Endometriotic lesions of the lower troncular nerves.

Although exceptional, endometriotic lesions of the troncular nerves of the lower limb may occur and are often diagnosed with delay. We report, hereby, the first case of femoral nerve endometriosis the treatment of which consisted of radical resection with femoral nerve transplant. We completed a review of the literature on sciatic nerve endometriotic lesions and discussed the physiopathology and surgical treatment.

[Contraception's choice: women's opinion, satisfaction and profile. Results of a French national survey of a representative sample of 5963 women]. / Contraception des femmes françaises de 15 à 45ans: enquête nationale sur un échantillon représentatif de 5963 femmes.

OBJECTIVES: To describe French women's use of contraceptive methods and study their satisfaction and expectations about contraception. PATIENTS AND METHODS: A survey carried out by mail questionnaire filled in by a representative sample group of French women aged 15 to 45 years (Panel Postal Metascope TNS Sofres) in June 2007. RESULTS: Of 10,000 questionnaires sent out, 6044 questionnaires were returned, of which 5963 were usable. Seventy-three percent of women surveyed used some method of contraception, of which 46% was an oral contraceptive, 15% an IUD and 7% used condoms. A minority used new contraceptive methods (implant, patch, vaginal ring). The average age at first sexual relationship was 17.8 years. It was 18.5 among 40-45-year-olds and gradually reduced to 16.7 in the under 25-year-olds. Twenty-three percent of pregnancies remain unwanted and unplanned. For 96% of patients, the choice of contraception was considered to be important. Thirty-six percent thought that contraception could be harmful to health. Only 63% of women believed themselves to be well informed the first time they used contraception. Satisfaction for contraception method was evaluated from 7.3/10 (condom) to 9.7/10 (sterilization). DISCUSSION AND CONCLUSION: Twenty-seven percent of women do not use any contraception and 23% of pregnancies are unwanted despite a large offering of contraceptives. Our study enables the drawing of 'patient-profiles' for the main methods of contraception in order to better determine women's expectations and to pass the findings on to health professionals.

[Uterine ishtmique transmural hernia: results of its repair on symptoms and fertility]. / Hernie transmurale isthmique de l'utérus : résultats de l'isthmorraphie sur la symptomatologie et la fertilité

OBJECTIVE: To study the effect of the surgical repair (isthmorraphy) of the large scar dehiscence after cesarean on symptoms and fertility for women who desire pregnancy. PATIENTS AND METHODS: In this retrospective study, 14 symptomatic patients, who desire a new pregnancy underwent a surgical repair by laparotomy, laparoscopic or vaginal technique. Five women experienced failure of Assistance Reproductive Technique (IVF or ICSI) for idiopathic secondary infertility. The dehiscent scars were evaluated by ultrasound, hysterography, hysteroscopy and magnetic resonance imaging. OUTCOME: Symptoms improvement was found in 92% of case. Ten pregnancy (71%) was obtained after surgical repair, 6 spontaneous and 4 after Assistance Reproductive Technique. Among the 5 women initially followed in the reproductive unit, 4 became pregnant, 3 after IVF or ICSI and 1 spontaneous. No operative complication occurred. The subsequent pregnancy was unremarkable with no uterine rupture. DISCUSSION: Large scar defect after cesarean can take shape of a complete absent of the anterior wall of the uterus. No incident has been proved in this condition. There is a lack of data concerning these isthmocele. The experience of hysteroscopic repair cannot be applied to these real large diverticule of the scar cesarean. The results of this study suggest a link between the isthmocele and reversible symptoms after surgery. The first results concerning the subsequent fertility after surgical repair seem interesting CONCLUSION: When a large scare defect (isthmocele) is found in symptomatic woman (pelvic pain, bleeding uterine, infertility), a surgical repair can be proposed, especially for woman who desire a new pregnancy.

[Permanent tubal hysteroscopic sterilization]. / Contraception permanente par pose hystéroscopique d'implants tubaires.

Tubal sterilization, of common practice all over the world, has had a quick spread in France since its legalization in 2001 and the income of a new hysteroscopic method. As a matter of fact, France is the second greater country for women having Essure® and the first country where Essure® method forestall surgical tubal ligation. Thus we focus on good practice and update knowledge about Essure® method.

Haemophilus parainfluenzae infective endocarditis associated with pelvic abscess: an uncommon complication of endometriosis.

