The Journal of Obstetrics and Gynecology of India

https://doi.org/10.1007/s13224-024-01945-1

ORIGINAL ARTICLE

Radical Oophorectomy for Advanced Ovarian Cancer: A Feasibility

Study from Tertiary Care Cancer Centre in Eastern India
Sony Nanda1 · Manoranjan Mahapatra1 · Janmejaya Mohapatra1 · Ashok Padhy1 · Bhagyalaxmi Nayak1 · Jita Parija1

Received: 11 August 2022 / Accepted: 5 January 2024

© Federation of Obstetric & Gynecological Societies of India 2024

Abstract
Background Radical oophorectomy was first performed by Hudson in order to remove an "intact ovarian tumour lodged in
the pelvis, with the entire peritoneum remaining attached". We report 16 cases of radical oophorectomy done at our institute
in the past 3 years and have analysed the perioperative morbidity as well as feasibility of performing the surgery without
much of perioperative complication.
Methods Twenty-three patients with advanced ovarian cancer who underwent modified en bloc pelvic resection at our
institute, between November 2018 and October 2021, were initially enrolled. Patients below 70 years, resectable disease
on CT scan and no significant comorbidities were included. Exclusion criteria were extra-abdominal metastasis, secondary
cancers or complete intestinal obstruction. Initially, 23 patients were enrolled out of which seven patients were excluded.
Hence, a total of 16 patients with ovarian cancer extensively infiltrating into nearby pelvic organs and peritoneum were
included. In Type 1 radical oophorectomy, retrograde modified radical hysterectomy alongwith in toto removal of the bilateral
adnexae, pelvic cul-de-sac and affected pelvic peritoneum is done. Type 2 radical oophorectomy includes total parietal and
visceral pelvic peritonectomy as well as an en bloc resection of the rectosigmoid colon below the peritoneal reflection.
Results Radical oophorectomy is feasible with acceptable complication rate. In our study, only one patient had burst abdomen
that too due to the poor nutritional status of the patient. There was no surgery-related deaths, but one patient succumbed to
pulmonary embolism 5 days after the operation.
Conclusion Hence, radical oophorectomy proves to be an effective, feasible and secure surgical technique in cases of
advanced ovarian malignancies with extensive involvement of peritoneum, pelvis and visceras.

Keywords Radical oophorectomy · Epithelial ovarian cancer · Hudson method · En bloc pelvic resection

Background malignancy [1]. Primary cytoreductive surgery, followed

by chemotherapy, is the currently recommended course
Amongst the newly diagnosed ovarian cancer patients, of treatment for ovarian carcinoma [2]. Numerous studies
most of them are diagnosed in an advanced stage, making show that patients who were optimally cytoreduced had
it the most common cause of death from gynecologic better survival rate than those who underwent suboptimal
cytoreduction [3–6]. Whether or not to perform a thorough
cytoreductive procedure depends on the likelihood of
Dr. Sony Nanda has completed her MCH Gynaecologic Oncology removing all visible disease [7]. In order to fully debulk
from Acharya Harihar Post Graduate Institute of Cancer in 2023.
advanced epithelial ovarian cancer (EOC) patients with
Currently she is posted as an Assistant Professor at JK Medical
College & Hospital. Dr. Manoranjan Mahapatra is an Associate extensive disease in pelvic and visceral organs, an en bloc
Professor. Dr. Janmejaya Mohapatra is an associate Professor. Dr. pelvic resection is performed [8].
Ashok Padhy is an assistant Professor. Dr. Bhagyalaxmi Nayak is a In toto pelvic resection of ovarian tumour alongwith
Professor. Dr. Jita Parija is a Professor.
rectosigmoid colectomy was initially reported in 1968 and
* Ashok Padhy 1973 separately by Hudson and Chir, which was labelled
[email protected] as “radical oophorectomy”. Radical oophorectomy was first
performed by Hudson in order to remove an "intact ovarian
1
Department of Gynaecologic Oncology, Acharya Harihara tumour lodged in the pelvis, with the entire peritoneum
Institute Of Cancer, Cuttack, Odisha, India

Vol.:(0123456789)
 S. Nanda et al.

