1. Patient characteristics
During the study period, 147 women with BOTs who received primary fertility-sparing surgical treatment were documented (Fig. 1). Excluded were the women whose surgery details were missing and those who were lost to follow-up within one month after the initial surgery. Finally, 132 women were included in the study (Table 1). Of the 132 patients, 54 undergone CSS and 78 undergone ISS. There were no significant differences in terms of age, histological type, peritoneal implantation, IFGO stage and postoperative chemotherapy between the two groups. There were significant differences in surgery procedure (p < 0.001).
Table 1
Baseline characteristics of patients
| CSS(n = 54) | ISS(n = 78) | p value |
Age (mean ± SD) | 27.00 ± 5.987 | 27.95 ± 5.422 | 0.345 |
Histological type (%) | | | 0.254 |
serous | 30(55.6%) | 51(65.4%) | |
mucinous | 24(44.4%) | 27(34.6%) | |
Peritoneal implantation (%) | | | 0.635 |
yes | 10(18.5%) | 12(15.4%) | |
no | 44(81.5%) | 66(84.6%) | |
FIGO stage (%) | | | 0.098 |
IA + IB | 36(66.7%) | 62(79.5%) | |
≥IC | 18(33.3%) | 16(20.5%) | |
Infertility (%) | | | 0.635 |
yes | 8(14.8%) | 14(17.9%) | |
no | 46(85.2%) | 64(82.1%) | |
Postoperative chemotherapy (%) | | | 0.458 |
yes | 11(20.4%) | 12(15.4%) | |
no | 43(79.6%) | 66(84.6%) | |
Surgery procedure (%) | | | < 0.001 |
UA | 41(75.9%) | 32(41.0%) | |
UC | 3(5.6%) | 31(39.7%) | |
UA + CC | 10(18.5%) | 7(9.0%) | |
BC | 0(0.0%) | 8(10.3%) | |
Survival state | | | 1.000 |
dead | 1(1.9%) | 1(1.3%) | |
alive | 53(98.1%) | 77(98.7%) | |
OS(months) | 65.049 ± 26.077 | 75.856 ± 43.269 | 0.076 |
Recurrence | | | < 0.001 |
yes | 7(13.0%) | 40(51.3%) | |
no | 47(87.0%) | 38(48.7%) | |
DFS(months) | 61.113 ± 26.023 | 49.431 ± 36.261 | 0.033 |
CSS: completely staging surgery |
ISS: incompletely staging surgery |
SD: standard deviation |
FIGO: International Federation of Gynecology and Obstetrics |
UA: unilateral adnexectomy |
UC: unilateral cystectomy |
UA + UC: unilateral adnexectomy with contralateral cystectomy |
BC: bilateral cystectomy |
OS: overall survival |
DFS: disease-free survival |
2. Oncologic outcomes
The median follow-up was 67.233 (range: 8.60–223.40) months. For the entire series, 47 patients (47/132 35.6%) had recurrence at 3.77 to 145.60 months after the initial surgery. The median interval of disease-free survival was 50.583 months. There were two disease-related deaths, and other patients were alive until the end of the follow-up. The total 5-year disease-free survival and overall survival rates were 69.6% and 99.2%, respectively. Chi-square analysis and Kaplan-Meier analysis showed no significant differences in overall survival between the CSS and ISS groups (p = 1.000 and 0.716, respectively) (Table 1 and Fig. 2a). The recurrence rate was significantly higher in the ISS group than the CSS group (51.3%% vs. 13.0%, p < 0.001). The Kaplan-Meier analysis revealed that the CSS group suffered fewer relapses and longer disease-free survival time than the ISS group (p = 0.003) (Fig. 2b).
3. Obstetric outcomes
Telephone interviews were conducted with all 132 patients (including the family members of the two dead patients) after FSS. Among them, 70 attempted to conceive were included in this part of the study (Table 2) and 62 women who did not try to conceive were removed. There were no significant differences in terms of staging surgery, IFGO stage, histological type, peritoneal implantation, postoperative menstruation, chemotherapy and infertility between the live birth group and the non-live-birth group. The two groups had significant differences in age and surgery procedure (p = 0.047 and 0.032, respectively).
