Surgical Management of Urinary Tract Endometriosis: A 1-year Longitudinal Multicenter Pilot Study at 31 French Hospitals (by the FRIENDS Group).

STUDY OBJECTIVE: To describe the surgical management and risks of postoperative complications of patients with urinary tract endometriosis in France in 2017. DESIGN: Multicenter retrospective cohort pilot study. SETTING: Departments of gynecology at 31 expert endometriosis centers. PATIENTS: All women managed surgically for urinary tract endometriosis from January 1, 2017, to December 31, 2017. We distinguished patients with isolated bladder endometriosis or isolated ureteral endometriosis (IUE) from those with endometriosis in both locations (mixed locations [ML]). INTERVENTIONS: Surgeons belonging to the French Colorectal Infiltrating Endometriosis Study (FRIENDS) group enrolled patients who filled a 24-item questionnaire on the day of the inclusion and 3 months later. Data were collected on operative routes, surgical management, and postoperative complications according to the Clavien-Dindo classification in a single anonymized database. MEASUREMENTS AND MAIN RESULTS: A total of 232 patients from 31 centers were included. Isolated bladder endometriosis was found in 82 patients (35.3%), IUE in 126 patients (54.4%), and ML in 24 patients (10.3%). Surgery was performed by laparoscopy, laparotomy, or robot-assisted laparoscopy in 74.1%, 11.2%, and 14.7% of the cases, respectively. Among the 150 ureteral lesions (IUE and ML), 114 were managed with ureterolysis (76%), 28 with ureteral resection (18.7%), 4 with nephrectomy (2.7%), and 23 with cystectomy (15.3%). Concerning bladder endometriosis, a partial cystectomy was performed in 94.3% of the cases. We reported 61 postoperative complications (26.3%): 44 low-grade complications according to the Clavien-Dindo classification (18%), 16 grade III complications (7%), and 1 grade IV complication (peritonitis). CONCLUSION: The surgical management of ureteral and bladder endometriosis is usually feasible and safe through laparoscopic surgery. Ureteral resection, when necessary, is more strongly associated with laparotomy and with more complications than other procedures. Prospective controlled studies are still mandatory to assess the best surgical management for patients.

Assessment of Synthetic Glue for Mesh Attachment in Laparoscopic Sacrocolpopexy: A Prospective Multicenter Pilot Study.

STUDY OBJECTIVE: To assess the anatomic efficacy and safety of synthetic glue to fix prosthetic material in laparoscopic sacrocolpopexy. DESIGN: A 1-year follow-up in a prospective multicenter pilot study between November 2013 and November 2014 (Canadian Task Force Classification II-2). SETTING: An academic urogynecology research hospital. PATIENTS: Seventy consecutive patients with Pelvic Organ Prolapse Quantification stage ≥3 anterior and/or medial prolapse underwent laparoscopic sacrocolpopexy. INTERVENTIONS: All women underwent laparoscopic sacrocolpopexy with the same standardized technique using a synthetic surgical glue to fix anterior and posterior meshes. MEASUREMENTS AND MAIN RESULTS: Patients were followed up at 1 month and 1 year, with anatomic and functional assessment (Pelvic Floor Distress Inventory-20, Pelvic Floor Impact Questionnaire-7, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12). Anatomic success was defined as 1-year Pelvic Organ Prolapse Quantification stage ≤1. Sixty-six patients were included; the mean age was 56.7 ± 1.2 years. The mean operative time was 145 ± 5 minutes. The mean glue fixation time was less than 2 minutes for both anterior and posterior meshes. The 1-year anatomic success rate was 87.5% in the anterior compartment (Ba at -2.3 cm, p < .0001) and 95.3% in the medial compartment (point C at -6.1 cm, p < .0001). There were no intra- or postoperative complications and no cases of mesh exposure; 5 cases of mesh shrinkage (7.8%) were observed at 1 year. The postoperative urinary stress incontinence rate was 29.7% at 1 year. Eight patients (12.1%) underwent revision surgery with transobturator tape. All quality of life scores showed significant improvement (p < .0001) at 1 year. CONCLUSION: Synthetic glue attachment of prosthetic material in laparoscopic sacrocolpopexy proved straightforward, safe, time-saving, and effective at 1 year. Prospective randomized studies will be needed to confirm the long-term benefit.

Sentinel node biopsy for the management of early stage endometrial cancer: long-term results of the SENTI-ENDO study.

