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Objective Bowel resection is frequently used when performing oncological surgery to obtain complete cytoreduction or to remove endometriosis in case of intestinal invasion. Acquiring the surgical skills to perform this kind of procedure is crucial to offer to our patients an optimal management. The aim of this study is to describe a 7-years surgical experience in bowel resections of a gynecologic surgeon and to determine his learning curves. Study Design This is a monocentric retrospective cohort study reporting digestive resection performed between January 2013 and April 2020 in the Gynecology Department of Strasbourg University Hospital. Ninety-one consecutive patients were assigned in two groups: gynecological cancer (n = 44) and deep infiltrating endometriosis (DIE) (n = 47). The main outcome measure was the postoperative complications rate at 30 days, based on the modified Clavien-Dindo severity system. Learning curves were evaluated using cumulative sum (CUSUM) analysis of operative time and risk-adjusted cumulative sum (RA-CUSUM) analysis of severe perioperative complications. Identification of predictive factors for operation duration and severe perioperative complication occurrence was conducted using multivariate analysis. Results Minor complications were found in 25% of cases. Major complication rate (Clavien-Dindo ≥ IIIa) was 14% in total and only involved patients operated for cancer. The CUSUM curve for operative time peaked at the 35th case and showed a downward slope after the 45th case. Significant predictive factors of operating time were cytoreductive tumoral surgery, size of the bowel resection and laparoscopic surgery, while learning phase 3 significantly decreased it. The RA-CUSUM curve for severe perioperative complications (Clavien-Dindo ≥ IIIa) showed a progressive decrease in the complication rate as the number of interventions increases without showing clear inflection points. Only cardiopulmonary pathologies were found as significant predictive factor of severe complications. Conclusion Proficiency in performing highly complex surgery was achieved after approximately 45 cases, cancer and DIE all together. Acceptable rates of severe perioperative complications were observed even during the initial learning period and are comparable with those found in the literature concerning bowel resection performed by gynecologic oncologists but also by general and digestive surgeons.

According to French guidelines, hyperthermic intraperitoneal chemotherapy (HIPEC) can be performed for Federation of Gynecology and Obstetrics stage III primary epithelial ovarian, tubal, and peritoneal cancers that are initially unresectable after 3 or 4 cycles of intravenous chemotherapy. The main objective of this preliminary study was to analyze the components necessary for the establishment of HIPEC in an expert gynecological oncological surgery center. The secondary objective was to compare HIPEC using conventional laparotomy and laparoscopic approaches.We conducted a single-center retrospective study of patients who received HIPEC. All patients who met the criteria of the French HIPEC guidelines were included from 2019 to 2021.Prior to HIPEC, there were a mean of 3.7 courses of neoadjuvant chemotherapy with carboplatin and paclitaxel. Of the 16 patients who received HIPEC, 9 (56.2%) underwent HIPEC laparoscopically, while 7 (43.8%) underwent laparotomy. There were no differences between the rates of intra- and postoperative complications between the two groups. (p 0.05). The duration of hospitalization was significantly shorter in patients who were operated laparoscopically than in those treated using laparotomy (55.6%10 days vs. 0 by laparotomy, p = 0.01). There was also a tendency, although not significant, for a more rapid resumption of adjuvant chemotherapy in the laparoscopy group, with 57.1% resuming chemotherapy in6 weeks compared to 42.9% in the laparotomy group (p = 0.52).This study demonstrates the feasibility of HIPEC in a center with expertise in gynecological surgery when there is a suitable technical platform and close collaboration between the different teams involved. We also showed the first cases of HIPEC using laparoscopy, which seems to be a promising approach.

Introduction Pelvic lymph node dissection has been the standard of care for patients with early cervical cancer. Sentinel node (SN) mapping is safe and feasible and may increase the detection of metastatic disease, but benefits of omitting pelvic lymph node dissection in terms of decreased morbidity have not been demonstrated. Materials and methods In an open-label study, patients with early cervical carcinoma (FIGO 2009 stage IA2 to IIA1) were randomly assigned to SN resection alone (SN arm) or SN and pelvic lymph node dissection (SN + PLND arm). SN resection was followed by radical surgery of the tumour (radical hysterectomy or radical trachelectomy). The primary end-point was morbidity related to the lymph node dissection; 3-year recurrence-free survival was a secondary end-point. Results A total of 206 patients were eligible and randomly assigned to the SN arm (105 patients) or SN + PLND arm (101 patients). Most patients had stage IB1 lesion (87.4%). No false-negative case was observed in SN + PLND arm. Lymphatic morbidity was significantly lower in the SN arm (31.4%) than in the SN + PLND arm (51.5%; p = 0.0046), as was the rate of postoperative neurological symptoms (7.8% vs. 20.6%, p = 0.01, respectively). However, there was no significant difference in the proportion of patients with significant lymphoedema between the two groups. During the 6-month postoperative period, the difference in morbidity decreased over time. The 3-year recurrence-free survival was not significantly different (92.0% in SN arm and 94.4% in SN + PLND arm). Conclusion SN resection alone is associated with early decreased lymphatic morbidity when compared with SN + PLND in early cervical cancer.

Objective The purpose of this study was to compare two groups of patients presenting advanced ovarian carcinoma benefiting from neoadjuvant chemotherapy (NAC) followed by cytoreductive surgery: after 3–4 cycles (group 1) or ≥ 5 cycles (group 2), regarding overall survival (OS) and progression-free survival (PFS), complications related to surgery as well as the extent of cytoreduction were assessed. Study design We conducted a retrospective, multicenter cohort study in nine referral centers of France, reviewing the charts of all patients who underwent NAC between January 2000 and June 2017. We performed an OS analysis using multivariate Cox regression models adjusted for potential confounders. We also analyzed PFS and surgery-related morbidity. Results Of 501 patients included, 236 (47.1 %) benefited from ≤ 4 NAC cycles and 265 (52.9 %) from ≥ 5 NAC cycles. Characteristics data were similar in both groups. The rate of achievement of complete surgery was similar in both groups (p = 0.28). Surgical morbidity and postoperative complications showed no significant differences between both groups. The median OS was 54.2 months, 64 months for group 1 and 49.2 months for group 2. The 5-year survival rate was 45.6 % and 27.6 %. This difference was not statistically significant [HR 1.81 (0.89–3.71), p = 0.09]. Five-year PFS was 19.7 % and 11.7 % respectively (p = 0.31). Conclusion In a large series of advanced ovarian cancer, patients receiving late IDS (≥ 5 NAC cycles) seem to show a poorer prognosis than patients operated on earlier. The survival appears to be mainly determined by optimal resection and response to chemotherapy.

Objective To assess the incidence of serious complications and reoperations for recurrence after surgery for pelvic organ prolapse (POP) and compare the three most common types of repair. Design Prospective cohort study using a registry. Setting Nineteen French surgical centres. Population A total of 2309 women participated between 2017 and 2019. Methods A multivariate analysis including an inverse probability of treatment weighting approach was used to obtain three comparable groups. Main outcome measures Serious complications and subsequent reoperations for POP recurrence. Results The median follow-up time was 17.6 months. Surgeries were native tissue vaginal repairs (n = 504), transvaginal mesh placements (n = 692) and laparoscopic sacropexies with mesh (n = 1113). Serious complications occurred among 52 women (2.3%), and reoperation for POP recurrence was required for 32 women (1.4%). At 1 year the cumulative weighted incidence of serious complications was 1.8% for native tissue vaginal repair, 3.9% for transvaginal mesh and 2.2% for sacropexy, and the rates for reoperation for recurrence of POP were 1.5, 0.7 and 1.1%, respectively. Compared with native tissue vaginal repair, the risk of serious complications was higher in the transvaginal mesh group (weighted hazard ratio, wHR 3.84, 95% CI 2.43-6.08) and the sacropexy group (wHR 2.48, 95% CI 1.45-4.23), whereas the risk of reoperation for prolapse recurrence was lower in both the transvaginal mesh (wHR 0.22, 95% CI 0.13-0.39) and sacropexy (wHR 0.29, 95% CI 0.18-0.47) groups. Conclusions Our results suggest that native tissue vaginal repairs have the lowest risk of serious complications but the highest risk of reoperation for recurrence. These results are useful for informing women and for shared decision making. Tweetable abstract Laparoscopic sacropexy had fewer serious complications than transvaginal mesh and fewer reoperations for recurrence than vaginal repair.

