Ovarian transposition by laparoscopy before radiotherapy in the treatment of hodgkin's disease

Laparoscopic Adnexal Transposition: Novel Surgical Technique

Abstract

Treatment of some cancers diagnosed at an early stage with expectation of prolonged survival has permitted the consideration of salvaging the reproductive and hormonal function of premenopausal female patients. When radiation to the pelvic area is part of treatment, this will almost always result in ovarian failure. To protect the ovaries, an oophoropexy may be performed, which involves moving the ovaries away from the radiation field. This procedure may be performed via laparoscopy. Some women undergoing laparoscopic radical hysterectomy may also be candidates for laparoscopic transposition. Because failure rates are still reported to be high, we developed a novel technique to mobilize the adnexa, which we present in this paper and attached movie.

After separating the adnexa from the uterus and developing the infundibulopelvic (IP) ligament, a retroperitoneal tunnel is developed from the pelvis to the transposition opening laterally. The adnexa are moved through this tunnel, avoiding torsion of the vessels, and are brought through the opening back into the peritoneum. The adnexa are now fixed securely to the posterolateral abdominal wall with nonabsorbable sutures.

Several issues permit better results using this technique. The IP ligament remains retroperitoneal and itself is outside the field of radiation. There is no kinking of the ovarian blood supply on the peritoneal fold. The location of the transposition is way above the field of radiation, preventing scatter injury. Even if one or both of the sutures fail, placement of the ovary will not change because of the peritoneum it has been brought through. This and the final location of the IP ligament retroperitoneally may enforce the ovary to it outside of the radiation field and prevent possible migration of the ovary back to the pelvis. This technique has advantages, which may offer the ovaries a better chance to resume hormonal function.

Underuse of ovarian transposition in reproductive-aged cancer patients treated by primary or adjuvant pelvic irradiation

AIM

To investigate the application status of ovarian transposition (OT) in reproductive-aged cancer patients undergoing radiation therapy.

MATERIAL & METHODS

Between November 1999 and December 2008, 2524 patients had received pelvic irradiation at Seoul National University Hospital. We filtered the patients with the indications of (i) within 12 to 40 years of age, and (ii) receiving primary or adjuvant pelvic irradiation. There were 241 patients within 12 to 40 years of age. After excluding 133 patients with metastatic disease or under palliative radiation treatment, 108 patients were discovered appropriate for OT. We analyzed the application status of OT, surgical types of OT, cancer types and radiation types in those 108 patients.

RESULTS

Cervical cancer was the major indication (n = 68, 62.9%). Another 37.1% of indicated disease were composed of rectal cancer (n = 19), vulvo-vaginal cancer (n = 4), non-Hodgkin's lymphoma (n = 3), and other pelvic tumors (n = 14). Among the 108 patients, only 31 (28.7%) patients had received OT before pelvic irradiation. Most of the operations were applied on cervical cancer patients (n = 29) and only two procedures on rectal and endometrial cancer, respectively. OT had been mostly performed during laparotomy. Laparoscopic procedure was applied in only one case with advanced cervical cancer.

CONCLUSIONS

Although OT could be a preventive measure of premature ovarian failure from radiation therapy, this procedure has been considerably underused at our institution. This procedure should be applied more widely to preserve the fertility and improve the quality of life in reproductive-aged cancer patients.

Laparoscopic ovarian transposition before pelvic irradiation: a Saudi tertiary center experience

OBJECTIVE

To report the authors' experience with laparoscopic ovarian transposition and ovarian function preservation in women who require pelvic irradiation as part of their cancer therapy.

DESIGN

Cohort study.

SETTING

The gynecologic oncology service in a referral tertiary/quaternary medical center in Saudi Arabia.

PATIENTS

Twenty-three premenopausal patients treated with radiotherapy for a pelvic malignancy.

INTERVENTIONS

Laparoscopic ovarian transposition to paracolic gutters with uterine conservation.

MAIN OUTCOME MEASURES

Preservation of ovarian function assessed by patients' symptoms and serum follicle-stimulating hormone level.

RESULTS

Bilateral laparoscopic ovarian transposition was performed in 23 patients: 15 with cervical cancer, 4 with rectal cancer, 3 with Ewing sarcoma, and 1 with Hodgkin lymphoma. No immediate intraoperative or postoperative complications were observed. Three patients were lost to follow-up. Ovarian preservation was achieved in 13 (65%) of 20 patients. Seven patients with low follicle-stimulating hormone levels had regular uterine bleeding at follow-up.

