[Linguistic adaptation of the endometriosis health profile 5: EHP 5]

OBJECTIVES

The aim of this work was to develop a French version of an English quality of life questionnaire specific of endometriosis: endometriosis health profile 5.

MATERIALS AND METHODS

After many translations and reverse translations, we got a first French version of EHP 5. This scale was then distributed in two centres: Poissy and Versailles. This questionnaire was completed by women with endometriosis proven and chronic pain. We studied acceptability and feasibility.

RESULTS

Eighteen patients were included. All items have been completed satisfactorily. Our version was described as understandable and easy to complete.

CONCLUSION

Our work consisted in developing a French version of EHP 5 which was very well received by the patient. However, the psychometric and clinical validation remains to be done.

[Essure implants for tubal sterilisation in France]

OBJECTIVES

Law no. 2001-588 of 4 July 2001 liberalised the practice of tubal sterilisation in France, at the same time as a new hysteroscopic method of female sterilization appeared. The growth of this method has been spurred by the reduced need for analgesia, absence of incision and scar, reduced duration of hospitalization and diminution of costs. The aim of this study was to analyse the use of the Essure procedure in France.

PATIENTS AND METHODS

This multicentre study covered seven French facilities from January 2004 through June 2006. This study included 1061 attempted placements of the Essure micro-insert, marketed by Conceptus SAS (France).

RESULTS

The first placement attempt was successful in 992 cases (94.4%). The success rate for second attempts was 59% (n = 23). Mean VAS was 3,23 +/- 0.19. Ninety-three percent of patients undergoing Essure placement were satisfied or very satisfied.

DISCUSSION AND CONCLUSION

Tubal sterilisation with Essure micro-inserts is a reliable and reproducible method that requires a short period of training. In the future, the hysteroscopic pathway will replace the laparoscopic route.

[Fetal injuries during cesarean: frequency, risk factors and prevention]

During the cesarean section, the immediate proximity of the scalpel blade to the fetus exposes this latter to possible injuries. This article aims at reflecting on the measures to be developed in the prevention of fetal injuries during the cesarean section after a bibliographical analysis of the available data. Occurring in about 1% of the cesarean cases, the fetal injuries are most often minimal and localized at the scalp or the face, rarely requiring a surgical repair. Sometimes, they can have a functional, aesthetic, psychological and forensic impact. The associated risk factors substantially are the emergency cesarean, the "cutaneous incision/delivery" delay and a T- or J-shaped uterine incision. In this article we expose simple means enabling an incision of the uterine cavity, thus minimizing the fetal risk.

[Urinary functional and urodynamic preoperative evaluation of patients with deep pelvic surgical endometriosis: about 12 cases]

OBJECTIVES

Laparoscopic surgery of deep endometriosis, including uterosacral ligament and rectal localisation, generally induces postoperative urinary disorders, caused by sacral plexus nerve lesions. However, during presurgical consultation, patients with these symptoms frequently present some urinary disorders. Our objective was to prospectively evaluate the reality of pre-existant urinary disorders by performing urodynamic tests.

PATIENTS AND METHODS

This study is a prospective, descriptive and non-comparative study about 12 consecutive patients consulting for a surgical assumption of deep endometriosis, including clinical and radiological lesions on the uterosacral ligaments, on the uterine torus and/or on the rectum.

RESULTS

A total of 12 patients whose ages ranged from 24 to 42 (mean age 34.6 +/-5.3 years). The mean parity was 0.5+/- 0.8 children (0-2). A clinical examination and multiple preoperative imaging techniques (abdominopelvic ultrasonography [US] and Magnetic Resonance Imaging [MRI]) were used to diagnose a deep endometriosis. During consultation, four patients presented no urinary dysfunction (33%). The eight other patients presented at least one of the following symptoms: increased daytime frequency, urinary incontinence, straining, increased night time frequency, urgency, mictional burns, bladder cramps, reduction in the bladder sensation. Any urinary infection was systematically eliminated. Multiple imaging techniques allowed to diagnose: an adnexal lesion in three cases (25%), adenomyosis in three cases (25%). Endometriosis was detected on the rectum in eight cases (66.7%), on the uterine torus in nine cases (75%) and on the uterosacral ligaments in 10 cases (83.3%). No vesical localisation was found. The urodynamic tests performed before surgery were totally normal in only two cases (16.7%). Three patients had a true postmictional residue (25%), but only one was pathological (more than 100 mL). The mean urethral fence pressure was 87.8 +/- 33.5 cm H20 (38-150). Four patients had a urethral hypertonia (30%), three patients a urethral instability (25%), three patients a dysuria (25%), two patients a hypersensitive bladder (16.7%), two patients had an insufficiency of the urethral sphincter (16.7%), one patient a big hypoesthetic bladder (8.3%) and one patient a small bladder capacity.

