[Laparoscopic ultrasound-guided radiofrequency ablation of uterine fibroid : a retrospective study]

Objective : To assess clinical and radiological efficacy and safety of laparoscopic ultrasound-guided radiofrequency ablation of uterine leiomyomas. Material and Methods : Thirty-three patients with symptomatic uterine leiomyomas FIGO type 2 to 7, have undergone a laparoscopic ultrasound-guided radiofrequency ablation at Croix Rousse university hospital center (Hospices Civils de Lyon) and at Saint-Vincent de Paul hospital in Lille, between june 2020 and december 2022. The characteristics of each myoma and the symptoms were assessed with pelvic MRI and with Higham score, SSS and HRQL scores preoperatively and at 6 months. Results : A total of 54 fibroids have been treated in 33 patients. We observed a significant decrease of the volume 6 months after the surgery, on average 21ml (55,97 ml vs 74,37 ml, 95%CI [7,13 - 34,88], p=0.001). The maximum diameter of each fibroid was also significantly reduced on average 11,78mm (41,89 vs 52,06, IC 95% [8,83 - 14,73], p<0,05). We noticed a significant decrease of the NRS for dysmenorrhea on average 2.79 points (2,1 vs 4,89, 95%CI [1,14-4,42], p<0,05). There was also a trend to improvement of menorrhagia, assess by Higham score. Indeed, 70,8% of the patients had menorrhagia. Menorrhagia was improved of 108,3 points with an average Higham score before surgery of 197,3versus 87,9 after surgery (IC 95% [47,9-168,8], p=0,001). Concerning UFS-QOL score: the symptom severity score (SSS) decreased on average 33 points, testifying of symptom improvement (27,04 vs 60,89, 95%CI [22,92 - 43,39], p<0,001) and the HRQL score increased on average 20 points testifying quality of life improvement (65,57 vs 42,7, 95%CI [15,83-37,85], p<0,001). No severe adverse event has been reported. Conclusion : In this first French study about radiofrequency ablation, we confirm its efficiency for improvement of symptoms and quality of life, but other study are mandatory to confirm the safety of this procedure in particular in patients with a wish to conceive.

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.

[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.

[Impact of the COVID-19 Outbreak on the management of patients with gynecological cancers]

OBJECTIVE

The exceptional health situation related to the SARS-Cov2 coronavirus pandemic (COVID-19) required a deep and very quickly adaptation of management practices in gynecological cancer. The main objective is to estimate the proportion of patients with treatment modifications.

METHOD

This is a multicenter prospective study conducted in 3 university gynecological cancer departments (HCLyon, France) during the period of confinement (March 16 to May 11, 2020). All patients with non-metastatic breast cancer or gynecological cancer were included. The planned treatment, postponement, delay and organizational modifications (RCP, teleconsultations) were studied.

RESULTS

Two hundred and five consecutive patients were included, average age 60.5±1.0. 7 patients (3.4%) had SARS-Cov-2 infection, 2 patients died. One hundred and twenty-two patients (59.5%) had a treatment maintained, 72 patients (35.1%) postponed, 11 patients (5.4%) cancelled. Of the 115 (56.1%) planned surgeries, 40 (34.8%) postponed, 7 cancelled (6.1%). 9 patients (7.8%) had a surgical modification. Of the 59 (28.8%) radiotherapy treatments scheduled, 24 (40.7%) postponed and 2 (3.4%) cancelled. Of the 56 (27.3%) chemotherapy treatment planned, 8 (14.3%) postponed and 2 (3.6%) cancelled. One hundred and forty-five patients (70.7%) have been discussed in multidisciplinary meeting. One hundred and fifty-eight patients (77%) had a teleconsultation system.

CONCLUSION

Our study assessed the impact of the COVID-19 pandemic on therapeutic management of patients with gynecological cancer during the period of confinement. This will probably improve our management of an eventual epidemic rebound or future health crisis.

Transrectal high-intensity focused ultrasound (HIFU) for management of rectosigmoid deep infiltrating endometriosis: results of Phase-I clinical trial

OBJECTIVES

Deep infiltrating endometriosis (DIE) of the rectosigmoid is associated with painful symptoms. When medical treatment is ineffective, surgical resection remains the standard treatment, despite significant risk of adverse events. High-intensity focused ultrasound (HIFU) is a minimally invasive ablative procedure. Focal One® is a transrectal HIFU (TR-HIFU) device used in prostate cancer treatment. The primary objective of this study was to confirm the feasibility of treatment with TR-HIFU in patients presenting with posterior DIE with rectosigmoid involvement. We also assessed its safety and clinical efficacy in this context.

