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Opportunistic salpingectomy for ovarian, fallopian tubal, and peritoneal carcinoma risk reduction
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Opportunistic salpingectomy for ovarian, fallopian tubal, and peritoneal carcinoma risk reduction
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Literature review current through: Mar 2017. | This topic last updated: Nov 14, 2016.

INTRODUCTION — Opportunistic salpingectomy is the removal of the fallopian tubes for primary prevention of epithelial carcinoma of the fallopian tube, ovary, or peritoneum in a woman undergoing pelvic surgery for another indication. This is an approach to prevention in women at average risk, rather than high risk, for these cancers. Women at high risk of ovarian cancer are typically advised to undergo risk-reducing salpingo-oophorectomy.

The preventive strategy of opportunistic salpingectomy was introduced in the 2010s. This was based on data regarding the role of fallopian tube in the development of what had previously been presumed to be primary ovarian cancers, as a site of primary carcinogenesis or a conduit for neoplastic cells or carcinogens.

Opportunistic salpingectomy for ovarian, tubal, and peritoneal carcinoma risk reduction in average-risk women is reviewed here. Risk-reducing salpingo-oophorectomy for women at high risk of carcinoma of the ovary, fallopian tube, or peritoneum and the pathogenesis of serous carcinoma of the ovary, tube, and peritoneum are discussed separately. (See "Risk-reducing bilateral salpingo-oophorectomy in women at high risk of epithelial ovarian and fallopian tubal cancer" and "Pathogenesis of ovarian, fallopian tubal, and peritoneal serous carcinomas".)

OVERVIEW AND RATIONALE — Ovarian cancer is a disease with a poor prognosis and limited options in terms of screening, diagnosis, and treatment. Ovarian cancer is the second most common type of gynecologic malignancy and the most common cause of death from gynecologic cancer. It is the fifth most common cause of cancer deaths in women. In the United States and Canada every year, over 25,000 women are newly diagnosed with ovarian cancer, and 16,000 women die from the disease [1]. (See "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Epidemiology and risk factors", section on 'Epidemiology'.)

Ovarian cancer typically presents at an advanced stage and has a poor prognosis (table 1 and table 2). Unfortunately, there are few current approaches to improve clinical outcomes for ovarian cancer. There are no effective screening tests. For women who present with symptoms suggestive of ovarian cancer or with an adnexal mass, evaluation with serum biomarkers and/or pelvic imaging has a low specificity, and many women with a benign adnexal mass undergo unnecessary surgery (in one study, ovarian cancer was found in only 3.5 percent of procedures performed for a suspicious adnexal mass [2]) [3-6]. (See "Screening for ovarian cancer" and "Approach to the patient with an adnexal mass".)

There has been little progress in improving ovarian cancer survival rates. Despite exciting innovations in surgical practice and chemotherapeutic agents, including targeted and antiangiogenic regimens, the overall survival rate for women with ovarian cancer has remained largely unchanged since the mid-1980s [7-9]. Specifically, in British Columbia, since the mid-1980s, minimal improvements of 1, 5, and 4 percent have been observed in the overall one-, three- and five-year survival rates, respectively [10,11].

There has been a shift in the understanding of ovarian cancer in two major ways, the different biologic behavior of the histologic subtypes of epithelial ovarian cancer (EOC) and the role of the fallopian tube in pathogenesis.

There is a greater appreciation that ovarian cancer is not a single entity, and that the varied molecular profile and biologic behavior of different histologic subtypes require differing clinical strategies. This variation in clinical behavior poses challenges to effective screening, early detection, and treatment of ovarian, tubal, and peritoneal carcinoma and may require different approaches based on histology. The most common histologic subtype is high-grade serous (>70 percent of EOCs), which typically presents at stage III or IV (table 1) and has a poor prognosis (table 2). The next most common histologic subtypes are endometrioid and clear cell carcinomas (each at approximately 10 percent). Low-grade serous carcinomas (4 percent) are genomically and biologically distinct from high-grade serous carcinomas and are slow growing with relative insensitivity to platinum-based chemotherapy. Finally, mucinous carcinomas (less than 4 percent of EOCs) typically present at an early stage and have a different pathogenesis than high-grade serous carcinomas [12]. (See "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Histopathology" and 'Role of the fallopian tube' below.)