OBJECTIVE: We report the long-term results of the SENTI-ENDO study evaluating the impact of sentinel lymph node (SLN) biopsy on management and survival in patients with early stages of endometrial cancer (EC). METHODS: Patients with FIGO stage I-II EC underwent pelvic SLN biopsy after cervical dual injection (technetium and patent blue) and systematic pelvic node dissection. This study is a secondary endpoint reporting the long-term recurrence free survival (RFS) and the impact of the SLN procedure on adjuvant therapies. RESULTS: The median follow-up was 50 months (range: 3-77 months). Eighteen of the 125 patients (14.4%) experienced a recurrence. The 50-month recurrence-free survival (RFS) was 84.7% with no difference between patients with and without detected SLN (p = 0.09). Among patients with detected SLN (111), no difference in RFS was observed between those with and without positive SLN (p = 0.5). In the whole population, adjuvant therapy was performed in low-, intermediate- and high-risk groups in 31 of 64 patients (48.4%), 28 of 37 patients (75.7%) and 14 of 17 patients (82.3%), respectively (p = 0.0001). For the 111 patients with detected SLN, EBRT was performed in 27 of the 89 with negative SLN and in 11 of the 14 with positive SLN (p = 0.001). Chemotherapy was performed more frequently in patients with positive SLN (6/12, 50%) than in patients with negative SLN (7/56, 12.5%) (p = 0.009). CONCLUSIONS: Our results support the impact of SLN biopsy on surgical management and indications for adjuvant therapies. Further studies are required to assess the clinical impact of the SLN biopsy in early stage EC.

Long-term symptoms, quality of life, and fertility after colorectal resection for endometriosis: extended analysis of a randomized controlled trial comparing laparoscopically assisted to open surgery.

BACKGROUND: To evaluate the long-term symptoms, quality of life (QOL), and fertility after colorectal resection for endometriosis. METHODS: Extended analysis of a randomized controlled trial including 52 patients with colorectal endometriosis, comparing laparoscopically assisted to open colorectal resection. All included patients were invited to complete questionnaires evaluating the presence and intensity of symptoms and QOL using the SF-36 and fertility at a mean (SD) follow-up of 50.7 (13.8) months. We compared symptoms intensity and QOL before and after surgery at short- (mean follow-up of 19 months) and long-term (mean follow-up of 51 months). RESULTS: Persistent improvement in QOL was noted after surgery without differences between short and long term. Self-catheterization >6 months was the sole factor decreasing the long-term QOL (P = 0.02). No difference in symptoms and QOL was noted according to the route. Among the 28 patients (53.8%) wishing to conceive, 12 (42.9%) conceived within a mean (SD) time of 17 (13) months. No difference in fertility including pregnancy after IVF was noted between the routes, but spontaneous pregnancy occurred only after laparoscopy (P = 0.016). CONCLUSIONS: Symptoms and QOL improvements after colorectal resection last for over 4 years without difference between the routes. Thank to a lower intra- and postoperative complications and higher spontaneous pregnancy rate, laparoscopic colorectal resection should be the first surgical approach.

Three-dimensional ultrasound in the management of bladder endometriosis.

STUDY OBJECTIVE: To assess the performance of three-dimensional (3D) ultrasound with color Doppler in the diagnosis of bladder endometriosis compared with magnetic resonance imaging (MRI) and cystoscopy. DESIGN: Canadian Task Force classification II-3. SETTING: Department of gynecology and obstetrics of a university hospital. PATIENTS: Eight women who reported urinary tract symptoms suggestive of bladder endometriosis between May 2012 and November 2013. INTERVENTIONS: For all cases, we assessed the size of the endometriotic nodule, its location on the bladder wall, and the distance between the lesion and the ureteral meatus, with pelvic 3D ultrasound (full bladder), uro-MRI, and cystoscopy. The results were compared with the postoperative histopathologic findings. MEASUREMENTS AND MAIN RESULTS: The pathology results differed from those produced by imaging by a mean ± SD of -3.5 ± 6.4 mm on transvaginal ultrasound (TVUS) and -5.75 ± 11.9 mm) for MRI. There was no significant difference between imaging and pathology findings (p = .20) or between the 2 imaging findings (TVUS and MRI) (p = .73). Results showed a trend toward better accuracy for 3D ultrasound than MRI with smaller SDs (p = .08). Cystoscopy and ultrasound were compared; however, without any tools to assess the distance in cystoscopy, no statistical result was possible. CONCLUSION: Ultrasound seems to be superior to cystoscopy and is at least as effective as MRI in diagnosing and planning the surgery for bladder endometriosis.

