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Objectives Deep infiltrating endometriosis (DIE) of the rectosigmoid is associated with painful symptoms. When medical treatment is ineffective, surgical resection remains the standard treatment, despite significant risk of adverse events. High‐intensity focused ultrasound (HIFU) is a minimally invasive ablative procedure. Focal One® is a transrectal HIFU (TR‐HIFU) device used in prostate cancer treatment. The primary objective of this study was to confirm the feasibility of treatment with TR‐HIFU in patients presenting with posterior DIE with rectosigmoid involvement. We also assessed its safety and clinical efficacy in this context. Methods This was a non‐controlled, prospective, Phase‐I clinical trial in a French University Hospital which is a multidisciplinary center for management of endometriosis. Included were patients older than 25 years, without plans to conceive within 6 months, who presented with a single lesion of posterior DIE, with rectosigmoid invasion, after failure of hormonal therapy. All lesions were assessed preoperatively using transvaginal sonography and magnetic resonance imaging. Patients completed questionnaires on gynecological and intestinal symptoms (similar to a visual analog scale (VAS)), and on quality of life (Medical Outcomes Study 36‐item short‐form survey (SF‐36) and, for the second half of patients recruited, symptom scoring system for constipation (KESS), female sexual function index (FSFI) and endometriosis health profile short‐version score (EHP‐5)), before, and at 1, 3 and 6 months after, TR‐HIFU treatment with a Focal One real‐time ultrasound‐guided HIFU device. Results Twenty‐three consecutive patients were included in the study between September 2015 and October 2019. All 23 lesions were visualized, giving a detection rate of 100%. Twenty lesions were treated (‘feasibility rate’, 87.0%): in 13 the whole lesion was treated and in seven the lesion was treated partially. The mean duration of the TR‐HIFU procedure was 55.6 min. We observed a significant improvement in VAS score at 6 months, with differences relative to preoperative scores as follows, for: dysmenorrhea (–3.6, P = 0.004), dyspareunia (–2.4, P = 0.006), diarrhea (–3.0, P = 0.006), constipation (–3.0, P = 0.002), dyschezia (–3.2, P = 0.003), false urge to defecate (–3.3, P = 0.007), posterior pelvic pain (–3.8, P = 0.002) and asthenia (–3.8, P = 0.002). There was also a significant improvement in the SF‐36 score, with an increase at 6 months relative to the preoperative score in both the physical component summary (+ 9.3%, P = 0.002) and mental component summary (+ 10.9%, P = 0.017). No major complications occurred during or after any procedure. Conclusions TR‐HIFU therapy for posterior DIE is feasible. If its efficacy and safety are confirmed, it could be a minimally invasive alternative to surgery for the treatment of rectosigmoid endometriosis. © 2019 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Resume Objectif Evaluer les complications et l’efficacite sur le plan de la douleur et des symptomes fonctionnels urinaires de la chirurgie pour atteinte endometriosique profonde vesicale ou ureterale. Methode Etude retrospective des complications postoperatoires (Clavien-Dindo), de la douleur (echelle visuelle analogique [EVA]) et du retentissement fonctionnel (Urinary Symptom Profile [USP]) des patientes operees pour une endometriose vesicale ou ureterale entre 2007 et 2015 au CHU de Lyon. Resultats Parmi les 31 patientes presentant une atteinte vesicale, 83,9 % ont beneficie d’une cystectomie partielle et 16,1 % d’une resection extra-muqueuse. En cas d’atteinte ureterale (20 patientes), 85 % des patientes ont eu une resection ureterale avec reimplantation vesicale et 15 % une ureterolyse seule. Le taux de complications de grade III etait respectivement de 6 % et 0 % apres chirurgie pour atteinte vesicale et ureterale. Aucune complication de grade IV ou V n’a ete observee. L’EVA moyenne de douleur vesicale a 42 mois de suivi diminuait de 5,3 ± 4,2 a 0,3 ± 0,9 (p Conclusion La prise en charge chirurgicale multidisciplinaire de l’endometriose des voies urinaires est associee a un faible taux de complications severes et a une amelioration significative a long terme de tous les symptomes douloureux sans sequelles fonctionnelles.

Splenosis is a pathology resulting from a rupture of the spleen due to a trauma or a surgery. We report the case of a patient presenting with a splenosis, initially diagnosed as endometriosis-related pelvic nodules, the most frequent cause of pelvic nodules in women. We will describe the imaging strategy that led to the final diagnosis of splenosis.

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.

