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Am J Obstet Gynecol. Author manuscript; available in PMC 2018 November 01.
Published in final edited form as:
Am J Obstet Gynecol. 2017 November ; 217(5): 605.e1–605.e5. doi:10.1016/j.ajog.2017.07.017.
Feasibility of prophylactic salpingectomy during vaginal
hysterectomy
Author Manuscript
Danielle D. Antosh, MD, Rachel High, DO, Heidi W. Brown, MD, MAS, Sallie S. Oliphant, MD,
MSc, Husam Abed, MD, Nisha Philip, MBBS, and Cara L. Grimes, MD, MAS
From the Departments of Obstetrics and Gynecology at Houston Methodist Hospital, Houston, TX
(Drs Antosh and High); University of Wisconsin School of Medicine and Public Health, Madison,
WI (Dr Brown); University of Arkansas for Medical Sciences, Little Rock, AR (Dr Oliphant);
University of Mississippi Medical Center, Jackson, MS (Dr Abed); and Columbia University
Medical Center, New York, NY (Ms Philip and Dr Grimes).
Abstract
BACKGROUND: The American Congress of Obstetricians and Gynecologists recommends that
“the surgeon and patient discuss the potential benefits of the removal of the fallopian tubes during
a hysterectomy in women at population risk of ovarian cancer who are not having an
oophorectomy,” resulting in an increasing rate of salpingectomy at the time of hysterectomy. Rates
of salpingectomy are highest for laparoscopic and lowest for vaginal hysterectomy.
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OBJECTIVE: The primary objective of this study was to determine the feasibility of bilateral
salpingectomy at the time of vaginal hysterectomy. Secondary objectives included identification of
factors associated with unsuccessful salpingectomy and assessment of its impact on operating
time, blood loss, surgical complications, and menopausal symptoms.
STUDY DESIGN: This was a multicenter, prospective study of patients undergoing planned
vaginal hysterectomy with bilateral salpingectomy. Baseline medical data along with operative
findings, operative time, and blood loss for salpingectomy were recorded. Uterine weight and
pathology reports for all fallopian tubes were reviewed. Patients completed the Menopause Rating
Scale at baseline and at postoperative follow-up. Descriptive analyses were performed to
characterize the sample and compare those with successful and unsuccessful completion of
planned salpingectomy using Student t test, and χ2 test when appropriate. Questionnaire scores
were compared using paired t tests.
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RESULTS: Among 77 patients offered enrollment, 74 consented (96%), and complete data were
available regarding primary outcome for 69 (93%). Mean age was 51 years. Median body mass
index was 29.1 kg/m2; median vaginal parity was 2, and 41% were postmenopausal. The
indications for hysterectomy included prolapse (78%), heavy menstrual bleeding (20%), and
fibroids (11%). When excluding conversions to alternate routes, vaginal salpingectomy was
successfully performed in 52/64 (81%) women. Mean operating time for bilateral salpingectomy
was 11 (±5.6) minutes, with additional estimated blood loss of 6 (±16.3) mL. There were 8
surgical complications: 3 hemorrhages >500 mL and 5 conversions to alternate routes of surgery,
Corresponding author: Danielle D. Antosh, MD. ddantosh@houstonmethodist.org. Presented at the 43rd meeting of the Society of
Gynecologic Surgeons, San Antonio, TX, March 28, 2017.
Antosh et al.
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but none of these were due to the salpingectomy. Mean uterine weight was 102 g and there were
no malignancies on fallopian tube pathology. Among the 17 patients in whom planned bilateral
salpingectomy was not completed, unilateral salpingectomy was performed in 7 patients. Reasons
for noncompletion included: tubes high in the pelvis (8), conversion to alternate route for
pathology (4), bowel or sidewall adhesions (3), tubes absent (1), and ovarian adhesions (1). Prior
adnexal surgery (odds ratio, 2.9; 95% confidence interval, 1.5–5.5; P – .006) and uterine fibroids
(odds ratio, 5.8; 95% confidence interval, 1.5–22.5; P = .02) were the only significant factors
associated with unsuccessful bilateral salpingectomy. Mean menopause scores improved after
successful salpingectomy (12.7 vs 8.6; P < .001).
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CONCLUSION: Vaginal salpingectomy is feasible in the majority of women undergoing vaginal
hysterectomy and increases operating time by 11 minutes and blood loss by 6 mL. Women with
prior adnexal surgery or uterine fibroids should be counseled about the possibility that removal
may not be feasible.
