Sacrospinous ligament fixation: medium and long-term anatomical results, functional and quality of life results.

BACKGROUND: To evaluate the medium and long-term anatomical results of sacrospinous ligament fixation (SLF) and its impact on quality of life (QoL). METHODS: We conducted a retrospective and observational single centre study. Fifty-nine patients were interviewed using the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire and underwent physical examination using POP-Q several years after SLF. Primary outcome was the comparison of anatomic results of SLF at medium-term (group 1: 1-5 years after surgery) and long-term (group 2: more than 5 years after surgery). The secondary outcome was QoL evaluation. RESULTS: The overall recurrence and complication rates were respectively 22% and 10%, with no significant differences between groups 1 and 2. The recurrence rate was similar in both groups [twelve (35%) in group 1 and nine (20%) in group 2, p = 0.09]. Two patients (12%) in the recurrence and none in the no recurrence group had clinical symptoms (p = 0.08). Two patients (12%) in the recurrence and one patient (2%) in the no-recurrence group had a significant impact on their quality of life (p = 0.12). CONCLUSION: This study showed sustainable anatomic and functional results of SLF in medium and long-term analysis with overall low morbidity.

Managing an obstetrics and gynaecology department in time of COVID pandemic: safety and efficacy first at Foch hospital.

Obstetrics and Gynecology department in France were not ready for the outbreak of the COVID pandemic, but ingenuity and dedication of personnel allowed to perform safely and avoid nocomial transmission of COVID.

[Uterus transplantation: state of knowledge and ethical reflection]. / Greffe utérine : état des lieux et réflexion éthique.

Uterus transplantation: state of knowledge and ethical reflection. Nowadays is uterine transplantation the only treatment for absolute uterine infertility. This experimental surgery is spreading worldwide since the past two years. The first livebirths from uterus transplantations from living donors in Sweden gave the impetus for more research. Since several team works on the uterine transplantation from living or deceased donors. Uterus transplantation and the choice between live and deceased donor raises up technical and ethical questions.

Greffe utérine : état des lieux et réflexion éthique. La greffe utérine est à ce jour le seul traitement de la stérilité d'origine utérine. Cette chirurgie expérimentale est en expansion à travers le monde, en particulier depuis ces deux dernières années. L'élan a été donné par les premières naissances obtenues en Suède en 2014 à l'issue de greffes à partir de donneuses vivantes. Depuis, plusieurs équipes travaillent sur la greffe à partir de donneuses vivantes mais également en état de mort encéphalique. La greffe utérine en tant que telle ainsi que le choix entre les donneuses vivantes et décédées soulèvent de nombreuses questions techniques et éthiques.

Antiphospholipid syndrome and other autoimmune diseases associated with chronic intervillositis.

OBJECTIVES: Chronic intervillositis of unknown etiology (CIUE) is characterized by an intervillous infiltrate of mononuclear cells and a high recurrence rate of adverse obstetrical outcomes. The aim was to describe obstetrical history in patients with at least one event characterized by CIUE, and the possible impact of systematic investigation of an underlying autoimmune disease on the obstetrical outcome of subsequent pregnancies. METHODS: We retrospectively reviewed all pregnancies in patients having experienced at least one adverse obstetric outcome associated with chronic intervillositis of unknown etiology diagnosed by placental histological analysis between 2004 and 2011 in our university hospital. For each patient, data pertaining to obstetrical history, treatments during pregnancies, the results of systematic investigation of an underlying autoimmune disease, and treatments as well as obstetrical outcome in subsequent pregnancies, were collected. RESULTS: Twelve patients with 38 pregnancies were included [median age 30 (22; 40 years)]. Autoimmune disease or autoimmune antibodies (AID group) were found in 7/12 patients: primary antiphospholipid syndrome (APS) (n = 4), Sjögren's syndrome (n = 1), pernicious anemia (n = 1) and celiac disease (n = 1). When comparing pregnancies of patients with and without AID, there was no difference with regard to the type of obstetrical events or live-born babies, in spite of appropriate treatment. Corticosteroids (prednisone 10 mg/day) were used in only 2 cases with AID (Sjögren's syndrome and APS; n = 1 each), and these 2 pregnancies resulted in live-born babies. CONCLUSION: This study shows that the immunological assessment in patients with CIUE raises the possibility of a specific severity when AID or obstetrical APS is associated with CIUE, since conventional treatment did not improve obstetrical outcome in these patients as compared to those without autoimmune diseases. The benefit of immunosuppressant agents in this subset of patients needs further evaluation.

