[Efficiency of the transobturator suburethral tape in the treatment of 61 patients presenting intrinsic sphincter deficiency]. / Efficacité de la voie trans-obturatrice dans le traitement de l'incontinence urinaire d'effort par insuffisance sphinctérienne urétrale: à propos de 61 cas.

OBJECTIVES: To evaluate the effectiveness of the transobturator route in the treatment of intrinsic sphincter deficiency in the stress urinary incontinence. PATIENTS AND METHODS: This is a retrospective multicenter study. Sixty-one patients with a low-uretral closure pressure were treated for stress urinary incontinence using the transobturator route. The intrinsic sphincter deficiency was defined according to criteria of the Société internationale francophone urodynamique (Sifud). The satisfaction of the patients was appreciated in postoperative consultation in the short run (six to 12 months) and by using the questionnaire "Contilife" evaluating the quality of postoperative life in the long run. The failure was defined when the patients declared themselves dissatisfied during the postoperative consultation and/or if their "Contilife" score was lower than seven (out of 10). RESULTS: The short-term evaluation reveals a rate of satisfaction of 92%. The questionnaire "Contilife" reveals 70% of very satisfied or satisfied patients. Eighteen percent of failure is noted. The majority of the patients in failure had urinary urgencies and/or overactive bladder. DISCUSSION AND CONCLUSION: Transobturator vaginal tape can be used in the treatment of patients having a low-uretral closure pressure. The patients must be informed of a success rate slightly lower than in women having a primary genuine stress incontinence.

[Impact of osteopathic manipulative therapy in patient with deep with colorectal endometriosis: A classification based on symptoms and quality of life]. / Intérêt clinique du traitement ostéopathique chez les patientes ayant une endométriose colorectale : classification fondée sur les symptômes et la qualité de vie.

OBJECTIVES: A prospective study to evaluate the clinical impact of osteopathic manipulative therapy (OMT) on symptoms and quality of life (QOL) of patients with colorectal endometriosis. METHODS: Forty-six patients with colorectal endometriosis completed the SF-36 QOL and symptoms questionnaire before and after OMT. A comparison and clustering analysis was performed to identify subgroups of patient's profile and symptom classification. RESULTS: The mean age of the patients was 32±6.2 years. Prior surgery for endometriosis was recorded in 73.9 % of cases but none for deep infiltrating endometriosis. About three-quarters of the patients were nulliparous. The time between pre- and post-OMT completion of questionnaires was 28 days (15-63), A significant improvement in SF-36 QOL physical component summary (P<0.001) and mental component summary (P<0.001) was observed after OMT. Similarly, a significant improvement in gynecological, digestive and general symptoms values was observed. A clustering analysis allowed to identify four profiles of patients with colorectal endometriosis based on symptoms and a respective OMT gain of 30 %, 60 %, 64 % et 45 %. CONCLUSIONS: Our results support that OMT improve QOL and endometriosis symptoms of patients with colorectal endometriosis. Moreover, this symptom classification based on OMT gain can serve to design future randomized trial.

Gonadotrophin-releasing hormone agonist and laparoscopic myomectomy.

The indications for operative laparoscopy have expanded greatly over the past decades, as its many advantages over laparotomy have been recognized. We report our techniques and short-term results concerning myomectomy by laparoscopy. From January 1, 1990 to October 1, 1991, 147 intraperitoneal myomectomies were performed in 70 patients: 46 of 70 were treated preoperatively with a depot gonadotrophin-releasing hormone agonist. No complications were observed. In selected cases, with the advantages of laparoscopic surgery, laparoscopic myomectomy appears to be a safe technique.

Risk factors for ectopic pregnancy in 556 pregnancies after in vitro fertilization: implications for preventive management.

