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A higher risk of human papillomavirus (HPV)-related cervical intra-epithelial neoplasia (CIN) is suspected among females with cystic fibrosis (CF).We conducted a single center prospective cohort study among females attending the Lyon adult CF center. We performed a cervical cytology (Hologic Thinprep®) and HPV testing with genotyping (Clinical Arrays Papillomavirus; Genomica, enabling 35 genotype detection, 20 of which are high-risk (HR-HPV)) at inclusion. We followed all females with positive HPV tests at 6, 12 and 24 months to evaluate HPV persistence, and performed a colposcopy in cases of abnormal cytology.We included eighty-five participants, 18 (21%) of whom were lung-transplanted. The mean age at inclusion was 31.9 (range 18-59) years. The prevalence of HPV (all types) was 31.8%. HR-HPV was found in 25.9% of the whole cohort, 44.4% of transplanted patients, and 20.1% of nontransplanted patients. Genotype-specific HR-HPV persistence at 12 months was 43.5% among transplanted and 34.6% among nontransplanted patients. Overall, 17.6% (15/85) of females had an abnormal cytology: 44.4% (8/18) among transplanted and 10.4% (7/67) among nontransplanted patients. CIN was identified in 12 (14.1%) patients (6 low-grade, 6 high-grade). High-grade CIN developed in 4 nontransplanted patients.Transplanted females had high HR-HPV, abnormal cervical cytology and CIN prevalence rates compared to large published cohorts in the general non-CF population. Although HR-HPV prevalence and persistence were globally not significantly different in nontransplanted females compared to the general population, we reported high frequencies of abnormal cytology and CIN. Cervical cancer screening and prevention should be promoted among females with CF.

In France, we are lacking an identified pathway for training in gynaecological cancer surgery. The four competent French learned societies, the SFOG, the CNGOF, the SFCO and the SCGP, supported by the CNU of ObstetricsGynaecology- and UNICANCER, agreed to materialize this course and attest it by a certification awarded by a national jury.The national committee of certification in gynaecological oncology made up of 10 members, representing the 6 concerned organizations, set itself 5 objectives: the definition of the eligibility criteria for training centres; the determination of a check-list to be filled by the candidate; the determination of a targeted curriculum for the training in gynecological oncological surgery; the determination of the assets necessary for the certification of a candidate already in practice; and the practical organization of the certification.Criteria for approval of centres for training included 150 gynaecological cancer cases per year, among which 100 excisional surgeries, including 20 advanced-stage ovarian cancers. For certification of candidate who followed the curriculum established by the committee or by validation of prior experience for an actual practitioner, a candidate must validate a logbook and fill out a checklist including 4 parts: theoretical and practical training; research and publications; teaching and subscription to a continuing education program. The accomplished elements of the logbook and the checklist will be evaluated by a score. The first certification session is planned for the end of 2021.The optimisation of the surgical management of patients treated for gynaecological cancer is achieved through the identification of a training course and the certification, by a national jury, of the skills of surgeons who have completed it.

To draw up recommendations on the use of prophylactic gynecologic procedures during surgery for other indications.A consensus panel of 19 experts was convened. A formal conflict of interest policy was established at the onset of the process and applied throughout. The entire study was performed independently without funding from pharmaceutical companies or medical device manufacturers. The panel applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system to evaluate the quality of evidence on which the recommendations were based. The authors were advised against making strong recommendations in the presence of low-quality evidence. Some recommendations were ungraded.The panel studied 22 key questions on seven prophylactic procedures: 1) salpingectomy, 2) fimbriectomy, 3) salpingo-oophorectomy, 4) ablation of peritoneal endometriosis, 5) adhesiolysis, 6) endometrial excision or ablation, and 7) cervical ablation.The literature search and application of the GRADE system resulted in 34 recommendations. Six were supported by high-quality evidence (GRADE 1+/-) and 28 by low-quality evidence (GRADE 2+/-). Recommendations on two questions were left ungraded due to a lack of evidence in the literature.A high level of consensus was achieved among the experts regarding the use of prophylactic gynecologic procedures. The ensuing recommendations should result in improved current practice.

This study aimed at assessing perioperative results of robot-assisted laparoscopy (RAL) in the context of deep infiltrating endometriosis (DIE).This retrospective French multicentric study included all patients with DIE who underwent surgical treatment managed by RAL (Da Vinci® System). From November 2008 to June 2019, patients were included in a single European database, in Robotic Assisted Laparoscopic Gynecologic Surgery, with Society of European Robotic Gynecological Surgery collaboration. Patients had different DIE sites as follows: gynecological, urological, or digestive, or combinations of these. Surgical procedures and perioperative complications were evaluated. To assess complications, patients were divided into the following four groups according to surgical procedure and DIE site: gynecological only; gynecological and urological; gynecological and digestive; and gynecological, urological, and digestive.A total of 460 patients treated at one of eight health-care facilities from November 2008 to June 2019 were included. Median operative time was 245 min (IQR 186-320), surgeon console time was 138 ± 75 min and estimated blood loss was 70.0 mL ± 107 mL. Among this patient sample, 42.1% had a multidisciplinary surgical approach with a digestive or urology surgeon in addition to gynecology surgeon (25.5% and 16.6% of cases, respectively). Among those with intraoperative complications (n = 25, 5.4%) were primarily conversion to laparotomy (n = 6, 2.0%), transfusion (n = 2, 0.6%), and organ wounds (n = 8, 1.7%). Overall, 5.6% had severe postoperative complications (Clavien-Dindo classification ≥ Grade 3).This is among the largest published series addressing RAL for DIE. Interest in this procedure appears promising, with no observed increases in blood loss or in peri- or post-operative complications. DIE laparoscopic surgery can require complex surgical procedures performed by multidisciplinary surgical teams. Thus, it may be one of the best candidates for RAL within gynecology surgery.

