Isthmoceles - Accuracy of imaging diagnosis and clinical correlation with histology: A prospective cohort study.

Background: Isthmoceles are a growing clinical concern. Objectives: To evaluate the accuracy of diagnosis of isthmoceles by imaging and to correlate the dimensions with clinical symptoms and histopathology. Materials and Methods: Prospective study of women (n=60) with ≥1 C-section undergoing hysterectomy. Isthmoceles were measured by imaging before surgery and macroscopically on the specimen after hysterectomy, followed by histological analysis. Main outcome measures: Accuracy of isthmocele diagnosis, correlation with clinical symptoms, and histopathological findings. Result: By imaging, isthmoceles were slightly deeper (P=0.0176) and shorter (P=0.0045) than macroscopic measurements. Differences were typically small (≤3mm). Defined as an indentation of ≥2 mm at site of C-section scar, imaging diagnosed 2 isthmoceles consequently not seen by histology and missed 3. Number of prior C-sections increased isthmocele severity but neither the incidence nor the remaining myometrial thickness (RMT) did. Severity correlated positively with symptoms and histology. However, clinical use was limited. Histological analysis revealed presence of thick wall vessels in 100%, elastosis in 40%, and adenomyosis in 38%. Isthmocele lining was asynchronous with the menstrual phase in 31%. Conclusions: Dimensions of isthmoceles by imaging were largely accurate with occasionally large differences observed. Number of C-sections did not increase isthmocele incidence, only severity. Indication for surgery remains clinical, considering dimensions and symptoms. What is new?: Dimensions of isthmoceles should be confirmed before surgery since uterine contractions might change those dimensions. Symptoms increase with dimensions of isthmoceles but are not specific. Endometrial lining within the isthmocele can be asynchronous with the menstrual phase.

Oxidised cellulose-based reaction mimicking a suspicious ovarian mass: a case report and a systematic review.

Oxidised regenerated cellulose was introduced 60 years ago to control diffuse bleeding from large surfaces. Although considered safe and effective, foreign body reactions can mimic suspicious masses in several organs. We describe the third case, reported in PubMed, of an oxidised regenerated cellulose-based granuloma mimicking a suspicious ovarian tumour on MRI. During surgery, the diagnosis was suspected by granulomatous tissue and confirmed by pathology. The follow-up after the excision was uneventful. Although a rare complication, physicians should be aware of this presentation and of the recommendation to remove excess Surgicel after the bleeding has stopped.

The importance of rotation to teach secure half-hitch sequences in surgery.

Background: Knot security of half-knot (H) sequences varies with rotation, but half-knots risk destabilisation. Objectives: To investigate the rotation of half-hitch (S) sequences on knot security. Materials and Methods: The loop and knot security of symmetrical and asymmetrical sliding and blocking half-hitch sequences was measured using a tensiometer. Results: Loop security of symmetrical sliding half-hitch sequences is much higher than asymmetrical sequences, increasing from 6+2 to 21+2 and from 27+6 to 48+5 Newton (N) for 2 and 4 half-hitches respectively (both P<0.0001). Symmetrical sliding sequences are more compact and remain in the same plane, squeezing the passive thread, while asymmetrical sequences rotate loosely around the passive end. Blocking sequences are superior when asymmetrical since changing the passive end acts like changing rotation, transforming the asymmetrical sliding into a symmetrical blocking half-hitch on the new passive thread. The knot security of 2 sliding and 1 blocking half-hitch doubles from 52+3 to 98+2 N for the worst (asymmetric sliding and symmetric blocking, SSaSsb) or best rotation sequences (SSsSab). Adding a second asymmetric blocking half-hitch (Sab) increases security further to 105+3 N. The overall knot security of four-throw, correctly rotated, half-hitch (SSsSabSab) or half-knot (H2H1sH1s, H2H2a and H2H2s) sequences is similar for four suture diameters. Conclusion: Rotation affects the security of half-hitch sequences, which should be symmetrical when sliding, and asymmetrical when blocking. What is new?: Half-hitch sequences are clinically superior to half-knot sequences. They do not risk destabilisation, and loop security improves approximation of tissues under traction, permitting tight knots.

