Synergy of the microRNA Ratio as a Promising Diagnosis Biomarker for Mucinous Borderline and Malignant Ovarian Tumors.

Epithelial ovarian cancers (EOCs) are a heterogeneous collection of malignancies, each with their own developmental origin, clinical behavior and molecular profile. With less than 5% of EOC cases, mucinous ovarian carcinoma is a rare form with a poor prognosis and a 5-year survival of 11% for advanced stages (III/IV). At the early stages, these malignant forms are clinically difficult to distinguish from borderline (15%) and benign (80%) forms with a better prognosis due to the large size and heterogeneity of mucinous tumors. Improving their diagnosis is therefore a challenge with regard to the risk of under-treating a malignant form or of unnecessarily undertaking radical surgical excision. The involvement of microRNAs (miRNAs) in tumor progression and their potential as biomarkers of diagnosis are becoming increasingly recognized. In this study, the comparison of miRNA microarray expression profiles between malignant and borderline tumor FFPE samples identified 10 down-regulated and 5 up-regulated malignant miRNAs, which were validated by individual RT-qPCR. To overcome normalization issues and to improve the accuracy of the results, a ratio analysis combining paired up-regulated and down-regulated miRNAs was performed. Although 21/50 miRNA expression ratios were significantly different between malignant and borderline tumor samples, any ratio could perfectly discriminate the two groups. However, a combination of 14 pairs of miRNA ratios (double ratio) showed high discriminatory potential, with 100% of accuracy in distinguishing malignant and borderline ovarian tumors, which suggests that miRNAs may hold significant clinical potential as a diagnostic tool. In summary, these ratio miRNA-based signatures may help to improve the precision of histological diagnosis, likely to provide a preoperative diagnosis in order to adapt surgical procedures.

Pelvic floor disorders and sexuality in women with ovarian cancer: A systematic review.

INTRODUCTION: Pelvic floor disorders (PFD) are common conditions impacting quality of life and sexuality may worsen after ovarian cancer therapies. Our objective was to describe the prevalence of PFD and sexuality in women with ovarian cancer (OC). METHODS: We reviewed articles indexed in the MEDLINE database until June 2020 and selected articles assessing UI, POP, FI and sexual dysfunction in a population of women with OC. RESULTS: Of 360 articles, 18 were included: four assessed UI, two assessed POP, three FI, and 13 sexual dysfunction. PFD findings were highly heterogeneous due to the definitions used and the populations studied. The prevalence of any type of UI in patients with OC before treatment is around 50%, and about 17% report feeling a bulge in their vagina. These rates are similar to those reported in women without cancer. Similarly, the main post-treatment UI scores were not significantly different from women without cancer. Fecal incontinence has been less studied in women with OC but reported as affecting 4% of patients preoperatively and 16% postoperatively. About half of the women are sexually active after surgical treatment with high reported rates of dyspareunia (40-80%) and vaginal dryness (60-80%). Compared with healthy women, some authors found that OC patients had greater problems with loss of desire and poorer sexual function scores; other authors did not find a significant difference. CONCLUSIONS: While PFD seem to be common in women after treatment for OC, the rates are not higher than in the general population. Overall, there is a higher prevalence of UI and sexual dysfunction compared with bowel dysfunction. More prospective studies are needed to explore the impact of gynecologic cancers and their treatments on pelvic floor function and pelvic health-related quality of life.

New Pointers for Surgical Staging of Borderline Ovarian Tumors.

