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Background Childbirth is a physiological process with significant medical risk, given that neurological impairment due to the birthing process can occur at any time. Improvements in risk assessment and anticipatory interventions are constantly needed; however, the birthing process is difficult to assess using simple imaging technology because the maternal bony pelvis and fetal skeleton interfere with visualizing the soft tissues. Magnetic resonance imaging (MRI) is a noninvasive technique with no ionizing radiation that can monitor the biomechanics of the birthing process. However, the effective use of this modality requires teamwork and the implementation of the appropriate safeguards to achieve appropriate safety levels. Objective This study describes a clinically effective and safe method to perform real-time MRI during the birthing process. We reported the experience of our team as part of the IMAGINAITRE study protocol (France), which aimed to better understand the biomechanics of childbirth. Methods A total of 27 pregnant women were examined with 3D MRI sequences before going into labor using a 1-Tesla open-field MRI. Of these 27 patients, 7 (26%) subsequently had another set of 3D MRI sequences during the second stage of labor. Volumes of 2D images were transformed into finite element 3D reconstructions. Polygonal meshes for each part of the fetal body were used to study fetal head moldability and brain compression. Results All 7 observed babies showed a sugarloaf skull deformity and brain compression at the middle strait. The fetus showing the greatest degree of molding and brain shape deformation weighed 4525 g and was born spontaneously but also presented with a low Apgar score. In this case, observable brain shape deformation demonstrated that brain compression had occurred, and it was not necessarily well tolerated by the fetus. Depending on fetal head moldability, these observations suggest that cephalopelvic disproportion can result in either obstructed labor or major fetal head molding with brain compression. Conclusions This study suggests the presence of skull moldability as a confounding factor explaining why MRI, even with the best precision to measure radiological landmarks, fails to accurately predict the modality of childbirth. This introduces the fetal head compliance criterion as a way to better understand cephalopelvic disproportion mechanisms in obstetrics. MRI might be the best imaging technology by which to explore all combined aspects of cephalopelvic disproportion and achieve a better understanding of the underlying mechanisms of fetal head molding and moldability.

UNSTRUCTURED Childbirth is a physiologic process with significant medical risk, as neurological impairment due to the birthing process can occur at any time. Improvements in risk assessment and anticipatory interventions are constantly needed; however, the birthing process is difficult to assess using simple imaging technology since the maternal bony pelvis and fetal skeleton interfere with visualizing the soft tissues. Magnetic resonance imaging (MRI) is a non-invasive technique with no ionizing radiation that can monitor the biomechanics of the birthing process. Effective utilization of this modality, however, requires teamwork and implementation of the appropriate safeguards to achieve appropriate safety levels. This article describes a clinically effective and safe method to perform real-time MRI during the birthing process. We report the experience of our team as part of the IMAGINAITRE research protocol (France), which aimed better understand of the biomechanics of childbirth.

To describe the observable MRI changes in the urogenital sinus during the second stage of labor and delivery by comparing the changes in the positions of the anatomical structures of the maternal perineum using MRI-based vector 3-D models. Seven pregnant women underwent 3-D MRI sequences using a Philips 1 T Panorama open MRI during the pre-labor period and during the second stage of labor. A 3-D vector reconstruction platform (BABYPROGRESS, France) enabled the transformation of volumes of 2-D images into finite element meshes. The polygonal meshes labeled with the principal components of the urogenital sinus were used as part of a biomechanical study of the pressure exerted on the perineum during fetal descent. The expansion of the urogenital sinus was observed in all patients. Qualitative stretching was observed toward the rear and bottom of the iliococcygeus, pubococcygeus, puborectalis and obturator internus muscles. Significant length differences were measured along the iliococcygeus and pubococcygeus muscles but not along the tendinous arch of the levator ani or the puborectalis muscle. The inversion of the levator ani muscle curvature was accompanied by the transmission of pressure generated during fetal descent to the pubic muscle insertions and the descent of the tendinous arch of the levator ani. Mechanical pressures responsible for the tensioning of the constituent muscles of the urogenital sinus were qualitatively identified during the second stage of labor. MRI-based vector 3-D models allow the quantitative assessment of levator ani muscle stretching during labor, but 2-D MRI is not sufficient for describing perineal expansion. Vector 3-D models from larger scale studies have the potential to aid in the calibration of a realistic simulation based on the consideration of the reaction of each muscular element. These models offer perspectives to enhance our knowledge regarding perineal expansion during childbirth as a risk factor for postpartum perineal defects.

To compare open and laparoscopic surgery in the management of non-epithelial ovarian malignancies.Retrospective study from University Hospital of Clermont-Ferrand, France, of 20 patients undergoing surgery for non-epithelial ovarian malignancies. We compared the outcome of 13 open surgeries and 7 laparoscopic surgeries. The main outcome measures were stage and size of the tumor, surgical procedure, hospital stay, adjuvant treatment, follow-up and fertility.The mean age of the patients and the type of tumor at the time of diagnosis were similar in the two groups but the tumor size was significantly larger in the laparotomy group (14.0cm vs. 6.7cm; p0.05). Treatment was conservative in 85.6% vs. 61.5% in the laparoscopy and laparotomy groups respectively. Tumor stages were not statistically different in the two groups. The hospital stay was shorter in the laparoscopy group (3.1 days vs. 6.9 days p=0.03) and there were no differences in terms of complications, surgical procedures, number of lymph nodes removed and adjuvant treatment.Laparoscopy respecting the usual oncologic principles appears to be a good alternative to laparotomy for the initial management of non-epithelial ovarian malignancies. The limiting factors of this technique remain the tumor size, the tumor stages and the surgeon's experience.

To demonstrate and describe fetal head molding and brain shape changes during delivery, we used three-dimensional (3D) magnetic resonance imaging (MRI) and 3D finite element mesh reconstructions to compare the fetal head between prelabor and the second stage of labor. A total of 27 pregnant women were examined with 3D MRI sequences before going into labor using a 1 Tesla open field MRI. Seven of these patients subsequently had another set of 3D MRI sequences during the second stage of labor. Volumes of 2D images were transformed into finite element 3D reconstructions. Polygonal meshes for each part of the fetal body were used to study fetal head molding and brain shape changes. Varying degrees of fetal head molding were present in the infants of all seven patients studied during the second phase of labor compared with the images acquired before birth. The cranial deformation, however, was no longer observed after birth in five out of the seven newborns, whose post-natal cranial parameters were identical to those measured before delivery. The changing shape of the fetal brain following the molding process and constraints on the brain tissue were observed in all the fetuses. Of the three fetuses presenting the greatest molding of the skull bones and brain shape deformation, two were delivered by cesarean-section (one after a forceps failure and one for engagement default), while the fetus presenting with the greatest skull molding and brain shape deformation was born physiologically. This study demonstrates the value of 3D MRI study with 3D finite element mesh reconstruction during the second stage of labor to reveal how the fetal brain is impacted by the molding of the cranial bones. Fetal head molding was systematically observed when the fetal head was engaged between the superior pelvic strait and the middle brim.

