[Vaginal flap for rectovaginal fistulae in Crohn's disease]. / Traitement des fistules recto-vaginales de la maladie de Crohn par lambeau d'avancement vaginal.

OBJECTIVES: To evaluate efficacy and functional results (sexual activity) of vaginal flap for rectovaginal fistula in Crohn's disease. PATIENTS AND METHODS: From May 2004 to March 2008, we proposed a vaginal flap in patients who had a rectovaginal fistula in Crohn's disease and for which rectal flap was technically impossible. Monitoring included a clinical examination at 1 month and every 3 months for 1 year, Perianal Disease Activity Index for sexual activity evaluation. Every year and in April 2009 the nursing team during a telephone interview filled a standardized questionnaire. RESULTS: We treated 5 patients. At 6 months, 4 of 5 patients were healed. At 7 months, 1 patient presented a new flare up of CD with reopening of the fistula. The other 3 patients were still healed at a median follow-up of 30.66 months (15 to 59). One patient presented dyspareunia during 3 months. DISCUSSION AND CONCLUSION: Vaginal flap is an effective technique that entails neither prolonged dyspareunia nor fecal incontinence. Stoma is not systematic.

Respective consequences of abdominal, vaginal, and laparoscopic hysterectomies on women's sexuality.

OBJECTIVE: To determine the relative effects of abdominal, vaginal or laparoscopic approaches for hysterectomy on female sexuality. STUDY DESIGN: One hundred and seventy women who underwent abdominal (n=68), vaginal (n=67), and laparoscopic (n=35) hysterectomy for benign disease were studied. Pre- and postoperative sexuality was assessed by questionnaire. RESULTS: Overall, sexuality after hysterectomy remained unchanged in 60.4% of cases, and improved or deteriorated in 21.3 and 18.3%, respectively. Postoperative delay in resuming sexual activity was shorter after vaginal (45.2+/-6.7 days) hysterectomy than after abdominal hysterectomy (62.4+/-9.3 days). Deterioration of sexual function occurred more frequently after abdominal hysterectomy (24%) than after vaginal (13.5%) or laparoscopic (8.5%) hysterectomy. CONCLUSION: These results indicate that the impact of vaginal and laparoscopic hysterectomy on women's sexuality may be milder than that of abdominal hysterectomy.

Intraoperative testosterone assay for virilizing ovarian tumor topographic assessment: report of a Leydig cell tumor of the ovary in a premenopausal woman with an adrenal incidentaloma.

Ovarian virilizing tumors are rare and can lead to assessment difficulties because of their small size. A 41-yr-old female was referred for evaluation of hirsutism that had increased within the previous 3 yr. Menstrual cycle length was normal. Plasma testosterone was 3.9 ng/ml (normal range, 0.2-0.8 ng/ml), was not suppressible by 2 mg dexamethasone (4.3 ng/ml), and was increased (6.3 ng/ml) after three daily injections of hCG (5000 IU). Abdominal computed tomography scan showed an adrenal nodule (13 x 6 mm) that remained unchanged after 3 months. Ultrasound examination of the pelvis was normal. Ovarian and adrenal venous catheterization did not yield additional information. Topographic assessment was made by intraoperative measurement of testosterone in the samples taken from each ovarian vein (competitive chemiluminescent immunoassay ADVIA Centaur; right ovarian vein, 105 ng/ml; left ovarian vein, 5 ng/ml; peripheral blood, 7 ng/ml). Right annexectomy resulted in normalization of testosterone levels (0.22 ng/ml). Histopathological examination found a Leydig cell tumor of hilar type (1.5 cm). This observation illustrates the usefulness of intraoperative measurement of testosterone by a rapid automated technique for topographic assessment of ovarian virilizing tumor in premenopausal women.

[Ureteral and vesicular endometriosis: case report]. / Endométriose urétérale et vésicale: à propos d'une observation.

The authors report a case of both vesical and ureteral endometriosis diagnosed after recurrent acute pyelonephitis. A Gonadotrophin-Releasing Hormone (GnRH) agonist therapy and a conservative endoscopic management is started allowing an almost complete regression of the lesions. A review of the literature is presented about this unexceptional localisation of endometriosis (1 to 2% of all endometriosis).

