Jul 2, 2013

Salpingectomy With Hysterectomy May Reduce Cancer Risk

Bilateral salpingectomy at the time of ovarian-preserving hysterectomy results in no increased morbidity and is becoming more accepted by patients and surgeons as a risk-reducing strategy for both serous carcinoma and adnexal masses, new research suggests.

“Emerging data that point to the fallopian tube as the site of origin for serous pelvic tumors led us and others to hypothesize that salpingectomy at the time of hysterectomy could have a real impact on the roughly 600,000 hysterectomies performed each year,” investigator Christine Holschneider, MD, from the University of California at Los Angeles (UCLA), told Medscape Medical News.

The ongoing British Columbia Ovarian Cancer Prevention Project estimates a 50% reduction in ovarian cancer in 20 years because salpingectomy is being performed at the time of hysterectomy or tubal sterilization, she said.

“However, some of that benefit will hopefully be seen much sooner,” Dr. Holschneider noted. “The potential for the prevention of posthysterectomy adnexal masses is a much more immediate benefit. The tubal remnant, if not removed, can lead to hydrosalpinx, which requires additional surgery in up to 8% of patients. If these could be prevented with salpingectomy at the time of hysterectomy, a lot of pain, anxiety, and expenditure of healthcare dollars could be spared with minimal additional upfront effort.”

The study involved 620 hysterectomies with ovarian preservation performed at Olive View-UCLA Medical Center, explained Susan Park, MD, who presented the findings here at the American Congress of Obstetricians and Gynecologists 61st Annual Clinical Meeting.

Oncologic or peripartum hysterectomies were excluded from the analysis. The majority of procedures did not involve salpingectomy, but 133 did.

Investigators used a retrospective cohort design to evaluate patient and provider acceptance of bilateral salpingectomy and a case–control study to evaluate outcomes.

The case–control analysis matched salpingectomy patients 2:1 with control subjects, and divided them by type of surgery: abdominal hysterectomy, laparoscopic hysterectomy, and vaginal hysterectomy.

There were no differences between case and control subjects for age, ethnicity, body mass index, or uterine size, and no significant difference in surgical morbidity, including operating room time, estimated blood loss, postoperative complications, length of hospital stay, readmission, or infection.

Table. Outcomes After Hysterectomy With or Without Salpingectomy

Outcome Abdominal With (n = 101) Abdominal Without (n = 202) Laparoscopic With (n = 17) Laparoscopic Without (n = 34) Vaginal With (n = 15) Vaginal Without (n = 30)
Operation room time, min 183 185 210 216 161 152
Estimated blood loss, cc 350 300 200 100 200 250
Length of stay, days 3 3 2 1 1 2
Readmission, n 3 10 0 0 0 2
Infection, n 5 11 0 1 0 1

In terms of procedure acceptance, 100% of patients who underwent abdominal or laparoscopic hysterectomy accepted salpingectomy when offered; fewer patients who underwent vaginal hysterectomy (94%) were willing to undergo salpingectomy. Those who declined did so unless gross cancer was visualized, said Dr. Park.

A practice change at UCLA in 2011 encouraging — but not requiring — providers to offer all patients bilateral salpingectomy at the time of ovarian-preserving hysterectomy has seen the rate of this procedure rise from roughly 3% in 2009 and 2010, to 26% in 2011, to 73% in 2012, she said.

Last year, 91%, 81%, and 43% of patients who underwent abdominal, laparoscopic, or vaginal hysterectomy, respectively, underwent this procedure, she reported.

Reasons for lower rates among vaginal hysterectomy patients include difficulty visualizing the tubes, which is common, and abnormal anatomy or adhesive disease, said Dr. Holschneider.

“It is well recognized that removal of the adnexa is more difficult during vaginal hysterectomy simply because they lie deep in the pelvis,” she said. “From the transvaginal surgical perspective at the end of a long, narrow tube, they may simply be hard to reach.”

We are pleased that our American colleagues apparently share our view on the issue.

However, this should not discourage surgeons from choosing the vaginal route, Dr. Holschneider continued. “Based on current data and the fact that vaginal hysterectomy is the route of hysterectomy with the lowest associated morbidity, a patient’s route of hysterectomy should be determined by the indication for her surgery,” she explained. “The proposal of salpingectomy at the time of hysterectomy is incidental — with no need for expansion or change of the surgical route and technique.”

Dr. Holschneider went on to explain that there is currently wide variation in routine practice across centers when it comes to offering salpingectomy at time of ovarian-preserving hysterectomy. She said that at this year’s annual meeting of the Society of Gynecologic Oncology, in an ad hoc poll during a plenary session, “roughly half the audience indicated that they offer the procedure routinely.”

Asked by Medscape Medical News to comment on the study, Johannes Dietl, MD, from the University of Würzburg in Germany, said that “these results are fully compatible with our own, still unpublished, data. We are pleased that our American colleagues apparently share our view on the issue.”

Since 2011, Dr. Dietl and his team “have routinely removed the ampullary part and the fimbriated end of the fallopian tubes concomitant with hysterectomy. Likewise, patients requesting sterilization increasingly want to have their fallopian tubes removed, especially when the intervention can be performed during cesarean section,” he said.

“As a consequence, none of these patients showed early complications, like hydrosalpinx or tubal prolapse into the vagina,” Dr. Dietl pointed out. “Still, a more extended follow-up will be required to assess whether prophylactic salpingectomy really has the desired effect on the prevention of serous ovarian cancer. Given the high mortality associated with this disease, we nevertheless consider this potentially preventive and well-tolerated intervention to be already justified, especially because there are no effective alternatives.”

Dr. Park, Dr. Holschneider, and Dr. Dietl have disclosed no relevant financial relationships.

The American Congress of Obstetricians and Gynecologists (ACOG) 61st Annual Clinical Meeting: Abstract SY10. Presented May 8, 2013.

— Kate Johnson

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