Endometriosis is difficult to diagnose clinically. Transvaginal sonography (TVS) is a procedure that is known to be operator-dependent, which mean that published evidences has to be balanced with the level of the sonographer that produced the data. The objective of this publication was to assess the performances of the sonography in the diagnosis of endometriosis in order to establish the French national recommendations. We searched the MEDLINE database for publication from January 2000 to September 2017 using keywords associated with endometriosis and sonography. Eighty-four trial and reviews published in English or French were included. Ovarian endometrioma can usually be diagnosed by a non-expert sonographer, especially when its aspect is typical. In case of an ovarian cyst with atypical presentation, it is recommended to control the sonography by a referent or to perform an MRI. In menopaused women, any ovarian cyst should be considered as a cancer until proven otherwise. In the diagnosis of posterior deep invasive endometriosis (DIE), TVS with sensitivity and specificity of 96 and 99% respectively, seems at least equivalent if not superior to MRI. However, these performances are related to expert sonographers. To reach sufficient efficiency in posterior DIE, the estimated learning curve for a sonographer is 44 cases. When posterior DIE is suspected, we recommend proposing a TVS "performed by an expert" or a MRI "at least interpreted by an expert". In anterior DIE, TVS has a good specificity (100%), but its sensitivity is poor in the literature (64%). TVS is therefore not able to eliminate the diagnosis. However a renal ultrasound should be proposed each time a urinary endometriosis is confirmed, and should be considered whenever posterior DIE is diagnosed especially the lesion is superior to 3cm.

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.

Splenosis is a pathology resulting from a rupture of the spleen due to a trauma or a surgery. We report the case of a patient presenting with a splenosis, initially diagnosed as endometriosis-related pelvic nodules, the most frequent cause of pelvic nodules in women. We will describe the imaging strategy that led to the final diagnosis of splenosis.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 41 - N° 3 - p. 227-234

Please cite this paper as: Rouzier R, Bergzoll C, Brun J, Dubernard G, Selle F, Uzan S, Pomel C, Darai E. The role of lymph node resection in ovarian cancer: analysis of the surveillance, epidemiology, and end results (SEER) database. BJOG 2010;117:1451–1458. Objective The therapeutic role of lymphadenectomy on the survival in patients with ovarian cancer is controversial. The aim of this study was to evaluate the survival impact of lymphadenectomy, depending on the disease stage and extent of the surgery. Design The surveillance, epidemiology, and end results (SEER) registry provided ovarian cancer data from 17 registries. Setting Surveillance, Epidemiology, and End Results database. Population The study population comprised 49 783 patients. Methods Survival was studied according to the number of lymph nodes removed, with stratifications on disease stage and extent of surgery. Main outcome measure The 5-year cause-specific survival rate. Results The median follow up for patients alive at the last follow-up visit was 39 months. The five-year cause-specific survival rates were 37, 62, and 71% for the groups in which no lymph nodes were examined, in which between one and nine nodes were examined, and in which ten or more nodes were examined, respectively (P

Placental growth factor (PlGF) is a pro-angiogenic factor mainly assessed in preeclampsia in which its blood concentration is decreased. The aim of this study was to dose the blood concentration of PlGF in women with fetal intra-uterine growth restriction (IUGR) without associated preeclampsia at the time of diagnosis.Case/control study: IUGR was defined by a fetal biometry with abnormal uterine and/or umbilical doppler (n=23). This group was compared to a control group of fetuses (n=25) matched for gestational age at blood sampling for the dosage of maternal seric PlGF. Women with preeclampsia were not included.The plasma PlGF concentration was 11pg/mL (IQR [11-42,8]) in the IUGR group vs 287pg/mL [135-439] in the control group (P0.001) and this difference was available after adjustment for gestational age at the time of blood sampling (P0.001). PlGF sensitivity and specificity for discrimination were respectively 87% (CI 95% [66-97]) and 88% (CI 95% [69-97]).Maternal serum PlGF concentrations were very low in IUGR group compared with those of the control group.

Resume Les urgences ophtalmologiques arterielles sont principalement representees par les occlusions de l’artere centrale de la retine (OACR), ou d’une de ses branches, et par les neuropathies ischemiques anterieures aigues (NOIAA). Ces deux affections partagent de nombreux points communs : apparition brutale d’une baisse d’acuite visuelle severe ou d’une amputation du champ visuel, pronostic visuel tres souvent pejoratif, et mecanismes physiopathogeniques. En effet, si l’arteriosclerose est la cause la plus frequente des OACR et des NOIAA, il est imperatif de toujours rechercher une maladie emboligene et surtout une arterite gigantocellulaire de Horton. Dans ce dernier cas, il convient au moindre doute de debuter un traitement par corticosteroides intraveineux a fortes doses pour eviter l’atteinte de l’œil controlateral ou des occlusions arterielles dans d’autres territoires.