Supplemental Digital Content is available in the text., In 1994, a pilot program of cervical cancer screening was introduced in the Alsace region, France. Women aged 25–65 years were proposed to have one Pap smear every 3 years. The objective was to assess cervical morbidity in Alsace before the human papillomavirus vaccinated population reaches the age of screening. Data on cervical lesions and cancers were collected by EVE for the period September 2008 to August 2011 from existing medical services and cytopathology laboratories in Alsace. Cytological and histological data were completed with data from the two cancer registries covering the region (Bas-Rhin and Haut-Rhin). Cancer incidence rates were computed for the target population (truncated to 25–64 years) and were age standardized according to the world reference population. World standardized incidence rates for the whole female population were obtained from the two cancer registries. During 2008–2011, 565 153 smears were performed in 498 913 women aged 25–64 years, representing an average of 1.13 smears/woman and 1.62 smears/screened woman. The overall screening coverage was 70.1% over the 3-year period. Histologically confirmed high-grade lesions were found in 2303 women (0.5%). Moreover, 215 cervical cancers were reported among women aged 25–64 years (crude and standardized truncated incidence rate of 10.6 and 10.0/100 000 women-years, respectively). The overall screening coverage of 70% at 3 years is higher than the national rate (57%), and the overall cancer incidence of 5.5/100 000 is below the national French level. The EVE database will be useful to assess trends in cervical morbidity over time and to further assess the effect of screening as well as of human papillomavirus vaccination.

Efficient primary (vaccination) and secondary (screening) prevention strategies have the potential to eliminate cervical cancer worldwide. In this context, surveillance of HPV infections remains mandatory to assess the efficacy and the impact of screening and vaccination policies. Therefore there is a need to safely store cervical samples to conduct long-term studies in vaccinated and non-vaccinated subjects. Up-dated data on cervical specimen preservation on FTA® cards indicate that HPV DNA can be safely retrieved after 54 months of storage. A concordance of 97 % was achieved between HPV genotypes detected in initial cervical samples and on FTA® cards 4.5 years later. Even if a drop in HPV viral loads was observed in some cases at 4.5 years, using FTA® cards for safe and long-term storage of cervical samples represents an interesting option.

Purpose. To assess the value of sentinel lymph node (SLN) sampling in high risk endometrial cancer according to the ESMO-ESGO-ESTRO classification. Methods. We performed a comprehensive search on PubMed for clinical trials evaluating SLN sampling in patients with high risk endometrial cancer: stage I endometrioid, grade 3, with at least 50% myometrial invasion, regardless of lymphovascular space invasion status; or stage II; or node-negative stage III endometrioid, no residual disease; or non-endometrioid (serous or clear cell or undifferentiated carcinoma, or carcinosarcoma). All patients underwent SLN sampling followed by pelvic with or without para-aortic lymphadenectomy. Results. We included 17 original studies concerning 1322 women. Mean detection rates were 89% for unilateral and 68% for bilateral. Pooled sensitivity was 88.5% (95%CI: 81.2–93.2%), negative predictive value was 96.0% (95%CI: 93.1–97.7%), and false negative rate was 11.5% (95%CI: 6.8; 18.8%). We noted heterogeneity in SLN techniques between studies, concerning the tracer and its detection, the injection site, the number of injections, and the surgical approach. Finally, we found a correlation between the number of patients included and the SLN sampling performances. Discussion. This meta-analysis estimated the SLN sampling performances in high risk endometrial cancer patients. Data from the literature show the feasibility, the safety, the limits, and the impact on surgical de-escalation of this technique. In conclusion, our study supports the hypothesis that SLN sampling could be a valuable technique to diagnose lymph node involvement for patients with high risk endometrial cancer in replacement of conventional lymphadenectomy. Consequently, randomized clinical trials are necessary to confirm this hypothesis.

Background: The population of interest to this study comprised individuals with advanced-stage ovarian carcinoma who were exposed to neoadjuvant chemotherapy (NAC) followed by interval debulking surgery (IDS). Those who had not received systematic lymphadenectomy (SL, Group 1) were compared to those who had received SL (Group 2). Outcome measures included progression-free survival (PFS), overall survival (OS), and surgical complications. Methods: This was a retrospective, multicenter cohort study in nine referral centers of France between January 2000 and June 2017. OS analysis using the multivariate Cox regression model was performed. PFS and surgery-related morbidity were analyzed. Results: Of the 255 patients included, 100 were in Group 1 and 155 in Group 2. Patient majority was, on average, younger and less comorbid, with predominant R0 surgery in Group 2. Dindo&ndash, Clavien score was similar between the two groups (p = 0.15). Median OS was 26.8 months in Group 2 and 27.6 months in Group 1. SL was not statistically significant on OS (p = 0.7). Median PFS was 18.3 months in Group 2 and 16.6 months in Group 1. SL had positive impact on PFS (p = 0.005). Conclusions: patients who had received SL (Group 2) had significantly higher PFS regardless of node-positivity status when compared to those who had not received SL (Group 1).

Objective The main aim of this study is to evaluate operative and postoperative morbidity of laparoscopic pelvic lymphadenectomy as well as its potential impact on the postoperative management in patients with an intermediate-risk of endometrial cancer. Methods We did a retrospective study between January 2009 and December 2013. We included all patients operated by laparoscopy for endometrial cancer presumed to have an intermediate-risk of recurrence. Pelvic lymphadenectomy in this group of patients was performed at the discretion of operating surgeons. Patients were consequently divided into two groups according to whether or not pelvic lymphadenectomy was performed. We made a comparative analysis between these two groups. Results Overall, 116 patients were managed for endometrial cancer presumed to be intermediate-risk. Among these, 93 received treatment with laparoscopy and were included in the study. Patients’ characteristics did not differ between the two groups. The mean duration of surgery was significantly longer when pelvic lymphadenectomy was performed. The average number of retrieved lymph nodes was 13 and we had seven patients with positive lymph nodes (10%). Conclusion Pelvic lymphadenectomy allows a better postoperative classification for some patients without more complication.

