[Treatment of ovarian cysts by laparoscopy]. / Traitement des kystes de l'ovaire par coelioscopie.

OBJECTIVE: to define limits, risks and results in the long term of laparoscopic treatment of ovarian tumors. METHOD: retrospective study of adnexal tumors managed initially by laparoscopy from January 1986 to December 1992, among which 9 cancers, 25 borderline tumors, and 769 benign lesions. The ultrasonographic appearance was known for 698 of 803 lesions. 86 patients were postmenopausal (92 lesions). RESULTS: we treated 191 functional cysts, 160 serous cystadenomas, 178 endometriomas, 105 dermoid cysts, 39 mucinous cystadenomas and 96 miscellaneous lesions among which fibrothecomas, paraadnexal cysts, ovarian pregnancies, ovarian abscess. There is a great diversity of ultrasonographic patterns for a same histological type, specially for functional cysts and borderline tumors. Laparoscopic exploration has misdiagnosed two cancers and 10 borderline tumors and considered wrongly as suspects 19 benign lesions. 714 procedures have been led to term by laparoscopy, 89 have been ended by laparotomy, 26 for suspicion of malignancy and 50 for dissection failure. 27 postoperative complications have been counted among which 2 grafts on trocard sites after non protected extraction of one dermoid cyst and one borderline tumor. CONCLUSION: ultrasonographic appearance could not predict reliably the organic or functional nor benign or malignant character of an adnexal mass. Even careful laparoscopic examination can underestimate early stage ovarian cancer or borderline tumors. When diagnosed during or after laparoscopic procedure an ovarian cancer should always be managed by laparotomy. On the other hand, some borderline tumors can be treated by exclusive laparoscopy. When malignancy is suspected, an adnexectomy can be performed laparoscopically as a biopsy and allows a quick and appropriate treatment after paraffin-embedded sections. Both intraperitoneal and transparietal techniques have a minimal morbidity and allow a feasibility of more than 90%. The management of postmenopausal ovarian tumors differs only by the use of systematic oophorectomy if surgical procedure is indicated.

[Myomectomy: laparoscopy or laparotomy]. / Myomectomie: coelioscopie ou laparotomie?

OBJECTIVE: The purpose of this study of 109 myomectomies is to evaluate the feasibility, limits and results in term of fertility of the laparoscopic myomectomy. MATERIAL AND METHODS: Retrospective study from January 1990 to December 1993, including 109 patients having had a myomectomy, 39 by laparotomy (35,7%) and 70 by laparoscopy. RESULTS: The average number of myomas extracted by laparoscopy and by laparotomy were 1.5 and 6.7 respectively. The diameter of the major myoma was 7 cm in the laparotomic group versus 6.2 cm in the laparoscopic group. Among 70 myomectomies approached by laparoscopy, 29 (41,4%) have necessitated a laparoconversion. The reason of this conversion was mainly the size of the myoma (superior 5 cm) in 21 cases, the number of myomas (superior 5) in 6 cases, the interstitiel location of the myoma in 1 case and a per-operative hemorrhage in 1 case. Among 109 patients having had a myomectomy, 60 (55%) desired a pregnancy including 22 patients having laparoscopy myomectomy. Among these 22 patients, 8 have been pregnant (36.4%) allowing 9 pregnancies (4 deliveries, 4 missed abortions and 1 intrauterin fetal death). CONCLUSION: Our results confirm that the laparoscopic myomectomy would have to be reserved to patients presenting to the most 4 myomas with a diameter < or = 7 cm. Results in term of fertility of the laparoscopic myomectomy are similar to these of patients having a laparoconversion.

Epithelial ovarian carcinoma of low malignant potential.

OBJECTIVE: The aim of this study was to evaluate the interest of sonographic features, serum marker tumors and conservative treatment especially by laparoscopic approach of epithelial ovarian tumors of low malignant potential (or borderline tumors). STUDY DESIGN: Thirty-four patients with 40 epithelial ovarian tumors of low malignant potential treated at Bichat Claude Bernard hospital were reviewed. Of these patients, 29 had preoperative sonographic control (85.2%), 19 (55.8%) had pretreatment serum CA 125 determination, 17 (50%) serum CA 199 determination and 19 CEA serum levels. Twenty patients (58.8%) had serous tumor and 14 (41.2%) had mucinous tumor. Six out of the 20 serous lesions were bilateral. Of the patients 31 (91%) had a stage I disease, one had stage II (3%) disease and two had stage III (6%) disease. Nine patients (26.5%) had laparotomic management, 25 (73.5%) had first laparoscopic management with seven laparoconversions (28%). RESULTS: The majority of borderline tumors (67.7%) exhibited multilocular aspects and seven patients had benign features (unilocular smooth sonolucent). Seven out of the 19 CA 125 serum levels were up to 35 U/ml; 4/17 CA 199 serum levels were above 40 U/ml but the CEA serum levels were always normal. Eighteen patients (52.9%) had radical surgery and 16 patients (47.1%) had conservative surgery including 7 cystectomies. Seven patients (20.6%) had subsequent laparotomic treatment, (five after laparoscopic management, one after laparoconversion management and another one after laparotomic surgery) and no residual disease was found. Fourteen patients (41.1%) had preoperative cyst rupture (13 during laparoscopic management). Four recurrences in stage I disease occurred; one after unilateral salpingo-oophorectomy, three after cystectomy but only one recurrence was in ipsilateral ovary. All four recurrences were diagnosed by sonographic control and one was associated with CA 125 serum level elevation. Ten laparoscopic second look were negative. CONCLUSION: No specific sonographic aspect exists for borderline tumors but it is the best way to detect recurrence. The preoperative CA 125 serum levels was elevated in 36.8% of patients. The conservative treatment including laparoscopic procedure in borderline ovarian tumors appears to have a high risk of peroperative rupture but the rate of recurrence is similar to laparotomic treatment.

