Opportunistic Salpingectomy Universal

Hannah Palm, MDDept. OB/GYN, University of New

Mexico Health Sciences Center

Disclosures● I am a resident, not an expert

Arguments FORuniversal opportunistic salpingectomDecreases risk of ovarian cancer

No increased risks associated with the procedure

Can be done for all routes of hysterectomy

No impact on ovarian reserve

Cost-effective

Ovarian cancer: the silent and deadly k

Lifetime risk: 1.3%

5 year survival rate: 46.6%

NIH, National Cancer Institute, SEER data

NIH, National Cancer Institute, SEER data

Walker, et al. Cancer, 2015

SGO statement, 2013“A paradigm shift in our understanding of pelvic serous carcinomas suggests

that the site of origin may be the fallopian tube.

For women at population risk (average) for ovarian cancer, salpingectomy should be considered (a fte r com ple tion of ch ildbearing) a t the tim e of

hyste rectom y, in lieu of tuba l liga tion , and a lso a t the tim e of o the r pe lvic surgery.”

Kwon, et al. ACOG, 2015

No increased

risks!

Till, JMIG, Jan 2018

Not enough evidence?

Powell, ACOG, 2017

Westberg, Contraception, 2017

Tubal Occlusion(n=68) Salpingectomy(n=81)

Immediate complication 1.4% 1.2%

Short-term complication 14.7% 4.9%

Surgical time 38 土 15 min 44 土 13 min

All hysterectomies are fair game Laparoscopic?

Abdominal?

Vaginal?

Till, JMIG, Jan 2018

Salpingectomy in Vaginal Hysterectomy?❏ Success rate of bilateral salpingectomy

(BS) at time of TVH: 88%❏ Subsequent adnexal surgery:

❏ With BS: 4%❏ Without BS: 12%

❏ Sm all increased risk in com plica tions with BS (7.95% vs 7.68%)

❏ BS decreases risk of:❏ Ovarian cance r d iagnosis: 1 in 225 hysts❏ Ovarian cance r dea th : 1 in 450 hysts

❏ BS decreases cost of trea tm ent: ❏ $7350 with BS vs $8113 withou t BS

CONCLUSION:- 3 complications for prevention of 5

cancer diagnoses- 6 complications for prevention of 5

cancer deaths

Cadish, et al. AJOG, 2017

Impact on Ovarian Reserve

Impact on Ovarian Reserve

Kotlyar, JMIG, 2017

Thermal spread!

Ovarian manipulation during surgery!

Decreased collateral blood flow!

AMH, FSHAntral follicle count

ConceptionAge at menopause

No overall impact on ovarian reserve!

Herman, AJOG, 2017

Cost-effective

Kwon, et al. ACOG, 2015

Kwon, et al. ACOG, 2015

Conclusions:Decreases risk of ovarian cancer

No increased risks associated with the procedure

Does not affect route of hysterectomy

No impact on ovarian reserve

Cost-effective

SGO statement, 2013“A paradigm shift in our understanding of pelvic serous carcinomas suggests

that the site of origin may be the fallopian tube.

For women at population risk (average) for ovarian cancer, salpingectomy should be considered (a fte r com ple tion of ch ildbearing) a t the tim e of

hyste rectom y, in lieu of tuba l liga tion , and a lso a t the tim e of o the r pe lvic surgery.”

RebuttalUniversal Salpingectomy

RebuttalSalpingectomy versus tubal occlusion

To do surgery or to withhold?

The art of vaginal hysterectomy

Just a piece or the whole thing?Falconer, et al (2015):

- Sterilization procedures: HR 0.72- Unilateral salpingectomy: HR 0.71- Bilateral salpingectomy: HR 0.35

Madsen, et al (2015): - Unilateral salpingectomy: OR 0.9- Bilateral salpingectomy: 0.58

Yoon, et al (2016): - Bilateral salpingectomy: OR 0.51

Conclusion: - Bilateral Salpingectomy: OR 0.51- Sterilization procedures: RR 0.68 to 0.88

Lessard, et al (2014):- Bilateral salpingectomy or distal

fimbriectomy: OR 0.22

Ely, L., & Truong, M. (2017). JMIG.Cochrane review:

Kwon, et al. ACOG, 2015

Increasing surgical capacity in LIC could avert loss of 77.2 million disability-adjusted life

years per year

Vaginal hysterectomy: still alive and kic

Mikhail, et al. JMIG, 2016

Till, JMIG, Jan 2018

Vaginal hysterectomy

To recommend or to not recommend?❏ Should National Societies Recommend Opportunistic Salpingectomy?

❏ Journal of Gynecologic Oncology, Ju ly 2017

“Associa tion does not p rove causa lity, and we have no p rospective da ta showing tha t opportun istic sa lp ingectom y reduces the risk for ovarian cance r. Until [the re is p rospective da ta ] na tiona l socie tie s and ind ividua l physicians and pa tien ts will need to m ake recom m endations and decisions withou t an evidence base of p rospective stud ie s. Sta tem ents by socie tie s a round the world ind ica te tha t m any conside r the potential benefit of opportunistic salpingectomy in reducing mortality from a most difficult disease greater than the risk .”

