The anatomy of the sacrospinous ligament: how to avoid complications related to the sacrospinous fixation procedure for treatment of pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: Historically, the sacrospinous ligament (SSL) has been used to treat POP in order to restore the apical compartment through a posterior or an anterior vaginal approach. The SSL is located in a complex anatomical region, rich in neurovascular structures that must be avoided to reduce complications such as acute hemorrhage or chronic pelvic pain. The aim of this three-dimensional (3D) video describing the SSL anatomy is to show the anatomical concerns related to the dissection and the suture of this ligament. METHODS: We conducted a research of anatomical articles about vascular and nerve structures located in the SSL region, in order to increase the anatomical knowledge and show the best placement of sutures to reduce complications related to SSL suspension procedures. RESULTS: We showed the medial part of the SSL to be most suitable for the placement of the suture during SSL fixation procedures, in order to avoid nerve and vessel injuries. However, nerves to the coccygeus and levator ani muscle can course on the medial part of the SSL, the portion of the SSL where we recommended to pass the suture. CONCLUSIONS: Knowledge of the SSL anatomy is crucial and during surgical training it is clearly indicated to stay far away (almost 2 cm) from the ischial spine to avoid nerve and vascular injuries.

vNOTES Hysterectomy: What about Obese Patients?

STUDY OBJECTIVE: To compare the surgical outcomes of hysterectomy by vaginal natural orifice transluminal endoscopic surgery (vNOTES) for patients with body mass index (BMI) <30 and BMI ≥30. DESIGN: A retrospective cohort study. SETTING: A French teaching hospital. PATIENTS: All patients who underwent a vNOTES hysterectomy from February 2020 to January 2022 were included (N = 200). The vNOTES approach was chosen for all patients requiring a hysterectomy, unless the procedure was for endometriosis or cancer (except grade 1 endometrioid adenocarcinoma). INTERVENTIONS: Patients were categorized into 2 groups based on their BMI (<30 or ≥30 kg/m2). The population characteristics, surgical outcomes, and hospitalization outcomes were compared. The main outcome was the intraoperative conversion rate. Secondary end points were blood loss, operative time, perioperative and postoperative complications, and same-day surgery management. MEASUREMENTS AND MAIN RESULTS: A total of 146 patients were included in the BMI <30 group, and 54 patients in the BMI ≥30 group. There was no statistical difference between obese and nonobese patients concerning intraoperative conversion (p = .150), with 4 cases occurring in the BMI <30 group (2.74%) and 4 occurring in the BMI ≥30 group (7.41%). Operative times were longer in obese patients (115.93 min [±55.28] vs 79.78 min [±40.38], p <.001). There was no significant difference in blood loss (p = .337) or perioperative and postoperative complications (p = .346 and p = .612, respectively). The ability to complete the surgery as a same-day procedure was no different between obese and nonobese patients (p = .150). CONCLUSION: The results concerning intraoperative conversion and perioperative and postoperative complications show that vNOTES hysterectomies seem to be feasible for obese patients. When same-day surgery was decided before surgery, no more obese than nonobese patients were converted to conventional hospitalization. Further studies are needed to confirm these observations.

Comparing vNOTES Hysterectomy with Laparoscopic Hysterectomy for Large Uteri.

