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OBJECTIVE: To compare the effect of corticosteroids combined with local anaesthetic versus local anaesthetic alone during infiltrations of the pudendal nerve for pudendal nerve entrapment. DESIGN: Randomised, double-blind, controlled trial. SETTING: Multicentre study. POPULATION: 201 patients were included in the study, with a subgroup of 122 women. METHODS: CT-guided pudendal nerve infiltrations were performed in the sacrospinous ligament and Alcock's canal. There were three study arms: patients in Arm A (n = 68) had local anaesthetic alone, those in Arm B (n = 66) had local anaesthetic plus corticosteroid and those in Arm C (n = 67) local anaesthetic plus corticosteroid with a large volume of normal saline. MAIN OUTCOME MEASURES: The primary end-point was the pain intensity score at 3 months. Patients were regarded as responders (at least a 30-point improvement on a 100-point visual analogue scale of mean maximum pain over a 2-week period) or nonresponders. RESULTS: Three months' postinfiltration, 11.8% of patients in the local anaesthetic only arm (Arm A) were responders versus 14.3% in the local anaesthetic plus corticosteroid arms (Arms B and C). This difference was not statistically significant (P = 0.62). No statistically significant difference was observed in the female subgroup between Arm A and Arms B and C (P = 0.09). No significant difference was detected for the various pain assessment procedures, functional criteria or quality-of-life criteria. CONCLUSIONS: Corticosteroids provide no additional therapeutic benefits compared with local anaesthetic and should therefore no longer be used. TWEETABLE ABSTRACT: Steroid infiltrations do not improve the results of local anaesthetic infiltrations in pudendal neuralgia.
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Corticosteroides/administração & dosagem , Anestésicos Locais/administração & dosagem , Lidocaína/administração & dosagem , Bloqueio Nervoso/métodos , Neuralgia do Pudendo/terapia , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Humanos , Pessoa de Meia-Idade , Medição da Dor , Estudos Prospectivos , Nervo Pudendo , Radiografia Intervencionista/métodos , Resultado do TratamentoRESUMO
INTRODUCTION AND HYPOTHESIS: This aim of this study was to evaluate the feasibility and usefulness of an ovine model for training in vaginal surgery. METHODS: Four senior urogynaecological surgeons and five residents attended five sessions of vaginal surgery for pelvic organ prolapse (POP) in five old multiparous female sheep. Urogynaecological examinations were performed and measurements similar to the POP-Q classification in humans were obtained. Standard POP surgical procedures with and without mesh were performed. A pelvic CT scan was done on one animal and the structures were compared with the pelvic structures in a woman. After the feasibility of vaginal surgery had been established in three cadavers, surgery was performed in two living animals under general anaesthesia and was followed by laparoscopy to explore the internal pelvic anatomy. RESULTS: We found anatomic similarities in the vaginal and pelvic structures between sheep and women. After caudal traction on the cervix, all five sheep had significant POP of stage 3 or 4. We proved the feasibility of all types of vaginal surgery in this animal model: traditional anterior and posterior repair, apex fixation and anterior wall repair with mesh. The video shows the internal pelvic anatomy and different vaginal procedures. CONCLUSION: This study showed that training in vaginal surgery for POP is feasible and useful in an animal model, the ewe, that has vaginal and pelvic structures very similar to those in women.