Transvaginal intratubal methotrexate treatment of ectopic pregnancy. Report of 100 cases.

Between November 1988 and December 1993, 100 patients with a common, unruptured ectopic pregnancy were treated with 1 mg/kg injection of intratubal methotrexate under transvaginal sonographic control. Patients were not excluded from this series on the basis of the size of the adnexal mass, the term of ectopic pregnancy or initial beta-human chorionic gonadotrophin (HCG) concentrations. Patients were excluded following uncertain diagnosis, signs of a ruptured ectopic pregnancy, or a significant haemoperitoneum on ultrasound scans. The mean age of the patients was 29.5 years (range 20-41). The mean gestational age and initial HCG concentration were 7.5 weeks (5-11) and 11,614 mIU/ml (192-105,000 respectively). Of the 100 patients, 22 (22%) had an ectopic pregnancy with active cardiac activity. Complete resolution was obtained in 78 out of these 100 ectopic pregnancies. Of these, 66 patients (85%) needed only one intratubal methotrexate injection, and 12 patients (15%) required a second i.m. methotrexate injection of 1 mg/kg. In this study, local treatment with one single intratubal methotrexate injection was successful in only 66% of patients. The mean resolution time for reduction of beta-HCG concentrations was 23.5 days (range 7-40). There was no statistically significant correlation between initial beta-HCG concentrations and outcomes after methotrexate treatment of ectopic pregnancy in our study. Where embryonal heart beats were observed, the success rate of the procedure was 40.9% (nine out of 22 cases). In the absence of cardiac activity, or when ultrasound examination showed no embryo, the success rate achieved was 84.6% (66 out of 78 cases) (P < 0.01). In all, 34 patients were considered to be incompletely cured after only one intratubal methotrexate injection: 12 patients required a second i.m. injection, a stagnation of beta-HCG concentrations was observed in 15 patients, abdominal pain occurred in six patients, and one patient suffered tubal rupture with haemoperitoneum. A total of 22 patients required secondary surgical management (salpingectomy). No biochemical or clinical side-effects of methotrexate treatment occurred. Tubal alteration ascribable to methotrexate injection occurred in one patient in our study. Out of 75 patients in this series who wished to conceive, 21 (28%) became pregnant within 1 year with the following outcomes: 11 pregnancies at term, three miscarriages, one induced abortion and six recurrent ectopic pregnancies (four occurred on the same side). Our findings suggest that treatment of common unruptured ectopic pregnancy without prior selection of patients, by a single intratubal methotrexate administration was associated with a 66% success rate. This was dependent only on the presence of embryonal heart beats and there was no correlation between the success rate and initial beta-HCG concentrations. Successful outcome after methotrexate administration for ectopic pregnancy could be perfected by way of an improved selection of patients based on inactive embryonal hearts and absence of a visualized embryo.

[Laparoscopy-assisted and -prepared hysterectomy. A series of 80 cases]. / Hystérectomie coelio-assistée et coelio-préparée. A propos d'une série de 80 cas.

OBJECTIVE: Our objective was to determine the interest of laparoscopic assisted vaginal hysterectomy. STUDY DESIGN: Between January 1991 to december 1994, 80 patients had laparoscopically assisted vaginal hysterectomy. We reviewed with particular emphasis characteristic indications, complications. RESULTS: Eighty were performed as laparoscopically assisted vaginal hysterectomy. 14 patients (17.5%) had laparotomy conversion; because of size of uterus in 3 cases, suspected ovarian tumor in 3 cases. Pelvic adherences in 4 cases, urinary tract injuries in 1 case, hypercapnia in 1 case, hemorrhage in 2 cases. 9 patients experienced febrile morbidity and 1 urinary infection. 1 patient received 2 units of packed red blood cells. The hospital stay was 5 days for laparoscopically assisted vaginal hysterectomy versus 5.9 for laparotomic hysterectomy. CONCLUSION: Laparoscopically assisted vaginal hysterectomy offers a technique to convert certain abdominal hysterectomies into vaginal hysterectomies with a 17.5% laparoconversion rate.

