Efficacy and safety of sterilisation procedures to reduce the risk of epithelial ovarian cancer: a systematic review comparing salpingectomy with tubal ligation

Figures & data

Figure 1. PRISMA flow diagram. Results of the systematic literature search.

Table 1. Quality assessment of included studies.

Table 2. Endocrine functions comparing salpingectomy with tubal ligation, measured as AMH, menstrual irregularities and time to menopause-related physician visit/initiation of menopausal hormone therapy.

Author Year	Study design Surgical route	No. of patients S vs TL	Dropouts	Outcome	Salpingectomy	Tubal ligation	p-value
Ganer 2017 [17]	RCT	22 vs 24	12	Change in AMH from the third trimester to 6–8 weeks postpartum (ng/mL), mean (SD)	+0.58 (0.98)	+0.39 (0.41)	0.45
	CS
Duncan 2018 [20]	Cohort	11 vs 37	6	Menstrual irregularities 12–24 months after the procedure (frequency)	27.3%	27%	0.99
	CS
Hanley 2020 [31]	Cohort	4952 vs 18,621		Time to menopause-related physician visit (aHR, 95% CI)	0.92 (0.77–1.10)	1
	Laparotomy, laparoscopy, vaginal
				Time to initiation of menopausal hormone therapy (aHR, 95% CI)	1.00 (0.89–1.12)	1

Abbreviations. aHR, adjusted hazard ratio adjusted for years of surgery, age at the time of surgery, gynaecologic comorbidities and surgical approach, AMH, anti-Müllerian hormone; CI, confidence interval; CS, caesarean section; RCT, randomised controlled trial; S, salpingectomy; SD, standard deviation; TL, tubal ligation.

Table 3. Surgical complication rates comparing salpingectomy with tubal ligation. Outcomes related to perioperative haemorrhage are excluded from this table and reported in Table 4.

Author Year	Study design, surgical route	No. of patients S vs TL	Complications	Salpingectomy n (%)	Tubal ligation n (%)	p-Value
Ganer 2017 [17]	RCT,	22 vs 24	Intraoperative	0	0	1.0
	CS		Postoperative complications	0	1 (4.1)	1.0
Garcia 2018 [16]	RCT,	19 vs 18	Reoperation	0	0
	CS		Wound infection	1 (6)	1 (6)	0.99
			Readmission within 7 days	0	0
			Emergency visit within 7 d	2 (11)	1 (6)	0.99
Subramaniam 2018 [15]	RCT,	40 vs 40	Intraoperative complications	0	1 (3)	0.49
	CS		Post-op complications	3 (8)	2 (5)	>0.99
			Wound infection	1 (3)	0	>0.99
Duncan 2018 [20]	Cohort,	41 vs 119	Composite surgical outcomes^a	8 (19.5)	15 (12.6)	0.28
	CS		Internal Organ Injury	1 (2.4)	3 (2.5)	>0.99
			Bowel	1 (2.4)	2 (1.7)
			Bladder		1 (0.8)
			Endometritis	1 (2.4)	1 (0.8)	0. 90
			Readmission	1 (2.4)	4 (3.2)	0.8
Ferrari 2019 [21]	Cohort,	245 vs 239	Intraoperative complications	13 (5.3)	7 (2.9)
	CS		PPC not related			0.23
			Iatrogenic injury	2 (0.8)	1 (0.4)
			Postoperative complications	13 (5.3)	6 (2.5)
			Relaparotomy	4 (1.6)	1 (0.4)
			Infections	5 (2.1)	0
Lehn 2018 [23]	Cohort, CS	90 vs 32	Prolonged hospitalisation, >4 days	2 (2.7)	1 (3.1)	0.01
			SSI	2 (2.7)	2 (6.3)	0.51
			Hospital readmission	2 (2.7)	1 (3.1)	>0.99
Levy 2020 [24]	Cohort, CS	116 vs 247	Postoperative infections within 6 weeks	2 (1.7)	17 (6.9)	0.04
			Readmission	0	6 (2.4)	0.18
			Composite morbidity outcome^b	14 (12)	56 (23)	<0.001
Shinar 2017 [18]	Cohort,	50 vs 90	Adjacent organ damage	0	1 (1)	1.0
	CS		Postpartum fever >38°	0	0	1.0
			Wound infection	0	0	1.0
			Re-laparotomy	1 (2)	0	0.33
Danis 2016 [29]	Cohort,	16 vs 64	Postoperative ileus	0	2 (3.1)
	Laparotomy
Kim 2019 [25]	Cohort,	180 vs 274	Intraoperative complications
	Laparoscopy		Any	3 (1.7)	6 (2.2)	1
			Bowel injury	0	2 (0.7)	0.52
			Genitourinary tract injury	0	0
			Vascular injury	1 (0.6)	0	0.40
			Other	2 (1.1)	4 (1.5)	1
			Postoperative complications	2 (1.1)	7 (2.6)	0.49
Westberg 2017 [26]	Cohort, Laparoscopy	81 vs 68	Immediate	1 (1.2) (anaesthesia related laryngospasm)	1 (1.4) (anaesthesia related angioedema)
			Short-term	4 (4.9) (1 SSI, 3 emergency contacts for pain)	10 (14.7) (4 SSI, 6 emergency contacts for pain)	0.051

