Screening and prevention of ovarian cancer.

Ovarian cancer remains the most lethal gynaecological malignancy with 314 000 cases and 207 000 deaths annually worldwide. Ovarian cancer cases and deaths are predicted to increase in Australia by 42% and 55% respectively by 2040. Earlier detection and significant downstaging of ovarian cancer have been demonstrated with multimodal screening in the largest randomised controlled trial of ovarian cancer screening in women at average population risk. However, none of the randomised trials have demonstrated a mortality benefit. Therefore, ovarian cancer screening is not currently recommended in women at average population risk. More frequent surveillance for ovarian cancer every three to four months in women at high risk has shown good performance characteristics and significant downstaging, but there is no available information on a survival benefit. Population testing offers an emerging novel strategy to identify women at high risk who can benefit from ovarian cancer prevention. Novel multicancer early detection biomarker, longitudinal multiple marker strategies, and new biomarkers are being investigated and evaluated for ovarian cancer screening. Risk-reducing salpingo-oophorectomy (RRSO) decreases ovarian cancer incidence and mortality and is recommended for women at over a 4-5% lifetime risk of ovarian cancer. Pre-menopausal women without contraindications to hormone replacement therapy (HRT) undergoing RRSO should be offered HRT until 51 years of age to minimise the detrimental consequences of premature menopause. Currently risk-reducing early salpingectomy and delayed oophorectomy (RRESDO) should only be offered to women at increased risk of ovarian cancer within the context of a research trial. Pre-menopausal early salpingectomy is associated with fewer menopausal symptoms and better sexual function than bilateral salpingo-oophorectomy. A Sectioning and Extensively Examining the Fimbria (SEE-FIM) protocol should be used for histopathological assessment in women at high risk of ovarian cancer who are undergoing surgical prevention. Opportunistic salpingectomy may be offered at routine gynaecological surgery to all women who have completed their family. Long term prospective opportunistic salpingectomy studies are needed to determine the effect size of ovarian cancer risk reduction and the impact on menopause.

Complications after opportunistic salpingectomy compared with tubal ligation at cesarean section: a retrospective cohort study.

OBJECTIVE: To compare perioperative and postoperative complications in patients who underwent opportunistic salpingectomy (OS) (removal of the fallopian tubes for ovarian cancer risk reduction during another surgery) at the time of cesarean section (C-section) with those in patients who underwent tubal ligation. DESIGN: A population-based, retrospective cohort study. SETTING: British Columbia, Canada. PATIENT(S): A total of 18,184 patients were included in this study, of whom 8,440 and 9,744 underwent OS and tubal ligation, respectively. INTERVENTION(S): Patients who underwent OS during a C-section were compared with those who underwent tubal ligation during a C-section. MAIN OUTCOME MEASURE(S): We examined the perioperative outcomes, including operating room time, length of hospital stay, surgical complications such as infections, anemia, incision complications, injury to a pelvic organ, or operating room return; postoperative complications, including physician visits for a postoperative infection or visits that resulted in ultrasound or laboratory examinations and hospital readmissions in the 6 weeks after discharge; and likelihood to fill a prescription for antibiotics or analgesics. RESULT(S): The OS group had decreased odds of perioperative complications compared with the tubal ligation group (adjusted odds ratio [aOR], 0.77; 95% confidence interval [CI], 0.61-0.99). Patients who underwent OS did not have increased risks of physician visits for surgical complications, such as infection, or hospital readmissions in the 6 weeks after hospital discharge. In addition, these patients had 18% and 23% increased odds of filling prescriptions for nonsteroidal anti-inflammatory drugs (aOR, 1.18; 95% CI, 1.07-1.28) and opioids (aOR, 1.23%; 95% CI, 1.12-1.35), respectively. CONCLUSION(S): In this population-based, real-world study of OS at C-section, we report decreased perioperative complications and no difference in postoperative complications between patients who underwent OS and those who underwent tubal ligation. Patients who underwent OS had an increased likelihood of filling a prescription for nonsteroidal anti-inflammatory drugs and opioids in the 6 weeks after hospital discharge. This result should be interpreted with caution because we did not have data on over-the-counter medication use and, thus, not all prescription analgesics were captured in our data. Our data suggest that OS after C-section is a safe way to provide effective contraception and ovarian cancer risk reduction.

Bilateral salpingectomy as an option of permanent contraception at time of caesarean section: A survey of practice.

