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Sir, Safety issues surrounding reimplantation of ovarian tissue retrieved at the time of a cancer diagnosis have been a cause of concern for many years.1-3 Here, we report a case of a central nervous system (CNS) primitive neuroectodermal tumor (PNET) relapse 6 years after ovarian tissue transplantation. In 2001, a 17-year-old patient was diagnosed with supratentorial PNET on the right orbitofrontal lobe of the cerebrum and underwent two operations for tumor removal. Prior to adjuvant chemotherapy, ovarian tissue biopsy and cryopreservation by slow-freezing were carried out, and no malignant cells were detected in the retrieved ovarian tissue. Follicle density (primordial follicles/mm3) was 55.7 ± 14.6 (SD). [...]

Summary Reimplantation of cryopreserved ovarian tissue (OT) can successfully restore ovarian function in young cancer patients after gonadotoxic treatment. However, for patients with leukaemia, there is a risk of malignant cell transmission. Our objective was to evaluate minimal disseminated disease in OT from leukaemia patients and test a follicle isolation technique to obtain disease-free follicle suspensions. Cryopreserved OT from 12 leukaemia patients was thawed and analysed by histology and long-term xenografting in immunosuppressed mice. In 10 patients, follicles were isolated from OT, and polymerase chain reaction (PCR) was performed on tissue, digested ovarian suspensions and isolated follicle suspensions to investigate leukaemic cell presence. Mean patient age was 17·1 years. An average of 3·2 follicles were isolated per mm² of cortex. Xenografting of OT induced leukaemic masses in 2/12 mice. PCR identified leukaemic cell presence in 66% of OT. Malignant cells were also detected in digested ovarian suspensions. However, none of the follicle samples (>2300 follicles tested) showed any malignant cell presence after washing. This study demonstrates that it is possible to recover large numbers of viable follicles from cryopreserved OT of leukaemia patients. All isolated and washed follicle suspensions tested negative for leukaemic cells, giving leukaemia patients genuine hope of fertility restoration.

The intraperitoneal biocompatibility of PDMS, polyHEMA and pEVA was investigated in rats, rabbits and rhesus monkeys. No inflammation was evidenced by hematological analyses and measurement of inflammatory markers throughout the experiment and by post-mortem examination of the pelvic cavity. After 3 or 6 months, histological analysis revealed fibrous tissue encapsulating PDMS and PEVA implants in all species and polyHEMA implants in rabbits and monkeys. Calcium deposits were observed inside polyHEMA implants. The intraperitoneal biocompatibility of all 3 polymers makes them suitable for the design of drug delivery systems, which may be of great interest for pathologies confined to the pelvic cavity.

Several options are currently available for the preservation of fertility in cancer patients: embryo cryopreservation, oocyte cryopreservation or ovarian tissue cryopreservation. The choice of the most suitable strategy for preserving fertility depends on different parameters: the type and timing of chemotherapy, the type of cancer, the patient's age and the partner status. Cryopreservation of ovarian tissue is the only option available for prepubertal girls and woman who cannot delay the start of chemotherapy. So far, 15 live births have been obtained after orthotopic transplantation of cryopreserved ovarian tissue.

The aim of this study was to evaluate the complication rate after total and subtotal laparoscopic hysterectomy for benign disease performed by the same surgeon after an adequate learning curve. We conducted a prospective evaluation of complications in a continuous series of 400 women undergoing laparoscopic subtotal hysterectomy (LASH) or total laparoscopic hysterectomy (TLH) between October 2005 and January 2009. In the LASH group (n = 148), both the minor and major complication rates were 1.35% (n = 2; n = 2), whereas in the TLH group (n = 252), the rate was 1.59% for major complications (n = 4) and 0% for minor complications, clearly confirming that laparoscopic hysterectomy is safe in experienced hands, especially in terms of urinary tract injuries.

