Robotic assisted versus laparoscopic surgery for deep endometriosis: a meta-analysis of current evidence

Endometriosis is a benign inflammatory onco-mimetic disease affecting 10-15% of women in the world. When it is refractory to medical treatments, surgery may be required. Usually, laparoscopy is the preferred approach, but robotic surgery has gained popularity in the last 15 years. This study aims to evaluate the safety and efficacy of robotic-assisted laparoscopic surgery (RAS) versus conventional laparoscopic surgery (LPS) in the treatment of endometriosis. This study adheres to PRISMA guidelines and is registered with PROSPERO. Studies reporting perioperative data comparing RAS and LPS surgery in patients with endometriosis querying PubMed, Google Scholar and ClinicalTrials.gov were included in the analysis. The Quality Assessment of Diagnostic Accuracy Studies 2 tool (QUADAS-2) was used for the quality assessment of the selected articles. Fourteen studies were identified, including 2709 patients with endometriosis stage I-IV for the meta-analysis. There were no significant differences between RAS and LPS in terms of intraoperative and postoperative complications, conversion rate and estimated blood loss. However, patients in the RAS group have a longer operative time (p < 0.0001) and longer hospital stay (p = 0.020) than those in the laparoscopic group. Robotic surgery is not inferior to laparoscopy in patients with endometriosis in terms of surgical outcomes; however, RAS requires longer operative times and longer hospital stay. The benefits of robotic surgery should be sought in the easiest potential integration of robotic platforms with new technologies. Prospective studies comparing laparoscopy to the new robotic systems are desirable for greater robustness of scientific evidence.

[Interest of multidisciplinary consultation meetings dedicated to endometriosis: From a series of 682 patients]

OBJECTIVE

We decided to conduct a study based on these multidisciplinary team (MDT) in order to investigate their impact at the University Hospitals of Strasbourg and look for ways to improve this MDT.

METHODS

This is a retrospective study of the 682 patients presented to endometriosis MDT from its inception in March 2017 to December 2020.

RESULTS

The MDT decision was different from that initially proposed by the patient's referent for 406 patients (60%). Surgery was chosen for 417 patients (61%) and assisted reproduction for 261 patients (38%). A review of the MRI by a referring radiologist was carried out for 348 cases (51%), with a modification of the results for 255 patients (73%). Initial underestimation of lesions was noted in 198 cases.

CONCLUSION

Our study has shown the importance of MDT in endometriosis since the therapeutic proposal was modified in 60% of cases. In addition, we supported the importance of radiologists specializing in this field since they made a modification in two-thirds of the MRIs reread. These results show the importance of collegial discussions, which can modify the decisions of medical teams. This underlines the importance of setting up endometriosis networks.

Ultrasound-guided robotic surgical procedures: a systematic review

INTRODUCTION

Ultrasound has been nicknamed "the surgeon's stethoscope". The advantages of laparoscopic ultrasound beyond a substitute for the sense of touch are considerable, especially for robotic surgery. Being able to see through parenchyma and into vascular structures enables to avoid unnecessary dissection by providing a thorough assessment at every stage without the need for contrast media or ionising radiation. The limitations of restricted angulation and access within the abdominal cavity during laparoscopy can be overcome by robotic handling of miniaturised ultrasound probes and the use of various and specific frequencies will meet tissue- and organ-specific characteristics. The aim of this systematic review was to assess the reported applications of intraoperative ultrasound-guided robotic surgery and to outline future perspectives.

METHODS

The study adhered to the PRISMA guidelines. PubMed, Google Scholar, ScienceDirect and ClinicalTrials.gov were searched up to October 2023. Manuscripts reporting data on ultrasound-guided robotic procedures were included in the qualitative analysis.

RESULTS

20 studies met the inclusion criteria. The majority (53%) were related to the field of general surgery during liver, pancreas, spleen, gallbladder/bile duct, vascular and rectal surgery. This was followed by other fields of oncological surgery (42%) including urology, lung surgery, and retroperitoneal lymphadenectomy for metastases. Among the studies, ten (53%) focused on locating tumoral lesions and defining resection margins, four (15%) were designed to test the feasibility of robotic ultrasound-guided surgery, while two (10.5%) aimed to compare robotic and laparoscopic ultrasound probes. Additionally two studies (10.5%) evaluated the robotic drop-in probe one (5%) assessed the hepatic tissue consistency and another one (5%) aimed to visualize the blood flow in the splenic artery.

CONCLUSION

The advantages of robotic instrumentation, including ergonomics, dexterity, and precision of movements, are of relevance for robotic intraoperative ultrasound (RIOUS). The present systematic review demonstrates the virtue of RIOUS to support surgeons and potentially reduce minimally invasive procedure times.

Study of the feasibility of outpatient sacrocolpopexy by laparoscopy

INTRODUCTION

Laparoscopic sacrocolpopexy (LSCP) is currently the gold standard surgical technique for treating pelvic prolapse. This study aimed to evaluate the feasibility of laparoscopic sacrocolpopexy in ambulatory care.

PATIENTS AND METHODS

This prospective study was conducted to evaluate the feasibility of LSCP in women who visited the outpatient department of obstetrics and gynecology at the University Hospital of Strasbourg between July 2018 and December 2021. All women with indications for laparoscopic sacrocolpopexy for prolapse treatment who were willing to be treated as outpatients were included. The main criterion of the study was to evaluate the rate of re-hospitalization between discharge from the outpatient department after LSCP and postoperative follow-up consultations.

RESULTS

Among the whole population (57/200, 28.5 %) included, 4 (7 %) were hospitalized. The quality of life was not altered with a preserved EuroQol (EQ-5D) quality of life score with a mean score of 73±18.4 standard deviation (SD) 95 % confidence interval (CI) (67.9; 78.1) on postoperative day 3 (D3) and 91.2 ± 16.3 SD 95 % CI (86.2-96) on D30. On D1, D2, D3, and D7, the anxiety rate evaluated by State-Trait Anxiety Inventory score (STAI Y-A) remained low, with mean scores of 24.8 ± 9.6 SD 95 % [23.4-26.5] on D30. All patients were satisfied or very satisfied with the procedure and outpatient management, with an average score of 9.6/10 (range: 8-10).

CONCLUSION

This prospective, monocentric study evaluating the feasibility of outpatient LSCP reported demonstrated low rates of complications and re-hospitalization after outpatient management. Furthermore, the patients' quality of life was not altered, and they patients were satisfied with this type of management.

Laparoscopic-Assisted Vaginal Trachelectomy with Prophylactic Cerclage: A Safe Fertility-Sparing Treatment for Early Stage Cervical Cancer

BACKGROUND

In recent years fertility-sparing treatments are increasingly developing in patients with early stage cervical cancer.1,2 Among these, trachelectomy represents a milestone with a wide range of surgical approaches,3 evidence of oncological safety, and positive obstetric outcomes.4 PATIENTS AND METHODS: A 26-year-old patient underwent conization for CIN3 with a subsequent diagnosis of squamous cervical cancer stage FIGO IB1. After a negative laparoscopic bilateral pelvic nodes sampling and the radiologic evidence [positron emission tomography-computed tomography (PET-CT) and magnetic resonance imaging (MRI)] of a disease limited to the cervix, the patient was a candidate for trachelectomy according to her fertility-sparing desire.