BACKGROUND: Opportunistic bilateral salpingectomy during benign gynaecologic surgery is advocated as a risk-reducing strategy due to the inverse association of epithelial ovarian cancers observed in epidemiological studies in a low-risk setting. Currently, no formal guidance exists for permanent surgical contraception at time of caesarean section in Australia. AIMS: Our aim was to survey Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) regarding bilateral salpingectomy compared to other procedures offered for permanent contraception at the time of caesarean section. MATERIALS AND METHODS: An online survey was utilised to collect clinician demographics, opinions, barriers, and justifications in regard to options of permanent surgical contraception at time of caesarean section. RESULTS: Bilateral salpingectomy was identified as the most effective method of permanent contraception at time of caesarean section. However, only 62% of respondents offer the procedure as a method of permanent contraception. The two most common reasons for clinicians to offer bilateral salpingectomy at time of caesarean section were evidence suggesting a link between the fallopian tube and gynaecological cancer (80%) and efficacy as a permanent form of contraception (16%). The primary barrier identified by 51% of respondents was perceived increased risk of surgical complications, followed by reasoning that it would not allow the possibility of future tubal reversal. CONCLUSION: This study identifies diverse opinions on surgical approach to permanent contraception at time of caesarean section and offered by clinicians of RANZCOG. Further research is required to establish safety profiles and short- and long-term risks of bilateral salpingectomy.

Complete Compared With Partial Salpingectomy for Postpartum Sterilization.

In this narrative review, we describe evidence regarding the associated risks, benefits, and cost effectiveness of postpartum complete salpingectomy compared with partial salpingectomy. Permanent contraception can be performed via several methods, but complete salpingectomy is becoming more common secondary to its coincident benefit of ovarian cancer risk reduction. Small prospective studies and larger retrospective cohort studies have demonstrated the feasibility and safety of complete salpingectomy in the postpartum period. Additionally, multiple cost-effectiveness analyses have demonstrated the cost effectiveness of this method secondary to ovarian cancer reduction over the life span. Although future larger cohort studies will allow for more precise estimates of the effect of complete salpingectomy on ovarian cancer risk and incidence of rare complications, current data suggest that complete salpingectomy should be offered to patients as a method of permanent contraception in the postpartum period.

Salpingectomy for the Primary Prevention of Ovarian Cancer: A Systematic Review.

Importance: Most ovarian cancers originate in the fimbriated end of the fallopian tube. This has led to the hypothesis that surgical resection of the fallopian tubes at the time of gynecologic and nongynecologic surgical procedures-referred to as an opportunistic salpingectomy-may prevent the development of epithelial ovarian cancer for women at an average risk of developing the disease. Objective: To compile a comprehensive, state-of-the-science review examining the current landscape of performing bilateral salpingectomy for ovarian cancer prevention. Evidence Review: A systematic review of the literature was performed on March 4, 2022, to identify studies examining salpingectomy for ovarian cancer prevention. This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 statement. Four databases were selected: PubMed via the National Library of Medicine's PubMed.gov, Embase via Elsevier's Embase.com, Cochrane Central Register of Controlled Trials (CENTRAL) via Wiley's Cochrane Library, and Northern Light Life Sciences Conference Abstracts via Ovid. A total of 20 gray literature sources, including 1 database, 2 registers, 1 repository, 1 index, 1 archive, 1 preprint server, 1 agency, and 12 organizations, were also searched. Findings: The initial search produced 1089 results; a total of 158 publications were included in the final review. Salpingectomy has been associated with ovarian cancer risk reduction of approximately 80%. Studies have demonstrated that salpingectomy was safe, cost-effective, and was not associated with an earlier age of menopause onset. With widespread implementation, salpingectomy has the potential to reduce ovarian cancer mortality in the US by an estimated 15%. Both physician and patient awareness regarding the adnexa as the origin for most ovarian cancers, as well as the existence of salpingectomy and its potential benefits in reducing ovarian cancer risk, has increased during the past decade. Raising awareness and developing effective implementation strategies are essential. Conclusions and Relevance: The results of this systematic review suggest that bilateral salpingectomy for ovarian cancer prevention was safe and feasible and has the potential to be a cost-effective and cost-saving strategy across the population. Prospective studies to demonstrate long-term survival outcomes and feasibility in nongynecologic surgical procedures are warranted.

Risk of ovarian cancer after salpingectomy and tubal ligation: Prospects on histology and time since the procedure.

OBJECTIVE: Recent theories propose that most epithelial ovarian cancer (EOC), depending on histological type, originate from other gynecological tissues and involve the ovary secondarily. According to these theories, any protective effect of salpingectomy and tubal ligation may vary by histological type. The study aim was to examine the association between salpingectomy and tubal ligation, respectively, and risk of EOC, with a focus on associations specific for histological types. METHODS: We identified EOC cases and matching controls in national registries and gathered information on surgical procedures and potential confounders. Conditional logistic regression was used to estimate odds ratio (OR) with 95% confidence interval (CI) of EOC related to salpingectomy and tubal ligation, respectively, overall and stratified by histological type. Furthermore, we investigated the association according to timing of the procedures. RESULTS: Our study comprised 16,822 EOC cases. Each case was matched with 40 controls. There was an overall EOC risk reduction after unilateral (OR = 0.73; 95% CI: 0.60-0.87) and bilateral salpingectomy (OR = 0.46; 95% CI: 0.31-0.67). A slight risk reduction was seen among women with previous tubal ligation (OR = 0.91; 95% CI: 0.83-0.99). For salpingectomy, the risk reduction increased with increasing time since the surgical procedure and was only present among women younger than 50 years at salpingectomy. Unilateral and bilateral salpingectomy was associated with a risk reduction for most histological types. CONCLUSION: The association between previous salpingectomy and reduced risk of several histological subtypes of EOC supports the suggested theories about the site of origin of EOC and may be of clinical importance.

