[The ESTHYME study. Women's satisfaction after hysteroscopic sterilization (Essure micro-insert). A retrospective multicenter survey]. / Etude ESTHYME. Stérilisation selon le procédé Essure : vécu des femmes. Enquête multicentrique rétrospective.

OBJECTIVE: To assess the satisfaction and recovery of women undergoing sterilization with a permanent birth control device (Essure micro-insert). PATIENTS AND METHODS: French multicenter survey carried out in 12 public and private hospitals. One thousand and thirty-two patients undergoing permanent hysteroscopic sterilization (Essure micro-insert) between 2002 and 2006 were enrolled. An anonymous satisfaction questionnaire was sent to all patients. Demographic data as well as the level of tolerance and acceptability of the procedure were analyzed. Seven hundred and two (68%) patients responded to the questionnaire. RESULTS: Forty-five percent of all procedures were done without anaesthesia, and 55% under local or general anaesthesia or neuroleptanalgesia. Mean age was 42 years. Sterilization was a personal decision in 62% of cases. Only one out of three women (33%) was informed of the law of sterilization's legalization. Patients came to know about this procedure by their gynecologist (74%), or by media (14%). Eighty-four percent of patients considered the level of tolerance during the procedure from no pain to moderate pain. The method without anesthaesia is described painless in 24% of cases when the surgeon has done more than 50 procedures versus 11% when he has done less than 50 (P = 0.012). Seventy-seven percent of patients were appreciative of following the procedure on the monitor screen. Patients returned to everyday life within 24 h in 90% of cases, whereas 24 h return to work was attained in 75%. The procedure without general anesthesia offered a quicker return to work (80% within 24 h) than the procedure carried out with general anesthesia (59%, P < 0.05). The memory of the procedure was described as "very good" to "acceptable" in 96% of cases. Most of the patients (98%) would recommend this procedure to their friends. DISCUSSION AND CONCLUSION: The results of this national survey confirm that hysteroscopic sterilization is associated with good overall satisfaction, because it is a fast, easy and safe method of permanent sterilization with good levels of tolerance and immediate recovery. The technique without anaesthesia is now recommended. Its tolerance is improved with surgeon's experience.

[Evolution of surgical operations for female stress urinary incontinence in Gynaecology departments of Parisian public hospitals between 2002 and 2004]. / Evolution des interventions chirurgicales pour incontinence urinaire d'effort chez la femme dans les services de chirurgie gynécologique de l'Assistance Publique des Hôpitaux de Paris entre 2002 et 2004.

OBJECTIVE: To appreciate the evolution of surgical operations for female stress urinary incontinence. PATIENTS AND METHODS: Sixteen gynaecology departments of Parisian public hospitals were surveyed by postal questionnaire about their surgical practice for the treatment of female stress urinary incontinence in two successive periods, between 1st September 2002 and 31st August 2003 inclusive, and between the 1st of September 2003 and the 31st of August 2004 inclusive. The number, the type of operation, the type of suburethral tapes and their surgical routes were detailed. RESULTS: The participation rate in the survey was 87.5%. Suburethral slings represent the technique of choice for stress urinary incontinence (505 [86.2%] in 2002-2003 and 468 [92.7%] in 2003-2004, P < 0.001). Other practices are exceptional. The transobturator approach has widely progressed between the two periods of the study (157 [31.1%] and 302 [64.5%], P < 0.001), and is more often performed than the ascending retropubic approach (245 [48.5%] in 2002-2003 and 117 [25.0%] in 2003-2004, P < 0.001). DISCUSSION AND CONCLUSION: Suburethral tape placement is nowadays the main surgical treatment for female stress urinary incontinence, in Gynaecology departments in Parisian public hospitals, in particular the transobturator approach.