Comparison of morbidity and survival between primary and interval cytoreductive surgery in patients after modified posterior pelvic exenteration for advanced ovarian cancer.

OBJECTIVE: Surgical management of advanced ovarian cancer often requires low modified posterior pelvic exenteration (MPE) to achieved complete resection. The aim of this study was to evaluate the morbidity of MPE at the time of primary cytoreductive surgery (PCS) and interval cytoreductive surgery (ICS) after neoadjuvant chemotherapy. MATERIALS AND METHODS: From 2001 to 2009, 63 patients underwent MPE for advanced ovarian cancer. We analyzed and compared surgical characteristics and postoperative courses between PCS and ICS. RESULTS: Modified posterior pelvic exenteration was performed during PCS for 50 patients (79%) and during ICS for 13 patients (21%). Complete cytoreduction was achieved in 80% of patients (84% in the PCS group and 69% in the ICS group; ns). There was no significant difference between the PCS and ICS groups in the type and the rate of standards or radical surgical procedures. Patients with ICS had a shorter length of stay in the intensive care unit (0.9 vs 2.7 days; P = 0.009), but there was no difference in the total length of hospitalization (P = 0.94). The global rate of postoperative complications was 76%. No differences were found between the 2 groups in digestive or extradigestive complications, iterative surgery, or interventional radiology procedures. The median overall survival was 49.4 months in the PCS group and 27.1 months in the ICS group (P = 0.27), and the median progression-free survival time in both groups was 20 months. CONCLUSIONS: There was no difference in the occurrence of postoperative complications between PCS and ICS, especially in morbidity related to MPE. The specific morbidity of this surgical procedure remained low compared with the overall morbidity in cases of extensive surgery.

Collateral damage of COVID-19 pandemic: The impact on a gynecologic surgery department.

OBJECTIVE: This study focuses on changes in gynecologic surgical activity at Hospital Foch, Paris, France during the first French COVID lockdown in 2020. Additional goals include the evaluation the extent of the postponement suffered for each type of surgery and estimate the possible negative impact for patients. STUDY DESIGN: Single-center, retrospective, chart-review cohort study in the gynecology department of Hospital Foch. Comparison of all patients scheduled, postponed and operated during the first COVID lockdown (March 14, to May 11, 2020) versus the same period in 2019. Postponed surgeries were classified into 4 scheduling interval categories according to the Society of Gynecology Oncology (SGO) recommendations: urgent (without delay), semi-urgent (1-4 weeks), non-urgent (>4-12 weeks) and elective (>3 months) and evaluated to determine whether COVID-19-related delays of surgeries fell within guidelines. The potential "loss of chance" or medical risk associated with postponed surgeries was estimated according to a composite criterion including death, aggravation of expected tumor stages/grades in cancers, increase in surgical complexity compared to that initially planned, need for preoperative transfusions, start of morphine consumption during preoperative treatment for opiate-naive patients, additional hospitalization or consultations in emergency room and delay in treatment when surgery was urgent. RESULTS: During the 2020 French COVID lockdown, 61 patients had a surgical procedure and 114 were postponed; in the comparator 2019 group, 232 patients underwent surgical procedures, indicating an overall decrease of 65% of activity. Analysis of differences between the two years revealed a reduction of 64% in emergency procedures, 90% of functional pathologies, and 13% of cancers. According to SGO guidelines, the only type of surgical procedures that had excessive delay was the semi-urgent group, where time to surgery was 6.7 weeks [range 5.4-10 weeks] instead of the recommended interval of 1-4 weeks. Among postponed surgeries there were 10 patients (8.7%) with a potential "loss of chance" according to the composite criteria, all included in the semi-urgent group. CONCLUSION: The COVID 19 pandemic was responsible for a significant decrease of activity in the surgical department of Hospital Foch. Difficulty of rescheduling surgeries was responsible for an increased delay in semi-urgent operations. In almost 9% of postponed surgeries, there was a potential "loss of chance", which likely represents only the tip of iceberg of collateral damages due to COVID 19 pandemic in this surgical unit. These data show the importance of continuing to treat pathologies requiring urgent or semi-urgent surgery during pandemics.

