Indications for 

Salpingectomy
12
Roberta Venturella

Anatomical and Functional Considerations

The uterine tubes (Fallopian Tubes, FT) are two hollow

muscle-­mucosal organs, about 10–12 cm long, divided into
three portions: the intramural, the isthmic and the ampullary
ones. This last portion terminates in an enlarged end, called
infundibulum, with some protrusions called fimbriae. The
ovarian fimbria, in particular, is connected through the meso-
salpinx to the ovary. The tubal ostium, laterally, is the site
where the tubal canal meets the pelvic cavity, while the uter-
ine opening of the FT is the entrance into the uterine cavity,
the utero-tubal junction (Fig. 12.1).
As the cervix and endometrium, also the FT are derived
from the müllerian ducts. The wall of the tube has a Fig. 12.1  Normal tubal anatomy
mucous layer and a muscle one, thicker in the medial part
of the tube. The contraction of the muscle bundles allows
the tubes having their own peristaltic motility. The muco- five days the embryo reachs the uterine cavity and on about
sal layer is covered with cells, some of which ciliated, that the sixth day implants on the wall of the fundus of the
determine a bidirectional internal movement of fluids and uterus.
cells, both to the uterus and towards the pelvis. The pro- Given their bidirectional motility, moreover, the FT are
duction of cilia on these cells is increased by Estrogens. able to let cells, pathogens, blood and substances from the
Scattered between the ciliated cells are secretory cells, vagina, the cervix and the endometrium to reach the
which contain apical granules and produce the tubular abdomino-­pelvic cavity.
fluid. The number of these cells is increased by
Progesterone, while Estrogens increase their secretory
activity. The tubal fluid contains nutrients as lipids and  enign Tubal Pathologies as Indication
B
glycogen for spermatozoa, oocytes, and zygotes and also to Salpingectomy
promote capacitation of the sperm.
After ovulation, physiologically, the oocyte is caught by Inflammatory diseases are the most important tubal disor-
the fimbriated end and travels to the ampulla of the uterine ders, due to their frequency and their consequences, some-
tube where the sperm are met and fertilization occurs. The times serious [1].
fertilized ovum, now a zygote, comes towards the uterus FT indeed, placed between the uterus and ovaries, are fre-
thanks to the activity of tubal cilia and muscle. After four to quently infected by one of these two organs. The communi-
cation with the peritoneal cavity, moreover, exposes the tube
also to any abdominal infection. Appendicitis is a frequent
R. Venturella, MD
source of descending infection. Rarely, the tubal infection is
Department of Obstetrics and Gynecology, Magna Graecia
University of Catanzaro, Catanzaro, Italy transmitted by blood, as in the case of tuberculous
e-mail: [email protected] salpingitis.

