[Sentinel node identification in breast cancer: logistic aspects]. / Identification du ganglion sentinelle dans le cancer du sein : aspects logistiques.

Sentinel node identification has gained its place in early breast cancer surgical management before the results of prospective randomized trials. Published results can be explained by teams configurations and technical aspects can create some confusion in results analysis. Logistic aspects confers a specificity for each team. Sentinel node technique should be reserved to experienced treatment center where it can be utilized routinely.

[Syphilis and pregnancy]. / Syphilis au cours de la grossesse.

Consequences of syphilis for mother, pregnancy, fetus and child are considerable, but preventable. Serological screening must be offered at the first prenatal visit, using both a treponemal (eg. TPHA) and a non treponemal (eg. VDRL or RPR) test. When the results are compatible with any type of active syphilis, treatment is required. The treatment of choice is penicillin: benzathine penicillin G, 2.4 million units intramuscular, repeated one week later, and most authors recommend a third dose if a late latent syphilis is suspected, or in case of coinfection with HIV. Women with a proven penicillin allergy can be desensitized. Alternative therapies, such as macrolids, are less well evaluated. Follow-up during and after therapy must not be neglected. In case of Jarisch-Herxheimer reaction, the mother should be managed on an inpatient basis, and the fetus carefully monitored. The VDRL should be repeated (usually every trimester), and therapy be renewed if there is not a significant decrease in titer. The fetus should be followed by serial ultrasound examinations. Finally, the child must be followed up clinically and biologically, and treated in case of congenital syphilis. The residual risk of adverse outcome is increased in case of reinfection, lack of maternal therapy or incomplete treatment, or when diagnosis and therapy are performed late in pregnancy.

[Breast-conserving therapy in breast cancer]. / Nouvelles approches du traitement conservateur du cancer du sein.

The combination of lumpectomy, axillary node treatment and radiotherapy of the breast is the base of breast-conserving therapy. This combination of surgery and radiotherapy is now accepted as a standard treatment option for unifocal, non inflammatory lesion less than 3 cm. The widespread use of mammography to detect infraclinic breast carcinoma leads to a significant increase in the proportion of breast conserving treatment. Neoadjuvant therapeutics (chemotherapy, radiotherapy and hormonotherapy) can extend the standard indication to breast carcinoma larger than 3 cm. The standard definition is also modified by sentinel node biopsy, oncoplastic techniques and stereotactic surgery with satisfactory cosmetic results. The risk of local recurrence, particularly the margins, must be evaluated whatever the surgical treatment optimizing oncologic management.

Differences in postpartum morbidity in women who are infected with the human immunodeficiency virus after elective cesarean delivery, emergency cesarean delivery, or vaginal delivery.

OBJECTIVE: The aim of this study was to assess the impact of elective cesarean delivery on postpartum morbidity in women who are infected with the human immunodeficiency virus (HIV). STUDY DESIGN: We performed a retrospective study of 401 women who were infected with HIV who were delivered in a single reference center from 1989 through 1999. Women who had cesarean deliveries (n = 201), of which 109 were elective and 92 were emergency, were compared with a group of women who were delivered vaginally (n = 200), composed of the women who were infected with HIV preceding each cesarean delivery. RESULTS: One or more serious complications occurred after 12% of emergency cesarean deliveries, after 6.4% of elective cesarean deliveries, and after 4% of vaginal deliveries (P =.04). In a multivariate analysis, which was adjusted for maternal CD4 lymphocyte count and antepartum hemorrhage, the relative risk of any postpartum complication (serious or minor) was increased by 1.85 (range, 1.00-3.39) after elective cesarean delivery and 4.17 (range, 2.32-7.49) after emergency cesarean delivery, compared with vaginal deliveries (P =.0001). CONCLUSION: Postpartum morbidity in women who are infected with HIV was highest after emergency, rather than elective, cesarean deliveries.

The suburethral sling for female stress urinary incontinence: a retropubic or obturator approach?

STUDY OBJECTIVE: To evaluate the feasibility and safety of the obturator approach for placement of a vaginal suburethral sling indicated for women with stress urinary incontinence. DESIGN: Retrospective cohort analysis (Canadian Task Force classification IV). SETTING: University teaching hospital. PATIENTS: Forty-nine women suffering from stress incontinence. INTERVENTION: Analysis of the suburethral sling according to surgical approach during two consecutive periods: retropubic from January 1, 2001 through September 30, 2001, and obturator from October 1, 2001 through January 31, 2002. MEASUREMENTS AND MAIN RESULTS: During the study period, 25 patients underwent surgery with the retropubic approach and 24 with the obturator approach. The patient characteristics did not differ between the two groups. The obturator approach was feasible in all attempted procedures. The mean operative time was 46 minutes (range 20-90) for the retropubic approach compared with 32 minutes (range 15-50) for the obturator approach (p = .03). Two bladder injuries occurred with the former, none with the latter (although cystoscopy was not routinely performed) (p = .49). Similarly, significantly more patients in the retropubic approach group had difficulty with postoperative voiding compared with those in the obturator approach group (10 [40%] vs 2 [8%], p = .01). Only two patients, both in the retropubic group, had voiding difficulties for longer than 1 week. One month after surgery, continence results did not differ significantly between the two groups (p = .30). In the retropubic approach group, 20 (80%) of the women were cured, and substantial improvement was experienced by 5 (20%). In the obturator approach group, these figures were 20 (83%) and 3 (12.5%), respectively, with one surgical failure (4%). Those initial results were unchanged at last follow-up (mean follow-up was 13.7 +/- 3 months for the retropubic approach group and 7.2 +/- 2 months for the obturator approach group). CONCLUSION: The obturator approach for suburethral slings is feasible and safe and may limit both preoperative and postoperative complications. Our short-term continence results compare well with those achieved with the retropubic approach. A randomized study is now needed to compare these two approaches.