Case Report: Post-Partum SARS-CoV-2 Infection After the First French Uterus Transplantation.

Absolute uterus factor infertility, whether congenital or acquired, renders the woman unable to carry a child. Although uterus transplantation (UTx) is being increasingly performed as a non-vital procedure to address this unfortunate condition, the immunosuppression required presents risks that are further compounded by pregnancy and during the puerperium period. These vulnerabilities require avoidance of SARS-CoV-2 infection in pregnant UTx recipients especially during the third trimester, as accumulating evidence reveals increased risks of morbidity and mortality. Here we describe a successful UTx case with delivery of a healthy child, but in which both mother and neonate developed asymptomatic SARS-CoV-2 infection seven days after RNA vaccination, on day 35 post-partum. Although the patient was successfully treated with a combination therapy comprised of two monoclonal antibodies, this case highlights the challenges associated with performing UTx in the era of Covid-19. More broadly, the risks of performing non-vital organ transplantation during a pandemic should be discussed among team members and prospective patients, weighing the risks against the benefits in improving the quality of life, which were considerable for our patient who achieved motherhood with the birth of a healthy child.

Is the implantation of an artificial urinary sphincter with a large cuff in women with severe urinary incontinence associated with worse perioperative complications and functional outcomes than usual?

INTRODUCTION AND HYPOTHESIS: As the subsequent risks of complications and explantation increase with the size of the cuff, we aimed to assess functional outcomes after the implantation of an artificial urinary sphincter (AUS) with a large cuff (≥8 cm) in women with severe urinary incontinence. METHODS: Fifty women underwent an AUS placement with a large cuff between 1984 and 2007. Forty-three (86%) had previously undergone anti-incontinence procedures. The AUS was implanted with an open surgical technique using a transverse abdominal approach. The cuff was placed around the bladder neck between the periurethral fascia and the vagina. Perioperative complications were reviewed. To assess the resolution of urinary incontinence, all patients were seen at 1, 3, 6 and 12 months and yearly thereafter. RESULTS: The mean age was 59 ± 12.4 years (26-81). The mean BMI was 27.3 ± 5.1 (19-37). The mean pre-operative closure pressure was 19.1 ± 9.4 cmH(2)O (3-46). The mean hospital stay was 14.1 ± 5 days (5-28). The mean follow-up was 8 ± 5.6 years. Incontinence was completely resolved in 34 women (68%). The protective factors to avoid explantation were a number of gestations less than two (p = 0.04), a closure pressure higher than 19 cmH(2)O (p = 0.04) and a cuff size equivalent to 8 cm (p = 0.005). CONCLUSIONS: Specific anatomical conditions can sometimes lead to AUS implantation with a large cuff with encouraging outcomes. Thus, surgeons should not be reluctant to place a large cuff when the situation requires it.

Managing a Department of Obstetrics and Gynecology in Times of COVID-19 Outbreak: The Foch Hospital Experience.

Departments of Gynecology and Obstetrics, as other departments, were faced with a major challenge at the outbreak of the COVID-19 pandemic. Fast restructuring was necessary in order to provide the means for COVID-related care. In this article we share our 1-year experience in reshaping our activities, managing healthcare workers and securing a pathway for pregnant patients, including potential, and confirmed COVID-19 cases. Priorities were set on ensuring patients' and healthcare workers' safety. Key containment measures included facemasks, systematic screening, dedicated spaces for COVID-19 cases with reinforced measures and vaccination campaign.

Risks factors FOR wound complications after cesarean section.

