Adnexal torsion is a common cause of acute pelvic pain in women. This is followed by ovarian cyst rupture, pelvic inflammatory disease, malposition of intrauterine devices, and degenerating fibroids [1]. Torsion is a condition that affects the adnexa completely or partially and causes circulatory disorders in the ovary. Although this condition mostly affects the ovaries and tubes together, in rare cases, it may affect only one of them [2, 3, 4]. The most common clinical symptoms of torsion are acute lower abdominal pain, nausea, and vomiting [5]. Because the symptoms are nonspecific, it is difficult to recognize adnexal torsion early without clinical suspicion [6]. Imaging methods are important for diagnosing torsion. Ultrasonography (USG) and magnetic resonance imaging (MRI) can be particularly helpful in evaluating pelvic masses. However, the definitive diagnosis of adnexal torsion is made through surgery and direct observation [5].

Suspicion of adnexal torsion requires urgent intervention. As time passes from the moment the pain begins, the viability of the ovarian tissue decreases. To the best of our knowledge, it is unclear how long it takes for the damage to the ovary during the torsion process to become irreversible. Some studies have reported the return of normal ovarian function after 72 hours of torsion. However, it has been reported that there is a significant decrease in ovarian function after the 72nd hour [7, 8, 9, 10, 11]. Because most torsion cases present with acute pain, surgery can be planned as an emergency. However, in some cases, the findings are not so obvious, and the patient is kept under observation for a while before the decision for surgery. Because there is no definitive data regarding the timing of damage to the ovarian tissue, there is no clear information about the effect of the timing of surgery on ovarian function in these cases. In a study conducted on this subject, the results of patients who were operated on within 6 hours and those who were operated on within 6 to 24 hours were compared, and it was reported that waiting up to 24 hours did not reduce ovarian viability [12]. When we evaluated our data, since our center is a tertiary center and complicated cases mostly apply to our center, we decided that the 6-hour limit is an appropriate cut-off value for emergency cases, considering the time it took our cases to go to the emergency room and the process of being evaluated and operated on in our clinic after the emergency room evaluation.

The aim of our study was to evaluate the effect of surgical intervention timing (6 hours and $\ge$6 hours) on ovarian viability in adnexal torsion cases.

Our study was conducted retrospectively in the department of gynecology and obstetrics at Dokuz Eylul University Hospital between April 2023 and October 2023. The study was initiated after receiving the approval of the Dokuz Eylul University ethics committee (No:7992-GOA). Patients who presented to our clinic with acute abdominal pain and decided to undergo surgery (laparoscopy/laparotomy) due to suspicion of torsion between January 2018 and January 2023 were included in the study. The study was conducted in accordance with the principles of the Declaration of Helsinki 2008. Demographic characteristics of the patients (gravida, parity, age, menopause status, contraception method), clinical findings (pain, vaginal bleeding, vomiting, incidental), previous abdominal surgery, history of torsion, and ligamentopexy, laboratory findings (preoperative hemoglobin, preoperative leukocyte, hemoglobin decrease), imaging findings (whirpool sign, increased pelvic free fluid, adnexal diameter, Doppler flows, adnexal view), surgical method applied (ligamentopexy, detorsion, cystectomy, oophorectomy, hysterectomy + oophorectomy), surgical findings (torsion area, torsion type, torsion direction and number of turns, intraoperative necrosis status), surgical procedure time, hospitalization time, and pathology results were recorded from the files. The patients were divided into two groups according to the timing of the surgical procedure and compared in terms of the above data. Patients who were decided to undergo surgery within 6 hours after the onset of symptoms constitute group 1 (n = 26), and patients who were decided to undergo surgery after 6 hours after the onset of symptoms constitute group 2 (n = 36). Intraoperative necrosis was defined as a blue-purple-black color change in the ovarian tissue during surgery and no regression in the existing findings after detorsion.

The average age of the cases was found to be 32.5 years, and the average age of the cases in group 1 (27.5) was found to be significantly lower than that in the group 2 (41.5) (p 0.001). When the cases were compared in terms of gravida and parity, the gravida and parity rates of the cases in group 1 were found to be significantly lower than those in group 2 (p = 0.04 vs. p = 0.02). When compared in terms of menopausal status, there were no postmenopausal patients among the patients in group 1, whereas there were postmenopausal patients among the patients in group 2 (n = 10, 27.8%). The difference was found to be significant (p = 0.01). When both groups were compared in terms of the contraception method used, clinical findings, history of previous abdominal surgery, previous torsion history, and history of ligamentopexy, no difference was found. The demographic characteristics of the cases and the comparison of both groups in terms of these characteristics are summarized in Table 1.

