Concurrent vNOTES risk reducing bilateral salpingo-oophorectomy at the time of mastectomy in women with breast cancer and BReast CAncer (BRCA) gene mutation

Objective

Women with breast cancer and BRCA gene mutation should be offered bilateral risk reducing salpingo-oophorectomy (RRBSO) due to lifetime ovarian cancer risk. Laparoscopic BSO, either concurrently or following index mastectomy, is benchmark but vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) gaining traction as an alternative route. We report three novel cases of simultaneous “dual site” surgery in women with breast cancer and BRCA inheritance.

Methods

vNOTES RRBSO is performed prior to breast surgery during the “dual site” procedure. As recommended by National Comprehensive Cancer Network, salpingectomy was completed to the level of cornu and ovarian pedicle was excised distally to include 2 cm margin. Peritoneal cytology was obtained and bowel, omentum, appendix and pelvic organs were inspected. Data collected included age, BMI, Ca-125 levels, duration of surgery, estimated blood loss, length of stay, 24 hour VAS, peri-operative complications, sexual function (FSFI-6), and recovery status (RI-10).

Results

Three women underwent concomitant vNOTES RRBSO and mastectomy. Median operative time and postoperative stay were 45 mins and 26 hours and there were no complications. Sexual function appeared unaffected by the vNOTES approach (FSFI-6 median score 6 vs 4) and normal activity resumed within 23 days. Histology of fallopian tubes and ovaries was benign.

Conclusion

Concomitant vNOTES RRBSO and mastectomy avoids a second surgical admission and repeat anaesthesia and does not appear to delay recovery. Findings support adoption of vNOTES as a patient-friendly alternative which can be performed concurrently with mastectomy.