Experience, and gynaecological and reproductive health follow-up of young adult women who have undergone ovarian tissue cryopreservation.

RESEARCH QUESTION: What are the experience, and gynaecological and reproductive health outcomes in young adult women who have undergone ovarian tissue cryopreservation (OTC)? DESIGN: A retrospective observational study was conducted at a single institution between May 2019 and February 2021 including 87 women aged over 18 years undergoing OTC. Medical characteristics and questionnaire data collected more than 18 months after OTC were analysed. RESULTS: Close to 74% (n = 64/87) of women had a follow-up consultation and completed the questionnaire. Most women found the information provided on the OTC technique and the strategies proposed to restore fertility with ovarian tissue understandable and useful. The majority of patients thought that OTC had a positive impact on their well-being during disease treatment. Anti-Müllerian hormone serum concentration decreased significantly after treatment (P < 0.0001) and was significantly lower when patients received chemotherapy before OTC (P = 0.0039). The total cyclophosphamide equivalent dose was significantly higher in women with FSH concentrations above 25 IU/l after treatment (P = 0.0004). More than 70% of women who planned a pregnancy after the end of treatment succeeded, with a natural pregnancy rate close to 53%. Only nine patients (8.0%) underwent ovarian tissue transplantation for fertility restoration and six of them became pregnant and delivered at least once. CONCLUSION: Young adult women expressed a good satisfaction rate with OTC and that their experience had been beneficial. The usage rate of cryopreserved ovarian tissue remains low. The gynaecological and reproductive health follow-up consultation should be included in the supportive care provided following OTC.

Evolution of Bowel Complaints after Laparoscopic Endometriosis Surgery: A 1497 Women Comparative Study.

STUDY OBJECTIVE: To assess to what degree can digestive symptoms improve after endometriosis surgery for different localizations. DESIGN: A comparative retrospective study employing data prospectively recorded in the North-West Inter-Regional Female Cohort for Patients with Endometriosis (CIRENDO) from June 2009 to November 2018. SETTING: Two referral centers. PATIENTS: A total of 1497 women undergoing surgery because of pelvic endometriosis were divided into 3 groups: superficial endometriosis (Group 1, n = 396), deep endometriosis sparing the bowel (Group 2, n = 337), and deep endometriosis involving the bowel (Group 3, n = 764). INTERVENTIONS: Surgery for endometriosis. MEASUREMENTS AND MAIN RESULTS: Preoperative and postoperative gastrointestinal symptoms were evaluated with standardized questionnaires, including the Gastrointestinal Quality of Life Index (GIQLI) and Knowles-Eccersley-Scott-Symptom questionnaire (KESS). The degree of postoperative improvement in digestive symptoms was compared between the groups. The women in Group 3 were significantly symptomatic in terms of cycle-related gastrointestinal symptoms and scores of standardized questionnaires GIQLI and KESS. According to the 1-year postoperative evaluation, women in Group 3 experienced the most significant improvement in their gastrointestinal symptoms. CONCLUSION: Women with severe bowel symptoms and deep endometriosis infiltrating the bowel should be informed about the high probability of symptom improvement after the removal of bowel nodules. Conversely, in women without deep endometriosis, postoperatively, there is less improvement in baseline digestive complaints.

Live surgery of colorectal endometriosis broadcasted from a surgeon's routine operating theater is not associated with higher complications rate.

