,Ignacio RC,Bickler SW,Kling KM,Saenz NC,Fairbanks TJ,Lazar DA.Ovarian volume ratio is a reliable predictor of ovarian torsion in girls without The an adnexal mass [J]. J Pediatr Surg, 2021, 56 (1) : 180-182. The DOI: 10.1016/j.j pedsurg. 2020.09.031. Dasgupta R, Renaud E, Goldin AB,Baird R,Cameron DB, Arnold MA,Diefenbach KA,Gosain A. Ovarian torsion in pediatric and adolescent patients: Asystematic review [J]. J Pediatr Surg, 2018, does (7) : 1387-1391. The DOI: 10.1016/j.jpedsurg. 2017.10.053. Sun ZS,Duan XF,Yan XQ.Risk factors and predictive values of ovarian torsion necrosis in children[J].J Clin Ped Sur, 46-2024, 23 (1) : 50. DOI: 10.3760/cma. J.c.n101785-202311024-009. Novoa M,Friedman J,Mayrink M.Ovarian torsion: can we save the ovary? [J].Arch Gynecol Obstet,2021,304(1):191-195.DOI:10.1007/s00404-021-06008-8. Fuchs N, SmorgickN, Tovbin Y,Ami IB,Maymon R,Halperin R,Pansky M.Oophoropexy to prevent adnexal torsion: how, when, and for whom? [J]. J Minim Invasive Gynecol, 2010,(2):205-8. DOI: 10.1016 / j.jmig.2009.12.011. SmorgickN, Mor M,Dovev MN,Eisenberg N,Vaknin Z.Combined Utero-Ovarian and Round Ligament Oophoropexy for Recurrent Torsion of Normal Adnexa:ACase Series [J].J PediatrAdolesc Gynecol,2023, 4 (5) : 484-487. The DOI: 10.1016 / j.jpag. 2023.06.006. Spinelli C, Buti I, Pucci V,Liserre J, Alberti E, Nencini L, Alessandra M, Piccolo RL,Messineo A. Adnexal torsion in children and adolescents: new trends to conservative surgical approach-our experience and review of literature.Gynecol Endocrinol 2013;29(1):54-8. DOI:10.3109/09513590.2012.705377. Smorgick N,Mor M,Eisenberg N,Dovev MN, Vaknin Z.Recurrent torsion of otherwise normal adnexa: oophoropexy does not prevent recurrence[J].Arch Gynecol Obstet,2023,307(3):821-825. DOI:10.1007/s00404-022-06831-7. AkdamA,BorN,FouksY,Ram M, Laskov I,Levin I,Cohen A.Recurrent Ovarian Torsion: Risk Factors and Predictors for outcome of Oophoropexy[J].J Minim Invasive Gynecol, 2022 (8):1011-1018.DOI:10.1016 / j.jmig. 2022.05.007. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6031448","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":415907970,"identity":"09a2abab-3bec-43c8-bcc1-04f9bd2cd7a3","order_by":0,"name":"Fei Duan","email":"","orcid":"","institution":"Hebei Provincial Children's Hospital, Shijiazhuang","correspondingAuthor":false,"prefix":"","firstName":"Fei","middleName":"","lastName":"Duan","suffix":""},{"id":415907971,"identity":"ded842ea-b3ea-4479-ae88-fbc59a6b1a72","order_by":1,"name":"Huizhong Niu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAnElEQVRIiWNgGAWjYFAC5gZmBgYbHn7+BqK1MIK0pMlIzjhAmpbDNgYNCURqMJc+2Pa44M95HgOGA4wfPuYQocWyL7HdeAbPbR5zoJ8kZ24jQovBGcY2aR6J2zyWDQfYmHmJ12JwjsfgQAJJWhIOkKzlQDKP5IyDzcT6hfmYNM8fO3t+/uaDHz4SowUJMDaQpn4UjIJRMApGAW4AAI4QMM+5arwZAAAAAElFTkSuQmCC","orcid":"","institution":"Hebei Provincial Children's Hospital, Shijiazhuang","correspondingAuthor":true,"prefix":"","firstName":"Huizhong","middleName":"","lastName":"Niu","suffix":""}],"badges":[],"createdAt":"2025-02-14 14:33:54","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6031448/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6031448/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":76687916,"identity":"1a054dc6-f3b7-41d8-8463-f6d87dccdf92","added_by":"auto","created_at":"2025-02-19 16:29:53","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":222812,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative ultrasound of\"whirlpool sign\"\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6031448/v1/0811299d9e7b73a2a5f8284a.png"},{"id":76688695,"identity":"2fd8b668-df5b-4bcf-8b00-12554539332f","added_by":"auto","created_at":"2025-02-19 16:37:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":336438,"visible":true,"origin":"","legend":"\u003cp\u003eDe-torsion for torsion of normal ovary\u003c/p\u003e\n\u003cp\u003eA:ovarian torsion; B:ovarian de-torsion; C:placing back in their original anatomical position\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6031448/v1/d4a145a6d1793bf24810b315.png"},{"id":76687918,"identity":"e2bbfffa-7695-41e4-964a-f45f9b628e57","added_by":"auto","created_at":"2025-02-19 16:29:53","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":367192,"visible":true,"origin":"","legend":"\u003cp\u003eDe-torsion and removal of hematoma\u003c/p\u003e\n\u003cp\u003eA: ovarian torsion; B: ovarian de-torsion; C: Removal of hematoma; D:placing back in their original anatomical position\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6031448/v1/4fd3a09a50cafc78ece7f6bf.png"},{"id":76687920,"identity":"285c0424-c19f-4184-b2e0-2338c58b99a9","added_by":"auto","created_at":"2025-02-19 16:29:53","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":262274,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative and postoperative ultrasound examination\u003c/p\u003e\n\u003cp\u003eA: affected ovary; B: contralateral ovary; C: affected ovary 20 months after surgery; D: contralateral ovary 20 months after surgery\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6031448/v1/596a00cb6a90cc8eaf883cbc.png"},{"id":76687930,"identity":"9ae90bab-4671-4200-bb1c-2f1ca7b6fa6e","added_by":"auto","created_at":"2025-02-19 16:29:54","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":371473,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative and postoperative ultrasound examination\u003c/p\u003e\n\u003cp\u003eA: affected ovary; B: contralateral ovary; C: affected ovary 12 months after surgery; D: affected ovary is half as small as the contralateral ovary 12 months after surgery\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6031448/v1/23201f87716e2da8757ca905.png"},{"id":76690098,"identity":"11452680-29c9-4839-bedd-0aba7951e2cc","added_by":"auto","created_at":"2025-02-19 16:53:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2733624,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6031448/v1/263b7860-dedc-4e74-bf0c-9595ac763f84.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eDe-torsion without oophoropexy for torsion of normal ovary in children: a report of 10 cases\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOvarian torsion(OT) includes pathological ovary and normal ovary. Ovarian cyst or masses are the main risk factor for OT. OT without an adnexal mass is thought to be a lengthy utero-ovarian ligament and mesosalpinx that increase the risk of torsion\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e.A smaller uterus on the long axis has also been considered a risk factor\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e.Since no mass triggers torsion in these cases, normal ovaries are prone to re-torsion, especially in premenarcheal children\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.Various oophoropexy or shortening of the utero-ovarian ligament are usually used to reduce recurrence.However, the incidence of normal ovarian torsion in children is low and there are no standardized treatment criteria.Retrospective analysis of the clinical characteristics of 10 girls with normal ovarian torsion treated in our department.Observe the efficacy and prognosis of laparoscopic ovarian de-torsion without oophoropexy.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003e1. Research object\u003c/p\u003e\n\u003cp\u003eIn this retrospective study, 10 girls were underwent surgical treatment for torsion of normal ovarian in our department from May 2018 to December 2023.Exclude children with pathologic ovaries, including ovarian cysts, ovarian teratomas, and ovarian malignancies.Mean age of girls was 5 years and 8 months(4 months-12 years), all premenarchal children.The surgical procedure was laparoscopic de-torsion without oophoropexy.\u003c/p\u003e\n\u003cp\u003e2. Observation indicators\u003c/p\u003e\n\u003cp\u003eThe cases were categorized into atrophy group and non-atrophy group according to whether or not the ovaries recovered during follow-up.Comparison of age, clinical symptoms (fever, onset-operation time, nausea and vomiting), blood test [CRP, WBC, NE], intraoperative findings (affected side of ovarian torsion, degree of torsion, and color of the ovary) between the two groups.Ultrasound follow-up of children with recurrent OT.Monitoring of ovarian morphology and size and follicular development to assess whether ovarian function has recovered.