Radical Oophorectomy with Primary Stapled

Colorectal Anastomosis for Resection of Locally

Advanced Epithelial Ovarian Cancer
Robert E Bristow, MD, Marcela G del Carmen, MD, Howard S Kaufman, MD, FACS,
Fredrick J Montz, MD, FACS

BACKGROUND: The aim of this study was to describe the feasibility, associated morbidity, and efficacy of radical
oophorectomy with primary stapled colorectal anastomosis among patients with locally ad-
vanced ovarian cancer with contiguous extension to or encasement of the reproductive organs,
pelvic peritoneum, cul-de-sac, and sigmoid colon.
STUDY DESIGN: Thirty-one consecutive patients undergoing radical oophorectomy as part of an initial maximal
surgical effort for International Federation of Obstetrics and Gynecology (FIGO) stage IIIB–IV
ovarian cancer were prospectively collected from October 1, 1997 through November 30, 2001.
The surgical technique, associated morbidity, and clinical outcomes are described.
RESULTS: The median age was 63 years. All patients had advanced-stage epithelial ovarian cancer: FIGO
stage IIIB (6.5%), stage IIIC (64.5%), stage IV (29.0%). Median operating time was 240
minutes (range 165 to 330 minutes), and the median estimated blood loss was 700 mL (range
300 to 2,900 mL). All patients underwent en bloc rectosigmoid colectomy with primary stapled
anastomosis without protective intestinal diversion. There was one (3.2%) anastomotic break-
down requiring reoperation and colostomy. Complete clearance of macroscopic pelvic disease
was achieved in all cases. Overall, 87.1% of patients were left with optimal (ⱕ1 cm) residual
disease and 61.3% were visibly disease free. There were no postoperative deaths, but major and
minor postoperative morbidity occurred in 12.9% and 35.5% of patients, respectively. Blood
product transfusion was required in 29.0% of cases. Thirty patients received multiagent
platinum-based chemotherapy, with a median overall survival time of 39.5 months.
CONCLUSIONS: Radical oophorectomy with primary stapled anastomosis is an effective technique for resection
of locally advanced ovarian cancer and contributes significantly to a maximal cytoreductive
surgical effort. The associated morbidity is acceptable, and protective intestinal diversion ap-
pears unnecessary. ( J Am Coll Surg 2003;197:565-574. © 2003 by the American College of
Surgeons)

Ovarian cancer is the most lethal of all gynecologic ma-
lignancies. The American Cancer Society has estimated
that 23,300 new cases will be diagnosed in the United
No competing interests declared.
This work supported by the Elizabeth Frost Ovarian Cancer Research Fund.
Received December 26, 2002; Revised April 28, 2003; Accepted April 28,
2003.
From The Kelly Gynecologic Oncology Service, Departments of Gynecology
and Obstetrics and Oncology (Bristow, del Carmen, Montz), and the Depart-
ment of Surgery (Kaufman, Montz), The Johns Hopkins Medical Institu-
tions, Baltimore, MD.
Dr Kaufman’s current affiliation is Division of Colorectal Surgery, Depart-
ment of Surgery, University of Southern California Keck School of Medicine,
Los Angeles, CA.
Correspondence address: Robert E Bristow, MD, The Kelly Gynecologic
Oncology Service, Departments of Gynecology and Obstetrics and Oncol-
ogy, The Johns Hopkins Medical Institutions, 600 North Wolfe St, Phipps
#289, Baltimore, MD 21205.