The case of a woman with native mitral valve endocarditis due to Haemophilus parainfluenzae (HPI) associated with a pelvic abscess and endometriosis is reported. Although HPI is an infrequent pathogen involved in endocarditis, association to a gynaecological infection has never been reported. Endometriosis could increase this risk.

[State of the art about teaching hysteroscopy to gynaecologist surgeons in France and in Europe. CONFORM investigation into the training of the hysteroscopic placement of microinserts]. / Etat des lieux de la formation des chirurgiens gynécologues à l'hystéroscopie en France et en Europe. Enquête CONFORM sur la formation à la mise en place des implants de stérilisation tubaire par voie transcervicale.

OBJECTIVE: Since 2002, Conceptus company markets in France and Europe the Essure microinsert as permanent hysteroscopic intratubal sterilization, and organizes a meeting, a training and an assistance on a few cases. The data from this interview and the results of the first cases done with assistance of Conceptus instructors were collected prospectively between January 2004 to December 2006. The purpose is to make a state of the art about teaching hysteroscopy to gynaecologist surgeons in France and in Europe. PATIENTS AND METHODS: According to their statements about their knowledge of hysteroscopy practice, surgeons were classified in four groups. Group 1 included those who had a bad knowledge and a sporadic practice, group 2 those who had no formation and an empirical practice, group 3 those who had a regular practice and an incomplete formation or whose formation was in progress and group 4 those with fully-formed surgeons with a regular practice. RESULTS: One thousand one hundred and fourty-four women underwent hysteroscopic sterilisation with a global success rate of 92.13%. Were included 536 surgeons and 498 were evaluated. There were 80 (16.06%) surgeons in group 1, 149 (29.92%) in group 2, 121 (24.30%) in group 3 and 148 (29.72%) in group 4. Failure rates for each group were respectively 16.25%, 10.07%, 9.10% and 4.73% (p < or = 0.01). The presence of an instructor was associated with a fast improvement judging from the classification in a higher level group in 47.83%, 28.21% and 25% respectively for the groups 1 to 3 after the second visit and in 75%, 58.33% and 20% after the third visit. DISCUSSION AND CONCLUSION: It seems important to establish a modern and low-cost teaching program to improve surgeon's theoretical and practical formation in hysteroscopy in order to increase success rates and reduce possible complications. Theoretical formation has to include a good knowledge of the material and its use: diameter and form of the operative channel, obliquity of the scope, liquid of distension and kind of current used. Practical formation could be done at once with virtual models to get used with the manipulation of the scope and thanks to the use of different currents with the assistance of a trained surgeon.

[Bladder endometriosis: diagnosis and treatment. A series of 24 patients]. / Endométriose vésicale : diagnostic et traitement. A propos d'une série de 24 patientes.

OBJECTIVE: This study aims to show the treatment outcome in women affected by bladder endometriosis. PATIENTS AND METHODS: Retrospective review of records of 24 women with deep vesical endometriosis treated between 1998 and 2007. RESULTS: All cases had cyclic symptoms even though they were not specific. A percentage of 66% of women had concomitantly deep nodules of the rectovaginal septum and/or uterosacral ligaments. Five patients (20.8%) had previously undergone a transurethral resection (TUR) of the bladder lesion, but this therapy has failed in all cases. Partial cystectomy was carried out in 14 patients (60.8%) and an extramucosal dissection of the endometriotic lesion in nine patients (39.2%). Laparoscopy was used in 19 cases (82.6%). Recurrence of bladder endometriotic lesions was documented in two patients. This was mainly due to an incomplete initial treatment. Success rate, defined by total improvement of symptoms after the initial treatment, was estimated at 86.7% in this series. The only complication encountered was a pelvic hematoma with bladder compression that required a ureteral cannulation (JJ). Seven patients out of 11 became pregnant; four of them were infertile before the surgical treatment. DISCUSSION AND CONCLUSION: Diagnosis of bladder endometriosis is often difficult to make because of its non-specific symptoms. The management is mainly surgical and resection should be complete. TUR is not an optimal treatment for bladder endometriosis.

[Effects of electrostimulation (Veinoplus) on lower limbs venous insufficiency-related symptoms during pregnancy. Preliminary study]. / Effets de l'électrostimulation par Veinoplus sur les troubles circulatoires des membres inférieurs chez la femme enceinte. Etude préliminaire.

