Postoperative evaluation of chronic pain in patients with Mayer - Rokitansky - Küster - Hauser (MRKH) syndrome and uterine horn remnant: Experience of a tertiary referring gynaecological department.

INTRODUCTION: Patients with Mayer - Rokitansky - Küster - Hauser (MRKH) syndrome often experience chronic pelvic pain negatively impacting their life's quality. Our understanding of the factors involved in this symptom remains poor. The aim of our study was to further investigate the different components of this pelvic pain in patients with MRKH undergoing pelvic surgery. Our second objective was to assess the evolution of this pain in patients undergoing surgical removal of their uterine horn remnant. MATERIAL AND METHODS: We conducted a retrospective analysis of a cohort of patients treated in our tertiary referring gynaecological department. Patients included had a MRKH syndrome with at least one uterine horn remnant and all underwent at least one surgical procedure in our centre. Descriptive analysis of the main characteristics and of the management of these patients was conducted. Postoperative pain was evaluated using simple words and / or analgesic consumption evaluation. RESULTS: Between 1991 and 2013, twenty-one patients were included in our centre. Out of them, 20 (95 %) had chronic pelvic pain, mostly cyclic pain lasting 2-3 days. Fourteen patients had surgical removal of their uterine horns remnant and only 3 patients (21 %) had persistent pain at their postoperative visit. Surgical findings included peritoneal endometriosis in 8 patients (38 %) and other unexpected findings in 6. At pathological analysis, secretary endometrium in the uterine horn remnant was found in 11 patients (79 %). CONCLUSION: The origin of chronic pain in MRKH is combining several factors such as endometriosis or secretary endometrium. Surgical removal of uterine horn remnant improved most of our patients' pelvic chronic pain. Further studies should help improve our understanding of this specific entity.

Fertility and pregnancy outcomes in patients with bicorporeal uterus and blind hemivagina: 20 years of experience in a tertiary referral gynaecological department.

BACKGROUND: To evaluate fertility and pregnancy outcomes in patients with uterus bicorporeal and blind hemivagina. Our second objective was to investigate factors predicting fertility and pregnancy outcomes in those patients. MATERIAL AND METHODS: We conducted a retrospective analysis in a tertiary referring gynaecological department, in France. We included all patients with uterus bicorporeal and blind hemivagina who underwent at least one surgery in our centre. Initial characteristics of the patients included were extracted from their medical charts and patients were contacted to assess their fertility and pregnancies outcomes upon their consent to participate to the study. RESULTS: Between 1989 and 2010, 79 patients fulfilled inclusion criteria and were selected for analysis. Mean follow up of those patients was of 16.15 (QI 10-21) years. Forty-six patients (58.2%) returned the survey and among them, 21 (45.7%) were fertile, 8 (17.4%) were infertile and 17 (37%) never attempted to get pregnant following initial management. Forty-nine pregnancies were included to assess pregnancies outcomes: 11 (22.5%) early miscarriages, 1 (2.0%) extra-uterine pregnancy, 2 (4.1%) second semester miscarriages and 35 (71.4%) leaded to living birth. Nineteen (54.3%) deliveries occurred by caesarean section and 14 (40.0%) by vaginal delivery. Fifteen pregnancies (42.9%) were complicated. In univariate analysis, adhesiolysis performed at the time of initial surgery was the only factor associated with infertility (p=0.004). CONCLUSIONS: Fertility seems to be perfectly conserved in those patients and they do not have increased rate of adverse pregnancies outcomes.

[Secondary labiaplasty: Retrospective study about 44 cases. Annual report SOFCPRE 2019]. / Nymphoplastie secondaire : étude rétrospective à propos de 44 cas. Rapport annuel de la SOFCPRE 2019.

INTRODUCTION: Labiaplasty is a surgery currently booming. The number of publications on this subject is also increasing significantly. With the increase of the operated cases, we see more and more consultations for revisions after a labiaplasty, called secondary labiaplasty. The author reports here his experience with secondary labiaplasties in 44 cases. MATERIAL AND METHOD: The study carried out by the author reports 44 cases divided into two categories of secondary labiaplasties. The first category is characterized by a wound dehiscence, including those following the author's lambda laser procedures, which are easily repaired under local anesthesia after border cutting and suture. The second category is characterized by over-resections or real amputations or even remains of atypical flaps. DISCUSSION: The over-resection is a technical fault. In this case, the technique used to improve the aesthetic, functional and psychological aspect is the use of the remains of labia minora in the form of a flap to avoid a dog-ear appearance at the anterior and posterior part. The use of lipofilling of the labia majora is to mask the area and improve the function. The future of this surgery is probably the reconstruction of the labia minora by local flaps. CONCLUSION: The conclusion of the study is that it is imperative that surgeons performing labiaplasties be trained in both anatomy and labiaplasty techniques and avoid as much as possible over-resections and amputations, mending being often difficult.

