Abdominopelvic ultrasonographic findings after uncomplicated delivery.

PURPOSE: To prospectively determine the range of abdominopelvic ultrasonographic findings, including Doppler resistance index (RI) of uterine arteries, 2 and 24 hours after uncomplicated delivery. METHOD: Women who delivered vaginally or after cesarean section without complication from January 2012 to April 2012 in a tertiary care hospital were prospectively included. Abdominopelvic ultrasonography, including uterine artery resistance index (RI) at duplex Doppler ultrasonography, was performed 2 hours and 24 hours after delivery. RESULTS: Ninety-two women (mean age, 32.7 years) were included. Sixty-one (66%) delivered vaginally and 31 (34%) had cesarean section. Twenty-four hours after vaginal delivery, endometrial and anterior wall thicknesses dropped and uterine width increased (P<0.001). No changes in uterine length and posterior wall thickness were observed between 2 and 24 hours after delivery. Transient pelvic free-fluid effusion was observed in 1/92 woman (1%). Uterine artery RI increased significantly from 2 to 24 hours (0.50 vs 0.57, respectively; P<0.001). CONCLUSION: Pelvic free-fluid effusion is exceedingly rare in the early course of uncomplicated delivery. A significant increase in uterine artery RI during the 24 hours following uncomplicated delivery is a normal finding. It can be anticipated that familiarity with these findings would result in more confident diagnosis of complications.

[Operative technique: The clitoral transposition]. / Technique opératoire: la transposition clitoridienne.

Female sexual mutilations result in an important physical and mental suffering. A large number of women have been affected and require a global management, including surgical clitoral transposition. This surgical technique is allowing a rapid improvement of clinical symptoms. In this article, we will describe the indications and operative technique of the clitoral transposition.

[Sport and urinary incontinence in women]. / Incontinence urinaire chez la femme sportive.

Women are more attentive to their physical appearance and a quarter of French women use to practice a regular physical activity. Benefits of sport on general health are recognized. However, sport may be the cause of various diseases when it is poorly chosen or improperly performed. In literature, intensive exercise is a risk factor for urinary incontinence, defined as "the complaint of any involuntary leakage of urine". It is essentially stress urinary incontinence, occurring because of the phenomenon of intrabdominal hyperpressure, inherent with certain activities, and excess capacity of sphincters. Some sports are more risky than others, and high-level sportswomen are the most exposed. Health professionals must invest in information, screening, prevention, counseling and treatment track athletes So, the general practitioner and the doctor of sports play a vital role in informing, screening, prevention, therapeutic and monitoring of sportswomen. Better information is needed because according to the severity of incontinence and its impact, there are simple, effective, more or less invasive treatment options. The aim of this study was to establish an inventory of scientific knowledge and to improve the management of these patients.

[Diagnosis, treatment, and follow-up of cesarean scar pregnancy]. / Diagnostic, traitement et suivi des grossesses implantées sur cicatrice de césarienne.

OBJECTIVES: Cesarean scar pregnancy is a rare entity. This situation may induce uterine rupture and/or a massive life-threatening hemorrhage. The standard treatment is laparotomy surgery, but in situ injections to replace invasive surgery. The objective of this study was to focus on the diagnosis, optimal management and long-term follow-up of the patients. PATIENTS AND METHODS: Data from 6 patients with diagnosis of cesarean scar pregnancy between 2007 and 2013 at Lariboisière hospital were retrospectively collected. RESULTS: Endovaginal ultrasound succeeded to diagnose all cases. Four patients were treated with in situ injection of methotrexate performing a vaginal way (n=2) or laparoscopy (n=2) and two others using systemic injection. One patient was complicated by hemorrhagic shock requiring iterative embolizations. Three patients achieved a new pregnancy, with one recurrent scar pregnancy complicated by massive hemorrhage. DISCUSSION AND CONCLUSION: Diagnosis and treatment of cesarean scar pregnancies must be done precociously because of high hemorrhage risks. Endovaginal ultrasound is the gold standard exam. Treatment is non-consensual, but methotrexate in situ injection is effective and safer. Monitoring the decrease of HCG levels and ultrasonography supervision of gestational sac size and its vascularization must be performed. Due to the risk of recurrence, any subsequent pregnancy shows a high risk of complications.

[Impact of omission of axillary dissection on adjuvant therapy in patients with metastatic sentinel lymph nodes according to the ACOSOG Z0011 criteria]. / Impact de l'omission du curage axillaire sur les traitements adjuvants chez les patientes ayant un ganglion sentinelle métastatique et répondant aux critères d'inclusion de l'ACOSOG Z0011.