DISCUSSION AND CONCLUSION

Patients with deep endometriosis on the uterosacral ligaments and/or on the former face of the rectum frequently have urinary disorders. Consulting such patients is fundamental since it allows to diagnose them but it is not sufficient. Performing urodynamic tests can precisely determine and quantify real disorders. These disorders are neurological, probably related to lesions of the inferior hypogastric plexus and not to a lesion of the bladder. In this prospective study, there is no correlation between the preoperative disorders and the localisation of the lesions. A further study on a greater number of patients is necessary to define possible improvements and complications related to the surgery.

[Rupture of non-communicating rudimentary pregnant uterine horn in a pseudo-unicornuate uterus at 23 weeks of amenorrhea. Case report]

Pregnancy in the rudimentary horn of a unicornuate uterus is an extremely rare form of ectopic gestation associated with a high risk of uterine rupture. We report the case of a pregnancy developed in a non communicating rudimentary horn of a unicornuate uterus complicated by horn rupture at 23 weeks of amenorrhea showing as an acute abdominal pain and massive hemoperitoneum. This patient's uterine abnormality was known before, as this woman has delivered two years before at term a healthy boy by cesarean section. This past pregnancy was located in the normal horn and the non communicating rudimentary horn seemed at this time normal. This uterine malformation is presented with its gynecological and obstetrical entailments as well as methods that could prevent such outcome.

[Investigation on smoking during pregnancy in the Versailles suburbs]

OBJECTIVE

To investigate active and passive smoking during pregnancy in the Versailles suburbs before workshops for smoking cessation.

MATERIALS AND METHODS

Descriptive investigation of 1006 pregnant women in the perinatal community of the Versailles suburbs based on autoquestionnaire. The variables analysed included the characteristics of the mother during pregnancy, the presence of a smoking spouse and a professional exposition to passive smoking, the perception of risk linked to smoking, and the help for smoking cessation.

DISCUSSION AND CONCLUSION

An assistance to stop smoking could be suggested to smoking pregnant women and their spouses.

[Digestive endometriosis of the caecum and intussusception: about one case]

We report the case of a 40-years-old woman who had a caeco-colic intussusception on a digestive endometriosis. Such exceptional association can be life-threatening, requiring urgent surgery.

Fertilité après chirurgie cœlioscopique de l'endométriose pelvienne chez des patientes en échec de grossesse

OBJECTIVES

To evaluate fertility outcome after laparoscopic management of endometriosis in an infertile population.

MATERIALS AND METHODS

A retrospective analysis of 64 patients presenting more than one year infertility and a pregnancy-wish associated with minimal to severe endometriotic lesions (stage I to IV according to the revised American Fertility Society (rAFS) classification), treated using laparoscopic surgery in order to remove the entire lesions. We excluded women under 20 years and over 40, as well as those with other infertility factors (tubal non endometriosis-related, hormonal or sperm). Fertility of the remaining 34 patients was studied in relation to endometriosis stage and to pregnancy's mode (spontaneous or induced).

RESULTS

Pregnant women percentage was 65% (22 patients) within a 8.5 months (quartiles: 3; 15.5) [range: 1; 52] post-surgical time, and 86.5% pregnancies issued with a delivery. The rate of pregnant women depended on stage of endometriosis (89% for stages I-II, and 56% for stages III-IV). Sixty percent pregnancies were spontaneous within a 5 months (3; 9) [1; 52] post-surgical time to pregnancy average. When pregnancies were obtained with assisted reproductive techniques, the median post-surgical time to pregnancy was 12 months (9; 22) [2; 31]. Among women with stages I-II endometriosis, the median post-surgical time to pregnancy was 2 months when spontaneous and 20.5 months when induced (P=0.007). In case of stages III-IV endometriosis, pregnancy's delay was 8 and 12 months respectively (P=0.79). Among the 21% women who had had an induced pregnancy failure before surgery, 71% became pregnant and 80% spontaneously. Eighteen patients (53%) had an ovarian endometrioma and 50% of them became pregnant. Among the 4 patients who had colorectal endometriosis requiring colorectal resection, 1 pregnancy was obtained.

