[Interest of multidisciplinary consultation meetings dedicated to endometriosis: From a series of 682 patients]. / Intérêt des réunions de concertation pluridisciplinaires dédiées à l'endométriose : à partir d'une série de 682 patientes.

OBJECTIVE: We decided to conduct a study based on these multidisciplinary team (MDT) in order to investigate their impact at the University Hospitals of Strasbourg and look for ways to improve this MDT. METHODS: This is a retrospective study of the 682 patients presented to endometriosis MDT from its inception in March 2017 to December 2020. RESULTS: The MDT decision was different from that initially proposed by the patient's referent for 406 patients (60%). Surgery was chosen for 417 patients (61%) and assisted reproduction for 261 patients (38%). A review of the MRI by a referring radiologist was carried out for 348 cases (51%), with a modification of the results for 255 patients (73%). Initial underestimation of lesions was noted in 198 cases. CONCLUSION: Our study has shown the importance of MDT in endometriosis since the therapeutic proposal was modified in 60% of cases. In addition, we supported the importance of radiologists specializing in this field since they made a modification in two-thirds of the MRIs reread. These results show the importance of collegial discussions, which can modify the decisions of medical teams. This underlines the importance of setting up endometriosis networks.

Adenomyosis and obstetric complications: A retrospective case-control study.

OBJECTIVE: Adenomyosis is a uterine pathology affecting an increasing number of women of childbearing age. Its diagnosis is based upon histology or imaging [ultrasound or magnetic resonance imaging (MRI)]. Several studies have investigated the impact of adenomyosis on obstetric complications, with its diagnosis based on clinical symptoms, ultrasound or composite criteria. The aim of this study was to identify potential obstetric complications related to adenomyosis in women with an MRI-confirmed diagnosis. METHODS: A single centre retrospective case-control study was undertaken in pregnant patients with an MRI-confirmed diagnosis of adenomyosis between January 2013 and December 2017 at the University Hospitals of Strasbourg. Controls were matched in a 4:1 ratio for age, parity and body mass index. Multivariate analysis was performed to identify obstetric complications. RESULTS: In total, 291 women with an MRI-confirmed diagnosis of adenomyosis were identified during the study period. Of these, 89 patients achieved pregnancy after 24 weeks of gestation. The mean age of patients was 30.8 years. The adenomyosis group and the control group were comparable for matching criteria. Adenomyosis was found to be associated with increased risk of caesarean section [odds ratio (OR) 1.1, 95 % confidence interval (CI) 1.0-1.2; p = 0.03], intrauterine growth restriction (OR 1.3, 95 % CI 1.1-1.4; p < 0.001), postpartum haemorrhage (OR 1.2, 95 % CI 1.1- 1.4; p < 0.01), pre-eclampsia (OR 1.3, 95 % CI 1.0-1.6; p = 0.004) and previous spontaneous miscarriage (OR 2.09, 95 % CI 1.36-3.33; p < 0.001). Premature rupture of membranes, preterm delivery, severe intrauterine growth restriction and the risk of placenta praevia were not significantly higher in the adenomyosis group compared with the control group on multivariate analysis. CONCLUSION: This study demonstrates increased risk of several obstetric complications (caesarean section, intrauterine growth restriction, postpartum haemorrhage, pre-eclampsia, history of spontaneous miscarriage) in women with adenomyosis. To the authors' knowledge, this is the first study to use MRI as the sole criterion for diagnosis. These results could be complemented by larger-scale prospective studies in order to manage these patients more effectively during pregnancy.

Urological procedures performed by gynecologists: Activity profile in a gynecological surgery department, 10-year observation cohort.