\u003c/p\u003e\n\u003cp\u003e3. Statistical processing\u003c/p\u003e\n\u003cp\u003eData were analyzed using SPSS 27.0 (IBM, Armonk, NY).Normality test for measurement data using the Shapiro-Wilk test.Categorical data was expressed as proportions (%) and the x\u0026sup2; test was applied to compare differences between groups.Normally distributed data were expressed as x\u0026plusmn;s and analyzed using the independent samples t-test.Non-normally distributed data were expressed as M(Q 1 ,Q 3 ) and analyzed using the independent sample Mann-Whitney U test. A P value of less than 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn the past 4.5 years, our department has diagnosed and treated 70 cases of OT in children, with a total of 71 ovaries affected.Normal ovarian torsion totaled 10 cases, accounting for 14.1% of all OT (including pathological OT) during the same period in our department.9 girls were unilateral OT, and 1 child underwent ovarian torsion repositioning with ovarian cyst removal for the right ovary 2 months before the left normal OT.\u003c/p\u003e\n\u003cp\u003eUltrasound in all the children showed rotation at the root of the ovaries, namely \u0026quot;whirlpool sign\u0026quot; (see Fig.1).Patients were underwent urgent laparoscopy with surgically confirmed OT in the absence of an associated adnexal mass.The procedure was de-torsion with preserving the ovary tissue.The ovaries and fallopian tubes were placed back in their original anatomical position(see Fig.2).Hematoma removal was performed in 5 ovaries with severe hyperemia and edema. Incision of the ovarian cortex at the site of hemodynamic recovery to remove old blood clots and necrotic tissue to prevent re-torsion of the enlarged ovary(see Fig.3).Oophoropexy and utero-ovarian plication were not performed.Average timing of follow-up was 28.4 months (9 months - 43 months).1 case was lost, 4 cases had atrophy of the affected ovaries, and 5 cases had normal ovarian morphology and follicular development after surgery(see Fig.4).There were no complications such as recurrent torsion or abdominal infection during follow-up.\u003c/p\u003e\n\u003cp\u003eThere was statistical difference in terms of onset-operation time[5.00 (3.50, 23.75)h vs 0.54(0.48, 1.00)h], color of ovary(4/0 vs 1/4) ,preoperative CRP[(45.61\u0026plusmn;35.19)mg/L vs \u0026nbsp;(0.74\u0026plusmn;0.55)mg/L], and nausea and vomiting[1 case (25%) vs 5 cases (100%)].There was no statistical difference in terms of age [(6.08\u0026plusmn;5.72) vs (5.77\u0026plusmn;4.19)],affected side (left/right)(3/1 vs 2/3),fever [2 cases(50%) vs 0 cases(0%)],degree of OT,[(675.00\u0026plusmn;307.41)\u0026deg;vs (756.00\u0026plusmn;410.46) \u0026deg;], preoperative WBC [(13.13\u0026plusmn;4.31)\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L vs (8.30\u0026plusmn;2.10)\u0026times;109/L], preoperative NE [(8.08\u0026plusmn;3.52)\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L vs (6.34\u0026plusmn;2.18)\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L], postoperative WBC[10.75(9.30, 14.00)\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L vs 5.30(4.95,11.25)\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L], postoperative NE[(8.73\u0026plusmn;1.15)\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L vs (4.94\u0026plusmn;1.52)\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L], postoperative CRP [(56.9\u0026plusmn;48.91)mg/L vs (6.82\u0026plusmn;7.31)mg/L). (see Tab.1)\u003c/p\u003e\n\u003cp\u003eIntraoperative ovarian color,blue-black in 6 cases and dark red in 4 cases.Of \u0026nbsp;the 6 blue-black cases,4 had ovarian atrophied and disappeared.1 case was lost,and in 1 case,the affected ovary was half the size of the contralateral one with normal follicular development(see Fig.5).In atrophy group, girls all underwent surgery after 24 h of onset.They were 3 d, 5 d, 5 d, and 30 d.Atrophy was detected at follow-up at 4, 5, 10, and 10 months postoperatively.The remaining 6 girls had onset of symptoms within 24 h.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTab\u003c/strong\u003e \u003cstrong\u003e1\u003c/strong\u003e Results of univariate analysis of risk factors for OT atrophy\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eParameter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003epreoperativeWBC\u003c/p\u003e\n \u003cp\u003e(x\u0026plusmn;s,\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003epreoperativeNE\u003c/p\u003e\n \u003cp\u003e(x\u0026plusmn;s,\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003epreoperativeCRP\u003c/p\u003e\n \u003cp\u003e(x\u0026plusmn;s,mg/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003epostoperativeWBC\u003c/p\u003e\n \u003cp\u003eM(Q\u003csub\u003e1\u003c/sub\u003e,Q\u003csub\u003e3\u003c/sub\u003e)\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003epostoperativeNE\u003c/p\u003e\n \u003cp\u003e(x\u0026plusmn;s,\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003epostoperativeCRP\u003c/p\u003e\n \u003cp\u003e(x\u0026plusmn;s,mg/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eatrophy group\u003c/p\u003e\n \u003cp\u003e（n=4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.13\u0026plusmn;4.