Salpingectomy and salpingo-oophorectomy

ALSO KNOWN AS: Unilateral or bilateral salpingo-oophorectomy

DEFINITION: Salpingectomy is the surgical excision of one or both Fallopian tubes, which may be performed to diagnose suspicious tubo-ovarian masses that are, or may become, cancerous. Salpingo-oophorectomy includes surgical excision of one or both ovaries for the same reason.

Cancers diagnosed or treated: Invasive cervical, uterine, and ovarian cancers; hydatidiform mole; rarely, Fallopian tube cancer

Why performed: Salpingectomy is performed to remove and examine tubal or tubo-ovarian masses suspicious for cancer and to determine the extent of malignant disease spread. These masses may be fluid-filled (cystic), solid, or mixed, and they can be hormone-secreting or hormone-receptive. A salpingo-oophorectomy is often performed alongside a hysterectomy in women who are postmenopausal and are suspected of having an endometrial, tubal, or ovarian mass at risk for encroaching on other pelvic organs. It is also performed in women of childbearing age who have a suspected malignancy and have completed their families. Women with localized, unilateral disease who still wish to bear children may have only the diseased Fallopian tube and ovary removed. However, this is not recommended in light of the more common occurrence of disease in both tubes and ovaries. Salpingo-oophorectomy may also be done to remove masses of an infectious origin (for example, tubo-ovarian abscess caused by pelvic inflammatory disease) or endometriosis that has irreversibly damaged these organs. A bilateral salpingo-oophorectomy may be performed prophylactically when patients are at high risk for developing cancers associated with BRCA1 and BRCA2 genes, particularly ovarian and breast cancers.

Patient preparation: The patient undergoes preoperative evaluation for any contraindications to the procedure (such as a pregnancy test) and evaluation of coexisting diseases to determine her fitness to undergo surgery and general anesthesia. Patients are instructed to take nothing per mouth the night before the procedure.

Steps of the procedure: After the patient is anesthetized, placed in the lithotomy position, and the vagina, external genitalia, pubic area, and inner thighs have been surgically prepped and draped, a transverse or vertical incision is made above the pubic bone. An incision extended up to the level of the umbilicus is preferred, as it provides a wider surgical field and a wider incision through which a large mass can be removed. The incision is taken down to the pelvic cavity. The uterine and ovarian vessels are identified, dissected, and separated from the ureters. The supporting broad, round, and suspensory ovarian ligaments of the Fallopian tubes and ovaries with their vessels are dissected, isolated, cut, and ligated. In a simultaneous hysterectomy, the uterus and uterine vessels are also dissected away from other pelvic structures, cut, and ligated. When disease extending outside the reproductive tract is suspected, biopsies of suspicious lesions, sampling of lymph nodes around the pelvis and abdominal aorta, and abdominal cavity washings are done.

Laparoscopic surgery to remove the Fallopian tubes and ovaries is done in conjunction with a hysterectomy. It is done through two small abdominal incisions through which sleeved trochars accommodate a scope, and several instruments for probing, grasping, cutting, and cauterizing are inserted. The uterus, Fallopian tubes, ovaries, vessels, and ligaments are dissected, cut, and ligated. The organs are removed vaginally, and the remaining vaginal cuff is closed off.

In clinical studies, medical researchers continue to explore what options for salpingectomy and salpingo-oophorectomy are best suited to what patients. The trend has moved from risk-reducing salpingo-oophorectomy to risk-reducing salpingectomy with delayed oophorectomy in the twenty-first century. This method has been beneficial for patients who are at high risk for cancers due to genetic conditions, but they wish to preserve ovarian function and increase their quality of life following surgery. Opportunistic salpingectomy has also increased in commonality, especially when patients are undergoing another abdominal surgery. Further, medical researchers have continued to research the extent to which ovarian cancer originates in the fallopian tubes, increasing the importance of advances in salpingectomy and salpingo-oophorectomy. In the mid-2020s, comparing their results, several long-term studies followed patients with risk-reducing salpingectomy with delayed oophorectomy and standard salpingo-oophorectomy in high-risk women. 

