Adenomyosis and obstetric complications: A retrospective case-control study.

OBJECTIVE: Adenomyosis is a uterine pathology affecting an increasing number of women of childbearing age. Its diagnosis is based upon histology or imaging [ultrasound or magnetic resonance imaging (MRI)]. Several studies have investigated the impact of adenomyosis on obstetric complications, with its diagnosis based on clinical symptoms, ultrasound or composite criteria. The aim of this study was to identify potential obstetric complications related to adenomyosis in women with an MRI-confirmed diagnosis. METHODS: A single centre retrospective case-control study was undertaken in pregnant patients with an MRI-confirmed diagnosis of adenomyosis between January 2013 and December 2017 at the University Hospitals of Strasbourg. Controls were matched in a 4:1 ratio for age, parity and body mass index. Multivariate analysis was performed to identify obstetric complications. RESULTS: In total, 291 women with an MRI-confirmed diagnosis of adenomyosis were identified during the study period. Of these, 89 patients achieved pregnancy after 24 weeks of gestation. The mean age of patients was 30.8 years. The adenomyosis group and the control group were comparable for matching criteria. Adenomyosis was found to be associated with increased risk of caesarean section [odds ratio (OR) 1.1, 95 % confidence interval (CI) 1.0-1.2; p = 0.03], intrauterine growth restriction (OR 1.3, 95 % CI 1.1-1.4; p < 0.001), postpartum haemorrhage (OR 1.2, 95 % CI 1.1- 1.4; p < 0.01), pre-eclampsia (OR 1.3, 95 % CI 1.0-1.6; p = 0.004) and previous spontaneous miscarriage (OR 2.09, 95 % CI 1.36-3.33; p < 0.001). Premature rupture of membranes, preterm delivery, severe intrauterine growth restriction and the risk of placenta praevia were not significantly higher in the adenomyosis group compared with the control group on multivariate analysis. CONCLUSION: This study demonstrates increased risk of several obstetric complications (caesarean section, intrauterine growth restriction, postpartum haemorrhage, pre-eclampsia, history of spontaneous miscarriage) in women with adenomyosis. To the authors' knowledge, this is the first study to use MRI as the sole criterion for diagnosis. These results could be complemented by larger-scale prospective studies in order to manage these patients more effectively during pregnancy.

Percutaneous Imaging-guided Cryoablation of Endometriosis Scars of the Anterior Abdominal Wall.

STUDY OBJECTIVE: To evaluate the safety and clinical efficacy of percutaneous imaging-guided cryoablation for the management of anterior abdominal wall endometriosis. DESIGN: Patients with abdominal wall endometriosis underwent percutaneous imaging-guided cryoablation and had a 6-month follow-up. SETTING: Data dealing with patients' and anterior abdominal wall endometriosis (AAWE) characteristics, cryoablation, and clinical and radiologic outcomes were retrospectively collected and analyzed. PATIENTS: Twenty-nine consecutive patients underwent cryoablation from June 2020 to September 2022. INTERVENTIONS: Interventions were performed under US/computed tomography (CT) guidance or magnetic resonance imaging (MRI) guidance. Cryoprobes were directly inserted into the AAWE, and cryoablation was performed with a single 5 to 10 minute freezing cycle, which was stopped when the iceball expanded 3 to 5 mm beyond AAWE borders as assessed on intra-procedural cross-sectional imaging. MEASUREMENTS AND MAIN RESULTS: Fifteen patients (15/29; 51.7%) had prior endometriosis, 28 (28/29; 95.5%) had previous cesarian section, and 22 (22/29; 75.9%) referred association between symptoms and menses. Cryoablation was performed under local (16/29; 55.2%) or general anesthesia (13/29; 44.8%) and mainly in an out-patient basis (18/20; 62%). There was only one (1/29; 3.5%) minor procedure-related complication. Complete symptom relief was recorded in 62.1% (18/29) and 72.4% (21/29) patients at 1 and 6 months, respectively. In the whole population, pain significantly dropped at 6 months compared to the baseline (1.1 ± 2.3; range 0-8 vs 7.1 ± 1.9; range 3-10; p <.05). Eight (8/29; 27.6%) patients presented residual symptoms at 6 months, and 4 (4/29; 13.8%) had an MRI-confirmed residual/recurring disease. Contrast-enhanced MRI obtained for the first 14 (14/29; 48.3%) patients of the series, all without signs of residual/recurring disease, demonstrated a significantly smaller ablation area compared to the baseline volume of the AAWE (1.0 cm3 ± 1.4; range 0-4.7; vs 11.1 ± 9.9 cm3; range 0.6-36.4; p <.05). CONCLUSION: Percutaneous imaging-guided cryoablation of AAWE is safe and clinically effective in achieving pain relief.

