Nomogram for Predicting a Complex Ureteral Procedure in Pelvic Endometriosis Surgery.

STUDY OBJECTIVE: To develop a nomogram for predicting the type of ureteral procedure in pelvic deep endometriosis (DE) surgery (1) and to describe the factors and complications associated with the ureteral procedure (2). DESIGN: Retrospective monocentric study of 920 patients who underwent surgery for pelvic DE between June 2009 and March 2020 in the gynecologic surgery department of the Versailles Hospital Center. The main criterion was evaluation of the ureteral procedure, classified as simple (isolation of the ureter) or complex (dissection of the ureter, segmental ureteral resection, or nephroureterectomy). Postoperative complications, including ureteral stenosis and fistula formation, were tabulated. SETTING: Tertiary referral hospital and expert center in endometriosis. PATIENTS: A total of 920 patients with DE. INTERVENTIONS: Ureteral procedure during surgery for DE. MEASUREMENTS AND MAIN RESULTS: In total, 724 patients (79%) underwent a ureteral procedure, of which 307 (33%) were complex, including 17 (1.8%) segmental ureteral resections. In multivariate analysis, the predictive variables for a complex ureteral procedure were age (p = .036), a previous surgery for endometriosis (p <.01), and ureteral dilatation on magnetic resonance imaging (p <.001). The area under the curve for the model predicting a complex ureteral procedure was 0.68 (95% confidence interval, 0.60-0.71). A complex ureteral procedure was associated with a 3.5% rate of ureteral fistula (n = 15). CONCLUSION: Age, a previous surgery for endometriosis, a rectovaginal nodule size ≥30 mm, endometriotic involvement of the rectum or sigmoid, and ureteral dilatation are significantly associated with a complex ureteral procedure. Our results allowed us to build a nomogram that can be used to better inform patients, anticipate the therapeutic strategy, and optimize the modalities of postoperative surveillance.

Standardizing hysteroscopy teaching: development of a curriculum using the Delphi method.

BACKGROUND: Hysteroscopy is performed often and in many indications but is challenging to learn. Hands-on training in live patients faces ethical, legal, and economic obstacles. Virtual reality simulation may hold promise as a hysteroscopy training tool. No validated curriculum specific in hysteroscopy exists. The aim of this study was to develop a hysteroscopy curriculum, using the Delphi method to identify skill requirements. METHODS: Based on a literature review using the key words "curriculum," "simulation," and "hysteroscopy," we identified five technical and non-technical areas in which skills were required. Twenty hysteroscopy experts from different French hospital departments participated in Delphi rounds to select items in these five areas. The rounds were to be continued until 80-100% agreement was obtained for at least 60% of items. A curriculum was built based on the selected items and was evaluated in residents. RESULTS: From November 2014 to April 2015, 18 of 20 invited experts participated in three Delphi rounds. Of the 51 items selected during the first round, only 25 (49%) had 80-100% agreement during the second round, and a third round was therefore conducted. During this last round, 80-100% agreement was achieved for 31 (61%) items, which were used to create the curriculum. All 14 residents tested felt that a simulator training session was acceptable and helped them to improve their skills. CONCLUSIONS: We describe a simulation-based hysteroscopy curriculum focusing on skill requirements identified by a Delphi procedure. Its development allows standardization of training programs offered to residents.

Management of uterine rupture during molar pregnancy.

Gestational trophoblastic disease (GTD) is rare and encompasses several clinicopathologic forms from pre-malignant to malignant disorders. Clinical presentation is most of the time dominated by vaginal bleeding. Only few cases of uterine rupture during GTD have been reported in literature. We present the case of a female patient admitted to the hospital for hemorrhagic shock secondary to a uterine rupture due to an undiagnosed GTD. After an emergency laparoscopy, the patient underwent total hysterectomy with bilateral salpingectomy and bilateral ovarian cystectomy. Pulmonary metastasis were discovered on imaging after stagnation of the beta-hCG level. The surgical treatment was completed by 6 cycles of Methotrexate followed by 7 cycles of Actinomycine D with a good response.

Infertility management according to the Endometriosis Fertility Index in patients operated for endometriosis: What is the optimal time frame?

