Oophoropexy procedures appear to have limited efficacy in the prevention of recurrent torsion events in women diagnosed with torsion of otherwise normal adnexa, with recurrences having occurred in ¬70% of our cases. This finding is in accordance with previous anecdotal case reports which described recurrent torsion following fixation [8, 9]. Three retrospective case series described a post-oophoropexy recurrence rate in the range of 10–17% [2, 6, 10]. However, the follow-up time in those reports was either unspecified, short (~2 years), or incomplete, and the indications for oophoropexy were broad, including torsion of “pathologic” adnexa whose recurrence risk is very low .
The etiology of torsion and recurrent torsion involving otherwise normal adnexa is unknown. It has been hypothesized that elongated adnexal ligaments (the utero-ovarian ligaments in particular) may predispose to this condition. However, the utero-ovarian ligaments may also become elongated secondary to the repeated twisting of the adnexa at the time of torsion, making it difficult to differentiate between the cause and the effect of elongated ligaments.
The common practice of ovarian fixation for the prevention of torsion is to shorten the adnexal ligaments and/or anchor the ovary to an adjacent pelvic structure, such as the round ligaments, the uterus, the pelvic sidewalls, or the utero-sacral ligaments. Due to the rarity of this condition, the different fixation techniques have not been compared to date and the optimal procedure has not yet been determined. Following the high rate of failure with the utero-ovarian plication procedure in our patients, we now perform the combined utero-ovarian and round ligament fixation. The combined technique has the advantage of additional anchoring of the adnexa. However, this procedure is more technically difficult to execute and may cause occlusion of the fallopian tube in the process. Our study was too underpowered to compare the success rates of the different fixation techniques, and further studies are necessary.
Our practice has been to offer oophoropexy to patients who have experienced at least two torsion episodes. This practice may have contributed to the high failure rate of oophoropexy in our current study. If recurrent torsion events do cause further elongation of the adnexal ligaments, performing the oophoropexy after one episode of torsion may increase its success rate. Nevertheless, it is important to bear in mind that oophoropexy is often not technically feasible at the time of the first torsion episode because the massive adnexal enlargement and edema preclude effective suturing. As such, the optimal timing of oophoropexy remains a matter of controversy.
In the current study, the follow-up period for the non-recurrence group was shorter than for the recurrence group, albeit without reaching statistical significance. Thus, the recurrence rate may have been underestimated in our study, and longer follow-up may have revealed additional recurrences.
In the view of the failure of surgical techniques to prevent recurrent torsion, non-surgical strategies should be considered. These strategies include the prescription of hormonal contraceptives, with the view that small functional cysts may increase the risk for torsion. However, that approach has not been studied to date. Additionally, fertility preservation with oocyte or ovarian tissue cryopreservation may be considered in patients with high-order recurrences necessitating multiple surgeries. Such an approach should allow for unilateral salpingo-oophorectomy without fertility compromise.
Our study is limited by its relatively small cohort and its retrospective design. However, given the rarity of this condition, larger cohorts would only be feasible in a multi-center or population study.