Serious complications and recurrences after retropubic vs transobturator midurethral sling procedures for 2682 patients in the VIGI-MESH register

BACKGROUND

Midurethral slings are the gold standard for treating stress urinary incontinence, but their complications may raise concerns. Complications may differ by the approach used to place them.

OBJECTIVE

This study aimed to compare serious complications and reoperations for recurrence after midurethral sling procedures when using the retropubic vs the transobturator route for female stress urinary incontinence.

STUDY DESIGN

This analysis was of patients included in the French, multicenter VIGI-MESH register since February 2017 who received a midurethral sling for female stress urinary incontinence either by the retropubic or the transobturator route and excluded patients with single-incision slings. Follow-up continued until October 2021. Serious complications (Clavien-Dindo classification ≥ grade III) attributable to the midurethral sling and reoperations for recurrence were compared using Cox proportional hazard models including any associated surgery (hysterectomy or prolapse) and a frailty term to consider the center effect. Baseline differences were balanced by propensity score weighting. Analyses using the propensity score and Cox models were adjusted for baseline differences, center effect, and associated surgery.

RESULTS

A total of 1830 participants received a retropubic sling and 852 received a transobturator sling in 27 French centers that were placed by 167 surgeons. The cumulative 2-year estimate of serious complications was 5.8% (95% confidence interval, 4.8-7.0) in the retropubic group and 2.9% (95% confidence interval, 1.9-4.3) in the transobturator group, that is, after adjustment, half of the retropubic group was affected (adjusted hazard ratio, 0.41; 95% confidence interval, 0.3-0.6). The cumulative 2-year estimate of reoperation for recurrence of stress urinary incontinence was 2.7% (95% confidence interval, 2.0-3.6) in the retropubic group and 2.8% (95% confidence interval, 1.7-4.2) in the transobturator group with risk for revision for recurrence being higher in the transobturator group after adjustment (adjusted hazard ratio, 1.9; 95% confidence interval, 1.2-2.9); this surplus risk disappeared after exclusion of the patients with a previous surgery for stress urinary incontinence.

CONCLUSION

The transobturator route for midurethral sling placement is associated with a lower risk for serious complications but a higher risk for surgical reoperation for recurrence than the retropubic route. Despite the large number of surgeons involved, these risks were low. The data are therefore reassuring.

Anterior sacrospinous ligament fixation by the vaginal route in ten steps

Pelvic organ prolapse (POP) is a common condition affecting women, characterized by the descent of pelvic organs such as the vagina and uterus. While POP may not always cause symptoms, it can significantly impact a woman's quality of life. Diagnosis is typically made through clinical examination, and treatment options range from pelvic-floor physical therapy to surgery. Anterior sacrospinous ligament fixation (ASSLF) has emerged as a viable technique for treating apical prolapse vaginally. This procedure involves attaching the cervix or vaginal vault to the sacrospinous ligament, providing satisfactory results in the short term. Compared to the posterior approach, ASSLF shows similar efficacy, shorter operative time, and potentially fewer complications. Vaginal surgery offers advantages such as lower morbidity and cost, ability to address other pelvic conditions simultaneously, and suitability for managing recurrences. The presented case involves a 72-year-old woman with stage 3 cystocele, stage 3 hysterocele, stage 1 rectocele, and severe voiding dysfunction. After unsuccessful attempts with a pessary, surgical intervention becomes necessary. An instructive video article has been created to standardize the essential steps of ASSLF and facilitate resident education. The video demonstrates ten surgical steps, including installation/exposure, anterior vaginal wall infiltration, median anterior colpotomy, vesico-vaginal dissection, paravesical dissection, sacrospinous ligament suture, cystocele correction, colpotomy and vaginal wall repair, uterine anterior isthmus suture and sacrospinous ligament fixation, and colporrhaphy final closure. In conclusion, POP is a prevalent condition that can be effectively managed through techniques like ASSLF. Vaginal surgery offers several advantages, and proper training and standardization of surgical steps contribute to successful outcomes and resident education.

vNOTEsHC : Hysterectomy by transvaginal natural orifice transluminal endoscopic surgery versus laparoscopic for large uteri: study protocol for a multicentre randomised controlled trial

Background

In France, 62,000 hysterectomies are performed per year, 70% of which are benign. The choice of approach (laparotomy, laparoscopy or vaginal route) is particularly important in the case of large uterus (> 280g) which are associated with a higher risk of complications. The current data are not sufficient to favour one or other approach. A new medical device, the vNOTES (Natural Vaginal Orifice Transluminal Endoscopy System), offers the advantage of both laparoscopic and vaginal route for pelvic surgery.

