The cystic adnexal mass: patient selection, surgical techniques and long-term follow-up

Evaluating the Frequency and Characteristics of Unexpected Ovarian Malignancy in Postmenopausal Women Who Have Undergone Laparoscopic Surgery for Adnexal Masses - A Review of Five Years

Aim The aim of this study was to estimate the frequent existence of unexpected ovarian malignant lesions after laparoscopic surgery for an apparent benign adnexal mass and assess its clinical and ultrasound characteristics in postmenopausal women. Methods We re-examined the hospital records of 96 cases of postmenopausal women who underwent laparoscopic surgery for benign adnexal mass over five years. The age of the patient, parity, ultrasound findings, tumor markers level, intraoperative findings, and histopathological report were collected. Pearson's Chi-squared test and Fisher's exact test were used for statistical analysis, and a p-value of <0.05 was accepted as statistically significant. Results Of a total of 96, benign adnexal mass was in 93 (96.83%), an unexpected ovarian malignancy was observed in two (2.08%) cases, and one (1.04%) had a borderline ovarian tumor. Tumor marker CA-125 was done for all those cases of adnexal mass in postmenopausal women, and not a single case was found to have above 35 IU/ml, defined as the cut-off value for CA-125. Statistically significant differences were observed between the benign and malignant groups in relation to symptoms (p<0.05), ultrasound score (p=0.001), and bilaterality (p=0.013) of the tumor mass. Conclusion In postmenopausal women, the critical concern for laparoscopic surgery of benign adnexal mass is unexpected malignancy. So it is essential to select patients carefully for laparoscopic surgery. If a benign-looking adnexal mass turned out to be malignant on the histopathological report, we should try to post the patient for subsequent staging laparotomy as soon as possible.

Three-dimensional ultrasonography and power Doppler for discrimination between benign and malignant endometrium in premenopausal women with abnormal uterine bleeding

BACKGROUND

Ultrasonography has been extensively used in women suspected of having a gynecological malignancy. The aim of this study is to evaluate the efficacy of 3D ultrasonography and power Doppler for discrimination between benign and malignant endometrium in premenopausal women with abnormal uterine bleeding.

METHODS

This cross-sectional study included 78 premenopausal women with abnormal uterine bleeding scheduled for hysteroscopy and endometrial curettage. The endometrial thickness (ET), uterine artery pulsatility index (PI) and resistance index (RI), and endometrial volume (EV) and 3D power Doppler vascularization index (VI), flow index (FI), and vascularization flow index (VFI) were measured and compared with hysteroscopic and histopathologic findings.

RESULTS

The ET (P <0.001), EV (P <0.001), and endometrial VI (P <0.001) and VFI (P = 0.043) were significantly increased in patients with atypical endometrial hyperplasia and endometrial carcinoma (n = 10) than those with benign endometrium (n = 68); whereas, the uterine artery PI and RI and endometrial FI were not significantly different between the two groups. The best marker for discrimination between benign and malignant endometrium was the VI with an area under the ROC curve of 0.88 at a cutoff value of 0.81%.

CONCLUSION

3D ultrasonography and power Doppler, especially endometrial VI, may be useful for discrimination between benign and malignant endometrium in premenopausal women with abnormal uterine bleeding.

Adnexal masses suspected to be benign treated with laparoscopy

OBJECTIVE

Guidelines for referring women with pelvic masses suspicious for ovarian cancer to gynecologic oncologists have been developed by the American College of Obstetrician Gynecologists (ACOG). We set out to evaluate the negative predictive value of these guidelines and to assess a modified algorithm involving minimally invasive surgery in the treatment of women with masses suspected to be benign.

METHODS

257 consecutive patients with adnexal masses of 8cm to 13cm on preoperative ultrasound examination meeting Triage Criteria set forth in ACOG Committee Opinion 280. Patients meeting the selection criteria were scheduled for operative laparoscopy, washings, adnexectomy, bagging, and colpotomy. A total of 240 patients successfully completed intended treatment (93.38%), and 234 of these did not require admission (97.5%). There was a low incidence of significant complications: 97.50% of women were successfully treated as outpatients, 97.92% of surgeries lasted <136 minutes, and <97.08% had blood loss <200mL. The negative predictive value of ACOG Committee Opinion 280 Triage Criteria as a deselector for having invasive ovarian malignancy in our population was 95.57% for premenopausal and 90.91% for postmenopausal women.