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Procedimentos Cirúrgicos em Ginecologia/educação , Modelos Animais , Prolapso de Órgão Pélvico/cirurgia , Ovinos/cirurgia , Vagina/cirurgia , Animais , FemininoRESUMO
Background: Management of endometriosis should be based on the best available evidence. The pyramid of evidence reflects unbiased observations analysed with traditional statistics. Evidence-based medicine (EBM) is the clinical interpretation of these data by experts. Unfortunately, traditional statistical inference can refute but cannot confirm a hypothesis and clinical experience is considered a personal opinion. Objectives: A proof of concept to document clinical experience by considering each diagnosis and treatment as an experiment with an outcome, which is used to update subsequent management. Materials and Methods: Experience and knowledge-based questions were answered on a 0 to 10 visual analogue scale (VAS) by surgery-oriented clinicians with experience of > 50 surgeries for endometriosis. Results: The answers reflect the collective clinical experience of managing >10.000 women with endometriosis. Experience-based management was overall comparable as approved by >75% of answers rated ≥ 8/10 VAS. Knowledge-based management was more variable, reflecting debated issues and differences between experts and non-experts. Conclusions: The collective experience-based management of those with endometriosis is similar for surgery-oriented clinicians. Results do not conflict with EBM and are a Bayesian prior, to be confirmed, refuted or updated by further observations. What is new?: Collective experience-based management can be measured and is more than a personal opinion. This might extend EBM trial results to the entire population and add data difficult to obtain in RCTs, such as many aspects of surgery.
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OBJECTIVES: To evaluate the use of simulation among French Obstetrics and Gynecology residency programs. METHODS: A survey was conducted with all 28 French residency program directors. The questionnaire covered equipment and human resources, training programs, types of simulation tools and time spent. RESULTS: Of the cities hosting a residency program, 93% (26/28) responded regarding equipment and human resources, and 75% (21/28) responded regarding training program details. All respondents declared having at least one structure dedicated to simulation. A formal training program was reported by 81% (21/26) of cities. This training program was mandatory in 73% of the cases. There was a median number of seven senior trainers involved, three of whom had received a specific training in medical education. Most of declared simulation activities concerned technical skills in obstetrics and surgery. Simulations to practice breaking bad news were offered by 62% (13/21) of cities. The median number of half-days spent annually on simulation training was 55 (IQR: 38-83). CONCLUSION: Simulation training is now widely available among French residency programs. There remains heterogeneity between centers regarding equipment, time spent and content of simulation curricula. The French College of Teachers of Gynecology and Obstetrics has proposed a roadmap for the content of simulation-based training based on the results of this survey. An inventory of all existing "train the trainers" simulation programs in France is also provided.
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Ginecologia , Internato e Residência , Obstetrícia , Treinamento por Simulação , Feminino , Gravidez , Humanos , Obstetrícia/educação , Ginecologia/educação , Inquéritos e QuestionáriosRESUMO
Background: Advanced gynaecological procedures often include extensive pelvic dissections, with the nervous structures involved in the disease. Nerve-sparing and preservation is a key factor in reducing postoperative morbidity. Objectives: The goal of this review is to describe in detail the structure of the pelvic nerves and to gather information from other surgical specialties to give recommendations for safe nerve dissection applied in different gynaecological subspecialties. Materials and Methods: An extensive literature review was carried out in PubMed and Google Scholar. The search included articles concerning peripheral nerve anatomy, mechanisms of injury and different dissection techniques, with the most exhaustive being analysed for the review. Articles from different fields of medicine like orthopaedics, plastic surgery, maxillofacial surgery dealing with peripheral nerve injuries and repair have been reviewed. Results: The following review demonstrates the in-depth anatomy and mechanism of injury of the peripheral nerves, describes the different techniques for neurolysis and proposes some directions for safe nerve dissection. Conclusion: When performing complex gynaecological surgeries, the surgeon should avoid unnecessary nerve handling, apply nerve-sparing techniques whenever possible and use the new devices to preserve the nervous structures. Advanced gynaecological surgeries should be performed in specialised centres by expert surgeons with comprehensive knowledge in neuropelveology. What is new?: To our knowledge, this is the first article focused on peripheral nerves that collects data from such a wide range of specialties in order to propose the most comprehensive recommendations that could be applied in pelvic surgery.