RESULTS

The first laparoscopic time is dedicated to the safe opening of the vesicouterine and rectovaginal spaces until the medial pararectal fossa. Ureters are found and bilateral ureterolysis performed under vision. Colpotomy is then vaginally achieved, and the cervix is closed in a vaginal cuff to avoid tumor spread. Careful dissection of the anterior and posterior septa is carried out until reunification with laparoscopic dissection. Bilateral parametrectomy is performed. Vaginal trachelectomy is finalized with a negative deep margin at the frozen section. In the second laparoscopic time a monofilament polypropylene sling cerclage is bilaterally positioned from posterior to anterior through the broad ligaments and fixed anteriorly on the uterine isthmus to prevent an eventual preterm delivery.

CONCLUSION

Laparoscopic-assisted vaginal trachelectomy is a feasible procedure combining the conservative advantages of the vaginal approach and the oncological safety of laparoscopic spaces dissection with possible good obstetric outcomes.

Fostering Cardio-Endometriosis: A Call to Action for a Comprehensive Understanding of Cardiovascular Disease in Endometriosis

Recently, a growing body of evidence has highlighted a concerning link between endometriosis and cardiovascular disease. Endometriosis, a chronic, inflammatory hormone-dependent condition affecting 5 to 10% of reproductive-aged women worldwide, has long been associated with reproductive and gynecological consequences. However, emerging research has suggested that it may also contribute to adverse cardiovascular outcomes. This paper aims to shed light on the importance of recognizing cardio-endometriosis as a new and developing sphere of research in the field of cardiology, thereby urging the medical community to address this pressing issue.

Brachytherapy and surgery versus surgery alone for IB2 (FIGO 2018) cervical cancers: A FRANCOGYN study

OBJECTIVE

Evaluation of the management by first brachytherapy followed by radical hysterectomy (Wertheim type) compared to radical hysterectomy alone (Wertheim type) for the treatment of IB2 cervical cancer.

METHODS

Data from women with histologically proven FIGO stage IB2 cervical cancer treated between April 1996 and December 2016 were retrospectively abstracted from twelve French institutions with prospectively maintained databases.

RESULTS

Of the 211 patients with FIGO stage IB2 cervical cancer without lymph node involvement included, 136 had surgical treatment only and 75 had pelvic lymph node staging and brachytherapy followed by surgery. The surgery-only group had significantly more adjuvant treatment (29 vs. 3; p = 0.0002). A complete response was identified in 61 patients (81%) in the brachytherapy group. Postoperative complications were comparable (63,2% vs. 72%, p = 0,19) and consisted mainly of urinary (36vs. 27) and digestive (31 vs 22) complications and lymphoceles (4 vs. 1). Brachytherapy had no benefit in terms of progression-free survival (p = 0.14) or overall survival (p = 0.59). However, for tumors of between 20 and 30 mm, preoperative brachytherapy improved recurrence-free survival (p = 0.0095) but not overall survival (p = 0.41). This difference was not observed for larger tumors in terms of either recurrence-free survival (p = 0.55) or overall survival (p = 0.95).

CONCLUSION

Our study found that preoperative brachytherapy had no benefit for stage IB2 cervical cancers in terms of recurrence-free survival or overall survival. For tumor sizes between 2 and 3 cm, brachytherapy improves progression-free survival mainly by reducing pelvic recurrences without improving overall survival.

Effects of gender and socio-environmental factors on health-care access in oncology: a comprehensive, nationwide study in France

Background

Gender-based disparities in health-care are common and can affect access to care. We aimed to investigate the impact of gender and socio-environmental indicators on health-care access in oncology in France.

Methods

Using the national health insurance system database in France, we identified patients (aged ≥18 years) who were diagnosed with solid invasive cancers between the 1st of January 2018 and the 31st of December 2019. We ensured that only incident cases were identified by excluding patients with an existing cancer diagnosis in 2016 and 2017; skin cancers other than melanoma were also excluded. We extracted 71 socio-environmental variables related to patients' living environment and divided these into eight categories: inaccessibility to public transport, economic deprivation, unemployment, gender-related wage disparities, social isolation, educational barriers, familial hardship, and insecurity. We employed a mixed linear regression model to assess the influence of age, comorbidities, and all eight socio-environmental indices on health-care access, while evaluating the interaction with gender. Health-care access was measured using absolute and relative cancer care expertise indexes.

Findings

In total, 594,372 patients were included: 290,658 (49%) women and 303,714 (51%) men. With the exception of unemployment, all socio-environmental indices, age, and comorbidities were inversely correlated with health-care access. However, notable interactions with gender were observed, with a stronger association between socio-environmental factors and health-care access in women than in men. In particular, inaccessibility to public transport (coefficient for absolute cancer care expertise index = -1.10 [-1.22, -0.99], p < 0.0001), familial hardship (-0.64 [-0.72, -0.55], p < 0.0001), social isolation (-0.38 [-0.46, -0.30], p < 0.0001), insecurity (-0.29 [-0.37, -0.21], p < 0.0001), and economic deprivation (-0.13 [-0.19, -0.07], p < 0.0001) had a strong negative impact on health-care access in women.

Interpretation

Access to cancer care is determined by a complex interplay of gender and various socio-environmental factors. While gender is a significant component, it operates within the context of multiple socio-environmental influences. Future work should focus on developing targeted interventions to address these multifaceted barriers and promote equitable health-care access for both genders.

Funding

None.

Prognostic impact of cytoreductive surgery conducted with primary intent, versus cytoreductive surgery after neoadjuvant chemotherapy, in the management of patients with advanced epithelial ovarian cancers: a multicentre, propensity score-matched study from the FRANCOGYN group

OBJECTIVE

To compare survival and morbidity rates between primary cytoreductive surgery (pCRS) and interval cytoreductive surgery (iCRS) for epithelial ovarian cancer (EOC), using a propensity score.

DESIGN

We conducted a propensity score-matched cohort study, using data from the FRANCOGYN cohort.

SETTING

Retrospective, multicentre study of data from patients followed in 15 French department specialized in the treatment of ovarian cancer.

SAMPLE

Patients included were those with International Federation of Gynaecology and Obstetrics (FIGO) stage III or IV EOC, with peritoneal carcinomatosis, having undergone CRS.

METHODS

The propensity score was designed using pre-therapeutic variables associated with both treatment allocation and overall survival (OS).

MAIN OUTCOME MEASURES

The primary outcome was OS. Secondary outcomes included recurrence-free survival (RFS), quality of CRS and other variables related to surgical morbidity.

RESULTS

A total of 513 patients were included. Among these, 334 could be matched, forming 167 pairs. No difference in OS was found (hazard ratio, HR = 0.8, p = 0.32). There was also no difference in RFS (median = 26 months in both groups) nor in the rate of CRS leaving no macroscopic residual disease (pCRS 85%, iCRS 81.4%, p = 0.76). The rates of gastrointestinal tract resections, stoma, postoperative complications and hospital stay were significantly higher in the pCRS group.

CONCLUSIONS

Analysis of groups of patients made comparable by propensity score matching showed no difference in survival, but lower postoperative morbidity in patients treated with iCRS.

Management of patients with advanced epithelial ovarian cancer: a European survey

BACKGROUND

The aim of this study was to assess current European practices in the management of patients with advanced epithelial ovarian cancer in 2021.

