Combining Sclerotherapy with CO2 Laser Ablation for the Laparoscopic Management of Large Endometrioma: Advantages and Pitfalls.

STUDY OBJECTIVE: To demonstrate the feasibility of management of large endometrioma laparoscopically. DESIGN: Stepwise demonstration with narrated video footage of the laparoscopic 2-step procedure starting with alcohol sclerotherapy of the large endometrioma followed by CO2 laser ablation and 6-month follow-up. SETTING: The debate surrounding the best approach for the management of large endometriomas has been ongoing. Cystectomy especially when treating large endometriomas has been shown to decrease ovarian reserve proportionally to the endometrioma's size.2,4 This is why 2-step approaches have been considered to preserve the ovarian reserve.1,3 We present the case of a 22-year-old nulliparous woman who has primary severe dysmenorrhea resistant to medical treatment. Magnetic resonance imaging shows uterine adenomyosis and a 10 cm large endometrioma of the left ovary and no signs of deep infiltrative endometriosis. She has a desire for pregnancy in the distant future. INTERVENTION: The first step is the laparoscopic ethanol sclerotherapy. After emptying and rinsing the endometrioma's cavity through a 5 mm suction cannula, it is then filled with ethanol through a 14 French Foley catheter to avoid any overflow.5,6 After a time exposure of 10 minutes, the ethanol is withdrawn and the cavity rinsed (Figure 2). The second step of the surgery is performed 12 weeks later (Figure 3). Using CO2 laser, the untreated portion of the inner wall of the remaining endometrioma is vaporized along with remaining superficial endometriosis lesions (Figure 1). CONCLUSION: Laparoscopy sclerotherapy combined to CO2 laser ablation is a feasible technique for the management of a large endometrioma. Further research is still required to evaluate the benefit of a 2-step surgery approach over standard cystectomy and to understand the long-term effects of ethanol-induced ovarian fibrosis.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery Meshless Anterior Repair for the Treatment of Pelvic Organ Prolapse.

STUDY OBJECTIVE: To demonstrate the feasibility of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) meshless anterior repair for the treatment of pelvic organ prolapse (POP). DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: The vNOTES approach is a recent and rapidly developing technique that allows safe endoscopic transvaginal treatment of benign uterine pathologies [1]. Its use in the treatment of POP is still in its early stages; however, the first results are encouraging in terms of anatomy, functionality, and safety [2]. INTERVENTIONS: We describe the vNOTES technique of meshless anterior POP repair using a vaginal plastron [3]. The "vaginal plastron" technique uses an autologous vaginal strip that is left attached to the bladder and suspended from the arcus tendineus. After the delimitation of a 6 cm square vaginal strip, a lateral dissection is performed on each side between the bladder and the vaginal fascia to enter the paravesical space. The vaginal strip is left attached to the bladder wall and will later be fixed laterally to the arcus tendineus with 6 nonabsorbable monofilament sutures, caliber 0 (3 on each side of the plastron). The fixation points on the arcus tendineus concern the internal obturator fascia ventrally and the iliococcygeus fascia dorsally. The sutures are placed under endoscopic view using a transvaginal access platform (GelPOINT V-Path, Applied Medical, Rancho Santa Margarita, CA). After deflation and removal of the platform, the sutures are attached to the vaginal strip. Once the vaginal plastron is secured, the anterior vaginal wall is closed. CONCLUSION: The vNOTES approach offers an endoscopic anatomic view of the paravesical space, thus reducing any blind surgical procedure. It provides an alternative route in the performance of meshless anterior POP repair.

[Mastalgia : management and state of the art]. / Mastodynies : prise en charge et connaissances actuelles.

This article tries to facilitate the management of mastalgia. During their lifetime most women will experience breast pain. Many of them will visit a physician for this purpose, often led by the fear of cancer. However, in the absence of other clinical signs such as a lump or nipple discharge, the risk of malignancy remains low. In addition to the patient's medical history and physical examination, an imaging may be necessary. The absence of clinical or radiological abnormalities suffices to reassure patients in most cases. The management of mastalgia is based mainly on diet and life-style changes, the use of a well-suited bra and topical anti-inflammatory medication. In the case of mastalgia not responding to first line treatments, the patient should be referred to a breast-care unit.

Cet article cherche à faciliter la prise en charge des mastodynies. Au cours de leur vie, la majorité des femmes présenteront des mastodynies. Nombreuses sont celles qui consulteront leur médecin à cet égard, souvent par crainte d'un cancer. Cependant, en l'absence d'autres signes cliniques comme une masse ou un écoulement mamelonnaire, le risque de malignité reste faible. Outre l'anamnèse et l'examen clinique, une imagerie peut s'avérer nécessaire. L'absence d'anomalies cliniques ou radiologiques permet de rassurer les patientes dans la majorité des cas. Le traitement reposera essentiellement sur des mesures hygiéno-diététiques, le port d'un soutien-gorge adapté et l'utilisation d'anti-inflammatoires topiques. En cas de mastodynies invalidantes et réfractaires aux anti-inflammatoires, la patiente devra être adressée pour un suivi spécialisé.

[Update on Mycoplasma genitalium among women]. / Le point sur Mycoplasma genitalium chez la femme.

Mycoplasma genitalium (MG) is a sexually transmitted pathogen with a poorly understood natural history. Often asymptomatic, it has been associated with urogenital conditions. The implementation of NAAT (Nucleic Acide Amplification Test) has not only improved the detection of MG, but also brought to light the emergence of antibiotic resistances, hence challenging the proposed treatment strategies and questioning the indication for systematic screening. This article summarizes current knowledge on MG among women, over viewing incidence, prevalence and clinical implications. It resumes the last guidelines in terms of screening and treatment.

