Jean-Bernard Dubuisson

Relation between pain symptoms and the anatomic location of deep infiltrating endometriosis

OBJECTIVE To investigate whether specific types of pelvic pain are correlated with the anatomic locations of deeply infiltrating endometriosis (DIE). DESIGN Retrospective data analysis. SETTING University tertiary referral center. PATIENT(S) Two hundred and twenty-five women with pelvic pain symptoms and DIE. INTERVENTION(S) During surgery, we recorded the anatomic locations of DIE implants and associated endometriosis. MAIN OUTCOME MEASURE(S) We studied the incidence of pelvic pain symptoms including severe dysmenorrhea, deep dyspareunia, noncyclic chronic pelvic pain, painful defecation during menstruation, urinary tract symptoms, and gastrointestinal symptoms as related to the location of DIE. RESULT(S) The frequency of severe dysmenorrhea increased with Douglas pouch adhesions and decreased with parity. The frequency of dyspareunia increased with a uterosacral ligament DIE location and decreased when it involved the bladder. The frequency of noncyclic chronic pelvic pain was higher when it involved the bowel and was lower for women who were treated for infertility. The frequency of painful defecation during menstruation was higher when DIE involved the vagina; lower urinary tract symptoms were more frequent when DIE involved the bladder and less frequent in women with a lower body mass index. Gastrointestinal symptoms were associated with bowel or vaginal DIE locations. CONCLUSION(S) The types of pelvic pain are related to the anatomic location of DIE. Knowledge of the characteristics of pelvic pain symptoms is important in the preoperative assessment of patients with suspected DIE.

Major vascular injuries during gynecologic laparoscopy

BACKGROUND This study was undertaken to report our experience with major vascular injuries in gynecologic laparoscopy in order to specify the circumstances under which they occurred, the means of diagnosis, the risk factors, and the means for prevention. STUDY DESIGN Retrospective case review study. RESULTS Seventeen patients with 21 major vascular injuries were identified. The average age of the patients was 33.8 +/- 11.6 years, and the mean body index mass was 21.6 +/- 3.08 kg/m2. Three of four of the accidents occurred during the set-up phase of laparoscopy (13 cases; 76.5%), and in 4 cases (23.5%) the accident occurred during the laparoscopic surgery procedure. Eleven (84.6%) of the complications occurring during the set-up phase were secondary to insertion of the umbilical trocar and 2 (15.4%) to insertion of the needle used to create the pneumoperitoneum (P-needle). Half (6 cases; 54.5%) of the major vascular injuries secondary to insertion of the umbilical trocar were observed when reusable trocars were used. In every case, the diagnosis was made during the operation. Two patients died, and two others presented a serious complication (phlebitis; acute ischemia requiring reoperation). CONCLUSIONS Major vascular injuries are rare but serious complications of laparoscopic surgery. Prevention of these accidents relies on the surgeons experience and scrupulous respect of the safety rules. In the vast majority of cases, it is necessary to convert to laparotomy immediately, calling in a vascular surgeon.

Fertility after laparoscopic myomectomy of large intramural myomas: preliminary results.

Fertility outcome following laparoscopic myomectomy was evaluated. A prospective clinical study was carried out between October 1990 and October 1993 in 21 infertile patients who underwent laparoscopic myomectomy for a myoma measuring > or = 5 cm in diameter. The overall rate of intrauterine pregnancy was 33.3% (seven patients). Out of 12 patients with infertility factors associated with uterine myomas, three (25.0%) became pregnant, whereas four (44.4%) out of nine patients with no other associated infertility factor became pregnant. No uterine rupture was observed. Out of the seven pregnancies, four were spontaneous and began within 1 year of the operation. The other three were achieved after in-vitro fertilization in patients with associated infertility factors. In the four patients who gave birth by Caesarean section, no adhesions were found on the myomectomy scar. From these preliminary results, laparoscopic surgery for myomas seems to offer comparable results with those obtained by laparotomy.

