Investigating the medical journey of endometriosis-affected women: Results from a cross-sectional web-based survey (EndoVie) on 1,557 French women

OBJECTIVE

To investigate the medical journey and the quality of life of French endometriosis-affected women, from the onset of the symptoms to the therapeutic management.

STUDY DESIGN

Between January 15th 2020 and February 3rd 2020, a prospective cross-sectional web-based survey was conducted among women diagnosed with endometriosis. The questionnaire included 52 questions distributed in five sections (screening, sociodemographic characteristics, impacts on quality of life, SF36 questionnaire, management of endometriosis and proposals for care improvement).

RESULTS

One thousand five hundred fifty-seven endometriosis-affected women aged of 42±12.8 years answered the questionnaire. On average, 7 years elapsed between the first symptoms (at 23.8 ± 10.2 years) and the diagnosis (31.0 ± 8.9 years). The mean number of symptoms was 4.6 ± 2.3, with 82 % of women experiencing pain scores between 7 and 10/10. Following diagnosis, 66 % women received a medical treatment, mostly hormonal treatments (45 %), with a significant decrease in pain intensity (VAS scores after treatment = 4.9 ± 2.7, p < 0.001). Most women (62 %) had already been operated, among whom 22 % by laparotomy. Finally, patients reported numerous impacts on their daily lives, particularly on the sexual, psychological, and physical fields. The overall mean score of quality of life was 4.3 ± 2.6 /10.

CONCLUSION

This large prospective web-based survey underlines that the journey of women with endometriosis is long and difficult until diagnosis and efficient treatment. It emphasizes the urgent need to reduce the diagnostic delay and thereby the burden of endometriosis on women's lives. Moreover, the creation of referral multidisciplinary centers appears to be crucial to improve the management of the disease.

Update on the management of endometriosis-associated pain in France

The French National College of Obstetricians and Gynecologists (CNGOF) published guidelines for managing endometriosis-associated pain in 2018. Given the development of new pharmacological therapies and a review that was published in 2021, most national and international guidelines now suggest a new therapeutic approach. In addition, a novel validated screening method based on patient questionnaires and analysis of 109-miRNA saliva signatures, which combines biomarkers and artificial intelligence, opens up new avenues for overcoming diagnostic challenges in patients with pelvic pain and for avoiding laparoscopic surgery when sonography and MRI are not conclusive. Dienogest (DNG) 2 mg has been a reimbursable healthcare expense in France since 2020, and, according to recent studies, it is at least as effective as combined hormonal contraception (CHC) and can be used as an alternative to CHC for first-line treatment of endometriosis-associated pain. Since 2018, the literature concerning the use of DNG has grown considerably, and the French guidelines should be modified accordingly. The levonorgestrel intrauterine system (LNG IUS) and other available progestins per os, including DNG, or the subcutaneous implant, can be offered as first-line therapy, gonadotropin-releasing hormone (GnRH) agonists with add-back therapy (ABT) as second-line therapy. Oral GnRH antagonists are promising new medical treatments for women with endometriosis-associated pain. They competitively bind to GnRH receptors in the anterior pituitary, preventing native GnRH from binding to GnRH receptors and from stimulating the secretion of luteinizing hormone and follicle-stimulating hormone. Consequently, estradiol and progesterone production is reduced. Oral GnRH antagonists will soon be on the market in France. Given their mode of action, their efficacy is comparable to that of GnRH agonists, with the advantage of oral administration and rapid action with no flare-up effect. Combination therapy with ABT is likely to allow long-term treatment with minimal impact on bone mass. GnRH antagonists with ABT may thus be offered as second-line treatment as an alternative to GnRH agonists with ABT. This article presents an update on the management of endometriosis-associated pain in women who do not have an immediate desire for pregnancy.

The anatomy of the sacrospinous ligament: how to avoid complications related to the sacrospinous fixation procedure for treatment of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Historically, the sacrospinous ligament (SSL) has been used to treat POP in order to restore the apical compartment through a posterior or an anterior vaginal approach. The SSL is located in a complex anatomical region, rich in neurovascular structures that must be avoided to reduce complications such as acute hemorrhage or chronic pelvic pain. The aim of this three-dimensional (3D) video describing the SSL anatomy is to show the anatomical concerns related to the dissection and the suture of this ligament.

METHODS

We conducted a research of anatomical articles about vascular and nerve structures located in the SSL region, in order to increase the anatomical knowledge and show the best placement of sutures to reduce complications related to SSL suspension procedures.

RESULTS

We showed the medial part of the SSL to be most suitable for the placement of the suture during SSL fixation procedures, in order to avoid nerve and vessel injuries. However, nerves to the coccygeus and levator ani muscle can course on the medial part of the SSL, the portion of the SSL where we recommended to pass the suture.

CONCLUSIONS

Knowledge of the SSL anatomy is crucial and during surgical training it is clearly indicated to stay far away (almost 2 cm) from the ischial spine to avoid nerve and vascular injuries.

Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynaecologists and Obstetricians (CNGOF)

OBJECTIVE

To provide French guidelines for the management of women with abnormal uterine bleeding (AUB).

DESIGN

A consensus committee of 26 experts was formed. A formal conflict-of-interest policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding (i.e. pharmaceutical or medical device companies). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The last guidelines from the Collège National des Gynécologues et Obstétriciens Français on the management of women with AUB were published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescents; idiopathic AUB; endometrial hyperplasia and polyps; type 0-2 fibroids; type 3 or higher fibroids; and adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and evidence profiles were compiled. The GRADE® methodology was applied to the literature review and the formulation of recommendations.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 are strong and 17 weak. No response was found in the literature for 14 questions. We chose to abstain from recommendations rather than providing advice based solely on expert clinical experience.

