DOI: 10.1111/1471-0528.

16179 General gynaecology

www.bjog.org

Conservative surgery for ovarian torsion in

young women: perioperative complications and
national trends
RS Mandelbaum,a,b,* MB Smith,b CJ Violette,a,c S Matsuzaki,a K Matsushima,d M Klar,e
LD Roman,a,f RJ Paulson,b K Matsuoa,e,*
a
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
b
Division of Reproductive, Endocrinology, and Infertility, Department of Obstetrics and Gynecology, University of Southern California, Los
Angeles, CA, USA c Emory University School of Medicine, Atlanta, GA, USA d Department of Surgery, Keck School of Medicine of USC,
University of Southern California, Los Angeles, CA, USA e Department of Obstetrics and Gynecology, University of Freiburg, Freiburg,
Germany f Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
Correspondence: K Matsuo, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California,
2020 Zonal Avenue, IRD520, Los Angeles, CA 90033, USA. Email: koji.matsuo@med.usc.edu

Accepted 13 February 2020. Published Online 9 March 2020.

Objective To analyse populational trends and perioperative
complications following conservative surgery versus oophorectomy
in women <50 years of age with ovarian torsion.
Design Population-based retrospective observational study.
Setting Nationwide Inpatient Sample in the USA (2001–2015).
Population In all, 89 177 ovarian torsions including 20 597
(23.1%) conservative surgeries and 68 580 (76.9%)
oophorectomies.
Methods (1) Trend analysis to assess utilisation of conservative
surgery over time, (2) multivariable binary logistic regression to
identify independent factors associated with conservative surgery
and (3) inverse probability of treatment weighting with a
generalised estimating equation to analyze perioperative
complications.
Main outcome measures Trends, characteristics and complications
related to conservative surgery.
Results Performance of conservative surgery increased from 18.9
to 25.1% between 2001 and 2015 (32.8% relative increase,
P = 0.001) but decreased steadily after age 15, and sharply
declined after age 35 (P < 0.001). On multivariable analysis,
younger age exhibited the largest effect size for conservative
surgery among the independent factors (adjusted odds ratios
3.39–7.96, P < 0.001). In the weighted model, conservative
surgery was associated with an approximately 30% decreased risk
of perioperative complications overall (10.0% versus 13.6%, odds
ratio 0.73, 95% confidence interval 0.62–0.85, P < 0.001) and was
not associated with venous thromboembolism (0.2 versus 0.3%,
P = 0.457) or sepsis (0.4 versus 0.3%, P = 0.638).
Conclusion There has been an increasing utilisation of
conservative surgery for ovarian torsion in the USA in recent
years. Our study suggests that conservative surgery for ovarian
torsion may not be associated with increased perioperative
complications.
Keywords Conservative surgery, fertility preservation, ovarian
conservation, ovarian torsion.
Tweetable abstract Conservative surgery for ovarian torsion may
not be associated with increased perioperative complications.
Linked article This article is commented on by BH Al Wattar and
Y Afifi, p. 966 in this issue. To view this mini commentary visit
https://doi.org/10.1111/1471-0528.16233.

Please cite this paper as: Mandelbaum RS, Smith MB, Violette CJ, Matsuzaki S, Matsushima K, Klar M, Roman LD, Paulson RJ, Matsuo K. Conservative
surgery for ovarian torsion in young women: perioperative complications and national trends. BJOG 2020;127:957–965.

*Contributed equally to the work.
Abstract presentation: Presented at 75th American Society of Reproductive
Medicine Scientific Congress & Expo, Philadelphia, PA, 12–16 October
2019 (Oral plenary at Scientific Congress Prize Paper Session).
Introduction
Ovarian torsion refers to the full or partial twisting of the
ovary around its suspensory ligamentous structures, result-
ing in compromise of the ovarian blood supply. Ischaemia