[Operative technique: The clitoral transposition]. / Technique opératoire: la transposition clitoridienne.

Female sexual mutilations result in an important physical and mental suffering. A large number of women have been affected and require a global management, including surgical clitoral transposition. This surgical technique is allowing a rapid improvement of clinical symptoms. In this article, we will describe the indications and operative technique of the clitoral transposition.

[Uterine ishtmique transmural hernia: results of its repair on symptoms and fertility]. / Hernie transmurale isthmique de l'utérus : résultats de l'isthmorraphie sur la symptomatologie et la fertilité

OBJECTIVE: To study the effect of the surgical repair (isthmorraphy) of the large scar dehiscence after cesarean on symptoms and fertility for women who desire pregnancy. PATIENTS AND METHODS: In this retrospective study, 14 symptomatic patients, who desire a new pregnancy underwent a surgical repair by laparotomy, laparoscopic or vaginal technique. Five women experienced failure of Assistance Reproductive Technique (IVF or ICSI) for idiopathic secondary infertility. The dehiscent scars were evaluated by ultrasound, hysterography, hysteroscopy and magnetic resonance imaging. OUTCOME: Symptoms improvement was found in 92% of case. Ten pregnancy (71%) was obtained after surgical repair, 6 spontaneous and 4 after Assistance Reproductive Technique. Among the 5 women initially followed in the reproductive unit, 4 became pregnant, 3 after IVF or ICSI and 1 spontaneous. No operative complication occurred. The subsequent pregnancy was unremarkable with no uterine rupture. DISCUSSION: Large scar defect after cesarean can take shape of a complete absent of the anterior wall of the uterus. No incident has been proved in this condition. There is a lack of data concerning these isthmocele. The experience of hysteroscopic repair cannot be applied to these real large diverticule of the scar cesarean. The results of this study suggest a link between the isthmocele and reversible symptoms after surgery. The first results concerning the subsequent fertility after surgical repair seem interesting CONCLUSION: When a large scare defect (isthmocele) is found in symptomatic woman (pelvic pain, bleeding uterine, infertility), a surgical repair can be proposed, especially for woman who desire a new pregnancy.

Human papillomavirus 16-specific T cell responses in classic HPV-related vulvar intra-epithelial neoplasia. Determination of strongly immunogenic regions from E6 and E7 proteins.

Cell-mediated immunity directed against human papillomavirus 16 (HPV-16) antigens was studied in 16 patients affected with classic vulvar intra-epithelial neoplasia (VIN), also known as bowenoid papulosis (BP). Ten patients had blood lymphocyte proliferative T cell responses directed against E6/2 (14-34) and/or E6/4 (45-68) peptides, which were identified in the present study as immunodominant among HPV-16 E6 and E7 large peptides. Ex vivo enzyme-linked immunospot-interferon (IFN)-gamma assay was positive in three patients who had proliferative responses. Twelve months later, proliferative T cell responses remained detectable in only six women and the immunodominant antigens remained the E6/2 (14-34) and E6/4 (45-68) peptides. The latter large fragments of peptides contained many epitopes able to bind to at least seven human leucocyte antigen (HLA) class I molecules and were strong binders to seven HLA-DR class II molecules. In order to build a therapeutic anti-HPV-16 vaccine, E6/2 (14-34) and E6/4 (45-68) fragments thus appear to be good candidates to increase HPV-specific effector T lymphocyte responses and clear classic VIN (BP) disease lesions.

[Pertussis vaccine coverage in postpartum women]. / Couverture vaccinale contre la coqueluche chez les femmes accouchées.

