[Short version of recommendations for enhanced recovery program (ERP) for cystectomy: Technical measures]. / Version courte des recommandations de la récupération ameliorée après chirurgie (RAAC) pour la cystectomie : mesures techniques.

INTRODUCTION: The enhanced recovery program (ERP) is a management mode whose objective is to reduce the risk of complications and allow the patient to recover more quickly all its functional capacities and to reintegrate at most quickly and safely in his usual environment. This intentionally synthetic document aims to disseminate in the urological community the main points of the ERP recommendations for cystectomy. This work, coordinated by AFU, involves several other partners. The full document is available on the "Urofrance" website. Another article will follow on organizational measures. METHOD: The development of the recommendations is based on the method "formalized consensus of experts" proposed by the HAS. The report is based on a systematic review of the literature (January 2006-May 2017), two rounds of iterative quotations and a national proofreading. Levels of proof of conclusions and gradation of recommendations are based on the HAS grid. RESULTS: The bibliographic strategy made it possible to retain 298 articles. Only the recommendations that obtained a strong agreement after the two rounds of iterative listing were retained. The recommendations presented here are in chronological form (before, during, after hospitalization). Twenty-six key points on the technical and organizational measures of ERP have been identified. CONCLUSION: The result of the literature review, supplemented by expert opinion, suggests a significant clinical interest in the application and dissemination of ERP for cystectomy, despite the limited data available for this indication.

Retrospective single-surgeon study of outcomes after laparoendoscopic single-site cholecystectomy and sigmoidectomy.

PURPOSE: Laparoendoscopic single-site (LESS) surgery is performed through a single port but requires a larger incision than conventional laparoscopy, which theoretically increases the risk of laparoscopic port hernia. Our primary objective is to determine the trocar site hernia rate among our patients. METHODS: This retrospective study is based on the analysis of demographic, intraoperative, and postoperative data of 219 patients who underwent cholecystectomy or sigmoidectomy by LESS surgery between December 1st, 2009 and November 30th, 2012. RESULTS: Cholecystectomy and sigmoidectomy LESS surgery were performed on 190 and 29 patients, respectively. Three patients developed a trocar site hernia within a median follow-up time of 34.7 months. Eleven patients were obese, 20 had a history of abdominal surgery, and 20 had a preoperative umbilical hernia but none of them developed a trocar site hernia, neither did the 11 subsequently pregnant women. Significant association was found between preoperative umbilical hernia and early complications including incisional cellulitis and hematoma. CONCLUSIONS: A rate of 1.4% of trocar site hernia was observed in our study population. This rate is similar to the one reported after conventional laparoscopy. Peri-umbilical incision, longer than that with conventional laparoscopy, allowed better preexisting hernia handling, made anatomical closing easier among obese patients, and facilitated specimen extraction thus limiting traumatic operations.

[Salpingo-oophorectomy by laparoendoscopic single-site surgery for everybody]. / L'annexectomie par cœlio-chirurgie mono-trocart pour tous.

OBJECTIVES: To study the adnexectomy by laparoendoscopic single-site surgery with conventional laparoscopic instruments, we standardised the technique of salpingo-oophorectomy. PATIENTS AND METHODS: In this prospective study, all patients with adnexectomies from June 2010 to January 2014 were included. Laparoendoscopic single-site adnexectomy with conventional instruments is described step by step in order to make it available for the majority of gynecologic surgeons. Laparoconversions and complications are also noted. RESULTS: We realized 42 bilateral salpingo-oophorectomies, 16 single salpingo-oophorectomy. The average operative time was 45min (15-120) with negligible blood losses. There were no laparoconversions and very few complications. After 15-20 adnexectomies, the procedure took less and less time. DISCUSSION AND CONCLUSION: Adnexectomy by laparoendoscopic single-site surgery procedure with conventional laparoscopic instruments is easily reproducible with standardized steps and has many advantages.

[Day case laparoscopic sacral colpopexy for genital prolapse]. / Prise en charge ambulatoire de la promontofixation laparoscopique pour prolapsus génital.