Purpose To compare pain symptoms and quality of life between epiphenomenon and endometriosis disease. Methods Between January 2004 and July 2008, 536 new cases of endometriosis confirmed by surgical biopsy were included in this observational cohort study (Auvergne Regional Cohort of Endometriosis). Questionnaires and visual analog scale scores for dysmenorrhoea, dyspareunia, chronic pelvic pain, premenstrual dysuria and dyschesia, quality of life instruments (SF-36), and sexual activity questionnaires were compared between group A (epiphenomenon group: 119 patients) and group B (endometriosis disease group: 318 patients with deep ovarian endometrioma and/or deep infiltrating nodules). Primary outcome was patient-reported pain rates. Secondary outcomes included quality-of-life tools. Results In cases of severe endometriosis, more pain at defecation and more dysmenorrhoea were observed than in cases of minimal endometriosis. The social repercussions and deterioration in quality of life were also affected, without any distinction between group A and B except for physical limitations. Quality of sex life was also affected in both groups. Conculsions This study confirms the ubiquitous pain symptoms of endometriosis. The lack of any correlation between functional symptomatology and anatomic severity of disease underlines how important it is not to neglect patients presenting what is called “minimal” endometriosis.

To assess the educational value of an ongoing interval practice laparoscopy training program among obstetrics and gynecology residents.Prospective cohort, multi-institutional recruitment study. We conducted structured laparoscopic training sessions for residents, using both inanimate and porcine models. The 6-day course was separated into two 3-day long modules conducted 2 months apart. A prospective evaluation of standardized tasks was performed using validated scales. Resident's performance was compared using the Student t test and Wilcoxon signed-rank test when appropriate.International Center of Endoscopic Surgery (CICE), Clermont-Ferrand, France.191 PGY2 or PGY3 residents from different institutions.Significant improvement in time and technical scores for both laparoscopic suturing and porcine nephrectomy was noted (p0.0001). After 2 months, we found no improvement in suturing time (p = 0.59) or technical scores (p = 0.62), and significant technical deterioration was observed for the right hand (p = 0.02). Porcine nephrectomy improvement remained significant after 2 months (p0.0001).Despite significant short-term educational value of interval practice in laparoscopic performance, some acquired skills seem to deteriorate faster than anticipated.

Objective To evaluate the feasibility of laparoscopic hysterectomy for uteri weighing more than 1000 g. Study design A retrospective study was conducted in a tertiary center of laparoscopic surgery including 38 women submitted to hysterectomy for uteri weighing more than 1000 g. Patients submitted to open hysterectomy were compared to those submitted to laparoscopic hysterectomy. The primary statistical endpoint was the complication rate. Secondary endpoints were operating time, estimated blood loss, length of hospital stay, and conversion to laparotomy. Results The patients’ mean age was 49.4 years and mean BMI was 25.2 kg/m2. The surgical intent was laparoscopic hysterectomy in 23 patients (60.5%) and laparotomy in 15 patients (39.5%). Conversion to open surgery was required in 4 patients (17.4%) due to inaccessibility of the pelvis at the beginning of surgery (n = 2), technical difficulties during surgery (n = 1), and intraoperative bleeding (n = 1). One patient in the laparotomy group had an intraoperative ureteral injury. Despite longer operative time (130 vs. 80 min, p = 0.002), laparoscopic surgery was associated with reduced length of hospital stay (3 vs. 6 days, p

This study was designed to compare the surgical outcomes of standard and reverse laparoscopic techniques for the treatment of rectovaginal endometriosis. A retrospective study was conducted in a teaching and research hospital (tertiary center), which included 75 women subjected to laparoscopic treatment of rectovaginal endometriosis that required both vaginal resection and rectal surgery. Standard and reverse laparoscopic techniques were compared in 35 and 40 women, respectively. Student’s t test, Mann–Whitney test, and Fisher’s exact test were performed to compare groups when needed; p

Our objective was to evaluate the impact of intraperitoneal pressure (IPP) and duration of a CO(2) pneumoperitoneum on the peritoneal fibrinolytic system during laparoscopic surgery.Human study: Patients undergoing laparoscopic surgery were divided into two groups: low (8 mmHg, n= 32) or standard (12 mmHg, n= 36) IPP. Normal peritoneum was collected from the parietal wall at the beginning of surgery and every 60 min thereafter. Mouse study: Mice were divided into three groups: low (2 mmHg) or high (8 mmHg) IPP or laparotomy. Peritoneal tissue was collected at 0, 4, 8, 24, 48 and 72 h, and 5 and 7 days after surgery. Real-time RT-PCR was performed in humans and mice to measure the levels of tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) mRNA in peritoneal tissues.Human study: The tPA/PAI-1 mRNA ratio was significantly decreased in the 12 mmHg group at 1 h [P0.0001 versus matched initial peritoneal biopsies (MI)]. The tPA/PAI-1 mRNA ratio decreased in both groups at 2 h (P.0.01 versus MI). Mouse study: The tPA/PAI-1 ratio was decreased at 0 h, and the difference was significant at 4 h in both the laparotomy (P0.001 versus controls, 0 h, 5 and 7 days) and high-IPP (P0.0001 versus 0, 48 and 72 h, 5 and 7 days) groups. No changes in tPA/PAI-1 ratio were observed in the low-IPP group.A low IPP and shorter duration of surgery appear to minimally impact the fibrinolytic system during a CO₂ pneumoperitoneum.