OBJECTIVE: The primary outcome was to determine risks factors for wound complications after cesarean section. Secondary outcome was the management of these complications. STUDY DESIGN: We performed a retrospective cohort study of consecutive cesarean deliveries performed at a secondary care facility between June 2017 and June 2019. Composite wound complications included infection, disruption and fluid collection occurring 30 days post-operatively. Medical records were reviewed and data including patient demographics, comorbidities, intra-partum characteristics were evaluated as potential risk factors for wound complications using multivariate logistic regression. Secondarily, post-operative management of wound complications was described. RESULTS: Among 1520 patients undergoing cesarean section during the period of study, 67 developed wound complications (4.4 %). Mean Duration of local wound care was 41.35 days (2-95). Mean number of wound care related visits in our hospital was 4.85(1-11). Multivariate logistic regression analysis showed 2 significant independant risk factors: preeclampsia with OR 5.60, 95 % CI 2.83, 11.11 (p:<0.001), and premature rupture of the membranes with OR 9.76, 95 % CI 2.13, 44.77 (p: 0.003). CONCLUSION: Preeclampsia and premature rupture of the membrane were independent risk factors for wound complications after cesarean section. Information regarding higher rates of wound complications and preventive measures should be provided to high-risk women prior to surgery.

Robotic Hysterectomy for Benign Indications: What Have We Learned from a Decade?

BACKGROUND AND OBJECTIVES: Robotic surgery data need a setback on many years of practice with high-volume surgeons to evaluate its real value. Our main objective was to study the impact of a decade of robotic surgery on minimally-invasive hysterectomies for benign indications. Our secondary objectives were to evaluate our results for high-volume surgeons and complex cases. METHODS: In this retrospective cohort study, we reviewed medical records at Foch Hospital, from 2010 to 2019, to evaluate the outcomes of robotic hysterectomies for benign disease. We compared the trends of benign hysterectomies done by laparoscopy and laparotomy during this period. We analyzed the proficiency group (≥ 75 cases per surgeon) and complex cases including obese patients and large uteri (>250 g). RESULTS: 495 hysterectomies were performed by robotic, 275 by laparotomy, and 130 by laparoscopy. The laparotomy approach decreased from 62% to 29%, whereas the robotic approach increased from 26% to 61%. The operating room (OR) time decreased in the proficiency group (157.3 ± 43.32 versus 178.6 ± 48.05, P = 0.005); whereas the uterine weight was higher (194.6 ± 158.6 versus 161.3 ± 139.4, P = 0.04). Lower EBL and shorter OR time were seen with uteri ≤ 250 g subgroup (64.24 ± 110.2 ml versus 116.63 ± 146.98 ml, P = 0.0004) (169.62 ± 47.50 min versus 192.44 ± 45.82 min, P = 0.0001). The estimated blood loss (EBL) was less in the BMI ≤ 30 subgroup (68.83 ± 119.24 ml versus 124.53 ± 186.14 ml, P = 0.0005). CONCLUSION: A shift was observed between the laparotomy and robotic approaches. High-volume surgeons were more efficient and showed a decrease in OR time after 75 cases despite an increase in uterine weight.

Analysis of blood parameters and molecular endometrial markers during early reperfusion in two ovine models of uterus transplantation.

The dissection of the veins is the trickiest step of Uterine transplantation (UTx). Performing the anastomosis of a single uterine vein could bring a therapeutic benefit and simplification of surgery and serve for managing unilateral venous thromboses. The objectives of this project were to evaluate the expression of early markers of ischemia-reperfusion and to compare findings following one or two vein anastomoses. Orthotopic uterine auto-transplantations were performed on an ovine model with anastomosis of either two (group 1) or one utero-ovarian veins (group 2). Blood gases, histology and ischemia- reperfusion markers transcripts (PTGS2, IL6, IL8, SOD2, C3, BAX/BCL2 and TLR4) were analyzed as well as PTGS2 protein expression using Western Blot and fluorescence immunolocalization on endometrial biopsies after 3h of reperfusion. Ten ewes were included in the experimentation, 4 were in group1, 3 in group 2, the others being sham operated controls. No significant differences were observed between the two phenotypes. Based on these results, the anastomosis of one single uterine vein appears to be an approach consistent with short-term graft survival. Further experiments will be needed to confirm the reliability of this approach, especially the long-term follow-up of the uterine graft including its ability to support gestation to term.

