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BACKGROUND: This study was a secondary analysis of the ROBOGYN-1004 trial conducted between 2010 and 2015. The study aimed to identify factors that affect postoperative morbidity after either robot-assisted laparoscopy (RL) or conventional laparoscopy (CL) in gynecologic oncology. METHODS: The study used two-level logistic regression analyses to evaluate the prognostic and predictive value of patient, surgery, and center characteristics in predicting severe postoperative morbidity 6 months after surgery. RESULTS: This analysis included 368 patients. Severe morbidity occurred in 49 (28 %) of 176 patients who underwent RL versus 41 (21 %) of 192 patients who underwent CL (p = 0.15). In the multivariate analysis, after adjustment for the treatment group (RL vs CL), the risk of severe morbidity increased significantly for patients who had poorer performance status, with an odds ratio (OR) of 1.62 for the 1-point difference in the WHO performance score (95 % CI 1.06-2.47; p = 0.027) and according to the type of surgery (p < 0.001). A focus on complex surgical acts showed significant more morbidity in the RL group than in the CL group at the less experienced centers (OR, 3.31; 95 % CI 1.0-11; p = 0.05) compared with no impact at the experienced centers (OR, 0.87; 95 % CI 0.38-1.99; p = 0.75). CONCLUSION: The findings suggest that the center's experience may have an impact on the risk of morbidity for patients undergoing complex robot-assisted surgical procedures.
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Neoplasias dos Genitais Femininos , Laparoscopia , Complicações Pós-Operatórias , Procedimentos Cirúrgicos Robóticos , Adulto , Idoso , Feminino , Humanos , Pessoa de Meia-Idade , Seguimentos , Neoplasias dos Genitais Femininos/cirurgia , Procedimentos Cirúrgicos em Ginecologia/métodos , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Morbidade , Complicações Pós-Operatórias/etiologia , Prognóstico , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/métodosRESUMO
BACKGROUND: Midurethral slings are the gold standard for treating stress urinary incontinence, but their complications may raise concerns. Complications may differ by the approach used to place them. OBJECTIVE: This study aimed to compare serious complications and reoperations for recurrence after midurethral sling procedures when using the retropubic vs the transobturator route for female stress urinary incontinence. STUDY DESIGN: This analysis was of patients included in the French, multicenter VIGI-MESH register since February 2017 who received a midurethral sling for female stress urinary incontinence either by the retropubic or the transobturator route and excluded patients with single-incision slings. Follow-up continued until October 2021. Serious complications (Clavien-Dindo classification ≥ grade III) attributable to the midurethral sling and reoperations for recurrence were compared using Cox proportional hazard models including any associated surgery (hysterectomy or prolapse) and a frailty term to consider the center effect. Baseline differences were balanced by propensity score weighting. Analyses using the propensity score and Cox models were adjusted for baseline differences, center effect, and associated surgery. RESULTS: A total of 1830 participants received a retropubic sling and 852 received a transobturator sling in 27 French centers that were placed by 167 surgeons. The cumulative 2-year estimate of serious complications was 5.8% (95% confidence interval, 4.8-7.0) in the retropubic group and 2.9% (95% confidence interval, 1.9-4.3) in the transobturator group, that is, after adjustment, half of the retropubic group was affected (adjusted hazard ratio, 0.41; 95% confidence interval, 0.3-0.6). The cumulative 2-year estimate of reoperation for recurrence of stress urinary incontinence was 2.7% (95% confidence interval, 2.0-3.6) in the retropubic group and 2.8% (95% confidence interval, 1.7-4.2) in the transobturator group with risk for revision for recurrence being higher in the transobturator group after adjustment (adjusted hazard ratio, 1.9; 95% confidence interval, 1.2-2.9); this surplus risk disappeared after exclusion of the patients with a previous surgery for stress urinary incontinence. CONCLUSION: The transobturator route for midurethral sling placement is associated with a lower risk for serious complications but a higher risk for surgical reoperation for recurrence than the retropubic route. Despite the large number of surgeons involved, these risks were low. The data are therefore reassuring.
