Ovarian Cystectomy Case File
Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG
Case 36
A 24-year-old nulliparous Caucasian woman presents to your office for her annual well-woman examination. She is a recent college graduate and has a monogamous relationship. Yearly Pap smears began at age 19 and have always been normal. She denies any medical conditions, and her only medication is a combination oral contraceptive pill (OCP). She does not smoke or engage in any illicit drug usage. She does drink alcohol socially.
On examination, you note no irregularities of the cervix or vagina on speculum examination; a Pap smear is performed. Bimanual examination reveals findings suggestive of an adnexal mass on the patient’s right side. Palpation of the mass does not provoke pain or discomfort. She denies recent unintentional weight loss or weight gain, early satiety, abdominal bloating, dyspareunia, or vaginal discharge. She states that she has been taking her OCP regularly as directed.
Urine pregnancy test was negative in the office and a confirmatory serum β-human chorionic gonadotropin (β-hCG) level was sent to the laboratory. Transvaginal ultrasound was performed in the office and an 8-cm mass with both solid and cystic characteristics was seen on the right ovary. The mass also had areas that appeared to be calcified within the cystic portion of the mass.
➤ What is the most likely diagnosis?
➤ What is your next step?
➤ What options for management may be utilized?
ANSWERS TO CASE 36:
Ovarian Cystectomy
Summary: This is a 24-year-old nulliparous Caucasian woman having an asymptomatic ovarian mass suggestive of a cystic teratoma. The patient has an unremarkable past medical history and is asymptomatic.
➤ Most likely diagnosis: Benign cystic teratoma (dermoid).
➤ Next step: Operative removal.
➤ Management options: Surgical excision either via laparotomy, laparoscopy, or a combination of these procedures.
ANALYSIS
Objectives
- List the surgical options available for ovarian cystectomy.
- Describe the diagnostic features of an ovarian cyst.
- Describe the potential complications that may arise and the solutions to them during removal of cyst.
Considerations
This is a 24-year-old Caucasian woman who presents for a routine yearly health maintenance visit. During the course of the visit, a right-sided adnexal mass is palpated during bimanual examination. Formal evaluation of the mass confirmed a right-sided ovarian mass consistent with a dermoid cyst. Pregnancy was excluded initially by urine pregnancy test, thus making the mass less likely to be an ectopic pregnancy.
The patient is further screened by questioning for evidence of ovarian cancer. The line of questioning did not provide evidence for suspicion of malignancy. Ultrasound imaging demonstrated characteristics of benign cystic teratoma. The image demonstrated regional diffuse bright echoes with or without posterior acoustic shadowing, shadowing echodensity, and a fluid-fluid level.
Further workup may be employed to differentiate the mass as benign or malignant. Dysgerminoma is a malignant form of germ cell tumor and the serum marker is lactate dehydrogenase 1 (LDH-1) and LDH-2. If this was to be suspected in the patient, it would be prudent to draw a baseline level as a way to measure response to treatment rather than a screening method. Serum markers have not been shown to be an accurate method for screening for ovarian malignancy.
Operative management is the treatment of choice in this patient. The possibility of bilateral involvement of both ovaries must be discussed with the patient. Malignant transformation is present in approximately 2% of teratomas, and thus the possibility of malignancy and the need for a staging procedure must be explained to the patient. Operative technique may be either via laparoscopic or laparotomy approach. Each approach has benefits and downfalls that the patient must be made aware of. Various methods within each modality will be discussed in detail in the following section.
As with any operation, the risk of complications must be addressed and taken into account before operation is attempted.
APPROACH TO
Ovarian Cystectomy
DEFINITIONS
TERATOMA: Tissue that recapitulates the three layers of the developing embryo (ectoderm, mesoderm, and endoderm). One or more of the layers may be represented. Mature (benign) or immature (malignant) subtypes further differentiate. Arise from a single germ and have a karyotype of 46,XX.
ROKITANSKY PROTUBERANCE: Area seen on both ultrasound and pathologic specimen where fatty tissue, teeth, and bone protrude into the lumen of the teratoma.
SPILLAGE: Potential complication arising from laparoscopic (minimally from laparotomy) surgery where the contents of the cystic mass may escape from a ruptured cyst into the abdominal cavity.
CLINICAL APPROACH
Benign Cystic Teratomas
Ovarian cysts are a common occurrence in both premenopausal and postmenopausal women. Germ cell tumors account for 20% to 25% of all ovarian tumors. The most common ovarian neoplasm in women younger than 30 years is the dermoid, accounting for 25% of all ovarian neoplasms.
