[Laparoscopic sacrocolpopexy for exteriorized pelvic organ prolapse: Mid-term functional results]. / Promontofixation cœlioscopique pour les prolapsus extériorisés: qualité de vie et résultats fonctionnels à moyen terme.

OBJECTIVES: To assess feasibility and postoperative outcomes associated with laparoscopic sacrocolpopexy in patients presenting with exteriorized pelvic organ prolapse (stage>3). METHODS: Prospective study involving patients undergoing laparoscopic sacrocolpopexy for advanced stage pelvic organ prolapse. Symptoms and quality of life were evaluated at baseline and at 1, 4 and 18 months after surgery using validated questionnaires (PFDI-20 and PFIQ-7). RESULTS: Sixty-three patients were included between September 2012 and January 2014. Sub-total hysterectomy and sub-urethral sling were performed at the time of surgery in 36% and 34% of patients, respectively. We observed 1 per-operative complication (bladder wound). De novo stress urinary incontinence and de novo dyspareunia persisting at 18 months occurred in 10% and 3% of cases, respectively. Recurrence rate was 1.6% at 18 months. The follow-up also revealed a significant and prolonged improvement in PFDI-20 and PFIQ-7 scores: from 98.8 at baseline to 33.9 at 18 months (P<0.01) and from 89.6 to 26.5 (P<0.001), respectively. CONCLUSION: Laparoscopic sacrocolpopexy seems feasible and safe in patients suffering from exteriorized pelvic organ prolapse, leading to high anatomic success rate. It is also associated with a prolonged improvement in quality of life and a positive impact on symptoms related to prolapse.

[Management of other ectopic pregnancies (cornual, interstitial, angular, ovarian)]. / Prise en charge des autres ectopies annexielles (cornuale, interstitielle, angulaire, ovarienne).

OBJECTIVES: To provide recommendations for management of interstitial and ovarian pregnancies. MATERIALS AND METHODS: A Medline search was conducted and discussed by a study group of experts. RESULTS: Ovarian and interstitial pregnancies are rare forms of ectopic pregnancy. Diagnostic criteria and methods are described on the basis of a review of the literature. Surgery is the usual management of interstitial pregnancy. Conservative treatment has replaced hysterectomy. Laparoscopy is an attractive way to manage interstitial pregnancies but laparotomy may still be used. Cornual resection is required. Medical treatment with methotrexate is another alternative. Local MTX seems to be more efficient than systemic administration. Management of interstitial pregnancy under laparoscopic control is an attractive way if feasible. Strong recommendations cannot be established due to the small number of reported cases reports. The pre therapeutic score cannot be used as doses are still not clear for interstitial pregnancies. For ovarian pregnancy, management is often surgical. Laparoscopy is more and more used for small gestational sacs. Methotrexate has also been used for ovarian pregnancies. Laparoscopic treatment associated with systemic MTX seems to be the more efficient way. CONCLUSION: Because of limited data it is very hard to establish recommendations from low power studies (NP 5).

[Fertility after laparoscopic treatment of ectopic pregnancy in a series of 138 patients]. / Fertilité après traitement chirurgical d'une grossesse extra-utérine.

OBJECTIVE: To evaluate fertility after laparoscopic treatment of ectopic pregnancy (EP). To investigate factors influencing fertility and EP recurrence. PATIENTS AND METHODS: Retrospective study of a series of 138 patients. Rate of intra uterine pregnancy, live births and recurrent EP were the main outcome measures. Subsequent fertility was assessed by calculating cumulative intrauterine pregnancy rates and were analyzed by log-rank tests and Cox regression. RESULTS: The multivariate analysis showed a better rate of intra uterine pregnancy in patients with normal controlateral tube and in women younger than 30. The average time before conception was 11.5 months. After 18 months of infertility the intra-uterine pregnancy rate was low but the EP recurrence rate increased after 24 months. In this study there was no difference between radical and conservative surgery treatment. CONCLUSION: Laparoscopy is useful in the management of ectopic pregnancy, especially in order to establish a prognosis for fertility.

The dose-range effects of sufentanil added to 0.125% bupivacaine on the quality of patient-controlled epidural analgesia during labor.

