Hubert Manhes

Dienogest is as effective as triptorelin in the treatment of endometriosis after laparoscopic surgery: results of a prospective, multicenter, randomized study

OBJECTIVE To compare the efficacy of Dienogest versus Decapeptyl at 3.75 mg as consolidation therapy for surgery in the treatment of endometriosis. DESIGN Multicenter, open, randomized, parallel-group clinical trial. SETTING Volunteer patients in an academic research environment. PATIENT(S) Women with grade 2, 3, and 4 (</=70) endometriosis at initial laparoscopy. INTERVENTION(S) We provided 16 weeks of treatment with Dienogest, 1 mg tablet daily; or with Decapeptyl, 3.75 mg IM injection every 4 weeks. MAIN OUTCOME MEASURE(S) A change in the patients Revised American Fertility Society score at the post-treatment laparoscopy. RESULT(S) From June 1994 to July 1998, 142 patients were enrolled in the trial. After exclusion for major protocol deviations, 59 patients were included in the Dienogest group and 61 in the Decapeptyl group. This study group was comparable to the first inclusion group. The patient demographic and clinical characteristics, median duration of endometriosis, Revised American Fertility Society scores, and Visual Analogic Squale (VAS) scores were comparable in both groups. Statistical analysis of efficacy was not significantly different between the two groups. Adverse events were reported by 87.7% of patients in the Dienogest group and 85.1% in the Decapeptyl group. Neither treatment affected patient body weight or vital signs. CONCLUSION(S) Dienogest is as effective as Decapeptyl for consolidation therapy after surgery for the treatment of endometriosis. The safety profile of dienogest differed from Decapeptyl (3.75 mg). Dienogest constitutes a new therapeutic alternative to the GnRH analogues.

Laparoscopic management of adnexal masses suspicious at ultrasound

Objective To evaluate the laparoscopic management of adnexal masses suspicious at ultrasound. Methods In a prospective study, adnexal masses suspicious at ultrasound were managed by laparoscopy. Indications for laparotomy included general contraindications to laparoscopy, obviously disseminated ovarian cancer, and technically impossible laparoscopic treatment. After laparoscopic diagnosis, frozen sections were used to confirm a diagnosis of malignancy. Treatment was performed by laparoscopy whenever feasible. Results Over a 3-year period, 247 of the 599 adnexal masses (41.2%) treated in our department were suspicious or solid at ultrasound. Seventeen patients were evaluated by laparotomy and 230 by laparoscopy. Overall, 204 women (82.6%) were treated by laparoscopy, including seven of the 37 malignant tumors (18.9%) and 197 of the 210 benign masses (93.8%). One case of tumor dissemination occurred after a laparoscopic adnexectomy and morcellation of a grade 1 immature teratoma. Conclusion Laparoscopic diagnosis of adnexal masses suspicious at ultrasound avoids many laparotomies for the treatment of benign masses and allows an improved inspection of the upper abdomen. The laparoscopic treatment of adnexal masses suspicious at surgery should be evaluated further in carefully designed prospective studies.

Multifactorial analysis of fertility after conservative laparoscopic treatment of ectopic pregnancy in a series of 223 patients

OBJECTIVES To lay down the criteria to clearly define whether conservative or radical laparoscopic treatment should be adopted in cases of ectopic pregnancies (EP). DESIGN Retrospective, noncomparative. SETTING At the University Hospital of Clermont Ferrand and the La Pergola Clinic at Vichy from July 1974 to December 1987. PATIENTS This study was carried out in 223 patients who had been treated laparoscopically for EP and who desired future childbearing and who were not lost to follow-up. MAIN OUTCOME MEASURES The measures chosen to achieve the objective included age, parity, size of hematosalpinx, volume of hemoperitoneum, tubal rupture, location, intrauterine device, ipsilateral and contralateral adhesions, and patients previous history of salpingitis, EP, solitary tube, and tubal infertility. RESULTS The general intrauterine pregnancy rate was 67% (149 patients) and the recurrence rate 12% (27 patients). The results according to the studied factors demonstrated that age, parity, and the type of the EP have no influence on the postectopic fertility. The history of the patient, ipsilateral adhesions, or contralateral tubal status significantly reduce the future fertility prognosis and risk of recurrence. CONCLUSIONS From a multivariable analysis, the authors propose a scoring system to choose the most suitable treatment to preserve fertility and to reduce the risk of recurrence ranging from laparoscopic conservative treatment to laparoscopic salpingectomy with contralateral sterilization.

Laparoscopic distal tuboplasty: report of 87 cases and a 4-year experience.

