weekly_question 1/11/2020

[Admin]

please write the answer and your justification, correct answer will be submitted after 48 hrs

An 11-year old premenarchal female presents with nausea, vomiting and right lower quadrant pain. An abdominal ultrasound demonstrates a six cm cystic and solid mass involving the right ovary with internal hemorrhage and calcifications. At laparoscopy, a torsed, blue irregularly enlarged right ovary is found. Upon detorsion, the ovary appears slightly more pink, but no plane can be identified between the mass and any identifiable ovarian tissue. The most appropriate next step for this patient with ovarian torsion is

A right oophorectomy.

B right salpingo-oophorectomy.

C right oophoropexy.

D cyst aspiration.

E remove ports and close.

[Admin]

correct answer

E remove ports and close.

Among factors shown to predict oophorectomy, one that is of particular concern is that surgical management by a pediatric surgeon is associated with a 2.3 to 5.9 times greater likelihood of oophorectomy compared to management by a pediatric and adolescent gynecologist. This observation, along with increased awareness of the impacts of surgical castration (bilateral oophorectomy or loss through torsion) on morbidity and mortality in women, represents a call to action for practice change which encourages ovarian salvage.

Two factors that are likely to influence operative decision making when dealing with a torsed ovary with an accompanying mass are the potential for recovery of viability and the likelihood that the mass is malignant.

Torsed ovaries can have a highly variable appearance ranging from edema to necrosis. A clinician’s ability to predict recovery of follicular function appears to be limited. For this reason, it has been recommended that even necrotic appearing torsed ovaries be left following detorsion.

The likelihood of malignancy is low: amongst torsed ovaries removed at surgery, the risk of malignancy is approximately two percent. Although presentation with torsion limits the investigations that can be done to help discriminate between benign and malignant masses, the history and physical examination (particularly the absence of precocious puberty or virilization) and the imaging features of a mature cystic teratoma make it extremely likely that the associated ovarian mass is benign.

In a case where resection of the mass with ovarian preservation might be difficult, it would be most appropriate to detorse and leave the ovary and then follow-up with imaging and tumor markers with possible reoperation for a persistent mass.

[Elvyn Alcántara]

D

[Bashar Dawud]

E

[Basma Waseem]

B

[Abusnaina mohammed]

D

[Aey]

B

[Admin]

correct answer

E remove ports and close.

Among factors shown to predict oophorectomy, one that is of particular concern is that surgical management by a pediatric surgeon is associated with a 2.3 to 5.9 times greater likelihood of oophorectomy compared to management by a pediatric and adolescent gynecologist. This observation, along with increased awareness of the impacts of surgical castration (bilateral oophorectomy or loss through torsion) on morbidity and mortality in women, represents a call to action for practice change which encourages ovarian salvage.

Two factors that are likely to influence operative decision making when dealing with a torsed ovary with an accompanying mass are the potential for recovery of viability and the likelihood that the mass is malignant.

Torsed ovaries can have a highly variable appearance ranging from edema to necrosis. A clinician’s ability to predict recovery of follicular function appears to be limited. For this reason, it has been recommended that even necrotic appearing torsed ovaries be left following detorsion.

The likelihood of malignancy is low: amongst torsed ovaries removed at surgery, the risk of malignancy is approximately two percent. Although presentation with torsion limits the investigations that can be done to help discriminate between benign and malignant masses, the history and physical examination (particularly the absence of precocious puberty or virilization) and the imaging features of a mature cystic teratoma make it extremely likely that the associated ovarian mass is benign.

In a case where resection of the mass with ovarian preservation might be difficult, it would be most appropriate to detorse and leave the ovary and then follow-up with imaging and tumor markers with possible reoperation for a persistent mass.