A correction was published in February 2016 for this title. Click here to view the correction.
Based on the current understanding of ovarian carcinogenesis and the safety of salpingectomy, the American College of Obstetricians and Gynecologists supports the following recommendations and conclusions:
- The surgeon and patient should discuss the potential benefits of the removal of the fallopian tubes during a hysterectomy in women at population risk of ovarian cancer who are not having an oophorectomy.
- When counseling women about laparoscopic sterilization methods, clinicians can communicate that bilateral salpingectomy can be considered a method that provides effective contraception.
- Prophylactic salpingectomy may offer clinicians the opportunity to prevent ovarian cancer in their patients.
- Randomized controlled trials are needed to support the validity of this approach to reduce the incidence of ovarian cancer.
Ovarian cancer has the highest mortality rate out of all types of gynecologic cancer and is the fifth leading cause of cancer deaths among women (1). The overall survival rate for women with epithelial ovarian cancer has improved marginally in the past 50 years. The more aggressive epithelial ovarian carcinomas represent 75% of all cases of ovarian cancer and are responsible for 90% of deaths due to ovarian cancer. Current attempts at screening for ovarian cancer have been unsuccessful and are associated with false-positive test results that lead to unnecessary surgery and surgical complications (1–4). Prophylactic salpingectomy may offer clinicians the opportunity to prevent ovarian cancer in their patients.
The most compelling theory of epithelial ovarian carcinogenesis suggests that serous, endometrioid, and clear cell carcinomas are derived from the fallopian tube and the endometrium and not directly from the ovary (5–9). This is in contrast to the traditional view of ovarian carcinogenesis in which ovarian surface epithelium (mesothelium) undergoes metaplastic changes leading to the different histologic types of epithelial ovarian cancer. In women with a genetic predisposition for ovarian cancer, lesions have been found in the fallopian tubes that closely resemble ovarian high-grade serous carcinomas or serous tubal intraepithelial carcinomas. These lesions are thought to be the primary source of ovarian carcinoma that secondarily involves the ovary. Genetics studies show that these tubal lesions express a common TP53 mutation, as do high-grade serous, high-grade endometrioid, and undifferentiated carcinomas. In addition, gene expression of high-grade serous carcinomas is more closely related to the fallopian tube morphology than the ovarian surface epithelium. High-grade serous carcinomas express a müllerian marker (PAX8) but not a mesothelial marker (calretinin). This research significantly affects two groups of women: 1) those at high risk for hereditary ovarian cancer and 2) those at population risk (no genetic predisposition for ovarian cancer) undergoing routine pelvic surgery. This Committee Opinion addresses women at population risk undergoing routine pelvic surgery for benign disease.
Tubal ligation has a protective effect specifically against endometrioid and clear cell carcinomas of the ovary, which supports the theory that these tumors may be due to retrograde menses of endometrial cells (10). By performing salpingectomy when patients undergo an operation during which the fallopian tubes could be removed in addition to the primary surgical procedure (eg, hysterectomy), the risk of ovarian cancer may be further reduced. Randomized controlled trials are needed to support the validity of this approach to reduce the incidence of ovarian cancer.
Salpingectomy at the time of hysterectomy or as a means of tubal sterilization appears to be safe, without an increase in complications, such as the need for blood transfusions and readmissions, compared with hysterectomy alone or tubal ligation (1). Additionally, ovarian function does not appear to be affected by salpingectomy at the time of hysterectomy based on surrogate serum markers or response to in vitro fertilization (11–14).
The surgeon and patient should discuss the potential benefits of the removal of the fallopian tubes during a hysterectomy in women at population risk of ovarian cancer who are not having an oophorectomy. Counseling women who are undergoing routine pelvic surgery about the risks and benefits of salpingectomy should include an informed consent discussion about the role of oophorectomy and bilateral salpingo-oophorectomy (BSO). Bilateral salpingo-oophorectomy that causes surgical menopause reduces the risk of ovarian cancer but may increase the risk of cardiovascular disease, osteoporosis, and cognitive impairment (15). In the Nurses’ Health Study, all-cause mortality and cancer mortality increased in women who received a BSO (16). The risk of ovarian cancer after hysterectomy with ovarian conservation is 0.1–0.75% (17). Death from ovarian cancer after tubo-ovarian conservation in the Nurses’ Health Study was 0.03% (16). The benefits of ovarian conservation decrease with age, and there is little benefit after age 65 years (18). Given current theories of ovarian carcinogenesis, ovarian conservation and salpingectomy may represent a better option than BSO for ovarian cancer risk reduction for most women undergoing other pelvic surgeries for benign disease. When counseling women about laparoscopic sterilization methods, clinicians can communicate that bilateral salpingectomy can be considered a method that provides effective contraception. Although there is no information about the effectiveness of complete salpingectomy as a method of sterilization, possible surrogates may include postpartum partial salpingectomy and interval partial salpingectomy, which were found to have 7.5 and 20.1 cumulative probability of pregnancy per 1,000 procedures, respectively, in the U.S. Collaborative Review of Sterilization study (19). In addition, health care providers should highlight that salpingectomy eliminates tubal reversal as an option for those women who experience regret and seek fertility options later.
