Opportunistic salpingectomy in female urologic surgery

Opportunistic salpingectomy (OS), the removal of fallopian tubes at the time of hysterectomy for non-cancer indications, has emerged over the past 2 decades as a promising procedure for reducing the risk of ovarian cancer. While definitive evidence of the benefit of OS in ovarian cancer prevention remains to be had, the current supporting literature is compelling and this practice is being evaluated for other types of surgery. (Also see, “Ovarian cancer risk and OS: Current evidence.")

In 2018, a survey of female pelvic medicine and reconstructive surgeons found that 82% of respondents discuss and/or perform OS at the time of pelvic organ prolapse repair (Int Urogynecol J April 14, 2018 [Epub ahead of print]). However, the sample size was small and did not include urologic surgeons. Given that over 200,000 prolapse procedures are performed annually, many of which are performed by urologists, there is an opportunity for including salpingectomy at the time of these procedures.

This article discusses surgical approaches to OS for urologists, risks of surgery, and cost.

Procedure steps

The current recommendation for OS is that the entire tube be removed. However, in cases when this is not feasible, such as adhesive disease or vaginal repair, removing the distal one-third of the fallopian tube, which includes the fimbria, is thought to be sufficient.

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Laparoscopic approach. Salpingectomy may be performed before or after pelvic reconstruction. The laparoscopic approach is as follows:

The fimbriated end of the fallopian tube (figure 1) is grasped with an atraumatic grasper such as an Allys clamp. The fallopian tube is then separated from the mesosalpinx (figure 1) using a vessel-sealing device such as a LigaSure. Care should be taken to perform the mesosalpingeal dissection close to the fallopian tube to avoid injuring the infidibulopelvic ligament, which contains the ovarian artery and disrupting ovarian anastomotic vessels within the broad ligament (figure 1, yellow arrow).

The vessel-sealing device is then used to dissect the fallopian tube off the mesosalpinx, moving proximally toward the uterine cornua (figure 2). It is then transected, after cauterization, approximately 1 cm to 2 cm from the cornua (figure 3). The tubal segment can be removed through a 5-mm or larger diameter port in most circumstances. The same procedure may be performed starting at the corunal end of the fallopian tube, 1 cm to 2 cm from the cornua itself, and dissecting the tube off of the mesosalpinx distally toward the fimbria.

Next:Laparotomy, vaginal approachLaparotomy. The procedure may also be performed via laparotomy in a similar fashion, but dissection of the tube from the mesosalpinx can be accomplished using monopolar cautery and the tube is ligated with a 0 or 2-0 vicryl suture near the cornua. Both the abdominal and laparoscopic approaches may be performed in a similar fashion during non-gynecologic surgeries.

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Vaginal approach. The vaginal approach for salpingectomy may be more challenging and can usually be performed after vaginal hysterectomy. A right-angle retractor is used to retract the ipsilateral side-wall, and a sponge stick is used to retract the bowel away from the fallopian tube. The fimbria is grasped with a Babcock clamp and cross clamped with either a Haney or Kelly clamp. It is not usually feasible to remove the full length of the tube via the vaginal approach, and studies have shown removal of the distal third of the fallopian tube is sufficient for OS.

The gynecologic and urogynecologic literature has shown that vaginal salpingectomy does not appreciably increase operative times or bleeding if an experienced surgeon is performing the procedure. At this time, there is not sufficient evidence to justify altering the surgical approach to hysterectomy or pelvic reconstructive procedures solely for the purpose of completing the salpingectomy.

Risks of opportunistic salpingectomy

While OS has been rapidly adopted by the gynecologic community over a relatively short time period due to the promise of preventing a cancer that is difficult to diagnose and treat, at this time there is no evidence that OS has led or will lead to a reduction in the incidence of ovarian cancer, and this data is likely still at least a decade away. Furthermore, some surgeons have concerns about long-term consequences of salpingectomy with ovarian conservation.

