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Opportunistic Adnexal Surgery

Opportunistic adnexal surgery — most commonly opportunistic salpingectomy (OS) — refers to removal of the fallopian tubes for primary prevention of tubo-ovarian carcinoma in women already undergoing pelvic or abdominal surgery for another indication.[1][2] The concept has rapidly become one of the most impactful preventive strategies in gynecologic oncology and is increasingly relevant to the urogynecologist who is operating in the pelvis for any reason.

Part I: Scientific rationale — the tubal hypothesis​

The foundation of opportunistic salpingectomy rests on a paradigm shift in understanding ovarian cancer pathogenesis:

Serous tubal intraepithelial carcinoma (STIC). Premalignant cells and early occult cancers have been detected in the fimbrial funnel region of the fallopian tube — but not on the ovarian surface — in risk-reducing salpingo-oophorectomy (RRSO) specimens from BRCA carriers.[3][4] STICs account for 38–62% of all high-grade serous adenocarcinomas and may be missed on routine pathological examination.[4] These findings challenged the traditional view that high-grade serous ovarian cancer (HGSOC) — the most common and lethal subtype — originates from the ovarian surface epithelium.

Key pathologic precursors distributed along the tube:[1]

  • Serous tubal intraepithelial lesions (STILs) and tubal intraepithelial lesions in transition — most frequently located in the fimbriated end.
  • Secretory cell outgrowths (SCOUTs) — distributed throughout the tube, supporting complete salpingectomy over fimbriectomy alone.

Part II: Magnitude of cancer-risk reduction​

The European Society of Gynaecological Oncology (ESGO) consensus published in JAMA (2026) synthesized the evidence:[6]

  • A 2025 meta-analysis (Tang et al.) of 1 cohort study and 4 case-control studies — bilateral salpingectomy associated with a 52% reduction in tubo-ovarian carcinoma risk (OR 0.48; 95% CI 0.33–0.69; p<0.001).[6]
  • Swedish population-based cohort (Falconer et al.) — 65% risk reduction (HR 0.35; 95% CI 0.17–0.73) after bilateral salpingectomy vs. unexposed women.[6][1]
  • Danish nationwide case-control (Madsen et al.) — 42% risk reduction (OR 0.58; 95% CI 0.36–0.95).[6]
  • Large Danish cohort (Duus et al., 2023; 16,822 EOC cases) — risk reduction after both unilateral (OR 0.73; 95% CI 0.60–0.87) and bilateral salpingectomy (OR 0.46; 95% CI 0.31–0.67), with the protective effect increasing with time since surgery and present across most histological subtypes.[7]
  • Kahn et al. systematic review (2023; 158 studies) — bilateral salpingectomy could reduce tubo-ovarian carcinoma risk by up to 80% and lower ovarian-cancer mortality in the US by 15% if broadly implemented.[5]
Bottom line

Multiple observational studies and meta-analyses show consistent association between opportunistic salpingectomy and lower tubo-ovarian carcinoma incidence, with risk reductions ranging from 42% to 80%.

Part III: Guideline recommendations​

SocietyYearKey recommendation
ACOG (Committee Opinion No. 774)2019Discuss potential benefits of fallopian tube removal during hysterectomy in women at population risk; salpingectomy should not alter intended route of hysterectomy; also feasible at cesarean delivery and as alternative to tubal ligation
ESGO (consensus statements)2026OS should be considered for all eligible women undergoing gynecological surgery and, when possible, non-gynecological pelvic or selected abdominal surgeries
NCCN (Genetic / Familial High-Risk Assessment)2026Salpingectomy is an option for average / uncertain-risk patients desiring surgical sterilization; for BRCA carriers, salpingectomy with delayed oophorectomy is an option (ideally within clinical trials)
FIGO2024Firmly supports use of salpingectomy opportunistically for ovarian-cancer risk reduction
German AGO / NOGGO / AGO Austria / AGO Swiss2025Patients should be informed of benefits; Austrian AGO recommends broad use without reservation
[1][2][6][8][3]

Part IV: Surgical technique​

Complete salpingectomy principles (ACOG)[1]​

  1. Remove the tube completely from its fimbriated end up to the uterotubal junction (cornua).
  2. The interstitial portions of the tubes do not need to be removed.
  3. Any fimbrial attachments on the ovary should be cauterized or removed.
  4. Complete salpingectomy is preferred over fimbriectomy because precursors can be found throughout the tube.
  5. If complete salpingectomy cannot be performed, removing as much tube as possible (excluding the interstitial portion) still has value.