BACKGROUND: Surgical management of borderline ovarian tumors (BOTs) is similar to that of ovarian cancer apart from lymphadenectomy. However, the complete procedure including peritoneal washing, infracolic omentectomy and random peritoneal biopsies remains a subject of controversy especially in presumed early stage BOTs. To evaluate the prognostic value of complete surgical staging on recurrence rates, recurrence free (RFS) and overall survival (OS) in a multicentre cohort of BOTs. METHODS: This retrospective multicentre study included 428 patients with BOTs diagnosed from January 1980 to December 2008. Survival estimates were based on Kaplan-Meier calculations and RFS defined as the time from the date of surgery to the date of recurrence. RESULTS: The median time of follow-up was 94.9 months (range: 60.00-207.3). The overall recurrence rate was 23.8 %. There was no difference in 5-year RFS between patients with and without complete surgical staging 78.1 % (95 % CI 68.9-88.6) and 70.9 % (95 % CI 64.6-77.8), (p = 0.0806). In the whole cohort, 5-year OS was higher for patients with complete surgical staging 98.4 % (95 % CI 96.8-1.0) and 93.8 % (95 % CI 88.1-1), (p = 0.0182) but this difference was not significant for patients with FIGO stage I 98.6 % (95 % CI 96.7-1) and 92.7 % (95 % CI 83.4-1.0), p = 0.1275, respectively. CONCLUSIONS: Complete staging surgery should be considered as a cornerstone treatment for patients with advanced stage BOT but not for those with stage I disease.

Nomogram to predict recurrence in patients with early- and advanced-stage mucinous and serous borderline ovarian tumors.

OBJECTIVE: Recurrence prediction is a cornerstone of patient management for borderline ovarian tumors. This study aimed to develop a nomogram predicting the recurrence probability in individual patients who had received primary surgical treatment. STUDY DESIGN: This retrospective multicenter study included 186 patients with borderline ovarian tumor diagnosed from January 1980 through December 2008. A multivariate logistic regression analysis of selected prognostic features was performed and a nomogram to predict recurrence was constructed. The nomogram was internally validated. RESULTS: The overall recurrence rate was 34.4% (64/186), with noninvasive and invasive forms in 29% (54/186) and 5.4% (10/186) of cases, respectively. International Federation of Gynecology and Obstetrics stage, age at diagnosis, histologic subtype, completeness of surgery, and type of surgery (radical vs fertility sparing) were associated with an increased risk of recurrence and were included in the nomogram. The predictive model had a concordance index of 0.78 (95% confidence interval, 0.76-0.80) and 0.77 (95% confidence interval, 0.75-0.79) before and after the 200 repetitions of bootstrap sample corrections, respectively, and showed good calibration. CONCLUSION: Our results support the use of the present nomogram based on 5 clinical and pathological characteristics to predict recurrence probability with a high concordance, hence to inform patients on surgical management. External validation is required to recommend this nomogram in routine practice.

Borderline ovarian tumour: pathological diagnostic dilemma and risk factors for invasive or lethal recurrence.

By comparison with ovarian carcinomas, borderline ovarian tumours are characterised clinically by superior overall survival, even in women with peritoneal spread. In this Review, we aimed to clarify the histological and clinical factors potentially defining a high-risk group in whom disease is likely to evolve to invasive disease. Invasive peritoneal implants (in serous borderline ovarian tumours) and residual disease after surgery were the two factors clearly identified. Other factors are controversial owing to increased risk of invasive recurrence: micropapillary patterns in serous borderline ovarian tumour, intraepithelial carcinoma in mucinous lesions, stromal microinvasion in serous lesions, and use of cystectomy in mucinous borderline ovarian tumours. The pathologist has a pivotal role in assessment of the borderline nature of ovarian tumours and in identification of high-risk criteria, most of which are histological. But, reproducibility of the histological interpretation of some of these potential criteria--eg, classification of peritoneal implants (particularly in desmoplastic subtype), stromal microinvasion, micropapillary patterns, and intraepithelial carcinoma in mucinous borderline ovarian tumours--remains unclear, and should be investigated.

Efficacy and aesthetic outcomes for quilting sutures in the prevention of seroma after mastectomy.

