RESUMEN
INTRODUCTION: Para-aortic lymphadenectomy plays a fundamental role in the surgical management of pelvic gynecological cancers. Two laparoscopic approaches exist: the transperitoneal (TP) and the extraperitoneal (EP). The aim of this study was to compare these 2 approaches in terms of surgical outcomes, specially the number of removed lymph nodes according to the surgical technique, and morbidity. MATERIALS AND METHOD: A single-center retrospective study was carried out at the Lariboisiere University Hospital between January 2011 and March 2020 including all patients who underwent para-aortic lymphadenectomy for the management of a pelvic gynecological cancer (cervix, endometrium, ovary). Univariate and multivariate analysis (logistic regression) were performed to compare the TP and the EP groups. RESULTS: 143 patients were included: 74 in the TP group and 69 in the RP group. The total duration of surgery was 220.8minutes in the TP group and 166.4minutes in the EP group (P<0.001 in multivariate analysis). No significant difference between groups were found in the average total number of lymph nodes removed but there was a statistically significant difference in the average latero-aortic number of lymph nodes removed: 8.5 lymph nodes in the TP group and 11.3 lymph nodes in the group RP (P<0.001 in multivariate analysis). There was no difference between groups in peri and postoperative morbidity. CONCLUSION: EP para-aortic lymphadenectomy reduces duration of surgery and increases the average latero-aortic number of lymph nodes removed with same morbidity compared to TP para-aortic lymphadenectomy, this confirming its preferred indication in endometrial and in cervical cancers.
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Neoplasias Endometriales , Laparoscopía , Neoplasias del Cuello Uterino , Neoplasias Endometriales/cirugía , Femenino , Humanos , Escisión del Ganglio Linfático , Ganglios Linfáticos/cirugía , Estudios Retrospectivos , Neoplasias del Cuello Uterino/cirugíaRESUMEN
OBJECTIVES: To evaluate feasibility of performing benign gynecologic pathology low pressure (7mmHg) laparoscopy (LPL) with AirSeal® system and to study benefits in terms of postoperative pain, when compared to a standard insufflation group (15mmHg). MATERIALS AND METHODS: In this prospective randomized pilot study, 60 patients had laparoscopy for gynecologic benign pathology: 30 with 7mmHg and AirSeal system, and 30 with 15mmHg standard insufflator. The primary endpoint was incidence of shoulder pain. A postoperative questionnaire was completed by each patient to assess shoulder pain (Numeric Rating Scale [NRS], from 0 to 10) at H4, H8, H24, and consumption of morphinics was notified. During each procedure, anesthesia parameters were collected (peak airway pressure, systolic blood pressure, end tidal CO2). RESULTS: Laparoscopy was performed on 30 patients in AirSeal®-LP group without need to increase pressure above 7mmHg, and no complication was reported. Incidence of shoulder pain was significantly lower in the AirSeal®-LP group (23.3% vs. 73.3%, P<0.001). NRS shoulder pain was significantly lower in AirSeal® LP group at hour 4, 8 and 24. Maximal values of ETCO2, systolic blood pressure, and peak airway pressure were significantly lower in AirSeal®-LP group. CONCLUSION: LP (7mmHg) laparoscopy with AirSeal® platform allows laparoscopic surgery with less postoperative shoulder pain. These results could facilitate the development of ambulatory laparoscopy.