Objectives

To demonstrate the superiority in terms of intraoperative and postoperative complications of the use of a natural orifice transluminal endoscopic hysterectomy system (vNOTES) versus laparoscopic hysterectomy for benign pathologies on estimated large volume uteri (>280g).

Materials and Methods

A randomised, double-blind, superiority trial will be performed at five hospital centres. Women with benign uterine pathology requiring hysterectomy and with a large uterus (> 280g) will be randomised to receive either laparoscopic or vNOTES hysterectomy.

Main outcome measures

The primary outcome will be the occurrence of intraoperative and postoperative complications within 6 weeks of surgery. Secondary outcomes will be conversion during surgery, duration of surgery and hospitalisation, postoperative pain, postoperative complications, resumption of sexual life and satisfaction with the surgical team.

Results

248 women will be randomised.

Conclusion

This trial will provide a better understanding of the approach to large uteri optimise the care of these thousands of women undergoing hysterectomy.

What’s new?

This trial will evaluate the vNotes for large uteri.

The psychological impact of therapeutic changes during the COVID-19-lockdown for gynaecological and breast cancer patients. J Gynecol Obstet Hum Reprod 2022;51:102311. [PMID: 35007776 PMCID: PMC8739811 DOI: 10.1016/j.jogoh.2022.102311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Objective

The exceptional health situation related to the Coronavirus 2019 (COVID-19) pandemic has required an in-depth and immediate reorganisation of gynaecological cancer care. The main objective was to assess the psychological impact of such treatment modifications during the lockdown period for gynaecological and breast cancer patients.

Patients and methods

A multicentre prospective study was conducted in three university gynaecological cancer wards (Hospices Civils de Lyon, France) during the French first lockdown (16th March to 11th May 2020). All patients with non-metastatic breast cancer or gynaecological cancer were included. Data was collected regarding treatment modifications (delay, cancellation, change of therapeutic plan). The psychological impact of treatment modifications during and after the lockdown was assessed by validated questionnaires (SF-12, EORTC-QLQ-C30, HADS).

Results

A total of 205 consecutive patients were included, aged 60.5 ± 1.0 years. Seven patients (3.4%) presented a SARS-CoV-2 infection, and two patients died. Treatment was maintained for 122 (59.5%) patients, postponed for 72 (35.1%) and cancelled for 11 (5.4%). During the lockdown, 35/118 (29.7%) patients suffered from confirmed anxiety and the mean fatigue-EORTC score was 48.00 ± 2.51; it was 38.64 ± 2.33 (p = 0.02) after the lockdown. After the lockdown and compared to the lockdown period, the mental SF-12 score and overall health status EORTC score were significantly higher (45.03 ± 1.06 vs 41.71 ± 1.15, p = 0.02 and 64.58 ± 1.66 vs 57.44 ± 2.02, p = 0.0007, respectively). The number of confirmed-anxiety cases was significantly higher amongst patients for whom treatment was delayed or cancelled (40.5% vs 23.7%, p = 0.04).

Conclusion

This study quantified the treatment modifications of gynaecological cancer patients during the COVID-19 lockdown and revealed a poorer psychological state and quality of life during this period, even for patients whose treatment plan was not actually modified. Anxiety was more significant in patients with a delayed or cancelled treatment.

Development of an innovative surgical navigation system for sacrospinous fixation in pelvic surgery

STUDY OBJECTIVE

To validate the use of an innovative navigation method for sacrospinous fixation in surgery-like conditions as a new teaching tool and surgical method.

DESIGN

2-month-experiment prospective pilot study between July and August 2021.