CONCLUSIONS

The 36 recommendations make it possible to specify the diagnostic and therapeutic strategies for various clinical situations practitioners encounter, from the simplest to the most complex.

Operative Hysteroscopy vs Vacuum Aspiration for Incomplete Spontaneous Abortion: A Randomized Clinical Trial

Importance

Vacuum aspiration is commonly used to remove retained products of conception in patients with incomplete spontaneous abortion. Scarring of the uterine cavity may occur, potentially impairing future fertility. A procedural alternative, operative hysteroscopy, has gained popularity with a presumption of better future fertility.

Objective

To assess the superiority of hysteroscopy to vacuum aspiration for subsequent pregnancy in patients with incomplete spontaneous abortion who intend to have future pregnancy.

Design, Setting, and Participants

The HY-PER randomized, controlled, single-blind trial included 574 patients between November 6, 2014, and May 3, 2017, with a 2-year duration of follow-up. This multicenter trial recruited patients in 15 French hospitals. Individuals aged 18 to 44 years and planned for surgery for an incomplete spontaneous abortion with plans to subsequently conceive were randomized in a 1:1 ratio.

Interventions

Surgical treatment by hysteroscopy (n = 288) or vacuum aspiration (n = 286).

Main Outcomes and Measures

The primary outcome was a pregnancy of at least 22 weeks' duration during 2-year follow-up.

Results

The intention-to-treat analyses included 563 women (mean [SD] age, 32.6 [5.4] years). All aspiration procedures were completed. The hysteroscopic procedure could not be completed for 19 patients (7%), 18 of which were converted to vacuum aspiration (8 with inability to completely resect, 7 with insufficient visualization, 2 with anesthetic complications that required a shortened procedure, 1 with equipment failure). One hysteroscopy failed due to a false passage during cervical dilatation. During the 2-year follow-up, 177 patients (62.8%) in the hysteroscopy group and 190 (67.6%) in the vacuum aspiration (control) group achieved the primary outcome (difference, -4.8% [95% CI, -13% to 3.0%]; P = .23). The time-to-event analyses showed no statistically significant difference between groups for the primary outcome (hazard ratio, 0.87 [95% CI, 0.71 to 1.07]). Duration of surgery and hospitalization were significantly longer for hysteroscopy. Rates of new miscarriages, ectopic pregnancies, Clavien-Dindo surgical complications of grade 3 or above (requiring surgical, endoscopic, or radiological intervention or life-threatening event or death), and reinterventions to remove remaining products of conception did not differ between groups.

Conclusions and Relevance

Surgical management by hysteroscopy of incomplete spontaneous abortions in patients intending to conceive again was not associated with more subsequent births or a better safety profile than vacuum aspiration. Moreover, operative hysteroscopy was not feasible in all cases.

Trial Registration

ClinicalTrials.gov Identifier: NCT02201732.

vNOTES Hysterectomy: What about Obese Patients?

STUDY OBJECTIVE

To compare the surgical outcomes of hysterectomy by vaginal natural orifice transluminal endoscopic surgery (vNOTES) for patients with body mass index (BMI) <30 and BMI ≥30.

DESIGN

A retrospective cohort study.

SETTING

A French teaching hospital.

PATIENTS

All patients who underwent a vNOTES hysterectomy from February 2020 to January 2022 were included (N = 200). The vNOTES approach was chosen for all patients requiring a hysterectomy, unless the procedure was for endometriosis or cancer (except grade 1 endometrioid adenocarcinoma).

INTERVENTIONS

Patients were categorized into 2 groups based on their BMI (<30 or ≥30 kg/m²). The population characteristics, surgical outcomes, and hospitalization outcomes were compared. The main outcome was the intraoperative conversion rate. Secondary end points were blood loss, operative time, perioperative and postoperative complications, and same-day surgery management.

MEASUREMENTS AND MAIN RESULTS

A total of 146 patients were included in the BMI <30 group, and 54 patients in the BMI ≥30 group. There was no statistical difference between obese and nonobese patients concerning intraoperative conversion (p = .150), with 4 cases occurring in the BMI <30 group (2.74%) and 4 occurring in the BMI ≥30 group (7.41%). Operative times were longer in obese patients (115.93 min [±55.28] vs 79.78 min [±40.38], p <.001). There was no significant difference in blood loss (p = .337) or perioperative and postoperative complications (p = .346 and p = .612, respectively). The ability to complete the surgery as a same-day procedure was no different between obese and nonobese patients (p = .150).

CONCLUSION

The results concerning intraoperative conversion and perioperative and postoperative complications show that vNOTES hysterectomies seem to be feasible for obese patients. When same-day surgery was decided before surgery, no more obese than nonobese patients were converted to conventional hospitalization. Further studies are needed to confirm these observations.

Long-Term Assessment of Pelvic Organ Prolapse Reoperation Risk in Obese Women: Vaginal and Laparoscopic Approaches

The aim of this study was to compare reoperation risks after pelvic organ prolapse repair at 5-year follow-up between obese, overweight, and normal-weight women and to assess these risks accounting for the surgical procedure. We performed a retrospective chart review of all the women who underwent POP repair by transvaginal mesh surgery between January 2005 and January 2009 or laparoscopic sacrocolpopexy between January 2003 and December 2013 at the Gynecologic Surgery Department of the Lille University Hospital. During the study period, 744 women who underwent POP repair were divided into three groups: 382 (51%), 240 (32%), and 122 (16%) in the nonobese group (BMI < 25 kg/m²), overweight group (25 kg/m² ≤ BMI < 30 kg/m²), and obese group (BMI ≥ 30 kg/m²), respectively. The primary outcome was global reoperation. The median duration of follow-up was 87 months. The risks of global reoperation did not significantly differ between the three BMI groups (adjusted HR (95% CI): 1.12 (0.69 to 1.82) for overweight women and 0.90 (0.46 to 1.74) for obese women compared to normal-weight women, adjusted p = 0.80), nor among the women who underwent transvaginal mesh surgery or laparoscopic sacrocolpopexy. The risks of reoperation for POP recurrence, stress urinary incontinence, or mesh-related complications did not significantly differ between the three BMI groups in the overall population nor accounting for the surgical procedure. In conclusion, obesity does not seem to be a risk factor of reoperation for POP recurrence, SUI, or mesh-related complications in the long term regardless of the surgical approach.