Vaginal and laparoscopic sub-urethral sling explantation.

INTRODUCTION AND HYPOTHESIS: The objective was to describe the different laparoscopic and vaginal steps of sub-urethral infected mesh explantation as well as an unexpected and unusual complication: a sub-mucosal calcification on the sub-urethral segment of the sling that was not infiltrating the urethra. METHODS: This was carried out at our University Teaching Hospital of Strasbourg. RESULTS: We show the complete removal of an infected retropubic sling in a patient who had already undergone three previous surgeries without resolution of symptoms. This is a difficult case requiring a laparoscopic approach of the space of Retzius, which has been less familiar to surgeons since the advent of the midurethral sling. We show how to approach this space in an inflammatory environment by specifying its anatomical limits. Moreover, a great deal can be learned from the occurrence of an infectious complication after the surgery and the presence of a large calcification on the prosthesis. In this context, we advise a systematic antibiotic treatment to avoid this kind of complication. CONCLUSIONS: Knowing the guidelines and the different surgical steps will help urogynecological surgeons to perform similar procedures in patients requiring removal of retropubic slings for complications such as infection and pain, where conservative management has not been successful. These cases must be discussed in a multidisciplinary meeting, as recommended by the French National Authority for Health, and managed in an expert establishment.

Do Surgeons Anticipate Women's Hopes and Fears Associated with Prolapse Repair? A Qualitative Analysis in the PROSPERE Trial.

Women's preoperative perceptions of pelvic-floor disorders may differ from those of their physicians. Our objective was to specify women's hopes and fears before cystocele repair, and to compare them to those that surgeons anticipate. We performed a secondary qualitative analysis of data from the PROSPERE trial. Among the 265 women included, 98% reported at least one hope and 86% one fear before surgery. Sixteen surgeons also completed the free expectations-questionnaire as a typical patient would. Women's hopes covered seven themes, and women's fears eleven. Women's hopes were concerning prolapse repair (60%), improvement of urinary function (39%), capacity for physical activities (28%), sexual function (27%), well-being (25%), and end of pain or heaviness (19%). Women's fears were concerning prolapse relapse (38%), perioperative concerns (28%), urinary disorders (26%), pain (19%), sexual problems (10%), and physical impairment (6%). Surgeons anticipated typical hopes and fears which were very similar to those the majority of women reported. However, only 60% of the women reported prolapse repair as an expectation. Women's expectations appear reasonable and consistent with the scientific literature on the improvement and the risk of relapse or complication related to cystocele repair. Our analysis encourages surgeons to consider individual woman's expectations before pelvic-floor repair.

Serious Complications and Recurrence following Sacrospinous Ligament Fixation for the Correction of Apical Prolapse.

Objective: To evaluate the rates of serious complications and reoperation for recurrence following sacrospinous ligament fixation (SSLF) for apical pelvic organ prolapse. Methods: This was a national registry ancillary cohort comparative study. The VIGI-MESH registry includes data from 24 French health centers prospectively collected between May 2017 and September 2021. Time to occurrence of a serious complication or reoperation for genital prolapse recurrence was explored using the Kaplan-Meier curve and Log-rank test. The inverse probability of treatment weighting, based on propensity scores, was used to adjust for between-group differences. Results: A total of 1359 women were included and four surgical groups were analyzed: Anterior SSLF with mesh (n = 566), Anterior SSLF with native tissue (n = 331), Posterior SSLF with mesh (n = 57), and Posterior SSLF with native tissue (n = 405). Clavien-Dindo Grade III complications or higher were reported in 34 (2.5%) cases, with no statistically significant differences between the groups. Pelvic organ prolapse recurrence requiring re-operation was reported in 44 (3.2%) women, this was higher following posterior compared with anterior SSLF (p = 0.0034). Conclusions: According to this large database ancillary study, sacrospinous ligament fixation is an effective and safe surgical treatment for apical prolapse. The different surgical approaches (anterior/posterior and with/without mesh) have comparable safety profiles. However, the anterior approach and the use of mesh were associated with a lower risk of reoperation for recurrence compared with the posterior approach and the use of native tissue, respectively.