© 2020 Royal College of Obstetricians and Gynaecologists 957

 Mandelbaum et al.
can cause tissue necrosis, potentially resulting in permanent
loss of the affected ovary. Prevalence is estimated to be
2–15% in women who present with an adnexal mass; how-
ever, a true prevalence is unknown as definitive clinical
diagnosis can only be made intraoperatively.1–5 The major-
ity of cases present in the setting of a benign mass, and
although ovarian torsion can occur in females of all ages, it
is most common in women of reproductive age who often
desire the potential for future fertility.
Oophorectomy was traditionally the standard treatment
of ovarian torsion due to the hypothetical risk of throm-
boembolic events following untwisting of the ovarian pedi-
cle or concern that a necrotic ovary left in situ may lead to
peritonitis or infection.6 Way et al. first published on con-
servative surgical management of ovarian torsion, i.e. ovar-
ian detorsion potentially followed by ovarian cystectomy or
cyst drainage but with preservation of the affected ovary, in
a small series of women in 1946.7 Subsequently, observa-
tional literature has continued to support conservative
approaches, both favouring ovarian preservation even with
necrotic-appearing ovaries and advocating the use of
laparoscopy.8–14
Studies have suggested no significant increase in compli-
cations with conservative surgery for ovarian torsion,
although existing evidence is based on few studies with
limited sample size.12,15–17 Practice patterns in the treat-
ment of ovarian torsion are also unknown. An understand-
ing of current practice patterns in the USA and the
incidence of perioperative complications is crucial to influ-
ence individual surgeon decision-making, set quality stan-
dards, fuel specialty-wide initiatives aimed at practice
change and identify specific target populations that warrant
attention. The objective of the current study was therefore
to examine the incidence of perioperative complications
following conservative surgery compared with oophorec-
tomy and to analyse recent populational trends in the sur-
gical management of ovarian torsion.
Material and methods
Data source
The Nationwide Inpatient Sample (NIS) is a publicly avail-
able and de-identified population-based database that is
distributed as part of the Healthcare Cost and Utilization
Project by the Agency for Healthcare Research and Qual-
ity.18 The NIS database includes hospital discharge data for
more than 36 million hospitalisations per year when
weighted, and it provides patient demographic and
resource-use information as well as hospital-specific data
such as location, bed size, and teaching status.
The NIS programme randomly captures approximately
20% of the actual inpatient admissions in the USA, and
when appropriately weighted represents over 90% of the
958
US population. The NIS programme only captures inpa-
tient hospitalisations, not procedures performed at ambula-
tory surgery centres. Readmission information is also not
obtainable from the NIS. The University of Southern Cali-
fornia Institutional Review Board deemed the study exempt
due to the use of publicly available de-identified data with-
out patient involvement.
Eligibility
This is a retrospective study examining the NIS database
between January 2001 and September 2015. Reproductive-
aged women, defined by the World Health Organization as
women aged 15–49, as well as paediatric patients younger
than age 15, who had a diagnosis of ovarian torsion were
eligible for the study. Women who did not undergo surgery
were excluded. Additionally, those with ovarian or tubal
malignancies were excluded from the analysis.
Clinical information
Among cases eligible for analysis, the following information
was abstracted from the NIS database: patient demograph-
ics, hospital information, operative details and outcomes
during the index admission. Patient demographics included
age, race and ethnicity, medical comorbidities, obesity, pri-
mary expected payer and median household income. The
Charlson Comorbidity Index was determined for each
patient. This 10-year mortality prediction formula is based
on the presence of one or more comorbidities, which were
ascertained using International Classification of Disease 9th
revision codes (ICD-9) coding and then weighted appropri-
ately to calculate a final score.19 Operative details including
surgical approach (laparotomy versus laparoscopy), pres-
ence of an adnexal mass, type of surgery performed and
incidence of perioperative complications were abstracted.
Hospital data included bed size, teaching status, hospital
region and urban–rural designation.18 Perioperative com-
plications were defined as the presence of any of the fol-
lowing in the index admission as described previously:20,21
urinary tract injury, intestinal injury, vascular injury, haem-
orrhage, postoperative shock, wound complications, venous
thromboembolism, cerebrovascular disease or stroke,
myocardial infarction, pneumonia, respiratory failure, sep-
sis or systemic inflammatory response syndrome (SIRS),
ileus or small bowel obstruction, acute kidney injury
(Appendix S1). In addition, position-dependent complica-
tions were assessed given increasing utilisation of laparo-
scopic surgery (Appendix S1). Length of stay for the index
admission was also collected.
Study definition
ICD-9 codes were used to differentiate surgical procedures
performed in women who had the diagnosis code for ovar-
ian torsion (620.5). Conservative surgery was defined as
© 2020 Royal College of Obstetricians and Gynaecologists

