Endometriosis: Age at diagnosis and the severity of the disease.

BACKGROUND: Endometriosis is often described as a progressive disease beginning with menarche and menstrual bleeding. However, this is controversial, as the origin of the disease remains unknown. The objective of this study was to investigate the association between the severity of endometriosis and age at initial diagnosis. MATERIAL AND METHODS: This prospective multicenter cohort study included 964 patients, newly and histologically diagnosed with endometriosis during laparoscopic treatment. The main outcome measures were diagnostic lesions with staging according to rAFS (revised American Fertility Society) scores, intensity of pain based on VAS (Visual Analog Scale) scores and quality of life from SF-36 questionnaire results. Age was treated as a categorical variable. Univariate and multivariable analyses (linear and multinomial ordinal) were conducted taking into account two by two multiple comparisons. The results were expressed with effect sizes and 95 % confidence intervals. MAIN FINDINGS: No significant association between age and rAFS stage was found (p = 0.053). The percentage of patients with a deep nodule ≥ 2 cm was respectively 20 %, 25 %, 21 %, 18 % and 9 % for patients aged ≤ 25, 26-30, 31-35, 36-40 and >40 years respectively (p = 0.005). For dysmenorrhea, 64 %, 61 %, 54 %, 51 % and 32 % of patients aged ≤25, 26-30, 31-35, 36-40 and >40 years respectively reported a VAS score of ≥7 (p ≤ 0.001). CONCLUSION: Prospective data obtained in patients newly diagnosed with endometriosis, revealed that the rAFS score is not related to patient age, and that the percentage of patients with a nodule ≥ 2 cm and severe dysmenorrhea did not increase with age. These percentages were significantly lower in patients aged > 40.

Automatic Smoke Analysis in Minimally Invasive Surgery by Image-Based Machine Learning.

INTRODUCTION: Minimally Invasive Surgery uses electrosurgical tools that generate smoke. This smoke reduces the visibility of the surgical site and spreads harmful substances with potential hazards for the surgical staff. Automatic image analysis may provide assistance. However, the existing studies are restricted to simple clear versus smoky image classification. MATERIALS AND METHODS: We propose a novel approach using surgical image analysis with machine learning, including deep neural networks. We address three tasks: 1) smoke quantification, which estimates the visual level of smoke, 2) smoke evacuation confidence, which estimates the level of confidence to evacuate smoke, and 3) smoke evacuation recommendation, which estimates the evacuation decision. We collected three datasets with expert annotations. We trained end-to-end neural networks for the three tasks. We also created indirect predictors using task 1 followed by linear regression to solve task 2 and using task 2 followed by binary classification to solve task 3. RESULTS: We observe a reasonable inter-expert variability for tasks 1 and a large one for tasks 2 and 3. For task 1, the expert error is 17.61 percentage points (pp) and the neural network error is 18.45 pp. For tasks 2, the best results are obtained from the indirect predictor based on task 1. For this task, the expert error is 27.35 pp and the predictor error is 23.60 pp. For task 3, the expert accuracy is 76.78% and the predictor accuracy is 81.30%. CONCLUSIONS: Smoke quantification, evacuation confidence, and evaluation recommendation can be achieved by automatic surgical image analysis with similar or better accuracy as the experts.

A systematic review comparing the safety, cost and carbon footprint of disposable and reusable laparoscopic devices.

INTRODUCTION: The objective of this systematic review of the literature is to compare a selection of currently utilized disposable and reusable laparoscopic medical devices in terms of safety (1st criteria), cost and carbon footprint. MATERIAL AND METHODS: A search was carried out on electronic databases for articles published up until 6 May 2022. The eligible works were prospective (randomized or not) or retrospective clinical or medical-economic comparative studies having compared disposable scissors, trocars, and mechanical endoscopic staplers to the same instruments in reusable. Two different independent examiners extracted the relevant data. RESULTS: Among the 2882 articles found, 156 abstracts were retained for examination. After comprehensive analysis concerning the safety and effectiveness of the instruments, we included four articles. A study on trocars highlighted increased vascular complications with disposable instruments, and another study found more perioperative incidents with a hybrid stapler as opposed to a disposable stapler. As regards cost analysis, we included 11 studies, all of which showed significantly higher costs with disposable instruments. The results of the one study on carbon footprints showed that hybrid instruments leave four times less of a carbon footprint than disposable instruments. CONCLUSION: The literature on the theme remains extremely limited. Our review demonstrated that from a medical and economic standpoint, reusable medical instruments, particularly trocars, presented appreciable advantages. While there exist few data on the ecological impact, those that do exist are unmistakably favorable to reusable instruments.

Brachytherapy and surgery versus surgery alone for IB2 (FIGO 2018) cervical cancers: A FRANCOGYN study.

