Stratégies thérapeutiques des tumeurs ovariennes présumées bénignes

[Retrospective evaluation of relevance of care in the management of presumed benign ovarian tumors]

INTRODUCTION

The relevance of care is defined by the right act, for the right patient, at the right time. We were interested in the relevance of the management of presumed benign ovarian tumors before and after the release of the CNGOF guidelines 2013 (French guidelines).

METHODS

This is a retrospective observational study conducted at the University Hospital in Strasburg France from 01/01/2013 to 31/12/2017 including all patients treated for a presumed benign ovarian cyst. We were interested in the diagnostic approach: relevance of the prescribed imaging and the use of CA 125 dosage, in the therapeutic approach: the relevance of the technique used as well as the relevance of the surgical indication. We compared our practices between 2013 and 2017 for these same items.

RESULTS

We included 682 cysts for 621 patients, the imaging performed was relevant in 55% of cases, not relevant but justified in 25% and irrelevant in 20%. The CA 125 assay or its absence of assay was relevant in 84% of cases. The surgical technique was relevant in 67% of cases and not relevant but justified in 29%. With a significant improvement 7.1% in 2013 of irrelevant against 0.9% for the year 2017. The surgical indication was relevant in 72% of cases, not relevant but justified in 20% and irrelevant in 2.7%.

CONCLUSIONS

The analysis of the relevance of care allows an evaluation of our practices. Professional recommendations can have an impact on the quality of care.

Pelvic endometriosis: Refer to the surgeon at the right moment: Pelvic endometriosis: When refer to the surgeon?

BACKGROUND

As endometriosis is not a single condition but different morphological types, it is easy to conceive that its management allow for a diversity of approaches. The objective of this literature review is about a simplified pathway through care for patients with endometriosis, and to target the right time for surgical treatment.

METHODS

Through a literature and references review, the different surgical care arrangements according to attainment, to symptoms and to the patients demands and expectations are reviewed.

RESULTS

An existing literature and recommendations synthesis has been done, and it was found that an optimum medical or surgical care rely on a multidisciplinary approach. Asymptomatic patients should not have surgery, and the medical treatment precede surgical treatment in numerous indications. In case of a surgical need, the right moment is determined by the recommendations, as noted in this article. Different aspects are necessary, the symptomatology, the intend to be pregnant and the recurrence of lesions in particular, but also the use of medically assisted reproduction or not.

CONCLUSION

In order to optimize the surgical treatment of patients with endometriosis, it is advisable to not refer these patients to the surgeon not too soon and not too late, furthermore if he's an expert. In all cases the treatment is multidisciplinary, and the most difficult cases are referred to multidisciplinary consultative reunion. The surgical treatment relies on "centre of expertise's" existence for some specific forms of deep endometriosis. The surgical treatment is a question of both pathology and timing.

BRIEF SUMMARY

In order to optimize the surgical treatment of endometriosis, it is advisable to refer patients to the surgeon at the right moment.

Surgical Technique for Endometrioma in 10 Steps

OBJECTIVE

Laparoscopic cystectomy for endometrioma has the advantages of a minimally invasive approach. The standardization and description of the technique are the main objectives of this video. We described the surgery in 10 steps, which could help to make this procedure easier and safer.

DESIGN

Step-by-step video demonstration of the technique.

SETTING

A French university tertiary care hospital.

INTERVENTION

Two standardized laparoscopic cystectomy were recorded to realize the video. The local institutional review board ruled that approval was not required because the video describes a technique and does not report a clinical case. This video presents a systematic approach to cystectomy for endometrioma clearly divided into 10 steps: (1) preoperative evaluation [1]; (2) diagnosis and exploration [2]; (3) adhesiolysis, mobilization of the ovary; (4) cyst rupture, exposition of the entry site; (5) identification of the cleavage plan; (6) endometrioma easy dissection; (7) endometrioma difficult dissection; (8) hemostasis, reconstruction of the ovary [3]; (9) exploration of the ovarian fossa; and (10) washing, extraction of the cyst [3,4].

CONCLUSION

Standardization of laparoscopic cystectomy for endometrioma could make this procedure easier and safer to perform. The 10 steps presented help to perform each part of the surgery in a logical sequence, making the procedure easier to realize. Moreover, the standardization of the surgical techniques may reduce the learning curve.

