Laparoscopic Diagnosis of Pelvic Masses - Is it Safe?
Frederick R. Jelovsek MD
If a pelvic, vaginal probe ultrasound shows a complex adnexal or ovarian mass and the doctor says exploratory surgery should be done to rule out possible ovarian cancer, is it safe to just have laparoscopic surgery or should a major abdominal incision be performed? This question comes up often because there is a fear that laparoscopy could spread a cancer if it were present, or lead to a delay of treatment if full surgery could not be performed at that time in that setting. If the woman is at low risk for cancer based on the ultrasound picture of the pelvic mass, studies have shown a low incidence of unsuspected cancer. The problem is confined to those situations where the ultrasound characteristics are more worrisome for malignancy.
A Recent Study
One study, Dottino PR, Levine DA, Ripley DL, Cohen CJ: Laparoscopic management of adnexal masses in premenopausal and postmenopausal women. Obstet Gynecol 1999;93:223-228, looked at over 160 patients who underwent laparoscopy for a pelvic mass on a gynecologic oncologic service at Mount Sinai School of Medicine, New York, New York, between 1992 and 1996. It answers women's questions that come up when that pelvic or ovarian mass is first found.
It seems that laparoscopic diagnosis of an ovarian mass would always be easier on the women than a large abdominal incision. Why is there any question that laparoscopy should not be the primary approach?
Most of the scientific journal articles suggest that adnexal masses suspicious for malignancy are best managed by laparotomy, a full abdominal incision. One concern about the use of laparoscopy includes the failure to diagnose a malignancy. When you just look at the outside of the ovary you can only tell a malignancy if it has spread outside the capsule of the ovary. If it is still inside the ovary it can look like a normal physiologic cyst. If a large incision has been made, the ovary can easily be opened to look internally. That is much more difficult at laparoscopy.
Another concern is that a surgeon is more likely to let tumor cells spill at the time of removal by laparoscopy than when there is a much larger incisional exposure. Finally, there is the fear that surgeons will just look and diagnose by laparoscopy and not perform the needed tumor resection at the time of laparoscopy, thus delaying treatment of the cancer.
The advantages of laparoscopy include decreased postoperative pain, shorter length of stay, quicker recovery time, less adhesion formation, and lower costs.
Questions About Ovarian Cancer and Test Results
How likely is it for a pelvic mass to be a cancer?
In this series, benign pathology was found in 87% of the patients, malignancy in 13% or 1 out of 8. All of the benign masses were managed (removed) laparoscopically.
What happens if it turns out to be a cancer?
If cancer is discovered a larger incision can be made and a full staging procedure and removal of all tumor and lymph nodes can be performed. While the laparoscopic part adds about 30 minutes more to the procedure than going straight to a full incision in the first place, the full procedure only has to be performed 1 in 8 times. The other 7 times, the patient's recovery is significantly shortened.
Can the diagnosis be wrong at laparoscopy?
Diagnosis at the time of surgery is made by "frozen section" pathological review. This technique is known not to be perfect and sometimes there is a discrepancy between the immediate pathological review using frozen section and the permanent pathological slide review about 48 hours later. This study had a 3% discrepancy rate between immediate and final pathology report, but that is the same rate found in other series at laparotomy. In other words there is no difference in this rate between laparoscopy and laparotomy.
Should my gynecologist do this procedure or do I need to go to a gynecologic oncologist?
It is difficult to answer this question. Most gynecologists feel comfortable treating Stage I disease with removal of the ovaries, uterus and omentum as well as removing pelvic lymph nodes to make sure there is not microscopic spread. They may not be comfortable removing extensive tumor involving bowel and urinary tract. On the other hand, even in this series less than 12% needed this further surgery.
Even if the gynecologist diagnoses malignancy but does not carry out the definitive surgical therapy, it is imperative that the surgery be carried out fairly quickly. It has been shown that delays of a month can have an effect on the curability of the cancer.
When should laparoscopy not be used for diagnosis of a possible cancer of the pelvis?
In this series, any patient that had findings suspicious for metastasis or had a mass that extends above the umbilicus (navel) was not included. They had initial full incisions. The series did include cases where ultrasound showed solid components or complex masses.