States in 2002, with 13,900 deaths directly attributable
to this disease.1 For patients with International Federa-
tion of Gynecology and Obstetrics (FIGO) stage III/IV
disease, survival determinants are multifactorial, but the
strongest clinician-driven predictors of clinical out-
comes are the amount of residual tumor after primary
cytoreductive surgery and the administration of
platinum-based chemotherapy.2-4 Locally advanced dis-
ease, with contiguous extension to or encasement of the
reproductive organs, pelvic peritoneum, cul-de-sac, and
sigmoid colon, can present a significant challenge to
surgeons operating on women with ovarian cancer. De-
signed for intact removal of a fixed ovarian tumor en
bloc with attached peritoneum and surrounding struc-
tures, the retroperitoneal technique of radical oophorec-

© 2003 by the American College of Surgeons ISSN 1072-7515/03/$21.00

Published by Elsevier Inc. 565 doi:10.1016/S1072-7515(03)00478-2
566 Bristow et al Radical Oophorectomy for Ovarian Cancer
Abbreviations and Acronyms
CEEA ⫽ circular end-to-end anastomosis
FIGO ⫽ International Federation of Gynecology and
Obstetrics
GOG ⫽ Gynecologic Oncology Group
JHMI ⫽ Johns Hopkins Medical Institutions
tomy was first described more than three decades ago.5,6
Although the basic principles of the procedure remain
the same, operative techniques, surgical instrumenta-
tion, and postoperative care have evolved during this
time period. The objectives of this study were to describe
the feasibility, associated morbidity, and efficacy of rad-
ical oophorectomy with primary stapled colorectal anas-
tomosis for the clearance of pan-pelvic disease among
patients with locally advanced ovarian cancer.
METHODS
Approval to conduct this study was obtained from the
Johns Hopkins Medical Institutions (JHMI) Clinical
Research Committee and Joint Committee on Clinical
Investigation. All patients undergoing primary surgical
intervention for a diagnosis of epithelial ovarian cancer
during a 50-month time period October 1, 1997
through November 30, 2001 at the JHMI were prospec-
tively entered into the Kelly Gynecologic Oncologic Ser-
vice clinical database. Patients undergoing a radical pel-
vic resection for FIGO stage III or IV disease were
specifically identified for additional study.
Classification and description of surgical technique
To define the scope of surgical resection with uniform
terminology, we have applied a descriptive classification
system to the radical oophorectomy procedure. Briefly, a
type I radical oophorectomy consists of a retrograde (de-
scribed below) modified radical hysterectomy (resection
of medial parametria and proximal vagina) with en bloc
resection of the adnexae, pelvic cul-de-sac tumor, and in-
volved pelvic peritoneum. The procedure is modified to
include removal of the residual cervix if a supracervical hys-
terectomy was previously performed or resection of the vag-
inal apex if both uterus and cervix were previously removed.
The procedure might include stripping of the peritoneum,
serosa, or both, of the anterior sigmoid colon or a limited
full-thickness segmental wedge-shaped resection of ante-
rior sigmoid wall with primary closure. A type II radical
oophorectomy consists of the previous procedure com-
J Am Coll Surg
bined with an en bloc resection of the rectosigmoid colon
with complete parietal pelvic peritonectomy to encompass
all pan-pelvic disease. Finally, a type III radical oophorec-
tomy is an extension of the type II procedure, incorporating
a portion of urinary bladder, pelvic ureter, or both with the
en bloc resection. This report is devoted only to patients
undergoing a type II or III radical oophorectomy, as
these are most commonly performed in clinical practice.
The primary indication for radical oophorectomy was
FIGO stage III or IV epithelial ovarian cancer with con-
fluent extension to and encasement of the reproductive
organs, pelvic peritoneum, cul-de-sac of Douglas, and
rectosigmoid colon (Fig. 1). Relative contraindications
to the procedure included a Gynecologic Oncology Group
(GOG) performance status score of 3 or greater (Karnofsky
score ⱕ40) or tumor distribution precluding an attempt at
optimal resection: extensive tumor infiltration of small
bowel mesenteric root, celiac axis nodal involvement, un-
resectable involvement of the porta hepatis, large-
volume (1 cm or more) unresectable extraabdominal
metastasis (eg, pulmonary), or multiple unresectable pa-
renchymal liver metastases. Radical oophorectomy was
generally limited to patients in whom the procedure
facilitated resection of all or nearly all (residual disease
less than 1 cm in maximal diameter) of their disease and
was not performed simply as palliation for a current or
impending large bowel obstruction in the setting of bulky
unresectable upper abdominal or extraabdominal disease.