Laparoscopic Ovarian Dermoid Cystectomy in 10 Steps

STUDY OBJECTIVE

Laparoscopic cystectomy for ovarian teratomas has the advantages of a minimally invasive approach [1]. The standardization and description of the technique are the main objectives of this video (Video 1). We described the surgery in 10 steps [2], which could help make this procedure easier and safer.

DESIGN

A step-by-step video demonstration of the technique.

SETTING

A French university tertiary care hospital.

PATIENTS

Patients with ovarian teratomas with indication for laparoscopic cystectomy [3]. The local institutional review board ruled that approval was not required for this video article because the video describes a technique and does not report a clinical case.

INTERVENTIONS

Standardized laparoscopic cystectomies were recorded to realize the video.

MEASUREMENTS AND MAIN RESULTS

This video presents a systematic approach to cystectomy for teratoma clearly divided into 10 steps: (1) planning of the surgery, (2) ergonomy and materials, (3) exploration and cytology, (4) prevention of peritoneal spillage [4], (5) mobilization of the ovary, (6) incision of the ovary, (7) dissection, (8) hemostasis, (9) exteriorization of the cyst, and (10) washing and exploration.

CONCLUSION

Standardization of laparoscopic cystectomy for ovarian teratoma could make this procedure easier and safer to perform. The 10 steps presented help to perform each part of the surgery in a logical sequence, making the procedure ergonomic and easier to adopt and learn. Moreover, the standardization of the surgical techniques could reduce the learning curve.

Preservation of fertility in surgery of benign and borderline malignant ovarian tumors

Benign ovarian tumors occur in 7% of women during their procreative years and involve both organic and functional tumors. The average age of onset for borderline ovarian tumors is ten years younger than that for ovarian cancers. Women with benign and borderline malignant ovarian tumors are therefore more likely to be affected by fertility issues. The causal link between infertility and benign ovarian tumor stems more from the therapeutic strategies adopted than from the histological nature of the benign ovarian tumor. The question of fertility preservation must therefore be addressed in the management of these patients through respect for "correct" surgical indications, through gestures centered around ovarian preservation, and finally, if necessary, by recourse to fertility preservation techniques.

[Management of endometrioma]

Preoperative evaluation: clinical examination, and research for associated lesions. Laparoscopic approach. Cystectomy: gold standard, conformed to the endometrioma pathophysiology (3 zones). Laser CO₂ Plasmajet^® vaporisation: important data lead to legitimate utilisation. Haemostasis: be patient! Use of bipolar energy sparingly. Look for other endometriotic lesions, and systematic treatment. Preoperative medical treatment not always useful. Postoperative treatment: decrease recurrence. Especially for patients with no immediate pregnancy desire.

[Recommendations for clinical practice: Presumed benign ovarian tumors--short text]

These guidelines from the French College of Gynecologists and Obstetricians on the diagnosis and treatment of presumed benign ovarian tumors (PBOT) concern physicians whether gynecologists, obstetricians, surgeons, radiologists, pediatricians, and general practitioners. Vaginal pelvic ultrasound is the first-line imaging examination in case of PBOT in adult women (grade A). In case of pure fluid unilocular mass less than 7 cm size, ultrasound is sufficient to characterize the mass (grade A). MRI is recommended as second-line to explore indeterminate masses or masses greater than 7 cm (grade B). Serum CA125 assay is not recommended as first-line diagnostic in adult women (grade C). Among women with a pure unilocular liquid cyst, hormonal therapy is ineffective (LE1) and is not recommended (grade A). Ultrasound-guided puncture is not recommended (grade B). In adult women without history of cancer, abstention is possible in case of asymptomatic pure unilocular cyst less than 10 cm (grade B). If symptoms develop, laparoscopy is the reference approach for PBOT surgical treatment (grade A). A conservative surgical treatment (cystectomy) should be preferred to oophorectomy in non-menopausal women without previous history of cancer (grade C). In cases of suspected adnexal torsion, laparoscopic surgical exploration is recommended (grade B). Conservative treatment, untwisting without oophorectomy, is recommended for non-menopausal women whatever the estimated duration of the twist and the macroscopic appearance of the ovary (grade B). During pregnancy, expectation is recommended for asymptomatic unilocular liquid masses less than 6 cm (grade C).