INTRODUCTION: Although live surgeries are routinely included in surgical congress programs, they are the subject of an ongoing debate in terms of patient safety and teaching value. The goal of our study was to assess the risk of postoperative complications related to live surgery broadcast from the surgeon's routine theater, in patients managed for deep endometriosis infiltrating the digestive tract. MATERIAL AND METHODS: We report a retrospective comparative study, enrolling women managed for colorectal endometriosis by a gynecologic surgeon, from September 2013 to March 2020 in two referral centers. We compared the rate of postoperative bowel fistula in women managed during live surgery in the routine operating theater, with that observed in women for whom surgery was not broadcast. RESULTS: Among 813 women, 33 (4.1% of cases) underwent surgical procedures transmitted live to various conference rooms located outside the hospital and were compared with 780 patients who underwent non-broadcast surgery. Women's age, body mass index, past surgical and obstetrical history, and major preoperative complaints were comparable. Cases presented with impaired constipation score, more frequent sciatic pain, and infiltration of the vagina, whereas overall revised American Fertility Society classification scores were more severe in controls. The rate of rectal nodules over 3 cm in size was comparable between the two groups (72.7% in cases vs. 72.1% in controls). Operative time was also comparable (153 ± 52 minutes vs. 148 ± 79 minutes). Cases were more frequently managed by disk excision of rectal nodules (63.7% vs. 30.3%), and more frequently involved the sacral plexus (18.2% vs. 7.3%). Postoperative complications were comparable between the two groups, in terms of bowel fistula (3% in the live surgery group vs. 4.1% in controls), pelvic abscess requiring secondary laparoscopy (3% vs. 4.9%), or bladder dysfunction requiring self-catheterization after discharge (6.1% vs. 5.3%). CONCLUSIONS: Performing laparoscopic management of colorectal endometriosis with live transmission of surgery from a surgeon's routine operating theater, is not related to a higher risk of major postoperative complications.

Surgical Management by Disk Excision or Rectal Resection of Low Rectal Endometriosis and Risk of Low Anterior Resection Syndrome: A Retrospective Comparative Study.

STUDY OBJECTIVE: To assess the risk of low anterior resection syndrome (LARS) between women managed by either disk excision or rectal resection for low rectal endometriosis. DESIGN: Retrospective study of a prospective database. SETTING: University hospital. PATIENTS: One hundred seventy-two patients managed by disk excision or rectal resection for deep endometriosis infiltrating the rectum <7 cm from the anal verge. INTERVENTIONS: Rectal disk excision and/or segmental resection using transanal staplers. MEASUREMENTS AND MAIN RESULTS: One hundred eight patients (62.8%) were treated by disk excision (group D) and 64 (37.2%) by rectal resection (group R). All patients answered the LARS score questionnaire. Follow-up was 33.3 ± 22 months for group D (range 12-108 months) and 37.3 ± 22.1 months (range 12-96 months) for group R (p = .25). The rates of rectovaginal fistula and pelvis abscess requiring radiologic drainage and surgery in the D and R groups were, respectively, 7.4% and 8.3% vs 7.8% and 9.3%. The rate of women with normal bowel movements postoperatively was higher in group D (61.1% vs 42.8%, p = .05). Women enrolled in group R reported higher frequency of stools (p <.001), clustering of stools (p = .02), and fecal urgency (p = .05). Regression logistic model revealed 2 independent risk factors for minor/major LARS: performing low rectal resection (adjusted odds ratio 2.28; 95% confidence interval, 1.1-4.7) and presenting with bladder atony requiring self-catheterization beyond postoperative day 7 (adjusted odds ratio 2.52; 95% confidence interval, 1.1-5.8). CONCLUSION: The probability of normal bowel movements is higher after disk excision than after low rectal resection in women with deep endometriosis infiltrating the low rectum.

Recurrences and fertility after endometrioma ablation in women with and without colorectal endometriosis: a prospective cohort study.

