The Fallopian tube - to be or not be removed. Opportunistic salpingectomy at benign hysterectomi

Abstract

Background: Opportunistic salpingectomy (OS) is increasingly common during benign hysterectomy as a preventive measure for epithelial ovarian cancer (EOC). However, there is limited research on the procedure's impact on complications, its long-term effects on ovarian function and the effect size of the risk reduction for EOC. A simplified dualistic classification model proposed in 2004 divides EOC into type I and II. While type I is believed to originate from benign precursor lesions in the ovaries potentially influenced by retrograde passage of endometrial cells and carcinogen agents through the Fallopian tubes, type II is believed to originate from lesions in the Fallopian tubes. Thus, gynecological interventions may impact the risk for each type differently. The decision to undergo OS as a preventive procedure should be guided by well-informed shared decision-making. However, the long-term experiences of women who have faced this choice remain unexplored. Aim: To identify knowledge gaps regarding the efficacy and safety of OS concomitant with benign hysterectomy. Examining gynecological interventions and its association with the risk of type I and II EOC. Exploring women’s perceptions of OS and assessing its impact on ovarian function one year after surgery. Methods: Paper I is a systematic review examining existing evidence on OS performed during benign hysterectomy, evaluating both the risks and benefits of the intervention. Paper II is a case-control study exploring the effect of gynecological surgeries; hysterectomy, salpingectomy and tubal ligation on the risk of type I and II EOC. Paper III is a qualitative study exploring women's experiences and perceptions of risks and benefits after benign hysterectomy, with or without OS, using focus group discussions. Paper IV is a sub-study to a national randomized controlled trial, investigating the effect of OS at hysterectomy on ovarian function, measured by anti-Müllerian hormone (AMH) before and one year after surgery. Results: No studies on OS and EOC risk were found (Paper I). Observational studies showed that EOC risk was reduced by 42-65% after indicated bilateral salpingectomy compared with no surgery. No difference in complication rates or short-term ovarian function was found with OS added to hysterectomy, but the certainty of evidence was low to very low for all outcomes. Salpingectomy was associated with a lower risk of type II EOC (OR 0.62; 95% CI 0.45, 0.85), while no association was not found for type I EOC (OR 1.16; 95% CI 0.75, 1.78) (paper II). Hysterectomy was associated with a reduced risk for type I EOC (OR 0.70; 95% CI 0.51, 0.98) and type II (OR 0.81; 95% CI 0.68, 0.96). Similar estimates were observed for tubal ligation; however, these results did not reach statistical significance. Women emphasized the importance of clear information and shared decision-making with a desire for personalized consultation and long-term support post-operatively to enhance well-being during menopause transition (paper III). The mean difference between groups of AMH change was -0.03 μg/L (95% CI -0.23, 0.18), the upper CI exceeding the pre-defined non-inferiority margin of 0.125 μg/L (paper IV). Despite the absolute difference in AMH changes between the groups being minimal, with the greatest reduction observed in the hysterectomy only group, non-inferiority of OS at hysterectomy regarding ovarian function, could not be demonstrated. Conclusion: This thesis concludes that the certainty of evidence on efficacy and safety of OS at benign hysterectomy is low. OS appears to have minimal impact on ovarian function one year post-surgery, though wide AMH variation suggests a greater effect in some individuals. Prospective randomized studies are needed before OS can be recommended for women at average risk of EOC, aligning with women’s desire for shared decision-making guided by high-quality evidence. Hysterectomy, salpingectomy, and tubal ligation may reduce the risk of EOC. Findings support the theories of the developmental pathways of type I and II EOC with the exception of no observed link between salpingectomy and a lower risk of type I EOC. Keywords: Opportunistic salpingectomy, hysterectomy, tubal ligation, ovarian function and ovarian cancer.