Several new intraoperative imaging techniques, often described under the generic term "optical biopsy", have been developed over the last twenty years. The term optical biopsy in fact covers two distinct approaches. The first is endomicroscopy, which provides the surgeon with histologic images comparable to those obtained by the pathologist in the laboratory. The second is image-guided surgery, which includes a variety of techniques, from fluorescence to sentinel node biopsy and real-time image fusion (enhanced reality). The diagnostic value of intraoperative histology, and the reproducibility of these methods outside the expert centers where they were initially developed, remains to be determined In particular, it remains to be seen whether they can avoid the need for conventional biopsy. The main issue will probably be to decide who is qualified to read these images: a surgeon with training in pathology, or a pathologist who examines images transmitted to the lab or directly in the operating room? Pathologic diagnosis may require several readings of the same slides, additional biopsy sections, or even additional staining procedures. The ability to examine living tissue in situ is a very attractive prospect and will probably represent a major step forward in diagnosis and treatment evaluation. It is difficult to know which of the many candidate techniques will finally be adopted, but the future seems to lie in a combination of image-guided surgery and endomicroscopy.

Objective To describe different approaches for diagnosis and management of proximal ectopic pregnancies (PP) in general population. Design Observational population based-study. Setting Regional ectopic pregnancy registry. Patient(s) Eighty-six PP registered from 1992 to 2008. Intervention(s) Surgical (radical or conservative), medical, or combined therapies. Main Outcome Measure(s) Epidemiologic characteristics, clinical presentation, hCG level, treatments performed, failure rate, and recurrence. Result(s) Mean gestational age was 48.2 days. Estimated incidence of PP was 2.7%. Abdominal pain and vaginal bleeding were the commonest symptoms. Two patients were admitted in hypovolemic shock. Diagnostic modalities included transvaginal ultrasound, abdominal ultrasonography, and laparoscopy in 38 (44%), 7 (8%), and 39 (45%) cases, respectively. Mean hCG level was 10,759 IU/L. Thirty-four patients underwent primary cornual resection (39.5%) by laparoscopy (n = 32) or laparotomy (n = 2). Twenty-seven patients (31.4%) underwent primary conservative surgery by laparoscopy: cornuostomy (n = 18) or extended salpigostomy (n = 9). Primary medical treatment with methotrexate was attempted in 14 patients (16.3%). Expectant management was attempted in one case (1.2%). Eleven cases received combined therapies (11.6%). Failure rates for medical and surgical treatments were 35.7% and 28%, respectively. No failures were noted among patients who received combined therapies. Conclusion(s) Proximal ectopic pregnancy remains a life-threatening condition. Diagnosis is challenging and requires a high index of suspicion. Despite available conservative strategies, management of PP remains heterogeneous.

The objective of this study was to evaluate long-term oncological outcomes of laparoscopic management of endometrial carcinoma (EC) in a large series of consecutive patients from two referral cancer centres. The study is a large retrospective study with 15-year follow-up. The clinical records of 207 consecutive women with clinical stage I EC managed by laparoscopy between 1990 and 2005 were reviewed. Laparoscopy included peritoneal washing, inspection of abdominal cavity, total laparoscopic hysterectomy + bilateral salpingo-oophorectomy and pelvic/para-aortic lymphadenectomy depending on the preoperative histology or frozen section results. Data collected included conversion rate, operative time, hospital stay, surgical complications, FIGO 1988 stage and 5-year survival. Laparoscopic procedures were converted to laparotomy in nine (4.3%) cases. Mean operative time was 173.2 min (70–300 min). Mean hospital stay was 5 days. The mean number of lymph nodes removed was 10 (2–25). Lymphadenectomy was considered not feasible in 20 cases (12.9%) due to technical difficulties. Intraoperative and postoperative complications were seen in 11 (5.6%) and 13 (6.6%) women, respectively. Histopathological results led to upstaging in 11.6% of cases. After a mean follow-up of 74.8 months (14–204 months), 5-year cause-specific and disease-free survival rates were 93.2% and 89.3%, respectively. Twenty-one (10.6%) patients developed recurrences. No port site metastases were identified. Laparoscopic management of EC is feasible, reproducible and does not worsen patient prognosis. It allows comprehensive surgical staging and the option of lymphadenectomy in a single surgical procedure without compromising the oncological radicality required. Our results show minimal morbidity and similar long-term outcomes than those obtained by laparotomy in the literature.

Surgery remains the best treatment for deep endometriosis. The surgical technique is essential to adequately manage the disease; however, the technique is rarely taught and reported in detail. Laparoscopic cystectomy for the treatment of ovarian endometrioma has been classically reported as a simple stripping technique; however, a meticulous technique appears to be necessary to adequately manage ovarian endometriomas, based on the natural history of the cyst. This paper reports in detail our current technique for laparoscopic cystectomy for ovarian endometrioma and all the tricks to permit reproduction, and even improvement of the technique by other surgeons.

In this retrospective study of 314 patients undergoing surgery for ovarian dermoid cysts, conducted over a 20-year period, we evaluated the impact of the routine use of laparoscopic surgery without recourse to laparotomy to retrieve the specimen, using an endoscopic retrieval bag placed under the cyst to prevent intraperitoneal spillage of cyst contents, and subsequent postoperative granulomatous peritonitis. Accidental cyst rupture was more frequent when a total laparoscopic approach was used (26/174 or 15% versus 39/140 or 28%; P = 0.005), but there were no cases of intraperitoneal spillage when an endoscopic bag was used. Two cases of granulomatous peritonitis developed out of 26 women with intraperitoneal spillage of cyst contents (8%). We conclude that the risk of granulomatous peritonitis can be minimised by undertaking laparoscopic removal of dermoid cysts with the routine intraoperative use of an endoscopic retrieval bag to prevent intraperitoneal spillage of cyst contents.