STUDY QUESTION: What are the recurrence and pregnancy rates in women managed for ovarian endometrioma by ablation using plasma energy with and without associated surgery for colorectal endometriosis? SUMMARY ANSWER: Concomitant management of colorectal endometriosis does not impact either risk of recurrences or probability of pregnancy in women managed for endometrioma ablation using plasma energy. WHAT IS KNOWN ALREADY: No consensus exists on how best to manage patients presenting with ovarian endometriomas and colorectal endometriosis, in terms of impact on fertility preservation and recurrence rates. STUDY DESIGN, SIZE, DURATION: A prospective series of consecutive patients managed for ovarian endometriomas by ablation using plasma energy, over a period of 48 consecutive months. The study included patients with associated colorectal endometriosis (n = 52) and those who were free of colorectal localizations of the disease (n = 72). No women were lost to follow-up. PARTICIPANTS/MATERIALS, SETTING, METHODS: The 124 women included in this study were managed for either unilateral or bilateral ovarian endometriomas using plasma energy at a university tertiary care center. Recurrences and pregnancy rate were compared in patients with and without colorectal endometriosis. The minimum length of follow-up was 1 year. Cyst recurrences were assessed using pelvic ultrasound and magnetic resonance imaging. Kaplan-Meier and actuarial life-table analysis were used to estimate the recurrence-free survival curve and the probability of pregnancy. The Cox model was used to assess independent predictive factors for recurrences. Pregnancy likelihood and independent predictors were estimated using a regression logistic model. MAIN RESULTS AND THE ROLE OF CHANCE: Mean follow-up was 32 ± 18 months. Forty-eight patients (40.3%) were presumed infertile and attended an assisted reproductive techniques (ART) center. Eighteen patients presented with a recurrence (14.5%). Bilateral localization of endometriomas was the only factor independently related to an increased risk of recurrences [hazard ratio 3.3, 95% confidence interval (CI) 1.2-9.4]. Of the 83 women wishing to conceive (66.9%), 51 became pregnant (61.4%) and 33 of these pregnancies were spontaneous (64.7%). The rates of pregnancy were 65.8% for the group of patients with associated colorectal endometriosis and 57.8% for controls (P = 0.50). Age over 35 years was the only independent factor for which association with pregnancy rates approached the significance threshold (adjusted odds ratio 0.35, 95% CI 0.12-1, P = 0.06). LIMITATIONS, REASONS FOR CAUTION: The study sample size may be insufficient to reveal statistically significant differences related to risk factors which have low impact on the probability of recurrence and pregnancy. Data on ovarian reserve before and after the procedure was not available in all patients, which would have added to our results and the discussion about treatment of endometrioma in general. WIDER IMPLICATIONS OF THE FINDINGS: Concomitant management of colorectal endometriosis does not impact either risk of recurrences or the probability of pregnancy in women having benefited from ovarian endometrioma ablation using plasma energy. Moreover, surgical management of colorectal and ovarian endometriosis may allow spontaneous conception in one out of three patients, thus reducing expenses related to ART management. STUDY FUNDING/COMPETING INTERESTS: No financial support was received for this study. Horace Roman reports personal fees for participating in a symposium and masterclass presenting his experience in the use of PlasmaJet.

Neonatal outcome of very preterm twins: policy of planned vaginal or cesarean delivery.

OBJECTIVE: The objective of the study was to compare neonatal mortality and morbidity in very preterm twins with the first twin in cephalic presentation in hospitals with a policy of planned vaginal delivery (PVD) and those with a policy of planned cesarean delivery (PCD). STUDY DESIGN: Women with preterm cephalic first twins delivered after preterm labor and/or premature preterm rupture of membranes from 26(0/7) to 31(6/7) weeks of gestation were identified from the databases of 6 perinatal centers and classified as PVD or PCD according to the center's management policy from 1999 to 2010. Severe neonatal morbidity was defined as any of the following: intraventricular hemorrhage grades 3-4, periventricular leukomalacia, necrotizing enterocolitis, bronchopulmonary dysplasia, and hospital death. The independent effect of the planned mode of delivery, defined by the center's management policy, was tested and quantified with a 2-level multivariable logistic regression. RESULTS: The PVD group included 248 women, and the PCD group 63. Maternal characteristics did not differ between the 2 groups. The rate of vaginal delivery was 85.9% (213 of 248) vs 20.6% (13 of 63) (P < .001), and the rate of cesarean delivery for the second twin was 1.6% (4 of 248) vs 4.8% (3 of 63) (P = .13) for PVD and PCD. PVD had no independent effect on either newborn hospital mortality or severe neonatal composite morbidity. CONCLUSION: A policy of planned vaginal delivery of very preterm twins with the first twin in cephalic presentation does not increase either severe neonatal morbidity or mortality.

Full-Thickness Disc Excision in Deep Endometriotic Nodules of the Rectum: A Prospective Cohort.