Adapting surgical skills from robotic-assisted radical hysterectomy in cervical cancer to uterine transplantation: a look to an optimistic future!

Uterus transplantation (UTx) is the first treatment for absolute uterine factor infertility. The first birth after human UTx in Sweden occurred in 2014 and very favourable results of the Swedish trial performed with laparotomy raised great hope. Several teams are leading their own trial among the world, but UTx is still in its experimental phase. Surgical intervention needs to be optimized. The long surgical duration (> 10 h), vascular dissection and risks of ureteral damages for live donors are major drawbacks. Minimal invasive surgery by means of robotic-assisted laparoscopy for live donors could become an improved option. Our collaborative Swedish-French team has initiated efforts to introduce minimal invasive surgery in one trial in Sweden and one in France. UTx is somewhat similar to a radical colpohysterectomy for arterial dissection. We describe a robotic-assisted radical colpohysterectomy and its transposition to uterus retrieval in a living donor. We report our experience on nine cases that were completed prior to our French UTx robot-assisted trial.

Uterus Transplantation with Live Donors: Screening Candidates in One French Center.

We report our experience regarding the profile and screening process of potential recipients (R) and their live donors (D) in our Uterus transplantation (UTx) trial from 2014 to 2020. The initial screening was performed using medical questionnaires and consultations. The second step of the screening consisted of two individual interviews with an independent multidisciplinary committee. Then, a complete medical, biological and imaging assessment of the directed living D, the R, and her partner was performed over a two-day hospitalization. A total of 239 women contacted our department: 165 potentials R and 74 potentials D. During the first step of screening, 141 R and 45 D were excluded. Only 12 R/D pairs were pursued. During inclusion, 10 R/D pairs were excluded. One R/D pair is still under evaluation. Finally, only 1 R/D pair was definitively included (0.6%), which led us to perform the first French UTx in March 2019 with a successful graft. The primary limiting factors of inclusion were due to very strict criteria and difficulty of having a suitable directed living D. The International Society of UTx (ISUTx) guidelines based on worldwide results of trials can help ease our inclusion criteria in the future while remaining safe for patients.

Hyperthermic intraperitoneal chemotherapy in ovarian cancer: an update.

In the treatment of advanced-stage epithelial ovarian cancer (EOC)-associated surgery and chemotherapy with intravenous platinum/taxane-based therapy most patients had early or late recurrence. Prevention of progression and recurrence is a major objective for the management of EOC. Recently, many clinical studies have evaluated the strategy with hyperthermic intraoperative intraperitoneal (IP) drug delivery. This is an update of hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) in EOC and a view for future strategies. Until recently studies on HIPEC in patients with EOC were mostly retrospective and heterogeneous. Thanks to recent clinical trials, it is reasonable to conclude that surgical cytoreduction and HIPEC is an interesting approach in the management of EOC without increasing morbidity.

An update on preoperative assessment of the resectability of advanced ovarian cancer.

The best prognosis for advanced ovarian cancer is provided by no residual disease after primary cytoreductive surgery. It is thus important to be able to predict resectability that will result in complete cytoreduction, while avoiding unnecessary surgery that may leave residual disease. No single procedure appears to be sufficiently accurate and reliable to predict resectability. The process should include a preoperative workup based on clinical examination, biomarkers, especially tumor markers, and imaging, for which computed tomography, as well as sonography, magnetic resonance imaging and positron-emission tomography, can be used. This workup should provide sufficient information to determine whether complete cytoreduction is possible or if not, to propose neoadjuvant chemotherapy which is preferable in this case. For the remaining patients, laparoscopy is broadly recommended as an ultimate triage step. However, its modalities are still debated, and several scores have been proposed for standardization and improving accuracy. The risk of false negatives requires a final assessment of resectability as the first stage of cytoreductive surgery by laparotomy. Composite models, consisting of several criteria of workup and, sometimes, laparoscopy have been proposed to improve the accuracy of the predictive process. Regardless of the modality, the process appears to be accurate and reliable for predicting residual disease but less so for predicting complete cytoreduction and thus avoiding unnecessary surgery and an inappropriate treatment strategy. Overall, the proposed procedures are heterogeneous, sometimes unvalidated, or do not consider advances in surgery. Future techniques and/or models are still needed to improve the prediction of complete resectability.

