Oophorectomy for Benign and Malignant Conditions

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Chapter 52

Oophorectomy for Benign and Malignant Conditions

Introduction

The ovary is a complex organ from both a histologic and a functional standpoint. As a result, numerous tumors, both benign and malignant, can arise in the adnexa. The surgical approach is often determined by the pathology as well as the desire to preserve gonadal function and fertility.

Although the vast majority of tumors arising in the ovary will be benign, especially in younger women, proper surgical management of ovarian or tubal malignancy is much more complex. Epithelial ovarian and tubal malignancies tend to metastasize early and spread along peritoneal surfaces throughout the abdomen. These surgeries are designed to render the patient with minimal residual disease and often require pelvic peritonectomy with en bloc rectosigmoid resection to clear the pelvis. Proper surgery often includes equally radical upper abdominal resection. Multiple studies have shown that complete cytoreduction of metastatic disease impacts both overall survival rates and progression-free survival rates in women with epithelial ovarian malignancy. Overall survival rates of 66 to 120 months is achievable even in women with advanced disease.

Preoperative Imaging

Preoperative imaging of an adnexal mass helps not only to characterize the tumor, but also to assess for ascites, hydronephrosis, lymphadenopathy, and omental implants that may impact the preoperative counseling and surgical approach. Ultrasonography is the most frequently used modality to assess a pelvic mass. It is readily accessible, noninvasive, and provides excellent characteristics of the lesion itself. The ultrasonographer should comment on lesion size, cystic/solid components, complexity, and Doppler flow along with evidence of hydronephrosis and ascites. Magnetic resonance imaging (MRI) can provide significantly more information about an ovarian tumor, but in reality MRI is rarely helpful in triaging an adnexal mass. Most lesions believed to be complex should be removed in all age groups. Computed tomography (CT) scans are essential to evaluate the retroperitoneum and upper abdomen in women with an ovarian mass that may be malignant.

Surgical Approach

The most prudent approach to a patient with an adnexal mass is made on the basis of the patient’s age, desire for future fertility/hormonal preservation, and imaging characteristics. Almost all pelvic masses in children, premenopausal girls, and postmenopausal women should be evaluated. Triage is made on the basis of imaging characteristics, symptoms, and concern for malignancy. Low-risk lesions, especially in premenopausal girls, can often be followed for spontaneous resolution, especially if these are primarily cystic in nature. Solid masses or complex masses in any age group are more likely to be malignant and usually require surgical evaluation. Tumor markers (e.g., CA125) should be obtained preoperatively, although these may be informative in only 90% of cases. The surgical approach, whether laparoscopic, robotic, or conventional laparotomy, depends on the nature of the lesion and the likelihood of identifying a malignancy.

Anatomy and Dissection of the Adnexa

The adnexa refers to both the ovary and fallopian tube. An intimate understanding of the vascular supply to the adnexa and the relationship to the underlying ureter and uterus is required before commencing surgery (Fig. 52-1). The general principles are similar regardless of surgical approach (open, laparoscopic, or robotic).

Gonadal Vessels and Infundibulopelvic Ligament

The best approach to removing a pelvic mass is first to open the retroperitoneum and identify the gonadal vessels and ureter. The gonadal blood supply, or infundibulopelvic ligament (IP), originates from the aorta and runs parallel to the ureter, crossing into the pelvis over the bifurcation of the common iliac vessels (Fig. 52-2, A).

These vessels run through the adnexa, providing blood supply to the ovary and fallopian tube, then anastomose to the uterus and become the utero-ovarian vessels. The peritoneum is incised lateral to the IP along the psoas muscle and external iliac artery and can be extended to the white line of Toldt. Gentle dissection with a large Kelly clamp along the sacrum will develop this space, with the gonadal vessels superiorly, the ureter on the medial leaf of the peritoneum, and the iliac vessels laterally.

The IP can then be isolated, clamped, and cut, with the ureter under direct visualization. The adnexa can be elevated out of the pelvis and its peritoneal attachments mobilized until reaching its attachment to the uterus, the utero-ovarian pedicle (Fig. 52-2, B).

Large Masses and Modified Approaches

Unfortunately, some ovarian tumors can routinely grow to be greater than 20 or 30 cm before they are identified. In these cases, it may not be possible to isolate the blood supply and identify the ureter before removing the mass itself (Fig. 52-3, A).