BACKGROUND: To date, a majority of patients presenting with large endometriosis of the rectum are managed worldwide by colorectal resection. However, postoperative rectal function may be impacted by radical rectal surgery. OBJECTIVE: The purpose of this study was to assess the postoperative outcomes of patients with rectal endometriosis who are managed by full-thickness disc excision and to compare outcomes of the 2 procedures using a transanal approach. DESIGN: This was a prospective study. SETTINGS: The study was conducted at a university hospital. PATIENTS: Fifty patients with colorectal endometriosis that was managed by disc excision between June 2009 and November 2014 were included in the study. INTERVENTIONS: The procedure included laparoscopic deep shaving, followed by full-thickness disc excision to remove the shaved rectal area. Disc excision was performed using a semicircular transanal stapler (the Rouen technique) in 20 patients, an end-to-end anastomosis circular transanal stapler in 28 patients, and transvaginal excision in 2 patients. MAIN OUTCOMES MEASURES: Preoperative and postoperative assessments of pelvic symptoms and digestive function using standardized gastrointestinal questionnaires were the main measures. RESULTS: The largest diameter of specimens achieved was significantly higher using the Rouen technique (58 ± 9 mm) than the end-to-end anastomosis stapler (34 ± 6 mm). Two rectovaginal fistulas were recorded (4%), and 8 patients presented with transitory bladder voiding (16%). Median postoperative values for the Gastrointestinal Quality of Life Index and the Knowles-Eccersley-Scott-Symptom Questionnaire improved progressively 1 and 3 years after surgery. For patients intending to get pregnant, the cumulative pregnancy rate was 80%, and 63% of pregnancies were spontaneous. LIMITATIONS: The study sample size is small and the design is not comparative; however, direct comparison of patients managed by disc excision and colorectal resection would be inappropriate, because of differences regarding nodule localization and size. CONCLUSIONS: Disc excision is a valuable alternative to colorectal resection in selected patients presenting with rectal endometriosis, achieving better preservation of rectal function. The Rouen technique allows for successful removal of large nodules of the low and midrectum, with favorable postoperative outcomes. (See video abstract, http://links.lww.com/DCR/A208.).

School-age outcomes following a randomized controlled trial of magnesium sulfate for neuroprotection of preterm infants.

In a French randomized trial, children at school-age demonstrated no evidence of harm from fetal exposure to MgSO4 before very preterm birth. Motor dysfunction/death, qualitative behavioral disorders, cognitive difficulties, school grade repetition, and education services were decreased in the children exposed to MgSO4, although the differences were not significant.

Bowel dysfunction before and after surgery for endometriosis.

The relationship between deep fibrotic endometriosis of the rectum and digestive symptoms as well as the impact of surgical treatment on digestive complaints appears increasingly complex. With the exception of cases in which the disease leads to rectal stenosis, it seems likely that certain digestive symptoms are a result of cyclic inflammatory phenomena leading to irritation of the digestive tract and not necessarily the result of actual involvement of the rectum by the disease itself because they frequently occur in women free of rectal nodules. Functional or inflammatory bowel diseases and rectal hypersensitivity may be associated with pelvic endometriosis and consequently joepardize the hypothetical causal relationship between the presence of a rectal nodule and digestive complaints. Women treated surgically for rectal endometriosis may continue to experience postoperative digestive complaints, such as constipation. Despite successful surgery free of intra- and postoperative complications and significant improvement in well-being and pelvic pain, several unpleasant digestive symptoms may be incompletely cured by the surgery. Furthermore, de novo postoperative digestive complaints may occur after rectal surgery. Retrospective data suggest that performing colorectal resection is related to less favorable digestive functional outcomes than the use of conservative procedures such as shaving or full-thickness disc excision. These hypotheses need to be confirmed by prospective randomized trials comparing rectal radical and conservative approaches. Bearing in mind the complex relationship between rectal nodules, digestive symptoms and rectal surgery, particular care must be taken in the preoperative assessment of digestive function and in choosing the most suitable surgical procedure.

Postoperative recurrence and fertility after endometrioma ablation using plasma energy: retrospective assessment of a 3-year experience.