The laboratory and imaging findings of the cases and the comparison of these findings between the groups are summarized in Table 2. When both groups were compared in terms of laboratory and imaging findings, no difference was detected between the groups.

The surgical findings of the cases and surgical procedures performed are summarized in Table 3. When both groups were compared in terms of torsion type, ligamentopexy application, intraoperative necrosis, torsion area, torsion direction, and hospitalization time, no difference was found between the groups. When the groups were compared in terms of the number of turns, surgical procedure applied, and surgery duration, a significant difference was found between the groups. The number of turns in group 1 (2 turns) was found to be significantly higher than that in group 2 (1 turn) (p = 0.01). The rate of hysterectomy + bilateral salpingoophorectomy (BSO) in the patients in group 2 (n = 10, 27.8%) was found to be significantly higher than in the patients in group 1 (n = 1, 3.8%) (p = 0.036). When compared in terms of surgery time, the surgery time in group 2 (22.5 hours) was found to be significantly longer than in group 1 (2 hours) (p 0.0001).

The pathology results according to the surgical procedures applied to the cases are summarized in Table 4. The pathology results of the cases who underwent detorsion and cystectomy were as follows: mature teratomas (n = 5), functional cysts (n = 9), benign mucinous cystadenomas (n = 2), paratubal cyst (n = 2). The pathology results of the cases who underwent unilateral salpingoophorectomy (USO) were as follows: functional cysts (n = 12), mature teratomas (n = 5), benign mucinous cystadenomas (n = 4), paratubal cyst (n = 1) and benign mucinous cystadenofibroma (n = 1). The pathology results of the cases who underwent hysterectomy and BSO were as follows: functional cysts (n = 4), benign mucinous cystadenomas (n = 3), benign mucinous cystadenofibroma (n = 2), adult-type granulosa cell tumor (n = 1), and serous carcinoma (n = 1).

Adnexal torsion can be seen frequently in women during the reproductive period [13]. In our study, although the average age of our patients was 32.5 years, in line with the general average, a wide age range was observed, with the youngest being 17 years and the oldest being 89. When we compared our cases by separating them according to the timing of surgical intervention, it was seen that the average age, gravida, and parity of the cases in which we decided to have surgery within 6 hours of the onset of symptoms was significantly lower (27.5 vs. 41.5, p 0.001) (p = 0.04 and p = 0.02). This significant difference may be related to being more sensitive in terms of preserving ovarian reserve and making the decision for surgery more quickly in young and childless women. In cases of suspected torsion, early diagnosis and surgical intervention are essential for preserving ovarian viability. Early detorsion reduces the risk of ovarian necrosis and increases ovarian viability [13, 14, 15]. According to the results of our study, it was observed that surgical decisions were made later in postmenopausal cases. This is because, in case of torsion that may occur in the postmenopausal period, the existing mass lesion may be suspicious of malignancy, and surgery planning is preferred under elective conditions rather than preparation for surgery under emergency conditions.

Loss of arterial flow on Doppler USG and increased volume in the torsioned ovary are important warning signs of torsion. However, because venous and lymphatic circulation are primarily affected, loss of arterial flow may not be observed in every case. Additionally, evaluation of the flow of the ovarian cortex may be misleading because of volume increase or mass compression. Therefore, in Doppler USG evaluation, attention should be paid primarily to the infundibulopelvic ligament. The presence of torsion in the ligament is called the “Whirpool Sign” and is more specific for torsion than other findings [16, 17, 18]. In our study, contrary to expectations, no significant relationship was found between the timing of surgery and imaging findings. In addition, no significant difference was detected between the two groups when ovarian tissue necrosis was evaluated during intraoperative examination (p = 0.3). Similarly, in the study by Yaakov et al. [12], no significant relationship was found between early surgical intervention and ovarian necrosis. In another study compiling articles examining the effects of intervention timing on ovarian ischemia, there was no clear data regarding the onset of symptoms and the onset of the ovarian ischemia process [13]. According to these results, there is no limitation in the clinical management of ovarian torsion cases in terms of surgical timing, such as the first 6 hours.