Mycoplasma genitalium (MG) est un pathogène sexuellement transmissible souvent asymptomatique, dont la pathogénicité est méconnue. Source croissante d'intérêt car mieux détecté depuis l'implémentation des NAAT (Nucleic Acide Amplification Test), MG serait incriminé dans diverses pathologies uro-génitales. L'émergence des résistances aux antibiotiques est un enjeu de taille dans le traitement de l'infection et soulève le débat sur l'utilité d'un dépistage systématique. Cet article résume l'état des connaissances actuelles au sujet de MG chez la femme : son incidence, sa prévalence ainsi que ses implications cliniques. Il fait la synthèse des dernières recommandations en termes de dépistage et de traitement.

Outcomes of robotically assisted laparoscopic lateral suspension (RALLS) with mesh for anterior and apical prolapse.

Abdominal sacral colpopexy/hysteropexy is the gold standard for the treatment of vaginal apex support. However, dissection of the promontory may expose to potentially life-threatening complications. To avoid this risk, laparoscopic lateral suspension with mesh is an alternative. Robotic assistance may be helpful in both techniques. The objective of our study was to evaluate outcomes of robotically assisted laparoscopic lateral suspension (RALLS) with mesh for anterior and apical pelvic organ prolapse (POP). From March 2012 to January 2018, 59 consecutive patients underwent RALLS using titanized polypropylene mesh. Between August 2017 and September 2019, all patients were contacted to assess outcome. We performed a clinical exam and asked them to complete the patient global impression of improvement (PGI-I) questionnaire. Fifty-four patients (91.5%) were available for follow-up. Mean age was 58.5 years (28.8-79.8). There were no perioperative complications. The mean follow-up was 33.6 months (11.2-74.1).The objective cure rate (no prolapse beyond hymen) and the subjective cure rate (PGI-I ≤ 2) were 83.3% and 77.2%, respectively. Five women (9.3%) were reoperated for POP recurrence. There was no erosion. Of the 20 women complaining of stress urinary incontinence (SUI) preoperatively, 12 (60%) were cured without any additional SUI procedure. Only two women (10%) required TVT for persistent grade 2 SUI. Two women (5.9%) developed de novo SUI, but none of them required an operation. RALLS repair for POP with mesh is safe and effective and may represent an alternative to sacral colpopexy/hysteropexy.

HPV self-testing for primary cervical cancer screening in Madagascar: VIA/VILI triage compliance in HPV-positive women.

OBJECTIVE: To assess triage compliance and the effect of the time from screening to triage on follow-up among HPV-positive women. METHODS: We recruited 1232 women in a screening campaign in Madagascar from February to October 2015. In the first period (February-May), HPV tests were performed remotely using the cobas test. In the second period (May-October), testing was performed on-site using the Xpert HPV assay. HPV-positive women were invited for triage with visual inspection with acetic acid (VIA) and Lugol's iodine (VILI). Systematic biopsy and endocervical brushing were performed on all HPV-positive women for quality control. Three groups were defined according to time from HPV testing to triage invitation for HPV-positive women-Group I: delayed (> 3 months), Group II: prompt (24-48 hours), and Group III: immediate (< 24 hours). RESULTS: A total 1232 self-sampled HPV tests were performed in the study period (496 in Group I, 512 in Group II, and 224 in Group III). Participants' mean age was 43.2 ± 9.3 years. Mean time from screening to VIA/VILI testing was 103.5 ± 43.6 days. Overall HPV prevalence was 28.0%. HPV prevalence was 27.2% in Group I (cobas test), 29.2% in Group 2 (Xpert test), and 26,7% in Group III (Xpert test). The VIA/VILI compliance rate was 77.8% for Group I, 82.7% for Group II, and 95.0% for Group III. Of women undergoing VIA/VILI, 56.3% in Group I and 43.5% in Groups II/III had positive results. Prevalence of cervical intraepithelial neoplasia grade 2 or worse among HPV-positive women was 9.8% for Group I and 6.8% for Groups II/III. Non-adherence was higher among rural women, uneducated women, and women in Group I. CONCLUSION: HPV-positive women with immediate VIA/VILI triage invitation had the best triage compliance. A single-day test and triage strategy is preferred for low-resource settings.

Web-based instrument to assess skills in visual inspection of the cervix among healthcare providers.

OBJECTIVE: To validate a web-based instrument for assessing healthcare providers' skills in visual inspection with acetic acid or Lugol iodine (VIA/VILI) for the diagnosis and management of cervical intraepithelial neoplasia. METHODS: An observational cross-sectional study enrolled healthcare providers in a web-based assessment of VIA/VILI skills between August and November 2014. Participants participated in a four-module training course, followed by a multiple-choice test with 70 questions based on cervical photographs of HPV-positive women participating in cervical screening. Logistic regression was used to identify relationships between independent variables and success on the test. RESULTS: Overall, 255 participants completed the test and 99 (38.8%) passed. No correlation was found between age or sex and test performance. Compared with other healthcare workers, physicians (odds ratio [OR] 1.91, 95% confidence interval [CI] 1.01-3.63; P=0.048), and participants with more colposcopy experience (OR 3.62, 95% CI 1.91-6.85; P<0.001) and postgraduate VIA/VILI training (OR 1.95, 95% CI 1.16-3.29; P=0.012) were more likely to pass the test. Participants who repeated the test (31/255 [12.2%]) were five times more likely to succeed on their second repeat (OR 5.89, 95% CI 1.46-23.73; P=0.013). CONCLUSION: Web-based training for VIA/VILI is feasible and can identify healthcare workers who are proficient in this technique.