STUDY OBJECTIVE: To assess recurrence and pregnancy rates in women with ovarian endometrioma treated via ablation using plasma energy. DESIGN: Retrospective non-comparative pilot study including 55 patients treated during 28 months, with prospective recording of data (Canadian Task Force classification II-2). SETTING: Tertiary referral center. PATIENTS: Fifty-five consecutive women with pelvic endometriosis in whom ovarian endometriomas were managed solely via ablation using plasma energy. The minimum follow-up was 1 year. INTERVENTION: Endometrioma ablation using plasma energy. MEASUREMENTS AND MAIN RESULTS: Information was obtained from the database of the North-West Inter Regional Female Cohort for Patients with Endometriosis, based on self-questionnaires completed before surgery, surgical and histologic data, and systematic recording of recurrences, pregnancy, and symptoms. Recurrences were assessed using pelvic ultrasound examination. Mean (SD) follow-up was 20.6 (7.2) months (range, 12-39 months). In 75% of patients, deep infiltrating endometriosis was treated, and 40% had colorectal involvement. Preoperative infertility was recorded in 42% of patients. The rate of postoperative recurrence was 10.9% for the entire series. Of 33 women who wished to conceive, 67% became pregnant, spontaneously in 59%. Time from surgery to the first pregnancy was 7.6 (4.3) months. After discontinuation of postoperative hormone therapy, the probability of not conceiving at 12 months was 0.36 (95% confidence interval, 0.19-0.53), and at 24 months was 0.27 (95% confidence interval, 0.12-0.44). CONCLUSIONS: Recurrence and pregnancy rates are encouraging in that they seem comparable to the best reported results after endometrioma cystectomy. Plasma energy may have an important role in the management of ovarian endometrioma in women seeking to conceive. Patients most in need of surgical procedures that can spare ovarian parenchyma, such as those with bilateral endometriomas or a history of ovarian surgery, may particularly benefit from ablation using plasma energy.

Combined transanal and laparoscopic approach for the treatment of deep endometriosis infiltrating the rectum.

BACKGROUND: Two surgical approaches are employed in the treatment of deep infiltrating endometriosis of the rectum (DIER): colorectal resection and nodule excision. In 2009, we introduced a new technique for transanal full thickness disc excision of endometriotic nodules infiltrating the low and middle rectum, using the Contour® Transtar™ stapler (Ethicon Endo-Surgery inc., Cincinnati, OH, USA). The aim of this retrospective study was to describe the technique and to present data on the feasibility of this technique. METHODS: From April 2009 to October 2010, all patients presenting with DIER and undergoing full thickness excision using the Contour® Transtar™ stapler were enrolled in the study. Pre-, intra- and post-operative data were collected and reported. RESULTS: Six nulliparous women were managed using this technique during the study period. The rectal wall discs removed measured from 40 × 45 to 60 × 50 mm. In two cases, microscopic foci were noted on one of the margins but in four cases the limits were clear. Operating time varied from 180 to 450 min. Four women were completely free of post-operative digestive complaints. CONCLUSIONS: Despite the small numbers in this series, our data suggest that the new technique of transanal rectal disc excision using the contour stapler may be applied in patients with infiltrating endometrial nodules of the rectum up to 10 cm from the anal margin and up to 5 cm in diameter. This new procedure promises to be a useful addition to the surgeon's armamentarium in a multidisciplinary approach to deep pelvic endometriosis.

Prophylactic attempt at manual rotation in brow presentation at full dilatation.

We report our management of brow presentation at full dilatation by a prophylactic attempt at manual rotation or immediate cesarean delivery, depending on practitioner training. During the study period, 49 women with brow presentation were collected for an overall 30 452 deliveries (1/621) and 22 (44.9%) of them were diagnosed at full dilatation. For the latter, an attempt at manual rotation was performed in 13 cases (59.1%) with no particular maternal or neonatal complications reported and vaginal delivery occurred in 10 (76.9%). Maternal and neonatal outcomes were similar between women with immediate cesarean section or prophylactic manual rotation, except for a shorter duration of hospitalization in the group with attempted manual rotation (p < 0.01). Prophylactic attempted manual rotation in brow presentation diagnosed at full dilatation may be associated with a high rate of vaginal delivery with no specific maternal or neonatal complications.

Influence of gestational age on fibrinolysis from birth to postnatal day 10.