UNLABELLED: To determine the minimal sufentanil concentration required to improve the quality of patient-controlled epidural analgesia during labor, we compared the efficacy of a combination of 0.125% bupivacaine with 1:800,000 epinephrine and different concentrations of sufentanil in a double-blinded randomized study. Concentrations were no sufentanil (n = 66), 0.078 microg/mL sufentanil (n = 65), 0.156 microg/mL sufentanil (n = 65), 0.312 microg/mL sufentanil (n = 65), and 0.468 microg/mL sufentanil (n = 67). The patient-controlled epidural analgesia setting was a 12-mL bolus dose and a 25-min lockout interval. Pain was scored at 5-6 cm, 7-8 cm, and full cervical dilation by using a 10-cm visual analog scale. At full cervical dilation, the pain scores were lower in the groups receiving a solution of at least 0.156 microg/mL sufentanil. Few differences were observed when using the larger concentrations, except for increased pruritus intensity. The duration of labor and the mode of delivery were similar in each group. Rescue analgesia, which consisted of 6 mL of 0.25% bupivacaine, was infrequent and comparable between groups. The use of the pump did not differ between groups. Adding a small concentration of sufentanil to 0.125% bupivacaine for patient-controlled epidural analgesia during labor improved the quality of analgesia but did not modify the bupivacaine requirement. Reducing the sufentanil concentrations to 0.156 microg/mL decreased the pruritus intensity without reducing analgesia. IMPLICATIONS: Adding a small concentration of sufentanil to 0.125% bupivacaine for patient-controlled epidural analgesia during labor improved the quality of analgesia but did not modify the bupivacaine requirement. Reducing the sufentanil concentrations to 0.156 microg/mL decreased the pruritus intensity without reducing analgesia.

Analysis of 676 cases of ductal carcinoma in situ of the breast from 1971 to 1995: diagnosis and treatment--the experience of one institute.

Six hundred seventy-six patients with ductal carcinoma in situ of the breast (DCIS) from 1971 to 1995 were included in the study. Computerized patient files were retrospectively analyzed. Clinical findings were less frequently reported to reveal DCIS after 1989. Positive mammographic findings were obtained in 87% of patients and were mainly represented by microcalcifications (79.4%). Treatment procedures were breast-conserving surgery (BCS) alone (37.5%), BCS followed by radiation (BCSR) (25.5%), or mastectomy (M) (37%). The actuarial local recurrence was 2.6% in the M group (94 months of follow-up), 14.5% in the BCS group (85,7 months of follow-up), and 7.5% in the BCSR group (78.8 months of follow-up). Predictive factors of recurrence in all patients were invaded margin status and age. In the BCS group, grade was also a predictive factor. The analysis per decade shows that the lesions currently diagnosed are less serious than those of the past. All the recurrence in patients with positive margins was in the same quadrant as the original lesion. This further emphasizes the need for clear margins.

[The value of hysteroscopy after repeated implantation failures with in vitro fertilization]. / Intérêt de l'hystéroscopie après échecs répétés d'implantation en fécondation in vitro.

OBJECT: we attempt to determine the usefulness of uterine re-assessment by hysteroscopy in women with two unsuccessful IVF-ET attempts. MATERIAL AND METHOD: This retrospective study concerns seventy-three infertile women who have had a repeat uterine hysteroscopy after two implantation failures in IVF. RESULTS: In half the cases, an abnormality was diagnosed. Cervical abnormalities (synechia, polyp, false passage) and hormono-dependent abnormalities (polyp, hyperplasia, submucous myoma) were the most frequent findings. The rate of pregnant women raises to twenty-two percent after treatment of these abnormalities. CONCLUSION: Regarding our experience, it seems legitimate to perform hysteroscopy in women who have had two IVF-ET failures before attempting a third procedure.

Management of septate uterus by flexible hysteroscopy and Nd:YAG laser.

OBJECTIVE: To evaluate the efficiency of flexible Nd-YAG laser hysteroscopic metroplasty. METHODS: We present a retrospective study of 17 patients treated for septate uteri between 1990 and 1995. The indication of hysteroscopy was recurrent abortion in nine cases and eight with primary infertility with indication of IVF in another five cases. We did not prescribe any pretreatment. A flexible hysteroscope with a 100-W Nd:YAG laser was used with glycine-controlled flow. The septum was divided by the laser after exploration of the cavity. We proposed a control office hysteroscopy 2 months after surgery to prevent uterine adhesions. RESULTS: There was no complication. Twelve patients conceived with 10 live births at term and two spontaneous abortions. Four are still infertile, two were lost from the study and two no longer desired pregnancy. Resectoscopic studies showed the same results. CONCLUSION: The advantages of this method are the excellent ergonomic properties of the fibroscope and the safety of the laser. We suggest that metroplasty does not improve the pregnancy rate but only the pregnancy outcome of these patients. However, for those with the indication of IVF the procedure seems useful in avoiding abortion.

[Recurrence after treatment of breast intraductal carcinoma]. / Les récidives après traitement des carcinomes intracanalaires du sein.