RRSO protocol — for high-risk patients (NCCN)[9]​

  • Perform minimally invasive laparoscopic surgery.
  • Survey upper abdomen, bowel surfaces, omentum, appendix, and pelvic organs.
  • Biopsy any abnormal peritoneal findings.
  • Obtain pelvic washing for cytology (50 cc normal saline).
  • Remove 2 cm of proximal ovarian vasculature / IP ligament, all tube up to the cornua, and all peritoneum surrounding the ovaries and tubes.
  • Minimal instrument handling to avoid traumatic exfoliation of cells.
  • Retrieve specimens in an endobag.
  • Process by SEE-FIM protocol (Sectioning and Extensively Examining the Fimbriated End).

SEE-FIM protocol​

The fimbriated end is amputated and sectioned longitudinally, while the remainder of the tube is sectioned at 2–3 mm intervals. SEE-FIM detects 25% more STICs than a single H&E section.[10] However, only 74% of laboratories perform SEE-FIM for risk-reducing specimens (83% academic vs. 66% non-academic), and only 41% of obstetrician-gynecologists follow this protocol vs. 91% of gynecologic oncologists.[4][11]

Surgical completeness​

The QOS study (Maryns et al., 2026) prospectively examined 201 adnexa from 115 patients and found OS was surgically complete in ~88% of patients — residual microscopic fimbrial tissue identified in 7.4% of adnexa (12.2% of patients). No STIC lesions were detected in residual tissue. Clinical impact of remnant fimbrial tissue on cancer-risk reduction remains uncertain.[12]

Part V: Safety and perioperative outcomes​

A. At hysterectomy​

ACOG states that salpingectomy at the time of hysterectomy does not increase the risk of complications — blood transfusions, readmissions, postoperative complications, infections, or fever — compared with hysterectomy alone.[1][2] An RCT (Song et al., n = 68) found no significant differences in operative time, blood loss, or complications between hysterectomy with vs. without OS.[6]

B. At cesarean delivery​

  • An RCT (Subramaniam et al., n = 80) found OS added a mean of 15 minutes vs. tubal ligation during cesarean delivery, with no adverse outcomes related to the sterilization procedure.[6]
  • Large Canadian population-based study (Rufin et al., 2024; n = 18,184) — decreased perioperative complications with OS vs. tubal ligation (aOR 0.77; 95% CI 0.61–0.99); no difference in postoperative complications or readmissions. Slightly increased odds of filling NSAID (aOR 1.18) and opioid (aOR 1.23) prescriptions.[13]
  • US national study (Mandelbaum et al., 2021; n = 3.8 million cesarean deliveries) — by 2018, 13.2% of cesarean deliveries included bilateral salpingectomy (up from 4.6% in 2015), surpassing tubal ligation. In propensity-matched analysis, the salpingectomy group had slightly higher rates of hemorrhage (3.8% vs. 3.1%) and hysterectomy (0.8% vs. 0.4%).[14]

C. At non-gynecologic surgery​

The ESGO consensus (2026) reports perioperative-safety findings consistent for both gynecological and non-gynecological procedures, including laparoscopic and open approaches. A vaginal approach may increase risk of complications vs. abdominal approaches.[6]

Part VI: Impact on ovarian function​

A critical question because the fallopian tubes derive blood supply from branches of the uterine and ovarian arteries.

