[Acceptability of intrauterine levonorgestrel delivery system (Mirena 52mg) after estrogen-progesterone oral contraception: results of a prospective multicentric study of 211 patients aged 25-35 years]

INTRODUCTION

Use of an intrauterine levonorgestrel (SIU-LNG) delivery system (Mirena 52mg has become popular in recent years, particularly among younger women. Mirena is currently the contraceptive method of choice used as an alternative to classical copper-containing intrauterine devices after oral contraception. The purpose of this study was to evaluate patient satisfaction among young women during the first year of use of the intrauterine hormonal system.

MATERIAL AND METHODS

This multicentric phase IV trial with a non-comparative methodology was conducted among 211 young women aged 25-35 years. The SIU-LNG was prescribed for women who wanted to change their contraception after oral estrogen progesterone taken for at least three months prior to inclusion in the study. A total of 211 patients were included and review was planned at one year: 197 patients (93.36%) were reviewed.

RESULTS

Mean patient age was 31.48+/-3.25 years. The SIU-LNG was inserted successfully at the first attempt in 99.05% of women. The continuation rate ws 85.65% at one year. Evaluation of cycle characteristics showed less voluminous blood loss and fewer dysmenorrheal phenomena as well as, in 40%, the development of amenorrhea. At the last visit, 85% of women were satisfied or very satisfied with this method of contraception.

CONCLUSION

As has been demonstrated in earlier studies, Mirena offers a contraception with a reliability equivalent to that of oral estrogen progesterone (IP: 0 - 0.2), with very few hormonal side effects due to the low plasma passage of levonorgestrel. Mirena is particularly well adapted for young women who desire a reliable long-term easty-to-use contraception after taking oral contraception.

Prise en charge des lésions malpighiennes intra-épithéliales de type CIN2 et CIN3 par vaporisation au laser

OBJECTIVES

This study was carried out over an 8-year period in order to evaluate the long-term effectiveness of laser CO2 vaporization in the treatment of squamous intraepithelial lesion of type CIN2 and CIN3.

MATERIALS AND METHODS

A retrospective study of 52 cases of cervical lesions of type CIN2 and CIN3 treated in first intention by laser CO2 vaporization was carried out at the hospital Jeanne-de-Flandre in CHRU of Lille from 1996 to 2003. This treatment was performed on only high-grade exo-cervical lesions, of small size (<2cm2), after a complete colposcopic examination.

RESULTS

Fifty-two patients were treated by first-intention laser vaporization only. Mean age was 29.4 years and 51.9% were nulliparous. At the first cyto-colposcopic control, there were 17 persistent lesions (32.7%). Among the 35 patients without persistent lesion, 29 achieved cure (absence of recurrence), 4 presented a recurrence and 2 were lost to follow-up.

CONCLUSION

The current data of the literature concerning the treatment by laser CO2 vaporization authorize application of this method for certain high-grade exocervical lesions after a complete colposcopic examination. This type of treatment remains less aggressive than a surgical treatment. The high rate of residual lesions in particular in the event of CIN3 can be due to an incomplete destruction of the lesion. Patients should thus be advised that monitoring is an integral part of the treatment. Laser vaporization could be limited to CIN1 and CIN2 lesions.

[Management of in situ cervical adenocarcinoma]

The management of adenocarcinoma in situ of the cervix (ACIS) is difficult because it is often diagnosed in younger women who may wish to preserve their potential of fertility. Conservative treatment has been accepted as an appropriate strategy but interrogations persist as to carcinological safety. We report a complete review of the literature on this subject where conservative attitude appears possible but is associated with recurrence risk (5 to 10%) and invasive disease (2%). Conditions to perform conservative management are: cold knife cone biopsy, negative margins, cone resection of at least 25 mm, realization of endocervical curettage and total patient compliance. In all cases, regular cytological and histological monitoring must be performed. If maintaining reproductive capacity is not desired, hysterectomy is systematically proposed to patient.

Traitement chirurgical du prolapsus génital chez les femmes âgées de plus de 80 ans

OBJECTIVES

The aim of this study was to assess the morbidity and the effectiveness of the vaginal surgical treatment for women over 80 years of age with genital prolapse.

MATERIALS AND METHODS

All the women over 80 years operated in our institution between 1996 and 2003 were reviewed retrospectively. We examined the risk and the effectiveness of this surgery.

RESULTS

Forty-eight women underwent surgery during this period. No colpocleisis was performed. The most frequent surgery was a combination of vaginal patch plastron, Richter's spinous fixation and posterior perineorrhaphy. No major intra- or post-operative complication occurred. One woman required blood transfusion. The most frequent postoperative complication was voiding difficulties (12%), which had disappeared 3 months later. A partial stenosis of a left ureter with ureterohydronephrosis occurred, requiring endoscopic dilatation. At 3 months, anatomic and functional outcome was good in 92% of women. The number of patients lost to follow-up at one year was to large to draw any conclusion.