OBJECTIVE: Evaluation of the management by first brachytherapy followed by radical hysterectomy (Wertheim type) compared to radical hysterectomy alone (Wertheim type) for the treatment of IB2 cervical cancer. METHODS: Data from women with histologically proven FIGO stage IB2 cervical cancer treated between April 1996 and December 2016 were retrospectively abstracted from twelve French institutions with prospectively maintained databases. RESULTS: Of the 211 patients with FIGO stage IB2 cervical cancer without lymph node involvement included, 136 had surgical treatment only and 75 had pelvic lymph node staging and brachytherapy followed by surgery. The surgery-only group had significantly more adjuvant treatment (29 vs. 3; p = 0.0002). A complete response was identified in 61 patients (81%) in the brachytherapy group. Postoperative complications were comparable (63,2% vs. 72%, p = 0,19) and consisted mainly of urinary (36vs. 27) and digestive (31 vs 22) complications and lymphoceles (4 vs. 1). Brachytherapy had no benefit in terms of progression-free survival (p = 0.14) or overall survival (p = 0.59). However, for tumors of between 20 and 30 mm, preoperative brachytherapy improved recurrence-free survival (p = 0.0095) but not overall survival (p = 0.41). This difference was not observed for larger tumors in terms of either recurrence-free survival (p = 0.55) or overall survival (p = 0.95). CONCLUSION: Our study found that preoperative brachytherapy had no benefit for stage IB2 cervical cancers in terms of recurrence-free survival or overall survival. For tumor sizes between 2 and 3 cm, brachytherapy improves progression-free survival mainly by reducing pelvic recurrences without improving overall survival.

Adherence to ESGO guidelines and impact on survival in obese patients with endometrial cancer: a multicentric retrospective study.

OBJECTIVES: Obesity is known to be both a major risk factor for endometrial cancer and associated with surgical complexity. Therefore, the management of patients with obesity is a challenge for surgeons and oncologists. The aim of this study is to assess the adherence to European Society of Gynaecological Oncology (ESGO) guidelines in morbidly obese patients (body mass index (BMI) >40 kg/m2). The secondary objectives were the impact on overall survival and recurrence-free survival. METHODS: All the patients who were treated for an endometrial cancer in the 11 cancer institutes of the FRANCOGYN group were included and classified into three weight groups: morbid (BMI >40 kg/m2), obese (BMI 30-40), and normal or overweight (BMI <30). Adherence to guidelines was evaluated for surgical management, lymph node staging, and adjuvant therapies. RESULTS: In total, 2375 patients were included: 1330 in the normal or overweight group, 763 in the obese group, and 282 in the morbid group. The surgical management of the morbid group was in accordance with the guidelines in only 30% of cases, compared with 44% for the obese group and 48% for the normal or overweight group (p<0.001); this was largely because of a lack of lymph node staging. Morbid group patients were more likely to receive the recommended adjuvant therapy (61%) than the obese group (52%) or the normal or overweight group (46%) (p<0.001). Weight had no impact on overall survival (p=0.6) and morbid group patients had better recurrence-free survival (p=0.04). CONCLUSION: Adherence to international guidelines for surgical management is significantly lower in morbid group patients, especially for lymph node staging. However, morbidly obese patients had more often the adequate adjuvant therapies. Morbid group patients had a better recurrence-free survival likely because of better prognosis tumors.

The impact of laparoscopic gynecological surgery training on the technicity index of a developing country center.

PURPOSE: To compare laparoscopic gynecological surgery training between a developed country's reference center (host center) and a public reference service in a developing country (home center), and use the technicity index (TI) to compare outcomes and to determine the impact of laparoscopic gynecological surgery fellowship training on the home center's TI. METHODS: The impact of training on the home center was assessed by comparing surgical performance before and after training. TI was assessed in 2017 in the host center, and before and after training in the home center. Epidemiological and clinical data, and information on reason for surgery, preoperative images, estimated intraoperative bleeding, operative time, surgical specimen weight, hospital stay length, complication and reintervention rates were collected from both institutions. Home center pre-training data were retrospectively collected between 2010 and 2013, while post-training data were prospectively collected between 2015 and 2017. A two-tail Z-score was used for TI comparison. RESULTS: The analysis included 366 hysterectomies performed at the host center in 2017, and 663 hysterectomies performed at the home center between 2015 and 2017. TI in the host center was 82.5%, while in the home center it was 6% before training and 22% after training. There were no statistical differences in length of hospital stay, preoperative uterine volume, surgical specimen weight and complication rate between centers. However, significantly shorter mean operative time and lower blood loss during surgery were observed in the host center. CONCLUSIONS: High-quality laparoscopic training in a world-renowned specialized center allowed standardizing laparoscopic hysterectomy procedures and helped to significantly improve TI in the recipient's center with comparable surgical outcomes.

Endometrial cancer of the very elderly: Management and survival in the Francogyn population.