Endometriosis and cardiovascular disease.

Endometriosis is a chronic gynaecological disease affecting 1 in 10 reproductive-age women. It is defined as the presence of endometrium-like tissue outside the uterus. Beyond this placid anatomical definition, endometriosis is a complex, hormonal, inflammatory, and systemic condition that poses significant familial, psychological, and economic burden. The interaction between the cardiovascular system and endometriosis has become a field of interest as the underlying mutual mechanisms become better understood. On the basis of accumulating fundamental and clinical evidence, it is likely that there exists a close relationship between endometriosis and the cardiovascular system. Therefore, investigating the endometriosis-cardiovascular interaction is highly clinically significant. In this review, we highlight our current understanding of the pathophysiology of endometriosis with systemic hormonal, pro-inflammatory, pro-angiogenic, immunologic, and genetic processes beyond the peritoneal microenvironment. Additionally, we provide current clinical evidence about how endometriosis interacts with cardiovascular risk factors and cardiovascular disease (CVD). To date, only small associations between endometriosis and CVD have been reported in observational studies, inherently limited by the potential influence of unmeasured confounding. Cardiovascular disease in women with endometriosis remains understudied, under-recognized, and underdiagnosed. More detailed study of the cardiovascular-endometriosis interaction is needed to fully understand its clinical relevance, underlying pathophysiology, possible means of early diagnosis and prevention.

Laparoscopic En Bloc Pelvic Resection with Rectosigmoid Resection and Anastomosis for Stage IIB Ovarian Cancer: Hudson's Procedure Revisited.

STUDY OBJECTIVE: To demonstrate a systematic approach to the laparoscopic en bloc pelvic resection with rectosigmoid resection and anastomosis as part of ovarian cancer treatment in a tertiary gynecologic surgery referral center. DESIGN: This video illustrates an en bloc pelvic resection performed par laparoscopy in 10 steps. SETTING: A 56-year-old patient with an advanced high-grade serous ovarian cancer extending into the rectum was amenable to primary debulking surgery in accordance with the French guidelines [1]. In diagnostic laparoscopy, a bilateral adnexectomy was performed, and the pelvic carcinomatosis was considered primarily resectable. Histopathology of the subsequent en bloc resection was consistent with stage IIB high-grade serous ovarian cancer with an indication for adjuvant chemotherapy. INTERVENTION: The Hudson's procedure revisited consists of a radical monobloc excision by way of a completely extraperitoneal dissection and total mobilization of the rectum. In this case, owing to rectal invasion, we achieved a laparoscopic radical resection including rectosigmoidectomy and primary anastomosis without the need for a defunctioning stoma [2]. CONCLUSION: Traditionally, an en bloc pelvic resection with rectosigmoid resection and anastomosis was performed by laparotomy. The feasibility of performing laparoscopic optimal cytoreductive surgery in selected patients with advanced ovarian cancer was recently demonstrated without compromising survival in case of low residual disease. The prognosis depends rather on the resectability than on the operative access. However, the radicality and completeness of the cytoreduction, as well as the potential risk of tumor seeding, remain controversially discussed. Here, we demonstrate the minimally invasive approach following the same operative strategy as in open surgery. In this way, the radicality of the "en bloc resection" entailing avoidance of tumor rupture, less bleeding, and less urethral injury is combined with the benefits of a minimally invasive access. In expert hands, this procedure can be performed laparoscopically for other pelvic malignancies with peritoneal carcinomatosis.

Nerve Anatomy Around Lumbo-aortic Lymphadenectomy by Retroperitoneal Approach.