Worldwide, mastectomy for breast cancer is one of the most frequently performed surgical procedures. As one of the main complications of mastectomy, seroma is associated with pain, infections and a prolonged hospital stay. We performed a prospective multicenter randomized trial to assess the efficacy and esthetic outcomes associated with quilting the skin flap. Eighty-seven patients were included. The proportion of patients with seroma on postoperative day 15 was significantly lower in the quilting group (12 out of 39 (30.8%)) than in a control group with conventional wound closure (21 out of 40 (52.5%); P = 0.05). The mean breast seroma volume was significantly lower in the quilting group (130.2 mL) than in the control group (236.8 mL; P = 0.02). There were no differences in the esthetic outcomes. The pain level on day 1 was similar in the quilting and control groups (mean visual analog scale score: 2.5 vs. 2.1, respectively; P = 0.3). Quilting the skin flap was associated with a lower prevalence of seroma and a lower seroma volume, and did not worsen the esthetic outcomes or pain levels. This technique is technically straightforward and should be offered to all patients scheduled for mastectomy.

RACCE Study: Impact of an enhanced recovery after surgery program (ERAS) in the management of endometrial cancer: A single-center retrospective study.

OBJECTIVE: This study evaluates the implementation of an ERAS program in the gynecological surgery department of Caen University Hospital and its impact on the management of endometrial cancer. The objective was to show its impact on the length of hospitalization of patients before and after its implementation. PATIENTS AND METHOD: We conducted a retrospective study including all women treated surgically for endometrial cancer at Caen University Hospital between January 1, 2015 and December 31, 2021. The ERAS program started in September 2017. We compared the pre-, intra- and postoperative characteristics of two groups: the first one concerning the period before the implementation of ERAS called « prior ERAS group ¼ and the second one after implementation called « post ERAS group ¼. RESULTS: A total of 198 patients were included in our study. 139 patients were included after ERAS implementation. Our study shows that there is a significant reduction in median length of stay between the post ERAS and prior ERAS groups respectively 3 and 4 days (p = 0.004). There was also a reduction of time to resume ambulation (p < 0.001) and re-feeding (p < 0.001) for the post ERAS group compared to the prior ERAS group. Complication rates (p = 0.87) and readmission rates (p = 0.28) were not significant. Overall survival was not significant (p = 0.28). CONCLUSION: ERAS is a safe and effective method in the overall management of patients allowing an improvement in the quality of patient care and accelerating recovery to a previous physiological state. Finally, this results in a reduction in the patient's length of stay, without impacting morbidity and readmission rate.

Validation of a Salivary miRNA Signature of Endometriosis - Interim Data.

BACKGROUND: The discovery of a saliva-based micro­ribonucleic acid (miRNA) signature for endometriosis in 2022 opened up new perspectives for early and noninvasive diagnosis of the disease. The 109-miRNA saliva signature is the product of miRNA biomarkers and artificial intelligence (AI) modeling. We designed a multicenter study to provide external validation of its diagnostic accuracy. We present here an interim analysis. METHODS: The first 200 patients included in the multicenter prospective ENDOmiRNA Saliva Test study (NCT05244668) were included for interim analysis. The study population comprised women from 18 to 43 years of age with a formal diagnosis of endometriosis or with suspected endometriosis. Epidemiologic, clinical, and saliva sequencing data were collected between November 2021 and March 2022. Genomewide miRNA expression profiling by small RNA sequencing using next-generation sequencing (NGS) was performed, and a random forest algorithm was used to assess the diagnostic accuracy. RESULTS: In this interim analysis of the external validation cohort, with a population prevalence of 79.5%, the 109-miRNA saliva diagnostic signature for endometriosis had a sensitivity of 96.2% (95% confidence interval [CI], 93.7 to 97.3%), specificity of 95.1% (95% CI, 85.2 to 99.1%), positive predictive value of 95.1% (95% CI, 85.2 to 99.1%), negative predictive value of 86.7% (95% CI, 77.6 to 90.3%), positive likelihood ratio of 19.7 (95% CI, 6.3 to 108.8), negative likelihood ratio of 0.04 (95% CI, 0.03 to 0.07), and area under the receiver operating characteristic curve of 0.96 (95% CI, 0.92 to 0.98). CONCLUSIONS: The use of NGS and AI in the sequencing and analysis of miRNA provided a saliva-based miRNA signature for endometriosis. Our interim analysis of a prospective multicenter external validation study provides support for its ongoing investigation as a diagnostic tool. (Funded by Ziwig and the Conseil Régional d'Ile de France [Grant EX024087]; ClinicalTrials.gov number, NCT05244668.)