Introduction: A second generation HPV vaccine has been developed for the prevention of anogenital cancers and precancerous lesions of the cervix, vulva, vagina, anus and of genital warts due to nine HPV types.We estimated the annual burden of these diseases attributable to the nine HPV types compared to HPV types from first generation vaccines in women and men in Europe. Material and methods: Incidence rates from the IARC database, cancer registries, the literature and Eurostat population data were used.The burden attributable to the HPV types targeted by both vaccines was estimated by applying the relative contribution of the respective HPV types from epidemiological studies. Results: In 2013, the number of new anogenital HPV-attributable cancers was 44,480 with 39,494 of these cases related to second vs. 33,285 to first generation vaccine types.Among the 284,373 to 541,621 new HPV-attributable anogenital precancerous lesions 235,364–448,423 and 135,025–256,830 were estimated to be related to second and first generation vaccine types, respectively.The annual number of new genital warts was 753,608–935,318, with 90% related to HPV6/11. Conclusions: These data demonstrate how the large public health impact that was achieved by the first generation HPV vaccines could be further increased by second generation vaccines. Keywords: HPV, Burden of disease, Cancer, Precancerous lesions, Genital warts, HPV vaccine

Health-related quality of life (QoL) in patients treated for ovarian cancer is directly and heavily impacted by the natural history of cancer, its evolution and its therapeutic modalities. The evaluation and consideration of various parameters of QoL seems to be a major issue. Indeed, on the one hand, it is essential to take into account the opinion of patients in the choice of therapeutic strategies for this cancer with a poor prognosis and, on the other hand, more and more studies show that QoL is an independent prognostic factor in ovarian cancer. Improvement in this case, in addition to being an endpoint by itself, would potentially improve the overall survival of patients. To date there are several tools to assess QOL of patients with ovarian cancer. The 2 questionnaires most commonly used are: FACT-O and the EORTC QLQ-OV28. The aim of our study was to evaluate from a review of the literature, the reciprocal effects of ovarian cancer on QoL and QoL on ovarian cancer survival, as well as specificities of each of the 2 questionnaires most commonly used in assessing the QoL.

Study Objective Two validated laparoscopic approaches for para-aortic lymphadenectomy (PAL) exist: the transperitoneal and the extraperitoneal. The aim of this study was to compare the surgical outcomes of both approaches. Design A retrospective review of all patients who underwent laparoscopic PAL for a gynecologic malignancy between January 2008 and October 2013. Setting University Hospital. Patients Two patients groups were compared: transperitoneal (n = 51) and extraperitoneal (n = 21). Interventions Paraaortic lymphadenectomy. Measurements and Main Results The χ 2 test, Fisher's exact test, or Student's t -test were used for univariate analysis and a stepwise logistic regression for multivariate analysis. The threshold of statistical significance was set at 0.05. All patient characteristics were similar between the 2 groups (p > .05 for all variables). There was only 1 (1.3%) conversion to laparotomy encountered in the transperitoneal PAL group and 3 conversions from extraperitoneal to transperitoneal PAL (14.2%). In 1 case of extraperitoneal PAL, the procedure was abandoned because of inadequate equipment (body mass index 48 kg/m 2 ). The mean duration of surgery was longer in the transperitoneal group: 200 min (35–360) versus 125.6 min (45–180) in the extraperitoneal group (p = .001). The mean number of harvested lymph nodes was higher in the transperitoneal group: 17 (4–37) versus 13 (3–25) in the extraperitoneal group (p = .029). There was no difference in postoperative course and complications between both groups in multivariate analysis. Conclusions In nonobese patients, the extraperitoneal PAL is associated with shorter surgical duration, whereas the transperitoneal approach was associated with a higher number of harvested lymph nodes. As a result of improved ergonomy, the transperitoneal approach enables laparoscopic management of operative complications.

Study Objective Lumboaortic lymphadenectomy is frequently performed in the surgical management of different gynecologic pelvic malignancies: cervical endometrial and ovarian cancer. The retroperitoneal access presents a real advantage, allowing direct access to vascular axes, thus avoiding bowel segments. The use of a vessel-sealing device could facilitate the technique by providing an ergonomic alternative to conventional tools such as a bipolar grasper and scissors. Here the surgical technique of laparoscopic retroperitoneal lumboaortic lymphadenectomy using a vessel-sealing device in 10 steps is described. Design Educative video (Canadian Task Force classification III). Setting Tertiary referral center in Strasbourg, France. Patients Women undergoing lumboaortic lymphadenectomy. Intervention Laparoscopic retroperitoneal lumboaortic lymphadenectomy using a vessel-sealing device. The local institutional review board approved the video. Measurements and Main Results The surgeon and assistant are positioned on the left of the patient and the column is placed in front. After peritoneal exploration 3 trocars are introduced in the left flank according to a very precise arrangement. We use a camera scope with a zero-degree view angle. After development of the extraperitoneal space and identification of the vascular landmarks, lymphadenectomy using a vessel-sealing device involves several steps in an anticlockwise direction starting from the left common iliac group. We first start with the lateroaortic group of lymph nodes. We then continue with the preaortic, interaorticocaval, and precaval supramesenteric group. After that, we perform the inframesenteric dissection of lymph nodes, the bifurcation of the aorta, and finally the right common iliac group. At the end of the procedure, in the absence of signs of metastatic lymph nodes, we open the peritoneum. Conclusion Retroperitoneal lumboaortic lymphadenectomy using a vessel-sealing device is useful because of better ergonomics of the multitasking instrument, avoiding alternating between scissors and bipolar forceps. The surgeon will be able to use both hands for exposure and for surgery. The presence of a metastatic ganglion is an important and decisive factor in the choice of adjuvant or neoadjuvant management of cancers, especially for cervical cancer.

Study Objective Laparoscopic transperitoneal lymphadenectomy has a few advantages. First, it is a minimally invasive approach, and the transperitoneal approach is also the best option when intra-abdominal surgery is indicated. Although the procedure was described more than 2 decades ago, there is a lack of diffusion of the technique. The main objective of this video is standardization and a simple description of the technique. We described this procedure in 10 logical steps, which should help to understand and perform this procedure. Methods This video presents a systematic approach to transperitoneal lumboaortic lymphadenectomy, which is clearly divided in 10 steps ordered in a counterclockwise direction. Results The 10 steps are as follows: step 1, retroperitoneal access; step 2, creating a space for subsequent lymphadenectomy and identification of anatomic landmarks; step 3, left common iliac lymph node dissection; step 4, right common iliac lymph node dissection; step 5, presacral lymph node dissection; step 6, lateroaortal lymph node dissection; step 7, laterocaval lymph node dissection; step 8, aortocaval lymph node dissection; step 9, vaginal extraction of bags with specimens; and step 10, vaginal suture. Conclusions Laparoscopic transperitoneal access to lumboaortic lymph nodes is an effective method of lymphadenectomy, which may bring benefits to a patient and physician. The presented 10 steps help to perform each part of surgery in a logical sequence, making the procedure ergonomic and easier to adopt and learn. Standardization of laparoscopic techniques could help to reduce the learning curve.