SETTING

Biomechanics laboratory academic research.

POPULATION

29 participants: 9 gynecological surgeons and 20 participants with no medical background.

MEASUREMENT AND MAIN RESULTS

The experiment was composed of two training phases dedicated to improve the hand-eye coordination and suture skills on a training mock-up, and of a suturing phase on a pelvic mock-up designed to recreate the surgery-like conditions of a sacrospinous fixation. The surgeons provided qualitative feedback on the bio-accuracy of the mock-ups and evaluated the ease-of-use of the navigation software. Non-surgeons were included to assess the progression of the suture performance between two experiments performed one week apart (Session 1 & 2). The main objective for participants was to reach a virtual target and to stitch sacrospinous ligaments. For Session 1, an overall comfort score of 7.2/10 was attributed to the tool; 14 (42%) surgeon suture attempts and 63 (65%) non-surgeon suture attempts were accurate (i.e. below the 5-mm threshold). 22 (67%) surgeon suture attempts and 28 (34%) non-surgeon suture attempts were fast (i.e. in the first two quantiles of the duration dataset). An improvement of the non-surgeon performance was observed between the two sessions in terms of duration (Session 1: 46±20 sec; Session 2: 37±18 sec; p=0.047) and distance (Session 1: 3.8±1.3 mm; Session 2: 3.2±1.4 mm; p=10^-5) for the last suturing exercise.

CONCLUSION

This new motion-capture-based navigation method for sacrospinous fixation tested under surgery-like conditions seemed to be accurate and effective. The next step will be to design a pelvis model more adapted to the constraints of a sacrospinous fixation and to validate the benefits of this method compared to current techniques.

Effective, simple and fast procedure for laparoscopic port-sites wounds closure

The closure of port-sites wounds, as the ultimate step of surgical laparoscopic procedures, can be allowed by threads, staples, surgical glue or adhesive sutures. We describe a simple and easy skin suturing technique which saves time and provides significant surgical ergonomics.

Glue mesh fixation in laparoscopic sacrocolpopexy: results at 3 years' follow-up

INTRODUCTION AND HYPOTHESIS

We assessed 3-year anatomic and functional results using synthetic glue to fix mesh in laparoscopic sacrocolpopexy.

METHODS

Prospective multicenter cohort study in three academic urogynecology departments. Seventy consecutive patients with stage ≥ 3 POP-Q (Pelvic Organ Prolapse Quantification) anterior and/or apical prolapse underwent laparoscopic sacrocolpopexy using synthetic surgical glue to fix anterior and posterior meshes to the vagina. Patients were followed up at 1, 2 and 3 years. Primary outcome was anterior and apical anatomic success (POP-Q stage ≤ 1) at 3 years. Secondary outcomes comprised functional results (international quality of life and sexuality scales), mesh-related morbidity and urinary incontinence at 3 years.

RESULTS

Mean age was 56.7 ± 1.2 years. Mean follow-up was 43 months. Anterior compartment anatomic success rate was 87% at 2 years (Ba, -2.4 cm; p < 0.0001) and 86.5% at 3 years (Ba, -2.3 cm; p < 0.0001); apical success was 96.3% at 2 years (C, -6.8 cm; p < 0.0001) and 97.3% at 3 years (C, -6.5 cm; p < 0.0001). All quality-of-life scores improved significantly and lastingly at 3 years: PFDI-20, PFIQ-7 and PISQ-12, respectively, p < 0.0001, p < 0.0001 and p = 0.01. There was one case of vaginal mesh exposure at 3 years (2.8%) and five of mesh shrinkage at 1 year (7.8%), none at 2 years and two at 3 years (5.4%). Urinary incontinence rate was 29.7% at 1 year, 14.8% at 2 years and 11.1% at 3 years.

CONCLUSION

Vaginal mesh adhesive in laparoscopic sacrocolpopexy remained effective at 3 years, with excellent tolerance and no specific complications. Anatomic and functional results were good and enduring in terms of both anterior and apical correction.