A proof of concept that experience-based management of endometriosis can complement evidence-based guidelines.

Background: Management of endometriosis should be based on the best available evidence. The pyramid of evidence reflects unbiased observations analysed with traditional statistics. Evidence-based medicine (EBM) is the clinical interpretation of these data by experts. Unfortunately, traditional statistical inference can refute but cannot confirm a hypothesis and clinical experience is considered a personal opinion. Objectives: A proof of concept to document clinical experience by considering each diagnosis and treatment as an experiment with an outcome, which is used to update subsequent management. Materials and Methods: Experience and knowledge-based questions were answered on a 0 to 10 visual analogue scale (VAS) by surgery-oriented clinicians with experience of > 50 surgeries for endometriosis. Results: The answers reflect the collective clinical experience of managing >10.000 women with endometriosis. Experience-based management was overall comparable as approved by >75% of answers rated ≥ 8/10 VAS. Knowledge-based management was more variable, reflecting debated issues and differences between experts and non-experts. Conclusions: The collective experience-based management of those with endometriosis is similar for surgery-oriented clinicians. Results do not conflict with EBM and are a Bayesian prior, to be confirmed, refuted or updated by further observations. What is new?: Collective experience-based management can be measured and is more than a personal opinion. This might extend EBM trial results to the entire population and add data difficult to obtain in RCTs, such as many aspects of surgery.

Reconsidering evidence-based management of endometriosis.

Background: Without an adequate animal model permitting experiments the pathophysiology of endometriosis remains unclear and without a non-invasive diagnosis, information is limited to symptomatic women. Lesions are macroscopically and biochemically variable. Hormonal medical therapy cannot be blinded since recognised by the patient and the evidence of extensive surgery is limited because of the combination of low numbers of interventions of variable difficulty with variable surgical skills. Experience is spread among specialists in imaging, medical therapy, infertility, pain and surgery. In addition, the limitations of traditional statistics and p-values to interpret results and the complementarity of Bayesian inference should be realised. Objectives: To review and discuss evidence in endometriosis management. Materials and Methods: A PubMed search for blinded randomised controlled trials in endometriosis. Results: Good-quality evidence is limited in endometriosis. Conclusions: Clinical experience remains undervalued especially for surgery. What is new?: Evidence-based medicine should integrate traditional statistical analysis and the limitations of P-values, with the complementary Bayesian inference which is predictive and sequential and more like clinical medicine. Since clinical experience is important for grading evidence, specific experience in the different disciplines of endometriosis should be used to judge trial designs and results. Finally, clinical medicine can be considered as a series of experiments controlled by the outcome. Therefore, the clinical opinion of many has more value than an opinion.

The severity and frequency distribution of endometriosis subtypes at different ages: a model to understand the natural history of endometriosis based on single centre/single surgeon data.

Background and Objective: to study the natural history of endometriosis. Materials and methods: the analysis of all women (n=2086) undergoing laparoscopy for pelvic pain and endometriosis between 1988 and 2011 at University Hospital Gasthuisberg. Main outcome measures: the severity of subtle, typical, cystic and deep endometriosis in adult women, with or without a pregnancy, as estimated by their pelvic area and their volume. Results: the number of women undergoing a laparoscopy increased up to 28 years of age and decreased thereafter. Between 24 and 44 years, the severity and relative frequencies of subtle, typical, cystic and deep lesions did not vary significantly. The number of women younger than 20 years was too small to ascertain the impression of less severe lesions. The severity of endometriosis lesions was not less in women with 1 or more previous pregnancies or with previous surgery. There was no bias over time since the type and severity of endometriosis lesions remained constant between 1988 and 2011. Conclusions: severity of endometriosis does not increase between 24 and 44 years of age, suggesting that growth is limited by intrinsic or extrinsic factors. Severity was not lower in women with a previous pregnancy. What is new: considering the time needed for lesions to become symptomatic together with the diagnostic delay, the decreasing number of laparoscopies after age 28 is compatible with a progressively declining risk of initiating endometriosis lesions after menarche, the remaining women being progessively less susceptible.