STUDY OBJECTIVE: Our study aimed to compare conventional laparoscopic hysterectomies (LHs) with vaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomies performed for patients with large uteri (weight >280 g) at our institution, which underwent a change in practice from conventional LH to vNOTES for large uteri. DESIGN: Retrospective cohort. SETTING: French tertiary university hospital. PATIENTS: Two cohorts: the last 54 patients who underwent vNOTES hysterectomy and the last 52 patients who underwent conventional LH for large uteri. INTERVENTION: Baseline characteristics and surgical outcomes were assessed, including uterine weight, mode of delivery for previous pregnancies, history of abdominal surgery, indication for hysterectomy, associated procedures, operative time (OT), complications, volume of intraoperative bleeding, and length of postoperative hospital stay. MEASUREMENTS AND MAIN RESULTS: Both groups were comparable, with a mean uterine weight of 586.4 ± 289.2 g in the laparoscopy group compared with 686.7 ± 374.6 g in the vNOTES group. There was a significant decrease in the OT in the vNOTES group with a median of 99 minutes (66.5-138.5 minutes) compared with 171 minutes (131-208 minutes) in the laparoscopy group, p <.001. The length of hospital stay was also decreased in the vNOTES group with a median of 0.5 nights compared with 2 nights in the laparoscopy group, p <.001. More patients were managed in an ambulatory setting in the vNOTES group (50% vs 3.7%, p <.001). Our study did not find any significant difference in terms of bleeding or the number of conversions to another surgical approach. The frequency of intraoperative and postoperative complications was very low. CONCLUSION: Compared with the laparoscopic approach, vNOTES hysterectomy for large uteri (>280 g) is associated with decreased OT, a shorter hospital stay, and increased performance in the ambulatory setting.

Operative Hysteroscopy vs Vacuum Aspiration for Incomplete Spontaneous Abortion: A Randomized Clinical Trial.

Importance: Vacuum aspiration is commonly used to remove retained products of conception in patients with incomplete spontaneous abortion. Scarring of the uterine cavity may occur, potentially impairing future fertility. A procedural alternative, operative hysteroscopy, has gained popularity with a presumption of better future fertility. Objective: To assess the superiority of hysteroscopy to vacuum aspiration for subsequent pregnancy in patients with incomplete spontaneous abortion who intend to have future pregnancy. Design, Setting, and Participants: The HY-PER randomized, controlled, single-blind trial included 574 patients between November 6, 2014, and May 3, 2017, with a 2-year duration of follow-up. This multicenter trial recruited patients in 15 French hospitals. Individuals aged 18 to 44 years and planned for surgery for an incomplete spontaneous abortion with plans to subsequently conceive were randomized in a 1:1 ratio. Interventions: Surgical treatment by hysteroscopy (n = 288) or vacuum aspiration (n = 286). Main Outcomes and Measures: The primary outcome was a pregnancy of at least 22 weeks' duration during 2-year follow-up. Results: The intention-to-treat analyses included 563 women (mean [SD] age, 32.6 [5.4] years). All aspiration procedures were completed. The hysteroscopic procedure could not be completed for 19 patients (7%), 18 of which were converted to vacuum aspiration (8 with inability to completely resect, 7 with insufficient visualization, 2 with anesthetic complications that required a shortened procedure, 1 with equipment failure). One hysteroscopy failed due to a false passage during cervical dilatation. During the 2-year follow-up, 177 patients (62.8%) in the hysteroscopy group and 190 (67.6%) in the vacuum aspiration (control) group achieved the primary outcome (difference, -4.8% [95% CI, -13% to 3.0%]; P = .23). The time-to-event analyses showed no statistically significant difference between groups for the primary outcome (hazard ratio, 0.87 [95% CI, 0.71 to 1.07]). Duration of surgery and hospitalization were significantly longer for hysteroscopy. Rates of new miscarriages, ectopic pregnancies, Clavien-Dindo surgical complications of grade 3 or above (requiring surgical, endoscopic, or radiological intervention or life-threatening event or death), and reinterventions to remove remaining products of conception did not differ between groups. Conclusions and Relevance: Surgical management by hysteroscopy of incomplete spontaneous abortions in patients intending to conceive again was not associated with more subsequent births or a better safety profile than vacuum aspiration. Moreover, operative hysteroscopy was not feasible in all cases. Trial Registration: ClinicalTrials.gov Identifier: NCT02201732.

Minimally invasive removal of deep contraceptive implants under continuous ultrasound guidance is effective, quick, and safe.

