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Oophorectomy and ovarian cystectomy

By Paula Lawrence,2014-01-29 02:46
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Oophorectomy and ovarian cystectomyand,AND

    Oophorectomy and ovarian cystectomy

    INTRODUCTION Ovarian pathology can occur at any time from fetal life to

    menopause. The most common surgical procedures for benign ovarian disease will

    be reviewed here. The initial approach to evaluation of an adnexal mass and surgical

    treatment of ovarian cancer are discussed elsewhere. (See "Overview of the

    evaluation and management of adnexal masses" and see "Differential diagnosis of

    the adnexal mass" and see "Epithelial ovarian cancer: Initial surgical management").

    OOPHORECTOMY VERSUS CYSTECTOMY The indications for ovarian surgery

    versus expectant management of an ovarian cyst depend upon the patient's age,

    findings on pelvic examination and with ultrasonography, and laboratory results.

    These issues are discussed in depth separately. (See "Overview of the evaluation and

    management of adnexal masses" and see "Differential diagnosis of the adnexal

    mass").

    When surgery is indicated for benign ovarian disease, preservation of ovarian tissue

    via cystectomy or enucleation of a solid tumor from the ovary is generally preferable

    to complete oophorectomy. When the ovary cannot be salvaged or insufficient viable

    tissue remains after attempts at conservation, oophorectomy is performed. In

    postmenopausal patients, no effort is made to preserve the ovary.

    Indications for oophorectomy include:

    ; Benign ovarian neoplasms that are not amenable to treatment by a lesser

    procedure (eg, cystectomy, enucleation, partial oophorectomy)

    ; Elective or risk-reducing oophorectomy with or without hysterectomy (see

    "Elective oophorectomy at hysterectomy" below)

    ; Adnexal (ovarian) torsion with necrosis (see "Ovarian and fallopian tube

    torsion")

    ; Ovarian malignancy (see "Epithelial ovarian cancer: Initial surgical

    management")

    ; Tuboovarian abscess unresponsive to antibiotics (see "Tuboovarian abscess")

    ; Definitive surgery for endometriosis (See "Overview of the treatment of

    endometriosis" and see "Laparoscopic surgery for treatment of infertility in women"

    and see "Diagnosis and management of ovarian endometriomas").

    ; Gastrointestinal or other metastatic cancer (eg, breast, lung, melanoma)

    Gastrointestinal cancer often metastasizes to the ovary. In one study, ovarian

    metastases were encountered in 25 percent of patients with an adenocarcinoma of the gastrointestinal tract; the metastases were occult in approximately one-half of these cases [1]. Therefore, oophorectomy and concomitant hysterectomy should be considered at the time of resection of the gastrointestinal cancer, especially in women approaching or beyond the perimenopausal years.

    ; Male pseudohermaphrodites, in whom the procedure is termed 'gonadectomy' An increased risk of gonadal malignancy occurs in phenotypic females with a Y chromosome in their karyotype [2-5]. These individuals should have their gonads

    removed to avoid the 20 to 30 percent risk of malignant tumors arising in this tissue [5-7]. Gonadectomy is delayed until after pubertal development in patients with complete androgen insensitivity, in which it is rare to develop a malignancy before 20 years of age. (See "Overview of ovarian germ cell tumors" section on

    Dysgerminoma).

    The gonadal streaks can be difficult to see and may lie very close to the external iliac artery or be herniated into the inguinal canal (show figure 1), thus laparotomy is the

    standard approach for both surgical ease and safety. Laparoscopic excision should only be attempted by experienced laparoscopists. There is no need to remove the uterus or the fallopian tubes; these organs can be preserved to permit future childbearing using donor oocytes.

    ASPIRATION AND FENESTRATION VERSUS CYSTECTOMY Aspiration of cyst

    contents is NOT recommended because no tissue is obtained for histopathology, cytology of cyst fluid is not reliable for exclusion of malignancy, there is a high rate of recurrence (11 to 65 percent) [8], and aspiration does not provide better results than simple observation [9]. These problems are less common with fenestration (ie, removing a full thickness, square portion of the cyst wall to create a window), but cystectomy is preferable. If the cyst is malignant, spillage of malignant cells into the peritoneal cavity is possible with both aspiration and fenestration. Aspiration followed by sclerotherapy via injection of methotrexate, tetracycline,

    alcohol, or erythromycin has been associated with a lower rate (4 to 38 percent) of cyst persistence or recurrence in observational series [8,10-13]. However, it is not

    clear that this intervention is more effective than expectant management since the studies were not adequately controlled.