Objective The exceptional health situation related to the Coronavirus 2019 (COVID-19) pandemic has required an in-depth and immediate reorganisation of gynaecological cancer care. The main objective was to assess the psychological impact of such treatment modifications during the lockdown period for gynaecological and breast cancer patients. Patients and methods A multicentre prospective study was conducted in three university gynaecological cancer wards (Hospices Civils de Lyon, France) during the French first lockdown (16th March to 11th May 2020). All patients with non-metastatic breast cancer or gynaecological cancer were included. Data was collected regarding treatment modifications (delay, cancellation, change of therapeutic plan). The psychological impact of treatment modifications during and after the lockdown was assessed by validated questionnaires (SF-12, EORTC-QLQ-C30, HADS). Results A total of 205 consecutive patients were included, aged 60.5 ± 1.0 years. Seven patients (3.4%) presented a SARS-CoV-2 infection, and two patients died. Treatment was maintained for 122 (59.5%) patients, postponed for 72 (35.1%) and cancelled for 11 (5.4%). During the lockdown, 35/118 (29.7%) patients suffered from confirmed anxiety and the mean fatigue-EORTC score was 48.00 ± 2.51; it was 38.64 ± 2.33 (p = 0.02) after the lockdown. After the lockdown and compared to the lockdown period, the mental SF-12 score and overall health status EORTC score were significantly higher (45.03 ± 1.06 vs 41.71 ± 1.15, p = 0.02 and 64.58 ± 1.66 vs 57.44 ± 2.02, p = 0.0007, respectively). The number of confirmed-anxiety cases was significantly higher amongst patients for whom treatment was delayed or cancelled (40.5% vs 23.7%, p = 0.04). Conclusion This study quantified the treatment modifications of gynaecological cancer patients during the COVID-19 lockdown and revealed a poorer psychological state and quality of life during this period, even for patients whose treatment plan was not actually modified. Anxiety was more significant in patients with a delayed or cancelled treatment.

Resume Objectif Elaborer un consensus d’experts concernant l’utilisation des estrogenes locaux dans l’incontinence urinaire feminine. Materiel et methode Suivant une methode de consensus formalise (DELPHI), un questionnaire a ete realise et envoye a un premier tour puis a un second tour d’experts. Le questionnaire etait compose de propositions de recommandation d’utilisation des estrogenes locaux dans le cadre de l’incontinence urinaire feminine. Le logiciel de sondage Survey Monkey ® a permis la diffusion du questionnaire et l’analyse des reponses obtenues. Resultats Huit experts ont repondu au questionnaire du premier tour. Sept formulations ont ete supprimees, 3 modifiees et 4 ajoutees au questionnaire du premier tour apres avis des experts. Vingt-six experts ont repondu au questionnaire du second tour dont 24 reponses completes. Dix des 21 propositions etaient approuvees a plus de 80 % dont 5 avec un accord fort qui concernaient le benefice reconnu des estrogenes locaux dans l‘incontinence urinaire par hyperactivite vesicale, l’absence de donnees de la litterature permettant de mettre en evidence un sur-risque de cancer hormonodependant sous estrogenes locaux et la necessite d’un suivi des patientes sous ce traitement. Six propositions ne faisaient pas l’objet d’un consensus et concernaient les modalites de prescription (duree maximale, dose minimale efficace, prescription avant chirurgie d’incontinence). Conclusion Bien que les estrogenes locaux n’aient pas d’AMM dans l’incontinence urinaire, plus de 80 % de ces experts reconnaissaient leur benefice dans la prise en charge d’une incontinence urinaire chez la femme presentant une atrophie vulvo-vaginale, plus particulierement dans le cas d’une incontinence urinaire par imperiosites. Niveau de preuve 4.

Resume Les tumeurs du site d’implantation trophoblastique sont des tumeurs gestationnelles rares. Ce cas clinique met en relief les difficultes diagnostiques et de traitement des tumeurs du site d’implantation trophoblastique de stade precoce. Patiente de 28 ans sans antecedent, G1P1 ayant accouche 11 mois auparavant a presente des metrorragies avec un taux d’HCG a 73 UI ayant conduit au diagnostic de fausse couche precoce. Le traitement de la fausse couche par hysteroscopie et curetage se complique menant a la realisation d’un scanner abdomino-pelvien et d’une echographie pelvienne qui montrent une hypervascularisation uterine atypique et une image intracavitaire heterogene. L’IRM pelvienne realisee evoque une tumeur du site d’implantation du trophoblaste de stade I. Une hysterectomie avec salpingectomie bilaterale et conservation ovarienne est realisee. Malgre le traitement standard par chirurgie le taux d’HCG ne se normalise pas avant sept mois postoperatoires. Ceci indique une chimiotherapie adjuvante que la patiente refuse. Le cas presente illustre les difficultes diagnostiques de la maladie. Il releve l’importance du reseau de seconde lecture propose par le centre de reference de maladie trophoblastique de Lyon. Il pose egalement le probleme de la chimiotherapie adjuvante dans certains cas de tumeur du site d’implantation trophoblastique de stade precoce. La difficulte est de definir les cas necessitant un traitement adjuvant. Les facteurs predictifs de chimiotherapie dans les stades precoces pourraient etre la taille tumorale, le degre d’infiltration du myometre et la mutation p53. Amenorrhee, metrorragies associees a une vascularisation atypique uterine, et evolution atypique des HCG

Cancer of the uterine cervix is the fourth most common cancer in women worldwide, and the fourth leading cause of cancer death in women. Squamous cell carcinoma is the first type of cervical cancer (about 75% of cases), and adenocarcinoma the second. Adenocarcinoma of the uterine cervix were redefined in the 2014 WHO classification. Endocervical adenocarcinoma, usual type, is the mose common. Mucinous adenocarcinoma were classified by this classification into different subtypes: gatric type, intestinal type and signet-ring cell type. This literature review shows the caracteristics of these various subtypes of cervical cancer, little known. These are physiopathological, clinical, cytological histological, pronostic caracteristics, and their treatments.

Adjuvant chemotherapy with carboplatin and paclitaxel is recommended for all high-grade ovarian or Fallopian tube cancers, stage FIGO I-IIA (grade A). After a complete first surgery, it is recommended to deliver 6 cycles of intravenous (grade A) or to propose intraperitoneal (grade B) chemotherapy, to be discussed with patient, according to the benefit/risk ratio. After a complete interval surgery for a FIGO III stage, the hyperthermic intra peritoneal chemotherapy (HIPEC) can be proposed in the same conditions of the OV-HIPEC trial (grade B). In case of tumor residue after surgery or FIGO stage IV, chemotherapy associated with bevacizumab is recommended (grade A). For BRCA mutated patient, Olaparib is recommended (grade B).