Preoperative imaging of deep endometriosis: pitfalls of a diagnostic test before surgery.

The usefulness of a test is determined by the clinical interpretation of its sensitivity and specificity. The pitfalls of a test with a surgical endpoint are described in this article, taking the diagnosis of deep endometriosis by imaging as an example, without discussing the management of deep endometriosis. Laparoscopy is not a 100% accurate "gold standard". Since it is not performed in women without symptoms, results are valid only for the group of women as specified in the indication for surgery. The confidence limits of accuracy estimations widen when accuracy is lower and when observations are less. Since positive and negative predictive values are inaccurate when prevalence of the disease is low, prevalence figures in the group of women investigated should be available. The accuracy of imaging should be stratified by clinically important aspects such as localisation and size of the lesion. The use of other variables as soft markers during ultrasonographic examination should be specified. It should be clear whether the accuracy of the test reflects symptoms and clinical examination and imaging combined, or whether the accuracy of the added value of imaging which requires Bayesian analysis. When imaging is used as an indication for surgery, circular reasoning should be avoided and the number of symptomatic women not undergoing surgery because of negative imaging should be reported. In conclusion, imaging reports should permit the clinician to judge the validity of the accuracy estimations of a diagnostic test, especially when used as an indication for surgery and when surgery is the gold standard to diagnose a disease.

From complication to litigation: The importance of non-technical skills in the management of complications.

Complications do occur in daily clinical life and can sometimes lead to litigation, which adversely affect the entire health care system, leading to a loss of confidence in medical providers, an increase in defensive medical practice and high professional indemnity insurance costs. Some complications are inevitable but can be minimised by completing a structured training programme. The likelihood of litigation can be reduced when adequate and clear information is given to the patient preoperatively. Non-technical skills are essential in complication management and crucial if confronted with litigation. Checklists and documentation of medication and surgical steps should be routine in all surgeries. Awareness of the complexity of the planned operation, theatre set-up and equipment are important in preventing complications. Mental preparation of surgeons is of the utmost importance in order to be able to confront any problem. When complications occur, remaining calm, calling for assistance, effective team leadership and harmony in the team are important in managing the situation. Good and effective communication with the patient and relatives, offering explanations, apologies and timely intervention without delays reduce the risk of litigation and strengthen any defence in court.

Infection as a potential cofactor in the genetic-epigenetic pathophysiology of endometriosis: a systematic review.

BACKGROUND: The genetic-epigenetic theory postulates that endometriosis is triggered by a cumulative set of genetic-epigenetic (GE) incidents. Pelvic and upper genital tract infection might induce GE incidents and thus play a role in the pathogenesis of endometriosis. Thus, this article aims to review the association of endometriosis with upper genital tract and pelvic infections. METHODS: Pubmed, Scopus and Google Scholar were searched for 'endometriosis AND (infection OR PID OR bacteria OR viruses OR microbiome OR microbiota)', for 'reproductive microbiome' and for 'reproductive microbiome AND endometriosis', respectively. All 384 articles, the first 120 'best match' articles in PubMed for 'reproductive microbiome' and the first 160 hits in Google Scholar for 'reproductive microbiome AND endomytriosis' were hand searched for data describing an association between endometriosis and bacterial, viral or other infections. All 31 articles found were included in this manuscript. RESULTS: Women with endometriosis have a significantly increased risk of lower genital tract infection, chronic endometritis, severe PID and surgical site infections after hysterectomy. They have more colony forming units of Gardnerella, Streptococcus, Enterococci and Escherichia coli in the endometrium. In the cervix Atopobium is absent, but Gardnerella, Streptococcus, Escherichia, Shigella, and Ureoplasma are increased. They have higher concentrations of Escherichia Coli and higher concentrations of bacterial endotoxins in menstrual blood. A Shigella/Escherichia dominant stool microbiome is more frequent. The peritoneal fluid of women with endometriosis contains higher concentrations of bacterial endotoxins and an increased incidence of mollicutes and of HPV viruses. Endometriosis lesions have a specific bacterial colonisation with more frequently mollicutes (54%) and both high and medium-risk HPV infections (11%). They contain DNA with 96% homology with Shigella. In mice transplanted endometrium changes the gut microbiome while the gut microbiome influences the growth of these endometriosis lesions. CONCLUSIONS: Endometriosis is associated with more upper genital tract and peritoneal infections. These infections might be co-factors causing GE incidents and influencing endometriosis growth.

