Percutaneous drainage as the treatment of choice for neonatal ovarian cysts

Transcription

1 Pediatr Radiol DOI /s ORIGINAL ARTICLE Ada Kessler. Hagith Nagar. Moshe Graif. Liat Ben-Sira. Elka Miller. Drora Fisher. Irith Hadas-Halperin Percutaneous drainage as the treatment of choice for neonatal ovarian cysts Received: 9 February 2006 / Revised: 21 April 2006 / Accepted: 2 May 2006 # Springer-Verlag 2006 Abstract Background: Involution of neonatal ovarian cysts occurs usually by 12 months. Persisting cysts larger than 4 cm are prone to torsion. Two modes of therapy are advocated: surgery and percutaneous US-guided cyst aspiration. Objective: To compare ovarian preservation following the use of US-guided aspiration or conventional surgery for the treatment of large asymptomatic neonatal ovarian cysts, and to suggest alternative treatment when intrauterine ovarian torsion occurs. Materials and methods: The study population comprised 25 baby girls with an ovarian cyst, 5 with a simple cyst and 20 with a complex cyst. Of these 25 infants, 8 had surgery and 17 had US-guided cyst aspiration. Results: In the surgical group of 8, 6 underwent oophorectomy, and in 2 the ovary was saved. In the aspirated group of 17, the ovary was saved in 10, and was lost in 5. At the time of this report one patient was still in the follow-up period, and one was lost to follow-up. Conclusion: US-guided aspiration of large neonatal cysts preserves ovarian tissue in a higher percentage of patients than surgery. It is safe, effective, and repeatable. We recommend US-guided aspiration of asymptomatic large ovarian cysts for salvage or for decompression if intrauterine ovarian torsion occurs. Surgery should be reserved for patients with acute torsion, intestinal obstruction and intestinal volvulus. Keywords Neonate. Ovarian cyst. Aspiration. Ultrasound A. Kessler (*). M. Graif. L. Ben-Sira. E. Miller Department of Radiology, Tel Aviv Souraski Medical Center, 6 Weizman, Tel Aviv, 64239, Israel kesslera@tasmc.health.gov.il Tel.: Fax: H. Nagar Pediatric Surgery, Tel Aviv Souraski Medical Center, Tel Aviv, Israel D. Fisher. I. Hadas-Halperin Department of Radiology, Shaare Zedek Medical Center, Jerusalem, Israel Introduction Small ovarian cysts (less than 0.9 cm) are present in 82% of neonatal ovaries, and macrocysts (larger than 0.9 cm) are present in 20 34%. They are usually a result of excessive stimulation by placental and maternal hormones [1 3]. The normal neonatal ovary appears on sonography as a homogeneous structure with scattered anechoic small follicular cysts (up to 4 5 mm in diameter) [4, 5]. After birth, circulating maternal hormone levels decrease, and spontaneous resolution of the cysts usually occurs within months [6, 7]. When the cysts are larger than 4 5 cm, complications can occur. These most commonly include ovarian torsion, intracystic hemorrhage, rupture resulting in hemoperitoneum, and intestinal obstruction. The incidence of torsion and hemorrhage might be as high as 42% [6]. Most neonatal ovarian torsions are associated with an underlying cyst, but rarely can occur in the absence of a cyst. Because torsion can result in ovarian necrosis, cysts larger than 4 5 cm should be treated [5 8]. Surgical cystectomy or fenestration is the traditional treatment; in most cases, this results in oophorectomy [4, 5]. In recent years percutaneous US-guided cyst aspiration has been suggested as an alternative therapeutic approach [7 10]. Our experience with 25 infants with large neonatal cysts is presented and discussed. Materials and methods IRB approval was not required for this study at our institution. The study population comprised 25 baby girls with ovarian cysts larger than 4 cm in diameter born between 1998 and The study was a retrospective analysis of ten infants treated during 1998 through 2000, supplemented by a prospective analysis of 15 infants managed during 2001 through The cysts were diagnosed in utero by sonography and confirmed sonographically on postnatal examination within 24 h of delivery. During the initial period of the study ( ), five of the ten infants

