This study suggests that mode of surgery and pregnancy status are the biggest factors in determining how premenopausal women with AT are managed at the time of emergency presentation. Pregnant women and women having laparoscopy are more likely to have conservative surgery. Our study also suggests that seniority of the consultant gynecologist involved, and being febrile at presentation, influence management decisions.
In our study, 52% of premenopausal women were conservatively managed at the time of emergency surgery for AT which is comparable to published rates of 20.6–65.4% [6, 10–15]. This is despite a difference in the definition of “conservative surgery”. If cystectomies were included in conservative surgery to be consistent with the published literature, our rate would increase to 72%. While cystectomy is ovarian-preserving surgery, it is still traumatic in that tissue planes are more difficult to differentiate within edematous ovarian tissue. This could potentially reduce the number of follicles or even lead to oophorectomy if hemostasis cannot be achieved, thereby affecting fertility and ovarian function. There is evidence that cystectomy at detorsion does impair ovarian function  and even stronger evidence for good ovarian recovery and function in almost all conservatively-managed AT cases based on ultrasound findings post-operatively [8, 9, 17–20]. In addition, as shown in our cohort and by Oelsner and Moro, there is the potential that the cyst excised is simply a functional cyst and that the ovarian trauma inflicted was therefore unnecessary [8, 15].
Our rate of conservative surgery for the decade of 2010–2020 is higher than the 30.8% rate reported in an Australian tertiary hospital from 1990–2000 , and the 20.6% reported in the United States also for 1990–2000 . This may reflect the trend that Mandelbaum showed in the United States where the rate of conservative surgery significantly increased from 18.9% in 2001 to 25.1% in 2015 . However, that study also noted that rates varied between areas and sizes of hospitals  further emphasizing that care for AT is not standardized.
We hypothesized that conservative surgery would be preferred in younger, nulliparous/low-parity patients to preserve fertility and hormonal health. We also hypothesized that larger ovarian masses would be more likely to have interventional surgery due to technical reasons. Surprisingly, factors such as parity, age and MOD were not shown to be statistically significantly different between the patients managed with conservative versus interventional surgery, or whether they had a laparoscopy or laparotomy. Only Ogburn’s paper attempted to identify differences between patients managed conservatively with those managed with salpingo-oophorectomy and it too found no difference in age or ovarian size . Our study did show, however, that pregnancy and mode of surgery were statistically significant factors in deciding between conservative vs interventional surgery, with pregnant women and women having laparoscopy being more likely to have conservative surgery. This may stem from a desire to minimize ovarian handling and trauma to the pregnancy. Laparotomy was associated with a higher likelihood of interventional surgery and our study goes on to show that laparotomy was more likely to occur where there was a senior gynecology consultant involved in the patient’s care. Flin noted in 2007 that “experienced surgeons may rely more on intuitive, pattern matching techniques” . It is possible that the senior consultants may have operated along these lines on two fronts. Firstly, they may have trained when ovarian-sparing surgery and laparoscopic techniques were not yet as widely adopted. Secondly, they may have been more likely to perform oophorectomy based on what the ovary looked like and the patient’s symptoms. This would be consistent with another study that identified that surgeons preferred to perform oophorectomies if the color of the adnexa was still blue-black at 10 minutes after detorsion . However, as previously mentioned, there is strong evidence for good recovery of ovarian function despite how they may appear at the time of surgery. There is also evidence for laparoscopy over laparotomy in general, including but not limited to shorter operating time, fewer post-operative complications, and shorter lengths of stay [6, 22].
As yet there are no diagnostic clinical or imaging criteria for AT. The most common symptoms of AT are sudden-onset abdominal pain that is intermittent, non-radiating, and associated with nausea and vomiting [4, 17, 20]. In our study, women had AT diagnosed in two settings - one group presented to the ED with acute symptoms such as pain, nausea and vomiting, requiring urgent management, whilst the other group had pain but not severe enough to need ED presentation and could therefore wait for their elective surgery dates. This is consistent with Way’s description that there are two different types of presentations for AT with two correspondingly different surgical findings, including “loosely twisted” pedicles that did not obstruct any of the ovarian vessels and therefore only had vague lower abdominal symptoms, and the “typical twisted ovarian” where “infarction was always seen” which presented as emergency cases with severe colicky pain . It was not within the scope of this study to explore false positive cases.
With regards to imaging, 98 (88%) of our emergency AT cases had any imaging (ultrasound or computed tomography) pre-operatively. Of them, 80 had doppler flows reported of whom 28 (35%) had normal flows, similar to published pre-operative diagnostic rates of 36.6–55.8% [5, 15, 23]. Other studies have found that ultrasound (US) diagnosis of AT has low sensitivity 70% and specificity 87% , where abnormal dopplers only have 61% sensitivity and 98% specificity . Budhram has suggested using MOD on US to help diagnose AT instead of dopplers as there is high sensitivity and specificity where MOD is greater than 5cm, at 91% and 92% respectively . However, 9% of our images reported MOD < 5cm. This is consistent with two other studies that cited 11%  and 55%  of cases having no ovarian masses on pre-operative imaging. Furthermore, Shalev reported that in cases where the AT was less than 360° at surgery, the mean MOD was 47.5mm compared to 29.6mm on the normal contralateral side mean .
The main strength of our study is its large cohort especially for a condition with infrequent diagnosis. Our data also covers the most recent decade and therefore provides a useful insight into current practice. In addition, as a single center study at a tertiary institution, the decision-making processes are not confounded by differences in access to resources or local protocols that may be in play across multiple locations.
The retrospective nature of this study is its primary limitation as it is inherently associated with data collection issues and dependent on the quality of documentation. Imaging reporting was not standardized with ovarian size sometimes reported by volume instead of diameter. Older images were not accessible for review. In addition, the potential for misclassification of cases or coding errors may have meant some AT cases were missed potentially leading to selection bias. Incidental findings of AT at elective surgery may not necessarily be documented in a way that can be easily identified through the hospital medical record coding system. Furthermore, the vast majority of patients who underwent conservative surgery did not attend their follow-up appointments with our gynecology service, thereby limiting our outcomes data.
This study identifies that premenopausal women who presented emergently with AT were statistically significantly more likely to have conservative surgery if they were pregnant or had their surgery via laparoscopy. This study also suggests that women were more likely to have a laparotomy if senior gynecology consultants were involved in their care or if they were febrile at presentation. These factors are important to identify so as to understand the decision-making process behind AT management for this cohort. Gynecologists should strongly consider applying the principles of conservative management of AT, as recommended by ACOG for adolescent patients, to premenopausal women presenting with AT emergently given that fertility and hormonal health preservation should be key considerations. Relevant organizations should also consider putting forth a set of consensus opinions or recommendations promoting conservative surgical management of AT to encourage this practice amongst clinicians.