[Prevention of port-site metastasis after laparoscopy]

Port-site metastasis is a major complication of surgical laparoscopy for gynaecologic oncology. Aetiology of port-site metastases is multifactorial. Surgical conditions and laparoscopic environment were determinant. Several means of prevention were evaluated to prevent occurrence of port-site metastases. Aim of this review is to report optimal surgical conditions, laparoscopic environment and means of prevention to decrease risk of port-site metastases.

[Open laparoscopy: analysis of complications due to first trocar insertion]

OBJECTIVE

To evaluate the complications of open laparoscopy during the set-up of laparoscopy in gynecologic surgery.

DESIGN

Retrospective study performed between February 1994 and January 2001 in a University Centre.

PATIENTS AND METHODS

1,562 patients underwent open laparoscopies. Procedures were performed by 8 gynaecological surgeons. Peri- and postoperative complications were assessed and analysed.

RESULTS

Major injuries concerned gastrointestinal tract: 2 perforations with immediate diagnosis and one postoperative occlusion treated by delayed laparotomy (0.19%). No death occurred. No vascular injuries and no bladder complications were noted.

CONCLUSION

We recommend open laparoscopy because of its innocuity and easiness. Advantages concern decrease of major vascular injuries and early recognition of bowel injuries.

Impact of different gases and pneumoperitoneum pressures on tumor growth during laparoscopy in a rat model

BACKGROUND

The influence on intraperitoneal tumor growth of the choice of gas and pneumoperitoneum pressure during laparoscopy is still unknown. This study compared tumor growth after laparoscopy with different gases and pneumoperitoneum pressures in an immunodeficient model.

METHODS

In an initial experiment, 60 nude rats were randomly allocated to undergo laparoscopy at different pneumoperitoneum pressures (gasless, 4 mmHg, or 8 mm Hg.) In a second experiment, 23 nude rats were randomly allocated to undergo laparoscopy with different gases (carbon dioxide or helium). Surgery was carried out 7 days after intraperitoneal injection of IGR-OV1 cells. The rats were killed 7 days after surgery. Tumor growth was assessed by the weight of the omental metastasis. For statistical analysis, we used analysis of variance (ANOVA).

RESULTS

Mean omental weight was similar for all groups, regardless of the pneumoperitoneum pressure (p = 0.86) or the type of gas (p = 0.80).

CONCLUSION

Physical parameters of gas have a limited impact on tumor growth.

Peritoneal closure reduces port site metastases: results of an experiment in a rat ovarian cancer model

BACKGROUND

The arm of this study was to assess the role of peritoneal closure in the prevention of port site metastasis after carbon dioxide (CO2) CO2 pneumoperitoneum.

METHODS

We developed a xenograft ovarian cancer model by intraperitoneal injection of 27 106 IGR-OV1 line cells in nude rats Seven days after the inoculation, the animals underwent a CO2 pneumoperitoneum. At the end of the procedure, port sites were randomly closed either with suture of peritoneum (n = 14, group A) or without suture of peritoneum (n = 12, group B). The rats were killed 7 days after surgery and their port site scars were resected. Tumor implantation was assessed by a pathologist who was blinded to the type of wound closure.

RESULTS

The animals in group B were significantly more likely to have at least one port site metastasis frequent (seven of 12, or 58.3%) than those in group A (two of 14, or (14.3%) (p = 0.037). Port sites with metastases were seen more frequently in group B (eight of 24, or (33.3%) than in group A (three of 28, or 10.7%) (p = 0.046).

CONCLUSIONS

Our results shows that peritoneum closure decreases the risk of port site metastasis.

Synthesis of the first ferrocene-labeled dideoxynucleotide and its use for 3'-redox end-labeling of 5'-modified single-stranded oligonucleotides

The target ferrocene-labeled dideoxynucleotide compound 5-[N-(beta-ferrocenyl-propanoyl)3-amino-propyn-1-yl]-2',3'-dideoxyuridine 5'-triphosphate, Fc-ddUTP, was synthesized and tested with terminal deoxynucleotidyl transferase for enzymatic 3'-redox-active end-labeling of 5'-phosphorylated single-stranded oligodeoxynucleotides. Starting from readily available 5-iodouridine and 3-ferrocenylpropanoic acid, the synthetic strategy elaborated here follows a mild multistep route. Each step involves reliable methods, and all ferrocene intermediates can be easily purified. Enzymatic 3'-ferrocene end-labeling of 5'-phosphorylated oligonucleotides is remarkably efficient, and 3'-ferrocene-labeled oligonucleotides can thus be prepared in sufficient amounts for further use in surface modifications.

Risk of discovering endometrial carcinoma or atypical hyperplasia during hysteroscopic surgery in postmenopausal women

STUDY OBJECTIVE

To assess the risk of diagnosing endometrial carcinoma or atypical hyperplasia in tissue resected during hysteroscopy performed for intrauterine pathology presumed benign in postmenopausal women.

DESIGN

A single-center prospective study (Canadian Task Force classification II-2).

SETTING

Department of Gynecology, La Conception Hospital, Marseille, France.

PATIENTS

Three hundred twenty-five women with intrauterine pathology, presumed benign, causing postmenopausal bleeding or bleeding related to hormone replacement therapy.

INTERVENTION

All women had an endometrial biopsy after diagnostic hysteroscopy to exclude endometrial carcinoma or atypical hyperplasia. Then they underwent hysteroscopic surgical resection (203, 62.5%) or endometrial ablation (122, 37.5%).

