[Pain assessment during medical abortion up to 14 weeks: A 1-year prospective comparative study]. / Évaluation de la douleur lors des interruptions volontaires de grossesse médicamenteuses jusqu'à 14 semaines d'aménorrhées : une étude prospective comparative sur 1 an.

OBJECTIVES: Pain assessment of patients requesting a medical abortion according to the term, up to 14 weeks, by a numerical rating scale (NRS). METHODS: This was a single-centre prospective observational study conducted at the University Hospitals of Strasbourg from 1st October 2019 to 31st December 2020. RESULTS: There was no significant difference in pain assessed by the NRS for medical abortion performed between 7-9 weeks and those performed between 9-14 weeks (6.5±2.5 vs. 6.6±2.2, P=0.85). Regardless of the term (before 7 weeks, between 7-9 weeks and between 9-14 weeks), patients felt relieved by taking painkillers in the case of medical abortion in 88.9%, 80.3% and 87.3% of cases respectively (P=0.18). The use of analgesics allowed a decrease of 3 points of the NRS in the 3 groups (P=0.67). Patients were more painful in case of medical protocol vs. surgical (maximum pain at 6.0±2.6 vs. 1.4±2.0, P<0.01), but declared to be relieved by analgesics in 85.1 and 94.3% of cases (P=0.24). CONCLUSIONS: As pain is similar whatever the term in the case of medical abortion, and its management by analgesics seems to be effective, this criterion should not guide the professional in the choice of method, particularly between 9 and 14 weeks. This choice must be made by the patient.

Bladder and Urinary Deep Pelvic Endometriosis: A Step-by-Step Standard Approach.

STUDY OBJECTIVE: To demonstrate how to treat bladder and ureteral deep pelvic endometriosis using a laparoscopic approach with partial cystectomy and resection and end-to-end anastomosis of the ureter. DESIGN: Step-by-step explanation of the surgery using a video approved by the local institutional review board. SETTING: University Hospital of Strasbourg, France. PATIENTS: A 27-year-old nulliparous woman with severe endometriosis stage IV (revised American Fertility Society classification score >40) of the bladder and left ureter. On pelvic magnetic resonance imaging, we found dilatation of the left ureter and left hydronephrosis induced by a 17-mm endometriosis nodule. A JJ probe was placed on the left ureter before the surgery because of dilatation of the ureter and decreased renal function. INTERVENTIONS: During the exploration, we found an abdominal cavity free of adhesion. There was an endometriosis implant in the bladder in front of the uterus and a large nodule of the left uterosacral ligament that was compressing the ureter. In the first step, we made a section of the round ligament to perform anterior ureterolysis and progressive dissection of the nodule surrounding the ureter. Once the nodule was resected, tight stenosis was observed approximately 1 cm from the bladder. The vesicouterine and vesicovaginal spaces were then dissected to pass under the nodule to the vagina. We opened the dome of the bladder using the thunderbeat (Olympus) and dissected the bladder to remove the transfixing nodule while staying away from the ureters. The closure of the bladder was performed by 2 lateral sutures and a running suture using a braided suture (V-Loc) 2-0, with good tightness as checked by a blue test. Ureteral resection was performed around the JJ probe in place to remove the stenotic zone; thereafter, we performed an end-to-end anastomosis of the ureter using 4 sutures of monofilament (Monocryl) 4-0 with a good anatomic result. Finally, an omentoplasty was fixed around the ureter using a 2-0 monofilament suture (Monocryl). MEASUREMENTS AND MAIN RESULTS: The postoperative course was uneventful. A Foley catheter was left in place for 10 days, and the JJ probe was removed 6 weeks later. The operative time was 140 minutes. The step-by-step explanation technique was simple with minimal operative difficulty and a low rate of morbidity. CONCLUSION: This video shows how deep urinary endometriosis can be treated laparoscopically. Mastering suturing is essential to avoid complications.