OBJECTIVE: To analyze risk factors for ectopic pregnancy (EP) after in vitro fertilization (IVF). DESIGN: A retrospective study of IVF pregnancies was performed between November 1983 and December 1989. SETTING: This study was conducted in a tertiary care center, the Port-Royal University Hospital. PATIENTS: Patients' records were reviewed for 48 EP and 508 intrauterine pregnancies obtained by IVF. INTERVENTIONS: Forty-six salpingectomies were performed for EP after IVF. MAIN OUTCOME MEASURE: We evaluated the impact on the ectopic rate of tubal status, the type of ovarian stimulation and luteal phase support, and the number of embryos transferred. RESULTS: Forty-three of 48 EP occurred in patients with tubal infertility. The rate of EP was significantly higher when the indication was tubal (11.1%) than when it was endometriosis (2.1%) or unexplained infertility (3.4%). Pathological findings revealed tubal lesions in all 46 salpingectomies. CONCLUSIONS: Ectopic pregnancy after IVF appears related to pre-existing tubal pathology. However, routine prophylactic salpingectomy to prevent the risk of EP does not appear justified.

Myomectomy by laparoscopy: a preliminary report of 43 cases.

OBJECTIVE: To evaluate the technique and short-term results of intraperitoneal (IP) myomectomies. DESIGN: From January 1, 1990, to March 1, 1991, IP myomectomies were performed in all cases in which it appeared feasible. SETTING: This study was conducted in a tertiary care center, the Port-Royal University Hospital. PATIENTS, PARTICIPANTS: Among 49 consecutive patients with interstitial or subserous myomas, 6 patients with voluminous, multiple myomas had laparotomies. Intraperitoneal myomectomy was performed in 43 patients. The indication for laparoscopy was a pelvic mass in 29 cases, infertility in 13, and severe endometriosis in 1 case. INTERVENTIONS: Thermocoagulation or monopolar coagulation was used for the uterine incision. Myometrium and serosa were sutured in 23 of 43 patients. Myomas were removed through the suprapubic puncture site after fragmentation of large myomas. MAIN OUTCOME MEASURE(S): We evaluated the length of the procedures, blood loss, and postoperative course. RESULTS: Ninety-two myomas were removed laparoscopically. No complication was observed. CONCLUSIONS: In selected cases, IP myomectomy appears to be a safe technique with the advantages of laparoscopic surgery.

A new in vitro fertilization technique: intravaginal culture.

Intravaginal culture (IVC) is a new technique elaborated by the authors for the fertilization and culture of human oocytes. Its principle consists of fertilization and early development of the eggs in a closed, air-free milieu without the addition of CO2. One to five ovocytes are deposited in a tube completely filled with 3 ml of culture medium less than 1 hour after their recovery, with 10,000 to 20,000 spermatozoa per ml previously prepared. The tube is then hermetically closed and it is placed in the maternal vagina and held by a diaphragm for incubation for 44 to 50 hours. After this time, the content of the tube is examined and embryos are transferred to the uterus. In the first 100 consecutive punctures, 22 clinical pregnancies were obtained: 17 deliveries, 3 spontaneous abortions, and 2 tubal pregnancies. Also, a randomized study comparing IVC to in vitro fertilization (IVF) was done (160 cycles) and no statistically different cleavage, transfer, or pregnancy rate was seen between IVC and IVF. By simplifying the laboratory manipulations, this technique decreases the cost of IVF and permits its standardization and diffusion. It creates a psychologic comfort permitting active participation of the mother in this stage of embryo development. Also, the use of this technique may give greater knowledge of human gamete metabolism and of the physiology of reproduction.

Transcervical cannulation of the fallopian tube for the management of ectopic pregnancy: prospective multicenter study.

OBJECTIVE: To determine the efficacy of transcervical tubal cannulation and intraluminal methotrexate injection for the management of tubal ectopic pregnancy (EP). DESIGN: Prospective multicenter study of 33 patients with tubal pregnancies. SETTING: Four university-based gynecology and radiology departments in three different countries: France, England, and Germany. PATIENTS: Thirty-three patients who presented with a clinical diagnosis of EP. INTERVENTIONS: Patients underwent transcervical tubal cannulation under fluoroscopic or ultrasound control and local injection of methotrexate (up to 50 mg). MAIN OUTCOME MEASURES: We evaluate the feasibility of transcervical tubal cannulation for the management of tubal pregnancy. RESULTS: Two patients elected to withdraw from the protocol. In the remaining 31 patients there was complete resolution of the EP in 27 (87%). Surgery was performed in 4 patients. Seventeen patients, 14 of whom desired pregnancies, were available for follow-up to assess the return of reproductive potential. Seven of 7 patients who subsequently underwent hysterosalpingography had patency of the affected tube. Five patients later had an intrauterine pregnancy. One patient had an early miscarriage, two have given birth, and two singleton pregnancies are still ongoing. The remaining patients are symptom free. CONCLUSIONS: This study demonstrates that transcervical tubal catheterization in patients with tubal pregnancies is feasible and can be performed without anesthesia or analgesia in most cases. Intraluminal methotrexate per se is capable of causing regression of the EP. This approach offers a new alternative for the treatment of selected patients with tubal EP.