METHODS

This was a non-controlled, prospective, Phase-I clinical trial in a French University Hospital which is a multidisciplinary center for management of endometriosis. Included were patients older than 25 years, without plans to conceive within 6 months, who presented with a single lesion of posterior DIE, with rectosigmoid invasion, after failure of hormonal therapy. All lesions were assessed preoperatively using transvaginal sonography and magnetic resonance imaging. Patients completed questionnaires on gynecological and intestinal symptoms (similar to a visual analog scale (VAS)), and on quality of life (Medical Outcomes Study 36-item short-form survey (SF-36) and, for the second half of patients recruited, symptom scoring system for constipation (KESS), female sexual function index (FSFI) and endometriosis health profile short-version score (EHP-5)), before, and at 1, 3 and 6 months after, TR-HIFU treatment with a Focal One real-time ultrasound-guided HIFU device.

RESULTS

Twenty-three consecutive patients were included in the study between September 2015 and October 2019. All 23 lesions were visualized, giving a detection rate of 100%. Twenty lesions were treated ('feasibility rate', 87.0%): in 13 the whole lesion was treated and in seven the lesion was treated partially. The mean duration of the TR-HIFU procedure was 55.6 min. We observed a significant improvement in VAS score at 6 months, with differences relative to preoperative scores as follows, for: dysmenorrhea (-3.6, P = 0.004), dyspareunia (-2.4, P = 0.006), diarrhea (-3.0, P = 0.006), constipation (-3.0, P = 0.002), dyschezia (-3.2, P = 0.003), false urge to defecate (-3.3, P = 0.007), posterior pelvic pain (-3.8, P = 0.002) and asthenia (-3.8, P = 0.002). There was also a significant improvement in the SF-36 score, with an increase at 6 months relative to the preoperative score in both the physical component summary (+ 9.3%, P = 0.002) and mental component summary (+ 10.9%, P = 0.017). No major complications occurred during or after any procedure.

CONCLUSIONS

TR-HIFU therapy for posterior DIE is feasible. If its efficacy and safety are confirmed, it could be a minimally invasive alternative to surgery for the treatment of rectosigmoid endometriosis. © 2019 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Surgical activity during the Covid-19 pandemic: Results for 112 patients in a French tertiary care center, a quality improvement study

BACKGROUND

After the emergence of Covid-19 in China, Hubei Province, the epidemic quickly spread to Europe. France was quickly hit and our institution was one of the first French university to receive patients infected with Sars-COV2. The predicted massive influx of patients motivated the cancellation of all elective surgical procedures planned to free hospitalization beds and to free intensive care beds. Nevertheless, we should properly select patients who will be canceled to avoid life-threatening. The retained surgical indications are surgical emergencies, oncologic surgery, and organ transplantation.

MATERIAL AND METHODS

We describe the organization of our institution which allows the continuation of these surgical activities while limiting the exposure of our patients to the Sars Cov2.

RESULTS

After 4 weeks of implementation of intra-hospital protocols for the control of the Covid-19 epidemic, 112 patients were operated on (104 oncology or emergency surgeries and 8 liver transplants). Only one case of post-operative contamination was observed. No mortality related to Covid-19 was noted. No cases of contamination of surgical care personnel have been reported.

CONCLUSION

We found that the performance of oncological or emergency surgery is possible, safe for both patients and caregivers.

Management of endometriosis: CNGOF/HAS clinical practice guidelines - Short version

First-line diagnostic investigations for endometriosis are physical examination and pelvic ultrasound. The second-line investigations are: targeted pelvic examination performed by an expert clinician, transvaginal ultrasound performed by an expert physician sonographer (radiologist or gynaecologist), and pelvic MRI. Management of endometriosis is recommended when the disease has a functional impact. Recommended first-line hormonal therapies for the management of endometriosis-related pain are combined hormonal contraceptives (CHCs) or the 52mg levonorgestrel-releasing intrauterine system (IUS). There is no evidence base on which to recommend systematic preoperative hormonal therapy solely to prevent surgical complications or facilitate surgery. After surgery for endometriosis, a CHC or 52mg levonorgestrel-releasing IUS is recommended as first-line treatment when pregnancy is not desired. In the event of failure of the initial treatment, recurrence, or multiorgan involvement, a multidisciplinary team meeting is recommended, involving physicians, surgeons and other professionals. A laparoscopic approach is recommended for surgical treatment of endometriosis. HRT can be offered to postmenopausal women who have undergone surgical treatment for endometriosis. Antigonadotrophic hormonal therapy is not recommended for patients with endometriosis and infertility to increase the chances of spontaneous pregnancy, including postoperatively. Fertility preservation options must be discussed with patients undergoing surgery for ovarian endometriomas.