OBJECTIVES: The results of the ACOSOG Z0011 questioned the usefulness of axillary lymph node dissection (ALND) in case of metastatic sentinel lymph node (SLN). The aim of our study was to assess the impact of the omission of ALND according to the inclusion criteria of the ACOSOG Z0011 study if SLN are metastatic but also the consequences on prescription of the application of a new standard of care for adjuvant treatment. PATIENTS AND METHODS: This retrospective study included, between November 2007 and January 2012, patients with T1-T2N0 breast cancer and metastatic SLN meeting the criteria for omission of completion ALND according to the study of the ACOSOG Z0011. Patients were submitted anonymously and randomly in multidisciplinary meeting (MM) 3 times: with complete information including ALND (MM1), with information from SLN alone (MM2) and with complete information of ALND according to the current protocols in 2013 (MM3). During each presentation, we collected the decision of the different adjuvant treatments proposed: chemotherapy, hormonal therapy, radiotherapy (with radiation fields). Then, we compared therapeutic proposals of the 3 presentations. RESULTS: Fifty-eight patients were eligible for inclusion criteria of the ACOSOG Z0011. Treatments actually proposed during MM1 consisted of 94.8 % of chemotherapy, 77.6 % of breast and lymph nodes radiotherapy and 91.4 % of hormone therapy. During the MM2, there was no significant difference compared to the decision taken during MM1. In fact, during MM2, we decided chemotherapy, radiotherapy and hormonotherapy respectively in 89.7, 79.3 and 91.4 % of the cases. During the MM3, it was shown a significant decrease in the indications of chemotherapy (82.8 %, P=0.03) and lymph nodes irradiation (56.9 %, P=0.02) compared to the therapeutic proposals of the MM1. DISCUSSION AND CONCLUSION: The lack of information of ALND does not seem to significantly alter indications for adjuvant treatment. Otherwise, the evolution of our references causes a decrease in adjuvant therapy.

International multicenter tool to predict the risk of four or more tumor-positive axillary lymph nodes in breast cancer patients with sentinel node macrometastases.

Recently, many centers have omitted routine axillary lymph node dissection (ALND) after metastatic sentinel node biopsy in breast cancer due to a growing body of literature. However, existing guidelines of adjuvant treatment planning are strongly based on axillary nodal stage. In this study, we aim to develop a novel international multicenter predictive tool to estimate a patient-specific risk of having four or more tumor-positive axillary lymph nodes (ALN) in patients with macrometastatic sentinel node(s) (SN). A series of 675 patients with macrometastatic SN and completion ALND from five European centers were analyzed by logistic regression analysis. A multivariate predictive model was created and validated internally by 367 additional patients and then externally by 760 additional patients from eight different centers. All statistical tests were two-sided. Prevalence of four or more tumor-positive ALN in each center's series (P = 0.010), number of metastatic SNs (P < 0.0001), number of negative SNs (P = 0.003), histological size of the primary tumor (P = 0.020), and extra-capsular extension of SN metastasis (P < 0.0001) were included in the predictive model. The model's area under the receiver operating characteristics curve was 0.766 in the internal validation and 0.774 in external validation. Our novel international multicenter-based predictive tool reliably estimates the risk of four or more axillary metastases after identifying macrometastatic SN(s) in breast cancer. Our tool performs well in internal and external validation, but needs to be further validated in each center before application to clinical use.

[Pregnancy follow-up and outcome in women with superficial vascular malformations]. / Malformations vasculaires superficielles : impact sur le suivi de grossesse et prise en charge à l'accouchement.

Superficial vascular malformations (MAV), so far called "superficial angioma", are uncommon and often unknown. The last classification, done by the "International Society for the Study of Vascular Anomalies", is essential to avoid diagnostic and therapeutic mistakes. Extramedullar localisations are rare. The coexistence of a pregnancy and a MAV states two problems: the medical and paraclinic supervision of the volume of the MAV and its risk of thrombosis with the choice of thrombosis prevention, and the mode of delivery and type of anaesthesia depending on its anatomical location. We revised the management of pregnant women with a MAV illustrating possible troubles to deal with. We reported the cases of two women having for the first one a pharyngolaryngeal MAV, the second a cutaneous MAV located on the leg and needing a multidisciplinary management with obstetricians, anaesthesists, hematologists, dermatologists, ENT, radiologists and pediatricians.

[Update on the epidemiology of genital prolapse]. / Etat des lieux de l'épidémiologie des prolapsus génitaux.

The prevalence of pelvic organ prolapse (POP) varies between 2.9 and 11.4% in questionnaire-based studies and from 31.8 to 97.7% according to the ICS Pelvic Organ Prolapse Classification (POPQ) anatomical classifications. The cumulative incidence of surgery for POP is as high as 70% in women more than 70-year-old. Aging is significantly associated with the prevalence and severity of POP. Pelvic disorders are a health economic challenge for the future due to the longer life expectancy of women and to an increasing demand for a better quality of life. Identification of risk factors will be critical in order to develop strategies to prevent the disease and limitate the need for surgical intervention.

[Risk factors and prevention of genitourinary prolapse]. / Facteurs de risque et prévention des prolapsus génito-urinaires.