Traditionally, most EOCs were considered to be primary ovarian neoplasms, and primary tubal or peritoneal cancers were thought to be rare. Research has found that high-grade serous carcinomas arise from the epithelium of the distal fallopian tube and may spread to the ovary. These neoplastic cells may also spread to the peritoneum and present as peritoneal carcinoma with no ovarian lesion. Thus, high-grade serous ovarian, fallopian tube, and peritoneal carcinomas are considered to be in the same biologic spectrum and behave similarly in terms of disease distribution, response to treatment, and outcomes.

Pathology nomenclature has changed in the past several years, evolving from the World Health Organization (WHO) criteria of 2003 to the International Collaboration on Cancer Reporting criteria for "tubo-ovarian high-grade serous cancer" criteria [13-15]. In addition, the 2014 International Federation of Gynecology and Obstetrics (FIGO)/Tumor, Nodes, Metastases (TNM) classification system merged ovarian, fallopian tubal, and peritoneal carcinomas (table 1) [16]. In this topic, these high-grade serous entities will be considered together and referred to as high-grade serous epithelial ovarian, fallopian tubal, or peritoneal carcinoma. (See 'Role of the fallopian tube' below.)

Given the limitations in screening and treatment of ovarian, fallopian tube, and peritoneal carcinoma, primary prevention approaches have been sought. For women at high risk of developing these malignancies (BRCA gene mutation, Lynch syndrome), risk-reducing bilateral salpingo-oophorectomy (rrBSO) is advised after completion of childbearing or, depending on the specific mutation and her family history, by age 40 or 45 [17-21]. However, in average-risk women, routinely performing salpingo-oophorectomy for ovarian cancer prevention would result in the loss of ovarian function and associated adverse health outcomes. (See "Elective oophorectomy or ovarian conservation at the time of hysterectomy", section on 'Risks of elective oophorectomy'.)

Based upon these factors and the potential of a precursor or primary lesion in the fallopian tube for apparent ovarian cancer, prophylactic salpingectomy has been proposed as a strategy for primary prevention.

ROLE OF THE FALLOPIAN TUBE — The understanding of the role of the fallopian tube in the pathogenesis of ovarian cancer has evolved based on data regarding preinvasive and early invasive lesions of the fallopian tube and data regarding tubal ligation and decreased epithelial ovarian cancer (EOC) risk.

Mechanisms — Hypotheses regarding the role of the fallopian tube in ovarian cancer pathogenesis are that the fallopian tube is initial site of carcinogenesis (high-grade serous carcinomas) and that it provides a conduit for cells or carcinogens to reach the ovary from the uterus (clear cell and endometrioid carcinomas) [22].

The fallopian tube appears to be the site of carcinogenesis for high-grade serous carcinomas that were previously classified as primary ovarian carcinomas, based on data from women with BRCA mutations and regarding sporadic carcinomas in the average-risk population. (See 'Fallopian tube and preinvasive lesions' below.)

In addition, disruption or removal of the fallopian tubes as in tubal ligation procedure has consistently been found to be associated with risk reduction in clear cell and endometrioid EOC. In these histotypes, the role of the fallopian tube is likely as a conduit for the passage of endometrium that can then implant on the ovary or in the peritoneal cavity [23-25]. (See 'Tubal ligation and ovarian cancer risk' below and "Endosalpingiosis".)

Some data suggest that the fallopian tube also serves as a conduit for carcinogens or inflammation that may increase the risk of developing ovarian cancer (eg, talc, pelvic inflammatory disease). However, the role of these factors is not well established. (See "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Epidemiology and risk factors", section on 'Talc and asbestos'.)

The pathogenesis of ovarian cancer is discussed in detail separately. (See "Pathogenesis of ovarian, fallopian tubal, and peritoneal serous carcinomas".)

Fallopian tube and preinvasive lesions — Fallopian tube cancer had historically been considered rare; however, early-stage tubal carcinoma or tubal precancers have been discovered in tubal specimens from women with or at high risk of ovarian or peritoneal serous carcinoma and shown in sporadic serous carcinomas in average-risk women as well. Subsequently, pathology nomenclature for ovarian, fallopian tube, and peritoneal serous carcinomas has completely changed.