INTRODUCTION: We aimed to describe management and survival of patients with endometrial cancer (EC) ≥80 years to identify poor prognosis criteria. METHODS: We collected clinical, histologic, surgical and follow-up data for patients with EC ≥ 80 years included in a multicenter French cohort (FRANCOGYN) who underwent primary surgical treatment from 1999 to 2019. The outcomes were overall survival (OS) and disease-free survival (DFS). We performed a descriptive analysis then a survival time analysis and comparison using the Kaplan Meier method and log-rank test. RESULTS: Of the 1647 patients with EC who received treatment during the study period, 184 (11.17%) were ≥80 years. The mean age was 84 years (±3.34). Thirty-three patients (25.4%) died during the follow-up period and 26 relapsed (18.4%). Forty-nine patients were lost to follow-up (27.37%). The median follow-up time was 15.3 months (4.9-28.8). The median OS and DFS was 16.4 months (6.3-24.9) and 13.6 months (4.5-26.6), respectively. Eighty-three patients received adjuvant therapy (45.11%), out of 95 who had a formal or relative indication. Four patients received adjuvant chemotherapy (2.6%), out of 61 who had a formal or relative indication. Inappropriate or underuse of chemotherapy was significantly associated with a lower median OS of 12.6 months [3.73-24] versus 17.3 months [7.93-41.77] when performed appropriately (HR = 4.14, CI 95% [1.62-10.56]), and a lower median DFS of 10.83 months [3.73-24] versus 17.3 months [7.93-28.5] (HR = 9.04, CI 95% [2.04-40.12]). CONCLUSION: Our results suggest that very elderly patients with EC should receive adjuvant chemotherapy according to the standard care guidelines.

Surgical complications and their impact for gynecological surgeons.

OBJECTIVES: Major clinical incidents can impact the healthcare professionals involved. This is of particular relevance in surgery, with the operating room being a high-risk zone for complications; however, there is few available data on how surgeons may be affected. The current study examined the impact of surgical complications on surgeon traumatic stress levels, emotional state, job performance, and coping strategies. METHODS: A questionnaire to evaluate the impact of surgical complications on surgeon traumatic stress levels, emotional state, and job performance was developed by our team and communicated via an online link to gynecological surgeons. RESULTS: A total of 72 gynecologic surgeons completed the questionnaire. Five percent had a Peritraumatic Distress Inventory (PDI) score of ≥15, revealing a high stress level, and 12% had an Impact of Event Scale-Revised (IES-R) score of ≥36, indicating acute traumatic stress. Our results show that following surgical incidents, surgeons receive support primarily from another surgical team member and that surgical practice may be impacted, leading in some cases to detrimental effects on patient care, notably reduced radicality in some surgical procedures. CONCLUSION: Surgeons may experience acute traumatic stress after serious surgical complications. Increased awareness of the negative consequences on surgeon emotional well-being is required, as well as improved access to support mechanisms. The study was approved by local ethics committee (IRB00013412, "CHU de Clermont Ferrand IRB #1," institutional review board number 2022-CF004).

Comparison of retroperitoneal and transperitoneal surgical routes in laparoscopic nodal staging for locally advanced cervical cancers (FIGO IB3-IVA).

BACKGROUND: This study compares morbidity and mortality associated with retroperitoneal and transperitoneal para-aortic lymphadenectomy (PAAL) for pretherapeutic nodal staging of locally advanced cervical cancers (FIGO IB3-IVA). METHODS: Pre-, per- and postoperative data of patients treated for locally advanced stage cervical cancer between 1999 and 2018 in 12 French referral centers (FRANCOGYN Study Group) were retrospectively collected. RESULTS: The study was conducted using a sample of 448 patients, of whom 223 (49,8%) underwent retroperitoneal (group 1) and 225 (50,2%) had transperitoneal PAAL (group 2). No differences were noted concerning clinical and histological characteristics between the two groups. Among these 448 patients, 23 (5,1%) had an intraoperative complication (9 (2,0%) in group 1 and 14 (3,1%) in group 2, p = 0.28) and 47 (10,5%) had a postoperative complication (22 (4,9%) in group 1 and 25 (5,6%) in group 2, p = 0.44), only one of which required revision surgery but the patient died. The length of hospital stay was significantly shorter in group 1 than in group 2 (3.97 versus 4.88 days, p < 0.001). There was no significant difference in mortality between the two groups; 34 of 223 patients in group 1 (15.3%) and 40 of 225 patients in group 2 (15.6%) died (HR = 0.968, 95% CI [0.591-1.585]). There was no significant difference in recurrence-free or overall survival between the two groups. CONCLUSION: Retroperitoneal PAAL appears as a valuable and safety surgical route for nodal staging in locally advanced cervical cancer compared with standard transperitoneal PAAL.

Impact of severe obesity in the management of patients with high-risk endometrial cancer: A FRANCOGYN study.

OBJECTIVE: To assess the surgical management and survival of severely obese patients with high-risk endometrial cancer. MATERIALS AND METHODS: Data from 269 patients with high-risk endometrial cancer who were treated between 2001 and 2018 were collected from a multicenter database (11 centers). We classified the patients according to their BMI and compared outcomes in two groups: a normal weight group of women with a BMI < 25 kg/m2, and a severe obesity group of women with a BMI ≥ 35 kg/m2. The groups were compared for epidemiologic, pathologic, management, relapse-free survival (RFS) and overall survival (OS) elements. RESULTS: Patients in the severe obesity group were younger (64 years vs. 68 years, p < 0.05) and had more comorbidities (hypertension, diabetes). They also had more locally advanced tumors and pelvic lymph node involvement (47% vs 24%, p < 0.05). The severely obese patients were less likely to undergo recommended surgical staging, with fewer lumbar aortic dissections than women of normal weight (23% vs 36%, p < 0.05) and fewer pelvic sentinel lymph node biopsies (26.5% vs 12.1%, p < 0.05). No difference in RFS or OS were observed between the two groups. CONCLUSION: Patients with severe obesity and high-risk endometrial cancer have more locally advanced tumors, and are less likely to be managed according to surgical recommendations. However, RFS and OS do not seem to be affected.