CONCLUSION

Complete transvaginal surgical treatment is a safe procedure for elderly women which provides good short-term effectiveness.

Les malformations artério-veineuses intra-utérines

Intra-uterine arteriovenous malformations are a possible etiology of persistent metrorrhagia especially in the event of a history of miscarriages, cornuale pregnancy, molar pregnancy or gravidic trophoblastic diseases. We report 4 cases of patients having an intra-uterine arteriovenous malformation. The diagnosis of such lesions calls upon first intention Doppler echography. This diagnosis is confirmed thereafter by angiography. The first intention treatment is embolization which can save time if carried out at the same time as the angiography. This treatment is rapid and final, enabling the patients to have other pregnancies later on. An echographic follow-up, according to a schedule which remains to be defined, is necessary in order to check the good involution of this type of vascular malformation.

Les prothèses synthétiques dans la cure de prolapsus génitaux par la voie vaginale : bilan en 2005

Since 1996, prosthetic meshes have become increasingly popular for transvaginal surgical cure of genital prolapse. In light of the growing number of proposed techniques and materials we reviewed the experience of the pioneers in order to provide surgeons with the most objective information available. We reviewed the literature indexed in Meline/PubMed and Current Contents retaining all work concerning resorbable and non-resorbable meshes. For the larger class of non-resorbable meshes we also reviewed articles by category of material, each type of mesh being carefully defined: different compositions of polypropylene, polyester, composite meshes and also insertion kits. Resorbable meshes were evaluated in two randomized studies which did not demonstrate better results than with simple folding known to have a high rate of recurrence. For polypropylene meshes, Marlex was studied in six trials which demonstrated a high rate of cure at one year but also a high rate of erosion which reached 25%. Use of Atrium was mentioned in three studies with a 6 to 12% recurrence rate and an erosion rate nearly reaching 20%. The majority of studies used Prolene and Gynemesh. Seventeen authors reported their experience, generally reviewing retrospective series, with recurrence rates of less than 10% for follow-up periods rarely greater than two years. A large variety of forms and sizes have been used, hindering comparisons. The rate of erosion was also quite variable, as high as 45%, demonstrating the need for a precise definition of erosion. Only recently have authors shown interest in the impact of prosthetic meshes on quality of life and sexual activity. An improvement is generally noted for defecation but the rate of dyspareunia has reached as high as 60%. Here again grades of prosthetic retraction should be better defined. Proposed to improve these phenomena, soft Prolene recently used by several authors does not appear to fulfil expectations. Since 2005, several precut polypropylene meshes have been proposed with an insertion kit. The Prolift kit has been followed prospectively in 100 patients undergoing regular surveillance. Surgipro has been used sporadically in small series but follow-up is still too short for proper assessment. Polyester meshes (Mersilene and Paritex) have been presented by three authors who have found them useful but reports have been vague concerning results and complications. Polytetrafluoroethylene has not been evaluated for transvaginal surgery, probably because of the poor tolerance of suburetral bands. For composite meshes, Vypro has been used by four authors who noted about 10% erosion but with a short follow-up insufficient to draw conclusions about the functional and anatomic outcome. Surfaced meshes, advocated for transvaginal treatments, have been studied in only two reports. Plevitex is a polypropylene mesh coated with collagen; another polyester composite with polyglactin 910. The rate of dyspareunia varied from 14 to 24%. Other composites with antiadherents or antiseptics are also proposed for transvaginal insertion but have not been studied. This work demonstrated the lack of sufficient evidence from prospective randomized trials and the lack of standardized techniques to draw any definite conclusions. While evidence is being accumulated on the lower rate of recurrence for anterior compartment prolapse, the lack of data on the rate of complications and patient quality of life is unacceptable for this functional surgery. We still have reservations about widespread use of synthetic meshes. A special chapter is detailed in appendix on post-operative complications. These new specific complications call to a new semiology, with a classification in 4 types and under-types, proposed by authors. Type 1: defects of healing. Type 2: the infection of the graft. Type 3: the shrinkage of the mesh. Type 4: erosions. Authors detail the symptoms of these 4 types as well as the prevention and the treatment of these complications.

Efficacy and complications in the surgical treatment of stress urinary incontinence by insertion of a silicone-coated polyester tape (Lift)

OBJECTIVES

To evaluate the efficacy and safety of a surgical treatment for stress urinary incontinence by implantation of a silicone-coated polyester tape (Lift).

MATERIALS AND METHODS

This retrospective study included 72 female patients having had a suburethral silicone-coated polyester tape inserted as treatment for stress urinary incontinence, combined or not with pelvic surgery. We recorded the patient's characteristics, the surgical procedure, the short and long-term results and complications.

