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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 12  |  Issue : 1  |  Page : 55-60

Laparoscopic approach to adnexal mass in adolescents: A retrospective analysis


Department of Endogynecology, Gem Hospital and Research Centre, Coimbatore, Tamil Nadu, India

Date of Web Publication25-Jul-2017

Correspondence Address:
Kavitha D Yogini
Department of Endogynecology, Gem Hospital and Research Centre, 45A, Pankaja Mills Road, Ramanathapuram, Coimbatore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_26_17

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  Abstract 

Background: Adnexal masses result from benign or malignant lesions of ovarian, tubal and paratubal origin as well as pregnancy related causes such as mullerian anomalies, infectious causes and ectopic pregnancy. The current study aimed to evaluate the preoperative diagnosis, surgical procedure and histopathological findings of adolescent girls who underwent laparoscopic surgery for adnexal mass in our hospital. Materials and Methods: A retrospective chart review of patients with adnexal mass was conducted over a period of one year from Jan 2014-2015. Overall 96 patients were included in the study after reviewing clinical records. In all the patients' malignancy was excluded by preoperative imaging with sonography, CT or MRI and tumor marker study. Results: Laparoscopy was the operative approach for all 96 patients. None resulted in malignant histology. Majority of the adnexal masses were simple cyst (28%), 11.4% were dermoid cyst, 2% were endometriotic cyst. One patient had tubal ectopic, 3 patients had Koch's abdomen and pelvis. Among them one 13 year old girl underwent rudimentary horn excision who presented as a para tubal mass with acute abdomen. Almost half of the patients (68.7%) presented with acute abdomen of which 41.6% were adnexal torsion. All adnexal masses were resected laparoscopically and the outcome was uneventful in all the patients. Conclusion: Laparoscopy is regarded as an appropriate surgical method for benign adnexal masses which was safe and effective even for giant ovarian cyst in well selected cases as most of the pelvic adnexal masses seen in adolescents and young girls are of benign nature.

Keywords: Adolescent, benign adnexal mass, laparoscopy


How to cite this article:
Yogini KD, Balasubramaniam D, Palanivelu C, Kakollu A. Laparoscopic approach to adnexal mass in adolescents: A retrospective analysis. J Datta Meghe Inst Med Sci Univ 2017;12:55-60

How to cite this URL:
Yogini KD, Balasubramaniam D, Palanivelu C, Kakollu A. Laparoscopic approach to adnexal mass in adolescents: A retrospective analysis. J Datta Meghe Inst Med Sci Univ [serial online] 2017 [cited 2019 Apr 18];12:55-60. Available from: http://www.journaldmims.com/text.asp?2017/12/1/55/211584


  Introduction Top


Adolescence starts with the beginning of physiologically normal puberty. This period roughly corresponds between the ages of 10 and 19 years as defined by the World Health Organisation.[1] The incidence of adnexal masses in the pediatric and adolescent population is approximately 2.6/100,000 lakh girls per year. Most of the adnexal masses during this period are functional ovarian cysts and benign neoplasms.[2] Nowadays, laparoscopic management of adnexal mass is one of the most frequently performed laparoscopic interventions. Careful and meticulous preoperative evaluation is important for the appropriate and successful use of laparoscopy. The exclusion of malignancy is the principal aim in the evaluation of an adnexal mass. The advantages of laparoscopic approach should in no way compromise the clinical outcome of a malignant adnexal mass. The laparoscopic puncture of a malignant ovarian mass though uncommon should be avoided whenever possible.[1] However, histopathology alone can definitively diagnose the nature of an adnexal mass as benign or malignant.[3]


  Materials and Methods Top


This is a retrospective analytical study in the Department of Endogynecology, GEM Hospital and Research Centre after approval by ethics committee. The medical records of 96 patients who were admitted to the gynecology department with a diagnosis of adnexal, tubouterine or ovarian benign neoplasm from January 2008 to January 2012 were analyzed. Patients below the age of twenty were included in the study. Those patients with an adnexal mass who were either managed medically or diagnosed with malignancy were excluded from the study. Data for all the patients were recorded in terms of age at the time of surgery, presenting complaint, menstrual complaints, cyst size on ultrasound, tumor markers (cancer antigen [CA] 125, CA 19-9, alpha-fetoprotein [AFP], β-human chorionic gonadotrophin, carcinoembryonic antigen), surgical procedure, preoperative findings, and definitive histopathology. For preoperative evaluation of adnexal mass, Ultrasound or computed tomography (CT), magnetic resonance imaging (MRI) was used. Data were entered into a Microsoft Excel database (Microsoft Corp., Redmond, WA, USA) and were coded and analyzed. The limitation of the study was that it was a retrospective study with a minimal number of patients due to the fact that benign adnexal masses requiring surgical intervention are less common in adolescents.