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Procedimientos Quirúrgicos Ginecológicos , Insuflación , Laparoscopía , Neumoperitoneo Artificial/métodos , Neumoperitoneo Artificial/normas , Adulto , Estudios de Factibilidad , Femenino , Procedimientos Quirúrgicos Ginecológicos/efectos adversos , Procedimientos Quirúrgicos Ginecológicos/métodos , Procedimientos Quirúrgicos Ginecológicos/normas , Humanos , Insuflación/efectos adversos , Insuflación/métodos , Insuflación/normas , Laparoscopía/efectos adversos , Laparoscopía/métodos , Laparoscopía/normas , Persona de Mediana Edad , Dimensión del Dolor , Dolor Postoperatorio/etiología , Proyectos Piloto , Neumoperitoneo Artificial/efectos adversos , Presión , Dolor de Hombro/etiología , Nivel de Atención , Adulto JovenRESUMEN
Postpartum lower limb motor and/or sensory deficit is an uncommon obstetrical complication. We aimed to identify its incidence, etiology, and precipitating factors, as well as the neurological prognosis by retrospectively analyzing the successive neurological evaluations, electrophysiological, and MRI data from all the consecutive patients with postpartum motor and/or sensory deficits of the lower limbs referred from the Lariboisière Obstetrical Department to the Lariboisière Neurophysiology Department, from January 2012 to June 2016, as well as data concerning labor and morphological characteristics of mother and baby. Thirteen patients (0.11% of the parturient women in the Lariboisière hospital) were included. Eight (62%) had lumbosacral plexopathy. Symptoms followed a first vaginal delivery in 10/13 patients (77%), in patients who were mostly overweight (mean patient BMI before pregnancy 25.6 ± 3.2 kg/m2). Labor duration was slightly longer than average (mean labor duration 8.9 ± 2.9 h). No other potentially precipitating factor was identified. Recovery was good in all patients, 7/11 (64%) made a rapid full recovery (mean recovery time 5 ± 2.5 weeks excluding one patient who had a normal neurological examination at 2 weeks but still complained of foot weakness that fully recovered in 1 year), and a minority (4/11, 36%) still complained of minor symptoms at time of follow-up, but showed marked improvement. New mothers presenting postpartum lower limb nerve injury should, therefore, be reassured.
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Extremidad Inferior , Traumatismos de los Nervios Periféricos/etiología , Traumatismos de los Nervios Periféricos/fisiopatología , Trastornos Puerperales/diagnóstico , Adulto , Electromiografía , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Extremidad Inferior/diagnóstico por imagen , Extremidad Inferior/fisiopatología , Imagen por Resonancia Magnética , Examen Neurológico , Parálisis/diagnóstico por imagen , Parálisis/epidemiología , Parálisis/etiología , Parálisis/fisiopatología , Traumatismos de los Nervios Periféricos/diagnóstico por imagen , Traumatismos de los Nervios Periféricos/epidemiología , Periodo Posparto , Embarazo , Pronóstico , Trastornos Puerperales/diagnóstico por imagen , Trastornos Puerperales/fisiopatología , Recuperación de la Función , Estudios Retrospectivos , Adulto JovenRESUMEN
OBJECTIVE: To assess the benefits of a multidisciplinary care among excised women with an initial surgery project and identify the reasons for discarding surgery. METHODS: Descriptive and retrospective study performed between the 1st of January 2006 and the 31st of December 2011 at the Armand Trousseau Hospital, Paris. All excised patients went through consultations with a mid-wife, a sexologist, a psychologist, a gynaecologist-obstetrician and, for some of them, underwent a clitoral reconstructive surgery. RESULTS: One hundred and sixty-nine patients were included: among them, 61 patients (36%) were operated and 108 patients (64%) have given spontaneously to surgery, 32% being reinforced by consultation. Ninety-one on 111 patients (82%) respondents were satisfied with their care pathway. The main motivation was to support identity for 39 patients operated (64%) while improving sex prevailed for 56 non-operated patients (52%). The study evidenced an improvement of the functional and sexual life quality after surgery: 17% experienced an orgasm versus 2% before surgery, 56% reported an increase in their libido and 41% a decrease in dyspareunia. CONCLUSION: Clitoral reconstructive surgery with multidisciplinary care tends to improve the functional and sexual life quality of excised patients, though it is not always necessary. Some of the patients discard their initial project of reconstructive surgery as in some of the cases, a multidisciplinary care only seems sufficient.