Ovarian torsion in a twin pregnancy at 32 weeks and 6 days: A case-report

BACKGROUND

Ovarian torsion during pregnancy is a rare event and occurs mostly during the first trimester. This is the first case describing the diagnosis and management of an ovarian torsion at 33 weeks in a twin pregnancy with a normal term delivery.

CASE SUMMARY

The patient presented with irregular uterine contraction due to an acute abdominal pain in the right iliac fossa. A cyst was discovered during the ultrasound scan on the right ovary and a torsion was highly suspected. A small laparotomy facing the ovarian mass after an ultrasound guidance was chosen. The patient finally delivered at 37 weeks.

CONCLUSION

The clinic holds a preponderant place in the diagnosis of ovarian torsion. Our surgical approach by laparotomy under ultrasound guidance was less risky than by laparoscopy.

Ectopic pregnancy management by V-NOTES technique

Ectopic pregnancy is a frequent and life-threatening risk of childbearing. Its management represents a mainstay of emergency gynecological surgery, and laparoscopy is the surgical gold standard technique. The technique of transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) for the management of ectopic pregnancy is presented herein. The procedure is illustrated by an instructive video article that standardizes the essential steps to make the technique ergonomic and easy to perform (step-by-step explanations). This surgical technique allows to consider vaginal salpingectomy using a combined cœlio-vaginal approach. After a posterior colpotomy, an Alexis retractor was inserted in the pouch of Douglas followed by the placement of a dedicated platform on which three trocars were fixed. Pneumoperitoneum was then achieved. Once the diagnosis of ruptured tubal ectopic pregnancy was established, a salpingectomy was performed. As a minimally invasive approach, this procedure has high patient acceptance and seems to improve favorable clinical outcomes.

Easy way to perform salpingectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) (with video)

The transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is a new minimally invasive and emerging technique. Feasibility and safety profiles of peritoneal access via transvaginal routes have been demonstrated especially for the adnexal surgery. In order to be reproducible and replicable with a standardized procedure, we propose the step-by-step video description of the vNOTES salpingectomy. The advantages of the vNOTES (low postoperative pain, faster postoperative recovery, scarless surgery) could lead to a promising alternative to conventional laparoscopic salpingectomy/adnexectomy.

[Impact of the COVID-19 Outbreak on the management of patients with gynecological cancers]

OBJECTIVE

The exceptional health situation related to the SARS-Cov2 coronavirus pandemic (COVID-19) required a deep and very quickly adaptation of management practices in gynecological cancer. The main objective is to estimate the proportion of patients with treatment modifications.

METHOD

This is a multicenter prospective study conducted in 3 university gynecological cancer departments (HCLyon, France) during the period of confinement (March 16 to May 11, 2020). All patients with non-metastatic breast cancer or gynecological cancer were included. The planned treatment, postponement, delay and organizational modifications (RCP, teleconsultations) were studied.

RESULTS

Two hundred and five consecutive patients were included, average age 60.5±1.0. 7 patients (3.4%) had SARS-Cov-2 infection, 2 patients died. One hundred and twenty-two patients (59.5%) had a treatment maintained, 72 patients (35.1%) postponed, 11 patients (5.4%) cancelled. Of the 115 (56.1%) planned surgeries, 40 (34.8%) postponed, 7 cancelled (6.1%). 9 patients (7.8%) had a surgical modification. Of the 59 (28.8%) radiotherapy treatments scheduled, 24 (40.7%) postponed and 2 (3.4%) cancelled. Of the 56 (27.3%) chemotherapy treatment planned, 8 (14.3%) postponed and 2 (3.6%) cancelled. One hundred and forty-five patients (70.7%) have been discussed in multidisciplinary meeting. One hundred and fifty-eight patients (77%) had a teleconsultation system.

CONCLUSION

Our study assessed the impact of the COVID-19 pandemic on therapeutic management of patients with gynecological cancer during the period of confinement. This will probably improve our management of an eventual epidemic rebound or future health crisis.

