Evidence - Bilateral salpingectomy, laparoscopic

• Opportunistic salpingectomy
• Sterilization
• Therapeutic salpingectomy

Opportunistic salpingectomy, also an oncologic prophylactic salpingectomy for ovarian cancer reduction. Approximately 7,000 women are diagnosed with ovarian cancer annually in Germany. In most cases, the cancer is detected at an advanced stage (FIGO III-IV, about 70%), resulting in a poor prognosis. Additionally, there is no good early detection method.

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, originate 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), a 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, a salpingectomy was performed for benign reasons, e.g., during sterilization or hysterectomy.
• It was shown that the involvement of the fallopian tubes was up to 75 percent in 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 a greater risk reduction for non-serous histologies (particularly endometrioid and clear cell carcinomas).

Mechanisms of risk reduction:

• Removal of the initial site of carcinogenesis (high-grade serous carcinomas)
• Removal of the tube for the passage of endometriotic or endosalpingiotic cells (clear cell and endometrioid carcinomas)
• Removal of the tube for the passage of carcinogens (e.g., talc) or inflammation (e.g., pelvic infection) before reaching the ovary.

The indication for bilateral opportunistic salpingectomy should only be made for patients undergoing pelvic surgery for another reason (e.g., hysterectomy for benign disease, permanent sterilization) and who have completed family planning. In patients at high risk for cancers of the fallopian tube, ovary, and peritoneum (e.g., BRCA gene mutation, Lynch syndrome), a risk-reducing bilateral salpingo-oophorectomy should be performed after a benefit-risk assessment.

Many studies have examined the perioperative course after an opportunistic salpingectomy:

• Extension of surgery time by about 10-16 minutes
• Blood loss: no difference
• Hospital stay: no difference
• Perioperative complications (infections, blood draws, rounds, further diagnostics): no difference
• Menopause: Onset of menopause was the same in both groups. However, one study showed that the Anti-Müllerian Hormone was slightly lower in the salpingectomy group.

Risk reduction of developing ovarian cancer:

A meta-analysis showed that with a follow-up period of 18-36 years, prophylactic bilateral salpingectomy vs. no salpingectomy reduced the risk by almost 50 percent adjusted to the study population. Overall, the risk of developing ovarian cancer was very low in both groups (0.8 and 0.7 percent, respectively).

Reference:

1. Center for Cancer Registry Data: Ovarian Cancer (Ovarian Carcinoma). www.krebsdaten.de/Krebs/DE/Content/Krebsarten/Eierstockkrebs/eierstockkrebs_node.html (last accessed on 7 February 2022).
2. Homepage. OVCARE. Available at: www.ovcare.ca (Accessed on September 08, 2021).
3. Crum CP, Drapkin R, Kindelberger D, et al. Lessons from BRCA: the tubal fimbria emerges as an origin for pelvic serous cancer. Clin Med Res 2007; 5:35.
4. Crum CP, Drapkin R, Miron A, et al. The distal fallopian tube: a new model for pelvic serous carcinogenesis. Curr Opin Obstet Gynecol 2007; 19:3.
5. Piek JM, van Diest PJ, Zweemer RP, et al. Dysplastic changes in prophylactically removed Fallopian tubes of women predisposed to developing ovarian cancer. J Pathol 2001; 195:451.
6. Tobacman JK, Greene MH, Tucker MA, et al. Intra-abdominal carcinomatosis after prophylactic oophorectomy in ovarian-cancer-prone families. Lancet 1982; 2:795.
7. Piver MS, Jishi MF, Tsukada Y, Nava G. Primary peritoneal carcinoma after prophylactic oophorectomy in women with a family history of ovarian cancer. A report of the Gilda Radner Familial Ovarian Cancer Registry. Cancer 1993; 71:2751.
8. Struewing JP, Watson P, Easton DF, et al. Prophylactic oophorectomy in inherited breast/ovarian cancer families. J Natl Cancer Inst Monogr 1995; :33.
9. Powell CB, Chen LM, McLennan J, et al. Risk-reducing salpingo-oophorectomy (RRSO) in BRCA mutation carriers: experience with a consecutive series of 111 patients using a standardized surgical-pathological protocol. Int J Gynecol Cancer 2011; 21:846.
10. Powell CB, Swisher EM, Cass I, et al. Long term follow up of BRCA1 and BRCA2 mutation carriers with unsuspected neoplasia identified at risk reducing salpingo-oophorectomy. Gynecol Oncol 2013; 129:364.
11. Reitsma W, de Bock GH, Oosterwijk JC, et al. Support of the 'fallopian tube hypothesis' in a prospective series of risk-reducing salpingo-oophorectomy specimens. Eur J Cancer 2013; 49:132.
12. Wethington SL, Park KJ, Soslow RA, et al. Clinical outcome of isolated serous tubal intraepithelial carcinomas (STIC). Int J Gynecol Cancer 2013; 23:1603.
13. Finch A, Shaw P, Rosen B, et al. Clinical and pathologic findings of prophylactic salpingo-oophorectomies in 159 BRCA1 and BRCA2 carriers. Gynecol Oncol 2006; 100:58.
14. Medeiros F, Muto MG, Lee Y, et al. The tubal fimbria is a preferred site for early adenocarcinoma in women with familial ovarian cancer syndrome. Am J Surg Pathol 2006; 30:230.
15. Colgan TJ, Murphy J, Cole DE, et al. Occult carcinoma in prophylactic oophorectomy specimens: prevalence and association with BRCA germline mutation status. Am J Surg Pathol 2001; 25:1283.
16. Callahan MJ, Crum CP, Medeiros F, et al. Primary fallopian tube malignancies in BRCA-positive women undergoing surgery for ovarian cancer risk reduction. J Clin Oncol 2007; 25:3985.
17. Gilks CB, Irving J, Köbel M, et al. Incidental nonuterine high-grade serous carcinomas arise in the fallopian tube in most cases: further evidence for the tubal origin of high-grade serous carcinomas. Am J Surg Pathol 2015; 39:357.
18. Morrison JC, Blanco LZ Jr, Vang R, Ronnett BM. Incidental serous tubal intraepithelial carcinoma and early invasive serous carcinoma in the nonprophylactic setting: analysis of a case series. Am J Surg Pathol 2015; 39:442.
19. Nishida N, Murakami F, Higaki K. Detection of serous precursor lesions in resected fallopian tubes from patients with benign diseases and a relatively low risk for ovarian cancer. Pathol Int 2016; 66:337.
20. Rabban JT, Garg K, Crawford B, et al. Early detection of high-grade tubal serous carcinoma in women at low risk for hereditary breast and ovarian cancer syndrome by systematic examination of fallopian tubes incidentally removed during benign surgery. Am J Surg Pathol 2014; 38:729.
21. Powell CB, Kenley E, Chen LM, et al. Risk-reducing salpingo-oophorectomy in BRCA mutation carriers: role of serial sectioning in the detection of occult malignancy. J Clin Oncol 2005; 23:127.
22. Kindelberger DW, Lee Y, Miron A, et al. Intraepithelial carcinoma of the fimbria and pelvic serous carcinoma: Evidence for a causal relationship. Am J Surg Pathol 2007; 31:161.
23. Carlson JW, Miron A, Jarboe EA, et al. Serous tubal intraepithelial carcinoma: its potential role in primary peritoneal serous carcinoma and serous cancer prevention. J Clin Oncol 2008; 26:4160.
24. Seidman JD, Zhao P, Yemelyanova A. "Primary peritoneal" high-grade serous carcinoma is very likely metastatic from serous tubal intraepithelial carcinoma: assessing the new paradigm of ovarian and pelvic serous carcinogenesis and its implications for screening for ovarian cancer. Gynecol Oncol 2011; 120:470.
25. Salvador S, Rempel A, Soslow RA, et al. Chromosomal instability in fallopian tube precursor lesions of serous carcinoma and frequent monoclonality of synchronous ovarian and fallopian tube mucosal serous carcinoma. Gynecol Oncol 2008; 110:408.
26. McLaughlin JR, Risch HA, Lubinski J, et al. Reproductive risk factors for ovarian cancer in carriers of BRCA1 or BRCA2 mutations: a case-control study. Lancet Oncol 2007; 8:26.
27. Rice MS, Hankinson SE, Tworoger SS. Tubal ligation, hysterectomy, unilateral oophorectomy, and risk of ovarian cancer in the Nurses' Health Studies. Fertil Steril 2014; 102:192.
28. Sieh W, Salvador S, McGuire V, et al. Tubal ligation and risk of ovarian cancer subtypes: a pooled analysis of case-control studies. Int J Epidemiol 2013; 42:579.
29. Tone AA, Salvador S, Finlayson SJ, et al. The role of the fallopian tube in ovarian cancer. Clin Adv Hematol Oncol 2012; 10:296.
30. Garrett LA, Growdon WB, Goodman A, et al. Endometriosis-associated ovarian malignancy: a retrospective analysis of presentation, treatment, and outcome. J Reprod Med 2013; 58:469.
31. Wiegand KC, Hennessy BT, Leung S, et al. A functional proteogenomic analysis of endometrioid and clear cell carcinomas using reverse phase protein array and mutation analysis: protein expression is histotype-specific and loss of ARID1A/BAF250a is associated with AKT phosphorylation. BMC Cancer 2014; 14:120.
32. Menon U, Gentry-Maharaj A, Burnell M, et al. Ovarian cancer population screening and mortality after long-term follow-up in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): a randomised controlled trial. Lancet 2021; 397:2182.
33. McAlpine JN, Hanley GE, Woo MM, et al. Opportunistic salpingectomy: uptake, risks, and complications of a regional initiative for ovarian cancer prevention. Am J Obstet Gynecol 2014; 210:471.e1.
34. Garcia C, Martin M, Tucker LY, et al. Experience With Opportunistic Salpingectomy in a Large, Community-Based Health System in the United States. Obstet Gynecol 2016; 128:277.
35. Hanley GE, Kwon JS, Finlayson SJ, et al. Extending the safety evidence for opportunistic salpingectomy in prevention of ovarian cancer: a cohort study from British Columbia, Canada. Am J Obstet Gynecol 2018; 219:172.e1.
36. Yoon SH, Kim SN, Shim SH, et al. Bilateral salpingectomy can reduce the risk of ovarian cancer in the general population: A meta-analysis. Eur J Cancer 2016; 55:38.
37. Hanley GE, Kwon JS, McAlpine JN, et al. Examining indicators of early menopause following opportunistic salpingectomy: a cohort study from British Columbia, Canada. Am J Obstet Gynecol 2020; 223:221.e1.