OBJECTIVE: To assess the risk of local recurrence of intraductal carcinoma of the breast with a large series and a review of literature. METHODS: We present a retrospective study of 331 cases treated for intraductal carcinoma of the breast. Only patients with at least 5 years follow-up were selected. We were specially interested in recurrence risk factors. In these patients with a long follow-up; pathology was reevaluated with new investigation technique. RESULTS: After a median follow-up of 109 months, 40 local recurrences were observed; these lesions were invasive in 23 cases. Only one patient had recurrence after mastectomy. For the others, they had lumpectomy associated with radiotherapy in 12 cases. Histologic features, grade and therapeutic options were evaluated as risk factors of local recurrence. CONCLUSION: Follow-up after lumpectomy for intraductal carcinoma was studied. The status of tumor margins was important; irradiation appeared useful, specially in case of high grade carcinoma but further large prospective randomized studies are needed. The use of prognostic index is interesting, but there are still unanswered questions.

Etiology, prognosis and management of nuchal cystic hygroma: 25 new cases and literature review.

OBJECTIVE: To develop an algorithm for the prenatal management of patients when a cystic hygroma is diagnosed by ultrasonography. METHODS: We report a personal series of 25 cases diagnosed between 10 and 23 weeks gestation and a review of the literature comprising a total of 999 cases. We focused on the etiologies and the value of various prognostic factors in the management of cystic hygromas. These include karyotype, alpha-fetoprotein levels, sonographic findings in the fetus and within the hygroma itself, and natural history. RESULTS: According to the literature, fetal chromosomal abnormalities were associated with cystic hygromas in 62% of the cases. Turner's syndrome remains the most common (33%) but Down's syndrome, Trisomy 18 and Trisomy 13 are not rare (15, 7 and 2%). Others have Mendelian abnormalities. The prognosis remains gloomy. The literature reports that only 9% of cases result in healthy children with normal karyotypes. The remaining 91% are either terminated (89%) or liveborn (2%), but with chromosome abnormalities or various malformations. CONCLUSION: The prognostic factors associated with a poor outcome are an abnormal karyotype and associated structural malformations. Resolution of the hygroma by 20 weeks gestation suggests a good prognosis, but is not definitive. All other factors evaluated do not appear to be of prognostic value at this time. Careful analysis of these prognostic factors is very important to identify the small percentage of normal children and to advise parents effectively for a future pregnancy.

Endometrial Nd-YAG laser ablation by hysterofibroscopy: long-term results of 137 cases.

OBJECTIVE: In our gynecology department, we have been performing endometrial laser ablation (ELA) under video control using a flexible hysteroscope since 1989. The aim of this study is to evaluate the long term results of our experience. STUDY DESIGN: We went back to the files of 137 patients treated between 1989 and 1993. These women (mean age 42 years) exhibited menorrhagia unamenable to medical treatments which had been developing for 28 months. Mean hysterometry was 9.8 cm. A hysteroscopy with ELA was performed. Our procedure lasts 19 min on average and uses 0.9 1 of glycocol. There were no perforations. Six patients presented a fever above 38 degrees C within the next 48 h; only one developed a true endometritis necessitating antibiotherapy. One patient who had received several GnRH agonist courses had a coagulation of the uterus and had to be hysterectomised. RESULTS: Nine patients were lost to follow-up; for the others, mean follow-up was 32 months. Seventeen women (13.3%) were hysterectomised, including the patient with a coagulation necrosis of the myometrium. In most cases, this was for undetected adenomyosis or fibromas evolving after hysteroscopy. Bleeding recurred in two other patients; they refused hysterectomy but should be counted as failures of this method. Among the 109 patients (85.1%) considered a success, 35 have had menopause since the procedure. CONCLUSION: ELA is a simple quick procedure which significantly reduces the number of hysterectomies. In addition, the economic value of ELA is beginning to be assessed in the literature. This long-term study should allow the indications to be better defined by eliminating patients with a high risk of failure and should lead to improved results.

Breast cancer and in vitro fertilization. About 32 cases.

Because of the increased risk of breast cancer for infertile nulliparous women, the suspected promoter role of estradiol in mammary carcinogenesis and the high frequency of ovulation inducer treatments, it was interesting to focus on the risk of breast cancer after such a treatment. We reviewed 32 cases during a retrospective survey in Assisted Reproductive Techniques (ART) centers in France. Because of the small sample size and the few cases published so far, no statistical study could be made. However, many observations may have gone unnoticed or were not published. Two hypotheses can be proposed: (1) the facilitating role of stimulation on potential infra-clinical or un-diagnosed cancers; (2) the initiation of new cancers. Consequently, we propose to establish a register for the follow-up of treated women to monitor the advent of new cancers and to increase the follow-up of patients with other associated risk factors.