Animal experiments have suggested that the laparoscopic peritoneal environment is hypoxic. This study aimed to investigate whether peritoneal tissue is hypoxic on a cellular level during a carbon dioxide (CO(2)) pneumoperitoneum at different intraperitoneal pressures (IPPs) and to determine the short-term effects of surgical injury on the hypoxia status of peritoneal tissue in the injured peritoneum and the distant noninjured peritoneum at cellular and molecular levels.Experiment 1: Mice were divided into five groups according to the following treatments: anesthesia alone, laparotomy, and CO(2) pneumoperitoneum at IPPs of 2, 8, or 15 mmHg. Over the course of each experiment, the peritoneal tissue-oxygen tension (PitO(2)) was continuously monitored. Experiment 2: On the first day, the mice were divided into three groups according to the following treatments: CO(2) pneumoperitoneum at an IPP of either 2 or 8 mmHg or laparotomy. The bilateral caudal epigastric arteries and uterine horns then were coagulated using a bipolar cautery device. On day 7, peritoneal tissue samples were collected for real-time reverse transcriptase-polymerase chain reaction (RT-PCR) and immunohistochemistry. In both experiments, pimonidazole hydrochloride was used to detect tissue hypoxia at a cellular level.Experiment 1: Peritoneal hypoxia at both tissue and cellular levels was detected only in the groups treated with an IPP of 15 mmHg (PitO(2): 5.2 ± 1.0 mmHg, mean ± SEM). Experiment 2: The percentage of pimonidazole immunostained mesothelial and stromal cells from the distant noninjured peritoneum was significantly higher in the group treated with an IPP of 8 mmHg than in the other groups. Hypoxia-inducible factor 1 alpha subunit mRNA expression in the distant noninjured peritoneum of the group treated with an IPP of 8 mmHg was significantly higher than in the control group (anesthesia alone).The CO(2) pneumoperitoneum itself did not cause peritoneal hypoxia at either a tissue or a cellular level in a mouse model when a low IPP was used.

Objective To assess the feasibility of sentinel lymph node (SLN) biopsy in gynecologic malignancies using natural orifices transluminal endoscopic surgery (NOTES) in an animal model. Methods Ten female pigs were operated. Patent blue dye was injected in the paracervical region. The endoscope was introduced through a right lateral colpotomy. Internal iliac vessels were visualized followed by the identification of external iliac vessels. Bilateral dissection was performed to achieve visualization of the aorta and the vena cava. SLN colored in blue were bluntly dissected and then excised. Results Mean operative time was 56±16 minutes. The mean number of SLN retrieved was 1.75±1.28. All but one SLN were identified by NOTES procedure. No major complication was observed in this series. A total of 19 SLN were harvested, of which 11 from the left side and 8 from the right side. Fifteen lymph nodes were obtained from the iliac vessels or the promontory and 4 from the lateral aortic or preaortic region. Conclusions In this study, we confirmed the feasibility of the SLN technique by NOTES. It can be considered as a potential alternative to reduce morbidity during staging procedures for gynecologic malignancies. Prospective randomized series are necessary to establish the safety and the real benefits of this new technique.

Leiomyomas are benign tumors frequently found in the fourth and fifth decades of life. Although the uterus is the most common site of origin of leiomyomas, they can develop at any site where there is smooth muscle cell. Extrauterine leiomyomas are not common and usually their diagnostic are more challenging. In this paper, we report one case of pelvic retroperitoneal leiomyoma associated to vulvar/perineal leiomyomas. A 47-year-old female patient presented with a 6-month history of deep dyspareunia, abdominal pain, dysuria, and pain during defecation. She had a previous history of two open myomectomies, a supracervical hysterectomy associated to the exeresis of a vulvar leiomyoma, and a left salpingo-oophorectomy. On vaginal examination, there was a tender and firm mass at the vaginal vault and along the posterior vaginal wall. There was another tumor at the left vulvar/perineal region measuring around 6 cm. Magnetic resonance imaging demonstrated the presence of a mass at the Douglas pouch measuring 14 × 10 × 10 cm suggestive of uterine leiomyomatosis. She underwent a successful laparoscopic resection of the pelvic tumor with an operative time of 210 min. The vulvar/perineal lesions were resected by vaginal approach. She presented an uneventful postoperative course and was discharged home 3 days after surgery. Histopathology confirmed the diagnosis of leiomyomas. Laparoscopic approach for pelvic retroperitoneal leiomyoma is feasible. It is important to keep in mind the possibility of this entity as a differential diagnosis of retroperitoneal masses in women.

The aim of this study was to investigate HOXA-10 expression in endometrium from infertile patients with different forms of endometriosis; with uterine fibromas, or with unexplained infertility and from normal fertile women.Expression levels of HOXA-10 mRNA and protein in endometrium were measured during the mid-secretory phase. This study utilized laser capture microdissection, real-time RT-PCR and immunohistochemistry.HOXA-10 mRNA and protein expression levels in endometrial stromal cells were significantly lower in infertile patients with different types of endometriosis (deep infiltrating endometriosis, ovarian endometriosis and superficial peritoneal endometriosis), with uterine myoma, and unexplained infertility patients as compared with healthy fertile controls. HOXA-10 mRNA expression levels of microdissected glandular epithelial cells were significantly lower than those of microdissected stromal cells, without significant differences among the different groups. No protein expression was detected in glandular epithelial cells. The percentage of patients with altered protein expression of HOXA-10 in stromal cells were significantly higher in patients with only superficial peritoneal endometriosis (100%, 20/20, P0.05) compared with the other infertile groups (deep infiltrating endometriosis: 72.7%, 16/22; ovarian endometriosis: 70.0%, 14/20; uterine myoma: 68.8%, 11/16; unexplained infertility: 55.6%, 5/9).The present findings suggested that altered expression of HOXA-10 in endometrial stromal cells during the window of implantation may be one of the potential molecular mechanisms of infertility in infertile patients, particularly in patients with only superficial peritoneal endometriosis. One of the underlying causes of infertility in patients with only superficial endometriosis may be altered expression of HOXA-10 in endometrial stromal cells.

The aim of this study was to evaluate the effectiveness of a fibrinogen and thrombin-coated hemostatic sponge (TachoSil®) in the prevention of postsurgical adhesions in a laparoscopic rat model and its histological effects on uterine and peritoneal parenchyma. Design was a prospective randomized blinded study. Setting was in International Laparoscopic Surgery Centre, Clermont-Ferrand, France. There were 100 sexually mature female Sprague–Dawley rats weighing 240 to 300 g and aged 6–8 weeks. A standardized severe surgical injury induced by scissors and 40-W bipolar coagulation in the rat uterine horn, corpus, and peritoneum was performed to induce adhesion formation. After trauma, group 1 (n = 50) received no treatment and group 2 rats (n = 50) received TachoSil® applied on injured areas. Twelve weeks after the procedure, repeat laparoscopy was performed and adhesions were scored according to their extent and severity. A hysterectomy and a peritoneal biopsy in the injured area were achieved by laparotomy in order to investigate on a possible earlier effect of TachoSil® on the uterine and peritoneal parenchyma in 49 rats of each group. TachoSil® group adhesion scores showed a significant decrease on the three injured areas: peritoneum (12.96 vs. 21.66), uterine horn (7.22 vs. 15.20), and uterine corpus (5.88 vs. 34.52). TachoSil® group also demonstrated a major decline of uterine fibrosis and inflammation. This study revealed that TachoSil®, an absorbable biomaterial, can reduce postoperative adhesions after laparoscopic surgery on a rat model. TachoSil® also prevents thermo-induced injuries on uterine parenchyma (less fibrosis and less inflammation).