ovarian detorsion with or without ovarian cystectomy, ovar-
ian cyst drainage or oophoropexy (Appendix S1).22,23 Dur-
ing the study period of January 2001 to September 2015,
these codes remained the same and are detailed in
Appendix S1. Obesity was defined by the ICD-9 coding as
body mass index of 30 kg/m2 or greater. ICD-9 codes were
also used to evaluate perioperative complications during the
index admission (Appendix S1). Venous thromboembolism
refers to deep vein thrombosis and pulmonary embolism.
Study objectives
The primary objective of the study was to analyse popula-
tional trends in the surgical management of ovarian torsion
over time and to identify the predictors of conservative
surgery for ovarian torsion. The secondary objective of the
analysis was to compare the incidence of perioperative
complications following conservative surgery compared
with oophorectomy.
Statistical considerations
The weighted values provided by the NIS programme were
used for national estimates in all trend analyses and to iden-
tify independent factors associated with conservative surgery.
Differences in continuous variables were assessed with Stu-
dent’s t-test. Differences in ordinal and categorical variables
were assessed with the Chi-square test. A binary logistic
regression model was fitted to identify independent factors
associated with conservative surgery for ovarian torsion. All
the collected covariates were entered in the final model, and
statistical estimates were generated to calculate the adjusted
odds ratio (OR) with 95% confidence interval (CI).
The Joinpoint Regression Program (version 4.4.0.0),
which is provided by the National Cancer Institute, was
utilised to evaluate temporal trends in conservative sur-
gery.24 Time point data were examined annually to identify
temporal changes as previously described.25 Temporal
trends were examined using linear segmented regression,
and log transformation was performed to determine the
annual percentage change with a 95% CI.
Propensity score-based inverse probability of treatment
weighting (PS-IPTW) was utilised to balance the inter-
group background differences between women who under-
went conservative surgery versus oophorectomy.26 The
IPTW model creates a weighted cohort that differs based
on treatment type (conservative surgery versus oophorec-
tomy) but is similar with respect to other baseline demo-
graphics. First, propensity scores for performance of
conservative surgery were determined by fitting a binary
logistic regression model that included patient demograph-
ics, hospital information and surgical approach.27 Patients
who received conservative surgery were assigned a weight
of 1/PS and those who received oophorectomy a weight of
1/(1-PS).26 Stabilised weights were used in the analysis, and
© 2020 Royal College of Obstetricians and Gynaecologists
Conservative surgery for ovarian torsion
the threshold technique was used at the 1st and 99th per-
centile of the weight distribution.26
In the PS-IPTW model, a proportional distribution of
baseline covariates was assessed for effect size, and a stan-
dardised difference (SD) of 0.10 or less was considered a sta-
tistically good balance between the two groups in this study.
After the PS-IPTW modelling, a generalised estimating equa-
tion model was used to estimate the magnitude of statistical
significance for perioperative complications following con-
servative surgery versus oophorectomy, expressed with OR
and 95% CI. In addition, doubly robust adjustment estima-
tors were applied to correct for any statistical unbalanced
variables as a sensitivity analysis in our study.28 With regard
to perioperative complications, we specifically evaluated total
number of perioperative complications, venous thromboem-
bolism (VTE), as well as sepsis or SIRS.
A sensitivity analysis was performed including cases of
malignancy. The rationale of this analysis is as follows: (1)
clinically it is often difficult to discriminate benign from
malignant tumours in the event of ovarian torsion, (2) the
decision-making process for surgical approach for ovarian
torsion is commonly not solely based on histology diagnosis
but on clinical findings and (3) intraoperative frozen section
may not be utilised in emergency settings. Outcomes were
also analysed based on the presence of an adnexal mass. In
addition, independent factors associated with VTE on multi-
variable analysis were assessed with a binary logistic regres-
sion model (conditional backward method).
All statistical analyses were based upon two-tailed
hypotheses, and a P < 0.05 was considered statistically sig-
nificant. Statistical Package for Social Sciences (IBM SPSS,
version 25.0, Armonk, NY, USA) was used for all analyses.
The STROBE guidelines were utilised to display the perfor-
mance of the observational study.29
Results
There were 125 374 women with ovarian torsion during the
study period, 89 177 of whom met inclusion criteria. Of
these women, 20 597 (23.1%, 95% CI 22.8–23.4) had conser-
vative ovarian-sparing surgery and 68 580 (76.9%) under-
went oophorectomy (Figure S1). In the entire cohort
(Table S1 and S2) the mean age was 29.1 years. The majority
of patients with ovarian torsion were white (45.4%), had few
comorbidities (Charlson Comorbidity Index of 0, 87.9%),
had private insurance (59.0%) and were treated at large bed
size (61.3%) and urban-teaching (51.1%) hospitals.
The type of conservative surgery for ovarian torsion by
surgical approach is shown in Table S3. Laparoscopy was
performed in 10 555 (55.7%) patients who underwent con-
servative surgery and 22 445 (32.7%) of those who under-
went oophorectomy. Laparoscopy was performed in the
majority of conservative surgeries that involved cyst
959
 Mandelbaum et al.

