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OBG-Speculum: E-Newsletter by dept of Obstetrics & Gynaecology, AIIMS, Gorakhpur, U.P.
OBG-Speculum: 2024 ISSN no.
Vol -2, Issue -1
Risk reducing Salpingo-oophorectomy (RRSO)
Dr Shikha Seth
Oophorectomy or Ovariectomy means removal of one or both of a woman’s ovaries. Salpingo-oophorectomy is often done concomitantly with hysterectomy thinking that it will avoid the subsequent ovarian diseases. Earlier it was a common practice to remove the ovaries (normal / functional) with a hysterectomy done at 40 -45 years of age women for any benign indication and called as Hysterectomy with Bilateral Salpingo-oophorectomy (BSO). Now with the evidence the concept is changing and Bilateral salpingectomy is done, preserving one or both ovaries if there is no evidence of ovarian disease or risk. Markov model argued on concurrent BSO at time of benign hysterectomy at 50 years and older. Overall survival is majorly dictated by the risk of cardio-vascular mortality. Recent literature has come up that concurrent BSO with hysterectomy should be done with caution especially for those who are at risk of ovarian cancer, because surgical removal of normal ovaries bilaterally leads to sudden depletion of oestrogen, and is associated with disorders of mood, sexuality, osteoporosis, neurological as dementia, depression, & cardiovascular problems associated with higher morbidity and mortality.
Oophorectomy should be done only in women with high life time risk of ovarian cancer due to gene mutation like BRCA 1, 2 and others because benefit of cancer prevention in high-risk cases outweighs the problems of other health problems.
Surgical steps of RRSO protocol as defined by NCCN.
1. Indication: a) BRCA 1 mutation – most common and highest risk of ovarian ca so RRSO be done between 35-40 years.
b) BRCA 2 mutant cases RRSO be done at 40-45 years of age
c) BRIP1, RAD51C, and RAD51D genes positives at 40-45 years of age.
2. Route: Better to do it through a minimal access route that is laparoscopically.
3. Exploration of the abdomen all around strategically seeing, bowel surface, omentum, appendix, pelvic organs, liver & gallbladder, pelvic & abdominal peritoneum.
4.Washings: Introduce 50-100ml normal saline and aspirate it to collect the peritoneal washing.
5. Biopsy wherever any suspicious lesion is there
6. Procedure:
It is always better to open the pelvic retroperitoneum near the level of promontory and visualize the ureters bilaterally and perform ureterolysis. Total Bilateral Salpingo-oophorectomy is done by removing 2cm of proximal Infundibulo-pelvic (IP)ligament which has ovarian vessels. The whole tube up to the cornua along with all surrounding dorsal peritoneum should be removed. Divide the utero ovarian ligament. In case of ovarian and tubal adhesions within POD or pelvic side walls peritoneal layers, there should be completely removed thoroughly in RRSO.
Energy sources as unipolar, bipolar or advanced ones like Ligasure or the Harmonic knife can be used for RRSO purposes based on availability.
7. Minimal handling of tube and ovaries to avoid any exfoliation of cells by trauma.
8. In-bag retrieval: both tubes and ovaries should be removed in endobag.
9. Pathological processing of the tube and ovary of the RRSO case should be more extensive and should be intimated clearly on the form. Maximal chances are there at the fimbrial end so SEE-FIM protocol is commonly used.
10. Positive pathology of malignancy or serous tubal intra-epithelial carcinoma (STIC) is an indication to refer to gynaecological oncologist.
Video link for the surgical steps can be checked in references.
References:
· Li J, Zhu M, Duan J, et al. Standardized steps of risk-reducing salpingo-oophorectomy following the National Comprehensive Cancer Network guideline protocol: a video demonstration. International Journal of Gynecologic Cancer Published Online First: 09 October 2023.
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