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Obstetrics & Gynecology 1999;93:223-228
© 1999 by The American College of Obstetricians and Gynecologists
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ORIGINAL RESEARCH

Laparoscopic Management of Adnexal Masses in Premenopausal and Postmenopausal Women

PETER R. DOTTINO, MD, DOUGLAS A. LEVINE, MD, DAYLENE L. RIPLEY, MD and CARMEL J. COHEN, MD

From the Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai School of Medicine, New York, New York.

Address reprint requests to: Carmel J. Cohen, MD Department of Obstetrics, Gynecology, and Reproductive Science Box 1173, Mount Sinai Medical Center One Gustave L. Levy Place New York, NY 10029 E-mail: ccohen{at}smtplink.mssm.edu


   Abstract
Top
Abstract
Materials and Methods
 Results
 Discussion
 References
 
Objective: To evaluate the feasibility and safety of laparoscopic adnexal mass removal in patients without preselection for benign pathology and assess the operative complications and findings.

Methods: All patients presenting to the gynecologic oncology service between April 1992 and April 1996 with adnexal masses were candidates for laparoscopic management. Patients underwent preoperative radiological studies and office pelvic examination. Laparoscopic management was attempted on patients without evidence of gross metastatic disease or masses that extended above the umbilicus. Laparotomy was performed if indicated by pathologic findings or technical difficulty. All removed adnexal masses were sent for immediate pathologic diagnosis. The type of procedure, intraoperative findings, and complications were all recorded at the time of procedure.

Results: One hundred sixty patients underwent laparoscopic evaluation for an adnexal mass. Benign pathology was discovered in 139 (87%, 95% confidence interval [CI] 84, 90) patients, and 141 (88%, 95% CI 86, 91) patients were managed laparoscopically. Reasons for laparotomy included technical difficulty, operative complications, or malignancy. Frozen section diagnosis was concordant with the final pathology reports in all but five patients (97% concordance), and no discrepancies resulted in treatment delays.

Conclusion: Laparoscopic management of adnexal masses can be successful in a gynecologic oncology population if there is expertise in operative laparoscopy, availability of immediate accurate pathologic examination, and appropriate further treatment where indicated.

Improvements in technology and skill continue to expand the role of laparoscopic surgery for the gynecologist, with removal of adnexal masses emerging as a major part of gynecologic laparoscopy. This development is not without controversy. In fact, it has been suggested that adnexal masses suspicious for cancer are best managed by laparotomy.1,2 Concerns regarding the laparoscopic management of adnexal masses include failure to diagnose ovarian malignancies, tumor spill-age, inability to proceed immediately with a staging procedure, and delay in therapy. The general intent of gynecologic cancer surgery should be efficient removal of cancer without causing spread or needlessly delaying additional therapy while avoiding morbidity.

In nononcology referral practices, it has been shown that the incidence of unexpected ovarian cancer is extremely low.3–6 There are few published studies that review the outcomes of laparoscopic surgery for adnexal masses in patients who are not specifically thought to be at low risk for malignancy.7,8 We feel that adnexal masses at high or low risk for cancer can be approached laparoscopically if a plan is in place for appropriate staging and treatment by laparotomy or laparoscopy. We report a four-year experience with the laparoscopic management of adnexal masses in patients at high and low risk for cancer who were treated by gynecologic oncologists. The incidence of cancer encountered as well as complication rates are discussed. The safety and feasibility of such an approach are also analyzed.


   Materials and Methods
Top
Abstract
 Materials and Methods
Results
 Discussion
 References
 
From April 1992 to April 1996, all patients undergoing evaluation for adnexal or pelvic mass by either of two gynecologic oncologists were candidates for laparoscopic management. All patients had either a preoperative pelvic sonogram or abdominal and pelvic computed tomography (CT) scan. Patients were excluded from study if the adnexal mass extended above the umbilicus, if a laparotomy was indicated for nonadnexal pelvic pathology, or if there was evidence of gross metastatic disease (ie, omental cake). No patients were excluded based upon the radiological studies of the adnexae. All procedures were performed solely by surgeons from the division of gynecologic oncology. Preoperatively, all patients were informed of and understood the need for possible laparotomy or other indicated procedures.