Preoperatively, all patients underwent a complete phys-
ical examination and routine biochemical and hematologic
laboratory assessment. Routine radiographic imaging in-
cluded a chest radiograph and abdominopelvic CT. Stan-
dard mammographic and colonoscopy screening recom-
mendations were followed whenever possible. All patients
received a full mechanical bowel preparation with either
oral polyethylene glycol lavage or Fleets phosphosoda the
day before surgery. Standard antibiotic prophylaxis con-
sisted of cefotetan 2 g intravenously or clindamycin 600 mg
intravenously 30 minutes before surgery. In patients with
gross intraoperative fecal contamination, broad-spectrum
antibiotic coverage was administered for 72 hours postop-
eratively. Antiembolism stockings and pneumatic com-
pression devices were routinely placed before induction
of anesthesia and continued until the patient was fully
ambulatory. All operations were performed with the pa-
tient in the modified dorsal lithotomy position.
Abdominal entry and exposure are achieved through a
midline xyphopublic incision with placement of a self-
Vol. 197, No. 4, October 2003 Bristow et al Radical Oophorectomy for Ovarian Cancer 567

Figure 1. Locally advanced ovarian cancer with confluent extension to and encasement of the
reproductive organs, pelvic peritoneum (including vesicouterine peritoneal reflection), cul-de-sac
of Douglas, and rectosigmoid colon. OvT, ovarian tumor; Ut, uterus.

retaining Bookwalter retractor (Codman Division, John-
son & Johnson). A comprehensive assessment of the extent
of disease is conducted, with particular attention to the
feasibility of upper abdominal cytoreduction. Initial efforts
are directed toward bulky upper abdominal disease to facil-
itate exposure to the pelvis and ensure a reasonable likeli-
hood of achieving an optimal (less than 1 cm) or complete
(no macroscopic residual) overall resection before under-
taking radical oophorectomy. Omentectomy, with mobili-
zation of the ascending and descending colon, is followed
by exploration of the abdominal retroperitoneum and de-
bulking of peritoneal tumor implants.
The radical oophorectomy procedure is initiated by
carrying the paracolic gutter incisions caudally into the
pelvis, along the psoas muscles bilaterally, moving ventro-
medially along the posterior margin of the symphisis pubis.
All pan-pelvic disease is circumscribed and included within
this peritoneal incision (Fig. 2). The pelvic dissection pro-
ceeds in a centripetal fashion. The round ligaments are
exposed retroperitoneally, ligated, and divided as laterally as
possible. The central tumor mass(es) should be devascular-
ized early in the course of the operation by securing the infun-
dibulopelvic ligaments (containing the ovarian vessels)
with suture ligatures and dividing them at or above the
pelvic brim. The ureters are mobilized from their attach-
ments to the medial leaf of the broad ligament, moving
from the pelvic brim to the tunnel of Wertheim, and held
for traction with vasa-loops. Medial mobilization of the
sigmoid colon will provide additional exposure to the left
pelvis and delineate the extent of bowel resection needed.
The proximal sigmoid colon is divided 2 cm to 3 cm above
the most proximal extent of gross tumor using an automated
linear gastrointestinal (GIA) stapling device (US Surgical or
Ethicon Inc). The mesentery of the sigmoid colon is then
divided, ligating individual vessels, including the superior
hemorrhoidal artery. The posterior pelvis is further mobi-
lized by developing the retrorectal (presacral) space caudally
to the level of pelvic floor musculature, clamping, dividing
and securing the rectal pillars (including the middle hem-
orrhoidal artery) in the process.
The pararectal and paravesicle spaces are further de-
veloped using a combination of sharp and blunt dissec-
568 Bristow et al Radical Oophorectomy for Ovarian Cancer J Am Coll Surg

Figure 2. Radical oophorectomy. A circumscribing peritoneal incision encompasses all pan-

pelvic disease, the round ligaments and ovarian vessels are divided, the ureters are mobilized,
and the anterior pelvic peritoneal tumor is dissected from the bladder muscularis.

