Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynaecologists and Obstetricians (CNGOF).

OBJECTIVE: To provide French guidelines for the management of women with abnormal uterine bleeding (AUB). DESIGN: A consensus committee of 26 experts was formed. A formal conflict-of-interest policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding (i.e. pharmaceutical or medical device companies). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS: The last guidelines from the Collège National des Gynécologues et Obstétriciens Français on the management of women with AUB were published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescents; idiopathic AUB; endometrial hyperplasia and polyps; type 0-2 fibroids; type 3 or higher fibroids; and adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and evidence profiles were compiled. The GRADE® methodology was applied to the literature review and the formulation of recommendations. RESULTS: The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 are strong and 17 weak. No response was found in the literature for 14 questions. We chose to abstain from recommendations rather than providing advice based solely on expert clinical experience. CONCLUSIONS: The 36 recommendations make it possible to specify the diagnostic and therapeutic strategies for various clinical situations practitioners encounter, from the simplest to the most complex.

[Simulation training for French obstetrics and gynecology residents: A national survey in 2022]. / Formation initiale par la simulation pour les internes français de gynécologie et obstétrique : état des lieux en 2022.

OBJECTIVES: To evaluate the use of simulation among French Obstetrics and Gynecology residency programs. METHODS: A survey was conducted with all 28 French residency program directors. The questionnaire covered equipment and human resources, training programs, types of simulation tools and time spent. RESULTS: Of the cities hosting a residency program, 93% (26/28) responded regarding equipment and human resources, and 75% (21/28) responded regarding training program details. All respondents declared having at least one structure dedicated to simulation. A formal training program was reported by 81% (21/26) of cities. This training program was mandatory in 73% of the cases. There was a median number of seven senior trainers involved, three of whom had received a specific training in medical education. Most of declared simulation activities concerned technical skills in obstetrics and surgery. Simulations to practice breaking bad news were offered by 62% (13/21) of cities. The median number of half-days spent annually on simulation training was 55 (IQR: 38-83). CONCLUSION: Simulation training is now widely available among French residency programs. There remains heterogeneity between centers regarding equipment, time spent and content of simulation curricula. The French College of Teachers of Gynecology and Obstetrics has proposed a roadmap for the content of simulation-based training based on the results of this survey. An inventory of all existing "train the trainers" simulation programs in France is also provided.

Initial experience with vNOTES hysterectomy for benign conditions in a French university hospital.

Background: Natural orifice transluminal endoscopic surgery by the vaginal route (vNOTES) is a new approach to performing hysterectomy. Clinical outcomes must be evaluated in centres that have started performing this technique. Objectives: To compare operative outcomes between vNOTES hysterectomy and laparoscopic hysterectomy during the introduction of the vNOTES approach in a teaching hospital. Material and Methods: A retrospective study was conducted from November 2019 to May 2021 at a French academic hospital in Marseille. The included patients underwent total hysterectomy for benign indications by vNOTES or conventional laparoscopy. Main outcome measures: Operative time, uterus weight, intraoperative complications, and postoperative complications according to the Clavien-Dindo classification. Results: Eighty-six patients underwent hysterectomy according to the selected criteria: 36 procedures were performed by vNOTES and 50 by laparoscopy. The mean operative time was shorter in the vNOTES group than in the laparoscopy group [116 min versus 149 min; p=0.003]. The mean uterus weight was not different between the vNOTES group and the laparoscopy group (238g versus 281g; p=0.572). Laparo-conversion occurred in one case in the vNOTES group (2.7%) and three cases in the laparoscopy group (3.4%). One Grade III postoperative complication occurred in the laparoscopy group, and no severe complication occurred in the vNOTES group. Conclusion: Operative outcomes of the vNOTES hysterectomy were favourable and support good feasibility without additional morbidity compared to laparoscopy. What is new?: During the introduction period of the vNOTES hysterectomy technique in a teaching hospital, reassuring operative outcomes and a low rate of complications were observed.

[Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynecologists and Obstetricians (CNGOF)]. / Prise en charge des ménorragies : recommandations pour la pratique clinique du Collège national des gynécologues et obstétriciens français (CNGOF).