[Laparoscopic ultrasound-guided radiofrequency ablation of uterine fibroid: A retrospective study]. / Myolyse des fibromes utérins par radiofréquence cœlioscopique sous contrôle échographique : à propos d'une série rétrospective.

OBJECTIVE: To assess clinical and radiological efficacy and safety of laparoscopic ultrasound-guided radiofrequency ablation of uterine leiomyomas. MATERIAL AND METHODS: Thirty-three patients with symptomatic uterine leiomyomas FIGO type 2 to 7, have undergone a laparoscopic ultrasound-guided radiofrequency ablation at Croix Rousse University Hospital Center (Hospices civils de Lyon) and at Saint-Vincent de Paul Hospital in Lille, between June 2020 and December 2022. The characteristics of each myoma and the symptoms were assessed with pelvic MRI and with Higham score, SSS and HRQL scores preoperatively and at 6 months. RESULTS: A total of 54 fibroids have been treated in 33 patients. We observed a significant decrease of the volume 6 months after the surgery, on average 21mL (55.97 vs. 74.37mL, 95% CI [7.13-34.88], P=0.001). The maximum diameter of each fibroid was also significantly reduced on average 11.78mm (41.89 vs. 52.06, 95% CI [8.83-14.73], P<0.05). We noticed a significant decrease of the NRS for dysmenorrhea on average 2.79 points (2.1 vs. 4.89, 95% CI [1.14-4.42], P<0.05). There was also a trend to improvement of menorrhagia, assess by Higham score. Indeed, 70.8% of the patients had menorrhagia. Menorrhagia was improved of 108,3 points with an average Higham score before surgery of 197.3 versus 87.9 after surgery (95% CI [47.9-168.8], P=0.001). Concerning UFS-QOL score: the symptom severity score (SSS) decreased on average 33 points, testifying of symptom improvement (27.04 vs. 60.89, 95% CI [22.92-43.39], P<0.001) and the HRQL score increased on average 20 points testifying quality of life improvement (65.57 vs. 42.7, 95% CI [15.83-37.85]. P<0.001). No severe adverse event has been reported. CONCLUSION: In this first French study about radiofrequency ablation. We confirm its efficiency for improvement of symptoms and quality of life but other study is mandatory to confirm the safety of this procedure in particular in patients with a wish to conceive.

Fibrinogen for the prediction of severe maternal complications in placental abruption with fetal death after 24 weeks of gestation.

OBJECTIVE: To assess the correlation between standard laboratory indicators at admission and severe maternal complications due to placental abruption (PA) with intrauterine fetal death (IUFD) after 24 weeks. METHODS: Retrospective study in three French tertiary referral hospitals. Correlation of laboratory indicators at admission (platelet count, prothrombin, activated partial thromboplastin time, fibrinogen) and severe maternal complications (massive transfusion, multiple organ failure, hysterectomy, or maternal deaths) in patients with PA and IUFD. RESULTS: Over 12 years, we identified 27/344 (7.8%) pregnant women presenting PA with IUFD. No patient had coagulopathy at admission. Fifteen individuals (55.5%) underwent delivery by cesarean section before or during labor. Fifteen individuals (55.5%) presented severe complications, and 17/27 (63%) lost more than 1 L of blood during delivery. Fibrinogen level was shown to be the laboratory indicator most correlated with severe complications (r = -0.52, P = 0.01). The receiver operating characteristic curve of fibrinogen less than 1.9 g/L in the prediction of severe complications (area under the curve = 0.80, 95% confidence interval [CI] 0.54-0.97) showed both a sensitivity and specificity of 83% (95% CI 54%-96%). CONCLUSIONS: In cases of IUFD with PA, fibrinogen levels at admission had a prognostic value for the prediction of severe maternal complications.

Comparison of diagnostic accuracy of frozen section with imprint cytology for intraoperative examination of sentinel lymph node in early-stage endometrial cancer: results of Senti-Endo study.