tion, exposing the cardinal ligament. Resection of any
bulky pelvic adenopathy at this point may facilitate ex-
posure to the central pelvis. The uterine vascular pedicles
are skeletonized, doubly ligated, and divided at the level
of the ureters (in the fashion of a modified radical hys-
terectomy), allowing additional lateral displacement of
the ureters from the central specimen7 (Fig. 2). The ret-
ropubic space of Retzuis is entered and a plane of dissec-
tion established between the muscular bladder wall and
tumor-laden anterior pelvic peritoneum. The anterior
pelvic peritoneum is deperitonealized (or “stripped”) in
a ventral-to-dorsal direction, inclusive of all tumor im-
plants occupying the anterior pelvis. Bovie electrocau-
tery (Valleylab Inc) (30 to 35 W, coagulation current) or
the argon beam coagulator (Conmed Corp) (80 W
power density) facilitates dissection of the anterior pelvic
peritoneum from the underlying bladder muscularis un-
til the pubovesicocervical fascia is reached. The anterior
pelvic peritoneal tumor is left attached to the uterine
specimen.
The hysterectomy is completed in a retrograde fash-
ion. The bladder is sharply mobilized ventrocaudally to
expose the proximal 2 cm to 3 cm of vagina. If the
anterior pelvic peritoneal tumor is densely adherent to
the cervix, the paravesicle spaces can be developed in a
lateral-to-medial direction below the level of the cervix
until the vesicovaginal space is reached. The vesicovagi-
nal space is virtually always free of disease and can be
used to define the proper plane of dissection between the
adherent tumor and the bladder wall. Occasionally, an
intentional cystotomy in the bladder dome, with partial
resection of the bladder wall, is required. At this junc-
ture, the need for partial ureterectomy is also deter-
mined. Ureteral reimplantation by ureteroneocysto-
tomy (with or without Boari flap and psoas hitch) is
normally delayed until the central specimen has been
removed. The proximal vagina is exposed and a trans-
verse anterior colpotomy is created using electrocautery,
exposing the inner vagina (Fig. 3A). An intraoperative
bimanual examination facilitates selecting the proper
site of vaginal incision. In cases in which a hysterectomy
has previously been performed, transvaginal placement
of a rectal dilator to elevate the vaginal cuff might facil-
itate anterior colpotomy. Heaney clamps are used to se-
quentially circumscribe the anterior and lateral vagina,
dividing and securing each pedicle in sequence. Place-
Vol. 197, No. 4, October 2003
Figure 3. Radical oophorectomy. (A) The anterior pelvic peritoneal
tumor has been dissected from the bladder dome, the proximal
vagina is exposed, and a transverse anterior colpotomy is created
using electrocautery to enter the vagina. (B) The remaining cardinal
ligament attachments are divided between Heaney clamps working
in a ventral-to-dorsal direction toward the cul-de-sac tumor mass.
ligs., ligaments.
ment of a narrow malleable retractor in the vaginal
tube will help to displace the bladder and distal ureters
anterolaterally during this portion of the dissection. The
remaining cardinal ligament attachments are divided
between Heaney clamps working in an anterior (ventral)
to posterior (dorsal) direction (Fig. 3B). The posterior
vaginal wall is incised and the rectovaginal space developed
sharply.
Dissection is carried inferiorly to a level 2 to 3 cm
below the lowermost extent of the cul-de-sac tumor
mass, which is then mobilized cephalad to preserve max-
Bristow et al Radical Oophorectomy for Ovarian Cancer 569
Figure 4. Radical oophorectomy. The rectovaginal space has been
developed to a level 2 to 3 cm below the caudal-most extent of the
cul-de-sac tumor mass, and the distal rectosigmoid colon is divided
using an automated stapling device.
imal length of the proximal rectum after transection. At
this point, the only remaining attachment is that of the
distal rectosigmoid colon, which is divided using a GIA
or thoracoabdominal (TA) automated stapling device
(US Surgical or Ethicon Inc) (Fig. 4). The central pelvic
tumor mass is removed en bloc with the rectosigmoid
colon (Fig. 5), leaving a macroscopically tumor-free op-
erative site (Fig. 6).
