Hervé Foulot

Myomectomy by laparoscopy: a preliminary report of 43 cases

OBJECTIVE To evaluate the technique and short-term results of intraperitoneal (IP) myomectomies. DESIGN From January 1, 1990, to March 1, 1991, IP myomectomies were performed in all cases in which it appeared feasible. SETTING This study was conducted in a tertiary care center, the Port-Royal University Hospital. PATIENTS, PARTICIPANTS Among 49 consecutive patients with interstitial or subserous myomas, 6 patients with voluminous, multiple myomas had laparotomies. Intraperitoneal myomectomy was performed in 43 patients. The indication for laparoscopy was a pelvic mass in 29 cases, infertility in 13, and severe endometriosis in 1 case. INTERVENTIONS Thermocoagulation or monopolar coagulation was used for the uterine incision. Myometrium and serosa were sutured in 23 of 43 patients. Myomas were removed through the suprapubic puncture site after fragmentation of large myomas. MAIN OUTCOME MEASURE(S) We evaluated the length of the procedures, blood loss, and postoperative course. RESULTS Ninety-two myomas were removed laparoscopically. No complication was observed. CONCLUSIONS In selected cases, IP myomectomy appears to be a safe technique with the advantages of laparoscopic surgery.

Associated ovarian endometrioma is a marker for greater severity of deeply infiltrating endometriosis

OBJECTIVE To investigate whether an associated ovarian endometrioma is a marker for severity of deep infiltrating endometriosis (DIE). DESIGN Observational study between June 1992 and December 2005. SETTING University tertiary referral center. PATIENT(S) Five hundred patients with histologically assessed DIE. INTERVENTION(S) Complete surgical exeresis of deep endometriotic lesions. MAIN OUTCOME MEASURE(S) Severity of the disease was quantified according to the mean number of DIE lesions and the type of main lesion. RESULT(S) In patients with associated ovarian endometrioma, the number of single isolated DIE lesions was statistically significantly lower (41.9% vs. 61.1%). The mean number of DIE lesions was statistically significantly higher in patients presenting with an associated ovarian endometrioma (2.51 +/- 1.72 vs. 1.64 +/- 1.0). For patients with associated ovarian endometrioma DIE lesions were more severe with an increased rate of vaginal, intestinal, and ureteral lesions. CONCLUSION(S) Associated ovarian endometrioma is a marker for the severity of the DIE. In a clinical context suggestive of DIE, when there is an ovarian endometrioma, the practitioner should investigate the extent of the disease to check for severe and multifocal DIE lesions.

In vitro fertilization without ovarian stimulation: a simplified protocol applied in 80 cycles

Ovulation induction with various hormonal agents has become a standard component of in vitro fertilization (IVF) cycles to obtain multiple oocytes. Failure to anticipate the retrieval of more than two oocytes often results in cancellation of the cycle. In this study, we report our results in 80 unstimulated IVF cycles. Serum estradiol (E2) and pelvic ultra-sound monitoring were begun on day 9 of the cycle. Human chorionic gonadotropin (hCG) was administered when the E2 level exceeded 180 pg/mL and the dominant follicle was greater than 18 mm. Eighteen pregnancies were obtained (22.5%/cycle), and 14 (17.5%/cycle) are ongoing. We conclude that favorable results can be obtained from unstimulated IVF cycles, despite replacement of a single embryo.

