Table of Contents
- Procedure Summary
- Authors
- Youtube Video
- What is Ovarian Transposition Prior to Pelvic Radiation Therapy: Indications & Techniques?
- What are the Risks of Ovarian Transposition Prior to Pelvic Radiation Therapy: Indications & Techniques?
- Video Transcript
Video Description
Oocytes are sensitive to radiation injury. Loss of ovarian function in reproductive aged women is associated with adverse sequelae. Ovarian transposition is a surgical procedure performed to protect oocytes from radiation injury in patients undergoing pelvic or low-abdominal radiation therapy for cancer treatment. This video highlights the various indications for ovarian transposition, demonstrates surgical techniques, and outlines the surgical steps to complete the procedure through a case presentation of a patient with cervical cancer. Potential postoperative complications and success rates are also reviewed. The video serves as a training tool to provide instructions to those interested in offering and performing the surgical procedure.
Presented By
Affiliations
Memorial University of Newfoundland
Watch on YouTube
Click here to watch this video on YouTube.
What is Ovarian Transposition Prior to Pelvic Radiation Therapy: Indications & Techniques?
Ovarian transposition before pelvic radiation therapy is a surgical procedure aimed at preserving ovarian function and fertility in patients undergoing radiation for pelvic cancers. Here’s an overview:
-
Purpose: Radiation therapy to the pelvis can damage the ovaries, leading to premature ovarian failure and infertility. Ovarian transposition (oophoropexy) moves the ovaries outside the radiation field to protect them from radiation exposure, allowing them to continue functioning.
-
Indications: This procedure is typically recommended for younger patients with pelvic cancers, such as cervical, rectal, or anal cancer, who wish to preserve their fertility or prevent early menopause. It is most beneficial when radiation is targeted to the pelvis without affecting areas to which the ovaries are moved.
-
Techniques: The ovaries are surgically repositioned, often to the lateral abdomen or above the pelvic brim, either laparoscopically or through open surgery. Clips may be placed on the ovaries to help radiation oncologists monitor their position during treatment. Surgeons aim to preserve blood flow to the ovaries to maintain hormonal function and minimize complications.
-
Considerations: The decision to proceed with ovarian transposition involves evaluating the type and intensity of radiation, patient age, and reproductive goals. In some cases, additional fertility-preserving methods, such as egg or embryo freezing, may be considered alongside transposition.
This approach can be an effective way to safeguard reproductive health and prevent early menopause in patients undergoing pelvic radiation.
What are the Risks of Ovarian Transposition Prior to Pelvic Radiation Therapy: Indications & Techniques?
Ovarian transposition prior to pelvic radiation therapy is a procedure to move the ovaries away from the radiation field, preserving fertility and hormone function. However, it comes with specific risks:
-
Ovarian Failure: Despite transposition, ovaries may still receive some radiation exposure, particularly if they remain within the scatter field, which can impair ovarian function and lead to early ovarian failure.
-
Surgical Risks: As with any surgical procedure, ovarian transposition carries risks like infection, bleeding, and damage to surrounding structures, including blood vessels and nerves in the pelvic area.
-
Risk of Adhesion Formation: The repositioning of the ovaries can lead to adhesions (scar tissue) that may cause chronic pelvic pain, discomfort, or complications in future surgeries.
-
Menstrual Irregularities: Ovarian transposition can sometimes disrupt normal blood supply or nerve connections, leading to irregular menstrual cycles or altered ovarian function.
-
Ectopic Pregnancy: If the patient becomes pregnant after transposition, there’s a small risk of ectopic pregnancy, especially if the ovaries are placed away from their usual anatomical position, making egg travel more difficult.
While ovarian transposition can be effective for fertility preservation, these risks highlight the importance of a tailored approach and thorough preoperative counseling.
Video Transcript: Ovarian Transposition Prior to Pelvic Radiation Therapy: Indications & Techniques
Ovarian transposition prior to pelvic radiation therapy. Indications and techniques. In patients undergoing pelvic radiation oocytes are sensitive to radiation injury. Radiation doses between ten and 20 gray will cause permanent loss of ovarian function, depending on the age of the patient, which will lead to premature menopause and the associated adverse sequelae.