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Slings Suburetrais , Incontinência Urinária por Estresse , Feminino , Humanos , Incontinência Urinária por Estresse/cirurgia , Incontinência Urinária por Estresse/etiologia , Slings Suburetrais/efeitos adversos , Telas Cirúrgicas , Procedimentos Cirúrgicos Urológicos/métodos , ReoperaçãoRESUMO
OBJECTIVE: To evaluate the health status and recovery of women after mid-urethral sling (MUS) revision in response to complications. DESIGN: Cross-sectional study using a questionnaire sent to women from a registry. SETTING: Twenty-two French surgical centres. POPULATION: A total of 287 women from the VIGI-MESH registry responded, having undergone MUS revision for complications. METHODS: Our sample of women were compared against a representative set of French women taken from the Eurostat database. Multivariate analysis was performed to identify clinical predictors for successful MUS revision. A qualitative analysis was carried out on free-text comments. MAIN OUTCOME MEASURES: Health status, defined by the Minimum European Health Module, and recovery, assessed by Patient Global Impression of Improvement. RESULTS: The response rate was 76% (287/378), with 49% of the women (141/287, 95% CI 43%-55%) reporting good health status, which was 8 points lower than that expected from the comparator French set (57%, 95% CI 55%-58%). Overall, 53% (147/275, 95% CI 47%-59%) of the women reported feeling much better after MUS revision. Just over one-third (35%, 95/275, 95% CI 29%-40%) of respondents reported poor health with little or no improvement. Multivariate analysis showed that being operated on for pain at revision was associated with worse self-perceived health than being operated on for exposure (OR 0.6, 95% CI 0.14-0.95); women with pre-existing comorbidity reported a poorer health status following MUS revision (OR 0.22, 95% CI 0.13-0.38). CONCLUSIONS: Our results suggest that half of the women recovered good health status after MUS revision, whereas a proportion appeared to be seriously affected by an MUS complication despite the revision.
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Aims: Evaluation of compliance with gynecological multidisciplinary tumor board (MTB) recommendations and its impact. Patients & methods: All patient records discussed in our MTB from 2018 to 2020 were analyzed. Results: We analyzed 437 MTB recommendations concerning 166 patients. Each patient was discussed an average of 2.6 (1.0-4.2) times. Of the 789 decisions, the decision was not followed 102 times (12.9%), corresponding to 85 MTB meetings (19.5%). Of these, 72 recommendations concerned therapeutic changes (70.5%), and 30 concerned non-therapeutic changes (29.5%). Of these 85 MTB decisions, 60 (71%) led to a new MTB submission. Noncompliance with MTB decisions decreased the overall survival (46 vs 138 months; p = 0.003). Conclusion: Improving compliance with MTB decisions is crucial to enhance patient outcomes.
In multidisciplinary tumor board (MTB) meetings, a team of experts discuss the diagnosis and management of cancer patients. While MTB treatment decisions and the reasoning behind them are well documented, the application of these decisions in practice and the associated impact on survival are unknown. This study evaluated compliance with recommendations made during gynecological weekly MTB meetings and the resulting impact on patient management. Between 2018 and 2020, 166 patients were discussed in 437 MTB meetings (each patient was discussed an average of 2.6 times during this period). Noncompliance with the MTB recommendations affected 85/437 MTB meetings (19.5%). Of these, 57 recommendations were therapeutic changes (67.1%) and 28 were non-therapeutic changes (32.9%). In 60 cases (71%), noncompliance with the MTB led to resubmission of the patient data to the MTB. Noncompliance with the board recommendations led to a decrease in patient survival (46 vs 138 months; p = 0.003). This study is expected to raise awareness among practitioners. Considered an essential part of the delivery of high-quality cancer treatment, the implementation of MTB decisions requires further verification.
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Neoplasias dos Genitais Femininos , Fidelidade a Diretrizes , Humanos , Neoplasias dos Genitais Femininos/terapia , Feminino , Avaliação de Resultados em Cuidados de Saúde , Estudos Retrospectivos , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou maisRESUMO
BACKGROUND: In patients treated for advanced ovarian cancer not suitable for complete primary surgery, interval surgery after three courses of neoadjuvant chemotherapy has been considered standard management since the EORTC randomized trial published in 2010. An alternative approach with delayed surgery after six courses of neoadjuvant chemotherapy was reported in retrospective series. PRIMARY OBJECTIVES: To assess the efficacy on progression free survival of interval cytoreduction surgery after three cycles of neoadjuvant chemotherapy compared with delayed surgery after six cycles of neoadjuvant chemotherapy. STUDY HYPOTHESIS: In women with ovarian cancer not suitable for primary surgical cytoreduction, surgery after six cycles of neoadjuvant chemotherapy will prove better disease-free survival than cytoreductive surgery after only three cycles. TRIAL DESIGN: CHRONO is a multicenter, randomized phase III trial. After three courses of neoadjuvant chemotherapy, eligible patients will be randomized (1:1) to either completion surgery followed by an additional five cycles of chemotherapy (control arm) or an additional three cycles of neoadjuvant chemotherapy followed by completion surgery and then two additional cycles of chemotherapy (experimental arm). Patients in both groups will receive eight total cycles of chemotherapy. MAJOR INCLUSION/EXCLUSION CRITERIA: The main inclusion criteria are histologically confirmed epithelial high-grade serous or endometrioid ovarian cancer, documented FIGO stage IIIB-IVA unsuitable for complete primary surgery but considered resectable after three courses of neoadjuvant chemotherapy. The main exclusion criteria are mucinous, clear cell, carcinosarcoma, or low-grade serous histologies. PRIMARY ENDPOINT: The primary endpoint is progression-free survival. SAMPLE SIZE: 210 eligible patients ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS: The estimated date for completing accrual will be Q2 2023. The estimated date for presentation of the first results is Q3 2028. TRIAL REGISTRATION NUMBER: NCT03579394.