Complete salpingectomy is preferred over fimbriectomy (20); however, if complete salpingectomy cannot be performed, then removing as much of the fallopian tubes as possible, excluding the interstitial portion, still may have value (21). Studies of risk-reducing surgery for patients with BRCA mutations demonstrated that 1–5% of those women had early tubal malignancy; in most of these cases of malignancy, an early intraepithelial component was located in the fimbriated end of the fallopian tube (21, 22). Earlier benign lesions (serous tubal intraepithelial lesions and tubal intraepithelial lesions in transition) and a concept of surrogate precursor, called secretory cell outgrowths, have been implicated in the development of tubal dysplasia and tubal carcinomas (20). Serous tubal intraepithelial lesions and tubal intraepithelial lesions in transition are most frequently located in the fimbriated end of the uterine tube, whereas secretory cell outgrowths are distributed throughout the tube.
The pathologic specimen processing in low-risk women should include representative sections of the fallopian tube, any suspicious lesions, and an entire sectioning of the fimbriae (20). Salpingectomy should remove the tube completely from its fimbriated end and up to the uterotubal junction; the interstitial portions of the tubes do not need to be removed. Any fimbrial attachments on the ovary should be cauterized or removed. In addition, salpingectomy should be performed with meticulous attention. Care should be taken not to interrupt blood supply to the ovary through the infundibulopelvic ligament because the collateral vasculature from the tubal mesosalpinx is occluded during the tubal removal. Preservation of the utero-ovarian ligament is recommended.
Initiatives to increase salpingectomy have been shown to be successful (1). Based on one physician survey, most surgeons (54%) perform salpingectomy with hysterectomy, whereas a minority (7.2%) perform salpingectomy for sterilization (23). Other than a significant increase in operative time for salpingectomy with hysterectomy (16 minutes) and with sterilization (10 minutes), no significant differences in operative times or complication rates for salpingectomy have been identified (1).
The approach to hysterectomy or sterilization should not be influenced by the theoretical benefit of salpingectomy. Surgeons should continue to observe and practice minimally invasive techniques. A vaginal hysterectomy should not be changed to a laparoscopic hysterectomy simply to perform a salpingectomy. The choice of sterilization procedure should be based on the risks and benefits of the hysteroscopic and laparoscopic approaches. If a laparoscopic approach is elected, then the risks and benefits of salpingectomy should be discussed. The safety of vaginal hysterectomy and hysteroscopic sterilization has been well established (24, 25).
- McAlpine JN, Hanley GE, Woo MM, Tone AA, Rozenberg N, Swenerton KD, et al. Opportunistic salpingectomy: uptake, risks, and complications of a regional initiative for ovarian cancer prevention. Ovarian Cancer Research Program of British Columbia. Am J Obstet Gynecol 2014;210:471.e1–471.e11. [PubMed] [Full Text] ⇦
- Partridge E, Kreimer AR, Greenlee RT, Williams C, Xu JL, Church TR, et al. Results from four rounds of ovarian cancer screening in a randomized trial. PLCO Project Team. Obstet Gynecol 2009;113:775–82. [PubMed] [Obstetrics & Gynecology] ⇦
- Buys SS, Partridge E, Black A, Johnson CC, Lamerato L, Isaacs C, et al. Effect of screening on ovarian cancer mortality: the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial. PLCO Project Team. JAMA 2011;305:2295–303. [PubMed] [Full Text] ⇦
- The role of the obstetrician-gynecologist in the early detection of epithelial ovarian cancer. Committee Opinion No. 477. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:742–6. [PubMed] [Obstetrics & Gynecology] ⇦
- Kurman RJ, Shih I. The origin and pathogenesis of epithelial ovarian cancer: a proposed unifying theory. Am J Surg Pathol 2010;34:433–43. [PubMed] [Full Text] ⇦