OBJECTIVE: To assess if electrostimulation of lower limbs relieves lower limbs venous insufficiency-related symptoms during pregnancy. PATIENTS AND METHODS: A two-step study was conducted. First, a monocentric prospective preliminary study including 30 pregnant women was conducted to assess the effects of electrostimulation on fetal monitoring and uterine contractions. Then, a multicentric prospective non-randomised study including 58 pregnant women with a gestational age between 23 and 33 weeks of amenorrhoea was conducted to evaluate the electrostimulation treatment. This evaluation was based on a clinical examination performed pre- and post-treatment, a CIVIQ questionnaire filled out pre- and post-treatment and a daily diary filled out by the patient during treatment duration. Treatment duration was 21 days including two daily treatment sequences of 20 min. Three groups of patients were identified based on initial intensity of venous insufficiency-related symptoms (group 1 minor symptoms, group 2 moderate symptoms, group 3 severe symptoms). RESULTS: Preliminary study showed no interferences between electrostimulation and fetal cardiac rhythm, uterine contractions and maternal uterine and fetal umbilical arteries Doppler. Concerning the evaluation of the electrostimulation: in group 1, electrostimulation significantly reduced heavy legs sensation (p<0,001) and calves pain (p=0,02) between the beginning and the end of the treatment. The four scores calculated with the CIVIQ questionnaire decreased after treatment and a significant reduction was noted for generalised pain feeling (p=0,04) and psychological impact (p=0,03). In group 2, a significant decrease was noted for tiredness (p<0,001), heavy legs sensation (p<0,001), calves pain (p<0,001) and edema (p=0,02) between the beginning and the end of the treatment. The four scores calculated with the CIVIQ questionnaire significantly decrease after 21 days of treatment. In group 3, a significant decrease of heavy legs sensation (p=0,03) and calves and malleoli perimeters (p<0,05) was noted. After 21 days of treatment, the four scores calculated with the CIVIQ questionnaire significantly decrease (p<0,05). When comparing the three groups, beneficial effects of the treatment are most marked in group 2 regarding subjective symptoms, CIVIQ questionnaire scores and leg pain. According to the patients, effectiveness and tolerance of the treatment ranged from good to excellent in the three groups. DISCUSSION AND CONCLUSION: Electrostimulation is an effective and well-tolerated treatment of lower limbs venous insufficiency-related symptoms in pregnant women. Its use during pregnancy did not show any effects on fetus and pregnancy.

[Surgical and functional results of rectosigmoidal resection for severe endometriosis]. / Résection rectosigmoïdienne pour endométriose profonde : résultats chirurgicaux et fonctionnels.

OBJECTIVES: Indications of colorectal resection for endometriosis are controversial because of the risk of major complications. This study aims to evaluate the value of different diagnostic tests in decision-making, and to evaluate the surgical results and complications, as well as long-term functional results after surgery. PATIENTS AND METHODS: In the set of a retrospective case series, 50 patients who have been admitted for a colorectal resection because of deep endometriosis were included. Most of them have had an MRI and an endorectal ultrasonography. Specific questionnaires have been proposed in order to evaluate symptoms, sexuality (BISF-W) and quality of life (EHP-30). RESULTS: For the diagnosis of rectal involvement, the sensitivity of MRI and endorectal ultrasonography were 55 and 100%, respectively. Forty-one colorectal amputations and nine partial colorectal resections have been done by 24 laparotomies, two laparoscopies and 24 laparoconversions. Major complications included six (12.5%) digestive fistulas, three (6%) anastomotic strictures, one ureterovaginal fistula and one ureteral stricture. Risk factors associated with digestive fistulas were the association of a vaginal opening (p=0.002) and an additional ileocaecal resection (p=0.007). The mean follow-up period was of 42 months. A significant improvement of dysmenorrhea (p<10(-4)), dyschesia (p<10(-4)), chronic pelvic pain (p<10(-4)), and of some digestive symptoms such as catamenial epreintes (p=0.002) and catamenial diarrheas (p=0.006), was noted. We noted postoperative 14 dysurias, six constipations and 12 rectal polykynesias. Four patients have had deep recurrent lesions. Twenty patients had a desire of pregnancy after the operation, 17 pregnancies were obtained (eight spontaneous and nine by ART) giving birth to 14 living children. Sexuality evaluation was below normal range. The quality of life was improved for most of the items. The global satisfaction was good (91%). DISCUSSION AND CONCLUSION: Colorectal resection for deep endometriosis improve significantly most of the pain symptoms, but the women should have detailed counselling about the risks of major complications and recurrence.

[Vaginal or laparoscopic assisted vaginal myomectomy: interest in the double way]. / Myomectomie par voie vaginale ou coeliovaginale : intérêt de la double voie d'abord.