Faced to an undetermined ovarian mass on ultrasound, an MRI is recommended and the ROMA score (combining CA125 and HE4) can be proposed (grade A). In case of suspected early stage ovarian or fallopian tube cancer, omentectomy (at least infracolonic), appendectomy, multiple peritoneal biopsies, peritoneal cytology (grade C) and pelvic and para-aortic lymphadenectomy are recommended (grade B) for all histological types, except for the expansive mucinous subtype where lymphadenectomy may be omitted (grade C). Minimally invasive surgery is recommended for early stage ovarian cancer, if there is no risk of tumor rupture (grade B). Laparoscopic exploration for multiple biopsies (grade A) and to evaluate carcinomatosis score (at least using the Fagotti score) (grade C) are recommended to estimate the possibility of a complete surgery (i.e. no macroscopic residue). Complete medial laparotomy surgery is recommended for advanced cancers (grade B). It is recommended in advanced cancers to perform para-aortic and pelvic lymphadenectomy in case of clinical or radiological suspicion of metastatic lymph node (grade B). In the absence of clinical or radiological lymphadenopathy and in case of complete peritoneal surgery during an initial surgery for advanced cancer, it is possible not to perform a lymphadenectomy because it does not modify the medical treatment and the overall survival (grade B). Primary surgery is recommended when no tumor residue is possible (grade B).

Diagnosis and treatment of endometriosis may be complex and therefore justify the discussion of therapeutic decisions in a multidisciplinary endometriosis board (MEB). The development of endometriosis regional expert centers requires an assessment of the quality and relevance of MEB.Qualitiative retrospective study on patients whose management was discussed in Centre Hospitalier Lyon-Sud between June 2013 and December 2017.Among 376 patients presented in MEB, 309 (80.2%) were painful and 184 (59.5%) had complex endometriosis. A complete clinical evaluation was performed in 120 (38.8%) patients. MRI was performed for 370 (98.4%) patients including 303 (81.9%) with a second reading by an expert radiologist. These second readings allowed a diagnosis correction in 88 (60.7 %) patients with complex endometriosis. MR enterography (27.8 %) and rectal endoscopic sonography (14.4%) were the most frequently used third-line exams to complete the initial imaging of digestive lesion in patients with rectal endometriosis. Surgery was proposed for 199 (52,9%) patients including 108 (58,7%) with complex endometriosis.One of the major interests of MEB in endometriosis is the second reading of MRI, which, by identifying complex endometriosis initially undiagnosed or underestimated, enabled to better discuss the benefits/risks of therapeutic choices, and to organize complex surgeries when those were retained. The development of MEB in regional expert centers will contribute to optimizing the relevance of care for patients with endometriosis.

Resume Objectifs L’examen extemporane du ganglion sentinelle (GS) dans le cancer du sein permet de realiser un curage axillaire, si necessaire, dans le meme temps operatoire et d’organiser les traitements adjuvants sans delai. Neanmoins, la frequence de l’envahissement ganglionnaire est relativement faible et le taux de faux-negatifs est non negligeable, ce qui pose la question de l’interet de l’examen extemporane. L’objectif de cette etude etait d’analyser la frequence des cas ou l’examen extemporane a apporte un benefice pour la prise en charge therapeutique des patientes. Methodes Etude retrospective, monocentrique sur 293 patientes presentant un cancer du sein pT1 ou pT2, ayant beneficie de la technique du GS. Resultats Un total de 289 patientes ont eu un examen extemporane du GS. Le taux de detection peroperatoire etait de 98,6 %. A l’examen extemporane, le GS etait negatif, positif et non realise dans 252 (86 %), 37 (12,6 %) et 4 (1,4 %) cas, respectivement. Au total, cet examen a mis en evidence 48,7 % des GS envahis (37/76). A l’examen definitif, il y avait 17 % de macro-metastases, 5,8 % de micro-metastases et 3 % de cellules tumorales isolees. Le taux de faux-negatifs etait de 13,5 %. Cinquante-huit patientes (19,8 %) ont eu un curage, 39 dans le meme temps operatoire et 19 dans un second temps. Dans 62 % des cas, le curage etait negatif. L’examen extemporane a apporte un benefice therapeutique (realisation d’un curage synchrone) dans 12,8 % des cas. Conclusion L’examen extemporane du GS apporte un benefice limite dans la prise en charge therapeutique des patientes du fait du fort taux de faux-negatifs. La diffusion de l’echographie axillaire preoperatoire pourrait diminuer la sensibilite de l’examen extemporane et remettre en question son interet.

Resume But Evaluer les consequences des nephrectomies laparoscopiques avec extraction vaginale sur la qualite de vie sexuelle. Materiel Depuis 2010, 16 patientes ont beneficie d’une nephrectomie laparoscopique avec extraction vaginale. L’âge moyen etait de 53,8 ans. Toutes les patientes ont eu prealablement un examen gynecologique pour evaluer la faisabilite de l’extraction par cette voie. Afin d’evaluer objectivement la sexualite, un questionnaire de qualite de vie sexuelle, le Female Sexual Function Index (FSFI), etait remis a chaque patiente en pre- puis en postoperatoire. Resultats La duree moyenne de sejour a ete de 2,2 jours (0–5 jours). Quinze patientes (94 %) ont complete le questionnaire FSFI pre- et postoperatoire. Trois patientes n’avaient pas d’activite sexuelle et une etait vierge. Le score FSFI moyen preoperatoire etait de 24,2 et de 24,3 en postoperatoire. Les scores etaient comparables dans chacun des 6 domaines explores par le questionnaire, avec notamment un score de satisfaction preoperatoire de 4,5 contre 4,4 postoperatoire. Nous n’avons pas observe plus de dyspareunies en postoperatoire et il n’etait pas plus difficile d’atteindre l’orgasme apres l’intervention. Il n’existait pas de difference statistiquement significative entre la periode pre- et postoperatoire. Conclusion Ces resultats preliminaires semblent demontrer l’absence de consequences sur la qualite de vie sexuelle de la nephrectomie laparoscopique avec extraction vaginale. Niveau de preuve 5.

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

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

The Collège national des gynécologues obstétriciens français (CNGOF), in agreement with the Société de chirurgie gynécologique et pelvienne (SCGP), has set up a commission in 2017 to define endometriosis expert centres, with the aim of optimizing endometriosis care in France.The committee included members from university and general hospitals as well as private facilities, representing medical, surgical and radiological aspects of endometriosis care. Opinion of endometriosis patients' associations was obtained prior to writing this work. The final text was presented and unanimously validated by the members of the CNGOF Board of Directors at its meeting of October 13, 2017.Based on analysis of current management of endometriosis and the last ten years opportunities in France, the committee has been able to define the contours of endometriosis expert centres. The objectives, production specifications, mode of operation, missions and funding for these centres were described. The following missions have been specifically defined: territorial organization, global and referral care, communication and teaching as well as research and evaluation.Because of its daily impact for women and its economic burden in France, endometriosis justifies launching of expert centres throughout the country with formal accreditation by health authorities, ideally as part of the National Health Plan.

