In our review of the literature, we found reports of 45 cases of pediatric isolated fallopian tube torsion. The mean age of the patients at presentation was 13.2 years .
Several risk factors for tubal torsion in adults have been identified: pelvic inflammatory disease, prior pelvic surgery, previous ectopic pregnancy, endometriosis and paratubal cysts . Currently, there are no clearly identified risk factors for the development of isolated torsion of the fallopian tube in the pediatric population, but the authors of a recent report suggested that a congenital malformation of the tube in the peri-pubertal age could be a significant risk factor .
Hydrosalpinx is a very rare finding in adolescent girls without a history of pelvic inflammatory disease, and its exact pathogenesis is not clear. Sporadic cases of non-inflammatory hydrosalpinx have been reported as post-surgical complications or as complications of peritoneal drains .
Although the presumed course of events in our patient is that hydrosalpinx provoked torsion of the fallopian tube, the possibility that hydrosalpinx was a consequence rather than the cause of the torsion, which could have been provoked by a pre-existing fimbrial cyst, must also be considered. However, unclear etiology should have no impact on therapeutic decision-making in the clinical setting of fallopian tube torsion. The pathology report in our present case confirmed that the excised structure was indeed a cystically altered fallopian tube.
The onset of symptoms in patients such as ours is acute 60% of the time. Peritoneal signs are present in one-third of the patients, but other symptoms are non-specific . Diagnostic imaging (ultrasound and computed tomography) reveal a cystic mass, but rarely differentiate the origin of the mass . The patient’s clinical status will determine the amount and type of pre-operative checkup as well as the urgency of surgery. Most commonly, the diagnosis is made during exploratory surgery.
Few therapeutic options for isolated tubal torsion have been reported to date. Complete or partial salpingectomy is indicated in cases of ischemic, irreversible changes of the tubal wall. Laparoscopic tubal clip occlusion has been described as an alternative to salpingectomy . Radical excision with concomitant tubal pathology, suspected neoplastic changes or hemorrhage is a reasonable choice. A conservative approach such as preservative surgery—either detorsion or partial resection—is another option.
In pediatric patients, the future conception capacity of the patient should always be taken into account. Therefore, partial tubal salvage and neosalpingostomy creation are especially important issues in treating adolescent girls. It is acknowledged that salvage of the ovary is a safe choice in the pediatric population, regardless of how necrotic the ovary appears to be [8, 9]. The same philosophy can be applied to tubal salvage after a preliminary evaluation of tubal status .
Neosalpingostomy in premenarchal girls with fallopian tube torsion has been reported recently [3, 10]. Boukaidi et al. proposed a two-stage procedure in which the first step is detorsion of the torqued fallopian tube with puncture of the hydrosalpinx for cytologic and bacteriologic analysis to rule out malignancy and infectious disease. Neosalpingostomy is performed in the second step if the tube is judged to be salvageable after salpingoscopic evaluation. Although we did not perform a salpingoscopic evaluation of the fallopian tube in our patient, the macroscopic appearance of the proximal ampullary and isthmic parts of the tube was favorable, which encouraged us to proceed with neosalpingostomy.
Restorative surgery raises two major concerns. How functional will the fallopian tube be after preservation surgery? Does the potential benefit outweigh the risks of infection and ectopic pregnancy?
Spontaneous conception and successful in vitro fertilization (IVF) after tube-preserving surgery are controversial issues. Fair chances of spontaneous conception, as well as more successful IVF-assisted pregnancies, have been reported after a conservative surgical approach as opposed to salpingectomy . Histological examination could help to determine the viability of the tube remnant and resection plane . However, serious concerns remain that a restored tube could expose the patient to a high, unnecessary risk of ectopic pregnancy . According to Bayrak et al., functional repair of hydrosalpinx in adult patients treated for infertility by laparoscopic neosalpingostomy is not recommended because of the dismal spontaneous pregnancy rate and an up to 70% incidence of recurrence of hydrosalpinx, which requires a second surgery before IVF .
Does operative fixation of the tube prevent recurrent torsion? Salpingopexy seems reasonable but could change the normal anatomy of the pelvis, either by moving the adnexa outside the pelvis or by distorting the close relationship between the ovary and the fimbriated portion of the tube. Shortening of the mesosalpinx to reduce the tubal mobility may also impair the blood supply to the adjacent ovary .