RESULTS

Seventy-two patients were operated, 60 of whom were fully evaluated. The average follow-up was 17 months. On 48 patients (80%) the treatment was successful, 3 (5%) were improved, and 9 (15%) were regarded as a failure. Dysuria occurred in six (10%) patients, five were de novo, and one was persistent. Ten patients (16.6%) presented de novo urge incontinence. The main complication was a higher rate of severe infections, accompanied by defective healing (4, i.e. 6.7%).

CONCLUSION

The procedure using a silicone-coated polyester tape seems to be efficient, but insufficiently secure. This higher rejection rate leads us to prefer other synthetic materials proved to be better tolerated.

Endométriose et infertilité

Relationship between infertility and endometriosis is still controversial. Many mechanisms have been reported such as anatomical disorders, biologic and cytological modifications of peritoneal liquid, functional ovarian and endometrial disorders, reduced embryo quality. Management of infertility related to endometriosis is difficult and no consensus has been published yet. Following recent clinical data, therapeutic strategies are discussed.

Prise en charge de l'endométriose urinaire

Endometriosis of the urinary tract (bladder and/or ureter) is rare and concerns 1-2% of cases of endometriosis. Surgical management is usually mandatory. Rate of peri operative morbidity is low. There is a risk of functional (dysuria, chronic hypogastric pains, imperiosity) and anatomical recurrences (0-15 and 0-10% respectively). Surgical treatment of bladder and/or ureteral endometriosis requires informed consent of patients and multidisciplinary management.

Tumeurs de l'ovaire et CA 125 en 2006

The authors propose to report progress on the use of the CA 125 serum assay. It affects three situations: screening, diagnosis and the follow-up of the patients dealt with ovarian tumour either of benign or malignant nature. For each situation the interest and the relevance of CA 125 assay will be approached.

Le HELLP syndrome : diagnostic et prise en charge thérapeutique

Management of HELLP syndrome is still controversial. In order to improve maternal and foetal prognosis, 2 approaches are usually considered: immediate termination of pregnancy (risk of foetal complications related to prematurity) or conservative treatment (maternal risk of complications related to hematologic disorders). Choice of treatment needs to be taken after evaluation of the maternal and fetal risk/benefit ratio.

Facteurs de risque des expositions prothétiques après cure de prolapsus génital par voie vaginale

OBJECTIVES

Prosthetic reinforcement in the surgical repair of pelvic prolapse by the vaginal approach is currently on the increase. However, this technique is not without tolerance-related problems. The most frequently described complication is prosthesis exposure, including erosion and delayed healing. It is independent of a granuloma and a major infection as pelvic cellulitis. Its mechanism is associated with defective vaginal healing. The purpose of our study is to define the risk factors for exposure of the prosthetic material.

PATIENTS AND METHODS

Two hundred and seventy-seven medical records relating to patients undergoing surgery due to pelvic prolapse were included in our study. The treatment of genital prolapse was managed via the vaginal approach with polypropylene mesh. This is a continuous, retrospective study conducted over a period of 24 months.

RESULTS

Thirty-four cases of prosthesis exposure were observed in the 2 months following surgery, which represents an incidence of 12.27%. The risk factors are concomitant hysterectomy [odds ratio 5.17 (P = 0.001)] and inverted T colpotomy [odds ratio 6.06 (P = 0.01)]. The protective factors are preservation of the uterus and the performance of a minor colpotomy in patients who had already undergone a hysterectomy or in those whose uterus had been preserved [odds ratio 5.16 (P = 0.0001)].

DISCUSSION AND CONCLUSION

In our study, we have only found risk factors of operative protocol. In fact, other information as age, menopause status or medical history of the patient is not significant. The uterus must be preserved and the number and extent of colpotomies needed to insert the prosthesis must be limited.

Prise en charge des expositions de prothèse après cure de prolapsus génitaux par voie vaginale

INTRODUCTION

Prosthetic reinforcement by the vaginal approach for surgical repair of pelvic prolapse is experiencing increasing popularity despite problems with tolerance. The most frequently described complication is prosthesis exposure, also known as erosion or granuloma. The mechanism is associated with defective vaginal healing and is independent of major infection such as pelvic cellulitis.

OBJECTIVES

The purpose of our study was to define the course of this complication and the best therapeutic strategy for patients with prosthesis exposure.

MATERIALS AND METHOD

Our continuous and retrospective study conducted over a period of 24 months between January 2002 and December 2003 recorded 34 files. These patients underwent prosthetic treatment via the vaginal approach of genital prolapse associated with prosthesis exposure. The procedure, known as TVM (Tension free Vaginal Mesh), involves the insertion without fixing of a synthetic prosthesis in areas of bladder-vagina and rectum-vagina detachment.

