Management of adnexal masses: role and risk of laparoscopy

Laparoscopic surgery has become the gold standard in the treatment of benign adnexal masses, whereas laparotomy remains the standard for the treatment of malignant tumors. The laparoscopic management of adnexal masses remains controversial because of the potential risks of cancer dissemination suggested by many case reports and national surveys. Experimental data show potential advantages and disadvantages for the laparoscopic treatment of gynecologic cancer. Since the risk of dissemination appears high when a large number of malignant cells are present, adnexal tumors with external growths and bulky lymph nodes may be considered contra-indications to CO(2) laparoscopy. Surgical diagnosis is the key to adequate management of adnexal masses. In our experience, laparoscopic diagnosis of malignancy is reliable after a careful pre-operative evaluation has been performed. Moreover, national surveys have revealed that despite suspicious laparoscopic findings, many malignant masses were considered benign at the outset. Using strict guidelines, laparoscopic diagnosis can be proposed for both non-suspicious and complex masses, thus avoiding many unnecessary laparotomies for benign masses suspicious at ultrasound. The more controversial limits of laparoscopic treatment are discussed. If a laparotomy was performed for all masses suspicious at surgery, 80% of the cases would be treated by laparoscopy. The role of laparoscopy for restaging and second-look operations for ovarian cancer requires further evaluation.