© Springer International Publishing Switzerland 2018 149

I. Alkatout, L. Mettler (eds.), Hysterectomy, DOI 10.1007/978-3-319-22497-8_12
150 R. Venturella

More often, the infectious processes ascending from the shared by reproductive gynecologists [3]. The hydrosalpinx
lower genital tract extend to the tube and reach the peritoneal fluid, indeed, is able to reach the uterine cavity, in which
cavity, leading to Pelvic Inflammatory Disease (PID) [1]. embryos try to implant, and exerts a toxic effect on this deli-
The narrow tubal lumen undergoes important conse- cate phase of pregnancy.
quences in case of inflammation. The mucosal edema can Laparoscopic salpingectomy has been demonstrated to
completely occlude the utero-tubal junction, preventing be an effective option for avoiding this negative reproduc-
drainage of inflammatory secretions in the uterine cavity. tive interference, improving pregnancy rates and removing
This causes the onset of acute salpingitis, in which the tube the risk of PID and ectopic pregnancies. Whenever laparos-
is red, swollen, tortuous, with thickened wall and the lumen copy is not recommended due to the presence of dense pel-
filled with pus. The progress of each salpingitis is very slow. vic adhesions, hysteroscopic insertion of device seems a
Exceptionally acute inflammation can heal spontaneously very effective option for management of hydrosalpinx
and the restoration of tubal anatomy and function occurs. before IVF [4].
Usually, however, the infection becomes chronic and causes Recently, a systematic review and meta-analysis of stud-
permanent tubal occlusion (Fig. 12.2). The tube becomes ies comparing the pregnancy outcomes in hydrosalpinx
more dilated, takes the form of a sausage and is filled with patients treated with salpingectomy versus those treated with
pus, leukocytes or plasma-cells (pyosalpinx). The drainage proximal tubal occlusion prior to IVF has been published
of this infected tube into abdominal cavity can cause the [5]. In this study, comparable responses to controlled ovarian
insurgence of peritonitis. hyperstimulation and pregnancy outcome were observed
The purulent content may gradually melt turning into a between groups, demonstrating that salpingectomy does not
serous or sero-hematic fluid (hydrosalpinx or ­hematosalpinx). worsen reproductive prognosis of patients in which exci-
This conditions can remain asymptomatic for a long time, sional surgery is chosen.
and the diagnosis is often difficult or accidental. When sal- Hydrosalpinx is also the most frequent (35.5 %) compli-
pingitis becomes chronic, the peritoneal adhesions surround- cation of the blind-ended remnants of the FT in patients
ing the tube and ovaries distort the course of the FT and undergoing hysterectomy with tubal preservation [6]. Others
cause infertility. pathologies that may emerge from retained FT are tube pro-
In tubal factor infertility, when the cause is bilateral lapse, torsion, PID, benign and malignant Fallopian Tube
hydrosalpinx, in vitro fertilization (IVF) is now considering tumors.
the first option rather than attempting to restore tubal func- Other frequent causes of peritoneal adhesions, responsi-
tion [2]. The hydrosalpinges themselves, however, adversely ble of anatomical and functional FT alterations, are previous
affect IVF outcomes, reducing the implantation rate and pelvic and abdominal surgeries, especially if performed by
increasing the risk of miscarriage [3]. Among the pathogenic laparotomy. Caesarean sections, surgeries for uterine myo-
mechanisms proposed, embryotoxic effects, mechanical mas or ovarian cysts, but especially the presence of perito-
flushing and changes in endometrial receptivity are the most neal or ovarian endometriosis are well-known risk factors for
tubal alterations and occlusion.
Many variables have to be considered when counseling
patients with tubal alterations regarding corrective surgery or
direct IVF. The chronological and ovarian age of the woman,
the site and extent of tubal pathology, the semen analysis of
the male partner, the presence of other infertility factors
(such as ovarian endometriosis), the experience of the sur-
geon and the quality and success rate of the referring IVF
center are the most important. Given the costs and benefits
associated to both surgery and IVF, the ideal candidate for
surgical tubal restoration is probably a young woman, with
no other infertility factors, a partner with a normal semen
analysis and a tubal anatomy amenable to repair. Conversely,
patients with extensive omolateral dense peritubal adhesions
from endometriosis and/or dilated tubes (>3 cm) with thick
fibrotic walls have poor prognosis: in all these cases the tube
is usually damaged beyond repair and omolateral salpingec-
tomy is indicated when pregnancy can be achieved by spon-
Fig. 12.2  Hysterosalpingografic image suggestive of right taneous attempts. In patients with tubal factor infertility,
hydrosalpinx however, IVF has a higher pregnancy rate per cycle and this
12  Indications for Salpingectomy 151