RESULTS

In 33 cases out of 34, the exposure site was located on the anterior colpotomy scar (97%). These prosthesis exposures were managed in two stages, using antiseptic treatment first. This treatment cured 9 patients (26.47%). In the event of failure, a procedure was carried out under brief general anesthesia on an outpatient basis or during a 24-hour hospital stay. This single resection was sufficient for 20 patients (88%). Two patients nevertheless required a second removal procedure (8%) and one patient a third procedure (4%). To notice, one patient presented with a bladder-vagina fistula after resection. This observation of a bladder-vagina fistula following partial removal led us to recommend a blue test and/or cystoscopy as routine practice for each procedure.

CONCLUSION

With this new vaginal approach for prolapse repair, it is important to monitor prosthesis exposure. To manage exposures, it is necessary to begin with antiseptic or estrogenic treatment. In the event of failure, a partial resection is warranted. We recommend careful prosthesis resection and systematic verification of the bladder.

[Strategy for management of ovarian immature teratoma. About three cases and review]

Ovarian immature teratoma is a malignant germ cell tumor and represents less than 1% of ovarian malignant tumors. Tissues are derived from the three germ layers (endo-, meso- and ectoderm). Tumor grading is based on the amount of immature neuroepithelium present. The prognosis is directly correlated to histologic grade. Rapid growth leads to large tumors with an early diagnosis. Therapeutic management is balanced between adjuvant chemotherapy and surgery alone. Nevertheless, as immature teratoma mostly occurs in young women, the main objective is to preserve fertility.

[Clinical study and prognosis of 56 cases of vulvar intraepithelial neoplasia]

OBJECTIVE

To study main clinical characteristics of patients with vulvar intraepithelial neoplasia 3 (VIN3). To investigate the long-term outcome and risk factors associated with recurrence or progression to invasive carcinoma.

PATIENTS AND METHODS

Retrospective study of 56 patients with VIN3 from January 1st 1995 to December 31st 2003.

RESULTS

Lesions were unifocal for 30 patients (53.6%) whereas they were multifocal for 26 patients (46.4%). When the lesion was multifocal, women were younger than in the unifocal group (41.2+/-16.7 vs. 52.5+/-13.5 years, P<0.03). Clinical symptoms, disease characteristics and medical history were not different between the two groups. Clinical HPV infections were more frequent in the multifocal group (65.4 vs. 23.3%, P<0.01). The mean follow-up was 39 months. Nine patients (16.1%) had recurrence of VIN3. Progression to invasive carcinoma occurred in 4 patients (7.1%). Multifocal lesions, occult micro-invasive disease and positive margins were related to recurrence or progression to invasive carcinoma. However, age at diagnosis, HPV infection, lichen sclerosis, immunosuppression and initial treatment did not correlate with evolution.

DISCUSSION AND CONCLUSION

Recurrence and progression to invasive carcinoma can occur during VIN3 evolution. Our results confirm previous reports and suggest that all patients need a long-term follow-up regardless of patients' age or clinical characteristics.

[Phyllodes tumor of the breast: analysis of 8 patients]

INTRODUCTION

Phyllodes tumors of breast are rare and usually benign. These are histologically fibro-epithelial tumors similar to fibroadenomas. Histological confirmation on the operative specimen is required to establish the diagnosis and histological pronostic of phyllode tumors.

MATERIALS AND METHODS

We reviewed 8 cases of phyllodes tumors and the literature to report the circumstances of occurrence of these tumors, and their specific clinical diagnosis, therapeutic, prognostic features.

RESULTS

62.5% of patients were nulliparous. The mean age at diagnosis was 33.4 years. Mean tumor size was 3.75 cm. Tumours predominated on the right side (87.5%) and upper-outer quadrant (62.5%). Imaging findings were helpful for diagnosis. Aspiration cytology demonstrated the phyllode tumor in 43% of patients. Wide tumorectomy was performed in seven patients. One patient underwent mastectomy and radiotherapy and chemotherapy. The recurrence rate (37.5%) justifies wide margin excision. There were no deaths in our series.

DISCUSSION

and conclusion. These results together with those reported in the literature show that the loco-regional and general spread depends on margin surgery.

Perineal Cellulitis Following Trans-Obturator Sub-Urethral Tape Uratape

OBJECTIVE

We report two cases of perineal cellulitis due to the surgical treatment of female stress urinary incontinence with a trans-obturator sub-urethral tape of Uratape (Porgés).

METHODS

Treatment and follow up of their complication were performed at the CHRU of Lille.

RESULTS

In both cases, this complication is related to prolonged vaginal exposition of the tape. Vaginal erosion always occurs next to the silicon coated section of the tape.

CONCLUSION

Such a complication has never been described yet. It shows a lack of data concerning human tissue tolerance of sub-urethral tapes constituents. Such examples should call for caution against new materials, all the more so as they have not yet been validated by large scale studies.