  Results Top


In our study, from 2008 to 2014, a total of 96 cases with an adnexal mass who were young girls underwent laparoscopic surgery. The mean age of patients in our study was 16 years (range 6–20 years) with a mode of 19 years. Most of the patients (61.5%) were aged between 16 and 19 years. Only one patient (age 6 years) presented with an adnexal mass below the age of 10 years and 37.5% were aged between 10 and 15 years. Among the 96 girls, 84 (87.5%) had attained menarche whereas 12 (12.5%) of them were premenarcheal [Figure 1]. 67.8% (65) of patients presented in an emergency whereas the remaining 32.2% (31) had chronic symptoms.
Figure 1: Graphical presentation of premenarcheal and postmenarcheal patients

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The most common presentation in our study was acute pain abdomen with vomiting [Table 1] 65 patients (67.7%) presented with pain and vomiting. Two patients were asymptomatic wherein the diagnosis of an adnexal mass was incidental. Other presentations noted in our study were chronic pain abdomen, abdominal distension, dysmenorrhea, and menstrual complaints.
Table 1: Presenting complaints

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The mean diameter of the adnexal mass in our study was 9.1 cm (range 3–37 cm). About 67.8% (65) cysts were less than the size of 10 cm. Among them, 6 patients (6 of 65) had increased values of tumor markers. 20.8% (20) were between the size of 10–15 cm [Table 2] 7.3% (7) of the cysts were larger than 15 cm. Tumor markers were measured in all patients (n = 96). Of all the patients, 12 patients (12.5%) had an abnormal result and in the remaining 84 patients (87.5%), tumor marker levels were normal.
Table 2: Data analysis in ovarian cysts of large size (>15 cm)

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All our patients underwent ultrasound study of abdomen and pelvis, in those few patients where further imaging was required, CT or MRI was done. Ultrasound examination was correlated with peroperative findings and histopathology of the adnexal mass. In 82 patients (85.4%), the diagnosis on ultrasound was in accordance with peroperative and histopathological diagnosis. 14 patients (14.6%) had a different diagnosis preoperatively and histopathologically when compared with the preoperative ultrasound diagnosis. In 2 patients, who were preoperatively diagnosed with serous cystadenoma on ultrasound, the ovaries were noted to be polycystic peroperatively and ovarian drilling was done. The accuracy of diagnosing an adnexal mass by ultrasound alone in our study was 93%.

The management of all the 96 patients in our study was by laparoscopic surgery. The procedures performed were ovarian cystectomy, paratubal or paraovarian cystectomy, salpingectomy, salpingo-oophorectomy, detorsion and ovariopexy, excision of a rudimentary horn. In 70.83% (68) patients, the ovaries were preserved. The histopathological findings of all the 96 patients in our study were either a nonneoplastic mass or a benign neoplasm. 68.8% were nonneoplastic, and 28.12% were benign neoplastic. In 3.2%, the histopathology was not necessary and hence not done.
Figure 2: Graphical presentation of Tumor markers

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Adnexal mass that had undergone torsion was seen in 40 patients (41.7%). All the cases presented as an acute emergency. 23 patients (57.5%) who presented with adnexal torsion were aged between 16 and 19 years, 16 patients (40%) were in the age group of 10 to 15 years. One patient (2.5%) was below the age of 10 years. Among all the patients who presented with adnexal torsion, 82.5% (33) had attained menarche and 7% (17.5%) were premenarcheal. The mean diameter of adnexal mass undergoing torsion in our study was 8 cm. Tumor markers were normal (92.5%) in majority except for three patients in whom the tumor markers were raised in spite of a benign histology. The procedures performed were cystectomy, detorsion with or without oophoropexy, salpingectomy, and oophorectomy. Most of the adnexal mass that had presented with torsion were simple cysts (35%) and hemorrhagic cysts (25%) on histopathology. 15% (6 of 40) were paratubal cysts that had undergone torsion. 10% (4 of 40) of them were dermoid cysts. The remaining were polycystic ovary (5%), corpus luteal cyst (2.5%), endometriotic cyst (2.5%), serous cystadenoma (2.5%), and hydrosalpinx (2.5%) [Table 1], [Table 2], [Table 3], [Table 4].
Table 3: Patient demographics and clinical evaluation