METHODS

A 58-question electronic survey was distributed anonymously to the members of six European learned societies. Initial diagnostic workup and staging, pathological data, surgical data, treatments and follow-up strategies were assessed.

RESULTS

A total of 171 participants from 17 European countries responded to emailed surveys. Most participants were experienced practitioners (superior than 15 years of experience) specializing in gynecology-obstetrics (29.8%), surgical oncology (25.1%), and oncogynecology (21.6%). According to most (64.8%) participants, less than 50% of patients were eligible for primary debulking surgery. Variations in the rate of primary debulking surgery depending on the country of origin of the practitioners were observed in this study. The LION study criteria were applied in 70.4% of cases during PDS and 27.1% after chemotherapy. In cases of BRCA1-2 mutations, olaparib was given by 75.0-84.8% of respondents, whereas niraparib was given in cases of BRCA wild-type diseases.

CONCLUSIONS

This study sheds light on current practices and attitudes regarding the management of patients with advanced epithelial ovarian cancer in Europe in 2021.

Validation of a Salivary miRNA Signature of Endometriosis - Interim Data

Salivary miRNA Signature of EndometriosisThis interim analysis of the prospective, multicenter, external validation ENDOmiRNA Saliva Test study, confirms the diagnostic performance and reproducibility of the saliva miRNA signature for endometriosis. At a population prevalence of ∼80%, the miRNA signature had a sensitivity of 96.2%, specificity of 95.1%, and area under the curve of 0.96.

Deep infiltrating endometriosis: Laparoscopic nerve-sparing surgery and use of neutral argon plasma

OBJECTIVE

To present a minimally approach to the management of deep pelvic endometriosis by nerve-sparing surgery and use of neutral argon plasma for extensive endometriotic lesions.

DESIGN

This is a clinical case video of a 29 years-old patient, affected by deep pelvic endometriosis with primary dysmenorrhea, deep dyspareunia, chronic pelvic pain and dyschezia. Pelvic MRI shows a right ovarian endometrioma measuring 5 cm, a thickening of the right uterosacral ligament and a uterine torus nodule.

SETTING

Laparoscopy video.

INTERVENTION

This laparoscopic surgery begins by an adhesiolysis of the sigmoid and a blue tube test to check the correct permeability of the tubes. A bilateral ureterolysis is performed before the excision of a torus lesion and adhesiolysis of the rectovaginal septum. A fine dissection of the uterosacral ligament by nerve-sparing surgery is realized to respect the hypogastric nerve in the Okabayashi space. Endometriosis nodules of the lumbo-ovarian ligaments and multiples endometriosis peritoneal implants, inaccessible to a complete excision, are destroyed by argon plasma vaporization. A cystectomy of the right endometrioma and an appendectomy are performed at the end.

CONCLUSION

The surgical management of deep infiltrating endometriosis is complex, with the recent contribution of new technical procedures such as nerve-sparing surgery to reduce postoperative urinary complications, or argon plasma for ablation of extended peritoneal implants or endometrioma to preserve ovarian function.

Bilateral posterior Richter sacrospinous fixation with native tissue: anatomical and functional results and quality of life assessment over 10 years

INTRODUCTION

Pelvic organ prolapse (POP) is a common condition that affects 50% of women who have given birth in their lifetime. With stop of vaginal mesh sale in 2019, the sacrospinous fixation technique according to Richter with native tissue has seen its incidence tripled in 15 years. Classically, sacrospinous fixation according to Richter is performed unilaterally, however its unilateral or bilateral character is controversial. Objective of this work is to evaluate the efficacy and safety of bilateral sacrospinous fixation according to Richter by the posterior approach with native tissue (SSB).

METHODS

We performed a retrospective single-center study. From March 12, 2010 to March 23, 2020, all first-time operated patients who underwent SSB in CHU Strasbourg gynecological surgery unit for symptomatic POP management were included. The main endpoint of our work is the anatomical and functional success rate at 12 and 24 months. The secondary judgment criteria of our work were based on the postoperative evaluation of patient's quality of life according to the PFDI-20 score as well as the rate of postoperative complications.

RESULTS

77 patients were included in our work. The anatomical success rate at 12 months is 94% and 81% at 24 months regardless of the compartment affected. The functional success rate is 94% at 12 months and 82% at 24 months. Quality of life evaluation through the PFDI-20 scale revealed a clear improvement in the symptomatology related to POP: 127/300 +/- 27.3. preoperatively and 59.8 ± 14.7 postoperatively.

CONCLUSION

Bilateral sacrospinous fixation according to Richter by posterior approach with native tissue is a safe and effective surgical technique allowing a clear improvement in patients quality of life.

A Suggested Modification to FIGO Stage IV Epithelial Ovarian Cancer

International Federation of Gynecology and Obstetrics (FIGO) staging classification for stage IV epithelial ovarian cancer (EOC) separates stages IVA (pleural effusion) and IVB (parenchymal and/or extra-abdominal lymph node metastases). We aimed to evaluate its prognostic impact and to compare survival according to the initial metastatic location. We conducted a multicenter study between 2000 and 2020, including patients with a FIGO stage IV EOC. Primary endpoint was overall survival (OS). The secondary endpoints were progression-free survival (PFS) and recurrence rates. We included 307 patients: 98 (32%) had FIGO stage IVA and 209 (68%) had FIGO stage IVB. The median OS and PFS of stage IVA patients were significantly lower than those of stage IVB patients (31 versus 45 months (p = 0.02) and 18 versus 25 months (p = 0.01), respectively). Recurrence rate was higher in stage IVA than IVB patients (65% versus 47% (p = 0.004)). Initial pleural involvement was a poor prognostic factor with a median OS of 35 months versus 49 months for patients without initial pleural involvement (p = 0.024). Patients with FIGO stage IVA had a worse prognosis than patients with FIGO stage IVB EOC. Pleural involvement appears to be relevant for predicting survival. We suggest a modification of the current FIGO staging classification.

Endometrial cancer of the very elderly: Management and survival in the Francogyn population

INTRODUCTION

We aimed to describe management and survival of patients with endometrial cancer (EC) ≥80 years to identify poor prognosis criteria.

METHODS

We collected clinical, histologic, surgical and follow-up data for patients with EC ≥ 80 years included in a multicenter French cohort (FRANCOGYN) who underwent primary surgical treatment from 1999 to 2019. The outcomes were overall survival (OS) and disease-free survival (DFS). We performed a descriptive analysis then a survival time analysis and comparison using the Kaplan Meier method and log-rank test.

RESULTS

Of the 1647 patients with EC who received treatment during the study period, 184 (11.17%) were ≥80 years. The mean age was 84 years (±3.34). Thirty-three patients (25.4%) died during the follow-up period and 26 relapsed (18.4%). Forty-nine patients were lost to follow-up (27.37%). The median follow-up time was 15.3 months (4.9-28.8). The median OS and DFS was 16.4 months (6.3-24.9) and 13.6 months (4.5-26.6), respectively. Eighty-three patients received adjuvant therapy (45.11%), out of 95 who had a formal or relative indication. Four patients received adjuvant chemotherapy (2.6%), out of 61 who had a formal or relative indication. Inappropriate or underuse of chemotherapy was significantly associated with a lower median OS of 12.6 months [3.73-24] versus 17.3 months [7.93-41.77] when performed appropriately (HR = 4.14, CI 95% [1.62-10.56]), and a lower median DFS of 10.83 months [3.73-24] versus 17.3 months [7.93-28.5] (HR = 9.04, CI 95% [2.04-40.12]).