The definition of Endometriosis Expert Centres.

Endometriosis is a common condition that causes pain and infertility. It can lead to absenteeism and also to multiple surgeries with a consequent risk of impaired fertility, and constitutes a major public health cost. Despite the existence of numerous national and international guidelines, the management of endometriosis remains suboptimal. To address this issue, the French College of Gynaecologists and Obstetricians (CNGOF) and the Society of Gynaecological and Pelvic Surgery (SCGP) convened a committee of experts tasked with defining the criteria for establishing a system of care networks, headed by Expert Centres, covering all of mainland France and its overseas territories. This document sets out the criteria for the designation of Expert Centres. It will serve as a guide for the authorities concerned, to ensure that the means are provided to adequately manage patients with endometriosis.

Retroperitoneal primitive neuroectodermal tumor (PNET): case report and review of literature.

Primitive Neuroectodermal tumor belongs to the family of Ewing's tumor and is characterized by at (11;22) (q24;ql2) or at (21;22) (q22;ql2) translocation. Retroperitoneal primitive neuroectodermal tumor (PNET) are rare, usually affect young adults, and are often diagnosed late. There is no specific characteristics for imaging. The diagnosis is made on histological examination of the surgical spec- imen or biopsies. Radiotherapy and chemotherapy complete the treatment. The authors report the case of a 26-year-old patient who only had pelvic discomfort. Diagnostic laparoscopy showed a retroperitoneal and retrovesical mass of five centimeters. The patient benefited from adjuvant chemotherapy and radiotherapy. She is free of disease 30 months after treatment.

Obesity in laparoscopic surgery.

Since the 1980s, minimally invasive techniques have been applied to an increasing number and variety of surgical procedures with a gradual increase in the complexity of procedures being successfully performed laparoscopically. In the past, obesity was considered a contraindication to laparoscopy due to the higher risk of co-morbid conditions such as diabetes, hypertension, coronary artery disease and venous thromboembolism. Performing laparoscopic gynaecological procedures in morbidly obese patients is no longer a rare phenomenon; however, it does necessitate changes in clinical practice patterns. Understanding of the physiological changes induced by laparoscopy, particularly in obese patients, is important so that these may be counteracted and adverse outcomes avoided. Laparoscopy in obese patients confers certain advantages such as shorter hospital stay, less post-operative pain and fewer wound infections. In addition to these benefits, minimal-access surgery has been demonstrated as safe and effective in obese patients; however, specific surgical strategies and operative techniques may need to be adopted.

Excellence needs training "Certified programme in endoscopic surgery".

The complexity of modern surgery has increased the demands and challenges to surgical education and quality control. Today the endoscopic approach is preferred because it increases the surgical possibilities and decreases patient discomfort. Implementing endoscopic surgery without specific training leads to decrease in surgical performance and increase in patient morbidity and mortality. Research of the European Academy for Gynaecological Surgery (+he Academy) has resulted in the establishment of a structured certification and diploma programme with three levels of expertise. One level should be passed to obtain access to the next level. Furthermore one should first pass +he Academy skill exam before entering the clinical surgical competence programme. The European Society for Gynaecological Endoscopy (ESGE) has defined the different diplomas, whereas the Bachelor diploma is seen as a prerequisite to start the in OR one to one clinical training aiming to provide endoscopic skilled individuals to the clinical one to one training. Further diplomas are the Minimal invasive Gynaecological Surgeon (MIGS), master in hysteroscopy and the laparoscopic pelvic surgeon. This programme is based on the best available scientific evidence. It counteracts the problem of the traditional surgical apprentice tutor model and increases patient safety and surgical performance. It is seen as a major step toward standardization of endoscopic surgical training in general.