INTRODUCTION: The proximity of the urinary tract to the female genital tract explains its possible involvement in pelvic gynaecological cancer or deep endometriosis. Surgical treatment is aimed at improving overall survival and recurrence-free survival of patients, as well as restoring normal anatomy and functional integrity depending on the pathology. These operations are accompanied by significant post-operative complications. Thus, the urological procedures performed must be rigorously justified, and the different resection and reconstruction techniques adapted to the pathology and the level of infiltration. OBJECTIVE: To describe the activity profile, over the last ten years, of a gynaecological surgery department in terms of urological procedures in the management of patients with deep endometriosis and pelvic carcinology. STUDY DESIGN: This is a monocentric retrospective observational study, including all patients who underwent a urological procedure by a gynaecological surgeon only, as part of the management of pelvic gynaecological cancers or deep endometriosis, at the University Hospital Centre (CHU) of Strasbourg, between January 1st 2010 and April 31st 2021. The variables studied were early postoperative complications, the rate of surgical reintervention, operating time, length of hospital stay, the need for peri-operative drainage or transfusion, and post-operative functional disorders. RESULTS: A total of 86 patients were included, 27 in the pelvic gynaecological cancer group and 59 in the deep endometriosis group. 61.6% of patients received uretero-vesical catheterization, 60.5% partial cystectomy, 10.5% psoic bladder ureteral reimplantation, and 3.5% trans-ileal Bricker skin ureterostomy. The mean operating time was 316 min in the pelvic gynaecological cancer group and 198.9 min in the deep endometriosis group. The average hospital stay was 11.5 days, 22.3 days for patients treated for pelvic cancer and 6.3 days for those treated for endometriosis. The rate of minor post-operative complications was 8.2% of cases, and major post-operative complications 17.4% of cases, the majority of which were in the gynecological cancer group. There were no cases of intra- or early post-operative death. Early postoperative urinary complications affected 14.0% of the total patients, mostly in the gynaecological cancer group with 33.3% of patients, but only 5.1% of patients in the deep endometriosis group. The total reoperation rate within 60 days postoperatively was 15.1%, 40.7% for patients treated for gynaecological cancer and 3.4% for those treated for deep pelvic endometriosis. The rate of reoperations for urinary complications was 11.6% of total patients, or 76.9% of total reoperations. 15 patients received labile blood products intra- or postoperatively, 11 in the pelvic gynaecological cancer group and 4 in the endometriosis group. CONCLUSION: Our overall results appear comparable to those reported in the literature and are particularly satisfactory in terms of post-operative complications after partial cystectomy in the management of deep endometriosis compared to other gynaecological departments. This work encourages us to continue and improve the training of gynaecological surgeons in terms of multidisciplinary surgical procedures, including urological ones, to obtain a global vision of the pathology and to allow an optimal quality of care for the patients.

Percutaneous Imaging-guided Cryoablation of Endometriosis Scars of the Anterior Abdominal Wall.

STUDY OBJECTIVE: To evaluate the safety and clinical efficacy of percutaneous imaging-guided cryoablation for the management of anterior abdominal wall endometriosis. DESIGN: Patients with abdominal wall endometriosis underwent percutaneous imaging-guided cryoablation and had a 6-month follow-up. SETTING: Data dealing with patients' and anterior abdominal wall endometriosis (AAWE) characteristics, cryoablation, and clinical and radiologic outcomes were retrospectively collected and analyzed. PATIENTS: Twenty-nine consecutive patients underwent cryoablation from June 2020 to September 2022. INTERVENTIONS: Interventions were performed under US/computed tomography (CT) guidance or magnetic resonance imaging (MRI) guidance. Cryoprobes were directly inserted into the AAWE, and cryoablation was performed with a single 5 to 10 minute freezing cycle, which was stopped when the iceball expanded 3 to 5 mm beyond AAWE borders as assessed on intra-procedural cross-sectional imaging. MEASUREMENTS AND MAIN RESULTS: Fifteen patients (15/29; 51.7%) had prior endometriosis, 28 (28/29; 95.5%) had previous cesarian section, and 22 (22/29; 75.9%) referred association between symptoms and menses. Cryoablation was performed under local (16/29; 55.2%) or general anesthesia (13/29; 44.8%) and mainly in an out-patient basis (18/20; 62%). There was only one (1/29; 3.5%) minor procedure-related complication. Complete symptom relief was recorded in 62.1% (18/29) and 72.4% (21/29) patients at 1 and 6 months, respectively. In the whole population, pain significantly dropped at 6 months compared to the baseline (1.1 ± 2.3; range 0-8 vs 7.1 ± 1.9; range 3-10; p <.05). Eight (8/29; 27.6%) patients presented residual symptoms at 6 months, and 4 (4/29; 13.8%) had an MRI-confirmed residual/recurring disease. Contrast-enhanced MRI obtained for the first 14 (14/29; 48.3%) patients of the series, all without signs of residual/recurring disease, demonstrated a significantly smaller ablation area compared to the baseline volume of the AAWE (1.0 cm3 ± 1.4; range 0-4.7; vs 11.1 ± 9.9 cm3; range 0.6-36.4; p <.05). CONCLUSION: Percutaneous imaging-guided cryoablation of AAWE is safe and clinically effective in achieving pain relief.