Abbreviations. CS, caesarean section; HC, historical controls; PPC, postpartum permanent contraception; RCT, randomised controlled trial; S, salpingectomy; SSI, surgical site infection; TL, tubal ligation.

^aComposite surgical outcome, need for transfusion, internal organ injury, endometritis, postpartum haemorrhage, and hospital readmission.

^bComposite morbidity outcome, positive if a subject possessed any of the following 6 outcomes: a postoperative haemoglobin level <7 g/dL; an estimated blood loss ≥1000 mL; symptomatic anaemia; hospitalised >4 days; required readmission within 30 days of discharge; or identified to have a postoperative infection.

Table 4. Surgical outcomes related to perioperative haemorrhage comparing salpingectomy with tubal ligation.

Author Year	Study design, surgical route	No. of patients	Complications	Salpingectomy	Tubal ligation	p-Value
		S vs TL
Ganer 2017 [17]	RCT, CS	22 vs 24	Postoperative Hgb decrease (g/dL)	0.85 (±1.01)	1.1 (±1.07)	0.39
Garcia 2018 [16]	RCT,	19 vs 18	EBL (mL)	600 [500–700]	700 [600–700]	0.09
	CS		Change in Hct (%)	5.3 (±2.7)	4.0 (±2.6)	0.14
			Transfusion	0	1 (6)	0.49
Subramaniam 2018 [15]	RCT,	40 vs 40	Total procedure EBL (mL)	1,007 (±426)	930 (±221)	0.56
	CS		Sterilisation procedure EBL (mL)	17 (±14)	6 (±4)	<0.001
				10 [5–25]	5 [5–10]
			Intraoperative complications	0	1 (3)	0.49
			Change in Hct (%)	7.2 (±5.9)	4.9 (±3.4)	0.12
				6.0 [3.9–8.7]	4.5 [2.9–7.2]
			Blood transfusion	2 (5)	3 (8)	>0.99
Duncan 2018 [20]	Cohort,	41 vs 119	Postpartum haemorrhage	5 (12.2)	17 (14.3)	0.97
	CS		Need for transfusion	5 (12)	10 (9)	0.54
Ferrari 2019 [21]	Cohort, CS	245 vs 239	Intraoperative complications	13 (5.3)	7 (2.9)
			PPC related
			Bleeding	1 (0.4)	2 (0.9)
			PPC not related			0.23
			Bleeding	10 (4.1)	4 (1.6)
			Postoperative complications	13 (5.3)	6 (2.5)
			Hgb decline > 3 g/dL	4 (1.6)	5 (2.1)	0.11
			EBL (mL)	920 [870–970]	910 [865–955]	0.34
			Blood transfusion	6 (2.8)	4 (1.72)	0.68
Ida 2016 [22]	Cohort,	22 vs 45	EBL (mL)	916 [450–2140]	847 [293–2965]	0.475
	CS
Lehn 2018 [23]	Cohort,	90 vs 32	EBL (mL)	700 [500–800]	600 [500–925]	0.16
	CS		EBL > 1000 mL	5 (6.8)	4 (12.5)	0.94
			Blood transfusion	1 (1.4)	2 (6.3)	0.21
Levy 2020 [24]	Cohort,	116 vs 247	EBL (mL)	800 [700–800]	800 [700–800]	0.89