BACKGROUND: In early-stage endometrial cancer, intraoperative examination of sentinel lymph nodes (SLNs) can predict nodal involvement and avoid a second surgical procedure. Our goal was to determine the diagnostic accuracy (DA) of intraoperative examination in diagnosing metastatic pelvic SLNs. METHODS: This was a retrospective study, including 125 patients with early stage endometrial cancer. Results of intraoperative examination by frozen section (FS) or imprint cytology (IC) were compared with final histology (serial sectioning and immunohistochemistry (IHC)). The diagnostic value of intraoperative examination was calculated. RESULTS: Of the 111 patients with SLNs detected (89%), 87 (78.5%) had an intraoperative examination (30 with FS and 57 with IC). Intraoperative examination detected SLN metastases in 9 of 16 patients with metastatic SLN at definitive histology (sensitivity = 56.3%): macrometastasis in 8 and micrometastasis in 1. Seven false-negative cases were found (43.7%; micrometastases in 6 and isolated tumor cells in 1). The DA of intraoperative examination was 92% (95% confidence interval (CI), 84-96.7). For FS and IC, DA was 97.3% (95% CI, 85.8-99.9) and 88% (95% CI, 75.7-95.5), respectively. CONCLUSIONS: FS has better DA than IC for intraoperative examination of SLNs in endometrial cancer. The main limitation of both techniques is in detecting micrometastasis and isolated tumor cells.

Detection rate and diagnostic accuracy of sentinel-node biopsy in early stage endometrial cancer: a prospective multicentre study (SENTI-ENDO).

BACKGROUND: Retrospective single-centre series have shown the feasibility of sentinel lymph-node (SLN) identification in endometrial cancer. We did a prospective, multicentre cohort study to assess the detection rate and diagnostic accuracy of the SLN procedure in predicting the pathological pelvic-node status in patients with early stage endometrial cancer. METHODS: Patients with International Federation of Gynecology and Obstetrics (FIGO) stage I-II endometrial cancer had pelvic SLN assessment via cervical dual injection (with technetium and patent blue), and systematic pelvic-node dissection. All lymph nodes were histopathologically examined and SLNs were serial sectioned and examined by immunochemistry. The primary endpoint was estimation of the negative predictive value (NPV) of sentinel-node biopsy per hemipelvis. This is an ongoing study for which recruitment has ended. The study is registered with ClinicalTrials.gov, number NCT00987051. FINDINGS: From July 5, 2007, to Aug 4, 2009, 133 patients were enrolled at nine centres in France. No complications occurred after injection of technetium colloid and no anaphylactic reactions were noted after patent blue injection. No surgical complications were reported during SLN biopsy, including procedures that involved conversion to open surgery. At least one SLN was detected in 111 of the 125 eligible patients. 19 of 111 (17%) had pelvic-lymph-node metastases. Five of 111 patients (5%) had an associated SLN in the para-aortic area. Considering the hemipelvis as the unit of analysis, NPV was 100% (95% CI 95-100) and sensitivity 100% (63-100). Considering the patient as the unit of analysis, three patients had false-negative results (two had metastatic nodes in the contralateral pelvic area and one in the para-aortic area), giving an NPV of 97% (95% CI 91-99) and sensitivity of 84% (62-95). All three of these patients had type 2 endometrial cancer. Immunohistochemistry and serial sectioning detected metastases undiagnosed by conventional histology in nine of 111 (8%) patients with detected SLNs, representing nine of the 19 patients (47%) with metastases. SLN biopsy upstaged 10% of patients with low-risk and 15% of those with intermediate-risk endometrial cancer. INTERPRETATION: SLN biopsy with cervical dual labelling could be a trade-off between systematic lymphadenectomy and no dissection at all in patients with endometrial cancer of low or intermediate risk. Moreover, our study suggests that SLN biopsy could provide important data to tailor adjuvant therapy. FUNDING: Direction Interrégionale de Recherche Clinique, Ile-de-France, Assistance Publique-Hôpitaux de Paris.

Evaluation of an e-learning program for the diagnosis of rectosigmoid endometriosis with rectal water contrast transvaginal ultrasonography (rectosonography).

This study aimed to evaluate the value of an e-learning program for the diagnosis of rectosigmoid endometriosis lesions using rectal water contrast transvaginal ultrasonography (rectosonography/RSG). Theoretical RSG training using videos with a commentary was offered online to healthcare professionals involved in ultrasound screening for endometriosis. A test (without correction) with 24 RSG video loops was used to assess the participants' baseline level before the training and their improvement afterwards. If the success rate post-training was below 80 %, the participant could start over with another series of 24 videos. Between February and June 2020, thirty participants took the training course (of which 80 % were obstetrics-gynaecology residents). The e-learning program resulted in a significant performance increase in the diagnosis of rectosigmoid endometriosis lesions, with a higher test success rate after the training compared to before (74.4 % and 63.6 % respectively; +10.8 %; 95 % CI [6,6; 15]; p < 0.001). Significant improvement was also observed regarding the overall skills involved in the ultrasound diagnosis of deep infiltrating endometriosis (+9.2 %; p < 0.001), the accurate diagnosis of the height of bowel lesions (+14.7 %; p < 0.001) and uterosacral ligament lesions (+8%; p < 0.005). In conclusion, our e-learning program led to a significant improvement of the diagnostic performance of digestive endometriosis using transvaginal ultrasound with intrarectal water contrast (rectosonography). Adding feedback to the post-test video loops could further increase the efficacy of the e-learning training.

