Gynecologic Considerations for the General Surgeon

Robert L Giuntoli, II, MDDivision of Gynecologic Surgery

Penn Medicine

• Review female pelvic anatomy• Hysterectomy and salpingo oophorectomy: The Basics• Management of incidental adnexal masses

Objectives

Anatomy: Female Pelvis

• Pelvic bones:– Hip bones (ilium, ischium, pubis) sacrum, coccyx

• Organs– Bladder, rectum, uterus, tubes, ovaries, ureters,

cecum, appendix

• Blood vessels– Common Iliac, internal iliac, external Iliac, gonadal

• Avascular planes– Retropubic, vesicovaginal, rectovaginal, presacral,

paravesical x2, pararectal x2

Anatomy: Female Pelvis

Female Pelvic Anatomy: Pelvic Bones

Female Pelvic Anatomy: Overview

Female Pelvic Anatomy: Peritoneum and Vessels

Female Pelvic Anatomy: Uterus, Tubes and Ovaries

Female Pelvic Anatomy: Pelvic Vessels

Female Pelvic Anatomy: Internal Iliac Artery

Female Pelvic Anatomy: Gonadal Vessels

Female Pelvic Anatomy: Avascular Planes

Hysterectomy and Salpingectomy

• Class I (Extrafascial Hyst):– Complete removal of the cervix. – Uterine vessels ligated at internal os.

• Class II (Modified Radical Hyst): – Partial mobilization of the ureters (paracervical). – Uterine vessels ligated medial to ureters.– Uterosacral ligaments ligated midway between uterus

and sacrum.– Medial half of cardinal ligament excised.– Upper 1/3 of vagina excised.

1 Piver et al. Obstet Gynecol 1974;44:265.

Five Classes of Hysterectomy 1

• Class III (Radical Hyst):– Almost complete mobilization of the ureters (paracervical

and pubovesicle). – Uterine vessels ligated at origin from interal iliac a.– Uterosacral ligaments ligated at sacral attachment.– Cardinal ligament excised at pelvic wall.– Upper 1/2 of vagina excised.

– Class IV:– Complete mobilization of the ureter.– Superior vesicle artery is sacrificed– Upper 3/4 of vagina excised.

1 Piver et al. Obstet Gynecol 1974;44:265.

Five Classes of Hysterectomy 1

• Class V:– Involved portion of distal ureter and/or bladder exicised.– Reimplantation of ureter may be performed.

1 Piver et al. Obstet Gynecol 1974;44:265.

Five Classes of Hysterectomy 1

Class IClass IIClass III

Classes of Hysterectomy 1

1 Piver et al. Obstet Gynecol 1974;44:265.

Retroperitoneal Structures

Bilateral Salpingo oophorectomy

Film

Current Statistics

2019, Ten Leading New Cancer Cases (Estimated) in U.S. Females

- Siegel et al, CA Cancer J Clin 2019; 69(1):7-34.

2019, Ten Leading Causes of Cancer Deaths (Estimated) in U.S. Females

- Siegel et al, CA Cancer J Clin 2019; 69(1):7-34.

Ovarian CancerUSA Statistics – 2019

• 22,530 new cases annually• 13,980 deaths annually• Ranks 5th – CA related deaths in women• 1/70 lifetime risk (1.4%)

- Siegel et al, CA Cancer J Clin 2019; 69(1):7-34.

Ovarian Structure

Germ Cells

StromaEpithelium

• Epithelial: – Traditionally felt to develop from ovarian surface epithelium– Probably develop from tubal epithelium– 80 - 90% of ovarian cancers– Most common after age 35– Incude serous, mucinous, endometrioid, clear cell histology

• Germ cell tumors: – Develop from germ cells– 5 - 10% of ovarian cancers– Almost always seen before age 35– Include dysgerminoma, immature teratoma, yolk sac tumor

• Sex cord stromal tumors: – Develop from supporting tissue of ovary & sex cords– 5 - 10% of ovarian cancers– Evenly distributed throughout all ages– Include Granulosa cell tumor, Serotoli-Leydig tumors

Classification of Ovarian Neoplasms

Epithelial Germ Cell Sex Cord Stromal

Occurrence (%) 80-90 5-10 5-10Age (yrs) Range 30-79+ <35 50-79+

Peak Incidence 65 20 60Stage Distribution

I & II 30 70 80+III & IV 70 30 < 20

Survival %Stages I & II 75-95 95+ 75-90Stages III & IV 15-20 80+ 75-90

Ovarian MalignancyHistologic Type

• Examination under anesthesia• Approach

– Midline incision (supra-umbilical)– Laparoscopy

• Cytologic washings• Intra-abdominal exploration• TAH / BSO (USO if fertility desired)• Omentectomy• Appendectomy• Pelvic / Aortic lymph node sampling• Biopsy

– suspicious findings– normal appearing high-risk sites

Comprehensive Surgical Staging

Comprehensive Surgical Staging

• Staging only required for cancer cases• Most important step is documenting pathology• Many ovarian masses are benign• Consider cystectomy in premenopausal woman

– However risks rupture

• In premenopausal women especially in laparoscopic cases, it is better to be conservative a risk a second surgery than to remove a normal ovary

Ovarian Carcinoma: FIGO Staging

Stage I IA: one ovaryIB: both ovariesIC: IA or IB + ‘C’ criteria

Stage II IIA: uterus, fallopian tubeIIB: other pelvic structures

Stage III IIIA1: Pos retroperitoneal nodes; (i) ≤10mm, (ii)>10mmIIIA2: microscopic abdominal seedingIIIB: abdominal implants ≤ 2cmIIIC: abdominal implants > 2cm