Salpingectomy and the Risk of Ovarian Cancer in Ontario.

Importance: A body of pathological and clinical evidence supports the position that the fallopian tube is the site of origin for a large proportion of high-grade serous ovarian cancers. Consequently, salpingectomy is now considered for permanent contraception (in lieu of tubal ligation) or ovarian cancer prevention (performed opportunistically at the time of surgical procedures for benign gynecologic conditions). Objective: To evaluate the association between salpingectomy and the risk of invasive epithelial ovarian, fallopian tube, and peritoneal cancer. Design, Setting, and Participants: This population-based retrospective cohort study included all women aged 18 to 80 years who were eligible for health care services in Ontario, Canada. Participants were identified using administrative health databases from Ontario between January 1, 1992, and December 31, 2019. A total of 131 516 women were included in the primary (matched) analysis. Women were followed up until December 31, 2021. Exposures: Salpingectomy (with and without hysterectomy) vs no pelvic procedure (control condition) among women in the general population. Main Outcomes and Measures: Women with a unilateral or bilateral salpingectomy in Ontario between April 1, 1992, and December 31, 2019, were matched 1:3 to women with no pelvic procedure from the general population. Cox proportional hazards regression models were used to estimate the hazard ratios (HRs) and 95% CIs for ovarian, fallopian tube, and peritoneal cancer combined. Results: Among 131 516 women (mean [SD] age, 42.2 [7.6] years), 32 879 underwent a unilateral or bilateral salpingectomy, and 98 637 did not undergo a pelvic procedure. After a mean (range) follow-up of 7.4 (0-29.2) years in the salpingectomy group and 7.5 (0-29.2) years in the nonsurgical control group, there were 31 incident cancers (0.09%) and 117 incident cancers (0.12%), respectively (HR, 0.82; 95% CI, 0.55-1.21). The HR for cancer incidence was 0.87 (95% CI, 0.53-1.44) when comparing those with salpingectomy vs those with hysterectomy alone. Conclusions and Relevance: In this cohort study, no association was found between salpingectomy and the risk of ovarian cancer; however, this observation was based on few incident cases and a relatively short follow-up time. Studies with additional years of follow-up are necessary to define the true level of potential risk reduction with salpingectomy, although longer follow-up will also be a challenge unless collaborative efforts that pool data are undertaken.

Clinical improvement after Essure® devices removal: a systematic review.

PURPOSE: Essure® implant is a permanently implanted minimally invasive birth control device for women (female sterilisation) widely used between 2002 and 2018. Many adverse events were reported by patients. Increasingly removal procedures have been performed in symptomatic patients. However, there is a lack of in-depth studies on clinical improvement after Essure® removal. We aimed to review all clinical studies about symptoms and quality of life (QoL) after removal procedures. MATERIALS AND METHODS: A review of literature in electronic search in Medline and Embase databases from January 2002 to January 2022 using the following keywords: Essure; Essure removal; quality of life; symptomatology improvement. RESULTS: Out of 764 articles in the initial database, 18 clinical studies were eligible for inclusion in our literature review. Overall clinical improvement rates after removal ranged from 21% to 98%. All symptoms were less frequent after Essure® removal, although with large discrepancies between studies. Lack of improvement was reported between 1% to 15% of patients. Rate of patients with improvement of QoL after removal ranged from 58 to 98%. The pain was reported as significantly reduced after the surgery. CONCLUSIONS: In the available literature, Essure® removal in symptomatic patients may improve symptoms and quality of life. This should be discussed in the benefits and risks ratio before deciding on the best option of management.

Essure® removal in symptomatic patients may improve symptoms and quality of life.

Adoption of Complete Bilateral Salpingectomy for Permanent Contraception at Time of Cesarean Delivery in Rhode Island.

