Bilateral salpingectomy: An opportunity to reduce cancer risk
Tubal sterilization failures
In a landmark 1996 publication, Peterson et al prospectively enrolled 10,865 women undergoing tubal sterilization at academic medical centers across the nation, and followed them for 8 to 14 years after their surgery.10 This study revealed an unexpectedly high long-term failure rate after tubal sterilization (overall 18.5 per 1000 women-years or nearly 2%). There were major differences in failure rates between commonly performed sterilization techniques. Failure rates were also much greater in younger women and reached over 5% (per 1000 women-years) for women aged < 27 undergoing bipolar cautery procedures. Despite the notoriety of this report, its findings have failed to influence the day-to-day practice of most physicians.
Tubal ligation failures often result in ectopic pregnancies. These failures most often arise from fistula formation at the proximal scar site, allowing egress of sperm into the peritoneal cavity, where they may successfully encounter and fertilize an oocyte within the distal segment of the fallopian tube.
The world literature contains only 3 case reports of sterilization failure following BS (all were intrauterine pregnancies). Because the distal end of the fallopian tube is the location for most ectopic pregnancies after sterilization failure and would be absent after BS, virtually all ectopic pregnancies after sterilization failure would be prevented by performing complete bilateral salpingectomy instead of tubal ligation.
Finally, while tubal ligation may block retrograde passage of endometrial cells associated with clear cell and endometrioid cell ovarian cancers, it will not protect against HGSC that originates in the distal fallopian tube.
Recent recognition that many high-grade serous epithelial carcinomas of the ovary arise from precursor lesions in the distal fallopian tube requires an urgent reassessment of our thinking about the post-reproductive fallopian tube. That tube serves no physiological role and provides no benefit to women in whom it is retained (unlike the ovary, preservation of which may reduce mortality). The residual tube remains a possible site of infection, is at risk for torsion, may undergo malignant transformation in BRCA1/2+ carriers and in low-risk women alike, and is also the most likely site for ectopic pregnancy after sterilization failure.
BS removes the conduit responsible for the retrograde passage of endometrial glands (which reduces the risk of endometriosis–associated clear cell and endometrioid ovarian cancers) along with removing the distal tube where the STIC lesions seem to typically arise.
Recent data from a Danish study of more than 13,000 ovarian cancer cases confirm that BS reduces the risk of epithelial ovarian cancer by 42% (OR 0.58).11 Removal at the time of hysterectomy or tubal sterilization adds minimal risk to a planned intra-abdominal surgical procedure and has the potential to greatly reduce the occurrence of our most deadly gynecologic malignancy.
Applying the number needed to treat of 100 to the more than 700,000 sterilization procedures performed every year in the United States alone would yield 7000 fewer ovarian cancers annually, a nearly one-third reduction.
We suggest that all women who are undergoing gynecologic surgery after having completed childbearing be counseled about the lack of benefit and possible harm from retaining the post-reproductive fallopian tube. BS should be recommended to all women undergoing hysterectomy (regardless of whether oophorectomy is planned) and it should be offered preferentially to women desiring permanent female sterilization in place of less effective alternatives (bipolar cautery, Pomeroy partial salpingectomy, etc.).
We believe data support the relative safety of these measures, and in the absence of effective screening, these simple changes in surgical practice could have a significant impact in the prevention of ovarian cancer.
While this is indeed a paradigm shift, perhaps ob/gyns should be asking themselves: “Why keep an organ with no ongoing physiological role when it can be safely removed at the time of planned surgery, and leaving it in situ places the woman at risk for a potentially preventable cancer?”