Ovarian Residual Syndrome

　　ORS (ovarian residue syndrome) often occurs in patients with a history of difficult pelvic surgery. If the first operation is difficult due to abundant pelvic blood vessels and difficult hemostasis, or due to pelvic tissue adhesion, which makes the anatomical relationship unclear and difficult to separate, or due to the tumor changing the structure, shape, and adjacent relationships between normal tissues, causing difficulties in surgery and leaving some ovarian tissue unremoved, these residual ovarian tissues and other ovarian tissues in the pelvic cavity, although the cortex has no blood supply from the ovary, can still experience necrosis, cystic change, and tumor-like change, even maintaining their function continuously. In addition, widespread pelvic adhesions are the main cause of pain.

　　During the surgery for pelvic endometriosis, pelvic inflammation, and tumor, the following factors can cause the ovary not to be completely removed:

　　1, Local vascular hyperplasia and congestion make hemostasis difficult.

　　2, Adhesion causes local anatomical changes, making separation difficult.

　　3, Tumor compression and displacement cause local anatomical changes.

　　4, When clamping the infundibulopelvic ligament during surgery, if it is too close to the ovary, it can also lead to incomplete removal of the ovary.

　　The residual ovarian tissue adherent to the pelvic peritoneum can obtain blood supply from surrounding tissues, continue to have endocrine function, and due to the reaction of surrounding tissues to the follicular fluid containing various enzymes, it becomes widely adherent, forming a pelvic mass, causing a series of symptoms and signs.

　　5, In recent times, it is more common for ORS to occur after laparoscopic oophorectomy.

　　Individual patients with ovarian residue syndrome may have concurrent ovarian cancer and pelvic fibrous tissue adhesion, which belong to serious gynecological diseases, seriously endangering women's health. Therefore, once symptoms are found, timely treatment is essential.

　　Since ORS (ovarian residue syndrome) often occurs after difficult pelvic surgery, its clinical manifestations are also complex. They can be summarized as follows:

　　1, The most common clinical manifestation of ORS is lower abdominal pain accompanied by pelvic mass, which often occurs several weeks to several years after the difficult bilateral oophorectomy, most commonly within 5 years after the operation. Lower abdominal pain accounts for about 65%, and pelvic mass accounts for about 75%.

　　2, The pain manifestation is diverse, ranging from persistent to intermittent, with periodic or continuous dull pain, stabbing pain, or progressive abdominal pain on one or both sides of the lower abdomen. It may radiate to the perineum, part of it to the back, and in some cases, the pain is severe enough to require emergency treatment.

　　3, There is a sense of pelvic pressure.

　　4, Most patients have sexual pain or difficulty during intercourse.

　　5, A few cases may present with rib pain due to invasion of the fallopian tube and frequent urinary tract infections. Functional ovarian residual tissue can cause bladder outlet obstruction, leading to acute urinary retention. The residual ovary is prone to cystic change, causing distal ureteral obstruction, and intravenous pyelography can show ureteral dilation or displacement. The characteristics of urinary tract obstruction are periodic attacks, manifested as renal colic, hematuria, and bladder irritation symptoms, etc.

　　In addition to hormone level testing and tumor marker testing, the following examination results should also be combined to diagnose ovarian residual syndrome.

　　1, Intra-venous pyelography can show renal pelvis dilation and ureteral displacement.

　　2, Ultrasound examination shows a mass with a small amount of fluid surrounding it.

　　3, CT examination not only can locate and determine the size of the mass but also helps in the diagnosis of patients with symptoms but no palpable mass in clinical practice.

　　4, Laparoscopic examination.

　　5, Histopathological examination.

　　Patients with ovarian residual syndrome should ensure adequate calorie and protein intake in their diet, eat more fresh fruits and vegetables, arrange meal times reasonably, and pay attention to the following details.

　　1, Breakfast and dinner should be arranged before 6 am and after 7 pm respectively, extending the interval between medication and eating to reduce drug reactions.

　　2, Drink plenty of water to promote toxin excretion, at least 2000 milliliters daily. Milk, soy milk, and mung bean soup are helpful in excreting toxins released by cancer cells.

