Laparoscopic Surgery for Complex Ovarian Masses

August 2000, Vol. 7, No. 3

The Journal of the American Association of Gynecologic Laparoscopists

Laparoscopic Surgery for Complex Ovarian Masses U. Ulrich, M.D., W. Paulus, M.D., A. Schneider, M.D., MPH, and J. Keckstein, M.D.

Abstract Study Objective. To assess the value of laparoscopy in managing complex ovarian masses. Design. Retrospective, observational analysis (Canadian Task Force classification II-2). Setting. University-based, tertiary level center for endoscopic surgery. Patients. Two hundred eleven consecutive women. Interventions. Laparoscopic surgery including ovary-preserving surgery, salpingo-oophorectomy, adhesiolysis, and pelvic lymphadenectomy. Measurements and Main Results. Patients were selected on the basis of preoperative ultrasound findings. Intraoperative appearance of the tumors as well as results from frozen section examinations were compared with histologic results. Two hundred sixteen pelvic masses were benign. In 10 patients, early ovarian cancer, borderline tumors, tubal cancer, or secondary ovarian, nongynecologic pathology was managed primarily by laparoscopy and confirmed histologically. Three of these 10 women underwent standard radical open surgery within 1 week. The true nature of masses was not recognized at the time of laparoscopy in three patients with malignant findings. Patients with malignant tumors were followed for 5 years. Conclusion. Although most complex ovarian masses can be managed by laparoscopy, the possibility of overlooking malignancy remains, even with frozen section examination. Whether or not laparoscopy compromises clinical outcome compared with laparotomy is not fully understood. Prospective studies to address this important clinical question are urgently needed. (J Am Assoc Gynecol Laparosc 7(3):373–380, 2000)

ing is still incomplete, especially as there are no longterm follow-up results of well-designed, prospective studies evaluating the impact of laparoscopic surgery for malignant ovarian tumors on patient survival.7 Despite this, increasing numbers of authors reported successful laparoscopic management of complex ovarian masses,8–10 including malignant neoplasms.4 In this retrospective analysis of laparoscopic management of pelvic masses, we compared intraoperative

Laparoscopy in the management of complex ovarian masses is controversial.1,2 For some it is an affront to the rules of classic tumor surgery,3 whereas others concluded that an endoscopic approach to even stage I ovarian cancer may be considered proper care.4,5 The major concern is the possibility of overlooking malignancy and inadvertently opening the tumor with spillage of contents into the abdominal cavity, which may worsen the patient’s prognosis.6 Our understand-

From the Departments of Obstetrics and Gynecology, University of Ulm School of Medicine, Ulm, Germany (all authors); University of Jena School of Medicine, Jena, Germany (Dr. Schneider), and University of Bonn School of Medicine, Bonn, Germany (Dr. Ulrich); and Hospital of the Province of Carinthia, Villach, Austria (Dr. Keckstein). Address reprint requests to Uwe Ulrich, M.D., Department of Obstetrics and Gynecology, University of Bonn School of Medicine, Sigmund Freud Strasse 25, 53105 Bonn, Germany; fax 49 228 287 5446. Presented in part at the 7th Congress of the European Society for Gynaecological Endoscopy, Lausanne, Switzerland, December 6–9, 1998. Accepted for publication April 4, 2000. Reprinted from the JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS, August 2000, Vol. 7 No. 3 © 2000 The American Association of Gynecologic Laparoscopists. All rights reserved. This work may not be reproduced in any form or by any means without written permission from the AAGL. This includes but is not limited to, the posting of electronic files on the Internet, transferring electronic files to other persons, distributing printed output, and photocopying. To order multiple reprints of an individual article or request authorization to make photocopies, please contact the AAGL.

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Laparoscopic Surgery for Complex Ovarian Masses Ulrich et al

in only 48 patients, tumor marker levels were excluded from the analysis. The diagnosis at the time of laparoscopy, in some cases supported by frozen section examination, was plotted against the histologic result (Table 2). The type of surgery was recorded for each histologic group. All operations were almost exclusively performed by three surgeons (JK, UU, AS). Patients were followed by office visits as well as telephone calls to both patients and referring physicians.

assessment with histologic results, and evaluated 5-year follow-up data for patients with malignant disease. Materials and Methods From January 1990–October 1994, 211 women had 226 complex cystic or solid adnexal masses managed by laparoscopic surgery. The patients’ mean age was 43 years (range 7–80 yrs) and varied according to histology (Table 1). Informed consent always involved possible laparotomy, with pros and cons of laparoscopy versus laparotomy especially with respect to possible malignancy. Patients were selected on the basis of preoperative ultrasonographic examinations. Premenopausal women under 40 years of age with simple ovarian cysts, that is, unilocular cysts with thin walls, without vegetations or other echogenic material, that were smaller than 8 cm in diameter were excluded.11 Simple cysts in children or postmenopausal women, and those larger than 8 cm in diameter in premenopausal patients were included in the analysis. (Adnexal masses that fulfilled exclusion criteria accounted for another 1000 patients, none of whom had a malignancy; J. Keckstein, unpublished data.) Also excluded were women in whom laparotomy was performed during the same surgical session because laparoscopic completion of the procedure was deemed inappropriate after inspection of the tumor. Ultrasonographic examination performed with a 7.5-MHz vaginal probe showed most masses to have complex appearance. As CA 125 levels were available

Operative Technique Videolaparoscopy was used with the 10-mm camera port inserted through an umbilical incision. Three additional 5-mm cannulas were introduced suprapubically. First, the adnexal mass as well as the whole abdominal cavity, diaphragm, liver surface, and bowel were inspected thoroughly. Salpingo-oophorectomy and oophorectomy were performed by transecting the infundibulopelvic and utero-ovarian ligaments after their ligation with endo-sutures (Ethicon, Norderstedt, Germany), or by Endo GIA (Auto Suture; US Surgical, Inc., Norwalk, CT). In each case, the ureter was identified before transecting the ligaments or applying the Endo GIA. In ovary-preserving surgery for large masses, the tumors were punctured with a 5-mm cannula through which the suction-irrigator was introduced. The liquid content of the tumor was evacuated by intermittent suction and irrigation until it was clear. In some cases cystoscopy was carried out by introducing a 5-mm endoscope through the cannula directly into the tumor to visualize the inner cyst wall. For smaller

TABLE 1. Histologic Diagnoses with Regard to Patients’ Age, Tumor Diameter, and Type of Surgery Performed (median [range])a

Histologic Diagnosis Simple cyst Serous cystadenoma Mucinous cystadenoma Mature teratoma Fibroma Endometrioma Hydrosalpinx Parovarian cyst

No. of Tumors/ No. of Patients

Age (yrs)

Tumor Diameter (cm)

57/54 31/28 14/14 73/70 12/12 9/6 7/5 10/9

49 (7–80) 53 (27–75) 49 (29–72) 32 (12–51) 60.5 (38–78) 43 (34–50) 55 (40–70) 48 (21–77)

5.5 (2.5–17.1) 4.8 (2.2–12) 8 (2.5–16) 6 (2.4–11.8) 3.9 (1.6–8.8) 5.7 (3.3–13) 5.8 (4.4–7.8) 5 (2–7.8)

aHistologic groups with fewer than five patients are mentioned in the text.

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Ovary-Preserving Surgery