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Terapia Neoadjuvante , Neoplasias Ovarianas , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Carcinoma Epitelial do Ovário/patologia , Quimioterapia Adjuvante , Procedimentos Cirúrgicos de Citorredução/métodos , Feminino , Humanos , Neoplasias Ovarianas/tratamento farmacológico , Neoplasias Ovarianas/patologia , Neoplasias Ovarianas/cirurgia , Estudos RetrospectivosRESUMO
The optimal time interval between myomectomy and pregnancy is unclear and no specific guidelines exist. The aim of this review was to study the time interval from myomectomy to pregnancy and the occurrence of uterine rupture after myomectomy. Randomized controlled trials, cohort studies and retrospective studies were used to assess the primary objective, and case reports, cases series or letters to the editor for the secondary objective. Only articles reporting myomectomy performed via the vaginal route, laparotomy, laparoscopy or robot-assisted surgery were selected for inclusion. Among 3852 women who wanted to become pregnant after the surgery, 2889 became pregnant, accounting for 3000 pregnancies (77.9%) and 2097 live births (54.4%). Mean time between myomectomy and pregnancy was estimated at 17.6 months (SD 9.2) for 2451 pregnant women. Among 1016 women, a third were advised to delay attempting to conceive for between 3 and 6 months and another third for between 6 and 12 months. A total of 70 spontaneous uterine ruptures with a mean gestational age of 31 weeks at occurrence were identified. No linear relationship was found between gestational age at the event and time interval from myomectomy to conception (Pâ¯=â¯0.706). There are insufficient data to advise a minimal time interval between myomectomy and conception.
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Fertilização/fisiologia , Cuidado Pré-Concepcional , Miomectomia Uterina/reabilitação , Aconselhamento Diretivo/métodos , Aconselhamento Diretivo/estatística & dados numéricos , Feminino , Humanos , Recém-Nascido , Laparoscopia/reabilitação , Cuidado Pré-Concepcional/métodos , Gravidez , Fatores de Tempo , Tempo para Engravidar/fisiologiaRESUMO
PURPOSE: To assess feasibility of a standardized robot-assisted hysterectomy managed by resident and supervised by senior surgeon using dual-console on a 21-step grid (max score = 42) assessing resident autonomy. METHODS: A total of seven patients managed between September 2019 and March 2020 by six residents in gynecology and obstetrics were included. Standardized robot-assisted hysterectomy for endometrial cancer or adenomyosis was performed. RESULTS: No conversion to laparotomy, no intra- or post-operative incidents were reported. Mean score on the evaluation scale was 29.8 out of 42 (SD = 7.3). Mean operative time was 104 min (SD = 23). Mean average suturing time was, respectively, 335 s (SD = 57 s) and 270 s (SD = 53 s) for the first and the fourth knot. There was a 65 s improvement between the first and the fourth intracorporeal knot (p = 0.043). The perceived workload evaluated with the NASA TLX score showed a low level of stress (Temporal demand = 1.6 /10), and a low level of frustration (Frustration level = 3.6/10). Experience gained during the surgery was felt to be important (Commitment = 8.6/10). CONCLUSION: Standardized robot-assisted hysterectomy managed by a resident supervised by a senior surgeon using the dual-console seems feasible. This tool could be useful to assess residents' surgical skills.
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Competência Clínica , Ginecologia/educação , Histerectomia/educação , Internato e Residência , Procedimentos Cirúrgicos Robóticos/educação , Idoso , Feminino , França , Humanos , Laparoscopia/educação , Pessoa de Meia-Idade , Projetos Piloto , Estudos ProspectivosRESUMO
OBJECTIVE: In gynecologic oncology, minimally invasive surgery using conventional laparoscopy (CL) decreases the incidence of severe morbidity compared to open surgery. In 2005, robot-assisted laparoscopy (RL) was approved for use in gynecology in the US. This study aimed to assess whether RL is superior to CL in terms of morbidity incidence. METHODS: ROBOGYN-1004 (ClinicalTrials.gov, NCT01247779) was a multicenter, phase III, superiority randomized trial that compared RL and CL in patients with gynecologic cancer requiring minimally invasive surgery. Patients were recruited between 2010 and 2015. The primary endpoint was incidence of severe perioperative morbidity (severe complications during or 6 months after surgery). RESULTS: Overall, 369 of 385 patients were included in the as-treated analysis: 176 and 193 underwent RL and CL, respectively. The median operating time for RL was 190 (range, 75-432) minutes and for CL was 145 (33-407) minutes (p < 0.001). The blood loss volumes for the corresponding procedures were 100 (0-2500) and 50 (0-1000) mL (p = 0.003), respectively. The overall rates of conversion to open surgery for the corresponding procedures were 7% (10/176) and 5% (10/193), respectively (p = 0.52). Severe perioperative morbidity occurred in 28% (49/176) and 21% (41/192) of patients who underwent RL and CL, respectively (p = 0.15). At a median follow-up of 25.1 months (range, 0.6-78.2), no significant differences in overall and disease-free survival were observed between the groups. CONCLUSIONS: RL was not found superior to CL with regard to the incidence of severe perioperative morbidity in patients with gynecologic cancer. In addition, RL involved a longer operating time than CL.