- Erickson BK, Conner MG, Landen CN Jr. The role of the fallopian tube in the origin of ovarian cancer. Am J Obstet Gynecol 2013;209:409–14. [PubMed] [Full Text] ⇦
- Crum CP. Intercepting pelvic cancer in the distal fallopian tube: theories and realities. Mol Oncol 2009;3:165–70. [PubMed] [Full Text] ⇦
- Kindelberger DW, Lee Y, Miron A, Hirsch MS, Feltmate C, Medeiros F, et al. Intraepithelial carcinoma of the fimbria and pelvic serous carcinoma: Evidence for a causal relationship. Am J Surg Pathol 2007;31:161–9. [PubMed] ⇦
- Kamran MW, Vaughan D, Crosby D, Wahab NA, Saadeh FA, Gleeson N. Opportunistic and interventional salpingectomy in women at risk: a strategy for preventing pelvic serous cancer (PSC). Eur J Obstet Gynecol Reprod Biol 2013;170:251–4. [PubMed] [Full Text] ⇦
- Rosenblatt KA, Thomas DB. Reduced risk of ovarian cancer in women with a tubal ligation or hysterectomy. The World Health Organization Collaborative Study of Neoplasia and Steroid Contraceptives. Cancer Epidemiol Biomarkers Prev 1996;5:933–5. [PubMed] [Full Text] ⇦
- Findley AD, Siedhoff MT, Hobbs KA, Steege JF, Carey ET, McCall CA, et al. Short-term effects of salpingectomy during laparoscopic hysterectomy on ovarian reserve: a pilot randomized controlled trial. Fertil Steril 2013;100:1704–8. [PubMed] [Full Text] ⇦
- Sezik M, Ozkaya O, Demir F, Sezik HT, Kaya H. Total salpingectomy during abdominal hysterectomy: effects on ovarian reserve and ovarian stromal blood flow. J Obstet Gynaecol Res 2007;33:863–9. [PubMed] ⇦
- Morelli M, Venturella R, Mocciaro R, Di Cello A, Rania E, Lico D, et al. Prophylactic salpingectomy in premenopausal low-risk women for ovarian cancer: primum non nocere. Gynecol Oncol 2013;129:448–51. [PubMed] [Full Text] ⇦
- Almog B, Wagman I, Bibi G, Raz Y, Azem F, Groutz A, et al. Effects of salpingectomy on ovarian response in controlled ovarian hyperstimulation for in vitro fertilization: a reappraisal. Fertil Steril 2011;95:2474–6. [PubMed] [Full Text] ⇦
- Shuster LT, Gostout BS, Grossardt BR, Rocca WA. Prophylactic oophorectomy in premenopausal women and long-term health. Menopause Int 2008;14:111–6. [PubMed] [Full Text] ⇦
- Parker WH, Broder MS, Chang E, Feskanich D, Farquhar C, Liu Z, et al. Ovarian conservation at the time of hysterectomy and long-term health outcomes in the nurses’ health study. Obstet Gynecol 2009;113:1027–37. [PubMed] [Obstetrics & Gynecology] ⇦
- Parker WH. Bilateral oophorectomy versus ovarian conservation: effects on long-term women’s health. J Minim Invasive Gynecol 2010;17:161–6. [PubMed] [Full Text] ⇦
- Parker WH, Broder MS, Liu Z, Shoupe D, Farquhar C, Berek JS. Ovarian conservation at the time of hysterectomy for benign disease. Obstet Gynecol 2005;106:219–26. [PubMed] [Obstetrics & Gynecology] ⇦
- Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Trussell J. The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol 1996;174:1161–8; discussion 1168–70. [PubMed] ⇦
- Chene G, Rahimi K, Mes-Masson AM, Provencher D. Surgical implications of the potential new tubal pathway for ovarian carcinogenesis. J Minim Invasive Gynecol 2013;20:153–9. [PubMed] [Full Text] ⇦
- Cass I, Holschneider C, Datta N, Barbuto D, Walts AE, Karlan BY. BRCA-mutation-associated fallopian tube carcinoma: a distinct clinical phenotype? Obstet Gynecol 2005;106:1327–34. [PubMed] [Obstetrics & Gynecology] ⇦
- Callahan MJ, Crum CP, Medeiros F, Kindelberger DW, Elvin JA, Garber JE, et al. Primary fallopian tube malignancies in BRCA-positive women undergoing surgery for ovarian cancer risk reduction. J Clin Oncol 2007;25:3985–90. [PubMed] [Full Text] ⇦
- Gill SE, Mills BB. Physician opinions regarding elective bilateral salpingectomy with hysterectomy and for sterilization. J Minim Invasive Gynecol 2013;20:517–21. [PubMed] [Full Text] ⇦
- Choosing the route of hysterectomy for benign disease. ACOG Committee Opinion No. 444. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:1156–8. [PubMed] [Obstetrics & Gynecology] ⇦
- Benefits and risks of sterilization. Practice Bulletin No. 133. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:392–404. [PubMed] [Obstetrics & Gynecology] ⇦