Long-Term Outcomes after Pelvic Organ Prolapse Repair in Young Women

The aim of the study was to describe the long-term outcomes of Pelvis Organ Prolapse (POP) repair in women under 40 years old. A retrospective chart review of all POP repairs performed in women ≤40 years old between January 1997 and December 2015 in the Gynecologic Surgery Department of Lille University Hospital was performed. Inclusion criteria were all women ≤40 years old who underwent a POP repair with a stage ≥2 POP according to the Baden and Walker classification. The study population was separated into three groups: a sacrohysteropexy group, a vaginal native tissue repair (NTR) group, and a transvaginal mesh surgery (VMS) group. The primary outcome was reoperation procedures for a symptomatic recurrent POP. Secondary outcomes were other complications. During the study period, 43 women ≤ 40 years old who underwent a POP repair were included and separated into three groups: 28 patients (68%), 8 patients (19%), and 7 patients (16%) in the sacrohysteropexy, VMS, and NTR groups respectively. The mean followup time was 83 ± 52 months. POP recurrence, reoperated or not, was essentially diagnosed in the VMS group (87.5%) and the NTR group (50%). POP recurrence repairs were performed for nine patients (21%): 7%, 62.5%, and 25% in the sacrohysteropexy, VMS, and NTR groups, respectively. Global reoperation concerned 10 patients (23%) whatever the type of POP surgery, mainly patients from the VMS group (75%) and from the NTR group (25%). It occurred in only 7% of patients from the sacrohysteropexy group. Two patients (4%) presented a vaginal exposure of the mesh (in the VMS group). De novo stress urinary incontinence was encountered by nine patients (21%): 29% and 12.5% in the sacrohysteropexy and NTR groups, respectively. Despite the risk of recurrence, POP repair should be proposed to young women in order to restore their quality of life. Vaginal native tissue repair or sacrohysteropexy should be performed after explaining to women the advantages and disadvantages of each procedure.

[Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynecologists and Obstetricians (CNGOF)]

OBJECTIVE

To provide French guidelines for the management of women with abnormal uterine bleeding (AUB).

DESIGN

A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, or medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The last guidelines from the Collège national des gynécologues et obstétriciens français (CNGOF) on the management of women with AUB was published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescent; idiopathic AUB; endometrial hyperplasia and polyps; fibroids type 0 to 2; fibroids type 3 and more; adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 present a strong agreement and 17 a weak agreement. Fourteen questions did not find any response in the literature. We preferred to abstain from recommending instead of providing expert advice.

CONCLUSIONS

The 36 recommendations made it possible to specify the diagnostic and therapeutic strategies of various clinical situations managed by the practitioner, from the simplest to the most complex.

Risk factors for immediate failure of outpatient surgery in gynecologic surgery

OBJECTIVE

To describe the risk factors for immediate failure of gynecologic outpatient surgery. The secondary objective was to describe the risk factors for rehospitalization within 30 days after surgery.

METHODS

This is a single-center retrospective cohort study conducted on all patients operated on in outpatient surgery in gynecology at the Lille University Hospital. The primary outcome was defined as any unanticipated admission to the inpatient postoperative care unit on the day of the operation. The secondary outcome was defined as any rehospitalization within 30 days following the intervention. Our statistical analysis included 916 patients operated on between January and July 2019.

RESULTS

In our study, 84 patients (9.2%) had an immediate failure of outpatient surgery. The most frequent etiologies were surgical (58.3%). In multivariate analysis with logistic regression, the following variables were associated with an increased risk of immediate failure of outpatient surgery: urogynecologic surgery (P < 0.001), complex laparoscopy (P = 0.004), endometriosis surgery (P < 0.001), and a duration of intervention longer than 1 hour (P < 0.001).

CONCLUSION

We find an increased risk of immediate failure of gynecologic outpatient surgery depending on the type of surgery as well as for surgeries lasting more than 1 hour.

Cystic adenomyoma surgery

OBJECTIVE

Cystic adenomyoma is a lesion located within the myometrium. It is lined with endometrium and has hemorrhagic content. This rare entity has been described as a focal form of adenomyosis. However, it is poorly understood, and the management of symptomatic patients is not codified. Our objective is to evaluate the effectiveness of treatment with planned surgery for cystic adenomyoma on symptoms and fertility in a retrospective series of patients.

STUDY DESIGN

This is a retrospective study between January 2011 and January 2018 in a university hospital of patients that had surgery for cystic adenomyoma with uterine preservation.

RESULTS

Pre-operative, per-operative, and post-operative data were recorded. Of the 18 patients included, 3 were lost to follow-up; 15 underwent laparoscopic surgery and 3 operative hysteroscopies. Complications during and after surgery were rare, involving only 3 patients, and of low severity. One patient saw no improvement in pain after surgery and 2 patients saw only partial improvement in their pain; 7 patients achieved at least one pregnancy with favorable outcome after surgery.

CONCLUSION

Based on this series, we argue that conservative surgical treatment for cystic adenomyoma generally improves pain and fertility without causing morbidity.

Minimally invasive removal of deep contraceptive implants under continuous ultrasound guidance is effective, quick, and safe

Objectives

The aim of this study was to assess the feasibility, performance, and complications of a non-surgical, minimally-invasive procedure of deep contraceptive implant removal under continuous ultrasound guidance.

