4.2.1 Differential Diagnosis and Diagnosis

Ovarian cysts can be divided into two main categories: functional (physiologic) or pathologic. Functional cysts refer to ovarian cysts that develop as part of the normal ovulatory function of the ovary. Thus, depending on where a woman is during her menstrual cycle, functional cysts can include follicular or corpus luteum cysts. Almost all women will develop a functional cyst during their lifetime. Theca-lutein cysts are also functional cysts that can develop during pregnancy as a result of exposure to increasing levels of human chorionic gonadotropin. In contrast, pathologic ovarian cysts are not related to the menstrual cycle and are further subcategorized into benign or malignant entities [2,3] (Box 4.1). In women of reproductive age, almost all ovarian cysts are either functional or benign. The overall incidence of malignant transformation of benign ovarian cysts in premenopausal women is 1:1,000, increasing to 3:1,000 after age 50 [3].

Any evaluation of ovarian cysts must include a detailed medical history and thorough physical examination. Specific attention must be paid to any family history of endometriosis, breast or ovarian cancer. Symptoms such as nonspecific bloating, abdominal distention, unintentional weight loss, early satiety, or increased urinary frequency should alert the physician to the possibility of malignancy. Personal symptoms suggestive of endometriosis should also be accounted for. The physical examination should include palpation of the cervical, supraclavicular, axillary, and groin lymph nodes [2]. In addition to an abdominal and pelvic examination, a rectovaginal examination should be considered in women with symptoms of endometriosis. Of note, pelvic examination has a very poor sensitivity (<50%) for detecting ovarian cysts [4], and this is further reduced in patients with a body mass index (BMI) >30 kg/m².

Transvaginal ultrasonography (TVUS) of the pelvis is perhaps the single most effective modality for diagnosing ovarian cysts [3]. Ultrasonographic examination assesses the size, laterality, and characteristics of the cysts, including the presence or absence of papillary excrescences, septations, mural nodules, or pelvic ascites [2]. Benign cysts are typically simple in appearance, have thin smooth walls, lack solid components, are septated, demonstrate internal blood flow on color Doppler, and do not have a definitive cut-off for size [5]. Common benign cysts encountered in reproductive age women include simple cysts, serous or mucinous cystadenomas, endometriomas, and mature cystic teratomas. Endometriomas are characterized by ground glass echogenicity and one to four compartments without any papillary structures [6]. Mature cystic teratomas are associated with fat-fluid levels, diffuse high-amplitude echoes, and shadowing echogenicity [7]. Table 4.1 summarizes the sensitivity, specificity, positive predictive value, and negative predictive value of TVUS to diagnose functional ovarian cysts, endometriomas, and mature cystic teratomas [8].

Other imaging modalities such as computed tomography (CT) or magnetic resonance imaging (MRI) are not indicated for the initial evaluation of ovarian cysts but may occasionally be helpful to further elucidate the nature of the cysts after ultrasound imaging [2]. Finally, laboratory testing for tumor markers such as CA-125, lactate dehydrogenase, alpha-fetoprotein, or human chorionic gonadotropin are generally not indicated when ovarian cysts are simple, thin-walled, and <5 cm in diameter [9].

4.2.2 Management of Ovarian Cysts – See Ovarian Cystectomy Video

Simple ovarian cysts measuring <5 cm can be managed expectantly, as more than two-thirds of these cysts will regress spontaneously within three menstrual cycles [5,10]. Alternatively, combined oral contraceptives may be used to facilitate cyst regression and prevent new cyst formation [11]. Other medical adjuncts that can be used include progestins, gonadotropin-releasing hormone agonists, and antagonists. Ovarian cysts persisting after expectant and medical management may not be functional.

The decision to proceed with surgery depends on a number of factors. If the cyst is benign in appearance by imaging and asymptomatic, then expectant management may be pursued with close follow-up. If the cyst is >10 cm then surgery is typically recommended. Other considerations for surgical intervention include symptom relief and reducing the possibility of ovarian torsion, which would place the patient at risk of losing the ovary. Any cyst that has features indicative of malignancy by imaging and/or laboratory results should be addressed surgically by an appropriately trained surgeon.

