Ovarian Remnant
Swapna Kollikonda
General Principles
Definition
Ovarian remnant syndrome (ORS) is the condition of persistent, histologically confirmed ovarian cortical tissue, in patients who have undergone oophorectomy. Kaufmann reported ORS in 1962 and it was described in 1970 by Shemwell and Weed.
Follicular cyst, endometriosis, corpus luteum, serous cystadenoma, adenocarcinoma, clear cell carcinoma, and endometrioid carcinoma can exist in the ovarian remnant.
Risk factors leading to ORS include poor surgical technique, altered pelvic anatomy secondary to adhesions from previous surgery, endometriosis, pelvic inflammatory disease, ruptured appendix, and inflammatory bowel disease. Increased incidence of ORS after laparoscopic oophorectomy may be because of improper use of looped suture ligatures or the linear stapler as per small study done by Nezhat et al.7 Morcellation technique also contributed to increased risk by incomplete extraction of ovarian fragments resulting in implantation of ovarian tissue at different sites.
Growing awareness and advanced imaging technology led to an increased detection of these cases.
As there is a rise in laparoscopic ovarian surgeries, ovarian tissues can be implanted to port sites, anterior abdominal wall, and other abdominal organs leading to ORS.
Usually, remnant ovarian tissue is encased in the scar tissue from prior surgeries, endometriosis, or PID. Expansion of this tissue can lead to chronic pain which is one of the
common presenting symptoms. Ovarian remnants can be found in 18% of patients with pelvic pain after oophorectomy.1 Other less common presenting symptoms are pelvic mass, back pain, variable bowel symptoms, and ureteric compression symptoms. Symptoms usually start 1 to 3 years after oophorectomy.
Differential Diagnosis
Residual ovary syndrome (secondary to retained ovary)
Supernumerary ovaries (the development of extra ovaries during embryogenesis through the arrest of migrating gonocytes that contain ovarian follicle tissue)
The most important concept in the differential diagnosis is to exclude other causes of chronic pelvic pain such as painful bladder syndrome, myofascial pelvic floor disorders, and irritable bowel syndrome.
Anatomic Considerations
The ovarian remnant can also be found adherent to the lateral pelvic wall (most common), vaginal vault, bladder, bowel wall, ureter, or uterosacral ligament.
Nonoperative Management
Suppression of ovarian tissue is the mainstay of treatment. This can be done by giving gonadotropin-releasing hormone analogues, danazol, birth control pills, depot medroxyprogesterone acetate injection, or etonogestrel implant. Levonorgestrel IUD can be considered if uterus is still present. None of these methods have been shown to be superior to other.
Irradiation has also been used but is least favorable because of the risk of damage to surrounding tissue.
Imaging and Other Diagnostics
Occasionally on pelvic examination we can palpate adnexal mass suggestive of ovarian remnant which needs to be confirmed by further imaging studies.
Transvaginal ultrasound is the main stay and cost-effective modality of imaging.
CT and MRI sometimes may help for preoperative preparation if the ovarian remnant is near to ureters, bladder, and bowel, or if ultrasound findings are inconclusive.
FSH and estradiol levels can also supplement the diagnosis along with the imaging studies. The level of FSH and estradiol should be in premenopausal range (FSH <40 mIU/mL and estradiol >30 pg/mL). If patient is on hormone replacement therapy, stop estrogen at least 10 days prior to testing these hormone levels.
Gonadotropin-releasing hormone analogue stimulation test is also helpful to diagnose the condition with an elevation of estradiol levels from day 1 to day 4 after receiving 3 days of leuprolide acetate (1 mg SC/d).
Preoperative Planning
Intraoperative laparoscopic ultrasonography8 may be helpful in detecting ovarian remnants especially in patients with distorted pelvic anatomy.
Administration of clomiphene citrate (50 to 100 mg twice daily for 10 days) may help to make the ovarian tissue more prominent.