STUDY OBJECTIVE: To describe the anatomy of the nerves during a laparoscopic retroperitoneal para-aortic lymphadenectomy with prioritization of their preservation. DESIGN: Demonstration of a nerve-preserving para-aortic lymphadenectomy. SETTING: A 65-year-old woman with no significant medical history underwent diagnostic laparoscopy for evaluation of a right ovarian mass. In the absence of peritoneal carcinomatosis, bilateral adnexectomy wasperformed with pathology revealing a high-grade tubo-ovarian serous carcinoma. In accordance with French Guidelines for management of ovarian cancer, operative staging including pelvic and para-aortic lymphadenectomy was recommended [1]. Final pathology following staging surgery was consistent with stage IA high-grade serous ovarian cancer prompting administration of adjuvant chemotherapy postoperatively. INTERVENTIONS: We performed a lumbo-aortic lymphadenectomy with preservation of the following nerves: the superior hypogastric plexus, the lumbar splanchnic nerves and the sympathetic trunk. CONCLUSION: Although there are conflicting data as to the benefit of staging lymphadenectomy in women with presumed early stage high-grade serous ovarian cancer, current French Guidelines recommend its performance. When doing so, effort should be made to avoid injury to adjacent normal structures, and in doing so, minimize potential morbidity. The neural structures preserved in this case are part of the sympathetic contingent and participate in the innervation of the abdomen and pelvic viscera. The sympathetic contingent is responsible for the vasomotricity but is also involved in the contraction of the internal genitalia during orgasm and in the inhibition of the peristaltic contractions of the rectum. As such, its preservation may avoid certain postoperative complaints. When possible to do so without compromising essential elements of a cancer surgery, preservation of nerves should be considered.

Prospective evaluation of the connected biofeedback EMY Kegel trainer in the management of stress urinary incontinence.

INTRODUCTION: The aim of this study was to evaluate changes in the quality of life with the connected biofeedback EMY Kegel trainer in patients suffering from stress urinary incontinence. Materiel and methods: This was a prospective, single-center, non-comparative study, which took place between September 2019 and October 2020, in the University Hospitals of Strasbourg. Eligible patients were instructed to use the EMY probe for a minimum of 10 min per day for five days per week. To assess quality of life and urinary symptoms, the Contilife and ICIQ-SF scores were completed each month until the final visit (M3). The PGI-I was also completed at 3 months to assess the benefit of the EMY Kegel Trainer. RESULTS: A total of 55 patients were included. At the inclusion visit (M0), the mean Contilife and ICIQ-SF scores were respectively at 6.6 ± 1.5 and 10.5 ± 3.0 points. At the final visit (M3), the mean Contilife score increased to 9.2 ± 1.0, indicating an improvement in quality of life. The mean ICIQ-SF score decreased to 4.2 ± 4.0, indicating an improvement in urinary symptoms. The PGI-I questionnaire identified a positive assessement of the EMY Kegel trainer. On the 55 patients included, 35 (64%) reported completing at least 36 sessions during the study, i.e. an average of 3 sessions per week. CONCLUSIONS: This study suggests that perineal rehabilitation by biofeedback using the EMY Kegel trainer might be beneficial.

Report of two cases of Accessory Cavitated Uterine Mass (ACUM): Diagnostic challenge for MRI.

Cystic adenomyosis is an unusual form of adenomyosis, characterized by a well-circumscribed cavitated endometrial gland and stroma, ≥ 1 cm in diameter, located within the myometrium. Few cases have been reported in the gynecological literature, with confusing naming such as: juvenile cystic adenomyosis, cystic myometrial lesions, cystic adenomyoma or juvenile adenomyotic cysts. The current preferred terminology is accessory cavitated uterine mass /or malformation (ACUM). We report here the cases of two 17 and 18 -year-old nulliparous women, who complained of severe dysmenorrhea early after the onset of menarche, with none or partial efficiency of medical treatment. MRI findings, with a follow-up in one case and surgical treatment in both cases, are described with an emphasis on physiopathology. The typical MR appearance is a large well-circumscribed round mass within the external myometrium, composed by an inner cystic hemorrhagic layer surrounded by a thick fibrous crown. The first-line treatment is laparoscopic surgery with mass resection. This typical MRI pattern must be a part of the knowledge of the radiologists.