[Management of endometriosis: CNGOF-HAS practice guidelines (short version)]

First-line investigations to diagnose endometriosis are clinical examination and pelvic ultrasound. Second-line investigations include pelvic examination performed by a referent clinician, transvaginal ultrasound performed by a referent echographist, and pelvic MRI. It is recommended to treat endometriosis when it is symptomatic. First-line hormonal treatments recommended for the management of painful endometriosis are combined with hormonal contraceptives or levonorgestrel 52mg IUD. There is no evidence to recommend systematic preoperative hormonal therapy for the unique purpose of preventing the risk of surgical complications or facilitating surgery. After endometriosis surgery, combined hormonal contraceptives or levonorgestrel SIU 52mg are recommended as first-line therapy in the absence of desire of pregnancy. In case of initial treatment failure, recurrence, or multiple organ involvement by endometriosis, medico-surgical and multidisciplinary discussion is recommended. The laparoscopic approach is recommended for the surgical treatment of endometriosis. HRT may be offered in postmenopausal women operated for endometriosis. In case of infertility related to endometriosis, it is not recommended to prescribe anti-gonadotropic hormone therapy to increase the rate of spontaneous pregnancy, including postoperatively. The possibilities of fertility preservation should be discussed with the patient in case of surgery for ovarian endometrioma.

[Pelvic nodules in a young woman: All is not endometriosis!]

Splenosis is a pathology resulting from a rupture of the spleen due to a trauma or a surgery. We report the case of a patient presenting with a splenosis, initially diagnosed as endometriosis-related pelvic nodules, the most frequent cause of pelvic nodules in women. We will describe the imaging strategy that led to the final diagnosis of splenosis.

[Intra-uterine growth restriction impact on maternal serum concentration of PlGF (placental growth factor): A case control study]

OBJECTIVES

Placental growth factor (PlGF) is a pro-angiogenic factor mainly assessed in preeclampsia in which its blood concentration is decreased. The aim of this study was to dose the blood concentration of PlGF in women with fetal intra-uterine growth restriction (IUGR) without associated preeclampsia at the time of diagnosis.

METHODS

Case/control study: IUGR was defined by a fetal biometry with abnormal uterine and/or umbilical doppler (n=23). This group was compared to a control group of fetuses (n=25) matched for gestational age at blood sampling for the dosage of maternal seric PlGF. Women with preeclampsia were not included.

RESULTS

The plasma PlGF concentration was 11pg/mL (IQR [11-42,8]) in the IUGR group vs 287pg/mL [135-439] in the control group (P<0.001) and this difference was available after adjustment for gestational age at the time of blood sampling (P<0.001). PlGF sensitivity and specificity for discrimination were respectively 87% (CI 95% [66-97]) and 88% (CI 95% [69-97]).

CONCLUSION

Maternal serum PlGF concentrations were very low in IUGR group compared with those of the control group.

[Indications for methotrexate in gynecology outside the first-line treatment of ectopic tubal pregnancies]

The objective of this work is to discuss the indications for methotrexate in gynecology outside the first-line treatment of tubal ectopic pregnancy. In tubal ectopic pregnancy, the prophylactic use of systemic methotrexate can be discussed when performing laparoscopic salpingotomy. In case of failure of salpingotomy, administration seems justified especially if it avoids re-intervention. The combination of methotrexate with other therapies such as mifepristone, potassium chloride or gefitinib is not recommended in the treatment of ectopic pregnancy. For non-tubal ectopic pregnancy, the intramuscular or local administration of methotrexate is an acceptable treatment for uncomplicated interstitial pregnancies. For uncomplicated cervical or cesarean scar pregnancies, the local administration of methotrexate should be considered as a first-line treatment. For ovarian pregnancies, methotrexate should not be a first-line treatment, surgical treatment remains the standard. Asymptomatic women presenting with a pregnancy of unknown location and plateauing serum hCG concentration<2000 UI/L can be managed expectantly: it is recommended to take an additional quantitative hCG serum level after 48 hours. Thus, methotrexate is not recommended in the first intention. Other gynecological indications were discussed: methotrexate is not recommended in the management of first-trimester miscarriages or in the management of placenta accreta.