OBJECTIVE: Complete bilateral salpingectomy (CBS) can decrease the risk of developing ovarian cancer, although adoption of CBS at cesarean delivery (CD) for permanent contraception has been low. The primary objective was to measure the annual rates of CBS at CD before and after an educational initiative. The secondary objective was to assess rates of providers who offer CBS at CD and their comfort level with the procedure. METHODS: We performed an observational study of OBGYN physicians who perform CD at a single institution. We compared the annual rates of CBS among CD with permanent contraception procedures from the year before and the year after an in-person OBGYN Grand Rounds presentation on December 5, 2019 reviewing the latest research on opportunistic CBS at the time of CD. To evaluate the secondary objectives, anonymous surveys were administered to physicians in-person the month before the presentation. The statistical analysis included chi-square, Fisher's exact test, T-test, ANOVA, and the Cochran-Armitage trend test. RESULTS: After our educational intervention, annual rates of CBS at CD increased from 5.1% [12/05/2018-12/04/2019] to 31.8% [12/5/2019-12/4/2020] (p<0.001), and up to 52% in the last study quarter (p<0.001). Surgical outcomes were similar between tubal ligation and CBS, except for a 5-minute increased total operative time for CBS (p=0.005). Fifty physicians completed the survey prior to the presentation (93% response rate). All physicians offered CBS at time of hysterectomy and interval sterilization, while only 36% offered CBS at time of CD. More physicians felt comfortable performing a CBS with bipolar electrocautery (90%) than suture ligation (56%). CONCLUSION: Our presentation-based educational initiative was associated with a significant increase in performance of CBS at the time of CD.

Patient perspectives on risk-reducing salpingectomy with delayed oophorectomy for ovarian cancer risk-reduction: A systematic review of the literature.

OBJECTIVE: Increasing evidence suggests the fallopian tube as the site of origin of BRCA1/2-associated high-grade ovarian cancers. Several ongoing trials are evaluating salpingectomy with delayed oophorectomy (RRSDO) for ovarian cancer risk reduction and patients are beginning to ask their clinicians about this surgical option. This study sought to systematically review the available literature examining patient preferences regarding RRSDO and risk-reducing salpingo-oophorectomy (RRSO) to provide clinicians with an understanding of patient values, concerns, and priorities surrounding ovarian cancer risk-reducing surgery. METHODS: We conducted a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO No.: CRD42023400690). We searched key electronic databases to identify studies evaluating acceptance and surgical decision-making regarding RRSO and RRSDO among patients with an increased risk of ovarian cancer. RESULTS: The search yielded 239 results, among which six publications met the systematic review inclusion criteria. Acceptance of RRSDO was evaluated in all studies and ranged from 34% to 71%. Factors positively impacting patients' acceptance of RRSDO included: avoidance of surgical menopause, preservation of fertility, concerns about sexual dysfunction, family history of breast cancer, and avoidance of hormone replacement therapy. Factors limiting this acceptance reported by patients included concerns regarding oncologic safety, surgical timing, and surgical complications. CONCLUSION: To date, few studies have explored patient perspectives surrounding RRSDO. Collectively, the limited data available indicate a high level of acceptance among BRCA1/2 carriers, and provides insight regarding both facilitating and limiting factors associated with patient preferences to better equip clinicians in the counseling and support of their patients.

TUBectomy with delayed oophorectomy as an alternative to risk-reducing salpingo-oophorectomy in high-risk women to assess the safety of prevention: the TUBA-WISP II study protocol.

BACKGROUND: Risk-reducing salpingectomy with delayed oophorectomy has gained interest for individuals at high risk for tubo-ovarian cancer as there is compelling evidence that especially high-grade serous carcinoma originates in the fallopian tubes. Two studies have demonstrated a positive effect of salpingectomy on menopause-related quality of life and sexual health compared with standard risk-reducing salpingo-oophorectomy. PRIMARY OBJECTIVE: To investigate whether salpingectomy with delayed oophorectomy is non-inferior to the current standard salpingo-oophorectomy for the prevention of tubo-ovarian cancer among individuals at high inherited risk. STUDY HYPOTHESIS: We hypothesize that postponement of oophorectomy after salpingectomy, to the age of 40-45 (BRCA1) or 45-50 (BRCA2) years, compared with the current standard salpingo-oophorectomy at age 35-40 (BRCA1) or 40-45 (BRCA2) years, is non-inferior in regard to tubo-ovarian cancer risk. TRIAL DESIGN: In this international prospective preference trial, participants will choose between the novel salpingectomy with delayed oophorectomy and the current standard salpingo-oophorectomy. Salpingectomy can be performed after the completion of childbearing and between the age of 25 and 40 (BRCA1), 25 and 45 (BRCA2), or 25 and 50 (BRIP1, RAD51C, and RAD51D pathogenic variant carriers) years. Subsequent oophorectomy is recommended at a maximum delay of 5 years beyond the upper limit of the current guideline age for salpingo-oophorectomy. The current National Comprehensive Cancer Network (NCCN) guideline age, which is also the recommended age for salpingo-oophorectomy within the study, is 35-40 years for BRCA1, 40-45 years for BRCA2, and 45-50 years for BRIP1, RAD51C, and RAD51D pathogenic variant carriers. MAJOR INCLUSION/EXCLUSION CRITERIA: Premenopausal individuals with a documented class IV or V germline pathogenic variant in the BRCA1, BRCA2, BRIP1, RAD51C, or RAD51D gene who have completed childbearing are eligible for participation. Participants may have a personal history of a non-ovarian malignancy. PRIMARY ENDPOINT: The primary outcome is the cumulative tubo-ovarian cancer incidence at the target age: 46 years for BRCA1 and 51 years for BRCA2 pathogenic variant carriers. SAMPLE SIZE: The sample size to ensure sufficient power to test non-inferiority of salpingectomy with delayed oophorectomy compared with salpingo-oophorectomy requires 1500 BRCA1 and 1500 BRCA2 pathogenic variant carriers. ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS: Participant recruitment is expected to be completed at the end of 2026 (total recruitment period of 5 years). The primary outcome is expected to be available in 2036 (minimal follow-up period of 10 years). TRIAL REGISTRATION NUMBER: NCT04294927.