Women with germline BRCA1 and BRCA2 mutations have an approximately 40 to 60 and 20 to 30 percent lifetime risk, respectively, for developing ovarian cancer (table 3) [26]. Risk-reducing bilateral salpingo-oophorectomy (rrBSO) after completion of childbearing or by age 40 to 45 years is advised for these women and reduces the risk of ovarian, fallopian tube, and peritoneal carcinoma by greater than 80 percent. (See "Risk-reducing bilateral salpingo-oophorectomy in women at high risk of epithelial ovarian and fallopian tubal cancer", section on 'Cancer risk reduction' and "Management of patients at high risk for breast and ovarian cancer", section on 'Bilateral salpingo-oophorectomy'.)

Evaluation of the fallopian tube specimens from rrBSO procedures in women with BRCA1 and BRCA2 mutations has revealed occult tubal carcinomas and preinvasive lesions. Early studies revealed the presence of small tubal carcinomas in approximately 5 to 15 percent of cases [27-33]. By contrast, intensive examination of the ovaries in these women failed to find premalignant or malignant epithelial changes [28,29,34-37]. Preinvasive lesions in the distal fallopian tubes (serous tubal intraepithelial carcinoma [STIC]) have been identified in 1 to 6 percent of high-risk women undergoing rrBSO [35,37-39].

An important component of the studies of rrBSO specimens has been the use of the Sectioning and Extensively Examining the Fimbria (SEE-FIM) protocol, which is a technique for sectioning and examination of the fallopian tube for pathologic evaluation. SEE-FIM was developed to maximize the detection of fallopian tube neoplasia [35,40]. Using this protocol, tubal involvement has been found in up to 75 percent of women diagnosed with ovarian or primary peritoneal high-grade serous carcinoma (with and without BRCA mutations) [41-43], including the presence of fimbrial STICs in 40 to 60 percent [43-47]. Initially, STICs were not observed in women with nongynecologic or benign conditions [46]. However, STICs have been documented in women who are not at high risk for developing ovarian cancer and who underwent surgeries for benign conditions [48,49].

Based upon these findings, it has been proposed that tubal neoplasia is the primary lesion in high-grade serous pelvic carcinomas and that these lesions spread to the ovary and peritoneum [50,51]. These findings may also account for the observed residual risk (up to 11 percent) of peritoneal high-grade serous carcinoma following oophorectomy without removal of the fallopian tubes in BRCA1,2 mutation carriers [52-54].

Preinvasive lesions have also been found in the fallopian tubes of women who are not at high risk for ovarian cancer and have not yet developed cancer, although these are rare [49,55,56]. Tubal specimens from average-risk women are typically from women who undergo sterilization or hysterectomy for benign indications. Many or most of these women are younger than 65 years, which is the average age of diagnosis of ovarian cancer in the general population, thus the low incidence of STICs is not surprising. Notably, STICs are frequently found in both high-risk and average-risk women who have developed high-grade serous carcinoma, suggesting this precursor step is shared across all serous cancers.

The pathogenesis, risk factors, and protective factors for ovarian, tubal, and peritoneal carcinomas are discussed in detail separately. (See "Pathogenesis of ovarian, fallopian tubal, and peritoneal serous carcinomas" and "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Epidemiology and risk factors".)

Tubal ligation and ovarian cancer risk — Tubal ligation is associated with a decrease in ovarian cancer risk [57-61]. Tubal ligation refers to a variety of techniques that destroy, occlude, or excise a portion of the fallopian tube. Techniques include surgical clips or rings, cauterization, or partial salpingectomy. The data on tubal ligation and ovarian cancer do not generally include hysteroscopic methods. Most studies of tubal ligation and ovarian cancer do not report results for specific methods of tubal ligation. (See "Overview of female sterilization".)

Among the largest studies to illustrate the relationship between tubal ligation and ovarian cancer were the Nurses’ Health Study and Nurses’ Health Study II. These two prospective cohort studies included over 230,000 women (29,340 had tubal ligation) and found that tubal ligation overall was associated with a decreased risk of ovarian cancer (hazard ratio [HR] 0.76, 95% CI 0.64-0.90) [62]. A significant effect was found for nonserous carcinomas (HR 0.57, 95% CI 0.40-0.82), but not for serous carcinomas (HR 0.89, 95% CI 0.72-1.10). The effect also only reached significance among women younger than age 35 (HR 0.67, 95% CI 0.49-0.90).