Vaginal and laparoscopic sub-urethral sling explantation.

INTRODUCTION AND HYPOTHESIS: The objective was to describe the different laparoscopic and vaginal steps of sub-urethral infected mesh explantation as well as an unexpected and unusual complication: a sub-mucosal calcification on the sub-urethral segment of the sling that was not infiltrating the urethra. METHODS: This was carried out at our University Teaching Hospital of Strasbourg. RESULTS: We show the complete removal of an infected retropubic sling in a patient who had already undergone three previous surgeries without resolution of symptoms. This is a difficult case requiring a laparoscopic approach of the space of Retzius, which has been less familiar to surgeons since the advent of the midurethral sling. We show how to approach this space in an inflammatory environment by specifying its anatomical limits. Moreover, a great deal can be learned from the occurrence of an infectious complication after the surgery and the presence of a large calcification on the prosthesis. In this context, we advise a systematic antibiotic treatment to avoid this kind of complication. CONCLUSIONS: Knowing the guidelines and the different surgical steps will help urogynecological surgeons to perform similar procedures in patients requiring removal of retropubic slings for complications such as infection and pain, where conservative management has not been successful. These cases must be discussed in a multidisciplinary meeting, as recommended by the French National Authority for Health, and managed in an expert establishment.

Endometriosis and cardiovascular disease.

Endometriosis is a chronic gynaecological disease affecting 1 in 10 reproductive-age women. It is defined as the presence of endometrium-like tissue outside the uterus. Beyond this placid anatomical definition, endometriosis is a complex, hormonal, inflammatory, and systemic condition that poses significant familial, psychological, and economic burden. The interaction between the cardiovascular system and endometriosis has become a field of interest as the underlying mutual mechanisms become better understood. On the basis of accumulating fundamental and clinical evidence, it is likely that there exists a close relationship between endometriosis and the cardiovascular system. Therefore, investigating the endometriosis-cardiovascular interaction is highly clinically significant. In this review, we highlight our current understanding of the pathophysiology of endometriosis with systemic hormonal, pro-inflammatory, pro-angiogenic, immunologic, and genetic processes beyond the peritoneal microenvironment. Additionally, we provide current clinical evidence about how endometriosis interacts with cardiovascular risk factors and cardiovascular disease (CVD). To date, only small associations between endometriosis and CVD have been reported in observational studies, inherently limited by the potential influence of unmeasured confounding. Cardiovascular disease in women with endometriosis remains understudied, under-recognized, and underdiagnosed. More detailed study of the cardiovascular-endometriosis interaction is needed to fully understand its clinical relevance, underlying pathophysiology, possible means of early diagnosis and prevention.

Laparoscopic En Bloc Pelvic Resection with Rectosigmoid Resection and Anastomosis for Stage IIB Ovarian Cancer: Hudson's Procedure Revisited.