Dermoid cysts, or benign cystic teratomas, are a member of the germ cell tumor family. These tumors primarily arise during the reproductive years but may occur in both the postmenopausal and prepubescent women. These tumors have the ability to produce adult tissue: skin, bone, teeth, hair, and dermal tissue. Generally dermoids are unilateral, but 10% to 15% are bilateral. The gross appearance is a smooth outside wall with a yellowish appearance due to the sebaceous fatty tissue within the cyst. Size may range from 0.5 cm to more than 40 cm in diameter. Approximately 90% will be less than 15 cm in diameter. The cellular composition is derived from all three layers of embryonic origin: ectoderm, mesoderm, and endoderm. Malignancy may be present in 2% of cases.
Most teratomas are discovered incidentally at time of examination or imaging for an unrelated reason. Thus, the most common symptom is an asymptomatic patient. Patients with symptoms usually present with abdominal pain, abdominal mass or swelling, and abnormal uterine bleeding. Abnormal uterine bleeding and its subsequent relief after cyst removal suggest hormone synthesis by the tumor. Histologic evaluation has not shown evidence of endocrine function.
Complications that arise from dermoid cysts include torsion and rupture. Torsion is the presenting symptom in 11% to 20% of cases, depending on the study. Torsion has been seen to be more common during pregnancy. Rupture is relatively uncommon but serious. Chemical peritonitis and adhesion formation may result. Infection and malignant change are other potential complications. The logic and reasoning behind removal of the cyst lies in the potential for complications such as torsion, spontaneous rupture, risk of chemical peritonitis, and malignancy.
Diagnostic Evaluation Debate ensues concerning the proper workup for ovarian masses. O’Connell and associates demonstrated the reliability of transvaginal ultrasonographic diagnosis associated with negative cancer antigen 125 (CA-125), and clinical oncological examination provide a highly certain diagnosis of benign ovarian swelling and hence dermoid cysts.1 The utilization of tumor markers before operative intervention has been addressed and currently not specific enough to be used as a reliable screening tool, rather usage has been implemented in order to evaluate response to treatment and recurrence. Beyond the scope of this case is proper transvaginal ultrasonographic diagnosis to differentiate a benign cyst from one that may be suspicious for malignancy. The importance of this weighs heavily in regard to the modality of operative removal of the cyst. Suspicion of malignancy would necessitate a proper oncology workup and possibly staging. Benacerraf et al. report a 15% failure rate in the ultrasonographic diagnosis of malignant cysts.2 Morgante and associates suggest that frozen section at time of removal in patients where suspicion of malignancy is present (> age 40 with uncertain ultrasonographic parameters and high tumor marker levels) is crucial.3
Surgical Approach The classic modality utilized in removal of ovarian cysts is via open laparotomy. Laparoscopic approaches have also been utilized with equal success rates. Operative approaches via laparoscopy or vaginal routes without laparoscope efforts have been demonstrated to be viable options. The size of the tumor, perceived mobility of the adnexa, possibility of malignancy, and the skill of the surgeon must be considered when choosing the best method for removal.
Open laparotomy is the traditional method of removal of benign ovarian cysts. In the premenopausal women, removal of the ovarian cysts is performed. In the postmenopausal women, oophorectomy and salpingectomy are standards of care. The method of removal of the cyst in the premenopausal women in this case would be cystectomy. An elliptical incision is made through the cortex of the ovary (see Figure 36–1). The placement of this incision is debatable, with some advocating for it to be as near as possible to the functional part of the ovary while others arguing that it should be placed at the apex of the dome of the cyst. The importance of the initial incision is to allow for symmetric reconstruction of the ovary. Development of a plane is then performed using a blunt instrument (Figure 36–2). Fine-needle electrocautery may also be used to develop the plane. After properly separating the cyst wall from the overlying ovarian cortex, the cyst can be shelled out without rupture. Rupture has been encountered in 4% to 13% of tumor removals via laparotomy even with the most precise techniques. This is generally due to the thin nature of the cyst wall. Packing the pelvis with wet laparotomy pads before attempts at cyst removal has been described as a way to prevent contamination if rupture were to occur. A wet surgical towel encompassing the infundibulopelvic ligament has been utilized at our institution as a means to protect the pelvis if
Figure 36–1. An incision is made on the surface of the ovary.(Reproduced,with permission,
from Schorge JO, Schaffer JI, Halvorson LM, et al. Williams Gynecology. New
York:McGraw-Hill, 2008:925.)