MEASUREMENTS AND MAIN RESULTS

Two cases each (0.6%) of endometrial carcinoma and endometrial atypical hyperplasia were discovered that were missed by preoperative evaluations.

CONCLUSION

Outpatient hysteroscopy and endometrial biopsy do not eliminate the finding of carcinoma or endometrial atypical hyperplasia, as these disorders may be discovered during hysteroscopic surgery.

Port-site recurrence following laparoscopic para-aortic lymphadenectomy for squamous carcinoma of the cervix

A port site tumour recurrence (PSR) followed laparoscopic para-aortic lymphadenectomy in a 46-year-old woman with stage IIb squamous carcinoma of the cervix. It occurred at the site used for removal of affected lymph nodes 7 months after surgery and completion of radiation and chemotherapy. It was associated with an increase in the size of tumour.

Endometrial biopsy during outpatient hysteroscopy: evaluation and comparison of two devices

OBJECTIVE

Association of office hysteroscopy with outpatient endometrial biopsy is interesting to evaluate correctly endometrium. Purpose of this study was to evaluate and compare two endometrial biopsy devices during outpatient hysteroscopy, based on effectiveness and tolerance of the procedure.

STUDY DESIGN

A single blind, randomised prospective study.

RESULTS

200 patients were randomised into two groups following outpatient hysteroscopy: 100 were biopsied with Vacurette and 100 biopsed with Pipelle. Pipelle was less painful compared to Vacurette (1.1+0.2 versus 1.6+0.3; P<0.001), no matter hormonal status (1+0.3 versus 2+0.6; P<0.001 in premenopausal subgroup and 1+0.3 versus 1.4+0.3; P<0.001 in postmenopausal subgroup). Vacurette was more effective than Pipelle (64/100 versus 48/100; P=0.02), in case of normal or hypertrophic endometrium (56/72 (77%) versus 40/65 (61%); P=0.04) but not in case of atrophic endometrium (8/28 (29%) versus 8/35 (23%); P=0.6). Among the 112 patients with adequate sample, histologic results were normal, except for three cases of endometrial hyperplasia. Among the 88 patients with inadequate sample, 47 (53%) presented an atrophic endometrial aspect at hysteroscopy, whereas 41 (47%) were considered as normal.

CONCLUSIONS

Vacurette was more effective though more painful than Pipelle. Both instruments were, however, well tolerated. Both instruments were not very effective in case of atrophic endometrium. Outpatient hysteroscopy combined with endometrial biopsy may help avoid further investigations.

Influence of peritoneal factors on port-site metastases in a xenograft ovarian cancer model

OBJECTIVE

We determine the main physical effects of pneumoperitoneum on tumour dissemination and port-site metastases occurrence.

DESIGN

A prospective randomised study in rats.

METHODS

A human ovarian cancer cell line (IGR-OV1) was xenografted in nude rats. Seven days after cancer inoculation, surgery was performed. Rats were randomised in two main groups and underwent either: gasless laparoscopy (n = 20) CO2 laparoscopy with pneumoperitoneum pressure at 4 mmHg (n = 20), or 8 mmHg (n = 20) with in each case, increasing operative duration: 30,60,90 or 120 minutes (five rats for each time). Animals were killed seven days after the intervention.

MAIN OUTCOME MEASURES

Tumour dissemination and frequency of port-site metastases.

RESULTS

Tumour dissemination was not influenced by gas pressures or duration of procedure. The rate of rats with at least one port-site metastasis (one or two) was similar in all groups: gasless: n = 10/20; 4 mmHg CO2: 5/20; 8 mmHg CO2: 7/20,(P = 0.26). The number of port-site metastases were significantly higher in the gasless group compared with the 4 mmHg CO2 group (15/40 (37.5%) vs 5/40 (12.5%), P = 0.01). Difference was not significant between the 8mmHg group and the gasless group (9/40(22.5%) vs 15/40(37.5%), P = 0.14) or the 4mmHg group (9/40(37.5%) vs 5/40 (12.5%), P = 0.24). Duration of procedures had no significant influence on port-site metastases rate (P > 0.05).

CONCLUSIONS

Unlike previous animal studies, port-site metastases were more frequent with gasless laparoscopy than with CO2 pneumoperitoneum. Local peritoneal factors could play an important role in port-site metastases mechanism.

Effect of pneumoperitoneum on circulating tumor DNA

BACKGROUND

Release and circulation of tumor DNA could be favored by surgery. No data is available for the effect of laparoscopy on this phenomenon.

MATERIAL AND METHODS

The aim of this study was to assess the impact of CO2 laparoscopy on circulating tumor DNA. Two xenografts of ovarian cancer were obtained by intraperitoneal inoculation (IP) of IGR-OV1 or NIH:OVCAR-3 cells in nude rats. CO2 laparoscopy (L), gasless laparoscopy (GL), midline laparotomy (ML) or general anesthesia as a control (C) were randomly carried out when the tumor graft was present in the peritoneal cavity. A sterile blood sample was taken in each case as soon as the experiment was completed. DNA was subsequently extracted and amplified (PCR, primers HLA GH 26 and HLA GH 27 specific for human DNA). In each model, we compared the influence of each surgical approach on circulating tumor DNA. Statistics were performed with the Wilcoxon test and Fisher exact test. 1:

RESULTS

Eighteen rats were included in each group. Our protocol could detect an amount of tumor DNA equivalent to 10 cells/ml of blood. This technique was specific. Circulating tumor DNA was frequently observed in the IGR-OV1 model (45 to 50%), without significant difference between groups (p=0.6). In the NIH: OVCAR-3 model, the detection rate ranged from 22% (control group) to 64% (gasless group); but the overall comparison between the four groups was not significant (p = 0.2).