To develop a consensus of experts on the use of local estrogens in female urinary incontinence.Following a formalized consensus method (DELPHI), a questionnaire was produced and sent to a first round and then to a second round of experts. The questionnaire consisted of proposals for recommendations for the use of local estrogens in the context of female urinary incontinence. The Survey MonkeyEight experts responded to the first round questionnaire. Seven formulations were deleted, 3 amended and 4 added to the first round questionnaire following expert advice. Twenty-six experts replied to the second round questionnaire, 24 of which were complete. Ten of the 21 proposals were approved at more than 80%, including five with strong agreement regarding the recognized benefit of local estrogens in urinary incontinence due to overactive bladder, the absence of data from the literature to demonstrate over-risk of hormone-dependent cancer under local estrogens and the need for follow-up of patients under this treatment. Six proposals were not the subject of a consensus and concerned the prescription modalities (maximum duration, effective minimum dose, prescription before surgery for incontinence).Although local estrogens did not have regulatory approval in urinary incontinence, more than 80% of these experts recognized their benefit in the management of urinary incontinence in women with vulvo-vaginal atrophy, particularly in the case of urinary urge incontinence.4.

To assess postoperative complications, improvement of pain symptoms and residual urinary functional symptoms after surgery for deep infiltrative endometriosis affecting ureter or bladder.Retrospective study of complications (Clavien-Dindo classification), pain (visual analog scale [VAS]) and urinary functional symptoms (Urinary Symptom Profile questionnaire [USP]) of patients surgically treated between 2007 and 2015 in University Hospitals of Lyon.Among 31 patients with endometriosis involving the bladder, 83.9% had a partial cystectomy and 16.1% an extra-mucosal resection. Among patients (n=20) with ureteral involvement, 85% had ureterectomy with ureterocystoneostomy and 15% had only ureterolysis. Grade III postoperative complications occurred in 6% and 0% of patients with bladder or ureteral surgery, respectively and no grade IV or V complications were reported. Mean bladder VAS dropped from 5.3±4.2 to 0.3±0.9 after a follow-up of 42 months (P0.0001). In patients with ureteral involvement, mean flank VAS dropped from 3.6 to 0.9 after a follow-up of 33 months (P0.0005). Mean postoperative USP score for dysuria and detrusor overactivity were 1.35/9 and 2.48/21 in case of bladder involvement, and 1.10/9 and 2.15/21 in case of ureteral involvement.Multidisciplinary surgical management of deep infiltrative endometriosis affecting urinary tract was associated to a low risk of severe postoperative complications and to a long-term significant improvement of pain symptoms without significant residual functional urinary symptoms.

Resume Objectif Etudier la faisabilite et rapporter les resultats initiaux de la nephrectomie laparoscopique avec extraction vaginale chez les patientes obeses ou en surpoids. Patientes et methodes Trois patientes ayant un IMC superieur a 28 kg/m 2 ont ete operees. L’âge etait de 51 ; 52 et 65 ans et l’IMC etait de 45,7 ; 57,3 et 28. Les trois patientes avaient un diabete non insulinodependant et une hypertension arterielle (HTA). Deux patientes etaient multipares et une nullipare. Les trois patientes ont subi une nephrectomie laparoscopique standard puis une extraction vaginale de la piece operatoire par une courte incision du cul-de-sac vaginal posterieur. L’alimentation etait normale des le lendemain de l’intervention. Il n’y avait pas de prescription de morphinique dans le service. Resultats Il n’y a pas eu de complication peroperatoire. Les durees d’intervention etaient de 288 ; 188 et 196 minutes. Les pertes sanguines etaient de 200 ; 120 et 100 mL. Les suites postoperatoires ont ete simples, avec une deambulation normale a j1. Les durees de sejour ont ete de deux, trois et cinq jours. Les patientes ont ete revues en consultation un mois plus tard sans evenement particulier avec une reprise normale de leur activite sexuelle. Conclusion La nephrectomie laparoscopique avec extraction vaginale etait une technique realisable chez les patientes obeses ou en surcharge ponderale. La morbidite parietale (infection, eventration) etait diminuee du fait de la petite taille des incisions abdominales.

Resume La majorite des lesions du sein chez l’homme est d’origine benigne. La gynecomastie est une pathologie tres frequente, correspondant a une croissance de la glande mammaire suite a des modifications hormonales. Trois formes radiologiques ont ete decrites : nodulaire, dendritique et diffuse. Son principal diagnostic differentiel est l’adipomastie, correspondant a des depots adipeux dans le tissu sous-cutane. Le cancer du sein chez l’homme est rare. Ses principaux facteurs de risque sont des pathologies responsables de desordres hormonaux, des antecedents d’irradiation thoracique et des antecedents familiaux de cancer du sein (notamment dans les familles porteuses d’une mutation du gene BRCA2 ). La mammographie montre le plus souvent une masse sans calcifications. L’echographie est utile au bilan d’extension local et permet de detecter des adenomegalies axillaires. L’IRM n’a pas actuellement d’indication pour le bilan du cancer du sein masculin. La clinique seule permet le plus souvent de differencier les lesions benignes des lesions malignes. L’imagerie ne doit pas etre realisee de facon systematique mais doit etre reservee aux patients pour lesquels le diagnostic clinique est incertain ou qui presentent des facteurs de risque de cancer du sein, ainsi que pour guider les biopsies et pour le bilan d’extension.

Gestational trophoblastic diseases include placental pathologies comprising fertilization abnormalities (hydatidiform moles) and malignant lesions (choriocarcinoma, placental site trophoblastic tumor and epithelioid trophoblastic tumor). Due to their low incidence and heterogeneity, their diagnosis, management and treatment are not always optimal. Following the example of other European countries, a national registration system with two reference centers has been set up to guide physicians and patients and to propose individualized management. The centers offer their expertise through a systematic centralised pathology review by a panel of experts. HCG values are plotted in regression curves. In case of gestational trophoblastic neoplasia, an imaging work-up is proposed, from which the FIGO score and stage are derived and will guide the choice of treatment. Belgian centers offer a multidisciplinary approach, in partnership with the referent physician. More information for practitioners and patients is available on a web site: www.mole-chorio-bgog.eu, which also harbours a forum of discussion.