The mechanisms promoting postoperative peritoneal tumor dissemination are unclear. This study aimed to investigate postoperative tumor dissemination over time on both tissue and molecular levels.For this study, C57BL6 mice were randomized into four groups: anesthesia alone (control), carbon dioxide (CO(2)) pneumoperitoneum at low (2 mmHg) or high (8 mmHg) intraperitoneal pressure (IPP), and laparotomy. A mouse ovarian cancer cell line (ID8) was injected intraperitoneally just before surgery. The groups were further subdivided into three groups, and a laparotomy was performed to evaluate tumor dissemination on postoperative day (POD) 7, 14, or 42.The incidence of cancer cell invasion into the muscle layers of the abdominal wall was significantly higher in the laparotomy and high-IPP groups than in the low-IPP and control groups on PODs 7 and 42. Expression levels of beta 1 integrin, cMet, urokinase-type plasminogen activator (uPA), urokinase-type plasminogen activator receptor (uPAR), and type-1 plasminogen activator inhibitor (PAI-1) mRNA in the disseminated nodules were not significantly different among the four groups on POD 7. However, the expression levels of all these genes in the disseminated nodules in the laparotomy group were significantly higher on POD 14 than on POD 7. They then returned to control levels on POD 42. There were no significant differences in the expression levels of any of these genes among the groups on POD 42.The current study suggests that the molecular mechanisms underlying postoperative peritoneal tumor dissemination may differ between a laparotomy and CO(2) pneumoperitoneum. Therefore, strategies targeting postoperative tumor dissemination likely will need to account for the surgical environment.

We report one case of unilateral ovarian Sertoli-Leydig tumor with intermediate grade and heterologous element, in a young woman with clinical and biological typical presentation. We discuss 2D and 3D ultrasonographic and doppler features.

Resume Objectifs Evaluer les resultats de la promontofixation cœlioscopique avec l’echographie – a savoir observer le comportement dynamique de la prothese, mesurer avec precision sa position et en deduire la faisabilite de cet examen. Patientes et methodes L’intervention consistait en une hysterectomie subtotale per-cœlioscopique, suivie d’une promontofixation du col restant avec une meche anterieure intervesicovaginale, une meche posterieure interrectovaginale reunies et fixees au promontoire. Une echographie a ete realisee chez quinze patientes, permettant de visualiser dans le plan sagittal la position des bandelettes. La distance par rapport au col vesical en avant et par rapport au sphincter anal en arriere a ete mesuree au repos, a la poussee et a la retenue. L’etalement de la bandelette a ete apprecie ainsi que son comportement dynamique. Resultats La distance bandelette anterieure–col vesical est en moyenne de 12 mm au repos, 15 mm a la poussee et 13 mm a la retenue. La bandelette posterieure est mesuree en moyenne a 30, 26 et 31 mm du sphincter anal au repos, a la poussee et a la retenue. La bandelette est dans tous les cas etalee, voire plissee, jamais tendue. Les enregistrements video montrent que la promontofixation n’entrave pas la dynamique pelvienne. Discussion et conclusion L’echographie est apparue dans cette etude comme un examen simple et efficace pour visualiser et mesurer les protheses. Elle pourrait etre une aide a l’examen clinique pour expliquer un echec ou une complication postoperatoire.

We report two cases of persistent [correction of persistant] perineal pain in postpartum period due to transfixation of the anus with a suture and the contribution of perineal ultrasound in the diagnosis of unusual perineal pain.

Objective To evaluate the effect of protein kinase C inhibition on surgically induced endometriosis in mice. Design Prospective, randomized study. Setting Academic facility. Animals Sixty adult female C57BJ6 mice. Intervention(s) On day −7, oral gavage of a vehicle alone or of a protein kinase C inhibitor (100 mg/kg/day, once a day) was started and continued for 1 week in donor groups A and B, respectively. On day 0, uterine fragments from donor group A were implanted into recipient mice. Recipient mice were divided randomly into two groups: group 1 (vehicle) and group 2 (protein kinase C inhibitor). Uterine fragments from donor group B were implanted into recipient mice, and they were divided randomly into two groups: group 3 (vehicle) and group 4 (protein kinase C inhibitor). Oral gavage of a protein kinase C inhibitor (100 mg/kg/day, once a day) or vehicle was continued for 1 week. Main Outcome Measure(s) Presence and number of ectopic implants. Result(s) The number of mice that developed ectopic implants was significantly lower in groups 3 (40%) and 4 (30%) than in group 1 (100%). The number of ectopic implants was significantly lower in groups 2, 3, and 4 than in group 1. Conclusion(s) Protein kinase C inhibitor use partially prevented the development of ectopic implants in a mouse model of endometriosis.

RESUME La coelioscopie permet la realisation de la plupart les interventions oncologiques. En gynecologie, l’efficacite oncologique de l’endoscopie operatoire n’a ete confirmee par des etudes prospectives randomisees que dans le cadre du cancer de l’endometre. Pour le cancer de l’endometre, en l’absence de signe de dissemination peritoneale, la coelioscopie doit etre reserve au stade I clinique avec un volume uterin et un acces vaginal permettant une extraction aisee de l’uterus. Dans le cancer du col, le traitement endoscopique doit etre reserve aux patientes N- porteuses d’une tumeur de moins de 2 cm de diametre. La coelioscopie est la methode de choix pour le diagnostic chirurgical des tumeurs annexielles. La ponction des lesions kystiques doit etre evitee autant que possible. Le traitement endoscopique des tumeurs borderline est possible. Le traitement des cancers ovariens invasifs doit etre realise par laparotomie quel que soit le stade de la lesion. Mais la coelioscopie diagnostic est un moyen indispensable pour permettre qu’un traitement chirurgica optimal soit propose a toutes les malades porteuses d’un cancer avance de l’ovaire. Le restaging des patientes initialement traitees pour une tumeur consideree comme benigne est une bonne indication de coelioscopie. La connaissance des principes de la chirurgie oncologique et de l’endoscopie est un pre requis indispensable a la mise en œuvre de ces techniques. L’enseignement, l’organisation et la diffusion de l’endoscopie oncologique sont des enjeux majeurs de la chirurgie gynecologique pour les annees a venir.