Additional mobilization of the proximal sigmoid
colon might be required to ensure a tension-free colo-
rectal anastomosis.8 Intestinal continuity is reestab-
lished, using a circular end-to-end anastomosis
(CEEA) automated stapling device (Fig. 7) (US Sur-
gical or Ethicon Inc). The security of the anastomosis
is confirmed by inspecting the resection rings to en-
sure two complete “donuts” of colon and filling the
pelvis with saline, while manually obstructing the
proximal colon, and instilling 150 to 200 mL of air
into the rectum to demonstrate an airtight anastomosis.
In most cases, a closed suction drainage system is placed
within the pelvis and removed when the output is less than
200 mL per 24-hour period. Nasogastric suction is not
routinely used, and parenteral nutrition is administered at
the discretion of the attending surgeon.
570 Bristow et al Radical Oophorectomy for Ovarian Cancer
Figure 5. Radical oophorectomy. En bloc specimen, including
uterus, adnexae, anterior pelvic peritoneal tumor, cul-de-sac tumor
mass, and rectosigmoid colon. CT, cul-de-sac tumor; Ut, uterus.
Data abstraction
Individual subjects were identified prospectively at the
time of surgery and data collected from inpatient and
ambulatory medical records. Demographic data, opera-
tive findings, surgical procedures performed, amount of
residual disease, and final pathology diagnosis were re-
corded for all patients. Followup information included
significant postoperative morbidity within 30 days of
Figure 7. Radical oophorectomy. Intestinal continuity is reestab-
lished using a circular end-to-end anastomosis (CEEA) automated
stapling device.
J Am Coll Surg
Figure 6. Radical oophorectomy. The pelvis is macroscopically
tumor-free after en bloc resection.
surgery, chemotherapeutic agents administered and du-
ration of treatment, the date of clinical or radiographic
progression of disease or recurrence, the date of last fol-
lowup or death, and disease status at last followup. For
overall survival analysis, event time distributions were
estimated using the method of Kaplan and Meier.9
RESULTS
Patient characteristics
Thirty-one consecutive patients underwent a primary
maximal surgical effort at the JHMI that included Type
II (n ⫽ 29) or Type III (n ⫽ 2) radical oophorectomy
for epithelial ovarian cancer with confluent involvement
of pelvic viscera during the study period. The FIGO
stage distribution was as follows: stage IIIB (2 patients),
stage IIIC (20 patients), stage IV (9 patients). Three
patients had received three cycles of neoadjuvant chemo-
therapy with carboplatin and paclitaxel before their ini-
tial surgical procedure for FIGO stage IV serous ovarian
carcinoma. One patient (stage IIIC disease) was treated
with three cycles of carboplatin and paclitaxel chemo-
therapy after a suboptimal attempt at primary cytore-
ductive surgery at an outside institution before under-
going radical oophorectomy at JHMI. The remaining
27 patients all underwent surgical exploration before
receiving chemotherapy. At the time of radical oopho-
Vol. 197, No. 4, October 2003 Bristow et al Radical Oophorectomy for Ovarian Cancer 571

Table 1. Clinicopathologic Patient Characteristics Table 2. Surgical Procedures Performed in 31 Patients Un-
Characteristic Data dergoing Radical Oophorectomy
Median age, y (range) 63 (40 to 85) Procedure n %
Serum CA125, U/mL Total omentectomy 28 90.3
Median 1,122 Infracolic omentectomy 3 9.7
Mean 2,524 Retroperitoneal lymph node
Range 74 to 17,935 sampling/excision 28 90.3*
Performance status* Peritoneal tumor implant
excision or ablation 23 74.2
0 12 (38.7%)
Ileocecal or small bowel
1 14 (45.2%) resection 9 29.0
2 5 (16.1%) Diaphragm stripping or
3 resection 7 22.6
Ascites volume, mL Right or left hemicolectomy 3 9.7
Median 2,700 Subtotal transverse colectomy† 2 6.5
Mean 2,494 Splenectomy 2 6.5
Range 100 to 7,000 Liver resection 1 3.2
Histology, n (%) Cholecystectomy 1 3.2
Serous 26 (83.9) *Retroperitoneal lymph nodes contained metastatic disease in 17 of 28 pa-
Mixed serous and endometrioid 2 (6.5) tients (60.7%).
