Effects of hysterectomy with simultaneous bilateral salpingectomy on the subsequent pelvic mass

Hysterectomy is the most common gynecological operation and is widely accepted as the final treatment of many common gynecological diseases. However, the risk of reoperation increased due to complications of hysterectomy, such as pelvic adhesion. The recurrence of pelvic mass after hysterectomy is the common reason for reoperation [1‐3]. It had been reported that simultaneous bilateral salpingectomy during hysterectomy may reduce the incidence of ovarian serous carcinoma and some benign pelvic diseases, thus reducing the risk of reoperation after hysterectomy [4‐6]. Simultaneous bilateral salpingectomy has been routinely carried out in many medical institutions at present. However, few studies have explained whether salpingectomy affects the time of pelvic mass onset, clinical characteristics and pathological types of pelvic masses after hysterectomy in patients who have been treated again for various pelvic masses.

This study reviewed the medical records of patients received reoperation for pelvic masses following hysterectomy due to benign diseases, compared the clinical and pathological features in patients who underwent hysterectomy with or without bilateral salpingectomy, and analyzed the possible influence of simultaneous salpingectomy on the recurrence of pelvic masses.

The statistical analysis was performed using SPSS 23.0 (SPSS Inc., Chicago, IL, USA) in reference to whether the fallopian tubes were resected or not. Receiver Operating Characteristic (ROC) curve was constructed to define the optimal cutoff value for age of hysterectomy (< 45 years vs ≥45 years), age of the operation for pelvic mass (< 52 years vs ≥52 years), and time interval from the hysterectomy to the onset of pelvic mass (< 5 years vs ≥5 years) (Table 1, Fig. 1). Continuous variables were summarized with medians and interquartile ranges. Two groups were analyzed by independent t test, and multiple groups were analyzed by one-way ANOVA. The categorical variables were summarized with rates using Chi-square test or Fisher’s exact test to analyze. Variables with P < 0.05 by univariate analysis were included in multivariate analysis, and logistic regression model was used for fitting with P < 0.05 considered statistical significance. All analysis was two-sided and significance level was set at P < 0.05.

Hysterectomy is one of the most commonly used surgical methods for gynecological benign diseases. Patients always hope that they will not receive reoperation for gynecological diseases when hysterectomy was performed, which is not the case. The occurrence of pelvic masses after hysterectomy is one of the most common causes for reoperation. 39% of women who underwent hysterectomy for benign gynecologic indications received elective bilateral salpingo-oophorectomy to prevent ovarian cancer [7]. Recent studies shown that prophylactic bilateral salpingectomy is helpful not only in preventing high-grade serous type ovarian cancer, but also in decreasing adnexal pathologies [8]. Question was raised subsequently on whether or not the fallopian tubes are resected during hysterectomy relate to the nature and origin of the subsequent pelvic masses. However, there is no consensus on whether bilateral fallopian tubes should be resected with hysterectomy for benign diseases in premenopausal women.

Total of 247 patients were enrolled in this study. In simple hysterectomy group, the most common chief complaints for the onset of pelvic mass were found by physical examination, abdominal distension and anorexia. Most common chief complaints in hysterectomy with salpingectomy group were found by physical examination and abdominal pain. 20.20% benign masses were derived from oviduct, and no malignant masses were derived from oviduct for the former group. Neither benign nor malignant masses were derived from oviduct in the latter group.

It has been thought that the fallopian tube has little physiological function after completing fertility, and may have potential of inducing cancer. More and more evidences show that ovarian cancer, especially high-grade serous carcinoma, originates from the fallopian tube. Malignant transformation of the fallopian tube can lead not only to fallopian tubal carcinoma, but also lead to the occurrence of ovarian and peritoneal carcinoma [2, 3]. Bilateral salpingectomy can reduce the risk of ovarian carcinoma for women with BRCA1/2 gene mutations or general population [9‐12].

In addition, the retained fallopian tubes have the risk of secondary benign lesions, such as hydrosalpinx, fallopian tube ovarian abscess, fallopian tube prolapse, mesenchymal cyst of oviduct, etc. [13]. It has been reported that the risk of reoperation due to tubal diseases after hysterectomy without bilateral salpingectomy is twice as high as that with bilateral salpingectomy. Morse, et al. reported that women who underwent hysterectomy had 8% lifetime risk of reoperation for hydrosalpinx [14]. Another retrospective study reported that patients without preventive salpingectomy had a higher incidence of adnexal benign tumors (26.9% vs 13.9%, P = 0.02) [15]. The percentage of simple hysterectomy and hysterectomy with bilateral salpingectomy in our study is similar to those of Shiber Linda Dalal, et al. (80.16, and 5.67% respectively in the former one; 76, and 4% respectively in the latter one,) [16]. Shiber, et al. revealed that 82% of pelvic masses following hysterectomy are benign, and 18% were malignant. 12.4% were derived from fallopian tubes, accounting for 6.7% of benign masses and 12.9% of malignant masses. Therefore, the authors suggest that simultaneous salpingectomy with hysterectomy may reduce the incidence of benign tumors derived from the fallopian tubes. In this study, 68.2% of the pelvic masses in the simple hysterectomy group were benign and 31.8% were malignant. Tubular masses accounted for 16.2% of the total pelvic masses and 21.5% of the benign masses, and there were no malignant tumors. In the simultaneous salpingectomy group, 57.1% of the pelvic masses were benign and 42.9% were malignant with none of the masses derived from fallopian tube. Therefore, the results of this study are in accordance to the results of Shiber that hysterectomy combined with simultaneous bilateral salpingectomy may reduce the incidence of fallopian tubes derived pelvic masses, which accounted for 12.4–16.2% of total pelvic masses and 6.7–21.5% of total benign pelvic masses.

Furthermore, we compared the clinicopathological data of patients who underwent hysterectomy with and without simultaneous bilateral salpingectomy in this study. After adjusting the factors of more patients with endometriosis or adenomyosis in salpingectomy group, we found that there was no statistical difference between two groups on the age of pelvic mass onset, time interval between twice operations, main complaints when pelvic mass was found, and proportion of benign and malignant tumors. We also found that salpingectomy lead to no difference on the malignant pelvic masses between two groups, but cause difference on the benign pelvic masses. On the one hand, there were fewer cases with salpingectomy in this study, which may affect the statistical results. On the other hand, the objects of this study were the patients who underwent reoperation due to pelvic mass after simple hysterectomy with and without simultaneous bilateral salpingectomy, and we did not enrolled all patients underwent hysterectomy. Therefore, result of this study cannot concluded that simultaneous salpingectomy cannot reduce the incidence of benign and malignant masses, and cannot make difference on the nature of the pelvic masses. The prospective study we are currently conducting may help explaining this issue.

In conclusion, the results of this study showed that 14.65% of the pelvic masses in the hysterectomy group originated from fallopian tubes, accounting for 21.48% of the benign masses, while the pelvic masses in the salpingectomy group had no tumors originating from fallopian tubes. Therefore, hysterectomy with simultaneous bilateral salpingectomy may reduce the recurrence of pelvic masses, especially benign pelvic masses. However, there were no significant differences in clinical features and pathological types between the two groups.