After the procedure: The patient is monitored in the postanesthesia care unit until she is fully awake, and her vital signs are stable. Once the patient is stable in the unit, she may be discharged to the gynecologic ward for postoperative monitoring. Once the patient is stable, ambulatory, urinating, and eating, she may be discharged home after a few days.

Risks: The most significant risk of a salpingectomy is an ectopic pregnancy. Other risks include deep vein thrombosis, pulmonary embolism, perforation of the bladder or bowel, and intractable bleeding.

Results: Cross-sectional examination of grossly normal and diseased Fallopian tubes should be done, documenting size, depth of penetration, and location along the length of the specimen, although primary tubal cancers account for only about 1 percent of all female reproductive tract cancers. When a mass encompassing both the Fallopian tube and ovary is encountered intraoperatively, it is presumed to be of ovarian origin until proven otherwise during pathological examination, where tubal tissue is recognized within the mass. A gross and microscopic examination of tubal or ovarian masses may reveal whether they are cancerous by evaluating individual cells and the tissue architecture for signs of cancerous changes. On gross examination, masses that preserve the outer tissue surrounding the ovaries can suggest no malignancy but cannot eliminate the possibility of early invasive cancer. Central necrosis and hemorrhage may be present in large tumors as they outgrow their blood supply. However, they do not necessarily imply malignancy, as they can occur in both benign and malignant masses. Microscopic changes pointing to a nonmalignant tumor origin include increased but orderly growth of ovarian cells but no elements of abnormal growth of abnormal cells and distortion of the tissue architecture. Microscopic examinations that reveal disordered growth and abnormal cells of tubal or ovarian origin are suggestive of Fallopian tube cancer or ovarian cancer. An invasive hydatidiform mole that has spread from the uterus can exhibit characteristic cells and tissues of placental and fetal origin. Lymph node samples and washings from the abdominal cavity possessing cancerous cells strongly suggest microscopic spread outside the reproductive tract.

Bibliography

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Society of Gynecologic Oncology. "SGO Clinical Practice Statement: Salpingectomy for Ovarian Cancer Prevention." Society of Gynecologic Oncology, Nov. 2013, www.sgo.org/resources/sgo-clinical-practice-statement-salpingectomy-for-ovarian-cancer-prevention. Accessed 5 July 2024.

“Salpingectomy.” Johns Hopkins Medicine, www.hopkinsmedicine.org/health/treatment-tests-and-therapies/salpingectomy. Accessed 5 July 2024.

Steenbeek, M. P., Harmsen, M. G., Hoogerbrugge, N., et al. "Association of Salpingectomy With Delayed Oophorectomy Versus Salpingo-oophorectomy With Quality of Life in BRCA1/2 Pathogenic Variant Carriers: A Nonrandomized Controlled Trial." JAMA Oncology, vol. 7, no. 8, 2021, pp. 1203–1212, doi:10.1001/jamaoncol.2021.1590.

Steenbeek, Miranda P., et al. "TUBectomy with Delayed Oophorectomy As an Alternative to Risk-reducing Salpingo-oophorectomy in High-risk Women to Assess the Safety of Prevention: The TUBA-WISP II Study Protocol." International Journal of Gynecological Cancer, vol. 33, no. 6, 2023, pp. 982-987, doi.org/10.1136/ijgc-2023-004377. Accessed 5 July 2024.

Tellawi, Rauda A., and Vadim V. Morozov. "Prophylactic Salpingectomy: The Future of Ovarian Cancer Prevention?" Contemporary OB/GYN, 1 Mar. 2014, www.contemporaryobgyn.net/view/prophylactic-salpingectomy-future-ovarian-cancer-prevention. Accessed 5 July 2024.