Keywords
benign; fallopian; hysterectomy; prophylactic; salpingectomy; vaginal
Introduction
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Hysterectomy is one of the most common operations performed in the United States, with
>400,000 per year.1 Of women who undergo hysterectomy for benign gynecologic
indications, 39% have elective bilateral salpingooophorectomy (BSO) to prevent ovarian
cancer.2 Premenopausal women and women age <65 years may consider ovarian
conservation, as preserving ovaries prevents bone resorption, and surgical menopause
increases long-term risk of psychosexual, cognitive, and both fatal and nonfatal
cardiovascular disease.3–5 Although more patients of younger ages are electing for ovarian
conservation, there may be benefit to performing salpingectomy. Increasing evidence
demonstrates that high-grade serous carcinoma, the most lethal ovarian malignancy, actually
originates in the distal fallopian tube and not in the ovaries.6–8 In November 2013, the
Society of Gynecologic Oncology issued a clinical practice statement suggesting that in
women who choose to retain their ovaries, salpingectomy should be considered at the time
of hysterectomy or other pelvic surgery for women at average risk for ovarian cancer.9 The
American Congress of Obstetricians and Gynecologists (ACOG) also recommends that
surgeons offer and discuss the benefits of salpingectomy to patients undergoing
hysterectomy.10
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Despite the recommendations from the Society of Gynecologic Oncology and ACOG and
the rising rate of prophylactic salpingectomies, salpingectomy at the time of vaginal
hysterectomy is low and has not been extensively studied. One large retrospective cohort of
>12,000 hysterectomies reported only 17% of vaginal hysterectomies had salpingectomy
performed.11 There have been several studies evaluating the success of removing ovaries
vaginally, which show that BSO during vaginal hysterectomy is safe and feasible. Two thirds
or more of vaginal hysterectomies with prophylactic salpingo-oophorectomy are completed
with minimal or no increases in operative time and surgical morbidity.12 It isunclear what
proportion of patients can have prophylactic salpingectomy successfully performed at the
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time of vaginal hysterectomy. We suspect surgeons may be discouraged from vaginal
salpingectomy at the time of vaginal hysterectomy with the thought it is technically
challenging and may increase operative time and potentially blood loss. Given surgeons may
be deterred from removing the fallopian tubes vaginally, we aimed to determine the
feasibility of bilateral salpingectomy at the time of vaginal hysterectomy.
Materials and Methods
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This prospective, observational study was performed by the Collaborative Research in Pelvic
Surgery (CoRPS) Consortium. Columbia University Medical Center served as the datacoordinating center according to the existing Data Use Agreement for CoRPS Consortium
members. The trial protocol was approved by the CoRPS Consortium Steering Committee
and institutional review board approval was obtained from each of the 4 recruiting centers
(Houston Methodist Hospital 2014–10414; University of Wisconsin-Madison 2014–1185;
Columbia University Medical Center 2014-AAAN5704; and University of Arkansas for
Medical Sciences 2014–203426).
Women (age 18 ≥years) planning prophylactic bilateral salpingectomy at the time of vaginal
hysterectomy were recruited from October 2014 through November 2016. Exclusion criteria
included women with: (1) a history of removal of a fallopian tube or ovary,(2) known
tuboovarian pathology, and(3) desire for/planning oophorectomy at the time of
hysterectomy. All women planning prophylactic vaginal salpingectomy at the time of
vaginal hysterectomy were invited to participate by their gynecologic surgeon and informed
consent was obtained.
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Each participant was assigned a study identification number used for all case report forms
and data entry into REDCap, thus creating a deidentified database compliant with the Health
Insurance Portability and Accountability Act.
The primary outcome was proportion of planned bilateral salpingectomies successfully
completed vaginally. Secondary outcomes included: (1) additional length of time and
estimated blood loss (EBL) associated with prophylactic bilateral salpingectomy at the time
of vaginal hysterectomy; (2) factors associated with noncompletion of planned
salpingectomy; and (3) change in menopausal symptoms following hysterectomy with
salpingectomy.
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Data regarding age, body mass index (BMI), parity, pertinent medical and surgical history,
and pelvic organ prolapse were abstracted from the medical record prior to surgery. Surgical
procedure, intraoperative findings, complications, salpingectomy start and end time, and
EBL for salpingectomy were recorded in the operating room. After hemostasis of
hysterectomy pedicles had been assured, salpingectomy operative time started when the
surgeon first grasped the adnexal pedicle to search for the fallopian tube on the first side.