OBJECTIVE: To demonstrate the feasibility of day case laparoscopic sacral colpopexy with the help of a fast tracking protocol. METHODS: Three motivated patients suffering from external cystocele have been strictly selected from September 2011 to October 2011 according to criteria such as Body Mass Index, ASA score, comorbidities et French day case rules. Laparoscopic sacral colpopexies consisted in anterior and posterior polyesther meshes sutured with non-resorbable wires. We are used to proceed through a SILS(©) unique ombilical port. We have used standard and straight laparoscopic instruments and laparoscope. The bladder catheter has been removed two hours after surgery, the patients have been encouraged to stand up and they have received a light meal before Chung score has been quoted. The patients have been discharged in the evening before 7 pm. RESULTS: The patients are 65, 67 and 66 years old, two of them had a past history of pelvic surgery. We did not deplore any complication during the procedure, no blood loss, no laparoscopic conversion (additional trocar); the procedures durations were 92, 120 and 124 min. These three patients have not been readmitted. Clinical examination has been scheduled between 6 and 8 weeks after surgery. We did not describe any pelvic or parietal complication, no early recurrence. CONCLUSION: We have demonstrated here the feasibility in good security conditions of day case laparoscopic sacral colpopexy for genital prolapse. A fast tracking protocol is essential and selecting the patients is required.

[Feasibility of laparoendoscopic single-site surgery in gynecology with conventional laparoscopic instruments]. / Faisabilité de la cœliochirurgie gynécologique par mono-trocart avec instruments droits standards.

OBJECTIVES: To describe the safety and efficacy of single-port access for laparoscopic surgery in gynecology with conventional laparoscopic instruments. PATIENTS AND METHODS: In this prospective study, we report our experience with 90 patients who underwent Single Port Access (SPA) laparoscopic surgery for gynecologic pathology with the use of the SILS(®) Port Multiple Instrument Access Port (Covidien(®), Mansfield, MA). RESULTS: We realised 15 ovarian cystectomies, 30 salpingo-oophrectomies with 14 one side, 9 lysis of adhesions, 7 distal tubal repairs, 6 salpingectomy, 8 other procedures. The mean surgical time is 47 min (25-120). One conversion to conventional laparoscopy and one in laparotomy were performed. The mean duration stay is 2 days [1-3]. DISCUSSION AND CONCLUSION: SPA in gynecology is feasible with conventional laparoscopic instruments. SPA surgery represents the newest frontier in minimally invasive surgery.

[IgA deficiency and multiple Staphylococcus aureus perirenal abscesses. A case report]. / Déficit en IgA et abcès péri-rénaux multiples à Staphylococcus aureus. A propos d'une observation.

The authors report the case of a patient with IgA deficiency who presented with a low-grade renal abscess. Due to the atypical nature of the clinical features and imaging, the diagnosis was not established prior to surgery. Despite radical surgery, the abscess recurred several weeks later. In the light of this case, the authors discuss the various possible diagnoses that must be considered in the presence of these types of images and the therapeutic approach during initial management. They discuss the various immune deficiencies to be investigated in a particular infectious context.

[Fertility disorders attributable to the use of diethylstilbestrol during intrauterine life]. / Les troubles de la fertilité imputables à l'imprégnation par le diéthylstilbestrol pendant la vie intra-utérine.

A lot has been written about the abnormalities seen in children born to women treated with distilbene during pregnancy. The author reviews the current state of the certainties and the doubts. It seems that the increased number of miscarriages, extra-uterine pregnancies and perinatal deaths are probably due to the maternal treatment which is also responsible for semen abnormalities.

