What is the recommended treatment for a complex cystic mass in the adnexal (adnexa of the uterus) area?

Treatment of Complex Cystic Adnexal Masses

For complex cystic adnexal masses, surgical management via laparoscopic cystectomy or adnexectomy is the definitive treatment, with the specific approach determined by ultrasound characteristics, CA-125 levels, patient age, and fertility desires. 1

Initial Risk Stratification

The first critical step is determining malignancy risk through imaging and biomarkers:

• Ultrasound features suggesting benign disease include: cysts <10 cm, distinct borders, no irregular solid components, thin septa (<3 mm with ≤3 partitions), thin wall (<3 mm), absence of vegetations, and normal Doppler flow 1, 2
• Measure serum CA-125: Normal values (<35 U/mL) combined with benign ultrasound features have a 100% negative predictive value for malignancy in postmenopausal women 3, 4
• MRI with diffusion-weighted sequences can be added when ultrasound is indeterminate, achieving 95% accuracy in distinguishing benign from malignant lesions 1

Treatment Algorithm by Patient Category

Premenopausal Women

For complex cysts <10 cm with benign features:

• Laparoscopic cystectomy is preferred to preserve ovarian tissue and fertility 5
• Annual surveillance is an alternative if surgery is declined, though younger women should proceed directly to surgical removal 5
• Laparoscopy offers shorter hospital stays, less postoperative pain, and faster return to normal activity (mean 5 days) 4, 6

For complex cysts ≥10 cm:

• Surgical removal is mandatory due to increased technical difficulty and torsion risk 5
• Laparoscopy-assisted cystectomy is feasible for cysts 10-20 cm with mean operative time of 48 minutes and hospital stay of 1.5 days 6

Postmenopausal Women

For non-complex cysts with normal CA-125:

• Laparoscopic bilateral oophorectomy is the preferred procedure, with 100% positive predictive value for benign disease when selection criteria are met 3
• Mean operative time is 70 minutes with 12-hour hospital stay 4

For complex cysts or elevated CA-125:

• Exploratory laparotomy is indicated, as 30.7% of these cases harbor malignancy 3

Pregnant Women

Surgical intervention is indicated when:

• Symptoms develop (pain, torsion)
• Mass is ≥5 cm and persists beyond first trimester
• Suspicion of malignancy exists 1

Laparoscopic approach is preferred over laparotomy with demonstrated benefits including shorter hospital stays, less pain, lower blood loss, and reduced risks of fetal loss and preterm birth 1

Critical technical considerations for pregnancy:

• Left lateral decubitus positioning after first trimester 1
• Insufflation pressure ≤12-15 mm Hg (maximum 20-25 mm Hg only during port placement) 1
• Port placement adjusted for fundal height using ultrasound guidance 1
• Intraoperative capnography monitoring 1
• Pre- and postoperative fetal heart rate monitoring for viable fetuses 1
• Venous thromboembolism prophylaxis with low-molecular-weight heparin 1
• Do not delay necessary surgery based on gestational age 1

Intraoperative Management

Laparoscopic technique must include:

• Peritoneal cytology collection 7
• Thorough inspection of ovaries, peritoneum, and abdomen 7, 2
• Use of extraction pouch to prevent spillage 2
• If malignancy suspected: immediate conversion to laparotomy via vertical midline incision 7, 2

The laparoscopic diagnosis of malignancy has 100% sensitivity and 100% negative predictive value when performed with strict guidelines 7

Common Pitfalls to Avoid

• Do not perform laparoscopy if ultrasound shows irregular solid components, thick septa (>3 mm), ascites, matted bowel, or CA-125 is elevated—these require laparotomy 1, 3, 2
• Avoid intraperitoneal rupture of cyst contents; convert to laparotomy if rupture risk is high 2
• Do not use routine tocolytics in pregnant patients undergoing surgery 1
• Instrument cleaning and trocar tract treatment with cytotoxic agents (chlorhexidine or povidone-iodine) is essential if malignancy is discovered 2

Specific Histologic Subtypes

Dermoid cysts (most common requiring surgery at 32%):

• Diagnosed by echogenic attenuating components with macroscopic fat and calcifications on ultrasound 1, 5
• Laparoscopic cystectomy is definitive treatment 5

Endometriomas (15% of surgical cases):

• Identified by low-level internal echoes and nonvascular solid components 1
• Cystectomy preferred over drainage alone 1

Functional cysts and cystadenomas:

• 70% resolve spontaneously, particularly in pregnancy 1
• Observation acceptable if <5 cm with benign features 1