PROBLEM: Intercellular adhesion molecule-1 (ICAM-1) is thought to play an important role in pathophysiological processes in endometrial tissue. The aim of this study was to quantify and compare the expression of ICAM-1 mRNA and protein in cultured endometrial epithelial cells (EEC) versus endometrial stromal cells (ESC). METHOD OF STUDY: EEC and ESC were isolated from human endometrium and cultured. At confluency, ICAM-1 mRNA was measured by real-time reverse transcriptase-polymerase chain reaction, the membrane-bound form (mICAM-1) by immunocytodensitometry, and the soluble form (sICAM-1) by enzyme-linked immunosorbent assay. RESULTS: At the transcriptional level, we observed a 1.7-fold increase in ICAM-1 expression in EEC versus ESC. mICAM-1 immunostaining in EEC [cell-relative membrane-bound signal-specific optical density (CR-M-SOD): 0.056 +/- 0.05] was stronger (P < 0.05) than in ESC (CR-M-SOD: 0.009 +/- 0.07). EEC were found to secrete more (P < 0.01) sICAM-1 ([sICAM-1] = 15.59 +/- 2.96 ng/mL) than ESC ([sICAM-1] = 5.14 +/- 2.61 ng/mL). CONCLUSIONS: Cultured EEC constitutively express significantly more ICAM-1 mRNA and protein than ESC.

Setting Three surgical units were involved in a prospective comparative study: the Pavillon Paul Gelle in Roubaix, France for vaginal hysterectomies; the Hotel Dieu Polyclinic in Clermont-Ferrand, France for total percoelioscopic hysterectomies; and the Saint-Luc Clinic in Brussels, Belgium for subtotal percoelioscopic hysterectomies. Patients and Methods The inclusion criteria were age (38-55 years old), the patients were either not menopausal or else they had received alternative therapies for menopause, and had mild uterine pathology with or without castration signs, but without pelvic pain. The vaginal or coelioscopic approach had to be practicable. Those patients with psychiatric histories, or with prolapses or stress incontinence which demanded surgery were excluded. Contraindications to any of the approaches (uterine volume larger than umbilicus, major previous pelvic surgery, severe endometriosis and virginity) were also considered to be exclusion criteria. A total of 82 patients who had undergone 31 vaginal hysterectomies, 31 total coelioscopic hysterectomies and 20 subtotal coelioscopic hysterectomies were followed up 1 year after the operation. Results The population characteristics in the three groups were similar. Operating times were 70.8 min for vaginal hysterectomies (VH), 67.6 min for total percoelioscopic hysterectomies (TPCH) and 111.5 min for subtotal percoelioscopic hysterectomies (SPCH). The mean hospital stay was comparable in the three groups. The mean uterine weight was 225 g for the VH group, 281 g for the TPCH and 206.5 g for the SPCH group (P was not significant). The pain evaluation scales used by the patients during their hospital stay did not show any significant difference between the three groups. The mean times before patients could walk, return to work or resume sexual intercourse showed no significant differences between the groups. Mild urinary signs were reported in the mid-term without any significant difference. Physical activity improved in 38.7% of the patients who had undergone VH, in 46.6% who had undergone TPCH and in 60% who had undergone SPCH (Pnot significant). Those patients who had undergone SPCH resumed satisfactory sexual intercourse significantly earlier (P = 0.0002). Intercourse was not significantly modified in the three groups. Quality of life was generally and significantly improved for 80.6%,96.5% and 70%, respectively, of the patients in the VH, TPCH and SPCH groups. Conclusion Although some surgical teams are still reluctant to practise coelioscopic hysterectomies, all three hysterectomy types were finally demonstrated to be equivalent in this study. They were proved to be feasible even in patients with a large uterus. Operating times are no longer unfavourable factors when coelioscopies are performed by highly skilled surgeons.

The concept that peritoneal endometriosis, ovarian endometriosis and adenomyotic nodules of the rectovaginal septum are three different entities has been clearly demonstrated by Nisolle & Donnez in 1997. In other words, peritoneal and ovarian endometriosis are diseases of the intraperitoneal space while the adenomyotic rectovaginal nodule is a retroperitoneal disease. If we agree that the most widely accepted theory, the transplantation theory, proposed by Sampson in 1927, can explain the pathogenesis of peritoneal endometriosis, there is strong evidence of an extraperitoneal origin for the adenomyotic nodule. We suggest that the retroperitoneal space should be definitely considered to be the origin of this adenomyotic disease, and the concept of deeply infiltrating endometriosis should be finally abandoned.