　　3, Eat more foods rich in vitamin C and vitamin E, calcium, and folic acid:

　　4, Eat fish and shrimp 2-3 times a week, persist in drinking milk, and eat more carrots.

　　5, Persist in physical exercise and reduce the frequency of passive smoking.

　　6, Avoid wearing shaping underwear for a long time.

　　7, Avoid excessive dieting for weight loss and long-term malnutrition.

　　8, Avoid smoking, alcohol, and spicy foods.

　　9, Avoid greasy, fried, moldy, preserved foods, and warm, stimulating blood foods.

　　According to the different degrees of ovarian residual syndrome in patients, there are several treatment methods for this disease.
　　One, Drug treatment
　　1, For patients with mild symptoms, oral contraceptives (such as desogestrel) can be used for cyclic treatment to suppress the hypothalamus-pituitary-ovary axis function, causing the ovary not to ovulate and atrophy. Generally, it takes 2-3 months of medication, and most patients can alleviate pelvic pain and reduce the size of the mass.
　　2, Gonadotropin-releasing hormone analogs (GnRHa) can alleviate symptoms and signs in patients due to their ability to suppress ovarian function.
　　3, Long-acting high-dose progestins can achieve therapeutic effects by inhibiting the ovary's排卵function, commonly using long-acting progestins at a dose of 100-150mg by intramuscular injection once a month.
　　4, Androgens work by counteracting estrogens to alleviate pelvic congestion and relieve pain, commonly using methyltestosterone (methyltestosterone) taken sublingually at a dose of 5mg daily for one month, and if effective, it can be continued for another 1-2 months.
　　Second, radiotherapy
　　Shemwell et al. used castration dose radiation to irradiate the pelvis, remove ovarian function, and alleviate pelvic pain symptoms, but there are reports that pelvic radiotherapy, with a dose of up to 10Gy, has not improved the symptoms. This is because ORS patients often have pelvic adhesions, fixed intestines, and pelvic radiotherapy is prone to damage the intestines, causing enteritis, so radiotherapy is not easily accepted by patients.
　　Third, surgical treatment
　　Currently, the removal of residual ovarian tissue by surgery is still the main treatment method, which can further clarify the diagnosis and achieve complete treatment. 10% to 30% of ORS patients cannot completely remove the residual ovarian tissue during surgery, and 8% to 10% of ORS patients may still have recurrence after surgery. The operation should carefully separate the retroperitoneum, expose the ureters and main blood vessels, and completely remove the residual ovarian tissue. Since ovarian residual tissue syndrome often occurs in difficult surgery or multiple surgeries, the patient's pelvic adhesions are significant, requiring extensive separation, so the operation time is longer and the blood loss is more, with an average blood loss of 600ml (200-1000ml) reported in the literature. There are also many complications after surgery, such as ureteral and intestinal injuries. In some cases, intestinal resection and anastomosis may be performed due to dense adhesions, and ureteral bladder anastomosis may be performed due to ureteral injury. Some may undergo exploratory cystotomy, and for those with urinary tract symptoms, cystoscopy and retrograde pyelography should be performed during surgery, and a ureteral catheter should be placed in front of the residual ovarian tissue to avoid ureteral injury.
　　Fourth, the issue of prophylactic oophorectomy
　　To prevent the occurrence of this syndrome, some people believe that the ovaries must be removed when the uterus is removed, but considering that this syndrome is rare, it is not advisable to perform a prophylactic oophorectomy alone. Regarding the prophylactic removal of the healthy ovary during hysterectomy, opinions vary among experts. Many scholars believe that prophylactic oophorectomy should be performed during hysterectomy or determined by age. If the ovaries are preserved, a biopsy should be performed first to prevent the occurrence of ovarian cancer. However, some scholars believe that it is not necessary to perform a prophylactic oophorectomy. In addition, after examining the ovarian function preserved by vaginal cytology, basal body temperature, postmenopausal symptoms, and blood and urine hormone levels, a consistent result is obtained, and it is believed that the preserved ovaries still have long-term function.