COMMENTARY

Opportunistic Salpingectomy During Hysterectomy: Upsides and Downsides

Peter Kovacs, MD, PhD

Disclosures

March 20, 2019

Hysterectomy: Take the Tubes Too?

Hysterectomy, for the management of such benign conditions as fibroids, menometrorrhagia, and endometrial hyperplasia, is among the most common gynecologic surgeries. It can be performed vaginally or via the abdominal route (laparotomy or laparoscopy). At the time of surgery, other pelvic organs (fallopian tubes, ovaries) can be inspected and removed, if indicated. An unhealthy fallopian tube affected by previous salpingitis is typically removed.

Over the years, a debate has surrounded the question of what to do with healthy fallopian tubes at the time of hysterectomy for benign indications.

What's the downside of bilateral salpingectomy at the time of hysterectomy?

Outcomes of Bilateral Salpingectomy

A recent study[1] evaluated the incidence of menopausal symptoms and surgical complications following bilateral salpingectomy at the time of hysterectomy.

This retrospective cohort study included 4906 women who underwent abdominal or laparoscopic hysterectomy between 2013 and 2016, with postoperative follow-up for a year. New-onset menopausal symptoms and postoperative complication rates were identified. Bilateral salpingectomy was performed in 37.8% of the hysterectomies executed in 2016.

The women who chose to have their tubes removed were slightly older and had higher parity. The hospital stay was longer by 0.1 day after bilateral salpingectomy, a statistically significant difference.

After 1 year of follow-up, minor complications were more frequent in women who had their tubes removed (adjusted relative risk [aRR], 1.35; 95% confidence interval [CI], 1.01-1.83). Rates of menopausal symptoms were similar between the two groups before but not after surgery. One year postoperatively, menopausal symptoms were more common in the hysterectomy + bilateral salpingectomy group compared with the hysterectomy-only group (aRR, 1.33; 95% CI, 1.04-1.69). The onset of symptoms was age-dependent and the risk was significantly increased in women aged 44 to 49 years (aRR, 1.53; 95% CI, 1.06-2.20).

The study's conclusion was that women undergoing bilateral salpingectomy at the time of hysterectomy were at higher risk for minor surgical complications and menopausal symptoms postoperatively.

Viewpoint

Ovarian cancer is the 8th most common cancer among women, with a lifetime risk of 1.3%.[2] The median age at diagnosis is 63 years.[2] Early cancer is rarely associated with specific symptoms and there are no screening tests with good predictive value.[3] Therefore, most cancers are diagnosed at an advanced stage, when treatments have poor efficacy.

Known risks for ovarian cancer include both reproductive and genetic factors.[4] Bilateral oophorectomy upon completing childbearing in high-risk cases has been shown to significantly reduce the ovarian cancer risk, but the endocrine activity of the ovaries is removed as well.[3]

Some epithelial cancers, especially serous ovarian cancers, are thought to originate from the fimbriated end of the fallopian tubes. It has been proposed and shown that salpingectomy alone can reduce the risk for ovarian cancer.[5] However, salpingectomy may affect ovarian function through compromised blood flow and ischemic damage.

Postoperative ovarian function can be assessed with hormonal markers (antimüllerian hormone, follicle-stimulating hormone), but so far no negative impact was shown.[6] However, postsurgical ovarian activity can be evaluated by the occurrence of symptoms associated with reduced hormonal activity. This register-based study found that women who had their tubes taken out at the time of hysterectomy were more likely to develop menopausal symptoms indicating ovarian dysfunction. This was especially true among perimenopausal women (44-49 years), when the ovarian reserve is likely to be low to begin with.

It is yet to be determined whether the overall benefit of reducing the risk for a rare cancer associated with high mortality outweighs the risk of accelerating the menopausal changes that influence health and quality of life. Cost-benefit analysis may further guide these decisions. For now, women who need a hysterectomy should be advised that benefits as well as risks are associated with opportunistic salpingectomy. Individual risk for ovarian cancer should be assessed and taken into consideration when recommendations are made.

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