Patient selection key to laparoscopic management of the adnexal mass.(THE MASTER CLASS)

Carefully selected patients with adnexal masses may benefit greatly from undergoing laparoscopic surgery as opposed to laparotomy. Recovery is shorter and less painful; most patients are discharged the same day and return to work within a week to 10 days.

Nonetheless, the laparoscopic approach in postmenopausal women was quite controversial when we began to make the case for it, first in a pilot study in 1990 (Am. J. Obstet. Gynecol. 1990;163:1574-7) and then in a 1994 paper presenting our experience with 61 patients (J. Am. Coll. Surg. 1994;179:733-7). I am pleased to note that in the ensuing years, the laparoscopic management of adnexal masses in appropriate patients has won over most critics.

The controversy in those early years centered around the argument that it was too difficult to determine which patients were at low risk for ovarian malignancy and thus would be considered "appropriate" candidates for laparoscopy. Minimally invasive surgery was thought to potentially expose patients with cancer to the risk of intraoperative rupture of a malignant mass, with the resultant seeding of the tumor into the peritoneal cavity.

Using careful patient selection and appropriate intraoperative evaluation and management, however, not a single postmenopausal patient whom we chose for laparoscopic treatment--using the selection criteria we defined--was diagnosed with ovarian cancer at the time of surgery.

Fortunately, the selection criteria that are used to distinguish patients with a low risk of malignancy have proved to be remarkably accurate when they are used and correctly applied.

All patients should undergo a thorough clinical examination, transvaginal ultrasound, and--in postmenopausal patients only--cancer antigen 125 (CA 125) testing. In premenopausal patients, CA 125 findings are nonspecific, and the test has a high false-positive rate.

Adnexal masses that are fixed, irregular, or solid are suspicious for malignancy. The presence of ascites or an upper abdominal mass should be considered indicative of cancer until proved otherwise. On ultrasound, suspicious findings include a mass with irregular borders, papillations, solid areas, thick septa, ascites, or matted bowel. A CA 125 value greater than 35 U/mL in a post-menopausal patient is not conclusive, but adds to my reluctance to perform laparoscopic surgery.