INTRODUCTION: The Endometriosis Fertility Index (EFI) is a validated score for predicting the postoperative spontaneous pregnancy rate in patients undergoing endometriosis surgery. However, the practical use of the EFI to advise patients about postoperative fertility management is unclear. MATERIALS AND METHODS: All patients participating in the ENDOQUAL study-a prospective observational bi-center cohort study conducted between 01/2012 and 06/2018-who underwent surgery for infertility were asked to complete a questionnaire collecting time and mode of conception. Statistical analysis was performed with the Fine and Gray model of competing risks and analysis of fertility according to the EFI. RESULTS: Of the 234 patients analyzed, 104 (44.4%) conceived postoperatively including 58 (55.8%) spontaneous pregnancies. An EFI of 0-4 for spontaneous pregnancies was associated with a lower cumulative pregnancy incidence compared to an EFI of 5-10 (52 versus 34 pregnancies respectively, Subdistribution Hazard Ratio (SHR) = 0.47; 95% CI [0.2; 1.1]; p = 0.08). An EFI of 0-4 was associated with a higher cumulative pregnancy rate for pregnancies obtained by artificial reproduction technology (ART), compared to an EFI of 5-10 (12 versus 6 pregnancies respectively, SHR = 1.9; CI95% [0.96; 3.8]; p = 0.06). Fecundability decreased from 12 months for EFI 0-4 and from 24 months for EFI 5-10. CONCLUSION: Our analysis suggests that patients with an unfavorable EFI (≤4) have more ART pregnancies than patients with a favorable EFI (≥5) and should be referred for ART shortly after surgery. Patients with a favorable EFI may attempt spontaneous pregnancy for 24 months before referral.

Resection of deep-infiltrating endometriosis could be a risk factor for uterine rupture: a case series with review of the literature.

OBJECTIVE: To highlight the possible correlation between deep-infiltrating endometriosis (DIE) resection and subsequent uterine rupture. DESIGN: Case series and review of the literature. SETTING: Endometriosis referral hospitals. PATIENTS: Seven young women who underwent laparoscopic resection of DIE, six of whom had uterine rupture before or during labor; the seventh patient had a posterior wall defect that placed her at increased risk of future uterine rupture. INTERVENTIONS: Diagnosis of uterine rupture before or during labor in patients with a history of prior resection of DIE, leading to delivery by emergency delivery section or emergency laparotomy for exploration and repair. MAIN OUTCOME MEASURES: Immediate neonate and maternal salvaging caesarean delivery or laparotomy followed by surgical correction of the rupture. RESULTS: As of 2019, no publications in the literature had considered uterine rupture among the obstetric complications of endometriosis. The reporting of such findings is crucial because of the increase in surgical management of endometriosis. We report seven cases of uterine rupture in pregnancy in women who had undergone resection of DIE. In six patients, surgeons found uterine rupture at the level of the previous resected endometriosis and diagnosed a posterior wall defect at the same level in one patient. CONCLUSIONS: Our case series sheds light on the potential increased risk of uterine rupture during pregnancy among women who have had a prior resection of DIE. In future, if these patients are considered high-risk pregnancy cases, their care should be managed by high-risk obstetric specialists.

Assessment of sentinel nodes for gynecologic malignancies by natural orifices transluminal endoscopic surgery (NOTES): preliminary report.

OBJECTIVE: To assess the feasibility of sentinel lymph node (SLN) biopsy in gynecologic malignancies using natural orifices transluminal endoscopic surgery (NOTES) in an animal model. METHODS: Ten female pigs were operated. Patent blue dye was injected in the paracervical region. The endoscope was introduced through a right lateral colpotomy. Internal iliac vessels were visualized followed by the identification of external iliac vessels. Bilateral dissection was performed to achieve visualization of the aorta and the vena cava. SLN colored in blue were bluntly dissected and then excised. RESULTS: Mean operative time was 56+/-16 minutes. The mean number of SLN retrieved was 1.75+/-1.28. All but one SLN were identified by NOTES procedure. No major complication was observed in this series. A total of 19 SLN were harvested, of which 11 from the left side and 8 from the right side. Fifteen lymph nodes were obtained from the iliac vessels or the promontory and 4 from the lateral aortic or preaortic region. CONCLUSIONS: In this study, we confirmed the feasibility of the SLN technique by NOTES. It can be considered as a potential alternative to reduce morbidity during staging procedures for gynecologic malignancies. Prospective randomized series are necessary to establish the safety and the real benefits of this new technique.

Massive hemoperitoneum due to uterine perforation by the Bakri Balloon, during the treatment of postpartum hemorrhage.

The current case describes a very rare complication of Bakri Balloon during the treatment of postpartum hemorrhage; a massive hemoperitoneum with a hemodynamic shock, due to a migration through the right broad ligament, with an anterior uterine rupture, and an irreversible wound of the right uterine artery. This event occurred even if the unfold placement was controlled with ultrasound guidance, to a patient who has never had abdominal surgery (Cesarean section included).

