[Results of surgical clitoral repair after ritual excision: 453 cases]. / Résultats de la réparation chirurgicale du clitoris après mutilation sexuelle: 453 cas.

OBJECTIVE: Ritual excision is responsible for urologic, gynaecologic and obstetrical complications, whose surgical treatment has been fully described. Sexual sequelae deserve the same attention. We describe and analyze the results of a surgical procedure for clitoral rehabilitation. PATIENTS AND METHODS: Women requesting this surgery between 1992 and 2005 have been prospectively included in this study. The skin covering the stump was resected and the clitoris identified. The suspensor ligament was sectioned in order to mobilize the stump, the sclerous tissues were removed from the extremity and the neo glans brought to a normal situation. Pre operative pain and clitoral impairment were assessed within five categories. The same was done with anatomical and functional postoperative results at six months. RESULTS: Four hundred and fifty-three patients have been completely evaluated. Hospitalisation stay was 24 hours and the procedure never lasted more than 30 minutes. Minor early complications were recorded in 58 patients (hematoma, disrupture of the suture, pain). Four patients reported persisting pain at four months. A visible clitoral massif could be restored in 87% of the cases and a real improvement in clitoral function was obtained in 75% of the patients. DISCUSSION AND CONCLUSION: This surgical procedure is easy and reliable. It provides promising cosmetic and functional results with minor complications.

[Interpretation of sentinel node identification in vulvar cancer]. / Interprétation de l'identification du ganglion sentinelle dans les cancers vulvaires.

OBJECTIVE: Sentinel node (SN) identification in vulvar carcinoma would avoid groin dissection and its complications in early stages, but we first have to validate the method, as an unrecognised node metastasis is detrimental to survival. PATIENTS AND METHODS: Since June 2002, 38 patients with T1 or T2 lesions underwent SN identification by radioactive tracer injection and scintigraphy with, on the following day, per operative use of a handheld probe +/- patent blue dye. In case of a midline lesion, a bilateral inguinal dissection was performed whatever the result of SN identification. SN free from disease were ultrastaged with immunohistochemistry. RESULTS: 1 or more SN were identified in 36 out of 38 patients. 64 groins were analysed, 15 with node metastases. In 9 out of these 15 cases the SN was metastatic, in 5 it had not been identified, and in 1 it was a false negative. In these last 6 cases, there were massively metastatic nodes in the groin. In 19 out of the 26 midline lesions the surgeon identified only unilateral SN. The side without SN contained metastatic nodes in 5 cases. DISCUSSION AND CONCLUSION: Failure in SN identification is sometimes related to a massively invaded node. This should be taken into account especially in the management of midline tumors where a seemingly unilateral drainage at scintigraphy warrants nevertheless a surgical assessment of the mute groin.

[Ectopic pregnancy with etonogestrel contraceptive implant (Implanon): first case]. / Grossesse extra-utérine survenue sous contraception par implant d'étonogestrel (Implanon): premier cas.

We describe the first case of ectopic pregnancy occurring in a patient with an etonogestrel contraceptive implant (Implanon). There was no factor predisposing to a failure of the technique (implant in place for less than 2 years and normal BMI). In addition there was no risk factor for an ectopic location of the pregnancy. We discuss the role of the micro progestative in the location of the pregnancy. This case report emphasizes the fact that ectopic pregnancy should not be ruled out in women taking this contraception, however efficient it is otherwise.

[Verrucous carcinoma of the vulva: a tailored treatment]. / Carcinomes verruqueux vulvaires: un traitement sur mesure.

OBJECTIVE: Verrucous carcinoma is a rare form of vulvar squamous carcinoma, with particular clinical presentation and histological description. We analyze the specificity of the treatment of this form. MATERIALS AND METHODS: We analyzed the records of 8 patients treated in our hospital between 1995 and 2001. In the absence of an associated lesion, the treatment was partial vulvectomy without lymph node dissection. A close follow-up was then organized. RESULTS: Mean age was 76 years (range 54 to 92). In 7 out of the 8 cases we found an associated lesion: invasive squamous carcinoma, VIN III or lichen. Two patients later developed a squamous carcinoma. Two others died because of intercurrent diseases. The last four patients are doing well. CONCLUSION: We confirm the efficacy of the treatment generally proposed: partial vulvectomy, without lymph node dissection and without complementary treatment but with a close follow-up. The coexistence of other vulvar lesions such as lichen is remarkable in our series.

[Criteria of pregnancy termination in women with preeclampsia]. / Critères d'extraction foetale dans la prééclampsie.