A meta-analysis of 13 population-based studies including over 10,000 patients found a significant decrease in the risk of serous carcinoma in women who underwent tubal ligation (odds ratio [OR] 0.81, 95% CI 0.74-0.89) [63]. There was an even greater decrease in the risk of nonserous histologic subtypes of ovarian cancer, including endometrioid (OR 0.48, 95% CI 0.40-0.59), clear cell (OR 0.52, 95% CI 0.40-0.67), and mucinous (OR 0.68, 95% CI 0.52-0.89) carcinomas.

Other representative studies include:

The Million Woman Study (n = 1,278,783), a prospective study in the United Kingdom, found that women with a tubal ligation had significantly decreased risks of cancer of the ovary (relative risk [RR] 0.80, 95% CI 0.76-0.85), fallopian tube (RR 0.60, 95% CI 0.37-0.96), and peritoneum (RR 0.81, 95% CI 0.66-0.98) [64]. The association of tubal ligation with decreased risk varied by histology, with a significant decrease in risk of high-grade serous carcinomas (RR 0.77, 95% CI 0.67-0.89), endometrioid (RR 0.54, 95% CI 0.43-0.69), and clear cell tumors (RR 0.55, 95% CI 0.39-0.77), but no significant decrease in risk of low-grade serous tumors (RR 1.13, 95% CI 0.89-1.42) or mucinous tumors (RR 0.99, 95% CI 0.84-1.18) [65].

A population-based cohort study (n = 251,465) in Sweden in women who underwent surgery for benign indications that included occlusion or removal of the fallopian tubes (sterilization, salpingectomy, salpingo-oophorectomy) found a significant decrease in ovarian cancer rates in women who underwent hysterectomy (HR 0.79, 95% CI 0.70-0.88), hysterectomy with bilateral salpingo-oophorectomy (HR 0.06, 95% CI 0.03-0.12), or sterilization (HR 0.72, 95% CI 0.64-0.81) compared with women who did not have these procedures [66].

A case-control study based on data from a Danish national database of over 13,000 women with EOC (345 had undergone tubal ligation) found that tubal ligation overall was associated with a statistically significant decrease in the risk of EOC (OR 0.87, 95% CI 0.78-0.98). A subset analysis found that this decrease was statistically significant for endometrioid ovarian carcinoma (OR 0.66, 95% CI 0.47-0.93), but not for serous carcinomas (OR 0.92, 95% CI 0.79-1.08) [67].

A case-control study found that women with a prior tubal ligation (n = 290 cases, 432 controls) had a significant decrease in the odds of EOC (OR 0.82, 95% CI 0.68-0.97) [68].

The Rochester Epidemiology Project performed a population-based, case-control study examining women with serous EOC/peritoneal cancer who had undergone tubal sterilization over a 44-year period (14 cases and 46 controls) [69]. They found a lower risk of EOC/peritoneal cancer following tubal ligation/sterilization (41 percent lower for all types of tubal sterilization and 64 percent lower for excisional tubal sterilization), but these did not reach statistical significance.

The effect in nonserous tumors is likely due to a different protective mechanism than in the BRCA mutation population, who tend to develop high-grade serous carcinomas. As noted above, high-grade carcinomas may originate in the fallopian tubes. Clear cell and endometrioid carcinomas are thought to result from passage of endometriotic or endosalpingiotic cells through the tubes. (See 'Mechanisms' above.)

OPPORTUNISTIC SALPINGECTOMY — Opportunistic salpingectomy has been proposed as a primary prevention strategy for women at average risk of carcinoma of the ovary, fallopian tube, and peritoneum.

Definition — Opportunistic salpingectomy as a strategy was first presented in September 2010 by the British Columbia Ovarian Cancer Research (OVCARE) team, which distributed an educational video to all practicing obstetricians/gynecologists in the province outlining the rationale and technical procedure of opportunistic salpingectomy [70].