CONCLUSIONS

These findings suggest that in a context of more than one year infertility only related to endometriosis, it is reasonable to offer these patients a complete operative laparoscopic treatment of their lesions, which enables 65% of them to be pregnant within a 8.5 months post-surgical median time to pregnancy and spontaneously in 60%. In case of stages I-II endometriosis we suggest a spontaneous pregnancy try during 8 to 12 months before starting induced pregnancy therapeutics instead of stages III-IV endometriosis where induced methods should be used after only 6 or 8 months.

Prise en charge de l'endométriose: évaluation clinique et biologique

No symptom is pathognomonic for endometriosis. Main symptoms are pain (chronic pelvic pain, dysmenorrhea, deep dyspareunia, pain on defecation, cyclic pain) and infertility (grade C). There is no relation between rAFS endometriosis classification and symptoms intensity and frequency (grade B). Endometriosic lesions location and symptoms type are related to each other as well as symptoms intensity and lesions deepness or adhesion numbers (grade B). Clinical evidence is the same for infertile endometriosic women (grade C). Screening for depression is required among patients suffering from chronic endometriosic pelvic pain (grade C). Clinical examination includes: 1) retrocervix area inspection as well as upper part of posterior vaginal wall in search for typical bluish lesions (grade B); 2) vaginal examination in search for: a) uterosacral ligaments nodules (grade B); b) pain in uterosacral ligaments extension (grade B); 3) re-examination during menstruation increases its performance (grade B). No biological check-up in endometriosis diagnosis is necessary (grade A). CA 125 increase is related to: endometriomas and deep lesions volume (grade B), surgically treated infertile women prognosis (grade B). Presurgical endometriosis diagnosis is bettered by using diagnosis pattern in selected population (grade B). Rating scales are recommended in diagnosis and therapeutic follow up (grade B). Quality of life scales are useful to evaluate therapeutic efficiency (grade B).

[Ovarian and peritoneal sarcoidosis mimicking an ovarian cancer]

Ovarian and peritoneal sarcoidosis is a very rare condition, with an atypical clinical presentation close to that of ovarian cancer. An erroneous diagnosis could induce a definitive castration. A 38-year-old woman was admitted because of ascites and weight loss. A computerized tomography scan revealed multiple soft tissue nodules in the pelvis, on the ovaries as well as peritoneal deposits. Histological examination after laparoscopic biopsy was indicative of sarcoidosis. Corticosteroids were given to the patient and the symptoms quickly subsided. This case with its clinical presentation is discussed in comparison with previously reported cases.

Traitement cœlioscopique de l'endométriose profonde. À propos de 118 cas

OBJECTIVE

To evaluate risks and benefits of laparoscopic surgery of deep endometriosis, especially with bowel involvement with the aim of improve the inform consent of patients and choice of adequate management.

PATIENTS AND METHODS

Observational continuous study on 118 patients suffering from deep endometriosis (48 with bowel endometriosis) treated by laparoscopic surgery.

RESULTS

95.6% of the patients improved their symptoms (93.7% for dyspareunia). Upon the 29 infertile patients, 21 (72%) got pregnant, including 14 (66%) spontaneously. During operative time, 3 laparotomies occurred, two of them for haemorrhage. During postoperative time, 4 major complications (2 rectal fistulas and 2 ureteral necrosis) and minor complications occurred.

DISCUSSION AND CONCLUSIONS

Those data confirm the efficiency of laparoscopic treatment of deep endometriosis especially for pain relief and fertility. Nevertheless, few but severe complications may occur. Therefore, it is imperative to deliver clear, loyal and appropriate information before to proceed to such a treatment.

[Caesarean section: closure or non-closure of peritoneum? A randomized trial of postoperative morbidity]

OBJECTIVE

To evaluate postoperative morbidity with non-closure of the visceral and parietal peritoneum during caesarean section.

PATIENTS AND METHODS

A prospective randomized study of 170 patients. Operative time, postoperative pain, postoperative morbidity (febrile morbidity, wound haematoma, wound infection, postoperative ileus) and length of hospital stay were compared between the two groups.

RESULTS

Duration of operation was significantly shorter without peritoneal closure (38.89 vs 42.00 minutes; P<0.05). Wound haematoma were more frequent when peritoneum was closed (P<0.029). There were no significant difference between the two groups for postoperative ileus, length of hospital stay, postoperative pain and other complications.

DISCUSSION AND CONCLUSION

We report the first French study on this subject. In this study, non-closure of both visceral and parietal peritoneum is associated with shorter operation duration and seems to reduce immediate complications. A long-term evaluation of morbidity, regarding adhesions is necessary.