[Vaginal hysterectomy in fibroma. Apropos of 453 cases. Retrospective comparison with 509 cases of abdominal hysterectomy]. / Hystérectomie vaginale pour fibrome. A propos de 453 cas. Comparaison rétrospective à 509 hystérectomies abdominales.

The authors present a series of 962 hysterectomies for fibroma carried out between January 1981 and December 1995 in the Department of Gynecology and Obstetrics of CHU Toulouse-La Grave. They carried out 453 vaginal hysterectomies and 509 abdominal hysterectomies. They compared the largest series reported in the literature, between vaginal and abdominal technique. The vaginal route has the obvious advantages of speed of operation, less operative trauma, lower risk of thrombo-embolic disease and the hospital stay is shorter. Laparoscopic assistance allows to extend indications of vaginal route.

[Ovarian cancer and pregnancy]. / Cancer de l'ovaire et grossesse.

The authors report 6 cases of carcinoma of the ovary presenting during pregnancy in the Department of Gynecology and Obstetrics of La Grave University Hospital, Toulouse, between 1972 and 1994. Analysis of this series is followed by a review of the literature which reveals that carcinoma of the ovary fortunately remains a rare event during pregnancy. All reported series conclude that the diagnosis is made at an early stage. Management depends in great part on the age of the pregnancy and stage of malignancy. During the first 6 months, immediate surgery is essential, with sacrifice of the pregnancy, except at stage IA1. During the final 3 months, surgery is delayed until fetal maturity. This classical attitude is currently being questioned. This classical attitude is currently being questioned. Some teams feel that conservative treatment followed by chemotherapy is possible, thereby preserving the pregnancy. The choice of the couple must always be taken into account when making these management decisions.

[Tamoxifen and cervico-vaginal cytology]. / Tamoxifène et frottis cervico-vaginal.

The impact of tamoxifen on the genital tract was assessed by cervico-vaginal cytology. Fifty two post-menopausal patients treated with tamoxifen for breast cancer were regularly monitored, with a pre-treatment reference smear showing a profoundly menopausal status, followed by an anual smear. Smears returned to a functional status in 44% of patients after 2 to 5 years treatment. The agonist effect of tamoxifen appears to be beyond any doubt, and responsible for certain adverse reactions. This should not bring into question the usefulness of the drug, but indicates the need for regular monitoring and, in the presence of a functional smear, further investigation by vaginal ultrasonography is essential in order to evaluate the status of the endometrium.

Influence of ovarian cysts on the results of in vitro fertilization.

OBJECTIVE: To determine if ovarian cysts are associated with a particular basal endocrine profile and impair follicular growth. DESIGN: Retrospective study. SETTING: In Vitro Fertilization (IVF) Center. PATIENTS: Nine hundred fourteen stimulation cycles stimulated with a combination of luteinizing hormone-releasing hormone analogues (LH-RH-a) and human menopausal gonadotropins (hMG) in a long protocol in an IVF program. RESULTS: After 15 days of LH-RH-a therapy, ovarian cysts (> or = 20 mm) were observed in 8% of cases. These cysts were not related to a particular basal endocrine profile and did not impair follicular growth and IVF results. However, puncturing these cysts enhanced the quality of subsequent follicular growth. On the contrary, cysts appearing during hMG treatment (> or = 25 mm) were related with a lower LH:follicle-stimulating hormone ratio (0.79 +/- 0.52 versus 0.92 +/- 0.74 in absence of cyst) and to a lower ovarian response as assessed by the maximal estradiol level to the total number of hMG ampules ratio (51.6 +/- 36.5 versus 65.9 +/- 47.9 in absence of cyst). However, this difference had no influence on the pregnancy per stimulation rate (18% versus 16% in absence of cyst; not significant). CONCLUSIONS: Results show that the pathogens of ovarian cysts appearing during the blockage phase and during the stimulation phase are different. However, they do not impair the results of IVF, and thus it is not necessary to cancel the attempt in case of ovarian cyst.