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.08\u0026plusmn;3.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e45.61\u0026plusmn;35.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.75\u003c/p\u003e\n \u003cp\u003e（9.30, 14.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.73\u0026plusmn;1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e56.9\u0026plusmn;48.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNon atrophy group\u003c/p\u003e\n \u003cp\u003e（n=5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.30\u0026plusmn;2.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.34\u0026plusmn;2.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.74\u0026plusmn;0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.30（4.95,11.25）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.94\u0026plusmn;1.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.82\u0026plusmn;7.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003et/U\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003et=-2.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003et=-0.913\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003et=-2.903\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eU=3.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003et=-1.895\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003et=-2.298\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.062\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.392\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"609\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eParameter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eage\u003c/p\u003e\n \u003cp\u003e(x\u0026plusmn;s,years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eaffected side\u003c/p\u003e\n \u003cp\u003e（L/R,cases）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFever\u003c/p\u003e\n \u003cp\u003e(case％)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003enausea and vomiting\u003c/p\u003e\n \u003cp\u003e(cases％)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eonset-operation time(M(Q\u003csub\u003e1\u003c/sub\u003e,Q\u003csub\u003e3\u003c/sub\u003e),days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003etorsion degree\u003c/p\u003e\n \u003cp\u003e(x\u0026plusmn;s,\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ecolor of ovary\u003c/p\u003e\n \u003cp\u003e(blue-black/dark red,cases)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eatrophy group\u003c/p\u003e\n \u003cp\u003e（n=4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.08\u0026plusmn;5.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3(75)/1(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2(50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.00\u003c/p\u003e\n \u003cp\u003e(3.50, 23.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e675.00\u0026plusmn;307.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4(100)/0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003enon-atrophy group（n=5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.77\u0026plusmn;4.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2(40)/3(60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003cp\u003e(0.48, 1.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e756.00\u0026plusmn;410.