2 who were born with an ovarian cyst larger than 4 cm underwent surgery and the other 5 had cyst aspiration. During the second arm of this study ( ), 3 of the 15 infants underwent surgery and 12 had cyst aspiration. Indications for surgery such as acute torsion, bleeding and bowel obstruction were identical throughout the study. For the purposes of this study, the infants were divided into two groups consisting of 8 infants who were treated surgically (group A) and 17 infants who underwent US-guided cyst aspiration (group B). In both groups, treatment was carried out within 24 h of delivery. Of the 17 infants who were treated with percutaneous drainage, 2 had also undergone intrauterine aspiration. Prior to aspiration, a normal coagulation profile was required and informed consent was obtained from the parents. Drainage procedures were performed under local anesthesia (one hospital) or under sedation (second hospital). A 21- or 23-gauge needle was inserted under US guidance into the cyst, and the contents were aspirated. The relatively large size of the cysts enabled a suitable acoustic window for percutaneous aspiration in all patients. In 17 infants, 20 aspirations were performed under US guidance. In three infants the procedure was repeated 1 week to 3 weeks after the first one because of fluid reaccumulation. The average duration of the procedure was about 20 min. The amount of aspirated fluid varied between 13 ml and 30 ml. When the contents were thick or hemorrhagic, complete evacuation could not be achieved, and the procedure was discontinued when the cyst diameter was reduced to 2.5 cm or less. Sonographic follow-up was performed at 1 week, 2 weeks, 1 month, 5 months and Fig. 1 Neonatal ovarian cyst. a Simple cyst. Note the wall is thin and the contents totally anechoic. b Complex neonatal ovarian cyst. The cyst wall is delicate (short arrow); however, multiple transverse septa are demonstrated inside (long arrows). c Complex neonatal torsed ovarian cyst. The cyst contains echogenic material compatible with hemorrhage (H) with a fluid-debris level (arrowheads ) and septa (thin arrow). d Note that the wall of the cyst is highly echogenic (arrows), representing a calcified wall. No evidence of flow is seen by Doppler examination

3 1 year of age, or until a normal ovary or a calcified remnant was visualized. Results Five of the cysts were simple; 20 were complex, containing small particles and septa. Cysts that contained dense echogenic material, thick septa, and an echogenic calcified wall were suspected to represent ovarian torsion (Fig. 1). Of the 20 complex cysts, 8 were suspected of being torsed (3 in the surgical group and 5 in the aspiration group). Intestinal complications such as volvulus were not encountered in this series. Group A Of the eight infants who underwent surgical treatment, six required oophorectomy because of technical inability to separate the cyst from the ovary (three infants) or because of ovarian necrosis (three infants). In two infants, unroofing of the cyst was possible and the ovaries were saved. Group B Of the 17 infants who underwent percutaneous aspiration, 10 were found to have normal ovaries at 1-year follow-up (Fig. 2), three demonstrated a small calcified ovarian remnant (Fig. 3), and in two there was total loss of visualization of any ovarian remnant. One patient was lost to follow-up. At the time of this report, final evaluation was in progress in the remaining infant; the first follow-up studies have shown significant diminution in ovarian cyst diameter. No complications were encountered during or after the aspiration procedure in any of the patients. Analysis of the fluid biochemistry showed a high amount of estradiol, progesterone, and testosterone, confirming the etiology as ovarian. Cytology did not show any evidence of malignant cells. Discussion Neonatal ovarian cysts were considered rare before the widespread use of antenatal sonography [4 8, 11]. As simple neonatal ovarian cysts are almost always functional, malignancy is really not part of the differential diagnosis. A simple ovarian cyst is diagnosed when the walls are thin, smooth and without internal echoes. A cyst containing echogenic material, fluid-debris level, retracting clot, septa and an echogenic calcified wall is likely to represent internal bleeding because of hemorrhagic infarction secondary to torsion. The echogenic wall signifies dystrophic calcifications secondary to infarction [7]. Most neonatal ovarian torsions are associated with an underlying cyst but rarely occur in normal ovaries. In normal adnexa torsion can occur because of spasm of the adnexal structure or hemodynamic changes of the mesosalpinx. Developmental abnormalities of the fallopian tubes or mesosalpinx can also lead to torsion. Torsion can also occur in the diseased ovary or tube associated with tumor or trauma, usually in older girls. Simple cysts smaller than 4 cm can be left Fig. 2 Neonatal complex ovarian cyst with salvage of the ovary. a Large complex cyst before percutaneous drainage. b Four months later. Resolution of the cyst and a normal ovary with small normal follicles are demonstrated (arrows) untreated since most will disappear on follow-up US examinations. However, symptomatic cysts that cause pain, irritability, vomiting, fever, abdominal distension, leukocytosis or peritonitis warrant intervention. Although spontaneous resolution of ovarian cysts 5 6 cm in diameter has been reported, large ovarian cysts are associated with a high rate of complications, notably ovarian torsion and hemorrhage with risk to future fertility [5 9, 11]. Simple cysts less than 4 cm require only serial sonographic followup examinations on the first day of life, at 1 week of age, then once monthly [12]. Percutaneous aspiration has been advocated for simple cysts larger than 4 cm [9, 10, 13], and laparoscopic intervention [13, 14] or open laparotomy [4 8, 11] when the cyst is complex, enlarging, symptomatic or with signs of torsion. There are no disadvantages to cyst aspiration beyond the risk of injury to adjacent organs, such as perforation of bowel. Surgical approaches include aspiration, cystectomy and oophorectomy. Unfortunately, even when there is no evidence of torsion, oophorectomy is frequently performed because of the close adherence of the cyst to the remaining ovarian tissue.