Trachelectomy: How is it actually done? A review from FRANCOGYN group Titre: Trachélectomie: comment faire en pratique ? Revue de la littérature par le groupe FRANCOGYN.

Because of the peak incidence of cervical cancer between the ages of 35 and 44 and the increasing age of first pregnancy, the issue of fertility preservation in cases of early-stage cervical cancer in women in this reproductive age category arises. Early-stage cervical cancer patients have a good prognosis and are surgically treated in cases of mildly aggressive human papillomavirus-related histological type (squamous cell carcinoma, adenocarcinoma), FIGO stage IA to IB1 (i.e., <2 cm), with shallow stromal invasion (<10 mm) and without the presence of lymph-vascular space invasion or lymph node or regional involvement. Under these conditions, conservative treatment by trachelectomy, which has recurrence-free and overall survival rates equivalent to that of hysterectomy, may be considered. After a complete pre-therapeutic assessment, including pelvic lymphadenectomy, to eliminate all contraindications to conservative treatment, a simple or enlarged trachelectomy can be chosen. According to some authors, the route of entry (vaginal, simple or robot-assisted laparoscopy, laparotomy) has no significant effect on survival or fertility, although the literature on the subject is limited. Trachelectomy offers good results in terms of fertility, with an estimated pregnancy rate of between 23% and 55% and a live birth rate of 70%. The significant reduction of the cervix associated with the procedure increases the risk of prematurity. However, this can be prevented by the use of a permanent cerclage. Close follow-up of these patients is essential for a minimum period of 5 years in order to detect any recurrence or postoperative complications.

Management of peritoneal pseudomyxoma in pregnant women: A case report and review of the literature.

The incidence of neoplasia during pregnancy is low, 1/1000 pregnancies. The most common cancers diagnosed during pregnancy are breast and cervical cancer. Pseudomyxoma peritonei (PMP) is a rare syndrome (1/1 000 000) characterized by the presence of gelatinous ascites and disseminated intra-peritoneal mucinous tumors. The origin of this syndrome is, in most of cases, a tumor of the appendix. A PMP diagnosis during pregnancy is an extremely rare event. We present the medical history of a 34-year-old woman diagnosed with a PMP at 29 weeks of amenorrhea, during the management of an ovarian masse. We preserved the pregnancy until 37 weeks of amenorrhea. She had a vaginal delivery. At 4 weeks post-partum, she had an extensive cytoreduction with intraperitoneal chemotherapy. We present literature review of PMP discover during pregnancy and a discussion about treatment of these PMP. We also discuss management of an ovarian masse diagnosis during pregnancy.

Prophylactic procedures associated with gynecological surgery for the management of superficial endometriosis and adhesions. Clinical practice guidelines from the French College of Gynecologists and Obstetricians (CNGOF)✰.

OBJECTIVE: To provide guidelines from the French College of Obstetricians and Gynecologists (CNGOF), based on the best currently available evidence, for the prophylactic procedures associated with gynecological surgery for benign disease such as superficial endometriosis lesions and adhesions. METHODS: The CNGOF has decided to adopt the AGREE II and GRADE systems for grading scientific evidence. Each recommendation for practice was allocated a grade that reflects the quality of evidence (QE) (clinical practice guidelines). RESULTS: Endometriosis and pelvic pain Superficial endometriosis can be entirely asymptomatic. Surgical treatment of asymptomatic superficial peritoneal endometriosis is not recommended in women of childbearing age for the prevention of pelvic pain, especially in case of proximity to noble organs (e.g., the ureters, rectum and sigmoid, and ovaries in nulligravida) as there is no evidence that the disease will progress to become symptomatic (low level of evidence). In case of accidental discovery of superficial endometriosis in women of childbearing age with pelvic pain, it is recommended that the lesions are excised, if surgically accessible. Removal of superficial endometriosis lesions in patients with painful symptoms improves quality of life and pain (low level of evidence). Endometriosis and infertility It appears that women with isolated superficial endometriosis diagnosed by laparoscopy with histological confirmation have a significantly higher incidence of primary infertility than patients without endometriosis. However, there is no data regarding the impact of treatment of these lesions on the fertility in these women or on the natural course of their disease (low level of evidence). It is recommended that excision is performed rather than monopolar coagulation of superficial endometriosis lesions in infertile women, as this results in a higher spontaneous pregnancy rate (low level of evidence). Adhesions and pelvic pain There is limited data in the literature regarding the benefit of performing systematic adhesiolysis during laparoscopy to prevent pelvic pain when incidental pelvic adhesions are discovered. For patients with pelvic pain, it is probably better not to perform adhesiolysis to prevent pelvic pain, although this can be decided on a case-by-case basis depending on the extent of the adhesions, the topography, and the type of surgery considered (low level of evidence). For asymptomatic patients, it is recommended not to perform adhesiolysis to prevent pelvic pain due to the lack of clear efficacy both short- or long-term and due to the increased risk of surgical injuries (low level of evidence). Adhesions and infertility There is limited data in the literature regarding the potential benefit of performing systematic adhesiolysis when there is an incidental discovery of pelvic adhesions during laparoscopy to prevent infertility. For infertile women, in the event of fortuitous discovery of adhesions at laparoscopy, it is probably better not to perform complex adhesiolysis. Only adhesiolysis of tubo-ovarian adhesions that are minimal or slight in terms of their extension and/or their nature may be useful to improve the chances of spontaneous pregnancy. However, it remains to be decided on a case-by-case basis depending on other potential causes of infertility (low level of evidence). For women without known infertility issues, it is probably better not to perform systematic adhesiolysis in order to improve their pregnancy chances, considering the balance between the unknown benefit and the risks of complications inherent to surgery (low level of evidence). CONCLUSION: Further investigations are needed in order to increase the quality of management regarding associated interventions such as the treatment of superficial endometriosis or adhesions performed during a gynecologic surgical procedure and, thereby, bolster these recommendations.

