Overview

The normal ovary by nature is a partially cystic structure. Most ovarian cysts develop as consequence
of disordered ovulation in which the follicle fails to release the oocyte. The follicular cells continue to
secrete fluid and expand the follicle, which over time can become cystic. Ovarian cysts are quite
common and involve all age groups, occurring in both symptomatic and nonsymptomatic females. [1]Six
percent of 5000 healthy women in a study reported by Campbell et al had detectable adnexal masses
on transabdominal ultrasound. Of these, 90% were cystic with most diagnosed as simple cysts. [2]

The ovaries are the female pelvic reproductive organs that house the ova and are also responsible for
the production of sex hormones. They are paired organs located on either side of the uterus within the
broad ligament below the uterine (fallopian) tubes. The ovary is within the ovarian fossa, a space that
is bound by the external iliac vessels, obliterated umbilical artery, and the ureter. The ovaries are
responsible for housing and releasing ova, or eggs, necessary for reproduction. For more information
about the relevant anatomy, see Ovary Anatomy.

Indeed, ovarian cysts were the fourth most common gynecologic cause of hospital admissions
according to a late 1980s study by Grimes and Hughes.[3] Most cysts spontaneously resolve while
some will persist. The persistent ovarian cysts are most likely to be surgically managed. The standard
surgical approach to presumptively benign ovarian cysts is the laparoscopic ovarian cystectomy.
Indeed, it is one of the most common procedures performed by the practicing obstetrician
gynecologist.

In this article, the pathophysiology of ovarian cysts is briefly reviewed to provide a foundation for
understanding the ovary and benign cyst formation. The remainder of the article concentrates on the
patient evaluation and surgical approaches to cyst removal.

Pathophysiology of ovarian cyst formation

Obstetrician-gynecologists and surgeons most commonly encounter 3 types of benign ovarian cysts.
They include functional (follicular and corpus luteum) cysts, mature cystic teratomas, and
endometriomas. Functional cysts form in reproductive-aged females during folliculogenesis and are
either follicular or corpus luteal in origin.

The cysts occur during the process of normal female reproductive physiology, hence their functional
designation. The pathogenesis of follicular cyst formation is complex and is associated with the
release of anterior pituitary hormones. In these cases, the traditional feedback mechanisms are not
synchronized and the luteinizing hormone surge is muted. [4]

Consequently, the oocyte is not released by the follicle, which in turn fails to involute and continues to
grow, sometimes achieving cystic proportions. Corpus luteum cysts develop after ovulation through an
unknown mechanism. They can become quite large and torsed and, thus, are more likely to be
associated with pain and in some cases delayed menses. Some cysts autonomously function such as
those associated with the McCune-Albright syndrome and can achieve large sizes.

Mature cystic teratomas (MCTs) or dermoids are actually benign germ cell tumors that are partially
cystic. They can occur over a broad range of ages, yet more than 70% occur during the reproductive
years.[5] They are thought to develop from a single primordial germ cell that has completed meiosis I
and is meiosis II-suppressed.[6] This theory is supported by the anatomic distribution of teratomas
throughout the migration pathway of primordial germ cells from the yolk sac to the gonadal ridges.
[7]
MCTs are composed of all 3 germ layers: ectoderm, mesoderm, and endoderm. They are usually
unilateral, measure 2-4 cm in diameter, and are filled with thick sebaceous material, hair, calcifications
and sometimes teeth (see images below). [8] Some are even hormonally active.[9] Unlike simple cysts,
MCTs do not resolve spontaneously. Most require surgical intervention. They are more likely than
other benign cysts to be associated with ovarian torsion.

Indications
Absolute indications for ovarian cystectomy include the following: definitive diagnostic confirmation of
an ovarian cyst, removal of symptomatic cysts, and exclusion of ovarian cancer. Additional indications
include cyst size larger than 7.6 cm, cysts that do not resolve after 2-3 mo of close observation,
bilateral lesions, and ultrasound imaging findings that deviate from a simple functional cyst. Note that
both the patient's age at the time of detection and as well as cyst type can influence surgical
indications as reviewed below.