†
Mucinous 2 (6.5) En bloc with omentectomy.
Clear cell 1 (3.2)
Tumor grade, n (%) in excess of 1,000 mL occurred in seven patients
1 2 (6.5) (22.6%). Nine patients (29.0%) required intraoperative
2 8 (25.8) or postoperative transfusion of packed red blood cells
3 21 (67.7) (range 1 to 5 U, median 2 U, mean 2.6 U). Twenty
*Gynecologic Oncology Group scoring. patients (64.5%) were transferred directly to the surgical
intensive care unit immediately postoperatively, for a
rectomy, 22 of 31 patients (71%) had ascites volume median stay of 2 days (range 1 to 12 days). The median
greater than or equal to 1,000 mL. Additional clinico- time to tolerating a regular diet was 6 days (range 3 to 14
pathologic patient characteristics are shown in Table 1. days). Thirteen patients received parenteral nutrition
postoperatively (median 8 days, range 6 to 14 days).
Surgical results and postoperative treatment There were no perioperative deaths, but four patients
Radical oophorectomy included hysterectomy in 21 pa- (12.9%) experienced significant life-threatening postop-
tients, trachelectomy (after previous supracervical hys- erative complications (pulmonary embolism, sepsis, up-
terectomy) in 2 patients, and uni- or bilateral salpingo- per gastrointestinal hemorrhage). Minor postoperative
oophorectomy only (after earlier total hysterectomy) in morbidity (incisional cellulitis, urinary tract infection,
8 patients. In all cases, rectosigmoid colon resections ileus more than 7 days) occurred in 11 patients (35.5%).
were completed below the peritoneal reflection and in- There were no instances of prolonged (beyond 7 post-
testinal continuity reestablished using a CEEA stapler operative days) bladder dysfunction. One patient
(25 mm to 33 mm). Additional surgical procedures are (3.2%) experienced a postoperative breakdown of the
shown in Table 2. Twenty-seven patients (87.1%) were colorectal anastomosis on postoperative day 5 and re-
left with residual disease measuring 1 cm or more in quired reexploration, with diverting colostomy. This
maximal diameter. Of these, 19 patients underwent was the only patient in this series requiring reoperation.
complete cytoreduction of all visible disease, represent- The median length of hospital stay was 11 days (range 4
ing 61.3% of the total study group and 70.4% of those to 23 days), and 22 patients received chemotherapy be-
with optimal cytoreduction. fore discharge.
Operative time ranged from 165 to 330 minutes, with
a median time of 240 minutes (mean 235.3 minutes). Followup and survival analysis
The median estimated blood loss was 700 mL (mean Postoperatively, one patient declined further treatment
821 mL, range 300 to 2,900 mL). Estimated blood loss and was lost to followup 43 days after surgery. Of the 30
572 Bristow et al Radical Oophorectomy for Ovarian Cancer
Figure 8. Overall survival of 30 patients undergoing radical oopho-
rectomy for International Federation of Gynecology and Obstetrics
stage III (n ⫽ 21) or stage IV (n ⫽ 9) epithelial ovarian cancer.
patients receiving chemotherapy, carboplatin plus pacli-
taxel was administered to 24; 5 patients received cispla-
tin plus paclitaxel plus topotecan as part of a cooperative
group investigational study protocol (GOG protocol
#9602). One patient received single agent carboplatin.
