Evidence - Bilateral adnexectomy, lavage cytology, laparoscopy

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 portion of the cyst wall to create a window.
• Problems less frequent: Compared to aspiration.
• Risk with 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 watchful waiting 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 evidence 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. The 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 of gastrointestinal or other cancers (e.g., breast, lung, melanoma)
   1. Ovarian metastases occur in 25% of patients with a gastrointestinal tract 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.

In the past, the preservation of ovarian function in postmenopausal women was often neglected because it was assumed that the ovaries were no longer active after menopause. However, recent studies have shown that women who maintain their ovarian function until the age of 65 have a lower overall mortality rate than those who underwent elective oophorectomy. Women who have an oophorectomy before the age of 55 have an 8.58% higher mortality rate by the age of 80, and for oophorectomy before the age of 59, the increased mortality rate is 3.92%. These benefits of ovarian preservation persist until the age of 75, although the benefit decreases and the excess mortality with oophorectomy is less than 1%.

Additionally, the data show that women under 65 clearly benefit from ovarian preservation. An oophorectomy increases the risk of dying from coronary heart disease in this age group. After the age of 65, the increased mortality rate shifts mainly to hip fractures. Since ovarian cancer, except in cases with documented germline mutations and familial high-risk pedigrees, is a relatively rare cause of death, there is no significant reduction in mortality from an oophorectomy before the age of 65.

A revised analysis of these data showed that patients with hysterectomy and oophorectomy from the age of 50 had similar survival rates up to the age of 80, but there are limitations to the study results as predominantly white patients were in the study cohorts and the salpingectomy status was unknown.

For this reason, an assessment of ovarian cancer risk should be investigated before planned gynecological procedures. This assessment includes, among other things, determining family medical history, genetic predispositions, and individual health risks. A comprehensive analysis is necessary to develop preventive measures and individual treatment plans.

Although bilateral oophorectomy significantly reduces the risk of developing ovarian cancer, it does not completely eliminate it. An additional salpingectomy can further reduce the risk. Studies have found that the fallopian tubes are often the origin of most epithelial ovarian carcinomas, tubal carcinomas, and peritoneal carcinomas.

In 2010, the British Columbia Ovarian Cancer Research (OVCARE) team proposed prophylactic salpingectomy as a strategy for primary prevention of ovarian cancer, based on the following observations:

• Carcinogenesis: Most ovarian carcinomas, especially high-grade serous carcinoma, arise from the epithelium of the distal fallopian tube rather than the ovary itself.
• In patients at high risk for ovarian cancer (e.g., patients with BRCA1 and BRCA2 mutations), risk-reducing bilateral salpingo-oophorectomy was performed, where occult tubal carcinomas and/or premalignant lesions in the fallopian tube were found, which could not be found in the ovary.
• Premalignant lesions were also found in the fallopian tubes of patients with average risk. Here, salpingectomy was performed for benign reasons, such as during sterilization or hysterectomy.
• It was shown that the involvement of the fallopian tubes was present in up to 75 percent of patients diagnosed with ovarian or primary peritoneal serous carcinoma (with and without BRCA mutations), including the presence of fimbrial precancers up to 60 percent.
• Tubal ligation can also reduce the risk of ovarian cancer, with large retrospective studies showing greater risk reduction for non-serous histologies (particularly endometrioid and clear cell carcinomas).

Risk Reduction for Ovarian Cancer

Nurses' Health Study (NHS):

• Prospective cohort study with approximately 30,000 participants.
• Average age at surgery: 43 to 47 years.
• Follow-up period: up to 28 years.
• Fewer deaths from ovarian cancer in the group with hysterectomy and bilateral oophorectomy compared to hysterectomy alone (4 versus 44 deaths; HR 0.06, 95% CI 0.02-0.17).

Women's Health Initiative (WHI) Observational Study:

• Prospective study with 25,448 women.
• 56% of participants had a concurrent BSO.
• Average follow-up period: 7.6 years.
• Fewer cases of ovarian cancer in the bilateral salpingo-oophorectomy group (2 versus 33 per 10,000 women).
• Limitations: Short follow-up duration and long period between surgery and study enrollment.

Canadian Cohort Study:

• Includes over 195,000 patients between 1996 and 2010.
• 24% of patients had a concurrent bilateral salpingo-oophorectomy.
• Cumulative 20-year incidence rate for ovarian cancer was lower in the bilateral salpingo-oophorectomy group (0.08% versus 0.46%; absolute risk difference 0.38%, 95% CI 0.32-0.45).

Risk Reduction for Breast Cancer

Nurses' Health Study (NHS):

• Reduction in breast cancer incidence only in patients who underwent the procedure at 47.5 years or younger.

WHI Observational Study:

• Reduction in breast cancer risk only in patients who underwent oophorectomy under the age of 40 and did not receive estrogen therapy.

Meta-Analysis of 21 Cohort Studies:

• Patients under 45 who had concurrent bilateral salpingo-oophorectomy (BSO) had a lower risk of developing breast cancer (HR 0.75, 95% CI 0.69-0.82; five studies).
• Breast cancer incidence rates were similar in patients over 50 (four studies).

Conclusion on the Choice of Oophorectomy

Premenopausal Patients:

• Preservation of ovaries preferred
• Bilateral oophorectomy has long-term health consequences.
• Exception: Oophorectomy for other pelvic pathologies (e.g., endometriosis, pelvic pain).

