[Robotic surgery program in gynecology: Lessons from the first 100 procedures]. / Implantation d'un programme de chirurgie robotique gynécologique : leçons à retenir des 100 premières procédures.

INTRODUCTION: The objective of this work is to report the first 6 months of a robotic program in a surgical gynecological team, trained in advanced laparoscopy, in terms of operating times, complication rate, analgesic consumption and average duration of hospitalization. METHODS: This is a prospective observational study, intended to treat. RESULTS: During the study period, 98 women underwent laparoscopic robot assisted surgery. The average BMI was 27.2kg/m2 (±7). Malignant diseases accounted for 41% of operative indications. Comparing the first 30 procedures to the last 30 procedures, there is a significant decrease in docking times: 14.7min (±7.0) vs 8.9min (±5.0), P=0.009. There is also a trend towards a decrease in operative times for hysterectomy: 151.9min (±56.2) vs 113min (±51.4), P=0.08. The rates of complications were not significantly different at the beginning and end of inclusion during the study (10.0% vs 16.7%). CONCLUSION: The implementation of a robotic surgery program in a gynecological surgery department does not lead to an increase in complications for the patients, including for the first procedures. The learning curve mainly allows a reduction in the robot's installation time.

[Medical treatment of ectopic pregnancy: a randomized clinical trial comparing metotrexate-mifepristone and methotrexate-placebo]. / Traitement médical des grossesses extra-utérines: un essai clinique randomisé comparant méthotrexate-mifépristone et placebo-méthotrexate.

BACKGROUND: Medical treatment of ectopic pregnancy is widespread. To increase the efficacy of methotrexate, combination with mifepristone has been proposed. METHODS: We performed a large prospective multicentre double-blind sequential randomized trial in order to compare the efficacy of methotrexate and mifepristone (600 mg given orally) versus methotrexate and placebo. RESULTS: Two hundred twelve ectopic pregnancies were randomized. There was no significant difference in the initial characteristics between the 2 groups. There was no significant difference in the success rate of medical treatment between the methotrexate-mifepristone (n=113) and the methotrexate-placebo group (n=99): 79.6% (90/113) vs 74.2% (72/97) respectively, RR [95% CI]: 1.07 [0.92-1.25], p=0.41. However, there was a quantitative interaction between progesterone level and effect of treatment: when progesterone level was 10 ng/l, the efficacy of the combination of mifepristone and methotrexate was significantly higher than the combination of methotrexate and placebo, with a 83.3% success rate (15/18) vs 38.5% (5/13) respectively. CONCLUSION: Our study failed to demonstrate any benefit of the addition of mifepristone to methotrexate. By contrast, the quantitative interaction between treatment effect and base line serum progesterone suggested that this combination could be reserved to ectopic pregnancies associated with high serum progesterone concentrations.

High prevalence of cervical intra-epithelial neoplasia in women treated for pelvic inflammatory disease.

Because human papillomavirus (HPV) is sexually transmitted, as are pelvic inflammatory disease (PID) agents, the authors investigated whether cervical intra-epithelial neoplasia (CIN) are more frequent in women under treatment for PID. The study involved 298 patients hospitalized for PID, in whom CIN were investigated by smears and colposcopy. CIN were diagnosed in 42 patients, i.e. in 14% of patients: 21 low-grade CIN and 21 high-grade CIN, including one case of early-stage microinvasion. These figures are to be compared to the 0.5-4% of pre-cancerous lesions found in the general population. Screening smears are frequently inaccurate and direct colposcopy appeared preferable. No clinical study of this type has been published before, but certain authors have mentioned a high CIN incidence in patients with PID histories or followed up in sexually transmitted disease centers. These results show that CIN are more frequent in patients treated for PID; CIN should be investigated systematically in this population.

[Value of screening for cervical intraepithelial neoplasia in women treated for adnexitis]. / Intérêt de la recherche des néoplasies intra-épithéliales du col utérin chez les femmes traitées pour annexite.

OBJECTIVE: To demonstrate that women treated for PID constitute a population with a specially high incidence of cervical intraepithelial neoplasia (CIN) and who should be screened for CIN. POPULATIONS AND METHODS: Retrospective, non-comparative study of 260 patients treated for PID in the Gynecology-Obstetrics Department of Hôtel-Dieu hospital in Rennes (France) from December 1st, 1989 to May 31st, 1996. CIN screening was performed by smear tests and colposcopy. RESULTS: Cervical lesions were detected in 39 patients (15%): five CIN 3 (including one early-stage microinvasion), twelve CIN 2 and 22 CIN 1 and/or condylomas, i.e., 6.5% high grade and 8.5% low grade lesions. Colposcopy in this case proved to be more effective than smears for screening. DISCUSSION: According to epidemiological studies, sexual behavior is a major risk factor of CIN, due to the role played by sexually transmissible human papillomavirus in their pathogenesis. Because the main risk factor of PID is sexual activity, it is likely that CIN are more frequent in women with PID. Our study clearly established that fact because the prevalence of CIN in the general population is only 0.5 to 4% according to literature reports. CONCLUSION: We are in favor of CIN screening in women treated for PID, and in our view colposcopy is the preferred method.

Diagnosis and therapy for ampullary tumors: 63 cases.

From 1970 to 1992 a total of 63 patients underwent operation for ampullary tumor: 40 pancreatoduodenectomies (PDs), 3 total PDs, 8 ampullectomies, and 12 bypass or exploratory laparotomies. The resectability rate was 68%. There were 9 benign tumors, 1 anaplastic tumor, and 53 adenocarcinomas. According to Martin's classification, there were 7 stage I, 11 stage II, 14 stage III, and 21 stage IV tumors. All patients with stage I, II, and III tumors underwent resection. Patients with stage IV tumors had either resection (n = 11) or bypass (n = 10). The mean duration of hospital stay was 20.6 days. Operative mortality was 12.7% for the whole series and 7.5% after PD (2.5% for the last 10 years). Overall survival was 40% at 5 years (85% for stage I, 65% for stage II, 44% for stage III, and 8% for stage IV). Survival was better for stages I, II, and III after PD than after ampullectomy. For stage IV patients survival was 70% after PD versus 20% after bypass at 1 year and 25% versus 0% after 2 years. In our opinion, PD should be proposed even for benign lesions because two of our patients had to undergo repeat operation (PD) 4 and 22 years later, respectively, for stage IV disease. PD is our choice for all tumors of the ampulla.