Opportunistic Salpingectomy for the Primary Prevention of Ovarian Cancer

In Germany, more than 7000 women develop ovarian carcinoma, and more than 5000 women with this diagnosis die, every year (1). To date, there is no effective early detection strategy.

Complete removal of the fallopian tubes (salpingectomy) has been identified as an approach that can significantly reduce the risk of ovarian cancer, even in women without a genetic predisposition for cancer (2). This agrees with the increasing body of research since 2010 on the pathogenesis of ovarian cancer, which indicate that the most common and aggressive subtype (high-grade serous carcinoma [HGSC]) develops from precursor lesions in the fallopian tubes (3).

Based on these data, a trend has been established for carrying out opportunistic salpingectomy (OS)—that is, removing the fallopian tubes while preserving the ovaries, to reduce the risk of malignant and benign diseases following a pelvic operation such as a hysterectomy. OS has been routinely performed in numerous clinics in Germany, including at the Department of Gynecology of the Jena University Hospital since 2005 (4). An impairment of the ovarian function by a correctly performed OS has not been shown.

As of 2018, 13 of the 130 member countries of the International Federation of Gynecology and Obstetrics (FIGO) have issued statements on OS. Of these, nine were clearly in favor, and four expressed reservations, including the one from the German specialist association (5). This article examines whether performing OS in Germany has nevertheless developed into a de facto standard.

Methods

The case numbers for the main diagnoses or surgeries, performed individually or in combination according to OPS coding, were queried from the German Federal Statistical Office (Destatis, Special Evaluation of Diagnostic-Related Group [DRG] Statistics): appendectomies (5-470*), salpingectomies (5-661*), salpingo-oophorectomies (5-653*), sterilizations (5-663*; destruction and closure of the fallopian tubes), and hysterectomies ([5-682*; partial extirpation of the uterus] + [5-683*; total extirpation of the uterus]). The survey applies to all hospitals in Germany with DRG reimbursement according to Section 1 of the Hospital Remuneration Act and refers to discharged inpatients (including deaths and hospital day cases) without duplicates in the OPS 4-digit code. The identity of the patients, the side on which the salpingectomy was performed, and any given information about the option of OS were not recorded. Case numbers for the outpatient sector are currently not available (according to the KBV [Association of Statutory Health Insurance Physicians] on 4 May, 2022).

Results

In 2020, 50 398 cases of salpingectomy were performed, about four times more compared to 2005 (with 12 286 cases) (figure). The number of salpingectomies performed showed little change until 2011 (with 12 167 cases). However, there was an increase of at least 5000 salpingectomies per year from 2012 (19 475) to 2018 (54 382), mostly in combination with a hysterectomy (with 37 732 combined procedures in 2020).

Figure.

Development of case numbers for hysterectomies, salpingectomies, hysterectomies in combination with a salpingectomy, salpingo-oophorectomy and sterilizations (tubal closure) for the years 2005 to 2020. Inpatients discharged from the hospital (including deaths and hospital day cases) are shown for the selected OPS codes (with no duplicates at the level of the OPS 4-digit code) for German hospitals that are reimbursed according to the DRG system. Numbers are taken from information from the Federal Statistical Office (Special Evaluation of DRG Statistics), with our graphical representation.

The number of inpatient procedures of sterilization using tubal ligation showed a moderate increase, from 6943 (2005) to 9243 (2020) (figure).

The number of cases of removal of the fallopian tubes and ovaries (salpingo-oophorectomy) remained stable over the period examined (2005: 40 355; 2020: 40 485), while the number of hysterectomies performed fell sharply (2005: 146 665; 2020: 83 174) (figure).

In 2020, more than half of the hysterectomies in women between the ages of 30 and 54 were performed in combination with a salpingectomy, and even more than two thirds in women in the 35– to 49-year-old age range (table). Following menopause, however, the adnexa are usually completely removed (salpingo-oophorectomy) (table).

Table. Number of hysterectomies in 2020 according to age groups.

Age in years	Hysterectomy, total	Hysterectomy with salpingectomy	Hysterectomy with salpingo-oophorectomy
Under 30	1052	216 (21)	685 (65)
30–34	2093	1192 (57)	290 (14)
35–39	5972	3913 (66)	535 (9)
40–44	12 669	8 747 (69)	1114 (9)
45–49	16 709	11 472 (69)	1903 (11)
50–54	13 073	7 441 (57)	3059 (23)
55–59	7581	2 264 (30)	3627 (48)
60–64	6196	972 (16)	3549 (57)
65–69	5879	681 (12)	3519 (60)
70 and older	11 939	827 (7)	7144 (60)
Unknown*	11	7	0
Total	83 174	37 732 (45)	25 425 (31)

Hysterectomies performed, given as the total number (5-682* or 5-683*) or as the number and percentage (in brackets) in combination with salpingectomy (5-682* or 5-683* and 5-661*) or salpingo-oophorectomy ([5-682* or 5-683* and 5-653*] + 5-683.1* + 5-683.2* + 5-683.6 + 5-683.7). Cases are for inpatients with a hospital discharge (including deaths and hospital day cases) for the selected OPS codes (without duplication at the level of the OPS 4-digit code) from German hospitals that are reimbursed according to the DRG system. Numbers are from information of the German Federal Statistical Office (Special Evaluation of DRG Statistics), with our own calculation and presentation. * In the breakdown by age groups, the German Federal Statistical Office does not issue very small case numbers (≤ 2), for reasons of data protection. This can lead to a difference between the total number determined without an age breakdown and the sum of the age-defined cases. This difference is shown here as “age unknown”.

Two thirds (67%) of salpingectomies in 2020 were coded with principal diagnoses, representing a benign indication for hysterectomy, and only 11% with tubal disease. The number of cases according to frequency were: D25 (uterine leiomyoma): 21 383; N80 (endometriosis): 5039; N81 (female genital prolapse): 4101; N92 (excessive, frequent, or irregular menstruation): 3235; N83 (non-inflammatory disorders of ovary, fallopian tube, and broad ligament): 2069; N70 (salpingitis): 1871; O00 (extra-uterine pregnancy): 1686.

Discussion

The development of the number of cases in the inpatient sector of the German health system proves that there is an increased implementation of OS in the context of hysterectomy for benign indications, despite the current lack of recommendation from specialist societies. In a survey of German gynecologists, which we conducted together with the North-East German Society for Gynecological Oncology (NOGGO e.V.) and the Ovary Commission of the Working Group for Gynecological Oncology (AGO e.V.), confirms the acceptance and frequent use of OS (manuscript forthcoming). Carrying out an OS could be favored by the increase in laparoscopic interventions with access to tubes (laparoscopic + laparoscope-assisted vaginal hysterectomies; 2005: 10%, 2020: 57%), with a decrease in purely transvaginal hysterectomies (2005: 50%; 2020: 21%) (German Federal Office of Statistics). From our point of view, an adjustment of the expert consensus recommendations in Germany and other countries is necessary in order to give the practicing physicians a secure basis for this procedure, which is now very frequently performed (for comparison: 49 697 appendectomies in 2020). We recommend an interdisciplinary agreement on a uniform approach to counseling, indication, and implementation of OS, as well as for the histopathological work-up for detecting precursor lesions of ovarian carcinoma. Existing data from clinical studies and routine documentation regarding the clinical benefits, risks, and the health-economic balance of OS should be evaluated and collected in a prospective national register in the future. Women seeking permanent contraception should be informed about the advantages and disadvantages of salpingectomy.