Opportunistic salpingectomy is defined as removal of the fallopian tubes in a woman undergoing pelvic surgery for another indication. It is appropriate in women who have completed childbearing or no longer plan to use their own fallopian tubes for fertility purposes. If there are no indications for oophorectomy, the ovaries are conserved. The fallopian tube has not historically been considered an independent structure in surgical decision-making, and its surgical removal or preservation has generally depended upon the surgical plan for the ovary. Common procedures that may potentially include opportunistic salpingectomy include:

Hysterectomy for benign indications

In place of tubal ligation for women who desire sterilization

Opportunistic salpingectomy should not take the place of risk-reducing bilateral salpingo-oophorectomy (rrBSO) in women at high risk. (See "Risk-reducing bilateral salpingo-oophorectomy in women at high risk of epithelial ovarian and fallopian tubal cancer", section on 'Candidates for risk-reducing BSO'.)

The goal of opportunistic salpingectomy is removal of the distal one-third (fimbria and infundibulum, portion of ampulla) of both fallopian tubes (figure 1). Research has shown that the distal fimbriated end harbors the majority of cancers and preinvasive lesions in both the general population and BRCA1 and BRCA2 mutation carriers. Where possible, the entire tube can be removed. This may be accomplished using any surgical route (open, laparoscopic, robotic, or vaginal). (See 'Role of the fallopian tube' above and 'Procedure' below.)

Informed consent — For patients planning hysterectomy or tubal sterilization, counseling may include the option of opportunistic salpingectomy. This should include a comprehensive review of the potential risks and benefits. Importantly, women should be counseled that it will take at least 10 years of data to be able to measure the impact of opportunistic salpingectomy on the incidence of ovarian, fallopian tubal, or peritoneal cancers, as we follow the cohort of women in whom this procedure has been performed as they mature to the age of developing these cancers.

Procedure

Technique at hysterectomy:

Elevate the fallopian tube and dissect along the mesosalpinx immediately below the tube to allow separation from the ovary. Any cautery/dissection tool may be used. Care should be taken not to compromise the ovarian vessels within the infundibulopelvic ligament. The technique at vaginal hysterectomy is described separately. (See "Vaginal hysterectomy", section on 'Adnexal evaluation and surgery'.)

Proceed with hysterectomy as usual with the tubes removed en bloc (attached at the cornua of the uterus).

Technique at sterilization procedure:

Elevate the fallopian tube and dissect along the mesosalpinx immediately below the tube to allow separation from the ovary. Any cautery/dissection tool may be used, taking care not to compromise the ovarian vessels within the infundibulopelvic ligament.

Divide the tubes. If a partial salpingectomy is performed, the incision should be in isthmic portion, 0.5 to 1 cm from the cornua (figure 1). Complete salpingectomy may also be performed.

Remove tubes (route of removal depends upon surgical approach [open, vaginal, laparoscopic]). It is not necessary to place normal-appearing fallopian tube from a patient at average risk of ovarian cancer in a containment bag for removal.

Outcome — Opportunistic salpingectomy is not associated with an increase in short-term morbidity. There are no data regarding long-term impact on ovarian, tubal, and peritoneal cancer rates or on ovarian function, and studies are underway.

Ovarian cancer risk reduction — The data to support opportunistic salpingectomy are based on the impact of salpingectomy performed for indications other than ovarian cancer risk reduction, mainly sterilization.

Available data regarding ovarian cancer risk reduction associated with salpingectomy include [71]:

A Swedish population-based cohort study (n = 251,465) in women who underwent surgery for benign indications found a statistically significant decrease in risk of ovarian cancer with salpingectomy compared with "unexposed" women who had no surgical procedure (hazard ratio [HR] 0.65, 95% CI 0.52-0.81) [66]. Compared with no salpingectomy, both bilateral salpingectomy (HR 0.35, 95% CI 0.17-0.73) and unilateral salpingectomy (HR 0.71, 95% CI 0.56-0.91) were associated with a significant decrease in ovarian cancer, but the degree of risk reduction was greater for bilateral salpingectomy.

A Danish case-control study of over 13,000 women with ovarian cancer included 17 women who underwent bilateral salpingectomy; among those women there was a 42 percent decrease in the risk of epithelial ovarian carcinoma compared with controls [67].

