Can the risks associated with uterine sarcoma morcellation really be prevented? Overview of the role of uterine morcellation in 2018.

OBJECTIVES: The objective of this literature review is to reiterate the epidemiology, clinical signs, and radiological signs that should be consistent with a uterine sarcoma as well as the precautionary pre- and postoperative principles that help prevent morcellation of uterine sarcomas when treating patients with uterine fibroids. METHOD: We conducted this literature review by consulting the Pubmed, Medline, and Cochrane Systematic Review databases up to 28/02/2017 using the following keywords: fibroid, myoma, leiomyoma, sarcoma, leiosarcoma, uterine cancer, myomectomy, hysterectomy, morcellation, and uterine morcellation. We also used the reference lists of the selected articles to find more data on the websites of North-American and European learned societies that specialise in obstetrics and gynaecology. RESULTS: In the case of morcellation of uterine fibroids, the risk of an undiagnosed uterine sarcoma is estimated to be between 1 in 278 to 1 in 1960 women. Preoperative examination, free informed consent following discussion about the risks and complications associated with morcellation, as well as research on the contraindications to the use of morcellation are the crucial points addressed by learned societies. The main solution recommended at present is morcellation confined to a laparoscopic bag. CONCLUSION: There is a risk of morcellating an occult sarcoma when performing a myomectomyor hysterectomy for fibroids. Implementing the use of morcellation containment bags should be the norm. The use of minimally invasive surgery (laparoscopic orvaginal) and the associated benefit-risk ratio compared to a laparotomy should also be discussed with the patient before the operation.

[Surgical management of endometrioma: Result of French practice survey]. / Prise en charge de l'endométriome par les chirurgiens gynécologues français : résultats d'une enquête de pratique.

OBJECTIVES: There are many national and international recommendations and guidelines for the management of patients with endometrioma. In this study, we aimed to evaluate the impact of these recommendations on the practice of French surgeons, and to assess their knowledge about the management of endometriomas. MATERIALS AND METHODS: A self-questionnaire has been sent to the French members of the Society of Gynecologic Surgery and Pelvic (SCGP) in May 2015. RESULTS: One hundred and forty-four members of the society (36 %) participated in the survey. Most of the practitioners (71 %) followed recommendations of the Collège National des Gynécologues Obstétriciens (CNGOF), 38 % followed the guidelines of European Society of Human Reproduction and Embryology (ESHRE). One hundred percent of the surgeons declared that they practice laparoscopy when a surgical removal of the endometrioma is indicated. About treatment with GnRH analogue, 38 % of the practitioners declared that they prescribe an add back therapy immediately after the surgery, 43 % at 3 months, and 14 % declared that they never prescribe this treatment. CONCLUSIONS: French surgeons consider the recommendations are useful in their clinical practice; they primarily apply the guidelines of the CNGOF.

Evaluation of sentinel lymph node biopsy after previous breast surgery for breast cancer: GATA study.

AIM: Sentinel lymph node (SLN) biopsy was recently recommended after prior breast tumour surgery and lymphadenectomy is not the gold standard anymore for nodal staging after a lesion's removal. The purpose of our study was to evaluate the good practices of use of SLN biopsy in this context. PATIENTS AND METHODS: From 2006 to 2012, 138 patients having undergone a surgical biopsy without prior diagnosis of an invasive carcinoma with a definitive histological analysis in favour of this diagnosis were included in a prospective observational multicentric study. Each patient had a nodal staging following SLN biopsy with subsequent systematic lymphadenectomy. RESULTS: The detection rate of SLN was 85.5%. The average number of SLNs found was 1.9. The relative detection failure risk rate was multiplied by 4 in the event of an interval of less than 36 days between the SLN biopsy and the previous breast surgery, and by 9 in the event of using a single-tracer detection method. The false negative rate was 6.25%. The prevalence of metastatic axillary node involvement was 11.6%. In 69% of cases only the SLN was metastatic. The post-operative seroma rate was 19.5%. CONCLUSION: Previous conservative breast tumour surgery does not affect the accuracy of the SLN biopsy. A sufficient interval of greater than 36 days between the two operations could allow to improve the SLN detection rate, although further studies are needed to validate this statement. CLINICAL TRIAL REGISTRATION NUMBER: NCT00293865.