The impact of the COVID-19 coronavirus pandemic on the surgical management of gynecological cancers: Analysis of the multicenter database of the French SCGP and the FRANCOGYN group.

INTRODUCTION: The coronavirus SARS-CoV-2 (COVID-19) pandemic has put tremendous pressure on the French healthcare system. Almost all hospital departments have had to profoundly modify their activity to cope with the crisis. In this context, the surgical management of cancers has been a topic of debate as care strategies were tailored to avoid any delay in treatment that could be detrimental to patient wellbeing while being careful not to overload intensive care units. The primary objective of this study was to observe changes in the surgical management of pelvic cancers during the COVID-19 pandemic in France. MATERIAL AND METHODS: This study analyzed data from the prospective multi-center cohort study conducted by the French Society for Pelvic and Gynecological Surgery (SCGP) with methodological support from the French (FRANCOGYN) Group. All members of the SCGP received by e-mail a link allowing them to include patients who were scheduled to undergo gynecological carcinologic surgery between March 16th 2020 and May 11th 2020. Demographic data, the characteristics of cancers and the impact of the crisis in terms of changes to the usual recommended coarse of care were collected. RESULTS: A total of 181 patients with a median age 63 years were included in the cohort. In total, 31 patients had cervical cancer, 76 patients had endometrial cancer, 52 patients had ovarian or tubal cancer, 5 patients had a borderline tumor of the ovary, and 17 patients had vulvar cancer. During the study period, the care strategy was changed for 49 (27%) patients with postponed for 35 (19.3%) patients, and canceled for 7 (3.9%) patients. Surgical treatment was maintained for 139 (76.8%) patients. Management with neoadjuvant chemotherapy was offered to 19 (10,5%) patients and a change in surgical choice was made for 5 (2,8%) patients. In total, 8 (4,4%) patients tested positive for COVID-19. Data also shows a greater number of therapeutic changes in cases of ovarian cancer as well as a cancelation of a lumbo-aortic lymphadenectomy in one patient with cervical cancer. Hospital consultants estimated a direct detrimental impact of the COVID-19 pandemic for 39 patients, representing 22% of gynecological cancers. CONCLUSION: This study provided observational data of the impact of the COVID-19 health crisis on the surgical management of gynecological cancers.

Borderline ovarian tumors: French guidelines from the CNGOF. Part 1. Epidemiology, biopathology, imaging and biomarkers.

