The role of progestin subdermal implant in the management of adenomyosis: a systematic review.

PURPOSE: The long-acting reversible contraception progestin subdermal implant (ENG implant) may be effective to improve endometriosis-related symptoms. Since adenomyosis is a histopathological form of endometriosis, we aimed to evaluate the effectiveness of ENG implant in adenomyosis management. MATERIALS AND METHODS: Electronic search in Medline, Scopus, Embase databases and Google Scholar using combinations of the following keywords: Progestin; subdermal implant; Implanon; Nexplanon; Adenomyosis; Endometriosis. RESULTS: Out of 889 articles in the initial database, 5 prospective observational studies were eligible for inclusion in our literature review. Our review involving 152 participants found a significant reduction in pelvic pain and dysmenorrhoea (baseline median VAS score ranged from 10 to 7.62 before implantation vs VAS score ranged from 1.81 to 0.1 after implantation) as well as an increase in the levels of haemoglobin after implantation of the device (from 86 g/L to 129 g/L after implantation). Moreover, the improvement may be sustained throughout the long-term follow-up visits (until 36 months). The most common adverse events were changes in bleeding patterns which were tolerable in most cases. CONCLUSION: ENG implant may be a relevant and promising medical option in the management of adenomyosis. Nevertheless, randomised controlled trials and prospective studies with larger cohorts are needed to confirm the potential role of ENG implant in the management of adenomyosis.

The etonogestrel-releasing subdermal contraceptive implant may be a relevant medical option in the management of adenomyosis.

The psychological impact of therapeutic changes during the COVID-19-lockdown for gynaecological and breast cancer patients.

OBJECTIVE: The exceptional health situation related to the Coronavirus 2019 (COVID-19) pandemic has required an in-depth and immediate reorganisation of gynaecological cancer care. The main objective was to assess the psychological impact of such treatment modifications during the lockdown period for gynaecological and breast cancer patients. PATIENTS AND METHODS: A multicentre prospective study was conducted in three university gynaecological cancer wards (Hospices Civils de Lyon, France) during the French first lockdown (16th March to 11th May 2020). All patients with non-metastatic breast cancer or gynaecological cancer were included. Data was collected regarding treatment modifications (delay, cancellation, change of therapeutic plan). The psychological impact of treatment modifications during and after the lockdown was assessed by validated questionnaires (SF-12, EORTC-QLQ-C30, HADS). RESULTS: A total of 205 consecutive patients were included, aged 60.5 ± 1.0 years. Seven patients (3.4%) presented a SARS-CoV-2 infection, and two patients died. Treatment was maintained for 122 (59.5%) patients, postponed for 72 (35.1%) and cancelled for 11 (5.4%). During the lockdown, 35/118 (29.7%) patients suffered from confirmed anxiety and the mean fatigue-EORTC score was 48.00 ± 2.51; it was 38.64 ± 2.33 (p = 0.02) after the lockdown. After the lockdown and compared to the lockdown period, the mental SF-12 score and overall health status EORTC score were significantly higher (45.03 ± 1.06 vs 41.71 ± 1.15, p = 0.02 and 64.58 ± 1.66 vs 57.44 ± 2.02, p = 0.0007, respectively). The number of confirmed-anxiety cases was significantly higher amongst patients for whom treatment was delayed or cancelled (40.5% vs 23.7%, p = 0.04). CONCLUSION: This study quantified the treatment modifications of gynaecological cancer patients during the COVID-19 lockdown and revealed a poorer psychological state and quality of life during this period, even for patients whose treatment plan was not actually modified. Anxiety was more significant in patients with a delayed or cancelled treatment.

Glue mesh fixation in laparoscopic sacrocolpopexy: results at 3 years' follow-up.

INTRODUCTION AND HYPOTHESIS: We assessed 3-year anatomic and functional results using synthetic glue to fix mesh in laparoscopic sacrocolpopexy. METHODS: Prospective multicenter cohort study in three academic urogynecology departments. Seventy consecutive patients with stage ≥ 3 POP-Q (Pelvic Organ Prolapse Quantification) anterior and/or apical prolapse underwent laparoscopic sacrocolpopexy using synthetic surgical glue to fix anterior and posterior meshes to the vagina. Patients were followed up at 1, 2 and 3 years. Primary outcome was anterior and apical anatomic success (POP-Q stage ≤ 1) at 3 years. Secondary outcomes comprised functional results (international quality of life and sexuality scales), mesh-related morbidity and urinary incontinence at 3 years. RESULTS: Mean age was 56.7 ± 1.2 years. Mean follow-up was 43 months. Anterior compartment anatomic success rate was 87% at 2 years (Ba, -2.4 cm; p < 0.0001) and 86.5% at 3 years (Ba, -2.3 cm; p < 0.0001); apical success was 96.3% at 2 years (C, -6.8 cm; p < 0.0001) and 97.3% at 3 years (C, -6.5 cm; p < 0.0001). All quality-of-life scores improved significantly and lastingly at 3 years: PFDI-20, PFIQ-7 and PISQ-12, respectively, p < 0.0001, p < 0.0001 and p = 0.01. There was one case of vaginal mesh exposure at 3 years (2.8%) and five of mesh shrinkage at 1 year (7.8%), none at 2 years and two at 3 years (5.4%). Urinary incontinence rate was 29.7% at 1 year, 14.8% at 2 years and 11.1% at 3 years. CONCLUSION: Vaginal mesh adhesive in laparoscopic sacrocolpopexy remained effective at 3 years, with excellent tolerance and no specific complications. Anatomic and functional results were good and enduring in terms of both anterior and apical correction.

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

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

Easy way for elytrocele treatment by the vaginal route without mesh (with video).