Figure 1. Trends of conservative surgery for ovarian torsion between 2001 and 2015. Trends of conservative surgery for ovarian torsion are shown
per (A) calendar year and (B) age at diagnosis. The y-axis is truncated to 0–30% for panel A and 0–60% for panel B. Black dots represent observed
values, and bars represent 95% confidence interval. Red lines represent modelled lines.

drainage (84.7%) or detorsion alone (68.8%), whereas the
majority of oophoropexies (71.1%) were performed via
laparotomy. The distribution of surgical approach for ovar-
ian cystectomy was equal between laparoscopy and laparo-
tomy (49.9 versus 50.1%).
On univariable analysis, age, year of surgery, race and eth-
nicity, body habitus, medical comorbidities, household
income and payer type, hospital bed size, hospital teaching
status, hospital region, presence of adnexal mass and surgical
approach were all associated with conservative surgery (all,
P < 0.001) (Table S2). On multivariable analysis, conserva-
tive surgery was more likely to be performed in younger
women, those with more recent year of surgery, those of His-
panic or Asian race, those with higher income, those who

960 © 2020 Royal College of Obstetricians and Gynaecologists

 Conservative surgery for ovarian torsion

had laparoscopic surgery, those who had a diagnosis of sensitivity analysis including cases of ovarian malignancy,
adnexal mass and those who had surgery at medium or large similar results were demonstrated (Figure S3).
and urban-teaching hospitals in Northeast, Midwest or West
regions (all, adjusted-P < 0.001) (Table S2). Conversely,
Discussion
Native American women, those with higher comorbidity and
women with larger body habitus were more likely to undergo Main findings
oophorectomy (all, P < 0.001). Key results of our study are that conservative surgery for
Performance of conservative surgery significantly ovarian torsion is not associated with an increased risk of
increased from 18.9% in 2001 to 25.1% in 2015 (32.8% rel- perioperative complications during hospital admission,
ative increase, P = 0.001) (Figure 1A). Utilisation of specifically of thromboembolic events or sepsis, and that
laparoscopy also increased significantly from 30.5% in 2001 rates of conservative surgery and laparoscopy are increasing
to 42.4% in 2015 (39.0% relative increase, P < 0.001). but vary depending on patient demographics, hospital and
Rates of conservative surgery were highest at nearly 40% in geographical factors.
children and adolescents; however, after the age of 15,
when the rate of conservative surgery was 38.6%, rates of Standardized difference
conservative surgery steadily declined to 22.9% at 35 years 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7
(40.6% relative decrease, P < 0.001; Figure 1B). An even
more accelerated decrease was observed after age 35 (22.9%
at 35 years old to 3.3% at 49 years old, 85.6% relative Age
decrease, P < 0.001).
In the PS-IPTW model, covariates were largely well-bal- Surgery type
anced between the conservative surgery group and the
oophorectomy group except for a slight size effect in age Adnx mass
without clinical significance (Figure 2). In a generalised
estimating equation model, conservative surgery was associ- Hp teaching
ated with a lower risk of perioperative complications (10.0
versus 13.6%, OR 0.70, 95% CI 0.61–0.82, P < 0.001; Fig- Charlson index
ure 3A). After controlling for age, conservative surgery was
still associated with a significantly decreased risk of periop- Income
erative complications of 27% (OR 0.73, 95% CI 0.62–0.85,
P < 0.001). Year
In particular, conservative surgery was not associated
with VTE (0.2 versus 0.3%, OR 0.67, 95% CI 0.24–1.92 Obesity
P = 0.457; Figure 3B), sepsis or SIRS (0.4 versus 0.3%, OR
1.24, 95% CI 0.51–2.99, P = 0.638; Figure 3C). Older age, Hp region
higher medical comorbidity and longer length of stay were
all independently associated with an increased VTE risk Tax payer
(all, P < 0.05; Table S4). The median length of stay was 2
days (IQR 2–3) for both cohorts. Conservative surgery was Hp size
associated with a decreased length of stay >4 days com- Before
Race After
pared with the laparotomy group (7.2 versus 10.7%, OR
0.65, 95% CI 0.54–0.78, P < 0.001).
When limited to those with a diagnosis of an adnexal
mass, conservative surgery also significantly increased from Figure 2. Standardised difference before and after PS-IPTW. The PS-
IPTW model creates a weighted cohort that differs based on treatment
21.8 to 27.5% during the study period (26.1% relative
type (conservative surgery versus oophorectomy) but is similar with
increase, P = 0.006; Figure S2). Moreover, conservative sur- respect to other baseline demographics. Standardised difference
gery was associated with a decreased risk of any periopera- indicates size effect, and a value of 0.10 or less indicates a statistically
tive complication (9.3 versus 13.7%, OR 0.67, 95% CI good balance between the two groups, and values of 0.2, 0.5 and 0.8
0.57–0.79, P < 0.001) and was not associated with risk of were used for the cut-off of small, medium and large size effect.
Missing cases for hospital bed size and teaching status were not
VTE (0.2 versus 0.3%, OR 0.60, 95% CI 0.20–1.79,
included in the model due to multicollinearity. Unknown surgical
P = 0.363) or of sepsis/SIRS (0.4 versus 0.3%, OR 1.37, modality cases were also excluded from the model due to the absence
95% CI 0.55–3.39, P = 0.497) compared with the of cases in the oophorectomy group. Hp, hospital; PS-IPTW, propensity
oophorectomy group in the weighted model. In the score inverse probability of treatment weighting.

