Lise Lecointre

Adolescent Endometriosis: Report of a Series of 55 Cases With a Focus on Clinical Presentation and Long-Term Issues.

STUDY OBJECTIVE To report the clinical presentation and long-term issues of adolescent endometriosis. DESIGN Retrospective cohort study. SETTING Single private clinical center, Bordeaux, France. PATIENTS Adolescents with a confirmed diagnosis of endometriosis. INTERVENTIONS Surgical excision or ablation or lesions performed at laparoscopy. MEASUREMENTS AND MAIN RESULTS Fifty-five adolescents, ages from 12 to 19 years (mean age 17.8), who were diagnosed with endometriosis from March 1998 to April 2013 were included in the study. Pain of various types was the leading symptom in all patients, except 2. Twenty-three patients had an adnexal mass identified preoperatively, and 5 had an associated infertility issue at the time of diagnostic laparoscopy. Four patients had an associated genital malformation. Fifty-one percent of the patients had a history of appendectomy. A familial history of endometriosis was reported by 19 patients (34.5%), with a first-degree relative affected in 14 cases (25.45%), and 47.3% of patients were smoking at least 5 cigarettes a day. Superficial implants was encountered in 31 cases (56.4%), endometriomas in 18 cases (32.72%), and deep infiltrating endometriosis (DIE) in 6 cases (10.90%). Sixty percent of patients were scored as stages I to II and 40% as stages III to IV. Five patients were lost to follow-up, and 37 had a follow-up ranging from 36 to 315 months (mean follow-up 125.5 months). Among the 50 patients not lost to follow-up, 13 (26%) had either no pain, or improved and had acceptable pain with medical treatment. Seventeen patients of the 50 adolescents not lost to follow-up (34%) underwent a repeat laparoscopy. A subsequent laparoscopic and/or magnetic resonance imaging scan was performed in 35 patients because of persistent pain. Among these, there was 12 endometriomas (7 recurrences) and 12 DIEs (3 recurrences), giving recurrence rates for endometriomas and DIEs of 36.84% and 50%, respectively. During the study, 18 patients wished to have a child. Thirteen had a delivery (72.2%), and 9 pregnancies occurred in patients who initially presented with stage I to II endometriosis. Of the 11 patients who had subfertility, 6 successfully conceived (54.5%). CONCLUSIONS Adolescent endometriosis is not a rare condition. In our study a familial history was reported in more than one-third of patients. Among those patients treated for DIE, there was a trend for higher rates of recurrences (symptoms or lesions) that required repeat laparoscopy. However, the impact on subsequent fertility appeared to have been limited.

Predicting the difficulty of operative vaginal delivery by ultrasound measurement of fetal head station

BACKGROUND: Clinical assessment of fetal head station is difficult and subjective; it is mandatory before attempting operative vaginal delivery. OBJECTIVE: The principal objective of our study was to assess whether measurement of the perineum‐to‐skull ultrasound distance was predictive of a difficult operative vaginal delivery. Secondary objectives included evaluation of the interobserver reproducibility of perineum‐to‐skull ultrasound distance and comparison of this measurement and digital examination in predicting a difficult operative delivery. STUDY DESIGN: This was a prospective cohort study including all cases of operative vaginal deliveries in singleton pregnancies in cephalic presentation >34 weeks’ gestation, from 2012 through 2015. All data were entered prospectively in a medical record system specially devised to meet the requirements of this study. RESULTS: Of the 659 patients in whom perineum‐to‐skull ultrasound distance was measured prior to operative vaginal delivery, 120 (18%) met the composite criterion for a difficult extraction. Perineum‐to‐skull ultrasound distance measurement of ≥40 mm was significantly associated with the occurrence of a difficult extraction based on the composite criterion, after adjustment for parity, presentation type, and fetal macrosomia (odds ratio, 2.38; 95% confidence interval, 1.51–3.74; P = .0002). The intraclass correlation coefficient between the perineum‐to‐skull ultrasound distance measured by the first operator and that measured by the second operator was 0.96 (95% confidence interval, 0.95–0.97; P < .0001). Based on the receiver operating characteristic curve analyses, perineum‐to‐skull ultrasound distance was a more accurate predictor of difficult operative delivery than digital vaginal examination (P = .036). CONCLUSION: Measurement of the perineum‐fetal skull ultrasound distance is a reproducible and predictive index of the difficulty of instrumental extraction. Ultrasound is a useful supplementary tool to the usual clinical findings.