[Ectopic pregnancy: criteria to choose therapy]. / Grossesse extra-utérine: critères du choix thérapeutique.

The ectopic pregnancy (EP) could be treated by spontaneous resolution, or medical treatment or laparoscopic treatment. Spontaneous resolution of EP with beta hCG < 1,000 mUl/ml, plasmatic progesterone < 5 ng/ml had 74% success rate. Methotrexate (MTX) injection is the common Medical treatment of EP with beta hCG < or = 5,000 mUl/ml and mean diameter of EP < or = 3 cm: a single dose of 50 mg/m2 or 1 mg/kg intramuscular injection had 93.4% success rate; local injection under sonographic control (1 mg/kg) had 80.2% success rate. The surgical conservative treatment by laparoscopy had 94% success rate.

[Ovarian hyperstimulation syndrome and thrombosis. Apropos of a case of thrombosis of the internal jugular vein. Review of the literature]. / Syndrome d'hyperstimulation ovarienne et thrombose. A propos d'un cas de thrombose de la veine jugulaire interne. Revue de la littérature.

Thrombosis of the internal jugular vein was associated with a severe syndrome of ovarian hyperstimulation. After in vitro fertilization, a twin pregnancy was obtained in a 31-year-old patient with severe endometriosis. On the day of follicle collection, plasma oestradiol was 3050 mg/ml. Ten ovocytes were collected and 3 embryos were implanted. A syndrome of severe ovarian hyperstimulation (ascites, pleural effusion) developed 3 weeks later and symptomatic treatment was given. Phlebitis of the upper left limb was diagnosed at 9 weeks amenorrhoea and echo-Doppler confirmed the diagnosis of subclavian and internal jugular venous thrombosis. Search for a cause was negative excepting a frank drop in protein S activity to 35%. Post-partum assay and assay in family members confirmed that the deficiency was acquired during pregnancy. The clinical course was favourable with anticoagulant therapy (heparin, then low-molecular weight heparin). Intra-uterine death of one of the fetuses occurred at 21 weeks amenorrhoea and a 2,550 g girl was born by vaginal delivery at 36 weeks. The Apgar score at birth was 10/10. In a review of the literature on vascular events in fertilization, programmes showed that severe syndromes of ovarian hyperstimulation, endogenous hyperestrogenism, multiple pregnancy and predominance of upper limb are the most frequently observed criteria. We emphasize the importance of preventing these thromboembolic events with subcutaneous heparin during the first trimester of pregnancy followed by low-molecular weight heparin, particularly in patients with a history of thromboembolism and/or patients with severe ovarian hyperstimulation.

Transcervical falloposcopy: preliminary experience.

The new technique of endoluminal tubal exploration was evaluated by performing transcervical falloposcopy instead of chromoperturbation under control of concurrent laparoscopy. In this feasibility study, catheterization was performed with the use of either a transhysteroscopic or a free-hand tubal cannulation technique. A total of 66 patients were investigated for primary or secondary infertility with proximal and/or distal suspected tubal defects on the basis of prior hysterosalpingography; three patients were investigated for unruptured tubal pregnancy; two patients were investigated to localize the tip of the tubal embryo transfer catheter. Transcervical catheterization was successful in 110 of the 130 tubes (84.6%). Successful and informative falloposcopy was achieved in 30% of the 110 cannulated tubes. The transcervical free-hand cannulation technique was as effective as the transhysteroscopic approach. Recanalization of at least one tube was achieved in 83% of women with proximal obstruction. Tubal cannulation by the tubal embryo transfer catheter was confirmed by falloposcopy in the two cases where free-hand catheterization was used. This study confirms that it is possible to visualize the tubal lumen and demonstrates that the free-hand cannulation technique is a simple and effective alternative to the transhysteroscopic approach. However, further progress in catheter technology has to be achieved in order to perform regularly successful transcervical falloposcopy in damaged tubes.

[Celioscopic removal of cysts: a fortuitous histological discovery of an ovarian carcinoma. A case report]. / Kystectomie percoelioscopique: découverte histologique fortuite d'un carcinome ovarien. A propos d'un cas.

The authors report a case of cancer of the ovary that had not been recognised but which was discovered after laparoscopic surgical cystectomy. Laparoscopy is very reliable in a presumptive diagnosis of the nature of an ovarian mass, but in this case shows that the operator has to be very attentive especially when there is a rapid recurrence of cyst formation in the ovary that has been operated on. They discuss the indications for intra-peritoneal laparoscopic ovariectomy in short term recurrences after ovarian cyst removal and in particular when these were mucinous. For most authors the risk of dissemination when an ovarian cyst which has proved to be malignant is punctured, seems to be nil, and unlikely to effect the prognosis. It may be possible that in the future the diagnosis of these cases can be improved when the clinical picture, the ultrasound picture and the laparoscopic picture are added to a new development of intraperitoneal laparoscopic ultrasound which will make it possible to view the contents of the cyst with direct contact.