Short-term ovarian reserve — reassuring:

  • Systematic review and meta-analysis (Gelderblom et al., 2022; 15 studies) — no significant reduction in AMH (MD −0.07 ng/mL; 95% CI −0.18 to 0.05), AFC, E2, FSH, or LH after OS.[15]
  • Pooled analysis (Mohamed et al., 2017) — no significant AMH reduction (weighted mean difference −0.10 ng/mL; 95% CI −0.19 to 0.00; I² = 0%).[6]
  • Multiple RCTs (Asgari et al., Findley et al.) confirmed no significant difference in AMH or FSH 3 months postoperatively.[6]

Long-term menopause outcomes — mixed:

  • British Columbia cohort (Hanley et al., 2020; n = 41,413) — no difference in time to physician visits for menopause (aHR 0.98; 95% CI 0.88–1.09) or time to filling HRT prescriptions after OS at hysterectomy, including age-stratified analyses with ≥5 years of follow-up.[16]
  • Swedish registry study (Collins et al.) — 33% increased risk of menopausal symptoms 1 year after hysterectomy with OS vs. hysterectomy alone (RR 1.33; 95% CI 1.04–1.69).[6]

The ESGO consensus concludes that OS does not impair short-term ovarian function and does not appear to affect age at menopause, but long-term data remain limited and a possible impact cannot be fully excluded. Premenopausal women should be counseled accordingly.[6]

Rapid adoption in the US​

Mandelbaum et al. (2020), National Inpatient Sample 2001–2015 — OS at benign hysterectomy increased from 2.4% in 2001 to 58.4% by 2015 — a 10.2-fold increase after the 2010 publication of the tubal hypothesis (aOR 5.42; 95% CI 5.34–5.51).[17]

The magnitude of missed opportunity​

Moufarrij et al. (2025), JAMA Surg:[18]

  • Among 1,877 patients with HGSOC, 23.7% (445) had missed opportunities for salpingectomy — 54.2% had prior tubal ligation / hysterectomy without salpingectomy, and 45.8% had other abdominopelvic surgeries.
  • A 43.2% missed-opportunity rate for germline genetic testing and reflex risk-reducing surgery was also identified among patients with an affected first-degree relative.

Tischer et al. (2025) — nearly 60% of patients with HGSOC had ≥1 prior abdominal or pelvic surgery where OS could have been performed, often decades before diagnosis (median 30 years). Most common prior gynecologic procedure was tubal ligation (33%); most common general-surgery procedure was cholecystectomy (53.4%).[19]

Part VIII: Expanding beyond gynecologic surgery​

A frontier area is incorporation of OS into non-gynecologic abdominopelvic procedures:

  • Cholecystectomy — Matsuo et al. (2023) cost-effectiveness analysis: OS at laparoscopic cholecystectomy was cost-effective (ICER $11,162–$26,463 / QALY), preventing 30–39 ovarian-cancer cases per 5,000 women depending on age.[20] Wright et al. (2025) estimated that if OS were performed in 80% of cholecystectomies in women ≥40, 279 lifetime ovarian-cancer cases could be prevented per annual cohort.[21]
  • Broader implementation — Adjei et al. (2025) cost-effectiveness analysis of OS during 6 common abdominopelvic procedures (hysterectomy, appendectomy, cholecystectomy, gastric bypass, hernia repair, colectomy): OS was incrementally cost-saving ($2,176 per procedure) with more QALYs gained, yielding $18.78 million in healthcare savings for a single annual cohort.[22]
  • Kather et al. (2025) modeled OS at any suitable abdominal surgery in Germany — could reduce ovarian-cancer cases by 15.3% (vs. 5.5% with OS only at hysterectomy / sterilization), with an ICER of −€8,686 / QALY (cost-saving).[23]

Part IX: Salpingectomy vs. oophorectomy — key distinctions​

A critical distinction must be made between salpingectomy (tube removal only) and oophorectomy (ovary removal):

FeatureOpportunistic salpingectomyBilateral salpingo-oophorectomy (BSO)
Target populationAverage-risk women undergoing pelvic / abdominal surgeryHigh-risk women (BRCA1/2 carriers) or specific indications
Ovarian-cancer risk reduction42–80% (primarily HGSOC)>90% (all subtypes)
Effect on ovarian functionPreserved (no surgical menopause)Induces surgical menopause
Cardiovascular riskNo increaseIncreased (especially if premenopausal without HRT)
Bone healthNo impactIncreased osteoporosis risk
Cognitive effectsNonePotential cognitive impairment
Breast-cancer riskNo reductionReduced (magnitude uncertain, may be gene-specific)
HRT requirementNot neededRecommended for premenopausal women
Residual cancer riskOvarian stromal / germ-cell tumors; peritoneal carcinomaResidual peritoneal carcinoma risk
[1][2][5][6][24]