CONCLUSION

Our results suggest that very elderly patients with EC should receive adjuvant chemotherapy according to the standard care guidelines.

Feasibility and clinical value of virtual reality for deep infiltrating pelvic endometriosis: A case report

Deep infiltrating pelvic endometriosis and its surgical management is associated with a risk of major postoperative complications. Magnetic Resonance Imaging (MRI) is recommended preoperatively in order to obtain the most precise mapping of the extent of endometriotic lesions. The aim of this work was to assess the feasibility and clinical interest of 3D modeling by surface rendering as a preoperative planning tool in a patient with deep infiltrating pelvic endometriosis. We report on a 42 years old patient with history of endometriosis and persistent pain underwent pre operative imaging with MRI that was consistent with deep infiltrating endometriosis. A 3D model of the deep infiltrating endometriosis was generated from the MRI and retrospectively compared to the intra-operative findings. The nodule's location and relationship to the uterus and the rectum was clearly defined by the 3D model and correlated with surgical findings. Virtual reality based on 3D models could be an interesting tool to assist in the preoperative planning of complex surgeries.

[Application in France of the 2021 European recommendations on endometrial cancer]

The latest European recommendations of the European Societies of Gynecological Oncology (ESGO), Radiotherapy and Oncology (ESTRO) and Anatomopathology (ESP) concerning the management of patients with endometrial cancer were published in 2021. On behalf of the French Society of Gynecologic Oncology (SFOG) and the SFOG campus, we wish to summarize for the French-speaking readership the main measures with a more specific application for France. We also incorporate data from a Delphi survey conducted with a panel of French and French-speaking Swiss experts. The data presented in this article relate to histo-molecular characteristics, radiological data of endometrial cancer, and management of low-risk, intermediate-risk, intermediate-high-risk, and metastatic cancers. The aim of this review article is to show the application of the latest international recommendations to clinicians and pathologists for the implementation of these recommendations.

Impact of the Area of Residence of Ovarian Cancer Patients on Overall Survival

Survival disparities persist in ovarian cancer and may be linked to the environments in which patients live. The main objective of this study was to analyze the global impact of the area of residence of ovarian cancer patients on overall survival. The data were obtained from the Surveillance, Epidemiology and End Results (SEER) database. We included all the patients with epithelial ovarian cancers diagnosed between 2010 and 2016. The areas of residence were analyzed by the hierarchical clustering of the principal components to group similar counties. A multivariable Cox proportional hazards model was then fitted to evaluate the independent effect of each predictor on overall survival. We included a total of 16,806 patients. The clustering algorithm assigned the 607 counties to four clusters, with cluster 1 being the most disadvantaged and cluster 4 having the highest socioeconomic status and best access to care. The area of residence cluster remained a statistically significant independent predictor of overall survival in the multivariable analysis. The patients living in cluster 1 had a risk of death more than 25% higher than that of the patients living in cluster 4. This study highlights the importance of considering the sociodemographic factors within the patient's area of residence when developing a care plan and follow-up.

Risk Factors for Recurrence of Borderline Ovarian Tumours after Conservative Surgery and Impact on Fertility: A Multicentre Study by the Francogyn Group

Introduction: Borderline ovarian tumours (BOT) represent 10–20% of epithelial tumours of the ovary. Although their prognosis is excellent, the recurrence rate can be as high as 30%, and recurrence in the infiltrative form accounts for 3% to 5% of recurrences. Affecting, in one third of cases, women of childbearing age, the surgical strategy with ovarian conservation is now recommended despite a significant risk of recurrence. Few studies have focused exclusively on patients who have received ovarian conservative treatment in an attempt to identify factors predictive of recurrence and the impact on fertility. The objective of this study was to identify the risk factors for recurrence of BOT after conservative treatment and the impact on fertility. Material and methods: This was a retrospective, multicentre study of women who received conservative surgery for BOT between February 1997 and September 2020. We divided the patients into two groups, the “R group” with recurrence and the “NR group” without recurrence. Results: Of 175 patients included, 35 had a recurrence (R group, 20%) and 140 had no recurrence (NR group, 80%). With a mean follow-up of 30 months (IQ 8–62.5), the overall recurrence rate was 20%. Recurrence was BOT in 17.7% (31/175) and invasive in 2.3% (4/175). The mean time to recurrence was 29.5 months (IQ 16.5–52.5). Initial complete peritoneal staging (ICPS) was performed in 42.5% of patients (n = 75). In multivariate analysis, age at diagnosis, nulliparity, advanced FIGO stage, the presence of peritoneal implants, and the presence of a micropapillary component for serous tumours were factors influencing the occurrence of recurrence. The post-surgery fertility rate was 67%. Conclusion: This multicentre study is to date one of the largest studies analysing the risk factors for recurrence of BOT after conservative surgery. Five risk factors were found: age at diagnosis, nulliparity, advanced FIGO stage, the presence of implants, and a micropapillary component. Only 25% of the patients with recurrence underwent ICPS. These results reinforce the interest of initial peritoneal staging to avoid ignoring an advanced tumour stage.

[A curriculum based certification of competence in gynaecologic surgical oncology]

OBJECTIVE

In France, we are lacking an identified pathway for training in gynaecological cancer surgery. The four competent French learned societies, the SFOG, the CNGOF, the SFCO and the SCGP, supported by the CNU of Obstetrics &Gynaecology- and UNICANCER, agreed to materialize this course and attest it by a certification awarded by a national jury.

MATERIAL AND METHODS

The national committee of certification in gynaecological oncology made up of 10 members, representing the 6 concerned organizations, set itself 5 objectives: the definition of the eligibility criteria for training centres; the determination of a check-list to be filled by the candidate; the determination of a targeted curriculum for the training in gynecological oncological surgery; the determination of the assets necessary for the certification of a candidate already in practice; and the practical organization of the certification.

RESULTS

Criteria for approval of centres for training included 150 gynaecological cancer cases per year, among which 100 excisional surgeries, including 20 advanced-stage ovarian cancers. For certification of candidate who followed the curriculum established by the committee or by validation of prior experience for an actual practitioner, a candidate must validate a logbook and fill out a checklist including 4 parts: theoretical and practical training; research and publications; teaching and subscription to a continuing education program. The accomplished elements of the logbook and the checklist will be evaluated by a score. The first certification session is planned for the end of 2021.

CONCLUSION

The optimisation of the surgical management of patients treated for gynaecological cancer is achieved through the identification of a training course and the certification, by a national jury, of the skills of surgeons who have completed it.

Lymphovascular space invasion and Estrogen Receptor status in high-grade serous ovarian cancer-a multicenter study by the FRANCOGYN group

BACKGROUND

The aim of this study was to evaluate the impact of Lymphovascular Space Invasion (LVSI) on Overall Survival (OS) and Recurrence-Free Survival (RFS) in patients managed for high-grade serous epithelial ovarian cancer (HGSOC).

MATERIALS AND METHODS

Retrospective multicenter study by the FRANCOGYN research group between January 2001 and December 2018. All patients managed for HGSOC and for whom histological slides for the review of LVSI were available, were included. The characteristics of patients with LVSI (LVSI group) were compared to those without LVSI (No LVSI group). A Cox analysis for OS and RFS analysis was performed in all populations.