Assessment of the effectiveness of opportunistic salpingectomy for prevention of ovarian cancer will require at least 10 years of follow-up from its introduction in 2010 to discern a measurable difference. It will likely take longer to demonstrate an impact for the cohort of women who underwent salpingectomy for sterilization purposes, as the average age of salpingectomy for sterilization is 34.8 years [72], more than 20 years younger than the average age of diagnosis for nongenetic ovarian cancer in Canada [73]. As such, the impact of salpingectomy in ovarian cancer prevention and on histologic distribution of ovarian cancers in British Columbia will be the focus of the ongoing long-term study.

Implementation and morbidity — Since the introduction of opportunistic salpingectomy as a potential ovarian cancer risk reduction strategy in 2010, it appears that many surgeons have adopted this approach [74-77]. The increased rate of salpingectomy procedures does not appear to be associated with a significant increase in surgical morbidity.

In terms of implementation of opportunistic salpingectomy, rates of salpingectomy at hysterectomy (rather than bilateral salpingo-oophorectomy [BSO]) and sterilization have increased since 2000, but the studies do not report whether the indication was ovarian cancer prevention. Representative studies include:

In Canada, the percentage of hysterectomies with bilateral salpingectomy increased from <1 percent in 2006 to >11 percent in 2011 [69].

A national United States study of over 400,000 hysterectomies for benign indications, from 1998 to 2011, showed rates of bilateral salpingectomy increased significantly throughout the study period, with an estimated 8 percent annual increase from 1998 through 2008, followed by a sharp 24 percent increase annually during the last four years of the study period [76]. From 1998 through 2001, there was a 2.2 percent increase in the rate of BSO per year; however, this was followed by a consistent 3.6 percent annual decline in the BSO rate, from 49.7 percent in 2001 to 33.4 percent in 2011.

A retrospective, population-based cohort study in British Columbia included over 40,000 women and found significant increases in the rate of salpingectomy performed either at the time of hysterectomy or a procedure for sterilization [72]. Among the total number of hysterectomies, the proportion of procedures that included salpingectomy alone increased (5 to 35 percent), while the rate of hysterectomies that included bilateral salpingo-oophorectomy remained stable (40 to 44 percent). Among sterilization procedures, the proportion of salpingectomy increased (<1 to 33 percent).

Opportunistic salpingectomy does not appear to substantively increase operative time or the risk of morbidity. In the population-based study in British Columbia, salpingectomy performed with hysterectomy added an average of 16 minutes to operative time, and sterilization with salpingectomy was 10 minutes longer than tubal ligation [72]. There were no differences in the rate of blood transfusion or readmission. Hysterectomy with salpingectomy was not associated with a longer hospital stay than hysterectomy alone.

A retrospective study of hysterectomies in a large health care system in the United States (n = 12,143) reported an increase in the rate of salpingectomy from 15 percent in 2011, to 45 percent in 2012, to 73 percent in 2014 [78]. Salpingectomy was more common in laparoscopic hysterectomy than other routes. Salpingectomy was associated with slightly less blood loss and a short operative duration, but this may be due to lower blood loss in laparoscopic procedures or selection of less complicated cases for salpingectomy. Physicians surveyed (n = 249) reported that the most important barriers to performing salpingectomy included: difficulty in accessing the fallopian tube, increased complications, forgot to address preoperatively, and no evidence.

A randomized trial (n = 68) to evaluate opportunistic salpingectomy assigned women in Korea undergoing laparoscopic hysterectomy to salpingectomy or no salpingectomy and found no differences in operative duration, blood loss, or complications [79].

Studies of postoperative morbidity with longer follow-up are needed, and other outcomes that warrant investigation include rates of infection requiring antibiotics, increased clinician visits, or increased need for pharmacologic pain relief. These studies are a part of a long-term population-based program currently underway in British Columbia.

Ovarian function — It is uncertain whether salpingectomy impacts ovarian blood supply and hormonal function (eg, fertility, age of menopause). Hysterectomy is known to be associated with earlier menopause, although this effect is not well understood. (See "Choosing a route of hysterectomy for benign disease", section on 'Earlier menopause or decreased ovarian reserve'.)