Technique d’imagerie par fluorescence : intérêt diagnostique et thérapeutique en gynécologie

Fluorescence techniques are presently used by several medical and surgical disciplines (dermatology, pneumology, urology, gastrointestinal surgery) for the diagnosis of pre-cancerous and cancerous lesions. The technique is based on the application of 5-aminolevulinic acid (5-ALA) which induces the production of an endogen photosensitizer: protoporphyrin IX (PpIX). Fluorescence detection of the infraclinical dysplasia lesion is based on the contrast between fluorescent pathological tissue and non-fluorescent healthy tissue. Moreover, there is a correlation between the degree of tissue dysplasia and fluorescence intensity. Fluorescence imaging could allow easier detection of infraclinical lesions enabling more well-targeted treatment. In gynecology, many experimental and clinical studies have been conducted on the detection and treatment of cervical dysplasia and the diagnosis and treatment of vaginal and vulvar diseases as well as the diagnosis of peritoneal micrometastasis from ovarian cancer, the diagnosis and treatment of endometrial alterations, and the treatment of locoregional recurrent skin breast cancer. The aim of this work is to present the fundamental principles of fluorescence imaging technical and to expose the diagnostic and therapeutic prospects in gynecology.

Prise en charge des mutilations génitales féminines de type III

Female genital mutilation (FGM) consists in a non-therapeutic removal of part or all of the external genitalia and /or injury to the external genitalia. This practice in common in a few African countries and in Middle East. Mass immigration of African women to Europe in the past decade has brought the problems of FGM to these countries. There are four types of FGM. Many early (hemorrhage, infectious) and/or late (uro-gynecologic and obstetric) complications can be associated. The dermoid clitoridia cyst is the most frequently complication. Rigorous obstetrical labor monitoring is not possible. Therefore labor is longer and there are many delivery complications. The treatment is based on Gabbar's deinfibulation surgery which can be proposed when there are uro-gynecologic complications, or during pregnancy and labor. This method can lead to spontaneous vaginal delivery without perineal trauma. The aim of this article was to share our experience and inform obstetrician-gynecologists about FGM.

Étude objective de résistance des ligaments pelviens utilisés dans les cures de prolapsus et d'incontinence urinaire d'effort

OBJECTIVE

Underline the objective strength of the pelvic ligaments.

PATIENTS AND METHODS

Twenty nine human female pelvis cadavers, whose storage conditions differed, were used in our study. In each cadaver we dissected all the ligaments used in pelvic surgery. A subjective clinical evaluation of the ligament properties was performed by visual observation as well as by finger palpation. Ligaments were classified into three groups in terms of thickness and apparent strength following finger palpation, high, doubtful and low apparent quality ligaments. Then a suture taking the entire ligament switched the ligaments and a force was applied on the vagina axis until tearing. The device used for strength measurement during traction was a Samson type force gauge, which was developed for the purpose of our study. Results were given in Newtons.

RESULTS

We found a great variability in the values obtained at tearing with maximal values at 200 newtons and minimal at 22. Individually measured, ligament strength varied between individuals, and for a same patient between the type of ligaments and the side. The pre-vertebral ligament was on average the strongest. For bilateral ligaments, there was no difference between the left and right side. The iliopectineal ligament was statistically significantly stronger than sacrospinous and arcus tendineus of pelvic fascia. There was a correlation between subjective evaluation and objective strength measurements.

DISCUSSION AND CONCLUSION

We performed the only study of the strength of pelvic ligaments at tearing. These are, however, routinely used in the cure of prolapse and urinary incontinence. Our results show that there is a great variability in strength between individuals, and for a same patient between the types of ligaments and side. These observations could explain some of the surgical intervention failures and demonstrate the importance of per-operative strength evaluation. Per-operative subjective evaluation on strength is related to objective measurements and could be used to determine the type of ligaments to be used for surgical assembly suspension.

L'antécédent de césarienne est un facteur de risque opératoire de l'hystérectomie vaginale

OBJECTIVE

We describe the intra and postoperative frequency of complications in vaginal hysterectomies for benign disorders in patients with a history of caesarean section.

PATIENTS AND METHODS

Since 1996, 963 hysterectomies have been performed in our institution. 76.94% were performed exclusively by vaginal route (n = 741), 10.1% (n = 98) were by laparoscopic-assisted vaginal route and 12.9%, by pure abdominal route. We compared two groups of patients who underwent vaginal hysterectomy, with or without history of caesarean section. In each group we recorded the characteristics of the population and compared the intra and postoperative data, such as bladder or digestive tract wounds and haemorrhages. We used analysis of variance tests to compare means, chi2-tests and Fisher's exact tests for comparisons of numbers. A probability of P < 0.05 was adopted as the limit of significance.

RESULTS

The frequency of haemorrhages was significantly higher in the patients with a history of caesareans. Bladder and intestine injury rates are significantly higher in the previous caesarean section group, but not significant for the bowel injuries. We compared the cumulative frequency of complications between the two groups. In the group with previous caesarean section, we recorded 18.3% of intra operative complications. In the group without history of caesarean section, we recorded 3.58% of complications. There is a significant difference between the cumulative frequency of complications in the two populations of patients in favour of the sub group without a history of caesarean scar (P < 0.0001).