OBJECTIVES: The aim of this study was to assess the feasibility, performance, and complications of a non-surgical, minimally-invasive procedure of deep contraceptive implant removal under continuous ultrasound guidance. METHODS: The ultrasound-guided procedure consisted of local anesthesia using lidocaine chlorhydrate 1% (10 mg/mL) with a 21-G needle, followed by hydrodissection using NaCl 0.9% (9 mg/mL) and implant extraction using a Hartmann grasping microforceps. The parameters studied were the implant localization, success and complication rates, pain throughout the intervention, volumes of lidocaïne and NaCl used, duration of the procedure, and size of the incision. Between November 2019 and January 2021, 45 patients were referred to the musculoskeletal radiology department for ultrasound-guided removal of a deep contraceptive implant and were all retrospectively included. RESULTS: All implants were successfully removed en bloc (100%). The mean incision size was 2.7 ± 0.5 mm. The mean duration of the extraction procedure was 7.7 ± 6.3 min. There were no major complications (infection, nerve, or vessel damage). As a minor complication, 21 patients (46.7%) reported a benign superficial skin ecchymosis at the puncture site, spontaneously regressing in less than 1 week. The procedure was very well-tolerated, with low pain rating throughout (1.0 ± 1.5/10 during implant extraction). CONCLUSIONS: Minimally invasive removal of deep contraceptive implants under continuous ultrasound guidance alone is feasible, effective, and safe. In the present cohort, all implants were successfully removed, whatever the location, with short procedural time, small incision size, low pain levels, and no significant complications. This procedure could become a gold standard in this indication. KEY POINTS: • Minimally invasive removal of deep contraceptive implants under continuous ultrasound guidance alone is feasible, which led to a success rate of 100% whatever the location (even close to neurovascular structures), with only a small skin incision (2.7 ± 0.5 mm). • The procedure was safe, quick, without any major complications, and very well tolerated in terms of pain. • This minimally invasive ultrasound-guided procedure could become the future gold standard for the removal of deep contraceptive implants, as an alternative to surgical extraction, even for implants in difficult locations such as subfascial ones or those close to neurovascular structures.

Is V-NOTES Hysterectomy as Safe and Feasible as Outpatient Surgery Compared with Vaginal Hysterectomy?

STUDY OBJECTIVE: The vaginal approach is the reference surgical route to perform hysterectomy for benign pathologies. Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) is a new technique that would overcome the limitations of vaginal surgery by allowing a complete exploration of the peritoneal cavity and a constant visual control of the adjacent structures. The aim of this study is to assess the V-NOTES technique compared with vaginal hysterectomy (VH). DESIGN: A retrospective cohort study. SETTING: French teaching hospital. PATIENTS: The first 50 V-NOTES hysterectomies were included successively and compared with the last 50 VH performed from March 2019 to November 2020. The study concerned all patients requiring hysterectomy unless it was for endometriosis or cancer (except for grade 1 endometrioid adenocarcinoma). INTERVENTIONS: The baseline characteristics and the surgical outcomes were compared. The main outcome assessed was the performing of outpatient surgery. Secondary end points were uterine weight and intraoperative and postoperative complications. MEASUREMENTS AND MAIN RESULTS: The rate of outpatient surgery did not differ between the 2 surgical techniques (p = .23). The success rate of outpatient management was 77% in the V-NOTES group versus 75% in the VH group (p = .85). There was no difference in surgical outcomes between the 2 groups, except for the rate of salpingectomies or adnexectomies, which was significantly higher in the V-NOTES group, with 100% of patients undergoing one of these procedures, compared with 60% of patients in the vaginal route group (p < .001). There were 2 cases of re-admission in the month following the intervention in the vaginal group and 0 cases in the V-NOTES group. CONCLUSION: Hysterectomy by V-NOTES can be performed as a safe and adequate alternative to VH. This surgical route is a good candidate for outpatient management. However, more studies need to be conducted to confirm these findings.

