Bilateral salpingectomy: An opportunity to reduce cancer risk
Risks of BS at time of hysterectomy
Ghezzi et al. studied women with benign disease undergoing total laparoscopic hysterectomy (TLH) with BS versus historic controls who underwent TLH alone.4 They found no significant differences in estimated blood loss, operative time, or intraoperative complications, but did note a statistically significant reduced risk of short-term (1-30 days) febrile morbidity in the salpingectomy group. They attributed this lower risk of infection, at least in part, to the role of salpingectomy in prevention of tubo-ovarian abscesses, which were seen in 2 women in the control group.
Morelli et al. published a retrospective case control study comparing premenopausal women after hysterectomy either without (2008–2010) or with salpingectomy (2010–2012).5 There were no differences between groups in operative time, postoperative length of stay, time to return to normal activity, surgical complication rates, or ultrasonic or hormonal markers of ovarian function.
However, the largest study confirming the perioperative safety of BS comes from the innovative work being done by the Ovarian Cancer Research Program of British Columbia.6 These investigators initiated an educational campaign directed at all gynecologists in British Columbia about the role of the fallopian tube in ovarian cancer and they encouraged their physicians to consider BS: (1) at the time of hysterectomy, even when the ovaries were being preserved, and (2) for permanent sterilization in place of tubal ligation. Their data included hysterectomy and tubal ligations performed (2008-2011) in almost 44,000 women before and after the educational ovarian cancer prevention campaign. They showed a significant uptake in BS procedures, with minimal additional operative time and no significant differences in perioperative complications. They concluded: “Fundamental for this initiative to continue, we are assured that this surgical intervention is safe and achievable.”6
Does BS alone affect ovarian function?
Dar at al. studied women undergoing ovarian stimulation for in vitro fertilization (IVF) before and after salpingectomy for ectopic pregnancy, using each woman as her own control and evaluating the operated versus non-operated sides.7 They found no significant differences in peak estradiol levels, gonadotropin requirements, oocytes retrieved from operated versus non-operated sides, fertilization rates or embryo quality.
Lass et al. compared IVF cycles in women in whom unilateral salpingectomy for ectopic pregnancy had been performed versus women with unexplained or male factor infertility.8 There was equivalence in total numbers of follicles on sonogram, total number of oocytes retrieved, peak estradiol levels, and pregnancy rates between the 2 groups.
Does BS at time of hysterectomy affect ovarian function?
Sezik et al. performed a randomized trial of total abdominal hysterectomy +/- salpingectomy in premenopausal women with regular menses and a normal basal follicle-stimulating hormone (FSH) level.9 They found no significant differences in postoperative FSH, estradiol levels, or ovarian volumes, although they did find that ovarian blood flow parameters improved in both groups after surgery. Therefore, it would appear that at the time of hysterectomy we are not adding significant risk by including BS, but by omitting it we are incurring significant lifetime risk of tubal pathology.
Broadening the discussion from cancer prevention, it is important to assess the benign pathologic potential of the fallopian tube. Left in situ it can develop infection or hydrosalpinx, contribute to ovarian or tubal torsion, and is the site for ectopic pregnancy, especially after tubal sterilization.