Objective To determine the efficacy and the safety of a combined laparoscopic and vaginal approach to the management of genital prolapse. Design,A retrospective case series. Setting Gynaecological unit of a university hospital. Subjects 45 women with total genital, cervical or vaginal prolapse examined between November 1995 and November 1997. Interventions All the patients underwent a simple combined vaginal and laparoscopic technique. A polypropylene mesh was attached to the posterior part of the cervix: or the vaginal vault and the body of the first sacral or fifth lumbar vertebra. A tacking device (Origin Tacker System) was used. Results Follow up ranged from 6 to 30 months. Combined vaginal and laparoscopic surgery was faster than laparotomy and use of the tacking technique provided an easy, quick and effective fixation of the mesh to the vertebra in all cases but one. There was one recurrence due to inappropriate fixation of the mesh to the cervix. In another case, the vault was well fixed but an enterocele appeared 1 month later and required classical vaginal management. One serious complication (sciatic nerve compression) was caused by inappropriate tacking of one coil. Conclusion Our results suggest that a combined vaginal and laparoscopic sacrofixation approach can be an effective and quick alternative for prolapse therapy.

OBJECTIVE: Laparoscopic procedure with excision of deep fibrotic endometriotic nodules of the rectovaginal septum and histological study of the lesions. SETTING: An academic teaching hospital. PARTICIPANTS: A series of 500 women undergoing laparoscopy for pelvic pain or infertility. RESULTS: Laparoscopic (n = 497) and laparotomic (n = 3) excision of endometriotic nodules resulted in considerable pain relief. Histologically the rectovaginal nodule was similar to an adenomyoma as it was a circumscribed nodular aggregate of smooth muscle and endometrial glands and stroma. The variations in oestrogen receptor and progesterone receptor content suggested a regulatory mechanism different from that of eutopic endometrium. CONCLUSION: This form of disease should be considered as an entity distinct from peritoneal and ovarian endometriosis, and originating from the Mullerian rests present in the rectovaginal septum.

Morphological and morphometric data showed similarities between eutopic endometrium and red peritoneal lesions, suggesting that these lesions are the first stage of early implantation of endometrial glands and stroma. An inflammatory reaction provokes scarification and the lesions become black. The subsequent fibrosis leads to areas of white opacification which are probably inactive. Three different types of ovarian endometriosis were described: superficial haemorrhagic lesions; haemorrhagic cysts, and deeply infiltrating ovarian endometriosis. We showed that the mesothelium covering the ovary can invaginate in the ovarian cortex pushing back the primordial follicles. These mesothelial invaginations were in a continuum with endometriotic tissue, strongly suggesting the metaplasia theory as an explanation for the pathogenesis of ovarian endometriomas. Endometriotic rectovaginal nodules were histologically similar to adenomyomas, consisting of smooth muscle hyperplasia with active glandular epithelium and scanty stroma. Immunocytochemical results showed the poor differentiation and the hormonal independence of these lesions and indicated a close relationship with their mesodermal Mullerian origin. These three types of lesions, peritoneal, ovarian and rectovaginal, must be considered as three different entities with different pathogeneses.

Endometriosis most commonly affects the pelvic peritoneum close to the ovaries, including the uterosacral ligaments, the ovarian fossa peritoneum, and the peritoneum of the cul-de-sac. The increased diagnosis of endometriosis at laparoscopy can be explained by the increased experience and ability of the surgeon to detect such subtle lesions. The greatest change has been in the case of “subtle” lesions, which increased from 15% in 1986 to 65% in 1988. The diagnosis of peritoneal endometriosis at the time of laparoscopy is often made by the observation of typically puckered black or bluish lesions. There are, in addition, numerous subtle appearances of peritoneal endometriosis. These lesions, frequently nonpigmented, were diagnosed as endometriosis following confirmation by biopsy by Jansen and Russell in 1986.