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Clítoris/cirugía , Comunicación Interdisciplinaria , Procedimientos de Cirugía Plástica , Adolescente , Adulto , Dispareunia/cirugía , Femenino , Humanos , Persona de Mediana Edad , Orgasmo , Paris , Satisfacción del Paciente , Procedimientos de Cirugía Plástica/psicología , Estudios Retrospectivos , SexualidadRESUMEN
OBJECTIVES: To evaluate the management of prenatally diagnosed cleft lip with or without cleft palate and the immediate postnatal outcome. MATERIAL AND METHODS: Retrospective study of all cases of cleft lip with or without cleft palate referred to our fetal medicine unit, between January 2005 and January 2011. The anatomical type of cleft, associated malformations, and the postnatal outcome were reviewed. RESULTS: Forty-three cases of fetal cleft lip with or without cleft palate were reviewed. The mean gestational age at diagnosis was 24 weeks ± 4. The postnatal distribution of clefts was: 30 cleft lip and palate (70%) and 13 cleft lip (30%). The prenatal diagnosis of the cleft type was exact in 27 cases (62.8%). Nine cases had associated anomalies (21%), detected prenatally in three cases (37.5%). There was no karyotypical abnormality. Six pregnancies were terminated (14%). The immediate postnatal outcome was comparable with unselected newborns. CONCLUSION: The prenatal diagnosis of cleft lip with or without cleft palate is correct, with two thirds of exact diagnoses. Large clefts palate are the best detected. Associated malformations cannot always be diagnosed by prenatal ultrasound, but have to be searched for because they modify the fetal outcome.
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Labio Leporino/diagnóstico , Fisura del Paladar/diagnóstico , Diagnóstico Prenatal , Labio Leporino/complicaciones , Labio Leporino/embriología , Fisura del Paladar/complicaciones , Fisura del Paladar/embriología , Femenino , Edad Gestacional , Humanos , Recién Nacido , Cariotipificación , Embarazo , Estudios Retrospectivos , Ultrasonografía PrenatalAsunto(s)
Registros de Hospitales/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Mortinato/epidemiología , Estadísticas Vitales , Adulto , Femenino , Mortalidad Fetal , Gestión de la Información en Salud/normas , Registros de Hospitales/normas , Maternidades/organización & administración , Maternidades/estadística & datos numéricos , Humanos , Recién Nacido , Paris/epidemiología , Alta del Paciente/normas , Embarazo , Práctica de Salud Pública/normas , Sistema de Registros/normas , Sistema de Registros/estadística & datos numéricos , Adulto JovenRESUMEN
The objective of this study was to evaluate the variation over 5 years of functional discomfort associated with pelvic organ prolapse (POP) repaired by sacrospinous ligament fixation (SLF). A total of 178 women who had undergone SLF from 1992 to 2001. In 2002 and 2008, patients were sent a questionnaire including the pelvic floor distress inventory (PFDI-20); 79 responded and comparison of those data served to evaluate subjective signs at 5 years. This population was divided into two groups: ≤60 and >60 years old, and their 2002-2008 differences were compared. The outcomes were satisfaction, functional results and sexuality. Mean follow-up was 115 (72-173) months. Our results showed the long-term stability of SLF functional outcomes for women >60 years. However, for those≤60 years, functional outcomes and satisfaction had declined at 5 years.
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Ligamentos/cirugía , Prolapso de Órgano Pélvico/cirugía , Factores de Edad , Anciano , Femenino , Humanos , Persona de Mediana Edad , Complicaciones Posoperatorias , Calidad de Vida , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
Cervical pregnancy is a rare form of ectopic pregnancy defined by the implantation of the blastocyst in the cervical canal. Most of the cervical pregnancies have been reported in patients with a history of vacuum curettage or caesarean section. The authors report a case of cervical pregnancy occurred after a failure of medical abortion. A literature review discusses the possibility of a cervical secondary implantation and describes the management of such pregnancies.
