Surgery of abdominal wall endometriosis associated with clear-cell carcinoma: Case report and review

Abdominal wall is a rare location for endometriosis, with a reported incidence of parietal endometriosis of approximately 0.03 to 0.4%. It most often occurs in the aftermath of a caesarean section and is associated with pelvic endometriosis in only 5 to 15% of cases. Rare cases of malignant transformation have been described, mainly in the form of clear-cell tumours. We report the case of a 52-year-old patient with a history of endometriosis who presented with a retractile parietal mass at the level of her caesarean scar. Histological analysis confirmed a clear-cell adenocarcinoma (CCC). Few cases of endometriosis - associated CCC are described in the literature. A review of the literature suggests radical surgical treatment combined with adjuvant radio-chemotherapy. However, the prognosis is poor. The aim of this case report is to suggest the diagnosis of malignant transformation in the presence of a rapidly evolving parietal mass in the context of endometriosis and a history of caesarean section.

Validation of the Sexual Activity Questionnaire in women with endometriosis

STUDY QUESTION

Is the Sexual Activity Questionnaire (SAQ) a valid tool for patients treated for symptomatic endometriosis?

SUMMARY ANSWER

For women having surgical treatment for endometriosis, we determined that the SAQ is a valid and responsive tool.

WHAT IS KNOWN ALREADY

Endometriosis adversely affects sexual quality of life. Suitable validated sexual quality of life instruments for endometriosis are lacking both in clinical practice and for research.

STUDY, DESIGN, SIZE, DURATION

A total of 367 women with proven endometriosis undergoing medical or surgical treatment were included in an observational study conducted between 1 January 2012 and 31 December 2014 in two French tertiary care centers. Both hospitals are reference centers for endometriosis treatment. Of these 367 women, 267 were sexually active and constituted the baseline population.

PARTICPANTS/MATERIALS, SETTINGS, METHODS

Women >18 years old with histological or radiological proven endometriosis, consulting for painful symptoms of at least 3 months duration, infertility, or other symptoms (bleeding, cysts) were invited to complete self-administered questionnaires before (T0) and 12 months after treatment (T1). Tests of data quality included descriptive statistics of the data, missing data levels, floor and ceiling effects, structural validity and internal consistency.The construct validity was obtained by testing presupposed relationships between previously established SAQ scores and prespecified characteristics of the patients by comparing different subgroups of patients at T0. Sensitivity to change was subsequently calculated by comparing the SAQ score between T1 and T0 overall and for different subgroups of treatment. Effect sizes (to T1) were calculated according to Cohen's method. The minimally important difference was estimated by a step-wise triangulation approach (including anchor-based method).

MAIN RESULTS AND THE ROLE OF CHANCE

In total, 267 sexually active patients (204 surgical and 63 medical treatment) completed the SAQ at T0 and 136 (50.9%) at T1. The SAQ score ranged from 2.0 to 28.0 (mean ± SD: 16.8 ± 5.7).The SAQ score was one-dimensional according to the scree plot with good internal consistency (Cronbach alpha = 0.78, 95% CI 0.74-0.81) and had good discriminative ability according to pain descriptors and quality of life in endometriosis. The SAQ was responsive in patients treated by surgery but the effect size was low (0.3, 95% CI (0.0-0.6), P = 0.01). The minimally important difference was determined at 2.2.

LIMITATIONS, REASONS FOR CAUTION

The effect size for medical treatment was non-significant. Other effect sizes were low but statistically significant. This could be explained by lower libido due to progestin intake, which was used for both surgically and medically treated patients.

WIDER IMPLICATIONS OF THE FINDINGS

The SAQ is easy to use, valid and effective in assessing sexual quality of life in patients with endometriosis. This patient-reported score could be used as a primary outcome for future clinical studies. The minimally important difference estimation will be useful for future research. We recommend using 2.2 for the minimally important difference of the SAQ.

STUDY FUNDING/COMPETING INTEREST(S)

This work was funded by the 'Direction à la Recherche Clinique et à l'Innovation' of Versailles, France and the 'Institut de Recherche en Santé de la Femme' (IRSF). The authors have no conflicts of interest to declare.