Improved performances in gynaecological ultrasonography have enabled an increasing number of often asymptomatic endometrial polyps to be detected. Most of these polyps are removed surgically, as a precautionary measure, so as not to miss a case of endometrial cancer. Nonetheless, this management strategy is based solely on the sonographer's judgement and a number of these operations, which are probably of no benefit, could be avoided. In order to do so, risk factors for malignancy need to be identified.Estimate the prevalence of lesions in menopausal patients with a pre-operative diagnosis of endometrial polyp. Establish risk factors for malignancy.This is a single-centre retrospective study. Enrolment criteria were menopausal patients aged over 45 who had undergone hysteroscopic resection of a polyp. Pre-op diagnosis was made either by ultrasonography or diagnostic hysteroscopy. Malignant lesions included cancers and atypical hyperplasia. Benign lesions consisted of simple polyps, non-atypical simple hyperplasia and non-atypical complex hyperplasia. Risk factors studied were existing abnormal uterine bleeding, endometrial thickness, personal or first-degree family history of gynaecological cancer (breast, cervix, endometrium, ovary) and age on diagnosis.631 patients were enrolled of whom 30 presented a malignant disorder (4.75%); 579 patients (91.76%) presented a simple polyp, 11 a non-atypical simple hyperplasia (1.74%) and 11 a non-atypical complex hyperplasia (1.74%). On univariate analysis age alone proved to be statistically significant (OR 1.05; 95%CI=[1.02-1.09] p0.01), with a threshold of 59 years of age on the ROC curve. On multivariate analysis, factors predictive of a malignant lesion were age (OR=1.06; 95%CI [1.02-1.10]), existence of AUB (OR=2.4; 95% CI [1.07-5.42]) and family history (OR=2.88; 95%CI [1.08-7.67]). Neither the univariate nor multivariate model was able to demonstrate a statistically significant relationship with respect to endometrial thickness. The risk of malignancy was 12.3% in patients aged over 59 presenting AUB. For all other subgroups, the risk varied between 2.31 and 3.78%.The risk of a malignant lesion appears to be high (12%) in menopausal patients aged over 59 presenting an endometrial polyp detected when there is pre-existing AUB. In this situation, hysteroscopic resection of endometrial polyps should therefore be routinely proposed. For other patients, the risk of a malignant lesion is low but not insignificant, standing at about 3%. Each patient record should therefore be discussed on an individual case basis, taking into consideration the patient's pre-existing conditions, after providing clear and appropriate information.

Study Objective To illustrate laparoscopic sacral colpopexy for pelvic organ prolapse, a new method using a simplified mesh fixation technique, with only 6 fixing points. Design Step-by-step explanation of the surgery using video (educative video). The video was approved by the local institutional review board. Setting University Hospital of Strasbourg, France (Canadian Task Force Classification III). Patients Women with multicompartment prolapse. Intervention We first dissected the promontorium and vertically incise the posterior parietal peritoneum on the right pelvic sidewall up the pouch of Douglas. We then dissect the rectovaginal septum up to the anal cap, laterally exposing the puborectalis muscle on each side. Middle rectal vessels can be coagulated and cut without increasing the risk of digestive disorders (especially constipation), but it is preferable to conserve them if the space is sufficient for suture. Then, we dissect the vesicovaginal space and realized the subtotal hysterectomy. Finally, we realized the fastening of the anterior and posterior meshes. The particularity is that we performed only 6 points for fixing the meshes: 1 on the puborectalis muscle on each side without tension (to reduce the risk of mesh contracture, dyspareunia, and chronic pelvic pain), 1 for the fixing of the anterior mesh on the anterior vaginal wall at the level of the bladder neck, and 1 on each side of the cervix for the reconstitution of the pericervical ring gathering together the anterior mesh, the pubocervical fascia, and the insertion of the uterosacral ligament at the level of the cervix and the posterior mesh. The sixth stitch fastened 1 of 2 meshes to the anterior paravertebral ligament at the level of the sacral promontory. We finished with the peritonization. Main Results The duration of surgery lasts approximately 120 minutes in well-experienced hands. Based on our experience the 6-point technique was relatively simple (few laparoscopic stiches) with few operative difficulties and was also associated with a low rate of reintervention. Conclusion Surgical management of middle compartment prolapse could be performed quickly and efficiently under laparoscopy with the “6-points” technique.

Objective To identify whether women presenting with reactive cellular changes (RCC) on their cervical smear face an increased risk for developing high grade cervical intraepithelial neoplasia (CIN2-3) or cancer as compared with women with an entirely normal smear. Study design French data from the association in charge of organized cervical cancer screening in Bas-Rhin administrative region were used to establish a cohort of 96,215 women presenting with a smear classified as entirely normal or with RCC during the year 2001. The Kaplan-Meyer method was used to calculate the probabilities of CIN2-3 and cancer at seven years of follow-up. Univariate and multivariate survival analyses were performed using Cox proportional hazard models. Results Among the 95,559 women included in the final analysis, 32.2% presented a smear with RCC. After seven years of follow-up, 441 women developed a CIN2-3 and 35 a cancer. Probability of CIN2-3 was increased in the RCC group as compared with the group of women with a normal smear (0.7% versus 0.5%, p = 0.002). Multivariate analyses showed that, compared with a normal cervical smear, RCC were associated with a significant 37% increased risk of CIN2-3 (HR = 1.37 CI95 [1.13–1.66]). However, the risk of cancer was not significantly increased (HR = 1.11 CI95 [0.55–2.23]). Conclusion This study showed that, at seven years, women with RCC on their cervical smear face an increased risk of CIN2-3 but no significant increased risk of cancer. The distinction between entirely normal and RCC cervical smears should therefore not lead to specific clinical management.

Resume Objectif Evaluer la pertinence de l’imagerie par resonance magnetique (IRM) pelvienne, de la biopsie d’endometre (BE) et du curetage dans l’identification des cancers de l’endometre susceptibles de beneficier d’une lymphadenectomie. Patientes et methodes Etude retrospective portant sur une serie continue de patientes operees d’un cancer de l’endometre limite a l’uterus entre janvier 2004 et decembre 2008. Les resultats du bilan preoperatoire concernant les stades evalues a l’IRM, les types et les grades histologiques evalues a la BE et/ou au curetage uterin ont ete confrontes aux resultats de l’analyse histologique definitive. Resultats Cent-soixante-neuf patientes ont ete incluses dont 90 (53,3 %) ont beneficie d’une IRM, 112 (66,2 %) d’un curetage et 61 (36,6 %) d’une BE. La sensibilite (SN), specificite (SP), valeur predictive positive (VPP) et negative (VPN) respectives de l’IRM dans l’identification d’un groupe susceptible de beneficier d’une lymphadenectomie etaient de 65,6 %, 87,2 %, 77,7 %, 79,2 %. Pour la BE et le curetage la SN, SP, VPP et VPN etaient de ; 42,9 %, 96,9 %, 85 %, 79,5 % ; 80,6 %, 98,3 %, 96,2 % et 90,6 % respectivement. 37,8 % des cancers a faible risque de metastases ganglionnaires au bilan preoperatoire se sont averes etre a haut risque a l’examen histologique definitif. Discussion et conclusion Le bilan preoperatoire comportant un ou plusieurs de ces examens : IRM, BE et curetage uterin est performant dans le diagnostic du cancer de l’endometre susceptible de beneficier d’une lymphadenectomie. Cependant, une sous-estimation du risque est retrouvee dans un tiers des cas environ.

The aim of the study was to determine which mathematical formula of specimen dimensions is the most accurate method of determining volume of the excised specimen at loop excision of the transformation zone.A multicenter prospective observational study was conducted. A total of 258 patients who had a loop excision of the transformation zone performed as treatment of cervical intraepithelial neoplasia 2-3 were included. The dimensions and the volume of the specimen were measured at the time of the procedure, before formaldehyde fixation. The volume was measured by immersing the specimen in a graduated cylinder using Archimedes fluid displacement technique. The measured volume was compared with the calculated volume using different volume formulas, that is, a cone, a cylinder, a parallelepiped, and a hemiellipsoid. The main outcome measure was the relationship between calculated volume (using the dimensions of thickness, length, and circumference) and the measured volume of the specimen.The mean (SD) thickness, length, and circumference of specimens were 8.8 mm (3.8), 12.7 mm (5.9), and 45.7 mm (16.8), respectively. The mean (SD) measured volume was 2.53 (1.49) mL. Using the formula for the volume of a cone, a cylinder, a parallelepiped and a hemiellipsoid, estimated volumes were 1.03 mL (1.22), 3.10 mL (3.65), 6.20 mL (7.31), and 2.07 mL (2.44), respectively. The highest intraclass correlation coefficient between measured and calculated volume was observed when using the formula for the volume of a hemiellipsoid specimen (0.47, 95% CI = 0.36-0.56).The hemiellipsoid formula is the most accurate determinant of the excised volume. Other formulas do not allow for an accurate estimation of the excised volume.