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Table 4: Definitive histopathological results of all patients operated for adnexal mass

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  Discussion Top


Adnexal masses in adolescent girls are an enigma, and they pose a notable challenge in management. The priority while formulating a plan for management has shifted toward organ preservation in the recent years, unlike the conventional aggressive approach. Adnexal masses in adolescents are more likely to be benign. However, evaluation of any adnexal mass in an adolescent is mandatory and should be meticulous to exclude malignancy.[4]

All the patients in our study have been managed with laparoscopic surgery for a benign pathology. The mean age of our study population was 16 years, and the greater numbers of them were aged between 16 and 19. This was in accordance with the study done by Kim et al.[5] where the mean age was 17.1 years. Functional cysts predominate in postmenarcheal girls secondary to changes in hormonal milieu at puberty.[6] Concurrent with other studies,[6],[7] 87.5% of the girls included in our study were postmenarcheal.

The majority (67%) of our patients presented as an emergency with acute abdominal pain and vomiting. 10.4% of them had chronic abdominal pain and 9.3% with abdominal distension. As many as 50%–70% patients presented with pain abdomen in several studies.[6],[7],[8],[9],[10],[11]

Tumor markers were measured preoperatively in all the patients to exclude possible malignancy. As CA 125 has limited specificity in adolescence,[12] CA 19-9, AFP, carcinoembryonic antigen, lactate dehydrogenase were assessed additionally. An elevated level of CA 125 was with a value above 65 U/ml as all our patients were young and accounted for the premenopausal age group.[12],[13],[14],[15],[16],[17] Due to the high probability of a false positive or misleading result, an isolated elevated CA 125 level was not considered to be definitely predictive of malignancy. There were two patients with CA 125 value above 100 U/ml of whom one was diagnosed with Koch's abdomen and the other with a hemorrhagic cyst on histopathology. Serum CA 125 can be elevated in various conditions including endometriosis, pelvic inflammatory disease, tuberculous peritonitis, liver cirrhosis, chronic renal failure, pleural effusion and pancreas or colorectal cancer, as well as in postoperative status.[18],[19],[20],[21],[22],[23],[24] Therefore, a differential diagnosis of Koch's abdomen or a chronic inflammatory etiology is to be borne in mind for an elevated CA 125 especially in an endemic region.

All the patients were preoperatively assessed by ultrasound. Those cases where the ultrasound examination was inconclusive or suspicious of malignancy further required either a CT or MRI. Ultrasound is well known to be the gold standard in evaluating an adnexal mass.[12],[25],[26] The mean diameter of adnexal mass was 9.1 cm. Similar observations were reported in other studies as well (6.27). The sensitivity of ultrasound in diagnosing a benign adnexal mass in this study was 89.1% with a positive predictive value of 95.3%. Marret showed the sensitivity of ultrasound to be 80% which is comparable to ours.[27] In a study by van Calster et al.,[28] 98% of benign adnexal masses in premenopausal women were correctly classified by pattern recognition. The same in our study was 85.4%. The higher recognition in their study could be due to the use of transvaginal scan for all patients whereas we have universally done transabdominal evaluation as our entire study group was adolescents.

The conventional approach to adnexal mass was laparotomy and unilateral salpingo-oophorectomy).[29] This has evolved immensely with the advent of gynecological endoscopy and emphasis on ovarian conservative surgery.[30],[31] Laparoscopic surgery is increasingly being accepted as the procedure of choice in adolescents.[32],[33] Laparoscopy offers the advantages of better visualization, shorter hospital stay, faster recovery, lesser postoperative pain and a tremendous cosmetic appeal in the adolescent age group.[34],[35],[36],[37] The challenges faced during laparoscopic surgery in adolescents are attributed to the anatomical differences in comparison with adult women. None of our patients experienced major complications, and postoperative recovery was unremarkable.