CONCLUSION

In this experimental trial, CO2 laparoscopy had no deleterious effect on circulating tumor DNA. Biologic characteristics of tumors could also play a role.

[Vaginal hysterectomy:apropos of a series of 1008 interventions]

STUDY AIM

The aim of this study was to analyse our vaginal hysterectomies performed for prolapsed uterus and non prolapsed uterus with benign disease. For the latter indication, a comparison was made with abdominal hysterectomy.

PATIENTS AND METHODS

From february 1986 to december 1998, 1008 vaginal hysterectomies were performed in our department: 219 for prolapsed uterus and 789 for non prolapsed uterus with benign disease. During the same time, 217 abdominal hysterectomies were performed for non prolapsed uterus with benign disease.

RESULTS

Intra-operative and post-operative complications had the same rates in the two groups. Owing to the low number of abdominal hysterectomies, we cannot draw a valuable conclusion. The study of the literature shows in this field an advantage for the vaginal hysterectomy; mean time hospitalization was shorter in the vaginal group.

CONCLUSION

Advantages of vaginal hysterectomy are multiple: aesthetic, shorter hospitalization, quicker recovery. The low rate of vaginal hysterectomy on non prolapsed uterus with non malignant disease is linked with the lack in training of surgeons for the vaginal approach. In these cases, a rate of 70% is a realistic one in a well trained hospital center.

[Evaluation of cost of laparoscopic surgery in gynecology]

The objective of this work was to evaluate hospital and postoperative costs associated with gynecologic laparoscopic surgery for benign pathologies. Hospital costs were broken down into several categories: operating room, postoperative hospitalization, pharmacy, surgical instruments, sterilization of reused equipment, food and laundry, indirect costs. The mean total costs for the hospitalization time were 8547,2 francs. Medical charges in recovery time were calculated with the help of the Social Security. These charges represented less than 5% of the total cost associated with the procedure.

Vaginal birth following two previous cesarean sections

OBJECTIVE

To evaluate the management of vaginal delivery among women with two previous cesarean sections. The maternal and fetal morbidities of this attitude were studied.

SETTING

University hospital.

DESIGN

Retrospective study made over 6 years, from January 1st 1990 to December 31st 1995.

PATIENTS

Among 180 patients with two uterine scars, 96 patients with cephalic presentation and normal pelvic dimensions were allowed trial of labor.

RESULTS

The rate of vaginal birth following trial of labor was 65.6%. Three patients had an uterine scar dehiscence; among them, one hysterectomy was performed for haemorrhage with uterine atony. Neonatal issue was always favorable. Twenty-two newborns had superior birthweights compared to those born from the preceding cesarean section.

CONCLUSION

Trial of labor following two previous cesarean sections is acceptable in the majority of cases. It leads to a high vaginal delivery rate and low maternal and fetal morbidity.

[Port-site metastases following laparoscopic surgery]

Laparoscopy for malignancy resection has been followed by description of metastatic laparoscopic port sites. Recently published clinical, experimental studies and case reports related to this problem are reviewed. Frequency of port-site metastases for gallbladder, colorectal and ovarian cancers seem to differ. Ascites and staging during laparoscopy are probably risk factors for port-site metastases. Clinical presentations of port-site metastases are exposed and experimental studies show that pneumoperitoneum, nature of gas as well as local factors were probably implicated. Hypothetical mechanisms of port-site metastases are discussed; it is likely that the aetiology are multifactorial. Preventive strategies of port-site metastases are proposed. Further research in this area is necessary to understand mechanisms of port-site metastases.

Hysteroscopic resection of endometrial polyps: a study of 195 cases

OBJECTIVE

To ascertain the therapeutic efficiency of hysteroscopic resection for the treatment of endometrial polyps in women with abnormal uterine bleeding and postmenopausal metrorrhagia.

SETTING

University hospital.

DESIGN

Retrospective consecutive patient follow-up.

MATERIAL AND METHODS

From 1987 to 1997, 195 patients with haemorrhagic endometrial polyps were treated with hysteroscopic resection in our department.

RESULTS

Five complications occurred, but no major complications were noted. A total of 89.2% of the patients remained in contact after hospitalization. After long term follow-up (5.2 years), successful results were obtained in 80% of the patients with polyp resection without associated endometrial ablation. Further surgery (hysterectomy) was required in only five women.

CONCLUSION

Transcervical resection is the gold standard for treatment of endometrial polyps.

[Value of endocervical margin examination of conization specimens. Prospective study conducted on 150 patients]

OBJECTIVE

To assess the usefulness of frozen sections (FS) on endocervical margin in surgical conization or loop electrosurgical specimens.

MATERIAL AND METHODS

In a prospective study, 150 patients were treated from October 1995 to December 1997: 69 cases without FS, 81 cases with FS. CIN on frozen section resulted in an immediate additional resection.

