Ovarian Cystectomy
Sharon Sutherland
General Principles
Definition
An ovarian cyst is a fluid-filled sac located on the surface or within the wall of the ovary. Simple cysts contain serous fluid with no opacities or solid elements, whereas complex cysts contain semisolid or solid elements.
Differential Diagnosis
Benign ovarian: functional cyst, endometrioma, mature teratoma, serous cystadenoma, mucinous cystadenoma.
Benign tubal: tubo-ovarian abscess, ectopic pregnancy, hydrosalpinx, paratubal cyst.
Malignant ovarian: germ cell tumor, sex cord–stromal cell tumor, epithelial carcinoma of ovary or fallopian tube, metastatic tumors.
Nongynecologic: diverticular or appendiceal abscess or mucocele, bladder or urethral diverticulum, peritoneal inclusion cyst.
Anatomic Considerations
Major considerations in planning the surgical approach include patient habitus, history of prior abdominal or pelvic surgery, and comorbidities predictive of pelvic adhesive disease and risk of intraoperative injury to adjacent structures.
Most patients, including those who are morbidly obese, are good candidates for minimally invasive surgery if there is a low suspicion for ovarian malignancy. Laparoscopic ovarian cystectomy with or without robotic assistance has been shown to reduce postoperative morbidity and recovery time compared to laparotomy.
Nonoperative Management
Asymptomatic simple cysts up to 10 cm in diameter, coupled with a normal CA125 level, may be expectantly managed, even in postmenopausal patients.1
Symptoms that may be related to an ovarian cyst include pelvic or lower back pain, dyspareunia, abdominal distension, and urinary frequency or urgency. For patients with mild symptoms, conservative management may include pelvic rest and over-the-counter analgesics.
Most functional cysts, including corpus luteum, theca lutein cysts, and ovarian follicular cysts, may have increased vascularity, internal lace-like patterns, multilocular components, or they may be thin walled and unilocular.2 Fortunately, they usually spontaneously resolve within 3 months. For patients presenting with symptomatic functional cysts, ovulation suppression with combination oral contraceptives may reduce the frequency of functional cysts and associated symptoms; however, oral contraceptives have not been shown to accelerate the resolution of existing functional ovarian cysts.3
For patients with symptomatic, multiple functional cysts due to infertility treatment, ultrasound-guided cyst aspiration may be used to reduce symptoms pending the natural resolution of the cysts.
Percutaneous drainage of cysts per ultrasound guidance is generally not effective in long-term resolution of nonfunctional cysts, and may be complicated by hemorrhage and injury to adjacent structures.1
The most common benign complex cysts are mature teratomas or dermoid cysts and ovarian endometriomas. For detailed management of an ovarian endometrioma, see Chapter 12.
In asymptomatic women with ultrasound findings that are pathognomonic for dermoid cysts,2 expectant management may be offered if there are no other circumstances or signs that indicate risk for malignancy.4 In a study of women who were expectantly managed, over 75% were followed without need for surgery for a median period of 12.6 months. Ovarian cystectomy was more likely undertaken in younger women, women of increasing parity, past history of ovarian cyst, bilateral ovarian cysts, or larger size of ovarian cyst.4
When there is a high suspicion for malignancy, a careful presurgical evaluation should include an assessment of the patient’s genetic risk, imaging studies, and serum tumor markers.
Ovarian cystectomy is contraindicated if a mass is suspicious for cancer based on transvaginal ultrasound findings, CA125 levels, and/or clinical assessment. For suspected malignancy in women desiring fertility, preoperative or intraoperative consultation with gynecologic oncology as well as with an infertility specialist is recommended to optimize patient’s treatment and to preserve fertility when possible.
Imaging and Other Diagnostics
Transvaginal ultrasound is the primary modality for evaluation of ovarian cysts. Management of an asymptomatic cyst is largely based on ultrasound findings, which include the size and echotexture of the ovarian cyst, laterality, and any signs that increase likelihood of malignancy, such as thick (greater than 3 mm) septations, mural nodules, irregular borders, complex internal elements with Doppler flow, and free fluid in the pelvis. Unilocular cysts with thin walls, regular borders, and no internal echoes are very likely to be benign.
CT and MRI of the pelvis should not be used routinely. They should be reserved for evaluating the pelvis for metastatic disease or to determine the etiology of nonovarian adnexal masses, such as pedunculated leiomyomata.