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1(20)/4(80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003et/U/\u0026chi;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003et=0.096\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eU=0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003et=-0.326\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.926\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.357\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.167\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.048\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.754\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eWBC: white blood cell count; NE: neutrophil; CRP: C-reaction protein\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDe-torsion of normal ovary without oophoropexy in children had no recurrent torsion in follow up.Ovarian atrophy had prolonged onset, darker ovaries and higher preoperative CRP than non-atrophic children, but had a lower incidence of nausea and vomiting.All women with acute abdomen should consider the possibility of OT.Prolonged OT may result in the loss of ovarian function, so early diagnosis and prompt treatment are crucial.OT is more secondary to pathologic ovaries, such as cysts or tumors.Torsion of normal ovary is rare,but more common in children than in adults,as many as 15%-50༅\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. One recent study reported about 11.3༅\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. The rate of diagnostic delay in patients without a mass is almost three times as often as those with a mass\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e.In our team, 4 out of 10 children with normal ovarian torsion gradually atrophied and disappeared during follow-up, up to 40%.\u003c/p\u003e \u003cp\u003eA number of theories have been proposed to explain the torsion of normal ovary, including congenitally long ovarian ligament or abnormal laxity of the pelvic ligaments leading to increased ovarian activity\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Moreover, larger-than-normal-sized ovaries are a risk factor for torsion\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e.OT is most often seen on the right side, probably because the sigmoid colon in the left iliac fossa reduces adnexal motility\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e.However, 60% of the girls in our center are on the left side, which may be because of the small number of cases.The diagnosis of OT without mass is relatively difficult and the most common diagnostic method remains ultrasound.Ovarian asymmetry is a measure of reference.Ultrasound measurement of ovarian volume ratio (OVR)\u0026thinsp;\u0026gt;\u0026thinsp;2.5 is a predictor of OT in children without an adnexal mass, and OVR does not change with age\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e.Our sonographers usually measure two ovarian diameters instead of three.So the ovarian volume could not be calculated, but the ultrasound clearly showed \"whirlpool sign\" at the root of the ovary.The follicular development is detected at follow-up to assess the recovery of ovarian function, as the blood supply to the ovaries allows for follicles alive.The presence of follicles is a surrogate indicator of fertility, and of course successful ovulation and fertilization are the gold standard for assessing ovarian function\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e .\u003c/p\u003e \u003cp\u003eA study found the degree of OT, nausea and vomiting, fever, time from onset to operation, WBC, CRP, and NE are risk factors for predicting OT necrosis\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e.Ovarian necrosis depends mainly on the time from onset to surgery. It has been shown that patients with histopathologically necrotic ovaries had pain episodes more often than 24 h, but not all patients who undergo surgery after 24 h have necrotic ovaries\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e.Some physicians, especially internists, have a insufficient knowledge of pediatric OT, leading to delayed diagnosis.A child in our center was seen twice in the emergency internal medicine department of our hospital for abdominal pain, but the doctor did not consider ovarian disease and no ultrasound examination of the adnexa was performed.Five days later, the girl's abdominal pain was not relieved,and examination at our department revealed OT.The left torsion ovary had atrophied and disappeared at the 5-month postoperative follow-up.In this study,ovarian atrophy is more likely to occur in children with prolonged onset, darker ovaries and higher preoperative CRP, but less likely to occur with nausea and vomiting.This may be due to the longer duration of