Ovarian endometrioma: severe pelvic pain is associated with deeply infiltrating endometriosis

BACKGROUND The objective of this study was to evaluate the significance of severe preoperative pain for patients presenting with ovarian endometrioma (OMA). METHODS Three hundred consecutive patients with histologically proven OMA were enrolled at a single university tertiary referral centre between January 2004 and May 2010. Complete surgical excision of all recognizable endometriotic lesions was performed for each patient. Pain intensity was assessed with a 10-cm visual analogue scale (VAS). Pain was considered as severe when VAS was ≥ 7. Prospective preoperative assessment of type and severity of pain symptoms (VAS) was compared with the peroperative findings (surgical removal and histological analysis) of endometriomas and associated deeply infiltrating endometriosis. Correlations were sought with univariate analysis and a multiple regression logistic model. RESULTS After multiple logistic regression analysis, uterosacral ligaments involvement was related with a high severity of chronic pelvic pain [odds ratios (OR) = 2.1; 95% confidence interval (CI): 1.1-4.3] and deep dyspareunia (OR = 2.0; 95% CI: 1.1-3.5); vaginal involvement was related with a higher intensity of lower urinary symptoms (OR = 13.4; 95% CI: 3.2-55.8); intestinal involvement was related with an increased severity of dysmenorrhoea (OR = 5.2; 95% CI: 2.7-10.3) and gastro-intestinal symptoms (OR = 7.1; 95% CI: 3.3-15.3). CONCLUSIONS In case of OMA, severe pelvic pain is significantly associated with deeply infiltrating lesions. In this situation, the practitioner should perform an appropriate preoperative imaging work-up in order to evaluate the existence of associated deep nodules and inform the patient in order to plan the surgical intervention strategy.

High rate of recurrence of cervical intraepithelial neoplasia after surgery in HIV-positive women.

Objective:Our study investigated the rate of recurrence of cervical intraepithelial neoplasia (CIN) in HIV-positive women after surgery in the era of highly active antiretroviral therapy (HAART). Methods:One hundred twenty-one HIV-positive women were followed-up with cytology, colposcopy, and histology after surgery for CIN. We conducted univariate and multivariate analyses to determine the relation between recurrence of CIN and risk factors using Cox proportional hazard models with left truncation. Results:The rate of recurrence of any CIN was 22.3 per 100 patient-years and the rate of high-grade CIN was 8.6 per 100 patient-years during 166 and 279 patient-years of follow-up, respectively. In multivariate analysis, a positive margin was associated with a risk of recurrence of any CIN (relative risk [RR] = 3.5, 95% confidence interval [CI]: 1.2-9.8) and a risk of recurrence of high-grade CIN (RR = 9.0, 95% CI: 2.2-36.5). CD4 counts <200 cells/mm3 were associated with a risk of recurrence of any CIN (RR = 9.4, 95% CI: 2.7-32.7) but not with a risk of recurrence of high-grade CIN. HAART exhibited a protective effect on the recurrence of any CIN (RR = 0.3, 95% CI: 0.1-0.7) and of high-grade CIN (RR = 0.2, 95% CI: 0.1-0.7). Conclusion:CD4 cell counts <200/mm3 and a positive margin were predictors of recurrence, whereas HAART had a strong protective effect. Although surgery is highly effective in immunocompetent patients, it seems to be effective only in preventing progression to cancer in HIV-infected women.

Surgical Management of Deeply Infiltrating Endometriosis: An Update

Abstract: 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.

Reproductive outcome after laparoscopic salpingectomy for tubal pregnancy

Since 1983, we have performed laparoscopic salpingectomy as a routine procedure for ectopic pregnancy (EP) in cases where conservative management is impossible or contraindicated. The main indications are a ruptured tubal gestation, a pathological tube, a history of tuboplasty, and an ipsilateral recurrence. This technique is simple, quick, and safe. Reproductive outcome after laparoscopic total salpingectomy for EP was evaluated in 125 cases between January 1983 and December 1987. The pregnancy rate was 33.6%. In our population, there was a high proportion of patients with a pathological or absent contralateral tube (74.4%). In patients with a normal contralateral tube (32 cases), the live birth rate (46.9%) was greater but not significantly than in patients (39 cases) with a patent but pathological tube (25.6%). In vitro fertilization (IVF) was performed in 59 patients; clinical pregnancy was obtained in 40.7% of cases. These encouraging results lead us rapidly to consider IVF in patients with a pathological contralateral tube.