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Neoplasias dos Genitais Femininos/cirurgia , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Intervalo Livre de Doença , Feminino , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Morbidade , Período Perioperatório , Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/métodos , Taxa de Sobrevida , Adulto JovemRESUMO
Uterine transplantation from a deceased donor could become an available option for widely treating uterine infertility. However, this procedure requires more precise knowledge about the graft's tolerance to extended cold ischemia. Here, we sought to assess the uterine metabolic alterations after extended cold ischemic storage in a model of auto-transplantation in ewe. A total of 14 uterine auto-transplantations were performed, divided into 2 groups: 7 after 3 h of cold ischemia time (CIT) and 7 after 24 h. Venous uterine blood was collected before uterus retrieval and during reperfusion (30, 60 and 90 min); thereafter, blood gases, lactate, glucose and amino acids (AAs) were analyzed. Apoptosis analyses were performed before uterus retrieval and following reperfusion in uterus biopsies. A total of 12 uterine auto-transplantations were successfully performed and 7 ewes were alive ≥8 days after transplantation. After reperfusion, a decrease in pH, a rise of lactate and lactate/glucose ratio and a delayed decrease of pO2 were found in the 3 h CIT group. No significant variation of these parameters was observed in the 24 h CIT group. Significant decreases of AAs were observed during reperfusion and these decreases were more pronounced and concerned a larger number of compounds in the 24 h CIT group than in the 3 h CIT group. There was no significant uterine apoptotic signal in either group. Overall, these results suggest that extended CIT storage delayed restoration of aerobic glycolysis and induced an increase in AA requirements of the uterus after reperfusion. However, this biochemical alteration did not reduce success rate for uterine transplantation.
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Isquemia Fria , Modelos Animais , Preservação de Órgãos , Ovinos , Útero/metabolismo , Útero/transplante , Aminoácidos/metabolismo , Animais , Isquemia Fria/métodos , Isquemia Fria/veterinária , Temperatura Baixa , Feminino , Glucose/metabolismo , Glicólise/fisiologia , Sobrevivência de Enxerto/fisiologia , Humanos , Isquemia/metabolismo , Isquemia/patologia , Ácido Láctico/metabolismo , Preservação de Órgãos/efeitos adversos , Preservação de Órgãos/métodos , Ovinos/metabolismo , Coleta de Tecidos e Órgãos/efeitos adversos , Coleta de Tecidos e Órgãos/métodos , Transplante AutólogoRESUMO
BACKGROUND: Three randomized trials have concluded at non inferiority of omission of complementary axillary lymph node dissection (cALND) for patients with involved sentinel node (SN). However, we can outline strong limitations of these trials to validate this attitude with a high scientific level. We designed the SERC randomized trial ( ClinicalTrials.gov , number NCT01717131) to compare outcomes in patients with SN involvement treated with ALND or no further axillary treatment. The aim of this study was to analyze results of the first 1000 patients included. METHODS: SERC trial is a multicenter non-inferiority phase 3 trial. Multivariate logistic regression analysis was used to identify independent factors associated with adjuvant chemotherapy administration and non-sentinel node (NSN) involvement. RESULTS: Of the 963 patients included in the analysis set, 478 were randomized to receive cALND and 485 SLNB alone. All patient demographics and tumor characteristics were balanced between the two arms. SN ITC was present in 6.3% patients (57/903), micro metastases in 33.0% (298), macro metastases in 60.7% (548) and 289 (34.2%) were non eligible to Z0011 trial criteria. Whole breast or chest wall irradiation was delivered in 95.9% (896/934) of patients, adjuvant chemotherapy in 69.5% (644/926), endocrine therapy in 89.6% (673/751) and the proportions were similar in the two arms. The overall rate of positive NSN was 19% (84/442) for patients with cALND. Crude rates of positive NSN according to SN status were 4.5% for ITC (1/22), 9.5% for micro metastases (13/137), 23.9% for macro metastases (61/255) and were respectively 29.36% (64/218), 9.33% (7/75) and 7.94% (10/126) when chemotherapy was administered after cALND, before cALND and for patients without chemotherapy. CONCLUSION: The main objective of SERC trial is to demonstrate non inferiority of cALND omission. A strong interaction between timing of cALND and chemotherapy with positive NSN rate was observed. TRIAL REGISTRATION: This study is registered with ClinicalTrials.gov , number NCT01717131 October 19, 2012.
