Laparoscopy for Ovarian & adenexal cyst in Children

Ovarian masses occur in children and young girls and can be discovered due to symptoms, on physical examination, and/or through imaging studies.

Ovarian masses may represent physiologic cysts, benign neoplasms, or malignant neoplasms. They may be associated with pain or present as an asymptomatic mass. Although relatively rare, they are the most common genital neoplasms occurring in childhood [1]. Historically, all ovarian masses discovered in infants, children, and adolescents were removed surgically. However, the identification of tumor markers and advances in radiologic imaging allow a more conservative approach to the management of these neoplasms, with ovarian preservation as the standard except in cases of cancer.

The majority of ovarian tumors in girls and adolescents are of germ cell origin. By comparison, epithelial tumors account for the largest proportion of ovarian neoplasms in adults. Most childhood ovarian masses are benign. However, it is important for the clinician to establish an early diagnosis to reduce the risk of ovarian torsion with possible loss of adnexa and to improve the prognosis for those lesions that are malignant.

In adolescence, ovarian cysts can develop in response to fluctuating levels of female sex hormones during the menstrual cycle. The cause of ovarian tumors in infants and children is unknown.

Symptoms maybe non specific symptoms, or could depend on the size, location and type of growth. Children may experience the following symptoms:

  • A feeling of pressure or fullness in the abdomen or pelvis
  • A firm, painless swelling in the lower abdomen
  • Frequent urination or retention of urine
  • Persistent abdominal pain
  • Nausea
  • Vomiting
  • Sometimes, ovarian cysts are painful if they cause the ovary to twist on its root, because blood is blocked from the ovary. In this situation, the child will likely experience severe abdominal pain and may vomit.

In girls younger than 8, an ovarian tumor or cyst may cause secretions of estrogen, producing symptoms such as:

  • Breast enlargement
  • Pubic hair
  • Vaginal discharge or bleeding
  • Abnormal menstrual bleeding

 

Because most ovarian cysts don’t cause symptoms and go away on their own, they may go completely unnoticed. If the child has pain or irregular periods, investigations may include:

  • A pelvic ultrasound. To see for ovaries, uterus and bladder. A full bladder may be necessary for the test. If the ultrasound detects a cyst, repeat the ultrasound in two to eight weeks to see for change in size. If the ultrasound shows a cyst filled with clear fluid it is unlikely a tumor; if it shows debris in the cyst fluid or solid parts, further testing is likely to be recommend.
  • The mass is removed with great care not to spill the contents of the mass if there is a concern for malignancy.
  • Urine and blood tests
  • Computerized Tomography Scan.

 

Treatment may include:

  • Watchful waiting. Most ovarian cysts go away without any treatment.
  • Draining. Cyst bigger than two inches across, it may need to be drained with a needle to keep it from twisting and pinching off the ovary’s blood supply.
  • Sometimes an ovarian cyst may not go away and needs to be removed. In this case, a surgeon would remove the cyst while leaving the rest of the ovary in place.
  • If the Ovarian mass is diagnosed as a tumor, treatment may include:

Surgery.

  • If the tumor is benign (non-cancerous). The cyst may be removed laparoscopically preserving the rest of the ovary (2). Ovarian torsion if missed in a pediatric age group potentiates high morbidity. Abdominal pain in the female child represents a challenging differential diagnosis and increases awareness of clinical presentation as reported in this case. Ovarian preservation in children offers benefits of normal puberty and future fertility. Prompt diagnosis and emergent surgical intervention is required for ovarian salvage.
  • If the tumor is malignant (Cancerous) It may be removed by open surgery.

 

References:

  1. Breen JL, Maxson WS. Ovarian tumors in children and adolescents. Clin Obstet Gynecol 1977; 20:607.
  2. Agarwal P, Agarwal P, Bagdi R, Balagopal S, Ramasundaram M, Paramaswamy B. Ovarian preservation in children for adenexal pathology, current trends in laparoscopic management and our experience. J Indian Assoc Pediatr Surg 2014; Mar 19(2):65- 9.doi:10.4103/0971-9261.129594.

 

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