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Postpartum salpingectomy: a procedure whose time has come

      Related article, page 106.
      Despite advances in treatment, ovarian cancer remains one of the most lethal malignancies; in the United States in 2018, there will be approximately 22,240 new cases of ovarian cancer and 14,070 ovarian cancer deaths.
      • Torre L.A.
      • Trabert B.
      • DeSantis C.E.
      • et al.
      Ovarian cancer statistics, 2018.
      There is increasing evidence that ovarian cancer may arise from the fallopian tube; hence, it has become routine in the last few years to perform a salpingectomy at the time of hysterectomy or sterilization procedure to decrease the woman’s risk of developing this disease.
      • Mikhail E.
      • Salemi J.L.
      • Mogos M.F.
      • Hart S.
      • Salihu H.M.
      • Imudia A.N.
      National trends of adnexal surgeries at the time of hysterectomy for benign indication, United States, 1998-2011.
      Piek et al
      • Piek J.M.
      • van Diest P.J.
      • Zweemer R.P.
      • et al.
      Dysplastic changes in prophylactically removed fallopian tubes of women predisposed to developing ovarian cancer.
      in 2001 found that noninvasive dysplastic areas of fallopian tubes removed from patients with BRCA mutations at the time of risk-reducing bilateral salpingo-oophorectomy resembled high-grade serous ovarian cancer.
      • Erickson B.K.
      • Conner M.G.
      • Landen Jr., C.N.
      The role of the fallopian tube in the origin of ovarian cancer.
      The author subsequently opined that most hereditary serous carcinomas of the ovary might originate from the epithelium of the tube, whose cells then spill onto the surface of the ovary
      • Erickson B.K.
      • Conner M.G.
      • Landen Jr., C.N.
      The role of the fallopian tube in the origin of ovarian cancer.
      • Piek J.M.
      • Verheijen R.H.
      • Kenemans P.
      • Massuger L.F.
      • Bulten H.
      • van Diest P.J.
      BRCA1/2-related ovarian cancers are of tubal origin: a hypothesis.
      rather than the cancer arising from the ovary itself. Supporting this hypothesis, these regions of tubal dysplasia share genetic characteristics with high-grade serous ovarian carcinomas, including the predominance of p53 mutations.
      • Erickson B.K.
      • Conner M.G.
      • Landen Jr., C.N.
      The role of the fallopian tube in the origin of ovarian cancer.
      Kindelberger et al
      • Kindelberger D.W.
      • Lee Y.
      • Miron A.
      • et al.
      Intraepithelial carcinoma of the fimbria and pelvic serous carcinoma: evidence for a causal relationship.
      showed that in low-risk women (without BRCA mutations or a significant family history of ovarian cancer), 75% of pelvic serous carcinomas had areas of tubal intraepithelial carcinomas, 93% of which were in the distal fimbriae.
      • Erickson B.K.
      • Conner M.G.
      • Landen Jr., C.N.
      The role of the fallopian tube in the origin of ovarian cancer.
      While occlusion or removal of the midportion of the tube (leaving the fimbriae in situ, as in a tubal ligation), has been associated with a decreased risk of ovarian cancer,
      • Cibula D.
      • Widschwendter M.
      • Majek O.
      • Dusek L.
      Tubal ligation and the risk of ovarian cancer: review and meta-analysis.
      • Tone A.A.
      • Salvador S.
      • Finlayson S.J.
      • et al.
      The role of the fallopian tube in ovarian cancer.
      it is far less than with a complete salpingectomy.
      • Lessard-Anderson C.R.
      • Handlogten K.S.
      • Molitor R.J.
      • et al.
      Effect of tubal sterilization technique on risk of serous epithelial ovarian and primary peritoneal carcinoma.
      Clinically substantiating these discoveries, a large population-based cohort study using a Swedish registry of >5.5 million women showed that women with previous tubal surgery did, in fact, have a lower risk of ovarian cancer.
      • Falconer H.
      • Yin L.
      • Gronberg H.
      • Altman D.
      Ovarian cancer risk after salpingectomy: a nationwide population-based study.
      Importantly, there was a 65% decreased risk of ovarian cancer when a bilateral salpingectomy was performed (hazard ratio, 0.35; 95% confidence interval, 0.17–0.73).
      • Falconer H.
      • Yin L.
      • Gronberg H.
      • Altman D.
      Ovarian cancer risk after salpingectomy: a nationwide population-based study.
      A 64% risk reduction after salpingectomy was also found in a retrospective study of serous ovarian cancer patients matched with controls from the Mayo Clinic.
      • Lessard-Anderson C.R.
      • Handlogten K.S.
      • Molitor R.J.
      • et al.
      Effect of tubal sterilization technique on risk of serous epithelial ovarian and primary peritoneal carcinoma.
      The pattern of these findings led the Society of Gynecologic Oncology in 2013 to recommend discussion of salpingectomy with patients at the time of hysterectomy or sterilization and for the American Congress of Obstetricians and Gynecologists to do the same in 2015. Such recommendations led to initiatives to support salpingectomy as a routine procedure with dramatic results; in British Columbia, the uptake of bilateral salpingectomy increased significantly both at the time of hysterectomy (5–35%) and sterilization (0.4–33.3%).
      • McAlpine J.N.
      • Hanley G.E.
      • Woo M.M.
      • et al.
      Ovarian Cancer Research Program of British Columbia. Opportunistic salpingectomy: uptake, risks, and complications of a regional initiative for ovarian cancer prevention.