Resume Le glaucome chronique a angle ouvert (GAO) est un probleme de sante publique par sa frequence et sa potentielle gravite. La prevalence du GAO augmente avec l’âge pour atteindre 5 % des patients de plus de 75 ans. Il s’agit d’une neuropathie optique chronique evolutive dont l’hypertonie intraoculaire est le principal facteur de risque. La prise en charge therapeutique consiste a faire baisser la pression intraoculaire (PIO) jusqu’a une PIO cible. Les differents effets indesirables systemiques et locaux des medicaments topiques proposes dans le GAO sont detailles en fonction des familles de medicaments : beta-bloquants, analogues des prostaglandines, inhibiteurs de l’anhydrase carbonique et alpha-2-agonistes. Il est indispensable de bien comprendre l’interet des traitements du GAO, et de ne pas meconnaitre leurs effets indesirables ainsi que leurs interactions chez les personnes âgees, souvent polymedicamentees.

Resume Grâce aux progres recents de la cœliochirurgie, il est devenu desormais possible de pratiquer le traitement du prolapsus genital par cœliochirurgie. L’objectif de ce travail est de rapporter notre experience d’une technique cœliochirurgicale que nous avons recemment mise au point. Cette technique est derivee de celle decrite par Kapandji en laparotomie. Elle consiste a effectuer une suspension colpo-uterine en utilisant deux bandelettes placees en hamac transversal. Les resultats obtenus dans cette etude portant sur 47 patientes sont encourageants. Les complications per- et postoperatoires sont rares et n’ont entraine aucune sequelle. Les resultats, a court terme, sur le plan fonctionnel sont excellents dans la mesure ou, avec un recul de 21 ± 11 mois, 89,6 % des patientes sont satisfaites a l’interrogatoire, et 81,2 % presentent un resultat anatomique parfait avec un recul de 15 ± 10 mois.

The objective of this work is to discuss the indications for methotrexate in gynecology outside the first-line treatment of tubal ectopic pregnancy. In tubal ectopic pregnancy, the prophylactic use of systemic methotrexate can be discussed when performing laparoscopic salpingotomy. In case of failure of salpingotomy, administration seems justified especially if it avoids re-intervention. The combination of methotrexate with other therapies such as mifepristone, potassium chloride or gefitinib is not recommended in the treatment of ectopic pregnancy. For non-tubal ectopic pregnancy, the intramuscular or local administration of methotrexate is an acceptable treatment for uncomplicated interstitial pregnancies. For uncomplicated cervical or cesarean scar pregnancies, the local administration of methotrexate should be considered as a first-line treatment. For ovarian pregnancies, methotrexate should not be a first-line treatment, surgical treatment remains the standard. Asymptomatic women presenting with a pregnancy of unknown location and plateauing serum hCG concentration2000 UI/L can be managed expectantly: it is recommended to take an additional quantitative hCG serum level after 48 hours. Thus, methotrexate is not recommended in the first intention. Other gynecological indications were discussed: methotrexate is not recommended in the management of first-trimester miscarriages or in the management of placenta accreta.

Resume La degenerescence maculaire liee a l’âge est la cause principale de malvoyance chez les sujets âges. L’interet de la prise en charge reside plus dans la prevention des complications, que dans le traitement des stades ou la vision centrale est definitivement compromise. Les facteurs nutritionnels impliques dans la pathogenie de la DMLA sont les anti-oxydants (vitamine A, C, zinc), les carotenoides (luteine et zeaxanthine), et les acides gras polyinsatures a longue chaine (omega-3). L’etude AREDS (Age-Related Eye Disease Study) a demontre l’interet d’une supplementation en vitamines anti-oxydantes et zinc. Les agents anti-oxydants a base de vitamine A et E associes au zinc ont fait la preuve de leur efficacite statistiquement significative dans les groupes a haut risque de complication (prevention secondaire). Des etudes analogues sont necessaires pour confirmer le role de la luteine et de la zeaxanthine et celui des omega-3 dans le cadre de la prevention primaire.