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Neoplasias da Mama/terapia , Excisão de Linfonodo/métodos , Avaliação de Resultados em Cuidados de Saúde/métodos , Linfonodo Sentinela/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Axila , Neoplasias da Mama/patologia , Quimioterapia Adjuvante/métodos , Feminino , Humanos , Modelos Logísticos , Pessoa de Meia-Idade , Análise Multivariada , Micrometástase de Neoplasia , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Biópsia de Linfonodo SentinelaRESUMO
AIM: To describe class I and II human leucocyte antigen (HLA) expression using different uterine tissues in the perspective of uterus transplantation. METHODS: Human uterine tissues were obtained from 12 women who had undergone hysterectomy for the treatment of benign disease. HLA class I and HLA-antigen D related (DR) expression were assessed via immunochemistry. HLA class I expression in the uterus was compared with expression in other organs and tissues, including kidney and myocardium samples. RESULTS: HLA class I expression was strong in the endometrial glands and mild in the myometrium. Staining of endometrial glands was similar to glomerular staining in the kidney. The myometrium seems to express HLA class I similarly to hepatocytes and myocardial cells. HLA class I expression in the uterus did not differ in younger or post-menopausal women. HLA-DR was expressed in the endometrial glands, but not in the myometrium. A lack of HLA-DR expression seemed to be correlated with cell proliferation. CONCLUSION: HLA expression in the endometrium and myometrium is different. The endometrium should be the major target of alloreactive response. As for other transplanted organs, assessment of HLA unacceptable antigens and multiple immunosuppressive treatments is necessary in uterus transplantation.
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Antígenos HLA/metabolismo , Útero/metabolismo , Útero/transplante , Adulto , Idoso , Feminino , Humanos , Rim/metabolismo , Fígado/metabolismo , Menopausa , Pessoa de Meia-Idade , Músculo Estriado/metabolismo , Miocárdio/metabolismo , Miométrio/metabolismoRESUMO
INTRODUCTION: Q fever is an ubiquitous zoonosis caused by Coxiella burnetii. Its tropism for the uterus is a potential source of obstetric complications. MATERIALS AND METHODS: We describe the obstetric consequences of Q fever diagnosed during pregnancy from a series of cases. When an antenatal diagnosis was made, antibiotic therapy with roxithromycin (Rulid(®)) was started until delivery. RESULTS: Between 2007 and 2012, 30 patients were treated for Q fever diagnosed during pregnancy, i.e. 1.9 cases per 1000 people. The most common reasons for performing serology was intrauterine growth retardation, preterm labor and oligoamnios. Q fever was diagnosed as acute and chronic in 26 and 4 cases, respectively. Progression to chronic disease occurred in 8 % of acute forms of the diseases. The prevalence of obstetric complications was 66 %, including 10 % foetal deaths, 31 % preterm delivery and 27 % low birthweight <10th percentile. The obstetric complication rate amongst the 22 patients treated with ante partum macrolides was 60, 30 % of which involved prematurity and 33 % involved low growth. No cases of foetal death were found on treatment and no congenital malformation and placental or neonatal injury was found. No case of disease reactivation was diagnosed in the eight patients who became pregnant again. CONCLUSION: Q fever during pregnancy is responsible for severe obstetric complications. It must be diagnosed early and its clinical forms known in order to start appropriate antibiotic therapy.
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Antibacterianos/uso terapêutico , Complicações Infecciosas na Gravidez/epidemiologia , Febre Q/complicações , Adulto , Doença Crônica , Coxiella burnetii/isolamento & purificação , Feminino , Morte Fetal/etiologia , Retardo do Crescimento Fetal/etiologia , Hospitais Universitários , Humanos , Trabalho de Parto Prematuro/etiologia , Placenta/patologia , Gravidez , Complicações Infecciosas na Gravidez/diagnóstico , Diagnóstico Pré-Natal , Prevalência , Febre Q/epidemiologia , Estudos Retrospectivos , Adulto JovemRESUMO
PURPOSE: We conducted a survey to assess the performance of preoperative staging and the application of French surgical guidelines in women with presumed stage I endometrial cancer (EC). METHODS: The survey included 26 questions about the number of patients in low-, intermediate-, and high-risk groups operated on in 2012, the proportion of patients upstaged or downstaged by the examination of the uterus, and the proportion of subsequent surgery for lymph node dissection. RESULTS: Thirty-two (70 %) of the 46 French university hospitals responded to the questionnaire. Among 886 patients with EC treated, 661 had stage 1 EC. The rates of presumed preoperative type 1 low-, intermediate-, high-risk EC and type 2 EC were 310 (46.9 %), 218 (33 %), 39 (5.9 %), and 94 (14.2 %) respectively. Among 567 type 1 patients, 35 % were upstaged and 6 % were downstaged. Fair agreement was found between preoperative and postoperative risk assessment (κ = 0.37). Patients with presumed low- and intermediate-risk EC upstaged postoperatively to FIGO stage II/III were more likely to have a restaging operation than patients upstaged to type 1 high-risk FIGO stage I EC: 37/70 (52.8 %) versus 26/75 (34.6 %), p = 0.027. The proportions of patients undergoing the recommended subsequent pelvic and/or para-aortic lymph node dissection were low: 34/85 (40 %) and 47/145 (32.4 %) respectively. Lymph node samplings were mainly performed by laparoscopy: 31/34 (91.2 %) and 40/47 (85.1 %) for pelvic and para-aortic dissection respectively. CONCLUSIONS: Our survey showed that the performance of preoperative assessment of FIGO stage I EC was moderate and that adherence to the guidelines was low.