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OBJECTIVE: to evaluate the complications after surgery for deep endometriosis. DESIGN: retrospective study. SETTING: data from the CHU Estaing database and patients' charts between January 1987 and December 2007. SAMPLE: all women given surgical treatment for deep endometriosis. METHODS: women who underwent surgery for deep endometriosis were reviewed for intra- and postoperative complications. MAIN OUTCOME MEASURES: primary outcomes were rates of intra- and postoperative complications. Complications were compared according to the procedure performed. RESULTS: a total of 568 women were included in the study, with a mean age of 32.4 years. The mean estimated diameter of the nodule felt by vaginal examination was 1.8 cm (ranging from 0.5 to 7 cm). Laparoscopic surgery was performed in 560 women (98.6%), and conversion was required in 2.3%. The mean operative time was 155 minutes. Intraoperative complications occurred in 12 women (2.1%), including six minor (1.05%) and six major (1.05%) complications. Postoperative complications developed in 79 women (13.9%), including 54 minor (9.5%) and 26 major (4.6%) complications (one woman had both minor and major postoperative complications). The overall major postoperative complication rate for women who underwent any type of rectal surgery (shaving, excision and suture, or segmental resection) was 9.3% (21 out of 226), compared with only 1.5% for the other women (five out of 342) (P < .01). Shaving presented less major postoperative complications compared with segmental resection (24 versus 6.7%; P = 0.004). CONCLUSIONS: surgery for deep endometriosis is feasible, but it is associated with major complications, especially when any type of rectal surgery must be performed.
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Endometriose/cirurgia , Complicações Intraoperatórias/etiologia , Complicações Pós-Operatórias/etiologia , Doenças Retais/cirurgia , Doenças Uterinas/cirurgia , Doenças Vaginais/cirurgia , Adulto , Estudos de Viabilidade , Feminino , Humanos , Tempo de Internação , Pessoa de Meia-Idade , Pelve , Estudos Retrospectivos , Adulto JovemRESUMO
The pelvic organ prolapse (POP) is a common gynaecological problem, affecting nearly 50% of women over 40. The sacrocolpopexy using a synthetic mesh is now considered the "gold standard" for management of women with apical prolapse. In April 2019 the FDA placed a ban on the production of transvaginal meshes for prolapse due to late complications. The meshes for abdominal repair of POP are still used, but in future they may also be prohibited. The goal of the following video is to present a mesh-less modification of two techniques used for apical organ prolapse, the sacrocolpopexy and the pectopexy.
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OBJECTIVE: The aim of this study was to assess incidence, causes and consequences of equipment failures in a high volume, advanced endoscopic surgery department. METHODS: This is a prospectical observational single centre study between April and July of 2019 in the Gynecological surgery department of the Estaing University Hospital of Clermont-Ferrand, France. During the study period, 171 laparoscopies were observed. Data were collected real time by three supernumerary observers. RESULTS: In total, 66 (38.6%) laparoscopies were complicated by equipment failures. The bipolar cable and forceps accounted for 31% of the total amount of malfunctions in laparoscopy. Causes of malfunctions were in 45% due to the instrument per se and in 43% due to the incorrect combination of elements. Less commonly, the equipment was not available or a mismatched was reported. The total length of the surgery increased by 1.35% due to the malfunctions. Human error was identified in 50% of cases. No morbility, neither mortality was reported in this series; however we observed 34 malfunctions that could have led to serious consequences for the patients and 3 incidents induced a real consequence on the operation workflow. CONCLUSIONS: Equipment failure is a common event in endoscopy. On the opposite, time wasted for the malfunctions is low in laparoscopy, as it only accounts for 1.35% of the overall surgical time. Human decisions contributed to malfunctions in almost half of cases. This alarming finding may advise for intensification in training on instruments of the whole surgical team.