Laparoscopic ovarian cystectomy is the preferred approach for the surgical management of benign ovarian cysts (see Video 4.1). Three 5 mm ports are commonly used – one in the umbilicus, one in the right lower quadrant, and one in the left lower quadrant. A 10 mm umbilical port may be used to facilitate removal of the specimen. The ovary is stabilized using graspers and dilute vasopressin (20 U/100 ml of injectable saline) is injected between the ovarian cortex and cyst wall to help develop the surgical plane by hydrodissection (Figure 4.1). This step also serves to aid hemostasis and minimize the need for electrocautery with potential thermal injury to the cortex.

Figure 4.1 Dilute vasopressin is injected between the ovarian cortex and cyst wall.

The ovarian cortex is incised down to the cyst wall with cold scissors, unipolar energy, or laser on the anti-mesenteric aspect to avoid damaging the vascular hilum (Figure 4.2). The incision should also be placed to avoid damage to the fimbria. It is important to preserve all of the ovarian cortex, even if it is stretched thin across a large cyst so as not to diminish the ovarian reserve. An elliptical incision that allows a portion of the ovarian cortex to be removed with the cyst should never be used. The incision should be made large enough to allow removal of the cyst from the ovary. It is important to recognize that all the oocytes are located in the ovarian cortex so care should be taken to avoid damage to the cortex by using excessive cautery or energy. After the cyst is identified, the cyst wall is separated from the ovary using a combination of blunt and sharp dissection. Blunt dissection is preferred and is easy if one is in the correct plane. Blunt dissection is accomplished by applying traction and countertraction with grasping instruments on the ovarian tissue and/or cyst wall to facilitate peeling the ovarian cortex off the cyst wall (Figures 4.3 and 4.4). Hydrodissection may also be helpful. Other techniques include grasping the ovarian cortex and rolling the instrument to roll the cortex off the cyst like a sardine can.

Figure 4.2 The ovarian cortex is incised with the unipolar hook to the cyst wall.

Figure 4.3 One edge of the ovarian cortex is grasped with an Allis while another Allis grasper is used to bluntly develop the plane between the ovary and the cyst.

Figure 4.4 The edge of the cortex is everted and held with the Allis as blunt dissection continues.

Care should be taken to keep the cyst intact in most cases (Figure 4.5). If the cyst ruptures, then trying to contain the cyst fluid in the posterior cul-de-sac is important, especially with a dermoid cyst, as postoperative chemical peritonitis may result. Copious irrigation with saline or lactated ringers should be used to remove all the cyst fluid. The fatty cyst contents will float to the surface of the irrigation used and are fairly easy to identify. Performing cystectomy within a containment system has been advocated to avoid spilling the cyst contents. In cases of very large cysts, decompressing the cyst by aspirating its contents can facilitate separating the cyst from the ovary. Simple cysts can be aspirated with a laparoscopic injection needle. To aspirate the thick contents of an endometrioma or dermoid cyst, a 5 mm opening is created to allow the suction or irrigator tube to be inserted into the cyst cavity.

Figure 4.5 The last attachments between the cyst and the ovary are bluntly separated.

Once the cyst is excised from the ovary (Figure 4.6), it is placed into an endoscopic retrieval bag through a 10 mm umbilical port and decompressed by suction aspiration if still intact (Figure 4.7). Enlarging the lateral ports requires facial closure with the risk of entrapment of the ilio-inguinal or ilio-hypogastric nerves leading to postoperative pain. Incisional hernias are also more common in lateral ports. A suprapubic port is a cosmetic location for tissue removal and the incision can be easily enlarged if needed. Care should be taken to avoid damage to the bladder.

Figure 4.6 The cyst has been removed intact.

Figure 4.7 The cyst is placed in an endo-catch bag for removal through the 10 mm umbilical port.