RESULTS

Over the study period, 410 patients were included in the thirteen institutions. Among them, 289 patients had LVSI (33.9%). LVSI was an independent predictive factor for poorer Overall and Recurrence-Free Survival. LVSI affected OS (p<0.001) and RFS (p<0.001), Association of LVSI status and estrogen receptor status (ER) also affected OS and RFS (p=0.04; p=0.04 respectively).

CONCLUSION

The presence of LVSI in HGSOC has an impact on OS and RFS and should be routinely included in the pathology examination along with ER status.

Results of a 2021 French National Survey on Management of Patients with Advanced Stage Epithelial Ovarian Cancer

BACKGROUND

The aim of this study was to assess current French practices in the management of patients with advanced epithelial ovarian cancer.

METHOD

a 58-question electronic survey was distributed anonymously to the members of the SFOG (French Society of Gynaecological Oncology), GINECO-ARCAGY (National Investigators Group for Ovarian and Breast Cancer Studies in France) and FRANCOGYN (French research group in oncological and gynaecological surgery). Initial diagnostic workup and staging, pathological data, surgical data, treatments and follow-up strategies were assessed.

RESULTS

a total of 107 participants responded to emailed surveys. Most of the respondents were obstetrician-gynaecologists (37.4%), surgical oncologists (34.6%) and medical oncologists (17.8%). According to most (76.8%) participants, less than 50% of patients were eligible for primary debulking surgery (PDS). The LION study criteria were applied in 69.5% of cases during PDS and 39% after chemotherapy. The timing of BRCA testing was very heterogeneous and ranged from 1 to 6 months. The use of bevacizumab as an adjuvant schedule was lower in cases of no residual disease (for 54.5% of respondents) compared to cases of residual disease (for 63.6% of respondents). In cases of BRCA1-2 mutations, olaparib was given by 75.8-84.8% of respondents, whereas niraparib was given in cases of BRCA wild-type diseases.

CONCLUSION

this survey provides an extensive and a unique review of current French practices in the management of patients with advanced epithelial ovarian cancer in 2021.

[Guidelines for Clinical Practice of the French College of Obstetricians and Gynecologists 2021: Prophylactic procedures associated with gynecologic surgery]

OBJECTIVE

To draw up recommendations on the use of prophylactic gynecologic procedures during surgery for other indications.

DESIGN

A consensus panel of 19 experts was convened. A formal conflict of interest policy was established at the onset of the process and applied throughout. The entire study was performed independently without funding from pharmaceutical companies or medical device manufacturers. The panel applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system to evaluate the quality of evidence on which the recommendations were based. The authors were advised against making strong recommendations in the presence of low-quality evidence. Some recommendations were ungraded.

METHODS

The panel studied 22 key questions on seven prophylactic procedures: 1) salpingectomy, 2) fimbriectomy, 3) salpingo-oophorectomy, 4) ablation of peritoneal endometriosis, 5) adhesiolysis, 6) endometrial excision or ablation, and 7) cervical ablation.

RESULTS

The literature search and application of the GRADE system resulted in 34 recommendations. Six were supported by high-quality evidence (GRADE 1+/-) and 28 by low-quality evidence (GRADE 2+/-). Recommendations on two questions were left ungraded due to a lack of evidence in the literature.

CONCLUSIONS

A high level of consensus was achieved among the experts regarding the use of prophylactic gynecologic procedures. The ensuing recommendations should result in improved current practice.

[Outpatient laparoscopic hysterectomy in France: A monocentric randomized trial]

OBJECTIVE

To demonstrate the feasibility of outpatient laparoscopic hysterectomy using the assessment of post-operative quality of life.

METHODS

A prospective randomized single-center trial was performed in France between 2013 and 2016. A total of 42 patients needed laparoscopic hysterectomy was included. Postoperative quality of life was assessed using the standardized Euroquol questionnaire. Patients filled the score before the operation and then on the 3rd and 30th postoperative day. Secondary outcomes were assessment of postoperative pain, overall quality of life, analgesic use, and anxiety. The patients were randomized into two groups, group A with a conventional hospital stay of 2 to 3 days and group B with a short stay and a discharge the day after the intervention.

RESULTS

Twenty-one patients were randomized to group A as well as group B. We did not find any significant differences between the two groups in our study either on our primary outcome or in the seconds ones. On day 3, the average of Euroquol score was 0.68 for group A against 0.50 for group B (P=0.05). Likewise, the scores for postoperative pain were similar with 70.6 in group A and 61.8 in group B (P=0.21). The trend was the same for quality of life score or anxiety.

CONCLUSION

Our study shows the possibility and the safety of outpatient laparoscopic hysterectomy.

Long-term outcomes of primary cystocele repair by transvaginal mesh surgery versus laparoscopic mesh sacropexy: extended follow up of the PROSPERE multicentre randomised trial

OBJECTIVE

To compare the effectiveness and safety of laparoscopic sacropexy (LS) and transvaginal mesh (TVM) at 4 years.

DESIGN

Extended follow up of a randomised trial.

SETTING

Eleven centres.

POPULATION

Women with cystocele stage ≥2 (pelvic organ prolapse quantification [POP-Q], aged 45-75 years without previous prolapse surgery.

METHODS

Synthetic non-absorbable mesh placed in the vesicovaginal space and sutured to the promontory (LS) or maintained by arms through pelvic ligaments and/or muscles (TVM).

MAIN OUTCOME MEASURES

Functional outcomes (pelvic floor distress inventory [PFDI-20] as primary outcome); anatomical assessment (POP-Q), composite outcome of success; re-interventions for complications.

RESULTS

A total of 220 out of 262 randomised patients have been followed at 4 years. PFDI-20 significantly improved in both groups and was better (but below the minimal clinically important difference) after LS (mean difference -7.2 points; 95% CI -14.0 to -0.05; P = 0.029). The improvement in quality of life and the success rate (LS 70%, 61-81% versus TVM 71%, 62-81%; hazard ratio 0.92, 95% CI 0.55-1.54; P = 0.75) were similar. POP-Q measurements did not differ, except for point C (LS -57 mm versus TVM -48 mm, P = 0.0093). The grade III or higher complication rate was lower after LS (2%, 0-4.7%) than after TVM (8.7%, 3.4-13.7%; hazard ratio 4.6, 95% CI 1.007-21.0, P = 0.049)).

CONCLUSIONS

Both techniques provided improvement and similar success rates. LS had a better benefit-harm balance with fewer re-interventions due to complications. TVM remains an option when LS is not feasible.

TWEETABLE ABSTRACT

At 4 years, Laparoscopic Sacropexy (LS) had a better benefit-harm balance with fewer re-interventions due to complications than Trans-Vaginal Mesh (TVM).

[National certification for gynecological cancer surgery]

OBJECTIVE

In France, we are lacking an identified pathway for training in gynaecological cancer surgery. The four competent French learned societies: the SFOG, the CNGOF, the SFCO and the SCGP supported by the CNU of Obstetrics & Gynaecology, and UNICANCER agreed to materialize this course and attest it by a certification awarded by a national jury.