A single protocol was followed for all patients. Trocars were placed either directly or by open technique at the umbilicus, suprapubically, and in one or both lower quadrants. Initially, upon visualizing the abdomen and pelvis, any fluid was aspirated and sent for cytology. If no fluid was present, peritoneal washings were taken from the cul-de-sac and submitted for cytologic evaluation. Next, a thorough evaluation was made of the pelvis and abdomen including the adnexae, peritoneal surfaces, liver, diaphragm, omentum, and paracolic gutters. Any suspicious or abnormal appearing areas were biopsied and sent to pathology. At this point, possibility for the intact, complete removal of the mass without spillage was assessed. Cysts larger than 10 cm were first aspirated using a Topel cyst-aspiration apparatus (Cook Ob/Gyn, Spencer, IN) to decompress the tumor while preventing leakage of cyst fluid. All adnexal masses were placed into synthetic bags and subsequently removed through the suprapubic port to avoid intraperitoneal spillage of the surgical specimen and contamination of the abdominal wall during removal.

All adnexal masses were sent for immediate pathologic evaluation and management decisions were dependent upon the frozen section findings. Cancers diagnosed by laparoscopy were either treated by immediate laparotomy or managed laparoscopically. Surgical principles followed during laparotomy for the removal of specimens also were adhered to laparoscopically. This included careful dissection around surgical specimens to remove them intact. At the conclusion of each case hemostasis was assured, the midline laparoscopic incisions were closed in layers, and the lateral (5 mm) incisions had only skin closure. Demographics, preoperative and postoperative diagnoses, complications, type of procedure, blood loss, and pathologic diagnoses were recorded for each patient.


   Results
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Abstract
 Materials and Methods
 Results
Discussion
 References
 
There were 160 patients in our gynecologic oncology service treated by laparoscopy for an adnexal or pelvic mass. Descriptive characteristics are shown in Table 1Go. Benign pathology was discovered in 139 (87%, 95% confidence interval [CI] 84, 90) patients, borderline tumors in eight (5%), ovarian cancers in nine (6%), and nongynecologic cancers in four (3%) (Table 2Go). All eight borderline tumors were initially managed laparoscopically; however, two required conversion for trocar vascular injuries. The nine malignant ovarian tumors included six epithelial ovarian tumors and three sex cord-stromal tumors. Of the six epithelial ovarian cancers, four underwent immediate staging laparotomies, one underwent an immediate staging laparoscopy, and one was initially diagnosed as borderline at the time of laparoscopic adnexectomy and later discovered to be malignant. Subsequently, this patient received a full course of chemotherapy beginning 2 weeks postoperatively followed by laparoscopic end-staging that revealed no evidence of disease. There were two stage IA epithelial tumors, one each of stage IIC, IIIA, IIIC, and IV. Of the three sex cord-stromal tumors, two were managed with laparoscopic adnexectomies and one was managed through laparotomy because of a small bowel injury. The sex cord-stromal tumors included two Sertoli-Leydig cell tumors and one granulosa cell tumor. During the laparoscopic removal of an "apparent" stage I granulosa cell tumor there was intraperitoneal spillage. This patient was subsequently offered reoperation for complete staging, chemotherapy, or observation. The patient elected to be observed and had a pelvic recurrence 2 years postoperatively. No other patient was observed to have intraperitoneal spillage in the study population. Of the epithelial ovarian cancers four (66%) occurred in postmenopausal women, whereas one (33%) of the sex cord-stromal tumors occurred in a postmenopausal patient. The four nongynecologic tumors included three metastatic breast cancers and one malignant lymphoma. Of the three breast cancers metastatic to the adnexa, one was managed with laparoscopically-assisted vaginal hysterectomy and bilateral salpingo-oophorectomy, one with laparotomy and cytoreduction, and one with laparoscopic pelvic biopsy to determine the primary site of cancer. The patient with lymphoma had a previous history of breast cancer, a 3-cm complex pelvic mass on sonography, para-aortic lymphadenopathy on CT scan, benign adnexal cysts at the time of surgery, but malignant internal iliac lymph nodes.


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  		Table 1. Demographic Characteristics
 

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  		Table 2. Pathology and Procedures of Study Population
 
Laparoscopic management was successful for 141 (88%, 95% CI 86, 91) patients and included adnexectomies, cystectomies, appendectomies, and assisted vaginal hysterectomies (Table 2Go). Of the 19 patients requiring laparotomy, nine (6%) cases were converted electively at the discretion of the operating surgeon, five (3%) cases were converted due to operative complications, and five (3%) cases were converted based on frozen section reports indicating a malignancy which required either staging laparotomy or cytoreduction. Of the nine cases electively converted to laparotomy, eight were due to anticipated technical difficulties with either extensive adhesions or large surgical specimens and one for suspicious pathology. Of the five operative complications, three were converted due to vascular trocar injuries, one had a small bowel injury, and one had persistent bleeding from pelvic adhesions (Table 3Go). Of the five cancers managed by laparotomy, three required complete staging laparotomies for ovarian adenocarcinoma; stages IIC, IIIA, and IV, one required debulking of metastatic ovarian adenocarcinoma; stage IIIC, and one required debulking for metastatic breast cancer.