CONCLUSIONS

Laparoscopic adnexectomy, bagging, and colpotomy is a desirable goal for patients with ovarian masses in the 8cm to 13cm range meeting selection criteria affording a minimally invasive approach with attendant benefits including outpatient treatment (97.5%), few complications, low likelihood of iatrogenic rupture of the ovarian capsule (1.25%), and low necessity for reoperation after final pathology is evaluated (6.03%). Negative predictive value of ACOG Committee Opinion 280 is confirmed in a community gynecology practice and is recommended to form the basis of a new treatment algorithm for women with adnexal masses.

Laparoscopy versus laparotomy for benign ovarian tumour

BACKGROUND

Over the last 10 years laparoscopy and minilaparotomy have become increasingly common approaches for the surgical removal of benign ovarian tumours. However, in the event that a tumour is found to be malignant, laparotomy is the appropriate procedure. Careful preoperative assessment including transvaginal ultrasound with morphological scoring, colour doppler assessment of vascular quality, and serum cancer antigen 125 (CA 125) level is desirable.

OBJECTIVES

To determine the benefits, harms, and cost of laparoscopy or minilaparotomy compared with laparotomy in women with benign ovarian tumours.

SEARCH STRATEGY

We searched electronic databases, trial registers, and reference lists of published trial reports. Reference lists from trials and review articles were searched.

SELECTION CRITERIA

All randomised controlled trials comparing either laparoscopy or minilaparotomy with laparotomy for benign ovarian tumours.

DATA COLLECTION AND ANALYSIS

Eight review authors independently assessed the eligibility and quality of each study and extracted the data.

MAIN RESULTS

The results of nine randomised controlled trials (N = 482 women) showed that laparoscopic surgery was associated with fewer adverse events of surgery (surgical injury or postoperative complications including fever or infection) (OR 0.3, 95% CI 0.2 to 0.5), less postoperative pain (VAS score WMD -2.4, 95% CI -2.7 to -2.0), greater likelihood of being pain free after two days (OR 7.42, 95% CI 4.86 to 11.33), and fewer days in hospital (WMD -2.88, 95% CI -3.1 to -2.7) than with laparotomy.In one study that reported costs, laparoscopy was associated with a significant reduction in costs compared to laparotomy (WMD - USD 1045, 95% CI -1348 to -742) in 1993. Very high levels of heterogeneity made it inappropriate to pool data on duration of surgery.Three RCTs compared laparoscopy versus minilaparotomy and found that laparoscopy was associated with reduced odds of any adverse event (surgical injury or postoperative complications) (OR 0.10, 95% CI 0 to 0.8) and lower VAS scores for pain (WMD -1.0, 95% CI -1.6 to -0.45). Duration of hospital stay ranged between 1 and 2.2 days, with substantial heterogeneity.

AUTHORS' CONCLUSIONS

In women undergoing surgery for benign ovarian tumours, laparoscopy was associated with a reduction in fever, urinary tract infection, postoperative complications, postoperative pain, number of days in hospital, and total cost. These findings should be interpreted with caution since only a small number of studies were identified. These included a total of only 769 women and not all of the important outcomes were reported in each study.

Triage for surgical management of ovarian tumors in asymptomatic women: assessment of an ultrasound-based scoring system

OBJECTIVES

To prospectively evaluate an ultrasound-based scoring system as a method for triaging asymptomatic women presenting with an adnexal mass for surgical treatment.

METHODS

Two hundred and four adnexal masses in 189 asymptomatic women undergoing elective surgical treatment at our institution were included in this prospective study. Patients were evaluated by transvaginal power Doppler ultrasound imaging before surgery. Patients were classified as low risk or high risk for malignancy according to an ultrasound-based scoring system. Women with a low risk for malignancy were scheduled for laparoscopy and patients with a high risk for malignancy were scheduled for laparotomy. However, patients classified as low risk by the ultrasound scoring system, but with a tumor size >or= 10 cm or clinical suspicion of pelvic adhesions, were instead considered to be at intermediate risk and were scheduled for laparotomy. Some patients classified as high risk were scheduled for an operative laparoscopy by an expert in gynecological oncology.