A complete salpingectomy is not a classic method for sterilization, although the complete salpingectomy has significantly increased in recent years. The perioperative risks are comparable to those of tubal ligation using a ring, bipolar electrosurgery, or a titanium clip, with the operation time having minimally increased.

Advantages and disadvantages of sterilization:

• Reduced risk of ovarian cancer: A salpingectomy reduces the risk of epithelial ovarian, fallopian tube, and peritoneal carcinoma (see Opportunistic Salpingectomy), but a tubal ligation also reduces the risk.
• Post-ablation tubal sterilization syndrome: After salpingectomy or tubal ligation with subsequent endometrial ablation, cyclic or intermittent pelvic pain may occur.
• Possibly reduced rates of endometrial cancer: In a meta-analysis of eight cohort and case-control studies, tubal ligation was associated with lower rates of endometrial cancer.
• Ovarian reserve – There is no substantial evidence that patients experienced earlier menopause.
• Sexual function: remained unchanged.
• Breast cancer: no association.

Reference:

1. Powell CB, Alabaster A, Simmons S, et al. Salpingectomy for Sterilization: Change in Practice in a Large Integrated Health Care System, 2011-2016. Obstet Gynecol 2017; 130:961.
2. Westberg J, Scott F, Creinin MD. Safety outcomes of female sterilization by salpingectomy and tubal occlusion. Contraception 2017.
3. Loghmani L, Saedi N, Omani-Samani R, et al. Tubal ligation and endometrial Cancer risk: a global systematic review and meta-analysis. BMC Cancer 2019; 19:942.
4. Ganer Herman H, Gluck O, Keidar R, et al. Ovarian reserve following cesarean section with salpingectomy vs tubal ligation: a randomized trial. Am J Obstet Gynecol 2017; 217:472.e1.
5. Costello C, Hillis SD, Marchbanks PA, et al. The effect of interval tubal sterilization on sexual interest and pleasure. Obstet Gynecol 2002; 100:511.