    ELECTIVE OOPHORECTOMY AT HYSTERECTOMY Women who undergo

    hysterectomy at age 40 or older are often offered concurrent elective oophorectomy. The decision regarding removal or conservation of ovaries depends mainly upon the

    future risk of ovarian cancer versus hormonal and cardiovascular changes resulting

    from oophorectomy (show table 1). Hormonal effects will differ between pre- or

    postmenopausal women. Other factors include the likelihood of future ovarian

    symptoms or surgery. The American College of Obstetricians and Gynecologists

    guidelines regarding elective or risk reducing salpingo-oophorectomy are shown in

    the table (show table 2):

    ; Bilateral salpingo-oophorectomy should be offered to women with BRCA1 and

    BRCA2 mutations after completion of childbearing.

    ; Women with family histories suggestive of BRCA1 and BRCA2 mutations

    should be referred for genetic counseling and evaluation for BRCA testing. ; For women with an increased risk of ovarian cancer, risk-reducing salpingo-

    oophorectomy should include careful inspection of the peritoneal cavity, pelvic

    washings, removal of the fallopian tubes, and ligation of the ovarian vessels at the

    pelvic brim.

    ; Strong consideration should be made for retaining normal ovaries in

    premenopausal women who are not at increased genetic risk of ovarian cancer. ; Given the risk of ovarian cancer in postmenopausal women, ovarian removal

    at the time of hysterectomy should be considered for these women. ; Women with endometriosis, pelvic inflammatory disease, and chronic pelvic

    pain are at higher risk of reoperation; consequently, the risk of subsequent ovarian

    surgery if the ovaries are retained should be weighed against the benefit of ovarian

    retention in these patients.

    Counseling of patients regarding whether to undergo oophorectomy at time of

    hysterectomy should include the following factors:

    Advantages Advantages of elective oophorectomy at the time of hysterectomy

    include:

    Ovarian cancer risk reduction Elective or risk-reducing oophorectomy reduces,

    but does not eliminate, the risk of developing ovarian cancer. Ovarian-like cancers in

    the peritoneum, known as papillary serous carcinoma of the peritoneum (PSCP), can

    develop after oophorectomy. Oophorectomy performed for ovarian cancer risk

    reduction should include removal of the fallopian tubes since occult primary fallopian

    tube cancers have been reported in women undergoing risk reducing salpingo-

    oophorectomy.

    The magnitude of risk reduction depends upon a women's risk of ovarian cancer (show table 3). Women with BRCA mutations have a lifetime ovarian cancer risk of 13 percent or greater compared with 1.5 percent in the general population. For women in whom the risk falls below this level, there is no standard threshold regarding who should undergo elective oophorectomy. Counseling of these patients must be individualized and should include review of all advantages and disadvantages of the procedure. Risk reducing oophorectomy for women with a genetic predisposition to ovarian or breast cancer is discussed in detail separately. (See "Risk reducing salpingo-oophorectomy in women at high risk of epithelial ovarian cancer" and see "Endometrial and ovarian cancer screening and prevention in women with Lynch syndrome (hereditary nonpolyposis colorectal cancer)").

    The largest study to evaluate the degree of ovarian cancer risk reduction with oophorectomy at time of hysterectomy was a prospective observational study of 29,380 women age 30 or older who underwent hysterectomy with or without bilateral oophorectomy who participated in the Nurses' Health Study [14]. Data were

    adjusted for family history of ovarian cancer and duration of oral contraceptive use. Women who did versus did not undergo oophorectomy had significant reductions in ovarian cancer incidence (hazard ratio 0.04, 95% CI 0.01-0.09; 305 versus 339 cases per 100,000 person-year) and mortality (hazard ratio 0.06, 95% CI 0.02-0.21; 1 versus 14 deaths per 100,000 person-year); this risk reduction was similar regardless of age at hysterectomy.

    Breast cancer risk reduction The reduced risk of breast cancer that is

    associated with oophorectomy is likely due to reduced exposure to estrogen from the premenopausal ovary. Accordingly, the risk reduction varies by age at time of oophorectomy. This was illustrated in the Nurses' Health Study report described in the preceding section [14]. Data were adjusted for family history of breast cancer and use of estrogen therapy. A significant reduction in breast cancer incidence was found only in women who underwent oophorectomy at less than 45 years old (hazard ratio 0.6, 95% CI 0.5-0.7; 222 versus 315 cases per 100,000 person-year) and not in women 45 years or older. No significant difference in breast cancer mortality was found in any age group.