Management and prognosis of borderline ovarian Brenner tumors.

OBJECTIVE: The borderline ovarian Brenner tumor (BOBT) of the ovary is a rare tumor, and fewer than 25 cases have been reported in the literature. The aim of this study was to determine the prognosis of a series of BOBT collected in 2 reference centers. METHODS: A retrospective review of patients with BOBT treated or referred to our institutions. A centralized histological review by a reference pathologist and data on the clinical characteristics, management, and outcomes of patients were required for inclusion. RESULTS: Ten patients were identified between 2000 and 2010. The median age of patients was 69 years (range, 52-84 years). Eight patients had pure BOBT and 2 had mixed histotype (mucinous and Brenner tumor). All patients had unilateral tumor and a stage I disease. No case of stromal microinvasion or intraepithelial carcinoma was observed. Among 5 patients with data on the follow-up, 1 lethal recurrence (50 months after initial surgery) was observed (the first reported in the literature). CONCLUSIONS: During the management of BOBT, peritoneal staging surgery is not required because all patients reported in the present series (and all but one in the literature) had stage I disease. One recurrence had occurred in this retrospective series. Nevertheless, among 35 cases (including those in the present study) reported in the literature with outcomes, this tumor carries a good prognosis. The power of this conclusion is, however, limited because of the relatively small number of patients studied (but this is a rare entity) and the short follow-up period.

Management and prognosis of clear cell borderline ovarian tumor.

BACKGROUND: The clear cell borderline ovarian tumor (CCBOT) of the ovary is a rare tumor accounting for less than 1% of BOT. Fewer than 25 cases have been reported in the literature (including details on clinical management and outcomes). The aim of this study was to determine the prognosis of a series of CCBOTs collected in 2 reference centers. PATIENTS AND METHODS: This was a retrospective review of patients with CCBOT treated or referred to our institutions. A centralized histological review by a reference pathologist and data on the clinical characteristics, management, and outcomes of patients were required for inclusion. RESULTS: Twelve patients were identified between 2000 and 2010. The median age of patients was 68 years (range, 36-83 years). Two had been treated conservatively and 9 radically (data unknown in 1). The tumor was unilateral in 11 cases. All patients had stage I disease. All cases were CCBOT with an adenofibromatous pattern. Stromal microinvasion or intraepithelial carcinoma was histologically associated in 2 and 3 cases, respectively. Four of the 12 patients had synchronous endometrial disorders (but no endometrioid carcinoma). No cases were histologically associated with endometriosis. Four patients were lost to follow-up. Among 8 other patients, after a median period of 28 months (range, 2-129 months), no recurrence had occurred (1 patient had died of another disease). CONCLUSION: Clear cell borderline ovarian tumor carries a good prognosis. All tumors are stage I; therefore, surgical staging is not necessary in most of the cases. Conservative treatment could be proposed to young patients, but uterine curettage would then be required in cases of uterine preservation.

Impact of uterine fibroid surgery on lower urinary tract symptoms.

OBJECTIVE: Uterine fibroids are often associated with lower urinary tract symptoms (LUTS), the exact prevalence of which has been underexplored. Our main objective was to evaluate the effect of surgical treatment of fibroids on LUTS. Our secondary objectives were to assess the prevalence of LUTS in women undergoing fibroid surgery and to analyze the relationship between the characteristics of fibroids and the severity of symptoms. METHODS: This was a prospective study of women conducted between 2019 and 2021. The main endpoint was the change in the total UDI-6, IIQ7, ICIQ-SF and CONTILIFE scores preoperatively and 6 weeks postoperatively. RESULTS: Of the 55 included women, 63.6% had frequency and 60% had urgency. Six weeks postoperatively, urinary symptoms had significantly improved for all scores. The presence of an anterior fibroid was significantly associated with higher urinary symptom scores for the UDI-6 (p = 0.007) and ICIQ-SF scores (p = 0.04). The size of the uterus or dominant fibroid was not significantly associated with the severity of urinary symptoms. CONCLUSION: Fibroids are often associated with symptoms of overactive bladder. An anterior location of the fibroid appears to be associated with greater severity scores. Surgical treatment appears to reduce urinary symptoms 6 weeks postoperatively.