[Young women with atypical endometrial hyperplasia or endometrial adenocarcinoma stage I: will conservative treatment allow pregnancy? Results of a French multicentric survey]. / Hyperplasies atypiques et carcinomes de l'endomètre de stade I chez la femme jeune désirant une grossesse: le traitement conservateur est-il envisageable? Résultats d'une étude multicentrique française.

OBJECTIVES: To analyse the carcinological and obstetrical results of young women with atypical endometrial hyperplasia or endometrial adenocarcinoma, treated in a conservative way to allow pregnancy. PATIENTS AND METHODS: A retrospective analysis of 13 cases (5 adenocarcinomas and 8 atypical hyperplasias) followed in 8 French centers between 1997 and 2004. RESULTS: After 4.6 months of conservative treatment, there were no residual lesions in 61.5% of the cases. Progestatives seem to be the most effective treatment. Tumoral regression makes it possible to plan a pregnancy, with childbirth in 25% of the cases. In these frequently infertile patients, all the techniques of assisted reproduction can be used. Recurrences are not rare after hormonal treatment (37.5%), so, total hysterectomy is justified after delivery. DISCUSSION AND CONCLUSION: Conservative treatment for young women with atypical endometrial hyperplasia or endometrial adenocarcinoma stage I can be considered in some cases to enable pregnancy.

[Assisted reproductive technologies after conservative management of borderline or invasive ovarian tumours]. / Assistance médicale à la procréation après traitement conservateur d'une tumeur de l'ovaire invasive ou à la limite de la malignité.

OBJECTIVE: Ovulation induction, the usual resort of Assisted Reproductive Technologies (ART), has been suspected of carrying a responsibility in the genesis of ovarian tumours. For patients with a borderline or invasive ovarian tumour, treated by conservative surgery and desiring to become pregnant, the problem is thus of a possible resort to the Assisted Reproductive Technologies. PATIENTS AND METHODS: This is a multicenter, national and retrospective study. 40 operated patients between January 1971 and January 2001 have been included. 27 patients (67.5%) had a borderline tumour, 10 (25%) a non-epithelial tumour (germinal or stromal) and 3 (7.5%) an epithelial invasive carcinoma. All these patients have benefited from a conservative surgical management of fertility. The Assisted Reproductive Technologies were simple stimulation for 5 women and IVF for the 35 others. The effectiveness and the risks of Assisted Reproductive Technologies have been estimated respectively by the number of pregnancies obtained and the recurrence rates. RESULTS: With a global follow-up of 372 months (January 1971: date of the primary surgical procedure--June 2002: closing of the study), 17 patients have obtained 17 pregnancies with the Assisted Reproductive Technologies, rate of 42.5% (17/40): 1 spontaneous abortion, 16 delivery with 23 children (triple pregnancies and 3 twin pregnancies). 3 patients treated for a borderline tumour have had a recurrence after induction of ovulation. Among the 40 patients, no one presented an evolved disease at the last news. The patients who had a recurrence had a delay to begin the Assisted Reproductive Technologies significantly lower than the patients who had no recurrence. DISCUSSION AND CONCLUSION: The assisted reproductive technologies for patients who had been treated for a borderline or invasive ovarian tumour, and who were infertile in spite of conservative management, have allowed 42.5% of these women to obtain a pregnancy and does not seem to increase significantly the risk of recurrence.

[Diagnostic hysteroscopy and risk of peritoneal dissemination of tumor cells]. / Hystéroscopie diagnostique et risque de contamination péritonéale par les cellules tumorales.

