Ovarian Masses The now-routine application of ultrasound technology to gynecologic examinations led to the more frequent detection of ovarian cysts, sometimes as an incidental finding. Ultrasonography is a relatively easy diagnostic study to perform, but this ease led to the labeling of physiologic ovarian morphology and cystic follicles, as pathologic and the subsequent referral of patients for therapies, including surgery, without indications. Treatment of ovarian masses that are suspected to be functional tumors is expectant (Fig. 14.24). A number of randomized prospective studies showed no acceleration of the resolution of functional ovarian cysts (some of which were associated with the use of clomiphene citrate or human menopausal gonadotropins) with oral contraceptives compared with observation alone (200). Oral contraceptives are effective in reducing the risk of subsequent ovarian cysts and may be appropriate for women who desire both contraception and their noncontraceptive benefits.
Symptomatic cysts should be evaluated promptly, although mildly symptomatic masses suspected to be functional should be managed with analgesics rather than surgery to avoid the risk of surgical complications, including the development of adhesions that may impair subsequent fertility. Surgical intervention is warranted in the presence of severe pain or the suspicion of malignancy or torsion. On ultrasonography, large cysts and those that have multiloculations, solid components, septa, papillae, and increased blood ﬂow should be suspected of neoplasia (219) (Fig. 24.25). If a malignant mass is suspected at any age, surgical evaluation should be performed promptly.
Ovarian or adnexal torsion is suspected on the basis of peritoneal signs and the acuity of onset. Doppler ﬂow studies suggesting abnormal ﬂow are predictive of torsion, although torsion can be seen with normal ﬂow (223). The absence of internal ovarian ﬂow is not specific to torsion and may be seen with cystic lesions, although in these situations peripheral ﬂow usually can be visualized.
The management of suspected ovarian torsion, which can occur at any age from prepubertal to postmenopausal, is surgical. When torsion is confirmed by laparoscopy, untwisting of the mass and ovarian preservation rather than extirpation are generally indicated (224,225). The value of oophoropexy in preventing recurrent torsion is not well established.
Ultrasonographic or CT-directed aspiration procedures of ovarian masses should not be used in women in whom there is a suspicion of malignancy. In the past, laparoscopic surgery for ovarian masses was reserved for diagnostic or therapeutic purposes in patients at very low risk for malignancy. Although it is feasible to perform laparoscopic surgical staging and treatment of ovarian low-malignant-potential tumors and early-stage ovarian cancer safely, the role of laparoscopy versus laparotomy in a woman with ovarian cancer is debated (226). Concerns related to laparoscopy in managing gynecologic malignancy include the accuracy of intraoperative diagnosis, inadequate resection, significance of tumor spillage, inaccurate or delayed surgical staging, delay in therapy, and the possibility of port-site metastasis. In laparoscopic oophorectomy for presumed benign disease, there is a possibility of a missed diagnosis of malignancy, even with frozen section, which would necessitate reexploration. Whether laparoscopic management results in long-term compromise of outcome or significant benefits remains unclear and, consequently, so does the role of laparoscopic management of complex masses that may be malignant (227,228).
Figure 14.29 Laparoscopic appearance of benign ovarian mass (dermoid cyst).