Tumors of trophoblast implantation site TTSI are rare gestational tumors. This case highlights the diagnostic difficulties and treatment of tumors of trophoblastic implantation site early. Patient of 28 years with no medical history, G1P1 who gave birth 11 months ago presented bleeding with an HCG level of 73IU that led to the diagnosis of early miscarriage. Treatment of miscarriage by hysteroscopy and curettage is complicated leading to the realization of an abdominopelvic CT and pelvic ultrasound that show an atypical uterine vascularity and an intracavitary heterogeneous mass. The pelvic MRI performed evokes a TTSI stage I. A hysterectomy with bilateral salpingectomy and ovarian conservation is achieved. Despite the standard treatment with surgery the HCG levels do not normalize before seven months after surgery. This indicates an adjuvant chemotherapy, the patient refuses. The presented case illustrates the diagnostic difficulties of the disease. He noted the importance of the second reading network proposed by the specialized center in Lyon. It also raises the question of adjuvant chemotherapy in some cases of early stage TTSI. The challenge is to define cases requiring adjuvant therapy. Predictors of chemotherapy in early stages could be tumor size, degree of infiltration of the myometrium and mutation p53. Amenorrhea, bleeding associated with uterine atypical vascularization, and atypical development of HCG1000IU and/or unusual complications of treatment of miscarriage should evoke a tumor site trophoblastic implantation. Hysterectomy is the first treatment in early stages. Tumor size, degree of infiltration of the myometrium and mutation p53 are predictors to assess in multicentre studies to define the indications of postoperative chemotherapy.

Resume Objectifs Confirmer l’interet du GYN Trainer® (modele d’entrainement a la laparoscopie avec webcam) pour l’apprentissage de la chirurgie laparoscopique. Patients et methode Le modele a ete teste lors de six exercices d’entrainement par dix internes de gynecologie-obstetrique. Un groupe temoin compose de six chirurgiens gynecologues experimentes permettait d’evaluer le score de performance final. Les evaluations ont ete a la fois quantitatives et qualitatives. Resultats L’acquisition totale moyenne etait de 35 % et l’ensemble des donnees montrait l’amelioration globale apportee par l’entrainement pour tous les internes et pour tous les exercices, malgre la perte partielle d’acquisition entre les entrainements estimee a 8 %. Les operateurs etaient globalement satisfaits de l’apport et des qualites techniques de ce modele (3,8/5). Discussion et conclusion Les resultats de ce travail confirment qu’un tel modele permet a des chirurgiens en formation de progresser de maniere significative. Le GYN Trainer® est un outil performant et peu onereux qui permet d’acquerir ou d’ameliorer les gestes de base de la cœlioscopie.

An accidental transmission of placental choriocarcinoma (CC) from a multiorgan donor to four recipients is reported. The donor was a 26-year-old pregnant woman, died from a cerebral hemorrhage. Histological examination demonstrated the presence of a placental CC. Diagnosis of CC transmission was established on the basis of an increase of human chorionic gonadotrophin hormone (hCG) level. The recipient of combined pancreas-kidney is still in complete remission 2 years after the beginning of chemotherapy without removal of the grafted organs which show optimal function. The recipient of a single kidney was rapidly transplantectomized and treated with actinomycin. At 2 years, she remains in remission. Liver recipient showed intestinal metastasis and died from digestive hemorrhage after an initial response to chemotherapy. Heart recipient had an initial remission under EMA-CO, but at the last report, he showed diffuse metastasis. Published reports on CC transmission are rare. The long-lasting remission of our pancreas-kidney recipient and her good outcome after 2 years make our observation original. Moreover, the high rate of transmission demonstrates the high malignant potential of CC in immunosuppressed patients. Chemotherapy combined or not with transplantectomy in case of nonvital organ, should be discussed.

Gestational trophoblastic neoplasia (GTN) comprises a spectrum of malignant tumors derived from the trophoblast including the invasive mole (IM), the choriocarcinoma (CH), the placental site trophoblastic tumor (PSTT) and the epithelioid trophoblastic tumor (ETT). PSTT is a rare entity with less than 300 cases reported and accounts for 1–2% of GTN. Kurman et al. (1976) first described this pathology in 1976 and named it trophoblastic pseudotumor. The malignant potential of PSTT was recognized later, leading to the current nomenclature. It is derived from the intermediate cytotrophoblast. PSTT most often presents with amenorrhea or abnormal bleeding together with uterine enlargement. However, a wide range of other presenting symptoms has been reported such as abdominal pain, uterine rupture and galactorrhea (Gillespie and Hancock, 2009). This slow-growing tumor tends to stay initially in the uterus but more than 30% of patients have metastatic disease at the time of presentation (Schmid et al., 2009). The sites of metastases include the peritoneum, the lung, the liver and the brain. PSTT may follow any gestational event, normal or pathological pregnancy. In a series of 55 cases (Baergen et al., 2006), the diagnosis was made within an interval of 34 months following a previous gestation, mainly affecting women of childbearing age. The prognosis of PSTT depends on the disease's extent (Schmid et al., 2009; Baergen et al., 2006; Feltmate et al., 2001). The outcome of patients treated for early-stage diseases is usually favorable. Hysterectomy is the preferred treatment for women with localized disease. For selected cases, partial myometrectomy may be performed to preserve fertility (Saso et al., 2012). The prognosis drops rapidly when metastatic disease is present. For advanced-stage diseases, a combination of surgery and polychemotherapy is required. We report the case of a patient who develops a recurrence of an ignored PSTT at the vaginal vault diagnosed 8 years after her last pregnancy and 4 years after a hysterectomy for benign condition.

Both laparoscopic techniques (excision and ablation) for the treatment of superficial peritoneal endometriosis are equally effective (EL2). For the treatment of ovarian endometriomas larger than 3 cm, laparoscopic cystectomy is superior to drainage and coagulation (EL1). Excision of deep rectovaginal endometriosis with or without rectal invasion significantly reduces endometriosis-associated pain (EL4). Laparoscopic partial bladder cystectomy is easier for dome endometriosis than vesical base lesions (EL4). Hysterectomy with ovarian conservation is associated with a high risk of pain recurrence (EL4). Despite bilateral oophorectomy, pain recurrence can occur with hormonal treatment (EL2). Rates of major (ureteral, vesical, intestinal or vascular) complications of endometriosis surgery range from 0.1 to 15% of patients. Higher rates are more common with deep endometriosis surgery (EL2). Patients should be aware of these specific major complications. It is advisable to explain that pain improves, either partially or completely, in about 80% of patients.