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Gerenciamento Clínico , Neoplasias do Endométrio/cirurgia , Excisão de Linfonodo , Neoplasias Pélvicas/cirurgia , Padrões de Prática Médica , Idoso , Neoplasias do Endométrio/patologia , Feminino , Seguimentos , França , Humanos , Laparoscopia , Gradação de Tumores , Estadiamento de Neoplasias , Neoplasias Pélvicas/patologia , Período Pós-Operatório , Prognóstico , Inquéritos e QuestionáriosRESUMO
BACKGROUND: To report the feasibility and reproducibility of single-port extraperitoneal para-aortic (PA) lymphadenectomy exclusively using conventional instruments in locally advanced cervical cancer (LACC) and to evaluate the learning curve. METHODS: From January 2011 to January 2013, 52 a total of consecutive patients with LACC were candidates for extraperitoneal PA lymphadenectomy via an original single-port approach that we developed. All patients underwent positron emission tomography-computed tomography that indicated no PA uptake. RESULTS: Fifty consecutive patients underwent single-port staging surgery. Two patients had peritoneal carcinomatosis and were not submitted to PA lymphadenectomy. Median age and body mass index were, respectively 47 (range 27-68) years and 23 (range 16-37) kg/m(2). In one case, lymphadenectomy was unfeasible because of renal vessel anomalies (a bifurcated left renal vein crossed the aorta at the level of the inferior mesenteric artery), and two nodes were removed. Conventional instruments were used in all cases. The median operative time was 180 (range 110-270) min. The median and mean number of nodes removed were, respectively, 18 (range 2-47) and 19.4. Six (12 %) patients had metastatic PA disease. No conversion to laparotomy or conventional multiport laparoscopy was required. The median postoperative hospital stay and the interval between staging surgery and the beginning of chemoradiation were, respectively, 2 (range 1-26) days and 16.5 (range 1-60) days. The learning curve was evaluated at seven procedures with a decreased median operative time at 160 (range 110-240) min. CONCLUSIONS: Extraperitoneal staging via a single-port left iliac approach is feasible with conventional tools, is reproducible and safe, and offers a high degree of cosmetic satisfaction.
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Laparoscopia/instrumentação , Laparoscopia/métodos , Excisão de Linfonodo/métodos , Neoplasias do Colo do Útero/cirurgia , Adulto , Idoso , Estudos de Viabilidade , Feminino , Humanos , Tempo de Internação , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Duração da Cirurgia , Tomografia por Emissão de Pósitrons , Reprodutibilidade dos Testes , Tomografia Computadorizada por Raios X , Neoplasias do Colo do Útero/diagnóstico , Neoplasias do Colo do Útero/patologiaRESUMO
AIM: Our goal was to demonstrate the feasibility of pelvic magnetic resonance imaging (MRI) in the ewe. MATERIAL AND METHODS: Two ewes underwent a pelvic 3 Tesla MRI scan, under light anesthesia, with T2-weighted fast spin-echo images and T1-weighted spoiled gradient-echo images. Multiplan T1 weighted images were also obtained after the intravenous injection of a contrast product. One ewe was anestrous and the other one had undergone ovarian stimulation. RESULTS: No incident occurred during the examination. Both the uterus (with two horns) and the ovaries were identified. The intensity of the endometrial, myometrial and ovarian signals was similar to that encountered in women. The uterus and ovaries could be enhanced in both cases. Pelvic vasculature was also studied. In the case of hormonal stimulation, the endometrium was thicker, follicular growth was identified and enhancement seemed greater. CONCLUSION: MRI in the ewe is feasible and could be helpful in experimental gynecologic research, especially in uterus transplantation.