STUDY OBJECTIVE: To demonstrate a systematic approach to the laparoscopic en bloc pelvic resection with rectosigmoid resection and anastomosis as part of ovarian cancer treatment in a tertiary gynecologic surgery referral center. DESIGN: This video illustrates an en bloc pelvic resection performed par laparoscopy in 10 steps. SETTING: A 56-year-old patient with an advanced high-grade serous ovarian cancer extending into the rectum was amenable to primary debulking surgery in accordance with the French guidelines [1]. In diagnostic laparoscopy, a bilateral adnexectomy was performed, and the pelvic carcinomatosis was considered primarily resectable. Histopathology of the subsequent en bloc resection was consistent with stage IIB high-grade serous ovarian cancer with an indication for adjuvant chemotherapy. INTERVENTION: The Hudson's procedure revisited consists of a radical monobloc excision by way of a completely extraperitoneal dissection and total mobilization of the rectum. In this case, owing to rectal invasion, we achieved a laparoscopic radical resection including rectosigmoidectomy and primary anastomosis without the need for a defunctioning stoma [2]. CONCLUSION: Traditionally, an en bloc pelvic resection with rectosigmoid resection and anastomosis was performed by laparotomy. The feasibility of performing laparoscopic optimal cytoreductive surgery in selected patients with advanced ovarian cancer was recently demonstrated without compromising survival in case of low residual disease. The prognosis depends rather on the resectability than on the operative access. However, the radicality and completeness of the cytoreduction, as well as the potential risk of tumor seeding, remain controversially discussed. Here, we demonstrate the minimally invasive approach following the same operative strategy as in open surgery. In this way, the radicality of the "en bloc resection" entailing avoidance of tumor rupture, less bleeding, and less urethral injury is combined with the benefits of a minimally invasive access. In expert hands, this procedure can be performed laparoscopically for other pelvic malignancies with peritoneal carcinomatosis.

Nerve Anatomy Around Lumbo-aortic Lymphadenectomy by Retroperitoneal Approach.

STUDY OBJECTIVE: To describe the anatomy of the nerves during a laparoscopic retroperitoneal para-aortic lymphadenectomy with prioritization of their preservation. DESIGN: Demonstration of a nerve-preserving para-aortic lymphadenectomy. SETTING: A 65-year-old woman with no significant medical history underwent diagnostic laparoscopy for evaluation of a right ovarian mass. In the absence of peritoneal carcinomatosis, bilateral adnexectomy wasperformed with pathology revealing a high-grade tubo-ovarian serous carcinoma. In accordance with French Guidelines for management of ovarian cancer, operative staging including pelvic and para-aortic lymphadenectomy was recommended [1]. Final pathology following staging surgery was consistent with stage IA high-grade serous ovarian cancer prompting administration of adjuvant chemotherapy postoperatively. INTERVENTIONS: We performed a lumbo-aortic lymphadenectomy with preservation of the following nerves: the superior hypogastric plexus, the lumbar splanchnic nerves and the sympathetic trunk. CONCLUSION: Although there are conflicting data as to the benefit of staging lymphadenectomy in women with presumed early stage high-grade serous ovarian cancer, current French Guidelines recommend its performance. When doing so, effort should be made to avoid injury to adjacent normal structures, and in doing so, minimize potential morbidity. The neural structures preserved in this case are part of the sympathetic contingent and participate in the innervation of the abdomen and pelvic viscera. The sympathetic contingent is responsible for the vasomotricity but is also involved in the contraction of the internal genitalia during orgasm and in the inhibition of the peristaltic contractions of the rectum. As such, its preservation may avoid certain postoperative complaints. When possible to do so without compromising essential elements of a cancer surgery, preservation of nerves should be considered.

Prospective evaluation of the connected biofeedback EMY Kegel trainer in the management of stress urinary incontinence.

INTRODUCTION: The aim of this study was to evaluate changes in the quality of life with the connected biofeedback EMY Kegel trainer in patients suffering from stress urinary incontinence. Materiel and methods: This was a prospective, single-center, non-comparative study, which took place between September 2019 and October 2020, in the University Hospitals of Strasbourg. Eligible patients were instructed to use the EMY probe for a minimum of 10 min per day for five days per week. To assess quality of life and urinary symptoms, the Contilife and ICIQ-SF scores were completed each month until the final visit (M3). The PGI-I was also completed at 3 months to assess the benefit of the EMY Kegel Trainer. RESULTS: A total of 55 patients were included. At the inclusion visit (M0), the mean Contilife and ICIQ-SF scores were respectively at 6.6 ± 1.5 and 10.5 ± 3.0 points. At the final visit (M3), the mean Contilife score increased to 9.2 ± 1.0, indicating an improvement in quality of life. The mean ICIQ-SF score decreased to 4.2 ± 4.0, indicating an improvement in urinary symptoms. The PGI-I questionnaire identified a positive assessement of the EMY Kegel trainer. On the 55 patients included, 35 (64%) reported completing at least 36 sessions during the study, i.e. an average of 3 sessions per week. CONCLUSIONS: This study suggests that perineal rehabilitation by biofeedback using the EMY Kegel trainer might be beneficial.