Questions have been raised about the safety of diagnostic hysteroscopy preceding surgical treatment of endometrial carcinoma. Several studies showed that the risk of a positive cytology among patients presenting endometrial adenocarcinoma was increased after diagnostic hysteroscopy, suggesting a peritoneal dissemination of tumor cells due to the exploration. We studied this hypothesis on the basis of a systematic review of the scientific data. Five studies fulfilling inclusion criteria have been selected and have been introduced into a fixed model of meta-analysis. On a total of 756 studied patients, 79 presented a positive peritoneal cytology. The diagnostic hysteroscopy did not increase significantly the risk of abdominal dissemination of tumor cells, the peritoneal cytology being positive among 38 patients in the group having undergone this intervention vs 41 patients in the control group (OR = 1,64; 95% CI: 0,96-2,80). In conclusion, no formal evidence is currently available concerning the role of diagnostic hysteroscopy on the frequency of peritoneal dissemination of tumor cells, or on the vital prognosis of the patients presenting with endometrial carcinoma. From the data available, there is not any reason to avoid diagnostic hysteroscopy in the initial workup of endometrial cancer.

[Hysterectomies in patients with no history of vaginal delivery. A study of 243 cases]. / Les hystérectomies chez les patientes n'ayant jamais accouché par voie basse. Une étude de 243 cas.

OBJECTIVE: The object of this study was to audit the policy of hysterectomy in nulliparous women in a university hospital. PATIENTS AND METHODS: A retrospective medical records analysis of all hysterectomies performed during an 8-year period. Patients with no history of vaginal delivery were stratified into three groups: group 1, patients who underwent abdominal hysterectomies; group 2, patients undergoing vaginal hysterectomy (2a) or laparoscopy-assisted vaginal hysterectomy (2b). The groups were compared as to demographic data, surgical complications and outcomes. RESULTS: During the study period, there were 243 hysterectomies in patients with no history of vaginal delivery. Among these, vaginal hysterectomies (group 2) were undertaken in 75% (182 patients) and successfully performed in all but 13 patients (7.1%). Mean uterine weight was 943 grams in group 1 and 370 grams in group 2. Abdominal route (group 1) was associated with longer operative time (average: 105 min) than vaginal route (group 2a; 81 min) but shorter operative time that laparoscopy-assisted vaginal route (group 2b; 173 min). There was no significant difference in mean estimated blood loss and complications rates between groups 1 and 2. Hospital stay was shorter in group 2. Laparoscopic assistance was not associated with bigger uteri, neither with fewer complications. DISCUSSION AND CONCLUSION: Nulliparity should no longer be considered a contraindication to vaginal hysterectomy. In such patients, many more hysterectomies should be carried out vaginally and laparoscopic assistance does not offer obvious advantages over the standard vaginal approach.

[Update on medical treatment of female stress urinary incontinence]. / Traitement médical de l'incontinence urinaire d'effort: état de la situation.

A reasonable assumption is that incontinence would be relieved by increasing urethral resistance through stimulating alpha-adrenergic receptors in urethral smooth muscle. A review of available medical treatment of stress urinary incontinence is done. Alpha-receptor agonists are not in common use because of systemic side-effects. Estrogens do not seem to have beneficial effect on stress urinary incontinence. Currently, new molecules such as duloxetine, are uptake inhibitor of serotonin and noradrenaline could provide a noninvasive therapy for patients with urinary incontinence. Further studies to identify clinical applications are required.

[Conservative treatment of endometrial cancer and atypical hyperplasia]. / Traitement conservateur du cancer et des hyperplasies atypiques de l'endomètre.

Endometrial carcinoma is the most frequent pelvic cancer encountered in women. The discovery of an endometrial carcinoma in a woman seeking pregnancy cannot be considered as exceptional. The medical alternative to the classic radical surgical treatment is studied in a review. Treatment with progestins might be considered and discussed with the couple in special indications. The oncologic risk to which this treatment exposes is limited. However, the application and the surveillance of this therapeutic protocol must obey strict rules, in order to recognize without delay any resistance to treatment. The spontaneous fertility of such patients seems weak, most probably because of their age, but assisted reproductive techniques (ART) could be considered in particular cases. Secondary hysterectomy is controversial, but a recent tendency is to widen this practice is becoming apparent.