MATERIAL AND METHODS

The national committee of certification in gynaecological oncology made up of ten members, representing the 6 concerned organizations, set itself five objectives: the definition of the eligibility criteria for training centres; the determination of a check-list to be filled by the candidate; the determination of a targeted curriculum for the training in gynecological oncological surgery; the determination of the assets necessary for the certification of a candidate already in practice; and the practical organization of the certification.

RESULTS

Criteria for approval of centres for training included 150 gynaecological cancer cases per year, among which 100 excisional surgeries, including twenty advanced-stage ovarian cancers. For certification of candidate who followed the curriculum established by the committee or by validation of prior experience for an actual practitioner, a candidate must validate a logbook and fill out a checklist including four parts: theoretical and practical training; research and publications; teaching and subscription to a continuing education program. The accomplished elements of the logbook and the checklist will be evaluated by a score. The first certification session is planned for the end of 2021.

Anatomical basis of lymph node detection in gynecologic cancers: a review from a surgical perspective

Pelvic and para-aortic lymphadenectomy are associated with increased risk of complications and are responsible for a significant proportion of morbidity and impaired quality of life following surgical management of pelvic malignancies. Sentinel lymph node (SLN) was developed as a trade-off between systematic and no lymphadenectomy to limit morbidity while conserving good oncological staging and outcomes. In this comprehensive review, we aimed to synthetize the anatomical basis of the SLN procedure in patients with pelvic malignancies from a surgical perspective. The reliability of the SLN procedure is based on the knowledge of the dissemination pathways for each type of tumors. The most recent understanding of the uterine lymphatic anatomy defined three consistent channels: an upper paracervical pathway (UPP) with draining medial external and/or obturator lymph nodes; a lower paracervical pathway (LPP) with draining internal iliac and/or presacral lymph nodes and the infundibulo-pelvic pathway (IPP) with a course along the fallopian tube and upper broad ligament via the infundibulo-pelvic ligament to its origin. In patients with endometrial cancer, most SLNs are located on the UPP pathway: obturator and external iliac whereas 80% of the SLNs in patients with cervical cancer are located in the external iliac, interiliac and obturator area. Surgical training is a key step toward improving detection rates and exhaustiveness of SLN research while reducing overall morbidity. This is all the more important that the indications for performing complete lymphadenectomy are becoming increasingly rare.

Relevance of Laparoscopic Surgery for Ovarian Cancer in Well-selected Patients: A Propensity-matched Comparison With Laparotomy

BACKGROUND/AIM

This study aimed to evaluate the relevance of laparoscopy in comparison with laparotomy in the management of ovarian cancer in well-selected patients.

PATIENTS AND METHODS

Data of consecutive ovarian cancer patients treated by laparoscopy were matched 1:1 to a cohort of patients operated by laparotomy using a propensity score matching. The inclusion criteria included patients who underwent a complete staging procedure in the early stages and optimal upfront or interval debulking surgery for advanced ovarian cancer.

RESULTS

In total, 153 patients were included. Propensity score matching led to the analysis of 41 well-balanced pairs of patients. For a median follow-up of 34.0 [19.0-64.0] months and 38.0 [24.5-75.0] months, respectively, no difference was found between the two groups in regards to overall survival (p=0.28) and disease-free survival (p=0.89).

CONCLUSION

In well-selected patients, laparoscopic surgery may be a safe and effective alternative to laparotomy.

Management of borderline ovarian tumours during pregnancy: Results of a French multi-centre study

OBJECTIVE

To assess the diagnostic and prognostic characteristics of borderline ovarian tumours (BOTs) detected during pregnancy, and to establish an inventory of French practices.

MATERIALS AND METHODS

A retrospective multi-centre case study of 14 patients treated for BOTs, diagnosed during pregnancy between 2005 and 2017, in five French pelvic cancerology expert centres, including data on clinical characteristics, histological tumour characteristics, surgical procedure, adjuvant treatments, follow-up and fertility.

RESULTS

The mean age of patients was 29.3 [standard deviation (SD) 6.2] years. Most BOTs were diagnosed on ultrasonography in the first trimester (85.7 %), and most of these cases (78.5 %) also underwent magnetic resonance imaging to confirm the diagnosis (true positives 54.5 %). Most patients underwent surgery during pregnancy (57 %), with complete staging surgery in two cases (14.3 %). Laparoscopy was performed more frequently than other procedures (50 %), and unilateral adnexectomy was more common than cystectomy (57.5 %). Tumour size influenced the surgical approach significantly (mean size 7.5 cm for laparoscopy, 11.9 cm for laparoconversion, 14 cm for primary laparotomy; P = 0.08), but the type of resection did not. Most patients were initially diagnosed with International Federation of Gynecology and Obstetrics stage IA (92.8 %) tumours, but many were upstaged after complete restaging surgery (57.1 %). Most BOTs were serous (50 %), two cases had a micropapillary component (28.5 %), and one case had a micro-invasive implant. BOTs were bilateral in two cases (14.2 %). Mean follow-up was 31.4 (SD 14.8) months. Recurrent lesions occurred in two patients (14.2 %) and no deaths have been recorded to date among the study population.

CONCLUSION

BOTs remain rare, but this study - despite its small sample size - supports the hypothesis that BOTs during pregnancy have potentially aggressive characteristics.

Recurrence Pattern of Cervical Cancer Based on the Platinum Sensitivity Concept: A Multi-Institutional Study from the FRANCOGYN Group

The standard of care for patients with advanced cervical cancer (ACC) includes platinum-based chemotherapy. The concept of platinum sensitivity is a major prognostic factor for patients with ovarian cancer. The aim of this study was to validate the applicability of the platinum sensitivity concept to ACC patients, and to estimate its prognostic interest in terms of overall survival (OS) and pattern of recurrence (location, timing). Data of women with histologically proven FIGO 2019 stages IB3-IV ACC, treated between May 2000 and November 2017 with platinum-based regimens, were retrospectively abstracted from 12 institutions from the FRANCOGYN Group. Respective 3-year OSs were 52% (95% CI: 40.8%-66.8%), 21.6% (95% CI: 12.6%-37.2%), and 14.6% (95% CI: 4.2%-50.2%), in case of recurrence <6 months, between 6 and 17 months, and ≥18 months (p < 0.001). Risk of metastatic or multisite recurrence was significantly higher in case of recurrence <6 months, and risk of local or isolated infradiaphragmatic nodal recurrence was significantly higher in case of recurrence >18 months (p < 0.001). In multivariate analysis, platinum sensitivity status was a strong prognostic factor for OS after recurrence, independent of histological grade, lympho-vascular space involvement, final lymph node status, and treatment. Platinum sensitivity status may help to classify patients in three prognostic subgroups for OS after recurrence, and appears to be a strong prognostic factor correlated to the pattern of recurrence.