OBJECTIVE: Since July 2006, it has been recommended to give a booster of a pertussis vaccine to women just after delivery, if they have received their last dose more than 10 years before. The aim of this study was to evaluate the pertussis vaccine coverage in a cohort of women just after delivery. PATIENTS AND METHODS: All patients (n=31) hospitalized in postpartum unit on the 15th September 2006 were included in the study. They were submitted a questionnaire and medical records available in the department were reviewed. RESULTS: The vaccination coverage was not indicated in any medical records. Only six patients claimed they knew their pertussis vaccination status (less than five years: two patients, between five and 10 years: two patients, more than 10 years: two patients). Two patients had their vaccination booklet. The pertussis vaccine coverage is probably very low. DISCUSSION AND CONCLUSION: The information about pertussis vaccine status in postpartum women is not available currently because it is not recorded by medical team and is unknown by patients themselves. An effort in educating obstetricians and corrective actions are necessary if we want the recent vaccine schedule to be followed.

[Epidemiology of vulvar intra-epithelial neoplasias]. / Epidémiologie des néoplasies vulvaires intraépithéliales.

The vulvar intraepithelial neoplasia has been identified as one of the 12 neoplasias whose incidence increases in the developed countries. The vulvar intraepithelial neoplasia (VIN) and invasive vulvar cancer incidence increases by 2.4% per annum; and this principally in young women. The VIN account for 57% of the vulvar neoplasias and are actually more frequent than invasive carcinomas. In the United States, between 1973 and 2000, the incidence of the VIN increased by 411% against 20% for invasive cancers. Similar figures were reported from Norwegian registers. The VIN have a different age distribution than invasive cancers: the incidence of the VIN increases until the age of 40-49 years then decreases while the incidence of invasive cancers increases after 50 years without real peak of incidence. The increase in the incidence of VIN could be followed by an increase in the incidence of invasive cancers but the unknowns on the natural history of the VIN and the impact of the treatments make any extrapolation hazardous. The association between the VIN and the human papillomavirus (HPV) has been well established. It should be noted that, contrary to the cervical neoplasia that are related for nearly 100% to the HPV, only 30-40% of invasive cancers of the vulva are related to HPV, while the other carcinomas are related to the evolution of a vulvar lichen sclerous. The HPV induce various types of anogenital lesion according to their genotype. These lesions can be benign for the HPV6 and 11 and preneoplastic or neoplastic for the HPV16 and 18. The presence of HPV16 and 18 is found in 70 to 80% of the VIN suggesting that HPV vaccines could decrease the incidence VIN and HPV related invasive vulvar cancer.

[Interpretation of sentinel node identification in vulvar cancer]. / Interprétation de l'identification du ganglion sentinelle dans les cancers vulvaires.

OBJECTIVE: Sentinel node (SN) identification in vulvar carcinoma would avoid groin dissection and its complications in early stages, but we first have to validate the method, as an unrecognised node metastasis is detrimental to survival. PATIENTS AND METHODS: Since June 2002, 38 patients with T1 or T2 lesions underwent SN identification by radioactive tracer injection and scintigraphy with, on the following day, per operative use of a handheld probe +/- patent blue dye. In case of a midline lesion, a bilateral inguinal dissection was performed whatever the result of SN identification. SN free from disease were ultrastaged with immunohistochemistry. RESULTS: 1 or more SN were identified in 36 out of 38 patients. 64 groins were analysed, 15 with node metastases. In 9 out of these 15 cases the SN was metastatic, in 5 it had not been identified, and in 1 it was a false negative. In these last 6 cases, there were massively metastatic nodes in the groin. In 19 out of the 26 midline lesions the surgeon identified only unilateral SN. The side without SN contained metastatic nodes in 5 cases. DISCUSSION AND CONCLUSION: Failure in SN identification is sometimes related to a massively invaded node. This should be taken into account especially in the management of midline tumors where a seemingly unilateral drainage at scintigraphy warrants nevertheless a surgical assessment of the mute groin.

[Ectopic pregnancy with etonogestrel contraceptive implant (Implanon): first case]. / Grossesse extra-utérine survenue sous contraception par implant d'étonogestrel (Implanon): premier cas.

We describe the first case of ectopic pregnancy occurring in a patient with an etonogestrel contraceptive implant (Implanon). There was no factor predisposing to a failure of the technique (implant in place for less than 2 years and normal BMI). In addition there was no risk factor for an ectopic location of the pregnancy. We discuss the role of the micro progestative in the location of the pregnancy. This case report emphasizes the fact that ectopic pregnancy should not be ruled out in women taking this contraception, however efficient it is otherwise.

Significance of ovarian histology in the management of patients presenting a premature ovarian failure.