Recurrence of Leiomyomata after Laparoscopic Myomectomy

STUDY OBJECTIVE To assess recurrence of leiomyomata after laparoscopic myomectomy (LM) and evaluate predictive factors of recurrence. DESIGN Observational study (Canadian Task Force classification II-2). SETTING University hospital. PATIENTS One hundred ninety-six women. INTERVENTION Laparoscopic myomectomy with mean follow-up of 47 months. MEASUREMENTS AND RESULTS Myoma recurrence included recurrence of initial symptomatology before LM, recurrence at clinical examination, and appearance of a myoma 2 cm or larger on ultrasound examination. Recurrence was observed in 45 patients (22.9%). The mean time before recurrence was 42 months (range 4-95 mo). Eight women (4.08%) required reoperation. The cumulative recurrence risk was 12.7% at 2 years and 16.7% at 5 years. Predictive factors for recurrence were number of myomas and nulliparity. CONCLUSION According to our results, the cumulative rate of myoma recurrence within 5 years appears greater after LM than after laparotomy. However, this should not lead us to reject laparoscopy, which has many advantages compared with laparotomy, in particular its low morbidity.

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.

Management of Deep Endometriosis

Deep endometriosis is defined as an endometriotic lesion that penetrates the retroperitoneal space for a distance of ≥5 mm. Deep endometriosis is extremely active, occurs in phase with eutopic endometrium, evolves progressively with age, and is most often located in the pouch of Douglas, the rectovaginal septum, the uterosacral ligaments, and occasionally in the uterovesical fold. These lesions are associated with pelvic pain, the intensity of which is proportional to the depth of penetration. It is clear that choice of treatment depends on the location of the endometriotic lesion. In this paper we describe our methods for the initial diagnosis and subsequent treatment of deep endometriosis. These include consultation and clinical examination protocols, use of rectal endoscopic ultrasonography (EUS), magnetic resonance imaging (MRI), and transvaginal ultrasonography techniques in diagnosis and surgical treatment approaches.

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.

Contact hysteroscopy: Another method of endoscopic examination of the uterine cavity

Recently there has been renewed interest in hysteroscopy which, since its discovery a century ago, has been in a state of uncertainty. Classical hysteroscopes all require the dilatation of the uterine cavity by the injection of a fluid under pressure. With contact hysteroscopy, the image is obtained by the applciation of the end of the apparatus against the uterine mucosa. This simplifies the equipment and opens up new possibilities. The results of more than 1,000 contact hysteroscopies done in the various circumstances of gynecology and the pathology of pregnancy are presented. The facility of this technique should contribute to the increased use of visual exploration of the uterine cavity, the advantages of which have already been shown.

Robotic Surgery in Gynecology.

Minimally invasive surgery (MIS) can be considered as the greatest surgical innovation over the past 30 years. It revolutionized surgical practice with well-proven advantages over traditional open surgery: reduced surgical trauma and incision-related complications, such as surgical-site infections, postoperative pain and hernia, reduced hospital stay, and improved cosmetic outcome. Nonetheless, proficiency in MIS can be technically challenging as conventional laparoscopy is associated with several limitations as the two-dimensional (2D) monitor reduction in-depth perception, camera instability, limited range of motion, and steep learning curves. The surgeon has a low force feedback, which allows simple gestures, respect for tissues, and more effective treatment of complications. Since the 1980s, several computer sciences and robotics projects have been set up to overcome the difficulties encountered with conventional laparoscopy, to augment the surgeon’s skills, achieve accuracy and high precision during complex surgery, and facilitate widespread of MIS. Surgical instruments are guided by haptic interfaces that replicate and filter hand movements. Robotically assisted technology offers advantages that include improved three-dimensional stereoscopic vision, wristed instruments that improve dexterity, and tremor canceling software that improves surgical precision.