Table 2
Characteristics of patients who attempted to conceive after the FSS
| Women with live births (n = 34) | Women without live births (n = 36) | p value |
Age (mean ± SD) | 26.62 ± 3.908 | 28.64 ± 4.402 | 0.047 |
Staging surgery | | | 0.385 |
CSS | 9(26.5%) | 13(36.1%) | |
ISS | 25(73.5%) | 23(63.9%) | |
Surgery procedure (%) | | | 0.032 |
UA | 19(55.9%) | 14(38.9%) | |
UC | 13(38.2%) | 10(27.8%) | |
UA + CC | 2(5.9%) | 8(22.2%) | |
BC | 0(0.0%) | 4(11.1%) | |
IFGO stage (%) | | | 0.705 |
IA + IB | 25(73.5%) | 25(69.4%) | |
≥IC | 9(26.5%) | 11(30.6%) | |
Histological type (%) | | | 0.246 |
serous | 25(73.5%) | 28(77.8%) | |
mucinous | 9(26.5%) | 8(22.2%) | |
Peritoneal implantation | | | 0.231 |
yes | 7(20.6%) | 12(33.3%) | |
no | 27(79.4%) | 24(66.7%) | |
Postoperative menstruation | | | 0.845 |
regular | 20(58.8%) | 22(61.1%) | |
irregular | 14(41.2%) | 14(38.9%) | |
Chemotherapy | | | 0.208 |
yes | 6(17.6%) | 11(30.6%) | |
no | 28(82.4%) | 25(69.4%) | |
Infertility (%) | | | 0.231 |
no | 27(79.4%) | 24(66.7%) | |
yes | 7(20.6%) | 12(33.3%) | |
FSS: fertility-sparing surgery |
CSS: completely staging surgery |
ISS: incompletely staging surgery |
SD: standard deviation |
FIGO: International Federation of Gynecology and Obstetrics |
UA: unilateral adnexectomy |
UC: unilateral cystectomy |
UA + UC: unilateral adnexectomy with contralateral cystectomy |
BC: bilateral cystectomy |
To find out the factors affecting the live birth intervals after FSS, all the listed covariates in Table 3 were entered into the initial Cox proportional hazard model with backward logistic stepwise regression method. The final hazard regression model (Table 3) showed that age, surgery procedure and chemotherapy was statistically related to live birth intervals after FSS. Yet only age was identified as the independent risk factor for patients’ live births in the multivariate analysis (adjusted odds ratio = 0.902, 95%CI 0.823–0.988, p = 0.027). Adjusted analysis was not possible for BC because no cases were observed in the BC group.
Table 3
Cox proportional hazard regression models for live birth intervals.
| p value | 95% CI |
Age | 0.027 | 0.823–0.988 |
Surgery procedure | 0.479 | |
UC | 0.626 | 0.408–1.715 |
UA + CC | 0.117 | 0.070–1.345 |
BC | 0.979 | |
Chemotherapy | 0.111 | 0.191–1.185 |
UC: unilateral cystectomy |
UA + UC: unilateral adnexectomy with contralateral cystectomy |
BC: bilateral cystectomy |
Univariate and multivariate analysis showed no statistical differences in live births between CSS and ISS. The live birth rate was 40.9% (9/22) in CSS, compared with 52.1% (25/48) in ISS group, indicating no statistical significance (p = 0.385) between the two groups. The crude odds ratio for CSS was 0.885 (p = 0.755, 95% CI: 0.411–1.903); the adjusted odds ratio decreased to 0.848 (p = 0.700, 95% CI = 0.366–1.963) after the adjustment for age, chemotherapy and surgery procedure.
Of the 70 patients who attempted to conceive after FSS, 34 patients (48.5%) gave birth successfully. Live birth intervals after FSS was 31.86 ± 19.325 (range: 4.93–82.17) months. Two patients had UA during pregnancy and gave birth successfully. Among the 34 patients who gave birth, 27 (27/34, 79.4%) were conceived naturally, while seven (7/34, 20.6%) underwent ovulation induction and in vitro fertilization (IVF) treatment. These pregnancies resulted in 31 full-term deliveries and three premature deliveries. Nineteen patients had cesarean section and 15 had spontaneous delivery. The hydatid mole was seen in one case, and ongoing pregnancy in one at the time of analysis.