In vitro fertilization without ovarian stimulation: a simplified protocol applied in 80 cycles.

Ovulation induction with various hormonal agents has become a standard component of in vitro fertilization (IVF) cycles to obtain multiple oocytes. Failure to anticipate the retrieval of more than two oocytes often results in cancellation of the cycle. In this study, we report our results in 80 unstimulated IVF cycles. Serum estradiol (E2) and pelvic ultra-sound monitoring were begun on day 9 of the cycle. Human chorionic gonadotropin (hCG) was administered when the E2 level exceeded 180 pg/mL and the dominant follicle was greater than 18 mm. Eighteen pregnancies were obtained (22.5%/cycle), and 14 (17.5%/cycle) are ongoing. We conclude that favorable results can be obtained from unstimulated IVF cycles, despite replacement of a single embryo.

Terminal tuboplasties by laparoscopy: 65 consecutive cases.

A series of 65 consecutive laparoscopic distal tuboplasties, performed from May 1986 to May 1988 is reported. Thirty-one were fimbrioplasties and 34 were neosalpingostomies. Outcome was evaluated at 18 months postoperatively. Twenty-two patients obtained pregnancies (33.8%), of which 18 were intrauterine (27.7%). The intrauterine pregnancy rate was 25.8% after fimbrioplasty and 29.4% after neosalpingostomy. These results are comparable with those obtained after microsurgery. Progress in operative laparoscopy may be attributed to the development of an appropriate atraumatic instrumentation and the CO2 laser. The major advantage of laparoscopic techniques is their availability at the time of diagnostic laparoscopy. Immediate opening of hydrosalpinges allows for precise evaluation of the tubal mucosa, thereby establishing prognosis. In cases with a severely altered mucosa, in vitro fertilization may be considered immediately. When the mucosa is satisfactory, laparoscopic fimbrioplasty or neosalpingostomy may be performed. Within 1 year after one of these procedures, a pregnancy is generally achieved in 1 of 3 patients.

Reproductive outcome after laparoscopic salpingectomy for tubal pregnancy.

Since 1983, we have performed laparoscopic salpingectomy as a routine procedure for ectopic pregnancy (EP) in cases where conservative management is impossible or contraindicated. The main indications are a ruptured tubal gestation, a pathological tube, a history of tuboplasty, and an ipsilateral recurrence. This technique is simple, quick, and safe. Reproductive outcome after laparoscopic total salpingectomy for EP was evaluated in 125 cases between January 1983 and December 1987. The pregnancy rate was 33.6%. In our population, there was a high proportion of patients with a pathological or absent contralateral tube (74.4%). In patients with a normal contralateral tube (32 cases), the live birth rate (46.9%) was greater but not significantly than in patients (39 cases) with a patent but pathological tube (25.6%). In vitro fertilization (IVF) was performed in 59 patients; clinical pregnancy was obtained in 40.7% of cases. These encouraging results lead us rapidly to consider IVF in patients with a pathological contralateral tube.

[Deep pelvic endometriosis: management and proposal for a "surgical classification"]. / L'endométriose pelvienne profonde: prise en charge thérapeutique et proposition d'une << classification chirurgicale >>

Deep pelvic endometriosis presents essentially in the form of a painful syndrome dominated by deep dyspareunia and painful functional symptoms that recur according to the menstrual cycle, with the semiology directly correlated with the location of the lesions (bladder, rectum). It is essential to investigate these deep endometriosis lesions and draw up a precise map, which is the only way to be sure that exeresis will be complete. The treatment of first intention remains surgery, and medical treatment is only palliative in the majority of cases. Success of treatment depends on how radical surgical exeresis is. Based on analysis of the anatomical distribution of deep pelvic endometriosis lesions, a "surgical classification" is proposed with the aim of establishing standard modes for surgical treatment. Further studies are required to clarify the place and modes for pre- and postoperative medical treatment.