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Ovário/anatomia & histologia , Carneiro Doméstico/anatomia & histologia , Útero/anatomia & histologia , Animais , Animais Endogâmicos , Meios de Contraste/administração & dosagem , Estudos de Viabilidade , Feminino , França , Gadolínio/administração & dosagem , Injeções Intravenosas , Imageamento por Ressonância Magnética/veterinária , Ovário/irrigação sanguínea , Útero/irrigação sanguíneaRESUMO
Epithelial ovarian cancer is mostly discovered at the stage of peritoneal carcinosis. Complete cytoreductive surgery improves overall survival. The Fagotti score is a predictive score of resectability based on peritoneal laparoscopic exploratory. Our aim was to study the inter-observer concordance in an external validation of the Fagotti score. An observational, prospective, multicenter study was conducted using the Francogyn research network. The primary outcome was inter-observer concordance of the Fagotti score. 15 patients in which an ovarian mass was discovered were included. For each patient, the first exploratory laparoscopy before any treatment/chemotherapy was recorded. This bank of 15 videos was subject to blind review accompanied by a Fagotti score rating by 11 gynecological surgeons specializing in oncology. A total of 165 blind reviews were performed. Inter-observer concordance was very good for the Fagotti score with an intraclass correlation coefficient (ICC) of 0.83 [95% CI 0.71; 0.93]. Inter-observer concordance for the adjusted Fagotti score, which accounts for unexplorable areas with extensive carcinomatosis, resulted in an ICC of 0.64 [95% CI 0.46; 0.82]. According to the reviewers, the three least explorable parameters were mesentery involvement, stomach infiltration and liver damage. The ICC of the explorable Fagotti score, i.e. score with deletion of the parameters most often unexplored by laparoscopy, was 0.86 [0.75-0.94]. This study confirms the reproducibility of the Fagotti score during first assessment laparoscopies in cases of advanced ovarian cancer. The explorable Fagotti score has an equivalent or better inter-observer concordance than the Fagotti score.
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Neoplasias Ovarianas , Humanos , Feminino , Neoplasias Ovarianas/patologia , Neoplasias Ovarianas/mortalidade , Neoplasias Ovarianas/cirurgia , Pessoa de Meia-Idade , Estudos Prospectivos , Idoso , Laparoscopia , Variações Dependentes do Observador , Procedimentos Cirúrgicos de Citorredução , Carcinoma Epitelial do Ovário/patologia , Carcinoma Epitelial do Ovário/mortalidade , Adulto , Reprodutibilidade dos TestesRESUMO
BACKGROUND: The aim of this prospective study was to evaluate the accuracy of the peritoneal cancer index (PCI) between laparoscopy and laparotomy and to evaluate the reproducibility of this index between 2 surgeons (junior vs senior) in advanced-stage ovarian cancer (ASOC). In ASOC, the quality of cytoreductive surgery, which is the main prognostic factor, is correlated with the extent of the disease and thus with the PCI. The reliability of this scoring index between different surgeons during laparoscopy and laparotomy has not been investigated in this disease. METHODS: Between April 2010 and October 2011, for each of the 29 patients undergoing complete cytoreductive surgery, 1 senior surgeon and 1 junior surgeon quantified the PCI score at 3 time points on the same day: during laparoscopy and during laparotomy, at the beginning and at the end. A concordance analysis was conducted with Bland and Altman's method and estimated by intraclass correlation coefficients. RESULTS: There was high concordance of the PCI score between the junior and senior surgeons during the laparoscopic and laparotomic procedures: the mean differences were not significantly different from 0 (P < 0.05) and 95% limits of agreement were ± 3.5 and ± 3.0, respectively. Laparoscopy underestimated the PCI score by approximately 2 points compared to the beginning of the laparotomy: the mean biases were -2.0 (95% confidence interval, -2.8 to -1.2) for the senior surgeon and -2.2 (95% confidence interval, -3.1 to 1.3) for the junior surgeon. CONCLUSIONS: The PCI is reproducible and reliable for evaluating peritoneal spread in ASOC.
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Cistadenocarcinoma Seroso/patologia , Cistadenocarcinoma Seroso/cirurgia , Indicadores Básicos de Saúde , Laparoscopia , Laparotomia , Neoplasias Ovarianas/patologia , Neoplasias Ovarianas/cirurgia , Cavidade Peritoneal/cirurgia , Adulto , Idoso , Cistadenocarcinoma Seroso/epidemiologia , Progressão da Doença , Feminino , Humanos , Laparoscopia/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Neoplasias Ovarianas/epidemiologia , Cavidade Peritoneal/patologia , Neoplasias Peritoneais/epidemiologia , Neoplasias Peritoneais/secundário , Neoplasias Peritoneais/cirurgia , Reprodutibilidade dos Testes , Carga TumoralRESUMO
In France, maternal smoking, active or passive, remains one of the highest in Europe. At the same time, there is an increase in the number of low birth weight (<2500 g) and premature (<37 weeks of amenorrhea) newborns. The objective of this narrative review is to examine the impact of active or passive maternal smoking on birth weight or prematurity rates, and to consider the benefits of policies to stop or control smoking. This is a narrative review that analyzes and discusses the major articles published over the past 20 years regarding the role of active or passive maternal smoking on the risk of low birth weight or preterm delivery. Articles were selected using the following keywords: maternal smoking, low birth weight, preterm birth, smoking cessation, passive smoking, exhaled carbon monoxide, tobacco control policies. Active smoking is associated, in a dose-response relationship, with increased risks of low birth weight and preterm delivery. Passive smoking, mainly related to the presence of a smoking spouse, increases the risk of low birth weight and preterm birth. Our review confirmed also the benefits of smoking cessation, even in the third trimester, in reducing the risk of small for gestation age or fetal growth restriction and preterm birth. Several studies of tobacco control policies have been shown to be effective in significantly reducing maternal smoking. There is sufficient evidence to infer a causal link between active or passive maternal smoking and low birth weight or preterm delivery. This causal link is compelling and sufficient to justify intensifying efforts to promote rapid progress in tobacco control policies, with the vision of a tobacco-free generation, and smoking cessation with best practices during preconception or pregnancy.