OBJECTIVE: To compare components of the fibrinolytic cascade in newborns of gestational age ranging from extreme prematurity to full term, at birth and for the next 10 days, and in their mothers at delivery. STUDY DESIGN: We studied 10 extremely preterm neonates, 10 very preterm neonates, 10 moderately preterm neonates, 10 full-term neonates, and their mothers (n = 40). We measured the antigen levels of tissue-type plasminogen activator (t-PA), plasminogen activator inhibitors 1 (PAI-1) and 2 (PAI-2), and thrombin-activatable fibrinolysis inhibitor, as well as PAI-1 activity, in neonates at birth and on postnatal days 3 and 10 and in mothers at delivery. RESULTS: On day 10, both PAI-1 antigen and activity were higher in extremely preterm neonates than in full-term neonates (P = .004 and <.0006, respectively), and the t-PA/PAI-1 activity ratio was lower in the extremely preterm and very preterm neonates compared with the full-term neonates (P = .002 and .017, respectively). No significant differences in the fibrinolytic system components were seen among the 4 groups of mothers. CONCLUSIONS: The development of fibrinolysis suppression in extremely preterm infants within 10 days after birth may contribute to the increased risk of periventricular hemorrhagic infarction in these infants.

Surgical management of deep infiltrating endometriosis of the rectum: pleading for a symptom-guided approach.

Two surgical approaches are usually employed in the treatment of deep infiltrating endometriosis of the rectum (DIER): colorectal resection removing the rectal segment affected by the disease, and nodule excision either without opening the rectum (shaving) or by removing the nodule along with the surrounding rectal wall (full thickness or disc excision). Although the present available data are from retrospective series reported by surgeons who generally perform only one technique, there is no evidence to support the risk of recurrences as a valid argument in favour of colorectal resection over rectal nodule excision. The advantage of a lower morbidity associated with nodule excision is not necessarily at the cost of an increased rate of pain recurrences, especially in women benefiting from post-operative medical treatment. The symptom-guided surgical approach in DIER primarily focuses on the relief of digestive symptoms and pelvic pains, rather than on mandatory 'carcinologic' resection of lesions. In addition, the risk of new post-operative unpleasant symptoms as a result of a compulsory and systematic excision of all endometriotic foci may be avoided. In a majority of cases, pelvic anatomy and digestive function can be restored by shaving or disc excision, as well as by colorectal resection; thus digestive complaints can be resolved even when the rectum is conserved. The most accurate evaluation of the results of DIER surgery should be provided by post-operative evolution in digestive function. Even though quality of life is improved for the majority of patients managed by colorectal resection, the question is whether or not a greater health improvement can be achieved by performing nodule excision, which avoids various post-operative and functional digestive complications. In addition, continuous medical treatment leads to a decrease in endometriotic nodules and prevents post-operative pain recurrences. Instead of choosing between medical and surgical management in the treatment of DIER, it is most likely that the two therapies should be associated.

Transvaginal mesh repair of pelvic organ prolapse by the transobturator-infracoccygeal hammock technique: long-term anatomical and functional outcomes.

AIMS: To evaluate long-term anatomical and functional outcomes of the transobturator-infracoccygeal hammock repair for complex genital prolapse with a porcine collagen-coated polypropylene mesh. METHODS: A prospective observational study comparing pre- and postoperative outcomes, using pelvic organ prolapse quantification (POP-Q) measurements, pelvic floor distress inventory (PFDI), and pelvic floor impact questionnaire (PFIQ) scores. RESULTS: One hundred fourteen women with recurrent, advanced, or posthysterectomy genital prolapse were enrolled. During follow-up (median value 57 months), 101 patients were available for assessment. Overall anatomical success rate was 96%, with significant improvement in quality-of-life. Three patients experienced symptomatic recurrent posterior prolapse. Seven had persistent stress urinary incontinence. Mesh exposure occurred in 6.9% of cases, including an infected hematoma that required partial excision of the mesh. No severe adverse event or change in sexual function was observed. CONCLUSIONS: The transobturator-infracoccygeal hammock is well tolerated with effective long-term anatomical and functional results for complex genital prolapse. In our experience and compared to the data of the literature, the use of collagen-coated versus uncoated polypropylene meshes seems to decrease local morbidity.

Long-term psychological impact of severe postpartum hemorrhage.