Preeclampsia remains an important cause of maternal and neonatal mortality and morbidity. Delivery is always the appropriate therapy for the mother but may be responsible for neonatal adverse outcomes, particularly when it occurs at less than < 34 weeks' gestation. In women with severe preeclampsia at < 34 weeks expectant management to improve neonatal mortality and morbidity may be performed under close monitoring of both the mother and the fetus. Any severe condition of the mother (HELLP syndrome, abruptio placentae, eclampsia) or the fetus (abnormal fetal heart rate) should lead to prompt delivery. In women with mild preeclampsia, expectant management should be performed until 38 weeks gestation.

[Sentinel node biopsy in breast cancer. Improving reliability of results]. / Ganglion sentinelle et cancer du sein. Amélioration de la fiabilité des prélèvements.

OBJECTIVES: Sentinel node (SN) biopsy in breast cancer has a relatively high false negative rate, frequently exceeding 10%, for predicting the axillary nodal status. When the SN is identified using the patent blue dye technique, we advocate subjecting it to a verification of its blue colour by the pathologist as quality control. PATIENTS AND METHODS: One hundred and twenty-two consecutive patients with an operable breast cancer underwent a SN biopsy procedure with patent blue dye injected peritumourally. The SN biopsy was routinely followed by an axillary dissection. Initially each SN was examined histopathologically in a standard fashion. Then the non metastatic SNs were checked to ensure that they were blue by macroscopic examination of the paraffin blocks in which they had been embeded. Finally, a search for micrometastasis using immunohistochemistry was performed on all SNs which were non metastatic and confirmed to be blue. RESULTS: In 107 (88%) of 122 patients a SN was identified by the surgeon. After standard histological examination, 32 of 107 SNs proved to contain metastatic tumour. 75 SNs were not metastatic, of which 3 were false negative which would have given a false negative rate of 8.5%(3/35). After checking the paraffin blocks of the 75 non metastatic SN, 62 of the 75 were confirmed blue from which there were 2 false negatives giving a false negative rate of 5.8% (2/34). The 62 confirmed blue nodes were then assessed for micrometastasis. 20 nodes proved to be micrometastatic and there remained one false negative. This gave a final false negative rate of 1.8% (1/53). The false negative rate was thus reduced from 8.5% to 1.8% after colour quality control and identification of micrometastasi. DISCUSSION: In this series the procedure of histopathological quality control of the SN identified with the patent blue only technique resulted in a valuable reduction in the false negative rate.

Paget's disease of the vulva: results of different conservative treatments.

OBJECTIVE: To evaluate three conservative treatments for vulvar Paget's disease: wide excision, laser alone, or limited surgery associated with laser. STUDY DESIGN: A retrospective analysis of 52 patients treated with wide excision (31 cases), limited surgery, and peripheral laser [Br J Obstet Gynecol 1995;102:359], or laser alone [Gynecol Oncol 1975;3:46]. RESULTS: Mean time to recurrence was 1+/-0.6 years after laser alone, 1.9+/-1.5 years after the association limited excision and peripheral laser, and 2.7+/-1 years after wide excision alone. At 1 year recurrence rates were 67% after laser alone, 33% after the association laser plus surgery, and 23% after wide excision. CONCLUSION: Conservative management preserves vulvar anatomy and function, but recurrence rates are high.

Hypertrophy of labia minora: experience with 163 reductions.

OBJECTIVE: Our purpose was to describe the surgical procedure, its results, and its complications and to determine whether patients are satisfied with surgical reduction of labia minora in cases of hypertrophy. STUDY DESIGN: The records of 163 patients who underwent reduction of the labia minora during a 9-year period were reviewed. The ages of the patients ranged from 12 to 67 years (median, 26). Motives for requesting surgery were aesthetic concerns in 87% of the cases, discomfort in clothing in 64%, discomfort with exercise in 26%, and entry dyspareunia in 43%. Anatomic results were assessed 1 month postoperatively. Patient satisfaction was assessed by means of a mailed questionnaire. RESULTS: No surgery-related significant complications were noticed. Anatomic results were satisfactory for 151 patients (93%). Ninety-eight completed questionnaires were returned. Eighty-one patients (83%) found that the results after surgery were satisfactory. Eighty-seven (89%) were satisfied with the aesthetic result, and 91 (93%) approved the functional outcome. Four patients (4%) would not undergo the same procedure again. CONCLUSION: Labia minora reduction is a simple surgical procedure associated with a high degree of patient satisfaction.

[Autologous breast reconstruction with latissimus dorsi flap]. / Reconstruction mammaire autologue par lambeau de grand dorsal.

The gold standard technique for autologous breast reconstruction is the transverse rectus abdominis flap (TRAM). Recently, techniques of harvesting a latissimus dorsi flap have been modified in such a way as to increase the flap and allow breast reconstruction without an associated implant. The aim of this study was to evaluate aesthetic results obtained with this method and to assess early morbidity related to the changes in the technique. Between January 1994 and August 1998, 43 patients underwent breast reconstruction with an autologous latissimus dorsi flap. Their postoperative outcome was compared to that of 30 patients who underwent reconstruction with a latissimus dorsi flap associated with an implant. These 43 patients were asked to come back for aesthetic evaluation by a physician and to answer a questionnaire about cosmetic results. Mean duration of follow-up was 18.6 months (range 8 to 60). Mean size of the breast reconstructed with this technique was 340 g (up to 835 g). Dorsal seroma was the most frequent complication (72%), followed by delayed dorsal healing (19%). The frequency of seroma was significantly increased when compared to a classic latissimus dorsi flap (P = 0.003), but frequency of skin slough was not. The aesthetic result was considered satisfactory in 93% of the cases by the patient and 77% of the cases by the physician. In conclusion, the extended latissimus dorsi flap allows reconstruction of small and medium size breasts, with a good aesthetic result. This flap appears to be an interesting alternative to the TRAM flap for autologous reconstruction in selected patients.

Predictive value of early human chorionic gonadotrophin serum profiles for fetal growth retardation.

The possibility of using first trimester maternal serum human chorionic gonadotrophin (HCG) profiles to predict fetal growth retardation (FGR) was tested in 236 women with singleton pregnancies obtained after in-vitro fertilization (IVF). Pregnancies were monitored by serial analysis (two or more) of serum HCG at at least 48 h intervals. Serum was obtained between the 13th and the 35th day after conception (i.e. on the day of IVF). Early miscarriage occurred in 23.7% and FGR in 10.9% of pregnancies. Serum HCG profiles were higher than the 90th and lower than the 10th percentile in 12.3% and 19.5% of the cases respectively. FGR was significantly more frequent in women with serum HCG profiles lower than the 10th percentile than in women with normal profiles (45.5% versus 7.2%; P < 0.001), with a relative risk of 6.5 (95% confidence interval 2.7-15.6). FGR rates were similar in women with normal and high profiles of serum HCG. Pre-eclampsia and premature delivery rates were similar in women with normal and abnormal profiles of serum HCG. First trimester serum HCG should be further investigated as a potential marker of FGR.

In vitro studies of the interactions between platelets and amniotic membranes: a potential treatment for preterm premature rupture of the membranes.

OBJECTIVE: Thus far there is no satisfactory treatment for preterm premature rupture of the amniotic membranes. To evaluate the use of platelets to seal the membranes, we investigated in vitro interactions between platelets and the membranes. STUDY DESIGN: Platelet aggregation in the presence of amnion, chorion, and amniotic fluid was quantified. Platelet adhesion to the fetal membranes was investigated by electron microscopy. In addition, a model system was designed to evaluate the capacity of platelets to seal a standardized puncture in the membranes. RESULTS: Platelets aggregated in response to amnion but not to chorion or amniotic fluid. Adhesion and activation occurred on connective tissues underlying amnion and chorion but not on the amniotic epithelium. Platelets sealed a puncture in fetal membranes, and the platelet plug was visualized by electron microscopy. CONCLUSIONS: Exposed connective tissue of amniotic membranes was demonstrated to trigger platelet adhesion, aggregation, and activation, and platelets were shown to seal a standardized puncture in fetal membranes. Our results indicate that platelets might be useful for treatment of ruptured membranes after needle puncture.

Congenital adenomatoid malformation of the lung: when is active fetal therapy indicated?

OBJECTIVE: Although aggressive fetal therapies such as thoracoamniotic shunting can be applied to cystic adenomatoid malformations of the lung diagnosed in utero, there is no clear consensus regarding their indications. Our purpose was to evaluate a management policy in which aggressive fetal therapy was restricted to those cases complicated by major polyhydramnios or hydrops; all other cases were managed conservatively. STUDY DESIGN: A prospective cohort study of 33 cases with a prenatal diagnosis of cystic adenomatoid malformations of the lung was performed. Thoracoamniotic shunting was offered only in nine macrocystic cases with acute polyhydramnios or hydrops. RESULTS: Four cases were diagnosed postnatally as sequestrations. Of 12 cases complicated by acute polyhydramnios or hydrops, 5 survived (1 type III with spontaneous incomplete resolution in utero, 4 type I with substantial volume reduction after shunting). The 17 cases without acute polyhydramnios or hydrops were managed conservatively and survived. CONCLUSION: Conservative management is indicated in cases of cystic adenomatoid malformations of the lung without acute polyhydramnios or hydrops.

Longitudinal vaginal septum: a retrospective study of 202 cases.

OBJECTIVE: To assess issues and management of longitudinal vaginal septum. STUDY DESIGN: The charts of 202 patients referred for a longitudinal vaginal septum over a 24 year period were reviewed. RESULTS: The most common septa were complete and high partial. Associated uterine malformations were frequent (87.8% of the cases), especially in complete or partial high septum (99.4%). The septum was asymptomatic in 56.4% of the cases. Obstetrical concerns are mainly related to a uterine malformation, but a thick septum may be responsible for dystocia. CONCLUSION: Less than half of the vaginal septa are symptomatic enough to require surgical treatment. However, for obstetrical issues management should include a thorough evaluation of uterine anatomy and preventive section of the septum even when asymptomatic.

