What are the next steps in managing a patient with a history of hysterectomy and left oophorectomy with an unobserved right ovary but no focal lesion?

Management of Post-Hysterectomy Patient with Unobserved Right Ovary

A transvaginal ultrasound should be performed to better visualize the right ovary and assess for any potential pathology.

Background and Risk Assessment

The patient has undergone hysterectomy and left oophorectomy, with the right ovary described as "not accurately seen" on imaging, measuring approximately 2.19 x 1.52 cm. While no focal lesion is noted, incomplete visualization of the remaining ovary warrants further evaluation.

Key Considerations:

• Post-hysterectomy patients with retained ovaries have a significant risk of developing ovarian pathology requiring reoperation (residual ovary syndrome)
• The incidence of residual ovary syndrome is approximately 2.85%, with most cases occurring within the first 5-10 years after hysterectomy 1
• Studies show that approximately 50.7% of women with retained ovaries after hysterectomy develop pelvic lesions on follow-up imaging 2
• The presence of ovarian follicles in postmenopausal women is particularly concerning and requires thorough evaluation 3

Recommended Management Algorithm

1. Immediate Next Step: Transvaginal Ultrasound

   • Provides better visualization of the right ovary
   • Allows assessment of specific concerning features including:
     • Ovarian size and volume (>10 ml is concerning)
     • Presence of solid components or papillary projections
     • Multilocular appearance
     • Irregular walls
     • Vascularity assessment with color Doppler 3

2. If Ovary Is Well-Visualized and Normal on Transvaginal Ultrasound:

   • Schedule regular gynecologic follow-up every 6-12 months
   • Regular gynecologic follow-up is recommended for all women after hysterectomy 4
   • Longer follow-up intervals may be appropriate for women who have had a total hysterectomy and oophorectomy 4

3. If Ovary Remains Poorly Visualized or Shows Concerning Features:

   • Proceed to pelvic MRI for further characterization
   • MRI provides superior soft tissue contrast and can better characterize ovarian pathology 4

4. If Concerning Features Are Identified:

   • Refer to gynecologic oncology for surgical evaluation
   • Consider completion surgery (right oophorectomy) 4
   • After completion of childbearing in patients who underwent unilateral salpingo-oophorectomy (USO), completion surgery should be considered 4

Special Considerations

Age-Related Factors:

• If the patient is premenopausal and <45 years old: Ovarian preservation may be reasonable if no concerning features are identified
• If the patient is >45 years old or postmenopausal: Consider completion oophorectomy due to increased risk of residual ovary syndrome 1

Risk of Residual Ovary Syndrome:

• 71.3% of patients with residual ovary syndrome present with chronic pelvic pain
• 24.6% present with asymptomatic pelvic masses found during routine follow-up
• Histological examination reveals functional cysts (50.7%), benign neoplasms (42.6%), and ovarian carcinoma (12.3%) 1

Potential Complications:

• Retained ovaries after hysterectomy can develop various pathologies including:
  • Functional cysts
  • Benign neoplasms
  • Malignant transformation
  • Ovarian torsion (rare but possible even after oophoropexy) 5

Follow-up Recommendations

• If ovary is preserved: Regular gynecologic examinations every 6-12 months
• Consider CA-125 or other tumor markers if clinically indicated, though their routine use is not recommended for surveillance 4
• Patient education regarding symptoms that should prompt evaluation:
  • New pelvic or abdominal pain
  • Bloating or abdominal distension
  • Changes in bowel or bladder habits

By following this algorithm, you can ensure appropriate monitoring and timely intervention for this patient with a partially visualized right ovary after hysterectomy and left oophorectomy.