Preliminary observational study of the implementation of hyperthermic intraperitoneal chemotherapy in ovarian cancer in the gynecological surgery department at the University Hospital of Strasbourg.

OBJECTIVE: According to French guidelines, hyperthermic intraperitoneal chemotherapy (HIPEC) can be performed for Federation of Gynecology and Obstetrics stage III primary epithelial ovarian, tubal, and peritoneal cancers that are initially unresectable after 3 or 4 cycles of intravenous chemotherapy. The main objective of this preliminary study was to analyze the components necessary for the establishment of HIPEC in an expert gynecological oncological surgery center. The secondary objective was to compare HIPEC using conventional laparotomy and laparoscopic approaches. METHODS: We conducted a single-center retrospective study of patients who received HIPEC. All patients who met the criteria of the French HIPEC guidelines were included from 2019 to 2021. RESULTS: Prior to HIPEC, there were a mean of 3.7 courses of neoadjuvant chemotherapy with carboplatin and paclitaxel. Of the 16 patients who received HIPEC, 9 (56.2%) underwent HIPEC laparoscopically, while 7 (43.8%) underwent laparotomy. There were no differences between the rates of intra- and postoperative complications between the two groups. (p > 0.05). The duration of hospitalization was significantly shorter in patients who were operated laparoscopically than in those treated using laparotomy (55.6% <10 days vs. 0 by laparotomy, p = 0.01). There was also a tendency, although not significant, for a more rapid resumption of adjuvant chemotherapy in the laparoscopy group, with 57.1% resuming chemotherapy in <6 weeks compared to 42.9% in the laparotomy group (p = 0.52). CONCLUSIONS: This study demonstrates the feasibility of HIPEC in a center with expertise in gynecological surgery when there is a suitable technical platform and close collaboration between the different teams involved. We also showed the first cases of HIPEC using laparoscopy, which seems to be a promising approach.

Bowel resection performed by gynecologists - Outcomes and learning curves. Activity profile in a Gynecology Department: 7-year observational cohort.

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

Human papillomavirus (HPV) vaccine coverage rates (VCRs) in France: A French claims data study.

BACKGROUND: The French Cancer Plan 2014-2019 had a target of 60% HPV vaccine coverage. The PAPILLON study investigated the annual age-specific vaccination initiation rates and cumulative partial and complete vaccination rates in France from 2017 to 2022. It also identified the factors associated with vaccination in different age groups and those associated with the type of completion of the vaccination scheme (partial vs full vaccination). METHODS: For this publication, all females recorded in the French National Claims database who initiated HPV vaccination between 1 July 2007 and 31 December 2018 and were aged between 11 and 19 years at initiation were included. Annual HPV vaccination initiation rates were estimated in 11- to 14-year-old (target population) and 15- to 19-year-old females (catch-up). Cumulative vaccine coverage rates (VCRs) were estimated among those who were 15, 16, 20 and 21 years old. Partial vaccination was defined by dispensing of at least one dose of HPV vaccine by the pharmacy, while full vaccination was defined by two or three doses dispensed by a pharmacy over an 18-month period, according to current French recommendations based on the age at vaccination initiation. RESULTS: Among the 465,629 females who initiated HPV vaccination in 2017 or 2018, the initiation rate increased from 7.7 to 11.1% in 11- to 14-year-old girls and from 4.5 to 6.5% in 15- to 19-year-old females. In 2017 and 2018, the cumulative VCRs for partial vaccination by age 15 were 28.2% and 32.8%, respectively, while by age 20, they were 41.6% and 38.8%. The cumulative VCRs for full vaccination were 15.6% and 18.6% by age 16, while they were 25.9 and 23.6% by age 20. HPV vaccination initiation and completion were strongly associated with the use of health services. CONCLUSION: Overall, the HPV VCR substantively increased between 2017 and 2018, which is positive evidence of the resumption of vaccination. Updates in 2022 should confirm these results.