information need to be discussed with the patient to provide In 2014, in a new open-label, multicentre, international,
assistance in her decision making. randomised controlled trial, women aged 18 years and older
The second most frequent benign condition affecting the with a laparoscopically confirmed tubal pregnancy and a
FT is the ectopic pregnancy (EP). Between 1 and 2 % of live healthy contralateral tube were randomly assigned to receive
births in developed countries, and as high as 4 % of pregnan- salpingotomy or salpingectomy [12]. In this study, the cumu-
cies involving assisted reproductive technology [7] are com- lative ongoing pregnancy rate was 60.7 % after salpingotomy
plicated by EP, in which the embryo is implanted outside the and 56.2 % after salpingectomy (difference not significant
uterine cavity. between groups). Persistent trophoblast, however, occurred
At least 93 % of ectopic pregnancies are located in a FT more frequently in the salpingotomy group than in the sal-
(Fig. 12.3) [8]. Of these, 75 % are located in the ampullar pingectomy group (7 % vs < 1 %). Repeat ectopic pregnancy
portion, 13 % are located in the isthmus, and 12 % in the occurred in 8 % of women in the salpingotomy group and
fimbriae [7] but ectopic implantation can also occur in the 5 % of those in the salpingectomy group. The number of
cervix, ovaries, and abdomen. ongoing pregnancies after ovulation induction, intrauterine
EP can be a life-threatening condition as it is responsible insemination, or IVF did not differ significantly between the
for 6 % of maternal deaths during the first trimester of preg- groups.
nancy [8]. Meta-analysis of data substantiated the results of the trial
In a typical tubal pregnancy, the embryo adheres to the so that authors concluded that in women with a tubal EP and
lining of the FT and burrows into the tubal wall. Commonly, a healthy contralateral tube, salpingotomy does not signifi-
it invades vessels and causes intratubal bleeding, which may cantly improve fertility prospects compared with
discharges the implanted embryo out of the tube as a tubal salpingectomy.
abortion. Sometimes this bleeding might be heavy enough to
threaten the life of the woman, even if, in developed coun-
tries, this event is today luckily rare.  alignant and Pre-neoplastic Tubal
M
Identified risk factors for EP include: PID, infertility, use Pathologies as Indication to Salpingectomy
of an intrauterine device (IUD), previous exposure to toxi-
cants, tubal or intrauterine surgery (e.g. D&C), smoking, Historically, primitive tumors of the FT were described as
previous EP, and tubal ligation [9]. rare [13]. In women with advanced peritoneal carcinoma, the
Fertility following EP is dependent from several factors, involvement of the ovary usually hides and incorporates the
the most important of which is a prior history of infertility fallopian tube, drawing the attention of surgeons and pathol-
[10]. The treatment choice seems not to play a great role. A ogists and resulting in a diagnosis of ovarian primary carci-
recent randomized study concluded that the rates of intra- noma. In those cases, however, salpingectomy is only a little
uterine pregnancy two years after treatment of EP are part of the more radical surgical procedure that is total hys-
approximately 64 % with excisional surgery, 67 % with terectomy plus bilateral salpingo-oophorectomy, with pelvic
methotrexate, and 70 % with conservative surgery (salpin- and aortic lymph node dissection when indicated.
gotomy) [11]. Recently, however, morphologic, immune-histochemical
and molecular studies [14, 15] have led to the development
of a new theory on the pathogenesis of Epithelial Ovarian
Carcinomas (EOCs) based on a dualistic model of carcino-
genesis [15], which identifies type II neoplasia (high-grade
serous (HGSC), high-grade endometrioid, malignant mixed
mesodermal tumours and undifferentiated carcinomas) as
cancers typically genetically unstable, aggressive and pre-
sented in advanced stages [15]. Among these, HGSC is the
most common Ovarian Cancer (OC), responsible for the
higher death rate among the others types.
Interestingly, the new proposed theory shifts the early
events of carcinogenesis to the FT instead of the ovary [15],
suggesting that types II tumors derive from the epithelium of
the Fallopian tube, whereas clear cell and endometrioid
tumors derive from endometrial tissue that migrate to the
ovary by retrograde menstruation [14].
These observations have been mainly collected from
Fig. 12.3  Laparoscopic view of a left tubal ectopic pregnancy women carrying BRCA1/2 mutations and undergoing
152 R. Venturella