RESULTS

In the group without FS, 13 patients had involved endocervical margin by high-grade CIN (18.8%). Frozen section was impossible in a conization specimen that was too short. FS revealed 64 normal glandular epitheliums, seven squamous metaplasias in which two lesions were under-evaluated (being in fact CIN on permanent sections), eight high-grade CIN followed by additional resection in six cases and two invasive carcinomas. Endocervical margin on additionals section were always free of disease. The rate of failure was 2.6% among 77 cases. This rate corresponded to two under-evaluations. Invasive carcinoma and CIN without additional resection were excluded because frozen section only allowed a peroperative diagnosis. The average height of the cone and the rate of complications were similar. Repeat surgery was necessary in nine cases in the group without frozen section, in which five showed residual lesions, absent in the other group.

CONCLUSION

The ultimate histological interpretation was never difficult after frozen section. This method permits reduction of cases with involved cone margin and residual lesions and, despite some limitations, it may be useful for surgical management.

[Conization with positive margins: what strategy should be adopted?]

OBJECTIVE

To define recommended treatment in cases of positive margins on cone biopsy specimens.

PATIENTS AND METHODS

This single-center retrospective study concerned 220 conizations performed between January 1996 and June 1998. The results of 70 conizations (31.8%) with positive margins were analysed. There were 32 cold knife conizations (mean age: 43 years) and 38 conizations by the loop electrosurgical excision procedure (mean age: 33 years).

RESULTS

Mean depth of conization was 15.94 mm for cold knife conization and 10.08 mm for loop electrosurgical conization. Fifteen patients were excluded (5 with invasive cancer and 10 were lost to follow-up). This study included 55 patients with a mean 12-month follow-up. Six underwent hysterectomy for mini-invasion on the specimen or advanced age. Eleven underwent a second conization (followed by hysterectomy in 2 cases). The other 38 patients were submitted to simple surveillance with cervico-vaginal cytology and colposcopic examination. The rate of residual lesions (cervical intra-epithelial neoplasia: CIN 3) after conization with positive margin was 14.5% (n = 8).

CONCLUSION

Residual persistent dysplasia is not present in all patients after conization with positive margins. Cytology and colposcopy allow detection of dysplasia, indicating the need for a second conization. In women with no desire for further pregnancy, systematic repeat surgery must be recommended.

[Malaria in Vietnam: what is the awareness of risk for travel in 2000?]

Increasing numbers of people are travelling to Vietnam. From december 1st 1998 to april 31 1999, we surveyed by questionnaire 191 travellers who consulted at health centres attached to French diplomatic representations (Hanoi, Ho-Chi-Minh Ville) in order to evaluate their prophylaxis practices with regard to malaria; 59% of these travellers were taking no preventive measures whatsoever, while the rest were following an often ill-adapted treatment.

Hysteroscopic metroplasty for septate uterus and repetitive abortions: reproductive outcome

OBJECTIVES

The aim of this study is to assess fertility outcome and obstetrical prognosis of 63 patients after hysteroscopic section of uterine septa.

MATERIALS AND METHODS

This is a retrospective study about 63 patients consulting for septate uterus and repeated pregnancy loss or abnormal fetal presentation between January 1988 and December 1996 in La Conception hospital in Marseille. Septal lysis was performed with microscissors or resectoscope. Statistical analysis was performed using the CHI2-test.

RESULTS

The anatomical result was considered satisfactory in 57.1% of cases. Forty-five pregnancies were obtained, two after an IVF-program in 56 patients. Twenty-eight living children were born: twenty-six at term. Twenty patients delivered normally. Two women are still pregnant. Obstetrical prognosis of these patients is statistically improved by the treatment (P=0.001).

CONCLUSION

Obstetrical prognosis of patients presenting repeated pregnancy loss and septate uterus is statistically improved by hysteroscopic metroplasty.

The new techniques of gynaecologic laparoscopy. Gasless, open Hasson, optic trocar

BACKGROUND

New techniques of laparoscopy: gasless, open Hasson, optic trocars allow to avoid the risks of vessel and bowel injuries. The objective of this study was to evaluate the capability of a retractor system as an alternative to conventional technique without pneumoperitoneum and to assess if the system facilitates the use of conventional surgical instruments during gynaecological surgery.

METHODS

DESIGN

Prospective evaluation.

SETTING

University-affiliated county hospital.

PATIENTS

Gasless laparoscopy surgery was performed on 49 patients between December 1995 and July 1996 with a retractor system without pneumoperitoneum consisting of an intrabdominal retractor using conventional surgical and laparoscopic instruments and to enable a simultaneous vaginal approach.

RESULTS

Gasless laparoscopy was successful in 44 (90%) of cases. A simultaneous vaginal approach was used in one third of indications including vaginal myomectomy and laparoscopic assisted hysterectomy. Conversion to laparotomy was required in 5% of cases. Mean procedure duration was 90 minutes and mean hospitalisation time was 5.7 days.

CONCLUSIONS

The introduction of new techniques of laparoscopy: gasless, open Hasson, optic trocars has broadened the application of operative laparoscopy. Gasless technique in lieu of conventional laparoscopy can be performed reliably and safely for most gynaecological indications. The most outstanding benefit of this method is that it can be combined with a vaginal approach which is not possible using a pneumoperitoneum due to gas leakage. The place of gasless laparoscopy will depend on continuing development by instrument manufacturers, in order to achieve an instrument providing vision as good as that seen with the pneumoperitoneum.