Prophylactic salpingectomy with delayed oophorectomy as a two-staged alternative for primary prevention of ovarian cancer in BRCA1/2 mutation carriers: women's point of view.

OBJECTIVE: This study aimed to determine BRCA -mutation carrier women's interest and acceptability of participating in a study examining prophylactic salpingectomy with delayed oophorectomy (PSDO) as an alternative to the current recommendation for bilateral salpingo-oophorectomy for risk reduction. METHODS: This is a cross-sectional questionnaire-based study. All women visiting the high-risk clinics for hereditary breast and ovarian cancer in a single tertiary medical center were asked to complete a questionnaire concerning the two-stage approach from October 2018 to December 2019. Before completing the questionnaire, detailed explanation was given by a senior physician regarding the procedure, related background, possible risks, and benefits. RESULTS: The study population included 293 women, of whom 183 (62.4%) were BRCA1 mutation carriers, 97 (33.1%) were BRCA2 mutation carriers, and 13 (4.4%) had unknown familial mutation. Risk-reducing surgery was completed in 160 (55.17%) of the women. First-degree and second-degree family history was reported in 166 (57.24%) and 52 (17.9%) of the women, respectively. Among women surveyed, more than half of the women (n = 66 [51%]) who had yet to undergo risk-reducing surgery reported interest in having PSDO. Similarly, among those who had already received prophylactic surgery, 64 (40%) also considered PSDO to be an acceptable alternative. Multivariate logistic regression analysis found family history of related malignancies to be the only independent factor associated with reduced interest in a study of PSDO (odds ratio, 0.15 [95% confidence interval, 0.29-0.77]; P = 0.02). CONCLUSIONS: Overall, BRCA -mutation carrier women indicated interest in PSDO risk-reducing surgery, taking into consideration the potential additional risk. These findings suggest that a clinical study exploring the equivalence of PSDO as alternative treatment is feasible.

HOPPSA update: changes in the study protocol of Hysterectomy and OPPortunistic SAlpingectomy, a registry-based randomized controlled trial.

BACKGROUND: The HOPPSA trial is a multi-center national registry-based randomized controlled trial to test the safety and effectiveness of performing opportunistic salpingectomy at hysterectomy to reduce the risk of epithelial ovarian cancer (EOC). The study protocol was first published in January 2019 and is available at https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-018-3083-8 . Here, we report amendments made to the study protocol since commencement of the trial. CHANGES IN METHODS AND ANALYSIS: The primary outcomes analyses have been changed. (1) Complications will be analyzed using binomial generalized estimating equation (GEE) with log link function, while the unadjusted analyses according to Miettinen and Nurminen will be performed as a sensitivity analysis. (2) Absolute change in Menopause Rating Scale (MRS) will primarily be analyzed using a mixed effects model, adjusted for baseline MRS and center as a random effect. (3) Time to EOC will be analyzed using the mixed effects Cox regression model with center as random effect, while the unadjusted log-rank test will be performed as a sensitivity analysis. The primary outcome Complications will be based solely on the specific assessment in the GynOp quality registry. The Clavien-Dindo classification will be evaluated as a secondary outcome. Furthermore, MRS is also measured three years postoperatively to better pinpoint the onset of menopausal symptoms. DISCUSSION: The changes to the protocol mainly concern the analyses of data. No changes to recruitment, randomization, intervention, or follow-up of primary outcomes have been made. An interim analysis during 2021 concluded that the study should continue until the target sample size is reached. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03045965 . Registered 8 February 2017.

Interstitial Ectopic Pregnancy: Laparoscopic Cornuostomy.

