Laparoscopic Management of Adnexal Masses
Abstract & Commentary
Synopsis: Adnexal masses thought to be benign pre-operatively were successfully removed in three-fourths of cases with adverse events primarily related to concurrent hysterectomy.
Source: Havrilesky LJ, et al. Obstet Gynecol. 2003; 102:243-251.
A retrospective study of 396 patients undergoing laparoscopic management for a 7-year period at a single institution was performed. Complications were statistically more likely if hysterectomy was also being performed or if the mass was of a smaller size. Laparotomy was required in 25% and was associated with larger mass size, previous hysterectomy and younger patient age. The incidence of rupture of the mass was 25%, associated with concurrent/previous hysterectomy, and a younger patient. Blood loss in excess of 500 cc was associated with concurrent hysterectomy. Malignancy was found in 2% without increased adverse outcomes associated with laparoscopic management.
Comment by Frank W. Ling, MD
So the laparoscopic management of adnexal masses appears to be a safe one—for either a generalist or a gynecologic oncologist. At least that was the case between 1994 and 2001 at Duke University. The data were gathered from the experience of 46 different gynecologic surgeons, only a few of whom were oncologists. The factors most likely associated with increased morbidity were previous abdominal surgery, prior hysterectomy, and a larger size mass, but because the overall complication rate was so low, none of the above is considered a contraindication to a laparoscopic approach.
You may be wondering about the potential effect of intra-operative rupture of adnexal masses that turn out to be malignant. The literature has conflicting reports with no compelling evidence that intra-operative rupture results in a worse prognosis. It should be noted, however, that intra-operative rupture of a malignancy is usually treated with chemotherapy, thereby adversely affecting quality of life.
Despite reports that metastatic lesions can be found in up to 25% of laparoscopic port sites in cases of malignancy, none were found among the 8 cases of cancer in this series. Havrilesky and associates do not recommend laparoscopic management of masses that are suspicious of being malignant but remain supportive of laparoscopic surgery in cases thought to be benign.
Okay, so what is the take-home message? First, each case should be thoroughly evaluated for the possibility of malignancy pre-operatively so that the optimal surgical approach can be chosen. Second, there definitely is "wiggle room" for the gynecologic surgeon in each case (ie, an adnexal mass does not necessitate a laparotomy) but the surgeon should make the decision with his/her own expertise and comfort in mind. Unilocular cystic masses would suggest a benign lesion, but these findings should also take into account any family history of ovarian cancer, the CA 125 level, and the patient’s level of anxiety. It’s tough enough for a patient to have to deal with the potential of ovarian cancer. These data provide the reassurance that the risks and morbidity of surgery can be minimized with a less invasive operative approach. Keep it in mind. It will come in handy.