Adelman and Sharp (2018) emphasized that at no age does there appear to be a survival benefit associated with oophorectomy at benign hysterectomy, and that ovarian-cancer risk reduction may be accomplished with salpingectomy alone while avoiding the deleterious effects of surgical menopause on cardiovascular health, mortality, cognition, and sexual function.[24]

Part X: Salpingectomy with delayed oophorectomy (high-risk patients)​

For BRCA1/2 carriers not yet ready for oophorectomy, NCCN recognizes salpingectomy as an option with planned completion oophorectomy per gene-specific guidelines:[8][9]

  • BRCA1 — recommend RRSO between ages 35–40.
  • BRCA2 — reasonable to delay RRSO until ages 40–45.
  • If salpingectomy is performed first, completion oophorectomy is recommended per gene-specific timelines.
  • SEE-FIM protocol and pelvic washings should be performed at salpingectomy.
  • Clinical trials of interval salpingectomy and delayed oophorectomy are ongoing — strong consideration of study participation is recommended.
  • Consider continuation of combination OCP or hormonal IUD for continued ovarian-cancer risk reduction while ovaries remain in place.

NCCN explicitly notes that the prevention benefits of salpingectomy alone are not yet proven in high-risk patients, and patients remain at risk for developing ovarian cancer after salpingectomy without oophorectomy.[9]

Part XI: Management of incidental adnexal masses​

When an adnexal mass is encountered during surgery, ACOG Practice Bulletin No. 174 provides guidance:[25]

  • Observation is recommended when ultrasonographic morphology suggests benign disease — simple cysts up to 10 cm may be safely monitored even in postmenopausal patients.
  • Minimally invasive surgery is preferred for presumed benign masses.
  • Ovarian preservation should be prioritized in premenopausal women who have not completed childbearing.
  • Aspiration of cyst fluid is generally contraindicated when malignancy is suspected (sensitivity only 50–74%; risk of peritoneal seeding).
  • Adnexal torsion — conservation should be prioritized; ovarian function is preserved in >90% of cases 3 months after detorsion, even with evidence of necrosis at exploration.[25]

The IOTA5 study (Froyman et al., 2019; n = 3,512 conservatively managed ovarian tumors) demonstrated that conservative management of presumed benign adnexal masses is safe, with the most common indication for eventual surgery being patient request, fertility concerns, or opportunistic / prophylactic removal — rather than malignant transformation.[26]

ACOG recommends that counseling for women undergoing routine pelvic surgery include:[1]

  1. The potential benefits of fallopian-tube removal for ovarian-cancer risk reduction.
  2. That OS significantly decreases but does not eliminate ovarian-cancer risk entirely.
  3. An informed-consent discussion about the role of oophorectomy and BSO — including that BSO causes surgical menopause and may increase risks of cardiovascular disease, other cancers, osteoporosis, cognitive impairment, and all-cause mortality.
  4. That ovarian function does not appear to be affected by salpingectomy based on surrogate serum markers.
  5. That plans for OS should not alter the intended route of hysterectomy.
  6. For patients desiring permanent sterilization, the risks and benefits of salpingectomy vs. tubal ligation.