[Endoscopic management of gynecological malignancies: an update. 2007]. / Coelioscopie et cancer en gynécologie: le point en 2007.

All the different surgical procedures used to treat gynecologic cancers have already been performed with the endoscopic approach. However, the prospective randomized trials required to confirm the oncologic efficacy of this approach are still lacking in gynecology, whereas such studies are available for abdominal surgery. Animal studies suggest that the risk of tumor dissemination in the non traumatized peritoneum may be higher after pneumoperitoneum than after laparotomy, and they also show the importance of the surgeon's experience and technique. All the parameters of pneumoperitoneum can influence the risk of postoperative dissemination. By controlling these parameters we may, in future, be able to create a peritoneal environment suitable for oncologic indications and thereby prevent or minimize the risk of peritoneal dissemination and postoperative tumor growth. In endometrial cancer, the laparoscopic approach should be reserved for clinical stage I disease, if the volume of the uterus and local conditions are appropriate for vaginal extraction. In cervical cancer, the laparoscopic approach should be reserved for patients with favorable prognostic factors (stage IB, less than 2 cm in diameter). Laparoscopy is the gold standard for surgical diagnosis of adnexal masses, but puncture should be avoided whenever possible. Surgical treatment of invasive ovarian cancer should use laparotomy, whatever the stage. In contrast, restaging of early ovarian cancer initially managed as a benign mass is a good indication for the laparoscopic approach. Laparoscopic management of tumors with low malignant potential should include complete staging of the peritoneum. An excellent knowledge of the principles of endoscopy and of oncologic surgery is required. Training in endoscopic oncological techniques will be a major challenge in the field of gynecologic surgery in coming years.

[Management of myoma: what is the place for hysterectomy and how to perform it?]. / Traitement des myomes : quelle est la place de l'hystérectomie et selon quelle technique ?

Hysterectomy is the most effective treatment for symptomatic myoma with no possible recurrence. Hysterectomy for myoma is associated with a high rate of patient satisfaction (95%). Quality of life is globally improved by hysterectomy, as is sexuality with less pelvic pain, asthenia, urinary symptoms and impaired mental health. Vaginal and laparoscopic routes should be preferred to diminish blood loss, hospital stay and postoperative pain. Patients with hysterectomy are at twice as much risk of requiring surgical treatment for incontinence later on. Stress urinary incontinence must be looked for during the preoperative history-taking.

Therapeutic management of uterine fibroid tumors: updated French guidelines.

The medical management of symptomatic non-submucosal uterine fibroid tumors (leiomyomas or myomas) is based on the treatment of abnormal uterine bleeding by any of the following: progestogens, a levonorgestrel-releasing intrauterine device, tranexamic acid, nonsteroidal anti-inflammatory drugs, or GnRH analogs. Selective progesterone receptor modulators are currently being evaluated and have recently been approved for fibroid treatment. Neither combined estrogen-progestogen contraception nor hormone treatment of the menopause is contraindicated in women with fibroids. When pregnancy is desired, whether or not infertility is being treated by assisted reproductive technology, hysteroscopic resection in one or two separate procedures of submucosal fibroids less than 4 cm in length is recommended, regardless of whether they are symptomatic. Interstitial, also known as intramural, fibroids have a negative effect on fertility but treating them does not improve fertility. Myomectomy is therefore indicated only for symptomatic fibroids; depending on their size and number, and may be performed by laparoscopy or laparotomy. Physicians must explain to women the potential consequences of myomas and myomectomy on future pregnancy. For perimenopausal women who have been informed of the alternatives and the risks, hysterectomy is the most effective treatment for symptomatic fibroids and is associated with a high rate of patient satisfaction. When possible, the vaginal or laparoscopic routes should be preferred to laparotomy for hysterectomies for fibroids considered typical on imaging. Because uterine artery embolization is an effective treatment with low long-term morbidity, it is an option for symptomatic fibroids in women who do not want to become pregnant, and a validated alternative to myomectomy and hysterectomy that must be offered to patients. Myolysis is under assessment, and research on its use is recommended. Isolated laparoscopic ligation of the uterine arteries is a potential alternative to uterine artery embolization; it also complements myomectomy by reducing intraoperative bleeding. It is possible to use second-generation techniques of endometrial ablation to treat submucosal fibroids in women whose families are complete. Subtotal hysterectomy is a possible alternative to total hysterectomy for fibroid treatment, given that by laparotomy the former has a lower complication rate than the latter, while by laparoscopy, these rates are the same. In each case, the patient is informed about the benefit and risk associated with each therapeutic option.