All patients, including those treated initially with neo-
adjuvant chemotherapy, completed a minimum of six
cycles after radical oophorectomy. Fifteen patients un-
derwent second-look surgery (14 laparoscopy, 1 laparot-
omy). Seven of these patients (46.6%) had persistent
disease detected at second-look surgery (six microscopi-
cally positive, one macroscopically positive). No patient
was found to have persistent pelvic disease at the time of
second-look surgery.
Thirty patients were available for survival analysis.
The median followup time for surviving patients was
21.7 months (range 7.2 months to 57.4 months). At last
followup, 6 patients (20%) were dead of disease, 10
patients (33.3%) were alive with disease, and 14 patients
(46.7%) were alive with no evidence of disease. The
median overall survival time for all patients was 39.5
months (Fig. 8). At last followup, 15 patients (48.4%)
had experienced clinical recurrence or progression of dis-
ease. Five patients had a pelvic component of disease as
J Am Coll Surg
their first site of progression, representing 16.7% of the
30 evaluable patients.
DISCUSSION
For patients with FIGO stage III/IV ovarian cancer, the
amount of residual disease before initiating cytotoxic
chemotherapy has been shown to be a powerful and
consistent determinant of overall survival.3,10-17 Al-
though the contribution of tumor biology to this obser-
vation cannot be overlooked, primary cytoreductive sur-
gery is the accepted standard initial therapy for women
with advanced epithelial ovarian cancer. The literature
has consistently demonstrated that patients with no vis-
ible or only small volume residual tumor experience a
two- to three-fold extension in median survival time
compared with those left with bulky residual tumor.17-20
Contemporary 5-year survival rates now approach 50%
for patients with optimally cytoreduced stage III/IV
disease.17-19,21 Not uncommonly, advanced ovarian can-
cer will present with confluent disease extending to or
encasing the reproductive organs and other pelvic vis-
cera, which might lead to an abbreviated debulking pro-
cedure or abandonment of primary surgery altogeth-
er.15,22 In some series, as many as 47% of patients with
advanced ovarian cancer might be left with suboptimal
large-volume residual pelvic disease.23-25 Given the poor
prognosis in such cases, every effort should be made to
resect even the most locally advanced ovarian cancer
when upper abdominal disease is not prohibitive.
Radical extirpative procedures for locally advanced
ovarian cancer have evolved since 1965, when Barber
and Brunschwig26 first reported 22 patients undergoing
pelvic exenteration. In this series, the postoperative mor-
tality rate was 23% and there were only two longterm
survivors. In 1968 and 1973, Hudson and Chir5,6 pub-
lished two reports describing a technique they termed
“radical oophorectomy,” specifically designed for the in-
tact removal of a fixed ovarian tumor en bloc with at-
tached peritoneum and surrounding structures. These
authors observed that ovarian cancer tumor growth usu-
ally respects peritoneal demarcations, and they advo-
cated a retroperitoneal approach, using the “false cap-
sule” of the ovarian tumor within the pouch of Douglas
to effect en bloc excision. During the past 30 years,
varying terminology has been used to describe modifi-
cations of this procedure, including: en bloc rectosig-
moid colectomy,20,27-31 reverse hysterocolposigmoidec-
tomy,32 complete parietal and visceral peritonectomy,8
Vol. 197, No. 4, October 2003 Bristow et al
en bloc pelvic peritoneal resection of the intrapelvic vis-
cera,33 and modified posterior exenteration.34
Terminology aside, the cardinal feature of the radical
oophorectomy procedure is the retroperitoneal ap-
proach to ovarian cancer encasing the pelvic viscera, us-
ing the tendency of epithelial ovarian cancer to respect
peritoneal planes of demarcation to surgical advantage.