© 2020 Royal College of Obstetricians and Gynaecologists 961

 Mandelbaum et al.
Figure 3. Perioperative complication associated with conservative
surgery for ovarian torsion in the PS-IPTW model. Complication rate per
group is shown for (A) any perioperative complication, (B) venous
thromboembolism (VTE) (including PE) and (C) sepsis or systemic
inflammatory response syndrome (SIRS). Bars represent 95% confidence
intervals.
Strengths and limitations
The results of this study add to prior literature in a mean-
ingful way given the populational sample size, which is use-
ful both to understand nationwide trends and to examine
rare events such as ovarian torsion. This study is likely
among the largest to report the surgical management of
ovarian torsion.
962
Limitations of all studies of this nature include potential
misclassification of cases or coding errors, and the lack of
several key variables for analysis that undoubtedly impact
surgical decision-making and patient outcomes. The NIS
does not have information detailing intraoperative appear-
ance of the ovary, nor does it include time from presenta-
tion to surgery or surgeon type (gynaecologist versus
general surgeon), all of which as stated above are crucial
variables that very likely had a significant impact on ovar-
ian viability and decision to perform oophorectomy. Infor-
mation regarding past surgical history, especially for prior
torsion, menopausal status, parity and future fertility
desires, was not available in this database, and may all have
affected the decision to perform oophorectomy.
Second, we were unable to differentiate the timing of
perioperative complications in this dataset (pre-, intra- or
postoperative). Surgical details such as blood loss and oper-
ating time were not available for analysis. This database
also only captures inpatient cases, thus cases managed in
the outpatient setting with same day surgery were unable
to be captured, potentially resulting in selection bias.
Third, diagnosis of ovarian torsion is reliant on use of
coding; it is possible that patients with a pelvic mass that was
indeed undergoing torsion may have not been coded as such
and thus would potentially have been missed, causing selec-
tion bias. Follow-up information cannot be ascertained in
the NIS, thus we could not account for any complications
that might have occurred after hospital discharge or evaluate
ovarian function during follow up. Finally, the NIS is limited
to patients in the USA; thus the generalisability of these data
to other patient populations may be limited.
Interpretations
Despite mounting evidence over the past few decades sup-
porting conservative surgery for ovarian torsion, it is strik-
ing that in this populational study, oophorectomy was
performed in 77% of women of reproductive age with
ovarian torsion. The oophorectomy rate in this study is
similar to other US populational data in paediatric patients
(58–78%).30,31 Rates of conservative surgery may be even
lower in other countries, making this study particularly
applicable to the global arena.32,33 Limited comparative
data exist on women >18 years; however, in the largest
existing review to our knowledge, including a total of 979
patients, 69% underwent oophorectomy, consistent with
what is reported in this study.15 In contrast, a small study
on 94 patients treated at a single centre reported only a
35% rate of oophorectomy in women <40 years, highlight-
ing variability in practice patterns.23
In our study, rates of conservative surgery also varied based
on hospital and geographical factors. This may suggest a dif-
ferential uptake of current evidence supporting ovarian
preservation. Another factor that may contribute is the
© 2020 Royal College of Obstetricians and Gynaecologists