4 Fig. 3 Percutaneous sonographically guided aspiration of a complex ovarian cyst secondary to intrauterine ovarian torsion. a The right ovary demonstrates a large complex cyst containing echogenic material (H) consistent with hemorrhage. b A hyperechoic calcified rim (arrowheads) is seen in the periphery of the cyst, suggesting intrauterine torsion of the left ovary. c A needle (arrow) is inserted and 40 ml of bloody material is aspirated. d Follow-up 6 months later. A small calcified remnant of the torsed ovary is demonstrated (between calipers) In our series, when surgery was performed, unroofing of the cyst and ovarian salvage was achieved in only two patients (25%). In one of the surgically treated patients, the parents initially refused aspiration but later rushed the baby to the emergency room with signs of acute ovarian torsion that required oophorectomy. In utero decompression of ovarian cysts under sonographic guidance [7] might prevent torsion, as neonatal ovarian torsion generally occurs during pregnancy or delivery. Experience with this procedure is insufficient, and potentially severe complications such as cyst rupture and peritonitis preclude its widespread acceptance [7]. In our series, two infants had undergone uncomplicated intrauterine ovarian cyst drainage, but the cysts refilled and postnatal drainage was required. In both instances, the ovaries were salvaged. Our results suggest that transabdominal, sonographically guided cyst puncture is preferable to surgery in the treatment of large ovarian cysts. In ten (59%) of those who underwent cyst aspiration the ovaries were preserved, compared to only two (25%) of those treated surgically. In five infants (29%), percutaneous aspiration could not save

5 the ovaries; however, in these five infants the ovaries were suspected to be torsed in utero based on their initial sonographic appearance. When compared to the surgically treated group with oophorectomy in 75% (six infants), this represents a better outcome. Refilling of the cyst is reported in 10 30% of the cases [6, 8]. Three of our patients had successful repeated aspiration with ovarian sparing. Therefore, at present, sonographically guided cyst aspiration is the standard practice in our institution in all asymptomatic, large neonatal ovarian cysts. When the baby is symptomatic and the sonographic appearance is suggestive of acute neonatal ovarian torsion, open or laparoscopic detorsion should be attempted. When the cyst is suspected to represent old (intrauterine) torsion, the ovary is beyond salvage. Although previous reports have recommended laparotomy or laparoscopy in these cases, percutaneous aspiration appears to provide a better outcome and should be recommended not for salvage of the ovary but for decompression and prevention of complications. Conclusion Percutaneous neonatal cyst aspiration offers several advantages. It is a minimally invasive procedure, does not require general anesthesia and enables preservation of ovarian tissue. The procedure is simple and safe, can be performed on an outpatient basis and can be repeated when necessary if the cyst refills. Laparotomy and laparoscopy should be reserved for emergency cases such as acute ovarian torsion, intestinal volvulus and intestinal obstruction. In all other cases we suggest that cyst decompression and ovarian salvage should be performed using percutaneous drainage. When compared to traditional surgical approaches, US-guided aspiration of large asymptomatic cysts is more likely to preserve ovarian tissue in a higher percentage of patients. Even when the ovary is beyond salvage because of intrauterine torsion, the treatment of choice is percutaneous US-guided cyst aspiration. References 1. Schmahmann S, Haller JO (1997) Neonatal ovarian cysts: pathogenesis, diagnosis and management. Pediatr Radiol 27: Nussbaum AR, Sanders RC, Benator RM, et al (1987) Spontaneous resolution of neonatal ovarian cysts. AJR 148: Meizner I, Levy A, Katz M, et al (1999) Fetal ovarian cysts: prenatal ultrasonographic detection and postnatal evaluation and treatment. Am J Obstet Gynecol 164: Muller-Leisse C, Bick U, Paulussen K, et al (1992) Ovarian cysts in the fetus and neonate changes in sonographic pattern in the follow-up and management. Pediatr Radiol 22: Luzzato C, Midrico P, Toffolutt T, et al (2001) Neonatal ovarian cyst management and follow-up. Pediatr Surg Int 6: Alrabeeah A, Galliani CA, Giacomantonia M, et al (1988) Neonatal ovarian torsion: report of three cases and review of the literature. Pediatr Pathol 8: Crombleholme TM, Craigo SD, Garmel S, et al (1997) Fetal ovarian cyst decompression to prevent torsion. J Pediatr Surg 32: Dolgin SE (2000) Ovarian masses in the newborn. Semin Pediatr Surg 9: Muller-Leisse C, Bick U, Paulussen K, et al (1992) Ovarian cysts in the fetus and neonate: changes in sonographic pattern in the follow-up and their management. Pediatr Radiol 22: Templeman CL, Reynolds AM, Hertweck SP, et al (2000) Laparoscopic management of ovarian cysts. J Am Assoc Gynecol Laparosc 7: Hengster P, Menardi G (1992) Ovarian cysts in the newborn. Pediatr Surg Int 7: Katz VL, McCoy MC, Kuller JA, et al (1996) Fetal ovarian torsion appearing as a solid abdominal mass. J Perinatol 16: Bryant AE, Laufer MR (2004) Fetal ovarian cysts: incidence, diagnosis and management. J Reprod Med 49: Esposito C, Garipoli V, Di Matteo G, et al (1998) Laparoscopic management of ovarian cysts in newborn. Surg Endosc 12: