Involving Animal Models in Uterine Transplantation.

Background: Absolute uterine factor infertility affects 0. 2% women of childbearing age around the world. Uterine transplantation (UTx) is a promising solution for many of them since the first birth from UTx was described by the Swedish team in 2014. The success of Utx in humans has become possible after a systematic and meticulous approach involving years of research on animal models. To date, more than 80 UTx procedures have been performed worldwide and 30 children were born. Material and Method: This review summarizes the research preparation conducted in animals before beginning UTx in humans. It focuses on the advantages and limits of each animal model, their place in surgical training, and current contribution in research to improve UTx successes in humans. The different steps in the process of UTx have been analyzed, such as imaging, surgery, ischemia-reperfusion effects, rejection markers, immunosuppressive treatment, and pregnancy. Conclusion: Animal models have played an essential role in the implementation of UTx, which is a highly complex procedure. While respecting the 3R requirements (replacement, refinement, and reduction), the surgical training using large animal models, such as notably ewes remain irreplaceable for teams wishing to initiate a UTx program. Furthermore, animal models are still mandatory in current research to improve the success rates of UTx in humans as well as to reduce the morbidity associated with this experimental infertility treatment.

Collateral damage of COVID-19 pandemic: The impact on a gynecologic surgery department.

OBJECTIVE: This study focuses on changes in gynecologic surgical activity at Hospital Foch, Paris, France during the first French COVID lockdown in 2020. Additional goals include the evaluation the extent of the postponement suffered for each type of surgery and estimate the possible negative impact for patients. STUDY DESIGN: Single-center, retrospective, chart-review cohort study in the gynecology department of Hospital Foch. Comparison of all patients scheduled, postponed and operated during the first COVID lockdown (March 14, to May 11, 2020) versus the same period in 2019. Postponed surgeries were classified into 4 scheduling interval categories according to the Society of Gynecology Oncology (SGO) recommendations: urgent (without delay), semi-urgent (1-4 weeks), non-urgent (>4-12 weeks) and elective (>3 months) and evaluated to determine whether COVID-19-related delays of surgeries fell within guidelines. The potential "loss of chance" or medical risk associated with postponed surgeries was estimated according to a composite criterion including death, aggravation of expected tumor stages/grades in cancers, increase in surgical complexity compared to that initially planned, need for preoperative transfusions, start of morphine consumption during preoperative treatment for opiate-naive patients, additional hospitalization or consultations in emergency room and delay in treatment when surgery was urgent. RESULTS: During the 2020 French COVID lockdown, 61 patients had a surgical procedure and 114 were postponed; in the comparator 2019 group, 232 patients underwent surgical procedures, indicating an overall decrease of 65% of activity. Analysis of differences between the two years revealed a reduction of 64% in emergency procedures, 90% of functional pathologies, and 13% of cancers. According to SGO guidelines, the only type of surgical procedures that had excessive delay was the semi-urgent group, where time to surgery was 6.7 weeks [range 5.4-10 weeks] instead of the recommended interval of 1-4 weeks. Among postponed surgeries there were 10 patients (8.7%) with a potential "loss of chance" according to the composite criteria, all included in the semi-urgent group. CONCLUSION: The COVID 19 pandemic was responsible for a significant decrease of activity in the surgical department of Hospital Foch. Difficulty of rescheduling surgeries was responsible for an increased delay in semi-urgent operations. In almost 9% of postponed surgeries, there was a potential "loss of chance", which likely represents only the tip of iceberg of collateral damages due to COVID 19 pandemic in this surgical unit. These data show the importance of continuing to treat pathologies requiring urgent or semi-urgent surgery during pandemics.

Analysis of blood parameters and molecular endometrial markers during early reperfusion in two ovine models of uterus transplantation.

The dissection of the veins is the trickiest step of Uterine transplantation (UTx). Performing the anastomosis of a single uterine vein could bring a therapeutic benefit and simplification of surgery and serve for managing unilateral venous thromboses. The objectives of this project were to evaluate the expression of early markers of ischemia-reperfusion and to compare findings following one or two vein anastomoses. Orthotopic uterine auto-transplantations were performed on an ovine model with anastomosis of either two (group 1) or one utero-ovarian veins (group 2). Blood gases, histology and ischemia- reperfusion markers transcripts (PTGS2, IL6, IL8, SOD2, C3, BAX/BCL2 and TLR4) were analyzed as well as PTGS2 protein expression using Western Blot and fluorescence immunolocalization on endometrial biopsies after 3h of reperfusion. Ten ewes were included in the experimentation, 4 were in group1, 3 in group 2, the others being sham operated controls. No significant differences were observed between the two phenotypes. Based on these results, the anastomosis of one single uterine vein appears to be an approach consistent with short-term graft survival. Further experiments will be needed to confirm the reliability of this approach, especially the long-term follow-up of the uterine graft including its ability to support gestation to term.

Managing a Department of Obstetrics and Gynecology in Times of COVID-19 Outbreak: The Foch Hospital Experience.

Departments of Gynecology and Obstetrics, as other departments, were faced with a major challenge at the outbreak of the COVID-19 pandemic. Fast restructuring was necessary in order to provide the means for COVID-related care. In this article we share our 1-year experience in reshaping our activities, managing healthcare workers and securing a pathway for pregnant patients, including potential, and confirmed COVID-19 cases. Priorities were set on ensuring patients' and healthcare workers' safety. Key containment measures included facemasks, systematic screening, dedicated spaces for COVID-19 cases with reinforced measures and vaccination campaign.

