‘Opportunistic’ Salpingectomy at the Time of Hysterectomy: Risks vs Benefits
BACKGROUND AND PURPOSE:
To prevent ovarian cancer, ACOG guidance recommends a discussion with patients who are undergoing hysterectomy with ovarian conservation to consider opportunistic salpingectomy
Salpingectomy during laparoscopic and open hysterectomy adds minimal time with no additional complications
Salpingectomy during vaginal hysterectomy requires additional skills and may be associated with a modest increase in complications
Cadish et al. (AJOG, 2017), using decision analysis and cost-effectiveness models, sought to compare risk/benefit between women undergoing vaginal hysterectomy alone vs vaginal hysterectomy with planned salpingectomy
Researchers created a decision analysis model
Effectiveness outcomes were ovarian cancer incidence and mortality as well as major surgical complications
Modeled complications included transfusion, conversion to laparotomy or laparoscopy, abscess/hematoma requiring intervention, ileus, readmission, and reoperation within 30 days
Costs were gathered from published literature and Medicare reimbursement data
Complication rates were determined from published literature and National Surgical Quality Improvement Program database
More major complications were associated when salpingectomy was added to vaginal hysterectomy (7.95% vs 7.68%)
Complications included transfusion, conversion to laparotomy or laparoscopy, abscess/hematoma requiring intervention, ileus, readmission, and reoperation within 30 days
However, including salpingectomy during vaginal hysterectomy was the dominant cost-effective strategy because
It is a less expensive strategy than not performing salpingectomy ($7350.62 vs $8113.45)
Switching from a policy of vaginal hysterectomy alone to a policy of routine planned salpingectomy prevents a diagnosis of ovarian cancer in 1 of every 225 women undergoing surgery
1 ovarian cancer death would be prevented among every 450 women having surgery
Sensitivity analysis demonstrated the driving force behind increased costs was the operating room costs for increased risk of future benign adnexal surgeries
The finding of planned salpingectomy as the dominant strategy persisted even without taking in to account the cost of potential cancer treatments
Salpingectomy during vaginal hysterectomy was cost-effective and a superior strategy than hysterectomy alone
Efforts should be made to strengthen vaginal hysterectomy training and techniques related to salpingectomy
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