Methods

The ultrasound-guided procedure consisted of local anesthesia using lidocaine chlorhydrate 1% (10 mg/mL) with a 21-G needle, followed by hydrodissection using NaCl 0.9% (9 mg/mL) and implant extraction using a Hartmann grasping microforceps. The parameters studied were the implant localization, success and complication rates, pain throughout the intervention, volumes of lidocaïne and NaCl used, duration of the procedure, and size of the incision. Between November 2019 and January 2021, 45 patients were referred to the musculoskeletal radiology department for ultrasound-guided removal of a deep contraceptive implant and were all retrospectively included.

Results

All implants were successfully removed en bloc (100%). The mean incision size was 2.7 ± 0.5 mm. The mean duration of the extraction procedure was 7.7 ± 6.3 min. There were no major complications (infection, nerve, or vessel damage). As a minor complication, 21 patients (46.7%) reported a benign superficial skin ecchymosis at the puncture site, spontaneously regressing in less than 1 week. The procedure was very well-tolerated, with low pain rating throughout (1.0 ± 1.5/10 during implant extraction).

Conclusions

Minimally invasive removal of deep contraceptive implants under continuous ultrasound guidance alone is feasible, effective, and safe. In the present cohort, all implants were successfully removed, whatever the location, with short procedural time, small incision size, low pain levels, and no significant complications. This procedure could become a gold standard in this indication.

Key Points

• Minimally invasive removal of deep contraceptive implants under continuous ultrasound guidance alone is feasible, which led to a success rate of 100% whatever the location (even close to neurovascular structures), with only a small skin incision (2.7 ± 0.5 mm).

• The procedure was safe, quick, without any major complications, and very well tolerated in terms of pain.

• This minimally invasive ultrasound-guided procedure could become the future gold standard for the removal of deep contraceptive implants, as an alternative to surgical extraction, even for implants in difficult locations such as subfascial ones or those close to neurovascular structures.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08263-4.

Surgical techniques for the removal of Essure® microinserts: a literature review on current practice

PURPOSE

To evaluate the different techniques for Essure^® microinserts removal and to assess the risk of fracture of the device and the intra- and post-operative complications in relation to surgical technique variants.

METHODS

Electronic search in Medline, Scopus and Embase databases using the following keywords: Essure; Essure removal; Essure surgical technique.

RESULTS

Out of 95 articles in the initial database, 17 studies were eligible for inclusion in our literature review. Several surgical techniques have been described in which the most frequent were laparoscopic salpingectomy (LS), laparoscopic cornuectomy (LC), laparoscopic or vaginal hysterectomy (LH, VH) with en-bloc salpingectomy. There were more fractures of the device with the LS procedure (6.25%) followed by the LC technique (2.77%), while there was no fracture with hysterectomy. However, peri-and post-operative complications were more severe and frequent with hysterectomy in comparison with the LC and LS procedures (respectively 8.1% Clavien Dindo grade 3 for the hysterectomy group, 1.11% for the LC procedure and 0.69% for the LS technique).

CONCLUSION

Due to the lack of standardised surgical treatment guidelines, a system of care networks for symptomatic patients with adverse effects related to Essure^® headed by specialised centres may offer a suitable and high-quality management with the appropriate removal techniques within two objectives: limiting the risk of fracture (with an en-bloc removal of the Essure^® microinserts) and avoiding intra- and post-operative complications.

Change over time in the surgical management of pelvic organ prolapse between 2008 and 2014 in France: patient profiles, surgical approaches, and outcomes

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse (POP) is a common pathological condition that may require surgical management. Several surgical treatment options are possible, and practice varies from one center to another. The objective of the present study was to describe the surgical management and outcomes of POP in France from 2008 to 2014.

METHODS

We performed a retrospective cohort study of all patients operated on for POP from 2008 to 2014, according to the French national hospital discharge summary database. Patient characteristics, surgical approaches, concomitant hysterectomy and/or incontinence surgery, the length of stay, the proportion of day-case operations, and patient outcomes were analyzed.

RESULTS

We analyzed 310,938 hospital stays with POP surgery between 2008 and 2014; 130,908 (42%) of the operations took place in hospitals performing more than 100 prolapse surgical procedures per year. The proportion of day-case operations was low, but rose significantly from 1.2% to 4.6% during the study period. More than half of the operations featured a vaginal approach. The proportions of operations with concomitant hysterectomy or urinary incontinence surgery fell from 41.0% to 36.1% and from 33.0% to 25.8% respectively. The proportions of laparoscopic procedures increased. The mortality rate was stable (0.07% for all years).

CONCLUSIONS

The number of patients undergoing POP surgery remained stable from 2008 to 2014. The proportion of laparoscopic procedures increased (in parallel with the rising proportion of day-case operations) and the proportion of procedures with concomitant hysterectomy or incontinence treatment decreased.

Symptom related to Essure® and evolution after removal: Outcomes of retrospective cohort

INTRODUCTION

The number of requests for Essure removal has grown continually over recent years. The objective is to describe the symptoms reported after Essure sterilization, methods of removal and results.

MATERIAL AND METHODS

Retrospective and single-centre cohort (Regional university hospital of Lille, France) was conducted. All women, having consulted from December 2016 to February 2019 for symptoms related to Essure insertion, were included. All the symptoms were noted. A second group was created that included patients who underwent Essure removal to evaluate the benefits of surgery on these symptoms.

RESULTS

The study included 98 patients. Most frequent symptoms were musculoskeletal pain (75 %), asthenia (63 %) and pelvic pain (55 %). Fifty-nine patients (60 %) underwent surgery. Surgery appeared beneficial with reduction of symptoms in 60 % of these patients, complete resolution in 33 % and no reduction of symptoms in 7%. Many symptoms were relieved by surgery with an overall decline of 96 % in menorrhagia, 94 % in metrorrhagia and 93 % in dyspareunia. However, other symptoms were not relieved by surgery like 100 % of sleep disorders, 70 % of abdominal pain cases and 57 % of memory impairment cases.