Learning Curve for the Detection of Deep Infiltrating Endometriosis and Adenomyosis with 3-D Transvaginal Water Contrast Sonography.

Three-dimensional rectosonography (RSG) is a transvaginal sonography technique using rectal water contrast and 3-D acquisitions. The main points of interest of 3-D RSG could be its easy accessibility and its quick learning curve, especially with respect to rectosigmoid lesions. The objective of this prospective observational study was to assess the learning curve of 3-D RSG for the diagnosis of rectosigmoid lesions and for various other locations of deep endometriosis (DE), endometriomas and adenomyosis. From April 2017 to November 2017, 116 patients with suspected pelvic endometriosis were referred to the Croix-Rousse University Hospital, and those who underwent 3-D RSG were included in our study. After a short training period, four residents were asked to perform 3-D RSG by themselves. Each procedure was systematically controlled immediately afterward by a single expert sonographer. The success of the procedure involved the correct identification of various locations of endometriosis (rectosigmoid, uterosacral ligament, retrocervical space, vagina, bladder and ovaries) and adenomyosis, using the expert sonographer's examination as the reference technique. The learning curve was generated using these data and assessed using the Learning Curve Cumulative Summation Test (LC-CUSUM) method. The pooled LC-CUSUM revealed that the required level of achievement was reached after 24 3-D RSGs were performed for the diagnosis of rectosigmoid lesions. All four residents were significantly competent in diagnosing rectosigmoid lesions at the end of their training period, with an α risk <0.05 (T1, p = 0.03; T2, p = 0.0002; T3, p = 0.05; T4, p = 0.02). The LC-CUSUM analysis confirmed that competency was achieved for vaginal DE, torus uterinum DE, US DE, bladder DE, endometriomas and adenomyosis within 17, 27, 38, 19, 17 and 33 scans, respectively. This study provides evidence that the skills required to diagnose endometriosis lesions and adenomyosis with 3-D RSG can be acquired after a brief learning period in an expert center.

Conservative surgical treatment of post-partum hemorrhage: Should we reconsider compression penetrating sutures?

OBJECTIVES: Evaluate the prevalence of uterine synechia after total uterine ligation (TUL) in comparison to TUL associated with compression-penetrating-sutures (CPS) in the conservative surgical management of severe postpartum hemorrhage (PPH). METHODS: Prospective observational study of pregnant women that underwent conservative surgical management for PPH in a single French tertiary referral center. We compared the risk of uterine synechia with TUL, in comparison to performing TUL in addition to CPS. The synechia rate was calculated after uterine cavity assessment by 3D hysterosonography. Hysterectomies, women with placenta accreta spectrum and patients that received additional embolization treatment were excluded. RESULTS: Over 6 years, 36 pregnant women underwent surgical treatment for PPH in 21,944 deliveries (1.64 per 1000). The median blood loss was 2700 [1570-3000] milliliters. Twenty-eight (77.7%) women underwent TUL, 8/36 (22.2%) underwent TUL in addition to CPS. Thirty-four (94,4%) cavity assessments were performed 2-to-6 months after delivery, since one woman of each group was lost to follow-up. When TUL was performed in addition to CPS, the prevalence of synechia was 42.9% (n = 3/7), versus 3.7% (n = 1/27) in TUL (p = 0.021; RR = 16.88, 95%CI [1.1-1051]). Synechia was absent in 30/34 (88.2%) women. CONCLUSION: The prevalence of synechia was very low after TUL unlike CPS. Further studies should evaluate TUL in the conservative surgical management of PPH, to confirm the lower prevalence of synechiae in TUL and evaluate its impact on fertility.

Live birth rate after cervicoisthmic cerclage in patients with previous late miscarriage and/or premature delivery.