remaining attached". Subsequently, 25 cases (23 with Subject and Methods

cancer) undergoing the procedure between 1965 and 1972
were reported by Hudson [9]. In this retrospective observational analysis, medical records
Reverse hysterocolposigmoidectomy, modified posterior of our institute were searched for the patients who have
exenteration, en bloc pelvic peritoneal resection [10], en bloc undergone radical oophorectomy between November 2018
rectosigmoid colectomy and complete parietal and visceral and October 2021. Twenty-three patients with advanced
peritonectomy [11] are some of the other terminologies EOC who underwent modified en bloc pelvic resection at
for the modified procedures used in the described surgical the Department of Gynecologic Oncology, Acharya Harihar
method [9]. Post Graduate Institute of Cancer (AHPGIC), Cuttack,
In Type 1 radical oophorectomy, retrograde modified between November 2018 and October 2021, were initially
radical hysterectomy alongwith in toto removal of the enrolled. Age under 70, Eastern Cooperative Oncology
bilateral adnexae, pelvic cul-de-sac and affected pelvic Group (ECOG) performance level 0 or 1, resectable illness
peritoneum is done. Type 2 radical oophorectomy includes determined by computed tomography (CT) scan, absence of
total parietal and visceral pelvic peritonectomy as well as severe comorbidities and written consent were the inclusion
an en bloc resection of the rectosigmoid colon below the criteria. Exclusion criteria were extra-abdominal metastasis,
peritoneal reflection. A part of the bladder with or without other organ parenchymal involvement leading to organ
pelvic ureter is included in a Type 3 radical oophorectomy, resections, other malignant pathologies, active infections
which is an annexure of a Type 1 or Type 2 resection. or complete intestinal obstruction and those who did not
Here, we report 16 cases of radical oophorectomy done give consent to participate. Out of those 23 patients, seven
at our institute in the past 3 years and have analysed the patients were excluded. Patients excluded was one patient
perioperative morbidity as well as feasibility of performing who had a history of carcinoma breast 10 years back, was
the surgery without much of perioperative complication. treated for the same and had now presented with ovarian
cancer, one patient had splenic parenchymal deposit so
splenectomy had been done alongwith Type 1 radical
Aims and Objectives oophorectomy, three patients did not give consent for the
study and another two patients were lost to follow-up and
The present study was performed with the objective to could not be contacted. Patients undergoing only radical
evaluate the outcomes and morbidities in advanced ovarian hysterectomy are not included in this study. Hence, a total
cancer patients who have undergone radical oophorectomy. of 16 patients were included in this study. Figure 1 depicts
the complete methodology of the study.
An en block pelvic resection was the prescribed course
of action. A circumscribing peritoneal incision is used
to commence the en bloc pelvic resection technique and
includes all pan-pelvic illness within this circumferential

Fig. 1  Flowchart depicting the

detailed methodology of the 23 PATIENTS ENROLLED
study
Ovarian cancer paents with extensive disease
, Age under 70 , (ECOG ) 0 or 1 , resectable illness on (CT)
scan, absence of severe comorbidies.

-1 PATIENT HAD H/O CA BREAST

(7paents) -1 PATIENT HAD SPLENIC PARENCHYMAL DEPOSIT
excluded - 3 PATIENTS DID NOT GIVE CONSENT

-2 PATIENTS WERE LOST TO FOLLOW UP.

TOTAL 16 PATIENTS FINALLY

INCLUDED .
Radical Oophorectomy for Advanced Ovarian Cancer: A Feasibility Study from Tertiary Care…

