Risks and benefits of opportunistic salpingectomy during vaginal hysterectomy: a decision analysis.
BACKGROUND
Fallopian tubes are commonly removed during laparoscopic and open hysterectomy to prevent ovarian and tubal cancer but are not routinely removed during vaginal hysterectomy because of perceptions of increased morbidity, difficulty, or inadequate surgical training.


OBJECTIVE
We sought to quantify complications and costs associated with a strategy of planned salpingectomy during vaginal hysterectomy.


STUDY DESIGN
We created a decision analysis model using TreeAgePro. Effectiveness outcomes included ovarian cancer incidence and mortality as well as major surgical complications. Modeled complications included transfusion, conversion to laparotomy or laparoscopy, abscess/hematoma requiring intervention, ileus, readmission, and reoperation within 30 days. We also modeled subsequent benign adnexal surgery beyond the postoperative window. Those whose procedures were converted from a vaginal route were assumed to undergo bilateral salpingectomy, regardless of treatment group, following American College of Obstetricians and Gynecologists guidelines. Costs were gathered from published literature and Medicare reimbursement data, with internal cost data from 892 hysterectomies at a single institution used to estimate costs when necessary. Complication rates were determined from published literature and from 13,397 vaginal hysterectomies recorded in the National Surgical Quality Improvement Program database from 2008 through 2013.


RESULTS
Switching from a policy of vaginal hysterectomy alone to a policy of routine planned salpingectomy prevents a diagnosis of ovarian cancer in 1 of every 225 women having surgery and prevents death from ovarian cancer in 1 of every 450 women having surgery. Overall, salpingectomy was a less expensive strategy than not performing salpingectomy ($7350.62 vs $8113.45). Sensitivity analysis demonstrated the driving force behind increased costs was the increased risk of subsequent benign adnexal surgery among women retaining their tubes. Planned opportunistic salpingectomy had more major complications than hysterectomy alone (7.95% vs 7.68%). Major complications included transfusion, conversion to laparotomy or laparoscopy, abscess/hematoma requiring intervention, ileus, readmission, and reoperation within 30 days. Therefore, routine salpingectomy results in 0.61 additional complications per case of cancer prevented and 1.21 additional complications per death prevented. A surgeon therefore must withstand an additional ∼3 complications to prevent 5 cancer diagnoses and ∼6 additional complications to prevent 5 cancer deaths.


CONCLUSION
Salpingectomy should routinely be performed with vaginal hysterectomy because it was the dominant and therefore cost-effective strategy. Complications are minimally increased, but the trade-off with cancer prevention is highly favorable.
['Cadish|Lauren A|LA|', 'Shepherd|Jonathan P|JP|', 'Barber|Emma L|EL|', 'Ridgeway|Beri|B|']
D000038:Abscess D000328:Adult D061887:Conversion to Open Surgery D003362:Cost-Benefit Analysis D003661:Decision Support Techniques D005260:Female D006406:Hematoma D006801:Humans D007045:Hysterectomy, Vaginal D045823:Ileus D010535:Laparoscopy D008875:Middle Aged D010051:Ovarian Neoplasms D010359:Patient Readmission D011183:Postoperative Complications D019106:Postoperative Hemorrhage D065286:Prophylactic Surgical Procedures D019057:Quality-Adjusted Life Years D012086:Reoperation D018570:Risk Assessment D058994:Salpingectomy D013530:Surgical Wound Infection
vaginal hysterectomy decision analysis ovarian cancer cost-effectiveness analysis opportunitistic salpingectomy