It is important to achieve excellent hemostasis following ovarian cystectomy. Excessive cautery of the ovary to achieve hemostasis post cystectomy risks damage to the ovary with diminished ovarian reserve and should be avoided. A key step during the cystectomy is to find the correct plane between the cyst and ovary. Dissecting in the correct plane during cyst removal decreases bleeding and ovarian trauma. Alternatively cauterizing bleeding vessels encountered during cystectomy can minimize need for use of cautery following removal.

To achieve hemostasis, bipolar energy is preferred over monopolar energy as it causes less thermal damage [1]. Coagulation should be used as sparingly as possible. If there is significant bleeding, typically seen at the base of the ovarian defect, then suture may be utilized to achieve hemostasis rather than cautery. If suture is used, then whole defect does not need to be closed, but only enough to achieve hemostasis. Studies that assessed AMH levels with bipolar cautery versus suturing for cystectomy yielded conflicting results with some studies showing a greater decline with cautery while others found no difference. Various hemostatic agents may also be utilized to limit the use of cautery.

The ovarian defect heals well without suture closure (Figure 4.8). Consideration should be given to reducing postoperative adhesion formation. Interceed is an absorbable sheet of oxidized regenerated cellulose which can be wrapped around the ovary at the completion of the case. It has been shown to result in significantly fewer adhesions and more adhesion-free ovaries following cystectomy for endometriomas. Unlike other anti-adhesion barriers such as Seprafilm and Gore-Tex, it is easy to apply laparoscopically, adheres without sutures, and is not permanent. Its limitation is that complete hemostasis must be achieved since blood renders the device ineffective. Icodextrin 4% solution is the only product approved by the FDA for adhesion prevention by laparoscopy. Unfortunately, it is minimally effective at best and may cause labial edema for several days as well as rare case reports of icodextrin leading to disseminated intravascular coagulopathy, pleural effusions, and peritoneal fibrosis.

Figure 4.8 After complete hemostasis is assured, the ovary is left to heal without suturing.

While the cystectomy procedure described earlier applies to cysts of all types, cystectomy for endometriomas may be more difficult as the cyst wall tends to be adherent to the ovary. In addition, dense ovarian adhesions to the uterus, bowel, and pelvic sidewall further increase the level of difficulty and surgical risk. For these reasons laparoscopic drainage with electrocoagulation or laser ablation of the cyst wall has been advocated as a simpler technique. A Cochrane review and subsequent meta-analysis indicated that laparoscopic cystectomy is associated with decreased recurrence of the endometrioma, decreased recurrence of pain, as well as higher rates of spontaneous conception compared to laparoscopic drainage and ablation of the cyst wall. However, cystectomy is associated with a significant reduction in ovarian reserve. The reduction is greater with bilateral and larger cysts. It is also greater for endometriomas compared to other benign cysts. This is likely due to endometriomas being more adherent to the ovary as mentioned above. As a result, significantly more normal ovarian tissue is removed during cystectomy for endometriomas vs non-endometrioma cysts. Furthermore, ovaries containing endometriomas have been shown to have a lower follicle density compared with non-endometrioma cysts. In fact, preoperative anti-müllerian hormone levels are lower in women with endometriomas. Another reason to favor cystectomy for endometriomas is to obtain a definitive tissue diagnosis as women with endometriomas have a significantly higher incidence of ovarian cancer, especially clear cell and endometrioid adenocarcinomas.

Some have proposed removing endometriomas prior to in vitro fertilization (IVF) to improve the ovarian response to stimulation, facilitate follicle monitoring and oocyte retrieval, reduce the risk of abscess if the endometrioma is punctured with the aspiration needle, and to avoid contamination of the endometrioma contents with follicular fluid. However, systematic reviews found no significant differences in the number of mature oocytes or the clinical pregnancy rates whether the endometriomas were removed or not prior to IVF. The practice guidelines from the American Society for Reproductive Medicine and the European Society of Human Reproductive and Embryology state that endometriomas, particularly those with a mean diameter below 4 cm, should not be systematically removed before IVF.