Management of endometriosis: CNGOF/HAS clinical practice guidelines - Short version

First-line diagnostic investigations for endometriosis are physical examination and pelvic ultrasound. The second-line investigations are: targeted pelvic examination performed by an expert clinician, transvaginal ultrasound performed by an expert physician sonographer (radiologist or gynaecologist), and pelvic MRI. Management of endometriosis is recommended when the disease has a functional impact. Recommended first-line hormonal therapies for the management of endometriosis-related pain are combined hormonal contraceptives (CHCs) or the 52mg levonorgestrel-releasing intrauterine system (IUS). There is no evidence base on which to recommend systematic preoperative hormonal therapy solely to prevent surgical complications or facilitate surgery. After surgery for endometriosis, a CHC or 52mg levonorgestrel-releasing IUS is recommended as first-line treatment when pregnancy is not desired. In the event of failure of the initial treatment, recurrence, or multiorgan involvement, a multidisciplinary team meeting is recommended, involving physicians, surgeons and other professionals. A laparoscopic approach is recommended for surgical treatment of endometriosis. HRT can be offered to postmenopausal women who have undergone surgical treatment for endometriosis. Antigonadotrophic hormonal therapy is not recommended for patients with endometriosis and infertility to increase the chances of spontaneous pregnancy, including postoperatively. Fertility preservation options must be discussed with patients undergoing surgery for ovarian endometriomas.

[Interest of hysterectomy with or without bilateral oophorectomy in the surgical treatment of endometriosis: CNGOF-HAS Endometriosis Guidelines]

OBJECTIVE

In women with symptomatic endometriosis and no desire for pregnancy, hysterectomy with or without bilateral oophorectomy is often presented as a definitive solution to their symptoms. Despite this radical treatment, it should be known that nearly 15% of these patients will have persistent pain. Thus the objective of this review was to determine the interest of total hysterectomy with or without bilateral oophorectomy for the treatment of deep endometriosis.

METHOD

The research was conducted from the US National Library of Medicine's National Institutes of Health from the following keywords: endometriosis, hysterectomy, oophorectomy, ovariectomy, radical treatment. Only articles written in English have been selected.

RESULTS AND RECOMMENDATIONS

Hysterectomy with or without bilateral oophorectomy, associated with endometriotic lesions exeresis could decrease the rate of recurrence and surgical reoperations compared to resection alone endometriosis lesions (NP4). In women with no desire for pregnancy, the benefit-risk balance of a hysterectomy, with or without bilateral oophorectomy, may be discussed in order to reduce the risk of recurrence of endometriotic disease (Expert Agreement). Taking into account the multiple adverse effects of early menopause on expectancy and quality of life (NP2), ovarian preservation should be discussed with the patient in case of hysterectomy for deep endometriosis (Expert Agreement). The use of menopausal hormone therapy (THM) does not appear to increase the symptoms of endometriosis after surgical castration (NP3). THM is not contraindicated in postmenopausal women with endometriosis (grade C).

[Management of endometriosis: CNGOF-HAS practice guidelines (short version)]

First-line investigations to diagnose endometriosis are clinical examination and pelvic ultrasound. Second-line investigations include pelvic examination performed by a referent clinician, transvaginal ultrasound performed by a referent echographist, and pelvic MRI. It is recommended to treat endometriosis when it is symptomatic. First-line hormonal treatments recommended for the management of painful endometriosis are combined with hormonal contraceptives or levonorgestrel 52mg IUD. There is no evidence to recommend systematic preoperative hormonal therapy for the unique purpose of preventing the risk of surgical complications or facilitating surgery. After endometriosis surgery, combined hormonal contraceptives or levonorgestrel SIU 52mg are recommended as first-line therapy in the absence of desire of pregnancy. In case of initial treatment failure, recurrence, or multiple organ involvement by endometriosis, medico-surgical and multidisciplinary discussion is recommended. The laparoscopic approach is recommended for the surgical treatment of endometriosis. HRT may be offered in postmenopausal women operated for endometriosis. In case of infertility related to endometriosis, it is not recommended to prescribe anti-gonadotropic hormone therapy to increase the rate of spontaneous pregnancy, including postoperatively. The possibilities of fertility preservation should be discussed with the patient in case of surgery for ovarian endometrioma.

Measuring health-related quality of life in women with endometriosis: comparing the clinimetric properties of the Endometriosis Health Profile-5 (EHP-5) and the EuroQol-5D (EQ-5D)

STUDY QUESTION

Which of the Endometriosis Health Profile-5 (EHP-5) and the EuroQol-5D (EQ-5D) is the most efficient to assess quality of life in women suffering from endometriosis?

SUMMARY ANSWER

Although EHP-5 and EQ-5D instruments had an excellent responsiveness, EHP-5 has a better discriminative ability than EQ-5 to measure health-related quality of life (HrQoL).

WHAT IS KNOWN ALREADY

Proper measurement of HrQoL is important in endometriosis. While many quality of life instruments are available, few have been completely validated in endometriosis. The EHP-5 and the EQ-5D are short and practical scales, which may be useful. Literature is lacking to determine which one is the most suitable in clinical practice or in clinical research.