STUDY OBJECTIVE: To demonstrate and discuss the technique of cornuostomy for surgical management of interstitial ectopic pregnancy. DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: Tertiary referral center in Manchester, United Kingdom. INTERVENTION: Interstitial ectopic pregnancies are rare but are associated with a higher mortality rate than other ectopic pregnancies [1,2]. It occurs when the fertilized embryo implants in the interstitial portion of the fallopian tube traversing the vascularized myometrium. When undiagnosed they present late in the second trimester associated with rupture and catastrophic bleeding, with a mortality rate of 2% to 2.5%.2 Diagnosis requires a degree of vigilance from the ultrasound operator because it is commonly misdiagnosed as intrauterine pregnancies. Surgical management options include laparoscopic cornual resection or cornuostomy. There is no consensus on the optimal surgical technique but cornuostomy is a more conservative approach associated with less disruption to uterine anatomy and loss of myometrium [3,4]. A 22-year-old gravida 4 woman presented at 7 weeks' gestation with right iliac fossa pain. Initial serum human chorionic gonadotropin was 18 136 IU/L. Transvaginal ultrasound scan showed an empty endometrial cavity and an echogenic "donut"-shaped mass within the right interstitial space, within the uterine serosa but outside the endometrial cavity (Supplemental Video 1). At laparoscopy the diagnosis of a right interstitial ectopic pregnancy was confirmed (Supplemental Video 2). Vasopressin 20 IU diluted in 80 mL of normal saline was injected around the base of the ectopic pregnancy. Monopolar diathermy was used to incise the overlying serosa followed by hydrodissection to separate the ectopic gestational sac from the myometrial attachment. The resulting defect was inspected and closed in 2 layers. Total operating time was 46 minutes. CONCLUSION: Although there is no clear evidence to guide the management of all interstitial ectopic pregnancies, an individualized approach taking into account the woman's previous history and future fertility plans and wishes is essential. In this case, given the woman's previous contralateral salpingectomy and her wishes for a conservative approach, a laparoscopic cornuostomy was likely the best option.

Management of interstitial pregnancy using laparoscopic salpingectomy with complete removal of the interstitial portion.

OBJECTIVE: To perform laparoscopic salpingectomy, including the entire interstitial portion of the fallopian tube, in the management of interstitial pregnancy. DESIGN: A step-by-step explanation of the surgical procedure using video with narration. SETTING: Obstetrics and Gynecology department of a hospital. PATIENT(S): A 23-year-old woman, gravida 1 para 0, presented asymptomatically to our hospital to undergo a pregnancy test. Her last menstrual period had occurred 6 weeks previously. Transvaginal ultrasound showed an empty uterine cavity and a right interstitial mass of 3.2 × 2.6 × 2.5 cm. It contained a chorionic sac and an embryonic bud of 0.2 cm long with a heartbeat and the presence of an "interstitial line sign." The myometrial layer surrounding the chorionic sac was 1 mm. The patient's beta-human chorionic gonadotropin level was 10,123 mIU/mL. INTERVENTION(S): On the basis of the anatomy of the interstitial portion of the fallopian tube, we treated interstitial pregnancy using laparoscopic salpingectomy, with complete removal of the interstitial portion containing the product of conception. The interstitial fallopian tube originates at the tubal ostium and follows a tortuous intramural course, progressing laterally away from the uterine cavity toward the isthmic portion. It is lined by muscular layers and an inner epithelium layer. The main blood supply of the interstitial portion is from the uterine artery's ascending branches to the fundus, extending a branch that supplies the cornu and the interstitial portion. Our approach has 3 key steps: 1) dissecting and coagulating the branch extending from the ascending branches to the fundus of the uterine artery, 2) incising the cornual serosa at the junction of the purple-blue interstitial pregnancy and the normal color myometrium, and 3) resecting the interstitial portion containing the product of conception along the outer layer of the oviduct without rupture. MAIN OUTCOME MEASURE(S): The interstitial portion containing the product of conception was removed entirely along the outer layer of the fallopian tube as a natural capsule without rupture. RESULTS(S): The surgery lasted for 43 min, and the volume of intraoperative blood loss was 5 mL. The pathology was confirmatory for interstitial pregnancy. The patient's beta-human chorionic gonadotropin levels decreased optimally. She had a normal postoperative course. CONCLUSION(S): This approach reduces intraoperative blood loss, minimizes myometrial loss and thermal injury, and effectively avoids persistent interstitial ectopic pregnancy. It is not limited by the device used, does not increase the surgery cost, and is greatly useful in treating a selected nonruptured distally or centrally implanted interstitial pregnancy.

Ovarian cancer prevention by opportunistic salpingectomy is a new de facto standard in Germany.