An tubal pregnancy belongs to the group of ectopic pregnancies, meaning a pregnancy outside the uterus. This is the most common form of ectopic pregnancies and can lead to an emergency situation in gynecology. The treatment options for an tubal pregnancy include:

1. expectant management
2. Medical therapy with methotrexate
3. Surgical approach: tubal-sparing such as salpingotomy or salpingectomy

Only a few patients are eligible for expectant management.

Decision between methotrexate and surgery:

• both have comparable efficacy and lead to similar conception probabilities
• Methotrexate therapy for:
  • hemodynamically stable patients
  • Serum beta-human chorionic gonadotropin (hCG) concentration ≤5000 mIU/ml.
  • no fetal cardiac activity
  • patient compliance for follow-up appointments
• Surgery for:
  • hemodynamically unstable patients
  • simultaneous pregnancy (intrauterine and ectopic pregnancy)
  • symptomatic patients (abdominal discomfort, possible sign of impending rupture)
  • abnormal hematological, renal, or hepatic laboratory values that could be worsened by methotrexate therapy and consequently lead to high morbidity or mortality.
  • In immunocompromised patients, patients with lung diseases or peptic ulcers
  • Hypersensitivity to methotrexate
  • Breastfeeding patients
  • Patients who prefer surgery to simultaneously perform sterilization or removal of a hydrosalpinx (increases the outcome in in-vitro fertilization)
  • in hemodynamically stable patients only if there is a high suspicion of an ectopic pregnancy, e.g., visible changes in the area of the fallopian tube during transvaginal sonography
  • Frustrated methotrexate therapy

Salpingotomy versus Salpingectomy:

There are two options to remove the tubal pregnancy.

• Salpingectomy (removal of the fallopian tube)
• Salpingotomy (incision of the fallopian tube to remove the tubal pregnancy, leaving the rest of the tube intact)

Both options lead to similar conception probabilities in subsequent pregnancies. The perioperative morbidity is similar in both procedures. If persistent bleeding occurs during salpingotomy, a salpingectomy must be performed. The risk of a recurrent tubal pregnancy does not differ in most studies. However, a meta-analysis showed that salpingotomy has a slightly higher conception probability of 72 versus 54 percent, but also a higher probability of recurrent tubal pregnancy 10 versus 4 percent.

A salpingectomy should be performed in the case of a ruptured ectopic pregnancy with severe damage to the tube, uncontrollable bleeding, or a very large ectopic pregnancy.

In most cases, a laparoscopy is performed. However, if a circulatory-relevant emergency situation occurs, the surgeon must decide whether a laparoscopic or open approach is chosen. The choice of access route in this emergency situation depends on the experience and expertise of the surgeon. Advantages of laparoscopy: shorter operation time, less perioperative blood loss, shorter hospital stay, shorter recovery time.

The patient should be thoroughly informed about the risk-benefit profile. Based on this, the therapy selection is then made jointly.

Reference:

1. Hajenius PJ, Mol F, Mol BW, et al. Interventions for tubal ectopic pregnancy. Cochrane Database Syst Rev 2007; :CD000324.
2. Mol F, Mol BW, Ankum WM, et al. Current evidence on surgery, systemic methotrexate and expectant management in the treatment of tubal ectopic pregnancy: a systematic review and meta-analysis. Hum Reprod Update 2008; 14:309.
3. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 94: Medical management of ectopic pregnancy. Obstet Gynecol 2008; 111:1479.
4. Practice Committee of American Society for Reproductive Medicine. Medical treatment of ectopic pregnancy: a committee opinion. Fertil Steril 2013; 100:638.
5. Hajenius PJ, Mol F, Mol BW, et al. Interventions for tubal ectopic pregnancy. Cochrane Database Syst Rev 2007; :CD000324.
6. Fernandez H, Capmas P, Lucot JP, et al. Fertility after ectopic pregnancy: the DEMETER randomized trial. Hum Reprod 2013; 28:1247.
7. Mol F, van Mello NM, Strandell A, et al. Salpingotomy versus salpingectomy in women with tubal pregnancy (ESEP study): an open-label, multicentre, randomised controlled trial. Lancet 2014; 383:1483.