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Laparoscopia , Falha de Equipamento , Feminino , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Humanos , Laparoscopia/efeitos adversos , Duração da Cirurgia , Instrumentos Cirúrgicos/efeitos adversosRESUMO
In this retrospective study of 314 patients undergoing surgery for ovarian dermoid cysts, conducted over a 20-year period, we evaluated the impact of the routine use of laparoscopic surgery without recourse to laparotomy to retrieve the specimen, using an endoscopic retrieval bag placed under the cyst to prevent intraperitoneal spillage of cyst contents, and subsequent postoperative granulomatous peritonitis. Accidental cyst rupture was more frequent when a total laparoscopic approach was used (26/174 or 15% versus 39/140 or 28%; P = 0.005), but there were no cases of intraperitoneal spillage when an endoscopic bag was used. Two cases of granulomatous peritonitis developed out of 26 women with intraperitoneal spillage of cyst contents (8%). We conclude that the risk of granulomatous peritonitis can be minimised by undertaking laparoscopic removal of dermoid cysts with the routine intraoperative use of an endoscopic retrieval bag to prevent intraperitoneal spillage of cyst contents.
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Cisto Dermoide/cirurgia , Laparoscopia/métodos , Neoplasias Ovarianas/cirurgia , Peritonite/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Adolescente , Adulto , Idoso , Feminino , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Manejo de Espécimes/métodos , Adulto JovemRESUMO
BACKGROUND: Structured laparoscopic training courses are important in surgical education. Different programmes have been proposed, but there is currently no evidence available comparing the performance of specialists versus residents in Obstetrics and Gynaecology at these courses. OBJECTIVE: To evaluate the impact of the laparoscopic component of Gynaecological Endoscopic Surgical Education and Assessment (GESEA) Training and Certification courses in two different populations. MATERIALS AND METHODS: Prospective cohort study. Two groups were analysed - participants of the Residents' Courses and participants of the Annual Francophone GESEA Diploma Course. Both groups were evaluated using the GESEA Level 1 laparoscopic standardised exercises and carried out in the International Center of Endoscopic Surgery (CICE), Clermont Ferrand, France in 2019. RESULTS: 57 French residents and 69 participants of the Annual GESEA Diploma were evaluated. The average age of participants in the Residents' Course was lower than those in the Annual Diploma Course (28.4±1.6 versus 35.2±8.0 years, p<0.001). Residents had higher previous experience in laparoscopic surgery (42% vs 36%, p< 0.001), in animal model surgery and in laparoscopic training box (67% vs 36% and 93% vs 67% respectively, p<0.001). Notable improvement was noted in both groups in the camera navigation exercise; first attempt 105±19 vs 117±9 seconds and final attempt 81±15 and 103±20 seconds respectively (p<0.001). CONCLUSIONS: Both groups improved significantly in most of the tests evaluated. French residents had better results in all evaluations, except in one aspect of the suture exercise (maintaining optimal results in performing the knot). After excluding the residents who attended the Annual Diploma Course, all the differences between both groups were statistically more significant.
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Spontaneous evolution of autoimmune hepatitis during pregnancy is not well known, nor are its consequences on pregnancy evolution. Immunosuppressive treatment during pregnancy is sometimes necessary but the long- and short-term consequences are unrecognized. We relate a patient's disease with autoimmune hepatitis and cirrhosis and three consecutive pregnancies with different obstetrical and medical complications.
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Azatioprina/efeitos adversos , Hepatite Autoimune/complicações , Imunossupressores/efeitos adversos , Prednisona/uso terapêutico , Adulto , Autoanticorpos/sangue , Azatioprina/uso terapêutico , Feminino , Hepatite Autoimune/tratamento farmacológico , Humanos , Imunossupressores/uso terapêutico , Recém-Nascido , Prednisona/efeitos adversos , Gravidez , Complicações Infecciosas na Gravidez , Resultado da GravidezRESUMO
Peritoneal adhesions remain a major public health problem despite the development of laparoscopy. The rules of microsurgery must be known and followed during any pelvic surgery, even in patients who no longer have a desire for pregnancy. Anti-adhesion products are numerous. All have interest, confirmed by anatomical studies showing a smaller extent or a lesser severity of adhesions associated with their use. No studies, however, show clinical benefit in terms of improved pain or postoperative fertility. Pneumoperitoneum parameters, humidification, and lower abdominal pressure should be optimized to limit peritoneal trauma. Peri-operative corticosteroids, whose benefit has been has been demonstrated in at least one randomized trial, should be systematically used.