incision. The round and infundibulopelvic ligaments are Table 1  Clinicopathologic features
ligated and cut following retroperitoneal pelvic dissection. Clinicopathologic feature Variables
The ureters are separated from the peritoneum and
mobilised. The urinary bladder is mobilised down, and Age 32–67 years 47.18 years
(mean)
the vesicovaginal space is created after the anterior pelvic
BMI (mean) 19–31 26.2
peritoneum overlying the bladder and its tumour nodules
ECOG 0 7
have been dissected caudally. At the level of the ureters,
1 9
the uterine arteries are divided, and the parametrium is
2 0
resected. Retrograde hysterectomy is done. The tumour and
Type of surgery Primary 7
peritoneum can be detached from the anterior surface of
IDS 9
the rectum and the sigmoid colon by sharp dissection in
Tumour histology HGSOC 8
Type I modification of radical oophorectomy, if there is only
LGSOC 1
superficial involvement of the tumour to the rectum. If the
Endometriod 5
tumour only partially (2 cm) invades the muscularis of the
Mucinous 1
rectum, a wedge-shaped section of the rectal wall can be
Clear cell 1
excised and reconstructed, using a fine monofilament suture
FIGO stage 2b 2
in interrupted inverting stitches that incorporate minimum
3b 4
mucosa and are positioned perpendicular to the long axis of
3c 9
the colon. In Type 2 radical oophorectomy alongwith the
4a 1
steps mentioned in Type 1 radical oophorectomy, an en bloc
Ascites <1 L 3
resection of the rectosigmoid colon below the peritoneal
>1 L 3
reflection is performed. The pelvis remains macroscopically
Nil 10
disease-free when the specimen is removed in one
piece along with the uterus, adnexa, pelvic peritoneum,
rectosigmoid colon (Type 2) and tumour deposits. This
procedure is a part of primary surgery, which utilised several had been done, rest two cases nodal dissection had not
types of peritonectomy together with associated resections been done. The surgery and hospital stay each had median
to remove all visible disease (Table 2). durations of 240 min (within a range of 180–280 min) and
8 days (between 7 and 28 days), respectively. The median
Statistical Analysis estimated blood loss (EBL) was approximately 500 ml.
Blood transfusions have been given to all 16 patients. The
The data were entered into Microsoft Excel sheet. SPSS average number of transfusions of red blood cells (RBCs)
version 22 was used for statistical analysis. Categorical was two (range: 0–4 units). The average number of days
variables were expressed as numbers and percentages while spent in the ICU was only 1 day (range: 1–4 d). Six patients
continuous variables were expressed as mean ± standard experienced perioperative complications. Two patients had
deviation (SD). subacute intestinal obstruction (SAIO), one patient had
burst abdomen and two patients had superficial surgical
site skin infection (SSSI). There were no any complications
Results specifically related to this procedure. One woman died
suddenly 5 days after surgery, but there were no surgery-
There were 16 patients altogether that were included in this related deaths. Although all patients received postop
study. Patients age ranged from 32 to 67 years, with a mean thromboprophylaxis, her death was caused due to pulmonary
age of 47.18 years. The body mass index (BMI) ranged embolism. Platinum-based treatment was administered to
from 19 to 31 kg/m2 with a median of 26.2 kg/m2. The most the rest 15 individuals who survived. The median interval
common histological type was high-grade serous ovarian between the initial operation and the beginning of the
cancer (HGSOC), which was found in 8 out of 16 (or 50%) chemotherapy treatment was 35 days (interval: 21–42 days)
cases. In 9 out of 16 patients (56.2%), the most prevalent (range: 6–28 months). The median follow-up time was
International Federation of Gynecology and Obstetrics 14 months. Throughout the period of surveillance, there
(FIGO) stage was IIIC confirmed. There were only three were no cases of recurrence in any of the patients.
patients with ascites that were more than 1000 ml (18.75 per Table 4 depicts the intraoperative disease burden at the
cent). Table 1 provides comprehensive information on the beginning of the procedure and the disease left after completion
pre-treatment and disease-related features. Tables 2 and 3 of surgery. In 12 cases (75%), complete cytoreduction score
display operative details. 14/16 cases lymph node dissection (CC) CC0 was achieved, three cases CC1 and, in only one
 S. Nanda et al.

Table 2  Type of peritonectomy Types of peritonectomy Additional resections No. of patients

Pelvic peritonectomy Uterus, adnexae and rectosigmoid colon 16

Upper quadrant peritonectomy omentectomy 14
Diaphragmatic stripping 2
Subcapsular liver deposits resection 1
Complete parietal peritonectomy 7
Anterior parietal wall peritonectomy Previous abdominal incisions 0
Umbilical metastatic deposits 1
Types of lymphadenectomy Selective BPLNs/PALNS 3
Systematic PALND/PALNS 11

Table 3  Intraoperative and perioperative details

Case no. Duration (mins) EBL (ml) ICU (days) Hospital BT (units) Perioperative complications Time interval between
stay (days) CRS and CHT (days)

1 250 700 3 10 4 Caecal seromuscular injury 40

2 180 500 1 8 2 SAIO 30
3 200 600 2 9 2 No 35
4 180 500 1 8 2 No 38
5 190 500 1 8 2 No 40
6 270 600 2 15 3 SAIO 42
7 210 650 2 9 2 No 34
8 240 600 5 12 1 No 35
9 200 500 1 9 2 No 30
10 190 450 1 28 2 Burst abdomen 32
11 250 600 1 9 3 SSSI 37
12 240 550 1 8 2 SSSI 48
13 260 400 1 7 3 No 25
14 240 500 1 8 2 No 21
15 250 500 1 8 2 No 30
16 280 800 4 Died 2 No Expired

EBL estimated blood loss, BT blood units transfused, CRS cytoreductive surgery and ChT chemotherapy

case, CC2 was achieved. The cases where CC0 could not be Discussion
achieved had a peritoneal carcinomatosis index (PCI) score of
more than 20. The case where CC2 was achieved had a PCI In advanced EOC, tumour dissemination to the peritoneal
score of 32. The median SCS (surgical complexity score) was surfaces of the bladder and bowel is common. En bloc
6 (range: 5–8). In all nine cases, where either Type 1 modified pelvic resections, with or without rectosigmoid colectomy,
or Type 2 was performed had bowel infiltration of the cancer might be beneficial for patients given the patterns of EOC
cells which was confirmed by histopathology. dissemination and potential remnants of microscopic
Figure 2 shows a postoperative picture of a Type 1 radical disease that may not be visible intraoperatively. In our
oophorectomy specimen. [Total abdominal hysterectomy institute, 16 cases of radical oophorectomy where there
with total peritonectomy and en bloc retrieval of the radical was extensive disease with the obliteration of cul-de-sac
oophorectomy specimen has been done.]
Radical Oophorectomy for Advanced Ovarian Cancer: A Feasibility Study from Tertiary Care…