Study Objective To demonstrate a technique of laparoscopic management of a rudimentary horn in a 12-year-old girl. Design A step-by-step explanation of the surgery using a video (instructive video) approved by the local institutional review board. Setting A university hospital (University Hospital of Strasbourg, Strasbourg, France). Patient A 12-year-old girl with a uterine rudimentary horn. Intervention We describe a case of a 12-year-old girl who had no medical history. She had her first menstruation at 11 years old with major left pelvic pain occurring each month. Ultrasonography showed a duplication of the uterus with a liquid collection on the left side; this type of malformation is called an accessory and cavitated uterine mass. Medical treatment was initiated with progestin. Magnetic resonance imaging showed a left noncommunicating rudimentary horn with a unicornuate uterus. No other malformation was present, particularly in the kidneys. A primary vaginal endoscopy was performed showing a single cervix without vaginal malformation. It was decided to perform a laparoscopic excision of the left rudimentary horn. We placed a 10-mm optical port into the umbilicus and 3 accessory 5-mm trocars. Evaluation of the abdominal cavity showed 2 normal adnexas with normal ovaries. We decided to start with a left salpingectomy using the Ligasure device (Medtronic, Minneapolis, MN), staying close to the tube to preserve ovarian vascularization. The remnant fimbria must be removed to avoid cancerization. Then, the vesicouterine septum was divided until we reached the cervix to dissect the bladder from the rudimentary horn. The broad ligament was fenestrated in order to push the left ureter laterally .The utero-ovarian pedicle was transected with the Ligasure device; the left ovary was preserved and vascularized by the left infundibulopelvic ligament. We then dissected the left uterine artery. The posterior peritoneum was opened. The resection of the rudimentary horn was performed by means of a monopolar hook. The dissection was performed slowly with selective coagulation until we reached the cavity of the horn, with old blood flowing out. The entire cavity was removed, and we confirmed the absence of communication with the other part of the uterus. Uterine reconstruction was performed with inverted separated stiches of a 2-0 braided suture, and, finally, an antiadhesion barrier was placed. Conclusions Laparoscopic management of a uterine rudimentary horn is feasible with satisfactory uterine reconstruction. This is not the first case of this surgery performed by laparoscopy. A similar case has been published in 2015 [1] , and recently another video [2] has been published describing 2 other cases.

Study Objective Laparoscopy using a single port improves morbidity while keeping the same level of requirement. This technique has been evaluated in gynecology for salpingectomy, ovarian surgery, and hysterectomy. Here, the authors illustrate a new use of a single port using the transvaginal approach. Design Case report (Canadian Task Force classification III). Setting Tertiary referral center in Strasbourg, France. Patient Woman age 59 years. Intervention Single-port platform used in the transvaginal approach for resection of sacrocolpopexy mesh. The local institutional review board approved the video. Measurements and Main Results A 59-year-old woman suffering from insulin-dependent diabetes and a tobacco user had 2 laparoscopic sacrocolpopexies for recurrent rectocele, the first in 2007 and the second in 2012. The sequences were marked by mesh erosion and granuloma in the vagina, requiring its surgical excision in 2016. The patient was then symptomatic, with an increasingly foul-smelling vaginal discharge with recurrent mesh erosion. Magnetic resonance imaging showed an abscess formation along the length of the mesh to the promontory. The patient then underwent surgery, realized under probabilistic antibiotic therapy, consisting of complete excision of the sacrocolpopexy mesh by the transvaginal approach. After putting the single-port trocar (GelPoint; Applied Medical, Rancho Santa Margarita, CA) into the vagina and obtaining distension with the insufflator (AirSeal; Conmed, Utica, NY), classic laparoscopic instruments were introduced by the single-port trocar. The mesh was entirely resected in the retroperitoneal space. Mesh was again used because the exposed space is almost always surrounded by loose granulation tissue that facilitates dissection and also prevents injury to adjacent structures such as bladder, rectum, and peritoneum. Moreover, the opening of adjacent structures will manifest gas leaks and, consequently, loss of the pneumovagina. At the end of procedure, the vagina is not closed to permit optimal drainage with a multitubular drain in the dissection space. The surgery lasted 60 minutes. The mesh excision was completed with relative ease, and there was no blood loss. Bacteriologic examination revealed the presence of Streptococcus anginosus, Klebsiella pneumoniae, and Bacteroides fragili. The operating suites were simple with great cicatrization after 6 weeks. The principal difficulties of this surgery were obtaining a good seal by the creation of cutaneous sutures. Finally, there are less conflicts between the instruments inside the single-port trocar used in transvaginally because of a more limited dissection space. Indeed, the rate of mesh erosion reached 2.4% and, in case of infection, justifies this excision. Conclusion The transvaginal use of a single-port trocar represents a good alternative, allowing easy resection of the sacrocolpopexy mesh while remaining in the retroperitoneal space.

Study Objective To describe 2 different surgical techniques for Essure removal on the same patient: the hysteroscopic and laparoscopic techniques. Design An educational video approved by the local institutional review board (Canadian Task Force classification III). Setting A university hospital (University Hospital of Strasbourg, Strasbourg, France). Patient A 46-year-old woman with many symptoms after Essure device implantation. An ultrasound found a right implant in the uterine cavity and a left intratubal implant. Interventions The first step was the hysteroscopic removal of the right implant. We viewed the 2 internal and external spirals, allowing the gripping of the whole device without risking any fragmentation or tubal lesion. The second step was bilateral salpingectomy with resection of the left interstitial tubal portion. We longitudinally incised the antimesial edge of the fallopian tube 2 to 3 cm from the tubal serous to the implant contact. A circumferential incision was performed at the uterine horn to circumscribe the interstitial tubal portion. The implant was released from the surrounding tissue. It was gently pulled to completely extract it and avoid spiral fragmentation. Then, we performed a bilateral total salpingectomy. An X-ray of the implants and pelvis was performed to ensure complete removal of the device. We made an X-stitch in the uterine horn to avoid the risk of fistula. Conclusion More and more patients are asking for the removal of their implants. The surgical technique has to be adapted to the location of the implants and has to allow their complete removal to avoid leaving fragments that can cause the persistence of side effects.

Objective: To evaluate the overall survival (OS) of patients with initially inoperable advanced ovarian cancer, tubal carcinoma, or primary peritoneal carcinoma of stages III or IV undergoing neoadjuvant chemotherapy (NAC) followed by cytoreductive surgery, according to the number of cycles performed. Methods: This retrospective study was conducted in three main oncology centres in the east of France, reviewing the charts of all patients who underwent NAC between January 1, 1998 and October 31, 2012. We performed an OS analysis using multivariate Cox regression models adjusted for potential confounders. We also analysed progression-free survival (PFS) as well as chemotherapy- and surgery-related morbidity. Results: Of the 204 patients included, 75 (36.8%) underwent ≤4 NAC cycles and 129 (63.2%) ≥5 NAC cycles. Characteristic data were similar in the two groups. Five-year OS was 35.0 and 25.8%, respectively. This difference was non-significant [HR = 1.06 (0.70-1.59), p = 0.79]. We also found no differences in PFS or morbidity between the two groups. Conclusions: The number of NAC cycles does not seem to play a role in the OS of patients with advanced ovarian cancer. Further evidence and prospective data are needed to assess the value of a high/low number of NAC cycles among these patients.