It is preferable to remove an ovarian mass intact, without rupture, to avoid seeding the peritoneum should malignancy exist. In cases of malignancy, the surgical approach should be modified in one of two ways. If the utero-ovarian pedicle can be identified, the safest approach is to sacrifice this pedicle first and proceed with the operation described earlier, but in reverse. This approach allows for the mobilization of the adnexa cephalad by incising the peritoneum along the pelvic side wall, thus allowing for the ureter to drop away from the gonadal blood supply. Once the dissection is carried to the pelvic brim, the IP generally is easily isolated and secured.

In some cases, neither the IP nor the utero-ovarian pedicle can be identified, and the mass itself can often be delivered through the incision and the adnexa itself clamped. In the author’s experience, there is little chance of inadvertently injuring the ureter because it runs deep to the IP pedicle (Fig. 52-3, B).

Nonetheless, it is prudent to develop the retroperitoneum once the mass has been removed, and identify the ureter to ensure it has been uninjured.

Radical Oophorectomy

In rare cases in which the previous techniques fail, or more often in the setting of an advanced pelvic malignancy, a more radical surgical approach becomes necessary. This is often the case when there is extensive pelvic pathology, such as stage IV endometriosis or advanced ovarian malignancy. Not only are the normal anatomic landmarks obscured, but the pelvic peritoneum is extensively involved in the disease process.

The resection of the adnexa in these patients starts in the upper abdomen at or near the origin of the gonadal blood supply. Generally, the white line of Toldt is developed bilaterally and the abdominal ureter and gonadal blood supply identified. It may be helpful to isolate the ureters at this point on vessel loops to keep them under continuous surveillance. Gentle tension facilitates the dissection. The gonadal vessels can be sacrificed at their origin or anywhere along their abdominal path. In the setting of an ovarian malignancy, the peritoneum overlying the gutters is incorporated along with this pedicle and taken en bloc into the pelvis, incorporating any extrapelvic disease (Fig. 52-4, A).

The dissection is then carried into the pelvis proper. Staying in the retroperitoneum, any involved peritoneal surfaces are included circumferentially to encompass the tumor. Anteriorly, the lateral pelvic side wall peritoneum is mobilized off the external iliac vessels and psoas muscle with gentle traction and monopolar cautery. The round ligaments are sacrificed at this point, and the bladder peritoneum can be resected when necessary, often without need for partial cystectomy.

This peritoneum is contiguous with the peritoneum overlying the uterus. Advanced ovarian malignancy disease almost always involves the posterior pelvic peritoneum and sigmoid mesentery, requiring rectosigmoid resection to eradicate the disease completely. Once the sigmoid is transected, the retroperitoneal dissection is carried laterally to encompass the anterior dissection and posteriorly along the sacrum. Similar to a colorectal malignancy, the dissection continues behind the rectum in the plane between the peritoneum and mesorectum (Fig. 52-4, B).

Unlike a situation involving colorectal cancer, the objective here is not to obtain gross margins, but to debulk gross tumor to microscopic, residual disease. In the vast majority of cases, the tumor respects the peritoneum, and the dissection down to the level of the levator muscles is unnecessary. Once beyond the rectal reflection, the rectum can be skeletonized.

At this point, the adnexal structures are completely incorporated in the surgical specimen. The procedure is completed by isolating the uterine arteries, either at their origins or just medial to where they cross the ureters. Dissection is carried down along the cervix until the cervicovaginal refection is identified. A colpotomy is performed and the rectovaginal septum developed. The rectum can then be transected with a stapling device and the specimen removed (Fig. 52-4, C).

Suggested Readings

Alcázar, JL, Royo, P, Jurado, M, et al. Triage for surgical management of ovarian tumors in asymptomatic women: assessment of an ultrasound-based scoring system. Ultrasound Obstet Gynecol. 2008;32(2):220–225.

Chang, SJ, Bristow, RE. Evolution of surgical treatment paradigms for advanced-stage ovarian cancer: redefining “optimal” residual disease. Gynecol Oncol. 2012;125(2):483–492.

Esselen, KM, Rodriguez, N, Growdon, W, et al. Patterns of recurrence in advanced epithelial ovarian, fallopian tube and peritoneal cancers treated with intraperitoneal chemotherapy. Gynecol Oncol. 2012;127(1):51–54.

Giuntoli, RL, 2nd., Vang, RS, Bristow, RE. Evaluation and management of adnexal masses during pregnancy. Clin Obstet Gynecol. 2006;49(3):492–505.

Moore, RG, Miller, MC, Disilvestro, P, et al. Evaluation of the diagnostic accuracy of the risk of ovarian malignancy algorithm in women with a pelvic mass. Obstet Gynecol. 2011;118(2 Pt 1):280–288.

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