Does the Number of Neoadjuvant Chemotherapy Cycles before Interval Debulking Surgery Influence Survival in Advanced Ovarian Cancer

Objective: To evaluate the overall survival (OS) of patients with initially inoperable advanced ovarian cancer, tubal carcinoma, or primary peritoneal carcinoma of stages III or IV undergoing neoadjuvant chemotherapy (NAC) followed by cytoreductive surgery, according to the number of cycles performed. Methods: This retrospective study was conducted in three main oncology centres in the east of France, reviewing the charts of all patients who underwent NAC between January 1, 1998 and October 31, 2012. We performed an OS analysis using multivariate Cox regression models adjusted for potential confounders. We also analysed progression-free survival (PFS) as well as chemotherapy- and surgery-related morbidity. Results: Of the 204 patients included, 75 (36.8%) underwent ≤4 NAC cycles and 129 (63.2%) ≥5 NAC cycles. Characteristic data were similar in the two groups. Five-year OS was 35.0 and 25.8%, respectively. This difference was non-significant [HR = 1.06 (0.70-1.59), p = 0.79]. We also found no differences in PFS or morbidity between the two groups. Conclusions: The number of NAC cycles does not seem to play a role in the OS of patients with advanced ovarian cancer. Further evidence and prospective data are needed to assess the value of a high/low number of NAC cycles among these patients.

Cesarean scar ectopic pregnancy. Laparoscopic resection and total scar dehiscence repair. A case report

STUDY OBJECTIVE To illustrate a laparoscopic technique for the resection of cesarean scar ectopic pregnancy, associated with isthmocele repair. DESIGN Case report (Canadian Task Force classification III). SETTING A tertiary referral center in Strasbourg, France. BACKGROUND Cesarean scar pregnancy is a rare form of ectopic pregnancy. The major risk of this type of pregnancy is the early uterine rupture with massive, sometimes life-threatening, bleeding. Thus, active management of these pregnancies starting immediately after diagnosis is crucial. Therapeutic options can be medical, surgical, or a combination. Numerous case reports or case series can be found in the literature, but there are few clinical studies, which are difficult to conduct because of case rarity and inconclusiveness. A 2016 meta-analysis that included 194 articles published between 1978 and 2014 (126 case reports, 45 cases series, and 23 clinical studies) concluded that hysteroscopy or laparoscopic hysterotomy seems to be the best first-line approach to treating cesarean scar ectopic pregnancy, with uterine artery embolization reserved for significant bleeding and/or a high suspicion index for arteriovenous malformation [1]. There is no consensus on the treatment of reference, however. PATIENT The case involves a 38-year-old primiparous women who underwent a cesarean section delivery in 2010 and who was diagnosed by ultrasound scan at 7 weeks gestation with cesarean scar ectopic pregnancy, which was confirmed by pelvic magnetic resonance imaging. The patient initially received medical treatment with 2 intramuscular injections of methotrexate and one local intragestational injection of KCl. Her initial human chorionic gonadotropin (hCG) level was 82 000 IU/L. Rigorous weekly biological and ultrasound monitoring revealed an involution of the ectopic pregnancy associated with decreasing hCG. No bleeding or infectious complications occurred during this period. After 10 weeks of monitoring, her hCG had stabilized at 300 IU/L, and a residual image persisted next to the cesarean scar, and thus surgical treatment was considered. INTERVENTION This video illustrates the laparoscopic resection of a cesarean scar ectopic pregnancy associated with isthmocele repair. The originality of this video lies in the fact that it is the first demonstration of the laparoscopic treatment of total caesarean scar dehiscence. MEASUREMENTS AND MAIN RESULTS The total operative time was 180 minutes. First, hysteroscopic evaluation revealed the cesarean scar dehiscence and the posterior pole of the ectopic pregnancy. Then the diagnosis of cesarean scar ectopic pregnancy was confirmed laparoscopically. The utero-ombilical truncs were clamped bilaterally. Complete enucleation of pregnancy was achieved after dissection of the vesicouterine peritoneum. Isthmocele repair was performed with closure in 2 planes. A blue dye test confirmed the tightness of the stitches. The utero-ombilical truncs were unclamped, and antiadhesion gel was applied to the new uterine scar [1]. The operation was performed successfully without complications. Intraoperative blood loss was <100 mL. The patient was discharged on postoperative day 3. No immediate complications were noticed. At 1 month after the intervention, ultrasound was normal. CONCLUSION Surgical management of caesarean scar ectopic pregnancy with total dehiscence of hysterotomy can be performed safely and efficiently under laparoscopy.

