Delayed hysteroscopic resection of retained tissues and uterine conservation after conservative treatment for placenta accreta.

BACKGROUND: Conservative management of both the uterus and the abnormal placenta, which is left inside the uterus at the time of delivery, is one option of placenta accreta management. Complete elimination of the residual placenta is the main challenge of this procedure. AIM: To report the role, efficacy and safety of hysteroscopic resection in women presenting with severe pelvic pain and chronic intra-uterine retention after conservative treatment of placenta accreta. MATERIAL AND METHODS: Four consecutive women who were treated with hysteroscopic resection of retained tissues after conservative treatment of placenta accreta or percreta at the time of delivery. Clinical files and surgical procedures were reviewed. All procedures were performed because of chronic pelvic pain and the absence of a complete spontaneous placental elimination. RESULTS: All procedures were successful and uneventful. The uterus was conserved with a complete disappearance of the symptoms in the four women, and two of them became pregnant. CONCLUSION: Hysteroscopic resection seems effective and safe for shortening the duration of placental elimination after conservative treatment in women with severe pelvic pain due to uterine retention. This approach allows conserving the uterus and future fertility.

Evaluation of symptomatic uterine fibroids in candidates for uterine artery embolization: comparison between ultrasonographic and MR imaging findings in 68 consecutive patients.

Ultrasonographic and magnetic resonance (MR) imaging examinations of 68 women with uterine fibroids were reviewed to determine whether MR imaging may alter the therapeutic approach based on ultrasonography alone before uterine embolization. Therapeutic decisions based on ultrasonography alone were compared to those obtained after MR imaging. Discordant findings between both examinations involved 51 women (75%), and 19 (28%) had their therapeutic approaches based on ultrasonography alone altered by MR imaging. Ultrasonography and MR imaging showed concordant findings in 17 women (25%) for whom no changes in therapeutic option were made. MR imaging alters the therapeutic approach based on ultrasonography alone in 28% of candidates for uterine artery embolization.

Conservative two-step procedure including uterine artery embolization with embosphere and surgical myomectomy for the treatment of multiple fibroids: preliminary experience.

OBJECTIVE: To evaluate the feasibility and safety of combined uterine artery embolization (UAE) using embosphere and surgical myomectomy as an alternative to radical hysterectomy in premenopausal women with multiple fibroids. MATERIALS AND METHODS: Mid-term clinical outcome (mean, 25 months) of 12 premenopausal women (mean age, 38 years) with multiple and large symptomatic fibroids who desired to retain their uterus and who were treated using combined UAE and surgical myomectomy were retrospectively analyzed. In all women, UAE alone was contraindicated because of large (>10 cm) or subserosal or submucosal fibroids and myomectomy alone was contraindicated because of too many (>10) fibroids. RESULTS: UAE and surgical myomectomy were successfully performed in all women. Myomectomy was performed using laparoscopy (n=6), open laparotomy (n=3), hysteroscopy (n=2), or laparoscopy and hysteroscopy (n=1). Mean serum hemoglobin level drop was 0.97 g/dL and no blood transfusion was needed. No immediate complications were observed and all women reported resumption of normal menses. During a mean follow-up period of 25 months (range, 14-37 months), complete resolution of initial symptoms along with decrease in uterine volume (mean, 48%) was observed in all women. No further hysterectomy was required in any woman. CONCLUSION: In premenopausal women with multiple fibroids, the two-step procedure is safe and effective alternative to radical hysterectomy, which allows preserving the uterus. Further prospective studies, however, should be done to determine the actual benefit of this combined approach on the incidence of subsequent pregnancies.

Routine use of abdominopelvic ultrasonography in severe postpartum hemorrhage: retrospective evaluation in 125 patients.

OBJECTIVE: The purpose of this study was to analyze the potential of abdominopelvic ultrasonography at the initial examination in women with severe postpartum hemorrhage. STUDY DESIGN: One hundred twenty-five women were included in the study. The therapeutic approaches that were performed to stop the bleeding were evaluated for each category of ultrasonographic finding. RESULTS: Seventy-one women (56.8%) had normal ultrasonography; 30 women (24%) had echogenic endometrial lining; 17 women (13.6%) had echogenic intrauterine mass, and 7 women (5.6%) had abdominopelvic free fluid effusion. Medical therapies allowed the bleeding to stop in 90.1% of women with normal ultrasonography, in 66.6% of women with echogenic endometrial lining, and in 29.4% of women with echogenic intrauterine mass. Pelvic embolization and surgery were performed less frequently in women who had normal ultrasonography results (9.9%) than in women with abnormal ultrasonography results (46.8%; P < .0001). CONCLUSION: A normal abdominopelvic ultrasonography is associated with a favorable outcome and can be considered to be a predictor for the effectiveness of conservative, noninvasive therapeutic approaches.

Conservative management of a Cesarean scar ectopic pregnancy: a case report.