DISCUSSION AND CONCLUSION

A history of single or multiple previous caesarean section increases the intra operative risk in vaginal hysterectomies. The surgeon must take into account the history of caesarean section and be attentive to the previous operating time of the bladder and uterine region especially at the time of opening the anterior peritoneal cul-de-sac. Nevertheless, uterine scarring as a sequel to caesareans must not be a contraindication to the vaginal route.

Routine CMV screening during pregnancy

Cytomegalovirus (CMV) screening during pregnancy has been widely discussed for several years, but still no consensus has been agreed. With a number of live births of 750,000 per year in France, we would expect 7500 infected infants at birth per year (rate of congenital infection of 1%). Among infected infants at birth, the number of severely infected foetuses would be approximately 75, the number of infants with severe sequelae would be 480, 675 approximately would present with hearing loss and the number of asymptomatic infants would be 6270. Five different preventive methods for congenital CMV infection are possible: (1) Routine CMV screening at the beginning of pregnancy for primary prevention. (2) Secondary prevention by antenatal diagnosis of congenital CMV infection complications. (3) Tertiary prevention by serological testing during pregnancy. (4) Tertiary prevention by serological screening at birth. (5) Tertiary prevention: Hearing loss screening at birth. The aims of this review are to define the advantages and disadvantages of these different methods of CMV screening during pregnancy and to determine if the current available information would make systematic testing acceptable.

Correspondance histologique des frottis cervico-utérins détectant un cancer ou une lésion de haut grade

OBJECTIVE

The aim of the study is to analyze the histological-cytological correlations for Pap smears having detected cancer or high-grade squamous intra-epithelial lesion (HSIL) of the cervix.

PATIENTS AND METHOD

The study about 311 women is retrospective. The average age is 36.4 years. Group 1 (histological diagnosis of high-grade or invasive lesion) includes 244 women (77.5%). Group 2 (histological diagnosis other than high-grade or invasive lesion) includes 37 women (11.9%) with a presumed diagnosis of HSIL. Group 3 (absence of histological follow-up) includes 30 women (9.6%) with a presumed diagnosis of HSIL.

RESULTS

In group 1, the presumed cytological diagnosis is HSIL in 229 cases, squamous carcinoma in 11 cases and adenocarcinoma in two cases. In this group, the average delay between the Pap smear and the first histology is equal to two months. It is longer than 6 months in seven cases. The diagnosis of cancer or high-grade lesion is confirmed histologically on a first biopsy of the cervix in 196 cases, a second or a third biopsy in 10 cases, an endocervical curettage in six cases and a surgical specimen in 32 cases. In the group 2, the histological diagnosis is normal-benign in 14 cases (presumed cytological false positives) and condyloma-CIN 1 in 23 cases (presumed overevaluations).

DISCUSSION AND CONCLUSION

Results highlight benefits of interactive exchanges between clinicians and pathologists, and the necessity of review of discordant cases by several pathologists in due time, with written comments and coding of the conclusions of the review. Histological follow-up is late or not done in some women.

Value of human papillomavirus testing after conization by loop electrosurgical excision for high-grade squamous intraepithelial lesions

OBJECTIVE

The aim of the study was to evaluate human papillomavirus (HPV) testing during the follow-up of patients after conization by loop electrosurgical excision for high-grade squamous intraepithelial lesion.

METHODS

A prospective study was conducted on 205 patients who underwent conization for high-grade squamous intraepithelial lesion (CIN 2 or 3). Loop electrosurgical excision procedure (LEEP) was used in all cases. High-risk HPV testing was realized by the Hybrid Capture II system before and 3 months after conization.

RESULTS

Of the 205 patients, 193 (94.1%) were positive for the HPV test before conization. Seventy-one were HPV positive after conization (34.6%). The margins were positive in 36.1%. Residual disease was observed in 27 cases (13.2%). Four patients (2%) developed a recurrence after a mean follow-up of 18.1 months (+/-12). There was no correlation between pretreatment HPV testing and the residual disease or recurrence. Patients with positive margins were significantly more likely to have residual disease than those with negative margins (P < 0.0001). Residual disease was more likely to occur when the posttreatment HPV test was positive (P < 10(-7)). All recurrences were observed in patients with a positive posttreatment HPV test (P < 0.05). Residual disease and recurrence were correctly predicted with a sensitivity of 81 and 100%, respectively, and a negative predictive value of 96 and 100%.

CONCLUSION

Posttreatment HPV testing could be useful in the follow-up of patients after conization. In case of negative posttreatment HPV testing, the frequency of follow-up could be reduced, particularly in those patients with free margins.