Tumor markers: CA125 may be helpful in preoperative evaluation of ovarian cysts particularly in postmenopausal patients. A normal value for CA125 is less than 35 units/mL. CA125 is elevated in 80% of patients with epithelial ovarian cancer but is normal in 50% of patients with ovarian cancer isolated to the ovary. The specificity of CA125 for ovarian malignancy is lower in patients of reproductive age, as CA125 may be elevated in benign conditions such as endometriosis and pelvic infection as well as in nongynecologic inflammatory conditions. The specificity and sensitivity of CA125 are the highest among postmenopausal women with an adnexal mass. Other tumor markers that may be helpful include quantitative beta human chorionic gonadotropin (beta-hCG), lactate dehydrogenase (LDH), and alpha-fetoprotein (AFP). Elevations in these markers may indicate increased risk for germ cell tumors, while elevation in inhibin A and B may indicate increased risk for granulosa cell tumor.
Cervical cultures: For patients presenting with pelvic pain suspicious for pelvic inflammatory disease, cultures should be collected and empiric antibiotic therapy is recommended per CDC guidelines. Surgical exploration may be necessary in patients with suspected tubo-ovarian abscess who do not improve clinically with conservative management.
For patients with suspected ectopic pregnancy based on menstrual history, imaging, and laboratory studies, evaluation should be undertaken for possible medical management, with surgical management reserved for those who are unstable or who do not meet criteria for medical management.
Preoperative Planning
A medical history should include information about menstrual pattern, contraceptive use, pregnancy, and gynecologic conditions including sexually transmitted diseases. A history of gastrointestinal, breast, or other pelvic malignancy may indicate a risk of metastasis to the ovary. Advancing age and menopausal status increase the risk of malignancy in women with adnexal masses.1
A surgical history should include specific detail about prior abdominal and/or pelvic surgeries as well as anesthesia complications or concerns.
A family history should include specific detail about gynecologic, urologic, breast, and gastrointestinal cancers, and referral to medical genetics should be considered if there is suspicion that patient may be at risk for heritable cancers.
Prior to surgery, the patient should be counseled:
About nonoperative as well as operative treatments for her clinical situation. In general, ovarian cystectomy should not be first-line treatment for women of reproductive age with functional cysts unless there is suspicion for ovarian torsion or the patient has failed conservative management.
About the risks of surgery, which include anesthesia complications, hemorrhage and need for blood products, infection, intraoperative injury to gastrointestinal, genitourinary, vascular and neural structures, and unplanned oophorectomy and/or salpingectomy with potential impact on fertility.
Conversion to laparotomy may be needed to complete the procedure safely, and its effect on her postoperative course.
Incorrect laterality assigned in imaging reports occurs; therefore, the patient should be consented about this possibility and for removal of the affected adnexal cyst.
Ovarian cystectomy may require conversion to oophorectomy with or without salpingectomy if there is uncontrollable bleeding, suspected malignancy, abscess, or necrosis.
About the possibility of malignancy and any plan for intraoperative or delayed evaluation by a gynecologic or surgical oncologist in the event of malignancy. Unless there is a surgical emergency, primary excision of suspected ovarian malignancy should be undertaken by a surgeon with specialized training in evaluation and management of gynecologic cancers.
There is a potential to decrease fertility after cystectomy especially for endometriomas due to excessive use of electrosurgery or inadvertent removal of normal tissue.
Patients with significant comorbidities should undergo preoperative medical and anesthesia evaluation. For patients with significant comorbidities, surgery may need to be delayed to allow for proper preoperative optimization.
Oophorectomy should be considered in perimenopausal and postmenopausal women undergoing surgery for ovarian cysts due to increased risk of malignancy with advancing age and as well as risk of recurrence of benign ovarian cysts.
Surgical Management
Ovarian cystectomy is the treatment of choice for symptomatic benign-appearing cysts in women of reproductive age that do not resolve with conservative management.
Approach
Laparoscopic approach is the gold-standard approach for suspected benign ovarian cystectomy.
Laparotomy should be undertaken as clinically indicated due to large mass size, high suspicion for malignancy or known extensive adhesive disease, and other factors, such as combined cases for colorectal disease. Laparotomy should be the approach of choice if the surgical team has insufficient equipment, training, skill, and/or experience to safely attempt minimally invasive surgery.
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