    Oophorectomy for breast cancer risk reduction in women with BRCA1 and BRCA2 mutations is discussed separately. (See "Options for women with a genetic predisposition to breast and ovarian cancer").

Avoidance of reoperation for ovarian pathology Reoperation for ovarian

    pathology, termed residual ovary syndrome (ROS), becomes necessary in 3 to 4 percent of women who retain one or both ovaries [15,16]. The majority of these

    surgeries are performed because of pelvic pain or a pelvic mass within five years of the hysterectomy. In one series of 73 women with ROS, histological examination revealed functional cysts, benign neoplasms, and ovarian carcinoma in 51, 43, and 12 percent of cases, respectively (some patients had more than one diagnosis) [15].

    In another study, the frequency of ROS was twice as high in women who had one ovary preserved, rather than both (7.6 versus 3.6 percent) [16]. In addition, ROS

    was more common in women who underwent hysterectomy at a young age, possibly because of the longer period of postprocedure ovarian function with a greater opportunity for functional ovarian pathology.

    Relief of bothersome symptoms related to continued ovarian function

     Relief of symptoms related to continued ovarian function can be an advantage for some women, such as those with cyclic migraine or epilepsy or premenstrual syndrome.

    Disadvantages Disadvantages of elective oophorectomy at the time of

    hysterectomy include:

    Sequelae of loss of natural ovarian hormones Hormonal effects of

    oophorectomy differ depending upon menopausal status. The mean age of menopause in the United States is approximately 51 years; only 3.8 percent of women who are ovulatory at age 40 become menopausal by age 45 [17]. In

    postmenopausal women, ovarian production of estrogen is greatly decreased, but there is no abrupt change in ovarian androgen production.

    Premenopausal oophorectomy results in loss of natural ovarian hormone secretion, which leads to vasomotor symptoms of surgically induced menopause (eg, hot flashes, vaginal dryness) and other sequelae of estrogen deficiency (eg, osteoporosis). Therefore, the positive effects of several years of physiologic estrogen production and the issues related to postmenopausal hormone therapy should be carefully considered before electively removing the ovaries of premenopausal women at hysterectomy. (See "Clinical manifestations and diagnosis of menopause" and see

    "Epidemiology and etiology of premenopausal osteoporosis").

    It has been proposed that androgens play a role in female sexual function; however, the magnitude of this role is uncertain. The assertion that low androgen levels are a

    primary factor in female sexual problems is based on the role of androgens in male sexuality and on the results of trials in which supraphysiologic doses of exogenous androgens exerted a positive influence on some aspects of female sexuality. The role of androgens in female sexual function is discussed in detail separately. (See "Sexual dysfunction in women: Epidemiology, risk factors, and evaluation", section on Role of

    androgens).

    The association between menopause and depression is controversial. A large prospective cohort study (n = 1151) of premenopausal women undergoing hysterectomy for benign indications found no association between bilateral oophorectomy and the development of depressive symptoms [18]. A full discussion

    of menopause and depression can be found separately. (See "Clinical manifestations and diagnosis of menopause", section on Depression).

    Lastly, the effects of estrogen on cognitive function are unclear. One study suggested premenopausal oophorectomy (unilateral or bilateral) increased in the risk of cognitive impairment compared to nonoophorectomized women, and the risk was higher in women who underwent oophorectomy at younger ages [19].

    Increased risk of cardiovascular disease Studies have suggested that

    premature menopause (natural or surgical) is associated with an increased risk of cardiovascular disease [14,20-23]; however, women who undergo surgical

    menopause appear to have other risk factors for cardiovascular disease, which may account for the increase in risk. (See "Determinants and management of cardiovascular risk in women", section on hysterectomy and see "Androgen

    production and therapy in women").

    The cardiovascular risks after oophorectomy were illustrated in the Nurses' Health Study report described in a preceding section (see "Ovarian cancer risk reduction"

    above) [14]. In women who did versus did not undergo bilateral oophorectomy at time of hysterectomy, a significant increase in coronary heart disease incidence was found only in women who underwent oophorectomy at less than 45 years old (hazard ratio 1.26, 95% CI 1.04-1.54; 281 versus 240 cases per 100,000 person-year) and not in women 45 years or older. No significant difference in coronary heart disease mortality was found in any age group.