illness or chronic torsion in the atrophy group, with less obvious gastrointestinal symptoms.As one study found, girls with severe abdominal pain were more likely to retain ovaries than those with mild abdominal pain.It may be because severe abdominal pain can be noticed early\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.Intraoperative visual assessment of ovarian necrosis is not a good predictor of true necrosis in histopathology\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e.Laparoscopic ovarian preservation is superior to adnexectomy in both adults and children, even if the ovary has a blue-black appearance\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e.Ovaries with a blue-black appearance may still be able to regain function after detorsion, but the chances are not good.Although there is now a consensus to preserve ovarian tissue, some medical center surgeons still perform adnexectomy based on the color of the ovary.The ovaries that appear blue-black are more likely to atrophy and disappear during follow-up.Although intraoperative ovarian color cannot represent the pathological examination, it can guide the surgeons to inform the condition to relatives in advance.If the ovaries shrink and disappear, it can increase the acceptance of girls and relatives.\u003c/p\u003e \u003cp\u003eThere is still controversy over its surgical strategy,what is not in dispute is that the adnexal structures should be preserved regardless of the ovarian appearance.Surgeons should not remove a torsed ovary unless oophorectomy is unavoidable, as in the case of severe necrotic ovary falls off\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e.Normal adnexal torsion in premenarchal girls is more likely to recur and therefore ovarian fixation is recommended for such patients\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.Various oophoropexy have been proposed, including suturing of the ovary to the round ligament,lateral pelvic wall,dorsal uterus,or sacral ligament, and utero-ovarian ligament folding to shorten the ligament\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.A novel oophorectomy procedure combining utero-ovarian ligament folding and suturing of the ovary to round ligament has recently been described\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Oophoropexy is also controversial.It may reduces fertility due to alterations in anatomy between the ovary and fallopian tube and interference with fallopian tube blood supply by sutures\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e.Moreover, there is still a certain recurrence rate after oophoropexy, and the ovarian tissue is edematous and fragile at the time of the first torsion episode, which affects effective suturing\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e.Recurrent torsion after oophoropexy was as high as 30% in a single-center study and the failure was associated with a long time to onset\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. Recently,19 girls who underwent oophoropexy with shortening of the utero-ovarian ligament were followed up for a mean of 90.9 months, and recurrent torsion occurred in 15 cases(78.9%) \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe recurrent torsion of normal ovary in children is not as high as previously reported, but with a high proportion of atrophy.Even if the chance of blue-black ovarian recovery is very small, the ovarian tissue should be preserved to provide fertility. Even the ovaries shrink and disappear, there's no adverse effect on the girls.Laparoscopic ovarian de-torsion without oophoropexy is feasible and no recurrent torsion occurred.Follicular development was detected and ovarian function was recovered in follow-up.This surgical method preserves the original anatomical position of the ovary relative to the fallopian tube, and the operation technique is simple.For the congested and edematous ovaries for which our team performed hematoma removal,there are no clear numerical criteria, and the assessment is based on the surgeon's experience.The number of cases in our center is small and more casese follow-up are needed to confirm its efficacy.In addition, many relatives expressed doubts or even refused to be screened for adnexal ultrasound in children. This article also hopes that more medical professionals and relatives will become aware of normal ovarian torsion in children.