Laparoscopy for adnexal torsion in pregnant women.

OBJECTIVE: To report on six cases of adnexal torsion in pregnant women treated by operative laparoscopy. STUDY DESIGN: A retrospective study. Between January 1989 and March 1996, 26 patients with adnexal torsion were treated by operative laparoscopy. Of these patients, six were pregnant (23%). The types of operative procedure and outcome were studied. RESULTS: Adnexal torsion occurred between 6 and 13 weeks of amenorrhea. Two cases involved hyperstimulation, 3 cases a functional cyst and 1 case a dermoid cyst. In 4 cases laparoscopic treatment consisted of untwisting followed by puncture of the ovarian cyst; in 1 case it involved intraperitoneal cystectomy and in another simple untwisting of the adnexa. The immediate postoperative history was uncomplicated. In one patient with ovarian hyperstimulation, torsion recurred three weeks after the initial operation. No miscarriages occurred. CONCLUSION: In the hands of skilled surgeons, laparoscopy is well suited to the diagnosis and treatment of adnexal torsion occurring during the first trimester of pregnancy. Beyond 16 weeks or when there is any suspicion of torsion on a suspected tumor, it is preferable to use laparotomy.

The role of laparoscopy in the diagnosis and management of heterotopic pregnancies.

The object of this report is to discuss diagnosis and treatment of heterotopic pregnancies. Thirteen consecutive cases referred to our institution are reviewed. In 54% of cases the heterotopic pregnancy was asymptomatic. The ectopic pregnancy was visualized prior to surgery in 69% of the cases. The treatment was surgical in every case and performed laparoscopically in 77% of cases. Ten patients underwent salpingectomy and three salpingostomy. In all, 60% of intrauterine pregnancies that were viable at the time of diagnosis of the heterotopic pregnancy had a favourable outcome. Diagnosis of heterotopic pregnancy is difficult. Laparoscopy allows both diagnosis and treatment, and the outcome of the intrauterine pregnancy is comparable to that obtained with laparotomy.

[Laparoscopic surgery of ovarian tumors during pregnancy]. / Coeliochirurgie des tumeurs ovariennes pendant la grossesse.

During the first trimester of the pregnancy, the management of benign ovarian cyst can be performed by laparoscopy. When ovarian tumor is bulky, suspicious and after 16 to 20 weeks this treatment must be realised by laparotomy.

Creation of a sigmoid neovagina: technique and results in 16 cases.

OBJECTIVE: For correction of the absence of vagina, sigmoidal colpoplasty is believed to provide a neovagina immediately adequate and with permanent patency. We present one of the largest series and discuss advantages and drawbacks of this procedure. STUDY DESIGN: Our personal technique is described and 16 consecutive cases are reviewed. Anatomical (depth and width of the neovagina) and functional (existence of discharge and coital function) aspects are addressed. RESULTS: An adequate neovagina was obtained in every case, however, in nine cases iterative dilatations were previously required. Two prolapses of the nevagina were noticed and required surgical treatment. The follow up ranges from 6 to 36 months. At this point, only nine patients report intercourse. In five cases a psychological brake is strongly suspected to interfere. Four patients experience significant discharge. CONCLUSION: Despite satisfactory anatomical results, the sigmoid neovagina is not always immediately suitable. Complete adequacy for coital function often requires prolonged care and support.

Congenital diaphragmatic hernia: can prenatal ultrasonography predict outcome?

OBJECTIVE: We wanted to establish whether prenatal ultrasonography predicts postnatal outcome in congenital diaphragmatic hernia. STUDY DESIGN: We designed a retrospective multicenter cohort study of 135 patients with congenital diaphragmatic hernia (122 left, 10 right, 2 bilateral, 1 anterior). In isolated left congenital diaphragmatic hernia five potential prenatal prognostic factors were studied: diagnosis at < or = 25 weeks' gestation, polyhydramnios, intrathoracic stomach, small abdomen, and major mediastinal shift. RESULTS: None of the 44 fetuses or infants who had multiple malformations survived. Of the 91 cases of isolated congenital diaphragmatic hernia, there were 82 live births; 76 of these infants had a left congenital diaphragmatic hernia. Of these, 51 (67%) died postnatally. A statistically significant relation was found between mortality and polyhydramnios, intrathoracic stomach, and major mediastinal shift. Mortality increased as a function of the number of these prognostic factors from 20% when none was present to 94% when all three were present. CONCLUSION: In the majority of cases of isolated left congenital diaphragmatic hernia the prognostic value of fetal ultrasonography is too low to alter perinatal management.