Three and Five-Year Mortality in Ovarian Cancer after Minimally Invasive Compared to Open Surgery: A Systematic Review and Meta-Analysis

As regards ovarian cancer, the use of minimally invasive surgery has steadily increased over the years. Reluctance persists, however, about its oncological outcomes. The main objective of this meta-analysis was to compare the three and five-year mortality of patients operated by minimally invasive surgery (MIS) for ovarian cancer to those operated by conventional open surgery (OPS), as well as their respective perioperative outcomes. PubMed, Cochrane library and CinicalTrials.gov were systematically searched, using the terms laparoscopy, laparoscopic or minimally invasive in combination with ovarian cancer or ovarian carcinoma. We finally included 19 observational studies with a total of 7213 patients. We found no statistically significant difference for five-year (relative risk (RR) = 0.89, 95% CI 0.53-1.49, p = 0.62)) and three-year mortality (RR = 0.95, 95% CI 0.80-1.12, p = 0.52) between the patients undergoing MIS and those operated by OPS. When five and three-year recurrences were analyzed, no statistically significant differences were also observed. Analysis in early and advanced stages subgroups showed no significant difference for survival outcomes, suggesting oncological safety of MIS in all stages. Whether the surgery was primary or interval debulking surgery in advanced ovarian cancer, did not influence the comparative results on mortality or recurrence. Although the available studies are retrospective, and mostly carry a high risk for bias and confounding, an overwhelming consistency of the evidence suggests the likely effectiveness of MIS in selected cases of ovarian cancer, even in advanced stages. To validate the use of MIS, the development of future randomized interventional studies should be a priority.

Randomized Study Comparing a Reusable Morcellator with a Resectoscope in the Hysteroscopic Treatment of Uterine Polyps: The RESMO Study

STUDY OBJECTIVE

To compare a reusable hysteroscopic morcellator and standard resectoscopes in the hysteroscopic management of uterine polyps.

DESIGN

Single-center randomized prospective single-blind trial (resectoscope-morcellator study).

SETTING

Centre Médico-chirurgical Obstétrique teaching hospital, Strasbourg University Hospitals, France.

PATIENTS

All patients presenting with a single endometrial polyp of size 1 cm or larger.

INTERVENTIONS

After consent, the patients were randomized into 2 groups: hysteroscopic morcellation (HM) group or standard resection (SR) group. Office-based review hysteroscopy was performed 6 weeks to 8 weeks after surgery. Primary end point: time of morcellation or resection.

SECONDARY OUTCOMES

total operating time (minutes), volume of fluid used (mL), fluid deficit (mL), number of morcellator or resectoscope insertions, operator comfort (visual analog scale: 0 to 10) and quality of vision (0 to 5), perioperative complications, completeness of resection, need to convert to another technique, pain assessment (visual analog scale), and length of hospitalization. At review hysteroscopy, we noted whether the resection or morcellation had been effective and if synechiae were present or absent. Statistical analyses followed Bayesian methods.

MEASUREMENTS AND MAIN RESULTS

Ninety patients were randomized: 45 in the HM group and 45 in the SR group. The average size of polyps at hysteroscopy was 13.3 mm. Morcellation time was lower than resection time (6.1 minutes vs 9 minutes; p [HM < SR] = .996). This also applied to total operating time (12.7 minutes vs 15.6 minutes; p [HM < SR] = .985), number of device insertions (1.50 vs 6; p [HM < SR] > .999), volume of fluid used (766.9 mL vs 1118.9 mL; p [HM < SR] = .994), and fluid deficit (60.2 mL vs 169.8 mL; p [HM < SR] = .989). Operator comfort was better in the HM group (8.4 vs 7.4; p [HM > SR] = .999) as was visualization (4 vs 3.7; p [HM > SR] = .911, highly probable). Operative complications were higher in the SR group (5 vs 0; p [HM < SR] = .989]. One patient in the SR group died after surgery owing to an anesthetic complication (anaphylactic shock complicated by pulmonary embolism). No differences were noted between the groups for pain assessment, length of hospitalization, and outcome on review hysteroscopy.

CONCLUSION

The reusable morcellator is quicker, uses less fluid with less deficit and fewer introductory maneuvers, and offers better comfort and visualization than the resectoscope while being as effective for the hysteroscopic treatment of uterine polyps.

Surgical traps in laparoscopic sacrocolpopexy for vaginal vault prolapse

OBJECTIVE

To describe the possible difficulties encountered in the event of laparoscopic sacrocolpopexy for vaginal vault prolapse and corresponding avoidance strategies.

METHODS

Video recordings of different laparoscopic sacrocolpopexies for vaginal vault prolapse showing various situations and difficulties. University Teaching Hospital of Strasbourg.

RESULTS

Although laparoscopic sacrocolpopexy for vaginal vault prolapse is becoming more common, achieving a good outcome remains challenging, especially with the vesicovaginal dissection. Bladder injuries are not rare and occur in about 2 to 6% of cases. Vaginal perforation is less common, but remains a risk. This video illustrates possible difficulties encountered and presents various strategies to avoid them. Several tips on exposing structures and following anatomical landmarks are described.

CONCLUSION

Knowing how to avoid these surgical traps will help trainee urogynecologic surgeons to perform laparoscopic sacrocolpopexy for vaginal vault prolapse.

Recommendations for the surgical management of gynecological cancers during the COVID-19 pandemic - FRANCOGYN group for the CNGOF

INTRODUCTION

In the context of the COVID-19 pandemic, specific recommendations are required for the management of patients with gynecologic cancer.

MATERIALS AND METHOD

The FRANCOGYN group of the National College of French Gynecologists and Obstetricians (CNGOF) convened to develop recommendations based on the consensus conference model.

RESULTS

If a patient with a gynecologic cancer presents with COVID-19, surgical management should be postponed for at least 15 days. For cervical cancer, radiotherapy and concomitant radiochemotherapy could replace surgery as first-line treatment and the value of lymph node staging should be reviewed on a case-by-case basis. For advanced ovarian cancers, neoadjuvant chemotherapy should be preferred over primary cytoreduction surgery. It is legitimate not to perform hyperthermic intraperitoneal chemotherapy during the COVID-19 pandemic. For patients who are scheduled to undergo interval surgery, chemotherapy can be continued and surgery performed after 6 cycles. For patients with early stage endometrial cancer of low and intermediate preoperative ESMO risk, hysterectomy with bilateral adnexectomy combined with a sentinel lymph node procedure is recommended. Surgery can be postponed for 1-2 months in low-risk endometrial cancers (FIGO Ia stage on MRI and grade 1-2 endometrioid cancer on endometrial biopsy). For patients of high ESMO risk, the MSKCC algorithm (combining PET-CT and sentinel lymph node biopsy) should be applied to avoid pelvic and lumbar-aortic lymphadenectomy.

CONCLUSION

During the COVID-19 pandemic, management of a patient with cancer should be adapted to limit the risks associated with the virus without incurring loss of chance.

Prognostic factors of overall survival for patients with FIGO stage IIIc or IVa ovarian cancer treated with neo-adjuvant chemotherapy followed by interval debulking surgery: A multicenter cohort analysis from the FRANCOGYN study group

INTRODUCTION

The aim of this study was to identify prognostic factors of overall survival in patients with FIGO stage IIIc or IVa ovarian cancer (OC) treated by neo-adjuvant chemotherapy (NAC) followed by interval debulking surgery.

MATERIALS AND METHODS

Data from 483 patients with ovarian cancer were retrospectively collected, from January 1, 2000 to December 31, 2016, from the FRANCOGYN database, regrouping data from 11 centers specialized in ovarian cancer treatment. Median overall survival was determined using the Kaplan-Meier method. Univariate and multivariate analysis were performed to define prognostic factors of overall survival.