Change over time in the surgical management of pelvic organ prolapse between 2008 and 2014 in France: patient profiles, surgical approaches, and outcomes.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP) is a common pathological condition that may require surgical management. Several surgical treatment options are possible, and practice varies from one center to another. The objective of the present study was to describe the surgical management and outcomes of POP in France from 2008 to 2014. METHODS: We performed a retrospective cohort study of all patients operated on for POP from 2008 to 2014, according to the French national hospital discharge summary database. Patient characteristics, surgical approaches, concomitant hysterectomy and/or incontinence surgery, the length of stay, the proportion of day-case operations, and patient outcomes were analyzed. RESULTS: We analyzed 310,938 hospital stays with POP surgery between 2008 and 2014; 130,908 (42%) of the operations took place in hospitals performing more than 100 prolapse surgical procedures per year. The proportion of day-case operations was low, but rose significantly from 1.2% to 4.6% during the study period. More than half of the operations featured a vaginal approach. The proportions of operations with concomitant hysterectomy or urinary incontinence surgery fell from 41.0% to 36.1% and from 33.0% to 25.8% respectively. The proportions of laparoscopic procedures increased. The mortality rate was stable (0.07% for all years). CONCLUSIONS: The number of patients undergoing POP surgery remained stable from 2008 to 2014. The proportion of laparoscopic procedures increased (in parallel with the rising proportion of day-case operations) and the proportion of procedures with concomitant hysterectomy or incontinence treatment decreased.

How we do an anterior sacrospinous ligament fixation for vaginal vault prolapse.

Since 2019, all vaginal mesh implants were removed from the market. Since, surgeons have only the autologous technique left to treat prolapse by vaginal route. The anterior sacrospinofixation is an alternative technique to treat vaginally apical prolapses. We have divided the anterior sacrospinous ligament fixation technique into 10 surgical steps: exposure, infiltration, vaginal incision, vesico-vaginal dissection, paravesical dissection, sacrospinous ligament suture (two passage in the SSL on each side, using a suture-capturing device), vaginal fixation, vaginal closure, sacrospinous ligament fixation and final closure. We have performed more than 50 ASSF. This technique is not very well known, and the surgeons are more used to approach the SSL by posterior way. We have included a video of the procedure and an anatomical drawing exhibiting the dissection of the SSL without eyes control. We also added tips and tricks to easily apprehend this new technique. The anterior approach seems to has several advantages compared to the traditional posterior technique. We want to share such a video on showing how to approach the paravesical fossa anteriorly without eyes control.

Complications and reoperation after pelvic organ prolapse, impact of hysterectomy, surgical approach and surgeon experience.

INTRODUCTION AND HYPOTHESIS: The surgical treatment of pelvic organ prolapse (POP) is associated with specific complications. Our primary objective was to assess the recurrence requiring reoperation after prolapse surgery, and our secondary objectives were to assess the early complications and secondary surgery for urinary incontinence. METHODS: Retrospective study of a population-based cohort of all hospital or outpatient stays including POP surgery from 2008 to 2014, using the French nationwide discharge summary database. We calculated the rates of hospital readmission following surgery as well as the rates of reoperation for recurrent prolapse and subsequent procedures performed for urinary incontinence. RESULTS: A total of 310,938 patients had undergone surgery for POP. Two hundred fourteen (0.07%) patients died, and 0.45% were admitted to an intensive care unit; 4.4% of the patients underwent surgery for the recurrence of prolapse. Concomitant hysterectomy in the first surgery was associated with a significantly lower risk of POP surgery recurrence: (hazard ratio (HR) [95% confidence interval (CI)] = 0.51 [0.49; 0.53]). A total of 1386 (2.5%) patients were readmitted to the hospital for early (30-day) complications of prolapse surgery. The most frequent reasons for early readmission were local infection (32.8%), hemorrhage (21.4%) and pain (17.2%). Risk factors for complications were obesity, hospitals with low levels of activity and associated incontinence surgery; 4.6% of the patients required secondary surgery for urinary incontinence; obesity was a risk factor (HR [95% CI] = 1.12 [1.01; 1.24]), and the vaginal route was a protective factor (odds ratio = 1.86 for laparoscopy, 1.44 for laparotomy and 1.25 for multiple approaches). CONCLUSIONS: POP surgery is associated with low rates of complication and recurrence. Complications occurred most commonly following combined surgeries for both prolapse and incontinence and in hospitals with low surgical volumes. Concomitant hysterectomy appears to be protective for the need for additional prolapse surgery, and the vaginal route leads to a lower frequency of secondary surgery for urinary incontinence.