The ESGO adds that age alone should not be used to withhold OS, although data are insufficient to determine which age group benefits most.[6]

Summary — key principles​

  1. Rationale — most HGSOC originates in the fimbriated end of the fallopian tube (STIC lesions), not the ovarian surface.[3][4]
  2. Risk reduction — bilateral salpingectomy reduces tubo-ovarian carcinoma risk by 42–80% across multiple meta-analyses.[6]
  3. Safety — OS adds minimal operative time, does not increase perioperative complications, and does not impair short-term ovarian reserve.[1][6][15]
  4. Indications — all eligible women undergoing gynecologic surgery; expanding to non-gynecologic abdominopelvic procedures.[6][20][22]
  5. Technique — complete removal from fimbria to uterotubal junction; SEE-FIM pathologic processing recommended.[1][9]
  6. Missed opportunities — ~24% of HGSOC patients had prior surgeries where OS could have been performed; ~60% had ≥1 prior abdominopelvic surgery.[18][19]
  7. Salpingectomy ≠ oophorectomy — OS preserves ovarian function and avoids surgical menopause, fundamentally different from BSO.[1][24]
  8. High-risk patients — salpingectomy with delayed oophorectomy is an option for BRCA carriers not yet ready for RRSO, ideally within clinical trials.[8][9]
  9. Cost-effectiveness — OS is cost-saving across multiple surgical contexts, with potential to save hundreds of millions in healthcare costs annually.[22][23][27]

Cross-references​

References​

1. Chohan L, Richardson DL. Opportunistic Salpingectomy as a Strategy for Epithelial Ovarian Cancer Prevention. American College of Obstetricians and Gynecologists; 2019.

2. American College of Obstetricians and Gynecologists. "ACOG Committee Opinion No. 774: opportunistic salpingectomy as a strategy for epithelial ovarian cancer prevention." Obstet Gynecol. 2019;133(4):e279–e284. doi:10.1097/AOG.0000000000003164

3. Pölcher M, Wimberger P, Meinhold-Heerlein I, et al. "Intergroup statement: opportunistic salpingectomy — molecular pathology, clinical outcomes and implications for practice (German Ovarian Cancer Commission, NOGGO, AGO Austria, AGO Swiss)." Arch Gynecol Obstet. 2025;311(5):1451–1459. doi:10.1007/s00404-025-07974-z

4. Sisodia RC, Del Carmen MG. "Lesions of the ovary and fallopian tube." N Engl J Med. 2022;387(8):727–736. doi:10.1056/NEJMra2108956

5. Kahn RM, Gordhandas S, Godwin K, et al. "Salpingectomy for the primary prevention of ovarian cancer: a systematic review." JAMA Surg. 2023;158(11):1204–1211. doi:10.1001/jamasurg.2023.4164

6. Piek JM, Schauwaert J, Ellis LB, et al. "Opportunistic salpingectomy for prevention of tubo-ovarian carcinoma." JAMA. 2026. doi:10.1001/jama.2025.24510

7. Duus AH, Zheng G, Baandrup L, Faber MT, Kjær SK. "Risk of ovarian cancer after salpingectomy and tubal ligation: prospects on histology and time since the procedure." Gynecol Oncol. 2023;177:125–131. doi:10.1016/j.ygyno.2023.08.016

8. National Comprehensive Cancer Network. Genetic / Familial High-Risk Assessment: Breast, Ovarian, Pancreatic, and Prostate. Updated 2026-02-19.

9. National Comprehensive Cancer Network. Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Cancer. Updated 2026-04-10.

10. Eleje GU, Eke AC, Ezebialu IU, et al. "Risk-reducing bilateral salpingo-oophorectomy in women with BRCA1 or BRCA2 mutations." Cochrane Database Syst Rev. 2018;8:CD012464. doi:10.1002/14651858.CD012464.pub2

11. Samimi G, Trabert B, Duggan MA, et al. "Processing of fallopian tube, ovary, and endometrial surgical pathology specimens: a survey of US laboratory practices." Gynecol Oncol. 2018;148(3):515–520. doi:10.1016/j.ygyno.2018.01.016

12. Maryns AS, Hamerlynck T, van Overberghe C, et al. "Opportunistic salpingectomy: is surgical completeness achieved? Insights from the QOS study." Eur J Obstet Gynecol Reprod Biol. 2026;321:115066. doi:10.1016/j.ejogrb.2026.115066

13. Rufin KGA, do Valle HA, McAlpine JN, Elwood C, Hanley GE. "Complications after opportunistic salpingectomy compared with tubal ligation at cesarean section: a retrospective cohort study." Fertil Steril. 2024;121(3):531–539. doi:10.1016/j.fertnstert.2023.11.031