Robotic Hysterectomy for Benign Indications: What Have We Learned from a Decade?

BACKGROUND AND OBJECTIVES: Robotic surgery data need a setback on many years of practice with high-volume surgeons to evaluate its real value. Our main objective was to study the impact of a decade of robotic surgery on minimally-invasive hysterectomies for benign indications. Our secondary objectives were to evaluate our results for high-volume surgeons and complex cases. METHODS: In this retrospective cohort study, we reviewed medical records at Foch Hospital, from 2010 to 2019, to evaluate the outcomes of robotic hysterectomies for benign disease. We compared the trends of benign hysterectomies done by laparoscopy and laparotomy during this period. We analyzed the proficiency group (≥ 75 cases per surgeon) and complex cases including obese patients and large uteri (>250 g). RESULTS: 495 hysterectomies were performed by robotic, 275 by laparotomy, and 130 by laparoscopy. The laparotomy approach decreased from 62% to 29%, whereas the robotic approach increased from 26% to 61%. The operating room (OR) time decreased in the proficiency group (157.3 ± 43.32 versus 178.6 ± 48.05, P = 0.005); whereas the uterine weight was higher (194.6 ± 158.6 versus 161.3 ± 139.4, P = 0.04). Lower EBL and shorter OR time were seen with uteri ≤ 250 g subgroup (64.24 ± 110.2 ml versus 116.63 ± 146.98 ml, P = 0.0004) (169.62 ± 47.50 min versus 192.44 ± 45.82 min, P = 0.0001). The estimated blood loss (EBL) was less in the BMI ≤ 30 subgroup (68.83 ± 119.24 ml versus 124.53 ± 186.14 ml, P = 0.0005). CONCLUSION: A shift was observed between the laparotomy and robotic approaches. High-volume surgeons were more efficient and showed a decrease in OR time after 75 cases despite an increase in uterine weight.

Sacrospinous ligament fixation: medium and long-term anatomical results, functional and quality of life results.

BACKGROUND: To evaluate the medium and long-term anatomical results of sacrospinous ligament fixation (SLF) and its impact on quality of life (QoL). METHODS: We conducted a retrospective and observational single centre study. Fifty-nine patients were interviewed using the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire and underwent physical examination using POP-Q several years after SLF. Primary outcome was the comparison of anatomic results of SLF at medium-term (group 1: 1-5 years after surgery) and long-term (group 2: more than 5 years after surgery). The secondary outcome was QoL evaluation. RESULTS: The overall recurrence and complication rates were respectively 22% and 10%, with no significant differences between groups 1 and 2. The recurrence rate was similar in both groups [twelve (35%) in group 1 and nine (20%) in group 2, p = 0.09]. Two patients (12%) in the recurrence and none in the no recurrence group had clinical symptoms (p = 0.08). Two patients (12%) in the recurrence and one patient (2%) in the no-recurrence group had a significant impact on their quality of life (p = 0.12). CONCLUSION: This study showed sustainable anatomic and functional results of SLF in medium and long-term analysis with overall low morbidity.

Critical steps for initiating an animal uterine transplantation model in sheep: Experience from a case series.

BACKGROUND: Recent reports have demonstrated uterus transplantation as a relevant solution to treat absolute uterine infertility. Training on animal models is a prerequisite to set up a uterine transplantation program in humans. Sheep have been used as an optimal model for training and research as they display similar vessels size to human. While the ovine model might seem easy there are many difficulties in performing this complex surgery. In this study we describe through our experience the critical initial steps toward building a learning curve toward an optimal ovine uterine transplantation model. MATERIALS: We performed nine orthotopic uterine autotransplantations using end-to-side anastomoses to the external iliac vessels in sheep. We recorded the duration of all surgical steps and pointed out specific difficulties and solution found. RESULTS: We were able to perform optimal uterine dissection after the first 5 cases and optimal bilateral arterial and venous anastomoses, after 7 and 9 cases respectively. The main factors associated to success rate were optimal exposure, appropriate equipment, careful vessel preparation and modification of the anastomosis technique. CONCLUSION: As uterine transplantation research programs are expanding, setting up an ovine model to train and perform research is critical. Such model is complex and requires optimized multidisciplinary approach to build an efficient learning curve.

[Uterus transplantation: state of knowledge and ethical reflection]. / Greffe utérine : état des lieux et réflexion éthique.

Uterus transplantation: state of knowledge and ethical reflection. Nowadays is uterine transplantation the only treatment for absolute uterine infertility. This experimental surgery is spreading worldwide since the past two years. The first livebirths from uterus transplantations from living donors in Sweden gave the impetus for more research. Since several team works on the uterine transplantation from living or deceased donors. Uterus transplantation and the choice between live and deceased donor raises up technical and ethical questions.

Greffe utérine : état des lieux et réflexion éthique. La greffe utérine est à ce jour le seul traitement de la stérilité d'origine utérine. Cette chirurgie expérimentale est en expansion à travers le monde, en particulier depuis ces deux dernières années. L'élan a été donné par les premières naissances obtenues en Suède en 2014 à l'issue de greffes à partir de donneuses vivantes. Depuis, plusieurs équipes travaillent sur la greffe à partir de donneuses vivantes mais également en état de mort encéphalique. La greffe utérine en tant que telle ainsi que le choix entre les donneuses vivantes et décédées soulèvent de nombreuses questions techniques et éthiques.