[Celiosurgery in gynecology. Indications, benefits and risks]. / La coeliochirurgie en gynécologie. Indications, bénéfices et risques.

Initially used exclusively for diagnosis, laparoscopy is now a surgical method in gynecology but also in many other specialties. In gynecology, the results of laparoscopic surgery are comparable to those obtained by laparotomy in many indications: ectopic pregnancy, ovarian cysts, endometriosis, tubo-peritoneal sterility... Because of the advantages of laparoscopic surgery over traditional surgical treatment by laparotomy, operative laparoscopy is, in these indications, now recognized to be the best choice of surgical treatment. The most important advantages of operative laparoscopy are the following: less esthetic drawbacks, minimal risk of parietal and infectious complications, lower risk of post operative adhesions, more comfortable post operative course and lower cost due to considerably shortened hospital stay and recovery period. The risk of complications is directly correlated to the surgeon's experience and the importance of the surgery performed.

[Technics of the use of CO2 laser in microsurgery of sterility. Experimental study. Clinical results]. / Techniques d'utilisation du laser CO2 en microchirurgie de la stérilité. Etude expérimentale. Résultats cliniques.

The authors describe their experience in the use of CO2 laser in microsurgical treatment of tubal sterility. An experimental study was carried out on Fallopian tubes in order to define the parameters for the use of CO2 laser in tubal surgery. Certain microsurgical techniques were altered when CO2 laser was used. The procedures were improved by the ease of surgery and the speed with which it could be carried out. Our clinical experience was on 153 patients who were operated on. In 66 laparotomies the combined use of microscope and CO2 laser seemed to improve the handling of tubal sterility.

[Total laparoscopic hysterectomy. Operative technique, results and indications]. / Hystérectomie totale per-coelioscopique. Technique opératoire, résultats et indications.

Total hysterectomy was performed via laparoscopy alone in 50 patients. In all cases, the operation was carried out using conventional, re-usable instruments (grasping forceps, laparoscopic scissors, bipolar coagulation). The mean duration of the operation was 163 min (range: 110-270 min). The mean drop in haemoglobin was 1.97 g/100 ml (range: 0-4 g/100 ml) and the average length of hospital stay was 3.9 days (range: 2-13 days). In one case (2%), we converted to laparotomy because a lateral myoma made it impossible to achieve haemostasis of the uterine pedicule under suitably safe conditions. No serious peri or post-operative complications were encountered. No second surgery was necessary and no transfusion was required. These results confirm that total laparoscopic hysterectomy via laparoscopy is a safe, feasable and reproductible technique. Future work will establish the exact place and methods for laparoscopic surgery for hysterectomy. Laparoscopic surgery is only indicated when vaginal hysterectomy is contraindicated or impossible. Laparoscopic hysterectomy constitutes an alternative to laparotomy rather than the vaginal hysterectomy. The combination of an immobile uterus and poor vaginal accessibility is the prime indication for total hysterectomy via laparotomy.

[Laparoscopic surgery of large uterine fibromas. Operative technique and results]. / Traitement coeliochirurgical des volumineux fibromes utérins. Technique opératoire et résultats.

OBJECTIVE. To describe the technique of laparoscopic myomectomy for large myomas (5 cm and more) and to evaluate the results. RESULTS. Only myomas which are complicated (and/or resistant to properly conducted medical treatment) require surgical treatment. Between October 1, 1990 and October 31, 1994, we carried out 72 laparoscopic myomectomies for intramural myomas measuring 5 cm or more, in 71 patients. The operations lasted 130 +/- 60 min (range: 40-330 min). We converted to laparotomy for two cases (2.7%). We observed no serious per or postoperative complications. We never needed a repeat operation, whether by laparotomy or by laparoscopy. CONCLUSION. Despite these encouraging results, it must be remembered that the operation is lengthy and difficult and is reversed for laparoscopic surgeons perfectly familiar with endoscopic knot tying. Although it is a difficult technique, laparoscopic myomectomy is possible even for large myomas and those that are completely intramural. These results need to be assessed over the long term especially with respect to the risk of adhesions and the quality of the laparoscopic suture.