OBJECTIVE: This study assesses the effectiveness of cervicoisthmic cerclage on the live birth rate, measured before and after performing this cerclage in a series of 62 patients with a history of late miscarriage and/or premature delivery. STUDY DESIGN: All patients who underwent cervicoisthmic cerclage in one of the 3 university hospitals of the Hospices Civils de Lyon, between January 1, 2010, and April 1, 2019, and with a history of at least one late miscarriage or spontaneous premature birth, were included. Obstetrical and neonatal data for all pregnancies before and after cervicoisthmic cerclage were collected from medical records, completed by a phone call to patients in case of missing data. RESULTS: We included 62 patients with a total of 224 pregnancies before and 95 pregnancies after cervicoisthmic cerclage. Forty-one (66%) cerclages were performed vaginally, 12 (19%) by laparotomy and 9 (15%) by laparoscopy. The live birth rate among all pregnancies evolving beyond 14 weeks was 23% before and 86% after cerclage (p < 0.01). The rate of delivery beyond 32 weeks was 13% before and 81% after cerclage, with a median term of delivery of 21 weeks and 37 weeks respectively. Twenty-two (35%) patients had at least one live birth before cerclage and 43 (69%) patients after cerclage. Five (8%) postoperative complications occurred (2 grade I, 2 grade II and 1 grade III). CONCLUSION: The markedly high live birth rate when compared to before the cerclage strongly suggests a major role for the technique of cervicoisthmic cerclage in patients with a heavy obstetrical history.

Urinary dysfunction after colorectal resection for endometriosis: results of a prospective randomized trial comparing laparoscopy to open surgery.

OBJECTIVE: To evaluate urinary symptoms before and after colorectal resection for endometriosis using validated questionnaires. STUDY DESIGN: We randomly assigned 52 patients with colorectal endometriosis to undergo laparoscopically assisted or open colorectal resection. The median follow-up was 19 months. Urinary symptoms were evaluated using the International Prostate Score Symptom and the Bristol Female Low Urinary Tract Symptoms questionnaires. RESULTS: Dysuria was observed in 29% of cases postoperatively. Using Bristol Female Low Urinary Tract Symptoms and International Prostate Score Symptom scores, an alteration was observed for voiding symptoms (P = .01 and P = .006, respectively). No difference was observed between the laparoscopy and the open surgery group. An alteration of the International Prostate Score Symptom voiding symptoms was observed in the group that did not undergo nerve sparing surgery (P = .048). An alteration of the International Prostate Score Symptom voiding symptoms was observed for patients who underwent vaginal resection (P = .01) and parametrial resection (P = .02). CONCLUSION: Our findings confirm that colorectal resection for endometriosis is a source of urinary dysfunction whatever the surgical route.

Bladder endometriosis: Preoperative MRI analysis with assessment of extension to ureteral orifices.

PURPOSE: The purpose of this study was to retrospectively evaluate the performance of magnetic resonance imaging (MRI) in locating endometriosis implants within the bladder wall with assessment of ureteral orifice extension using surgical findings as standard of reference. MATERIALS AND METHODS: MRI examinations of 39 consecutive women (mean age: 31.2±5.5 [SD] years; age range: 22-42years) operated in 3 university hospitals for bladder endometriosis over a 6-year period were reviewed by 2 independent readers. Interobserver agreement was assessed using Kappa tests. Results of consensus reading were used to calculate sensitivity, specificity and accuracy of MRI for the diagnosis, location and extent of endometriosis implants using surgical findings as the standard of reference. RESULTS: Mean bladder repletion volume was 134±110 [SD] mL (range: 21-479mL). The mean largest endometriosis implant diameter was 30±7 [SD] mm (range: 19-41mm). On MR images, 34/39 (87%) endometriosis implants were present in the two anterior thirds of the dome (k=0.45), 31/39 (79%) extended or were present in the posterior third pouch (k=0.92) and 25/39 (64%) extended into the bladder base (k=0.84) with sensitivities of 100% (31/31; 95% confidence interval [CI]: 89-100%), 100% (30/30; 95% CI: 88-100%) and 90% (19/21; 95% CI: 69-98%), respectively, specificities of 83% (5/6, 95% CI: 36-100), 88% (7/8, 95% CI: 47-100%), 87% (13/15; 95% CI: 52-96), respectively and accuracies of 97% (36/37, 95% CI: 86-100%), 97% (37/38; 95% CI: 86-100%), and 89% (32/36; 95% CI: 74-97%), respectively. In 9 (9/25; 36%) patients with bladder base involvement, a zero distance was reported between endometriosis implants and ureteral orifices, all but one presenting with low-to-moderate bladder volumes. In the two patients who needed ureteral resection-reimplantation, ureteral dilation was associated with a zero distance. External adenomyosis was reported in 26/39 (66%) patients (k=0.94). CONCLUSION: A dedicated preoperative MRI work-up for bladder endometriosis helps accurately depict and locate endometriosis implants. Adequate bladder filling is needed to improve appropriate estimate of the distance between endometriosis implants and ureteral orifices to better predict requirement of ureteral resection-reimplantation.