The incidence of ovarian tumors diagnosed during pregnancy is between 0.3 and 5.4% (LE2). The most common ovarian tumors diagnosed during pregnancy are functional cysts diagnosed incidentally during the first trimester ultrasound (LE2) and spontaneous regression is often observed. Dermoid cysts and cystadenoma are the most frequent organic benign ovarian tumors diagnosed during pregnancy (LE2). The main complication of presumed benign ovarian tumor (PBOT) during pregnancy is adnexal torsion and is estimated at around 8% (LE2), especially at the end of the first trimester and during the second trimester (LE4). Tumor markers are not reliable during pregnancy to assess the risk of malignancy of ovarian tumor (LE2). Ultrasound remains the gold standard for characterizing an ovarian tumor during pregnancy (LE3), but with a lower specificity for the diagnosis of malignancy. Pelvic MRI is accurate in the diagnosis of ovarian tumors during pregnancy and brings additional information to ultrasound (LE4). Ultrasound-guided aspiration of ovarian tumors is not recommended during pregnancy (grade C). Expectation is recommended in cases of PBOT during pregnancy, which does not enlarge (grade C). Whatever the gestational age, surgery is recommended in patients with symptoms suggesting an adnexal torsion (grade C). Laparoscopy is possible during the first and second trimester of pregnancy for the management of symptomatic PBOT (LE3). The risk of miscarriage following surgery (laparoscopy and laparotomy) for ovarian tumor during pregnancy is estimated at 2.8% (LE3). The route of delivery should not be modified by the ovarian tumour, except in case of praevia cyst requiring a cesarean section, a complication or suspicion of malignancy (grade C). Surgical treatment of PBOT may be performed during a cesarean section indicated for another reason. The risk of torsion is increased during the postpartum period (LE4).

In present study, we are assessing the efficiency of endometrial ablation by radiofrequency (Novasure(®)) for the treatment of abnormal uterine bleeding.A total of 90 patients underwent an endometrial ablation by radiofrequency for uterine bleeding between 2009 and 2012. For the postoperative follow-up, symptoms amelioration and eventual adverse-events were evaluated by a self-administered questionnaire given to all patients after the surgery.Sixty-five patients (74%) responded to the questionnaire with an average of 17.5 months. Among them, endometrial bleeding decreased in 92% of the cases (IC 95%; 86-99). The amenorrhea rate was 55% (IC 95%; 43-67) and 36% of the patients presented a diminution of menstrual bleeding after treatment. Thirty-two patients (36%) presented dysmenorrhea before the radiofrequency and 78% of them experienced an amelioration of the symptoms after treatment (IC 95%; 64-93). In 19 patients (21%), the cause of uterine bleeding was adenomyosis, among them, bleeding decreased in 84% of the cases (IC 95%; 71-98) and dysmenorrhea in 70%. (IC 95%; 41-97). Finally, 84% of the patients were satisfied with the result of the treatment.Our findings suggest that endometrial radiofrequency is effective for the treatment of menometrorrhagia, dysmenorrhea and also adenomyosis.

Cervical tuberculosis is a rare pathology, which can clinically look like a cervix cancer. The biopsy re-establishes the right diagnosis. The treatment is medical. The prognosis is primarily the infertility due to frequent associated general genital tuberculosis.

Various statistic predictive models have been developed to predict the status of the non-sentinel lymph nodes (NSLN) when the sentinel one was invaded by tumor cells in the case of breast invasive carcinoma. The objective of this study was to compare the accuracy of three of these statistic models: the MSKCC nomogram, the Tenon score and the MDA score. The study was conducted at Croix Rousse Hospital, Lyon, France.When sentinel lymph node is invaded by metastasis, complete lymph node dissection of the axilla can be avoided using statistic predictive models especially when talking about micrometastases and moreover about isolated tumor cells in the sentinel lymph node. Over the different existing models, we tested the three most used ones to determine the model that is most adapted to our everyday practice.The study population consisted of 77 women with an invasive breast cancer treated by complete axillary lymph node dissection for metastatic sentinel lymph node. Over the nine models already published, we focused on three of them due to their ease to use as well as their good preliminary results: the Memorial Sloan-Kettering Cancer Center nomogram (MSKCC), the Tenon score and the M.D Anderson score (MDA). Different criteria are used by these models, but all of them take in consideration: tumor size, multifocality, tumor type, lymphovascular invasion, hormonal receptors, number of sentinel lymph node resected, degree of sentinel lymph node invasion (i.e. macrometastasis, micrometastasis or isolated tumor cells) and histologic method used to diagnose sentinel lymph node invasion. These scores are validated depending on their false negative ratio as well as the proportion of patient selected as having a low risk of non-sentinel lymph node invasion. The major criterion for the MSKCC score is the calibration that compares the predicted likelihood of invasion and the histologically proved one.The rate of non-sentinel lymph node invasion was 37.6%. The discrimination of the three models was good with an AUC of 0.74 for both MSKCC nomogram and Tenon score and of 0.72% for MDA score. MSKCC nomogram was well calibrated (P=0.23). The false negative ratio was 0 (CI 95%: 0-18.1%) for MSKCC nomogram, 16.7% (CI 95%: 8.6%-27.8%) for Tenon score and 16% (CI 95%: 6.8-31%) for MDA score. The percentage of patients considered as having a low risk of invasion of the non-sentinel lymph node was 20.5% for MSKCC nomogram, 34.7% for MDA score and 47.4% for Tenon score.MSKCC nomogram seems to be the statistic model that is most adapted to the population we studied. To validate the Tenon and MDA score, we should have a most important population.