Objectives Although cervical cancer screening guidelines in France recommend a smear test every three years, many physicians order more regular screening. We aimed to assess the benefits or harms of shorter intervals between screenings, both for women and public health. Methods For a retrospective cohort of women aged 25–65 who had two normal smears and at least one additional smear, data were sourced from a regionally organized cervical cancer screening programme in France, with follow-up for nine years. Based on the interval between the second and third smear, two groups were formed; the first comprised overscreened women (interval Results Among 63,821 women, CIN2+ incidence rate per 10,000 women per year was 14.5 for 40,350 overscreened women, and 11.5 for 23,471 correctly screened women. Age-adjusted relative risk was 1.22[1.02; 1.46]. We found no significant difference for cancer (RR = 1.39; 95%CI = [0.60; 3.61]), but did find additional CIN1 in the overscreened group (RR = 2.09; 95%CI = [1.76; 2.51]). Conclusions A shorter interval between smears has a low benefit for CIN2+ lesion detection, which may not help avoid cancer. The excess number of CIN1 detected by overscreening may cause needless risk and excess costs due to overtreatment.

International audience; Objective The aim of the study was to assess whether direct colposcopic ă vision (DCV) of the cervix during large loop excision of the ă transformation zone (LLETZ) is associated with a decrease in the volume ă and dimensions of specimens or affects margin status at histology. ă Materials and Methods A prospective multicenter observational study of ă 216 women who underwent LLETZ for grades 2 and 3 cervical ă intraepithelial neoplasia was conducted. The volume and dimensions ă (circumference, length, and thickness) of the surgical specimens were ă measured before fixation. Data were compared according to the use of ă colposcopy during LLETZ. The following 3 groups were considered: LLETZ ă performed without colposcopy (n = 91), LLETZ performed immediately after ă colposcopy (n = 51), and LLETZ performed under DCV (n = 74). ă Results Patient characteristics were comparable with regard to age, ă parity, history of excision, indication of the procedure, and the size ă of the cervix. We found a significant decrease in all dimensions of the ă specimens obtained under DCV (p < .001). Margin status was not affected. ă After adjusting for confounders, the mean volumes were significantly ă lower in the DCV group (adjusted mean difference = -0.66 mL; 95% CI = ă -1.17 to -0.14). The probability that negative margins would be achieved ă together with the attainment of a volume less than 5 mL and a thickness ă less than 10 mm was the highest in the DCV group (adjusted OR = 2.80; ă 95% CI = 1.13 to 6.90). ă Conclusions Direct colposcopic vision is associated with a significant ă decrease in the volume and in all dimensions of LLETZ specimens with no ă compromise in the margin status.

Study Objective To demonstrate the technique of laparoscopic radical trachelectomy (LRT) and laparoscopic pelvic lymphadenectomy for early cervical cancer. Design Case report (Canadian Task Force Classification Study design III). Setting Tertiary referral centre in Strasbourg, France. Background Over the past 15 years, gynecologic oncologists have sought ways to preserve female fertility when treating invasive cervical cancer. Many cases of cervical cancer have been diagnosed in young women with a desire to preserve their fertility. As more women are delaying childbearing, fertility preservation has become an important consideration. Radical hysterectomy and bilateral pelvic lymphadenectomy represent the standard surgical treatment for stage IA2-IB1 cervical cancer. In some women with small localized invasive cervical cancer, there is hope for a pregnancy after treatment. Vaginal radical trachelectomy (VRT) is a fertilitypreserving surgical procedure for early-stage cervical cancers. The National Comprehensive Cancer Network has published guidelines stating that radical trachelectomy is part of the standard of care for women desiring to preserve their future fertility. VRTwas introduced in 1987 with its first reported use in 1994, and since then more than 1000 cases of VRT have been reported involving more than 250 live births. The tumor recurrence rate is between 4.2% and 5.3%, and the mortality rate is between 2.5% and 3.2%. However, VRT has several limitations despite results demonstrating the safety of the procedure. One limitation is that it is an inadequate procedure for nulliparous patients and those with history of previous conization with adverse vaginal anatomy. In addition, it is difficult to learn the techniques involved in radical vaginal surgery. Patients A 26 year-old nulliparous women with a FIGO Stage IB1 squamous cell tumor of the cervix. A first conisation was performed with no safe resection margins. Intervention In this video we show a type B laparoscopic radical trachelectomy with round ligament and uterine artery preservation. A laparoscopic pelvic lymphadenectomy was also performed. Our institutional review board approved this study. Measurements and Main Results Operative time was 240 minutes. Intraoperative blood loss was less than 100 mL. The operation was performed successfully with no intraoperative complications. Pathological findings demonstrated the presence of a cervical intraepithelial neoplasia 2 on the anterior lips from an 11 o'clock to a 1 o'clock position. Resection margins were safe. The surgical specimen did not show any residual invasive carcinoma. Twenty one lymph nodes were removed, 7 on the right side, and 14 on the left side. No metastatic adenopathy was found. The patient was discharged on day 11. After 5 months, no late complications or recurrence was detected. Conclusions LRT appears to be a safe option for women who intend to maintain their desire for a future pregnancy.

Resume L’utilisation du frottis cervical comme examen de depistage avant l’âge de 25 ans reste controverse. A ce jour, aucune etude randomisee ne valide la pratique d’un depistage plus precoce. L’impression de benefice individuel prevaut souvent malgre l’absence de preuves d’efficacite ou de rapport benefice–risque favorable. Une revue de la litterature prenant en consideration les donnees epidemiologiques, l’efficacite du depistage du cancer du col de l’uterus chez la femme jeune et les consequences medicales et economiques de ce depistage, fournit davantage d’arguments contre que pour, le depistage avant 25 ans.

The aim of our study was to evaluate the impact of systemic pelvic and para-aortic lymphadenectomy on survival in patients with advanced ovarian cancer after neoadjuvant chemotherapy.This multi-centric descriptive study included patients with initially inoperable advanced ovarian cancer, undergoing neoadjuvant chemotherapy followed by cytoreductive surgery with no residual tumor between 1998 and 2012. They were distributed into two groups depending on if they underwent lymphadenectomy or not during the interval surgery.Among the 101 included patients, 54 underwent lymphadenectomy and 47 did not. The multivariate analysis for overall survival showed no significant difference between the two groups [hazard ratio (HR)=1.88, confidence interval (CI)=0.89-3.94; p=0.08]. The multivariate analysis for progression-free survival showed no significant difference (HR=1.43, 95% CI=0.86-2.39; p=0.17).In patients with advanced ovarian cancer, treated by neoadjuvant chemotherapy and interval surgery with no residual tumor, lymphadenectomy does not seem to improve the survival rate.

Biobanking or collection and storage of specimens for future research purposes have become an essential tool in many fields of biomedical research and aims to provide a better understanding of disease mechanisms as well as the identification of disease-specific biomarkers that can navigate in complex diseases. In this study, we assessed the use of Flinders Technology Associates (FTA) cards as a long-term storage device for cervical specimens with suspected human papillomavirus (HPV) infections. HPV detection and genotyping results in liquid-based transport media were compared to HPV results from FTA cards. The overall agreement for the presence of any HPV infection between liquid-based medium and FTA cards stored for 1 year at ambient temperature was 100%. Reproducibility analysis of HPV detection and genotyping from FTA cards demonstrated that FTA cards are a reliable medium to store and preserve viral nucleic acids. Biobanking of cervical cells on FTA cards may provide a key resource for epidemiological and retrospective HPV studies.