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Aborto Inducido/efectos adversos , Aborto Retenido/diagnóstico , Embarazo Ectópico/inducido químicamente , Abortivos/efectos adversos , Aborto Retenido/etiología , Aborto Retenido/cirugía , Adulto , Cuello del Útero , Implantación del Embrión/fisiología , Femenino , Humanos , Histerectomía , Embarazo , Embarazo Ectópico/diagnóstico , Embarazo Ectópico/etiología , Embarazo Ectópico/cirugíaAsunto(s)
Ginatresia/etiología , Ginatresia/prevención & control , Legrado por Aspiración/efectos adversos , Aborto Inducido/efectos adversos , Adulto , Femenino , Ginatresia/epidemiología , Humanos , Ácido Hialurónico/uso terapéutico , Histeroscopía/efectos adversos , Infertilidad Femenina/etiología , Trastornos de la Menstruación/etiología , Embarazo , Complicaciones del Embarazo/etiología , Adherencias Tisulares/complicaciones , Adherencias Tisulares/epidemiología , Adherencias Tisulares/prevención & control , Enfermedades Uterinas/epidemiología , Enfermedades Uterinas/etiología , Enfermedades Uterinas/prevención & controlRESUMEN
This paper is the second of a two-part publication. The initial paper provided a comprehensive overview of the evidence on adhesions to allow gynaecological surgeons to be best informed on adhesions, their development, impact on patients, health systems and surgical outcomes. There is rising evidence that surgeons can take important steps to reduce the burden of adhesions. In this second paper, we review the various strategies to reduce the impact of adhesions, improve surgical outcomes and provide some practical proposals for action on adhesions. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. They should be considered for use particularly in high-risk surgery and in patients with adhesiogenic conditions. Further research into new strategies to prevent adhesions more effectively through an improved surgical environment, new and combination devices and pharmacological agents should be encouraged. Formal recommendations would ensure better prioritisation of adhesion-reduction within the French health system. Patients should also be better informed of the risks of adhesions.
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Procedimientos Quirúrgicos Ginecológicos/efectos adversos , Complicaciones Posoperatorias/prevención & control , Adherencias Tisulares/prevención & control , Abdomen/cirugía , Femenino , Humanos , Complicaciones Posoperatorias/etiología , Adherencias Tisulares/diagnóstico , Adherencias Tisulares/etiología , Resultado del TratamientoRESUMEN
Adhesions are the most frequent complications of abdominopelvic surgery, causing important short- and long-term problems, including infertility, chronic pelvic pain and a lifetime risk of small bowel obstruction. They also complicate future surgery with increased morbidity and mortality risk. They pose serious quality of life issues for many patients with associated social and healthcare costs. Despite advances in surgical techniques, including laparoscopy, the healthcare burden of adhesion-related complications has not changed in recent years. Adhesiolysis remains the main treatment although adhesions reform in many patients. The extent of the problem of adhesions has been underestimated by surgeons and the health authorities. There is rising evidence however that surgeons can take important steps to reduce the impact of adhesions. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. This paper is the first of a two-part publication providing a comprehensive overview of the evidence on adhesions to allow gynaecological surgeons to be best informed on adhesions, their development, impact on patients, health systems and surgical outcomes. In the second paper we review the various strategies to reduce the impact of adhesions and improve surgical outcomes to assist fellow surgeons in France to consider the adoption of adhesion reduction strategies in their own practice.