BACKGROUND: Premature ovarian failure (POF) is a heterogeneous syndrome, possibly due to mutations of genes involved in the normal development of the ovary and/or follicles. Based essentially on animal models, these mutations are associated with various ovarian phenotypes, from a complete absence of follicles to a partial follicular maturation. The aim of the present study was to determine whether ovarian histology, compared to pelvic ultrasonography, would be helpful in identifying which patients display an impaired follicular reserve and/or growth, and in orientating the search for POF aetiology. METHODS AND RESULTS: We studied a cohort of 61 patients suffering from POF with a normal karyotype. Their median age (range) at diagnosis was 26 years (15-39). The FSH plasma level was high, 67.0 IU/l (13-155). Estradiol and inhibin B plasma levels were low: 18.5 pmol/l (18.5-555) and 5 pg/ml (5-105) respectively. Both pelvic ultrasonography and ovarian biopsies were performed in each patient. The presence of follicles suggested at ultrasonography was confirmed at histology in 56% of the patients. Ovarian histology led to the distinction of two phenotypes: (i) small-sized ovaries, deprived of follicles; and (ii) normal-sized ovaries with partial follicular maturation. To confirm the value of ovarian biopsies, samples from 20 normal women were studied. These demonstrated that ovarian biopsy at random enables reliable assessment of follicular presence, especially when their size is <2 mm. CONCLUSION: Ovarian histology appears to be a reliable tool in evaluating the follicular reserve, and helpful and complementary to clinical and hormonal phenotyping in orienting the search for the various genetic causes of POF syndrome.

[Verrucous carcinoma of the vulva: a tailored treatment]. / Carcinomes verruqueux vulvaires: un traitement sur mesure.

OBJECTIVE: Verrucous carcinoma is a rare form of vulvar squamous carcinoma, with particular clinical presentation and histological description. We analyze the specificity of the treatment of this form. MATERIALS AND METHODS: We analyzed the records of 8 patients treated in our hospital between 1995 and 2001. In the absence of an associated lesion, the treatment was partial vulvectomy without lymph node dissection. A close follow-up was then organized. RESULTS: Mean age was 76 years (range 54 to 92). In 7 out of the 8 cases we found an associated lesion: invasive squamous carcinoma, VIN III or lichen. Two patients later developed a squamous carcinoma. Two others died because of intercurrent diseases. The last four patients are doing well. CONCLUSION: We confirm the efficacy of the treatment generally proposed: partial vulvectomy, without lymph node dissection and without complementary treatment but with a close follow-up. The coexistence of other vulvar lesions such as lichen is remarkable in our series.

[Criteria of pregnancy termination in women with preeclampsia]. / Critères d'extraction foetale dans la prééclampsie.

Preeclampsia remains an important cause of maternal and neonatal mortality and morbidity. Delivery is always the appropriate therapy for the mother but may be responsible for neonatal adverse outcomes, particularly when it occurs at less than < 34 weeks' gestation. In women with severe preeclampsia at < 34 weeks expectant management to improve neonatal mortality and morbidity may be performed under close monitoring of both the mother and the fetus. Any severe condition of the mother (HELLP syndrome, abruptio placentae, eclampsia) or the fetus (abnormal fetal heart rate) should lead to prompt delivery. In women with mild preeclampsia, expectant management should be performed until 38 weeks gestation.

[Great elongation of uterine cervix: retrospective study of 20 cases]. / Chirurgie de l'allongement hypertrophique du col utérin.

BACKGROUND: The aim of the study was to evaluate the safety and efficacy of the Musset Poitout surgical procedure consisting in an anterior uterosacral ligament transposition and a cervix amputation. The main indication is an uterovaginal prolapse with an isolated elongation of the cervix. METHODS: A retrospective consecutive series of 20 women with an elongation of uterine cervix undergoing Musset Poitout procedure over a 10 year period between 1990 and 2001 with analysis of per and post operative complications and success. Four Kelly urethral plications were performed in the same time. The patient's ages, time under anesthesia, change in hemoglobin, days of hospitalization, medical illnesses, complications and follow-up were assessed. Failure was defined as a symptomatic elongation of the cervix or a third degree hysterocele on examination. RESULTS: and discussion. The median age of Musset Poitout procedure was 43.9 years (range 23-83). General anaesthesia could be performed in all patients. Mean operation time was 67 minutes (range 40-130). No major per or post operative complications occurred. The average of post-operative bladder cathetherisation was 3.65 days, the average hospital stay was 6.3 days. Complications were insignificant: urinary tract infection in 2, voiding dysfunction in 2. All the patients but 2 were followed for a mean 59 months (range 6-127). There was one recurence (5.5%). CONCLUSION: In this preliminary assessment the Musset Poitout procedure offered significant avantages in a genital prolapse with elongation of the cervix.