In this fashion, the retroperitoneal spaces, uninvolved by
extensive intraperitoneal tumor, can be used to develop
the dissection in a centripetal fashion with maximum
safety to surrounding vital structures. The type II/III pro-
cedures performed in the current series achieved complete
clearance of macroscopic pan-pelvic disease in all cases
and contributed significantly to an overall maximal cy-
toreductive effort. It should be noted that the observed
rates of optimal and complete cytoreduction in the cur-
rent series might not reflect the surgical outcomes for all
patients with advanced ovarian cancer. Specifically, only
patients in whom a reasonable attempt at resection of upper
abdominal disease could be undertaken were submitted to
radical oophorectomy. Although this necessarily intro-
duces a component of selection bias, other authors have
reported equivalent rates of successful cytoreduction us-
ing a similar technique.8,16,20,21,25,30,31-35 In these reports,
overall optimal residual disease (ⱕ1 cm or 2 cm) was
achievable in 74% to 100% of patients, with almost
universal clearance of advanced pelvic tumor. The liter-
ature also suggests a reduced risk of pelvic failure (5.3%
to 9.4%) after radical oophorectomy, which is consistent
with our observation that just 16.7% of patients mani-
fested a pelvic component at first recurrence.35,36
Given the high proportion of patients with stage IV
disease, the observed median survival time of 39.5
months compares favorably with other contemporary
reports. The current data also demonstrate that the ex-
tensive surgery often required to achieve such clinical
outcomes is associated with a predictably high, but ac-
ceptable, risk of perioperative morbidity. Among pa-
tients undergoing a radical oophorectomy procedure,
the reported estimated blood loss ranges from 800 mL to
2,900 mL, with 12% to 49% of patients experiencing
significant postoperative complications.16,20,21,25,28,29,31-34
Nevertheless, operative mortality of radical oophorec-
tomy can be limited to 1.5% to 3.1% using an intensive
postoperative care program.20,29,30,34
Historically, there have been concerns about reestab-
lishing intestinal continuity in patients undergoing a
radical debulking operation for ovarian cancer requiring
Radical Oophorectomy for Ovarian Cancer 573
resection of the sigmoid colon. Such patients often have
large-volume ascites, can be nutritionally compromised
from the metabolic effects of an extensive tumor burden,
or have evidence of early bowel obstruction. Temporary
or permanent intestinal diversion was typically per-
formed in 12% to 59% of such patients.28-30,32,34,35,37 In
this series, primary colorectal anastomosis was accom-
plished in all cases using a CEEA automated stapling
device with only one instance (3.2%) of anastomotic
dehiscence requiring reoperation and colostomy despite
the fact that 71% of patients had ascites volume of 1,000
mL or more. Using both stapled and hand-sewn anasto-
moses, other authors have reported anastomotic break-
down in 0% to 8% of patients undergoing sigmoid co-
lectomy for ovarian cancer.20,27,29-32,37 Among patients
with large-volume ascites (500 mL or more), the inci-
dence of anastomotic dehiscence is just 2.1% to
3.1%.30,34 Taken together, these data suggest that protec-
tive intestinal diversion is unnecessary and that terminal
excretory function can be preserved in the majority of
patients undergoing radical oophorectomy.
In summary, surgeons operating on women with
ovarian cancer are frequently confronted with locally
advanced central pelvic disease with contiguous exten-
sion to or encasement of other pelvic viscera. Small-
volume residual disease has been consistently associated
with improved survival, and for the majority of patients
a maximal attempt at tumor cytoreduction will be war-
ranted. Radical oophorectomy is highly effective for
achieving complete clearance of macroscopic pelvic dis-
ease and, with advances in surgical technique and peri-
operative care, can be performed with acceptable mor-
bidity. On the other hand, patients with unresectable
upper abdominal disease are unlikely to derive a signifi-
cant survival benefit from a radical pelvic resection. In
such cases, intestinal diversion alone is the more appro-
priate surgical option.
Author contributions
Study conception and design: Bristow, del Carmen,
Kaufman, Montz
Acquisition of data: Bristow, del Carmen
Analysis and interpretation of data: Bristow, del Car-
men, Kaufman, Montz
Drafting of manuscript: Bristow, del Carmen, Kaufman,
Montz
Critical revision: del Carmen, Kaufman, Montz
Statistical expertise: Bristow
574 Bristow et al Radical Oophorectomy for Ovarian Cancer
Obtaining funding: Bristow
Supervision: Kaufman, Montz
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