availability of a gynaecologist at smaller/rural hospitals.
Oophorectomy is less likely to be performed when a gynaecol-
ogist is involved as compared with solely general or paediatric
surgeons.34,35 Age also had a significant effect on performance
of conservative surgery; it is surprising that the rate of conser-
vative treatment declined after the age of 14, given that most
females have not yet even entered childbearing years by that
age. This is likely multifactorial but may reflect mechanism of
ovarian torsion, as torsion is more likely in the setting of a
normal ovary in children, in the treatment setting for paedi-
atric patients or with the type of surgeon.1–3 As literature sup-
porting conservative surgery and guidelines for management
of ovarian torsion continue to be published, hopefully
oophorectomy rates will decrease and conservative surgery will
not be reserved for only the youngest patients, given benefits
of ovarian preservation in premenopausal women.36
Previously, the rationale for oophorectomy was largely
secondary to a theoretical risk of thromboembolism once the
ovarian pedicle was untwisted, with the potential to dislodge
a thrombus in the ovarian vein into the systemic circulation.
Two large reviews of the literature including studies found
no cases of thromboembolism following detorsion with ovar-
ian conservation.15,37 The concern regarding thromboem-
bolism was raised, based on two prior case reports involving
pulmonary embolism; however, these occurred following
oophorectomy not conservative surgery.15,38
Reasons for thromboembolism following ovarian torsion
may be multifactorial and be secondary to underlying
thrombophilia, immobility pre-/postoperatively or an
imbalance in pro-/anti-coagulant pathways due to activa-
tion of inflammatory pathways rather than ovarian torsion
itself.39 In our study, thromboembolic events were exceed-
ingly rare (0.2–0.3%), and were consistent with prior litera-
ture (0.2%).15,38 Therefore, concern for thromboembolic
events would not be a motivating factor for performing
oophorectomy in young women with ovarian torsion.
Oophorectomy may also have been conventionally per-
formed due to the assumption that a necrotic-appearing,
i.e. black or blue, ovary was nonviable. General surgical
principles ordinarily call for removal of necrotic tissues in
other anatomical sites to prevent infection and promote
healing.5 However, evidence suggests that despite a black or
blue appearance intraoperatively, the vast majority of
affected ovaries recover both function and appearance fol-
lowing detorsion.8,12,13,40 Several case series demonstrate
that nearly all ovaries that previously appeared necrotic on
gross examination at the time of detorsion, subsequently
appeared normal postoperatively, with follicle development
on transvaginal ultrasound.11–13,34,41–43
A histological study of rat ovaries following varying
degrees of ischaemia found that blue or black macroscopic
appearance, which is likely secondary to venous congestion
and lymphatic stasis with initial occlusion of the ovarian
© 2020 Royal College of Obstetricians and Gynaecologists
Conservative surgery for ovarian torsion
vein, did not correlate with histological findings or viability
of ovarian tissue following reperfusion.9 Even ovaries that
had been ischaemic for up to 24 hours were found to be
viable following reperfusion, with true necrosis and peri-
tonitis only occurring following ≥36 hours of ischaemia.9
Thus, gross intraoperative appearance of the ovary is not a