Table 4  Intraoperative details and involvement of bowel peritoneal surfaces have been
Case no. Type of radical PCI CC SCS performed. The cases where there was only superficial
oophorectomy rectosigmoid involvement upto ≤ 2 cm, Type 1 modified
radical oophorectomy was performed instead of Type 2
1 Type 1 modified 20 1 8
radical oophorectomy hence avoiding rectosigmoid colon
2 Type 1 modified 13 0 6
resection and anastomosis. By this type of modification,
3 Type 2 24 1 6
the morbidity associated with bowel resection was
4 Type 1 6 0 6
avoided.
5 Type 1 12 0 5
The most common type of radical oophorectomy in our
6 Type 2 32 2 8
study was Type I modified unlike Kim et al. [9] where they
7 Type 1 modified 20 0 5
had reported Type 2 radical oophorectomy to be the most
8 Type 2 21 1 6
common type: Type 1 (18%), Type 2 (74%) and Type 3 (8%).
9 Type 1 8 0 6
We were able to achieve CC0 in 75% of cases with radical
10 Type 1 8 0 5
oophorectomy even with the presence of extensive disease in
11 Type 1 modified 14 0 6
the pelvis. The four cases where CC0 could not be achieved
12 Type 1 modified 13 0 6
had a PCI score of more than 20. Except 1 case of burst
13 Type 1 7 0 6
abdomen, there were only minor complications observed
14 Type 1 modified 15 0 8
in our study. Minor complications were those that did not
15 Type 1 11 0 6
require readmission or have an effect on the patient's clinical
16 Type 1 modified 12 0 8
course. [Clavien–Dindo Grading of complications] The
PCI peritoneal carcinomatosis index, CC completeness of patient's poor nutritional status could be the cause of burst
cytoreduction and SCS surgical complexity score abdomen in our study. Prior to surgery, we usually check the
serum albumin levels; however, it was not helpful to detect
the patient's poor nutritional condition preoperatively. There
were no surgery-related deaths, but one patient succumbed
to pulmonary embolism 5 days after the operation. During
her hospital stay, she got combined pharmacologic and
mechanical venous thromboembolism (VTE) prophylactic
treatment. Since she was obese, with a BMI of 32.4 kg/m2,
which is a risk factor for VTE, the appraisal of the outlined
surgical treatment should not be impacted by her death 0.8
patients who underwent interval debulking surgery received
3 cycles of adjuvant chemotherapy, while the seven patients
who underwent primary cytoreductive surgery each received
6 cycles of paclitaxel and carboplatin. It took 35 days
from surgery to the beginning of chemotherapy, which
is comparable to the standard time frame of 4–5 weeks
noted in the literature [12, 13]. During the period of our
monitoring, there was no recurrence in any of our patients
who had been optimally debulked. Fourteen months (a range
of 6–28 months) after surgery was the median follow-up.
Progression-free survival (PFS) intervals described in the
literature range from 14 to 18 months [14]; therefore, we
think that radical oophorectomy in situations when the POD
is obliterated could potentially result in a longer PFS.
Besides this, the described method can also be used in
other conditions like adnexal mass with obliterated Pouch of
Doughlas (POD), grade IV endometriosis, endometriomas,
previous history of multiple surgeries where there is the
presence of dense adhesions around the uterus and the usual
surgical approach is impossible [15]. Besides malignancy
Fig. 2  Image showing postoperative specimen of Type 1 radical
oophorectomy (case of advanced CA ovary with extensive disease, even in cases of distorted anatomy of the pelvis encountered
enbloc retrieval done) during surgery, this approach will prove to be beneficial.
 S. Nanda et al.

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Funding No funding received. cytoreductive surgery and HIPEC. Pleura Perit. 2019. https://​doi.​
org/​10.​1515/​pp-​2019-​0015.
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interest. retrospective study. J Ovarian Resa. 2021;14(1):1–9.
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Ethical approval Ethical approval was waived by the Institutional time of adjuvant chemotherapy and survival in ovarian cancer
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and all the procedures being performed were part of the routine care. 2017;7(1):1–8.
14 Lee MJ, Vaughan-Shaw P, Vimalachandran D. ACPGBI GI
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participants included in the study. baseline risk factors for the development of postoperative ileus
in patients undergoing gastrointestinal surgery. Ann R Coll Surg
England. 2020;102(3):194–203.
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