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  		Table 3. Complication Rates and Comparison to Previously Published Studies
 
There were a total of three (2%) major postoperative complications and seven (4%) minor postoperative complications from the laparoscopic procedures (Table 3Go). The three major postoperative complications consisted of small bowel obstructions and two required reoperation at 2 and 8 weeks, respectively, whereas one was managed conservatively. The seven minor operative complications included four patients with low grade postoperative fevers, two patients requiring continued intubation postoperatively after lengthy procedures, and one patient with substantial subcutaneous emphysema. There were no genitourinary injuries.

There were five (3%) frozen section reports that were inconsistent with correspondent final pathology reports. In three patients, a cyst was initially reported as benign, but final pathology revealed a borderline tumor; in one patient, a malignant tumor was initially reported as possibly of borderline potential; and in one patient, a sex cord-stromal tumor was initially misdiagnosed. In all five of these cases, there was no significant delay in treatment attributable to the initial frozen section report. As mentioned previously, the patient with malignant pathology underwent six cycles of chemotherapy beginning 2 weeks postoperatively followed by laparoscopic end-staging that revealed no evidence of disease.


   Discussion
Top
Abstract
 Materials and Methods
 Results
 Discussion
References
 
The laparoscopic management of adnexal masses continues to evolve due to increased surgical expertise and technical progress. One of the major benefits of approaching all adnexal masses through laparoscopy is that many, if not most, patients will ultimately have benign pathology and can be spared exploratory laparotomy. It is possible to treat by laparoscopy select patients with adnexal masses who are at low risk for cancer. The incidence of unsuspected cancers discovered at the time of laparoscopy has been shown to be exceptionally low.6 Many advantages of laparoscopic surgery have clearly been demonstrated including shorter length of stay,18–21 decreased postoperative pain and recovery time,18,21,22 less adhesion formation,23 and diminished cost for individuals, hospitals, and society.20,24 If laparoscopy is to become a standard of care for the management of adnexal masses it is imperative that the intent of gynecologic cancer surgery is not sacrificed for the benefits of laparoscopy. Ideally, laparoscopy must be a safe substitute for laparotomy. Continual assessments must guarantee that less invasive surgery does not compromise accurate and timely diagnosis and treatment of cancer.

This study differs from previous reports in that patients with a suspicious adnexal mass were not excluded from laparoscopic management because of traditional preoperative criteria that include a solid, irregular, fixed, or complex pelvic mass on clinical exam or ultrasound imaging, and an elevated CA 125 in a postmenopausal woman. Furthermore, the patient population is unique because it is referred to a gynecologic oncology service. Previous studies have reported the outcome of laparoscopic management for carefully selected patients at low risk for malignancy, often from nononcology practices, and are frequently retrospective in methodology. This study was designed prospectively to review the intraoperative management and postoperative outcome of these laparoscopic procedures. Three frequent concerns surrounding the laparoscopic management of adnexal masses have been addressed: accuracy of intraoperative diagnosis, delay in staging, and tumor spillage.

Laparoscopic management of adnexal masses is clearly dependent upon immediate access to accurate pathology evaluation. In this series there was a 3% discrepancy between frozen section and final pathologic diagnoses, a rate similar to other reports.25 Patients were treated at the time of laparoscopy if the frozen section revealed a cancer, and similarly, the 3% of patients with discordance were treated immediately after diagnosis. We do not recommend a laparoscopic approach to adnexal pathology if immediate and accurate pathologic diagnosis is unavailable. Delays of more than 4 weeks from the time of initial diagnoses to the complete surgical staging for incidentally discovered ovarian cancer have been reported and adverse impact has been described.26 A recent study by Kindermann et al argued that even delays of 8 days from diagnosis to treatment can allow for disease progression.8 In their study, however, surgical specimens were frequently ruptured and morcellated possibly causing more rapid tumor dissemination. In a small number of patients, specimens were handled properly and the rate of progression before treatment was lower. It is unclear if there was disease progression in properly handled specimens when treatment was delayed less than 2 weeks.2,27 Frequently when ovarian cancer is diagnosed at laparotomy, chemotherapy is not initiated before 2 weeks postoperatively.