OBJECTIVE: To provide French guidelines for the management of women with abnormal uterine bleeding (AUB). DESIGN: A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, or medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS: The last guidelines from the Collège national des gynécologues et obstétriciens français (CNGOF) on the management of women with AUB was published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescent; idiopathic AUB; endometrial hyperplasia and polyps; fibroids type 0 to 2; fibroids type 3 and more; adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS: The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 present a strong agreement and 17 a weak agreement. Fourteen questions did not find any response in the literature. We preferred to abstain from recommending instead of providing expert advice. CONCLUSIONS: The 36 recommendations made it possible to specify the diagnostic and therapeutic strategies of various clinical situations managed by the practitioner, from the simplest to the most complex.

Surgical techniques for the removal of Essure® microinserts: a literature review on current practice.

PURPOSE: To evaluate the different techniques for Essure® microinserts removal and to assess the risk of fracture of the device and the intra- and post-operative complications in relation to surgical technique variants. METHODS: Electronic search in Medline, Scopus and Embase databases using the following keywords: Essure; Essure removal; Essure surgical technique. RESULTS: Out of 95 articles in the initial database, 17 studies were eligible for inclusion in our literature review. Several surgical techniques have been described in which the most frequent were laparoscopic salpingectomy (LS), laparoscopic cornuectomy (LC), laparoscopic or vaginal hysterectomy (LH, VH) with en-bloc salpingectomy. There were more fractures of the device with the LS procedure (6.25%) followed by the LC technique (2.77%), while there was no fracture with hysterectomy. However, peri-and post-operative complications were more severe and frequent with hysterectomy in comparison with the LC and LS procedures (respectively 8.1% Clavien Dindo grade 3 for the hysterectomy group, 1.11% for the LC procedure and 0.69% for the LS technique). CONCLUSION: Due to the lack of standardised surgical treatment guidelines, a system of care networks for symptomatic patients with adverse effects related to Essure® headed by specialised centres may offer a suitable and high-quality management with the appropriate removal techniques within two objectives: limiting the risk of fracture (with an en-bloc removal of the Essure® microinserts) and avoiding intra- and post-operative complications.

[Cesarean scare niche: Definition, diagnosis, risk factors, prevention, symptoms, adverse effects, and treatments]. / Isthmocèle : définition, diagnostic, facteurs de risque, prévention, symptômes, complications, et traitements.

OBJECTIVES: To review the definitions, diagnostic methods, risk factors, symptoms, and treatments for caesarean scar niche. METHODS: Review of the literature, critical reflection, and pragmatic advice. RESULTS: There is no consensus on the definition of caesarean scar niche. Some suggest an indentation≥2mm of the myometrium of the caesarean scar, but this is present in more than half of women with caesarean history and takes no account of woman's symptoms. The most popular diagnostic method is ultrasound±hysterosonography. Risks factors for niche are multiple Caesareans, Cesarean during labor with too low incision, and retroverted uterus. Symptoms include abnormal gynaecologic bleeding and pelvic pain, and their presence establish the "Caesarean scar syndrome". The risks of pregnancy with niche is poorly studied, but pregnancy is not contraindicated, even if the niche is untreated. The treatment of caesarean scar niche is mainly surgery and conservative. The former should be reserved for symptomatic patients, and those with secondary infertility and fertility treatment failure. Patients with residual myometrium thickness≥2.5mm may benefit from first-line hysteroscopic treatment, whereas a laparoscopic or vaginal approach could be offered in other cases. CONCLUSIONS: A pragmatic definition of caesarean scar niche as a disease including symptoms is the necessary prerequisite for the management of women. The treatment is mainly surgical, or conservative depending on the desire for subsequent pregnancy.

Magnetic resonance imaging in breast cancer management in the context of neo-adjuvant chemotherapy.

This review discusses the clinical applications of magnetic resonance imaging (MRI) for the assessment of neo-adjuvant chemotherapy (NAC) indication, axillary lymph node status, preNAC cancer prognosis, early and intermediate response to NAC, and post-NAC residual disease in patients with breast cancer. Contrast-enhanced MRI with analysis of the tumor morphological features and qualitative enhancement kinetics must be considered as the standard method for pre-NAC breast cancer staging and post-NAC residual disease assessment. Diffusion-weighted imaging (DWI) is easy to perform and may increase the specificity of breast MRI for tumor staging, and also for the assessment of tumor multifocality and multicentricity and lymph node status. It also provides an ancillary added value in the early and post-NAC response evaluation. Changes in the functional tumor volume are the main criterion for the early response analysis. Other MRI methods, such as quantitative perfusion analysis, MR spectroscopy and texture analysis, are still under study.

Mandatory completion of a box trainer curriculum prior to laparoscopic apprenticeship in the OR for surgical residents: A Before and After study.

