Practice of laparoscopic prolapse surgery in Europe - ESGE Survey.

Sacrocolpopexy is considered as the "gold standard" for management of women with apical prolapse. Numerous technical variants are being practiced. The first aim of this survey was to determine the habits of practice of laparoscopic sacrocolpopexy (LSCP) in Europe. The second aim was to determine whether surgeons who perform laparoscopic pelvic organ prolapse (POP) repair are familiar with the practice of alternative techniques and with mesh-less laparoscopic treatment of prolapse. The questionnaire was designed by the Urogynaecology Special Interest Group of the European Society for Gynaecological Endoscopy (ESGE). All ESGE-members were invited by email to respond to this survey consisting of 54 questions divided in different categories. Following review of ESGE member's responses, we have highlighted the great heterogeneity concerning the practice of LSCP and important variability in performance of concomitant surgeries. Alternative techniques are rarely used in practice. Furthermore, the lack of standardisation of the many surgical steps of a laparoscopic sacrocolpopexy is mainly due to the lack of evidence. There is a need for training and teaching in both standard and newer innovative techniques as well as the reporting of medium and long-term outcomes of both standard laparoscopic sacrocolpopexy and any of its alternatives.

[Uterine transplantation, ethical and social aspects]. / Aspects éthiques et sociaux de la transplantation utérine.

Uterine transplantation is now a possible treatment for absolute uterine infertility. It is currently proposed to women with Mayer-Rokitansky-Küster-Hauser syndrome but indications will likely to expand in the upcoming years. Despite the progressive standardization of the surgical technique and the reduction in perioperative morbidity for both donors and recipients, the number of transplants performed worldwide remains very low compared to the number of women potentially in need. This is partly due to the singularity of uterine transplantation: the uterus is not a vital organ since one can live without a uterus. It is a temporary transplantation that is not performed to extend life but to improve its quality, responding above all to a desire to conceive and bear a child. Beyond the strictly technical aspect, these particularities raise many ethical questions, both on an individual and social level, which should make us question the real place uterine transplantation should take in our society. Answering these questions will allow us to provide better guidance for future eligible couples and to anticipate ethical problems on the long run.

Effect of environmental and spatial factors on the phylogenetic and functional diversity of the Mediterranean tree communities of Europe.

The tree flora of the Mediterranean Basin contains an outstanding taxonomic richness and a high proportion of endemic taxa. Contrary to other regions of the Mediterranean biome, a comprehensive phylogenetic analysis of the relationship between phylogenetic diversity, trait diversity and environmental factors in a spatial ecological context is lacking. We inferred the first calibrated phylogeny of 203 native tree species occurring in the European Mediterranean Basin based on 12 DNA regions. Using a set of four functional traits, we computed phylogenetic diversity for all 10,042 grid cells of 10 × 10 km spatial resolution to completely cover Mediterranean Europe. Then, we tested the spatial influence of environmental factors on tree diversity. Our results suggest that the nature of the relationship between traits and phylogeny varies among the different studied traits and according to the evolutionary distance considered. Phylogenetic diversity and functional diversity of European Mediterranean trees correlated strongly with species richness. High values of these diversity indices were located in the north of the study area, at high altitude, and minimum temperature of the coldest month. In contrast, the two phylogenetic indices that were not correlated with species richness (Mean Phylogenetic Distance, Phylogenetic Species Variability) were located in the south of the study area and were positively correlated with high altitude, soil organic carbon stock and sand soil texture. Our study provides support for the use of phylogenies in conservation biology to assess ecosystem functioning, and provides insights for the implementation of sustainable forest ecosystem management.

FORTE - a multipurpose high-vacuum diffractometer for tender X-ray diffraction and spectroscopy at the SIRIUS beamline of Synchrotron SOLEIL.

A new high-vacuum multipurpose diffractometer (called FORTE from the French acronyms of the project) has recently been installed at the tender/hard X-ray SIRIUS beamline of Synchrotron SOLEIL, France. The geometry chosen allows one to work either in the classical Eulerian four-circle geometry for bulk X-ray diffraction (XRD) or in the z-axis geometry for surface XRD. The diffractometer nicely fits the characteristics of the SIRIUS beamline, optimized to work in the 1.1-4.5 keV range, and allows one to perform unprecedented diffraction anomalous fine structure (DAFS) experiments in the tender X-ray region, also around non-specular reflections, covering a large reciprocal-space volume. Installation of an X-ray fluorescence detector on a dedicated flange allows simultaneous DAFS and X-ray absorption (XAS) measurements. The access to the tender X-ray region paves the way to resonant investigations around the L-edges of second-row transition elements which are constituents of functional oxide materials. It also enables access to several edges of interest for semiconductors. Finally, the control architecture based on synchronized Delta Tau units opens up exciting perspectives for improvement of the mechanical sphere of confusion.