L’endometriose est une maladie benigne, tres invalidante et frequente, definie par la presence d’endometre, epithelium et stroma, en situation ectopique. Sa physiopathologie, et celle des douleurs qui l’accompagnent, est mal connue. Les signes cliniques de cette pathologie hormonodependante sont dysmenorrhee, dyspareunie et douleur chronique. On distingue deux grands types d’endometriose: l’endometriose superficielle ou minime et les formes severes ou infiltrantes. Meme s’il n’existe pas de parallelisme anatomoclinique, on sait que les lesions infiltrantes sont plus souvent a l’origine de dyspareunie, de troubles digestifs ou urinaires associes. Le traitement est soit un traitement medical qui stoppe la maladie en induisant une amenorrhee, soit un traitement chirurgical qui consiste en une destruction ou une excision des lesions. Ce traitement chirurgical est le plus souvent realise par coelioscopie. Les indications respectives de ces deux traitements dependent du type de lesion et des circonstances diagnostiques et cliniques.

BACKGROUND: Post-operative adhesion formation is a major clinical problem. Tissue oxygenation is one of the most important determinants in adhesion formation. The objective of this study was to investigate whether supplemental perioperative oxygen could reduce post-operative adhesion formation through increasing the peritoneal tissue oxygen tension (PitO 2 ) in a mouse model. METHODS: Adult C57BJ6 mice were randomly assigned to two groups: Group 1 (n = 20), Fraction of Inspired Oxygen (FiO 2 ): 0.21; Group 2 (n = 20), FiO 2 : 0.80. On day 0, over the course of the 90 min procedure including the 60 min of laparotomy, PitO 2 was continuously monitored. On day 7, a second laparotomy was performed to assess abdominal wound adhesions. Real-time RT-PCR was performed to measure expression levels of tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) mRNA in peritoneal tissues. RESULTS: The PitO 2 levels in Group 2 were significantly higher compared to Group 1 (P < 0.001) and controls (P < 0.003). There was no significant difference in the incidence of abdominal wound adhesions; however, the severity of adhesions was significantly reduced in Group 2 compared to Group 1 (P < 0.03). A significantly higher tPA/PAI-1 mRNA ratio was detected in Group 2 and the controls compared to Group 1 (P < 0.02 and P < 0.002, respectively). CONCLUSIONS: Supplemental perioperative oxygen may help to reduce post-operative adhesion formation.

Endometrial ablation has emerged as a viable alternative to hysterectomy in the treatment of medically intractable dysfunctional uterine bleeding. However, this procedure cannot guarantee complete removal of the entire endometrium. Cases of endometrial cancer after endometrial ablation have been reported in the literature. We reviewed the cases of patients who underwent hysteroscopic endometrial ablation by endometrial resection for abnormal uterine bleeding from 1994 to 2005 at the Department of Obstetrics and Gynecology, Polyclinique, Clermont-Ferrand University. Of the 3769 patients having had hysteroresections, four developed endometrial cancer after complete endometrial ablation (1.06 out of 1000). All four of these patients showed histological evidence of endometrial polyps at endometrial resection, and all of them presented risk factors for endometrial carcinoma, such as obesity and/or arterial hypertension. Endometrial cancer after hysteroscopic endometrial ablation is a rare but possible occurrence, even a long time after the operation. Close monitoring of patients who have undergone endometrial ablation for endometrial polyps and who present risk factors, such as obesity or hypertension, even after apparent total ablation of the endometrium is strongly recommended, independently of the presence of abnormal bleeding that can represent a late symptom of advanced endometrial cancer.

BACKGROUND Previous animal studies suggested that the peritoneal environment during a carbon dioxide (CO(2)) pneumoperitoneum is hypoxic and that this may contribute to the formation of intra-abdominal adhesions or the growth of malignant cells. There is no study, however, that investigates the relationship between anaesthesia, ventilation and the laparoscopic peritoneal environment to the development of hypoxia. The objective of this study is to monitor the peritoneal tissue-oxygen tension (PitO(2)) under various conditions including anaesthesia alone, during a CO(2) pneumoperitoneum at both low and high intraperitoneal pressure (IPP), and laparotomy, in animal models with controlled respiratory support (CRS). METHODS C57BL6 mice were divided into eight groups (n = 5) consisting of anaesthesia alone or with CO(2) pneumoperitoneum at low (2 mmHg) or high (8 mmHg) IPP or undergoing laparotomy. Groups were further subdivided into those with or without CRS with endotracheal intubation and mechanical ventilation. Over the course of the 1 h procedure, PitO(2) was continuously monitored. RESULTS Protocol 1. The PitO(2) levels (104.2 +/- 7.8 mmHg, mean +/- SEM) in non-injured peritoneum during a CO(2) pneumoperitoneum at a low IPP were elevated approximately 2-fold over the levels during laparotomy (49.8 +/- 15.0 mmHg) in ventilated mice. Protocol 2. After insufflation with CO(2), the PitO(2) was immediately elevated and maintained at a higher level. Following laparotomy, it decreased immediately. This elevation was not seen with air insufflation. CONCLUSION In mice, a significant elevation in PitO(2) occurs during a CO(2) pneumoperitoneum at low IPP with CRS.

Objective To investigate whether WT1 protein expression is altered in eutopic endometrium of endometriosis patients. Design Prospective study. Setting University hospital. Patient(s) Patients with endometriosis and fertile women with macroscopically normal pelvic cavities. Intervention(s) During surgery, endometrial tissues were obtained from 59 patients with deep infiltrating endometriosis, ovarian endometriosis, or only superficial peritoneal endometriosis. Control endometrial tissue samples were obtained from 40 fertile women who underwent laparoscopic tubal ligation or reversal of tubal sterilization. Main Outcome Measure(s) The percentage of nuclear surface positively immunostained for WT1 (PI) and WT1-positive microvessel density. Result(s) The PI was significantly lower in endometrial stromal cells from patients with deep infiltrating endometriosis than in stroma from control subjects during the midsecretory phase, whereas there was no significant difference between the two populations during the proliferative, early secretory, and late secretory phases. The PI was also significantly lower during the midsecretory phase in endometrial stromal cells from patients with ovarian endometriosis and superficial peritoneal endometriosis compared with control subjects. Conclusion(s) During the midsecretory phase, PI in endometrial stromal cells is down-regulated in patients with deep infiltrating endometriosis, ovarian endometriosis, and superficial peritoneal endometriosis compared with endometrium from healthy control subjects.