How we perform a posterior sacrospinous ligament fixation by the vaginal route.

Posterior sacrospinous fixation (SSF) was first described by Amreich in 1950 and then modified by Richter in 1968. The main difficulty of this technique is the pararectal approach with dissection under visual guidance. Our aim was to teach young surgeons to use this alternative technique for apical suspension and to facilitate the pararectal approach. We divide the sacrospinous ligament fixation technique into ten surgical steps: exposure, infiltration, vaginal incision, recto-vaginal dissection, pararectal dissection, SSL suture, vaginal fixation (with vaginal strips), vaginal closure, SSF and final closure. We have performed > 500 SSFs following the sacrospinous ligament fixation technique. Inexperienced surgeons are generally not comfortable with the dissection of the SSL. A video of the procedure with pararectal dissection, SSL identification and suturing clearly shown can help to perform this technique. The use of vaginal strips has been designed to help strengthen the vaginal part of the SSF. It is important to share such a video showing how to approach the pararectal fossa with a dissection under visual guidance. The aim is to help young surgeons better understand the surgical technique and dissection.

The anatomy of the sacral promontory: How to avoid complications of the sacrocolpopexy procedure.

Because of problems with vaginal meshes and the high rate of recurrences of native tissue repair, more and more surgeons treat pelvic organ prolapse with laparoscopic sacrocolpopexy. This surgery requires skilled surgeons. The first step of sacrocolpopexy is the dissection of tissues in front of the sacral promontory to reach the anterior longitudinal ligament. Some complications can occur during this dissection and the attachment of the mesh. This step is dangerous for surgeons because of the proximity of vessels, nerves, and ureters. The lack of knowledge of anatomy can lead to severe complications such as vascular, ureteral, or nerve injuries. These complications can be life-threatening. To show anatomic concerns when surgeons dissect and affix the mesh on the anterior longitudinal ligament, we have developed a video of the promontory anatomy. By reviewing anatomic articles about vessels, nerves, and ureters in this localization, we propose an educational tool to increase the anatomic knowledge to avoid severe complications. In this video, we show an alternative location for dissection and graft fixation when the surgeon believes that mesh cannot be fixed safely on the anterior surface of S1, as currently recommended.

Does sacrocolpopexy present heterogeneity in its surgical technique? A systematic review.

AIMS: Sacrocolpopexy (SCP) is an extensively studied and highly efficacious treatment for female pelvic organ prolapse (POP). We aimed to analyze the technical steps for performance of a SCP among all RCTs in the literature that compared it with different procedures, or that studied different routes for performing SCP. METHODS: Systematic review searching electronic databases for RCTs only. We extracted data for 13 points of interest; main outcomes were procedure standardization; depth of vaginal dissection; number of sutures in the vaginal wall; type of suture in the vaginal wall; type of mesh fixation to the sacrum; and type and shape of mesh used. RESULTS: Twenty-two RCTs were included. Most of them did not provide a full standardized description of the procedure steps. There was great heterogeneity in almost all steps of the operation, including the choice of materials for attaching the mesh to the vagina and sacrum-with both absorbable and non-absorbable sutures being used-and the extent of vaginal dissection for mesh fixation, with some studies dissecting only the apex, superficially, while others performed a full-length dissection. Choice of mesh material was more consensual, with polypropylene mesh being the most commonly used. CONCLUSIONS: SCP is a highly unstandardized procedure in the literature, albeit being used as a major comparator. Various RCTs compared alternative procedures with SCP, but the technical aspects have varied greatly, and studied outcomes could have been potentially influenced by these technical choices.