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Infertilidade/prevenção & controle , Laparoscopia/métodos , Microcirurgia/métodos , Doenças Peritoneais/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Aderências Teciduais/prevenção & controle , Humanos , Infertilidade/etiologia , Laparoscopia/efeitos adversos , Microcirurgia/efeitos adversos , Doenças Peritoneais/etiologia , Complicações Pós-Operatórias/etiologia , Aderências Teciduais/etiologiaRESUMO
In order to offer our patients, the "state of the art" treatment in gynaecology, we need a structured teaching program for trainees concerning the gynaecological skills. In recent years, training and education in endoscopic surgery has been critically reviewed. Clinicians, both surgeons as gynaecologists who perform endoscopic surgery without proper training of the specific psychomotor skills, are at higher risk to increased patient morbidity and mortality. The traditional apprentice-tutor model is no longer valid for developing all skills necessary in gynaecological surgery, particularly in endoscopy. Endoscopic training should happen at both the theoretical and the practical skill level. The acquisition of the correct knowledge regarding general laparoscopy, hysteroscopy and standard level procedures is as important as learning the necessary psychomotor skills to successfully perform endoscopic manipulations. Training in the operating room can only start when it is proven that knowledge and skills are present. To learn and train total abdominal hysterectomy by laparotomy there are inexpensive simple models that can be used, which are easy to reproduce. The development, construction, cost, and utility of a low-cost and anatomically representative vaginal hysterectomy simulator also has been described. The complexity of modern surgery has increased the demands and challenges to surgical education and the quality control.
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OBJECTIVES: To evaluate the feasibility and functional urinary and digestive results of nerve sparing techniques in endometriosis surgery. METHODS: A research on the medline/pubmed database using specific keywords (nerve sparing, endometriosis, pelvic nerves) identified 7 publications among about 50 whose purpose was to describe the feasibility, the techniques and the functional results of nerve preservation in this indication. Among them there are: 2 uncontrolled retrospective studies, 3 prospective non-randomized studies, a meta-analysis and a review of the literature. RESULTS: Nerve preservation requires a perfect knowledge of the anatomy of the pelvic autonomic system. The laparoscopic approach is preferred by the different authors due to its anatomical advantage. The feasibility of this technique seems to be demonstrated despite certain limitations in the different studies and depending of the retroperitoneal extension of the lesions. When feasible, it is likely to significantly improve postoperative urinary function (urinary retention) compared to a conventional technique. It is observed no difference regarding digestive function. CONCLUSIONS: Nerve sparing in this indication is a technique the feasibility of which has been demonstrated and is subject to the topography and extent of the disease. In the absence of invasion or entrapment of pelvic autonomic nerves by endometriosis, this technique improves postoperative voiding function (NP3). During pelvic surgery for endometriosis, it is recommended to identify and preserve autonomic pelvic nerves whenever possible (GradeC).
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Endometriose/cirurgia , Traumatismos dos Nervos Periféricos/prevenção & controle , Feminino , Humanos , Plexo Hipogástrico , Laparoscopia , Tratamentos com Preservação do Órgão , Pelve/inervação , Transtornos Urinários/prevenção & controleRESUMO
The article presents French guidelines for surgical management of endometriosis. Surgical treatment is recommended for mild to moderate endometriosis, as it decreases pelvic painful complaints and increases the likelihood of postoperative conception in infertile patients (A). Surgery may be proposed in symptomatic patients with ovarian endometriomas which diameter exceeds 20mm. Cystectomy allows for better postoperative pregnancy rates when compared to ablation using bipolar current, as well as for lower recurrences rates when compared to ablation using bipolar current or CO2 laser. Ablation of ovarian endometriomas using bipolar current is not recommended (B). Surgery may be employed in patients with deep endometriosis infiltrating the colon and the rectum, with good impact on painful complaints and postoperative conception. In these patients, laparoscopic route increases the likelihood of postoperative spontaneous conception when compared to open route. When compared to conservative rectal procedures (shaving or disc excision), segmental colorectal resection increases the risk of postoperative stenosis, requiring additional endoscopic or surgical procedures. In large deep endometriosis infiltrating the rectum (>20mm length of bowel infiltration), conservative rectal procedures do not improve postoperative digestive function when compared to segmental resection. In patients with bowel anastomosis, placing anti-adhesion agents on contact with bowel suture is not recommended, due to higher risk of bowel fistula (C). Various other recommendations are proposed in the text, however, they are based on studies with low level of evidence.