Contribution of Lymphoscintigraphy for Sentinel Lymph Node Biopsy in Women with Early Stage Endometrial Cancer: Results of the SENTI-ENDO Study

BACKGROUND

This study was designed to evaluate detection rate and anatomical location of sentinel lymph node (SLN) at lymphoscintigraphy, to compare short and long lymphoscintigraphy protocols, and to correlate lymphoscintigraphic and surgical mapping of SLN in patients with early-stage endometrial cancer (EC).

METHODS

Subanalysis of the prospective multicenter study Senti-endo performed from July 2007 to August 2009. Patients with stage I and II EC received four cervical injections of 0-2 mL of unfiltered technetium sulphur colloid the day before (long protocol) or the morning (short protocol) before surgery. SLN detection used a combined technetium/patent blue labeling technique, and all patients had a systematic bilateral pelvic lymphadenectomy.

RESULTS

A total of 133 patients were enrolled in the study and 118 (94.5 %) underwent a lymphoscintigraphy. Of these 118 patients, 44 (37 %) underwent a short protocol and 66 (56 %) a long protocol (data on lymphoscintigraphy were not available in eight patients). Lymphoscintigraphic detection rate was 74.6 % (34 % for short protocol and 60.2 % for long protocol). No difference in the detection rate was observed according to lymphoscintigraphy protocol (p = 0.22), but a higher number of SLN was noted for the long protocol (p = 0.02). Aberrant drainage was noted on lymphoscintigraphy in 30.5 % of the patients. Paraaortic SLNs were exclusively detected using the long protocol. A poor correlation was noted between short (κ test = 0.24) or long lymphoscintigraphy (κ test = 0.3) protocol and SLN surgical mapping.

CONCLUSIONS

Our study demonstrates that preoperative lymphoscintigraphy allowed a high SLN detection rate and that long lymphoscintigraphy protocol was associated with a higher detection of aberrant drainage especially in the paraaortic area.

Accuracy of a nomogram for prediction of lymph-node metastasis detected with conventional histopathology and ultrastaging in endometrial cancer

BACKGROUND

We developed a nomogram based on five clinical and pathological characteristics to predict lymph-node (LN) metastasis with a high concordance probability in endometrial cancer. Sentinel LN (SLN) biopsy has been suggested as a compromise between systematic lymphadenectomy and no dissection in patients with low-risk endometrial cancer.

METHODS

Patients with stage I-II endometrial cancer had pelvic SLN and systematic pelvic-node dissection. All LNs were histopathologically examined, and the SLNs were examined by immunohistochemistry. We compared the accuracy of the nomogram at predicting LN detected with conventional histopathology (macrometastasis) and ultrastaging procedure using SLN (micrometastasis).

RESULTS

Thirty-eight of the 187 patients (20%) had pelvic LN metastases, 20 had macrometastases and 18 had micrometastases. For the prediction of macrometastases, the nomogram showed good discrimination, with an area under the receiver operating characteristic curve (AUC) of 0.76, and was well calibrated (average error =2.1%). For the prediction of micro- and macrometastases, the nomogram showed poorer discrimination, with an AUC of 0.67, and was less well calibrated (average error =10.9%).

CONCLUSION

Our nomogram is accurate at predicting LN macrometastases but less accurate at predicting micrometastases. Our results suggest that micrometastases are an 'intermediate state' between disease-free LN and macrometastasis.

[Comparison of three models to predict non-sentinel lymph node status in breast cancer patients with metastatic sentinel lymph nodes: a retrospective study of 77 patients]

Various statistic predictive models have been developed to predict the status of the non-sentinel lymph nodes (NSLN) when the sentinel one was invaded by tumor cells in the case of breast invasive carcinoma. The objective of this study was to compare the accuracy of three of these statistic models: the MSKCC nomogram, the Tenon score and the MDA score. The study was conducted at Croix Rousse Hospital, Lyon, France.

OBJECTIVE

When sentinel lymph node is invaded by metastasis, complete lymph node dissection of the axilla can be avoided using statistic predictive models especially when talking about micrometastases and moreover about isolated tumor cells in the sentinel lymph node. Over the different existing models, we tested the three most used ones to determine the model that is most adapted to our everyday practice.

METHOD

The study population consisted of 77 women with an invasive breast cancer treated by complete axillary lymph node dissection for metastatic sentinel lymph node. Over the nine models already published, we focused on three of them due to their ease to use as well as their good preliminary results: the Memorial Sloan-Kettering Cancer Center nomogram (MSKCC), the Tenon score and the M.D Anderson score (MDA). Different criteria are used by these models, but all of them take in consideration: tumor size, multifocality, tumor type, lymphovascular invasion, hormonal receptors, number of sentinel lymph node resected, degree of sentinel lymph node invasion (i.e. macrometastasis, micrometastasis or isolated tumor cells) and histologic method used to diagnose sentinel lymph node invasion. These scores are validated depending on their false negative ratio as well as the proportion of patient selected as having a low risk of non-sentinel lymph node invasion. The major criterion for the MSKCC score is the calibration that compares the predicted likelihood of invasion and the histologically proved one.