Objective To investigate differentially expressed genes in epithelial and stromal cells of eutopic endometrium from patients with deep endometriosis and women with normal pelvic cavities using laser capture microdissection and complementary DNA microarrays. Design Prospective study. Setting University hospital. Patient(s) Patients with deep endometriosis and fertile women who underwent laparoscopic tubal ligation or reversal of tubal sterilization. Intervention(s) Endometrial tissue biopsies during the late proliferative phase and early, mid-, and late secretory phases. Main Outcome Measure(s) Genes that were regulated with a change greater than threefold were selected as differentially expressed genes. Validation was performed with real-time reverse transcriptase-polymerase chain reaction (RT-PCR). Result(s) Microarray analysis identified up-regulation during the late secretory phase (patients with endometriosis vs. controls) of several genes in two important signaling pathways: RAS/RAF/MAPK and PI3K. This included the genes RON, SOS, 14-3-3 protein eta, and uPAR in epithelial cells and KSR and PI3K p85 regulatory subunit alpha in stromal cells; real-time RT-PCR analysis validated up-regulation of all six genes. Conclusion(s) The RAS/RAF/MAPK and PI3K pathways may be involved in initial development of endometriosis.

Study Objective To discover the prevalence of adnexal torsion after laparoscopic hysterectomy Design Retrospective analysis (Canadian Task Force classification II-3). Setting A tertiary referral hospital. Patients One thousand thirty-three women underwent laparoscopic hysterectomies between the years 1995 and 2002. The mean age (± SD) of the women at the time of hysterectomy was 43.87 ± 4.28 years. Intervention Laparoscopic hysterectomy in which at least one adnexa was left intact. Measurements and Main Results The files of all women with adnexal torsion diagnosed by laparoscopy from 1995 to 2003 were retrospectively reviewed. In seven women, adnexal torsion occurred after laparoscopic hysterectomy. Torsion occurred 2.64 (± 1.79) years (mean ± SD) after hysterectomy. Torsion was treated by laparoscopy in all of the women; either oophorectomy or detorsion and ovariopexy was performed. We calculated the prevalence of this complication to be 7.91/1000. Conclusion Adnexal torsion can occur after laparoscopic hysterectomy.

The incidence of the spread of ovarian cancer after laparoscopic surgery is difficult to establish from the current literature. The prognosis incidence of a trocar site metastasis without peritoneal dissemination is not known. Data from general surgeons in prospective studies from a single institution suggested that in colon cancer the risk is low, whereas it seems to be much higher in multicentric studies of undiagnosed gallbladder cancer. Experimental studies suggested that laparoscopy has advantages and disadvantages. However, the risk of dissemination is high when a large number of malignant cells and a carbon dioxide pneumoperitoneum are present, a situation encountered when managing adnexal tumours with large vegetations. Animal studies will allow the development of a peritoneal environment adapted to the treatment of cancer. The ovary is an intraperitoneal organ and ovarian cancer a peritoneal disease, so the risk of peritoneal spread may be higher in ovarian cancer than in other gynecological cancers. A careful preoperative evaluation appears to be the best way to prevent these risks. It should also be used to choose which patient should be operated by which surgical team. The second step is a careful and cautious laparoscopic diagnosis, so that more than 98% of ovarian cancers encountered can be treated immediately and effectively. The laparoscopic management of ovarian cancer remains controversial; it should be performed only in prospective clinical trials. Until the results of such studies become available, an immediate vertical midline laparotomy remains the gold standard if a cancer is encountered.

a reconstruction tridimensionnelle (3D) a partir d’imagerie par resonance magnetique nucleaire (IRM) (1) d’echographie (2) ou de scanner (3) peut etre obtenue par technique en nuage de points, encore appelee « volume rendering » par les anglo-saxons, ou bien par une technique dite vectorielle qui necessite l’elaboration d’un maillage polygonal de type « fil de fer » moulant la surface des structures (4, 5). Cette derniere technique permet d’effectuer des evaluations volumiques precises, de realiser des comparaisons dynamiques, d’appliquer des deformations et d’animer les objets tridimensionnels. Un certain nombre de proprietes physiques et mecaniques peuvent egalement etre conferees a ces objets 3D, en vue d’une simulation en realite virtuelle a partir des donnees reelles des patients. Les techniques d’animation sont bien connues du monde informatique, et peuvent desormais servir a des applications medicales concretes. Nous presentons une technique d’animation fœtale a partir de reconstruction 3D vectorielle de patientes reelles, qui pourrait servir a la mise au point d’une serie d’outils de simulation d’accouchement pour la detection en routine des dystocies mecaniques.

A laparoscopic approach may be used to improve the surgical management of advanced ovarian cancer.

Objective: To compare tumor growth, intraperitoneal implantation, and abdominal wall metastasis after laparotomy and CO2 pneumoperitoneum in a rat ovarian cancer model. Methods: To mimic intraoperative rupture of an ovarian tumor in a syngenic rat ovarian carcinoma model, 105 malignant cells were injected intraperitoneally after a 5-cm vertical midline laparotomy or after the insufflation of a CO2 pneumoperitoneum achieved with 4 mmHg or 10 mmHg intra-abdominal pressure. Two weeks later, the intraperitoneal tumor growth and the tumor dissemination were evaluated semiquantitatively with a scoring system. The scores attributed to each organ were added to calculate the dissemination score of each animal. Results: The mean (± SD) dissemination score was 83.4 ± 12 in the laparotomy group and 67.3 ± 16 and 71.9 ± 17 in the 4 and 10 mmHg CO2 pneumoperitoneum groups, respectively (P < .01). The scores for the peritoneum were 21.8 ± 3.8 in the 10 mmHg pneumoperitoneum group and 18 ± 2.4 in the laparotomy group (P < .01). In the laparotomy group, the implant found along the midline scar accounted for a mean of 62.6 ± 15% of the peritoneal score, whereas the trocar site metastases did not influence the peritoneal score in the pneumoperitoneum groups. The incidence of wound metastasis was 96% in the laparotomy group and 55% and 54% in the 4 mmHg and 10 mmHg pneumoperitoneum groups, respectively. Conclusion: In this model, tumor growth was greater after laparotomy than after laparoscopy, but peritoneal tumor dissemination was more severe after CO2 pneumoperitoneum.