Claudin-1, miR-122 and apolipoprotein E transductions improve the permissivity of SNU-182, SNU-398 and SNU-449 hepatoma cells to hepatitis C virus.

Hepatitis C virus (HCV) is a human hepatotropic virus, but many hepatoma cell lines are not permissive to this virus. In a previous study, we observed that SNU-182, SNU-398 and SNU-449 hepatoma cell lines were nonpermissive to HCV. To understand the nonpermissivity, we evaluated the ability of each cell line to support the different steps of HCV life cycle (entry, replication and production of infectious particles). Using retroviral pseudoparticles pseudotyped with HCV envelope proteins and recombinant HCV produced in cell culture, we observed that low level or absence of claudin-1 (CLDN1) expression limited the viral entry process in SNU-182 and SNU-398 cells, respectively. Our results also showed that supplementation of the three cell lines with miR-122 partly restored the replication of a JFH1 HCV replicon. Finally, we observed that expression of apolipoprotein E (ApoE) was very low or undetectable in the three cell lines and that its ectopic expression permits the production of infectious viral particles in SNU-182 and SNU-398 cells but not in SNU-449 cells. Nevertheless, the supplementation of SNU-182, SNU-398 and SNU-449 cells with CLDN1, miR-122 and ApoE was not sufficient to render these cells as permissive as HuH-7 cells. Thus, these cell lines could serve as cell culture models for functional studies on the role of CLDN1, miR-122 and ApoE in HCV life cycle but also for the identification of new restriction and/or dependency host factors essential for HCV infection.

Laparoscopic Adnexectomy for Ovarian Torsion during Late Pregnancy: Case Report of a Non-Conservative Treatment and Literature Analysis.

Diagnosis of adnexial torsion is difficult during pregancy (1). The time of decision and laparoscopy is that of the risk of necrosis of the adnexa and, therefore, of the ovarian prognosis. The loss of an ovary can compromise the following fertility. Even if concerns related to laparoscopy in pregnant patients include a limited surgical field, with a risk of uterine injury and negative fetal effects of CO2 insufflation. Evidence base suggests that minimally invasive surgery can be safe and better than laparotomy for management of adnexal masses during late pregnancy with good postoperative and obstetric outcomes. If for most authors laparoscopy appears to become the best approach for ovarian torsion during pregnancy (2), nonetheless, the ideal surgical laparoscopic approach of adnexa in late pregnancy remains controversial. Since there is no technical gold standard to overcome surgical difficulties which could make laparoscopic procedures as real challenge in patients in second and third trimester (3); at least, in case of radical and non-conservative treatment, the risk for a first trimester of pregnancy is to remove the corpus luteum (1).

[Laparoscopic lateral suspension, another way to treat genital prolapse]. / La suspension latérale cœlioscopique, une autre façon de traiter les prolapsus génitaux.

The laparoscopic sacrocolpopexy is the treatment of choice of pelvic organ prolapses since more than twenty years. The laparoscopic lateral suspension with mesh is an alternative technique. Its originality is the subperitoneal passing of the lateral arm of the mesh in the lateral abdominal wall, leaving the skin above the iliac crest, in a place without risks of vascular, nerve, bowel injuries. We report in this article the results of the three main publications on the subject. The indications are cystocele and apical descent. It can be envisaged when the access of the promontory is difficult; for instance in the presence of obesity, adhesions, sigmoid megacolon, or low position of the left common iliac vein, partially covering the promontory. It is also a practical technique for surgeons having a moderate experience of the promontory access.

Myoma migration: an unexpected "effect" with Ulipristal acetate treatment.

OBJECTIVE: Uterine myomas are one of the most common benign tumours, occurring in 20-40% of women of reproductive age. Ulipristal acetate (UPA) is a possible option for medical treatment of myomas. It induces amenorrhea and can reduce myoma volume before surgical treatment. Since its introduction in our department, we uncovered an unknown effect: migration of myoma. CLINICAL CASE REPORTS: We describe three clinical case of myoma migration following three months UPA pre-operative treatment. The first woman presented with a FIGO 2 myoma, which migrated in FIGO 3. A previously planned hysteroscopy converted into a laparoscopy. The second woman also presented with a FIGO 2 myoma, which migrated in FIGO 3. Initially, a hysteroscopy was planned, but ultimately surgery was no longer required. The third woman presented with a FIGO 2-5 myoma, which migrated in FIGO 1. The previously planned laparoscopy converted into a vaginal myomectomy. CONCLUSIONS: UPA induces a proapoptotic and anti proliferative effect of leiomyoma cells. It reduces expression of VEGF and reduces collagen deposition in the extracellular matrix. These mechanisms could induce migration of myoma. UPA as pre-operative treatment can induce migration of myoma and, therefore, can lead to perioperative conversion of surgery.