[Contribution of a virtual hysteroscopic simulator in the learning of hysteroscopic myoma resection]. / Apport d'un simulateur d'hystéroscopie virtuelle dans l'apprentissage de la résection hystéroscopique de fibrome.

OBJECTIVES: Uterine myomas are a frequent pathology affecting 20% of women of reproductive age. Myomas induce abnormal uterine bleeding, pelvic pain and increase the risk of infertility and obstetrical complications. Symptomatic sub-mucosal myomas are classically treated by hysteroscopic resection. Simulation is a method of education and training. It could improve quality and security of cares. The aim of this study is to assess the interest of a hysteroscopic simulator for the resection of myoma by novice surgeons. METHODS: Twenty medical students were recruited, in a prospective study, in august 2014. The virtual-reality simulator VirtaMed HystSim™ (VirtaMed AG, Zurich, Switzerland) was used to perform the hysteroscopic training. All students received a short demonstration of myoma resection. The practice consists of a submucous myoma type 0 resection. The procedure and the evaluation were performed before and after a specific training in hysteroscopic resection of sixty minutes long. The main outcome criteria were time for the resection before and after training. The second criteria were fluid quantity used, number of contact between optic and uterine cavity and uterine perforation. RESULTS: Twenty students aged from 22 to 24 years were included. The time for the procedure was significantly reduced after training (170s versus 335s, P<0.01). There is the same for fluid quantity used (335 mL versus 717mL, P<0.01) and the number of contact between optic and uterine cavity (0.2 contact versus 3, P=0.012). No perforation occurred in the simulation. CONCLUSION: The results suggest that hysteroscopic simulator enhances and facilitates hysteroscopic resection for novice surgeons.

Angio-oedema induced by oestrogen contraceptives is mediated by bradykinin and is frequently associated with urticaria.

BACKGROUND: Hereditary C1-inhibitor (C1-Inh) deficiency is associated with 'bradykinin-mediated angio-oedema' (BK-AO) and is believed not to be associated with urticaria. Acquired AO has been related to oestrogen contraceptives. OBJECTIVE: To demonstrate that AO precipitated by oestrogens and characterized by nonfunctional C1-Inh is mediated by BK and to evaluate the occurrence of urticaria in these patients. METHODS: A retrospective evaluation of patients referred for AO related to oestrogen was undertaken. Circulating C1-Inh, high molecular weight kininogen (HK) and enzymes involved in the metabolism of bradykinin were investigated. RESULTS: Fifteen patients were included. HK cleavage concurrent to oestrogen intake was demonstrated in 10 patients with available plasma. Eight patients reported recurrent or chronic urticaria. Discontinuation of the contraceptive resulted in a return to native C1-Inh and HK in all cases studied and to normal kininogenase activity in all but one. The clinical manifestations completely disappeared in 6 patients and improved in 7 after the withdrawal of oestrogen. CONCLUSION: Patients display extensive cleavage of HK in the plasma, which supports that AO precipitated by oestrogen contraception is BK-mediated. Recurrent urticaria may have been underestimated in this context. The presence of recurrent urticaria should not systematically rule out the diagnosis of BK-AO when the history is suggestive.

[Laparoscopy for surgical treatment for uterine and ovarian cancer in France: a national practice survey]. / Place de la cœlioscopie dans le traitement chirurgical des cancers du col de l'utérus, de l'endomètre et de l'ovaire en France : résultats d'une enquête de pratique nationale.

AIM: The aim of this study was to describe the use of laparoscopy in gynecologic malignancies (cervical, endometrial and ovarian cancer, borderline included) in France during year 2005. PATIENTS AND METHODS: We have carried out a retrospective national practice survey during 12 months. Each university hospital (45 centers) and each cancer center (20 centers) received a questionnaire to evaluate their practice in laparoscopy. Centers performing less than ten cases per year in this indication were excluded. RESULTS: Among 65 centers, 31 answered and 19 were included. A total of 1397 surgical procedures for gynaecologic cancer was analysed. Laparoscopy was performed in 714 cases. In these cases, 51.1% (675 cases) of patients were treated by laparoscopy in France during year 2005. Seventy-four surgical procedures for cancer were performed each year per center and among them 38 by laparoscopy. The average cases number is 9.4 per surgeon. CONCLUSION: We found that 51.1% of cases of gynaecologic cancer surgery were performed by laparoscopy in France during 2005, representing 38 cases per centers and 9.4 per surgeon per year. This suggests that access to training for surgeons and care for patients is difficult.