Report of two cases of Accessory Cavitated Uterine Mass (ACUM): Diagnostic challenge for MRI.

Cystic adenomyosis is an unusual form of adenomyosis, characterized by a well-circumscribed cavitated endometrial gland and stroma, ≥ 1 cm in diameter, located within the myometrium. Few cases have been reported in the gynecological literature, with confusing naming such as: juvenile cystic adenomyosis, cystic myometrial lesions, cystic adenomyoma or juvenile adenomyotic cysts. The current preferred terminology is accessory cavitated uterine mass /or malformation (ACUM). We report here the cases of two 17 and 18 -year-old nulliparous women, who complained of severe dysmenorrhea early after the onset of menarche, with none or partial efficiency of medical treatment. MRI findings, with a follow-up in one case and surgical treatment in both cases, are described with an emphasis on physiopathology. The typical MR appearance is a large well-circumscribed round mass within the external myometrium, composed by an inner cystic hemorrhagic layer surrounded by a thick fibrous crown. The first-line treatment is laparoscopic surgery with mass resection. This typical MRI pattern must be a part of the knowledge of the radiologists.

Surgical management of deep pelvic endometriosis in France: Do we need to be a pelvic surgeon to deal with DPE?

INTRODUCTION: Endometriosis is a common disease in women, which requires a medical and surgical approach. Surgical societies recommend a multidisciplinary management in tertiary referral centers. The objective of our study is to assess the surgical management of endometriosis in France by studying the surgeons' attitude for bowel and urinary endometriosis. METHODS: We sent a survey to french endometriosis surgeons. We did a descriptive analysis and a comparative analysis between surgeons who believe endometriosis surgeons should be considered as "pelvic surgeons", able to treat bowel and urinary involvement. RESULTS: We included 90 answers, from gynaecologic surgeons from all over France. Gynaecologic surgeons perform minor bowel and urinary tract surgery, and more complex procedures are performed with digestive or urological surgeon (bowel resection 85% of cases, ureteric resection-anastomosis 84% of cases, ureteric reimplantation 91% of cases). Surgeons considering that gynaecologists should be able to deal with urinary and bowel endometriosis carry out more bowel and urinary procedures. They have an additional training in surgery and perform more endometriosis surgery every year. However, bowel and urinary endometriosis management by gynaecologic surgeons is contested amongst gynaecologists. CONCLUSION: To this day, there is no dedicated training in France to coach gynaecologist to perform such procedures. Multidisciplinary approach is essential for quality care, in expert centers. The basic education of gynaecologic surgeons does not allow them to perform complex pelvic surgeries, but qualifications can be gained for these interventions with a special training, and perform a greater number of surgeries.

Surgical Video Tutorial: Treatment of Congenital Vaginal Agenesis: Laparoscopic Modified Davydov in 8 Steps.