To analyze the reliability of endocervical curettage (ECC) in the diagnosis of high-grade cervical intraepithelial neoplasia and cervical cancer, and to identify risk factors associated with diagnostic underestimation.A retrospective study was carried-out involving 445 patients who underwent ECC for: endocervical lesion incompletely visible on colposcopy or inaccessible to biopsy; atypical glandular cells on smear, or discrepancy between colposcopic impression and cytological abnormalities.Comparison between ECC and final diagnosis showed a perfect match in 362 patients (81.3%). For 189 patients with pre-cancerous or cancerous endocervical lesions, the sensitivity, specificity, and positive and negative predictive values were 87.3%, 96.9%, 95.4% and 91.9%, respectively. No clinical, cytological or colposcopic characteristics were associated with significantly increased risk of diagnostic underestimation with ECC.ECC is a very reliable tool for reducing the number of unnecessary treatments, without increasing the risk of allowing some lesions to evolve into cancer.

Objective: To determine whether assessment of plasma fibronectin in primigravidae could predict the pregnant women expected to become preeclamptic. Methods: We performed a prospective blinded analysis of 156 apparently normotensive primigravidae in an outpatient clinic. Blood samples were taken at 6 week intervals from the 18th week and immediately after delivery or at the onset of preeclampsia. Plasma fibronectin was evaluated by ELISA. Evolution with gestational age was studied using regression curves. Results: We had 148 normal primigravidae (592 determinations). In three women, increased fibronectin anticipated preeclampsia by 3–4 weeks. Five women showed high levels only at the onset of preeclampsia. Sensitivity, specificity, positive and negative predictive values of increased fibronectin levels were 37.5% (95% CI=3.3–71.7), 96.6% (95% CI=93.7–99.6), 37.5% (95% CI=3.3–71.7) and 96.6% (95% CI=93.7–99.6), respectively. Conclusions: This study shows that plasma fibronectin levels could represent a specific marker for preeclampsia. Its sensitivity has to be improved but its high negative predictive value strongly argues against the development of preeclampsia within the next 4 weeks after the blood sampling.

Minor cytological abnormalities--low-grade squamous intraepithelial lesions (LGSIL) and atypical squamous cells of undetermined significance (ASCUS)--are the most frequent abnormalities observed in smears performed in screening for cervical cancer. Surveillance through repeated smears has been proposed as an alternative to immediate colposcopy to reduce cost and avoid overloading colposcopy clinics. The aim of this review is to discuss the advantages and inconveniences of cytological surveillance of women with ASCUS or LGSIL, as reported in the literature. Cervical smears are not sufficient to establish the precise diagnosis of a lesion. In fact, the mean prevalence of normal cervices, high-grade CINs and cancers is estimated to be 58%, 7% and 0.5% for ASCUS and 34%, 27% and 0.2% for LGSIL. Cytological surveillance shows that minor cytological abnormalities regress in 28-69% of cases. In 6-9%, cytological regression masks a high-grade CIN, and a cancer may develop sooner or later in 0.30-1.12% of cases. Cancers often occur in patients temporarily lost to surveillance or in those with normal smears alternating with smears showing minor abnormalities. Strict modalities of surveillance are therefore required. The surveillance has to be carried out with smears repeated every 4-6 months for 2 years. If all smears are normal the regular screening at 3-year intervals may be resumed. On the other hand, an immediate colposcopy is recommended if a new abnormality is observed in these consecutive smears, regardless of its severity and of the time elapsed since the initial abnormality was discovered. With these recommendations in mind, cytological surveillance may slightly reduce the number of colposcopies but without reducing significantly the cost. At present, no arguments based on cost or efficacy clearly favour cytological surveillance over immediate colposcopy.

Endometriosis is a common gynaecological pathology with pelvic and extra-pelvic localisations. We report a case of endometriosis of the round ligament revealed by an intermittent hernia. The endometriosis of the round ligament is unusual and the diagnosis may be difficult. The appearance of a roundish lump in the inguinal region associated with pain in relation to the menstrual cycle must raise the suspicion of endometriosis among the possible diagnosis. Ultrasonography and magnetic resonance imaging are the most useful examinations. But it is the histological examination of the surgical specimen that confirms the diagnosis.

OBJECTIVES Our aim was to assess the risks of directed biopsy in pregnant women and to compare its reliability to that of colposcopy. METHODS One hundred seventy six gravidas, whose final diagnosis could be ascertained either by the histological analysis of a surgical specimen or by a sufficiently informative postpartum follow-up, were examined by the same colposcopist. The reliability of colposcopy and directed biopsy were compared using the McNemar χ test for univariate analysis and the Mantel-Haenszel χ test for multivariate analysis. RESULTS Directed biopsies were performed in 128 patients (72.7%), only 1 of whom experienced hemorrhage requiring vaginal packing. No other complications occurred, and premature labor was not more frequent after biopsy. The reliability of biopsy was significantly higher than that of colposcopy (82.6 vs 65.2%; p < .005). Among patients with accurate biopsy but discordant colposcopy, the final diagnosis was normal cervix, low-grade cervical intraepithelial neoplasia (CIN), high-grade CIN, and cancer in 48.4, 29.0, 22.6, and 0% of cases, respectively. When results were stratified by final diagnosis, biopsy was no more accurate than was colposcopy, regardless of cytological findings, colposcopic impression, gestational age, parity, or colposcopist's experience. One of the two occult invasive cancers correctly diagnosed by biopsy had an unsatisfactory colposcopy suggesting invasion. CONCLUSIONS The difficulties of colposcopy during pregnancy and the minimal risks of directed biopsy justify a biopsy in gravidas when either cytology or colposcopy suggests at least a high-grade CIN, to ensure that no cancer has been overlooked.

OBJECTIVE: To compare the reliability of cytology with that of cervicography and with the use of both tests when screening for neoplasia of the cervix and to analyze the causes of false positive and false negative results with both methods. STUDY DESIGN: The results of cytology and cervicography in 1,709 patients (1,447 seen for routine screening, 82 for follow-up after treatment for cervical neoplasia and 180 referred because of cytologic anomalies) were correlated with colpohistologic findings. RESULTS: Cervicography entailed more defective examinations than did cytology (8.9% vs. 0.2%, P

OBJECTIVE: To compare the cytologic history of patients with cervical cancer with that of patients with high grade cervical intraepithelial neoplasia (CIN) in order to analyze the causes of screening failure. STUDY DESIGN: In 337 patients treated for high grade CIN and 86 women treated for cancer of the cervix, all cytologic reports from the last five years before diagnosis were reviewed, and slides of normal smears taken within three years of diagnosis were reexamined. RESULTS: Among patients with cancer, 32/86 (37.2 %) never had a smear, for 28/86 (32.6%) the time interval between screenings was greater than three years, 12/66 (18.2%) were incorrectly managed after the first abnormal smear, and 7/69 (10.1 %) had a normal smear within three years of diagnosis. Conversely, among patients with high grade CIN, 45/337 (13.4%) never had a smear, 60/337 (17.8%) had a time interval between screenings greater than three years, 120/337 (35. 6%) were incorrectly managed after the first abnormal smear, and 100/333 (30.0%) had a normal smear within three years of diagnosis. When compared with high grade CIN, cancer of the cervix was associated with absent or insufficient screening (adjusted odds ratio [aOR] = 3.28, 95% confidence interval (95% CI) = 1.86-5.80) but neither with incorrect management of the first abnormal smear (aOR = 1.32, 95% CI = 0.46-3.75 nor with a normal smear within three years of diagnosis (aOR = 0.22, 95% CI = 0.10-0.50). CONCLUSION: Better participation of patients is necessary to improve the efficacity of screening. Conversely, reducing the interval between smears to less than three years would cause a major increase in cost and earlier diagnosis of high grade CIN, but not a significant decrease in the number of cancers.