RESULTS

The rate of non-sentinel lymph node invasion was 37.6%. The discrimination of the three models was good with an AUC of 0.74 for both MSKCC nomogram and Tenon score and of 0.72% for MDA score. MSKCC nomogram was well calibrated (P=0.23). The false negative ratio was 0 (CI 95%: 0-18.1%) for MSKCC nomogram, 16.7% (CI 95%: 8.6%-27.8%) for Tenon score and 16% (CI 95%: 6.8-31%) for MDA score. The percentage of patients considered as having a low risk of invasion of the non-sentinel lymph node was 20.5% for MSKCC nomogram, 34.7% for MDA score and 47.4% for Tenon score.

CONCLUSION

MSKCC nomogram seems to be the statistic model that is most adapted to the population we studied. To validate the Tenon and MDA score, we should have a most important population.

[Relevance of quality of life questionnaires in women with endometriosis]

High recurrence rates have been reported in women treated for endometriosis despite advances in medical and surgical treatments improving both fertility and symptoms. It should therefore be considered a chronic disorder. In this particular setting, the main objectives for practitioners are to limit disease progression, recurrence and to improve quality of life (QOL). Previous studies have demonstrated a relation between an increase in pain intensity and a decrease in QOL. However, visual analogue scales to measure general well-being are insufficient to quantify the impact of endometriosis on QOL. Several generic questionnaires, mainly the SF-36, are available in various languages but are not specific of women with endometriosis. Some specific questionnaires are available but have been validated in English population for the most part rending comparison between countries difficult. Despite these limits, QOL should be systematically monitored over time by a validated questionnaire for this chronic disorder and could be a criterion for therapeutic strategy.

[Management of puerperal hematomas]

Puerperal hematoma is a rare complication of the postpartum period remaining imperfectly known. We present an update of knowledge on this particular type of puerperal haemorrhage threatening in some cases maternal prognosis. In vulvovaginal hematomas, the diagnosis relies on clinical findings whereas it requires medical imaging in the retroperitoneal localisations. Therapeutic approach also largely differs according to the localisation of the hematoma. We thus propose a synthesis of the critical care strategies depending on the type of the puerperal hematoma.

Use of the SF-36 questionnaire to predict quality-of-life improvement after laparoscopic colorectal resection for endometriosis

BACKGROUND

Laparoscopic colorectal resection for endometriosis can improve quality of life (QOL), but the results vary widely from one woman to another. The aim of this study was to determine whether the preoperative results on the Physical Component Summary (PCS) and Mental Component Summary (MCS) subscales of the SF-36 questionnaire could predict the improvement in QOL after surgery.

METHODS

The predictive value of the subscales was first evaluated on a training set of 57 patients. A mathematical model, quantified with respect to discrimination and calibration was then applied to the validation set of 36 patients.

RESULTS

Women with preoperative PCS and MCS scores below 37.5 and 44.5, respectively, had 80.7% and 84.2% probabilities of seeing their scores improve after surgery, whereas women with preoperative scores above 46.5 and 47.5, respectively, had probabilities of 0% and 10.7% to improve their scores.

CONCLUSIONS

With our mathematical model, the postoperative improvement in QOL can be reliably predicted. This model should help to identify those women who are most likely to benefit from this major surgery.

Laparoscopic restaging of borderline ovarian tumors

BACKGROUND

This study aimed to evaluate the feasibility and relevance of laparoscopic restaging surgery for women with borderline ovarian tumors.

METHODS

From March 2001 to February 2006, 42 women referred for borderline ovarian tumors after laparoscopy or laparotomy underwent a laparoscopic restaging operation. Of these women, 37 (88%) had undergone conservative surgery including unilateral cystectomy (n = 16), bilateral cystectomy (n = 1), and unilateral salpingo-oophorectomy (n = 20). The remaining five women (12%) had undergone radical surgery, including bilateral salpingo-oophorectomy (BSO) (n = 4) and hysterectomy with BSO (n = 1). Intraoperative rupture occurred in 13 cases.