Type B Laparoscopic Radical Trachelectomy with Uterine Artery Preservation for Stage IB1 Cervical Cancer

STUDY OBJECTIVE Radical trachelectomy has emerged as a valuable fertility-preserving treatment option for young women with early-stage cervical cancer [1]. Laparoscopic radical trachelectomy performed by trained surgeons can be a feasible and safe therapeutic option as a fertility-sparing surgical technique [2,3]. To the best of our knowledge, this is the first time the total laparoscopic approach of radical trachelectomy is being published. In this video, rather than the description of the technique step by step, we show how to conserve uterine arteries even if the importance of such conservation is questionable. DESIGN A case report. SETTING A tertiary referral center in Strasbourg, France. PATIENT A 37-year-old patient with no medical history who presented with stage IB1 invasive epidermoid cervical cancer. INTERVENTION In this video, we describe the fertility-sparing surgical procedure consisting of type B total laparoscopic radical trachelectomy with uterine artery preservation. The procedure consists of the following 10 steps: step 1, bilateral pelvic lymphadenectomy and opening of the para vesical fossa; step 2, opening of the pararectal fossa in between the ureter and the internal iliac artery on each side; step 3, ureteric dissection up to the ureteric canal; step 4, opening of the vesicouterine space and section of the vesicouterine ligament; step 5, posterior dissection with division of the uterosacral ligament approximately 20 mm from the uterine insertion; step 6, section of the descending branch of the uterine artery and skeletonization of the ascending branch up to the uterine isthmus level; step 7, trachelectomy with a monopolar hook; step 8, laparoscopic isthmovaginal stitches; step 9, laparoscopic cerclage; and step 10, peritoneal closure. MEASUREMENTS AND MAIN RESULTS The operative time was 420 minutes. The intraoperative blood loss was <200 mL. The operation was performed successfully with no intraoperative complications. The resection margins were safe. The patient was discharged on day 4. After 2 months, no late complications or recurrence were detected, and the patient had normal menstruation. CONCLUSION Type B laparoscopic radical trachelectomy with uterine artery preservation appears to be a safe option for women who intend to maintain their desire for a future pregnancy.

Hysteroscopic enlargement metroplasty for T-shaped uterus: 24 years’ experience at the Strasbourg Medico-Surgical and Obstetrical Centre (CMCO)