Minimally invasive management of Bartholin gland abscesses (with demonstrative video)

Bartholin gland abscesses are common problems in women and their management represents a mainstay of gynecology. Various treatment methods have been described. We present a technique performed under local anesthesia, without hospitalization or postoperative care. As part of a minimally invasive approach, this procedure promotes therapeutic de-escalation, has high patient acceptance, improves clinical outcomes and reduces costs. The procedure is highlighted through an instructive video article which standardizes the essential steps, to make the technique ergonomics and easy to perform (step-by-step explanation).

Virtual reality simulation to enhance laparoscopic salpingectomy skills

BACKGROUND

To assess skill enhancement and maintenance by virtual-reality simulation of laparoscopic salpingectomy in gynecologic surgery fellows. Skill acquisition by virtual-reality surgical simulation is an active field of research and technological development. Salpingectomy is one of the first gynecologic surgery techniques taught to fellows that requires accompanied learning.

METHODS

A single-center prospective study was performed in the University of Lyon, France, including 26 junior fellows (≤ 3 semesters' internship) performing laparoscopic salpingectomy exercises on a LapSim® virtual reality simulator. Salpingectomy was performed and timed on 3 trials in session 1 and 3 trials in session 2, at a 3-month interval. Analysis was based on students' subjective assessments and a senior surgeon's objective assessment of skill. Progress between the 2 sessions was assessed on McNemar test and Wilcoxon test for matched series.

RESULTS

26 junior specialist trainees performed all trials. Most performed anterograde salpingectomy, both in session 1 (69 %) and session 2 (86 %). Mean procedure time was significantly shorter in session 2: 6.10min versus 7.82min (p=0.0003). There was a significant decrease in blood loss between the first trial in session 1 and the last trial in session 2: 167ml versus 70.3ml (p=0.02). Subjective assessment showed a significant decrease in anxiety and significant increase in perceived efficacy, eye-hand coordination and ergonomics. Efficacy, performance quality and speed of execution as assessed by the senior surgeon all improved significantly from trial to trial, while hesitation significantly decreased.

CONCLUSIONS

The study showed that junior trainees improved their surgical skills on a short laparoscopic exercise using a virtual reality simulator. Virtual reality simulation is useful in the early learning curve, accelerating the acquisition of reflexes. Maintaining skill requires simulation sessions at shorter intervals.

Quality of life after laparoscopic removal of Essure® sterilization devices

Objective(s)

To assess changes in quality of life after laparoscopic removal of Essure^® sterilization devices (Bayer AG, Leverkusen, Germany).

Study Design

In this prospective observational study in an academic research hospital, 80 women with new or worsening symptoms since placement of Essure^® sterilization devices undergoing subsequent surgical removal were included. Laparoscopic removal of Essure^® devices and salpingectomy with or without cornual excision were performed. Concomitant uterine procedures could be associated where indicated for gynaecological complaints. Comparison using the T student test for coupled series was done in this before-and-after study.

Results

Health related quality of life (HRQL) was the primary outcome measured by the Short Form 12 (SF-12) questionnaire and a global 10 cm visual analogue scale (VAS). Secondary outcomes included assessment of pain, using continuous (VAS) and ordinal scales (Modified McGill Pain Questionnaire), menstrual bleeding (pictorial blood loss assessment chart (PBAC) score) and surgical feasibility and safety. There was a significant improvement in quality of life in both mental and physical health aspects of the SF-12 (34.02 (+/−1.19) vs. 49.61 (+/−1.42, P < .0001) and 36.55 (+/−0.99) vs. 43.32 (+/−1.18, P < .0001 respectively) as well as global VAS assessment (+2.91 (SD +/−0.27)) at the end of the first post-operative month. These improvements were maintained at three and six months. Mean pain decreased at one month following surgery compared to baseline (VAS 3.6 (+/−0.36) to 1.4 (+/−0.25), P < .0001 and McGill pain score 18.70 (+/−1.88) to 4.73 (+/−0.90), P < .0001). Improvements of a similar magnitude were observed when analysis was restricted to the 47 women without concomitant uterine surgery. No significant changes in bleeding were seen following of Essure^® device removal. Planned procedures were all successfully completed.

Conclusion

Laparoscopic removal of Essure® devices in symptomatic women is technically successful and associated with short and medium-term improvement in quality of life as well as reduction in pelvic pain.