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Endometriose/cirurgia , Adulto , Doenças do Colo/etiologia , Doenças do Colo/cirurgia , Cistectomia , Endometriose/complicações , Feminino , Humanos , Histerectomia , Laparoscopia , Doenças Retais/etiologia , Doenças Retais/cirurgia , Doenças Urológicas/etiologia , Doenças Urológicas/cirurgiaRESUMO
First-line investigations to diagnose endometriosis are clinical examination and pelvic ultrasound. Second-line investigations include pelvic examination performed by a referent clinician, transvaginal ultrasound performed by a referent echographist, and pelvic MRI. It is recommended to treat endometriosis when it is symptomatic. First-line hormonal treatments recommended for the management of painful endometriosis are combined with hormonal contraceptives or levonorgestrel 52mg IUD. There is no evidence to recommend systematic preoperative hormonal therapy for the unique purpose of preventing the risk of surgical complications or facilitating surgery. After endometriosis surgery, combined hormonal contraceptives or levonorgestrel SIU 52mg are recommended as first-line therapy in the absence of desire of pregnancy. In case of initial treatment failure, recurrence, or multiple organ involvement by endometriosis, medico-surgical and multidisciplinary discussion is recommended. The laparoscopic approach is recommended for the surgical treatment of endometriosis. HRT may be offered in postmenopausal women operated for endometriosis. In case of infertility related to endometriosis, it is not recommended to prescribe anti-gonadotropic hormone therapy to increase the rate of spontaneous pregnancy, including postoperatively. The possibilities of fertility preservation should be discussed with the patient in case of surgery for ovarian endometrioma.
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Endometriose/diagnóstico , Endometriose/terapia , Terapias Complementares , Anticoncepcionais Orais Hormonais , Diagnóstico por Imagem , Feminino , Exame Ginecológico , Humanos , Infertilidade Feminina/etiologia , Infertilidade Feminina/terapia , Educação de Pacientes como Assunto , Dor Pélvica/tratamento farmacológico , Dor Pélvica/etiologiaRESUMO
First-line diagnostic investigations for endometriosis are physical examination and pelvic ultrasound. The second-line investigations are: targeted pelvic examination performed by an expert clinician, transvaginal ultrasound performed by an expert physician sonographer (radiologist or gynaecologist), and pelvic MRI. Management of endometriosis is recommended when the disease has a functional impact. Recommended first-line hormonal therapies for the management of endometriosis-related pain are combined hormonal contraceptives (CHCs) or the 52mg levonorgestrel-releasing intrauterine system (IUS). There is no evidence base on which to recommend systematic preoperative hormonal therapy solely to prevent surgical complications or facilitate surgery. After surgery for endometriosis, a CHC or 52mg levonorgestrel-releasing IUS is recommended as first-line treatment when pregnancy is not desired. In the event of failure of the initial treatment, recurrence, or multiorgan involvement, a multidisciplinary team meeting is recommended, involving physicians, surgeons and other professionals. A laparoscopic approach is recommended for surgical treatment of endometriosis. HRT can be offered to postmenopausal women who have undergone surgical treatment for endometriosis. Antigonadotrophic hormonal therapy is not recommended for patients with endometriosis and infertility to increase the chances of spontaneous pregnancy, including postoperatively. Fertility preservation options must be discussed with patients undergoing surgery for ovarian endometriomas.