INTRODUCTION: Cesarean scar pregnancy is the rarest kind of ectopic pregnancy. The immediate prognosis depends on the risks associated with uterine rupture and massive bleeding. CASE PRESENTATION: A 32-year-old woman (gravida 2, para 1) presented with massive vaginal bleeding. A Cesarean scar pregnancy was diagnosed. She was treated by local methotrexate injection, followed by uterine artery embolization. Recurrence of bleeding necessitated two repeat embolizations. Hysteroscopy four months later revealed the presence of a uterine defect within the Cesarean section scar. CONCLUSION: Cesarean scar pregnancy should be diagnosed and treated as soon as possible to prevent severe complications and spare fertility.

Uterine conservation despite severe sepsis in a case of placenta accreta first treated conservatively: 3-month delayed successful removal of the placenta.

OBJECTIVE: To report a case of successful delayed removal of a placenta accreta first treated conservatively. Secondary infectious complications can occur after conservative management in cases of placenta accreta, most often leading to hysterectomy. DESIGN: Case report. SETTING: A French teaching hospital. PATIENT(S): A 33-year-old woman. INTERVENTION(S): A healthy 33-year-old woman underwent Cesarean section for her first pregnancy. Diagnosis of placenta accreta was made at ultrasound scanning for her second pregnancy. She was first treated conservatively. Hysterectomy was planned 3 months after conservative treatment because of sepsis attributed to uterine retention. (Hysterotomy was first realized.)-?? MAIN OUTCOME MEASURE(S): Uterine conservation. RESULT(S): The placenta was easily and successfully removed with no subsequent bleeding. The uterus was sutured and conserved. CONCLUSION(S): In cases of delayed sepsis because of uterine retention after conservative treatment for placenta accreta, when medical treatment remains unsuccessful, manual removal of the placenta should be attempted. This approach might allow improved uterine conservation rates in women with placenta accreta treated conservatively.

[Sentinel node biopsy in vulvar cancer]. / La technique du ganglion sentinelle dans le cancer de la vulve : état des lieux.

In vulvar cancer, lymph node status is a major prognostic factor. Currently, the reference regarding nodal exploration is the groin lymphadenectomy responsible for a significant morbidity. The sentinel node technique in breast cancer has become a standard of care. This technique has been studied for fifteen years in vulvar cancer, on small numbers because of its low incidence. There is not yet consensus about its use in practice. This article is a focus on this technology, its feasibility and the benefits of sentinel node detection applied to vulvar cancer.

[Hysteroscopic injection in sentinel node biopsy for endometrial cancer increases the frequency of para-aortic drainage: Is it necessary to reconsider the role of para-aortic lymphadenectomy?]. / L'injection hystéroscopique dans la biopsie du ganglion sentinelle pour cancer de l'endomètre augmente la fréquence du drainage para-aortique: faut-il reconsidérer la place de la lymphadénectomie para-aortique?

In cancer research, regional lymph node status is a major prognostic factor and a decision criterion for adjuvant therapy. The sentinel node procedure, which has emerged to reduce morbidity of extensive lymphadenectomy, remains a major step in the surgical management of various cancers. In endometrial cancer, the sentinel node biopsy is still at the stage of feasibility. The main problem of the diffusion of the sentinel node biopsy in endometrial cancer is the absence of injection site consensus. The different injection sites (myometrial, pericervical and hysteroscopy) allow to identify para-aortic lymph node drainage. In this article, we review the interest of hysteroscopic injection in endometrial cancer. This injection site could contribute to select the patients potentially being able to profit from a lombo-aortic lymphadenectomy.

Relation between severity of dysmenorrhea and endometrioma.

BACKGROUND: To evaluate the relationship between the severity of dysmenorrhea and endometrioma. METHODS: Descriptive study with prospective design. Two hundred and thirty-nine women with histologically proved endometriomas. The severity of dysmenorrhea was assessed prospectively with a 10-cm visual analog scale. Various indicators concerning the endometrioma and the extent of deep infiltrating endometriosis were recorded during surgery in 239 patients. Correlations were sought with a multiple regression logistic model. RESULTS: According to univariate analysis, the following variables were related to more severe dysmenorrhea: subperitoneal infiltration (uterosacral ligament and rectal infiltration) and R-AFS score of implants. None of the specific characteristics of endometriomas were associated with severe dysmenorrhea. After multiple regression analysis, rectal infiltration and R-AFS score of implants were the only factors that remained related to dysmenorrhea severity. CONCLUSIONS: When there is an endometrioma, severe dysmenorrhea is not directly related with the characteristics specific to these ovarian cysts. The associated deep infiltrating endometriotic lesions and in particular rectal infiltration could explain these symptoms.

Surgical management of deeply infiltrating endometriosis: an update.

Deeply infiltrating endometriosis (DIE) manifests itself mainly in the form of pain, predominantly deep dyspareunia, and painful functional symptoms that are aggravated monthly during menstruation, with the semiology being directly correlated with the location of the lesions (bladder, rectum). A workup to assess the extent of the disease is necessary to establish an accurate map of the DIE lesions, which is the essential condition to perform complete exeresis. The treatment of first intention is surgical, because medical treatments are only palliative in the majority of cases. Successful treatment depends on achieving radical surgical exeresis. Analysis of the anatomical distribution of the DIE lesions allows a "surgical classification" to be proposed to standardize the modalities of surgical treatment. Further studies are needed to specify the place and modalities of medical treatments preoperatively and postoperatively.