Successful treatment of extremely severe fetal anemia due to Kell alloimmunization

BACKGROUND

Repeated plasmapheresis was used to prevent fetal death from severe anti-Kell alloimmunization until intrauterine transfusions were feasible.

CASE

Repeated maternal plasma exchanges (N = 40) beginning at 7 weeks' gestation were used to treat severe anti-Kell alloimmunization. Ultrasound examination at 19 weeks' gestation revealed diffuse hydrops in this fetus (umbilical venous hemoglobin, 1.2 g/dL), which then required nine intrauterine transfusions through 34 weeks. A healthy 3840-g girl was delivered by cesarean delivery at 36 weeks. Despite aplastic anemia during the first 3 months of life, she is healthy and has no observable abnormalities at age 8.

CONCLUSION

A highly aggressive course of plasmapheresis and intrauterine transfusions can successfully treat fetal anemia caused by anti-Kell alloimmunization even when fetal hemoglobin is extremely low.

Management of female genital mutilation in Djibouti: the Peltier General hospital experience

Female genital mutilation (FGM) is still performed on 98% of Djiboutian women. Infibulation (FGM type 3) is the most widely used method of FGM in Djibouti. Even though this operation is mutilating, illegal and sometimes results in death, it is still practiced at approximately the same rate as in the past. Mass immigration of African women to Europe, Canada, Australia and the United States in the past decade has brought the problems of FGM to these countries. Female genital mutilation is a problem unfamiliar to most Western obstetrician-gynecologists. A tight infibulation can be a high risk for the mother and fetus if not handled by a skilled operator. It can lead to an unnecessary cesarean section as a result of the fear of handling infibulated women. Therefore, Western physicians need to be informed. The aim of this article was to share our experience of FGM. It will focus on FGM in Djibouti, its types, epidemiology and health consequences. It will present the management of obstetric and gynecologic complications and discuss medico-legal and health service measures to combat these dangerous and unnecessary practices

[Tumor markers and ovarian cysts]

A practical review of tumor markers, particularly CA125 is proposed. The questions are: what is the role of CA125 assay in cancer screening programs, can preoperative CA125 level predict the benign or malignant nature of an adnexal anomaly, can postoperative CA125 predict the quality of surgical resection of cancer of the ovary?

Torsion of a nongravid uterus: an unexpected complication of an ovarian cyst

Torsion of nongravid uterus is rare. Most reports occur during pregnancy. A case related to an adnexal mass, is described and the existing literature is reviewed.

[Cure of cystocele with vaginal patch]

OBJECTIVE

To describe an original technique for transvaginal cystocele repair and to report the anatomical and functional results of the first 47 patients operated by this technique. The operation combines suspension, by six sutures to the tendinous arches of the pelvic fascia, of a vaginal patch measuring 6 to 8 cm long by about 4 cm wide left in contact with the cystocele. The vaginal patch is then buried under the anterior colporraphy suture. Spinal fixation, hysterectomy, levator myorrhaphy or urinary incontinence repair are also performed as necessary.

METHODS

Descriptive retrospective study of 47 patients undergoing transvaginal repair of prolapse between October 1997 and June 1998. All patients presented external prolapse with grade III cystocele, associated with urinary incontinence in 38.3% of cases and hysterocele or vaginal prolapse in 87% of cases. The mean age of the patients was 69 years. The uterus was preserved in two cases, but hysterectomy was performed in the other 45 patients, together with Richter spinal fixation in 44 cases An associated levator myorrhaphy was performed in every case.

RESULTS

The mean follow-up was 16.4 months (range: 6 to 26 months) in 46 patients. The cystocele was considered to be cured in 93% of patients, one patient had an asymptomatic grade I cystocele and surgery was unsuccessful in two patients who developed recurrent grade II cystocele.

CONCLUSION

The technique presented here is a curative treatment for grade III cystocele in menopaused women associated with Richter spinal fixation, and prevents the risk of cystocele described after transvaginal treatment of prolapse by spinal fixation alone (10 to 20%). The short-term results are encouraging, but they need to be confirmed by a follow-up of at least 5 years.

The vaginal patch plastron for vaginal cure of cystocele. Preliminary results for 47 patients

OBJECTIVE

We describe a new surgical technique (the vaginal plastron) for the treatment of cystocele by the vaginal route. The technique is based on bladder support by a vaginal strip (6-8cm in length and 4cm in width), isolated from the anterior colpocele, left attached to the bladder, associated with a suspension of this strip by its fixation to the tendinous arch of the pelvic fascia by six lateral sutures (three on each side of the plastron). The vaginal plastron is then covered by tucking it under the anterior colporraphy.

