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Background 

Opportunistic salpingectomy at the time of hysterectomy, i.e., removing presumed healthy fallopian tubes when removing the uterus, is suggested to reduce the risk of ovarian cancer. However, the impact of opportunistic salpingectomy on complications and ovarian function is insufficiently studied. Furthermore, the perspectives of women with no increased risk of ovarian cancer facing the choice to undergo opportunistic salpingectomy at hysterectomy have not been previously explored. There is consensus that surgical complications are important to register, both for quality control and research. Nevertheless, internationally there is no agreement on when, how, and even what to register, which reduces the comparability. This thesis aimed to compare complication rates and menopausal symptoms after opportunistic salpingectomy, as well as to explore women’s views on hysterectomy and salpingectomy before surgery. Furthermore, it aimed to validate complication registration after uterine and adnexal surgery in the Swedish National Quality Register of Gynecological Surgery (GynOp).

Methods

A retrospective cohort study with data from GynOp (Paper I), explored the uptake of opportunistic salpingectomy in Sweden 1998-2016. Hysterectomy with bilateral salpingectomy vs hysterectomy only, performed 2013-2016, was compared regarding complications and menopausal symptoms one year after surgery. Paper II is a qualitative study, with focus group discussions including women waiting for hysterectomy in different parts of Sweden. The participants’ experiences and perceptions of health, healthcare, and potential outcomes of hysterectomy with or without salpingectomy were explored. For Paper III, a cross-sectional study based on a survey sent to Swedish gynecologists was conducted. Fictional cases describing various postoperative courses were used to explore interrater reliability in assessing complications according to the methods in GynOp. Finally, a cohort study including surgeries of the uterus and/or adnexa with benign indications 2017-2020 was conducted. Complications registered in GynOp, the National Patient Register, Prescribed Drug Register, and Cause of Death Register were compared (Paper IV).

Results

The uptake of bilateral salpingectomy at the time of hysterectomy increased from 1.9% in 2012 to 37.8% in 2016. Comparing hysterectomy with bilateral salpingectomy vs hysterectomy only, salpingectomy was associated with an increased risk of menopausal symptoms one year after surgery (adjusted relative risk (aRR) 1.35, 95% confidence interval (CI) 1.07-1.71)). A slight increase in mean length of hospital stay (0.1 day, 95% CI 0.01-0.17) was seen, as well as an increased risk of minor complications in unadjusted analysis (relative risk (RR) 1.36, 95% CI 1.05-1.77). The latter was, however, not significant after adjusting for potential confounders (aRR 1.29, 95% CI 0.92-1.82) (Paper I). Women waiting for hysterectomy expressed that healthcare personnel held differing perspectives from the women, both regarding the surgery and the health problems being the cause of surgery. They also perceived a dependency on the advice and opinion of the physician for the choice of surgical procedure and possibly having opportunistic salpingectomy (Paper II). Swedish gynecologists demonstrated high interrater reliability in assessing whether a complication had occurred (agreement >80% in 85% of cases (17/20)), and in using the Clavien-Dindo classification, (agreement >90% in 80% of cases (16/20)) in our survey. Cases with lower agreement rates were bordering between minor complications and normal postoperative course (Paper III). From 2017 to 2020, 32,537 surgeries of the uterus and/or adnexa were registered in GynOp (Paper IV). Higher rates of complications from discharge to three months were found in GynOp compared with the Patient Register (13.7% vs 6.9%). The coverage of all complications was 79.1% in GynOp and 46.1% in the Patient Register when linking the two registers. Of the included individuals, 12.7% had a prescription of antibiotics ≤30 days after surgery, indicating a postoperative infection.

Conclusions

This thesis suggests that bilateral salpingectomy at the time of hysterectomy affects ovarian function and might increase the risk of minor complications, concerns which must be properly addressed in the consultation before surgery as well as in future research. Research on surgical interventions require reliable tools for evaluating complications. In finding a higher rate of complications captured in GynOp compared with the health registers, and a high interrater reliability among Swedish gynecologists, the registration of complications in GynOp are validated. However, continued work is required with definitions of what is normal in recovery after any specific surgery, for reliable capture of complications and to provide adequate information before surgery.  Shared decision-making based on high quality scientific evidence of risks and benefits is important in all interventions, especially in prophylactic surgery, e.g., opportunistic salpingectomy.