High recurrence rates have been reported in women treated for endometriosis despite advances in medical and surgical treatments improving both fertility and symptoms. It should therefore be considered a chronic disorder. In this particular setting, the main objectives for practitioners are to limit disease progression, recurrence and to improve quality of life (QOL). Previous studies have demonstrated a relation between an increase in pain intensity and a decrease in QOL. However, visual analogue scales to measure general well-being are insufficient to quantify the impact of endometriosis on QOL. Several generic questionnaires, mainly the SF-36, are available in various languages but are not specific of women with endometriosis. Some specific questionnaires are available but have been validated in English population for the most part rending comparison between countries difficult. Despite these limits, QOL should be systematically monitored over time by a validated questionnaire for this chronic disorder and could be a criterion for therapeutic strategy.

Puerperal hematoma is a rare complication of the postpartum period remaining imperfectly known. We present an update of knowledge on this particular type of puerperal haemorrhage threatening in some cases maternal prognosis. In vulvovaginal hematomas, the diagnosis relies on clinical findings whereas it requires medical imaging in the retroperitoneal localisations. Therapeutic approach also largely differs according to the localisation of the hematoma. We thus propose a synthesis of the critical care strategies depending on the type of the puerperal hematoma.

To assess the efficiency of a new tool designed to shorten the decision-to-delivery interval (DDI) for emergency C-sections (CS).DDI comparisons during three 6-month periods in a third level maternity. In stage A we evaluated the spontaneous DDI, in stage B the DDI was measured after the introduction of a color-code communication tool related to the degree of urgency for CS (amber code indicated urgent CS with an ideal DDI of 30 min and red code for very urgent CS with an ideal DDI of 15 min). In stage C we assessed the impact of the color-codes related protocols implementation.Two hundred and fifty-three C-sections were included (211 urgent CS and 42 very urgent CS). Mean DDI decreased significantly from 42 min to 24 min between period A and period C for amber codes (corresponding to 43.2% and 82.1% of the objectives respectively) and from 24.9 min to 10.7 min for red codes (20% et 83.3% of the objectives).This study suggests that color-codes and their related application protocols significantly shorten the DDI during the evaluation periods.

This is a review of evolutive aspects in pelvic inflammatory disease (salpingitis, endometritis, pyosalpinx, tubo ovarian abscess) assessed by different imaging modalities (Ultrasound, CT, MRI and hysterosalpingography).

Spontaneous uterine rupture is a life threatening event, and the diagnosis is difficult in an unscarred uterus. Many factors can help prevent the catastrophic consequences.A 38-year-old multipara in labor was admitted at 39.5 weeks of gestation. Ultrasound suggested a macrosomic fetus but the cervix was well dilated. Labor was immediately monitored. Two hours later, the fetus developed progressive heart rate decelerations. While evaluating the unexplained anomaly, epigastric pain and vaginal bleeding prompted emergency cesarean delivery. The uterine tear was repaired with good evolution but the infant died a few days later.The association of multiparity, uterine distension and active labor could be considered as risk factors of uterine rupture in cases of unexplained anomalies in an unscarred uterus, making a catastrophic event preventable.

Three GnRH agonists are currently available in France in clinical medicine with the indication: "Genital or extragenital endometriosis (from stage I to stage IV of the rAFS classification [4] )." The 2004 Cochran meta-analysis showed a significant improvement in the pain score in patients treated with GnRH compared with placebo, with the effect lasting 12 months after cessation of the medication, but few data are available on their advantages in the perioperative situation and in deep endometriosis. A. Audebert found an advantage to preoperative use of GnRHa in severe cases of endometriosis, with a significantly higher rate of patients having surgery that was considered optimal at the end of the intervention, both in terms of the endometriosis lesions and adherences. The benefits of GnRH treatment before medically assisted procreation are, however, supported by the literature.