Implementing enhanced recovery after surgery programmes in a healthcare facility: issues and economic impacts.

For many specialties and operating techniques, enhanced recovery after surgery provides greater economic benefit if it is deployed across a whole healthcare institution rather than in just one or two departments. As with all innovations in the world of hospital care, the adoption of new procedures is a slow process because it is based on a consensual approach. To promote the dissemination and uptake of new practices at the local, national or institutional level, incentives must be developed and examples must be given. Successful deployment within a healthcare institution requires strategic adaptations in three areas: (i) the management of human resources dedicated to the patient pathway, (ii) a care unit architecture that facilitates working practices and patient management, and (iii) the use of digital tools and smart objects. Hospital decision-makers need to have a clear understanding of what is at stake, so that they can implement coordinated actions and encourage adoption. The investment required is hard to define because it results from a combination of skills and knowledge. At the institutional level, the return on investment is greater when the strategy is applied to all surgical specialties at once, since the structure can provide more care with fewer beds and fewer care units while maintaining the quality of patient management.

How Satisfied Are Women 6 Months after a Pessary Fitting for Pelvic Organ Prolapse?

BACKGROUND: The non-surgical solution for Pelvic Organ Prolapse (POP) typically consists of a pessary fitting. We aimed to assess patient satisfaction and symptom improvement 6 months after a pessary fitting and to identify risk factors associated with pessary failure. METHODS: Six months after a pessary fitting, patient satisfaction was assessed by the PGII score; symptoms and quality of life were assessed using validated questionnaires (PFDI-20, ICIQ-SF, PISQ-12, USP, and PFIQ-7). RESULTS: Of the 190 patients included in the study (mean age of 66.7 years), 141 (74%) and 113 (59%) completed the follow-up questionnaires at 1 and 6 months, respectively. Nearly all the women were menopausal (94.6%) and 45.2% declared being sexually active at inclusion. The satisfaction rate was 84.3% and 87.4% at 1 and 6 months, respectively. The global symptom score PFDI-20 had significantly improved at 6 months. A high body mass index (RR = 1.06, CI95%: [1.02-1.09]), as well as high PFDI-20 (1.05 [1.01-1.09]), PFIQ7 (1.04 [1.01, 1.08]), and PISQ12 scores at inclusion (0.75 [0.60, 0.93]), as well as higher GH and GH/TVL measurements (1.49 [1.25-1.78] and 1.39 [1.23-1.57], respectively) were associated with pessary failure. CONCLUSIONS: Pessary seems to be an effective treatment for POP with high patient satisfaction. Higher BMI, higher symptom scores, and greater genital hiatus measurements before insertion are risk factors for failure at 6 months.

Vaginal Pessary for Pelvic Organ Prolapse: A French Multidisciplinary Survey.