Opportunistic Salpingectomy at the Time of Benign Laparoscopic Hysterectomy: Assessment of Possible Complications and Histopathological p53-Signatures

Introduction

The aim of this study is to assess the prevalence of tubal histopathological abnormalities (serous tubal intraepithelial carcinoma STIC and p53 signatures) and the prevalence of perioperative and postoperative complications related to opportunistic laparoscopic salpingectomy in a low risk population.

Materials and Methods

In this observational prospective cohort, prophylactic bilateral salpingectomy during benign laparoscopic hysterectomy was systematically performed in 100 consecutive women. Peri- and postoperative complications were registered. Duration of salpingectomy and post-salpingectomy blood loss were also measured. Histopathological and immunohistochemical analysis with anti-p53 antibody were performed on the whole fallopian tubes according to a specific and validated protocol.

Results

Laparoscopic salpingectomy was always possible without any peri- or postoperative complication attributable to the salpingectomy itself. The mean duration was 428 seconds (354 – 596) and the blood loss was 9 cm ³ (2 – 15). Using histopathological and immunohistochemical assessment with anti-p53 antibody on 199 fallopian tubes (99 bilateral salpingectomies and one unilateral salpingectomy because of previous salpingectomy for ectopic pregnancy), there was a prevalence of 5.52% (11/199) of p53 signatures. No STIC were observed and no associated cancer.

Conclusions

Laparoscopic salpingectomy is both feasible and innocuous during benign hysterectomy. Meticulous histopathologic examination of the tubes may reveal specific abnormalities.

Complex ecological interactions of Staphylococcus aureus in tampons during menstruation

Menstrual toxic shock syndrome (mTSS) is a severe disease that occurs in healthy women vaginally colonized by Staphylococcus aureus producing toxic shock toxin 1 and who use tampons. The aim of the present study was to determine the impact of the composition of vaginal microbial communities on tampon colonisation by S. aureus during menses. We analysed the microbiota in menstrual fluids extracted from tampons from 108 healthy women and 7 mTSS cases. Using culture, S. aureus was detected in menstrual fluids of 40% of healthy volunteers and 100% of mTSS patients. Between class analysis of culturomic and 16S rRNA gene metabarcoding data indicated that the composition of the tampons' microbiota differs according to the presence or absence of S. aureus and identify discriminating genera. However, the bacterial communities of tampon fluid positive for S. aureus did not cluster together. No difference in tampon microbiome richness, diversity, and ecological distance was observed between tampon vaginal fluids with or without S. aureus, and between healthy donors carrying S. aureus and mTSS patients. Our results show that the vagina is a major niche of. S. aureus in tampon users and the composition of the tampon microbiota control its virulence though more complex interactions than simple inhibition by lactic acid-producing bacterial species.

Increased factor VIII plays a significant role in plasma hypercoagulability phenotype of patients with cirrhosis

Essentials The role of increased factor VIII in cirrhosis-induced hypercoagulability has never been demonstrated. Factor VIII and protein C effects were characterized by thrombin generation with thrombomodulin. Factor VIII elevation plays a significant role in cirrhosis-induced plasma hypercoagulability. Only protein C and factor VIII normalization led to thrombin generation similar to controls.