Surgical management of deep pelvic endometriosis in France: Do we need to be a pelvic surgeon to deal with DPE?

INTRODUCTION: Endometriosis is a common disease in women, which requires a medical and surgical approach. Surgical societies recommend a multidisciplinary management in tertiary referral centers. The objective of our study is to assess the surgical management of endometriosis in France by studying the surgeons' attitude for bowel and urinary endometriosis. METHODS: We sent a survey to french endometriosis surgeons. We did a descriptive analysis and a comparative analysis between surgeons who believe endometriosis surgeons should be considered as "pelvic surgeons", able to treat bowel and urinary involvement. RESULTS: We included 90 answers, from gynaecologic surgeons from all over France. Gynaecologic surgeons perform minor bowel and urinary tract surgery, and more complex procedures are performed with digestive or urological surgeon (bowel resection 85% of cases, ureteric resection-anastomosis 84% of cases, ureteric reimplantation 91% of cases). Surgeons considering that gynaecologists should be able to deal with urinary and bowel endometriosis carry out more bowel and urinary procedures. They have an additional training in surgery and perform more endometriosis surgery every year. However, bowel and urinary endometriosis management by gynaecologic surgeons is contested amongst gynaecologists. CONCLUSION: To this day, there is no dedicated training in France to coach gynaecologist to perform such procedures. Multidisciplinary approach is essential for quality care, in expert centers. The basic education of gynaecologic surgeons does not allow them to perform complex pelvic surgeries, but qualifications can be gained for these interventions with a special training, and perform a greater number of surgeries.

Surgical Video Tutorial: Treatment of Congenital Vaginal Agenesis: Laparoscopic Modified Davydov in 8 Steps.

OBJECTIVE: To describe the different steps of the Davydov surgical technique for creating a neovagina, emphasizing visualization of the rectovesical cleavage and peritoneal-vaginal anastomosis by laparoscopic and vaginal approaches. DESIGN: Production of a step-by-step surgical video tutorial with narrative video footage. SETTING: Uterovaginal agenesis is a rare congenital defect, observed in 1 case per 4000 to 5000 newborn female infants [1]. Vaginal agenesis treatment can be performed by different nonsurgical and surgical techniques that are based on neocavity creation. The Davydov intervention uses the pelvic peritoneum as "covering" tissue for a neocavity and avoids the use of allogenic or autologous transplants, traction devices, or specialized surgical equipment. It is a minimally invasive technique that provides long-term functionality and anatomically satisfying results [2]. INTERVENTIONS: We treated an 18-year-old patient with Mayer-Rokitansky-Küster-Hauser syndrome who underwent the Davydov procedure after dissatisfaction with the Franck self-expansion method. We created a neovagina using peritoneal flaps that were obtained after rectovesical cleavage by laparoscopic approach and were then fastened to the introitus by vaginal approach. Finally, the vaginal vault was reconstructed laparoscopically, and an intravaginal dilator was left in place. The result after 1 year showed the transition from a narrow vaginal dimple 2 cm in length to a neovagina 10 cm in length, permeable, well epithelialized, and correctly healed without associated stenosis. Sexual intercourse is satisfying for both partners. CONCLUSION: The Davydov technique is less invasive than other surgical techniques and allows good outcomes [3,4] without the invasive use of sigmoidal grafts, cutaneous flaps, or prostheses. It should be proposed to patients experiencing failure with the Franck nonsurgical method.

Cesarean scar pregnancy: Two case report and therapeutic management algorithm.

OBJECTIVE: We aimed to present two cases of cesarean scar pregnancy (CSP) and a literature review to discuss their management. CASES: We reported two cases of cesarean scar pregnancy (CSP) treated in Strasbourg's University Hospital between 2016 and 2018 and carried out an updated literature review concerning their treatment. RESULTS: The first case is a superficial implantation CSP managed by methotrexate (MTX) then ligation of the uterine arteries and echo-guided aspiration. The second case is a deep implantation CSP managed by MTX and then laparoscopic excision with clamping of the uterine arteries. In the literature, the most commonly used treatments are: MTX, echo-guided aspiration, and the combination of uterine artery embolization followed by echo-guided aspiration. CONCLUSION: We established an algorithm in which CSP treatment by MTX can be considered alone if criteria are met. If not, surgery, chosen according to the depth of implantation, will be associated with MTX with a preventive hemostasis procedure by embolization or ligation of the uterine arteries.