[Evaluation of two methods for endometrial sampling during diagnostic hysteroscopy]

OBJECTIVE

To compare two endometrial sampling devices, pipelle and vacurette, performed during hysteroscopy, based on the quality of material obtained and pain during the sampling.

PATIENTS AND METHODS

During the period from 01.03.96 to 01.12.97, 200 patients were consecutively randomized in a single blind prospective study. Efficacity was evaluated on the quality of material obtained and pain was graded on a scale of 0 to 5.

RESULTS

On the average the Vacurette was more painful (1.6 vs 1.1, p = 0.01). Vacurette biopsy was more effective than pipelle biopsy (64% vs 48%, p = 0.05). There was a significative difference of efficacity in the post-menopausal group (34% vs 13%, p = 0.05), but not in the pre-menopausal group (76% vs 64%, p > 0.05). When hysteroscopy diagnosed endometrial atrophy, there was no significative difference of efficacity (29% vs 23%, p > 0.05), whereas vacurette was significatively more effective when there was an other hysteroscopy diagnosis (78% vs 62%, p = 0.05). Both procedures were less effective in post-menopausal women (p = 0.001), and in case of endometrial atrophy (p = 0.001).

CONCLUSION

Both procedures were acceptable during ambulatory hysteroscopy. In our study, vacurette was more painful than pipelle. Vacurette was more effective but insufficient tissue for histologic evaluation was important in both procedures. This might be explained by the population included and the histologic method used.

[Evaluation of direct hospital and extra-hospital cost of operative hysteroscopy and vaginal hysterectomy]

The objective of this work was to evaluate hospital and postoperative costs associated with gynecologic surgery for benign uterine pathologies. We studied operative hysteroscopy and vaginal hysterectomy. Hospital costs were broken down into several categories: operating room, postoperative hospitalization, pharmacy surgical instruments, sterilization of reused equipment, food and laundry, indirect costs. The mean total costs for the hospitalization time were 4609.8 francs for hysteroscopic surgery and 7920.3 francs for vaginal hysterectomy. Medical charges in recovery time were calculated with the help of the Social Security. These charges represented 5% of the total cost associated with the procedure.

[The disinfection of non-autoclavable hysteroscopes in gynecology. Proposition of a protocol and organization of its management]

Iatrogenic infections may result from diagnostic hysteroscopy in case of non autoclavable equipment (such as fibrohysteroscopes) and because of new infectious agents (such as HIV, hepatitis, ...). The equipment should be completely and thoroughly disinfected according to the manufacturer's instructions to prevent infectious complications.

[Vaginal hysterectomy for non-prolapse uterus]

Vaginal hysterectomy in the treatment of non prolapsed uterus without malignant disease is a well codified technique. Per operative complications, post operative morbidity are less frequent and less serious than by abdominal surgery and convalescent time is less extended. Financial cost is lower compared with laparoscopic hysterectomy. The successful result of the vaginal way is determined by anatomic factors: volume and mobility of the uterus, accessibility of the vagina, but above all by the training of the surgeons. A rate of seventy per cent of hysterectomies performed by the vaginal way in the case of this indication is a realistic aim in a hospital center.

[Impact of adenomyosis on results of endometrial ablations]

The authors report the results of a retrospective series concerning 121 patients who presented abnormal uterine bleeding resistant to progestogen therapy. These patients were adenomyosis carriers and who underwent loop endometrial ablation. Over a maximum period of 8 years, the success rate was 56% following one endometrial resection and 67% following one or two resections. The study recorded a repeat resection level of 11%. Seventeen hysterectomies (19%) were performed because of the recurrence of abnormal uterine bleeding. These results are comparable to those observed in endometrial ablation performed for menorrhagia, all benign etiology included. Adenomyosis does not appear to be a factor in the failure of endometrial ablation, except in the case of deep adenomyosis which is difficult to diagnose pre-operatively.

Laparoscopic surgery in gynecology: randomized prospective study comparing pneumoperitoneum and abdominal wall suspension

OBJECTIVE

To compare laparoscopic surgery using insufflation of carbon dioxide gas with laparoscopic surgery using abdominal wall retractor in gynecology.

SETTING

University hospital.

DESIGN

Prospective randomized study.

MATERIAL AND METHODS

Fifty-one patients were assigned to the gasless laparoscopy group, and 52 patients were assigned to the laparoscopy group with pneumoperitoneum. Patients presented with ovarian cyst, endometriosis, acute salpingitis, hydrosalpinx and extra-uterine pregnancy.

RESULTS

No severe complications were noted. One conversion to laparotomy was performed in each group. Eight gasless laparoscopic procedures were converted into laparoscopy with pneumoperitoneum; difficulties appeared in patients with adhesions following laparotomy and in cases of unsatisfactory exposure of the pelvis. No differences appeared between the two groups in terms of complications, quality of the operative sequelae, and duration of hospitalization.

CONCLUSION

Gasless surgery is a recent technique and progress in modifying the equipment is necessary to reduce conversions.

Brachytherapy and vaginal hysterectomy for low-stage uterine cervix carcinoma

OBJECTIVE

The aim of this study was to assess safety and efficiency of a limited vaginal hysterectomy after brachytherapy in patients with early uterine cervix carcinoma without unfavorable prognostic factors. All tumors were less than 1.5 cm in diameter.