CONCLUSION

Symptoms related to Essure insertion are numerous. Although surgery appears beneficial, some adverse effects remain. Therefore, a preoperative aetiologic assessment and information about risk of surgery failure are important.

Feasibility of vaginal mesh for anterior vaginal wall prolapse in an ambulatory setting: A retrospective case series

INTRODUCTION

Vaginal mesh has been proven to be an effective aid in the treatment of cystocele. Could an ambulatory approach be feasible for the Uphold Lite®-mesh?

HYPOTHESIS

We investigate the feasibility of an ambulatory approach of Uphold Lite® insertion in a well-selected population. Risk factors for a non-successful ambulatory approach are identified.

METHODOLOGY

We conducted a retrospective case series of 236 women who underwent Uphold Lite® vaginal mesh insertion for the treatment of pelvic organ prolapse at our center. Indications for surgery were symptomatic anterior and/or apical prolapse, stages POPQ≥2. We compared women having an ambulatory approach, to those having a one day hospitalization planned but needed to stay. Comparisons between percentages were calculated using the chi-square or Fisher's exact test, depending on the number of women in each group. The mean comparisons were performed using the Student t-test, and the median test comparisons by the Kruskal-Wallis test. A difference was considered significant if p<0.05.

RESULTS

The most common reason for staying (85.7% of all ambulatory failures) after Uphold® surgery is the presence of an elevated post void residual. This complication was more found in the following: surgery in the afternoon, use of high-dose morphinics in general anesthesia, and in women with a higher parity.

CONCLUSIONS

Our study shows that Uphold® surgery in a one-day setting is feasible and safe. Women desiring this approach should be counselled on the 42.6% risk of one-day failure though, mostly due to non-validation of a post void residual. General anesthesia with high-dose morphinics, a higher parity, and surgery in the afternoon are risk factors for failure of an ambulatory protocol.

Fertiloscopy in women with unexplained infertility: Long-term cumulative pregnancy rate

OBJECTIVE

Fertiloscopy is as safe as laparoscopy in literature, but we don't know its relevance in women with unexplained infertility (UI). Our objective was to assess the effects of fertiloscopy procedures on the outcomes of subsequent pregnancy occurrences in patients with UI.

METHODS

Retrospective, single-center study of all patients followed up after fertiloscopy procedures between 2002 and 2007. The occurrence and outcome of pregnancies were studied in the five years following the procedure.

RESULTS

124 fertiloscopies were performed. Pelvic exploration was considered as sufficient in 83.8% of cases, of which no abnormalities were found in 78.2%. Laparoconversions occurred for 19 patients (16.5%). The pregnancy rate at five years was 76.9%. The mean delay for pregnancy occurrence was 10.7 months (±17).

CONCLUSION

The pregnancy rate in our study is similar to that after laparoscopy. Fertiloscopy, a less intrusive procedure, should be considered as a reliable option for the management of patients with UI.

Disappearance of a myoma after pregnancy in a 38 years old patient, treated by ulipristal acetate without success before getting pregnant

Uterine fibroids are the most common form of benign gynaecological tumors in women of childbearing age Piecak et al. (2017) [1]. These uterine fibroids can be responsible for abnormal uterine bleeding, pelvic pain, pelvic pressure and infertility Pritts et al. (2009), Ali and Al-Hendy (2017) [2,3]. Their treatment can be carried out according to several methods: medical treatment, uterine artery embolization or surgery (myomectomy or hysterectomy). Although surgery is the main option, there are medical treatments to reduce their size and decrease and control their symptoms. Ulipristal acetate (UPA) has been the first selective progesterone-receptor modulator approved for the preoperative and long-term treatment for uterine fibroids Ferrero et al. (2018) [4]. Here we present the case of a 38-years-old patient whose large fibroma (initially treated with UPA) totally disappeared after pregnancy.

The anatomy of the sacral promontory: How to avoid complications of the sacrocolpopexy procedure

Because of problems with vaginal meshes and the high rate of recurrences of native tissue repair, more and more surgeons treat pelvic organ prolapse with laparoscopic sacrocolpopexy. This surgery requires skilled surgeons. The first step of sacrocolpopexy is the dissection of tissues in front of the sacral promontory to reach the anterior longitudinal ligament. Some complications can occur during this dissection and the attachment of the mesh. This step is dangerous for surgeons because of the proximity of vessels, nerves, and ureters. The lack of knowledge of anatomy can lead to severe complications such as vascular, ureteral, or nerve injuries. These complications can be life-threatening. To show anatomic concerns when surgeons dissect and affix the mesh on the anterior longitudinal ligament, we have developed a video of the promontory anatomy. By reviewing anatomic articles about vessels, nerves, and ureters in this localization, we propose an educational tool to increase the anatomic knowledge to avoid severe complications. In this video, we show an alternative location for dissection and graft fixation when the surgeon believes that mesh cannot be fixed safely on the anterior surface of S1, as currently recommended.

Outpatient vaginal hysterectomy: Comparison of conventional suture ligature versus electrosurgical bipolar vessel sealing

OBJECTIVE

The aim of our study was to evaluate the feasibility of vaginal hysterectomy in an ambulatory care system and the best way to perform it between conventional and bipolar vessel sealing system ligatures.

