What is the recommended course of treatment for a female patient of reproductive age with occasional hypogastric pain and a dermoid cyst measuring 10x9 cm, scheduled to undergo a right oophorocystectomy?

Bioethical Analysis for Right Oophorocystectomy in Dermoid Cyst Case

Primary Recommendation

For a reproductive-age patient with a 10×9 cm dermoid cyst causing symptoms, surgical removal is indicated, but the procedure should prioritize ovarian preservation through cystectomy rather than oophorocystectomy to maintain fertility and hormonal function. 1, 2

Key Bioethical Considerations

Principle of Beneficence vs. Non-Maleficence

The size of this dermoid cyst (10 cm) places it at the threshold where surgical intervention is clearly indicated due to:

• Increased malignancy risk: Cysts ≥10 cm have a considerably increased risk of malignancy compared to smaller lesions 1
• Torsion risk: Dermoid cysts are a relatively common cause of adnexal torsion (22-33% in surgical series), particularly in younger women, though size alone is not the primary predictor 3
• Symptomatic burden: The patient's hypogastric pain represents quality of life impairment requiring intervention 1

Autonomy and Informed Consent

The patient must be counseled on fertility-sparing alternatives before proceeding:

• Cystectomy is the recommended approach for premenopausal women rather than oophorocystectomy, as it preserves ovarian function and fertility 2, 4
• Laparoscopic cystectomy offers advantages including reduced adhesion formation (critical for fertility), shorter hospital stay, less postoperative pain, and better cosmetic results 4, 5, 6
• The patient should understand that complete oophorectomy removes reproductive potential from that ovary and reduces ovarian reserve 2

Justice and Standard of Care

According to O-RADS US guidelines, dermoid cysts <10 cm in premenopausal patients can be managed with optional follow-up at 8-12 weeks and annual surveillance if not surgically removed 1, 2. However, at exactly 10 cm with symptoms, this patient falls into the category requiring surgical management by a gynecologist 1.

Surgical Approach Algorithm

Preoperative Evaluation

• Confirm diagnosis with imaging characteristics: hyperechoic components with acoustic shadowing, hyperechoic lines and dots (representing hair), or floating echogenic spherical structures 1, 2
• Consider MRI if diagnosis uncertain, as it can show pathognomonic fatty and calciferous content 7, 2
• Tumor markers have limited utility: CA 19-9 may be elevated (78% of cases) but this does not indicate malignancy in dermoid cysts 6

Recommended Surgical Technique

Laparoscopic cystectomy should be the primary approach for this patient:

• Performed by surgeons with considerable experience in advanced laparoscopic surgery 4
• Cystectomy preserves ovarian tissue and maintains fertility 2, 4
• For cysts >10 cm, aspiration of content during specimen removal is acceptable to facilitate extraction 6
• Minimal spillage occurs in approximately 42.5% of cases without causing chemical peritonitis when proper technique is used 5

When Oophorectomy May Be Justified

Complete oophorectomy would only be ethically appropriate if:

• Intraoperative findings reveal malignant transformation (occurs in 1-2% of dermoid cysts, typically in postmenopausal women) 1, 2
• The ovary is completely replaced by cyst with no salvageable ovarian tissue 4
• The patient has completed childbearing and explicitly requests removal after informed consent 1

Critical Pitfalls to Avoid

• Do not perform prophylactic oophorectomy in reproductive-age women without clear indication, as this violates the principle of proportionality 2
• Do not assume benignity without proper evaluation: While dermoid cysts are almost always benign, squamous cell carcinoma can arise (>80% of malignant transformations) 1
• Do not delay surgery in symptomatic patients with cysts ≥10 cm, as changing morphology or developing vascular components increases malignancy concern 1, 2

Postoperative Considerations

• If cystectomy is performed: Annual ultrasound surveillance should be considered for any residual ovarian tissue 1, 2
• If unexpected malignancy is found: Stage I disease confined to the ovary has excellent prognosis with adnexectomy alone; more advanced disease requires platinum-based chemotherapy but has poor prognosis 1, 2
• Fertility counseling: Patients should be informed that laparoscopic cystectomy results in fewer postoperative adhesions compared to open surgery, preserving future fertility 4

Ethical Framework Summary

The principle of proportionality demands that the least invasive, fertility-sparing approach be attempted first in this reproductive-age patient. Oophorocystectomy (complete ovary removal) represents overtreatment unless intraoperative findings justify it. The patient's autonomy requires full disclosure of conservative options, and the standard of care supports cystectomy as the primary approach 2, 4.