To evaluate the urinary side effects after laparoscopic surgery for deep endometriosis.Longitudinal study including 86 patients operated for deep pelvic endometriosis : 58 (68%) with colorectal endometriosis, 21 (24%) with utero-sacral ligament endometriosis and 7 (8%) with recto-vaginal septum endometriosis. Assessment of the urinary side effects was permormed using the Bristole Female Lower Urinary Tract Symptom questionnaire.On postsurgical follow-up, almost all patients described: hesistancy (p = 0.02), strain to start (p = 0.04), stopping flow (p = 0.01), incomplete emptying (p = 0.008) and reduce stream (p=0.02). Only patients who had resection of both utero-sacral ligaments had significative postsurgical urinary dysfunction with stopping flow (p = 0.02) and incomplete emptying (p = 0.004). Patients with colorectal resection had also significative postsurgical urinary dysfunction with hesitancy (p = 0.02), strain to start (p = 0.03), stopping flow (p = 0.007) and incomplete emptying (p = 0.004). In patients with rectal resection, urinary dysfunctions are raised when rectal resection is associated to resection of both utero-sacral ligaments.Postoperatively, urinary side effects occurred only in patients with segmental colorectal endometriosis resection associated with bilateral utero-sacral ligament resection. Sparing nerve surgery of the pelvic nerves, can reduce these urinary side effects.

After a pregnancy, there is a transitory increase in the risk of breast cancer. During the pregnancy, the number of mammary epithelial cells increases massively. This increase seems partly due to the expansion of stem cells and proliferating intermediate cells. This proliferation of epithelial cells is accompanied by angiogenesis and by recruitment of stromal cells, as well as changes of the extracellular matrix. During any pregnancy, there is cell trafficking between mother and foetus. Hematopoietic or mesenchymal foetal stem cells are transferred in maternal circulation and could be used by the tumor as support cells and take part in the tumoral development. The study of the mechanisms of this specific oncogenesis may help to develop chemoprevention strategies.

Trophoblast invasion in uterine pregnancy is fine-tuned for the remodelling of the uterine wall and its vascularization. Tubal pregnancy, which occurs in a limited number of patients, involves a dramatic trophoblast invasion in a context of a poor decidualization. By studying the histology of the extravillous trophoblast (EVC) in the anchoring villi, the Ki67 labelling, the location of several adhesion markers (cytokeratin-7, alpha1, alpha6, alphaV, beta1, beta4 integrin subunits and E-cadherin, V/E-cadherin), metalloproteinases (MMP-2, 9 and11), NOS2 and 3, we aimed to detect the specificity of tubal compared to intrauterine pregnancies. No difference could be observed between meso or anti-salpingial trophoblast proliferation or invasion using Ki67. Cytokeratin-7 allowed detection of spindle-shape EVCs and we identified some decidualized stromal cells. Integrins alpha1, beta1 and alphaV, and V/E-cadherin were expressed mainly in the distal EVC correspondingly to intrauterine pregnancy, with a poor expression of alpha1. Integrins alpha6 and beta4, E-cadherin were detected in the distal EVC in contrast to uterine pregnancy. MMP-2, 9, 11 were also shown in distal EVC. NOS2 and 3 labelled the perivascular EVC and NOS3 the endothelial cells of the tubal vessels. These changed distributions of adhesion molecules and MMP together with that of the basic and inducible NOS expressions could be related to mechanical effects in superficial implantation or to a failure of decidualization in tubal pregnancies.

Indications of GnRH analogues before and/or after surgery for endometriosis remain controversial. Although some studies have underlined a decrease in rAFS scores using GnRH analogues pre-operatively, data are insufficient to recommend their systematic use in routine. In the same way, despite an increase in symptom free period subsequent to the use of GnRH analogues post-operatively, no effect of this therapeutic on recurrence rate and fertility outcome has been proved. In addition to a meta-analysis on GnRH analogues in endometriotic women, further studies, especially in women with large endometriomas and with deep pelvic endometriosis, are required to clarify the indications of GnRH analogues associated with surgical management.

Placental tight and gap junctions and their adhesion molecules were studied by immunochemistry and electron microscopy in early and term placentas in order to clarify their pattern of expression during placental development. Early syncytio-cytotrophoblast contained tight junctions with occludin and gap junctions with connexins 40 and 43. At term, endothelial cells from arterioles had tight and gap junctions following each other. Occludin, claudins 3 and 5 were found at the paracellular clefts of endothelial cells together with connexins 32, 40 and 50. Stromal cells had mixed tight and gap junctions with connexins 32, 43, 50. Capillaries demonstrated interendothelial tight junctions with claudins 3 and 5, and small gap junctions. Taken together these observations showed that the numerous tight and gap junctions of the early placental syncytio-cytotrophoblast are observed in the foetal arterioles and capillaries in the term placenta. We conclude that the tightness of the placenta due to the junctions lying in the syncytio-cytotrophoblast in early pregnancy is maintained by the foetal endothelial layer in term pregnancy, with significant developmental changes of their transmembrane proteins.