Salpingectomy operative time ended when hemostasis was achieved of bilateral fallopian
tube pedicles. Participating surgeons used a standardized technique where a single or double
clamp was used to clamp across the mesosalpinx and a single or double suture-ligation was
used to secure the pedicle following excision of the fallopian tube. Salpingectomy included
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removal of the fimbria. Attending surgeons rather than residents or fellows performed all
salpingectomies.
Uterine weight and uterine and fallopian tube pathology were abstracted from pathology
reports postoperatively. Subjects completed the 11-item written Menopause Rating Scale
(MRS)13 at baseline (0–30 days prior to surgery) and postoperatively (6–12 weeks after date
of surgery). The MRS was utilized as a validated tool to see if menopausal symptoms were
affected by removal of the fallopian tubes. Investigators at each participating site uploaded
collected data into the REDCap database managed by the data-coordinating center.
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Descriptive analyses were performed to characterize the sample and determine the
proportion of planned salpingectomies successfully completed and additional length of time
and EBL associated with salpingectomy. Continuous variables were described with mean
(SD) and categorical variables were described with frequencies and percentages.
Comparative analyses were then performed between the successful and unsuccessful
salpingectomy groups. Statistical tests for continuous data were based on Student t test for
normally distributed data and categorical variables were compared using the χ2 test.
Menopausal symptoms following surgery were compared to baseline using paired t tests to
evaluate difference in MRS scores. Software (SPSS, Version16.0; IBM Corp, Armonk, NY)
was used for all analyses.
Results
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In all, 77 patients were offered enrollment into the study, and 74 patients accepted
participation and were consented (96%). Three patients canceled surgery and 2 patients
elected preoperatively for BSO. Therefore, 69 patients were included in the analysis.
Baseline characteristics were stratified by outcome of attempted salpingectomy status and
are included in Table 1. For the entire cohort of patients, mean age was 50.9 years, with a
BMI of 29.1, and 41% were postmenopausal. Indications for hysterectomy included
prolapse (78.3%), heavy menstrual bleeding (20.3%), and uterine fibroids (11%). Some
patients had >1 indication for hysterectomy.
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Overall, vaginal salpingectomy was successfully performed in 52/69 (75%) women. Of the
unsuccessful salpingectomy cases, there were 4 conversions to alternative routes due to
adhesions and other pelvic pathology, and 1 patient had unknown prior salpingectomy for
sterilization. When these patients were excluded from the analysis, the rate of successful
salpingectomy was 52/64 (81%). Risk factors for unsuccessful completion of salpingectomy
were history of adnexal surgery (odds ratio, 2.9; 95% confidence interval, 1.5–5.5; P = .006)
and fibroids as an indication for hysterectomy (odds ratio, 5.8; 95% confidence interval, 1.5–
22.5; P = .02). History of adnexal surgery includes prior tubal ligation or ovarian
cystectomy. There was a nonsignificant trend toward more successful completion of bilateral
salpingectomy with higher parity (P = .05) and with prolapse as an indication for
hysterectomy (P = .06). This would explain why more uterosacral ligament suspensions
were performed with women with successful salpingectomy (Table 2). Age, BMI, and
history of tubal ligation were not statistically significant factors associated with unsuccessful
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salpingectomy. Of the 20 patients with a history of adnexal surgery, 8 had unsuccessful
salpingectomy while 12 (60%) had successful bilateral salpingectomy.
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Mean operating time for bilateral salpingectomy was 11 (±5.6) minutes, with additional
mean EBL of 5.5 (±16.3) mL. There were 8 surgical complications, none of which were
related to salpingectomy: 5 conversions to alternate routes of surgery and 3 hemorrhages
>500 mL. Of the 3 patients with hemorrhage >500 mL, 1 was in the successful
salpingectomy group and 2 patients were in the unsuccessful salpingectomy group. There
were no blood transfusions or bladder, ureteral, or bowel injuries in our patients. In those
patients requiring conversion to alternate routes, 1 patient had a unicornuate uterus requiring
conversion to laparos-copy. Another patient had an ovarian mass detected vaginally
requiring laparoscopic salpingo-oophorectomy, and the third patient had a conversion to
mini-laparotomy due to dense pelvic adhesions to the uterus and bleeding. The fourth patient
had conversion to laparoscopy due to pelvic adhesions during hysterectomy. The fifth patient
had a successful vaginal salpingectomy but subsequently, the surgeon reported difficulty
visualizing the patient’s anatomy for vaginal vault suspension and required conversion to
laparoscopy.