STUDY DESIGN

We evaluated the short-term functional and anatomical results of the first 47 patients to have undergone this treatment between October 1997 and June 1998. The average age of the patients was 69 years. Cystoceles were associated with urinary stress incontinence in 38.3% of cases, with hysterocele or prolapse of the vaginal dome in 87.2% of cases, with an elytrocele in 19.1% of cases and a rectocele in 70.2% of cases. Of the 45 patients having had a hysterectomy combined with the vaginal plastron or in their past history, 44 (99.77%) had a Richter sacro-spino-fixation and 17 (38%) had a Campbell procedure combined with the vaginal plastron. All patients underwent a posterior perineorraphy with myorraphy of the elevators.

RESULTS

Average follow-up was 16.4 months with extremes of 6-26 months and concerned 46 patients (one patient was unavailable). Ninety-three percent of the cystoceles were considered treated. One case of imperfect anatomical outcome was noted (persistence of stage 1 cystocele in one patient) together with two other cases of failure of the treatment of cystocele (relapse to stage 2 cystocele).

CONCLUSION

Proposed as a curative treatment of cystocele and combined with the Richter fixation, the plastron provides a surgical solution to the problem of cystocele relapse arising after vaginal treatment of prolapse by sacro-spino-fixation alone (10-20% according to Richter). Short-term results are encouraging, however, medium- to long-term results (36-60 months) are necessary in order confirm the usefulness of this surgical technique.

[Gene therapy and ovarian cancer: update of clinical trials]

Ovarian cancer is the first leading cause of death from gynecologic cancer. Advances in therapy are needed to obtain complete response after surgery and/or chemotherapy. Gene therapy is a new alternative therapeutic approach. 380 gene therapy clinical trials (3173 patients) are going to be assessed. 63% of these trials concern therapy of cancer. 16 gene therapy clinical trails are applied to ovarian cancer. These 16 clinical trials assess different treatment strategies: Mutation compensation by replacement of an altered tumor suppressor gene (p53, BRCA1); Molecular chemotherapy by transfer of a suicide gene (HSV-tk gene); Antitumoral immunotherapy by cytokine gene transfer (IL2, IL12); Oncogene inhibition (erb-B2 gene); Multi Drug Resistance gene transfer. A knowledge of basis concepts of gene transfer strategies, is needed to understand these different treatment strategies. Thus, the goals of this review are, first, to provide the basis concepts of gene transfer strategies to the obstetrician-gynecologist and second, to submit recent gene therapy clinical trials about ovarian cancer.

Neuroendocrine tumors of the uterine cervix. Clinicopathologic study of five patients

Four main clinicopathologic features of neuroendocrine tumors (NETs) of the cervix may be stressed: primary diagnosis at an advanced stage, early nodal metastasis even for low disease, early failure of appropriate local treatment (surgery and/or radiation therapy) and aggressive clinical treatment. Five patients with NET of the uterine cervix (small cell carcinoma type) are reported (one stage I, two stages II, one stage III and one stage IV). One patient was treated by surgery combined with radiation therapy, one by surgery combined with chemotherapy and one by surgery with radiation therapy and chemotherapy. Two patients received radiation therapy alone. Three early stage patients are alive with no evidence of disease 8, 26 and 41 months after diagnosis. The two patients with advanced stage died of disease, 3 and 12 months respectively, after diagnosis. Combination chemotherapy (cisplatin and etoposide) is warranted in disseminated NETs. Neoadjuvant or adjuvant chemotherapy should be combined with radiation therapy and surgery even in early stages.

[The vaginal plastron for cure of cystocele]

We describe a new surgical technique (the vaginal plastron) for the treatment of cystocele by the vaginal route. The technique is based on bladder support by a vaginal strip, isolated from the anterior colpocele, left attached to the bladder, associated with a suspension of this strip by its fixation to the tendinous arch of the pelvic fascia by six lateral sutures (3 on each side of the plastron). Proposed as a curative treatment of cystocele and combined with the Richter fixation, the plastron provides a surgical solution to the problem of cystocele relapse arising after vaginal treatment of prolapse by sacro-spino-fixation alone (10 to 20% according to Richter).

Villoglandular papillary adenocarcinoma of the uterine cervix

Villoglandular papillary adenocarcinoma of the uterine cervix was recently (1989) described by three main histological features: exophytic proliferation, papillary architecture and mild to moderate cellular atypicality. The authors report a case of villoglandular papillary adenocarcinoma, clinical stage IB, which was peculiar because of its association with a co-existing and simultaneously discovered invasive squamous cell carcinoma. These two patterns were juxtaposed and not intermingled. The patient was treated with radical hysterectomy followed by vaginal radiation therapy. She remains without evidence of recurrence after 12 months of follow-up. Five main clinicopathological features of the villoglandular papillary adenocarcinoma could be stressed: rare histological variant (72 described cases), young age of patients (25-45 years old), superficial stromal invasion, usual association with other tumoral patterns (in situ or invasive adenocarcinoma as well as in situ or invasive squamous cell carcinoma) and excellent prognosis. For selected cases, a conservative surgical approach (cervical conization) was possible.