To evaluate the accuracy of MR imaging combined with sonography for the diagnosis of persistent adnexal masses during pregnancy.From January 1999 to November 2003, nine patients with a persistent adnexal masse were included in this retrospective study. All patients underwent both transvaginal and transabdominal sonography combined with MR imaging. Accuracy of imaging techniques was evaluated by comparison with histology.Adnexal masse was detected by systematic sonography in six women whereas three patients were symptomatic. Mean gestational age at the diagnosis was 17 weeks of amenorrhea (range 5-36). Mean tumor size was 96 mm (range 2-15). Two patients underwent a surgery during pregnancy; one for acute abdominal pain related to an adnexal torsion and the second for suspicion of malignancy. One patient underwent a caesarean delivery for obstetrical reasons. In all patients, benign ovarian tumours were found. For eight patients the diagnosis suspected by imaging techniques was confirmed by histology.The combination of sonography and MR imaging allows diagnosing accurately adnexal masses during pregnancy.

Cervical tuberculosis is a rare pathology, which can clinically look like a cervix cancer. The biopsy re-establishes the right diagnosis. The treatment is medical. The prognosis is primarily the infertility due to frequent associated general genital tuberculosis.

We report our experience with a new technique to treat genital prolapse: the laparoscopic lateral suspension with two meshes. This is a prospective longitudinal study of 47 women with genital prolapse. With a mean follow-up of 15.2 +/- 10 months (1-39), the anatomical result was perfect in 78.7% of the cases (37 patients). From the functional point of view, 89.3% were satisfied (42 patients). These good preliminary results need to be confirmed by other extensive studies.

Introduction Les infections a cryptocoque, plus frequentes chez le sujet immuno-deprime, sont a l’origine de complications oculaires. Materiels et Methodes Nous rapportons le cas d’un homme de 38 ans, seropositif pour le VIH, presentant une cryptococcose chorioretinienne presumee. Observation Le patient, dont la seropositivite a ete diagnostiquee en 1996, est en rupture therapeutique depuis de nombreuses annees. Il presente un febricule vesperal et des lesions cutanees crouteuses et prurigineuses. L’acuite visuelle corrigee est chiffree a 7/10 e P2 a droite et a gauche, l’examen des segments anterieurs et les tonus oculaires sont normaux. A l’examen du fond d’œil droit apres dilatation on observe la presence d’une lesion choroidienne jaune, arrondie, de 2,5 diametres papillaires, situee en nasal superieur. Le vitre est calme. A gauche le patient presente une hemorragie retinienne en tache et des nodules cotonneux. Le taux de CD4 est a 73/mm 3 . Sur les biopsies des lesions cutanees du visage on retrouve la presence de Cryptococcus Neoformans. L’antigenemie et l’antigenurie cryptocoque sont positives. La ponction lombaire permet d’objectiver la presence de cryptocoque dans le liquide cephalorachidien. Un traitement par Amphotericine B par voie intra veineuse est instaure. Discussion La cryptococcose oculaire, habituellement secondaire a une atteinte cerebro-meningee peut se manifester par une atteinte papillaire, une ophtalmoplegie, une chorioretinite, un abces retino-vitreen, une endophtalmie. Conclusion L’infection fongique opportuniste a Cryptococcus Neoformans affecte preferentiellement les meninges. L’atteinte oculaire la plus frequente est l’œdeme papillaire par augmentation de la pression intra crânienne. L’atteinte choroidienne est rare.

Introduction Ce cas illustre l’aspect trompeur que peut revetir un lymphome de MALT conjonctival (ou CALTOME). Objectifs et Methodes Une patiente de 70 ans sans antecedent notable se presente en consultation pour bilan d’un larmoiement chronique evoluant depuis plusieurs mois. L’examen clinique objective une hyperplasie lymphoide conjonctivale bilaterale d’aspect framboise, diffuse, floride avec envahissement des culs de sac conjonctivaux, des caroncules et dans une moindre mesure des conjonctives tarsales superieures. Cet aspect est evocateur d’une hyperplasie lymphoide benigne reactionnelle et est prelevee pour analyse histologique a titre systematique. Resultats Le diagnostic de lymphome B de la zone marginale extra ganglionnaire de type MALT est confirme par l’immuno-phenotypage (population lymphoide monoclonale CD20 +, CD5- et CD10-, CD23 +) et la biologie moleculaire. Un bilan d’extension comportant un myelogramme, une echographie thyroidienne, une fibroscopie gastro-duodenale revient negatif. Un traitement par chloraminophene est instaure permettant une regression clinique partielle des lesions. Discussion L’epaississement charnu saumone semi-lunaire d’un ou deux culs de sac conjonctivaux n’est pas l’unique aspect que peut revetir un CALTOME et l’aspect muriforme prolifique retrouve dans ce cas est tres peu decrit dans la litterature. Conclusion Devant toute tumeur conjonctivale y compris celles ayant un aspect benin, la biopsie, geste rapide, indolore, pouvant s’effectuer en consultation, s’impose.