Successful retrieval of human papillomavirus DNA after a 4.5 year storage on FTA elute cards.

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

Diagnostic Accuracy and Clinical Impact of Sentinel Lymph Node Sampling in Endometrial Cancer at High Risk of Recurrence: A Meta-Analysis.

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

Impact of Lymphadenectomy on Survival of Patients with Serous Advanced Ovarian Cancer After Neoadjuvant Chemotherapy: A French National Multicenter Study (FRANCOGYN).

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

Impact of neoadjuvant chemotherapy cycles on survival of patients with advanced ovarian cancer: A French national multicenter study (FRANCOGYN).

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

Cervical morbidity in Alsace, France: results from a regional organized cervical cancer screening program.

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

Risk Factors of Post-Large Loop Excision of the Transformation Zone Recurrent High-Grade Cervical Intraepithelial Lesion: A Prospective Cohort Study.

OBJECTIVE: The aim of the study was to identify the risk factors of post-large loop excision of the transformation zone (LLETZ) recurrent disease and the impact of colposcopic guidance at the time of LLETZ on that risk. MATERIALS AND METHODS: From December 2013 to July 2014, 204 patients who had undergone LLETZ for the treatment of high-grade intraepithelial lesion with fully visible cervical squamocolumnar junction were included. The use of colposcopy during each procedure was systematically documented. The dimensions and volume of LLETZ specimens were measured at the time of the procedure before formaldehyde fixation. All participants were invited for a follow-up. The primary endpoint was the diagnosis of post-LLETZ recurrent disease defined as the histologic diagnosis of a high-grade cervical intraepithelial lesion. RESULTS: The median duration of post-LLETZ follow-up was 25.8 months. Recurrent disease was diagnosed in 8 (3.6%) patients. Older than 38 years (adjusted hazard ratio [aHR] = 11.9, 95% CI = 1.6-86.0), history of excisional therapy (aHR = 21.6, 95% CI = 3.5-135.3), and the absence of colposcopy for the guidance of LLETZ (aHR = 6.4, 95% CI = 1.1-37.7) were found to significantly increase the risk of post-LLETZ recurrent disease. The dimensions and volume of the specimen were not found to have any impact. Only positive endocervical margins were identified to significantly increase the risk of post-LLETZ recurrent disease (aHR = 14.4, 95% CI = 2.0-101.1). CONCLUSIONS: Risk factors of post-LLETZ recurrent disease are older than 38 years, history of excisional therapy, positive endocervical margins, and lack of colposcopic guidance at the time of LLETZ.

Two Surgical Techniques for Essure Device Ablation: The Hysteroscopic Way and the Laparoscopic Way by Salpingectomy with Tubal Interstitial Resection.

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

Risk Factors of Inadequate Colposcopy After Large Loop Excision of the Transformation Zone: A Prospective Cohort Study.

OBJECTIVE: The aim of the study was to identify the risk factors of post-large loop excision of the transformation zone (LLETZ) inadequate colposcopy. MATERIALS AND METHODS: From December 2013 to July 2014, a total of 157 patients who had a LLETZ performed for the treatment of high-grade intraepithelial lesion with fully visible cervical squamocolumnar junction were included. All procedures were performed using semicircular loops. The use of colposcopy made during each procedure was systematically documented. Dimensions and volume of LLETZ specimens were measured at the time of procedure, before formaldehyde fixation. All participants were invited for a follow-up colposcopy 3 to 6 months after LLETZ. Primary end point was the diagnosis of post-LLETZ inadequate colposcopy, defined by a not fully visible cervical squamocolumnar junction and/or cervical stenosis. RESULTS: Colposcopies were performed in a mean (SD) delay of 136 (88) days and were inadequate in 22 (14%) cases. Factors found to significantly increase the probability of post-LLETZ inadequate colposcopy were a history of previous excisional cervical therapy [adjusted odds ratio (aOR) = 4.29, 95% CI = 1.12-16.37, p = .033] and the thickness of the specimen (aOR = 3.12, 95% CI = 1.02-9.60, p = .047). The use of colposcopy for the guidance of LLETZ was statistically associated with a decrease in the risk of post-LLETZ inadequate colposcopy (aOR = 0.19, 95% CI = 0.04-0.80, p = .024) as the achievement of negative endocervical margins (aOR = 0.26, 95% CI = 0.08-0.86, p = .027). CONCLUSIONS: Although the risk of post-LLETZ inadequate colposcopy is increased in patients with history of excisional therapy and with the thickness of the excised specimen, it could be reduced with the use of colposcopic guidance and the achievement of negative endocervical margins.

