Opportunistic Salpingectomy: A Surgical Approach to Reducing Ovarian Cancer Risk

SUMMARY:

ACOG recommends opportunistic bilateral salpingectomy as a strategy to reduce the risk of epithelial ovarian cancer in appropriate patients undergoing hysterectomy, permanent contraception, and other selected abdominal or pelvic surgeries. The recommendations apply to women at average ‘population’ risk for ovarian cancer and not those at high risk (for example BRCA mutation carriers). Risks and benefits should be discussed with women considering opportunistic salpingectomy. The following are key highlights from ACOG.

Science Behind the Guidance

• Many epithelial ovarian cancers do not appear to originate from ovary but rather
  • Fallopian tube epithelium (high-grade serous) or
  • Endometrial tissue reaching the ovary through the fallopian tubes (endometrioid and clear cell)
• Bilateral salpingectomy performed during hysterectomy, permanent contraception procedures, cesarean delivery, and other qualifying abdominal surgeries is expected to reduce future ovarian cancer risk.
• Meta-analyses: 49 to 52% risk reduction
• Note: Even if the above is correct, some ovarian cancers will arise from the ovary, not the tube | Opportunistic salpingectomy should not be considered 100% preventative

Risks Associated with Opportunistic Salpingectomy

• The following complications have not been demonstrated in women undergoing opportunistic salpingectomy
  • Infection | transfusion | readmission | postop complications
  • Ovarian function
    • Does not appear to be impaired in short-term
    • Long-term remains under investigation (e.g., timing of menopause)
• Increased surgical time by 6 to 16 minutes depending on procedure
  • Increased surgical time does not appear to be clinically significant
  • Not associated with increased complications

Note: ACOG states that “salpingectomy at the time of hysterectomy or as a means of tubal sterilization appears to be safe”

Benefits Compared to Bilateral Salpingo-Oophorectomy (BSO)

• Literature supports the option of opportunistic salpingectomy for ovarian cancer risk reduction in the setting of benign surgery
• BSO and resultant surgical menopause elevates risk for the following
  • Cardiovascular disease
  • Osteoporosis
  • Cognitive impairment
  • All cause-mortality
  • Cancers (lung, colon, bladder and ‘any cancer’ – see BMJ study below in ‘Learn More – Primary Sources’)
• There is “little benefit” to ovarian conservation >65 years of age

KEY POINTS:

• At time of hysterectomy
  • Routinely perform bilateral salpingectomy
• At time of nonhysterectomy gynecologic surgery
  • bilateral salpingectomy recommended for patients if
    • Procedure enters the peritoneal cavity
    • If future fertility is not desired
• Complete bilateral salpingectomy is the preferred tubal procedure for permanent contraception due to ovarian cancer risk reduction
• Support non-gyn surgical specialists in offering salpingectomy during nongynecologic abdominopelvic surgeries (counseling and technical assistance)
• Standalone salpingectomy solely for ovarian cancer risk reduction
  • May be considered in selected average-risk individuals who do not desire future fertility
  • Not recommended as routine approach as current evidence is insufficient

Technique

• Ideally, tube should be removed from fimbriated end to uterotubal junction
  • If not possible, remove as much as safely feasible
• Remove or cauterize fimbrial tissue if adherent to the ovary
• Choice of procedure
  • Consider the likelihood of successfully completing salpingectomy when counseling patients about surgical approach
  • If a planned approach (e.g,, vaginal vs laparoscopic hysterectomy) may reduce the chance of completing salpingectomy, disclose to the patient

Learn More – Primary Sources:

BMJ (2017): Removal of all ovarian tissue versus conserving ovarian tissue at time of hysterectomy in premenopausal patients with benign disease: study using routine data and data linkage

Tips and Tricks for Performing Salpingectomy at the Time of Laparoscopic Hysterectomy

ACOG Committee Opinion 774: Opportunistic Salpingectomy as a Strategy for Epithelial Ovarian Cancer Prevention

ACOG Clinical Practice Update: Salpingectomy for the Prevention of Epithelial Ovarian Cancer