PATIENTS AND METHODS

This was a prospective study of 32 patients with vaginal hysterectomy at Lille University Hospital between December 2013 and May 2015. Two surgical techniques were compared: conventional suture ligature (CSL) and electrosurgical bipolar vessel sealing (BVS). Patients stayed in classical hospitalization but were managed how if they were in an ambulatory unit to evaluate their capacity to come back home the same evening of the surgery. The evaluation of same-day discharge was based on Post Anesthetic Discharge Scoring System (PADSS) score?9/10 and Visual Analogic Scale (VAS) score?4/10. Other data collected were: operative time, uterus weight, peroperative bleeding, PADSS score at the 8th postoperative hour, VAS score at the 4th, 6th, 8th, 12th and 24th postoperative hours, the presence of postoperative nausea/vomiting and rehospitalization.

RESULTS

In the BVS group, 93.8% of patients validated the combined score (PADSS+VAS) on the evening of the intervention against 50% of patients in the CSL group (P<0.05). Hundred percent of BVS group patients were discharged on the day after surgery against 87.5% in the CSL group. The VAS was significantly lower in the BVS group at the 8th (1.4), 12th (1.2) and 24th (1.3) postoperative hours. Operative time was significantly shorter in the BVS group. We found more events such as nausea/vomiting in the CSL group.

CONCLUSION

Vaginal hysterectomy is feasible in an ambulatory care system most of times. By reducing postoperative pain, electrosurgical bipolar vessel sealing would promote outpatient hospitalization.

[Quality of life and symptoms before and after surgical treatment of rectovaginal fistula]

INTRODUCTION

Rectovaginal fistula requires a complex management because it has an important psychological impact associated with impaired quality of life of patients. Thus, the aim of our study was to evaluate the improvement of the quality of life of patients after surgical management.

METHODS

This is a retrospective study. We included patients operated between 2009 and 2014 for the treatment of a rectovaginal fistula, whose data were available and who agreed to answer a questionnaire. We evaluated the satisfaction of short-term and long-term patients on the answer to the basic PFDI-20 and PFIQ-7 questionnaires. We then evaluated whether there was an improvement in symptoms and quality of life after surgery.

RESULTS

Nine patients were included but only 4 patients completed the PFDI-20 and PFIQ-7 questionnaires. Fistula was secondary to either surgical intervention (44%, n=4) or complicated perineal tear (44%, n=4) or unknown cause (11%, n=1). After surgery, we found the short term a significant decrease in stool incontinence, as there was no stool incontinence (0/5) in the postoperative period, while preoperatively 55% (5/9) (P=0.03). Postoperatively, 33% (3/9) of the patients had genital discomfort and 44% (4/9) had gas incontinence compared to 0% preoperatively (P=0.2 and P=0.6). There appears to be an improvement in pelvic static disorders after surgical management. However, we found a slight improvement in nauseous leucorrhoea in the immediate postoperative period, as the prevalence decreased from 33% (3/9) preoperatively to 22% (2/9) postoperatively (P>0.9). In the long term, we observed an improvement in the sensation of perineal heaviness and gas incontinence because only 25% (1/4) of the 75% (3/4) preoperative patients still showed slight discomfort (P=0.5). The quality of life and the emotional state of the patients were no altered postoperatively. Indeed, preoperatively, 50% (2/4) of the patients reported anxiety compared to 0% (0/4) postoperatively (P=0.4). Similarly, 75% (3/4) complained of a decrease in their quality of life (social, sports, etc.) preoperatively compared with 0% (0/4) postoperatively (P>0.9).

CONCLUSION

A simple surgical management of rectovaginal fistulas would allow a significant decrease in stool incontinence and improved quality of life and their emotional state, which confirms the beneficial effect of this therapeutic strategy.

LEVEL OF EVIDENCE

4.

Pathophysiological aspects of cystocele with a 3D finite elements model

PURPOSES

The objective of this study is to design a 3D biomechanical model of the female pelvic system to assess pelvic organ suspension theories and understand cystocele mechanisms.

METHODS

A finite elements (FE) model was constructed to calculate the impact of suspension structure geometry on cystocele. The sample was a geometric model of a control patient's pelvic organs. The method used geometric reconstruction, implemented by the biomechanical properties of each anatomic structure. Various geometric configurations were simulated on the FE method to analyse the role of each structure and compare the two main anatomic theories.

RESULTS

The main outcome measure was a 3D biomechanical model of the female pelvic system. The various configurations of bladder displacement simulated mechanisms underlying medial, lateral and apical cystocele. FE simulation revealed that pubocervical fascia is the most influential structure in the onset of median cystocele (essentially after 40 % impairment). Lateral cystocele showed a stronger influence of arcus tendineus fasciae pelvis (ATFP) on vaginal wall displacement under short ATFP lengthening. In apical cystocele, the uterosacral ligament showed greater influence than the cardinal ligament. Suspension system elongation increased displacement by 25 % in each type of cystocele.

CONCLUSIONS

A 3D digital model enabled simulations of anatomic structures underlying cystocele to better understand cystocele pathophysiology. The model could be used to predict cystocele surgery results and personalising technique by preoperative simulation.

Sacral colpopexy: long-term mesh complications requiring reoperation(s)

INTRODUCTION AND HYPOTHESIS

Sacral colpopexy (SC) is a classic procedure used for the surgical treatment of pelvic organ prolapse. Although the procedure boasts excellent success rates, there are risks of complications and reoperation may be required. The purpose of this study was to evaluate the extent of complications following SC, requiring reoperation(s), and to describe the reoperations performed.

METHODS

A retrospective monocentric study of patients who were operated on following a mesh complication after SC was conducted, at Lille University Hospital, between January 2007 and January 2013. Information relating to medical and surgical history, SC surgical technique, type of complication, and reoperation techniques was gathered.

RESULTS

Twenty-seven patients required surgery for complications after SC. Nineteen patients were treated for vaginal mesh exposures (VME), four for intravesical mesh (including one with VME), one for ano-rectal dyschezia, one for spondylodiscitis with a VME, one for mesh infection, and one for vaginal fistula communicating with a collection in the ischio-coccygeal muscle. The median time between the initial SC and the first reoperation was 3.9 ± 5.7 years. The median operating time was 40 ± 95 min, and the length of hospital stay was 3.0 ± 3.0 days. Ten patients needed several interventions.