RESULTS

One hundred and thirty-four (65.7%) masses were considered to be low risk and were treated by a laparoscopically guided procedure. All these tumors were benign. Forty-seven (23%) masses were classified as high risk, of which 39 tumors were malignant and eight benign. Twenty-three (11.3%) tumors were considered to be intermediate risk and were scheduled for primary laparotomy. In this group, 21 (91.3%) tumors proved to be benign and two (8.7%) were malignant.

CONCLUSIONS

Ultrasound-based triage of asymptomatic women diagnosed with a persistent adnexal mass is effective for selecting the surgical approach.

Laparoscopy compared with laparoscopically guided minilaparotomy for large adnexal masses: a randomized controlled trial

OBJECTIVE

To address the efficacy in terms of intraperitoneal spillage of laparoscopically guided minilaparotomy compared with operative laparoscopy for large adnexal cysts.

METHODS

A randomized controlled trial was carried out at a tertiary referral center from January 2005 to September 2006. Sixty eligible patients affected by nonendometriotic adnexal cysts with diameter between 7 and 18 cm were randomly assigned to either operative laparoscopy or laparoscopically guided minilaparotomy.

RESULTS

The relative risk for intraperitoneal spillage among women treated with laparoscopy was 5.55 (95% confidence interval 1.88-16.33). Operative times were significantly shorter in patients who underwent laparoscopically guided minilaparotomy. Surgical difficulty was significantly higher in patients treated with laparoscopy. However, postoperative stay was shorter.

CONCLUSION

Laparoscopically guided minilaparotomy, when compared with laparoscopy, is able to reduce intraperitoneal spillage in patients with presumably benign large adnexal masses, with minimal increase in patient short- and long-term discomfort. Because data regarding the importance of intraperitoneal spillage during surgery for benign and malignant pathologies, as well as rupture rates during traditional laparotomy, are scarce, traditional laparotomy still represents the standard treatment. In women desiring a minimally invasive strategy for large cysts, laparoscopically guided minilaparotomy should be considered.

CLINICAL TRIAL REGISTRATION

Australian Clinical Trials Registry, www.actr.org.au, ACTR N012607000241437,

LEVEL OF EVIDENCE

I.

Laparoscopic management of enlarged serous cystadenoma in advanced pregnancy

Operative laparoscopy is changing the methods of treatment of the acute abdomen in advanced pregnancy. Diagnostic capabilities in identification of benign disease are becoming more sensitive with the use of advanced imaging ultrasound scanning and magnetic resonance imaging. This has changed the deciding factors in the handling of advanced-size adnexal masses with minimally invasive techniques for the conservative management and treatment in advancing pregnancies. This case shows the successful removal of a 6198-g ovarian serous cystadenoma by use of minimally invasive techniques.

Ovarian surgery and follicular reserve

In patients with cystic ovarian pathology, such as endometriomas, polycystic ovary syndrome, teratomas or benign tumors, there is a tendency towards abnormal ovarian function. Anovulation and sterility may occur. This review will summarize the normal physiology of the female gonad and the development of oogenesis from initial reproductive age to the menopause. Furthermore, the interaction between ovarian pathology and endocrinology will be described. The main focus is on the technique of ovarian-preserving surgery by laparoscopy. In addition, alternative therapeutic approaches and screening tests will be discussed.

Laparoscopy in patients over 60 years old: a prospective, randomized evaluation of laparoscopic versus open adnexectomy

OBJECTIVE

To compare objective and subjective parameters of surgical stress following laparoscopic and open adnexectomy in patients older than 60 years old.

STUDY DESIGN

Twenty patients with a benign ovarian tumour were prospectively randomized to undergo adnexectomy by a laparoscopic or an open surgical procedure. Measurements included C-reactive protein; interleukin-6 before, during, and after surgery; intensity and duration of postoperative pain; and complications and recovery period. Statistical analysis consisted of analysis of variance and a Mann-Whitney U test.

RESULTS

The levels of the interleukin-6 and C-reactive protein differed significantly between the 2 operative procedures (P = .013) in favor of the laparoscopic approach. The laparoscopic approach was associated with a reduction in operative morbidity, postoperative pain, analgesic requirement, and recovery period.

