What is the recommended treatment for an ovarian dermoid cyst?

Management of Ovarian Dermoid Cysts

Fertility-sparing surgery is the recommended treatment for ovarian dermoid cysts, with laparoscopic cystectomy being the preferred approach for most patients. 1

Diagnosis and Characteristics

• Dermoid cysts (mature teratomas) are the most common benign ovarian tumors, accounting for approximately 20% of all ovarian tumors 1
• They typically present with characteristic imaging features including fatty and calciferous content, hair, teeth, and cartilage that are pathognomonic on MRI 1
• Diagnosis is primarily made through imaging studies (ultrasound, MRI, CT) with ultrasound showing hyperechoic components with acoustic shadowing 1

Treatment Algorithm

Initial Management Based on Patient Characteristics

• For premenopausal patients with cysts <10 cm and asymptomatic:

  • Optional initial follow-up at 8-12 weeks to confirm diagnosis 1
  • Annual ultrasound surveillance if not surgically removed 1

• For postmenopausal patients with cysts <10 cm and confident diagnosis:

  • Annual ultrasound follow-up if not surgically excised 1
  • Higher vigilance is required due to increased risk of malignant transformation 1

Surgical Indications

Surgical removal is indicated for:

• Cysts >10 cm in size 1
• Changing morphology or developing vascular components 1
• Symptomatic cysts (pain, pressure, etc.) 1
• Risk of complications (torsion, rupture) 2

Surgical Approach

• Premenopausal women: Fertility-sparing surgery (ovarian cystectomy) is recommended 3, 1
• Postmenopausal women: Hysterectomy and bilateral salpingo-oophorectomy may be considered 1

Laparoscopic Technique

• Laparoscopic cystectomy is the preferred surgical approach with several advantages 2, 4:

  • Shorter hospital stay (mean 4.05 days vs. 6.96 days for open surgery) 2
  • Quicker recovery 2
  • Better cosmetic results 2
  • Preservation of ovarian tissue 5

• Specific laparoscopic techniques include:

  • Combination of hydrodissection and blunt dissection for maximum tissue sparing 5
  • Use of endoscopic impermeable sack for intact cyst extraction to prevent spillage 6
  • Thorough peritoneal washing if spillage occurs 4

Special Considerations

• In cases of dermoid cysts with malignant transformation (rare), more aggressive surgical management is required 1
• Vaginal approach with laparoscopic assistance may be considered as an alternative to total laparoscopic removal in selected cases 7
• Drainage of peritoneal cavity should be performed in patients with ruptured dermoid cysts to prevent chemical peritonitis 4

Follow-up Recommendations

• For conservatively managed cysts, follow-up imaging should be performed in 8-12 weeks to assess for stability or regression 8
• Annual ultrasound surveillance is recommended for patients with unresected dermoid cysts 1

Common Pitfalls and Caveats

• Risk of chemical peritonitis from cyst content spillage can be minimized with proper surgical technique including thorough peritoneal washing 4
• Even when the cyst seems to fill the entire ovary with no visible surrounding cortex on ultrasound, laparoscopic cystectomy with tissue preservation is still possible 5
• Recurrence rate after conservative treatment is approximately 4%, highlighting the importance of follow-up 6