Figure 4 shows the blood supply of the uterus, ovaries, and fallopian tubes. It is clear from the schematic that there is significant potential for the disruption of ovarian blood supply with salpingectomy. There has been concern that salpingectomy in premenopausal women could lead to earlier onset of menopause and resulting consequences of vasomotor symptoms, increased cardiovascular disease risk, and osteoporosis. However, studies evaluating anti-Müllerian hormone levels (a proxy of ovarian function), postoperative ovarian blood flow, and onset of menopausal symptoms have not shown a difference in women who did and did not have salpingectomy.

Increasing health care costs have also been cited as a possible result of salpingectomy, particularly in the absence of tangible risk reduction. Presently, studies have shown that at the time of hysterectomy, salpingectomy does not increase the cost of the procedure, but salpingectomy for sterilization has been shown to be less cost-effective than tubal ligation. Studies evaluating cost of salpingectomy at the time of pelvic floor reconstruction and non-gynecologic procedures are lacking.

Conclusion

Opportunistic salpingectomy has rapidly emerged as a promising procedure for the reduction of ovarian cancer. While definitive evidence of risk reduction is currently lacking, large-scale studies of tubal sterilization patients and salpingectomy for non-risk-reducing indications have strongly indicated the removal of the fallopian tube will lead to a reduction in the incidence of ovarian cancer.

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While more study must be done before there is universal adoption of this procedure, there is evidence to suggest that incorporation of salpingectomy into female pelvic reconstructive surgery is safe and will not lead to an appreciable increase in health care costs.

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There are 20,000 new cases of epithelial ovarian cancer diagnosed annually in the United States. While ovarian cancer accounts for fewer than 3% of cancers in women, it is the fifth most common cause of death in women from any cancer and the most common cause of death from gynecologic cancer. Survival, which is between 19% and 48% at 5 years depending on stage at diagnosis, has not changed appreciably in the past 3 decades.

One major reason for this is that ovarian cancer is most often diagnosed in advanced stages because it is often asymptomatic in early stages and effective screening strategies are lacking. Epithelial ovarian cancer has multiple subtypes, with the serous subtype being the most common (70% of all cases). Over the past 2 decades, histologic evidence has suggested that serous epithelial ovarian cancer arises from precursor lesions within the fallopian tubes, termed serous tubal intraepithelial carcinomas (STIC), rather than from the ovary itself. The exact percentage of epithelial ovarian cancers arising from STIC lesions is not entirely clear but is currently estimated at 50%.

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Over this same time period, multiple population-based studies demonstrated that female sterilization procedures-which include removal of a mid-tubal segment and occlusion with various devices including silicone rings and titanium clips or total removal of the fallopian tube-are associated with significant reductions in epithelial ovarian cancer incidence. Based on these findings, in 2010 the British Columbia Ovarian Cancer Research team developed and distributed an educational video to promote the practice of removing fallopian tubes at the time of hysterectomy for non-cancer indications, a practice termed opportunistic salpingectomy (OS). Since that time, this practice has gained widespread acceptance among gynecologic surgeons who perform hysterectomies and, in some cases, sterilization procedures.

OS refers to the removal of fallopian tubes in women who have a general population lifetime risk of developing ovarian cancer, which is around 1.5%. The American College of Obstetricians and Gynecologists (ACOG) currently does not make specific recommendations regarding OS, stating only that the risks and benefits should be discussed with patients and that surgical planning should not change based on whether or not a salpingectomy will be performed. However, a 2017 ACOG survey showed that 75% of gynecologists perform OS at the time of hysterectomy.

David Sheyn, MD

Adonis Hijaz, MD

Dr. Sheyn is a female pelvic medicine and reconstructive surgery fellow at Case Western Reserve University, and Dr. Hijaz is associate professor of urology, vice chairman of academics and research, and director of the University Hospitals Female Pelvic Medicine and Surgery Center at Urology Institute of University Hospitals Cleveland Medical Center, Cleveland.

Section Editor Christopher M. Gonzalez, MD, MBA, is professor and chair of the department of urology at Loyola University Chicago Stritch School of Medicine, Maywood, IL.