MATERIAL AND METHODS

Between October 1992 and December 1995, 22 patients with low-stage uterine cervix carcinoma (stage Ia2 with vascular invasion, 3 cases; stage Ib1, 19 cases) were included in this study. Patients underwent the following procedures: single utero-vaginal brachytherapy after a previous negative laparoscopic lymphadenectomy (median number of lymph nodes: 12) followed 6 weeks later by a limited vaginal hysterectomy.

RESULTS

Two mild intraoperative complications were noted. Venous hemorrhage (100 cc) occurred in one patient during lymphadenectomy and another patient experienced bladder injury during hysterectomy. These two complications were successfuly controlled with no need for laparotomy. Only one late complication was observed and was evaluated as a bladder grade G2(b) according to the Franco-Italian glossary. With a 30 (22-50) month follow-up, no recurrence was reported.

CONCLUSION

These results appear promising in patients with very early cervix carcinoma but remain to be confirmed on a larger scale.

[Hysteroscopic myomectomy. Functional results with an average follow-up of 6 years]

OBJECTIVE

In 1995, we presented our experience in hysteroscopic resection of hemorrhagic submucous fibroids in 196 patients. The objective of the present work was to analyze functional outcome three years later.

PATIENTS

One hundred ninety-six patients with abnormal uterine bleeding were treated between 1987 and 1993. Equipment, techniques, characteristics of the procedures and early results were detailed in the previous article.

RESULTS

With a mean follow-up of 73 months (range 50,104), results were: 13.8% of the patients were lost to follow-up; 68.4% had symptomatic improvement and failure was observed in 17.8% (subsequent hysterectomy in 12.7%). Forty-nine patients had repeat resection in this series; 61 became menopausal after surgery, and 21 were taking hormone replacement therapy with good results.

CONCLUSION

Developed as an alternative to hysterectomy, operative hysteroscopy has proven to be a safe and effective procedure. This treatment modality appears to give satisfactory long-term results, with a low rate of complications.

[Contribution of hysteroscopic surgery for the treatment of postmenopausal metrorrhagia]

OBJECTIVES

Determine the effectiveness of hysteroscopic surgery in persistent postmenopausal bleeding.

PATIENTS AND METHODS

Transcervical resection was performed in 176 women between the ages of 46-74 years. A benign cause was noted in 135 cases (polyps in 80 and submucous fibroids in 55); 37 patients had no significant disease and 4 had endometrial atypical hyperplasia missed in the preoperative evaluation. Patients underwent resection of polyp, resection of fibroid or endometrial ablation. Major operative complications were rare and included 3 perforations and one case of fluid overload. Patients were followed for 1-10 years after treatment (mean follow-up 52 months).

RESULTS

167 patients completed the study. Clinical manifestations disappeared in 85.2% of the patients; 15 patients had hysterectomy after the hysteroscopic procedure and 11 had repeat transcervical resection.

CONCLUSION

Hysteroscopic treatment can be effective in carefully selected patients with postmenopausal bleeding or abnormal uterine bleeding on hormone replacement therapy. The operative criteria should take the causes of bleeding and not just the age of patient into account.

[Role of diagnostic hysteroscopy in the exploration of postmenopausal metrorrhagia]

DIAGNOSIS

Diagnostic hysteroscopy is an effective method for identifying the causes of postmenopausal bleeding. It evaluates the uterine cavity and visualizes pathologic conditions such as endometrial polyps, submucous fibroids, and focal endometrial abnormalities including adenocarcinoma and its precursors.

FURTHER INFORMATION

With directed biopsy, diagnostic hysteroscopy also ensures the recognition of these lesions.

Continuous hormone replacement therapy for menopause combining nomegestrol acetate and gel, patch, or oral estrogen: a comparison of amenorrhea rates

This open-label, prospective, randomized, multicenter trial compared the incidence of amenorrhea in 54 postmenopausal women (mean age, 54.9 +/- 0.6 years) who underwent six 4-week cycles of continuous hormone replacement therapy combining a progestin-nomegestrol acetate 2.5 mg/d--plus one of three estrogens: percutaneous 17beta-estradiol gel (1.5 mg/d, group A), transdermal 17beta-estradiol patch (50 microg/d, group B), or oral estradiol valerate (2 mg/d, group C). Based on an intent-to-treat analysis, the rate of amenorrhea varied significantly according to which estrogen preparation was used. Calculated cycle by cycle, rates of amenorrhea were 67% to 83% for group A, 25% to 56% for group B, and 53% to 61% for group C. Overall rates of persistent amenorrhea were not statistically different between groups for cycles 1 through 3, but for cycles 4 through 6, significantly more women in groups A and C (67% and 46%, respectively) experienced amenorrhea than did those in group B (12%). Amenorrhea rates for the entire six-cycle period were 78% for group A, 48% for group B, and 60% for group C. These differences were not statistically significant. The differences in rates could not be attributed to endometrial atrophy, since when measured by transvaginal sonography, endometrial thickness did not differ significantly between groups. Of the original population, 7% withdrew prematurely because of bleeding. The data for all three groups confirmed that in two out of three women, the occurrence of amenorrhea during the first three cycles predicted continuation of amenorrhea during subsequent cycles and that for 51% of women, < or =10 days of bleeding during the first three cycles predicted amenorrhea during the last three cycles. Calculated as a function of the number of women included in the trial, the percentage of amenorrheic women (evaluated cycle by cycle or for the second three-cycle period) was highest when the progestin was combined with percutaneous 17beta-estradiol gel, although findings were similar with estradiol valerate. The percutaneous 17beta-estradiol gel was also associated with a higher percentage of amenorrheal cycles than was estradiol valerate or transdermal estrogen, although differences were significant only in comparison with the transdermal formulation. This difference may have positive clinical implications.