Figure 36–2. The ovarian cyst is bluntly dissected. (Reproduced, with permission,
from Schorge JO, Schaffer JI, Halvorson LM, et al. Williams Gynecology. New York:
McGraw-Hill, 2008:925.)
rupture occurs. Reconstruction of the ovary may or may not be utilized after the cyst has been removed. The technique involves obliteration of the dead space in a purse string fashion, using suture of a nonreactive material. The ovarian surface is then reapproximated using a subcortical running suture of a nonreactive suture, interrupted sutures of nonreactive suture, or a running “baseball” stitch using nonreactive suture (Figures 36–3 and 36–4). Care must be taken not to place suture in the ovarian cortex and disturb the normal ovarian structure. Excessive redundant thin cortex may be removed if necessary. Morgante et al. recommend not reconstructing the ovary after cystectomy.3 They site an increased risk of adhesion formation at the ovary that may impair reproductive function and cause postsurgical pain. If the ovary is reconstructed, they advocate using a barrier method to isolate the ovary to reduce adhesion formation. Further studies are required to compare the efficacy of these systems in reducing adhesion formation after laparoscopy and laparotomy.
Laparoscopy Laparoscopic methods of removal are the more common approach today with the advancement of laparoscopic techniques in the last two decades. The technique is similar to laparotomy in that an elliptical incision is made through the cortex of the ovary. As mentioned before, the placement of the incision should be made in such a manner as to not disturb
Figure 36–3. The ovary is then repaired using a continuous running closure. (Reproduced,with permission, from Schorge JO, Schaffer JI,Halvorson LM, et al. Williams Gynecology.New York:McGraw-Hill, 2008:926.)
Figure 36–4. The epithelium of the ovary is closed, sometimes using a “baseball stitch” to reduce the amount of suture on the ovarian surface, thus reducing adhesion risk.
the normal ovarian tissue and also to allow for reconstruction if so desired. Instruments utilized to make the incision generally involve and energy source of some kind. Fine-needle electrocautery, EndoShears (US Surgical Norwark, CT), harmonic scalpel, and the laser have all been described as methods to incise the cyst wall. Development of a plane is then performed using a combined approach either by using hydrodissection or by grasping the incised edges and separating the cyst wall from the overlying cortex with gentle symmetric pulling (Figure 36–5). Shelling of the cyst wall can be performed
Figure 36–5. Laparoscopic management of an ovarian cyst, often using hydrodissection to free the cyst from the ovarian tissue.
using the laser to focus energy at the adhesions between the cyst wall and the cortex, using a sharp instrument (ie, Endoshears, fine-needle electrocautery), hydrodissection, or with a combination of approaches. Energy source (ie, laser or bipolar cautery) may be used to achieve hemostasis. Ovarian reconstruction generally is not performed as discussed prior, but may be performed at this time. Removal of the cyst may be performed using an impermeable sac (Endobag: Ethicon, Somerville, New Jersey) through the 10-mm umbilical trocar site. If the cyst is too large to remove from this port, various methods have been described to remedy the situation. Decompression of the cyst by removal of cyst contents either via large-bore needle aspiration or by direct removal of tissue using a grasping instrument has been utilized. Enlarging an ancillary trocar incision is another option. Removal of the cyst using laparoscopy and colpotomy, as reported by Teng and associates, is another approach for removal of the large ovarian cyst.
Comparison of Laparotomy versus Laparoscopy
Comparison between laparotomy and laparoscopic procedures has been chronicled by Morgante and associates,3 Nezhat and associates,4 and Curtin.5 When consideration is given to blood loss, hospital stay, patient morbidity, cosmetic results, pain, need for analgesics, level of recovery after a week, and adhesion formation, all these parameters favor laparoscopic intervention. Laparotomy has been demonstrated to have a slight advantage in that it has less operative time to complete.