When torsioned ovaries were evaluated in terms of the number of rotations, there were significantly more rotations in group 1 than in group 2 (p = 0.01). According to this finding, it can be thought that as the number of rotations of the torsioned ovary increases, the decision for surgery is made earlier due to the interruption in arterial flow, more acute pain due to edema and inflammatory markers, and the more severe the clinic. However, no difference in other findings does not support this view.

In our results, it was found that the rate of hysterectomy + unilateral salpingoophorectomy in the second group was significantly higher (p = 0.036). This is because the average age of group 2 is higher and fertility preservation is not the primary choice. When both groups were compared in terms of surgery time, the surgery time of group 2 was significantly longer than group 1 (p 0.0001). The reason for this can be explained by the fact that surgeries in group 2 are more complicated because of pelvic mass and the hysterectomy rate is higher.

Functional ovarian cysts are the most common lesions in adnexal torsion. Another common lesion is mature cystic teratoma. In postmenopausal women, torsion may be more frequently associated with malignant masses. In a single-center study, a malignant mass was detected in 9% of postmenopausal cases, whereas this rate was observed to be 0.4% in premenopausal cases [19, 20, 21, 22, 23]. In our study, the number of mature cystic teratomas was found to be 10 (19%) among cases with pelvic masses. The number of functional cysts was 25 (48%). In line with the literature, the most common pathology among patients with pelvic masses was functional cysts in our study. Additionally, two malignant cases were detected in group 2. The malignancy rate among postmenopausal cases in our study was 20%. The reason why this rate is higher compared to the literature is thought to be because our center is a tertiary center to which complicated cases are referred.

As a result of our study, no significant difference was found in terms of ovarian ischemia findings between the cases treated within 6 hours from the onset of symptoms and after the 6th hour. According to this result, we can say that in cases of adnexal torsion, it is not necessary to urgently take the patients to surgery within the limit of 6 hours. However, it is also necessary to mention the important limitations of this study. A limitation of our study is that the evaluation of ovarian tissue depends on the subjective observation of the surgeon and that ovarian reserve was not evaluated in cases where oophorectomy was not performed. Evaluation of anti-mullerian hormone in cases that detorsion was applied, may also provide more objective results in terms of ovarian reserve. Additionally, the age difference between the groups is another limitation. Our primary concern in the torsion clinic is to preserve the ovarian reserve. Therefore, this concern decreases in postmenopausal and elderly patients who have completed their fertility. This may cause a delay in surgical decisions in clinical practice. However, our study contributes to the literature by evaluating the effect of the timing of surgery together with pathological data in adnexal torsion cases in a wide age range.

In conclusion, adnexal torsion is generally seen in women of reproductive age, however, it can also occur in postmenopausal women. In postmenopausal cases, the possibility that torsion may be associated with malignant masses should be kept in mind. In women of reproductive age, the concern for preserving ovarian reserve and viability comes to the fore. Early surgical intervention is important for preserving ovarian reserve and viability. With the current data, there is no definitive time limit for the effect of the timing of surgical intervention on ovarian viability in adnexal torsion. Conducting studies with more objective data and larger samples may provide more precise results, especially in terms of ovarian reserve preservation and early intervention timing.

The datasets generated and/or analyzed during the current study are not publicly available due to privacy and ethical restrictions. Because our data are official institutional data of patients admitted to the university hospital, they were used with permission and are not ethically appropriate for public sharing.

AA and OY designed the research study. AA and OY performed the research. OY analyzed the data. Both authors contributed to editorial changes in the manuscript. Both authors read and approved the final manuscript. Both authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

This study was approved by Dokuz Eylul University ethics committee (No:7992-GOA). Due to the retrospective nature of our study, the necessity for a study-specific informed consent form is waived. However, in accordance with the protocol of our university clinic, all patients are ethically obliged to provide informed consent prior to their hospitalization and surgical procedures. This consent explicitly includes authorization for the utilization of their data in scientific research endeavors.

We would like to thank all the peer reviewers for their opinions and suggestions.

This research received no external funding.

The authors declare that there is no conflict of interest.