Evidence - Adnexectomy, laparoscopic, robot-assisted laparoscopy (DaVinci)

In surgeries for the treatment of benign ovarian diseases, it is generally recommended to preserve as much functional ovarian tissue as possible, for example, through a cystectomy or the removal of a solid tumor from the ovary. A complete oophorectomy is only considered when the ovarian tissue can no longer be preserved or attempts to preserve the tissue are not sufficiently successful.

Aspiration and Fenestration versus Ovarian Cystectomy

Aspiration of cyst contents:

• Not recommended: No tissue for histopathology, cytology of cyst fluid unreliable for exclusion of malignancy.
• Recurrence rate: Up to 65%.
• Complication rate: 2.6%.
• Comparison: No better outcomes than simple observation.

Fenestration:

• Method: Removal of a full-thickness, square part of the cyst wall to create a window.
• Problems less frequent: Compared to aspiration.
• Risk in malignant cysts: Spillage of malignant cells into the peritoneal cavity possible.
• Cystectomy still preferred

Cystectomy:

• Preferred procedure: For the treatment of benign ovarian cysts.

Sclerotherapy after aspiration:

• Method: Injection of methotrexate, tetracycline, alcohol, or erythromycin after aspiration.
• Recurrence rate: 4 to 38% in cyst persistence or recurrence.
• Uncertainty: Efficacy compared to expectant management not sufficiently controlled.

Reference: 

1. Zanetta G, Lissoni A, Torri V, et al. Role of puncture and aspiration in expectant management of simple ovarian cysts: a randomized study. BMJ 1996; 313:1110.
2. Díaz de la Noval B, Rodríguez Suárez MJ, Fernández Ferrera CB, et al. Transvaginal Ultrasound-Guided Fine-Needle Aspiration of Adnexal Cysts With a Low Risk of Malignancy: Our Experience and Recommendations. J Ultrasound Med 2020; 39:1787.
3. Mesogitis S, Daskalakis G, Pilalis A, et al. Management of ovarian cysts with aspiration and methotrexate injection. Radiology 2005; 235:668.

1. Benign ovarian neoplasms that cannot be treated by ovarian cystectomy
2. Cyst rupture with bleeding and/or hemodynamic instability
3. Elective or risk-reducing salpingo-oophorectomy
4. Adnexal (ovarian) torsion with necrosis (rare).
   1. Occurs in about 2-15% of patients with ovarian masses.
   2. Emergency surgery is required, with a high risk of ovarian loss if the torsion is not quickly resolved.
5. Ovarian malignancy
   1. An open approach should be performed here according to the guideline
6. Tubo-ovarian abscess not responding to antibiotics.
   1. most common between the ages of 15 and 40
   2. Hemodynamically stable, no indication of ruptured abscess, abscess <7 cm in diameter, adequate response to antibiotic therapy, conservative management should be preferred
   3. in postmenopausal patients, surgical diagnosis and/or treatment should be performed instead of antibiotic therapy alone or minimally invasive drainage
   4. in postmenopausal patients, malignancy risk up to 47%
   5. No improvement, minimally invasive abscess drainage procedure
7. Definitive surgery for endometriosis:
   1. Oophorectomy may be necessary if symptoms are severe or do not respond to other therapies
   2. About 25% of patients who had an endometrioma resection experience a recurrence, oophorectomy is preferred for recurrent endometriomas, especially in patients who have completed their family planning.
   3. Risk of malignancy in an endometrioma is typically less than 0.8%, but increases with larger lesions (>9 cm) and advancing age of the patient (>45 years).
   4. Endometriomas with atypical appearance and in patients with increased risk for ovarian cancer should be removed.
8. Metastases from gastrointestinal or other cancers (e.g., breast, lung, melanoma)
   1. Ovarian metastases occur in 25% of patients with a gastrointestinal adenocarcinoma; in about half of these cases, the metastases are occult.
   2. Oophorectomy and simultaneous hysterectomy should be individualized based on age, type of malignancy, and location of the disease.
9. Patients with complete androgen insensitivity syndrome
   1. Increased risk of gonadal malignancy in phenotypic females with a Y chromosome in the karyotype.
   2. Risk of malignant tumors in this tissue is 20-30%.
   3. Gonadectomy should occur after pubertal development, as it is rare for malignancy to occur before the age of 20.

