cystectomy may be used, accompanied, just as with radical surgery, by the exploration of the cavity, omentectomy, peritoneal washing, resection of suspicious lesions, multiple peritoneal biopsies, and adnexectomy in mucinous bots. routine biopsy on the contralateral ovary is not considered necessary unless an abnormality appears macroscopically, since it increases the risk of postoperative adhesions and yet is not of great value diagnostically, since it might not produce a tumour sample, as also occurs with multiple peritoneal biopsies. with respect to adnexectomy, it should be borne in mind that this procedure appears to increase the risk of contralateral relapse. in addition, cystectomy, which produces an increased risk of recurrence on the ipsilateral ovary (31%), should be carried out only on women with bilateral tumours, with only one ovary, or on those patients who are extremely young, such that a loss of a large mass of ovarian tissue might negatively affect their fertility later on (though recent studies have obtained excellent fertility results in patients treated with unilateral salpingo-oophorectomy). the increased relapse rate after cystectomy may be caused by: intraoperative cyst rupture, the presence of a multifocal bot, or tumour margins affected after the cystectomy. most of these recurrences are borderline type, so they do not affect global survival rates. there has been much discussion as to whether conservative surgery, specifically, cystectomy, performed with laparoscopy could lead to higher relapse rates as compared with laparotomy, because of the increased risk of cyst rupture (14.9% versus 7.7%), incomplete staging, cellular dissemination, and increased trocar scarring. in spite of this, most of the studies were carried out retrospectively, so that if the laparoscopy is performed by a trained specialist, it provides such benefits as lower morbidity and fewer postsurgical adhesions, as well as less pain and a shorter hospital stay. in mucinous bots, cystectomy is not recommended as a treatment to preserve fertility due to the high risk of recurrence in the form of carcinoma (according to some studies up to 13% at ten years, compared with 2% at ten years for serous bots if not associated with invasive implants). in addition, the possibility of the co-existence of benign, borderline, and invasive cancer areas has been described in mucinous bots especially of the intestinal type, which implies that they should be carefully examined, given their great volume in some cases, and the treatment of choice will be salpingo-oophorectomy. for these reasons, mucinous bots are globally associated with a higher mortality rate. if survival is analysed according to histologic type, the worst results are found among patients with mucinous bots, with a global survival rate at ten years of approximately 94% as opposed to 96% for serous bots. for women under the age of 40 who desire to have children and present with a bot in stages ii and iii (with peritoneal implants), the surgical technique will vary according to the invasiveness of the implants: non-invasive implants are benign, so that conservative surgery may be safely used as long as total resectioning of the peritoneal implants is carried out. invasive implants: the presence of invasive implants is considered the second most relevant factor for a bad prognosis, although the majority of these implants remain stable or disappear when the primary tumour is removed. for those patients with invasive implants, radical surgery with complete re-sectioning of the implants is preferable. according to previous studies, women without invasive implants have a survival rate at 10 years of 95%, since the disease progresses in only 2% of cases. however, for patients with invasive implants, the survival rate at ten years falls to 60–70% and progression of the disease to invasive tumour occurs in 30% of cases. the risk of relapse for serious bots also depends on the invasiveness of the implants, at 11% for non-invasive implants, and rising to 45% for invasive implants at 15 years. recurrence with transformation into carcinoma may occur in up to 77% of cases, which leads to an elevated mortality rate. the debate continues over the possibility of completing the surgery in patients first treated with conservative surgery, through resectioning of the ipsilateral ovarian remnant and of the contralateral ovary as soon as these patients fulfil their childbearing desires. hysterectomy seems unnecessary for these women, since the appearance of recurrences of serous uterine tumours has not been observed. this treatment will only be indicated for those patients with bots with a high risk of recurrence (invasive implants, microinvasion, micropapillary patterns, or intracystic carcinoma). it may be possible to wait for recurrence to occur and then carry out radical surgery, since these conditions do not affect survival, probably because the majority occur in the spared ovary and can be successfully operated on. however, there is also the possibility of performing the radical surgery sooner because of the psychological impact produced by waiting for the relapse to occur, even risking recurrence in the form of an invasive tumour. surgery after recurrence table 2. factors that suggest a higher rate of invasive recurrence. serous bot with invasive implants serous bot with stromal microinvasion serous bot with micropapillary pattern mucinous bot with intraepithelial cancer mucinous bot after cystectomy peritoneal involvement after surgery there are two types of surgical treatment (table 2) for the ipsilateral ovary: conservative: all of the following requirements should be met: women < 40 years of age who want to preserve their fertility, who are committed to exhaustive follow-ups, and who do not have invasive implants. radical: for cases that present some of the following: patients > 40 years of age, their childbearing desires completed, would find it difficult to adhere to follow-up requirements, and invasive implants. when an extra-ovarian borderline or invasive relapse occurs, cytoreductive surgery as with primary ovarian cancer should be carried out. the optimum performance of this surgery is an independent prognostic factor, and will determine the patient’s survival, with death occurring in 12% of patients who were correctly treated as opposed to 60% of those who received insufficient treatment. adjuvant treatment it has not been demonstrated that adjuvant treatment (chemotherapy or radiation therapy) improves the survival rate for patients with bots. response to the usual cytotoxic agents is low, probably related to the slow proliferation of these tumours. neither do they seem to respond to oestrogen inhibitors in spite of being positive oestrogen receptors in 90% of cases. for this reason, there are no current indications for the use of chemotherapy or hormone therapy even in advanced cases. the only situation where the usefulness of chemotherapy has been demonstrated is after surgery for serous bots with invasive implants, for which cases the chemotherapy regimen used is the same as that for invasive carcinoma (consisting of a platinum-containing drug, such as cisplatin or carboplatin, and a mitotic inhibitor, such as paclitaxel or docetaxel). it appears that mutations in the kras or braf genes may produce cystoadenomas noted as serous bots, which could later evolve into low-degree serous carcinoma. in addition, mutation in the kras gene may be implicated in the origin of mucinous tumours, with their corresponding progression to mucinous carcinoma. these lines of study may serve in the development new therapeutic targets efficient for bots, since drugs and their use in this respect are yet to be fully developed. follow-ups twenty-five percent of recurrences were diagnosed after five years, though relapses may actually occur 15 years after surgery, so patients must be closely monitored for a long time. three follow-ups per year are recommended for the first two years, then one follow-up every six months during the next three to five years, and thereafter annually. close monitoring is advised for women who were treated with conservative surgery because of the high rate of relapse. follow-up visits should include clinical exploration, transvaginal ultrasound, and ca125 levels, even though some authors have suggested adding ca19.9 since it appears that some mucinous tumours do not mark ca125. the importance of blood markers is controversial especially at early stages, since in earlier publications, only 40% of women diagnosed with a stage i bot had elevated levels of ca125, but if we look at the figures for stages ii–iv the percentage rises to 83%. when a relapse is suspected, transvaginal ultrasound is the test of choice, and may be accompanied by a pelvic rm. if evolutive peritoneal or extra-peritoneal disease is suspected, patient testing may also include ct scan or pet.