Some data suggest that tubal ligation [80-85] and bilateral salpingectomy [86,87] decrease ovarian reserve. However, other data are reassuring:

A randomized trial of opportunistic salpingectomy found no additional short-term impact on ovarian reserve [79]. All women in the trial (n = 68) underwent laparoscopic hysterectomy and had significant decreases in antimüllerian hormone from preoperative to three-month postoperative levels, but there was no significant difference between the groups (salpingectomy: 12.5 percent decrease versus no salpingectomy: 10.8 percent decrease).

A retrospective study of 158 Italian women who underwent total laparoscopic hysterectomy with or without salpingectomy showed no significant difference before and three months after surgery in antimüllerian hormone, follicle-stimulating hormone, or antral follicle count [88]. This cohort has been followed for up to five years with no apparent differences in hormonal or sonographic parameters [89].

Further long-term data are needed. There is a study underway following women in British Columbia who have undergone bilateral salpingectomy for sterilization (eg, no concurrent hysterectomy) to see if age of menopause is different than in women who had tubal ligations. Results from this study will take several years to accrue as the age of these procedures (salpingectomies, or tubal ligations) is on average at least a decade earlier than age of natural menopause.

CLINICAL APPROACH — In our practice, we counsel women at average risk of ovarian, tubal, or peritoneal carcinoma who are undergoing hysterectomy for benign indications or sterilization about the risks and benefits of opportunistic salpingectomy and employ shared decision-making with the patient.

For most women who undergo hysterectomy with ovarian conservation, we perform salpingectomy. For women undergoing vaginal hysterectomy, removal of the tubes is feasible with a transvaginal approach or can be performed with laparoscopic assistance. We do not change the surgical route to be able to perform opportunistic salpingectomy, unless this is the strong preference of the patient.

For women undergoing surgical sterilization, we discuss all options for sterilization, including complete salpingectomy, and communicate that sterilization by salpingectomy is not reversible. We share the available data regarding minimal added surgical time and risk of morbidity. We offer opportunistic salpingectomy for permanent sterilization via laparoscopy or laparotomy, including at the time of cesarean section.

Risk-reducing bilateral salpingo-oophorectomy (rrBSO) remains the preferred approach for women at high risk. (See "Risk-reducing bilateral salpingo-oophorectomy in women at high risk of epithelial ovarian and fallopian tubal cancer", section on 'Surgical procedure'.)

The Society of Gynecologic Oncologists of Canada, Society of Gynecologic Oncology, American College of Obstetricians and Gynecologists, Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and German Society of Gynaecology and Obstetrics (Deutschen Gesellschaft für Gynäkologie und Geburtshilfe) support counseling women about opportunistic salpingectomy [90-94].

There are no long-term studies of the efficacy of opportunistic salpingectomy for primary prevention of ovarian, tubal, and peritoneal carcinomas, although these studies are underway. The best clinical estimate of the potential decrease in cancer risk is based on tubal ligation studies. These studies report an association of tubal ligation with an approximately 10 to 20 percent reduction in the incidence of high-grade serous carcinomas and 40 to 50 percent reduction in the incidence of endometrioid and clear cell carcinomas [62-69]. (See 'Tubal ligation and ovarian cancer risk' above.)

The risks of salpingectomy appear to be minimal. Removal of the tube appears to add <20 minutes to operative duration of hysterectomy or laparoscopic or open sterilization. There are few data on the morbidity, but the available data show no effect. The risk and impact of salpingectomy on ovarian function has not been established, and the limited data available are conflicting. (See 'Ovarian function' above.)

For average-risk women, traditionally, gynecologists had often performed elective bilateral salpingo-oophorectomy in women older than 40 years at the time of hysterectomy, with ovarian cancer prevention as the primary goal. However, practice has changed because oophorectomy in premenopausal women results in early menopause, and postmenopausal hormone therapy is no longer routinely prescribed. In addition, it appears that oophorectomy is associated with adverse outcomes, including all-cause mortality and cardiovascular disease. (See "Risk-reducing bilateral salpingo-oophorectomy in women at high risk of epithelial ovarian and fallopian tubal cancer" and "Menopausal hormone therapy: Benefits and risks" and "Elective oophorectomy or ovarian conservation at the time of hysterectomy".)