RESULTS

All 42 restaging operations were performed via the laparoscopic approach. There were no intraoperative complications, no laparoconversions, and no postoperative complications. Laparoscopic restaging identified two persistent borderline ovarian tumors (12%) in women who had initially undergone cystectomy. Seven women were upstaged (16.6%) because of positive cytology (n = 2), peritoneal biopsy (n = 2), or omentum (n = 3). Among the 28 women with initial Federation International of Gynaecology and Obstetrics (FIGO) stage Ia disease, the final stage was Ia for 24 women, Ib for 2 women, IIIa for 1 woman, and IIIc for 1 woman. Among the 12 women with initial stage Ic disease, 11 kept the same stage and 1 was upstaged to IIIc. The woman with initial stage IIa disease was upstaged to IIb, and the woman with initial stage IIc disease was upstaged to IIIc. The risk of upstaging was significantly higher among women with serous borderline tumors. Upstaging occurred in women with both initial stages I and II disease.

CONCLUSIONS

The results confirm the feasibility and safety of laparoscopic restaging operations for women with borderline ovarian tumors. Cystectomy was associated with a risk of persistent lesions. The risk of upstaging was higher for women with serous borderline ovarian tumors and women with initial FIGO stage I or II disease.

[Indications for GnRH analogs in the treatment of genital endometriosis]

Three GnRH agonists are currently available in France in clinical medicine with the indication: "Genital or extragenital endometriosis (from stage I to stage IV of the rAFS classification [4] )." The 2004 Cochran meta-analysis showed a significant improvement in the pain score in patients treated with GnRH compared with placebo, with the effect lasting 12 months after cessation of the medication, but few data are available on their advantages in the perioperative situation and in deep endometriosis. A. Audebert found an advantage to preoperative use of GnRHa in severe cases of endometriosis, with a significantly higher rate of patients having surgery that was considered optimal at the end of the intervention, both in terms of the endometriosis lesions and adherences. The benefits of GnRH treatment before medically assisted procreation are, however, supported by the literature.

[Assessment of the urinary side effects after surgery for deep pelvic endometriosis]

OBJECTIVE

To evaluate the urinary side effects after laparoscopic surgery for deep endometriosis.

PATIENTS AND METHOD

Longitudinal study including 86 patients operated for deep pelvic endometriosis : 58 (68%) with colorectal endometriosis, 21 (24%) with utero-sacral ligament endometriosis and 7 (8%) with recto-vaginal septum endometriosis. Assessment of the urinary side effects was permormed using the Bristole Female Lower Urinary Tract Symptom questionnaire.

RESULTS

On postsurgical follow-up, almost all patients described: hesistancy (p = 0.02), strain to start (p = 0.04), stopping flow (p = 0.01), incomplete emptying (p = 0.008) and reduce stream (p=0.02). Only patients who had resection of both utero-sacral ligaments had significative postsurgical urinary dysfunction with stopping flow (p = 0.02) and incomplete emptying (p = 0.004). Patients with colorectal resection had also significative postsurgical urinary dysfunction with hesitancy (p = 0.02), strain to start (p = 0.03), stopping flow (p = 0.007) and incomplete emptying (p = 0.004). In patients with rectal resection, urinary dysfunctions are raised when rectal resection is associated to resection of both utero-sacral ligaments.

CONCLUSION

Postoperatively, urinary side effects occurred only in patients with segmental colorectal endometriosis resection associated with bilateral utero-sacral ligament resection. Sparing nerve surgery of the pelvic nerves, can reduce these urinary side effects.

Laparoscopic segmental colorectal resection for endometriosis: limits and complications

BACKGROUND

Deep pelvic endometriosis with colorectal involvement is a complex disorder often requiring segmental bowel resection. This study investigated the limits and complications of laparoscopic segmental colorectal resection.

METHODS

Laparoscopic segmental colorectal resection was performed for 71 women with bowel endometriosis. Intra- and postoperative complications were evaluated, together with symptom outcomes, by means of questionnaires completed before and after surgery. Surgical procedures and complications were compared between the first part of the study (40 cases, previously published) and the second part (31 cases).

RESULTS

Of the 71 women, 64 (90%) underwent laparoscopic segmental colorectal resection, with 7 requiring laparoconversion. Major complications occurred in nine cases (12.6%), six with rectovaginal fistulae and three with pelvic abscesses. The mean operating time decreased significantly during the study (p < 0.05). The mean follow-up period after colorectal resection was 24.4 +/- 2.2 months. No differences in the rates of laparoconversion or complications were observed between the two periods, whereas major associated surgical procedures were more frequent during the second period. Dysmenorrhea (p < 0.0001), dyspareunia (p = 0.0001), pain at defecation (p = 0.0004), bowel movement pain or cramping (p < 0.0001), lower back pain (p < 0.0001), and asthenia (p < 0.0001) were improved after the operation, with no difference between the study periods.