PIP: In the early 1970s, the elevated rate of abnormalities in children of the 2-3 million US women and 260,000 French women treated with diethylstilbestrol (DES) during pregnancy began to be recognized. 4 kinds of cervicovaginal anomalies have been observed in women exposed to DES in utero: 1) 22-58% have been estimated to have morphologic anomalies with the timing of exposure to DES more important than the total dose 2) a high proportion has an insufficient cervical mucus not corrected by exogenous administration of estrogen 3) a high proportion develop cervical stenosis after cryosurgery, electrocoagulation, or conization and 4) the increased incidence of prematurity in infants of DES-exposed mothers has been attributed to cervical incompetence. 69% of 267 women studied had hysterographically demonstrated uterotubal malformations. A characteristic aspect was a T-shaped uterus but other anomalies were noted. Hysterographic anomalies were correlated with cervico-isthmic anatomic anomalies, anomalies of the vaginal epithelium, and with the date of 1st exposure to DES in utero. The total dose of DES did not affect the frequency of genital anomalies. Possible tubal anomalies have not been well studied, although 1 author has observed short and narrow tubes and other abnormalities. The number of extrauterine pregnancies is known to be elevated in women exposed to DES in utero. The possibility of an increased incidence of menstrual irregularity, dysmenorrhea, or oligomenorrhea in DES-exposed women has been suggested but remains controversial. The responsibility of DES exposure in utero for later reduced fertility is also in dispute. Higher rates of spontaneous abortion, extrauterine pregnancy, prematurity, and perinatal death have been reported in DES-exposed women. Increased incidence of stenosis of the meatus, hypospadias, epididymal cysts, testicular hypoplasia and other anomalies, cryptorchidism, microphallus, and varicocele have been reported in men exposed to DES in utero. Reduced sperm counts and anomalies in the volume of the ejaculate, percentage of sperm mobile, and sperm morphology have been reported in exposed men. Sperm anomalies may be responsible for reduced fertility in exposed men, but the exact extent is unknown.

[True and false regarding metabolic risk in contraception]. / Le vari et le faux sur le risque metabolique en contraception.

PIP: This article reviews the published literature on the relationship between combined OCs (oral contraceptives) administration and metabolic and cerebro- and cardiovascular effects. All retrospective studies show an increase in the risk of thromboembolic accidents, while only a few of the prospective studies do. A study of the Royal College of General Practitioners (RCGP) states that the risk of myocardial infarction is multiplied by 5.22 in OCs users, and that smoking, but not age, greatly increases the risk. All studies document an increase in risk of cerebrovascular effects; high arterial pressure and smoking increase the risk, but obesity does not. Synthetic estrogens increase triglyceride levels according to dosage, but progesterone does not. Estrogen increases cholesterol level, estroprogestational agents increase it slightly, while progesterone does not cause any increase. Synthetic estrogens tend to increase low density lipoprotein cholesterol and derivates of progesterone do not; high density lipoprotein levels are increased by estrogens but decreased by progesterone. Age, smoking and diabetes increase the risk. Recent studies of the RCGP eliminate the responsibility of estroprogestins in causing diabetes, while other authors think the opposite. In general, the literature does not agree on the metabolic side effects of combined OC use, and conclusions are often opposite between retrospective and prospective studies. There still are not any epidemiological studies on the metabolic side effects of the mini-pill.^ieng

[Gonadic dysgenesis and dicentric chromosome Y. A report of two cases, one of which had a gonadoblastoma (author's transl)]. / Dysgénésie gonadique et chromosome Y dicentrique. Rapport de deux cas dont un avec gonadoblastome.

The authors report two new cases of primary amenorrhoea due to the presence of a dicentric Y with a chromosome formula of 45,X/46,X,dic(Y). These two patients show how variable the clinical manifestations of these gonosome anomalies can be, since one had a Turner's syndrome and the other is a woman who looks completely normal but only has primary amenorrhoea. A review of the literature has brought to light only 45 cases similar to ours and shows the different clinical aspects of these patients who are 45,X/46,Xdic(Y). Finding that one of our patients had a gonadoblastoma has confirmed the need to carry out bilateral castration when there is a dysgenetic gonad with a Y chromosome, in order to treat or prevent a dysgenetic tumour from arising.