STUDY QUESTION What is the impact of hysteroscopic enlargement metroplasty for T-shaped uterus on the live birth rate? SUMMARY ANSWER Performing enlargement metroplasty appears to improve the obstetrical prognosis and fertility in patients with a T-shaped uterus. WHAT IS KNOWN ALREADY T-shaped uterus is linked to an excess of myometrium in the uterine walls giving rise to a subcornual constriction ring which causes dysmorphism and hypoplasia of the uterine cavity. It is commonly associated with infertility or a sequence of repeated miscarriages. STUDY DESIGN Single-centre observational cohort study in 112 patients who underwent enlargement metroplasty for T-shaped uterus between 1992 and 2016 in a Strasbourg university hospital centre. MAIN RESULTS The mean age of patients was 33.2; they had been attempting to conceive on average for 56 months for subfertile patients and 42.2 months for infertile patients. Prior to surgery, patients had succeeded in becoming pregnant 161 times, i.e. a mean gravidity of 1.4 pregnancies. For subfertile patients the mean gravidity was 2.67. Mean parity was 0.04. In the overall population, one hundred pregnancies occurred following enlargement metroplasty. The live birth rate increased in a statistically significant manner following enlargement metroplasty: 4 (2.5%) vs. 60 (60%), p < 0.05. In parallel, the miscarriage rate was statistically reduced: 126 (78.3%) vs. 22 (22%), pnull< .05. Intraoperative complications were 1 case of cervical laceration (0.9%) and 1 case of false passage (0.9%). Subsequent pregnancies remained at risk of miscarriage (22%) and premature delivery (20%) but not extra uterine gestation. Delivery took place by Caesarean section in 61% of cases. In the subgroup of infertile patients, the live birth rate was also markedly increased and 49% of pregnancies which occurred were spontaneous. LIMITATIONS This study was descriptive and retrospective. WIDER IMPLICATIONS These results are consistent with those in the literature. Hysteroscopic enlargement metroplasty is now a well-established technique with few complications but which should nevertheless be reserved for symptomatic patients.

Pelvic tuberculosis mimicking deep endometriosis

Pelvic tuberculosis is most frequently observed in developing countries and often leads to the misdiagnosis of pelvic malignancy. We report the first case of pelvic tuberculosis mimicking deep endometriosis.

Clinical presentation of endometriosis identified at interval laparoscopic tubal sterilization: Prospective series of 465 cases

OBJECTIVES Women seeking sterilization are usually parous and have no major complains, such as pelvic pain. This could be a good model to indirectly assess the prevalence of endometriosis in the general population. Prevalence of endometriosis in women undergoing tubal sterilization by laparoscopy has been assessed in 17 published reports. Results indicate a surprising wide variation of prevalence of endometriosis, ranging from 1.4% to 43.3%. This clinical study describes the prevalence and clinical presentations of endometriosis identified at interval laparoscopic tubal sterilization, as a close representation of endometriosis in general population. MATERIAL AND METHODS From July 1989 to February 2009, 465 women undergone interval laparoscopic tubal sterilization and were included in this series. Surgery was realised in a non universitary centre of gynecologic surgery. All patients were operated on by the same surgeon. A complete assessement of pelvic organs was achieved with a particular attention paid for endometriotic lesions. Endometriosis when present was staged according to r-AFS classification. Biopsies were sent for pathological examination to assess endometriosis. RESULTS Mean age of women was 40.7 years (range 15-49 years). 20 women were nulliparous and 12 others had a past history of endometriosis. Endometriosis was visually identified in 55 patients (11.82%), and confirmed by histologic examination in most of cases (50/55: 90.9%). The mean age of women presenting endometriosis at the onset of tubal ligation was 41.27 years. Cases with endometriosis were classified according to the r-AFS. 39,7,8 and 1 cases corresponded to stages I, II, III and IV respectively. In the 20 nulliparous women, the prevalence of endometriosis was 20% (4/20). At the time of laparoscopic sterilization, 91 women presented a painfull condition (dysmenorrhea mainly or dyspareunia). Endometriosis was identified in 16 of them (17.58%). In the group of 360 asymptomatic parous women, the prevalence of endometriosis was 10% (36/360). Nulliparity, associated pelvic pain and retroverted uterus were associated with increased prevalence of endometriosis, without being significant. CONCLUSION In our study, the prevalence of endometriosis identified at interval laparoscopic tubal sterilization was 11.82%. In parous asymptomatic women, the prevalence of endometriosis was 10%. The prevalence of endometriosis was slightly increased in nulliparous women, when pain was associated and in women with a retroverted uterus.