Resources1. Cadish LA, Shepherd JP, Barber EL, et al. (2017). Risks and benefits of opportunistic salpingectomy during vaginal hysterectomy:A decision analysis.American Journal of Obstetrics

and Gynecology,2. Debas, H.T., P. Donkor, A. Gawande, D. T. Jamison, M. E. Kruk, and C. N. Mock, editors. 2015. Essential Surgery. Disease Control Priorities, third edition, volume 1. Washington, DC:

World Bank. 3. Ely, L., & Truong, M. (2017). The role of opportunistic bilateral salpingectomy vs tubal occlusion or ligation for ovarian cancer prophylaxis.Journal of Minimally Invasive

Gynecology, 24(3), 371-378.4. Herman, H., Gluck, O., Keidar, R., & et al. (2017). Ovarian reserve following cesarean section with salpingectomy vs tubal ligation: A randomized trial.American Journal of Obstetrics

and Gynecology, 4725. Kotlyar, A., Gingold, J., & et al. (2017). The effect of salpingectomy on ovarian function.Journal of Minimally Invasive Gynecology, 24(4)6. Kwon, J., McAlpine, J., & et al. (2015). Costs and benefits of opportunistic salpingectomy as an ovarian cancer prevention strategy.American College of Obstetricians and

Gynecologists, 125(2), 338-345.7. Mikhail, E., Salemi, J., Wyman, A., & et al. (2016). Trends of bilateral salpingectomy during vaginal hysterectomy with and without laparoscopic assistance performed for benign

indications in the united states.The Journal of Minimally Invasive Gynecology, 23(7), 1063-1069.8. National cancer institute: Cancer stat facts: Ovarian cancer. (2017). Retrieved fromhttps://seer.cancer.gov/statfacts/html/ovary.html9. Powell, C., Alabaster, A., Simmons, S., & et al. (2017). Salpingectomy for sterilization: Change in practice in a large integrated health care system, 2011-2016.The American College

of Obstetricians and Gynecologists, 130(5), 961-967.10. Salpingectomy for ovarian cancer prevention. committee opinion no. 620. (2015). American College of Obstetricians and Gynecologists, 125, 279-281.11. Society of gynecologic oncology. (2017). Retrieved fromhttps://www.sgo.org/clinical-practice/guidelines/sgo-clinical-practice-statement-salpingectomy-for-ovarian-cancer-

prevention/12. Tamussino, K. (2017). Should national societies recommend opportunistic salpingectomy?Journal of Gynecologic Oncology, 28(4), e53.13. Till, S., Kobernik, E., & Kamdar, N., et al. (2018). The use of opportunistic salpingectomy at the time of benign hysterectomy.The Journal of Minimally Invasive Gynecology, 25(1),

53-61.14. Walker, J., Powell, B., & et al. (2015). Society of gynecologic oncology recommendations for the prevention of ovarian cancer.Cancer, 121(13)15. Westberg, J., Scott, F., & Creinin, M. (2017). Safety outcomes of female sterilization by salpingectomy and tubal occlusion.Contraception, 95, 505-508.

https://seer.cancer.gov/statfacts/html/ovary.htmlhttps://www.sgo.org/clinical-practice/guidelines/sgo-clinical-practice-statement-salpingectomy-for-ovarian-cancer-prevention/

Picture sources● http://ovarian.org/about-ovarian-cancer/what-are-the-signs-a-symptoms● https://judysmission.org/about-ovarian-cancer/● https://www.express.co.uk/pictures/pics/7220/Symptoms-ovarian-cancer-health-risks-signs-medical-pictures● http://healthwarnings.net/category/cancer/ovarian-cancer/● https://www.scoopnest.com/user/Hedgeye/574301867204829184● https://www.preciouslittlesleep.com/pediatrician-weighs-in-on-infant-reflux/● http://thenatpath.com/body/womens-health/natural-medicines-can-improve-diminished-ovarian-reserve-infertile-women/● https://toonclips.com/design/57113● https://www.coolfunnyquotes.com/author/anonymous/one-piece-of-cake/● http://giantgag.net/i-have-made-a-huge-mistake/● https://www.pinterest.com/pin/245868460881712031/● https://www.youtube.com/watch?v=OZ2SqgTdzdE● https://imgur.com/gallery/4Llom● https://stephenking.com/xf/index.php?threads/neesy.13408/page-2

http://ovarian.org/about-ovarian-cancer/what-are-the-signs-a-symptomshttps://judysmission.org/about-ovarian-cancer/https://www.express.co.uk/pictures/pics/7220/Symptoms-ovarian-cancer-health-risks-signs-medical-pictureshttp://healthwarnings.net/category/cancer/ovarian-cancer/https://www.scoopnest.com/user/Hedgeye/574301867204829184https://www.preciouslittlesleep.com/pediatrician-weighs-in-on-infant-reflux/http://thenatpath.com/body/womens-health/natural-medicines-can-improve-diminished-ovarian-reserve-infertile-women/https://toonclips.com/design/57113https://www.coolfunnyquotes.com/author/anonymous/one-piece-of-cake/http://giantgag.net/i-have-made-a-huge-mistake/https://www.pinterest.com/pin/245868460881712031/https://www.youtube.com/watch?v=OZ2SqgTdzdEhttps://imgur.com/gallery/4Llomhttps://stephenking.com/xf/index.php?threads/neesy.13408/page-2

Opportunistic Salpingectomy: UniversalDisclosuresArguments FOR universal opportunistic salpingectomyOvarian cancer: the silent and deadly killer...Slide Number 5Slide Number 6Slide Number 7SGO statement, 2013Slide Number 9Slide Number 10No increased risks!Slide Number 12Not enough evidence?All hysterectomies are fair game Slide Number 15Salpingectomy in Vaginal Hysterectomy?Impact on Ovarian ReserveImpact on Ovarian ReserveSlide Number 19Cost-effectiveSlide Number 21Slide Number 22Conclusions:SGO statement, 2013RebuttalRebuttalJust a piece or the whole thing?Slide Number 28Slide Number 29Slide Number 30Slide Number 31Vaginal hysterectomy: still alive and kickingSlide Number 33To recommend or to not recommend?Slide Number 35Slide Number 36ResourcesPicture sources