Resume But de l'etude Le retard de croissance intra-uterin (RCIU) est une pathologie frequemment rencontree en obstetrique et caracterisee par sa grande heterogeneite. L'hypotrophie est parfois constitutionnelle, mais elle peut aussi s'accompagner de souffrance fœtale et de risques vitaux pour l'enfant. Au cours de 35 grossesses compliquees de RCIU d'etiologies diverses, nous avons evalue sur le sang fœtal, preleve par cordocentese, differentes variables biochimiques, temoins de l'etat fonctionnel, respiratoire et metabolique, des fœtus. Le but de l'etude a ete d'identifier les modifications biologiques discriminantes, associees au retard de croissance et a la souffrance fœtale. Patients et methodes La population etudiee comprend 27 cas de RCIU severes, d'âge gestationnel 30,2 ± 4,6 semaines d'amenorrhee (SA) (repartis en 20 cas de RCIU isoles et sept cas de RCIU associes a un syndrome malformatif), ainsi que huit cas de RCIU moderes, d'âge gestationnel 26 ± 4,5 SA ; le caryotype etait normal pour tous les fœtus etudies. Un groupe de 73 fœtus normaux, d'âge gestationnel 26,3 ± 5,7 SA, a constitue une population de reference. Sur le sang veineux ombilical (SVO), ont ete mesures le pH, la pCO 2 , la concentration en bicarbonate, la pO 2 et la SaO 2 , ainsi que la teneur en glucose, pyruvate, lactate, acides gras libres, aceto-acetate, beta-hydroxybutyrate, cholesterol. Resultats Lorsque le retard de croissance est severe, mais isole, l'analyse du SVO a revele la frequence des perturbations acidobasiques et gazometriques : acidemie et hypoxemie dans 65 % des cas, hypercapnie dans 60 % des cas. Des anomalies metaboliques ont ete mises en evidence : diminution de la glycemie (35 % des cas), augmentation de la pyruvatemie et de la lactatemie (40 % des cas), majoration de la concentration serique en acides gras libres ; une diminution de la cholesterolemie veineuse ombilicale a ete constatee chez 70 % des fœtus. En presence d'un RCIU severe associe a un syndrome malformatif, les anomalies acidobasiques et metaboliques du SVO sont peu nombreuses ; la cholesterolemie veineuse ombilicale est cependant diminuee dans quelques cas. Lorsque le retard de croissance a ete classe modere, les modifications sont discretes et essentiellement gazometriques. Conclusion Un risque de souffrance fœtale, lie a une alteration du passage transplacentaire des gaz respiratoires et des substrats nutritifs, est present dans environ 60 % des cas de RCIU severe et isole ; une malnutrition fœtale chronique peut etre mise en cause, ayant des repercussions sur la croissance globale du fœtus. Dans les cas de retard de croissance associe a un syndrome malformatif, l'hypotrophie est vraisemblablement secondaire a une atteinte fœtale intrinseque, sans participation d'origine nutritionnelle.

The objective of the study was to provide guidelines for clinical practice from the French college of obstetrics and gynecology (CNGOF), based on the best evidence available, concerning hysterectomy for benign pathology.Each recommendation for practice was allocated a grade which depends on the level of evidence (guidelines for clinical practice method).Hysterectomy should be performed by a high volume surgeon (10 procedures of hysterectomy per year) (grade C). Rectal enema stimulant laxatives are not recommended prior to hysterectomy (grade C). It is recommended to carry out vaginal disinfection using povidone iodine solution prior to an hysterectomy (grade B). Antibioprophylaxis is recommended during a hysterectomy, regardless of the surgical route (grade B). The vaginal or the laparoscopic routes are recommended for hysterectomy for benign pathology (grade B), even if the uterus is large and/or the patient is obese (grade C). The choice between these two surgical approaches depends on others parameters, such as the surgeon's experience, the mode of anesthesia and organizational constraints (operative duration and medico economic factors). Hysterectomy by vaginal route is not contraindicated in nulliparous women (grade C) or in women with previous c-section (grade C). No specific technique to achieve hemostasis is recommended with a view to avoid urinary tract injuries (grade C). In the absence of ovarian pathology and personal or family history of breast/ovarian carcinoma, it is recommended to conserve ovaries in pre-menopausal women (grade B). Subtotal hysterectomy is not recommended in order to diminish the risk of per- or postoperative complications (grade B).The application of these recommendations should minimize risks associated with hysterectomy.

Intraoperative positive frozen section of sentinel axillary lymph node in breast cancer allows the full node dissection at the same time of the breast surgery and the enhancement of adjuvant therapies with no delay. The low frequency of node involvement and the high rate of false-negative, make consider the value of intraoperative frozen section. The aim of this study was to analyze the potential advantage of intraoperative frozen section performed routinely.Retrospective monocentric study of 293 patients, operated on for stage pT1 or pT2 breast cancer with a sentinel node biopsy (SNB).A total of 289 patients had an intraoperative frozen section of the SNB. A sentinel node was identified in 98.6% of the cases. On intraoperative section, sentinel node was negative, positive or was not performed in 252 (86%), 37 (12.6%) and 4 (1.4%) cases respectively. In total, ibtraoperative frozen sections identified 48.7% of the metastatic SNB (37/76). The metastatic lymph node distribution, after final histological analysis, was as follows: 17% macro metastasis, 5.8% micro metastasis and 3% isolated tumor cells. The false-negatives rate was 13.5%. Fifty-eight patients (19.8%) underwent axillary full lymph node dissection: 39 during a primary surgery and 19 during a secondary one. Histological analysis of the lymph nodes was totally negative in 62% of cases. Intraoperative frozen sections benefited to 12.8% of the patients who had their full lymph node dissection at the same surgery.The intraoperative frozen section of SNB benefits to a limited number of patients, due to its high rate of false-negatives. Sensitivity of frozen sections could be lowered if the preoperative axillary ultrasound examination becomes a routine, which would question its value.

To evaluate the consequences of laparoscopic nephrectomy with vaginal extraction on sexual quality of life.Sixteen patients (mean age: 53.8 years) who underwent laparoscopic nephrectomy with vaginal extraction between September 2010 and February 2014 were included in this monocentric prospective study. All patients underwent a preoperative gynecological examination to evaluate the feasibility of vaginal extraction. The sexual function of the patients was evaluated using the French version of the Female Sexual Function Index (FSFI). The patients completed an initial FSFI preoperatively then another postoperatively after the resumption of sexual activities.The mean hospital stay was 2.2 days (0-5 days). No postoperative complications were observed except for one case of bleeding at the vaginal incision 4 days after surgery, resolved with a single suture under local anesthesia. Fifteen patients (94%) completed both the pre- and postoperative FSFIs. Three patients were sexually inactive and one was a virgin. The pre- and postoperative mean FSFI overall scores were 24.2 and 24.3 respectively (p=0.39). Scores were comparable in all six of the domains assessed by the questionnaire. Particularly, the pre- and postoperative scores for satisfaction were 4.5 and 4.4 respectively. No increase in dyspareunia was observed after surgery, nor was it more difficult for our patients to reach orgasm after the intervention. No statistically significant differences were observed between the pre- and postoperative FSFI scores.Although preliminary, our results suggest that laparoscopic nephrectomy with vaginal extraction has no effect on the sexual quality of life of patients.