Complications and reoperations after laparoscopic sacrocolpopexy with a mean follow-up of 4 years.

INTRODUCTION AND HYPOTHESIS: There is a lack of knowledge concerning long-term reoperation and complications after laparoscopic sacrocolpopexy (LSCP). We analyzed the rates and indications and potential risk factors for reoperation after LSCP in a large series of consecutive patients. METHODS: This was a single-center, retrospective study including all patients who underwent LSCP between 2003 and 2013. Data regarding pelvic organ prolapse (POP), surgical modalities and perioperative complications were collected. Patients were then contacted by telephone or postal letter in 2014. The main outcome criteria were grade III Dindo classification complications: reoperation for POP recurrence, mesh complications, and urinary incontinence (UI). RESULTS: Between January 2003 and December 2013, a total of 464 consecutive patients (mean age, 59 years) underwent LSCP. Almost all (99.1 %) patients presented with POP ≥ grade 3 (POP-Q classification). Long-term evaluations were completed for 391 (84.1 %) patients. The median follow-up was 53.5 ± 28.2 months. The global reoperation rate was 12.5 %. The main reoperation indications were UI-related surgery in 21 patients (5.5 %), POP recurrence surgery in 20 patients (5.1 %), and mesh-related surgery in 11 patients (2.8 %). Multivariate analysis showed that older age at the time of initial surgery and concomitant subtotal hysterectomy were significant protective factors against global reoperation (HR = 0.606, CI 95 % [0.451-0.815] and 0.367, CI 95 % [0.193-0.698] respectively) and reduced the risk of POP recurrence surgery. CONCLUSION: Prolapse recurrence and mesh-related surgery occurred in 5.1 and 2.8 % of patients respectively, 4 years after laparoscopic sacrocolpopexy. Age and concomitant subtotal hysterectomy could play a role in the incidence of long-term reoperation.

Feasibility and benefits of the ewe as a model for vaginal surgery training.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate the ewe as an animal model for teaching and training in vaginal surgery. METHODS: Twenty-nine postgraduate surgeons attended a training course on vaginal prolapse surgery. After a review of human and sheep anatomy, the participants performed transvaginal meshes, vaginal hysterectomy, SSLF (Richter), and OAS repair in ewes and human cadavers. Participants completed questionnaires on the whole course. RESULTS: Questionnaires showed the significant superiority of ewes over human cadavers for all items evaluated regarding surgical dissections. Only identification of the sacrospinous ligament and the spine were judged to be similar in ewes and human cadavers. Participants noticed that ewe model is appropriate for vaginal prolapse surgery training for resident and for postgraduate surgeons. Two vaginal hysterectomies were also performed. Operating time, surgery, and anatomy were nearly identical to that of humans. The same conclusions were made while performing sacrospinous ligament fixation (Richter) and obstetric anal sphincter injury repair. CONCLUSION: This series indicates that the ewe is a useful animal model for teaching vaginal surgery.

Pathophysiological aspects of cystocele with a 3D finite elements model.

PURPOSES: The objective of this study is to design a 3D biomechanical model of the female pelvic system to assess pelvic organ suspension theories and understand cystocele mechanisms. METHODS: A finite elements (FE) model was constructed to calculate the impact of suspension structure geometry on cystocele. The sample was a geometric model of a control patient's pelvic organs. The method used geometric reconstruction, implemented by the biomechanical properties of each anatomic structure. Various geometric configurations were simulated on the FE method to analyse the role of each structure and compare the two main anatomic theories. RESULTS: The main outcome measure was a 3D biomechanical model of the female pelvic system. The various configurations of bladder displacement simulated mechanisms underlying medial, lateral and apical cystocele. FE simulation revealed that pubocervical fascia is the most influential structure in the onset of median cystocele (essentially after 40 % impairment). Lateral cystocele showed a stronger influence of arcus tendineus fasciae pelvis (ATFP) on vaginal wall displacement under short ATFP lengthening. In apical cystocele, the uterosacral ligament showed greater influence than the cardinal ligament. Suspension system elongation increased displacement by 25 % in each type of cystocele. CONCLUSIONS: A 3D digital model enabled simulations of anatomic structures underlying cystocele to better understand cystocele pathophysiology. The model could be used to predict cystocele surgery results and personalising technique by preoperative simulation.