Paradoxical ovarian stimulations in the use of LHRH analogs.

In the case of in vitro fertilization, LHRH analogs are used to induce an hypophysary blockage, before the phase of stimulation, via administration of exogenous gonadotropin. During in vitro fertilization attempts using LHRH analogs, the blockage is controlled after 14 days of treatment through measurement of the plasmatic estradiol and pelvic ultra-sonography. In this retrospective study, which concerned 1075 in vitro fertilization cycles, a paradoxical ovarian stimulation with LHRH analogs was observed in 93 cases (8.7%), with high estradiol levels and follicular growth (detected by ultra-sonography), in spite of low FSH and LH levels. In 4 cases, a follicular puncture was performed, which allowed to collect oocytes from which embryos were obtained, thus confirming the observed follicular growth and maturation. The most probable hypothesis explaining this phenomenon seems to be a direct ovarian stimulation, effectuated in vivo by LHRH analogs. This stimulation is only observed in certain patients, and apparently more frequently, with certain LHRH analogs, probably through a variation in the expression of ovarian LHRH receptors.

Paradoxical ovarian stimulations in the use of LHRH analogs.

In the case of in vitro fertilization, LHRH analogs are used to induce a hypophysial blockage before the phase of stimulation, via administration of exogenous gonadotropin. During in vitro fertilization attempts using LHRH analogs, the blockage is controlled after 14 days of treatment by measuring plasmatic estradiol and by pelvic ultrasonography. In this retrospective study, which concerned 1075 in vitro fertilization cycles, a paradoxical ovarian stimulation with LHRH analogs was observed in 93 cases (8.7%) with high estradiol levels and follicular growth (detected by ultrasonography), in spite of low FSH and LH levels. In 4 cases, a follicular puncture was performed, which made it possible to collect oocytes from which embryos were obtained, thus confirming the observed follicular growth and maturation. The most probable hypothesis explaining this phenomenon seems to be direct ovarian stimulation effectuated in vivo by LHRH analogs. This stimulation is only observed in certain patients, and, more frequently it seems, with certain LHRH analogs, which is probably due to a variation in the expression of ovarian LHRH receptors.

Randomized trial of three luteinizing hormone-releasing hormone analogues used for ovarian stimulation in an in vitro fertilization program.

OBJECTIVE: To determine if biochemical differences in luteinizing hormone-releasing hormone analogues (LH-RH-a) have a clinical influence, we studied three of these molecules: buserelin acetate (group B), triptorelin (group T), and leuprorelin (group L). DESIGN: Clinical trial. SETTING: In Vitro Fertilization (IVF) Center. PATIENTS: Two hundred forty-six patients, undergoing their first IVF attempt, were randomly allocated to one group. The analogues were used in a long protocol for ovarian stimulation in an IVF program. RESULTS: After 15 days of LH-RH-a therapy, the follicle-stimulating hormone level was lower in group B (2.9 +/- 1, 4.3 +/- 1.7, 4.8 +/- 2.1 UI/L for B, T, and L groups, respectively; P less than 0.001), although no difference was found in LH and estradiol (E2) levels. After follicular growth stimulation by human menopausal gonadotropins (hMG), E2 level was significantly lower in B group (1,799 +/- 1,101, 2,440 +/- 1,298, 2,137 +/- 1,044 pg/mL for B, T, and L groups, respectively; P less than 0.01), as well as the E2 level per hMG ampule (67 +/- 51, 97 +/- 61, 82 +/- 49 for B, T, and L groups respectively; P less than 0.01). The pregnancy per stimulated cycle rate was not significantly different among the groups. CONCLUSIONS: These results suggest that LH-RH-a could act not only on the pituitary but also on the ovaries. Moreover, these data suggest that buserelin acetate could be preferentially used for high responders and triptorelin for poor responders.

[Desmoid tumors of the anterior abdominal wall. Apropos of a case]. / Tumeurs desmoïdes de la paroi abdominale antérieure. A propos d'une observation.