Objective: Pessary fitting and follow-up for women with pelvic organ prolapse (POP) can be performed by different health care practitioners (HCPs). We aimed to investigate knowledge and current practices among the main HCPs involved in pessary use in France. Materials and Methods: We sent an electronic questionnaire about pessary use to the members of eight French learned societies between April and October 2020. Results: During the study period, 1017 HCPs responded to the questionnaire: 712 (70.0%) were doctors, 208 (20.4%) physiotherapists, 95 (9.3%) midwives, and 7 (0.6%) nurses. Of the respondents, 69.1% claimed to be comfortable with pessary fitting and follow-up, and 54.1% think that a pessary can be offered as a first-line treatment in the management of POP. However, 60.1% reported that the main indications for pessaries were "older women," 71.3% for women with contraindications to surgery, and 60.5% for women waiting for surgery. 23.9% do not prescribe local estrogen therapy with a pessary for postmenopausal women. The main pessaries used are the ring and cube types (63.7 and 57.5%, respectively). Wide introitus (53.3%), difficulties of use (56.3%), a short vagina (41.4%), and major unmasked urinary incontinence (47.2%) are considered to be the main risk factors for pessary failure. The most common complications related to pessaries reported by the patients are vaginal discharge (48.6%) and pain or discomfort (40.6%). Up to 43.4% of respondents considered that a follow-up visit every 3-6 months was optimal. The need for training ranged from 42.8% for nurses to 65.2% for general practitioners. Conclusions: This national multidisciplinary survey revealed that HCPs in France are on the whole comfortable with pessaries and mainly prescribe the ring and cube form. Even if opinion about pessaries appears to be changing, HCPs would welcome additional training to improve knowledge and practices.

Definition, general principles and expected benefits of enhanced recovery in surgery.

A multimodal approach to promoting recovery from surgery was first described by Henrik Kehlet in 1995. This approach has since been significantly developed and refined, and is now referred to as Enhanced Recovery in Surgery (ERS). The goal of ERS is to enable a patient to regain his/her pre-surgery physical and psychological state after a surgical procedure - notably by reducing the stress and the inflammatory response inevitably triggered by surgery. ERS protocols include anesthesia-related items (such as reducing the use of morphine) and surgical items (such as the use of minimally invasive routes, and limiting the postoperative use of drains and probes). Each step is essential - from patient information, education and adherence during the preoperative phase to involvement of the family circle and the attending physician with a view to early discharge. The term ERS corresponds to a set of principles for optimizing pre-, per- and postoperative care, the aim of which is to improve the post-operative course and the patient's experience by decreasing per- and postoperative complications and accelerating a return to the patient's pre-operative physical and psychological state. The use of ERS protocols is associated with a lower complication rate and a shorter hospital stay, regardless of the patient's age and comorbidities.

Combining prehabilitation with enhanced recovery programs in gynecological surgery.

Prehabilitation is a multimodal approach to preoperative care based on physical exercise, dietary/nutritional interventions, smoking and alcohol cessation, and psychological care. The goal is to reduce stress and apprehension, encourage general well-being, and thus optimize the patient's state of health before surgery. Prehabilitation encompasses all the actions undertaken between the diagnosis of the disease and the initiation of surgery to reduce the morbidity attributable to the latter. Although there are few literature data on prehabilitation in gynecological surgery, the management of moderate-to-severe undernutrition prior to gynecological oncology surgery reduces the risk of postoperative complications and increases the overall survival rate.

Perioperative parameters to consider for enhanced recovery in surgery (ERS) in gynecology (excluding breast surgery).

The current review explores the Enhanced Rehabilitation in Surgery (ERS) approach in the specific context of gynecological surgery. Implementation of an ERS protocol in gynecological surgery reduces postoperative complications and length of stay without increasing morbidity. An ERS approach is based on maintaining an adequate diet and hydration before the operation, according to the recommended time frame, to reduce the phenomenon of insulin resistance, and to optimize patient comfort. On the other hand, the use of anxiolytic treatment as premedication is not recommended. Systematic preoperative digestive preparation, a source of patient discomfort, is not associated with an improvement in the postoperative functional outcome or with a reduction in the rate of complications. A minimally invasive surgical approach is preferrable in the context of ERS. Prevention of surgical site infection includes measures such as optimized antibiotic prophylaxis, skin disinfection with alcoholic chlorhexidine, reduction in the use of drainage of the surgical site, and prevention of hypothermia. Early removal of the bladder catheter is associated with a reduction in the risk of urinary tract infection and a reduction in the length of hospital stay. Prevention of postoperative ileus is based on early refeeding, and prevention of postoperative nausea-vomiting in a multimodal strategy to be initiated during the intraoperative period. Intraoperative hydration should be aimed at achieving euvolemia. Pain control is based on a multimodal strategy to spare morphine use and may include locoregional analgesia. Medicines should be administered orally during the postoperative period to hasten the resumption of the patient's autonomy. The prevention of thromboembolic risk is based on a strategy combining drug prophylaxis, when indicated, and mechanical restraint, as well as early mobilization. However, the eclectic nature of the implementation of these measures as reported in the literature renders their interpretation difficult. Furthermore, beyond the application of one of these measures in isolation, the best benefit on the postoperative outcome is achieved by a combination of measures which then constitutes a global strategy allowing the objectives of the ERS to be met.