CONCLUSIONS

Laparoscopic ovarian transposition is a safe and effective procedure for preserving ovarian function. This procedure should be considered in all premenopausal women who need to undergo pelvic irradiation as part of their cancer treatment.

Impact of radiotherapy on fertility, pregnancy, and neonatal outcomes in female cancer patients

PURPOSE

Radiation has many potential long-term effects on cancer survivors. Female cancer patients may experience decreased fertility depending on the site irradiated. Oncologists should be aware of these consequences and discuss options for fertility preservation before initiating therapy.

METHODS AND MATERIALS

A comprehensive review of the existing literature was conducted. Studies reporting the outcomes for female patients treated with cranio-spinal, abdominal, or pelvic radiation reporting fertility, pregnancy, or neonatal-related outcomes were reviewed.

RESULTS

Cranio-spinal irradiation elicited significant hormonal changes in women that affected their ability to become pregnant later in life. Women treated with abdomino-pelvic radiation have an increased rate of uterine dysfunction leading to miscarriage, preterm labor, low birth weight, and placental abnormalities. Early menopause results from low-dose ovarian radiation. Ovarian transposition may decrease the rates of ovarian dysfunction.

CONCLUSIONS

There is a dose-dependent relationship between ovarian radiation therapy (RT) and premature menopause. Patients treated with RT must be aware of the impact of treatment on fertility and explore appropriate options.

Weibliche und männliche Fertilitätsstörungen und Risiken der assistierten Fertilisation

Ca. 10–15% der Paare im reproduktionsfähigen Alter bleiben ungewollt kinderlos. Der Anteil steigt tendentiell durch den zunehmend „späten Kinderwunsch“. Das durchschnittliche Alter der Erstgebärenden hat sich u.a. aus Gründen der Ausbildungszeit und Berufstätigkeit der Frau zwischen 1970 und 2000 vom 24. auf das 30. Lebensjahr verschoben. Eine gewollte Kinderlosigkeit kommt in ca. 10% der Ehen vor.

Laparoscopic fertility preservation

Advances in cancer therapy have improved the long-term survival of young patients suffering from malignancies. The adverse effects of the treatment, however, are sterility and loss of gonadal function especially in females. If preservation of fertility in males by sperm freezing is already established, for young women undergoing cancer treatment the availability of preserving the gonadal function and fertility has just begun. Diseases commonly treated with radiation or chemotherapeutic agents in young women are breast cancer, lymphoma, leukemia, blood dyscrasia, glomerulonephritis, lupus erythematosus, and rheumatoid arthritis.

Laparoscopic preservation of ovarian function: an underused procedure

OBJECTIVE

There are many young women undergoing irradiation or chemotherapy without having the option of preserving their ovarian function. Our purpose was to review the literature on laparoscopic ovarian transposition, to evaluate its efficacy, and to provide clinical opinion on the subject.

STUDY DESIGN

We evaluated the English articles on laparoscopic ovarian transposition identified through a MEDLINE search. We also report a case of laparoscopic ovarian tranposition in a 28-year-old woman with rectal cancer.

RESULTS

Laparoscopic ovarian transposition in women <40 years old is associated with preservation of ovarian function in 88.6% of cases. During and afer irradication, our patient never missed her menstrual periods.

CONCLUSION

Despite its simplicity and efficacy, this procedure is underused. We encourage clinicians to discuss and propose it to their patients.

Effects of cancer treatment on reproduction and fertility

OBJECTIVE

(1) To review the effects of cancer treatment on reproduction and fertility in both women and men and (2) to review current and new techniques that could be used to preserve fertility and hormone production in women who have undergone cancer treatment.

DATA SOURCES

Entries to MEDLINE and CANCERLIT through to October 2001 were searched for evidence relevant to this article.

METHODS OF STUDY SELECTION

This document is primarily based on large retrospective cohort series and case reports, as no randomized trials were available.

TABULATION, INTEGRATION, AND RESULTS

The first part of this review article focuses on the effects of radiation and chemotherapy on reproductive function and innovative medical and surgical techniques employed to minimize these effects. The second part of this article describes conservative methods of managing cervical, endometrial, and ovarian cancer for women who wish to preserve their fertility.

CONCLUSIONS

Over the last decade, there has been a trend toward trying to preserve reproductive function in young patients with malignancy. Information acquired over the last century on the reproductive effects of radiation and chemo-therapy has enabled us to tailor our treatment of various malignancies affecting young patients. As we learn more about the biology and clinical behaviour of gynaecologic malignancies, we are able to modify surgical management to preserve fertility in select cases. All of these trends are in keeping with our goal to optimize quality of life in cancer care without compromising safety or survival.