Salpingectomy With Ovarian Conservation Rates Vary Widely

Neil Osterweil

January 12, 2016

The rate of bilateral salpingectomy with ovarian conservation in 2012 was low among women who had hysterectomies for benign indications but were otherwise at low risk for ovarian cancer, according to the results of a new study published in the February issue of Obstetrics & Gynecology.

"We demonstrated marked variation in the practice of prophylactic salpingectomy among hospitals. The rate of bilateral salpingectomy with ovarian conservation ranged from 0% to 72.2% among 744 hospitals across the country," write Xiao Xu, PhD, and Vrunda Bhavasr Desai, MD, from the Yale School of Medicine in New Haven, Connecticut.

"Such variation cannot be attributed to a difference in patient case-mix because we focused on women without identified risk factors for ovarian cancer or subsequent ovarian operation," they report.

The majority (86.6%) of the 641,000 hysterectomies performed in the United States in 2011 were for benign indications, and many included concomitant oophorectomy performed for the prevention of ovarian cancer, the authors note.

Removing the ovaries, however, triggers menopause, which in turn may be associated with sexual function problems, as well as bone, cardiovascular, and cognitive complications.

In 2015, the American College of Obstetricians and Gynecologists (ACOG) guidelines recommended bilateral salpingectomy with ovarian conservation instead of bilateral salpingo-oophorectomy (BSO) for ovarian cancer prevention.

The guidelines note that current evidence of ovarian cancer development suggests that cancers arise in the fallopian tubes and endometrium, and not in the ovaries themselves.

"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. 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," the guidelines state.

To establish a baseline on hospital practices regarding bilateral salpingectomy with ovarian conservation before the ACOG guidelines were issued, Dr Xu and Dr Desai drew on data from the 2012 National Inpatient Sample to perform a cross-sectional study of women hospitalized for benign, nonobstetric hysterectomy. They excluded from their analysis women who were at risk for ovarian cancer or who had subsequent ovarian surgery.

They identified 20,635 women at low risk for ovarian cancer out of 63,306 women hospitalized for hysterectomies. Only 5.9% of these women (95% confidence interval, 5.4% - 6.5%) had bilateral salpingectomy with ovarian conservation, whereas 25.1% (95% confidence interval, 24.3% - 25.9%) underwent bilateral salpingectomy-oophorectomy, or removal of a remaining ovary and fallopian tube.

In multivariate regression analyses controlling for hospital type, location (urban vs rural), private vs public, and census region, the investigators found that the hospitals less likely to perform ovarian-conserving procedures in low-risk patients were those in the South vs the Northeast, and those with higher proportions of white patients.

Factors associated with a greater likelihood that low-risk patients would receive ovarian-conserving surgeries were medium- and high-volume vs low-volume institutions, and hospitals in which a high proportion of the procedures were performed laparoscopically.

There was no significant effect of indications for hysterectomy on a hospital's propensity for performing salpingectomy with or without ovarian conservation, however.

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2016;127:297-305.

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