PURPOSE: The most prevalent and aggressive subtype of epithelial ovarian carcinoma (EOC), high-grade serous carcinoma (HGSC), originates in many cases from the fallopian tubes. Because of poor prognosis and lack of effective screening for early detection, opportunistic salpingectomy (OS) for prevention of EOC is being implemented into clinical routine in several countries worldwide. Taking the opportunity of a gynecological surgery in women at average cancer risk, extramural fallopian tubes are completely resected preserving the ovaries with their infundibulopelvic blood supply. Until recently, only 13 of the 130 national partner societies of the International Federation of Obstetrics and Gynecology (FIGO) have published a statement on OS. This study aimed to analyze the acceptance of OS in Germany. METHODS: (1) Survey of German gynecologists in 2015 and 2022 by the Department of Gynecology of the Jena University Hospital in co-operation with the Department of Gynecology at Charité-University Medicine Berlin with support of NOGGO e. V. and AGO e. V. (2) Salpingectomy numbers in Germany for years 2005-2020 as retrieved from the Federal Statistical Office of Germany (Destatis). RESULTS: (1) Survey: Number of participants was 203 in 2015 and 166 in 2022, respectively. Nearly all respondents (2015: 92%, 2022: 98%) have already performed bilateral salpingectomy without oophorectomy in combination with benign hysterectomy with the intention to reduce the risk for malignant (2015: 96%, 2022: 97%) and benign (2015: 47%, 2022: 38%) disorders. Compared to 2015 (56.6%), considerably more survey participants performed OS in > 50% or in all cases in 2022 (89.0%). Recommendation of OS for all women with completed family planning at benign pelvic surgery was approved by 68% in 2015 and 74% in 2022. (2) Case number analysis: In 2020, four times more cases of salpingectomy were reported by German public hospitals compared to 2005 (n = 50,398 vs. n = 12,286). Of all inpatient hysterectomies in German hospitals in 2020, 45% were combined with salpingectomy, and more than 65% in women at the age of 35 to 49 years. CONCLUSION: Mounting scientific plausibility regarding involvement of fallopian tubes in the pathogenesis of EOC led to change of clinical acceptance of OS in many countries including in Germany. Case number data and widespread expert judgment demonstrate that OS has become a routine procedure in Germany and a de facto standard for primary prevention of EOC.

Distocia em tigre d'água-de-orelha-vermelha, Trachemys scripta elegans, wied (1839): relato de caso / Dystocia in red-eared slider, Trachemys scripta elegans, wied (1839): case report / Distocia en tortuga de orejas rojas, Trachemys scripta elegans, wied (1839): reporte de caso

Atualmente muitos répteis se tornaram animais de companhia e são mantidos como pet's exóticos. A espécie Trachemys scripta elegans, Wied (1839) é um animal exótico da América do Norte, sua identificação é realizada pelas marcas avermelhadas encontradas lateralmente a sua cabeça. Na rotina clínica as principais enfermidades que acometem os quelônios são as de origem reprodutiva, como a estase folicular e distocia. O objetivo deste trabalho foi relatar um caso recorrente de distocia em um tigre d'água fêmea, para isso, a anamnese, o histórico da paciente, e seus sinais clínicos, em conjunto com os exames complementares de imagem foram essenciais para se obter diagnóstico definitivo. O tratamento foi realizado com a indução medicamentosa utilizando borogluconato de cálcio, seguida da aplicação de ocitocina, esta trouxe resultados positivos para a eliminação dos ovos. Porém devido ao histórico do paciente, optou-se pela intervenção cirúrgica de ovariossalpingectomia, sendo está a maneira permanente de resolução da patologia. O protocolo terapêutico escolhido proporcionou um resultado satisfatório e bem estar ao animal.(AU)

Currently, many reptiles have become companion animals and are kept as exotic pets. The species Trachemys scripta elegans, Wied (1839) is an exotic animal from North America, and its identification is based on the reddish markings found laterally on its head. In routine clinical practice, the main diseases that affect chelonians are those of reproductive origin, such as follicular stasis and dystocia. The aim of this study was to report a recurrent case of dystocia in a female red-eared slider turtle. For this purpose, the patient's anamnesis, history, and clinical signs, along with complementary imaging exams, were essential to obtain a definitive diagnosis. The treatment involved medical induction using calcium borogluconate, followed by the administration of oxytocin, which yielded positive results in egg elimination. However, due to the patient's history, surgical intervention in the form of ovariosalpingectomy was chosen as the permanent solution to the pathology. The chosen therapeutic protocol provided a satisfactory outcome and improved the animal's well-being.(AU)

Actualmente muchos reptiles se han convertido en animales de compañía y se mantienen como mascotas exóticas. La especie Trachemys scripta elegans, Wied (1839) es un animal exótico de América del Norte, su identificación se realiza por las marcas rojizas que se encuentran lateralmente a su cabeza. En la rutina clínica, las principales enfermedades que afectan a los quelonios son las de origen reproductivo, como la estasis folicular y la distocia. El objetivo de este trabajo fue reportar un caso recurrente de distocia en una hembra de tigre de agua, para ello la anamnesis, la historia de la paciente y sus signos clínicos, junto con los exámenes imagenológicos complementarios fueron fundamentales para obtener un diagnóstico definitivo. El tratamiento se realizó con inducción farmacológica con borogluconato de calcio, seguido de la aplicación de oxitocina, que arrojó resultados positivos con la eliminación de huevos. Sin embargo, debido a los antecedentes de la paciente, se optó por la intervención quirúrgica de ovarialpingectomía, que es la forma definitiva de resolución de la patología. El protocolo terapéutico elegido proporcionó un resultado satisfactorio y bienestar al animal.(AU)

Opportunistic Salpingectomy at the Time of Laparoscopic Cholecystectomy for Ovarian Cancer Prevention: A Cost-effectiveness Analysis.