To generate a national biobank made up of samples of the highest quality for the purpose of inciting basic research on gestational trophoblastic diseases (GTD).Three priority axes of research were defined to optimize the nature, method of collection, and storage of the samples. These are: to enhance our understanding of GTD, develop new diagnostic tests, and identify new therapeutic targets. The protocol for patient inclusion and sample processing was determined after extensive literature review and collaboration with international experts in the field of GTD.For each patient with a GTD and for control patients (legally induced abortions), chorionic villi, decidua and tumor samples (fresh, immersed in RNA-protective solution and fixed in formaldehyde), blood (serum, plasma, RNA, and peripheral blood mononuclear cells), urine (supernatant), and cell cultures of villous cytotrophoblasts are prospectively collected. Associations are then made between the collected samples and numerous clinical and biological data, such as human chorionic gonadotropic plasma levels following curettage in the case of a hydatidiform mole.Such a collection of high quality samples and their associated data open up new perspectives for both national and international collaborative research projects.

Background We report the second case of enteric-type villous adenoma of the vulva. The differential diagnosis, histogenesis, and pathogenesis are discussed. Case A 66-year-old woman had a tumor resected from the posterior aspect of the vulva. The tumor was characterized by its villous architecture, with columnar epithelium and goblet cells. This vulvar tubulovillous adenoma was identical to a tumor resected 6 months before from this patient's rectal wall. Conclusion These two tumors behaved benignly, and the vulvar adenoma possibly originated with the mullerian vestige.

Objective The aim of this study was to assess the usefulness of color Doppler energy in the preoperative diagnosis of ovarian malignancy using multivariate logistic regression analysis. Methods One hundred and thirty adnexal masses were studied with transvaginal B-mode, color energy, and pulsed Doppler ultrasonography before surgery in order to develop a model that could be used to determine malignancy. Each ultrasonographic variable (tumor size, wall thickness, septal structure, echogenicity, papillary projection, density (solid or not)) was included individually or combined together as part of the Sassone ultrasound score. Intratumoral blood flow velocity waveforms were obtained to determine pulsatility index and resistance index and a more subjective parameter, location of tumor vascularity, was also assessed. Menopausal status and serum CA 125 levels were also entered as categorical variables. Sonographic parameters were entered alone, then associated with menopausal status and CA 125 serum levels, and finally with Doppler energy measurements. Our model was then validated in a group of 68 adnexal masses and compared to the model of Alcazar. Results Eighteen adnexal masses (13.8%) were malignant or of low malignant potential. Multivariate analysis showed that papillary projection of the tumor wall, cyst with solid parts, resistance index with a cut-off value of 0.53, CA 125, and central blood flow location, were the only factors to be independent predictors of malignancy. Menopausal status was not an independent factor. For the final model including the Doppler energy parameter the best sensitivity and specificity were 83% and 93%, respectively, at a cut-off value of 10% probability of malignancy compared to 83% and 87% for the morphological variables alone. Validation of the model showed its diagnostic performance to be as good as that reported in the original population and better than the model of Alcazar. Conclusion Sonographic analysis of adnexal masses including color Doppler energy shows the best predictive properties according to histological diagnosis, and improves preoperative diagnosis of malignancy. Copyright © 2002 International Society of Ultrasound in Obstetrics and Gynecology

To show the effectiveness of ultrasound-guided puncture in the treatment of lactational breast abscess and identify its risk factors.Retrospective descriptive study at the CHU of Lyon-Sud from December 2007 to December 2013, including patients with lactational breast abscess confirmed on ultrasound and treated with antibiotics and analgesics. Realisation of ultrasound-guided needle under local anesthesia by the radiologist and washing the cavity with physiological serum.Forty patients had lactational abscesses at an average of 10 weeks post-partum. Thirty-four patients were treated by needle aspiration, of which 2 had first surgical drainage. The average size of the abscess was 41.2mm. The success rate of needle aspiration was 91.2%. No cases of recurrence were observed, however, there were 5 fistulisations. In all, 91.2% were treated on an outpatient basis. In 87.8% of cases, breastfeeding was continued on the healthy side and in 48.5% of cases on the affected side. The major risk factor for abscess was mastitis in 91.1% of cases.Ultrasound guidance of needle aspiration should be gold standard for the treatment of lactational breast abscesses to continue breastfeeding including the affected side.

Adverse event reporting for laparoscopic promontofixation is highly variable and non-standardized in the literature. The aim of this study was to better characterize early postoperative complications of laparoscopic promontofixation for genital prolapse using a standardized reporting methodology.A retrospective study was conducted on 174 women with genital prolapse undergoing laparoscopic promontofixation from January 2008 to January 2013. Complications arising during the first month after surgery were reviewed according to the Clavien and Dindo classification.At least one postoperative adverse event was reported in 57 out of 174 (33 %) women, grade 1 in 22 patients (13 %), grade 2 in 31 patients (18 %) and grade 3 in 4 patients (2 %). No patient experienced a grade 4 or 5 complication. Fifty-three out of 57 (93 %) complications were grade 1 or 2. The most frequently reported adverse event (n=24; 14 %) was constipation (grade 2).Laparoscopic promontofixation is a safe procedure with almost exclusively benign (grade 1 or 2) early complications. The hypothesis of induction or increasing constipation by this type of genital prolapse surgery should be further evaluated.