Menopausal Patients:

• Oophorectomy can be health-neutral, but not consistently in studies
• From age 51 for cancer prevention possible, but after counseling on pros and cons

Reference:

1. Parker WH, Broder MS, Liu Z, et al. Ovarian conservation at the time of hysterectomy for benign disease. Obstet Gynecol 2005; 106:219.
2. Rush SK, Ma X, Newton MA, Rose SL. A Revised Markov Model Evaluating Oophorectomy at the Time of Hysterectomy for Benign Indication: Age 65 Years Revisited. Obstet Gynecol 2022; 139:735.
3. Parker WH, Broder MS, Chang E, et al. Ovarian conservation at the time of hysterectomy and long-term health outcomes in the nurses' health study. Obstet Gynecol 2009; 113:1027.
4. Parker WH, Feskanich D, Broder MS, et al. Long-term mortality associated with oophorectomy compared with ovarian conservation in the nurses' health study. Obstet Gynecol 2013; 121:709.
5. Jacoby VL, Grady D, Wactawski-Wende J, et al. Oophorectomy vs ovarian conservation with hysterectomy: cardiovascular disease, hip fracture, and cancer in the Women's Health Initiative Observational Study. Arch Intern Med 2011; 171:760.
6. Cusimano MC, Ferguson SE, Moineddin R, et al. Ovarian cancer incidence and death in average-risk women undergoing bilateral salpingo-oophorectomy at benign hysterectomy. Am J Obstet Gynecol 2022; 226:220.e1.
7. Hassan H, Allen I, Sofianopoulou E, et al. Long-term outcomes of hysterectomy with bilateral salpingo-oophorectomy: a systematic review and meta-analysis. Am J Obstet Gynecol 2024; 230:44.

General Information:

• Most ovarian surgeries for benign conditions are performed minimally invasively.
• In a large cohort study in the USA, a minimally invasive procedure was used in almost 90% of oophorectomies or ovarian cystectomies.

Advantages over Laparotomy:

• Shorter recovery time.
• Shorter hospital stay.
• Lower costs.
• Less adhesion formation (important for patients desiring fertility).
• Less febrile morbidity, lower incidence of urinary tract infections, postoperative pain, and complications.

Disadvantages of Minimally Invasive Procedures:

• Dissemination of malignant cells into the peritoneal cavity in malignant findings.
• Preoperative clinical and sonographic examinations, as well as the laparoscopic appearance of the ovary, cannot reliably predict which findings are malignant.
• In a study, it was shown that only 0.04% of the 13,739 cases of laparoscopic ovarian cyst surgeries were unexpectedly malignant.

Sonographic Criteria:

• Thin-walled, unilocular simple cysts are likely benign, even in postmenopausal patients.
• Cysts up to 10 cm can usually be treated laparoscopically.
• The IOTA criteria should be followed to reduce the risk of a malignant finding.

Minilaparotomy:

• Alternative minimally invasive method.
• Shorter operation time and learning curve than laparoscopy.
• Avoidance of pneumoperitoneum.
• Small suprapubic incision (4 to 9 cm).

Recommendations:

• Minimally invasive procedures are suitable for patients whose preoperative evaluation indicates a benign condition.
• In cases of intraoperative findings suspicious for malignancy (ascites, enlarged lymph nodes, etc.), conversion to open surgery is advisable.
• Complex cysts should be removed and not fenestrated.
• In minimally invasive procedures, a retrieval bag should be used to prevent the dissemination of malignant cells.
• For very large cysts or an adhesion site, an open approach is preferred.

Use of Robotic or Single-Port Laparoscopy:

• New minimally invasive approaches.
• Similar operation duration and complication rates as conventional laparoscopy.

Reference: 

1. Dioun S, Huang Y, Melamed A, et al. Trends in the Use of Minimally Invasive Adnexal Surgery in the United States. Obstet Gynecol 2021; 138:738.
2. Hidlebaugh DA, Vulgaropulos S, Orr RK. Treating adnexal masses. Operative laparoscopy vs. laparotomy. J Reprod Med 1997; 42:551.
3. Bisharah M, Tulandi T. Laparoscopic preservation of ovarian function: an underused procedure. Am J Obstet Gynecol 2003; 188:367.
4. Medeiros LR, Fachel JM, Garry R, et al. Laparoscopy versus laparotomy for benign ovarian tumours. Cochrane Database Syst Rev 2005; :CD004751.
5. Hulka JF, Parker WH, Surrey MW, Phillips JM. Management of ovarian masses. AAGL 1990 survey. J Reprod Med 1992; 37:599.
6. Fanfani F, Fagotti A, Ercoli A, et al. A prospective randomized study of laparoscopy and minilaparotomy in the management of benign adnexal masses. Hum Reprod 2004; 19:2367.
7. Benedetti-Panici P, Maneschi F, Cutillo G, et al. Surgery by minilaparotomy in benign gynecologic disease. Obstet Gynecol 1996; 87:456.
8. IOTA Simple Rules and SRrisk calculator to diagnose ovarian cancer. International Ovarian Tumor Analysis. Available at: https://www.iotagroup.org/iota-models-software/iota-simple-rules-and-srrisk-calculator-diagnose-ovarian-cancer (Accessed on March 20, 2019).