[Nipple discharge without palpable tumor. Experience of the Institut Curie from 1970 to 1984]. / Ecoulement par le mamelon sans tumeur palpable. Expérience de l'Institut Curie de 1970 à 1984.

Four hundred and ten women with serous or bleeding nipple discharge without palpable mass were treated by surgery in the Curie Institute between 1970 and 1984. The cancer rate in this group was 12.2 per cent. Galactography was of anatomical interest as it showed the canal at the origin of the discharge. Malignant cells were observed at cytological examination in only 17 per cent of intragalactophoric cancers. Surgical excision is necessary if the nipple discharge is uniporous and easily reproducible by areolar pressure, particularly in the post-menopausal period when the frequency of cancer is highest (17.7 per cent).

[Other indications: tubal sterilization, medically assisted procreation, salpingitis, fibromas]. / Les autres indications: stérilisation tubaire, procréation médicalement assistée, salpingites, fibromes.

Tubal sterilization is now commonly performed by laparoscopy. Among the available techniques, clips are easy to install and have a low failure rate. Laparoscopy is of considerable value in salpingitis for the diagnosis and treatment of tubo-ovarian abscesses. In medically assisted procreation, laparoscopy is less and less necessary. GIFT and, chiefly, ZIFT are still performed by laparoscopy in case of infertility with normal Fallopian tubes. Laparoscopic myomectomy is a more recent technique, but further experience is needed to assess its value compared with laparotomy.

PIP: Tubal sterilization is performed during laparoscopy in most cases under general anesthesia or under local anesthesia when clips are used. Electric techniques comprise bipolar coagulation or thermocoagulation. The Hulka clip and Filshie clip methods are most prevalent. The Yoon ring consisting of a silicone ring is also widely used. The failure rate of different tubal sterilization methods reaches about 5%, chiefly as a result of technical error. Complications are very rare, mainly bleeding of the middle portion which can be stopped by coagulation. Laparoscopy once was the only method of in vitro fertilization, i.e., by collecting ovocytes under general anesthesia. It is rapidly being replaced by echo-guided outpatient techniques of ovocyte collection under laparoscopy: GIFT and ZIFT. GIFT is intratubal transfer of gametes by follicular puncture. The aspirated follicular liquid is examined to harvest a maximum of 3 mature ovocytes that are mixed with about 50,000 previously prepared spermatozoa and reintroduced into the tubes. In ZIFT performed under echography ovocytes are inseminated with spermatozoa, and then a maximum of 3 zygotes are transferred into 1 tube. In unexplained or masculine sterility ZIFT is preferred, as the use of laparoscopy is also avoided. Laparoscopy is used for the diagnosis of salpingitis, especially in severe, acute cases. In operation it is used in the treatment of pyosalpinx, and satisfactory drainage of the abscess is often obtained with rapid regression of clinical symptoms. Myomectomy by laparoscopy is relatively recent, mostly reserved for myomas with a diameter of less than 5 cm once size has been measured by echography and a luteinizing hormone releasing hormone agonist has been taken for 2-3 months for reduction of its size. Hemostasis at the uterine implantation site of the myoma is achieved by thermocoagulation or monopolar coagulation.

[Surgical treatment of endometriosis]. / Traitements chirurgicaux de l'endométriose.

The surgical treatment of endometriosis, which used to be performed by laparotomy, is now in most cases performed by coelioscopy. The purpose of surgery is to destroy or remove as much as possible of the endometriotic lesions and to treat their sequelae, usually adhesions. In the majority of patients, the coelioscopic treatment can be carried out at the same as the initial diagnostic coelioscopy, the stay in hospital not exceeding 48 hours. The pregnancy rate obtained is similar to that reported with laparotomy, but the operator must have a long experience of operative coelioscopy.