The incidence (rate per 100 000) of borderline ovarian tumors (BOTs) increases progressively with age, starting at 15-19 years and peaking at around 4.5 cases per 100 000 at an age of 55-59 years (LE3) with a median age of 46 years. The five year survival for FIGO stages I, II, III and IV is 99.7 % (95 % CI: 96.2-100 %), 99.6 % (95 % CI: 92.6-100 %), 95.3 % (95 % CI: 91.8-97.4 %) and 77.1 % (95 % CI: 58.0-88.3 %), respectively (LE3). An epidemiological association exists between the individual risk of BOT and family history of BOT and certain other cancers (pancreatic, lung, bone, leukemia) (LE3), a personal history of benign ovarian cyst (LE2), a personal history of tubo-ovarian infection (LE3), the use of a levonorgestrel intrauterine device (LE3), oral contraceptive use (LE3), multiparity (LE3), Hormonal replacement therapy (LE3), high consumption of Coumestrol (LE4), medical treatment for infertility with progesterone (LE3) and non-steroidal anti-inflammatory drug use (LE3). Screening for BOTs is not recommended for patients (Grade C). The overall risk of recurrence of BOTs varies between 2% and 24 %, with an overall survival greater than 94 % at 10 years, and the risk of an invasive recurrence of a BOT ranges from 0.5 % to 3.8 %. The use of scores and nomograms can be useful in assessing the risk of recurrence, and providing patients with information (Grade C). The WHO classification is recommended for classifying BOTs. It is recommended that the presence of a microinvasive focus (<5 mm) and microinvasive carcinoma (<5 mm with an atypical nuclei and a desmoplastic stroma reaction) within a BOT be reported. In cases of serous BOT, it is recommended to specify the classic histological subtype or micropapillary / cribriform type (Grade C). When confronted with a BOT, it is recommended that the invasive or non-invasive nature of peritoneal implants can be investigated based solely on the invasion and destruction of underlying adipose or peritoneal tissue which has a desmoplastic stromal reaction where in contact with the invasive clusters (Grade B). For bilateral mucinous BOTs and / or in cases with peritoneal implants or peritoneal pseudomyxoma, it is recommended to also look for a primitive digestive or pancreato-biliary cancer (Grade C). It is recommended to sample ovarian tumors suspected of being BOTs by focusing samples on vegetations and solid components, with at least 1 sample per cm in tumors with a size less than 10 cm and 2 samples per cm in tumors with a size greater than 10 cm (Grade C). In cases of BOTs and in the absence of macroscopic omental involvement after careful macroscopic examination, it is recommended to perform at least 4-6 systematic sampling blocks and to include all peritoneal implants (Grade C). It is recommended to consult an expert pathologist in gynecology when a BOT suspicion requires intraoperative extemporaneous histology (grade C). Endo-vaginal and suprapubic ultrasonography are recommended for the analysis of an ovarian mass (Grade A). In case of an undetermined ovarian lesion on ultrasonography, it is recommended that a pelvic MRI be performed (Grade A). To analyze an adnexal mass with MRI, it is recommended to use an MRI protocol with T2, T1, T1 Fat Sat, dynamic and diffusion sequences as well as gadolinium injection (Grade B). To characterize an adnexal mass with MRI, it is recommended to include a score system for malignancy (ADNEX MR/O-RADS) (Grade C) in the report and to formulate a histological hypothesis (Grade C). Pelvic MRI is recommended to characterize a tumor suspected of being a BOT (Grade C). Macroscopic MRI features should be analyzed to differentiate BOT subtypes (Grade C). Pelvic ultrasound is the first-line examination for the detection and characterization of adnexal masses during pregnancy (Grade C). Pelvic MRI is recommended from 12 weeks of gestation in case of an indeterminate adnexal mass and should provide a diagnostic score (Grade C). Gadolinium injection must be minimized as fetal impairment has been proven (Grade C). It is recommended that serum levels of HE4 and CA125 be evaluated and that the ROMA score for the diagnosis of an indeterminate ovarian mass on imaging be used (grade A). In case of suspicion of a mucinous BOT on imaging, dosage of serum levels of CA 19-9 can be considered (Grade C). If the determination of tumor markers is normal preoperatively, routine dosage of tumor markers in BOT follow-up is not recommended (Grade C). In case of preoperative elevation in tumor markers, the determination of serum CA 125 levels is recommended in the follow-up of BOT (Grade B). When conservative treatment of a BOT has been adopted, the use of endovaginal and transabdominal ultrasonography is recommended during follow-up (Grade B).

Borderline ovarian tumors: French guidelines from the CNGOF. Part 2. Surgical management, follow-up, hormone replacement therapy, fertility management and preservation.