But Etudier l’aspect des precipites retro-descemetiques de l’iridocyclite heterochromique de Fuchs (FHC) en utilisant la microscopie confocale in vivo . Materiels et Methodes Les precipites retro-descemetiques de 8 patients consecutifs adresses dans le service pour une iridocyclite heterochromique de Fuchs ont ete examines entre mai et novembre 2006. L’âge moyen etait de 47 +/- 6 ans. L’atteinte uveitique etait unilaterale chez tous les patients (œil droit dans 3 cas). Le diagnostic d’iridocyclite heterochromique de Fuchs avait ete porte sur l’aspect clinique des signes inflammatoires et la negativite du bilan general a la recherche d’une cause infectieuse ou immunitaire de la maladie oculaire. Un patient avait deja ete opere de la cataracte au moment de la microscopie confocale in vivo , 1 patient avait deja ete opere de glaucome et 3 patients etaient traites par anti-glaucomateux. L’imagerie corneenne a ete realisee en periode stable (hors toute poussee inflammatoire). Resultats Le module HRT II a permis d’obtenir facilement et de facon indolore des images tres precises des precipites retro-descemetiques. L’aspect etait tres reproductible d’un patient a l’autre, avec une configuration en etoile et des ponts reliant les precipites entre eux. Discussion L’iridocyclite heterochromique de Fuchs est une cause classique d’uveite unilaterale et hypertonique. Si les aspects cliniques a la lampe a fente sont parfois tres evocateurs, certaines formes peuvent etre plus difficiles a diagnostiquer et/ou a differencier d’une uveite virale, notamment herpetique. L’aspect tres reproductible des precipites retro-descemetiques de l’iridocyclite heterochromique de Fuchs en microscopie confocale in vivo devrait alors permettre d’orienter le diagnostic etiologique. Conclusion L’aspect en microscopie confocale des precipites retrodescemetiques de l’iridocyclite heterochromique de Fuchs est tres reproductible et suggere que ce nouvel outil d’imagerie permet de participer au bilan etiologique d’une uveite unilaterale hypertonique.

But Decrire l’aspect et l’evolution d’une uveite a cytomegalovirus chez un patient immunocompetent. Materiels et Methodes Un patient de 35 ans, suivi depuis 8 ans pour une uveite unilaterale recidivante et hypertonique, a ete adresse dans le service en 1996. Le premier bilan etiologique etait entierement negatif, y compris pour la recherche de virus dans l’humeur aqueuse (PCR et anticorps). Entre 1996 et 2006, le patient a presente une moyenne de 3 recidives par an, survenant lors des tentatives de sevrage en steroides locaux. Lors d’une nouvelle recidive en 2006, une technique optimisee d’amplification genique (PCR) a montre la presence de genome du cytomegalovirus dans l’humeur aqueuse. L’analyse des precipites retro-descemetiques en microscopie confocale in vivo a montre un aspect particulier, en grappes de raisin et en etoiles a deux branches. Aucune cause d’immuno-depression n’a ete retrouvee, ni aucune autre cause d’uveite, infectieuse ou immunitaire. A la dose de 3g/j, le valaciclovir a permis de reduire l’inflammation sans recidive au moment du sevrage en steroides. Cependant, deux nouveaux episodes d’inflammation sont survenus en 3 mois sous un traitement d’entretien de 1 g/j puis 1,5 g/j. Une dose d’entretien de 2 g/j permet actuellement de controler la maladie virale (suivi 3 mois). Discussion Le cytomegalovirus est une cause rare d’uveite chez le patient immunocompetent. Comme dans les quelques cas deja decrits, il s’agissait d’une atteinte unilaterale, hypertonique, recidivante, sans atrophie irienne en secteur, avec quel-ques precipites grisâtres, ayant initialement fait evoquer le syndrome de Posner-Schlossman. L’aspect des precipites en microscopie confocale necessite d’etre confronte a celui observe dans les autres uveites infectieuses ou immunitaires. Conclusion Les uveites a cytomegalovirus du sujet immunocompetent peuvent etre confondues avec d’autres causes d’uveite unilaterale hypertonique. L’analyse en microscopie confocale devrait completer celle de l’humeur aqueuse par PCR dans des cas douteux.