We investigated relationships between delay of surgical diagnosis and severity of disease in 95 patients with symptomatic deep infiltrating endometriosis. The delay before surgical diagnosis of deep infiltrating endometriosis was significantly longer for patients with advanced stage IV (revised American Society for Reproductive Medicine [ASRM] score >70) disease than for those with stage I, II, III, or IV (revised ASRM score ≤70) disease.

Objective: To evaluate the laparoscopic management of adnexal masses suspicious at ultrasound. Methods: In a prospective study, adnexal masses suspicious at ultrasound were managed by laparoscopy. Indications for laparotomy included general contraindications to laparoscopy, obviously disseminated ovarian cancer, and technically impossible laparoscopic treatment. After laparoscopic diagnosis, frozen sections were used to confirm a diagnosis of malignancy. Treatment was performed by laparoscopy whenever feasible. Results: Over a 3-year period, 247 of the 599 adnexal masses (41.2%) treated in our department were suspicious or solid at ultrasound. Seventeen patients were evaluated by laparotomy and 230 by laparoscopy. Overall, 204 women (82.6%) were treated by laparoscopy, including seven of the 37 malignant tumors (18.9%) and 197 of the 210 benign masses (93.8%). One case of tumor dissemination occurred after a laparoscopic adnexectomy and morcellation of a grade 1 immature teratoma. Conclusion: Laparoscopic diagnosis of adnexal masses suspicious at ultrasound avoids many laparotomies for the treatment of benign masses and allows an improved inspection of the upper abdomen. The laparoscopic treatment of adnexal masses suspicious at surgery should be evaluated further in carefully designed prospective studies.

From their experience and from data in the literature, the authors try to define the respective place of the different treatments for endometriosis, especially those of operative laparoscopy. In cases of endometriosis-associated infertility, operative laparoscopy is the first line treatment and assisted reproductive technology (ART) the second one. Gonadotrophin-releasing hormone (GnRH) analogues are only useful in cases of extensive endometriosis to render surgery easier, and for ART. The average pregnancy rate following laparoscopic treatment is approximately 50% (range 34-80%). It is poorly related to the type of endometriosis except in cases of large adhesions and tubal involvement. However, duration of infertility, age and sperm quality have a direct influence on it. Therefore the authors propose a scheme for the management of endometriosis-associated infertility. In cases of pain, laparoscopic surgery can also be used; however, drugs have a more important role in these cases, to avoid recurrent surgery.

To evaluate the impact of obesity in the safety of laparoscopic hysterectomy.A retrospective study was conducted using a database of 2271 women undergoing laparoscopic hysterectomy for benign diseases between January 1995 and December 2008 at the Centre Hospitalier Universitaire Estaing (Clermont-Ferrand, France). Patients were divided into two groups according to the body mass index:30 kg/m(2) (n=2088) and ≥ 30 kg/m(2) (n=183). Primary outcomes were differences in conversion rates, operating time, estimated blood loss, intraoperative complications, and early postoperative complications.There was no difference in the operative time (121.3 versus 122.5 minutes; P=.71), in the difference between pre- and postoperative hemoglobin levels (1.8 versus 1.6 g/dL; P=.28), and in the conversion rate (4.6% versus 5.5%; P=.62) comparing the two groups. The overall intraoperative complication rate was 14.03% (n=293) and 13.66% (n=25) for nonobese and obese patients (P=.89), respectively. The overall postoperative complication rate was 8.81% (n=184) and 7.65% (n=14), respectively.Obesity does not have an adverse effect on the feasibility and safety of laparoscopic hysterectomy in experienced hands.

Hysterectomy is the most commonly performed major gynecologic procedure around the world. Benign diseases are responsible for more than 70% of the indications for hysterectomy and include menstrual disorders, fibroids, pelvic pain and uterine prolapse (Whiteman et al., 2008). Traditionally, hysterectomy is performed by laparotomy or by vaginal access (Clayton, 2006). In 1989, Reich et al. (1989) described the first totally laparoscopic hysterectomy, which is currently considered an alternative means of access to traditional techniques for hysterectomy. Despite the advantages of the laparoscopic and vaginal routes compared with laparotomy, this remains the most widely used access route for performing hysterectomy worldwide. In Denmark, 80% of hysterectomies for benign disease between 1988 and 1998 were performed by laparotomy (Gimbel et al., 2001). In the period between 1988 and 1990, approximately 1.7 million hysterectomies were performed in the United States and 75% were by the abdominal route (Wilcox et al., 1994). In 2003, 538,722 hysterectomies were performed for benign disease in the United States and the abdominal route was still the most common (66.1%), followed by vaginal (21.8%) and laparoscopic (11.8%). This study demonstrated that there was a statistically significant difference in the average hospital stay among the three types of surgical access (3 ± 0.03 days, 2 ± 0.03 days and 1.7 ± 0.03 days, respectively, p

To compare surgical outcomes of laparoscopic hysterectomy for benign diseases according to the uterine weight.Retrospective study (Canadian Task Force classification II-3).Teaching and research hospital, a tertiary center.Women undergoing laparoscopic hysterectomy for benign diseases.Patients were divided into three groups according to the uterine weight:250 g (n = 1300), 250 to 500 g (n = 614), and500 g (n = 178).Primary outcomes were differences in conversion rates, operating time, and blood loss. Secondary outcomes were differences in length of hospital stay, time to first bowel movement, time of bladder catheterization, and complications. Operating time increased according to the uterine weight (116.5 vs 124.1 vs 133 minutes; p.001). The rate of conversion was statistically higher only for patients with uteri500 g (3.3% vs 5% vs 13.5%; p.001). However, the difference between preoperative and postoperative hemoglobin levels was equivalent for the three groups, as well as the overall rates of minor and major intraoperative complications. There was no difference in the time of bladder catheterization, time to first bowel movement, length of hospital stay, and incidence of minor and major postoperative complications among the three groups.Despite longer operating time, there is no increase in the intraoperative or postoperative complication rates in those patients with enlarged uteri undergoing laparoscopic hysterectomy. Only conversion is higher in patients with uteri500 g.