INTRODUCTION: Training on laparoscopic box trainer (BT) improves surgical skills in the operating room (OR). Despite a large consensus on the educational value of the BT, its use is currently left up to local initiatives among French residency programs. This study evaluated the impact of a requirement to complete the Fundamentals of Laparoscopic Surgery (FLS) curriculum before starting companionship in the OR. METHODS: This was a "Before and After" study conducted in two French academic hospitals in 2015-2017. Gynaecology and urology residents were given open access to a FLS BT during a six-month surgical rotation. Residents in the first group (Before group) trained on the BT while receiving classic companionship. Residents in the second group (After group) had to complete the FLS curriculum before they were allowed to participate in laparoscopic procedures as a primary operator. Outcomes measures were the time to curriculum completion and the intracorporeal suturing performances based on two validated assessment tools (FLS and GOALS scores). RESULTS: Twenty-one surgical residents were included. All but two residents in the Before group completed the curriculum. The time to curriculum completion was longer in the Before group than the After group (69.5 days versus 28 days, P=0.001). Post-curriculum performances were lower in the Before group than in the After group for the FLS scores (452.5 versus 496, P=0.01) and the GOALS scores (14.5 versus 18, P=0.01). DISCUSSION: The mandatory completion of a BT curriculum prior to receiving active companionship in the OR is beneficial to residents in reducing time to curriculum completion and in enhancing laparoscopic skills on the BT.

[Primary management of endometrial carcinoma. Joint recommendations of the French society of gynecologic oncology (SFOG) and of the French college of obstetricians and gynecologists (CNGOF)]. / Prise en charge primaire des cancers de l'endomètre : recommandations SFOG-CNGOF.

OBJECTIVES: The management of endometrial carcinoma is constantly evolving. The SFOG and the CNGOF decided to jointly update the previous French recommendations (Institut national du cancer 2011) and to adapt to the French practice the 2015 recommendations elaborated at the time of joint European consensus conference with the participation of the three concerned European societies (ESGO, ESTRO, ESMO). MATERIAL AND METHODS: A strict methodology was used. A steering committee was put together. A systematic review of the literature since 2011 has been carried out. A first draft of the recommendations has been elaborated, with emphasis on high level of evidence. An external review by users representing all the concerned discipines and all kinds of practice was completed. Three hundred and four comments were sent by 54 reviewers. RESULTS: The management of endometrial carcinoma requires a precise preoperative workup. A provisional estimate of the final stage is provided. This estimation impact the level of surgical staging. Surgery should use a minimal invasive approach. The final pathology is the key of the decision concerning adjuvant therapy, which involves surveillance, radiation therapy, brachytherapy, or chemotherapy. CONCLUSION: The management algorithms allow a fast, state of the art based, answer to the clinical questions raised by the management of endometrial cancer. They must be used only in the setting of a multidisciplinary team at all stages of the management.

[Bowel injuries after port insertion in laparoscopy. Gynerisq's database analysis]. / Plaies digestives à l'insertion des trocarts en cœlioscopie. Analyse de la base de données de retour d'expérience de Gynerisq.

INTRODUCTION: Port insertion is a high-risk period during laparoscopy. The French Gynecologist and Obstetricians College (CNGOF) published recommendations in 2010 to minimize those risks. The aim of our analysis was to establish the accidents' circumstances and consequences and to determine if those incidents could have been depending on whether recommendations had been respected or not. MATERIAL AND METHODS: Gynerisq is an approved organism by the Haute Autorité de santé (HAS). Its mission is to evaluate and improve practices by a risk management centered approach. We analysed incidents reported by Gynerisq's adherents in an experience report database. RESULTS: Above 114 incidents analysed in the Gynerisq's database, we reported 31 bowel injuries. Those injuries occurred for 77.4% (24/31) during planned interventions. For 32.3% of the cases (10/31), interventions were judged complex by the surgeons. A total of 54.8% (17/31) of the patients had a history of laparotomy. Above 27 injuries occurred during Veress needle or open laparoscopy, 17 could have been avoided regarding to the surgeon. The causes reported were in 10 cases that the recommendations had not been respected, in 2 cases another cause and in 5 cases no causes were given to explain the incident. CONCLUSION: Our analysis shows that bowel injuries after port insertion, in open laparoscopy or Veress needle use, do not seem to occur only in an emergency context or during complicated interventions. However, most of the incidents occurred for patients with risk factors.

Methotrexate treatment for ectopic pregnancy after assisted reproductive technology: A case-control study.