Among the 17 patients for whom vaginal bilateral salpingectomy was unsuccessful, 7
underwent unilateral vaginal salpingectomy. Surgeon-identified reasons for unsuccessful
completion of salpingectomy included: fallopian tubes too high in the pelvis (8/17, 47%),
bowel adhesions to tubes (2/17, 12%), conversion to alternate route for pathology (4/17,
24%), tubal adhesions to ovary (1/17, 6%), tubal adhesions to pelvic sidewall (1/17, 6%),
and fallopian tubes were absent due to prior salpingectomy (1/17, 6%) (percentages equal
101% due to rounding).
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On gross examination of the fallopian tubes during surgery, surgeons noted ovarian cysts in
7% of patients and paratubal cysts in 13%. Mean uterine weight was 102.5 g and there was
no difference in mean uterine weight between successful and unsuccessful salpingectomy
groups (Table 2). There were no malignancies detected on fallopian tube pathology. In all,
20% of the final pathologic reports document paratubal cyst despite a lower account by the
surgeons intraoperatively. There was a significant decrease in total MRS scores from
preoperative to postoperative in the women with bilateral salpingectomy indicating less
bother (12.7 vs 8.6; P < .001). There was no difference in MRS scores between patients with
successful or unsuccessful salpingectomy (P =.91).
Comment
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Vaginal salpingectomy is feasible in the majority of women undergoing vaginal
hysterectomy and results in only minimal increases in operative times and blood loss. We
believe this is an important finding that adds to the literature supporting the safety of adnexal
surgery during vaginal hysterectomy. ACOG recommends vaginal hysterectomy as the
surgical approach of choice for benign indications and states that planned salpingooophorectomy should not preclude the utilization of the vaginal route.14 Despite this
recommendation, national surgical data reflect declining rates of vaginal hysterectomy and
increasing rates of laparoscopic and robotic-assisted hysterectomy.15 Although national rates
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of prophylactic salpingectomy are increasing, in keeping with ACOG support for this
practice to reduce ovarian cancer incidence, rates of salpingectomy at the time of vaginal
hysterectomy remain low.10,16,17 Our data support the continued use of vaginal
hysterectomy in a population of women desiring concurrent prophylactic salpingectomy for
benign indications.
Previous literature identified risk factors for failure to accomplish a vaginal oophorectomy
including obesity, nulli-parity, decreased vaginal access and space, lack of uterine descent,
increased uterine size, and tuboovarian disease.18
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The rate of successful salpingectomy in our study is similar to a previous study published in
Canada reporting a successful vaginal salpingectomy rate of 88%. Although this Canadian
study was limited by a retrospective design, it showed increasing age and pelvic adhesions
were risk factors with unsuccessful removal.19 Our study showed that prior adnexal surgery
and fibroids as an indication for surgery were associated with unsuccessful completion of
planned vaginal salpingectomy. Prior adnexal surgery may predispose to tubal adhesions to
the ovaries or surrounding structures that may increase difficulty of access to the fallopian
tubes for removal. Despite this increased potential challenge, the majority of patients with
prior adnexal surgery in our cohort had successful bilateral salpingectomy. We suggest that
this characteristic should not deter surgeons, but should motivate patient counseling
regarding this possibility. There may be additional risk factors for unsuccessful removal that
we were not able to identify due to the small group of unsuccessful salpingectomy cases.
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We saw a trend in improvement in MRS score in both groups 6–12 weeks postoperatively.
No definitive conclusions can be made regarding the impact of salpingectomy on ovarian
blood flow from these data, but we are reassured that symptoms did not appear worse
following surgery.
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Strengths of this study include its prospective design and our inclusion of a diverse group of
surgeons at multiple institutions. Our small sample size limits our ability to control for
multiple variables and does not power us to detect changes in MRS scores between groups in
which salpingectomy was or was not performed. While the sample size appears small, it is
important to consider the overall patient population of the recruiting surgeons, which
includes many postmenopausal patients who opt for prophylactic oophorectomy in addition
to salpingectomy. Therefore, these results are not necessarily generalizable to
postmenopausal patients planning vaginal hysterectomy with desire for prophylactic removal
of both tubes and ovaries. Furthermore, some premenopausal patients with advanced pelvic
organ prolapse opted for minimally invasive sacrocolpopexy rather than vaginal
hysterectomy and were not candidates for this study. The enrollment of 96% of eligible
patients is a strength of the study and the sample size is adequate for the descriptive analyses
performed. Another limitation is that many of our participating surgeons were
urogynecologists, so the majority of patients in this cohort had uterovaginal prolapse, which
may have increased the proportion of successfully completed vaginal salpingectomy. The
high rate of complications in this study may reflect the increased complexity of the
urogynecology patient population.