Ovarian transposition is a surgical procedure which relocates the ovaries out of the intended radiation field to prevent early menopause and to preserve hormonal and reproductive function.
Common malignancies, which are treated with pelvic radiation, include gynaecological malignancies such as cervical, vaginal, and uterine cancers. And also non gynaecological malignancies such as colorectal cancers and Hodgkin’s lymphoma.
Ovarian transposition can be performed electively or at the time of the therapeutic oncological surgery. Laparoscopy is the preferred elective method, given the benefits of minimally invasive surgery, including shorter hospital stays, fewer post-operative complications, and earlier initiation of radiation therapy.
Various transposition sites have been described, including anterior or lateral to the psoas muscle above the pelvic brim, the paracolic gutters, and within the pelvis in a lateral position.
The presented case is a 31-year-old female who was diagnosed with a stage IIIC1(r) adenocarcinoma of the cervix. A plan was made for concurrent chemoradiotherapy. The patient had completed childbearing. She was counselled regarding bilateral ovarian transposition and opportunistic bilateral salpingectomy prior to initiating treatment.
Entry into the abdominal cavity was achieved with a Veress needle and laparoscopic ports were placed. And infraumbilical, a suprapubic and bilateral lower quadrant ports were placed to facilitate laparoscopic suturing of the ovaries above the pelvic brim.
We performed a survey of the pelvic anatomy paying close attention to any signs of metastatic disease. Ureters were identified. Lymph node staging can be carried out at this point, if necessary, for complete disease staging.
An opportunistic bilateral salpingectomy was completed in the usual fashion to reduce the risk of ovarian carcinoma. With the fallopian tubes removed the utero-ovarian ligament was isolated, coagulated and transected, separating the ovary from the uterus. The posterior leaf of the broad ligament is grasped and incised, with care taken to keep the vascular infundibulopelvic pedicle intact.
Here, you can clearly visualise the ureter. An incision was made in the peritoneum at the site of the intended destination of the ovary above the pelvic brim, and lateral on the abdominal side wall, close to the hepatic and splenic flexures. Contemporary minimally invasive procedures favour transposition of the ovaries at least 1.5 to 2 cm above the pelvic brim in a lateral position.
Next, the ovary is grasped and mobilised cephalad to ensure that it can be relocated without tension. The retroperitoneal space was entered and the peritoneum was dissected cephalad.
A tunnel was developed under the peritoneum from the initial retroperitoneal space dissection to the superior peritoneal incision. An electrosurgical instrument was used to ensure that there was no retroperitoneal bleeding.
The ovary was gently grasped and brought through the tunnelled peritoneum to its new location. Retroperitoneal tunnelling of the ovary can help to prevent vascular torsion and decrease the risk of migration of the ovary back into the radiation field. The ovary is then secured to the abdominal side wall using a non-absorbable suture. Several knots were tied to maintain the ovary in its position.
Radiopaque surgical clips were then applied at the level of the suture knot, to later confirm the location of the transposed ovaries radiologically, and to help with radiation planning. Here you can see the ovaries in their new location. The surgical field was then assessed, and haemostasis was confirmed, ending the procedure.
Potential postoperative complications, specifically relevant to ovarian transposition, include risk of injury and or torsion of the ovarian blood supply, risk of symptomatic ovarian cyst, and although it’s rare, metastases to the transposed ovaries.
Data suggests that success rates of ovarian preservation are as high as 90% in patients who undergo ovarian transposition followed by brachytherapy and approximately 60% in those who are treated with external beam radiation. Data regarding fertility preservation is limited with one small study quoting an overall pregnancy rate of 32%.
With contemporary treatment advances, including intensity modulated radiation therapy, and volumetric modulated arc radiation therapy, damage to ovaries may be further reduced.
Minimally invasive ovarian transposition has been shown to be successful and safe with lower complication rates and shorter interval to initiation of radiation therapy. Ovarian transposition provides a feasible option for both hormonal and fertility preservation in patients undergoing pelvic radiation therapy and should be discussed as a part of cancer care.