For women who desire sterilization, the choice of procedure and the risk of sterilization regret are additional considerations. Postpartum sterilization is performed at the time of cesarean delivery or via a mini-laparotomy, and the technique used is typically partial salpingectomy. For these women, hysteroscopy is not an option. Women who undergo interval sterilization (not during a postpartum period) may have either laparoscopic or hysteroscopic procedure, and opportunistic salpingectomy cannot be performed hysteroscopically. Hysteroscopy does not require an incision or general anesthesia, but it is unclear which approach is associated with less morbidity. Women should be counseled first about the options for surgical approach, and then offered opportunistic salpingectomy only if planning laparoscopic or open sterilization. (See "Hysteroscopic sterilization", section on 'Comparison with other sterilization approaches'.)

Sterilization with complete salpingectomy cannot be reversed. The rate of sterilization regret is highest in women younger than 30 years (20 percent [95]) and with other characteristics (unmarried at time of sterilization, sterilization within three years of the youngest child, nonwhite race). Counseling for all women undergoing sterilization should emphasize that it is a permanent procedure. Women considering opportunistic salpingectomy should be assessed for risk factors for sterilization regret and informed that there is no possibility of a tubal reanastomosis.

In terms of cost, opportunistic salpingectomy adds a small amount to operative costs due to increased operative duration and possible use of additional instrumentation [96]. Further data are needed about the outcomes of this strategy to determine cost-effectiveness [97,98]. If ovarian cancer incidence is decreased, cost savings would be significant. The potential health economic and safety implications of this cancer prevention strategy are being further pursued through population-based administrative datasets that track health care use and costs for the entire population.

SUMMARY AND RECOMMENDATIONS

Epithelial ovarian carcinoma is the fifth most common cause of cancer deaths in women. There is no effective screening method, and early detection and treatment are limited. (See 'Overview and rationale' above.)

Opportunistic salpingectomy is the removal of the fallopian tubes for primary prevention of epithelial carcinoma of the fallopian tube, ovary, or peritoneum in average-risk women undergoing pelvic surgery for another indication. The most common eligible procedures are hysterectomy for benign indications and sterilization via laparoscopy or laparotomy. (See 'Definition' above.)

Epithelial carcinoma of the ovary, fallopian tube, and peritoneum are considered a single entity. Historically, the ovary was regarded as the most common primary site, but data suggest that many apparent ovarian high-grade serous carcinomas have a tubal precursor lesion. An association between tubal ligation and decreased risk gives additional support for the role of the fallopian tube in ovarian carcinoma pathogenesis. (See 'Role of the fallopian tube' above.)

Epithelial carcinoma of the ovary, tube, and peritoneum includes several histologic types with varied molecular profiles and biologic behavior. The most common histologic type is high-grade serous, which typically presents at stage III or IV and has a poor prognosis. (See 'Overview and rationale' above.)

The risks of salpingectomy appear to be minimal. Removal of the tube appears to add <20 minutes to operative duration of hysterectomy or laparoscopic or open sterilization and appears to have no effect on morbidity. The risk of an impact of salpingectomy on ovarian function is uncertain. (See 'Outcome' above.)

Further long-term study is needed to determine the efficacy of opportunistic salpingectomy for cancer prevention. (See 'Ovarian cancer risk reduction' above.)

In our practice, we counsel women at average risk of ovarian, tubal, or peritoneal carcinoma who are undergoing hysterectomy for benign indications or sterilization about the risks and benefits of opportunistic salpingectomy and employ shared decision-making with the patient. (See 'Clinical approach' above.)

For most women who undergo hysterectomy with ovarian conservation, we perform salpingectomy. For women undergoing vaginal hysterectomy, removal of the tubes is feasible with a transvaginal approach or can be performed with laparoscopic assistance. We do not change the surgical route to be able to perform opportunistic salpingectomy, unless this is the strong preference of the patient.

For women undergoing surgical sterilization, we discuss all options for sterilization, including complete salpingectomy, and communicate that sterilization by salpingectomy is not reversible. We share the available data regarding minimal added surgical time and risk of morbidity. We offer opportunistic salpingectomy for permanent sterilization via laparoscopy or laparotomy, including at the time of cesarean section.

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