STUDY DESIGN, SIZE, DURATION

This prospective and observational study conducted between 1 January 2012 and 31 December 2013 included a total of 253 consecutive women with proven endometriosis, undergoing medical or surgical treatment, in 2 French tertiary care centers.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

Women over 18 years consulting for painful symptoms of at least 3 months' duration or for infertility, with endometriosis proven histologically or radiologically, were requested to fill in the 2 scales before (T0) and 12 months after treatment (T1). Construct validity consisted in testing presupposed relationships between the scales and the characteristics of the patients or the endometriosis. Responsiveness to change was calculated for all patients and in each treatment group. Effect sizes were used according to Cohen's d method.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 216 women filled in completely all the questionnaires at T0 and 133 (61.6%) at T1. EHP-5 and EQ-5D had good discriminative abilities regarding the patients' symptoms, with significant superiority of EHP-5 concerning three of the nine hypotheses. The largest difference was that calculated for the 'intensity of dysmenorrhea' using the Visual Analogic Scale, with respectively effect size from Cohen's d (ES) = 0.86 95% CI (0.54-1.17) for EHP-5 versus 0.48 95% CI (0.16-0.79) for EQ-5D. There were no differences in EHP-5 or in EQ-5D scores between subgroups according to the characteristics of endometriosis. Overall responsiveness was excellent and equivalent for EHP-5 and for EQ-5D, with, respectively, ES = 0.81 95% CI (0.56-1.56) versus ES = 0.95 95% CI (0.68-1.20). In subgroup analyses, EHP-5 was responsive in case of medical treatment with ES = 0.93 95% CI (0.07-1.70), whereas EQ-5D was not, ES = 0.73 95% CI (-0.06-1.47).

LIMITATIONS, REASONS FOR CAUTION

Our study population included patients with symptomatic and mainly severe forms of endometriosis, which may suggest a spectrum bias. The evaluation of responsiveness in case of medical treatment was based on a small number of patients, which limits the interpretation of the difference found between the two scales in this subgroup.

WIDER IMPLICATIONS OF THE FINDINGS

EHP-5 is a simple, efficient and valid tool for evaluating quality of life in daily practice and also valuable to provide a primary outcome in clinical studies evaluating treatment efficacy.

STUDY FUNDING/COMPETING INTEREST(S)

This work was funded by the Direction à la Recherche Clinique et à l'Innovation of Versailles, France. The authors have no conflicts of interest.

TRIAL REGISTER NUMBER

None.

The definition of Endometriosis Expert Centres

Endometriosis is a common condition that causes pain and infertility. It can lead to absenteeism and also to multiple surgeries with a consequent risk of impaired fertility, and constitutes a major public health cost. Despite the existence of numerous national and international guidelines, the management of endometriosis remains suboptimal. To address this issue, the French College of Gynaecologists and Obstetricians (CNGOF) and the Society of Gynaecological and Pelvic Surgery (SCGP) convened a committee of experts tasked with defining the criteria for establishing a system of care networks, headed by Expert Centres, covering all of mainland France and its overseas territories. This document sets out the criteria for the designation of Expert Centres. It will serve as a guide for the authorities concerned, to ensure that the means are provided to adequately manage patients with endometriosis.

[Definition of endometriosis expert centres]

OBJECTIVES

The Collège national des gynécologues obstétriciens français (CNGOF), in agreement with the Société de chirurgie gynécologique et pelvienne (SCGP), has set up a commission in 2017 to define endometriosis expert centres, with the aim of optimizing endometriosis care in France.

METHODS

The committee included members from university and general hospitals as well as private facilities, representing medical, surgical and radiological aspects of endometriosis care. Opinion of endometriosis patients' associations was obtained prior to writing this work. The final text was presented and unanimously validated by the members of the CNGOF Board of Directors at its meeting of October 13, 2017.

RESULTS

Based on analysis of current management of endometriosis and the last ten years opportunities in France, the committee has been able to define the contours of endometriosis expert centres. The objectives, production specifications, mode of operation, missions and funding for these centres were described. The following missions have been specifically defined: territorial organization, global and referral care, communication and teaching as well as research and evaluation.

CONCLUSION

Because of its daily impact for women and its economic burden in France, endometriosis justifies launching of expert centres throughout the country with formal accreditation by health authorities, ideally as part of the National Health Plan.

A self-administered questionnaire to measure the painful symptoms of endometriosis: Results of a modified DELPHI survey of patients and physicians

PURPOSE

To develop a questionnaire based on patients' verbal descriptors, to measure the painful symptoms of endometriosis.