CONCLUSION

This case series provides a description of surgical interventions for complications related to sacral colpopexy. These complications may be serious and occur years after the initial surgery.

How to manage peroperative haemorrhage when vaginally treating genital prolapse

Surgery of genital prolapse causes haemorrhagic complications in about 1% of cases. The pelvis is highly vascular and accessing the usual landmarks of vaginal surgery, in particular the sciatic spine, is delicate work. Meticulous dissection of closed spaces is often difficult, and exposure and haemostatic procedures will be challenging in the event of any bleeding complication. When fixing prosthesis to the sacrospinous ligament, the inferior gluteal artery and its coccygeal branch are at risk. Fixation to the sacrospinous ligament must be performed more than 25mm away from the sciatic spine and, if possible, must not transfixiate it. Safe insertion of prosthesis requires sufficient experience, and an adequate learning curve. Being aware of vascular anatomy allows one to understand and treat haemorrhagic incidents. Packing or selective embolization seem to be the two methods to adopt, depending on the severity of bleeding and the conditions of exposure on the one hand, and on the technical resources available for embolization, on the other. Hypogastric ligature appears to be ineffective in this context.

[Genital prolapse surgery: state of the art of the vaginal approach]

Treatment of genital prolapse is mainly surgical. The vaginal approach is a shorter procedure than the abdominal approach with a quicker resumption of activity for the patients. We describe different techniques which are most often performed in our daily practice. For the complete prolapse affecting the three components of the pelvic floor, we most often associate a colpohysterectomy, a native tissue reinforcement for the treatment of cystocele, sub-symphyseal crossing of the uterosacral ligaments using the technique of Campbell and finally a suspension of the vaginal vault according to Richter with a levator myorraphy. Currently, native tissues used in these techniques tend to be superseded in our service by reinforcement prosthetic implants, which according to the latest French Health Higher Authority guidelines (November 14, 2007) "could be of interest in relapse surgery, if a clinical element raises fears of high risk of recurrence." In any case, patients seeking a surgical treatment of their genital prolapse must be fully informed of the specific risk related to each technique. They must also be informed of the long-term results or of the lack of available data, regarding techniques using native tissue or prostheses.

3D simulation of pelvic system numerical simulation for a better understanding of the contribution of the uterine ligaments

INTRODUCTION AND HYPOTHESIS

Genital prolapse remains a complex pathological condition. Physiopathology remains poorly understood, aetiology is multi-factorial, surgery is not always satisfying, as the rate of relapse cannot be overlooked. More over a good anatomical result will not always guarantee functional satisfaction. The aim of our study is to have a better understanding of the involvement of uterine ligaments in pelvic statics via 3D simulation.

METHODS

Simulation of pelvic mobility is performed with a validated numerical model in a normal situation (standing up to lying down) or induced pathological ones where parts of the constitutive elements of the model are virtually "cut" independently. Displacements are then discussed.

RESULTS

Numerical results have been compared with dynamic MRI for two volunteers. Dynamic sequences had 90 images, and 180 simulations have been validated. Results are coherent with clinical data and the literature, thus validating our mechanical approach. Uterine ligaments are involved in pelvic statics, but their lesions are not sufficient to generate a genital prolapse. Round ligaments play a part in uterine orientation; the utero-sacral ligaments support the uterus when standing up.

CONCLUSIONS

Pelvic normal and pathological mobility study via modelling and 3D simulation is a new strategy in understanding the complex multifactorial physiopathology of genital prolapse. This approach must be validated in a larger series of patients. Nevertheless, pelvic ligaments seem to play an important role in statics, especially, in agreement with a literature survey, utero-sacral ligaments in a standing position.

Visually induced postural reactivity is velocity-dependent at low temporal frequencies and frequency-dependent at high temporal frequencies

Visual stimulation alone is sufficient to produce visually induced postural reactivity (VIPR). While some studies have shown that VIPR increases with the velocity of a moving visual stimulus, others have shown that it decreases with the temporal frequency of an oscillating visual stimulus. These results seem contradictory given that these two variables co-vary in the same direction. The purpose of this study is to determine whether the VIPR can be different depending on the frequency range being considered. Twelve subjects were placed standing up in a virtual reality environment that simulated a black and white checkerboard at floor level. This checkerboard oscillated at seven frequencies (0.03–2.0 Hz) and three amplitudes (2, 4, and 8°), corresponding to nine velocities (0.125–32°/s). The virtual floor oscillated from left to right (mediolateral) or from front to back (anteroposterior). We calculated the subjects’ mean velocity (Ω) based on data from electromagnetic sensors positioned on the head and lower back. Our experiment shows that for temporal frequencies below 0.12 Hz, VIPR is visually dependent and increases with stimulus velocity. When stimulus velocity becomes too high, the body becomes incapable of following, and the VIPR saturates between 0.12 and 0.25 Hz. In this frequency range, maximal postural oscillation seems to depend on biomechanical constraints imposed by the positioning of the feet. For frequencies above 0.5 Hz, the body can no longer maintain the same oscillation state. This saturation may be linked to proprioceptive feedback mechanisms in the postural system.