RESULTS

The median overall survival was 52 after a median follow up of 30 months. After univariate analysis, factors significantly associated with decreased overall survival were; no pelvic and/or para-aortic lymphadenectomy (p = 0.002), residual disease (CC1/CC2/CC3) after surgery (p < 0.001), positive cytology after NAC (p < 0.001), omental disease after NAC (p = 0.002), no pathologic complete response (pCR) (p = 0.002). In multivariate analysis, factors significantly associated with decreased overall survival were; residual disease after surgery (HR = 1.93; CI95% (1.16-3.21), p = 0.01) and positive cytology after NAC (HR = 1.59; CI95% (1.01-2.55), p = 0.05). Patients with no residual disease after surgery had a median overall survival of 64 months versus 35 months for patients with residual disease. Patients with negative cytology after NAC had a median overall survival of 71 months versus 43 months for patients with positive cytology after NAC.

CONCLUSION

In this first and largest French based retrospective study, complete cytoreductive surgery in ovarian cancer remains the main prognostic factor of overall survival.

[Guidelines for surgical management of gynaecological cancer during pandemic COVID-19 period - FRANCOGYN group for the CNGOF]

INTRODUCTION

Recommendations for the management of patients with gynecological cancer during the COVID-19 pandemic period.

MATERIAL AND METHOD

Recommendations based on the consensus conference model.

RESULTS

In the case of a COVID-19 positive patient, surgical management should be postponed for at least 15 days. For cervical cancer, the place of surgery must be re-evaluated in relation to radiotherapy and Radio-Chemotherapy-Concomitant and the value of lymph node staging surgeries must be reviewed on a case-by-case basis. For advanced ovarian cancers, neo-adjuvant chemotherapy should be favored even if primary cytoreduction surgery could be envisaged. It is lawful not to offer hyperthermic intraperitoneal chemotherapy during a COVID-19 pandemic. In the case of patients who must undergo interval surgery, it is possible to continue the chemotherapy and to offer surgery after 6 cycles of chemotherapy. For early stage endometrial cancer, in case of low and intermediate preoperative ESMO risk, hysterectomy with bilateral annexectomy associated with a sentinel lymph node procedure should be favored. It is possible to consider postponing surgery for 1 to 2 months in low-risk endometrial cancers (FIGO Ia stage on MRI and grade 1-2 endometrioid cancer on endometrial biopsy). For high ESMO risk, it ispossible to favor the MSKCC algorithm (combining PET-CT and sentinel lymph node biopsy) in order to omit pelvic and lumbar-aortic lymphadenectomies.

CONCLUSION

During COVID-19 pandemic, patients suffering from cancer should not lose life chance, while limiting the risks associated with the virus.

Ovarian Cortex Transplantation

STUDY OBJECTIVE

To describe a laparoscopic technique for the transplantation of a cryopreserved ovarian cortex.

DESIGN

Educational video.

SETTING

University Hospital of Strasbourg, France.

INTERVENTIONS

A 28-year-old nulliparous woman presented with anaplastic T lymphoma and was then treated with chemotherapy. Before the treatment, the ovarian cortex was collected by laparoscopy to preserve fertility. Remission was achieved, but the patient suffered from premature ovarian failure. At the age of 32 years, she wished to become pregnant. The patient was thus included in the research protocol Development of Ovarian Tissue Autograft in Order to Restore Ovarian Function, and the transplantation site was chosen accordingly. The cortex was stored in liquid nitrogen at -196°C after slow congelation. To restore ovarian function and because of pregnancy desire, we transplanted the cryopreserved ovarian cortex in the right ovary and inside a pocket of the peritoneum of the left ovarian fossa. The first step included adhesiolysis to treat small adhesions developed after the first surgery. On the right, the ovarian cortex was opened by an antimesial incision with cold scissors. The cryopreserved ovarian cortex was placed through the cortex of the right ovary and fixed with stitches. On the left side, the peritoneum of the ovarian fossa was opened, and a subperitoneal pocket was dissected. The cortex was inserted. It was then closed with absorbable sutures or with a hemostatic pad. Six months after her surgery, the patient had natural cycles. We monitored an ovulation of both the sides. She underwent 3 in vitro fertilizations but with failures of embryo transfer. She conceived spontaneously a year after the surgery. She gave birth to a healthy child weighing 3300 g.

CONCLUSION

For patients who have suffered from premature ovarian failure owing to chemotherapy, ovarian cortex transplantation can restore the ovulatory function, allow in vitro fertilization, and permit, as in our case, a spontaneous pregnancy.

[Ambulatory minimally invasive hysterectomy: Limiting factors related to health professionals]

OBJECTIVES

The feasibility of minimally invasive hysterectomy for ambulatory benign pathology has been demonstrated in many international studies. France has a considerable delay of multifactorial origin in this field. The objective of this study is to identify the limiting factors related to health professionals to the realization of minimally invasive ambulatory hysterectomy and to determine possible strategies to increase its rate.

METHODS

This is a cross-sectional survey conducted over 2 months using a self-administered questionnaire sent by email to 180 gynecological surgeons in 2 French regions (Grand Est and Bourgogne-Franche Comté).

RESULTS

A total of 22% of health professionals responded to the survey. The vast majority of practitioners (60%) said they did not carry out ambulatory care by habit. The apprehension of the reaction of the patients (47.5%), the fear of delayed diagnosis of complications (12.5%), the management of pain in the postoperative period (42.5%) also participated in brake of the promotion of ambulatory care.

DISCUSSION

Improvement of the organisation of city and hospital management allowing a better continuity of care (70%), the economic valuation (37.5%) and the increase in the hourly amplitude of the ambulatory surgery unit (5%) would improve the rate of ambulatory care of minimally invasive hysterectomies, according to the gynecologist surgeons surveyed. In addition, a prospective study evaluating the quality of life of patients after ambulatory care of minimally invasive hysterectomy would allow better adherence of health professionals and patients to the ambulatory care project in 70% of cases.

CONCLUSION

The change of mentality of health professionals remains a priority for the promotion of ambulatory surgery in gynecology. Information and communication are therefore essential to the expansion of the ambulatory.

[Use of HPV virologic test for atypical glandular cells in Alsace between 2014 and 2016]

OBJECTIVES

The new recommendations by the National Institute of Cancer (January 2017) recommend the use of a complementary human papillomavirus (HPV) virologic test during the diagnosis of atypical glandular cells in pap smear. The aim of this study was the performance analysis of the HPV virologic test for the detection of significant histological cervical abnormalities (CIN2 or more) in case of atypical glandular cells before the new recommendations were published.

METHODS

We performed a descriptive and retrospective cohort study in Alsace between January 2014 and December 2016. We have included, from the EVE-association database, the patients with atypical glandular cells in pap smear.

RESULTS

In total, 1074 patients had a pap smear with atypical glandular cells ; 0.18% of total pap smears. This study included 152 patients who had a HPV test. We observed 6 cases of CIN2 (3.9%) and 12 cases of CIN3 (7.9%). No in situ adenocarcinoma nor invasive carcinoma were detected. The sensitivity of the HPV test was 88.9% (95% CI: [0.65; 0.99]), the specificity was 65.9% (95% CI: [0.55; 0.76]), the positive predictive value was 34% (95% CI: [0.21; 0.49]) and the negative predictive value was 96.8% (95% CI: [0.89; 0.99]).

CONCLUSION

The detection of HPV in atypical glandular cells seems to be powerful with an excellent negative predictive value but, because of moderate sensitivity and due to the risk of histologic lesion progression, the current recommendations should to be applied with care.