Laparoscopic Transperitoneal Para-Aortic Lymphadenectomy in 10 Steps.

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

Transvaginal Resection of an Infected Sacrocolpopexy Mesh by Single-Port Trocar.

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

Retroperitoneal Lumboaortic Lymphadenectomy Using a Vessel-Sealing Device in 10 Steps.

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

Laparoscopic Management of a Rudimentary Uterine Horn.

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

Reporting reactive cellular changes on smears among women who undergo cervical cancer screening: results of a cohort study after seven years of follow-up.

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

Risk of malignancy on suspicion of polyps in menopausal women.

Improved performances in gynaecological ultrasonography have enabled an increasing number of often asymptomatic endometrial polyps to be detected. Most of these polyps are removed surgically, as a precautionary measure, so as not to miss a case of endometrial cancer. Nonetheless, this management strategy is based solely on the sonographer's judgement and a number of these operations, which are probably of no benefit, could be avoided. In order to do so, risk factors for malignancy need to be identified. OBJECTIVE: Estimate the prevalence of lesions in menopausal patients with a pre-operative diagnosis of endometrial polyp. Establish risk factors for malignancy. STUDY DESIGN: This is a single-centre retrospective study. Enrolment criteria were menopausal patients aged over 45 who had undergone hysteroscopic resection of a polyp. Pre-op diagnosis was made either by ultrasonography or diagnostic hysteroscopy. Malignant lesions included cancers and atypical hyperplasia. Benign lesions consisted of simple polyps, non-atypical simple hyperplasia and non-atypical complex hyperplasia. Risk factors studied were existing abnormal uterine bleeding, endometrial thickness, personal or first-degree family history of gynaecological cancer (breast, cervix, endometrium, ovary) and age on diagnosis. RESULTS: 631 patients were enrolled of whom 30 presented a malignant disorder (4.75%); 579 patients (91.76%) presented a simple polyp, 11 a non-atypical simple hyperplasia (1.74%) and 11 a non-atypical complex hyperplasia (1.74%). On univariate analysis age alone proved to be statistically significant (OR 1.05; 95%CI=[1.02-1.09] p<0.01), with a threshold of 59 years of age on the ROC curve. On multivariate analysis, factors predictive of a malignant lesion were age (OR=1.06; 95%CI [1.02-1.10]), existence of AUB (OR=2.4; 95% CI [1.07-5.42]) and family history (OR=2.88; 95%CI [1.08-7.67]). Neither the univariate nor multivariate model was able to demonstrate a statistically significant relationship with respect to endometrial thickness. The risk of malignancy was 12.3% in patients aged over 59 presenting AUB. For all other subgroups, the risk varied between 2.31 and 3.78%. CONCLUSION: The risk of a malignant lesion appears to be high (12%) in menopausal patients aged over 59 presenting an endometrial polyp detected when there is pre-existing AUB. In this situation, hysteroscopic resection of endometrial polyps should therefore be routinely proposed. For other patients, the risk of a malignant lesion is low but not insignificant, standing at about 3%. Each patient record should therefore be discussed on an individual case basis, taking into consideration the patient's pre-existing conditions, after providing clear and appropriate information.

Laparoscopic Sacral Colpopexy: The "6-Points" Technique.

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

Type B Laparoscopic Radical Trachelectomy With Pelvic Lymphadenectomy for Early Cervical Cancer.

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