Fetal
Ovarian cysts in the developing fetus are more common than previously thought owing to their
detection by antenatal ultrasound imaging. They have been identified on routine obstetrical ultrasound
in 30-70% of fetuses, with the frequency increasing as gestation advances. [11] They are usually
unilateral and often resolve spontaneously. They originate as a consequence of ovarian stimulation
from combined maternal and fetal gonadotropins. Surgical management, including cyst aspiration, is
not usually indicated.[11, 12]

Neonatal
Ovarian cysts are thought to develop in neonates as a consequence of in utero hormonal
stimulation . They are also more common than previously thought. Approximately 30% of neonates
that underwent post mortem examination had ovarian cysts. [11] Most neonates are asymptomatic with
the cysts usually identified by ultrasound for unrelated indications. Many are simple cysts while others
are complex, rendering a benign diagnosis more difficult. They often regress spontaneously in the first
4-5 postnatal months. Cysts measuring greater than 5 cm are of concern in this age group as they
often torsed and can auto amputate. Bryan et al recommend aspiration to prevent torsion from
occurring.[11]Cystectomies are not usually indicated.

Prepubertal child
Ovarian cysts are usually seen in early childhood, age less than 6 yrs, and then again in the
peripubertal period when the hypothalamic pulse generator is the most active. Gonadotropin
stimulation of the ovary can cause some follicles to become cystic, with some cysts persisting.
[13]
Mature cystic teratomas (MCTs) represent 90% of all ovarian tumors in this age group. [5] Some cysts
are autonomously functioning and may secrete hormones such as those seen in the McCune-Albright
syndrome.[14] The presentation in the young child varies. Asymptomatic patients may present with a
palpable abdominal mass or increasing abdominal girth, while symptomatic children may present with
increasing abdominal pain.[13] McCune-Albright patients often present with signs indicative of
precocious puberty.[14] Cystectomies are not usually indicated since most resolve spontaneously.

The images below depict an ovarian cyst in a 10-month-old girl.

Ultrasound of an ovarian cyst in a 10-month-

old girl.
 Ovarian cyst in a 10-month-old girl. The
uterus and tubes are visible in the pelvis.
Menarchal adolescents and adults
Benign ovarian cysts are quite common in menarchal adolescents and adults. Most regress within 2-3
months after detection, while others persist. Features associated with persistent ovarian cysts include
cysts larger than 5 cm and complex morphologic findings on ultrasound.

The types of cysts that occur in reproductive age females differ from those encountered in early
childhood. The most common benign ovarian cysts in this population are endometriomas and MCTs.
Endometriomas are relatively common in the menarcheal teen and adult but are rarely seen in
childhood. Patients with endometriomas often present with dysmenorrhea and dyspareunia. They may
also present with pelvic pain, bloating, urinary frequency, menstrual irregularities, and/or constipation.

Young women with torsed ovarian cysts may present with nausea and vomiting along with acute
abdominal pain and require surgical intervention. MCTs are the most common ovarian neoplasms in
adolescents and account for nearly 70% of non-malignant ovarian neoplasms in females aged 30 yrs
or younger.[15] Patients with MCTs are usually asymptomatic and present with unrelated complaints.
Indeed, in this setting, the detection of MCTs is often an incidental finding. The most common
complaint in symptomatic patients is abdominal pain.[16]

The most common benign ovarian cysts seen in pregnant women are MCTs and corpus luteum cysts.
Acute complications have been reported to occur in less than 2% of these cases. [17, 18] Malignant
ovarian cysts are infrequent in reproductive-age women, occurring in 3.6-6.8% of this population. [17]

Postmenopausal
Unilocular small (< 5 cm) ovarian cysts in postmenopausal women have a low risk for malignancy.
The frequency for malignancy increases between 6-39% in this population when the cyst is large (>10
cm), has complex architecture (multilocular, thick septae, irregular cyst walls), or persists. [18] CA 125
measurements should be performed. Many postmenopausal women with large ovarian cysts are
asymptomatic because menstrual irregularities and dysmenorrhea are no longer indices of pathology.
When symptomatic, they can present with urinary frequency, constipation in addition to pelvic pain. [19]

The image below depicts a multilocular ovarian cyst.

 A 24-cm diameter multilocular right ovarian
cyst is seen with adjacent fallopian tube and uterus. The infundibulopelvic ligament carrying the ovarian artery and vein
has been divided.
Contraindications
Absolute contraindications for an ovarian cystectomy are controversial. Relative contraindications are
related to the surgical approach rather than to the cystectomy proper. Indeed, any ovarian lesion
suspicious for malignancy based on findings from the clinical history and/or physical examination,
ultrasound studies, or elevated CA 125 levels is a contraindication for laparoscopic ovarian
cystectomy, with laparotomy the procedure of choice.

