Surgical Techniques: Vaginal 4.3.2.1 Vaginal Salpingo-Oophorectomy
Aims and Methods
Vaginal removal of the adnexa is not a separate operation but is performed with vaginal hysterectomy (Chapter 5.3.2.7). Whether the adnexa, and especially the ovaries, are removed depends on the indication for surgery and the patient′s age and menopausal status. In post- or perimenopausal patients, the decision is almost entirely up to the patient, who should be provided with detailed information and counseling by her gynecologist. The question of whether and to what extent the ovaries still have a relevant endocrine function after estrogen and progesterone production has ceased is controversial. Some authors point to the undoubted continued production of testosterone and its importance for libido and sense of self in general. There are obvious major individual differences in both the objective and subjective relevance of this knowledge.
Indications and Contraindications
Indications
An example of an indication for salpingo-oophorectomy as part of a vaginal hysterectomy is endometrial carcinoma, when the ovaries should be removed as they are an early site of predilection for metastases. In early carcinoma of the cervix (stages IA and I B1), the rate of ovarian metastasis is less than 1% (squamous epithelial carcinoma) and less than 2% (adenocarcinoma), so that the ovaries can be left in an obviously premenopausal patient. As most oncologic surgery is performed via laparotomy or laparoscopy, this question arises only rarely with vaginal hysterectomy. The decision should also be discussed in detail with the patient when malignant disease is present. Laparoscopic lymphadenectomy usually provides an opportunity to assess the ovaries and if necessary obtain representative biopsies. In this situation, removal of the adnexa should be advised in the perimenopausal or postmenopausal patient. The premenopausal patient with a personal history or high-risk family history of breast cancer and ovarian cancer represents a special case. These points should always be enquired about and discussed in preparation for surgery. Depending on the patient′s age and wishes, “therapeutic” (for hormone-sensitive breast cancer) or prophylactic adnexectomy can be performed. It should be noted that this refers to management of the adnexa when hysterectomy is indicated.
Contraindications
Adnexectomy is contraindicated in young premenopausal women and in all women who have not given express consent beforehand. Whether adnexectomy should be performed in postmenopausal women is controversial. Studies do not demonstrate any survival advantage with prophylactic adnexectomy. Every gynecologic oncologist can recall an ovarian cancer in a 60-year-old patient who had hysterectomy (without adnexectomy) 5 years previously. And every gynecologic surgeon is familiar with the special challenges of an adnexal tumor, particularly on the left side, following hysterectomy (without adnexectomy).
Operation Risks and Informed Consent
Overall, the risks of the operation are not significantly increased by the adnexectomy. In individual cases, it can be difficult to remove very atrophic ovaries displaced out of the pelvis. In these cases, the indication for adnexectomy should be re-examined. Accordingly, a preoperative agreement is often made with the patient to remove the adnexa “if this can be done without difficulty.” The specific risks of vaginal adnexectomy are, in particular, injury to the ureter, which runs posterior to the infundibulopelvic ligament, and immediate or postoperative hemorrhage from a retracted or inadequately ligated infundibulopelvic ligament. The informed consent should document the discussion and decision on whether the hysterectomy is to be performed with or without adnexectomy.
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