[PROSPERE randomized controlled trial: laparoscopic sacropexy versus vaginal mesh for cystocele POP repair]. / Étude randomisée comparant la promontofixation cœlioscopique à la chirurgie prothétique par voie vaginale pour le traitement des cystocèles : PROSPERE (PROSthetic PElvic organ prolapse REpair).

BACKGROUND: Cystocele is a frequent and invalidating type of genital prolapse in woman. Sacropexy using synthetic mesh is considered the surgical gold standard, and the laparoscopic approach has supplanted the open abdominal route because it offers the same anatomical results with a lower morbidity. The use of mesh through the vaginal route may have many advantages: easiness to perform, shorter operative time and recovery, but may increase morbidity. In France, both laparoscopic sacropexy and vaginal mesh are commonly used to treat cystoceles. The French Haute Autorité de santé (HAS) has highlighted the lack of evaluation of safety assessment for vaginal meshes. METHOD/DESIGN: The main objective of the study is to compare the morbidity of laparoscopic sacropexy with vaginal mesh for cystocele repair. The primary endpoint will be the rate of surgical complications greater or equal to grade 2 of the Clavien-Dindo classification at 1-year follow-up. The secondary aims are to compare the functional results in the medium term (sexuality, urinary and bowel symptoms, pain), the impact on quality of life as well as anatomical results. PROSPERE is a randomized controlled trial conducted in 12 participating French hospitals. 262 patients, aged 45 to 75years old, with cystocele greater or equal to stage 2 of the POP-Q classification (isolated or not) will be included. Exclusion criterias are a previous surgical POP repair, and inability or contra-indication to one or the other technique. We have designed this study to answer the question of the choice between laparoscopic sacropexy and vaginal mesh for the treatment of cystocele. The PROSPERE trial aims to help better determine the indications for one or the other of these techniques, which are currently based on subjective choices or school attitudes. This is the reason why competent authorities have asked for such studies.

Are you good enough for your patients? The European certification model in laparoscopic surgery.

Quality control, training and education in gynaecological surgery are challenged and urgent measures are emerging. The implementation of a structured and validated program for training and quality control seems the most urgent measurement to be taken. The European Academy of Gynaecological Surgery has made a first attempt to do so. Through a practical and theoretical tests system, the skills of an individual surgeon is measured and the conditions to enter the different level of expertise are clearly defined. This certification system based on the best possible level of scientific evidence provides a first practical tool, universally implementable for a decent quality control and structured training program in Gynaecological laparoscopic surgery.

[Postoperative abdominal adhesions and their prevention in gynaecological surgery: II. How can they be prevented?]. / Adhérences postopératoires et leur prévention en chirurgie gynécologique : II. Comment les prévenir ?

This paper is the second of a two-part publication. The initial paper provided a comprehensive overview of the evidence on adhesions to allow gynaecological surgeons to be best informed on adhesions, their development, impact on patients, health systems and surgical outcomes. There is rising evidence that surgeons can take important steps to reduce the burden of adhesions. In this second paper, we review the various strategies to reduce the impact of adhesions, improve surgical outcomes and provide some practical proposals for action on adhesions. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. They should be considered for use particularly in high-risk surgery and in patients with adhesiogenic conditions. Further research into new strategies to prevent adhesions more effectively through an improved surgical environment, new and combination devices and pharmacological agents should be encouraged. Formal recommendations would ensure better prioritisation of adhesion-reduction within the French health system. Patients should also be better informed of the risks of adhesions.