The authors describe a case of a desmoid tumor of the anterior abdominal wall. From a review of the world literature, the main characteristics of these tumors are detailed, and the various pathophysiological hypotheses, demonstrating the necessity of exclusively surgical treatment, are presented.

[A new case of hydatidiform mole occurring on one of the ova of a twin pregnancy]. / Un nouveau cas de môle hydatiforme survenant dans l'un des oeufs d'une grossesse gémellaire.

The authors report here a new case of hydatid mole in one of the eggs of a mole pregnancy. 48 other cases have been reported in 13 publications. The birth of a viable, well-developed fetus is described in 13 instances (27%), fetal death in utero in 22 instances (46%), birth of a non-viable fetus 11 times (23%) and malignant degeneration twice (4%). Medical interruption of the pregnancy is indicated for the slightest sign of fetal anomaly or maternal complication. Prostaglandins may be used for that purpose. However, it is possible to let such a pregnancy follow its course.

[Evaluation of the economic burden in the respective indications of in vitro fertilization and tubal microsurgery at a regional hospital center]. / Evaluation du poids économique dans les indications respectives de la fécondation in vitro et de la microchirurgie tubaire dans un Centre Hospitalier Régional.

The authors have calculated the cost of obtaining and maintaining an intrauterine pregnancy to term by IVF and by tubal surgery according to the four classical indications. They have worked this out from local experience. The indications are: reversal of sterilization, surgery on proximal lesions, surgery on distal lesions and multifocal lesions. IVF is superior to surgery where the lesions are multifocal and possibly also in proximal blocks. But surgery is indicated in a large number of distal blocks and particularly in reversal of sterilization. The authors point out how difficult it is to extrapolate from national or international statistics. The choice must depend particularly on the experience of the local teams.

[HIV seropositivity and pregnancy. Apropos of 48 cases (how should they be managed at the present time?)]. / Séropositivité HIV et grossesse. A propos de 48 observations (quelle conduite à tenir pratique adopter aujourd'hui?)

We describe the gynaecological and obstetrical management of 48 HIV seropositive, pregnant women and review the literature. We did not find that pregnancy aggravated the development of the condition from the asymptomatic anti-HIV related complex (ARC) and AIDS. It seemed that fetal malformations, especially of the face, occurred most frequently in babies born to HIV seropositive mothers. Materno-fetal transmission of HIV was found in the uterus in 50% of our cases. In conclusion, we recommend safe contraception to prevent pregnancies in anti HIV seropositive women. If that fails, induced first trimester abortion is medically indicated and should be carried out if possible, as should strict medical control post-partum of both mother and child if the pregnancy is carried to term.

[Triploidy]. / La triploïdie.

Using their own experience which they described in 1984 and reviewing as well the literature of the condition since that time has led the authors to suggest that triploidy should be considered as a pathological entity with three clinical forms: early abortion, mid-trimester termination and the birth of triploidy fetuses either alive or dead. They discuss the clinical features, the ultrasound appearances, the pathological and anatomical details and the cytogenetics of triploidy. They differentiate this condition from trophoblast disease and from the central hydropic conditions which occur with normal caryotypes. They emphasize that there is a difference in the way classical molar pregnancy evolves and repeat again that the term "embryonic mole" should be avoided.

[Evaluation of systemic antibiotic preventive treatment in colorectal surgery]. / Appréciation de l'antibio-prophylaxie systémique en chirurgie colo-rectale.

A comparison was made of two methods of prophylactic antibiotic therapy against the septic complications of colonic and rectal surgery: --preoperative oral antibiotics associated with peroperative systemic antibiotics; --peroperative systemic antibiotics only, continued for 24 hours after surgery. Both types of antibiotic therapy were of short duration and were designed to cover aerobic and anaerobic organisms. Two groups of 30 patients were selected at random. They were homogeneous. The septic complication rate was 10% in the oral plus systemic and 24% in the systemic group. It is felt that the combination of oral and systemic antibiotics remains preferable, in particular bearing in mind the efficacy of oral metronidazole.