What is involved in a salpingo-oophorectomy (removal of the ovary and fallopian tube) for a female patient of reproductive age?

Salpingo-Oophorectomy: Comprehensive Overview for Reproductive-Age Women

What the Procedure Involves

Salpingo-oophorectomy removes the fallopian tube and ovary on one or both sides, and can be performed as a unilateral procedure (preserving fertility) or bilateral procedure (removing both ovaries and tubes), with the surgical approach and extent determined by the underlying indication—whether for cancer staging, risk reduction, or benign disease. 1

Core Surgical Components

For cancer cases, the procedure is part of comprehensive surgical staging that includes: 1

• Total abdominal hysterectomy with bilateral salpingo-oophorectomy as the standard approach for suspected ovarian malignancy 1
• Complete excision of the lumbar-ovarian vessels (infundibulopelvic ligaments) 1, 2
• Peritoneal washings or ascites collection for cytology 1, 2
• Infracolic omentectomy and appendicectomy 1
• Assessment and potential resection of pelvic and para-aortic lymph nodes 1
• Removal of the encapsulated mass intact to prevent spillage 1

For fertility preservation in young patients with early-stage, low-grade tumors or low malignant potential lesions: 1

• Unilateral salpingo-oophorectomy preserving the uterus and contralateral ovary is adequate for stage I disease 1
• Comprehensive surgical staging must still be performed, as approximately 30% of patients are upstaged with complete staging 1
• Examination of the contralateral ovary is mandatory 1
• Hysteroscopy and curettage to assess the uterine cavity 1

Surgical Approach Options

Minimally invasive techniques (laparoscopic or robotic) may be considered for: 1, 2

• Stage I disease in select patients when performed by an experienced gynecologic oncologist 1
• Prophylactic oophorectomy 1
• Benign indications 2

Critical pitfall: Never morcellate specimens outside of endoscopic bags, as this dramatically worsens prognosis if occult malignancy is discovered postoperatively 2

Laparoscopic advantages include shorter hospital stays and fewer moderate-to-severe postoperative complications compared to open procedures 2

Fertility Preservation Considerations

For reproductive-age women desiring future fertility, unilateral salpingo-oophorectomy is appropriate only when: 1

• Disease is confirmed stage IA or IB 1
• Tumor is grade 1 or 2 (not grade 3) 1
• Histology is non-clear cell type 1
• Complete surgical staging confirms no occult metastases 1

After fertility is complete, completion surgery with total hysterectomy and removal of the remaining ovary is recommended 1

Risk-Reducing Surgery in High-Risk Populations

For BRCA1/2 mutation carriers, bilateral salpingo-oophorectomy achieves: 1, 3

• 80-90% reduction in ovarian cancer risk 1, 3
• 77% reduction in all-cause mortality 4
• 45% reduction in breast cancer risk when performed premenopausally in BRCA1 carriers 4

However, residual risk remains: 3

• Primary peritoneal carcinoma can still develop (4.3% cumulative incidence at 20 years post-oophorectomy) 3
• 86% of peritoneal carcinomas following risk-reducing surgery occur in BRCA1 carriers specifically 4

Salpingectomy alone (removing tubes but preserving ovaries) is NOT recommended as standard care in BRCA carriers, as it lacks proven mortality benefit and does not provide breast cancer risk reduction 4

Hormonal Consequences and Mitigation

For premenopausal women undergoing bilateral oophorectomy, immediate and severe health risks include: 5

• Increased cardiovascular disease risk from premature estrogen deprivation 5
• Accelerated bone loss and osteoporosis 5
• Cognitive dysfunction 5
• Increased all-cause mortality when performed unnecessarily before natural menopause 5

Hormone replacement therapy (HRT) is mandatory to prevent these consequences: 5

• Initiate HRT immediately after surgery 5
• Continue until at least age 51 (average age of natural menopause) 5
• Estrogen-only HRT is appropriate after hysterectomy and has a more favorable safety profile than combined therapy 5

Critical pitfall: Failing to prescribe HRT in women within 10 years of menopause who undergo bilateral oophorectomy is a significant missed opportunity to prevent long-term morbidity 5

Opportunistic Salpingectomy for Cancer Prevention

For women undergoing hysterectomy or other pelvic surgery for benign indications, removal of the fallopian tubes (while preserving ovaries) reduces ovarian cancer risk: 6, 7

• The American College of Obstetricians and Gynecologists recommends discussing opportunistic salpingectomy with all women undergoing pelvic surgery 6, 7
• Salpingectomy does not increase surgical complications, blood transfusions, readmissions, or infections compared to hysterectomy alone 6, 7
• Ovarian function is not affected by salpingectomy based on serum markers and IVF response 6, 7
• The procedure does not eliminate ovarian cancer risk entirely but significantly reduces it 6, 7

Biological rationale: Tubal intraepithelial carcinoma (STIC) is detected in 5-8% of BRCA carriers undergoing risk-reducing surgery, with the fimbrial funnel region being the predominant site of origin for high-grade serous ovarian cancers 4, 8

Surgeon Qualifications

A gynecologic oncologist should perform the surgery (Category 1 recommendation) when cancer is suspected or confirmed, as published data demonstrate improved outcomes 1

Surgery should only be undertaken by teams offering multidisciplinary management with extensive experience in oncology, gynecology, general surgery, and endoscopic techniques 1

Documentation Requirements

The operative report must include: 1, 2

• Precise description of operative findings including tumor size, location, and extent 2
• All procedures performed 1
• Quality of excision margins 1
• Cytology results from ascites or peritoneal washings 1

Pathology review should follow the College of American Pathologists protocol for ovarian specimens 1