4.3.1 Diagnosis

The diagnosis of ovarian torsion is a clinical diagnosis made by assessing the patient’s history, physical exam, laboratory findings, and imaging. One cannot rely purely on imaging to make the diagnosis. Definitive diagnosis is made at laparoscopy. If the diagnosis is missed, the ovary may necrose with loss of function and potential negative implications for fertility. The key is to make the diagnosis before the blood flow to the ovary is compromised.

During torsion, compression of the ovarian vessels occurs. Venous and lymphatic outflow are compromised first, resulting in ovarian edema, which can then compress the thicker arterial walls [34]. Once arterial blood flow is compromised, the ovary undergoes progressive ischemia leading to possible necrosis, hemorrhage, infection, or peritonitis [34]. Depending on the progression of ovarian edema and/or ischemia, patients may present with acute unilateral abdominal or pelvic pain. The pain may radiate to the lumbo-sacral region and increase in duration and severity [37]. In up to 70% of the cases, ovarian torsion may be associated with nausea and vomiting [40]. Fever, flank pain, or generalized peritoneal signs can be present in a subset of patients. Given these signs and symptoms, a broad differential diagnosis, including appendicitis, nephrolithiasis, pelvic inflammatory disease, ectopic pregnancy, mesenteric lymphadenitis, and gastroenteritis, should be considered [35].

Physical examination may reveal a low-grade fever and mild tachycardia [35,37]. A unilateral palpable and tender adnexal mass may indicate ovarian torsion [37]. Abdominal exam may reveal peritoneal signs such as guarding or rebound. Most routine laboratory tests are normal, although occasional leukocytosis or sterile pyuria may be noted. Pelvic ultrasound is the most commonly utilized diagnostic modality in patients with suspected ovarian torsion [34,41]. Unilateral ovarian enlargement is generally seen in most patients with ovarian torsion. Other ultrasonographic signs include ovarian edema, pelvic-free fluid, and peripheral follicles in the torsed ovary [35,41]. The affected ovary may deviate to the side of the torsion and can lie medially and above its usual location [35]. Doppler imaging is frequently used in conjunction with US to improve its diagnostic accuracy. Studies have indicated that ovarian enlargement and the absence of ovarian venous Doppler flow are perhaps the most precise indicators of ovarian torsion [41,42]. Yet, most patients with ovarian torsion actually have ovarian enlargement with arterial and venous Doppler flow [41]. Thus, normal Doppler flow studies cannot exclude the diagnosis of ovarian torsion as they may reflect partial torsion [37,41]. It is also important to note that the diagnostic accuracy of US and Doppler imaging is largely affected by the ultrasound operator as well [42]. The use of CT and MRI have also been described in some special circumstances [43].

4.3.2 Treatment Considerations and Methods

Definitive diagnosis and treatment of ovarian torsion is achieved surgically, most often via laparoscopy [37]. Concomitant treatment of ovarian pathology should be considered during the definitive treatment of ovarian torsion as well.

4.3.2.2 Intraoperative Procedure

Treatment of ovarian torsion begins with diagnostic laparoscopy. Depending on the size of ovary and surgeon preference, a conventional three-port setup (5–12 mm) can be used. Simple untwisting of an ovary and/or fallopian tube can be performed with a blunt probe or nontraumatic laparoscopic instrument (Figures 4.9–4.11). Although initial adopters of this technique were concerned about the theoretical risk of dislodging and spreading vascular emboli [35,37], studies have shown that the risk of pulmonary emboli associated with de-torsion is approximately 0.2% [45]. Of note, many gynecologic surgeons may be dissuaded from simply untwisting a dark-blue or necrotic-looking ovary. However, most ischemic-appearing ovaries are found to have normal appearance, Doppler flow, and follicular development 6 weeks after de-torsion [34,46]. Although simple de-torsion with ovarian cyst aspiration has been described in some situations, such a management strategy is associated with higher rate of recurrence and surgical re-intervention [47]. Thus, most providers concur that ovarian cystectomy at the time of de-torsion is the ideal treatment strategy, albeit loss of tissue planes may occur due to ovarian edema [34,35,37].

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3. Chapter 11 – The Role of Robotics in Reproductive Surgery
4. Chapter 13 – Varicocele Repair

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