OBJECTIVE To evaluate fertility results after laparoscopic distal tuboplasty and to compare these results with those obtained previously with microsurgery. DESIGN Retrospective, nonrandomized. SETTING Department of Obstetrics and Gynecology at the University Hospital of Clermont-Ferrand, France. PATIENTS All the distal tuboplasties performed between October 1985 and June 1989 were included. Adnexal damage was assessed using tubal and adhesions scoring systems described previously. Tuboplasty was carried out bilaterally except when one tube was absent or severely damaged (tubal stage III or IV and/or with severe adhesions). Patients with bilateral severe adnexal damages were treated only if they refused to undergo in vitro fertilization. Laparoscopic tuboplasty was performed either with the CO2 laser or with conventional instruments. MAIN OUTCOME MEASURE Fertility after laparoscopic treatment was evaluated using simple and cumulative pregnancy rates (PRs) according to the adnexal damage and compared with the microsurgical results using PRs according to the adnexal damage. RESULTS The overall intrauterine and extrauterine PRs were 33.3% and 6.9%, respectively. Twenty-six of the 29 intrauterine pregnancies were obtained within the 1st postoperative year. According to tubal and adhesion stages, the results of laparoscopic distal tuboplasty are similar to those obtained using microsurgery. CONCLUSION We conclude that laparoscopic distal tuboplasty, when performed by experienced surgical laparoscopists, represents an effective alternative to microsurgery.

Incidence of bilateral adnexal disease in severe endometriosis (revised American Fertility Society [AFS], stage IV): should a stage V be included in the AFS classification?*

Studying the incidence of bilateral adnexal disease and dense adhesions, two groups of patients with severe endometriosis were distinguished, suggesting that a stage V needs to be considered in the AFS classification.

Techniques for Ablation and Excision of Endometriosis

The goals of surgical treatment of endometriosis are to completely ablate and/or excise active endometriotic tissue and correct anatomic distortions caused by adhesions and cystic lesions.1 Over the past few years, laparoscopic surgery has become a valuable addition to conventional and microsurgical approaches by laparotomy. The choice of approach (laparotomy or laparoscopy), surgical technique (excision, coagulation, vaporization), and instruments (CO2 laser, electrocautery, or scissors) is according to the surgeon’s preference (see Figs. 10.1 through 10.6 and color plates 10.1 through 10.6). The key issue is to adequately identify and treat the disease. By selecting the most effective surgical modality for each location and each patient, the desired postoperative results can best be achieved. A wide variety of surgical and medical treatments are now available, but it is important to take into account the limits of each approach.

Surgical treatment of ectopic pregnancy associated with predisposing factors of tuboperitoneal infertility

Abstract Objective: We sought to study the advantages of laparoscopic conservative treatment and pelvic reproductive surgery in patients with ectopic pregnancy and predisposing factors of tuboperitoneal infertility. Material and methods: Patients who had undergone laparoscopic treatment for ectopic pregnancy were considered, with factors for tuboperitoneal infertility, while patients who underwent previous salpingectomy or assisted reproductive technology were excluded. The groups treated by salpingotomy (conservative) or salpingectomy (radical) were compared in terms of spontaneous intrauterine pregnancy rate, cumulative one-year pregnancy rate and recurrence of ectopic pregnancy. We considered patients treated with adhesiolysis, fimbrioplasty, and neosalpingostomy for tubal pathology as part of the fertility surgery group. Results: Among 41 considered patients, 21 (51%) underwent conservative laparoscopic management of ectopic pregnancy. Twenty patients (49%) had salpingectomy. Despite the treatment of tuboperitoneal infertility factors in both groups, the pregnancy rate was significantly higher in the conservative group than in the radical one (76% vs 25%, p < 0.05). The overall cumulative rate of ectopic pregnancy recurrence was 22% and no significant difference was found between conservative and radical treatment (p 0.645). Conclusions:Salpingotomy should be preferred in all patients with ectopic pregnancy associated with factors of tuboperitoneal infertility. Infertility surgery clearly cannot help patients treated with salpingectomy, who obtain lower spontaneous pregnancy rates than those of the conservative group.

Increased diagnostic accuracy of laparoscopy in endometriosis using indigo carmine: a new technique

We read with interest and pleasure the technique proposed by Rauh-Hain and Laufer (1) to increase the diagnostic accuracy of laparoscopy in endometriosis. The diagnosis of superficial implants may be difficult, particularly the identification of the limits of the disease. Therefore, a staining technique would be useful to identify abnormal peritoneal areas helping the surgeons to decide the limits of the surgical treatment. We would like to propose three comments to this approach.

Treatment of Adnexal Masses and Laparoscopy

The laparoscopic treatment of adnexal masses has become the gold standard within the last few years. However, there are few extensive descriptions of the procedure; it is generally summarised as a “stripping” procedure without any detail. Nevertheless, a good laparoscopic technique and adequate surgical management are required to ensure optimal patient care. In this chapter, we will discuss: the treatment technique that should be adapted to each pathological diagnosis; postoperative adhesions; the limits of the laparoscopic approach, accounting for all the clinical and experimental data recently reported about tumour dissemination.

5-aminolevulinic acid (ALA) induced fluorescence for laparoscopic diagnosis of peritoneal metastasis : an experimental study

Ovarian cancer is the most frequent cause of gynecologic cancer-related death in the United States. In patients with advanced disease, the initial steps of the treatment, surgical debulking and chemotherapy are efficacious as evidenced by negative second look laparotomies or laparoscopies. However 1 5% to 50% of the patients with negative second look will subsequently experience recurring disease whithin 5 years and will inevitably die from the disease.(1) Therefore any approach which would improve the sensitivity and decrease the invasiveness of this procedure would be very attractive to improve the management and the quality of life of these patients.