Terminal tuboplasties by laparoscopy : 65 consecutive cases

A series of 65 consecutive laparoscopic distal tuboplasties, performed from May 1986 to May 1988 is reported. Thirty-one were fimbrioplasties and 34 were neosalpingostomies. Outcome was evaluated at 18 months postoperatively. Twenty-two patients obtained pregnancies (33.8%), of which 18 were intrauterine (27.7%). The intrauterine pregnancy rate was 25.8% after fimbrioplasty and 29.4% after neosalpingostomy. These results are comparable with those obtained after microsurgery. Progress in operative laparoscopy may be attributed to the development of an appropriate atraumatic instrumentation and the CO 2 laser. The major advantage of laparoscopic techniques is their availability at the time of diagnostic laparoscopy. Immediate opening of hydrosalpinges allows for precise evaluation of the tubal mucosa, thereby establishing prognosis. In cases with a severely altered mucosa, in vitro fertilization may be considered immediately. When the mucosa is satisfactory, laparoscopic fimbrioplasty or neosalpingostomy may be performed. Within 1 year after one of these procedures, a pregnancy is generally achieved in 1 of 3 patients.

A new in vitro fertilization technique: intravaginal culture.

Intravaginal culture (IVC) is a new technique elaborated by the authors for the fertilization and culture of human oocytes. Its principle consists of fertilization and early development of the eggs in a closed, air-free milieu without the addition of CO2. One to five ovocytes are deposited in a tube completely filled with 3 ml of culture medium less than 1 hour after their recovery, with 10,000 to 20,000 spermatozoa per ml previously prepared. The tube is then hermetically closed and it is placed in the maternal vagina and held by a diaphragm for incubation for 44 to 50 hours. After this time, the content of the tube is examined and embryos are transferred to the uterus. In the first 100 consecutive punctures, 22 clinical pregnancies were obtained: 17 deliveries, 3 spontaneous abortions, and 2 tubal pregnancies. Also, a randomized study comparing IVC to in vitro fertilization (IVF) was done (160 cycles) and no statistically different cleavage, transfer, or pregnancy rate was seen between IVC and IVF. By simplifying the laboratory manipulations, this technique decreases the cost of IVF and permits its standardization and diffusion. It creates a psychologic comfort permitting active participation of the mother in this stage of embryo development. Also, the use of this technique may give greater knowledge of human gamete metabolism and of the physiology of reproduction.

Surgical management of cervical intraepithelial neoplasia in HIV-infected women.

OBJECTIVE Rates higher than 50% of positive margin after surgical treatment of cervical intraepithelial neoplasia (CIN) have been reported in HIV-infected women. We evaluated the efficacy of two excisional procedures, loop excision of the transformation zone (LLETZ) and electrosurgical conisation, in obtaining complete excision of CIN in HIV-infected patients. STUDY DESIGN Eighty HIV-infected women with CIN or suspicion of cervical cancer underwent 86 surgical excisions. The indication of surgical modalities depended on both the size and location of the lesion and on the length of the cervix. Univariate logistic regression was used to identify factors associated with positive surgical margins. RESULTS Preoperative colposcopy failed to visualize the entire transformation zone in 39% of cases, and showed that 93% of the lesions had endocervical extension. LLETZ was performed in 30 cases and electrosurgical conisation in 56 cases. Resection was complete, with negative margins, in 77% of cases (95% confidence interval, CI: 62-92%) after LLETZ and in 71% of case (95% CI: 60-83%) after electrosurgical resection. Residual disease was mostly located in the endocervical portion of histological specimen. During follow-up late complications such as cervical stenosis or unsatisfactory colposcopy were not observed. CONCLUSION Endocervical extension of CIN being frequent among HIV-infected women, LLETZ should not be the preferred procedure. Appropriate surgical management leading in reducing the rate of positive margins may help decreasing the risk of persistence or recurrence of lesions.