    Procedure related complications Procedure-related complications can occur,

    especially if there is anatomic distortion from adhesions or other pelvic pathology.

    However, the frequency of complications is uncommon in the absence of such pathology.

    Summary The elective removal of ovaries in premenopausal women should be individualized in view of the complexity of decision making around risk of ovarian and breast cancer, use of hormone therapy, and cardiovascular disease. (See "Postmenopausal hormone therapy: Benefits and risks").

    In postmenopausal women, the benefits of continued ovarian androgen production are unclear compared with the risk of ovarian cancer in this age group; therefore, postmenopausal ovaries should generally be removed at the time of hysterectomy unless ovarian conservation is desired by the patient or oophorectomy adds surgical difficulty (eg, during a vaginal hysterectomy).

    In women with dense adnexal adhesions, the risk of procedure-related complications should also be weighed against the risks of retaining the ovaries. SURGICAL APPROACH

    Open laparotomy versus laparoscopy Most ovarian surgeries are for benign

    disease and can be performed laparoscopically. The major advantages to laparoscopy over laparotomy are reductions in recovery time, hospital stay, cost, and adhesion formation, which is particularly important in women in whom fertility is an issue [24,25]. Limited data from randomized trials also showed less febrile morbidity and a lower frequency of urinary tract infection, postoperative pain and postoperative complications with laparoscopy [26]. (See "Overview of gynecologic laparoscopic

    surgery"). Guidelines for preoperative referral to a gynecologic oncologist are described in the table (show table 4).

    A disadvantage of laparoscopic oophorectomy/cystectomy is the potential for spill of cancer cells if the mass is malignant (see "Spillage of malignant cells" below).

    Unfortunately, neither preoperative clinical and sonographic evaluation nor the laparoscopic appearance of the ovary can reliably predict which masses are malignant. However, it is unlikely that an inadvertent laparoscopic procedure for ovarian cancer will be performed if patients are carefully selected. A survey by the American Society of Gynecologic Laparoscopists reported unsuspected ovarian cancer was found in only 0.04 percent of 13,739 cases of laparoscopic ovarian cyst surgery [27].

    Clinical and sonographic criteria suggestive of ovarian malignancy are listed in the tables (show table 5 and show table 6) [28]. (See "Sonographic differentiation of

    benign versus malignant adnexal masses"). In general, a thin-walled unilocular

    simple cyst is likely to be benign, even in postmenopausal women. Two series including approximately 1000 thin-walled unilocular cysts in both premenopausal and postmenopausal women found no malignant tumors under 75 mm [29,30]. Thus,

    these cysts can usually be managed laparoscopically. An in-depth discussion of the approach to evaluation and management of adnexal masses can be found separately. (See "Overview of the evaluation and management of adnexal masses" and see

    "Differential diagnosis of the adnexal mass").

    There is increasing sentiment to evaluate some complex cysts with the laparoscope, since most of them are benign. There are no dogmatic recommendations for this group of patients and clinicians must individualize treatment according to their index of suspicion. The concern associated with the use of laparoscopy in this setting is that the prognosis may be worsened by cyst rupture if malignancy is encountered. Therefore, one must take into account the patient's age, medical condition, clinical examination (eg, fixed mass or mobile), sonographic appearance of the mass, and tumor markers (eg, CA-125) to gauge the likelihood of malignancy when deciding upon the proper operative approach. Laparoscopy should be reserved for those cases in which the risk of malignancy is very low. If a malignancy is encountered, the patient should immediately have the appropriate open surgical procedure for staging and definitive treatment, preferably with the assistance of a gynecologic oncologist (show table 7). Staging and treatment of ovarian cancer via a laparoscopic approach is under investigation [31]. (See "Epithelial ovarian cancer: Clinical manifestations, diagnostic evaluation, staging, and histopathology").

    Another approach is minilaparotomy, which some surgeons consider a minimally invasive procedure. Minilaparotomy has the advantages of a potentially shorter operating time and learning curve than laparoscopy and avoidance of pneumoperitoneum, but without the large incision associated with classical open laparotomy [32]. The procedure is performed by placing the patient in a steep Trendelenburg position and making a minimal suprapubic incision (4 to 9 cm) beneath the pubic hair line [33]. The abdominal fascia is opened 2 to 3 cm above the skin incision and the peritoneum is opened manually. Narrow Deaver retractors are used to allow frequent repositioning to optimize exposure of the surgical field. The following criteria should be met if this approach is employed: use of narrow and light instruments; exteriorization of the target organ; combined, unidirectional

    maneuvering of all the retractors; and prompt hemostasis by electrocoagulating forceps.