Utero-vaginal anastomosis in women with uterine cervix atresia: long-term follow-up and reproductive performance. A study of 18 cases.

BACKGROUND: Atresia of the uterine cervix is an uncommon Müllerian anomaly. Total hysterectomy remains the classical treatment of this malformation. The purpose of this study was to evaluate functional results and reproductive performance of women who had conservative surgical procedure. METHODS AND RESULTS: The medical records of 18 patients admitted to our centre between 1969 and 1998 for the treatment of uterine cervix atresia, were reviewed. Seven women had an associated high vaginal aplasia. Fifteen women had a history of abdominal or pelvic surgery before referral, with an unsuccessful attempt at canalization in five cases. Associated pelvic endometriosis or adhesions were observed in 12 cases. The utero-vaginal anastomosis procedure was performed successfully in all cases. A secondary stenosis of the anastomosis occurred in one case and this required canalization. Median follow-up after surgery was 4.5 years. Sexual intercourse was satisfactory for the 12 patients who began sexual activity. Ten patients had a pregnancy, four of which resulted in a total of six successful spontaneous pregnancies. Of the six remaining women, five had an evident cause of infertility. CONCLUSIONS: Utero-vaginal anastomosis should be proposed in women with congenital atresia of the uterine cervix, even when it is associated with vaginal aplasia. Early diagnosis and surgery appear necessary to avoid the development of pelvic associated lesions.

Paget's disease of the vulva: results of different conservative treatments.

OBJECTIVE: To evaluate three conservative treatments for vulvar Paget's disease: wide excision, laser alone, or limited surgery associated with laser. STUDY DESIGN: A retrospective analysis of 52 patients treated with wide excision (31 cases), limited surgery, and peripheral laser [Br J Obstet Gynecol 1995;102:359], or laser alone [Gynecol Oncol 1975;3:46]. RESULTS: Mean time to recurrence was 1+/-0.6 years after laser alone, 1.9+/-1.5 years after the association limited excision and peripheral laser, and 2.7+/-1 years after wide excision alone. At 1 year recurrence rates were 67% after laser alone, 33% after the association laser plus surgery, and 23% after wide excision. CONCLUSION: Conservative management preserves vulvar anatomy and function, but recurrence rates are high.

Failure of serum beta2-microglobulin levels as an early marker of preeclampsia.

OBJECTIVE: Our purpose was to determine whether second-trimester maternal serum beta(2)-microglobulin levels could be used to predict subsequent development of preeclampsia. STUDY DESIGN: We first did a cross-sectional study to compare serum concentrations of beta(2)-microglobulin between women with preeclampsia and normotensive women. Serum beta(2)-microglobulin concentrations of 11 consecutive patients hospitalized for preeclampsia were compared with those of 11 normotensive women hospitalized for threatened premature labor. The second part of the study consisted of a nested case-control study in which each woman in whom preeclampsia ultimately developed was matched with 2 women who remained normotensive throughout gestation. For that purpose a total of 450 consecutive healthy nulliparous women were studied prospectively. Blood samples were collected between 20 and 24.9 weeks' gestation and frozen at -20 degrees C until assay after groups had been selected. RESULTS: In the cross-sectional study serum beta(2)-microglobulin levels were significantly higher in women with preeclampsia than in control women (1.87 +/- 0.36 mg/L vs 1.01 +/- 0. 12 mg/L; t = 7.61; P <.0001). Among the 450 women who were followed up prospectively, preeclampsia developed in 7 (1.5 %). Fourteen of the women who remained normotensive were matched with the 7 women in whom preeclampsia ultimately developed. No difference was found in early serum beta(2)-microglobulin concentrations between women in whom preeclampsia subsequently developed and those who remained normotensive throughout gestation (1.02 +/- 0.12 vs 0.95 +/- 0.12 mg/L). CONCLUSIONS: Serum beta(2)-microglobulin levels do not predict subsequent preeclampsia.