[Surgical management of rectovaginal septum endometriosis from a continuous series of 50 cases]. / Prise en charge chirurgicale des endométrioses de la cloison rectovaginale. A propos d'une série continue de 50 cas.

OBJECTIVES: To assess the value of MRI and ano-rectal endosonography (ARES) for the diagnosis and surgical prognosis of rectovaginal septum endometriosis and to analyse the surgical management in order to evaluate its functional results and complications. PATIENTS AND METHODS: Retrospective study of 50 consecutive patients operated for a clinical presumption of endometriosis nodule of the recto vaginal septum. Thirty-nine patients had a MRI, 31 an ARES and 28 both exams. All the patients had a complete dissection of the rectovaginal septum and all lesions were excised. RESULTS: For the diagnosis of rectovaginal septum endometriosis nodule, MRI results are: sensitivity 73%, specificity 50%, positive predictive value (PPV) 89%, negative predictive value (NPV) 25%; for uterosacral ligaments involvement: sensitivity 84%, specificity 95%, PPV 94%, NPV 86% and for rectal wall infiltration: sensitivity 53%, specificity 82%, PPV 69%, NPV 69%. The ARES results for diagnosis of rectovaginal septum endometriosis nodule are: sensitivity 93%, specificity 100%, PPV 100%, NPV 50% and for rectal wall infiltration: sensitivity 100%, specificity 71%, PPV 81%, NPV 100%. ARES appeared more sensitive than MRI for the detection of rectal wall infiltration (P = 0.002) and for rectovaginal septum endometriosis nodule diagnosis (P = 0.03). Eighty-nine percent of the patients had a coelioscopy in first intention and 15 laparoconversions were performed, 11 in order to perform a digestive resection: 45 nodules were found. In 43cases the nodule was excised, associated to 19 digestive resections, 30 colpectomys, and 22 uterosacral ligaments resections. Three patients required an additional surgical treatment by Hartman's procedure with Mickulicz's drainage for peritonitis. Forty-one nodules were endometriosis nodules: the two other cases were fibrosis nodules. Thirty-three patients were interviewed about the evolution of their pains over a mean history of 20 months: 90% of the patients were satisfied with the management results. DISCUSSION AND CONCLUSIONS: Our data support the efficiency of MRI for rectovaginal septum endometriosis nodule and uterosacral ligaments involvement diagnosis; accord ARES to rectovaginal septum endometriosis nodule diagnosis and its reliability in establishing a diagnosis of rectal wall involvement. The surgical cure of rectovaginal septum nodules without digestive infiltration is performed by coelioscopic or coelio-vaginal procedure, but in case of associated digestive affliction, laparotomy is actually the standard procedure in order to achieve a complete cure of the lesions. Complications, in particular peritonitis, are not frequent. Our data support the efficiency of radical surgical treatment for the improvement of pain symptoms. Results on fertility seem to be satisfactory, but complication risks suggest being careful in this indication. Clinical examination during a catamenial period is essential in order to evoke the diagnosis. MRI yields a complete map of the sub-peritoneal and peritoneal lesions and ARES allows for the diagnosis of an infiltration of the rectal wall. Pre-operative association of those two exams is actually indispensable for the surgical management of those patients, which consists of complete excision of endometriosical lesions and is efficient at treating pain symptoms and fertility. Complications are rare but severe, therefore, justifying a cure in specialised centres.

[Evidence-based medicine: principles and applications to obstetrics and to gynecologic surgery]. / Médecine fondée sur les preuves: principes et applications à la chirurgie gynécologique et à l'obstétrique.

Evidence-based medicine is a concept developed by David Sackett and colleagues since 1980 at the Medical University center MacMaster, Hamilton city, Ontario. The main idea was to propose an evaluating tool of medical practice allowing a structured way of reasoning and the elimination of self-made opinion. We present a short explanation of evidence-based medicine and compare our daily practice in obstetrics and gynecologic surgery with this new practice paradigm.