Sacral colpopexy: long-term mesh complications requiring reoperation(s).

INTRODUCTION AND HYPOTHESIS: Sacral colpopexy (SC) is a classic procedure used for the surgical treatment of pelvic organ prolapse. Although the procedure boasts excellent success rates, there are risks of complications and reoperation may be required. The purpose of this study was to evaluate the extent of complications following SC, requiring reoperation(s), and to describe the reoperations performed. METHODS: A retrospective monocentric study of patients who were operated on following a mesh complication after SC was conducted, at Lille University Hospital, between January 2007 and January 2013. Information relating to medical and surgical history, SC surgical technique, type of complication, and reoperation techniques was gathered. RESULTS: Twenty-seven patients required surgery for complications after SC. Nineteen patients were treated for vaginal mesh exposures (VME), four for intravesical mesh (including one with VME), one for ano-rectal dyschezia, one for spondylodiscitis with a VME, one for mesh infection, and one for vaginal fistula communicating with a collection in the ischio-coccygeal muscle. The median time between the initial SC and the first reoperation was 3.9 ± 5.7 years. The median operating time was 40 ± 95 min, and the length of hospital stay was 3.0 ± 3.0 days. Ten patients needed several interventions. CONCLUSION: This case series provides a description of surgical interventions for complications related to sacral colpopexy. These complications may be serious and occur years after the initial surgery.

Investigating the medical journey of endometriosis-affected women: Results from a cross-sectional web-based survey (EndoVie) on 1,557 French women.

OBJECTIVE: To investigate the medical journey and the quality of life of French endometriosis-affected women, from the onset of the symptoms to the therapeutic management. STUDY DESIGN: Between January 15th 2020 and February 3rd 2020, a prospective cross-sectional web-based survey was conducted among women diagnosed with endometriosis. The questionnaire included 52 questions distributed in five sections (screening, sociodemographic characteristics, impacts on quality of life, SF36 questionnaire, management of endometriosis and proposals for care improvement). RESULTS: One thousand five hundred fifty-seven endometriosis-affected women aged of 42±12.8 years answered the questionnaire. On average, 7 years elapsed between the first symptoms (at 23.8 ± 10.2 years) and the diagnosis (31.0 ± 8.9 years). The mean number of symptoms was 4.6 ± 2.3, with 82 % of women experiencing pain scores between 7 and 10/10. Following diagnosis, 66 % women received a medical treatment, mostly hormonal treatments (45 %), with a significant decrease in pain intensity (VAS scores after treatment = 4.9 ± 2.7, p < 0.001). Most women (62 %) had already been operated, among whom 22 % by laparotomy. Finally, patients reported numerous impacts on their daily lives, particularly on the sexual, psychological, and physical fields. The overall mean score of quality of life was 4.3 ± 2.6 /10. CONCLUSION: This large prospective web-based survey underlines that the journey of women with endometriosis is long and difficult until diagnosis and efficient treatment. It emphasizes the urgent need to reduce the diagnostic delay and thereby the burden of endometriosis on women's lives. Moreover, the creation of referral multidisciplinary centers appears to be crucial to improve the management of the disease.

[Genital prolapse surgery: state of the art of the vaginal approach]. / Le prolapsus génital état des lieux de la chirurgie par voie vaginale.