      Despite this practice change in the field of gynecology, it has not expanded to the obstetric population. The current article entitled “Cost-effectiveness of opportunistic salpingectomy versus tubal ligation at the time of cesarean delivery” by Venkatesh et al
      • Venkatesh K.K.
      • Clark L.H.
      • Stamilio D.M.
      Cost-effectiveness of opportunistic salpingectomy vs tubal ligation at the time of cesarean delivery.
      and published in this edition of the Journal, attempts to determine the potential benefits and hazards of performing a bilateral salpingectomy in lieu of a postpartum tubal ligation. Approximately 340,000 postpartum bilateral tubal ligations are performed each year in the United States, and >100,000 of these are performed at the time of cesarean.
      • Venkatesh K.K.
      • Clark L.H.
      • Stamilio D.M.
      Cost-effectiveness of opportunistic salpingectomy vs tubal ligation at the time of cesarean delivery.
      This group of patients is, therefore, a large portion of the population in which the risk of developing ovarian cancer could be reduced. To analyze the impact that adoption of bilateral salpingectomy at the time of cesarean would have on the medical system and in prevention of ovarian cancer, the authors performed a cost-effectiveness analysis using estimated costs per procedure, perioperative complications, years of life expectancy gained (in quality-adjusted life-years), prevention of future pregnancies, and number of ovarian cancer cases and deaths prevented.
      • Venkatesh K.K.
      • Clark L.H.
      • Stamilio D.M.
      Cost-effectiveness of opportunistic salpingectomy vs tubal ligation at the time of cesarean delivery.
      Their analysis compared 3 strategies: bilateral tubal ligation, bilateral salpingectomy, and postpartum long-acting reversible contraception. Across all outcomes, long-acting reversible contraception was costlier and less effective, both in pregnancy and ovarian cancer prevention. Tubal ligation was initially less expensive than salpingectomy ($3588 vs $3651), but was less effective, resulting in fewer quality-adjusted life-years. Furthermore, using the previously demonstrated ovarian cancer risk reduction with salpingectomy of 64%, the authors concluded that salpingectomy would result in 422 fewer ovarian cancer diagnoses and 252 fewer ovarian cancer deaths in the study population (110,000 pregnant women desiring permanent sterilization at the time of cesarean) over 10 years. As a result, the base case analysis indicates that salpingectomy is more cost-effective and beneficial than any other method.
      The authors estimate an approximately 1% higher operative complication rate with salpingectomy over tubal ligation. However, if it is higher, then tubal ligation would be the preferred cost-effective strategy. They call for increased research to more precisely understand the operative risks. Prior to widespread adoption of salpingectomy at the time of hysterectomy or gynecologic sterilization, similar concerns were raised regarding both operative risk and postoperative implications. These were met, in turn, with several studies showing no difference in blood loss, complication rate, or ovarian function.
      • McAlpine J.N.
      • Hanley G.E.
      • Woo M.M.
      • et al.
      Ovarian Cancer Research Program of British Columbia. Opportunistic salpingectomy: uptake, risks, and complications of a regional initiative for ovarian cancer prevention.
      • Morelli M.
      • Venturella R.
      • Mocciaro R.
      • et al.
      Prophylactic salpingectomy in premenopausal low-risk women for ovarian cancer: primum non nocere.
      Retrospective studies have examined the operative risks of postpartum salpingectomy and found no difference compared to tubal ligation.
      • Danis R.B.
      • Della Badia C.R.
      • Richard S.D.
      Postpartum permanent sterilization: could bilateral salpingectomy replace bilateral tubal ligation?.
      • Shinar S.
      • Blecher Y.
      • Alpern S.
      • et al.
      Total bilateral salpingectomy versus partial bilateral salpingectomy for permanent sterilization during cesarean delivery.
      A recent randomized controlled trial by Subramaniam et al
      • Subramaniam A.
      • Blanchard C.T.
      • Erickson B.K.
      • et al.
      Feasibility of complete salpingectomy compared with standard postpartum tubal ligation at cesarean delivery: a randomized controlled trial.
      aimed to evaluate the feasibility of salpingectomy at the time of cesarean; 80 women undergoing cesarean were randomized to either bilateral salpingectomy or bilateral tubal ligation. While bilateral salpingectomy was successfully completed in just 68% of cases (vs 95% successful completion of tubal ligation) and operative time was 15 minutes longer, there was no difference in total procedure estimated blood loss or in postoperative complications. The authors concluded that bilateral salpingectomy should be considered at the time of cesarean for permanent sterilization.
      • Subramaniam A.
      • Blanchard C.T.
      • Erickson B.K.
      • et al.
      Feasibility of complete salpingectomy compared with standard postpartum tubal ligation at cesarean delivery: a randomized controlled trial.
      Given the demonstrated impact that bilateral salpingectomy has in the prevention of ovarian cancer and the high number of postpartum sterilizations that are performed each year in the United States, there is a great opportunity to expand prevention of ovarian cancer to this population. While ovarian cancer treatments continue to evolve, the persistently high mortality rates obligate us to improve prevention strategies. We commend the work performed by the authors in their well-designed cost-effectiveness model to this practice change and thank them for their contribution to this effort. An analysis of this sort is exceptionally important, as any real-time intervention will take many years to reach maturity. These data indicate that we can and should do our best to prevent ovarian cancer, beginning with the adoption of postpartum salpingectomy. Hopefully, this study will lead to others that will confirm these data.

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