OBJECTIVES: Ectopic pregnancy (EP) occurs in 2% to 5.6% of pregnancies achieved by assisted reproductive technology (ART). EP treatment options include medical treatment by uses of methotrexate (MTX) systemic injection. The objective of this study was to compare MTX treatment effectiveness for EP occurring spontaneously or following ART. METHODS: A case-control study performed in the department of obstetrics and gynecology at a tertiary health care center in France. Twenty EP achieved by ART (ART group) and 60 spontaneous EP (SEP group) received MTX treatment between January 2002 and May 2012. The main outcome measures were MTX treatment failure rates, number of MTX injections administered and recovery time. RESULTS: MTX treatment failure rates observed in ART and SEP groups were similar (3/20 [15%] versus 10/60 [17%]: OR=0.88 [0.22-3.58]). Mean duration of recovery time in patients with successful MTX treatment did not differ between ART and SEP groups (33±14 days versus 28±13 days, P=0.39). A second MTX injection was required more frequently in ART group than in SEP group (10/20 [50%] versus 10/60 [17%]: OR=5 [1.65-15.15]). CONCLUSIONS: It is concluded that MTX treatment is equally effective for spontaneous EP and EP achieved by ART, two injections of MTX being more frequently required in case of ART.

Laparoscopic sacrocolpopexy with a vaginal prosthetic adhesive.

STUDY OBJECTIVE: To evaluate the efficacy and safety of vaginal prosthetic adhesive (VPA) during laparoscopic sacrocolpopexy. DESIGN: Retrospective analysis of 35 first consecutive cases. SETTING: Gynecology Surgery Unit, Bouchard Clinic, Marseille, France. PATIENTS: Thirty-five women (age range: 35-85 years; average 60.8 years) presenting a genital prolapse assessed by a Pelvic Organ Prolapse Quantification (POP-Q) Score (stage 2 to 4). PROCEDURES: Modified laparoscopic sacrocolpopexy using a synthetic glue (Ifabond™, Peters Surgical(®)) to fix the mesh to the vagina (anterior and posterior) and to the levator ani. Two non-absorbable knots are used to secure the anterior mesh to the isthmus and to the promontory. MEASUREMENTS AND MAIN RESULTS: The average operating time was 68.4 minutes (45-115 min). No complications occurred during the procedure and early postoperative course. One patient (2.8%) experienced mesh exposure, and one patient (2.8%) experienced a subacute intestinal obstruction, which was resolved by a medical treatment. During a median follow-up at 13.2 months (range: 6-24.7 months), the surgical success rate (POP-Q<2) was 94.2% (two recurrences). The patient satisfaction rate was 87%. CONCLUSIONS: The VPA during laparoscopic sacrocolpopexy seems to be safe and effective at short term. This new procedure due to adhesive opens up a new path for the widespread use of sacrocolpopexy and for reduced operating times, which is often one obstacle with the dissection in the development of this technique.

Extensive mitochondrial introgression in North American Great Black-backed Gulls (Larus marinus) from the American Herring Gull (Larus smithsonianus) with little nuclear DNA impact.

Recent genetic studies have shown that introgression rates among loci may greatly vary according to their location in the genome. In particular, several cases of mito-nuclear discordances have been reported for a wide range of organisms. In the present study, we examine the causes of discordance between mitochondrial (mtDNA) and nuclear DNA introgression detected in North American populations of the Great Black-backed Gull (Larus marinus), a Holarctic species, from the Nearctic North American Herring Gull (Larus smithsonianus). Our results show that extensive unidirectional mtDNA introgression from Larus smithsonianus into Larus marinus in North America cannot be explained by ancestral polymorphism but most likely results from ancient hybridization events occurring when Larus marinus invaded the North America. Conversely, our nuclear DNA results based on 12 microsatellites detected very little introgression from Larus smithsonianus into North American Larus marinus. We discuss these results in the framework of demographic and selective mechanisms that have been postulated to explain mito-nuclear discrepancies. We were unable to demonstrate selection as the main cause of mito-nuclear introgression discordance but cannot dismiss the possible role of selection in the observed pattern. Among demographic explanations, only drift in small populations and bias in mate choice in an invasive context may explain our results. As it is often difficult to demonstrate that selection may be the main factor driving the introgression of mitochondrial DNA in natural populations, we advocate that evaluating alternative demographic neutral hypotheses may help to indirectly support or reject hypotheses invoking selective processes.

[Current and future use of surgical skills simulation in gynecologic resident education: a French national survey]. / Utilisation des simulateurs pour former les internes de chirurgie gynécologique en France : un état des lieux en 2013.