In the Early Stages (ES) of Borderline Ovarian Tumor (BOT), if surgery without risk of tumor rupture is possible, then laparoscopy with protected extraction is recommended over laparotomy (Grade C). In case of bilateral serous ES BOT treatment with a strategy to preserve fertility and/or endocrine function, bilateral cystectomy is recommended if possible (Grade B). In case of mucinous BOT treatment with a strategy to preserve fertility and/or endocrine function, unilateral adnexectomy is recommended (grade C). In the case of a mucinous BOT in a patient who has had an initial cystectomy, unilateral adnexectomy is recommended (grade C). In the case of treatment of a serous ES BOT in a patient who has had an initial cystectomy, with a strategy to preserve fertility and/or endocrine function, restaging surgery for adnexectomy is not recommended in the absence of suspicious residual lesions at the time of surgery and/or postoperative imaging (reference ultrasonography or pelvic MRI) (grade C). For serous or mucinous ES BOTs, routine hysterectomy is not recommended (Grade C). In cases of ES BOTs, lymphadenectomy is not recommended (Grade C). For ES BOTs, appendectomy is recommended only if there is a macroscopically pathological aspect to the appendix (Grade C). Restaging surgery is recommended in case of a serous BOT with a micropapillary aspect and an unsatisfactory inspection of the abdominal cavity during initial surgery (Grade C). Restaging surgery is recommended in cases of mucinous BOT if only a cystectomy has been performed or if the appendix has not been evaluated (Grade C). If restaging surgery is decided for an ES BOT, the following procedures should be performed: peritoneal cytology (grade C), omentectomy (there is no data in literature to recommend which type of omentectomy should be performed) (grade B), complete exploration of the abdominal cavity with peritoneal biopsies (grade C), visualization of the appendix +/- appendectomy in case of pathological macroscopic appearance (grade C) and unilateral adnexectomy in case of a mucinous BOT (grade C). In advanced stages of BOT it is not recommended to perform a lymphadenectomy as a routine procedure (Grade C). In cases of an advanced stage BOT, in a patient with a desire to fall pregnant, conservative treatment involving preservation of the uterus and all or part of the ovary may be proposed after a multidisciplinary meeting (Grade C). Second surgery aimed at removing all lesions, if not performed initially, is recommended in cases of advanced stage BOT (Grade C). It is not recommended to perform completion surgery after conservative treatment (preservation of the ovaries and the uterus) and after the achievement of fertility desire for a serous BOT (Grade B). After treatment for a BOT, follow-up beyond 5 years is recommended due to the median time to recurrence (Grade B). It is recommended that a systematic clinical examination be carried out during follow-up of a treated BOT (Grade B). In the particular case of an initial elevation of CA 125 levels, it is recommended to monitor CA 125 during follow up (Grade B). In cases treated conservatively (ovarian and uterine conservation), it is recommended to use endovaginal and transabdominal ultrasonography during the follow up period (Grade B). In the event of a recurrence of a BOT, in a woman of childbearing age, a conservative treatment strategy can again be proposed (Grade C). In the presence of non-invasive BOT implants, conservative treatment may be considered after a first non-invasive recurrence in women who wish to preserve their fertility (Grade C). Pelvic MRI is recommended after 12 weeks of amenorrhea in case of an undetermined adnexal mass and should be concluded with a diagnostic score (Grade C). The injection of gadolinium, in case of pregnancy, should be discussed on a case-by-case basis due to the proven risks for the foetus (Grade C). If feasible, a laparoscopic approach should be preferred during pregnancy (Grade C). A consultation with a specialist reproductive physician should be offered to patients with a BOT and of childbearing age (Grade C). It is recommended that patients be provided with full information on the risk of decreased ovarian reserve following to surgical treatment. It is recommended that the ovarian reserve be evaluated prior to surgical management of a suspected BOT (Grade C). When possible, a conservative surgical strategy is recommended to preserve fertility in women of childbearing age (Grade C). There is no specific data on the management of infertility following to conservative treatment of BOT. In case of durable infertility following to conservative treatment of BOT, a consultation with a specialist reproductive physician is required (Grade C). In the case of optimally treated BOT, there is no evidence in literature to contraindicate the use of Assisted Reproductive Techniques (ART). The use of hormonal contraception after serous or mucinous BOT is not contraindicated (Grade C). After treatment of a mucinous BOT, for women aged under 45 years, given the benefit of hormonal replacement therapy (HRT) on cardiovascular and bone risks, and the lack of hormone-sensitivity of mucinous BOTs, it is recommended to offer HRT (Grade C). After treatment of a mucinous BOT, for women over 45 years of age, there is no argument to contraindicate the use of HRT. HRT can be prescribed in case of a climacteric syndrome, as part of an individual benefit to risk assessment (Grade C).

Prophylactic procedures associated with gynecological surgery for the management of superficial endometriosis and adhesions. Clinical practice guidelines from the French College of Gynecologists and Obstetricians (CNGOF)

To provide guidelines from the French College of Obstetricians and Gynecologists (CNGOF), based on the best currently available evidence, for the prophylactic procedures associated with gynecological surgery for benign disease such as superficial endometriosis lesions and adhesions. The CNGOF has decided to adopt the AGREE II and GRADE systems for grading scientific evidence. Each recommendation for practice was allocated a grade that reflects the quality of evidence (QE) (clinical practice guidelines). Endometriosis and pelvic pain Superficial endometriosis can be entirely asymptomatic. Surgical treatment of asymptomatic superficial peritoneal endometriosis is not recommended in women of childbearing age for the prevention of pelvic pain, especially in case of proximity to noble organs (e.g., the ureters, rectum and sigmoid, and ovaries in nulligravida) as there is no evidence that the disease will progress to become symptomatic (low level of evidence). In case of accidental discovery of superficial endometriosis in women of childbearing age with pelvic pain, it is recommended that the lesions are excised, if surgically accessible. Removal of superficial endometriosis lesions in patients with painful symptoms improves quality of life and pain (low level of evidence). Endometriosis and infertility It appears that women with isolated superficial endometriosis diagnosed by laparoscopy with histological confirmation have a significantly higher incidence of primary infertility than patients without endometriosis. However, there is no data regarding the impact of treatment of these lesions on the fertility in these women or on the natural course of their disease (low level of evidence). It is recommended that excision is performed rather than monopolar coagulation of superficial endometriosis lesions in infertile women, as this results in a higher spontaneous pregnancy rate (low level of evidence). Adhesions and pelvic pain There is limited data in the literature regarding the benefit of performing systematic adhesiolysis during laparoscopy to prevent pelvic pain when incidental pelvic adhesions are discovered. For patients with pelvic pain, it is probably better not to perform adhesiolysis to prevent pelvic pain, although this can be decided on a case-by-case basis depending on the extent of the adhesions, the topography, and the type of surgery considered (low level of evidence). For asymptomatic patients, it is recommended not to perform adhesiolysis to prevent pelvic pain due to the lack of clear efficacy both short- or long-term and due to the increased risk of surgical injuries (low level of evidence). Adhesions and infertility There is limited data in the literature regarding the potential benefit of performing systematic adhesiolysis when there is an incidental discovery of pelvic adhesions during laparoscopy to prevent infertility. For infertile women, in the event of fortuitous discovery of adhesions at laparoscopy, it is probably better not to perform complex adhesiolysis. Only adhesiolysis of tubo-ovarian adhesions that are minimal or slight in terms of their extension and/or their nature may be useful to improve the chances of spontaneous pregnancy. However, it remains to be decided on a case-by-case basis depending on other potential causes of infertility (low level of evidence). For women without known infertility issues, it is probably better not to perform systematic adhesiolysis in order to improve their pregnancy chances, considering the balance between the unknown benefit and the risks of complications inherent to surgery (low level of evidence). Further investigations are needed in order to increase the quality of management regarding associated interventions such as the treatment of superficial endometriosis or adhesions performed during a gynecologic surgical procedure and, thereby, bolster these recommendations.

