Incidental Tubal Pathology Post Pelvic Prolapse Surgery: Review & Case Report

Objectives: A recent literature review examining the pathology specimens from prolapse surgeries reported a rate of incidental gynecologic malignancies and pre-malignancies between 0.22 to 1.3%. Few studies specifically report the incidence of fallopian tube findings, such as serous tubal intraepithelial lesion (STIL) and carcinoma (STIC), the latter of which presents a 10.5% five-year risk of developing high grade serous ovarian cancer. This study’s objectives were to 1) conduct a narrative review the limited existing research on incidental tubal pathology, and 2) report two new cases of incidental tubal pathology within the same year by a single surgeon to critically evaluate and understand lesion identification and post-surgical treatment of pelvic organ prolapse (POP) surgery treatment.

Methods: We performed a narrative review of the literature indexed in PubMed between January 2000 to October 2023 on incidental tubal pathology—including STIC and high-grade serous carcinoma—found incidentally during total hysterectomy in case studies published between January 2000 and December 2023. We also report two new cases of isolated, asymptomatic, incidental tubal pathology found after total hysterectomy for POP and how these cases were treated.

Results: Literature search yielded 588 results, with 12 articles reviewed and 4 included in the analysis (total of 4 cases) (Figure 1). Only one case report was in a patient undergoing an elective surgery for POP (Table 2).
Our case report details two instances of incidental tubal pathology after POP surgery 2023. Patient 1 is a 74-year-old woman with a history of tubal ligation, uterine fibroids, and POP who underwent a laparoscopically assisted vaginal hysterectomy (LAVH) bilateral salpingectomy with sacrocolpopexy in January 2023. Her left tube had two lesions: a STIC with increased Ki-67 expression and loss of p53, and a STIL with low Ki-67 proliferation and p53 overexpression. After consultation with gynecologic oncology a laparoscopic bilateral oophorectomy and peritoneal biopsies were performed February 2023. The pathology was benign. Treatment plan included annual CA-125 surveillance.
Patient 2 is a 73-year-old woman with a history of POP who underwent a transvaginal hysterectomy, left salpingectomy, uterosacral ligament suspension, enterocele plication with anterior repair August 2023. Pathology demonstrated focal intraepithelial atypia of the left tube with differential diagnoses including p53 signature precursor lesion versus focal STIL. After consultation with gynecologic oncology, she underwent robotic bilateral oophorectomy, right salpingectomy, and peritoneal biopsies January 2024. The pathology was benign. Genetic testing was recommended and declined. No further treatment needed.

Conclusions: These cases contribute to the literature on incidental tubal pathology after prolapse repair. The risk for tubal pathology should be considered in POP treatment. Patients with incidental tubal carcinoma should be monitored closely by gynecologic oncology due to the 20% ten-year risk for progression to ovarian cancer.