Treatment of fibromas.

This study defines the current modes of treatment of patients with uterine fibromas with a review of the literature. Progesterone treatments appear to be principally used in cases of minor functional symptomatology and we discuss recent studies of mifepristone. GnRH agonists are particularly effective in preoperative treatment for conservative surgery. The indications and results of hysteroscopic resection and laparoscopic myomectomy are compared to those of classic myomectomy and hysterectomy. The indications for myolysis are discussed.

A new method for the treatment of fibromas: interstitial laser hyperthermia using the Nd:YAG laser. Preliminary study.

Operative laparoscopy can replace hysterectomy in the treatment of submucous and subserosal uterine fibromyomas. Interstitial myomas are still treated using traditional methods. Using an Nd:YAG laser with a quartz fibre which diffuses the ray, we induced delayed necrosis of myoma secondary to the hyperthermia produced by this method-interstitial laser hyperthermia. We present an experimental study of fibromas from excised tissue. Optimal efficiency is achieved with continuous delivery at 5 W of power for 10 min. The temperature reaches 50 degrees C within a radius of 20 mm around the fibre. A clinical study was undertaken with the approval of the Ethics Committee. Seven patients suffering from symptomatic fibromas were treated by laparoscopy. Preliminary results at 12 months show that their symptoms have disappeared and the size of the fibromas has been reduced. A larger study is in progress.

[Uterine necrosis after Nd-YAG laser ablation of the endometrium. A case report]. / Nécrose utérine après réduction d'endomètre au laser nd:YAG. A propos d'un cas.

Myometrial coagulation necrosis occurred after LH-RH analogue treatment and Nd:YAG laser reduction of the endometrium. This rare complication occurred in a patient with adenomyosis.

[Breast cancer and hMG treatment: is there a relationship?]. / Cancer du sein et traitement par hMG: y a-t-il un lien?

The promoter effect of oestradiol in breast cancer, the higher risk of breast cancer in infertile nulliparous women and the increased use of treatments to include ovulation would suggest that the risk of cancer after this type of treatment might be affected. We thus evaluated the files of patients under 45 years of age treated for breast cancer at the Bergonié Foundation. Six such cases were found. Due to the small number of cases observed to date, no statistical analysis could be performed. Nevertheless, several cases may have gone unrecognized or unpublished. Two hypothesis might be involved: the facilitating effect of stimulation on infraclinical or undiagnosed cancers, initiation of new cancers. We thus propose: a register to follow treated women in order to monitor the appearance of new cases of cancer, improved surveillance in patients with other associated risk factors.

[Stage I and II endometrial cancer: should lymphadenectomy still be done?]. / Cancer de l'endomètre stades I et II: faut-il encore effectuer des lymphadénectomies?

Surgical treatment for endometrial carcinomas stage I and II is radical hysterectomy. The role of lymphadenectomy (pelvic and paraaortic) is under discussion. From a retrospective study (multivariate analysis of 320 patients treated by radiosurgical association) and a review of the literature, the authors limit the indications of lymphadenectomy to stage I grade 1 or 2 tumours and without deep tumours invasion into the myometrium (in that case only 10% of pelvic nodes will be involved). Stage II patients or stage I with grade 3 and/or deep tumour invasion into the myometrium do not require lymphadenectomy as post-operative pelvic external beam irradiation will be performed in all cases. Para-aortic lymphadenectomy is not useful as it increases morbidity and the adjuvant treatment in case of lymph node involvement does not improve the survival rate.

[Relapsing polychondritis. Apropos of 4 cases]. / La polychondrite chronique atrophiante. A propos de 4 observations.

More than three hundred and fifty cases of this ailment can be counted at the present time, an ailment coming into the wide framework of connective tissue diseases with systemic vasculitis. The auricle chondritis remains the most frequent initial localization and its almost constant throughout development. The nasal chondritis is distinguished by its evolution to the saddle-nose deformity. The tracheo-bronchial localization remains the most severe one because of a risk of stenosis. During an evolution made by bouts, the disease also involves rheumatoid, ocular, audio-vestibular, dermatological and renal symptoms. Though an immunologic mechanism seems to be the origin of the disease, the pathogenesis of polychondritis is still mysterious. The polychondritis treatment is based upon systemic steroids therapy and possibly upon immunosuppressive agents as well. Dapsone, recently brought into the polychondritis treatment have not superseded cortico-steroid therapy.