Fluorescence-guided management of deep endometriosis.

OBJECTIVE: To demonstrate the advantages of the fluorescence-guided surgery using indocyanine green (ICG) in the management of deep endometriotic nodules toward more complete and safe excision of the disease in cases when rectal shaving is performed. DESIGN: Surgical video demonstrating the result of the application of a fluorescent dye (ICG) during deep endometriosis surgery. The local institutional review board was consulted and ruled that approval was not required for this video article because the video describes a technique and the patient cannot be identified. SETTING: Tertiary-care university hospital. PATIENT(S): The patient underwent rectal shaving due to a deep endometriotic nodule located at the level of the rectovaginal septum. INTERVENTION(S): The procedure started with exploration of the lesion and the anatomical structures. The nodule is approached using the "reverse technique." As the nodule is infiltrating the vagina, complete resection of the posterior vaginal wall is performed. At the start of the rectal shaving, ICG is injected and its fluorescence effect is used to provide navigation for the surgeon during the excision. At the end of the procedure the vascularization of the bowel wall and the vagina are evaluated with the help of the ICG. MAIN OUTCOME MEASURE(S): Visual assessment and distinction between the borders of the endometriotic nodule and the rectal wall as a result of the fluorescence effect of the ICG. RESULT(S): After injection of the ICG, the borders of the healthy rectum are delineated and a clear distinction between the endometriotic nodule and the bowel wall is demonstrated. In addition, the effect of the ICG was used to assess the vascularization of the infiltrated organs (vagina and rectal wall). CONCLUSION(S): Deep endometriosis at the level of the rectum usually represents a solid fibrotic nodule. The fibrosis plays a major role in the development of the disease. Indocyanine green is a fluorescent contrast agent, routinely used in a wide range of specialties to assess the blood supply and vascularization of different organs and tissues. Based on the fibrotic nature of the disease, the fluorescence could facilitate the distinction between healthy vascularized tissues and the endometriotic nodule. In the presented case, using ICG, a clear difference between the nodule and the rectum is demonstrated, as well as the vascularization of the bowel wall and the vagina. The implementation of ICG during endometriosis surgery could provide navigation for the surgeon toward a more complete and safer treatment of the disease, reducing the risk of complications and reinterventions. Additional studies are needed to further evaluate ICG fluorescence-guided surgery in the management of deep endometriosis.

Long-Term Evolution of Quality of Life and Symptoms Following Surgical Treatment for Endometriosis: Different Trajectories for Which Patients?

Many studies have shown a global efficacy of laparoscopic surgery for patients with endometriosis in reducing painful symptoms and improving quality of life (QoL) in the short and long-term. The aim of this study was to analyze the different trajectories of long-term evolution in QoL and symptoms following surgical treatment for endometriosis, and to identify corresponding patient profiles. This prospective and multicenter cohort study concerned 962 patients who underwent laparoscopic treatment for endometriosis. QoL was evaluated using the Short Form (SF)-36 questionnaire and intensity of pain was reported using a visual analog scale prior to surgery and at 6, 12, 18, 24 and 36 months after surgery. Distinctive trajectories of pain and QoL evolution were identified using group-based trajectory modeling, an approach which gathers individuals into meaningful subgroups with statistically similar trajectories. Pelvic symptom trajectories (models of the evolution of dysmenorrhea, dyspareunia and chronic pelvic pain intensity over years) correspond to (1) patients with no pain or pain no longer after surgery, (2) patients with the biggest improvement in pain and (3) patients with continued severe pain after surgery. Our study reveals clear trajectories for the progression of symptoms and QoL after surgery that correspond to clusters of patients. This information may serve to complete information obtained from epidemiological methods currently used in selecting patients eligible for surgery.