[Uterine volume and vaginal hysterectomy: Interest and limits of uterine morcellation]. / Volume utérin et hystérectomie vaginale : intérêt et limites de l'hystérectomie vaginale.

Abdominal hysterectomy remains the preferred approach for large uteri or in case of narrow vaginal access. However, the traditional morcellation techniques allow safe and efficient extraction when choosing the vaginal route. Uterine volume reductive techniques do not increase perioperative morbidity thus complications do not seem to be linked to uterine size. There are numerous advantages of the vaginal route in comparison with laparotomy, such as aesthetic benefits, decreased postoperative pain, reduced hospital stay and recovery as well as decreased perioperative morbidity. Compared to laparoscopy, surgical outcomes and blood loss of the vaginal approach of a large uterus seem to be similar. Nevertheless, laparoscopic hysterectomy is associated with longer operative time and significant increase in hospital cost. Hence, a thorough knowledge and mastery of uterine morcellation techniques are essential when performing vaginal hysterectomy for large uteri or when the vagina is narrow. They must therefore continue to be taught, spread and regularly used in order to stretch the indications for vaginal hysterectomy in favour of an abdominal approach.

Verrucous Carcinoma of the Vulva: A Case Report and Review of the Literature.

Verrucous carcinoma of the vulva is a rare lesion (1). Affecting essentially postmenopausal women, this lesion is a distinct and particular entity in vulval carcinoma classification and its scalability is uncertain and unpredictable. Here, we present a case concerning a 48-year-old patient, without follow-up after a condyloma acuminate of the vulva (large left lip). The origin of this case will be discussed in this article. The treatment decided was only surgical. A review of literature shows the rarity of this lesion of the female genital tract.

The role of preventive uterine artery occlusion during laparoscopic myomectomy: a review of the literature.

PURPOSE: Surgical myomectomy is currently regarded as the standard conservative treatment for patients who wish to preserve their fertility. However, it presents two main problems: the intra- and postoperative risk of bleeding and the risk of recurrence of leiomyomas. Preventive occlusion of uterine arteries was described during laparoscopic myomectomy as one of the procedures addressing these issues. METHODS: We conducted a literature review to define the role of preventive uterine artery occlusion during laparoscopic myomectomy. RESULTS: Nine non-randomized case-control studies and two randomized controlled trials were identified. The permanent and bilateral uterine artery occlusion technique is the most studied in the literature. The main purpose of facilitating the operative procedure by reducing blood loss has not been clearly demonstrated in randomized trials. Observational comparative studies found an improvement in the effectiveness of treatment, both on clinical symptoms and on the recurrence of leiomyomas. Finally, there are few data examining the effect of uterine artery occlusion on later fertility in female patients of childbearing age, which limits its current use. CONCLUSION: The preventive occlusion of uterine arteries is a safe surgical technique that can be performed during laparoscopic myomectomy. Further randomized studies are needed to better define the role of uterine artery occlusion in the surgical strategy, especially for women who want to preserve their fertility.

Two case reports of a malignant germ cell tumor of ovary and a granulosa cell tumor: interest of tumoral immunochemistry in the identification and management.

OBJECTIVE: In this article, we present two case reports. The first case was a malignant germ cell tumor of the right ovary in a 23-year old woman and the second case was a bilateral undifferentiated granulosa cell tumor in a 71-year old woman. The aim of these reports is to illustrate the interest of the immunohistochemical analysis to define the correct diagnosis, to better classify these ovarian tumors and improve their management. METHODS: In this study, we report two cases. The first case concerns a 23-year old woman (A) with a mixed germ cell tumor of the right ovary [dysgerminoma (75%), yolk sac tumor (20%), and a mature teratoma (5%)], and the second case concerns a 71-year old woman (B) with a bilateral non-differentiated and necrotic granulosa cell tumor of both ovaries. The staging system was used according to both the classifications: International Federation of Gynaecology and Obstetrics 1987 for ovarian cancer and TNM code 2009. RESULTS: The immunostaining establishes the malignancy and the immunochemistry contributes to confirm effectively the right diagnosis (Tables 2 and 3). CONCLUSION: An immunohistochemical analysis is mandatory for the choice of chemotherapy to obtain a better response of the disease and improve the survival prognosis. The efficiency of the chemotherapy authorizes a conservative surgery including a unilateral salpingo-oophorectomy preserving fertility (A). Concerning the non-dysgerminoma tumor (B), and after a surgical staging and debulking, chemotherapy was recommended. The type of tumor and its histological feature conditioned the choice of treatment. The benefit of the immunohistological analysis in this case allowed the right adjuvant treatment.

