Endometriosis Foundation of America
Endometriosis 2013 / Pelvic Sidewall Surgery for Ovarian Remnant Syndrome & Endometriosis
Roseanne Kho, MD
Okay, let's just move on here. So, this is actually the largest series that has been presented in ovarian remnant syndrome from the Mayo Clinic spanning over 30 some years period of time involving over 186 patients. I will show you other studies that I can refer you to where we reviewed all of the literature that is available. What is interesting is that this was first defined in 1970 by Shemwell and Weed in the feline model that demonstrated that the ovaries have the capacity of re-implanting ovarian tissue; re-implanting and revascularizing despite previous removal. I talked briefly earlier about how this definition now has been defined and re-defined more recently. Let's just pause for a moment and talk about how this developed. Why does ovarian remnant syndrome occur and why is it a problem?
The etiology we know very clearly comes from inadvertent and incomplete removal at the time of surgery. Surgical technique at the time of the initial oophorectomy clearly plays a role, the presence of pelvic adhesions, and certainly endometriosis also play a role in the development of ovarian remnant syndrome. If we think about the surgical technique at the time of the initial oophorectomy, clamping and stapling right across the pedicle without going into the retroperitoneum that all the previous surgeons and speakers have talked about, this has certainly contributed to the dilemma. What has been nicely demonstrated, very elegantly demonstrated from France. is this study that showed that ovarian stroma can actually extend microscopically 1.5 cm beyond where we can see it surgically grossly in the field. If you think about that it would then make you much more careful during the time of excision.
This is a patient who came to us, 74 years of age, who had, as you can see, a staple that was put up right against the pedicle, right up against the sidewall and developed an ovarian remnant or residual disease many years later. Dr. Nezhat talked about how ovarian remnant syndrome can be much more common on the left side. As you know it is much more difficult to isolate the IP, the infundibulopelvic ligament, on the left side because of the adhesions from the sigmoid colon. Endometriosis is, as you know, the most common indication for the initial oophorectomy that we know about. Something to think about that the relative oophorectomy can occur not just with minimally invasive surgery, laparoscopy or robotics but also with laparotomy. And in this case series we show that it was actually very common after a previous laparotomy.
This was a study that came out recently, very interesting, that of a port site ovarian remnant syndrome where the patient presented five years later after one ovary was removed. It was attributed to the method of extraction. They had to cut up the specimen into several pieces and the patient presented later on with port site ovarian remnant tissue. They recommended, as we do with endometriosis, to put the specimen in the bag to avoid this complication.
How do we diagnose ovarian remnant syndrome? Clearly it starts from a clinical suspicion, a careful history taking and awareness of the possibility of this condition when the patient last anticipated menopausal symptom at the time after both ovaries have been removed that would make us think about the possibility of ovarian remnant tissue. We actually had a patient that came to us a month ago, the wife of a pediatrician in town. She went into surgery with a left ovarian endometrioma, which at the time of surgery was noted to have extensive endometriosis. The right ovary was compromised and had to be removed. The uterus was in place. Three months after the surgery she continued to have menses, had severe pain, and then came in to us for her surgery. Do know that ovarian remnant syndrome can present five to 20 years after the initial oophorectomy. They tend to present with pelvic pain and less commonly with a pelvic mass. Why the pelvic pain? Because the compression of the underlying structures, and also when there is endometriosis involved the residual ovarian tissue can stimulate endometriosis as well.
How do we diagnose? Is there any laboratory or imaging studies that are better to diagnose ovarian remnant syndrome? Certainly we have used FSH level and estradiol, although if it is not 100 percent sensitive know that in the patient who is in menopause the FSH or estradiol will not shed much light or help with the diagnosis. Imaging; in our series we have shown that the transvaginal ultrasound is highly effective and we do not need to always resort to a much more expensive imaging method. Have we used provocation of ovarian tissue with clomiphene citrate - certainly we have done that and it can be helpful but not completely diagnostic. So how do we use clomid? We would give 50 mg twice per day for ten days. You can do that before imaging or even before surgery in order for you to be able to identify the tissue. I want to emphasize that in terms of management medication is quite limited, radiotherapy is also limited. The primary approach to ovarian remnant syndrome is that of surgery and we recommend complete excision. I will go over our technique at the Mayo Clinic.
Something that is important to keep in mind is that there have been reports of ovarian remnant tissue involved with malignancy. This is from our study at the Mayo Clinic in Arizona for two of our 20 patients who actually had cancer of the ovarian tissue involved. In the literature there have been nine reported cases of malignant involvement in ovarian remnant syndrome. In ovarian remnant syndrome with ovarian cancer in 50 cases 50 percent of the time endometriosis was actually involved. In these reports as you all know, and many of the speakers have talked about, there is a three fold increase in the risk for ovarian cancer as well in endometriosis. If we think about these things it is even more important for us to be extremely vigilant with the patients who present to us with endometriosis in order to avoid future risks for ovarian cancer and also risk for ovarian remnant syndrome.
This is a recent article that we did where we reviewed the most recent publications in the last five years, again, emphasizing the need for careful removal at the time of initial oophorectomy in order to avoid ovarian remnant syndrome, in order to avoid recurrent endometriosis, and in order to avoid malignant transformation of the disease. How do we treat ovarian remnant syndrome at the Mayo Clinic? We talk about high re-ligation of the ovarian vessels at the level of the aortic bifurcation. What does that mean? It means going into the retroperitoneum, identifying and isolating your ovarian vessels after having identified your ureters and going ahead and re-ligating the vessels at that point. We perform ureterolysis so oftentimes ovarian remnant syndrome will attach immediately to the pelvic sidewall, immediately on top of the ureter, sometimes involving the bowel, sometimes involving the bladder and also the top of the vagina. This is why we would then recommend complete peritonectomy in these patients.
Let's just quickly run through this video here, just for a few minutes. This is at the time of the initial oophorectomy. We do recommend going into the retroperitoneum and dissecting the anterior leaf separately from the posterior leaf of the broad ligament. Here we have isolated the ovarian vessels. We are getting to the sidewall. We have identified the ureter right here at the pelvic brim where it is most superficial. We would then create the window beneath the superior to the ureter so that all of the ovarian vessels can be isolated. We would ligate it at this point allowing us then to completely excise the adnexa in order to avoid leaving behind any ovarian tissue.
Let's just go on to the next video here and I will end with this video to get this back on time. So just to show you how this is a perfect set up for ovarian remnant syndrome and a perfect set up for leaving behind endometriosis if we are not vigilant about knowing our anatomy. As Dr. Advincula talked about, knowing exactly where our spaces are. This is in a young woman who presented with a hydroureter and on this left side you can see how it is difficult. You will see this markedly dilated ureter right here; this is the entire ureter so isolating the IP. It also involves the uterosacral ligament sitting directly on top of the ureter. We would go ahead then, we have already taken down the adhesions from the sigmoid colon, staying immediately adjacent and on top of the ureter. We would go ahead and release the fibrotic tissue, staying a few millimeters away from the ovarian tissue in order to be able to excise this completely.
You have seen many, many videos here with this conference on techniques with endometriosis. Just to conclude, please be aware of ovarian remnant syndrome. It is definitely preventable. A vigilant, excellent surgical technique at the time of the initial oophorectomy is critical, particularly in cases that involve endometriosis, and be aware of the relationship between ovarian remnants syndrome and endometriosis with ovarian cancer.
Thank you so much for your attention.