Since elytrocele/enterocele may occur between 0.1% to 10% after hysterectomy, surgical techniques to repair elytrocele should be learnt to master. We propose the step-by-step description of the vaginal technique: dissection and resection of the peritoneal sac followed by a mini-invasive posterior transvaginal sacrospinous colpopexy.

Agonist anti-ChemR23 mAb reduces tissue neutrophil accumulation and triggers chronic inflammation resolution.

Resolution of inflammation is elicited by proresolving lipids, which activate GPCRs to induce neutrophil apoptosis, reduce neutrophil tissue recruitment, and promote macrophage efferocytosis. Transcriptional analyses in up to 300 patients with Inflammatory Bowel Disease (IBD) identified potential therapeutic targets mediating chronic inflammation. We found that ChemR23, a GPCR targeted by resolvin E1, is overexpressed in inflamed colon tissues of severe IBD patients unresponsive to anti-TNFα or anti-α4ß7 therapies and associated with significant mucosal neutrophil accumulation. We also identified an anti-ChemR23 agonist antibody that induces receptor signaling, promotes macrophage efferocytosis, and reduces neutrophil apoptosis at the site of inflammation. This ChemR23 mAb accelerated acute inflammation resolution and triggered resolution in ongoing chronic colitis models, with a significant decrease in tissue lesions, fibrosis and inflammation-driven tumors. Our findings suggest that failure of current IBD therapies may be associated with neutrophil infiltration and that ChemR23 is a promising therapeutic target for chronic inflammation.

Effective, simple and fast procedure for laparoscopic port-sites wounds closure.

The closure of port-sites wounds, as the ultimate step of surgical laparoscopic procedures, can be allowed by threads, staples, surgical glue or adhesive sutures. We describe a simple and easy skin suturing technique which saves time and provides significant surgical ergonomics.

Easy way to treat female stress urinary incontinence with bulking agents (with video).

Since the recent controversy about vaginal mesh implants, surgeons should use safe and effective devices and procedures to treat female stress urinary incontinence (SUI). We propose to describe the noninvasive and ambulatory technique of the urethral bulking procedure. Bulking agents are a simple, minimally invasive technique that can be offered in the treatment of female SUI.

Ectopic pregnancy management by V-NOTES technique.

Ectopic pregnancy is a frequent and life-threatening risk of childbearing. Its management represents a mainstay of emergency gynecological surgery, and laparoscopy is the surgical gold standard technique. The technique of transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) for the management of ectopic pregnancy is presented herein. The procedure is illustrated by an instructive video article that standardizes the essential steps to make the technique ergonomic and easy to perform (step-by-step explanations). This surgical technique allows to consider vaginal salpingectomy using a combined cœlio-vaginal approach. After a posterior colpotomy, an Alexis retractor was inserted in the pouch of Douglas followed by the placement of a dedicated platform on which three trocars were fixed. Pneumoperitoneum was then achieved. Once the diagnosis of ruptured tubal ectopic pregnancy was established, a salpingectomy was performed. As a minimally invasive approach, this procedure has high patient acceptance and seems to improve favorable clinical outcomes.

Easy way to perform salpingectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) (with video).

The transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is a new minimally invasive and emerging technique. Feasibility and safety profiles of peritoneal access via transvaginal routes have been demonstrated especially for the adnexal surgery. In order to be reproducible and replicable with a standardized procedure, we propose the step-by-step video description of the vNOTES salpingectomy. The advantages of the vNOTES (low postoperative pain, faster postoperative recovery, scarless surgery) could lead to a promising alternative to conventional laparoscopic salpingectomy/adnexectomy.

[Impact of the COVID-19 Outbreak on the management of patients with gynecological cancers]. / Impact de la pandémie de Covid-19 sur les modifications thérapeutiques des patientes atteintes de cancers gynécologiques.

OBJECTIVE: The exceptional health situation related to the SARS-Cov2 coronavirus pandemic (COVID-19) required a deep and very quickly adaptation of management practices in gynecological cancer. The main objective is to estimate the proportion of patients with treatment modifications. METHOD: This is a multicenter prospective study conducted in 3 university gynecological cancer departments (HCLyon, France) during the period of confinement (March 16 to May 11, 2020). All patients with non-metastatic breast cancer or gynecological cancer were included. The planned treatment, postponement, delay and organizational modifications (RCP, teleconsultations) were studied. RESULTS: Two hundred and five consecutive patients were included, average age 60.5±1.0. 7 patients (3.4%) had SARS-Cov-2 infection, 2 patients died. One hundred and twenty-two patients (59.5%) had a treatment maintained, 72 patients (35.1%) postponed, 11 patients (5.4%) cancelled. Of the 115 (56.1%) planned surgeries, 40 (34.8%) postponed, 7 cancelled (6.1%). 9 patients (7.8%) had a surgical modification. Of the 59 (28.8%) radiotherapy treatments scheduled, 24 (40.7%) postponed and 2 (3.4%) cancelled. Of the 56 (27.3%) chemotherapy treatment planned, 8 (14.3%) postponed and 2 (3.6%) cancelled. One hundred and forty-five patients (70.7%) have been discussed in multidisciplinary meeting. One hundred and fifty-eight patients (77%) had a teleconsultation system. CONCLUSION: Our study assessed the impact of the COVID-19 pandemic on therapeutic management of patients with gynecological cancer during the period of confinement. This will probably improve our management of an eventual epidemic rebound or future health crisis.

Easy mesh fixation to the promontory during sacrocolpopexy procedure.

We propose a simplified technique to approach the promontory and to fix the mesh on the anterior longitudinal ligament during the sacrocolpopexy procedure by using an instrument initially designed for the vaginal approach of the sacrospinous ligament. Using this easy technique in case of anatomic variations on the sacral promontory may avoid complications.