OBJECTIVE: To estimate the long-term psychological impact of severe postpartum hemorrhage in women whose uterus was preserved. DESIGN: Retrospective study. SETTING: University-affiliated tertiary referral center. POPULATION: All consecutive women who underwent embolization for postpartum hemorrhage between 1994 and 2007 and whose uterus was preserved were included. METHODS: Data were retrieved from medical files and semi-structured telephone interviews. In semi-structured interviews, women were asked about their perceptions and memories of the experience. MAIN OUTCOME MEASURES: Perceptions and memories of the postpartum hemorrhage during and after delivery. RESULTS: Follow-up was successful for 68 of the 91 (74.7%) women included. Of the 46 (67.6%) who reported negative memories of the delivery and postpartum period, the main memory for 24 was a fear of dying (35.3%). Of the 28 (41.2%) who reported continued repercussions, 16 (23.5%) thought about this delivery and its complications at least once a month, five (7.3%) reported persistent fear of dying, four (5.9%) reported sexual problems, and three (4.4%) women considered that the event was, at least in part, responsible for their subsequent divorce. Of the 15 women who had a subsequent full-term pregnancy, nine (60%) reported intense anxiety throughout the pregnancy, and one (6.7%) developed depression requiring antidepressant treatment during pregnancy. CONCLUSIONS: Severe postpartum hemorrhage may have a long-term psychological impact on women despite uterine preservation.

Outcomes of surgical management of deep infiltrating endometriosis of the ureter and urinary bladder.

OBJECTIVES: To report the outcomes of surgical management of urinary tract endometriosis and discuss the choice between conservative and radical surgery. MATERIALS AND METHODS: We reviewed data concerning women managed for ureteral or bladder deep infiltrating endometriosis in 5 surgical departments participating in the CIRENDO prospective database. Preoperative data, surgical procedure data, and postoperative outcomes were analyzed. RESULTS: Data from 30 women pooled in the database showed 15 women presenting with ureteral endometriosis, 14 women with bladder nodules, and 1 with both types of lesions. Ureterolysis was performed in 14 cases; the ureter was satisfactorily freed in 10 of these. In 4 women over 40 years old, who were undergoing definitive amenorrhea, moderate postoperative ureteral stenosis was tolerated and later improved in 3 cases, while the fourth underwent secondary ureteral resection and ureterocystoneostomy. Primary ureterectomy was carried out in 4 women. Two cases of intrinsic ureteral endometriosis were found in 5 ureter specimens. Four complications were related to surgical procedures on ureteral nodules, and 2 complications followed the removal of bladder endometriosis. Delayed postoperative outcomes were favorable with a significant improvement in painful symptoms and an absence of unpleasant urinary complaints, except for one patient with prolonged bladder denervation. CONCLUSION: Conservative surgery, in association with postoperative amenorrhea, can be proposed in a majority of cases of urinary tract endometriosis. Although the outcomes are generally favorable, the risk of postoperative complications should not be overlooked, as surgery tends to be performed in conjunction with other complex procedures such as colorectal surgery.

Direct proportional relationship between endometrioma size and ovarian parenchyma inadvertently removed during cystectomy, and its implication on the management of enlarged endometriomas.

BACKGROUND: The aim of this study was to estimate whether or not the size of an endometrioma is related to the thickness of the ovarian parenchyma inadvertently excised along with the cyst wall. METHODS: We performed a retrospective study including 35 women who had undergone endometrioma cystectomy, using an ovarian tissue sparing procedure. In total 38 specimens were studied by three pathologists as three women presented bilateral localizations, and all cyst diameters measured at least 30 mm. For each endometrioma, serial sections were performed, and on each section four different sites were randomly chosen to measure the thickness of glandular epithelium and stroma, of subjacent fibrosis, depending on the cyst, and of the ovarian parenchyma removed with the cyst. The diameter of the ovary was measured preoperatively either by MRI or ultrasound, and the area of the internal wall was then calculated. The relationships between the mean thickness of ovarian parenchyma removed and the variables were estimated and a multiple regression model identified independent predictors for ovarian parenchyma thickness. RESULTS: Adjacent ovarian tissue was found in 37 cases (97%). The mean thickness of ovarian tissue removed was 1173 +/- 711 microm and that of the cyst wall was 851 +/- 499 microm. The thickness of the ovarian parenchyma removed presented a direct proportional relationship with cyst diameter (P = 0.015), and consequently with cyst wall area (P = 0.032). This relationship with cyst diameter was independent after adjustment on other variables (P = 0.032). CONCLUSION: Endometrioma cystectomy even though performed with an accurate surgical technique leads to significant ovarian tissue removal, the thickness of which increases proportionally with cyst diameter.