[Reconstructive surgery of the clitoris after sexual mutilation]. / Chirurgie plastique reconstructrice du clitoris après mutilations sexuelles.

Ritual sexual mutilations cause gynaecologic, urologic and obstetric complications. Their surgical treatments like clitoris reconstruction or desinfibulation have been well studied. We describe the Dr Pierre Foldes's (2004, 2006a, b) surgical technique of clitoris reconstruction after ritual excision. After scar resection, clitoris knee and corporeal bodies are liberated with meticulous nerve sparing. A new clitoridian glans is created by cuneiform plasty and then reimplanted in an anatomic situation. The aim of the technique is to restore a normal anatomy and to obtain a sensory and functional organ. We also describe the desinfibulation technique in this article.

[Patient follow-up after treatment for breast cancer]. / Surveillance d'une femme traitée pour cancer du sein.

Patient follow-up after treatment for a breast cancer is based on the local recurrence risk. Annual mammography remains the main point of this follow-up and tumor markers detection has still no interest. Absence of benefit of an intensive clinical, biological and radiological surveillance has been proved for a long time but expert recommendations still are a subject of discussion although they knew no evolution for more than 10 years. Evolution of those follow-up modalities will depend on the future indications of MRI and PET. About distant recurrence, a better knowledge of the risk is now possible thanks to the tumor biological profile study. Nevertheless, intensification of follow-up for some kind of high-risk tumors will have interest only if we can propose a therapeutic alternative in metastatic situation.

[Surgery for invasive breast cancer]. / Chirurgie des cancers invasifs du sein (à l'exception de la reconstruction mammaire).

As most solid tumors, surgery is often the first step of the multidisciplinary management for breast cancers. Although mastectomy and axillar lymphadenectomy still have indications, conservative treatment and sentinel node detection are commonly used. Thanks to induction chemotherapy and oncoplastic techniques, surgery is conservative in most cases, even for important tumors without overall survival prejudice. There is no consensus about resection margins status but a limit of 2 to 3 mm seems to be reasonable while oncoplastic surgery allows large resection and good cosmetic outcomes. In this overview, we present the state of the art for breast cancer surgery including conservative and radical treatments, axillar lymphadenectomy and sentinel lymph node detection, margins status, oncoplastic techniques.

[Treatment of endometriosis by aromatase inhibitors: efficacy and side effects]. / Traitement de l'endométriose par les inhibiteurs de l'aromatase : efficacité thérapeutique et conséquences osseuses.

The recent demonstration that aromatase is expressed at higher levels in endometriosis implants than in normal endometrium has led to pilot studies using inhibitor aromatasis in patients with endometriosis. We conducted a systematic review of the literature and studied the efficacy of aromatase inhibitors on endometriosis. There were seventeen studies (case reports/series) evaluating outcomes of aromatase inhibitors. Studies suggest that aromatase inhibitors alone or co-administered with progestins, oral contraceptives or gonadotrophin releasing hormone (GnRH) agonist could reduce pain and endometriosis. There is only one randomized controlled trial comparing aromatase inhibitor+GnRH agonist and GnRH agonist and one study with eighty patients. Side-effects profiles of aromatase inhibitor regimens are favorable; it does not appear a significant bone loss. Aromatase inhibitors seem to have a promising effect on endometriosis but randomized controlled trials are needed to prove their effects and their safety.

[The fundal height measurements in single pregnancies and the detection of fetal growth retardation]. / La mesure de la hauteur utérine dans les grossesses uniques et le dépistage des retards de croissance intra-utérins.

Symphysis fundus measurements are a reliable mean for screening of fetal growth retardation. The techniques of the measurements, the curves of normality, and the efficiency of this method are discussed. A single formula is put forward to identify the patients witch can profit by extra ultrasound examinations and special clinical surveillance. In France, ultrasound examinations are scheduled at 22 and 32 weeks. Between 22 and 32 weeks, and after 32 weeks, symphysis fundus measurements are needed to suspect intra uterine fetal retardation, and, following suspicion, a new ultrasound examination is helpful.