To what extent is enhanced recovery in surgery used in French obstetrics and gynecology departments?

The objective of the present study was to evaluate the implementation of Enhanced Recovery in Surgery (ERS) in French obstetrics and gynecology departments. To achieve this objective, we drafted an online questionnaire about ERS protocols for cesarian sections and hysterectomies with a benign indication and put a hyperlink on the 'French National College of Gynecologists and Obstetricians' (Collège National des Gynécologues et Obstétriciens Français) website. We obtained 112 analyzable responses. Respectively 66% and 34% of the surveyed departments had established ERS protocols for cesarean sections and for hysterectomies with a benign indication. However, not all of the key ERS items were sufficiently implemented: despite the establishment of written protocols, the degree of compliance with the guidelines issued by the French-Speaking Group for Enhanced Recovery After Surgery (Groupement Francophone de Réhabilitation Améliorée Après Chirurgie) was variable. There are few published data on the implementation of ERS in obstetrics and gynecology departments worldwide. In 2010, the Enhanced Recovery After Surgery® Society issued guidelines and a checklist for an ERS protocol. The literature data suggest that for most surgical disciplines, the main ERS criteria are not well known or not widely applied. ERS protocols are still not widespread in French gynecologic surgery departments. Moreover, the application of some of the major ERS items differs markedly from one ERS program to other, which is likely to reduce the level of effectiveness. It therefore appears to be essential to formalize and promote ERS protocols in gynecological surgery.

Vaginal pessary for pelvic organ prolapse: A survey among french gynecological surgeons.

OBJECTIVE: Because pessaries may offer symptomatic improvement for women with pelvic organ prolapse (POP), the study aimed to assess the opinion and knowledge of participants to a french general surgical gynecological congress, about this device. MATERIAL AND METHODS: An anonymous survey was carried out near 150 surgeons attending a congress by handing them a questionnaire. RESULTS: The average age of the 70 respondents was 50 years. 87.7 % were comfortable with fitting and monitoring pessary, 54.3 % think that a pessary can be offered as a first-line treatment in the management of POP. However, main indications of vaginal device are still old women and contraindications to surgery ; 31.4 % do not associate local estrogen therapy with a pessary for postmenopausal women. CONCLUSION: The majority declares to be comfortable with pessaries, is ready to prescribe it as a first-line treatment and use local estrogen if necessary. Even if change of ideas seems to emerge about pessary, a change in beliefs and habits is still necessary. This progress can be achieved through doctors fully informed.

Borderline ovarian tumors: French guidelines from the CNGOF. Part 2. Surgical management, follow-up, hormone replacement therapy, fertility management and preservation.