METHODS

We performed a two-round modified DELPHI procedure mixing endometriosis patients and physicians to select a set of statements to describe the painful symptoms of endometriosis. Each panelist rated each statement based on diagnosis validity and clarity. The clinicians were experts in endometriosis management selected from various geographic regions in France. Patients were women with surgically confirmed endometriosis who volunteered from a patient association and from the recruitment of the participating physicians. The first round questions were derived from words and phrases in narratives of pain by endometriosis patients.

RESULTS

Overall, 76 experts were invited, and of these 56 (74%), comprising 33 patients and 23 gynecologists, responded to the first round questionnaire, and 40 (71.4%) to the second round. Among the 48 statements assessed in the first-round questionnaire, 11 were selected after completion of the two round DELPHI procedure. After discussion and rewording of some items, a total of 21 questions were selected during a final face-to-face meeting. The content of the final questionnaire is organized according to four dimensions: (i) spontaneous pelvic pain and dysmenorrhea, (ii) dyspareunia, (iii) painful bowel symptoms, (iv) and other symptoms. We also provide an English (UK) version produced using several steps of translation and back-translation.

CONCLUSIONS

The questionnaire has content validity to measure the subjective experiences of patients with painful endometriosis and can provide a solid basis on which to develop an efficient patient-centered outcome to measure the painful symptoms in therapeutic or in diagnostic studies of endometriosis.

Assessing technical competence in laparoscopic surgery in France: Ratification of the GOALS rating scale

BACKGROUND

The question of assessing surgical competence is the focus of mainly Anglo-Saxon studies. The GOALS questionnaire (Global Operative Assessment of Laparoscopic Skills) specific to laparoscopic surgery assessment has been developed since 2005. The aim of the study was to assess the metrological qualities of the GOALS questionnaire after ratification in French language.

METHODS

To produce a French version of the GOALS surgical competence assessing tool according to an established method (translation - backward translation - retranslation) and to check the metrological qualities (user satisfaction, acceptability, reliability and validity) of this questionnaire through observing residents while in training program on 22 residents in Gynaecology Obstetrics during the laparoscopy training, with the performance of a nephrectomy on a porcine model.

RESULTS

The discrepancies in the initial translations were mainly due literal translations. Only synonymous differences were observed in the two backward translations. Comparison with original version led to 8 minor changes. No changes occurred between the 2 French versions. Satisfaction surveys when using the GOALS questionnaire by both examiners and students are similar. Face and content validity seemed good and there is no significant discrepancy between the examiners and the students (11.5 [9-15]; 12.4 [9-15]; P=0.40). Assessment by examiners showed an median value of 17.8 [9-26] with good correlation (α=0.80). By contrast, self-assessment, although there is no significant discrepancy, showed heterogeneity. GOALS French version was able to prove a significant progression both in self-assessment and external evaluation between the act performed on the first nephrectomy on the first day of the first session of the training and the fourth nephrectomy performed on the first day of the second session of the training.

CONCLUSION

Our work allowed obtaining a GOALS French version with acceptable validity, good consistency between the assessments and ability to measure progress.

Reproducibility of the interpretation of coronal 3D ultrasound view of the uterus to evaluate the position of Essure® 3 months after hysteroscopic procedure

OBJECTIVE

Three-dimensional sonography is a good alternative method to assess the position of microinserts. Adequate position after three months allows for the interruption of other contraception. Objective is to evaluate inter-observer reproducibility of the interpretation of coronal transvaginal 3D ultrasound view of the uterus to evaluate the position of Essure^®.

STUDY DESIGN

Inter-observer reproducibility study. Fifty women underwent successful bilateral placement of microinserts (Essure^®) by hysteroscopy in the Department of Gynaecology of a teaching hospital and were included in the study. At three month, 3D ultrasound coronal views of the fifty uterus (accounting for one hundred microinserts) were assessed by five different observers and microinsert position was classified according to the classification described by Legendre et al. Inter-observer reproducibility in reading the 3D coronal view of the uterus was evaluated.

RESULTS

The k-value was disparate, from 0.26 to 0.82. Inter-observer reproducibility then ranged from fair to almost perfect, depending on a prior knowledge of the position classification.

CONCLUSIONS

Transvaginal 3D coronal view of the uterus is sufficient to assess the positioning of the microinserts when the practionner or the surgeon is familiar with the classification method.

[Analysis from the French DRG-based information system (PMSI) of conservative surgical treatment for abnormal uterine bleeding in 2008-2010]

OBJECTIVE

To evaluate the conservative surgical treatment for abnormal uterine bleeding from the Medicalized Information System Program (PMSI).