a b

Fig. 12.4  Histologic view of a serous intraepithelial tubal cancer lium (b), in which a distinct transition from normal tubal epithelium to
(STIC). In this H&E staining, (a) the STIC cells show polymorphic p53 positive STIC (p53 immunohistochemistry) is also shown
nuclei and a multilayer epithelium, compared with normal tubal epithe-

prophylactic salpingo-oophorectomy, in which most of showed as salpingectomy with hysterectomy for benign con-
the incidentally diagnosed in situ carcinomas or intraepi- ditions will reduce ovarian cancer risk at acceptable cost and
thelial precursors of cancers (STIC) were detected not in is a cost-effective alternative to tubal ligation for sterilization
the ovary but in the fimbrial end of the FT [16–18] (Fig. [33].
12.4). STIC were also subsequently diagnosed in many Concerning BRCA women, current recommendations
women not carrying BRCA mutations, thanks to an include bilateral salpingo- oophorectomy (PBSO) by the age
extended protocol of pathologic examination of the of 40 years or on completion of childbearing to reduce their
Fallopian Tubes (SEE-FIM) of patients operated for spo- risk of both ovarian and breast cancers. In these women,
radic HGSC [19–22]. indeed, PBS might reduce risk of OC and premature death
Based on these evidences, prophylactic bilateral salpin- secondary to cardiovascular disease, but it would not reduce
gectomy (PBS) without ovariectomy has been proposed as a breast cancer risk; conversely, PBSO is able to decrease the
new preventive approach to reduce the risk of sporadic neo- risk of OC and breast cancer by approximately 80–90 % and
plasia [23, 24] in women at population risk of ovarian cancer 50 %, respectively.
(i.e. those not carrying BRCA 1/2 mutations) [25], without
exposing these patients to the adverse effects of iatrogenic
premature menopause.  ermanent Contraception as Indication
P
Even if opinions vary regarding short and long term out- to Salpingectomy
comes of PBS [26, 27], consistent preliminary data demon-
strated its safety both in term of ovarian reserve preservation Surgical sterilization is the most used method worldwide
and surgical complication [28, 29]; moreover, several authors [34] involving 8.1 % of the 15-to 49-year-old married women
have shown a significant reduction in OC risk among women in developed countries, and 22.3 % of women of reproduc-
with previous bilateral salpingectomy compared to tubal tive age in less-developed countries [35].
preservation [30, 31] or unilateral salpingectomy [31]. Surgical sterilization it is often achieved by resection (i.e.
Therefore, a 2011 position paper by the Society of during a Caesarean section) or laparoscopic coagulation of the
Gynaecologic Oncology of Canada [25] encouraged physi- isthmic portion of the FT. The remnant segment of the tran-
cians to discuss the risks and benefits of PBS at the time of sected tube, however, frequently exhibits histological modifi-
hysterectomy or tubal ligation with women at population cations that let unsuccessful the micro-reanastomotic
risk for OC and this recommendation has been confirmed in procedures [36]; the most successful contraception, moreover,
2015 by the American College of Obstetricians and is recognized to be obtained by total salpingectomy [37].
Gynaecologists [32]. For those of women(1–2 %) who revise the previous deci-
The advantage of PBS has been estimated also in term of sion for sterilization for any reason, it was demonstrated that
cost-effectiveness. A recent analysis on PBS (elective salpin- the best method to obtain a pregnancy would be IVF [38], so
gectomy at hysterectomy or instead of tubal ligation), that bilateral salpingectomy doesn’t have any disadvantages
12  Indications for Salpingectomy 153

Fig. 12.5  Old and new indication

for salpingectomy

device in IVF patients when salpingectomy or laparoscopy is

in this population of women, while tubal preservation with contraindicated. Eur J Obstet Gynecol Reprod Biol.
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alternative to the abdominal approach. Current methodolo- mal tubal occlusion for hydrosalpinx prior to in vitro fertilization: a
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