[Postoperative abdominal adhesions and their prevention in gynaecological surgery: I. What should you know?]. / Adhérences postopératoires et leur prévention en chirurgie gynécologique : I. Ce qu'il faut savoir.

Adhesions are the most frequent complications of abdominopelvic surgery, causing important short- and long-term problems, including infertility, chronic pelvic pain and a lifetime risk of small bowel obstruction. They also complicate future surgery with increased morbidity and mortality risk. They pose serious quality of life issues for many patients with associated social and healthcare costs. Despite advances in surgical techniques, including laparoscopy, the healthcare burden of adhesion-related complications has not changed in recent years. Adhesiolysis remains the main treatment although adhesions reform in many patients. The extent of the problem of adhesions has been underestimated by surgeons and the health authorities. There is rising evidence however that surgeons can take important steps to reduce the impact of adhesions. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. This paper is the first of a two-part publication providing a comprehensive overview of the evidence on adhesions to allow gynaecological surgeons to be best informed on adhesions, their development, impact on patients, health systems and surgical outcomes. In the second paper we review the various strategies to reduce the impact of adhesions and improve surgical outcomes to assist fellow surgeons in France to consider the adoption of adhesion reduction strategies in their own practice.

Management of deep endometriosis.

Deep endometriosis is still a challenging disease in terms of diagnosis and treatment. About 10-12% of women of reproductive age will have a form of endometriosis. This can affect pelvic as well as extra pelvic locations. Risk of malignant transformation has been studied over a long period of time. Medical and surgical treatments can be proposed to patients for endometriosis-associated pain depending on the severity of symptoms and location of the disease. Results and outcomes are different according to different publications. Understanding of the benefit of surgical treatment on fertility is increasing. The place of medical and surgical treatment in recurrent symptoms or disease is also of interest. Presented here is a review on the management of endometriosis in the light of recent data. Further investigations in many fields of endometriosis are still required.

Setting up robotic surgery in gynaecology: the experience of the Strasbourg teaching hospital.

Teleoperated surgical robots could provide a genuine breakthrough in laparoscopy and it is for this reason that the development of robot-assisted laparoscopy is one of the priorities of the Strasbourg University Hospitals' strategic plan. The hospitals purchased a da Vinci S(®) robot in June 2006 and Strasbourg has, in IRCAD, one of the few robotic surgery training centres in the world. Our experience has, however, revealed the difficulties involved in setting up robotic surgery, the first of which are organizational issues. This prospective work was carried out between December 2007 and September 2008, primarily to examine the possibility of setting up robotic surgery on a regular basis for gynaecological surgical procedures at the Strasbourg University Hospitals. We maintained a "logbook" in which we prospectively noted all the resources implemented in setting up the robotic surgery service. The project was divided into two phases: the preparatory phase up until the first hysterectomy and then the second phase with the organization of subsequent hysterectomies. The first surgical procedure took 5 months to organize, and followed 25 interviews, 10 meetings, 53 telephone conversations and 48 e-mails with a total of 40 correspondents. The project was presented to seven separate groups, including the hospital medical commission, the gynaecology unit committee and the surgical staff. Fifteen members of the medical and paramedical team attended a two-day training course. Preparing the gynaecology department for robotic surgery required freeing up 8.5 days of "physician time" and 12.5 days of "nurse time". In the following five months, we performed five hysterectomies. Preparation for each procedure involved on average 5 interviews, 19 telephone conversations and 11 e-mails. The biggest obstacle was obtaining an operating slot, as on average it required 18 days, four telephone calls and four e-mails to be assigned a slot in the operating theatre schedule, which is prepared on average 28 days in advance. It is extremely important for organising robotic surgery and assembling the surgical teams to have a series of operating slots allocated a sufficiently long time in advance. Considerable benefits would be had by setting up a team of anaesthetists and especially perioperative nurses dedicated to robotic surgery.