OBJECTIVE: To describe the different steps of the Davydov surgical technique for creating a neovagina, emphasizing visualization of the rectovesical cleavage and peritoneal-vaginal anastomosis by laparoscopic and vaginal approaches. DESIGN: Production of a step-by-step surgical video tutorial with narrative video footage. SETTING: Uterovaginal agenesis is a rare congenital defect, observed in 1 case per 4000 to 5000 newborn female infants [1]. Vaginal agenesis treatment can be performed by different nonsurgical and surgical techniques that are based on neocavity creation. The Davydov intervention uses the pelvic peritoneum as "covering" tissue for a neocavity and avoids the use of allogenic or autologous transplants, traction devices, or specialized surgical equipment. It is a minimally invasive technique that provides long-term functionality and anatomically satisfying results [2]. INTERVENTIONS: We treated an 18-year-old patient with Mayer-Rokitansky-Küster-Hauser syndrome who underwent the Davydov procedure after dissatisfaction with the Franck self-expansion method. We created a neovagina using peritoneal flaps that were obtained after rectovesical cleavage by laparoscopic approach and were then fastened to the introitus by vaginal approach. Finally, the vaginal vault was reconstructed laparoscopically, and an intravaginal dilator was left in place. The result after 1 year showed the transition from a narrow vaginal dimple 2 cm in length to a neovagina 10 cm in length, permeable, well epithelialized, and correctly healed without associated stenosis. Sexual intercourse is satisfying for both partners. CONCLUSION: The Davydov technique is less invasive than other surgical techniques and allows good outcomes [3,4] without the invasive use of sigmoidal grafts, cutaneous flaps, or prostheses. It should be proposed to patients experiencing failure with the Franck nonsurgical method.

Cesarean scar pregnancy: Two case report and therapeutic management algorithm.

OBJECTIVE: We aimed to present two cases of cesarean scar pregnancy (CSP) and a literature review to discuss their management. CASES: We reported two cases of cesarean scar pregnancy (CSP) treated in Strasbourg's University Hospital between 2016 and 2018 and carried out an updated literature review concerning their treatment. RESULTS: The first case is a superficial implantation CSP managed by methotrexate (MTX) then ligation of the uterine arteries and echo-guided aspiration. The second case is a deep implantation CSP managed by MTX and then laparoscopic excision with clamping of the uterine arteries. In the literature, the most commonly used treatments are: MTX, echo-guided aspiration, and the combination of uterine artery embolization followed by echo-guided aspiration. CONCLUSION: We established an algorithm in which CSP treatment by MTX can be considered alone if criteria are met. If not, surgery, chosen according to the depth of implantation, will be associated with MTX with a preventive hemostasis procedure by embolization or ligation of the uterine arteries.

Randomized Study Comparing a Reusable Morcellator with a Resectoscope in the Hysteroscopic Treatment of Uterine Polyps: The RESMO Study.

STUDY OBJECTIVE: To compare a reusable hysteroscopic morcellator and standard resectoscopes in the hysteroscopic management of uterine polyps. DESIGN: Single-center randomized prospective single-blind trial (resectoscope-morcellator study). SETTING: Centre Médico-chirurgical Obstétrique teaching hospital, Strasbourg University Hospitals, France. PATIENTS: All patients presenting with a single endometrial polyp of size 1 cm or larger. INTERVENTIONS: After consent, the patients were randomized into 2 groups: hysteroscopic morcellation (HM) group or standard resection (SR) group. Office-based review hysteroscopy was performed 6 weeks to 8 weeks after surgery. Primary end point: time of morcellation or resection. SECONDARY OUTCOMES: total operating time (minutes), volume of fluid used (mL), fluid deficit (mL), number of morcellator or resectoscope insertions, operator comfort (visual analog scale: 0 to 10) and quality of vision (0 to 5), perioperative complications, completeness of resection, need to convert to another technique, pain assessment (visual analog scale), and length of hospitalization. At review hysteroscopy, we noted whether the resection or morcellation had been effective and if synechiae were present or absent. Statistical analyses followed Bayesian methods. MEASUREMENTS AND MAIN RESULTS: Ninety patients were randomized: 45 in the HM group and 45 in the SR group. The average size of polyps at hysteroscopy was 13.3 mm. Morcellation time was lower than resection time (6.1 minutes vs 9 minutes; p [HM < SR] = .996). This also applied to total operating time (12.7 minutes vs 15.6 minutes; p [HM < SR] = .985), number of device insertions (1.50 vs 6; p [HM < SR] > .999), volume of fluid used (766.9 mL vs 1118.9 mL; p [HM < SR] = .994), and fluid deficit (60.2 mL vs 169.8 mL; p [HM < SR] = .989). Operator comfort was better in the HM group (8.4 vs 7.4; p [HM > SR] = .999) as was visualization (4 vs 3.7; p [HM > SR] = .911, highly probable). Operative complications were higher in the SR group (5 vs 0; p [HM < SR] = .989]. One patient in the SR group died after surgery owing to an anesthetic complication (anaphylactic shock complicated by pulmonary embolism). No differences were noted between the groups for pain assessment, length of hospitalization, and outcome on review hysteroscopy. CONCLUSION: The reusable morcellator is quicker, uses less fluid with less deficit and fewer introductory maneuvers, and offers better comfort and visualization than the resectoscope while being as effective for the hysteroscopic treatment of uterine polyps.