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Procedimientos Quirúrgicos Ginecológicos/efectos adversos , Adherencias Tisulares/prevención & control , Abdomen , Femenino , Procedimientos Quirúrgicos Ginecológicos/métodos , Humanos , Infertilidad Femenina/etiología , Obstrucción Intestinal/etiología , Laparoscopía , Dolor Pélvico/etiología , Complicaciones Posoperatorias , Adherencias Tisulares/complicaciones , Adherencias Tisulares/terapia , Enfermedades UterinasRESUMEN
We describe a case involving spontaneous retroperitoneal hematoma complicating a normal delivery in a context of a Disseminated Intravascular Coagulation (DIVC) at the end of the pregnancy. Given the defaced symptomatology, an abdomino-pelvic scanner and an examination with a general anaesthesia made it possible to diagnose and to monitor the hematoma in intensive care. The correction of the hemostasis troubles and of the anemia, without another invasive intervention, allowed a return to home at the eighth day. The pathophysiological mechanisms underlying development and practicable treatments of this post-partum hematoma are discussed.
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Coagulación Intravascular Diseminada/complicaciones , Hematoma/diagnóstico , Periodo Periparto , Espacio Retroperitoneal , Adulto , Anemia/complicaciones , Anemia/terapia , Transfusión Sanguínea , Cuidados Críticos , Parto Obstétrico , Coagulación Intravascular Diseminada/terapia , Femenino , Hematoma/complicaciones , Hematoma/terapia , Humanos , Embarazo , Trastornos Puerperales/diagnósticoRESUMEN
BACKGROUND: Ovarian teratoma (OT) is the most common ovarian neoplasm in children. Oophorectomy has been the standard treatment but may impair fertility. The aim of this study was to investigate the feasibility and outcome of ovarian-sparing surgery (OSS) for OT. PROCEDURE: We retrospectively studied all children treated for OT at a pediatric teaching hospital in Paris, France, between March 1992 and July 2006. OSS was performed when deemed technically feasible in patients who had no lymphadenopathy by preoperative imaging or surgical exploration, normal tumor marker levels, and calcifications on radiographs. RESULTS: We identified 30 patients, including 29 with unilateral OT and 1 with synchronous bilateral OT. Emergent surgery was performed in five patients, among whom four had ovarian torsion requiring oophorectomy and one underwent OSS. Of the 26 OTs in the 25 remaining patients, 10 were managed with OSS and 16 with oophorectomy. Subsequently, ultrasound monitoring detected OT development in the contralateral ovary in 4 (14%) patients, after a median of 3 years (range, 1-14 years); OSS was performed in all four cases. The patient with bilateral synchronous OT, managed by OSS initially, underwent unilateral oophorectomy 3 years later for a recurrence. Overall OSS was performed for 15 (42%) OTs. CONCLUSIONS: Our results suggest recommendations for preserving fertility whenever possible without compromising the oncological prognosis. In particular, OSS should be reserved for patients who meet all criteria for localized mature teratoma. Long-term follow-up is crucial.
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Infertilidad Femenina/prevención & control , Neoplasias Ováricas/cirugía , Teratoma/cirugía , Niño , Preescolar , Femenino , Fertilidad , Estudios de Seguimiento , Humanos , Neoplasias Ováricas/complicaciones , Neoplasias Ováricas/diagnóstico por imagen , Estudios Retrospectivos , Tasa de Supervivencia , Teratoma/diagnóstico por imagen , Resultado del Tratamiento , UltrasonografíaRESUMEN
Management of intrauterine synechiae in a context of infertility remains a challenge, in spite of hysteroscopic microsurgery progress. There is no published prospective study to be used as a guideline. Anatomic, but most of all functional prognosis are directly correlated to the severity of adhesions and the number of surgical procedures required to complete treatment. Complications during surgery are not infrequent, but are well known and often benign. Obstetrical complications are much less frequent but often severe (abnormal placentation, uterine rupture). Recurrences are common enough to impose a systematic second-look diagnostic hysteroscopy. However, the benefit gained by the recovery of fertility (either spontaneous or not) remains superior, in my opinion, to the risks of the surgical management.