14. Mandelbaum RS, Matsuzaki S, Sangara RN, et al. "Paradigm shift from tubal ligation to opportunistic salpingectomy at cesarean delivery in the United States." Am J Obstet Gynecol. 2021;225(4):399.e1–399.e32. doi:10.1016/j.ajog.2021.06.074

15. Gelderblom ME, IntHout J, Dagovic L, et al. "The effect of opportunistic salpingectomy for primary prevention of ovarian cancer on ovarian reserve: a systematic review and meta-analysis." Maturitas. 2022;166:21–34. doi:10.1016/j.maturitas.2022.08.002

16. Hanley GE, Kwon JS, McAlpine JN, et al. "Examining indicators of early menopause following opportunistic salpingectomy: a cohort study from British Columbia, Canada." Am J Obstet Gynecol. 2020;223(2):221.e1–221.e11. doi:10.1016/j.ajog.2020.02.005

17. Mandelbaum RS, Adams CL, Yoshihara K, et al. "The rapid adoption of opportunistic salpingectomy at the time of hysterectomy for benign gynecologic disease in the United States." Am J Obstet Gynecol. 2020;223(5):721.e1–721.e18. doi:10.1016/j.ajog.2020.04.028

18. Moufarrij S, Hazimeh D, Rockwell T, et al. "Gauging the magnitude of missed opportunity for ovarian cancer prevention." JAMA Surg. 2025. doi:10.1001/jamasurg.2025.2810

19. Tischer KM, Islam NS, McGree ME, et al. "Quantifying opportunities to reduce high-grade serous ovarian cancer via opportunistic salpingectomy." Gynecol Oncol. 2025;203:165–170. doi:10.1016/j.ygyno.2025.10.028

20. Matsuo K, Chen L, Matsuzaki S, et al. "Opportunistic salpingectomy at the time of laparoscopic cholecystectomy for ovarian cancer prevention: a cost-effectiveness analysis." Ann Surg. 2023;277(5):e1116–e1123. doi:10.1097/SLA.0000000000005374

21. Wright JD, Chen L, Tymm C, et al. "Population-level reduction in ovarian cancer through performance of opportunistic salpingectomy at the time of cholecystectomy." Ann Surg. 2025. doi:10.1097/SLA.0000000000006940

22. Adjei NN, Yeh PG, Haas A, et al. "Opportunistic salpingectomy during gynecologic and non-gynecologic abdominopelvic procedures for ovarian cancer primary prevention: a cost-effectiveness analysis." Int J Gynecol Cancer. 2025:102884. doi:10.1016/j.ijgc.2025.102884

23. Kather A, Arefian H, Schneider C, Hartmann M, Runnebaum IB. "Ovarian cancer prevention through opportunistic salpingectomy during abdominal surgeries: a cost-effectiveness modeling study." PLoS Med. 2025;22(1):e1004514. doi:10.1371/journal.pmed.1004514

24. Adelman MR, Sharp HT. "Ovarian conservation vs removal at the time of benign hysterectomy." Am J Obstet Gynecol. 2018;218(3):269–279. doi:10.1016/j.ajog.2017.07.037

25. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology. "Practice Bulletin No. 174: evaluation and management of adnexal masses." Obstet Gynecol. 2016;128(5):e210–e226. doi:10.1097/AOG.0000000000001768

26. Froyman W, Landolfo C, De Cock B, et al. "Risk of complications in patients with conservatively managed ovarian tumours (IOTA5): a 2-year interim analysis of a multicentre, prospective, cohort study." Lancet Oncol. 2019;20(3):448–458. doi:10.1016/S1470-2045(18)30837-4

27. Naumann RW, Hughes BN, Brown J, Drury LK, Herzog TJ. "The impact of opportunistic salpingectomy on ovarian cancer mortality and healthcare costs: a call for universal insurance coverage." Am J Obstet Gynecol. 2021;225(4):397.e1–397.e6. doi:10.1016/j.ajog.2021.03.032