To compare the results of colposcopically directed biopsy with the final diagnosis established by the analysis of the surgical specimen, and to determine the clinical and colposcopic factors on which the reliability of biopsy is based.Five hundred and sixty-seven women were seen by the same colposcopist who also performed the directed biopsies and/or the endocervical curettage. The final histological diagnosis identified 29 normal aspects (5.2%), 58 low-grade cervical intraepithelial neoplasias (CIN) (10.2%), 448 high-grade CINs (79.0%), 16 microinvasive cancers (2.8%) and 16 occult invasive cancers (2.8%). The influence of several factors--such as age, parity, menopause, pregnancy, history of cervical treatment, site of the squamocolumnar junction, localization, size and severity of the lesions--on the pertinence of the biopsy was studied in a uni- and multifactorial analysis.Colposcopy was satisfactory in 399 patients (70.4%) in whom the colposcopic aspect was consistent with the final histological diagnosis in 81.2% of cases. The global agreement between biopsy diagnosis and final diagnosis was observed in 89.6% of cases. It was 84.2% for low-grade CINs, 95.8% for high-grade CINs, 31.2% for microinvasive cancers and 81.2% for invasive cancers. No clinical or colposcopic factor could be identified as independent factor associated with the diagnostic agreement with the directed biopsy. Conversely, concordance of biopsy was related to the final diagnosis since the only independent risk factors were a high-grade CIN (adjusted risk ratio (ARR)=1.52, 95% CI=1.11-2.08; p=0.006) and a microinvasive or invasive cancer (ARR=0.56, 95% CI=0.39 0.81; p=0.002).To ensure that a microinvasive cancer has not been overlooked, the excision of high-grade CINs seems to be justified, whatever the clinical status and the colposcopic aspect.

One of the possible mechanisms responsible for pre-eclampsia is a loss of efficiency of the L-arginine-nitric oxide pathway with subsequent inactivation of the guanylyl cyclases of the vascular smooth muscle cells. As a result there should be a decrease in plasma cyclic 3'-5' guanosine monophosphate (cGMP) concentrations in pre-eclampsia. We assessed the behavior of this nucleotid in the plasma of pre-eclamptic women.Sixteen pre-eclamptic women, 16 normotensive pregnant women matched for gestational age and six nonpregnant controls were investigated. Arterial blood pressure was recorded at inclusion time and then once-a-day until the fourth day after delivery concomitantly with the collection of blood samples for determining plasma cGMP, atrial natriuretic peptides (ANP), creatinine, uric acid and platelet counts. Also 24 h urines were simultaneously collected to calculate renal clearance of cGMP.Before the initiation of antihypertensive treatment, plasma cGMP levels were significantly higher (p0.01) in pre-eclampsia women as compared both to pregnant normotensive controls and nonpregnant women (7.02 +/- 0.9 versus 4.8 +/- 0.76 versus 1.93 +/- 0.15 pmol.ml-1, p0.01). Under antihypertensive treatment, cGMP levels decreased significantly (p0.05) to 5.48 +/- 0.9 pmol.ml-1. The increase of plasma cGMP was associated with high ANP levels; the likelihood that a renal impairment could account for an increase in plasma cGMP was ruled out because the clearance of creatinine was not impaired. Similarly the possibility of a significant linear correlation between cGMP levels and blood pressure values or biological data was excluded in these women.Plasma cGMP concentrations are increased in pre-eclampsia. They decrease to control values when blood pressure returns to normal values; they indicate enhanced guanylyl cyclase activation by ANP and additional factors, but cannot be considered as a direct index of the severity of pre-eclampsia.

We report the prenatal diagnosis of a hepatic hemangioma presenting as a heterogeneous mass (6 x 5 cm) of the fetal liver, thickly septated with calcifications. Pulsed Doppler confirmed the vascular pattern of the mass. Subsequent postnatal examinations and follow-up have documented the spontaneous regression of this benign tumor. Antenatal diagnosis of fetal liver masses and management after delivery are discussed.

An ELISA method was used to detect IgG and IgA directed against a synthetic peptide derived from the E2 ORF of the human papillomavirus (HPV) 16 in sera and in cervico-vaginal secretions from 20 women without evidence of HPV infection and from 41 women with histological diagnosis of HPV infection. The proportion of IgA positive sera (63.4% in the case-group vs. 20.0% in the control-group) and secretions (48.8% in the case-group vs. 15.0% in the control-group) was significantly higher in women with HPV infection and seemed to increase with the severity of the cervical lesion. Such a difference was not found for specific IgG. Comparing, for each patient, the antibody level in the serum and in the secretions, we found that the amount of IgA was at mean 2.4 times higher in the sera than in the secretions.

Objective: To compare the efficacy and cost-effectiveness of two reminding strategies addressed to women who did not respond to a first invitation to undergo cervical cancer screening. Study Design: A randomized study was carried out by a programme created in Alsace to organize cervical cancer screening. In total, 10,662 women who did not have a smear test 1 year after a first notice was sent, were randomly allocated to receive either a new letter with a reply coupon or a telephone call. The uptake of screening was measured using routine data. Efficacy and direct costs of the two methods were compared. Results: Uptake at 8 months was 6.3% [95% confidence interval (CI) 5.6–7.0%] for telephone calls and 5.8% (95% CI 5.2–6.4%) for letters. The difference was not significant. More information was collected through telephone calls than by letters, but with less reliability. Furthermore, telephone calls were more costly. Conclusions: We found that in our region, a mail reminder was as effective as, and less expensive than, a telephone call; moreover, it was applicable to the whole population, including patients without a telephone.

International audience; OBJECTIVE: We sought to evaluate the safety and efficacy of TG4001 in patients with human papillomavirus (HPV) 16-related cervical intraepithelial neoplasia (CIN) 2/3 at 6 and 12 months. STUDY DESIGN: In all, 21 patients with HPV 16-related CIN 2/3 received 3 weekly subcutaneous injections of TG4001. Regression of the CIN 2/3 lesion and the clearance of HPV 16 infection were monitored by cytology, colposcopy, and HPV DNA/messenger RNA (mRNA) detection. A clinical response was defined by no CIN 2/3 found on conization, or no conization performed because not suspected at cytology or colposcopy. RESULTS: Ten patients (48%) were evaluated as clinical responders at month 6. Nine patients experienced an improvement of their HPV 16 infection, by mRNA ± DNA eradication. HPV 16 mRNA clearance was associated with CIN 2/3 cytologic and colposcopic regression in 7 of 10 patients. At month 12, 7 of 8 patients without conization reported neither suspicion of CIN 2/3 relapse nor HPV 16 infection. The remaining patient was lost to follow-up. CONCLUSION: These promising data warrant further development of TG4001 in CIN 2/3 treatment.

Because of the natural history of precancerous cervical lesions, cancer of the cervix uteri is easily preventable by screening. Pap smear is an effective and simple test, not very expensive and harmless. In France, 3000 to 3500 new cases still occur every year especially due to insufficient participation of the target population but also because of low sensibility of the test and problems in the management of cytological abnormalities. Organisation of screening, following the Alsatian model, which has been operational for 15 years, would be a cost-effective strategy. Changing Pap smear for HPV testing needs careful assessment by national population based randomized studies before any routine use.