[Surgical hysteroscopy in the treatment of septate uterus: systemic treatment or selective indications]

OBJECTIVES

A retrospective study to evaluate the fertility rate after endoscopic hysteroplasty in the case of a septate uterus.

METHOD

From 1st January 1988-31st December 1996, 93 patients showing a septate uterus were treated by endoscopic hysteroplasty. The hospitalisation is short: one day surgery or out office. A control of uterine cavity by hysteroscopy did next to two months.

RESULTS

Patients were evaluated after a period in excess of 6 months (6 months-8 years). 63 pregnancies were achieved amongst the 84 patients to be reviewed (75%). The fertility rate achieved is higher amongst infertile patients (80.3%) compared with that of sterile patients (64%).

CONCLUSION

In the presence of septate uterus the endoscopic hysteroplasty is an efficient treatment in the case of secondary infertility and of unexplained sterility.

[Hysteroscopic surgery and fertility]

In the treatment of uterine lesions associated with infertility, such as septate uterus and synechiae, hysteroscopic surgery has replaced conventional abdominal surgery. Hysteroscopic metroplasty improves obstetrical prognosis in patients with septate uterus. Advantages of hysteroscopy are low morbidity rate, decreased hospitalization time, and absence of hysterotomy. Hysteroscopic surgery of synechiae allows to achieve good anatomical results in most of the cases. The first risk of this surgery is perforation. However, obstetrical results are uneven; pregnancy rates are low in cases of complex synechiae. Endometrial ablation is performed in patients presenting with abnormal uterine bleeding after failure of progestin therapy. Pregnancies following endometrial ablation have been described; term deliveries are still exceptional.

[Vaginal myomectomy]

The authors present a retrospective study of 26 patients who have benefited from vaginal myomectomy after culdotomy in the Conception hospital in Marseille between 1992 and 1997. The myomectomy whom technic is described, was performed unically through the vagina or laparoscopically assisted. The mean operating time was 94 mn. The myoma mean weight was 184.3 g. Three patients experienced an abdominal surgery, twice because of a vaginal inaccessness. The immediate and mean-term post-operative period was uncomplicated in most cases. For screened patients, vaginal myomectomy appears as an interesting alternative to abdominal or laparoscopic surgery.

[Birth after two cesarean sections: the role of trial of labor]

OBJECTIVE

To study the management of labor following two cesarean sections, we evaluated maternal and neonatal morbidity subsequent to this attitude.

PATIENTS AND METHODS

A retrospective study was conducted over a 6-year period (1-1-1990 to 31-12-1995) in 184 women presenting two uterine scars. Trial of labor was allowed in 96 cases with cephalic presentation and a normal pelvis.

RESULTS

The rate of vaginal birth was 65%. Three patients presented a uterine scar dehiscence and in one of them hemostasis hysterectomy for uterine atony was performed. Neonatal outcome was good in all cases.

CONCLUSION

Trial of labor after two cesarean sections is possible in the majority of cases. Rate of vaginal birth is high and maternal and fetal morbidity is low.

Uterine thermal balloon therapy for the treatment of menorrhagia: the first 300 patients from a multi-centre study. International Collaborative Uterine Thermal Balloon Working Group

OBJECTIVE

To evaluate the safety and efficacy of thermal balloon therapy for menorrhagia.

DESIGN

Prospective, observational study.

SETTING

Fifteen centres in Canada and Europe.

POPULATION

Two hundred and ninety-six eligible women for whom follow up data were available for three months or more. Eligible women included those for whom further fertility was not a concern, were not postmenopausal, suffered from intractable menorrhagia, had a normal uterine cavity, and who were fully informed regarding the investigational nature of uterine thermal balloon therapy.

METHODS

Three hundred and twenty-one procedures of balloon endometrial ablation were performed using the same protocol between June 1994 and August 1996. Exclusion criteria included structural uterine abnormality or (pre) malignant lesions. Treatment entailed controlled heating of fluid in an intrauterine balloon. General anaesthesia was employed in the 61% of procedures while local anaesthesia with or without sedation was used in 39% of cases.

ANALYSIS

Follow up data at 3 and/or 6, and/or 12 months were required for inclusion in the analysis. A paired t test, Wilcoxon signed-ranks test, and multiple and logistic regression analyses were used to evaluate the changes in bleeding and dysmenorrhoea patterns, and possible confounding variables, respectively. Success was defined as the subjective reduction of menses to eumenorrhoea or less.

RESULTS

No intra-operative complications occurred, and post-operative morbidity was minimal. Success of the procedure was constant over the year (range 88%-91%). Treatment led to a significant decrease in the duration of menstrual flow and severity of pain (P < 0.0001). Increasing age, higher balloon pressure, smaller uterine cavity, and a lesser degree of pre-procedure menorrhagia were associated with significantly improved results. Pre-treatment with gonadotrophin releasing hormone agonists increased amenorrhoea and spotting rates (P = 0.03), but was only used in 5% of cases.

CONCLUSION

Thermal balloon endometrial ablation appears to be safe, as well as effective in properly selected women with menorrhagia and is potentially an outpatient procedure.