Reference:

1. Togami S, Kobayashi H, Haruyama M, et al. A very rare case of endometriosis presenting with massive hemoperitoneum. J Minim Invasive Gynecol 2015; 22:691.
2. Ye M, Huang L, Wang Y. A massive haemorrhage caused by rupture of cystic cervical endometriosis. J Obstet Gynaecol 2012; 32:498.
3. Sanfilippo JS, Rock JA. Surgery for benign disease of the ovary. In: TeLinde's Operative Gynecology, 11th ed., Jones HW, Rock JA (Eds), Wolters Kluwer, 2015.
4. Takeda A, Hayashi S, Teranishi Y, et al. Chronic adnexal torsion: An under-recognized disease entity. Eur J Obstet Gynecol Reprod Biol 2017; 210:45.
5. Kokoska ER, Keller MS, Weber TR. Acute ovarian torsion in children. Am J Surg 2000; 180:462.
6. Anders JF, Powell EC. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med 2005; 159:532.
7. Hibbard LT. Adnexal torsion. Am J Obstet Gynecol 1985; 152:456.
8. Bouguizane S, Bibi H, Farhat Y, et al. [Adnexal torsion: a report of 135 cases]. J Gynecol Obstet Biol Reprod (Paris) 2003; 32:535.
9. Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF): Diagnostik, Therapie und Nachsorge maligner Ovarialtumoren, Langversion 6.01, 2024, AWMF-Registernummer: 032-035OL https://www.leitlinienprogrammonkologie.de/leitlinien/ovarialkarzinom/
10. Fouks Y, Cohen A, Shapira U, et al. Surgical Intervention in Patients with Tubo-Ovarian Abscess: Clinical Predictors and a Simple Risk Score. J Minim Invasive Gynecol 2019; 26:535.
11. PEDOWITZ P, BLOOMFIELD RD. RUPTURED ADNEXAL ABSCESS (TUBOOVARIAN) WITH GENERALIZED PERITONITIS. Am J Obstet Gynecol 1964; 88:721
12. Gil Y, Capmas P, Tulandi T. Tubo-ovarian abscess in postmenopausal women: A systematic review. J Gynecol Obstet Hum Reprod 2020; 49:101789.
13. Yagur Y, Weitzner O, Man-El G, et al. Conservative management for postmenopausal women with tubo-ovarian abscess. Menopause 2019; 26:793.
14. Raffi F, Metwally M, Amer S. The impact of excision of ovarian endometrioma on ovarian reserve: a systematic review and meta-analysis. J Clin Endocrinol Metab 2012; 97:3146.
15. Endometriosis Guideline of European Society of Human Reproduction and Embryology. 2022. Available at: https://www.eshre.eu/Guidelines-and-Legal/Guidelines/Endometriosis-guideline
16. Practice bulletin no. 114: management of endometriosis. Obstet Gynecol 2010; 116:223.
17. Practice Committee of the American Society for Reproductive Medicine. Treatment of pelvic pain associated with endometriosis: a committee opinion. Fertil Steril 2014; 101:927.
18. Barber HR. Ovarian cancer. CA Cancer J Clin 1986; 36:149.
19. Challa VR, Goud YG, Rangappa P, et al. "Ovarian Metastases from Colorectal Cancer: Our Experience". Indian J Surg Oncol 2015; 6:95.
20. Teter J, Boczkowski K. Occurrence of tumors in dysgenetic gonads. Cancer 1967; 20:1301.
21. Andrews J. Streak gonads and the Y chromosome. J Obstet Gynaecol Br Commonw 1971; 78:448.