Numerous epidemiological studies in recent years have involved the search for the principal risk factors of genitourinary prolapse. Although it has been agreed for a long time that vaginal delivery increases the risk of prolapse (proof level 1), on the other hand, the Cesarian section cannot be considered a completely effective preventative method (proof level 2). The pregnancy itself is a risk factor for prolapse (proof level 2). Certain obstetrical conditions contribute to the alterations of the perineal floor muscle: a foetus weighing more than four kilos, the use of instruments at birth (proof level 3). If the risk of prolapse increases with age, intrication with hormonal factors is important (proof level 2). The role of hormonal replacement therapy remains controversial. Antecedent pelvic surgery has also been identified as a risk factor (proof level 2). Other varying acquired factors have been documented. Obesity (BMI and abdominal perimeter), professional activity and intense physical activity (proof level 3), as well as constipation, increase the risk of prolapse. More thorough research into these varying factors is necessary in order to be able to argue for measures of prevention, obstetrical techniques having already evolved to ensure minimal damage to the perineal structure.

[Role of sentinel node biopsy in early-stage cervical cancer in the therapeutic strategy]. / Place du ganglion sentinelle dans la stratégie thérapeutique du cancer du col de l'utérus aux stades précoces.

Early-stage cervical cancer (IA2 and IB1) treatment consists in surgery with a radical colpohysterectomy associated to a systematic pelvic lymphadenectomy more or less a paraaortic lymphadenectomy (Wertheim-Meigs surgery). Pelvic lymph node involvement is the main independent prognostic factor and justifies an adjuvant therapy. Sentinel lymph node (SLN) procedure allows a reliable evaluation of the lymph node status thanks to an accurate histologic analysis. This procedure is still not validated in practice, which means the bilateral pelvic lymphadenectomy is systematically done whatever the lymph node status is. Nevertheless the purpose of the SLN biopsy in cervical cancer does not consist in avoiding an unnecessary lymphadenectomy, which is not really associated with a major morbidity. Actually, a better initial stadification would allow to fit to the risk of recurrence not only the radicality of the surgery, but also the adjuvant therapy. The morbidity of a radical surgery could be limited for good prognosis patients and avoided for the benefit of a concomitant chemoradiotherapy.

[State of the art about teaching hysteroscopy to gynaecologist surgeons in France and in Europe. CONFORM investigation into the training of the hysteroscopic placement of microinserts]. / Etat des lieux de la formation des chirurgiens gynécologues à l'hystéroscopie en France et en Europe. Enquête CONFORM sur la formation à la mise en place des implants de stérilisation tubaire par voie transcervicale.

OBJECTIVE: Since 2002, Conceptus company markets in France and Europe the Essure microinsert as permanent hysteroscopic intratubal sterilization, and organizes a meeting, a training and an assistance on a few cases. The data from this interview and the results of the first cases done with assistance of Conceptus instructors were collected prospectively between January 2004 to December 2006. The purpose is to make a state of the art about teaching hysteroscopy to gynaecologist surgeons in France and in Europe. PATIENTS AND METHODS: According to their statements about their knowledge of hysteroscopy practice, surgeons were classified in four groups. Group 1 included those who had a bad knowledge and a sporadic practice, group 2 those who had no formation and an empirical practice, group 3 those who had a regular practice and an incomplete formation or whose formation was in progress and group 4 those with fully-formed surgeons with a regular practice. RESULTS: One thousand one hundred and fourty-four women underwent hysteroscopic sterilisation with a global success rate of 92.13%. Were included 536 surgeons and 498 were evaluated. There were 80 (16.06%) surgeons in group 1, 149 (29.92%) in group 2, 121 (24.30%) in group 3 and 148 (29.72%) in group 4. Failure rates for each group were respectively 16.25%, 10.07%, 9.10% and 4.73% (p < or = 0.01). The presence of an instructor was associated with a fast improvement judging from the classification in a higher level group in 47.83%, 28.21% and 25% respectively for the groups 1 to 3 after the second visit and in 75%, 58.33% and 20% after the third visit. DISCUSSION AND CONCLUSION: It seems important to establish a modern and low-cost teaching program to improve surgeon's theoretical and practical formation in hysteroscopy in order to increase success rates and reduce possible complications. Theoretical formation has to include a good knowledge of the material and its use: diameter and form of the operative channel, obliquity of the scope, liquid of distension and kind of current used. Practical formation could be done at once with virtual models to get used with the manipulation of the scope and thanks to the use of different currents with the assistance of a trained surgeon.

[Sentinel lymph node biopsy under local anaesthesia: how to avoid the disadvantages of intraoperative examination?]. / Le prélèvement du ganglion sentinelle sous anesthésie locale ou comment s'affranchir des limites de l'analyse histologique peropératoire.

The sentinel lymph node procedure has become the standard in the surgical management of localised breast cancer. However, it is submitted to the uncertainties of intraoperative examination. Indeed, intraoperative examination has three major disadvantages: the type of histological method (frozen section versus imprint cytology), the size of sentinel node metastasis (macro- versus micrometastases) and the time requested for this technique. All of these limits are responsible for secondary re-interventions to complete axillary lymph node dissection. Few medical teams have described a new surgical strategy to avoid these limits. They proposed the detection of the sentinel lymph node under local anaesthesia and to wait for the definitive histological analysis before carrying out lumpectomy and axillary lymphadenectomy if necessary under general anaesthesia. We realized a review of the literature on this new procedure to evaluate its feasibility and to assess the technical aspects.