SUMMARY

Background In cirrhosis, thrombin generation (TG) studied in the presence of thrombomodulin (TM) indicates plasma hypercoagulability. Although the role of protein C (PC) deficiency has been investigated, the influence of an increase in the factor VIII level has never been addressed. Objectives We investigated the roles of high FVIII and low PC levels in increased TG in the presence of TM. Methods Blood samples were prospectively collected from 35 healthy controls and 93 patients with cirrhosis (Child-Turcotte-Pugh [CTP]-A, n = 61; CTP-B, n = 19; and CTP-C, n = 13) and FVIII levels > 150% (n = 48) and/or PC levels < 70% (n = 88). TG was performed with tissue factor (5 pm), phospholipids, and TM (4 nm). FVIII and PC levels were normalized by adding an inhibitory anti-FVIII antibody and exogenous PC, respectively. Results The endogenous thrombin potential (ETP) in the presence of TM was higher in patients than in controls. After FVIII normalization, the ETP (median) decreased from 929 nm min to 621 nm min (CTP-A), 1122 nm min to 1082 nm min (CTP-B), and 1221 nm min to 1143 nm min (CTP-C); after PC normalization, it decreased from 776 nm min to 566 nm min (CTP-A), 1120 nm min to 790 nm min (CTP-B), and 995 nm min to 790 nm min (CTP-C). The ETP was reduced by 17% and 30%, respectively, but normal TG was not restored. When both FVIII and PC levels were normalized, the ETP decreased from 929 nm min to 340 nm min (CTP-A), 1122 nm min to 506 nm min (CTP-B), and 1226 nm min to 586 nm min (CTP-C), becoming similar to control levels. Conclusion Cirrhosis-induced plasma hypercoagulability, as demonstrated in these experimental conditions, can be partly explained by opposite changes in two factors: PC level (decrease) and FVIII level (increase).

Cholangiopathy in critically ill patients surviving beyond the intensive care period: a multicentre survey in liver units

BACKGROUND

The outcome of cholangiopathy developing in intensive care unit (ICU) is not known in patients surviving their ICU stay.

AIM

To perform a survey in liver units, in order to clarify the course of cholangiopathy after surviving ICU stay.

METHODS

The files of the liver units affiliated to the French network for vascular liver disease were screened for cases of ICU cholangiopathy developing in patients with normal liver function tests on ICU admission, and no prior history of liver disease.

RESULTS

Between 2005 and 2015, 16 cases were retrieved. Extensive burns were the cause for admission to ICU in 11 patients. Serum alkaline phosphatase levels increased from day 11 (2-46) to a peak of 15 (4-32) × ULN on day 81 (12-511). Magnetic resonance cholangiography showed irregularities or frank stenosis of the intrahepatic ducts, and proximal extrahepatic ducts contrasting with a normal aspect of the distal common bile duct. Follow-up duration was 20.6 (4.7-71.8) months. Three patients were lost to follow-up; 2 patients died from liver failure and no patient was transplanted. One patient had worsening strictures of the intrahepatic bile ducts with jaundice. Nine patients had persistent but minor strictures of the intrahepatic bile ducts on MR cholangiography, and persistent cholestasis without jaundice. One patient had normal liver function tests.

CONCLUSIONS

In patients surviving their ICU stay, ICU cholangiopathy is not uniformly fatal in the short term or clinically symptomatic in the medium term. Preservation of the distal common bile duct appears to be a finding differentiating ICU cholangiopathy from other diffuse cholangiopathies.

[What haemostatic technique should we use for opportunistic salpingectomy during benign laparoscopic hysterectomy?]

OBJECTIVE

To compare ovarian function before and after laparoscopic hysterectomy with bilateral salpingectomy for benign lesions with two different systems of haemostasis.

METHODS

In this prospective randomized study comparing two types of energy used for coagulation in bilateral salpingectomy (group A: bipolar electric energy, versus group B: ultrasonic advanced energy [Harmonic^®]), forty consecutive non-menopausal patients undergoing laparoscopic hysterectomy for benign lesions were included. Values of anti-Müllerian hormone (AMH), LH and FSH, antral follicle count (AFC) and ovarian vascularization on bilateral Doppler ultrasound, quality of life (questionnaire) were assessed preoperatively and at 1 and 3 months postoperatively.

RESULTS

Preliminary analysis showed shorter salpingectomy operating time (P<0.0001) and less bleeding (P<0.005) in group B. In group A, there was no statistical difference except a decrease in AFC at 1 and 3 months on the right ovary (P=0.04). In group B, AMH levels were significantly lower postoperatively at 3 months and LH levels were increased at 3 months (respectively P=0.02 et P=0.04). There was no statistical difference in the ultrasonographic data. Quality of life did not significantly differ in both groups.

CONCLUSION

Preliminary findings showed reduced AMH levels at 3months postoperatively in ultrasonic energy group whereas there was no significative menopausal symptoms. It seems important to continue this study in order to know the real effects of both energy systems on the ovarian function.