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eK Xing:data collection, project development; ZG Zhang: project development, data management; YQ Dong: data collection and analysis; Hui Ren:The frst draft of the manuscript writing; JL G:project development and data analysis; Fei Duan:manuscript editing; HZ Niu:Manuscript revision and analysis. All of the co-authors participated in fnalizing the article and approved the final version of the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e The authors declare that no funds, grants, or other support was received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u0026nbsp;\u003c/strong\u003eThe authors declare they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e This study was performed in line with the principles of the Declaration of Helsinki.Approval was granted by the Medical Research Ethics Committee of Hebei Children\u0026apos;s Hospital (202407-37)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u0026nbsp; Informed consent was obtained from all guardians of the children included in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBreech LL, Hillard PJA. Adnexal torsion in pediatric and adolescent girls[J].Curr Opin Obstet Gynecol,2005; 17 (5) : 483-9. DOI: 10.1097/01. Gco. 0000179666.39548.78.\u003c/li\u003e\n\u003cli\u003eKaraman E,Beger B, Cetin O,Melek M,Karaman Y. Ovarian torsion in the normal ovary: a diagnostic challenge in postmenarchal adolescent girls in the emergency department[J]. Med Sci Monit, 2017,15:23:1312-1316.DOI:10.12659/msm.902099. \u003c/li\u003e\n\u003cli\u003eSmorgick N,Melcer Y,Sarig-Meth T,Maymon R,Vaknin Z,Pansky M. High risk of recurrent torsion in premenarchal girls with torsion of normal adnexa[J]. Fertil Steril, 2016; 105 (6) : 1561-1565.e3. DOI:10.1016 / j.fertnstert. 2016.02.010.\u003c/li\u003e\n\u003cli\u003eKives S,Gascon S,Dubuc E,Eyk NV.No.341-Diagnosis and Management of Adnexal Torsion in Children, Adolescents, and Adults [J]. J Obstet Gynaecol Can, 2017, 33 (2) 6:82-90.The DOI: 10.1016 / j.j. Ogc 2016.10.001.\u003c/li\u003e\n\u003cli\u003eSpinelli C,Tr\u0026ouml;bs RB,Nissen M, et al.Ovarian torsion in the pediatric population: predictive factors for ovarian-sparing surgery-an international retrospective multicenter study and a systematic review[J].Arch Gynecol Obstet2023,308(1):1-12.DOI:10.1007/s00404-022-06522-3.\u003c/li\u003e\n\u003cli\u003ePrieto JM,Kling KM,Ignacio RC,Bickler SW,Fairbanks TJ,Saenz NC,Nicholson SI,LazarDA. Premenarchal Patients Present Differently: A Twist on the Typical Patient Presenting with Ovarian Torsion[J]. J Pediatr Surg, 2019; 54 (12) : 2614-2616. The DOI: 10.1016 / j.j pedsurg. 2019.08.020.\u003c/li\u003e\n\u003cli\u003eKaraca SY, StileriA.Ovarian Torsion in Adolescents with and without ovarian mass: A Cross-sectional Study[J].J PediatrAdolesc Gynecol,2021,34(6):857-861.DOI:10.1016/j.jpag. 2021.05.007.\u003c/li\u003e\n\u003cli\u003eAbraham M,Keyser EA.Adnexal Torsion in Adolescents:ACOG Committee Opinion No, 783[J].Obstet Gynecol,2019,134(2):e56-e63.DOI:10.1097/AOG.0000000000003373.\u003c/li\u003e\n\u003cli\u003eHartman SJ,Prieto JM,NaheedyJH,Ignacio RC,Bickler SW,Kling KM,Saenz NC,Fairbanks TJ,Lazar DA.Ovarian volume ratio is a reliable predictor of ovarian torsion in girls without The an adnexal mass [J]. J Pediatr Surg, 2021, 56 (1) : 180-182. The DOI: 10.1016/j.j pedsurg. 2020.09.031.\u003c/li\u003e\n\u003cli\u003eDasgupta R, Renaud E, Goldin AB,Baird R,Cameron DB, Arnold MA,Diefenbach KA,Gosain A. Ovarian torsion in pediatric and adolescent patients: Asystematic review [J]. J Pediatr Surg, 2018, does (7) : 1387-1391. The DOI: 10.1016/j.jpedsurg. 2017.10.053.\u003c/li\u003e\n\u003cli\u003eSun ZS,Duan XF,Yan XQ.Risk factors and predictive values of ovarian torsion necrosis in children[J].J Clin Ped Sur, 46-2024, 23 (1) : 50. DOI: 10.3760/cma. J.c.n101785-202311024-009.\u003c/li\u003e\n\u003cli\u003eNovoa M,Friedman J,Mayrink M.Ovarian torsion: can we save the ovary? [J].Arch Gynecol Obstet,2021,304(1):191-195.DOI:10.1007/s00404-021-06008-8.\u003c/li\u003e\n\u003cli\u003eFuchs N, SmorgickN, Tovbin Y,Ami IB,Maymon R,Halperin R,Pansky M.Oophoropexy to prevent adnexal torsion: how, when, and for whom? [J]. J Minim Invasive Gynecol, 2010,(2):205-8. DOI: 10.1016 / j.jmig.2009.12.011.