Laparoscopic Management of a Rudimentary Uterine Horn

STUDY OBJECTIVE To demonstrate a technique of laparoscopic management of a rudimentary horn in a 12-year-old girl. DESIGN A step-by-step explanation of the surgery using a video (instructive video) approved by the local institutional review board. SETTING A university hospital (University Hospital of Strasbourg, Strasbourg, France). PATIENT A 12-year-old girl with a uterine rudimentary horn. INTERVENTION We describe a case of a 12-year-old girl who had no medical history. She had her first menstruation at 11 years old with major left pelvic pain occurring each month. Ultrasonography showed a duplication of the uterus with a liquid collection on the left side; this type of malformation is called an accessory and cavitated uterine mass. Medical treatment was initiated with progestin. Magnetic resonance imaging showed a left noncommunicating rudimentary horn with a unicornuate uterus. No other malformation was present, particularly in the kidneys. A primary vaginal endoscopy was performed showing a single cervix without vaginal malformation. It was decided to perform a laparoscopic excision of the left rudimentary horn. We placed a 10-mm optical port into the umbilicus and 3 accessory 5-mm trocars. Evaluation of the abdominal cavity showed 2 normal adnexas with normal ovaries. We decided to start with a left salpingectomy using the Ligasure device (Medtronic, Minneapolis, MN), staying close to the tube to preserve ovarian vascularization. The remnant fimbria must be removed to avoid cancerization. Then, the vesicouterine septum was divided until we reached the cervix to dissect the bladder from the rudimentary horn. The broad ligament was fenestrated in order to push the left ureter laterally .The utero-ovarian pedicle was transected with the Ligasure device; the left ovary was preserved and vascularized by the left infundibulopelvic ligament. We then dissected the left uterine artery. The posterior peritoneum was opened. The resection of the rudimentary horn was performed by means of a monopolar hook. The dissection was performed slowly with selective coagulation until we reached the cavity of the horn, with old blood flowing out. The entire cavity was removed, and we confirmed the absence of communication with the other part of the uterus. Uterine reconstruction was performed with inverted separated stiches of a 2-0 braided suture, and, finally, an antiadhesion barrier was placed. CONCLUSIONS Laparoscopic management of a uterine rudimentary horn is feasible with satisfactory uterine reconstruction. This is not the first case of this surgery performed by laparoscopy. A similar case has been published in 2015 [1], and recently another video [2] has been published describing 2 other cases.

Retroperitoneal Lumboaortic Lymphadenectomy Using a Vessel-Sealing Device in 10 Steps

STUDY OBJECTIVE Lumboaortic lymphadenectomy is frequently performed in the surgical management of different gynecologic pelvic malignancies: cervical endometrial and ovarian cancer. The retroperitoneal access presents a real advantage, allowing direct access to vascular axes, thus avoiding bowel segments. The use of a vessel-sealing device could facilitate the technique by providing an ergonomic alternative to conventional tools such as a bipolar grasper and scissors. Here the surgical technique of laparoscopic retroperitoneal lumboaortic lymphadenectomy using a vessel-sealing device in 10 steps is described. DESIGN Educative video (Canadian Task Force classification III). SETTING Tertiary referral center in Strasbourg, France. PATIENTS Women undergoing lumboaortic lymphadenectomy. INTERVENTION Laparoscopic retroperitoneal lumboaortic lymphadenectomy using a vessel-sealing device. The local institutional review board approved the video. MEASUREMENTS AND MAIN RESULTS The surgeon and assistant are positioned on the left of the patient and the column is placed in front. After peritoneal exploration 3 trocars are introduced in the left flank according to a very precise arrangement. We use a camera scope with a zero-degree view angle. After development of the extraperitoneal space and identification of the vascular landmarks, lymphadenectomy using a vessel-sealing device involves several steps in an anticlockwise direction starting from the left common iliac group. We first start with the lateroaortic group of lymph nodes. We then continue with the preaortic, interaorticocaval, and precaval supramesenteric group. After that, we perform the inframesenteric dissection of lymph nodes, the bifurcation of the aorta, and finally the right common iliac group. At the end of the procedure, in the absence of signs of metastatic lymph nodes, we open the peritoneum. CONCLUSION Retroperitoneal lumboaortic lymphadenectomy using a vessel-sealing device is useful because of better ergonomics of the multitasking instrument, avoiding alternating between scissors and bipolar forceps. The surgeon will be able to use both hands for exposure and for surgery. The presence of a metastatic ganglion is an important and decisive factor in the choice of adjuvant or neoadjuvant management of cancers, especially for cervical cancer.