In the Early Stages (ES) of Borderline Ovarian Tumor (BOT), if surgery without risk of tumor rupture is possible, then laparoscopy with protected extraction is recommended over laparotomy (Grade C). In case of bilateral serous ES BOT treatment with a strategy to preserve fertility and/or endocrine function, bilateral cystectomy is recommended if possible (Grade B). In case of mucinous BOT treatment with a strategy to preserve fertility and/or endocrine function, unilateral adnexectomy is recommended (grade C). In the case of a mucinous BOT in a patient who has had an initial cystectomy, unilateral adnexectomy is recommended (grade C). In the case of treatment of a serous ES BOT in a patient who has had an initial cystectomy, with a strategy to preserve fertility and/or endocrine function, restaging surgery for adnexectomy is not recommended in the absence of suspicious residual lesions at the time of surgery and/or postoperative imaging (reference ultrasonography or pelvic MRI) (grade C). For serous or mucinous ES BOTs, routine hysterectomy is not recommended (Grade C). In cases of ES BOTs, lymphadenectomy is not recommended (Grade C). For ES BOTs, appendectomy is recommended only if there is a macroscopically pathological aspect to the appendix (Grade C). Restaging surgery is recommended in case of a serous BOT with a micropapillary aspect and an unsatisfactory inspection of the abdominal cavity during initial surgery (Grade C). Restaging surgery is recommended in cases of mucinous BOT if only a cystectomy has been performed or if the appendix has not been evaluated (Grade C). If restaging surgery is decided for an ES BOT, the following procedures should be performed: peritoneal cytology (grade C), omentectomy (there is no data in literature to recommend which type of omentectomy should be performed) (grade B), complete exploration of the abdominal cavity with peritoneal biopsies (grade C), visualization of the appendix +/- appendectomy in case of pathological macroscopic appearance (grade C) and unilateral adnexectomy in case of a mucinous BOT (grade C). In advanced stages of BOT it is not recommended to perform a lymphadenectomy as a routine procedure (Grade C). In cases of an advanced stage BOT, in a patient with a desire to fall pregnant, conservative treatment involving preservation of the uterus and all or part of the ovary may be proposed after a multidisciplinary meeting (Grade C). Second surgery aimed at removing all lesions, if not performed initially, is recommended in cases of advanced stage BOT (Grade C). It is not recommended to perform completion surgery after conservative treatment (preservation of the ovaries and the uterus) and after the achievement of fertility desire for a serous BOT (Grade B). After treatment for a BOT, follow-up beyond 5 years is recommended due to the median time to recurrence (Grade B). It is recommended that a systematic clinical examination be carried out during follow-up of a treated BOT (Grade B). In the particular case of an initial elevation of CA 125 levels, it is recommended to monitor CA 125 during follow up (Grade B). In cases treated conservatively (ovarian and uterine conservation), it is recommended to use endovaginal and transabdominal ultrasonography during the follow up period (Grade B). In the event of a recurrence of a BOT, in a woman of childbearing age, a conservative treatment strategy can again be proposed (Grade C). In the presence of non-invasive BOT implants, conservative treatment may be considered after a first non-invasive recurrence in women who wish to preserve their fertility (Grade C). Pelvic MRI is recommended after 12 weeks of amenorrhea in case of an undetermined adnexal mass and should be concluded with a diagnostic score (Grade C). The injection of gadolinium, in case of pregnancy, should be discussed on a case-by-case basis due to the proven risks for the foetus (Grade C). If feasible, a laparoscopic approach should be preferred during pregnancy (Grade C). A consultation with a specialist reproductive physician should be offered to patients with a BOT and of childbearing age (Grade C). It is recommended that patients be provided with full information on the risk of decreased ovarian reserve following to surgical treatment. It is recommended that the ovarian reserve be evaluated prior to surgical management of a suspected BOT (Grade C). When possible, a conservative surgical strategy is recommended to preserve fertility in women of childbearing age (Grade C). There is no specific data on the management of infertility following to conservative treatment of BOT. In case of durable infertility following to conservative treatment of BOT, a consultation with a specialist reproductive physician is required (Grade C). In the case of optimally treated BOT, there is no evidence in literature to contraindicate the use of Assisted Reproductive Techniques (ART). The use of hormonal contraception after serous or mucinous BOT is not contraindicated (Grade C). After treatment of a mucinous BOT, for women aged under 45 years, given the benefit of hormonal replacement therapy (HRT) on cardiovascular and bone risks, and the lack of hormone-sensitivity of mucinous BOTs, it is recommended to offer HRT (Grade C). After treatment of a mucinous BOT, for women over 45 years of age, there is no argument to contraindicate the use of HRT. HRT can be prescribed in case of a climacteric syndrome, as part of an individual benefit to risk assessment (Grade C).