\u003c/li\u003e\n\u003cli\u003eSmorgickN, Mor M,Dovev MN,Eisenberg N,Vaknin Z.Combined Utero-Ovarian and Round Ligament Oophoropexy for Recurrent Torsion of Normal Adnexa:ACase Series [J].J PediatrAdolesc Gynecol,2023, 4 (5) : 484-487. The DOI: 10.1016 / j.jpag. 2023.06.006.\u003c/li\u003e\n\u003cli\u003eSpinelli C, Buti I, Pucci V,Liserre J, Alberti E, Nencini L, Alessandra M, Piccolo RL,Messineo A. Adnexal torsion in children and adolescents: new trends to conservative surgical approach-our experience and review of literature.Gynecol Endocrinol 2013;29(1):54-8. DOI:10.3109/09513590.2012.705377.\u003c/li\u003e\n\u003cli\u003eSmorgick N,Mor M,Eisenberg N,Dovev MN, Vaknin Z.Recurrent torsion of otherwise normal adnexa: oophoropexy does not prevent recurrence[J].Arch Gynecol Obstet,2023,307(3):821-825. DOI:10.1007/s00404-022-06831-7. \u003c/li\u003e\n\u003cli\u003eAkdamA,BorN,FouksY,Ram M, Laskov I,Levin I,Cohen A.Recurrent Ovarian Torsion: Risk Factors and Predictors for outcome of Oophoropexy[J].J Minim Invasive Gynecol, 2022 (8):1011-1018.DOI:10.1016 / j.jmig. 2022.05.007.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Normal ovarian torsion, De-torsion, Atrophy, Efficacy, Children","lastPublishedDoi":"10.21203/rs.3.rs-6031448/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6031448/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eStudy objective\u003c/strong\u003e Torsion of normal ovary is rare in children. There is no consensus on the optimal method. A preliminary study of the clinical features of normal ovarian torsion and the efficacy and feasibility of de-torsion without oophoropexy in children.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e Retrospective analysis of the clinical data of 10 girls with normal ovarian torsion treated \u0026nbsp;in the Department of General Surgery,Hebei Provincial Children's Hospital from May 2018 to December 2023.According to whether the ovaries have atrophied and disappeared during follow-up,they were categorized into atrophy group(4 cases) and non-atrophy group(5 cases).The age,affected side, nausea and vomiting,fever,onset-operation time,degree of torsion,color of ovary,preoperative and postoperative neutrophil(NE),C-reaction protein(CRP) and white blood cell(WBC) were compared between the two groups.The surgical procedure was laparoscopic de-torsion without oophoropexy.Hematoma removal in 5 cases of severely congested ovaries.Follow up the children for recurrent torsion and recovery of ovarian function.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e Childrenwith a diagnosis of normal ovarian torsion intraoperatively confirmed and surgically treated in our department.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eThere \u0026nbsp;was statistical differences in onset-operation time, color of ovary,preoperative CRP and nausea and vomiting(P\u0026lt;0.05).No statistical difference was found in age,affected side,fever,torsion degree, preoperative WBC and NE,postoperative WBC,NE and CRP(P\u0026gt;0.05). No recurrent torsion after laparoscopic de-torsion without oophoropexy.Normal ovarian morphology and functional recovery in the non-atrophy group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions \u003c/strong\u003eHigh incidence of atrophy after de-torsion of normal ovarian torsion in children.There was no recurrent torsion without oophoropexy.Children with longer onset, darker ovaries and higher preoperative CRP are more likely to develop ovarian atrophy postoperatively, but those with nausea and vomiting are less likely to develop ovarian atrophy.\u003c/p\u003e","manuscriptTitle":"De-torsion without oophoropexy for torsion of normal ovary in children: a report of 10 cases","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-19 16:29:48","doi":"10.21203/rs.3.rs-6031448/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"87cfc528-4102-4197-81d0-1516b6ae65bf","owner":[],"postedDate":"February 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-19T16:29:48+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-19 16:29:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6031448","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6031448","identity":"rs-6031448","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}