Therapeutic management of uterine fibroid tumors: updated French guidelines

The medical management of symptomatic non-submucosal uterine fibroid tumors (leiomyomas or myomas) is based on the treatment of abnormal uterine bleeding by any of the following: progestogens, a levonorgestrel-releasing intrauterine device, tranexamic acid, nonsteroidal anti-inflammatory drugs, or GnRH analogs. Selective progesterone receptor modulators are currently being evaluated and have recently been approved for fibroid treatment. Neither combined estrogen-progestogen contraception nor hormone treatment of the menopause is contraindicated in women with fibroids. When pregnancy is desired, whether or not infertility is being treated by assisted reproductive technology, hysteroscopic resection in one or two separate procedures of submucosal fibroids less than 4 cm in length is recommended, regardless of whether they are symptomatic. Interstitial, also known as intramural, fibroids have a negative effect on fertility but treating them does not improve fertility. Myomectomy is therefore indicated only for symptomatic fibroids; depending on their size and number, and may be performed by laparoscopy or laparotomy. Physicians must explain to women the potential consequences of myomas and myomectomy on future pregnancy. For perimenopausal women who have been informed of the alternatives and the risks, hysterectomy is the most effective treatment for symptomatic fibroids and is associated with a high rate of patient satisfaction. When possible, the vaginal or laparoscopic routes should be preferred to laparotomy for hysterectomies for fibroids considered typical on imaging. Because uterine artery embolization is an effective treatment with low long-term morbidity, it is an option for symptomatic fibroids in women who do not want to become pregnant, and a validated alternative to myomectomy and hysterectomy that must be offered to patients. Myolysis is under assessment, and research on its use is recommended. Isolated laparoscopic ligation of the uterine arteries is a potential alternative to uterine artery embolization; it also complements myomectomy by reducing intraoperative bleeding. It is possible to use second-generation techniques of endometrial ablation to treat submucosal fibroids in women whose families are complete. Subtotal hysterectomy is a possible alternative to total hysterectomy for fibroid treatment, given that by laparotomy the former has a lower complication rate than the latter, while by laparoscopy, these rates are the same. In each case, the patient is informed about the benefit and risk associated with each therapeutic option.

[Diagnosis and management of uterine perforations after intrauterine device insertion: a report of 11 cases]

OBJECTIVE

Intrauterine device insertion is common. It is however not harmless and uterine perforation can be serious.

PATIENTS AND METHODS

Eleven cases of uterine perforation after intrauterine device insertion were listed at Tourcoing hospital between 2005 and 2009. They were analyzed to identify risk factors of uterine perforation and specify management.

RESULTS

The main symptom was pelvic pain (4 cases), pregnancy occurrence (3 cases) or inability to remove the IUD (2 cases). The intrauterine device was set during the first 9 months of post-partum in 7 cases, 2 patients were still breastfeeding. Seven patients underwent laparoscopy, 2 needed switch for laparotomy, one was treated by laparotomy only and one was lost of follow-up.

DISCUSSION AND CONCLUSION

Incidence of uterine perforation after IUD insertion ranges from 0,1 to 3/1000. Pelvic pain is the most revealing symptom. Fifteen percent of perforations complicate with adjacent organ lesion. Perforation incidence seems greater if the intrauterine device is set during the 6 first weeks of post-partum and breastfeeding, but non influenced by operator practical experience. Ultrasound follow-up of patients carrying intrauterine device is controversial. Facing a suspicion of ectopic intrauterine device, pelvic ultrasound examination is the first step imaging modality and using 3D could be useful. If it fails to localize the intrauterine device, an abdominal X-ray must be performed. Ectopic intrauterine device removal is recommended.

[Twenty-two cases of uterine carcinosarcomas]

OBJECTIVES

Twenty-two uterine carcinosarcomas were treated and followed in two centers over 10 years. We wanted to describe them and review the literature on the subject.

PATIENTS AND METHODS

We describe all uterine carcinosarcomas treated in Lille, over 10 years, both in department of gynecology, Hospital Jeanne-de-Flandre (11 patients), and in department of gynecologic oncology of Centre Oscar-Lambret (11 patients).

RESULTS

For the 22 patients included, we give age at time of diagnosis, body mass index, pre and post surgical histology, details of surgical treatment, adjuvant treatment and evolution of the pathology. Mean age at time of diagnosis was 69.6. Sixty-eight percent of patients had overweight or obesity. Revealing symptoms were in 91% of cases post-menopausal meno- or metrorrhagias. Preoperatively, histology had an important number of false negative and, 57% of diagnoses were ignored in our study. All patients had first intention surgery, only 54% were yet at an early stage. Sixteen had association radiotherapy, eight of chemotherapy, two declined any adjuvant treatment. Ten patients died with a mean survival of 12.9 months, eight had a good evolution still at 35 months, two had recent pelvic relapse, two were lost to follow-up.

CONCLUSION

Uterine carcinosarcomas are rare, aggressive, yet not very well known tumors. First line treatment will be surgery with peritoneal cytology, hysterectomy, bilateral adnexectomy, pelvic and sometimes lumbo-aortic lymphadenectomy, omentectomy, peritoneal biopsies. Adjuvant chemotherapy has shown its interest in this type of tumor. Radiotherapy is still debated.

[Uterine horn rupture at 23 weeks gestation: a case report]

Bicornuate uterus with rudimentary horn is a rare disability. Pregnancy can accidentally settle inside the rudimentary horn; in this case, it becomes apparent by uterine rupture generally in the second trimester. Bicornuate uterus should be diagnosed early, before pregnancy if possible. Abdominal pain of unknown origin occurring during the second trimester of pregnancy is the most frequent sign.

[Reflections on the treatment of acropathia ulcerans et mutilans; interest of a removable appliance (author's transl)]

The authors report their experience in the treatment of acquired ulcerating and mutilating trophic lesions of the lower limbs. Ligature of the dorsalis pedis artery and of its collaterals did not give good results, according to the pathogenic concept of the authors, in which lesions of the nervous system predominate over vascular alterations. More important lesions (such as osteo-arthritis of the first and fifth metatarsals) require immobilization of the axis of the wounded toe, control of any superinfection and use of a plastic removable limb appliance.