Stage IV IVA: Pleural effusion with positive cytologyIVB: Extension beyond abdominal cavity including:

parenchymal liver and splenic metastases. Extra abdominal disease including inguinal nodes

‘C’ criteria(+) ascites/cytology

Surface tumorTumor rupture

Ovarian Carcinoma: Stage I Disease

Ovarian Carcinoma: Stage III Disease

• Compiled series of 294 patients undergoingre-staging laparotomy

• Occult metastasesare common

• 30% upstaged• 75% will be Stage III• Staging information

is critical for effectivetreatment planning

Site Biopsy (+)Cytology 19%Para-aortic nodes 12%Peritoneal biopsy 10%Pelvic nodes 9%Diaphragm 8%Omentum 7%

Rubin SC, Sutton GP. Ovarian Cancer 1993

Apparent Early-Stage Disease

Ovarian Cancer – Epithelial

• Conservative management of early stage invasive epithelial ovarian cancer

• 52 pts stage I EOC s/p USO staging with chemo as necessary

• Median follow up 68 months• 5 recurrences, 2 deaths• 71% of those attempting pregnancy succeeded

1 Shilder JM et al. Gynecol Oncol 2002;87:1.

Ovarian Cancer – Epithelial

• Borderline tumors treated conservatively if uterus and other ovary uninvolved 1,2

• Increases rate of recurrence• No change in overall survival

1 Morris RT et al. Obstet Gynecol 2000;95:541.2 Morice P et al. Fertil Steril 2001;75:92.

Ovarian Cancer – Germ Cell

• Germ Cell Tumors involving a single ovary can be treated with USO rather than TAH/BSO– Assumes no gross involvement

• 10-15% of dysgerminomas are bilateral • Stage IA dysgerminomas and Stage IA grade 1

immature teratomas - treated conservatively• All others require BEP

– 73 pts. 61% amenorrhea. 91% regained function 1

1 Low JJ et al. Cancer 2000;89:391.

Clinical Follow-Up

Stage IA, IB (grade 1 or 2)

Comprehensive Surgical Staging+ TAH/BSO (USO if fertility desired)

Frozen Section Diagnosis = Carcinoma

Early Stage Epithelial Ovarian Carcinoma

Stage IA, IB (grade 3)Stages IC, II (all grades)

ChemotherapyX 6 cycles

Treatment Plan

Epithelial Ovarian CancerScreening

Ovarian Cancer Screening Considerations

• Symptom Assessment, Physical Exam

• CA125

• Transvaginal Ultrasound

• Multimodal: CA125 and Ultrasound

Symptom Assessment• Prospective Case Control Study, 1709 Pts

• 128 pts with pelvic mass: 84 benign, 44 cancer

• 1. Symptoms (44% of cases)• Bloating• Increasing abdominal size• Urinary frequency

• 2. Symptom Characteristics• Severe• Frequent• Recent onset

Goff et al., JAMA, 2004, 291 (22):2705-2712

• Ovarian Cancer - Approximately 80%

• Other Cancers– pancreatic, breast, bladder, liver, lung, non-hodgkins

lymphoma

• Benign Disease– ovarian cysts, endometriosis, leiomyoma, tubo-ovarian

abscess, diverticulitits, tuberculosis, renal disease, cardiac disease, cirrhosis

• Physiologic Conditions– pregnancy, menstruation

Elevated CA125

Stage I 254 41%

Stage II 90 85%

Stage III 529 93%

Stage IV 169 97%

All 1042 80%

Kenemans et al, Eur J Obstet Gynec Reprod Bio,1993,49;115-24

Stage # of Pts ↑ CA125

Elevated CA125

Ultrasound

Simple Cyst Complex Cyst

• 78,216 patients enrolled (age 55-74)• Randomized to annual screening CA 15 (6yrs) and

transvaginal ultrasound (4yrs) vs. usual care• Ovarian cancer diagnosed in 212 (5.7/10k person-

yrs) in annual screening group vs. 176 (4.7/10k person-yrs) in usual care. NS

• Ovarian cancer deaths: 118 (3.1/10k person-yrs) in annual screening group vs. 100 (2.6/10k person-yrs) in usual care. NS

• 3285 False positives, 1080 surgeries performed in this group with a 15% serious complication rate.

Prostate, Lung, Colorectal, and Ovarian Cancer Screening (PLCO)

- Buys et al., JAMA, 2011, 305 (22):2295-2303.

• 202,638 women enrolled (age 50-74)• Randomized: annual multimodal screening with

CA125 interpretation with ROCA (MMS), annual transvaginal U/S screening (USS) or no screening

• The primary analysis gave a mortality reduction over years 0–14 of 15% (p=0·10) with MMS and 11% (p=0·21) with USS.

• Greater mortality reduction was noted in years 7-14• Screening not recommended based on these results

UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS)

- Jacobs et al., Lancet 2016; 387: 945–56

• Numerous companies have marketed tests that claim to screen for and detect ovarian cancer.

• Despite extensive research, currently no screening tests that are sensitive enough to reliably screen for ovarian ca w/o a high number of inaccurate results.

• Concerns about delaying effective preventive treatments for women w/o symptoms, but remain at increased risk for developing ovarian cancer.

• FDA recommends against using currently offered tests to screen for ovarian cancer

The FDA recommends against using screening tests for ovarian cancer screening

- FDA Safety Communication, September 7, 2016

Conclusions

• Pelvic anatomy is reasonably straightforward. However understanding the anatomy is crucial in avoiding complications.

• Simple hysterectomy most frequent. However radical hysterectomy utilized for cervical cancer and to avoid injury in complex cases.

• Conservative management of ovarian masses prudent in young women.