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Ginatresia/cirugía , Infertilidad Femenina/cirugía , Adherencias Tisulares/cirugía , Femenino , Humanos , Resultado del TratamientoRESUMEN
We report a posterior urethral valves case diagnosed at 33 week's gestation on a fetus presenting with anamnios and urinary ascites. In this fetus, the serum beta2 microglobuline rate was high, suggesting a very poor renal prognosis. At 1-year-old, the creatinine rate is nearly normal. In case of urinary ascites, the serum beta2 microglobuline rate could be improved in relation with the transperitoneal reabsorption of this protein.
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Ascitis/embriología , Enfermedades Fetales/sangre , Obstrucción Uretral/embriología , Microglobulina beta-2/sangre , Adulto , Ascitis/sangre , Ascitis/cirugía , Femenino , Sangre Fetal/química , Edad Gestacional , Humanos , Recién Nacido , Masculino , Embarazo , Resultado del Embarazo , Ultrasonografía Prenatal , Obstrucción Uretral/sangre , Obstrucción Uretral/diagnóstico por imagenRESUMEN
OBJECTIVE: To describe the preliminary results of fetal cardiac scanning in the first trimester of pregnancy for fetuses at higher risk for congenital heart defect (CHD). PATIENTS AND METHODS: Echocardiographic examination was performed at 12 to 14+6 in 67 patients at higher risk for fetal CHD. The indications for referral were: increased nuchal translucency more or equal to 99(e) centile (56 cases), risk of recurrence for CHD (eight cases), embryonic toxic exposure (eight cases), maternal disease (four cases). RESULTS: Complete examination of the fetal heart was possible in 54/55 cases. Fetal cardiac examination was normal in 58 cases (87 %). Six cases of severe CHD were diagnosed: hypoplastic left heart syndrome, pulmonary atresia with intact septum, complex univentricular CHD leading to termination of pregnancy, conotroncal Fallot like abnormality, and transposition of great arteries. Post-mortem examination was performed in three cases and confirmed the cardiac anomalies. DISCUSSION AND CONCLUSION: Our preliminary results confirmed that fetal heart scanning is feasible at the end of the first trimester of pregnancy. Severe CHD are amenable to prenatal diagnosis in the first trimester in the population at higher risk for CHD.
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Edad Gestacional , Cardiopatías Congénitas/diagnóstico por imagen , Ultrasonografía Prenatal , Femenino , Humanos , Medida de Translucencia Nucal , Embarazo , Primer Trimestre del Embarazo , Factores de RiesgoRESUMEN
BACKGROUND: Since the 1990s, governmental plans in France have imposed the regionalization of perinatal care to improve both safety and quality of care. The Eastern Paris Perinatal Network is under construction in health area 75-2, which includes the 11th, 12th, 13th and 20th arrondissements of Paris. A major issue is ensuring that the network can meet the needs of its target population. The objective is to define the network's target population of mothers and newborns. METHODS: We designed a matrix to help assess these needs and identify the data required to define the network's population. Four principal data sources were analyzed: the National Statistics and Economic Studies Institute (Insee) data, annual health facility activity data, national medical informatics program data, and 8th-day health certificates. RESULTS: The network's target population varies according to the precise perinatal period and the planning stage. For the conception period, it includes the general population and specifically all women of childbearing age (15-49 years). The health area included 672,000 inhabitants in 2006, 29% of them are women of childbearing age. The proportion of people born outside France and who are of foreign nationality ranges, according to arrondissement, from 13.2 to 20.0%; the mean for the Paris metropolitan area is 14.7%. Approximately 16,500 women gave birth in 2007, at nine obstetric facility sites in the health area (five level I, three level II, and one type III); only 41.46% of them resided in the health area. Approximately 2500 women living in the health area gave birth at a facility outside the area. The population likely to be covered by the network is thus estimated at approximately 19,000 women. CONCLUSION: A network must simultaneously take into account the local resident population and the population using its health care system. In an urban area such as Paris, where the health care supply is dense, it is essential for policy planning process to define the contours of the target population of a health network.