Additional contraindications depend on the cyst type and the indication(s) for surgery as well as the
approach to the patient. In the 1980s, the laparoscopic approach was contraindicated in obese
patients as well as patients having previous abdominal surgeries, a bowel obstruction, or a
coagulopathy. Currently, these conditions are considered relative contraindications. The use of the
open laparoscopic technique as well as the use of optical access trocars has rendered the
laparoscopic approach safe and feasible in many patients even if they have had previous surgeries.

Although no longer a contraindication, obesity does represent additional challenges. Not only is
obesity a risk factor for anesthesia-related complications such as airway obstruction and
cardiopulmonary dysfunction, but it also poses technical challenges for the surgeon. [20]

Mature cystic teratoma of the ovary

exhibiting multiple tissue types.
 Mature cystic teratoma of the ovary with
hair, sebaceous material, and thyroid tissue.
Endometriomas are hormonally active ovarian cysts with the hormone changes corresponding to
menstrual cycle phases. The origin of endometriomas has been controversial. Nezhat and coworkers
have suggested that 2 types of endometriomas exist: primary and secondary. [10] According to the
authors, primary endometriomas originate as invaginated surface endometrial glands. They develop
slowly over time and rarely achieve sizes greater than 5-6 cm. They are quite difficult to remove from
their fibrotic capsule at the time of cystectomies. Upon microscopic examination, both endometrial
glands and stroma are identified. Secondary endometriomas originate in functional cysts, with some
having their origins in a corpus luteum. These endometriomas are the classical chocolate cysts and
contain dark blood (see image below). Secondary endometriomas can achieve quite large sizes and
can be removed easily. Microscopic examination of a well-sampled specimen often reveals a corpus
luteum, endometrial glands,andstroma.[10]

Endometriosis. Chocolate cyst of the ovary.

Contraindications
Absolute contraindications for an ovarian cystectomy are controversial. Relative contraindications are
related to the surgical approach rather than to the cystectomy proper. Indeed, any ovarian lesion
suspicious for malignancy based on findings from the clinical history and/or physical examination,
ultrasound studies, or elevated CA 125 levels is a contraindication for laparoscopic ovarian
cystectomy, with laparotomy the procedure of choice.
 Additional contraindications depend on the cyst type and the indication(s) for surgery as well as the
approach to the patient. In the 1980s, the laparoscopic approach was contraindicated in obese
patients as well as patients having previous abdominal surgeries, a bowel obstruction, or a
coagulopathy. Currently, these conditions are considered relative contraindications. The use of the
open laparoscopic technique as well as the use of optical access trocars has rendered the
laparoscopic approach safe and feasible in many patients even if they have had previous surgeries.

Although no longer a contraindication, obesity does represent additional challenges. Not only is
obesity a risk factor for anesthesia-related complications such as airway obstruction and
cardiopulmonary dysfunction, but it also poses technical challenges for the surgeon. [20]

Anesthesia
General anesthesia is indicated for both the laparoscopic and robotic-assisted techniques since both
of these procedures require the surgeon to create a pneumoperitoneum. Although either spinal or
epidural anesthesia can be used for a laparotomy cystectomy, in most cases general anesthesia is
used.

Positioning
Patient positioning is contingent upon the surgical approach of the ovarian cystectomy. For
laparoscopy and robotic-assisted techniques, the dorsal lithotomy position is the preferred position as
it easily accommodates placement of a manipulator in the uterus for proper uterine positioning during
the procedure. Either the dorsal lithotomy or the dorsal supine position can be used for laparotomy
cystectomies. Uterine manipulators are not routinely used in this approach. It has been our
experience that without the uterine manipulator, the uterus and ovaries can more easily be
exteriorized during laparotomy cystectomies, thus allowing for working outside of the pelvis. In all
cases, Foley catheter placement is important.

Ovarian Cystectomy
 Author: Lawrence S Amesse, MD, PhD, MMM; Chief Editor: Michel E Rivlin, MD more...
Updated: Jan 26, 2015

http://emedicine.medscape.com/article/1848505-overview#a1