Virus-neutralizing antibodies to hepatitis C virus.

For a long time, the lack of an appropriate cell culture system has hampered the study of neutralizing antibody responses against hepatitis C virus (HCV). However, the last decade has seen the development of several model systems that have significantly advanced our understanding of viral entry and antibody neutralization. Studies of acutely infected patients suggest that a strong and early production of neutralizing antibodies may contribute to control the virus during the acute phase of HCV infection and facilitate viral elimination by cellular immune responses. It also emerges that the early antibody response mainly targets hypervariable region 1 (HVR1) of the envelope glycoprotein E2. This host response can lead to viral escape from neutralization by rapid amino acid changes in this hypervariable region. In contrast, cross-reactive neutralizing antibodies seem to appear later during HCV infection, and several mechanisms contribute to reduce their accessibility to their cognate epitopes. These include the masking of major conserved neutralizing epitopes by HVR1, specific N-linked glycans and the lipid moiety of the viral particle. Other potential mechanisms of evasion from the neutralizing antibody response include a modulation by high-density lipoproteins and interfering antibodies as well as the capacity of the virus to be transferred by cell-to-cell contacts. Finally, the recent identification of several highly conserved neutralizing epitopes provides some opportunities for the design and development of vaccine candidates that elicit a protective humoral immune response.

[Female sexuality after surgical treatment of symptomatic deep pelvic endometriosis]. / Sexualité féminine après chirurgie pour endométriose pelvienne profonde.

OBJECTIVES: The aim of this study is to assess the impact on sexuality of the surgical treatment in patients with symptomatic deep pelvic endometriosis. PATIENTS AND METHODS: The design is a single-center cohort prospective study including all patients with symptomatic pelvic endometriosis and regular sexual activity who underwent surgery between October 2009 and September 2010. Sexual function was evaluated by the "Brief Index of Sexual Functioning for Women" (BISF-W) questionnaire translated and validated in French, including a global evaluation by the Composite Score (CS). Pain symptoms related to endometriosis were evaluated by the Visual Analog Scale (VAS) and the simple Verbal Rating Scale (VRS). Questionnaires were answered before surgery. A standardized mid and long-term postoperative follow-up was performed to compare sexuality and pain symptoms. RESULTS: Twenty women were included in the study. Mean follow-up was 23.3 months. When compared to a French reference population, global preoperative sexual function was significatively deteriorated (CS=14.3±10.8 vs 32.2±12.6; P<0.001), especially for arousal, frequency of sexual activity, pleasure and orgasm. Significant improvements in sex life were observed after surgery at the long-term follow-up (CS=33.0±11.7 vs 14.3±10.8; P=0.02). and sexual function was similar to the reference population (CS=33.0±11.7 vs 32.2±12.6; P=0.806). At the mid-follow-up, a significant improvement in the intensity of dysmenorrhoea, non-cyclic pelvic pain, dyspareunia and bowel symptoms were observed on the VAS. At the long-term follow-up, dysmenorrhoea and dyspareunia were significatively ameliorated. Pelvic pain recurrence related to endometriosis was 13.3%. DISCUSSION AND CONCLUSION: Surgical management of deep pelvic endometriosis in symptomatic patients improves sexual life at the long term follow-up. Deep dyspareunia pain decreases significantly, although other conditions are involved in the improvement of sexual function.

Pathologies of the male breast.

The majority of breast lesions in men are benign. Gynaecomastia is a very common condition in which hormonal changes cause male breasts to enlarge. Three radiological patterns of gynaecomastia have been described: nodular, dendritic, and diffuse glandular pattern. The main differential diagnosis is lipomastia, which is when adipose tissue deposits are found in the subcutaneous tissue. Male breast cancer is rare. The main risk factors are pathologies that cause hormonal imbalances, a history of chest irradiation, and a family history of breast cancer (particularly in families carrying a mutation of the gene BRCA2). Mammography usually shows a mass with no calcifications. Sonography is useful to investigate local disease spread, and for detecting any enlarged axillary lymph nodes. MRI is not currently indicated to investigate male breast cancer. Very often, the clinical examination alone is enough to distinguish benign lesions from malignant lesions. Imaging must not be automatically carried out, but rather it should be used when the diagnosis is clinically uncertain or when patients present risk factors for breast cancer, as well as for guiding biopsies and for assessing disease spread.