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Our study demonstrated a minimal 11-minute increase in operative time and 6-mL increase
in EBL associated with salpingectomy. Further study is needed to identify predictors of
successful removal to improve patient counseling and enhance surgical selection. Vaginal
surgeons should feel confident that planned salpingectomy at the time of vaginal
hysterectomy is reasonable and likely to be successfully undertaken with minimal additional
time, blood loss, and risk.
Acknowledgment
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The authors would like to thank and acknowledge the following physicians who contributed to recruitment for this
study: Tristi Muir, MD, Houston Methodist Hospital, Houston, TX; Jin Hee Kim, MD, MS, Columbia University
Medical Center, New York, NY; Timothy Ryntz, MD, Columbia University Medical Center, New York, NY; Connie
Young, MD, Columbia University Medical Center, New York, NY; Dobie L. Giles, MD, University of Wisconsin
School of Medicine and Public Health, Madison, WI; Christine A. Heisler, MD, MS, University of Wisconsin
School of Medicine and Public Health, Madison, WI; and Susan Barr, MD, University of Arkansas for Medical
Sciences, Little Rock, AR.
Dr Antosh is site principal investigator for Cook Myo-site randomized trial, funded by Cook (ClinicalTrials.gov
identifier: NCT01893138). Dr Brown has research funding from the National Institutes of Health: K12 DK100022.
She is site principal investigator for LIBERATE, funded by Pelvalon (ClinicalTrials.gov identifier: NCT02428595).
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TABLE 1
Baseline characteristics
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N = 64
Age, y
kg/m2
Pvalue
Successful salpingectomy n = 52
Failed salpingectomy n = 12
51.2 (9.9)
48.9 (5.3)
.44
29.1 (17.1)
29.5 (9.8)
.94
Vaginal parity, mean (SD)
2.4 (1.1)
1.7 (1.1)
.05
Postmenopausal
23 (44.2)
4 (33.3)
.10
History of adnexal surgery
12 (23.1)
8 (66.7)
.006
History of tubal ligation
9 (17.3)
5 (41.7)
.08
Family history of breast or ovarian cancer
9 (17.3)
1 (8.3)
.65
44 (84.6)
7 (58.3)
.06
Body mass index,
Indication for hysterectomy
Prolapse
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Pelvic pain
1 (1.9)
1 (8.3)
.34
12 (23.1)
2 (16.7)
.48
Fibroids
3 (5.8)
4 (33.3)
.02
Other
4 (7.7)
1 (8.3)
.66
2
20 (38.4)
7 (58.3)
3
23 (44.2)
0 (0)
4
1 (1.9)
0 (0)
Abnormal uterine bleeding
Stage of prolapse, when prolapse present
.06
Values are N (%) unless otherwise noted.
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TABLE 2
Operative and postoperative data
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N = 64
Successful salpingectomy n = 52
Failed salpingectomy n = 12
Pvalue
Salpingectomy operative time, min, mean (SD)
10.9 (5.6)
N/A
N/A
Total estimated blood loss, mL, mean (SD)
196 (135)
275.4 (265.3)
.14
Salpingectomy estimated blood loss, mL, mean (SD)
5.5 (16.3)
N/A
N/A
Anterior repair
33 (63.5)
4 (33.3)
.06
Posterior repair
28 (53.8)
4 (33.3)
.17
3 (5.8)
1 (8.3)
.57
Uterosacral ligament fixation
43 (82.7)
5 (41.7)
.007
Midurethral sling
21 (40.4)
7 (58.3)
.21
3 (5.8)
1 (8.3)
.57
101.8 (83.2)
111.5 (64.3)
.72
Preoperative MRS scores, n = 64
12.7
11.9
.74
Postoperative MRS scores, n = 57
8.6
8.8
.91
Concomitant procedures
Sacrospinous ligament fixation
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Other
Uterine weight, g
Values are N (%) unless otherwise noted.
MRS, Menopause Rating Scale; N/A, not applicable.
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