Treatment of genital prolapse is mainly surgical. The vaginal approach is a shorter procedure than the abdominal approach with a quicker resumption of activity for the patients. We describe different techniques which are most often performed in our daily practice. For the complete prolapse affecting the three components of the pelvic floor, we most often associate a colpohysterectomy, a native tissue reinforcement for the treatment of cystocele, sub-symphyseal crossing of the uterosacral ligaments using the technique of Campbell and finally a suspension of the vaginal vault according to Richter with a levator myorraphy. Currently, native tissues used in these techniques tend to be superseded in our service by reinforcement prosthetic implants, which according to the latest French Health Higher Authority guidelines (November 14, 2007) "could be of interest in relapse surgery, if a clinical element raises fears of high risk of recurrence." In any case, patients seeking a surgical treatment of their genital prolapse must be fully informed of the specific risk related to each technique. They must also be informed of the long-term results or of the lack of available data, regarding techniques using native tissue or prostheses.

Update on the management of endometriosis-associated pain in France.

The French National College of Obstetricians and Gynecologists (CNGOF) published guidelines for managing endometriosis-associated pain in 2018. Given the development of new pharmacological therapies and a review that was published in 2021, most national and international guidelines now suggest a new therapeutic approach. In addition, a novel validated screening method based on patient questionnaires and analysis of 109-miRNA saliva signatures, which combines biomarkers and artificial intelligence, opens up new avenues for overcoming diagnostic challenges in patients with pelvic pain and for avoiding laparoscopic surgery when sonography and MRI are not conclusive. Dienogest (DNG) 2 mg has been a reimbursable healthcare expense in France since 2020, and, according to recent studies, it is at least as effective as combined hormonal contraception (CHC) and can be used as an alternative to CHC for first-line treatment of endometriosis-associated pain. Since 2018, the literature concerning the use of DNG has grown considerably, and the French guidelines should be modified accordingly. The levonorgestrel intrauterine system (LNG IUS) and other available progestins per os, including DNG, or the subcutaneous implant, can be offered as first-line therapy, gonadotropin-releasing hormone (GnRH) agonists with add-back therapy (ABT) as second-line therapy. Oral GnRH antagonists are promising new medical treatments for women with endometriosis-associated pain. They competitively bind to GnRH receptors in the anterior pituitary, preventing native GnRH from binding to GnRH receptors and from stimulating the secretion of luteinizing hormone and follicle-stimulating hormone. Consequently, estradiol and progesterone production is reduced. Oral GnRH antagonists will soon be on the market in France. Given their mode of action, their efficacy is comparable to that of GnRH agonists, with the advantage of oral administration and rapid action with no flare-up effect. Combination therapy with ABT is likely to allow long-term treatment with minimal impact on bone mass. GnRH antagonists with ABT may thus be offered as second-line treatment as an alternative to GnRH agonists with ABT. This article presents an update on the management of endometriosis-associated pain in women who do not have an immediate desire for pregnancy.

Cystic adenomyoma surgery.

OBJECTIVE: Cystic adenomyoma is a lesion located within the myometrium. It is lined with endometrium and has hemorrhagic content. This rare entity has been described as a focal form of adenomyosis. However, it is poorly understood, and the management of symptomatic patients is not codified. Our objective is to evaluate the effectiveness of treatment with planned surgery for cystic adenomyoma on symptoms and fertility in a retrospective series of patients. STUDY DESIGN: This is a retrospective study between January 2011 and January 2018 in a university hospital of patients that had surgery for cystic adenomyoma with uterine preservation. RESULTS: Pre-operative, per-operative, and post-operative data were recorded. Of the 18 patients included, 3 were lost to follow-up; 15 underwent laparoscopic surgery and 3 operative hysteroscopies. Complications during and after surgery were rare, involving only 3 patients, and of low severity. One patient saw no improvement in pain after surgery and 2 patients saw only partial improvement in their pain; 7 patients achieved at least one pregnancy with favorable outcome after surgery. CONCLUSION: Based on this series, we argue that conservative surgical treatment for cystic adenomyoma generally improves pain and fertility without causing morbidity.