    In summary, laparoscopy is the preferred technique for oophorectomy/cystectomy because it is associated with a smaller scar, faster recovery, lower cost, and lower frequency of postoperative adhesion formation than laparotomy. Situations in which the traditional open method is safer and more appropriate than the laparoscopic approach are when the surgeon and/or assistants are not experienced in the use of an operative laparoscope, when there are dense adnexal adhesions, when the ovary is very large, or when there is a high suspicion of malignancy. Minilaparotomy is an alternative "in-between" approach.

    Surgeons must use good judgment and be selective in the cases chosen for laparoscopic treatment. The following criteria are generally accepted guidelines:

    ; The laparoscopic approach is reasonable for patients whose preoperative evaluation suggests benign disease (show table 5 and show table 6). These patients

    include those with probable dermoids, endometriomas, or physiological cysts that have not resolved with conservative management or are associated with acute symptoms. A laparoscopy may be converted to a laparotomy if the surgeon

    See "Overview of gynecologic laparoscopic encounters a difficult dissection. (

    surgery").

    ; Intraoperative findings suspicious for malignancy (ascites, enlarged nodes, matted bowel, excrescences, multiple nodular areas) usually warrant conversion to an open evaluation. However, a smooth appearance on the surface of the cyst does not exclude the possibility of a malignancy.

    ; Removing cysts in a specimen bag reduces both operating time and spillage. Controlled intraperitoneal spillage of benign cyst contents (eg, cystic teratoma) does not increase postoperative morbidity as long as the peritoneal cavity is copiously lavaged.

    ; Cysts that are complex should be removed, not fenestrated, given the possibility of malignancy and high recurrence rates.

    ; A solid adnexal mass that is small enough to be removed intact via colpotomy or via a laparoscopic bag can be managed laparoscopically. Solid masses can also be mobilized laparoscopically and then removed through a mini-laporotomy incision.

    PROCEDURE

    Oophorectomy Oophorectomy may be performed through an abdominal incision, laparoscopically, or vaginally (at the time of hysterectomy).

    Open or laparoscopic approach After the abdomen is entered, pelvic and

    abdominal washings are obtained and saved to use for staging if a malignancy is subsequently diagnosed. The entire pelvis, abdomen and retroperitoneum (eg, diaphragm, omentum, viscera, kidneys) are inspected for sites suspicious for carcinoma (excrescences, thick adhesions, nodules, enlarged nodes) should be biopsied and sent for frozen section.

    If findings are consistent with benign disease, the infundibulopelvic ligament and ureter are identified. The peritoneum is incised parallel to the ovarian vessels and the retroperitoneal space is entered. Alternatively, the round ligament can be divided to enter the retroperitoneal space.

    Using either blunt dissection or meticulous sharp dissection with Metzenbaum scissors (preferable) or other laparoscopic instruments, the broad ligament is opened and the ureter identified on its medial, or posterior, leaf.

    If the fallopian tube is to be removed, the ovarian vessels are then elevated to allow good visualization of the nearby ureter, doubly clamped, divided, and the pedicles doubly ligated to ensure hemostasis (show figure 2A-C). Both the ovarian ligament

    and fallopian tube are clamped parallel and just lateral to the uterine cornu and then excised; the cornu is then ligated.

    If the fallopian tube is to be preserved, the multiple tubal branches of the ovarian artery should be clamped and ligated inferior and parallel to the tube in a systematic fashion. This separates the ovary from the fallopian tube and allows clear visualization of the ovarian branch of the uterine artery. Subsequently, the ovarian artery can be clamped, divided, and ligated. The utero-ovarian ligament is then clamped parallel and just lateral to the uterine cornu and excised; the cornu is then ligated.

    Some surgeons advocate performing a wedge resection of the fallopian tube stump and approximating the surrounding cornual edge of myometrium to decrease the chance of a uteroperitoneal fistula, ensure hemostasis, and prevent the theoretical risk of a cornual ectopic pregnancy. There are no data to support or refute this approach, which may add to the total blood loss and duration of the procedure.

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