CONCLUSION

This large series confirms the feasibility and efficacy of laparoscopic segmental colorectal resection. However, women must be informed of the risk for potentially severe complications.

Unscarred uterine rupture--case report and literature review

BACKGROUND

Spontaneous uterine rupture is a life threatening event, and the diagnosis is difficult in an unscarred uterus. Many factors can help prevent the catastrophic consequences.

CASE

A 38-year-old multipara in labor was admitted at 39.5 weeks of gestation. Ultrasound suggested a macrosomic fetus but the cervix was well dilated. Labor was immediately monitored. Two hours later, the fetus developed progressive heart rate decelerations. While evaluating the unexplained anomaly, epigastric pain and vaginal bleeding prompted emergency cesarean delivery. The uterine tear was repaired with good evolution but the infant died a few days later.

CONCLUSION

The association of multiparity, uterine distension and active labor could be considered as risk factors of uterine rupture in cases of unexplained anomalies in an unscarred uterus, making a catastrophic event preventable.

Immunohistochemistry of adhesion molecules, metalloproteinases and NO-synthases in extravillous trophoblast of tubal pregnancy

Trophoblast invasion in uterine pregnancy is fine-tuned for the remodelling of the uterine wall and its vascularization. Tubal pregnancy, which occurs in a limited number of patients, involves a dramatic trophoblast invasion in a context of a poor decidualization. By studying the histology of the extravillous trophoblast (EVC) in the anchoring villi, the Ki67 labelling, the location of several adhesion markers (cytokeratin-7, alpha1, alpha6, alphaV, beta1, beta4 integrin subunits and E-cadherin, V/E-cadherin), metalloproteinases (MMP-2, 9 and11), NOS2 and 3, we aimed to detect the specificity of tubal compared to intrauterine pregnancies. No difference could be observed between meso or anti-salpingial trophoblast proliferation or invasion using Ki67. Cytokeratin-7 allowed detection of spindle-shape EVCs and we identified some decidualized stromal cells. Integrins alpha1, beta1 and alphaV, and V/E-cadherin were expressed mainly in the distal EVC correspondingly to intrauterine pregnancy, with a poor expression of alpha1. Integrins alpha6 and beta4, E-cadherin were detected in the distal EVC in contrast to uterine pregnancy. MMP-2, 9, 11 were also shown in distal EVC. NOS2 and 3 labelled the perivascular EVC and NOS3 the endothelial cells of the tubal vessels. These changed distributions of adhesion molecules and MMP together with that of the basic and inducible NOS expressions could be related to mechanical effects in superficial implantation or to a failure of decidualization in tubal pregnancies.

Indications des analogues de la GnRH en pré- et postchirurgie pour endométriose

Indications of GnRH analogues before and/or after surgery for endometriosis remain controversial. Although some studies have underlined a decrease in rAFS scores using GnRH analogues pre-operatively, data are insufficient to recommend their systematic use in routine. In the same way, despite an increase in symptom free period subsequent to the use of GnRH analogues post-operatively, no effect of this therapeutic on recurrence rate and fertility outcome has been proved. In addition to a meta-analysis on GnRH analogues in endometriotic women, further studies, especially in women with large endometriomas and with deep pelvic endometriosis, are required to clarify the indications of GnRH analogues associated with surgical management.

Junctions and adhesion molecules in first trimester and term human placentas

Placental tight and gap junctions and their adhesion molecules were studied by immunochemistry and electron microscopy in early and term placentas in order to clarify their pattern of expression during placental development. Early syncytio-cytotrophoblast contained tight junctions with occludin and gap junctions with connexins 40 and 43. At term, endothelial cells from arterioles had tight and gap junctions following each other. Occludin, claudins 3 and 5 were found at the paracellular clefts of endothelial cells together with connexins 32, 40 and 50. Stromal cells had mixed tight and gap junctions with connexins 32, 43, 50. Capillaries demonstrated interendothelial tight junctions with claudins 3 and 5, and small gap junctions. Taken together these observations showed that the numerous tight and gap junctions of the early placental syncytio-cytotrophoblast are observed in the foetal arterioles and capillaries in the term placenta. We conclude that the tightness of the placenta due to the junctions lying in the syncytio-cytotrophoblast in early pregnancy is maintained by the foetal endothelial layer in term pregnancy, with significant developmental changes of their transmembrane proteins.