Randomized Study Comparing a Reusable Morcellator with a Resectoscope in the Hysteroscopic Treatment of Uterine Polyps: The RESMO Study.

STUDY OBJECTIVE: To compare a reusable hysteroscopic morcellator and standard resectoscopes in the hysteroscopic management of uterine polyps. DESIGN: Single-center randomized prospective single-blind trial (resectoscope-morcellator study). SETTING: Centre Médico-chirurgical Obstétrique teaching hospital, Strasbourg University Hospitals, France. PATIENTS: All patients presenting with a single endometrial polyp of size 1 cm or larger. INTERVENTIONS: After consent, the patients were randomized into 2 groups: hysteroscopic morcellation (HM) group or standard resection (SR) group. Office-based review hysteroscopy was performed 6 weeks to 8 weeks after surgery. Primary end point: time of morcellation or resection. SECONDARY OUTCOMES: total operating time (minutes), volume of fluid used (mL), fluid deficit (mL), number of morcellator or resectoscope insertions, operator comfort (visual analog scale: 0 to 10) and quality of vision (0 to 5), perioperative complications, completeness of resection, need to convert to another technique, pain assessment (visual analog scale), and length of hospitalization. At review hysteroscopy, we noted whether the resection or morcellation had been effective and if synechiae were present or absent. Statistical analyses followed Bayesian methods. MEASUREMENTS AND MAIN RESULTS: Ninety patients were randomized: 45 in the HM group and 45 in the SR group. The average size of polyps at hysteroscopy was 13.3 mm. Morcellation time was lower than resection time (6.1 minutes vs 9 minutes; p [HM < SR] = .996). This also applied to total operating time (12.7 minutes vs 15.6 minutes; p [HM < SR] = .985), number of device insertions (1.50 vs 6; p [HM < SR] > .999), volume of fluid used (766.9 mL vs 1118.9 mL; p [HM < SR] = .994), and fluid deficit (60.2 mL vs 169.8 mL; p [HM < SR] = .989). Operator comfort was better in the HM group (8.4 vs 7.4; p [HM > SR] = .999) as was visualization (4 vs 3.7; p [HM > SR] = .911, highly probable). Operative complications were higher in the SR group (5 vs 0; p [HM < SR] = .989]. One patient in the SR group died after surgery owing to an anesthetic complication (anaphylactic shock complicated by pulmonary embolism). No differences were noted between the groups for pain assessment, length of hospitalization, and outcome on review hysteroscopy. CONCLUSION: The reusable morcellator is quicker, uses less fluid with less deficit and fewer introductory maneuvers, and offers better comfort and visualization than the resectoscope while being as effective for the hysteroscopic treatment of uterine polyps.

Surgical traps in laparoscopic sacrocolpopexy for vaginal vault prolapse.

OBJECTIVE: To describe the possible difficulties encountered in the event of laparoscopic sacrocolpopexy for vaginal vault prolapse and corresponding avoidance strategies. METHODS: Video recordings of different laparoscopic sacrocolpopexies for vaginal vault prolapse showing various situations and difficulties. University Teaching Hospital of Strasbourg. RESULTS: Although laparoscopic sacrocolpopexy for vaginal vault prolapse is becoming more common, achieving a good outcome remains challenging, especially with the vesicovaginal dissection. Bladder injuries are not rare and occur in about 2 to 6% of cases. Vaginal perforation is less common, but remains a risk. This video illustrates possible difficulties encountered and presents various strategies to avoid them. Several tips on exposing structures and following anatomical landmarks are described. CONCLUSION: Knowing how to avoid these surgical traps will help trainee urogynecologic surgeons to perform laparoscopic sacrocolpopexy for vaginal vault prolapse.

Augmented reality in gynecologic laparoscopic surgery: development, evaluation of accuracy and clinical relevance of a device useful to identify ureters during surgery.