	CS		Postoperative Hgb (g/dL)	9.9 [8.9–10.8]	9.9 [8.9–10.8]	0.99
			Symptoms of anaemia	1 (0.9)	14 (5.7)	0.04
Parikh 2019 [25]	Cohort,
	CS and	42 vs 48	Mean change in Hgb	−0.18 g/dL 95%CI (−0.52 to 0.15)		0.99
	Postpartum	26 vs 36	Mean change in Hgb	−0.04 g/dL 95%CI (−0.35 to 0.44)		0.99
Powell 2017 [19]	Cohort, CS, laparotomy, laparoscopy and unknown	1734 vs	EBL (mL), Caesarean delivery	660 [450–800]	700 [500–800]	0.24
		9007	EBL (mL), Postpartum	250 [250–400]	200 [15–300]	0.04
			EBL (mL), Not related to pregnancy	5 [5–10]	5 [5–10]	0.65
Shinar 2017 [18]	Cohort,	50 vs 90	Hgb decline (g/dL)	0.6 [0.25–1.35]	0.8 [0.3–1.2]	0.90
	CS		Bleeding volume > 1000 mL	0	2 (2)	0.32
			Blood transfusion	1 (2)	2 (2)	1.0
Danis 2016 [29]	Cohort,	16 vs 64	Excessive bleeding	0	1 (1)
	Laparotomy		Incisional site haematoma	0	1 (1)	0.71*
McAlpine 2014 [30]	Cohort,	1,569 vs	Blood transfusion	6 (0.4)	74 (0.5)	0.415
	Laparotomy, laparoscopy and vaginal	13,719	Blood transfusion, adjusted odds ratio, 95% CI, adjusted for age	0.77 (0.56–1.23)	1	0.36
Kim 2019 [25]	Cohort,	180 vs 274	EBL (mL)
	Laparoscopy		>50	3 (1.7)	2 (0.7)	0.45
			Blood transfusion	0	0	–
Zerden 2018 [27]	Cohort,	13 vs 5	EBL (mL)	5 [5–10]	7 [5–10]	0.18
	Laparoscopy	n(HC) = 22	EBL(HC)		10 [5–10]	0.31

Abbreviations. CS, caesarean section; EBL, estimated blood loss; Hgb, haemoglobin; HC, historical controls; Hct, haematocrit; PPC, postpartum permanent contraception; RCT, randomised controlled trial; S, salpingectomy; TL, tubal ligation.

Data are presented as n (%), mean (±SD), median [Q1–Q3] unless otherwise specified.

*The p-value refers to the difference in all reported complications together (excessive bleeding, postoperative ileus and incisional site haematoma) as reported by Danis et al.

Figure 2. Meta-analyses comparing the sterilisation procedures salpingectomy and tubal ligation for the outcomes duration of surgery and Length of hospital stay. (A) Duration of surgery (min) at caesarean section in randomised controlled trials. (B) Duration of surgery (min) at caesarean section in cohort studies. (C) Duration of surgery (min) at laparoscopy in cohort studies. (D) Length of hospital stay (days) following sterilisations at caesarean section.

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