OBJECTIVES: To evaluate vaginal and laparoscopic-assisted vaginal myomectomy in order to find interest and indications of this two-way approach of myomectomy. PATIENTS AND METHODS: Retrospective study of 60 patients operated of a myomectomy by vaginal or laparoscopic-assisted vaginal way between December 1999 and January 2007. RESULTS: Thirty-three patients (55%) profited from an exclusive vaginal myomectomy (group 1) and 27 (45%) from a laparoscopic-assisted vaginal myomectomy (group 2). The vaginal gesture in group 2 was carried out mainly because of difficult dissections of deep interstitial myomes (60%) or for the closing of hysterotomies not accessible by coelioscopic way (40%). Mean operating time, blood loss and length of hospital stay were 120 minutes, 431 ml, 3.2 days in group 1 and 180 minutes, 437 ml, 5.1 days in group 2, respectively. Laparoconversions and notable complications rates were 9% in group 1 and 15% in group 2. DISCUSSION AND CONCLUSION: Laparoscopic-assisted vaginal myomectomy is interesting to widen indications of laparoscopic way for myomectomy. However, considering complications and rate of laparoconversion, it is necessary to define situations against indicating this gesture. The methods of prevention of the infection also remain to be found.

[Reproductive outcome after laparoscopic treatment of endometriosis in an infertile population]. / Fertilité après chirurgie coelioscopique de l'endométriose pelvienne chez des patientes en échec de grossesse.

OBJECTIVES: To evaluate fertility outcome after laparoscopic management of endometriosis in an infertile population. MATERIALS AND METHODS: A retrospective analysis of 64 patients presenting more than one year infertility and a pregnancy-wish associated with minimal to severe endometriotic lesions (stage I to IV according to the revised American Fertility Society (rAFS) classification), treated using laparoscopic surgery in order to remove the entire lesions. We excluded women under 20 years and over 40, as well as those with other infertility factors (tubal non endometriosis-related, hormonal or sperm). Fertility of the remaining 34 patients was studied in relation to endometriosis stage and to pregnancy's mode (spontaneous or induced). RESULTS: Pregnant women percentage was 65% (22 patients) within a 8.5 months (quartiles: 3; 15.5) [range: 1; 52] post-surgical time, and 86.5% pregnancies issued with a delivery. The rate of pregnant women depended on stage of endometriosis (89% for stages I-II, and 56% for stages III-IV). Sixty percent pregnancies were spontaneous within a 5 months (3; 9) [1; 52] post-surgical time to pregnancy average. When pregnancies were obtained with assisted reproductive techniques, the median post-surgical time to pregnancy was 12 months (9; 22) [2; 31]. Among women with stages I-II endometriosis, the median post-surgical time to pregnancy was 2 months when spontaneous and 20.5 months when induced (P=0.007). In case of stages III-IV endometriosis, pregnancy's delay was 8 and 12 months respectively (P=0.79). Among the 21% women who had had an induced pregnancy failure before surgery, 71% became pregnant and 80% spontaneously. Eighteen patients (53%) had an ovarian endometrioma and 50% of them became pregnant. Among the 4 patients who had colorectal endometriosis requiring colorectal resection, 1 pregnancy was obtained. CONCLUSIONS: These findings suggest that in a context of more than one year infertility only related to endometriosis, it is reasonable to offer these patients a complete operative laparoscopic treatment of their lesions, which enables 65% of them to be pregnant within a 8.5 months post-surgical median time to pregnancy and spontaneously in 60%. In case of stages I-II endometriosis we suggest a spontaneous pregnancy try during 8 to 12 months before starting induced pregnancy therapeutics instead of stages III-IV endometriosis where induced methods should be used after only 6 or 8 months.

[Ovarian and peritoneal sarcoidosis mimicking an ovarian cancer]. / Sarcoïdose péritonéale et ovarienne simulant un cancer de l'ovaire.

Ovarian and peritoneal sarcoidosis is a very rare condition, with an atypical clinical presentation close to that of ovarian cancer. An erroneous diagnosis could induce a definitive castration. A 38-year-old woman was admitted because of ascites and weight loss. A computerized tomography scan revealed multiple soft tissue nodules in the pelvis, on the ovaries as well as peritoneal deposits. Histological examination after laparoscopic biopsy was indicative of sarcoidosis. Corticosteroids were given to the patient and the symptoms quickly subsided. This case with its clinical presentation is discussed in comparison with previously reported cases.