Tumor spillage is a concern when operating laparoscopically. Dembo et al reviewed more than 500 cases of stage I epithelial ovarian cancer and found that tumor grade, dense adhesions, and large-volume ascites were predictors of relapse; though intraoperative cyst rupture did not affect prognosis.28 Sevelda et al showed that in 60 patients with stage I epithelial ovarian cancer rupture of the tumor during surgery had no influence on survival rates.29 Additionally, Sjövall et al have demonstrated that intraoperative rupture of tumor capsules did not adversely affect survival, but preoperative rupture or ascites did negatively influence outcomes.30 Thus, these studies have shown that tumor spillage does not adversely affect survival. In this series of cases, a sex cord-stromal tumor spilled during surgery, and while studies have not analyzed the impact of spillage in nonepithelial ovarian tumors, this patient’s tumor did recur locally.

The complication rates observed in this prospective study are comparable to those previously published (Table 3Go). Comparison to other reports can be misleading if differences in patient populations are not analyzed. Many reports describe diagnostic or minor operative laparoscopy, and most were not derived from oncology referral practices. Higher complication rates have been reported for patients undergoing more advanced laparoscopic surgery. Although many of our procedures were advanced, our three complications of trocar vascular injuries were high. All of these injuries occurred during direct trocar insertion in patients without previous surgery. Thus, we have begun performing open laparoscopy routinely. This technique is accomplished without vascular complications and with minimal increase in operative time.31 Our complications involving intraoperative bowel injury or postoperative bowel obstruction occurred exclusively in patients with previous abdominal surgery. As one would expect, the number of cancers discovered at time of laparoscopy is higher than other studies conducted in nononcology referral practices (Table 4Go). One-third of our patients with a history of a nongynecologic cancer were found to have metastatic disease at laparoscopy, a rate slightly higher than previous reports.


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  		Table 4. Malignancies Discovered at Laparoscopy and Comparison to Previously Published Studies
 
Besides sparing patients unnecessary laparotomy for diagnosis, operative laparoscopy can be employed for complete surgical staging. In this series, one of five patients with an intraoperative diagnosis of ovarian cancer received laparoscopic staging, and since the conclusion of this study, five subsequent early stage ovarian cancers have been discovered and were staged by laparoscopy. These will be reported separately.

This review illustrates the potential for laparoscopic management of adnexal masses in broadly selected patients. Many previously published reports regarding the laparoscopic management of adnexal masses had selection criteria that excluded patients with suspicious sonographic findings, postmenopausal adnexal masses, or elevated preoperative CA 125. We suggest that a diagnostic laparoscopy can be attempted for patients requiring surgery for an adnexal mass if there is no evidence of gross metastatic disease and the mass does not extend above the umbilicus. However, the operating surgeon must be skilled in advanced operative laparoscopy, immediate and accurate frozen section diagnosis should be available, and the patient must be prepared to receive an appropriate cancer operation if indicated. It is now possible with advanced technology and advanced skills to remove most adnexal masses including early stage ovarian cancer laparoscopically without violating the intent of gynecologic cancer surgery. While ours is not a randomized study, the operative morbidity and postoperative courses of these subjects compare favorably with patients in our department managed by laparotomy. Whether cure rates are comparable must await a larger experience and longer follow-up.


   Footnotes
 
PII S0029-7844(98)00425-6

Received December 15, 1997. Received in revised form August 10, 1998. Accepted August 13, 1998.


   References
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Abstract
 Materials and Methods
 Results
 Discussion
 References
 
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2. Kindermann G, Maassen V, Kuhn W. Laparoscopic management of ovarian tumors subsequently diagnosed as malignant: A survey from 127 German departments of obstetrics and gynecology. J Pelvic Surg 1996;2:245–51.

3. Nezhat F, Nezhat C, Welander CE, Benigno B. Four ovarian cancers diagnosed during laparoscopic management of 1011 women with adnexal masses. Am J Obstet Gynecol 1992;167: 790–6.[Medline]

4. Parker WH, Levine RL, Howard FM, Sansone B, Berek JS. A multicenter study of laparoscopic management of selected cystic adnexal masses in postmenopausal women. J Am Coll Surg 1994;179:733–7.[Medline]

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19. Lin P, Falcone T, Tulandi T. Excision of ovarian dermoid by laparoscopy and by laparotomy. Am J Obstet Gynecol 1995;173: 769–71.[Medline]

20. Howard FM. Surgical management of benign cystic teratoma: Laparoscopy versus laparotomy. J Reprod Med 1995;40:495–9.[Medline]

21. Mais V, Ajossa S, Piras B, Marongiu D, Guerriero S, Melis GB. Treatment of nonendometriotic benign adnexal cysts: A randomized comparison of laparoscopy and laparotomy. Obstet Gynecol 1995;86:770–4.[Abstract]

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