OBJECTIVE: To perform a cost-effectiveness analysis to examine the utility and effectiveness of OS performed at the time of elective cholecystectomy [laparoscopic cholecystectomy (LAP-CHOL)]. SUMMARY BACKGROUND DATA: OS has been adopted as a strategy to reduce the risk of ovarian cancer in women undergoing hysterectomy and tubal sterilization, although the procedure is rarely performed as a risk reducing strategy during other abdominopelvic procedures. METHODS: A decision model was created to examine women 40, 50, and 60 years of age undergoing LAP-CHOL with or without OS. The lifetime risk of ovarian cancer was assumed to be 1.17%, 1.09%, and 0.92% for women age 40, 50, and 60 years, respectively. OS was estimated to provide a 65% reduction in the risk of ovarian cancer and to require 30 additional minutes of operative time. We estimated the cost, quality-adjusted life-years, ovarian cancer cases and deaths prevented with OS. RESULTS: The additional cost of OS at LAP-CHOL ranged from $1898 to 1978. In a cohort of 5000 women, OS reduced the number of ovarian cancer cases by 39, 36, and 30 cases and deaths by 12, 14, and 16 in the age 40-, 50-, and 60-year-old cohorts, respectively. OS during LAP-CHOL was cost-effective, with incremental cost-effectiveness ratio of $11,162 to 26,463 in the 3 age models. In a probabilistic sensitivity analysis, incremental cost-effectiveness ratio for OS were less than $100,000 per quality-adjusted life-years in 90.5% or more of 1000 simulations. CONCLUSIONS: OS at the time of LAP-CHOL may be a cost-effective strategy to prevent ovarian cancer among average risk women.

Forensic Analysis of Eighteen Tubal Pregnancy-Related Medical Damage.

OBJECTIVES: To analyze the cases of medical damage after misdiagnosis of tubal pregnancy, to explore the causes of medical damage, the causal relationship between medical malpractice and the damage consequences, as well as the causative potency, in order to provide evaluation ideas for forensic identification of such cases. METHODS: Eighteen cases of forensic identification of tubal pregnancy related medical damage were collected and retrospectively analyzed from the aspects of age, maternity history, fertility requirements, risk factors, diagnosis and treatment, medical malpractice, damage consequences, and causative potency. RESULTS: All 18 cases were tubal pregnancy, of which 17 cases had medical malpractice, resulting in 14 cases of affected tubal resection, 2 cases of hemorrhagic shock death, 1 case of intrauterine fetal death and affected tubal resection. The other case had the consequence of affected tubal resection, but there was no malpractice in the treatment. CONCLUSIONS: Correct diagnosis is helpful to make appropriate treatment plan, prevent disease progression and reduce serious adverse consequences and the occurrence of medical disputes. Scientific and reasonable analysis of the causal relationship between medical malpractice and damage consequences and the causative potency is of great significance to the successful settlement of medical disputes.

Possible Association of Hysterectomy Accompanied with Opportunistic Salpingectomy with Early Menopause: A Retrospective Cohort Study.

Opportunistic salpingectomies (OSs) are concurrently performed with hysterectomies to prevent epithelial ovarian cancer. This study aimed to investigate the correlation between OS and early menopause in females who have undergone hysterectomies. This was a retrospective cohort study involving 79 females who had undergone a hysterectomy, with or without an OS, between January 2007 and December 2015. Their ages at surgery, at menopause, and the lengths of time from surgery to menopause were compared. An OS had been performed in 54 and not performed in 25 of the enrolled patients, comprising the OS and non-OS groups. Body mass index was significantly higher in the OS group (OS: 25.27 ± 4.17 vs. non-OS: 22.97 ± 3.27, p = 0.01). Additionally, menopausal sleep problems were more prevalent in the OS group than in the non-OS group (41% vs. 12%, p = 0.01). Notably, the time from surgery to menopause was significantly shorter in the OS group than in the non-OS group (OS: 1.84 ± 1.85 vs. non-OS: 2.93 ± 2.43, p = 0.031). After adjusting the covariates, the OS group was associated with a significantly shorter period between surgery and menopause (p = 0.029). In conclusion, these results showed that a hysterectomy plus an OS might cause earlier menopause than a hysterectomy only. An OS should be preoperatively discussed with patients regarding the possibility of early menopause. The findings of this study require further large-scale investigations to reinforce the results.