Early Second-Look Hysteroscopy: Prevention and Treatment of Intrauterine Post-surgical Adhesions.

Introduction: Intra-uterine adhesion (IUA) is one of the main causes of secondary infertility. The aim of this study was to evaluate the prevalence of IUA developing in women undergoing hysteroscopic resection for submucous myomas, polyps, and intrauterine synechiae and test the efficacy of second look hysteroscopy for diagnosing and treating post-surgical adhesions. Materials and Methods: We retrospectively collected data from reproductive age women who had a second look office hysteroscopy following hysteroscopic resection for myoma, polyp, or IUA at Foch hospital (Suresnes, France) between 2009 and 2017. Results: Six hundred and twenty two reproductive-age women underwent hysteroscopic resection for myoma, polyp, and/or IUA. Among them, 155 women had a second look hysteroscopy. In this group, 29/155 (18.7%) had IUA formation: 17/83 (20.5%) women who underwent hysteroscopic myomectomy, 5/46 (10.9%) women who underwent hysteroscopic polypectomy, and 7/26 (26.9%) women who underwent hysteroscopic lysis of adhesions. These IUA have been lysed by the office hysteroscopy procedure in 16/29 (55.2%) patients: 11/17 (64.7%), 2/5 (40%), and 3/7 (42.9%) in women who underwent hysteroscopic myomectomy, polypectomy and lysis of adhesion, respectively. Conclusion: IUA is a common complication of hysteroscopic surgery. Second look office hysteroscopy is an easy and effective procedure for diagnosing and removing newly formed IUA. It should be recommended for all women undergoing hysteroscopic resection for myomas, polyps, or IUA.

Albumin liver dialysis as pregnancy-saving procedure in cholestatic liver disease and intractable pruritus.

Progressive familial intrahepatic cholestasis type 3 (PFIC3) is a rare cholestatic liver disease. Such liver disease can get worse by female hormone disorder. Albumin dialysis or Molecular Adsorbent Recirculating System (MARS) has been reported to reverse severe cholestasis-linked pruritus. Here, we report the first use of MARS during a spontaneous pregnancy and its successful outcome in a patient with PFIC3 and intractable pruritus. Albumin dialysis could be considered as a pregnancy-saving procedure in pregnant women with severe cholestasis and refractory pruritus.

Critical steps for initiating an animal uterine transplantation model in sheep: Experience from a case series.

BACKGROUND: Recent reports have demonstrated uterus transplantation as a relevant solution to treat absolute uterine infertility. Training on animal models is a prerequisite to set up a uterine transplantation program in humans. Sheep have been used as an optimal model for training and research as they display similar vessels size to human. While the ovine model might seem easy there are many difficulties in performing this complex surgery. In this study we describe through our experience the critical initial steps toward building a learning curve toward an optimal ovine uterine transplantation model. MATERIALS: We performed nine orthotopic uterine autotransplantations using end-to-side anastomoses to the external iliac vessels in sheep. We recorded the duration of all surgical steps and pointed out specific difficulties and solution found. RESULTS: We were able to perform optimal uterine dissection after the first 5 cases and optimal bilateral arterial and venous anastomoses, after 7 and 9 cases respectively. The main factors associated to success rate were optimal exposure, appropriate equipment, careful vessel preparation and modification of the anastomosis technique. CONCLUSION: As uterine transplantation research programs are expanding, setting up an ovine model to train and perform research is critical. Such model is complex and requires optimized multidisciplinary approach to build an efficient learning curve.