Preoperative pyelography may also define status of ureter and can predict surgical obstacles.
An informed consent should be obtained explaining all possible risks such as but not limited to infection, hemorrhage, injury to visceral organs, and major blood vessels. The consent should also include procedures such as resection of involved intra-abdominal organs with repair.
Cystoscopy is indicated if ovarian remnant is near to bladder or requiring extensive ureterolysis and dissection of bladder. Administration of methylene blue or indigo carmine or sodium fluorescein will help visualization of ureteral jets during intraoperative cystoscopy.
Surgical Management
Surgery is often mainstay of treatment because of side effects or inadequate response to medical therapy or if medical management is contraindicated or ovarian remnant is causing obstructive symptoms to urinary and gastrointestinal systems or any suspicion of ovarian cancer in the ovarian remnant.6
Laparotomy, laparoscopy, or robotic-assisted laparoscopic routes have been used.
Laparoscopy has been shown to be equally effective as laparotomy. There are advantages to laparoscopy as the magnification provided by the laparoscope through high-definition video technology, facilitates micro-dissection of tissue planes and easier identification of the remnant tissue. Increased intra-abdominal pressure helps decreasing the oozing of blood from the dissection and allows superior visualization of the retroperitoneal space.3 In patients with multiple previous surgeries, laparoscopic approach may be less traumatic.
Robotic-assisted surgery provides 3D view for adhesiolysis. Robotics also provides more magnification and flexibility of instruments but disadvantages include lack of tactile sensation and cost.
Positioning
Lithotomy position in Allen stirrups is preferable for both laparotomy and laparoscopic approach. Proper positioning is important to avoid any nerve injuries.
Arms should be tucked to patient’s side in military position, semi-pronated, with adequate padding placement around bony prominences especially the elbows and wrists. It is important to avoid too much of abduction at shoulders to prevent brachial plexus injury.
Adequate restraints should be placed around chest.
Buttocks should be well supported at the edge of the table. Hips should be flexed to not more than 90 degrees at thigh and abducted to not more than 45 degrees to avoid obturator, sciatic, and femoral nerve injury. Appropriate padding is needed on lateral side of knee to avoid compression injury of common peroneal nerve. Knee should be flexed to 90 degrees with slight adduction. Feet also need good support with padding.
Once the uterine manipulator is placed, the stirrups can be brought down to make thighs and abdomen at the same level, knees flexed to 90 degrees and thighs adducted in order to facilitate flexible movements of instrument.
Assistants should avoid leaning on to the suspended inferior extremities during the surgery.
Table should be kept flat for initial entry ports and then changed to Trendelenburg (less than 30 degrees) position for accessory ports.
Use anti-skid methods such as vacuum beanbag, gel pad, etc. can be used to decrease movement during Trendelenburg position.
Approach
Goal of surgical approach is high ligation of infundibulopelvic ligament after identifying and lateralizing the ureter by opening the retroperitoneal space and developing the para-rectal space.
Entry into the retroperitoneal space can be achieved by the following two techniques:
The peritoneum next to the round ligament is cut and the space entered.
The second is to start at the pelvic brim under the ovarian vessels. The peritoneum is grasped, incised and the space entered.
With either approach the ureter is identified and dissected from the pelvic brim to the level where the uterine artery crosses. Complete dissection of the ureter allows hemostasis to safely be achieved around the remnant dissection. The para-rectal space is identified with the ureter laterally, the rectum and mesorectum medially, and the pelvic floor at its base.
The visible ovarian remnant should be removed along with surrounding healthy tissue to avoid any recurrence.
In a study done by Fennimore et al.,2 ovarian stroma extends up to 1.4 cm into infundibulopelvic ligament. So, isolating infundibulopelvic ligament at least 2 cm from ovarian tissue to clamp and cut plays a key role in prevention.
Ovarian Remnant Excision (Video 11.3)
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