The Fallopian Tube in the 21st Century: When, Why, and How to Consider Removal.

In January 2015, based on the available data on ovarian carcinogenesis and the safety of salpingectomy, both the American College of Obstetricians and Gynecologists (ACOG) and the American Cancer Society (ACS) recommended that surgeons should discuss the potential benefits of the prophylactic removal of the Fallopian tubes (FTs) for permanent contraception or during surgeries for benign pathologies with every woman at population risk for ovarian cancer (OC) [1, 2]. This is a potential revolution. Until the end of the 20th century, salpingectomy was considered to be an unworthy appendix of more complex gynecological surgeries or as an “emergency” measure to treat life-threatening conditions such as ruptured tubal pregnancies. However, increasing amounts of data are becoming available about the safety and efficacy of salpingectomy for the treatment of benign, malignant, and premalignant pathologies and the lack of any detrimental effects on ovarian hormonal functions. Inflammatory diseases are the most important benign tubal disorders because of their frequency, consequences, and severity [3]. Often the infectious processes ascend from the lower genital tract, extend to the tube, and reach the peritoneal cavity, leading to pelvic inflammatory disease [3]. Such infections typicallybecomechronic andcausepermanent occlusion and enlargements of the tube (hydrosalpinx) that distort the reproductive pelvic architecture and cause infertility [4]. In tubal factor infertility caused by bilateral hydrosalpinx, in vitro fertilization (IVF) is now considered the first option rather than attempting to restore tubal function [5]. However, the hydrosalpinges themselves adversely affect IVF outcomes by reducing the implantation rate and increasing the risk of miscarriage. Laparoscopic salpingectomy has been demonstrated to be an effective option for avoiding this negative reproductive interference. When laparoscopy is not recommended, hysteroscopic insertion of a specific device seems to be an alternative for the management of hydrosalpinx prior to IVF. Recently, a systematic review and meta-analysis of studies comparing the pregnancy outcomes of hydrosalpinx patients treatedwithsalpingectomyversusthose treatedwithproximal tubal occlusion prior to IVF showed comparable responses to controlled ovarian hyperstimulation and pregnancy outcomes between the groups, demonstrating that salpingectomy does not worsen the reproductive prognosis of patients for whom excisional surgery is chosen [3]. The other relevant benign condition that affects the FTs is ectopic pregnancy (EP). Between 1% and 2% of live births in developed countries are complicated by EP, in which the embryo implants outside the uterine cavity [6]. At least 93%of ectopic pregnancies are located in a FT. EP can be a lifethreatening condition, and it is responsible for 6% ofmaternal deaths during the first trimester of pregnancy. Fertility following EP is dependent on several factors, the most importantofwhich is aprior historyof infertility,whereas treatment choice does not seem to play a significant role. Recently, amulticenter randomized trial involvedwomenwith EP and a healthy contralateral tube who were randomly assigned to receive either salpingotomy or salpingectomy [7]. In this study, the cumulative ongoing pregnancy rates were not significant different between salpingotomy and salpingectomy. However, persistent trophoblasts occurred more frequently in the salpingotomy group than in the salpingectomy group (7% vs.,1%, relative risk: 15.0). Historically, primitive malignancies of the FT were described as rare. In women with advanced peritoneal carcinoma, the involvement of the ovary usually hides and incorporates the Fallopian tube and results in a diagnosis of ovarian primary carcinoma. However, recent studies have led to the development of a new theory about the pathogenesis of epithelial OC that classifies type II neoplasms as cancers that are typically genetically unstable, aggressive, and present in advanced stages. Among these cancers, highgrade, serous cancer (HGSC) is the most common OC and is responsible for a higher death rate than the other types. Interestingly, the newproposed theory shifts the early events of carcinogenesis to the FT instead of the ovary, suggesting that type II tumors derive from the epithelium of the FT, whereas clear cell and endometrioid tumors derive from endometrial tissue migrating to the ovary by retrograde menstruation [8]. These observations have primarily been collected from women carrying BRCA1/2 mutations and undergoing prophylactic salpingo-oophorectomy. In these women, most of the incidentally diagnosed intraepithelial precursors of