Surgical traps in laparoscopic sacrocolpopexy for vaginal vault prolapse.

OBJECTIVE: To describe the possible difficulties encountered in the event of laparoscopic sacrocolpopexy for vaginal vault prolapse and corresponding avoidance strategies. METHODS: Video recordings of different laparoscopic sacrocolpopexies for vaginal vault prolapse showing various situations and difficulties. University Teaching Hospital of Strasbourg. RESULTS: Although laparoscopic sacrocolpopexy for vaginal vault prolapse is becoming more common, achieving a good outcome remains challenging, especially with the vesicovaginal dissection. Bladder injuries are not rare and occur in about 2 to 6% of cases. Vaginal perforation is less common, but remains a risk. This video illustrates possible difficulties encountered and presents various strategies to avoid them. Several tips on exposing structures and following anatomical landmarks are described. CONCLUSION: Knowing how to avoid these surgical traps will help trainee urogynecologic surgeons to perform laparoscopic sacrocolpopexy for vaginal vault prolapse.

Risk of malignancy on suspicion of polyps in menopausal women.

Improved performances in gynaecological ultrasonography have enabled an increasing number of often asymptomatic endometrial polyps to be detected. Most of these polyps are removed surgically, as a precautionary measure, so as not to miss a case of endometrial cancer. Nonetheless, this management strategy is based solely on the sonographer's judgement and a number of these operations, which are probably of no benefit, could be avoided. In order to do so, risk factors for malignancy need to be identified. OBJECTIVE: Estimate the prevalence of lesions in menopausal patients with a pre-operative diagnosis of endometrial polyp. Establish risk factors for malignancy. STUDY DESIGN: This is a single-centre retrospective study. Enrolment criteria were menopausal patients aged over 45 who had undergone hysteroscopic resection of a polyp. Pre-op diagnosis was made either by ultrasonography or diagnostic hysteroscopy. Malignant lesions included cancers and atypical hyperplasia. Benign lesions consisted of simple polyps, non-atypical simple hyperplasia and non-atypical complex hyperplasia. Risk factors studied were existing abnormal uterine bleeding, endometrial thickness, personal or first-degree family history of gynaecological cancer (breast, cervix, endometrium, ovary) and age on diagnosis. RESULTS: 631 patients were enrolled of whom 30 presented a malignant disorder (4.75%); 579 patients (91.76%) presented a simple polyp, 11 a non-atypical simple hyperplasia (1.74%) and 11 a non-atypical complex hyperplasia (1.74%). On univariate analysis age alone proved to be statistically significant (OR 1.05; 95%CI=[1.02-1.09] p<0.01), with a threshold of 59 years of age on the ROC curve. On multivariate analysis, factors predictive of a malignant lesion were age (OR=1.06; 95%CI [1.02-1.10]), existence of AUB (OR=2.4; 95% CI [1.07-5.42]) and family history (OR=2.88; 95%CI [1.08-7.67]). Neither the univariate nor multivariate model was able to demonstrate a statistically significant relationship with respect to endometrial thickness. The risk of malignancy was 12.3% in patients aged over 59 presenting AUB. For all other subgroups, the risk varied between 2.31 and 3.78%. CONCLUSION: The risk of a malignant lesion appears to be high (12%) in menopausal patients aged over 59 presenting an endometrial polyp detected when there is pre-existing AUB. In this situation, hysteroscopic resection of endometrial polyps should therefore be routinely proposed. For other patients, the risk of a malignant lesion is low but not insignificant, standing at about 3%. Each patient record should therefore be discussed on an individual case basis, taking into consideration the patient's pre-existing conditions, after providing clear and appropriate information.