Intérêt de l'IRM associée à l'échographie pour la caractérisation des masses annexielles persistantes au cours de la grossesse : à propos de neuf cas

OBJECTIVE

To evaluate the accuracy of MR imaging combined with sonography for the diagnosis of persistent adnexal masses during pregnancy.

PATIENTS AND METHODS

From January 1999 to November 2003, nine patients with a persistent adnexal masse were included in this retrospective study. All patients underwent both transvaginal and transabdominal sonography combined with MR imaging. Accuracy of imaging techniques was evaluated by comparison with histology.

RESULTS

Adnexal masse was detected by systematic sonography in six women whereas three patients were symptomatic. Mean gestational age at the diagnosis was 17 weeks of amenorrhea (range 5-36). Mean tumor size was 96 mm (range 2-15). Two patients underwent a surgery during pregnancy; one for acute abdominal pain related to an adnexal torsion and the second for suspicion of malignancy. One patient underwent a caesarean delivery for obstetrical reasons. In all patients, benign ovarian tumours were found. For eight patients the diagnosis suspected by imaging techniques was confirmed by histology.

DISCUSSION AND CONCLUSION

The combination of sonography and MR imaging allows diagnosing accurately adnexal masses during pregnancy.

Prognosis of stage III or IV primary peritoneal serous papillary carcinoma

AIMS

To study the prognosis of patients with stage IIIC/IV primary peritoneal serous papillary carcinoma (PSPC) (study group) compared with that of patients with epithelial ovarian carcinoma (EOC) (control group).

METHODS

A retrospective case-control study including a study group of 37 patients who were matched with a control group of 37 patients. Patients were matched for the histologic subtype (serous tumor), tumor stage, tumor grade, residual disease at the end of debulking surgery (initial or interval) and age (+/-5 years).

RESULTS

Debulking surgery was performed initially or at interval surgery in respectively, 10 and 27 patients in the study group and 17 and 20 in the control group. All patients were treated with platinum-based chemotherapy (combined with paclitaxel in 33) in both groups. The overall survival rate at 3 years in the study and control groups was, respectively, 60% versus 55% (NS). However, event-free survival rates at 3 years (CI 95%) were statistically different (respectively, 29% in the study group versus 16% in the control group: p=0.008).

CONCLUSIONS

Peritoneal disease is more bulky in patients with PSPC. Neoadjuvant chemotherapy is more often required to achieve optimal debulking surgery in PSPC. Overall survival of patients with PSPC is similar to that of their EOC counterparts. Thus, the management of PSPC should not be different from that of advanced stage EOC.

Quality of life after sentinel lymph node biopsy in early breast cancer

AIM

This study assessed the effects of multiple therapeutic factors on quality of life (QOL) in the treatment of breast cancer.

METHODS

We surveyed 179 recurrence-free women with early breast cancer who had undergone a sentinel lymph node procedure, between January 1999 and June 2001. Age, tumour size, breast and axillary procedure, nodal status, chemotherapy, supra-clavicular fossa radiotherapy, and hormone therapy were tested as possible factors associated with poor QOL.

RESULTS

Information on QOL was obtained for 148 out of 179 patients. Age less than 55 years and chemotherapy were factors associated with impairment of physical well-being. Tumour size was associated with poor socio-familial well-being. Factors associated with altered arm subscale scores were age <55, axillary procedure, nodal status, chemotherapy and supra-clavicular fossa radiotherapy. Unexpectedly, sentinel lymph node (SLN) procedure delayed the onset of chemotherapy if the metastatic status of SLN was not diagnosed intra-operatively.

CONCLUSION

Efforts are needed to improve the QOL of young patients. Axillary procedure affects only QOL related to arm morbidity.

[Pseudotumoral tuberculosis of the cervix]

Cervical tuberculosis is a rare pathology, which can clinically look like a cervix cancer. The biopsy re-establishes the right diagnosis. The treatment is medical. The prognosis is primarily the infertility due to frequent associated general genital tuberculosis.

[Laparoscopic treatment of genital prolapse: lateral utero-vaginal suspension with 2 meshes. Results of a series of 47 patients]

We report our experience with a new technique to treat genital prolapse: the laparoscopic lateral suspension with two meshes. This is a prospective longitudinal study of 47 women with genital prolapse. With a mean follow-up of 15.2 +/- 10 months (1-39), the anatomical result was perfect in 78.7% of the cases (37 patients). From the functional point of view, 89.3% were satisfied (42 patients). These good preliminary results need to be confirmed by other extensive studies.