OBJECTIVE: To develop and evaluate a non-invasive surgical assistance based on augmented reality (AR) in the detection of ureters on animal model. METHOD: After an experimental prototyping step on two pigs to determine the optimal conditions for visualization of the ureter in AR, three pigs were operated three times at 1 week intervals. The intervention consisted of an identification of the ureter, with and without the assistance of AR. At the end of the intervention, a clip was placed on the AR-proposed ureter to evaluate its accuracy. By doing a cone beam computed tomography, we measured the distance between the contrasted ureter and the clips in the acquired volume. Thirteen videos were recorded, allowing subsequent evaluation of the clinical relevance of the device. RESULTS: The feasibility of the technique has been confirmed. The margin of error was 1.77 mm (± 1.56 mm) for ureter localization accuracy. In order to evaluate the perceived relevance and accuracy in the detection of AR-assisted ureter, 58 gynecological surgeons were shown the videos then questioned. Of the 754 responses obtained (13 videos × 58 surgeons), the ureter was identified in direct vision in 31.2% of cases versus 81.7% in AR (p value 3.62 × 10-7). When looking at pigs that had already had one or two operations, the ureter was identified in only 16% of cases with direct vision compared to 76.1% with AR (p-value 5.48 × 10-19). In addition, 67% of surgeons felt that AR allowed them to better identify the ureters and 61% that AR reconstruction was accurate. CONCLUSION: This first AR device showed a satisfactory precision in the detection of ureters with a favorable opinion of surgeons. This surgical assistance system could be helpful in the performance of difficult procedures, for example in the case of patients, which have undergone multiple surgeries in the past.

Ovarian Cortex Transplantation.

STUDY OBJECTIVE: To describe a laparoscopic technique for the transplantation of a cryopreserved ovarian cortex. DESIGN: Educational video. SETTING: University Hospital of Strasbourg, France. INTERVENTIONS: A 28-year-old nulliparous woman presented with anaplastic T lymphoma and was then treated with chemotherapy. Before the treatment, the ovarian cortex was collected by laparoscopy to preserve fertility. Remission was achieved, but the patient suffered from premature ovarian failure. At the age of 32 years, she wished to become pregnant. The patient was thus included in the research protocol Development of Ovarian Tissue Autograft in Order to Restore Ovarian Function, and the transplantation site was chosen accordingly. The cortex was stored in liquid nitrogen at -196°C after slow congelation. To restore ovarian function and because of pregnancy desire, we transplanted the cryopreserved ovarian cortex in the right ovary and inside a pocket of the peritoneum of the left ovarian fossa. The first step included adhesiolysis to treat small adhesions developed after the first surgery. On the right, the ovarian cortex was opened by an antimesial incision with cold scissors. The cryopreserved ovarian cortex was placed through the cortex of the right ovary and fixed with stitches. On the left side, the peritoneum of the ovarian fossa was opened, and a subperitoneal pocket was dissected. The cortex was inserted. It was then closed with absorbable sutures or with a hemostatic pad. Six months after her surgery, the patient had natural cycles. We monitored an ovulation of both the sides. She underwent 3 in vitro fertilizations but with failures of embryo transfer. She conceived spontaneously a year after the surgery. She gave birth to a healthy child weighing 3300 g. CONCLUSION: For patients who have suffered from premature ovarian failure owing to chemotherapy, ovarian cortex transplantation can restore the ovulatory function, allow in vitro fertilization, and permit, as in our case, a spontaneous pregnancy.

Organizing a uterus transplantation programme: The designation of Uterus Transplantation Centres in France.

Absolute uterine factor infertility affects several thousand young women in France. The first healthy child delivered to a uterus transplant recipient took place in 2014, and uterus transplantation is developing rapidly in many countries. The French College of Gynaecologists and Obstetricians (CNGOF) formed a uterus transplantation committee (CETUF) in 2015 to advance this technology in France. The CETUF sets out the criteria for the designation of Uterus Transplantation Centres. The objectives, requirements, operation and responsibilities of these centres have been described. Their responsibilities for organizing geographical coverage, continuity of care, communication, training, research and evaluation have been defined. This document will serve as a guide for the authorities concerned, to ensure that the means are provided to adequately manage patients with absolute uterine factor infertility who require uterus transplantation.