Human fetal livers (FL), between 16 and 24 weeks of gestation, were studied for their potential as a source of hematopoietic stem cells for prenatal and postnatal transplantation. In this report we give a quantitative evaluation of human FL as a source of candidate stem cells, and develop a protocol for the isolation of these cells free of microbial contaminants and almost free of mature T cells. Human FLs contained a median 1.9 x 10(9) viable cells and a mean of 1.3 x 10(8) CD34+/++ cells (range 1.1 x 10(7) to 4.7 x 10(8)). Regardless of gestational age, no significant differences were apparent in the numbers of total progenitors or in the numbers of candidate stem cells (CD34++ CD38- and CD34++CD4+), suggesting that the expansion in the liver of the early compartments of hematopoietic progenitors reaches a plateau after the sixteenth week of gestation. Colony-forming units culture (CFU-C) were found to range from 4.1 x 10(6) to 2.5 x 10(7) per FL. Positive selection of FL CD34++ cells was achieved using the Baxter Isolex 50 device. An average purity of 74% and yield of 29% of CD34+/++ cells was achieved. T cells were depleted by 99.95%, resulting in a mean of 6.5 x 10(3) T cells per processed liver. Analysis of candidate stem cell populations and primitive colony-forming cells (CFC) suggested a preferential enrichment of these cells over the total population of CD34+/++ cells. Processed CD34+/++cells were found to be sterile. In conclusion, purification of FL progenitors between 16 and 24 weeks of gestation results in a large number of early progenitors suitable for in utero and possibly post-natal transplantation.

To assess reproductive outcome of women affected by septate uterus after surgical correction.It is a retrospective study. The setting is a French university hospital. Surgery was performed on 66 patients between 2000 and 2010. Hysteroscopic metroplasty was performed in every group once the diagnosis was made. There were two groups: 35 patients affected by septate uterus had past history of miscarriages, preterm and term deliveries. Thirty-six patients had never been pregnant.In the group of 35 patients with a previous obstetric history, the rate of miscarriages was 57.1% before surgery and 10% after surgery. There was a significant gain of live birth ratio of 55% among women being pregnant after surgery compared to women being pregnant before surgery. For patients with no pregnancy before surgery, obstetrical results are the following ones: miscarriages 25.9%, preterm deliveries 11% and term deliveries 59.3%.Hysteroscopic septoplasty is an easy technique with few complications in our study. Hysteroscopic septoplasty is strongly recommended after recurrent miscarriages or premature deliveries. We use to propose surgery to every patient affected by septate uterus, even if they have never been pregnant.

To study the feasibility and to present results of laparoscopic nephrectomy with vaginal extraction in overweight or obese patients.Three patients having BMI28 kg/m(2) underwent surgery. Median age was 56 years, median BMI was 44.4. Medical history included for the three patients type 2 diabetes mellitus and arterial hypertension. Two of the three patients were multiparous, one was nulliparous. Patients underwent standard laparoscopic nephrectomy with vaginal extraction of the specimen through a short incision of the posterior vaginal fornix. Feeding was normal on the first operating day. No morphine was prescribed during hospitalization stay.No intraoperative complication occurred. Mean procedure time was 224 min. Mean blood loss was 140 mL. Postoperative period was uneventful and walking was normal on the first operating day. Hospitalization stays were 2, 3 and 5 days. One month follow up found no complication including normal sexual activity.Laparoscopic nephrectomy with vaginal extraction is a feasible technique in obese or overweight patients. Wound morbidity (infection, hernia) is reduced due to the small abdominal incisions.

Resume Objectifs Evaluer les effets de l'absence de curarisation sur le deroulement de l'acte operatoire et de l'anesthesie en cœliochirurgie gynecologique. Type d'etude Etude clinique prospective, randomisee, en double aveugle. Patientes Cinquante femmes de classe physique ASA 1 ou 2, non obeses, necessitant une cœlioscopie gynecologique reparties en un groupe avec curare (AC) et un sans curare (SC). Methode Apres premedication par hydroxyzine (100 mg) et alprazolam (0,5 mg) toutes les patientes ont recu l'association propofol (2,5 mg·kg1), sufentanil (0,4 μg·kg −1 ), midazolam (2 mg) et N 2 O-O 2 . Le groupe AC recevait 0,25 mg·kg −1 d'atracurium avant l'intubation, puis des doses supplementaires de curare, de maniere a maintenir un twitch (T1) inferieur a 10 % de la valeur de base. L'intubation tracheale etait realisee 90 s apres l'induction. La PAM, la FC, la PETCO 2 et la SpO 2 ont ete notees apres intubation, avant et pendant le pneumoperitoine, dont la pression maximale etait limitee a 15 mmHg. Un score d'intubation et un score des conditions chirurgicales ont ete etablis pour chaque patiente. Resultats Une baisse de la PAM et de FC a ete observee dans les deux groupes apres l'induction ; la diminution de la PAM etait plus importante dans le groupe SC (25 vs 15 % ; P 2 et de la pression d'insufflation de crete ont ete comparables et les conditions chirurgicales non differentes entre les deux groupes. L'intubation tracheale a ete jugee moins satisfaisante dans le groupe SC. Conclusions Les conditions chirurgicales et le deroulement de l'anesthesie ne sont pas influences par l'administration de curare pour des patientes jeunes et non obeses, lors de la c˦lioscopie gynecologique.

The aim of this study is to assess the impact on sexuality of the surgical treatment in patients with symptomatic deep pelvic endometriosis.The design is a single-center cohort prospective study including all patients with symptomatic pelvic endometriosis and regular sexual activity who underwent surgery between October 2009 and September 2010. Sexual function was evaluated by the "Brief Index of Sexual Functioning for Women" (BISF-W) questionnaire translated and validated in French, including a global evaluation by the Composite Score (CS). Pain symptoms related to endometriosis were evaluated by the Visual Analog Scale (VAS) and the simple Verbal Rating Scale (VRS). Questionnaires were answered before surgery. A standardized mid and long-term postoperative follow-up was performed to compare sexuality and pain symptoms.Twenty women were included in the study. Mean follow-up was 23.3 months. When compared to a French reference population, global preoperative sexual function was significatively deteriorated (CS=14.3±10.8 vs 32.2±12.6; P0.001), especially for arousal, frequency of sexual activity, pleasure and orgasm. Significant improvements in sex life were observed after surgery at the long-term follow-up (CS=33.0±11.7 vs 14.3±10.8; P=0.02). and sexual function was similar to the reference population (CS=33.0±11.7 vs 32.2±12.6; P=0.806). At the mid-follow-up, a significant improvement in the intensity of dysmenorrhoea, non-cyclic pelvic pain, dyspareunia and bowel symptoms were observed on the VAS. At the long-term follow-up, dysmenorrhoea and dyspareunia were significatively ameliorated. Pelvic pain recurrence related to endometriosis was 13.3%.Surgical management of deep pelvic endometriosis in symptomatic patients improves sexual life at the long term follow-up. Deep dyspareunia pain decreases significantly, although other conditions are involved in the improvement of sexual function.