The largest series thus far was reported by Seckin et al. comprising 79 adolescents younger than 20 years who underwent laparoscopic surgery for presumed benign cyst.[37] We had operated on 96 adolescents and in our experience Laparoscopic management is a safe, effective, and feasible option in adolescents. Among our patients, 70.83% had their ovaries preserved. This was comparable to the study by Kim et al. wherein the ovary could be salvaged in 65.1% of the patients.[5]

Simple cyst (29.2%) was the most common histopathology. In an analysis by Kinson et al.,[8] of all the adnexal masses, 57.9% were cystic and 17.1% were follicular cysts. Dermoid cyst was seen in 14.6%.[8] About 50% of them had presented with torsion. Although AFP is positive in solid tumors and CA 19-9 has specificity for dermoid, we observed that an elevated AFP in both patients was associated with dermoid.[38] Thus, AFP can be useful as a marker for diagnosing a mature cystic teratoma. Three patients who underwent laparoscopy for adnexal mass were preoperatively diagnosed with polycystic ovaries. One among them had presented with torsion and was managed for the same. In the other two patients who were preoperatively diagnosed with an adnexal mass, polycystic ovaries were noted intraoperatively, and laparoscopic ovarian drilling was done. Three patients were diagnosed with Tuberculosis. Surgery was planned in all of them for chronic abdominal pain and persistent ovarian cyst. Peroperatively, cyst was noted in only one patient whereas the other two had military tubercles and a peritoneal biopsy was taken in them.

One 13-year-old premenarcheal girl presented with acute abdomen with preoperative ultrasound suggestive of paraovarian mass. She was intraoperatively diagnosed with rudimentary horn that had undergone torsion and was managed with excision of the rudimentary horn.

Torsion is a gynecological emergency necessitating immediate intervention. It is all the more important in adolescent age group as the delay in intervention can cause permanent ovarian damage with an impact on future fertility. All patients with torsion (41.7%) presented with acute symptoms and underwent emergency laparoscopic surgery. 97% of the adnexal masses undergoing torsion are a result of benign pathology.[39] Torsion was more common on the right side as a result of protective effect of sigmoid colon on the left side, and simple cysts were the predominant adnexal masses that presented with torsion. The mean diameter of torsed mass was 7.4 cm. These findings are in agreement with various studies reporting the same.[40],[41] Ultrasound was of aid in correctly identifying 82.5% of these patients, and the remaining patients were taken up for surgery based on clinical diagnosis and blood evaluation. The diagnosis of ovarian torsion was supported by ultrasound, approximately, 87% accurate for ovarian pathology.[42]

Ovarian cysts are traditionally labeled large when more than 5 cm and giant or voluminous when more than 15 cm.[43] Giant adnexal masses have been managed customarily by laparotomy and cystectomy. We encountered seven cases with diameter over 15 cm. Of these seven cases, three were serous cystadenoma, and two were dermoid cysts. Tumor markers were normal in serous cystadenoma, and AFP was elevated in both the patients with dermoid. All the cases were managed laparoscopically. An initial 5 mm camera port was placed in the epigastrium and the second trocar was inserted into the cyst under direct vision. The cyst contents were aspirated without spillage followed by a cystectomy. Challenges in these cases were a difficult entry, less working space, risk of tumor spillage. While the rupture of stage I ovarian disease significantly affected the disease-free interval is concerning. Cyst rupture and potential tumor spillage were avoided in laparoscopy by the use of endobag to retrieve the mass and liberally extending the trocar incision to safely remove the mass intact in these cases.[44]

Limitation of this study is that this is an institution based and retrospective study, so the result obtained may or may not reflect the histological pattern.


  Conclusion Top


Laparoscopy is a favored approach in the surgical management of benign adnexal masses. Every effort should be taken to ensure maximal ovarian preservation for future fertility concerns. Ultrasound is a gold standard in preoperative evaluation to ascertain the benign nature of adnexal mass. The laparoscopic approach is effective and safe for managing adolescent adnexal masses.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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