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INTRODUCTION: We describe the incidence, impact on survival, and the risk factors for symptomatic lymphoceles in patients with ovarian cancer. METHODS: This retrospective study includes patients with ovarian cancer who had complete cytoreductive surgery and para-aortic and pelvic lymphadenectomy performed in our institute from 2005 to 2011. Patients were classified into two groups: patients with symptomatic lymphoceles and a control group. RESULTS: During the study period, 194 patients with epithelial ovarian cancer underwent cytoreductive surgery and a lymphadenectomy without macroscopic residual disease. Fifty-four patients had symptomatic lymphoceles (28%). In the multivariate analysis, only supraradical surgery was significantly and independently associated with the risk of symptomatic lymphoceles occurring postoperatively. Median follow-up was 24.8 months (range, 1-74 months). Survival rates were not significantly different between the symptomatic lymphocele group and the control group. Two-year disease-free survival rates were 54% for the lymphocele group and 48% for the control group. Two-year overall survival rates were 90% for the lymphocele group and 88% for the control group. CONCLUSIONS: Symptomatic lymphoceles occur frequently after cytoreductive surgery in ovarian cancer. Supraradical surgery is an independent risk factor. The occurrence of symptomatic lymphoceles does not decrease survival. Nevertheless, further studies are needed to reduce the risk of lymphoceles in such patients.
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Linfocele/epidemiologia , Neoplasias Epiteliais e Glandulares/patologia , Neoplasias Ovarianas/patologia , Adulto , Idoso , Carcinoma Epitelial do Ovário , Intervalo Livre de Doença , Feminino , Humanos , Incidência , Excisão de Linfonodo/efeitos adversos , Linfocele/etiologia , Linfocele/patologia , Pessoa de Meia-Idade , Neoplasia Residual , Neoplasias Epiteliais e Glandulares/complicações , Neoplasias Epiteliais e Glandulares/cirurgia , Razão de Chances , Neoplasias Ovarianas/complicações , Neoplasias Ovarianas/cirurgia , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Adulto JovemRESUMO
INTRODUCTION: The objectives of this study were to evaluate the effect of cessation of active smoking during the 1st, 2nd, and 3rd trimesters of pregnancy on the risk of reduced birth weight and prematurity using an exhaled carbon monoxide biomarker with a cut-off value ≥3 ppm as well as the effects of passive smoking. METHODS: This was a multicenter prospective cohort study involving pregnant smokers and non-smokers. Pregnant smokers were identified at the first prenatal visit before 15 weeks of amenorrhea by the number of cigarettes smoked per day and by the carbon monoxide breath test. Women were classified into 6 groups: non-smokers, passive smokers, first trimester cessation, second trimester cessation, third trimester cessation, and smoking throughout pregnancy. Smoking cessation was defined if the pregnant woman reported quitting smoking and if she achieved an exhaled CO level of <3 ppm. The association between smoking cessation and fetal growth restriction or prematurity was assessed by multivariate logistic regression. Passive smoking was defined for non-smoking women on declarative smoking status and exhaled CO ≥3 ppm. The association between passive smoking and fetal growth restriction or prematurity was assessed by multivariate logistic regression. RESULTS: The number of patients included was 5244. The incidence of fetal growth restriction below the 10th percentile was 10.6%, 12.1%, 8.5%, 9.1%, 21.1%, and 22.9%, respectively, for the non-smoking, passive smoking, first, second, third trimester cessation, and full-pregnancy smoking, groups. The risk of FGR compared to non-smokers was OR=2.3 (95% CI: 1.18-4.30, p=0.014) for patients who quit smoking in the third trimester, OR=2.5 (95% CI: 2.03-3.12, p<0.001) for women who smoked throughout pregnancy. After logistic regression, FGR (AOR=1.9; 95% CI: 0.96-3.82) for women who quit smoking in the 3rd trimester (AOR=1.8; 95% CI: 1.38-2.31, p<0.001). The risk of FGR <5th percentile was AOR=1.96 (95% CI: 1.36-2.48, p<0.001). CONCLUSIONS: Active or passive smoking during pregnancy is associated with an increased risk of intrauterine growth restriction and low birth weight. Cessation in the 1st and 2nd trimester reduces the risk of intrauterine growth restriction or low birth weight. Passive smoking has a deleterious impact on fetal development, intermediate to that of active smoking.