Surgical management of endometriotic women with pregnancy intention in France: A national snapshot of centers performing a high volume of endometriosis procedures.

OBJECTIVE: To provide a snapshot of the surgical management of endometriosis in French high-volume activity centers. METHODS: Analysis of prospectively collected data between November 2015 and May 2017 in 21 centers with a high volume of endometriosis surgery in France. Each facility could include up to 40 patients undergoing laparoscopy for endometriosis. Data were collected before and two months after surgery. RESULTS: 361 patients were enrolled in the study. Twenty-seven patients (7.48%) were lost to follow-up at the month 2 visit. Endometriosis stage was I-II in 33.70% of patients and III-IV in 66.30%. Uterosacral ligament resection was the most frequently performed procedure (50.97%) followed by rectal surgery (31.58%), ovarian procedures for endometrioma, procedures for ureters (21.33%) and the bladder (11.91%). Antiadhesion agents were employed in 215/361 (59.56%) patients. The median length of hospital stay after surgery was 2 (IQR 1 - 4) days. Post-operative complications were recorded in 9.34% of patients. Rectovaginal fistulae occurred in 8 patients (2.41%), pelvic abscess in 4 (1.20%) and bladder atony in 3 (0.90%). 17 patients (5.14%) required a second surgical procedure after a median time of 31 days (IQR 9 - 81). Two months after surgery, 95.09% of patients reported being satisfied or very satisfied with the surgery. CONCLUSION: Our study shows that surgical management of endometriosis in centers with a high volume of endometriosis surgery, mainly concerns women presenting with severe disease and deep localizations, with an overall risk of major complications inferior to 10% and a high rate of patient satisfaction.

Surgical management of diaphragmatic and thoracic endometriosis': A French multicentric descriptive study.

INTRODUCTION: Surgical management of Diaphragmatic and thoracic endometriosis (DTE) is still controversial, a thoracic or an abdominal approach can be proposed. METHODS: We conducted a multicentric retrospective study in 8 thoracic, gynecology or digestive surgery units in 5 French university hospitals. The main objective was to review the current management of DTE. RESULTS: 50 patients operated for DTE from 2010 to 2017 were included: 26 with a thoracic approach and 24 with an abdominal approach. Preoperative pelvic endometriosis (PE) concerned 25 patients. In 38 patients, DTE diagnosis was made on clinical symptoms (pneumothorax (n = 19), chronic or catamenial chest pain (n = 18) or hemopneumothorax (n = 1)). Median time from onset of symptoms to diagnosis was 47 months (0-212). PE surgery concurrently occurred in 22 patients. We report diaphragmatic nodules, pleuropulmonary nodules and diaphragmatic perforations in 42, 5 and 22 women respectively. Lesions were right-sided in 45 patients. Nodules were destructed in 12 cases and resected in 38 cases. When a diaphragmatic reconstruction was needed (n = 31), a simple suture was performed in 26 patients, while 5 patients needed a mesh repair. Pleural symphysis was performed for all patients who received a thoracic approach. DTE resection was considered complete in 46 patients. Three patients had severe 30-days complications of DTE surgery. Median follow-up was 20 months (range 1-69). Recurrence occurred in 10 patients. CONCLUSION: The results emphasize the importance of systematically looking for chest pain in patients suffering from PE and underline the lack of a standardized procedure and treatment in DTE.

Clinical characteristics of urinary tract endometriosis: A one-year national series of 232 patients from 31 endometriosis expert centers (by the FRIENDS group).