good indicator of ovarian viability and this would not be
used in surgical decision-making regarding oophorectomy.
Our study may also indirectly support ovarian preserva-
tion even in the setting of a necrotic-appearing ovary given
the fact that conservative surgery was not associated with
perioperative complications. While our results are consis-
tent with previous small studies that demonstrate no
increase in complications following conservative surgery as
compared with oophorectomy even with necrotic-appearing
ovaries, these observational data need to be followed by
randomised prospective studies, especially to confirm the
safety and utility of leaving necrotic-appearing ovaries
in situ following torsion.8,13,15,17,23
Conclusion
Over the past decades, despite increasing rates of conserva-
tive surgery, oophorectomy continues to be performed in
the majority of young women with ovarian torsion. Rates
of conservative surgery were also found to vary significantly
based on demographics, surgical, hospital and geographical
factors. Based on the fact that perioperative complications
during hospital admission are not increased with conserva-
tive surgery, combined with the clear benefits of ovarian
conservation with regard to future fertility and hormonal
function, this study supports performance of conservative
surgery whenever possible in young women with ovarian
torsion.
Disclosure of interests
Consultant, Quantgene (L.D.R.); advisory board, Tesaro,
GSK (M.K.); research funding, MSD (S.M.); honorarium,
Chugai, textbook editorial expense, Springer, and investiga-
tor meeting attendance expense, VBL Therapeutics (K.M.).
The other authors declare no conflicts of interest. Com-
pleted disclosure of interests forms are available to view
online as supporting information.
Contribution to authorship
Conceptualisation: K.M. Data curation: R.S.M. Formal anal-
ysis: K.M. Funding acquisition: K.M., L.D.R. Investigation:
R.S.M., M.B.S., C.J.V., S.M., K.M., M.K., L.D.R., R.J.P., K.M.
Methodology: K.M. Project administration: K.M. Resources:
all authors. Software: K.M., R.S.M. Supervision: K.M. Vali-
dation: K.M. Visualisation: K.M. Writing – original draft:
K.M. Writing – review and editing: R.S.M., M.B.S., C.J.V.,
S.M., K.M., M.K., L.D.R., R.J.P.
963
 Mandelbaum et al.
Details of ethics approval
NIS data are publicly available on the HCUP website for
access by researchers, hence the current study was
exempted for ethics approval (Ethical committee exemp-
tion: HS-16-00481, July 12, 2016).
Funding
Ensign Endowment for Gynecologic Cancer Research.
Supporting Information
Additional supporting information may be found online in
the Supporting Information section at the end of the article.
Figure S1. CONSORT diagram for patient selection
schema.
Figure S2. Trends of conservative surgery for ovarian
torsion between 2001 and 2015.
Figures S3. Sensitivity analysis cohort for perioperative
complications associated with conservative surgery for
ovarian torsion in the PS-IPTW model.
Table S1. Patient demographics.
Table S2. Patient demographics of women who under-
went surgery for ovarian torsion and multivariable analysis
for factors associated with conservative surgery.
Table S3. Type of conservative surgery for ovarian tor-
sion.
Table S4. Independent characteristics for venous throm-
boembolism.
Appendix S1. International Classification of Disease 9th
Edition (ICD-9) codes utilised in analysis. &
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