HPV typing by in situ hybridization on cervical cytologic smears with ASCUS

OBJECTIVE

To assess the prognostic significance of atypical squamous cells of undetermined significance (ASCUS) using an in situ hybridization (ISH) method for destined cervical cytologic smears and a cocktail of biotinylated DNA probes for human papillomavirus (HPV) 6, 11, 16, 18, 31 and 33.

STUDY DESIGN

Two HPV DNA probe mixtures were applied to the same smear for the simultaneous detection of high-risk HPV types 16, 18, 31 and 33 and low-risk HPV 6 and 11. ISH was carried out on 192 smears. Among them, 59 showed koilocytosis, 91 ASCUS and 42 normal features.

RESULTS

Low-risk HPV types were rarely found and associated mainly with koilocytosis (17%). High rates of potentially oncogenic HPV were detected in ASCUS (41%) and condyloma (73%). In addition, similar levels of positivity were found to be associated with ASCUS when using two probe mixtures specific to high-risk HPV: one included HPV genotypes 16 and 18 and the other, genotypes 31 and 33.

CONCLUSION

HPV DNA typing by ISH on cervical cytologic smears might improve the identification of women at high risk of developing precancerous and cancerous cervical lesions.

Prenatal diagnosis of fetal corpus callosum agenesis by ultrasonography and magnetic resonance imaging

Corpus callosum agenesis (CCA) was evaluated by ultrasound examination and magnetic resonance imaging (MRI) in 14 cases. Ultrasonography was able to suspect CCA by indirect signs but a definitive diagnosis of CCA was achieved in only four cases. MRI was able to diagnose complete CCA in 13 cases and showed absence of the posterior portion of the corpus callosum in one case. Additional neurological abnormalities including heterotopia, gyration anomaly, asymmetry of the cerebral hemispheres, and Dandy-Walker variant were documented in five cases, as well as an ocular anomaly which was present in one case, by MRI examination. Prenatal counselling for fetal agenesis of the corpus callosum is difficult as the prognosis is uncertain. The association with other cerebral abnormalities increases the likelihood of a poor outcome and ultrasonographic assessment of the fetal brain is limited. We found MRI to be a safe and useful additional procedure to complement ultrasonographic diagnosis or suspicion of CCA.

Endoscopic surgery. The end of classic surgery?

Gynecological endoscopy is now a well-established procedure and it has been proved that the laparoscopic surgical technique can be used in the management of most gynecological disorders thus replacing conventional laparotomic procedures. The latest indications apply to such functional pathologic conditions as urinary incontinence and genital prolapse, and oncology (radical hysterectomy, lymphadenectomy). Hysteroscopy has afforded an easier surgical approach to certain pathologies such as septate uterus and endometrial ablation. Indications of conventional surgery are getting fewer. Yet conventional surgery should be part of the training of the gynecologist surgeon as the laparotomic approach is still the only solution in the most difficult cases.

[Endometrial resection in the management of menometrorrhagia refractory to medical treatment]

The authors report the results of 197 endometrectomies and analyse the indications, complications and long-term results. A retrospective analysis was performed at La Conception Hospital. Department of Gynaecology-Obstetrics, Prof Blanc, Marseille, between June 1988 and June 1994. The mean follow up was 53 months. 197 endometrectomies were performed in 186 women during this period. The indication was menometrorrhagia failing to respond to medical therapy. We considered patients to be cured when they no longer suffered from menorrhagia or metrorrhagia and when hormone replacement therapy could be started or continued. The success rate with a follow-up of 7 years was 70%. The failure rate was correlated with the woman's age, hysterometry data and histological results. The complication rate was 2.5%. Endometrectomy appears to be a safe and successful technique for the treatment of menometrorrhagia.

[Identification and treatment of endometritis]

Endometritis represent a debatable entity because genital infectious disease is a contre-indication of endoscopy. So, the diagnosis is rarely realized by hysteroscopy. Two kinds of endometritis are discerned: acute endometritis characterized by an oedema of bleeding endometrium, covered by an abnormal mucus; chronic endometritis with areas of red endometrium, flushed, with a white central point, localized or scattered out the cavity. This is the "strawberry aspect". Whereas, the correlation between hysteroscopic aspect and histologic or bacteriologic samples exists in only 35% of cases. According to R. Frydman and J. Hamou, chronic endometritis is occurred among 22% of patients in IVF program, in 14% of unexplained infertility and 23.6% of women with an history of first trimester miscarriages. Chlamydiae an Ureaplasma seem to be the most frequent germs. In this way, in case of unexplained infertility, the hysteroscopic diagnosis of chronic endometritis can lead to an antibiotic treatment test.

[Role of endo-uterine resection using hysteroscopy in the treatment of sub-mucous hemorrhagic fibroma in the peri-menopausal period]

OBJECTIVES

To study retrospectively the long-term outcome after hysteroscopic treatment for intra-uterine fibromas.

METHODS

From October 1987 to January 1993, endo-uterine glycocol resection was performed in 196 patients with intra-uterine fibromas. The operation had to be repeated in 39 patients due to incomplete resection or recurrent symptomatology. Patients presented with menometrorrhage.

RESULTS

Intra-operative complications were rare, mainly uterine perforations (7 cases) or metabolic syndromes due to reabsorption of glycine (5 cases). Mean follow-up was 2.5 years. In all 196 women consulted for bleeding, good results were achieved in 81.1%.

CONCLUSION

Endo-uterine resection is a sure, effective and long-lasting treatment for intra-uterine fibromas.