OBJECTIVE: To review prospectively the clinical characteristics of patients suffering from urinary tract endometriosis (UTE) in France, in 2017. STUDY DESIGN: We conducted a prospective observational multicenter study including women managed surgically for UTE in 31 French endometriosis expert centers (FRIENDS group) from January 1, 2017 to December 31, 2017. We distinguished patient with isolated bladder endometriosis ("IBE") or isolated ureteral endometriosis ("IUE") and patients associating both locations (mixed locations "ML"). Surgeons belonging to FRIENDS group enrolled patients by filling a 24 items questionnaire the day of the surgery and 6 weeks later. Data on the locations of UTE, preoperative assessment, urinary symptoms and associated pelvic locations were collected in a single anonymized database. RESULTS: A total of 232 patients from 31 centers were included. IBE concerned 82 patients (35.3%), IUE 126 patients (54.4%) ML 24 patients (10.3%). 111 patients reported urinary symptoms (47.8%). IUE was more often asymptomatic than the rest of the locations (59.5% versus 43.3%, OR 1,92, p = 0.017). Associated deep infiltrating endometriosis (DIE) lesions were found in 193 patients (83.1%). IUE was significantly associated with other DIE lesions (82.5% versus 66%, OR2.4, p = 0.006), particularly with rectum or sigmoid nodules (57.1% versus 36.8%, OR 2.3, p = 0.002) and retrocervical space nodules (31.7% versus 19.8%, OR 1.9, p = 0.05). CONCLUSION: Our study reports the second largest series of patients operated from a UTE and shows that ureteral location seems more frequent, less symptomatic and more frequently associated to other DIE locations than bladder endometriosis.

Randomized trial of laparoscopically assisted versus open colorectal resection for endometriosis: morbidity, symptoms, quality of life, and fertility.

OBJECTIVE: We report the first randomized trial of laparoscopically assisted versus open colorectal resection for endometriosis focusing on perioperative complications, improvement in symptoms, quality of life, and fertility. SUMMARY OF BACKGROUND DATA: Bowel endometriosis is one of the most severe forms of endometriosis. Although laparoscopically assisted surgery is a validated technique for colorectal cancer, there are serious concerns about its appropriateness for endometriosis in young women wishing to conceive because it is almost invariably a traumatic procedure. METHODS: We conducted a noninferiority trial and randomly assigned 52 patients with colorectal endometriosis to undergo laparoscopically assisted or open colorectal resection. The median follow-up was 19 months. The primary end point was improvement in dyschesia. RESULTS: Overall, a significant improvement in digestive symptoms (dyschesia P < 0.0001, diarrhea P < 0.01, and bowel pain and cramping P < 0.0001), gynecologic symptoms (dysmenorrhea P < 0.0001 and dyspareunia P < 0.0001), and general symptoms (back pain P = 0.001 and asthenia P = 0.0001) was observed. No difference in the symptom delta values and quality of life was noted between the groups. Median blood loss was lower in the laparoscopic group (P < 0.05). Total number of complications was higher in the open surgery group (P = 0.04), especially grade 3 (P = 0.03). Pregnancy rate was higher in the laparoscopic group (P = 0.006), and the cumulative pregnancy rate was 60%. CONCLUSION: Our findings support that laparoscopy is a safe option for women requiring colorectal resection for endometriosis. Moreover, laparoscopy offers a higher pregnancy rate than open surgery with similar improvements in symptoms and in quality of life.

Virtual reality simulation to enhance laparoscopic salpingectomy skills.

BACKGROUND: To assess skill enhancement and maintenance by virtual-reality simulation of laparoscopic salpingectomy in gynecologic surgery fellows. Skill acquisition by virtual-reality surgical simulation is an active field of research and technological development. Salpingectomy is one of the first gynecologic surgery techniques taught to fellows that requires accompanied learning. METHODS: A single-center prospective study was performed in the University of Lyon, France, including 26 junior fellows (≤ 3 semesters' internship) performing laparoscopic salpingectomy exercises on a LapSim® virtual reality simulator. Salpingectomy was performed and timed on 3 trials in session 1 and 3 trials in session 2, at a 3-month interval. Analysis was based on students' subjective assessments and a senior surgeon's objective assessment of skill. Progress between the 2 sessions was assessed on McNemar test and Wilcoxon test for matched series. RESULTS: 26 junior specialist trainees performed all trials. Most performed anterograde salpingectomy, both in session 1 (69 %) and session 2 (86 %). Mean procedure time was significantly shorter in session 2: 6.10min versus 7.82min (p=0.0003). There was a significant decrease in blood loss between the first trial in session 1 and the last trial in session 2: 167ml versus 70.3ml (p=0.02). Subjective assessment showed a significant decrease in anxiety and significant increase in perceived efficacy, eye-hand coordination and ergonomics. Efficacy, performance quality and speed of execution as assessed by the senior surgeon all improved significantly from trial to trial, while hesitation significantly decreased. CONCLUSIONS: The study showed that junior trainees improved their surgical skills on a short laparoscopic exercise using a virtual reality simulator. Virtual reality simulation is useful in the early learning curve, accelerating the acquisition of reflexes. Maintaining skill requires simulation sessions at shorter intervals.