Spillage rates have been addressed and range from 15% to 100% for laparoscopy compared to 4% to 13% for laparotomy, as reported by Nezhat and associates.4 Mecke and Savvas addressed the potential complication that arises from spillage and found no serious complications in patients with intraperitoneal contamination.6 They advocate extensive irrigation of the abdominal cavity with sodium chloride until there is no fatty tissue remaining in the lavage. Nezhat and associates concluded that the risk of chemical peritonitis following laparoscopic removal of dermoid cysts was 0.2%.4
Although Dembo and associates reported that malignant ovarian cyst rupture may not affect the prognosis for ovarian cancer, spread of malignancy is still a potential problem for laparoscopic management.7 Pelvis washings should be performed during both laparoscopic and laparotomy procedures before cystectomy. Postoperative chemotherapy may be used in case of unexpected rupture of a malignant cyst.
Bilateral dermoids occur in approximately 10% to 15% of cases and would be removed. Current treatment involves preservation of the contralateral ovary if it grossly appears normal.
Comprehension Questions
36.1 A 54-year-old postmenopausal woman presents with a complaint of abdominal bloating and pelvic pressure over the last 4 months. Ultrasound shows a 16-cm left ovarian mass with both solid and cystic component. CA-125 levels are normal. What would be the proper management in this patient?
A. Observation
B. Ovarian cystectomy
C. Total abdominal hysterectomy and bilateral salpingo-oophorectomy
D. Operative laparoscopy with drainage of cyst
36.2 A 16-year-old G0 woman presents with acute right-sided continuous pain beginning 2 hours prior to presentation and the finding of a large complex adnexal mass on ultrasound. Her pregnancy test result is negative. She is thought to likely have ovarian torsion. Which of the following is the best initial management plan?
A. Pain medication and observation
B. Immediate exploratory laparotomy
C. Immediate laparoscopy
D. Chemotherapy
36.3 The finding of which tissue influences the grade and prognosis of malignant immature teratomas?
A Neuroepithelium
B. Bone
C. Hair
D. Teeth
ANSWERS
36.2 C. Torsion presents with approximately 16% of teratomas and may be the only presenting symptom. In this case, a negative serum pregnancy test would exclude an ectopic pregnancy. Torsion would be very likely in a teenager with an enlarged ovarian cyst, such as a benign cystic teratoma. This is an emergent situation. Surgical management must be employed expediently if preservation of the ovary is the focus. Immediate laparoscopy is indicated in this situation with evaluation of adnexal mass. A unilateral ovarian cystectomy or oophorectomy may be chosen, depending on the ability to reestablish blood flow after untwisting the pedicle, and no evidence of necrosis is present. Mage and associates demonstrated that the majority of patients with torsion can be treated with laparoscopic untwisting of adnexa (and removal of adnexal cyst), and no further intervention is needed.8
36.3 A. Teratomas are considered either mature or immature, depending on the histologic composition of the tissue. Mature teratomas are benign while immature teratomas are malignant. Immature teratomas account for 20% of the malignant ovarian tumors in women younger than 20 years. They comprise less than 1% of all ovarian cancers. These tumors do not occur in postmenopausal women. The prognosis for patients is related to the grade of the tumor. The grade of the tumor is based on the degree of immaturity. The highest grade (grade 3) tumors have a high proportion of neuroepithelium.
Clinical Pearls
See Table 1-2 for definition of level of evidence and strength of recommendation
➤ Serious complications are minimal in patients with intraperitoneal spillage of cystic contents and copious abdominal irrigation (Level B).
➤ Torsion is a potential and common complication of benign cystic teratomas (Level B).
➤ Malignancy occurs in less than 2% of teratomas (Level B).
➤ The majority of adnexal torsions from benign neoplasm can be laparoscopically untwisted with conservation of the ovary if surgical intervention is undertaken rapidly (Level B).
➤ Ultrasound fails to diagnose malignant ovarian cysts 15% of the time (Level B).
➤ Laparoscopic ovarian cystectomy should be the elective treatment for women with suspected dermoid cysts (Level C).
REFERENCES
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2. Benacerraf B, Finkler N, Wojciechowski C, Knapp R. Sonographic accuracy in the diagnosis of ovarian masses. J Reprod Med. 1990;35:491-495.
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5. Curtin J. Management of the adnexal mass. Gynecol Oncol. 1994;55:542-546.
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13. Rock JA, Jones HW III. Surgery for the benign disease of the ovary. In: Te Linde’s Operative Gynecology. 10th ed. Philadelphia: Lippincott Williams & Wilkins. 2008:629-646.
14. Sah SP, Uprety D, Rani S. Germ cell tumors of the ovary: a clinicopathologic study of 121 cases from Nepal. J Obstet Gynaecol Res. 2004;30(4):303-308.
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