CONCLUSIONS

Minimally invasive surgery is of particular benefit to elderly patients if there is a plan in place for appropriate staging and treatment by laparotomy for malignancy. It should be the first choice and may help to reduce postoperative complications.

Laparoscopy versus laparotomy for benign ovarian tumours

BACKGROUND

Over the last ten years laparoscopy has become an increasingly common approach for the surgical removal of benign ovarian tumours. There remains uncertainty as to the value of this intervention. This review has been undertaken to assess the available evidence for the benefits and harms of laparoscopic surgery for benign ovarian tumours compared to laparotomy.

OBJECTIVES

To determine the efficacy, safety and cost of laparoscopic surgery compared with laparotomy in women with ovarian tumours assumed to be benign.

SEARCH STRATEGY

We searched electronic databases, trials registers and reference lists of published trial reports. Review articles were also searched.

SELECTION CRITERIA

All randomised controlled trials comparing laparoscopy versus laparotomy for benign ovarian tumours.

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed each study's eligibility and quality and extracted data.

MAIN RESULTS

Six randomised controlled trials were identified involving 324 patients. Three subgroups of ovarian tumours were considered: any histological type of benign ovarian tumour, dermoid cysts and endometriomata. Surgical outcomes: The mean duration of surgery was longer in the laparoscopy group compared to the laparotomy group overall (WMD 11.39; 95% CI 0.57 to 22.22). However, heterogeneity was present with substantial inconsistency (I(2)=87%) . The heterogeneity found in these analyses was likely to reflect differences in the patient populations. Adverse effects of surgery: The pooled estimate for febrile morbidity decreased for laparoscopy compared to laparotomy (Peto OR 0.34; 95% CI 0.13 to 0.88). The odds of any adverse effect of surgery (total number of complications - surgical injury and/or post operative complications) were decreased after laparoscopic procedures (Peto OR 0.26; 95% CI 0.12 to 0.55). Short-term recovery: VAS pain scores favoured laparoscopy (WMD -2.36; 95% CI -2.07 to -2.03) andt he odds of being pain free were significantly greater for the laparoscopy group compared to laparotomy (Peto OR 7.35; 95% CI 4.3 to 12.56). Mean length of hospital stay was shorter in the laparoscopy group with reduction 2.79 days (95% CI -2.95 to -2.62) compared to laparotomy. Economic outcomes: There was a significant reduction of US$1045 (95% CI -1361 to -726.97) in the laparoscopy group compared to the laparotomy group in one trial of women with any type of benign ovarian tumour.

AUTHORS' CONCLUSIONS

In women undergoing surgery for benign ovarian tumours, laparoscopy is associated with a reduction in the following; febrile morbidity, urinary tract infection, post operative complications, post operative pain, days in hospital and total cost. These findings should be interpreted with caution as only a small number of studies were identified including a total of only 324 women and not all of the important outcomes were reported in each study.

Laparoscopic adnexectomy for benign tubo-ovarian disease using abdominal wall lift: a comparison to laparotomy

OBJECTIVES

To evaluate the results of laparoscopic adnexectomy using an abdominal wall-lifting device compared to laparotomy.

METHODS

From February 1997 to December 2001, laparoscopic adnexectomy was performed in 68 cases of benign diseases in a university hospital. Three cases (4.4%) were converted to laparotomy due to poor visualization. The control group was a similar cohort of 65 patients who underwent the same procedures using laparotomy.

RESULTS

There were 59 ovarian cysts and six tubal pregnancies in each group. Mean analgesic used, hospital stay, recovery period and blood loss were 11.5 mg, 2.0 days, 1.0 week and 49 ml, compared with 151.8 mg, 4.0 days, 3.0 weeks, and 122 ml in the laparotomy group (P<0.0005). Mean operating times and hospital charges were 81.7 min and 293.9 dollars (US), compared with 77.1 min (P=0.108) and 272.7 dollars (US) (P=0.033) in the laparotomy group. No serious complications were found in either group.

CONCLUSIONS

Gasless laparoscopic adnexectomy is a safe and effective technique to provide laparoscopic benefit with minimal increase in hospital charges.