Opportunistic salpingectomy during vaginal hysterectomy for a benign pathological condition

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate the surgical feasibility of opportunistic salpingectomy or salpingo-oophorectomy during benign vaginal hysterectomy (HV) and the prevalence of occult tubal lesions.

METHODS

In this prospective study from 1 September 2013 to 1 November 2015, the prevalence of bilateral salpingectomy with or without ovariectomy and the prevalence of histopathological and immunohistochemical tubal abnormalities were assessed.

RESULTS

A total 115 patients were included. Bilateral salpingectomy was performed in 85 patients (73.92%; group A) and was technically impossible in 30 patients (26.08%; group B). Older patients (62.9 vs 57.5 years, p = 0.009), menopausal status (83.33% vs 62.35%, p = 0.03) and elevated BMI (27.58 vs 25.05 p = 0.03) were statistically associated with failure of salpingectomy. There was only one case of postoperative hemorrhage in group A. There was no difference with regard to intra- or postoperative complications, blood loss, and operating time between the two groups. Among the 67 fallopian tubes analyzed with a validated histopathological protocol, there were 8 (11.94%) immunohistochemical abnormalities with a "p53 signature."

CONCLUSIONS

With the recent demonstration of a tubal origin of most ovarian cancer, opportunistic salpingectomy could be a theoretically relevant prevention strategy. Bilateral salpingectomy could be performed during benign vaginal hysterectomy by experienced surgeons. The advantages and disadvantages of exclusive salpingectomy during pelvic floor surgery should be discussed with the patients.

Simultaneous bilateral tubal ectopic pregnancy after intracytoplasmic sperm injection and embryo transfer, in a patient with Stage 3 endometriosis

Introduction

The incidence of extrauterine pregnancy increases to 2-12% following in vitro fertilization -embryo transfer. Several pathogenic theories have been suggested, including abnormal hormonal secretion or exogenous hormones administered in assisted reproductive technology (ART).

Case report

A 32-year-oId nulliparous woman with primary infertility and Stage 3 endometriosis was treated by ART with intracytoplasmic sperm injection and embryo transfer. The patient showed simultaneous bilateral extrauterine pregnancy, managed by laparoscopic salpingectomy.

Discussion

The various possible pathophysiological mechanisms are described, with a review of the literature on simultaneous bilateral extrauterine pregnancy following ART. In pregnancies following ART, ectopic pregnancy should always be screened for by serum β-human chorionic gonadotropin monitoring and transvaginal ultrasound until the implantation site can be confirmed as the incidence is higher than in spontaneous pregnancy. Even if serum β-human chorionic gonadotropin concentration increases normally, possible bilateral ectopic pregnancy should always be investigated if no intrauterine gestational sac can be seen.

Vaginal Neoplasia Induced by an Unusual Papillomavirus Subtype in a Woman with Inherited Chromosomally Integrated Human Herpesvirus Type 6A

We describe here a case of high-grade vaginal squamous lesion in a 54-year-old woman with a papillomaviruses (HPV) genital infection that developed from a cervical low-grade squamous intraepithelial lesion (SIL) to a high-grade SIL (H-SIL) on cytological examination. A colposcopy exam led to the detection of suspect vaginal lesions with granulomatous infiltrations, which were classified as a Vaginal Intra-Epithelial Neoplasia grade 2 after pathologists' analyses. After a laser vaginal surgery and a loop excision of the transformation zone, the analyses of the anatomical pieces using a near-complete HPV screening panel revealed an HPV-4 infection that was not detected before in cervical smears. This HPV-infection is associated with a high human herpesvirus type 6A (HHV-6A) viral load in the same anatomical piece. The presence of an inherited chromosomally integrated HHV-6A (iciHHV-6A) was proved in this patient by real-time polymerase chain reaction on hair follicles and nail. This case suggests reconsidering both the benign nature of low-grade lesions in the female genital tract and the well-known "good" prognosis of low-risk HPV infection, especially when iciHHV-6A is diagnosed. This clinical course insists on the benefits of the multiplex panel use or global sequencing in order to optimize biological testing sensitivity, and so enhance clinical management of infection-induced neoplasia.