OBJECTIVES: Simulation is a promising method to enhance surgical education in gynecology. The purpose of this study was to provide baseline information on the current use of simulators across French academic schools. MATERIALS AND METHODS: Two questionnaires were created, one specifically for residents and one for professors. Main issues included the type of simulators used and the kind of use made for training purposes. Opinions and agreement about the use of simulators were also asked. RESULTS: Twenty-six percent of residents (258/998) and 24% of professors (29/122) answered the questionnaire. Sixty-five percent of residents (167/258) had experienced simulators. Laparoscopic pelvic-trainers (84%) and sessions on alive pigs (63%) were most commonly used. Residents reported access to simulators most commonly during introductory sessions (51%) and days of academic workshops (38%). Residents believed simulators very useful for training. Professors agreed that simulators should become a required part of residency training, but were less enthusiastic regarding simulation becoming a part of certification for practice. CONCLUSION: Surgical skills simulators are already experienced by a majority of French gynecologic residents. However, the use of these educational tools varies among surgical schools and remains occasional for the majority of residents. There was a strong agreement that simulation technology should be a component of training.

[Prognostic value of early hCG changes after methotrexate injection for ectopic pregnancy]. / Valeur pronostique de la cinétique précoce du taux d'hCG après injection de méthotrexate pour grossesse extra-utérine.

OBJECTIVES: The purpose of this study was to evaluate the predictive value of early hCG changes on the risk of methotrexate (MTX) therapy failure for ectopic pregnancy. PATIENTS AND METHODS: This monocentric observational study compared the success of single-dose MTX therapy according to early hCG changes. Patients with a decrease of hCG value by at least 20% between day 1 and day 4 were followed up one month later only with an hCG concentration (group A, study protocol). The others patients were followed up with classic protocol, one time a week (group B). RESULTS: Of the 91 patients treated, there were 29 (31.9%) patients in the group A and 62 (68.1%) in the group B. The overall success rate of MTX treatment was 89%. The success rate of single-dose MTX therapy was significantly increased in group A (29/29 (100%) vs 30/62 (48.4%), P<0.001). The rate of patients requiring surgical treatment was significantly lower in group A (0/29 vs 10/62 (16%), P=0.02) (Table 1). CONCLUSION: The 20%-decrease cut-off between day 1 and day 4 appears to be a predictive factor to select patients with low failure rate after one MTX injection, allowing a less stringent follow-up.

Molecular phylogenetics and historical biogeography of the west-palearctic common toads (Bufo bufo species complex).

In most pan-Eurasiatic species complexes, two phenomena have been traditionally considered key processes of their cladogenesis and biogeography. First, it is hypothesized that the origin and development of the Central Asian Deserts generated a biogeographic barrier that fragmented past continuous distributions in Eastern and Western domains. Second, Pleistocene glaciations have been proposed as the main process driving the regional diversification within each of these domains. The European common toad and its closest relatives provide an interesting opportunity to examine the relative contributions of these paleogeographic and paleoclimatic events to the phylogeny and biogeography of a widespread Eurasiatic group. We investigate this issue by applying a multiproxy approach combining information from molecular phylogenies, a multiple correspondence analysis of allozyme data and species distribution models. Our study includes 304 specimens from 164 populations, covering most of the distributional range of the Bufo bufo species complex in the Western Palearctic. The phylogenies (ML and Bayesian analyses) were based on a total of 1988 bp of mitochondrial DNA encompassing three genes (tRNAval, 16S and ND1). A dataset with 173 species of the family Bufonidae was assembled to estimate the separation of the two pan-Eurasiatic species complexes of Bufo and to date the main biogeographic events within the Bufo bufo species complex. The allozyme study included sixteen protein systems, corresponding to 21 presumptive loci. Finally, the distribution models were based on maximum entropy. Our distribution models show that Eastern and Western species complexes are greatly isolated by the Central Asian Deserts, and our dating estimates place this divergence during the Middle Miocene, a moment in which different sources of evidence document a major upturn of the aridification rate of Central Asia. This climate-driven process likely separated the Eastern and Western species. At the level of the Western Palearctic, our dating estimates place most of the deepest phylogenetic structure before the Pleistocene, indicating that Pleistocene glaciations did not have a major role in splitting the major lineages. At a shallow level, the glacial dynamics contributed unevenly to the genetic structuring of populations, with a strong influence in the European-Caucasian populations, and a more relaxed effect in the Iberian populations.