MATERIALS AND METHODS

The diagnosis codes were selected from 10th version of the international classification disease. A transversal and longitudinal descriptive analysis was performed from hospital stays, patient's characteristics, medical procedures between 2008-2010.

RESULTS

Nineteen thousand six hundred and seventy-nine patients were admitted in hospital (public or private) for treatment of abnormal uterine bleeding. Endometrial ablation increased by 16,7%, 10.2% for first generation technique (G1) and 63.5% for second generation techniques (G2). G2 were used in 15% of indications. The median age was respectively 45.2±6.4 years old versus 45.8±4.9 years old for G2. The median length of hospital stay was 1.6 ±1with 69% of patients in ambulatory care. The likelihood to have a hysterectomy in the 3 years follow-up was higher after G1 than G2 treatments (P=0.0034) for the patients above 40 years old. In longitudinal study, defined only by endometrial hyperplasia, 11,532 patients were included and only 8.2% had been treated by G2.

CONCLUSION

In spite of the international guidelines since 2008, 85% of patients treated with first generation surgical technique. The failure rate defined by a re-ablation or a hysterectomy is higher after G1. This result must be discussed in relationship with cost effective aspects.

[Contraception's choice: women's opinion, satisfaction and profile. Results of a French national survey of a representative sample of 5963 women]

OBJECTIVES

To describe French women's use of contraceptive methods and study their satisfaction and expectations about contraception.

PATIENTS AND METHODS

A survey carried out by mail questionnaire filled in by a representative sample group of French women aged 15 to 45 years (Panel Postal Metascope TNS Sofres) in June 2007.

RESULTS

Of 10,000 questionnaires sent out, 6044 questionnaires were returned, of which 5963 were usable. Seventy-three percent of women surveyed used some method of contraception, of which 46% was an oral contraceptive, 15% an IUD and 7% used condoms. A minority used new contraceptive methods (implant, patch, vaginal ring). The average age at first sexual relationship was 17.8 years. It was 18.5 among 40-45-year-olds and gradually reduced to 16.7 in the under 25-year-olds. Twenty-three percent of pregnancies remain unwanted and unplanned. For 96% of patients, the choice of contraception was considered to be important. Thirty-six percent thought that contraception could be harmful to health. Only 63% of women believed themselves to be well informed the first time they used contraception. Satisfaction for contraception method was evaluated from 7.3/10 (condom) to 9.7/10 (sterilization).

DISCUSSION AND CONCLUSION

Twenty-seven percent of women do not use any contraception and 23% of pregnancies are unwanted despite a large offering of contraceptives. Our study enables the drawing of 'patient-profiles' for the main methods of contraception in order to better determine women's expectations and to pass the findings on to health professionals.

Tubal sterilization: pregnancy rates after hysteroscopic versus laparoscopic sterilization in France, 2006-2010

OBJECTIVE

To compare the rates of pregnancy among women who underwent Essure hysteroscopic sterilization versus tubal ligation in France between 2006 and 2010.

STUDY DESIGN

Retrospective cohort study.

SETTING

Hospital care in France (nationwide). Anonymised database of all hospital discharge summaries in France.

PATIENTS

Recruitment was based on procedure codes in the national database of hospital discharge summaries. The study included all women who underwent tubal sterilization by Essure microinserts or by tubal ligation and subsequently were hospitalised either for all unexpected pregnancies related diagnosis (e.g., miscarriage, legal abortion, or delivery) or for pregnancies following reversal microsurgery or invitro fertilization (IVF) treatment.

MEASUREMENTS AND MAIN RESULTS

During the study period, French hospitals performed 109,277 tubal sterilization procedures: 39,169 Essure sterilizations and 70,108 laparoscopic tubal ligations. The respective indication of both techniques depended on the surgeons' skill. The median age of the two populations was similar, 41 years (range 28-52) for Essure patients and 40 years (range 27-54) for those undergoing tubal ligation (p=0.42). A Cox model has been performed. Following sterilization, after adjustment on age Essure patients became pregnant at a significantly lower rate than laparoscopic ligation patients 0.36% versus 0.46%, respectively (HR=0.62 (040-096)), and their pregnancy rate of post-sterilization procedure was significantly lower (reversal microsurgeries: 0.02% versus 0.19% (p<0.001), IVF treatment: 0.08% versus 0.27%) (p<0.001). The pregnancy rates after IVF were 12.5% and 5.35%, respectively, and 0% and 11.36% after tubal repair.

CONCLUSION

This nationwide study of tubal sterilization demonstrates that Essure was associated with lower rates of pregnancy versus tubal ligation.

[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.