Total Laparoscopic Hysterectomy for Endometriosis and an Arteriovenous Malformation.

STUDY OBJECTIVE: To show laparoscopic management of an arteriovenous malformation in a patient with deep pelvic endometriosis DESIGN: A step-by-step explanation of the surgery using an instructive video. SETTING: Hautepierre University Hospital, Strasbourg, France. INTERVENTIONS: We describe the case of a 37-year-old patient presenting with deep pelvic endometriosis and a uterine arteriovenous malformation. Deep pelvic endometriosis was diagnosed during a tubal ligation in 2015. Laparoscopy also showed some pelvic varicosities. Hysteroscopy was performed to increase the diagnostic precision. Huge blood vessels with an arterial pulse on the anterior wall of the uterus were found. The endometriosis of the patient was very symptomatic; she suffered from dysmenorrhea, menorrhagia, intense dyspareunia, and dyschezia. Magnetic resonance imaging indicated a large arteriovenous shunt in the anterior part of the uterus and bladder endometriosis. After a pluridisciplinary medical staff meeting, we decided to begin treatment with luteinizing hormone-releasing hormone analogs. Then, she underwent embolization of the arteriovenous malformation, which produced regression of the lesions as indicated by reevaluation with magnetic resonance imaging. We decided to perform laparoscopic hysterectomy. Evaluation of the abdominal cavity showed diaphragm endometriosis, deep pelvic endometriosis, and the arteriovenous malformation. We started with left ureterolysis and opening of the rectovaginal septum. After that, we radically dissected the left side of the uterus with a left oophorectomy and then the right side, conserving the ovary. Then, we shaved the bladder for endometriosis removal. To finish, we performed a right salpingectomy with a right ovariopexy, vaginal closure, and coagulation of the diaphragm's nodules. The patient agreed to record and publish the surgery, and the local institutional review board gave its approval. CONCLUSION: To conclude, preoperative embolization of the arteriovenous shunt improves surgery, avoiding excessive bleeding and permitting easier radical hysterectomy for deep pelvic endometriosis. Similar cases have been published [1], but to our knowledge, our video is the first regarding this subject. It appears that embolization can fail, but hysterectomy remains the gold standard treatment [2].

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.

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.

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.

Evaluation of long-term neurodevelopment in twin-twin transfusion syndrome after laser therapy.

OBJECTIVE: The primary objective of our study was to evaluate the long-term neurodevelopment outcome after laser surgery for twin-twin transfusion syndrome (TTTS). The secondary objective was to identify perinatal prognostic factors associated with neurodevelopmental impairment. METHOD: This was a single-center cohort prospective study carried out in pregnancies complicated by TTTS and treated by laser. Neurodevleopmental assesment included the administration of Ages and Stages Questionnaires® (ASQ), for the infants between 2 and 5 years of age. RESULTS: A total of 187 patients underwent a laser for TTTS between 2004 and 2013. Significant brain lesions were detected in eight (2.9%) cases by ultrasound and/or magnetic resonance imaging including intraventricular hemorrhage, periventricular leukomalacia, and porencephaly. Questionnaires were administered to 126 children (50.4%) at 24 months or older at the moment of testing. There were 13.5% of those infants who had an abnormal ASQ (established as one area or more scoring < 2 SD) at 3.6 years ±1.3 follow-up. There was a higher rate of abnormal ASQ among the infants with a birth weight below the fifth percentile (p = 0.036). CONCLUSION: Twin-twin transfusion syndrome is associated with a risk of abnormal neurological development, even in case of laser surgery. Further studies are necessary to identify the risk factors for neurological impairment. © 2016 John Wiley & Sons, Ltd.

Development of a methodology for in vivo follow-up of hepatocellular carcinoma in hepatocyte specific Trim24-null mice treated with myo-inositol trispyrophosphate.

BACKGROUND: Genetically induced hepatocellular carcinoma (HCC) models are generally used to investigate carcinogenesis pathways, but very few attempts were made to valorize them for pharmacological testing. This study describes a micro-computed tomography (micro-CT) - based methodology for the diagnostic and lifelong follow-up of HCC in the hepatocyte-specific Trim24-null mouse line. Myo-inositol trispyrophosphate (ITPP) was tested as anti-cancer drug. METHODS: Partial hepatectomy was performed in 2 months-old Trim24-null mice, in order to accelerate the carcinogenesis process. HCC diagnosis was obtained by micro-CT scan with double contrast agent: 10 µl/g Fenestra™ LC was injected intraperitoneally 6 h prior to imaging and 10 µl/g Fenestra™ VC was injected intravenously 15 min prior to imaging. Twenty three hepatocyte-specific Trim24-null mice were considered for ITPP testing (3 mg/g/week intraperitoneally during 10 months in 12 mice, versus 11 controls). Lifelong follow-up was performed using micro-CT. Comparative analysis was performed using unpaired t test with Welch correction and survival curves were compared by log-rank test. Gene expression analysis was performed using the RT q-PCR technique. RESULTS: Double contrast micro-CT scan allowed HCC diagnosis as hypodense, isodense or hyperdense nodules. Positive predictive value was 81.3 %. Negative predictive value was 83.3 %. Tumor growth could be objectified by micro-CT scan before the ITPP treatment was started, and at 3 and 9 months follow-up. Significant progression of tumor volume was demonstrated in the both groups, with no difference between groups (p > 0.05). In the ITPP group, a mild decrease in tumor doubling time was first observed (31.9 +/- 12 days, p > 0.05) followed by a significant increase (59.8 +/- 18.3 days, p = 0.008). However, tumor doubling time was not different between groups (p > 0.05). Median survival after treatment initiation was 223 days (controls) versus 296 days (ITPP group, p = 0.0027). HIF1α, VEGF, glutamine synthase, osteopontin expression levels were not significantly modified at the end of follow-up. In the ITPP group, the p53 expression profile was inversed as compared to the control group, higher in non-tumor livers than in tumors. CONCLUSION: ITPP treatment allowed for a two-month survival improvement, with better tolerance of tumor burden and apoptosis increase in non-tumor, pathological livers.

Pyomyoma after abortion: Uterus conserving surgery is possible to maintain fertility. Case report.

INTRODUCTION: Pyomyoma is a rare complication associated with high rates of morbidity and mortality. PRESENTATION OF CASE: We report the case of a 28-year-old nulligravida patient presenting pyomyoma following a spontaneous abortion at fourteen weeks and four days. Fourteen days following spontaneous miscarriage she was referred to the hospital with abdominal pain and fever. An antibiotic treatment was initiated. However, after ten days, the patient's condition deteriorated and a decision for an emergency laparotomy made. The pyomyoma was successfully resected and the patient's postoperative recovery was uneventful. A new pregnancy was confirmed two years later. DISCUSSION: The diagnosis of pyomyoma can be difficult but surgical treatment is often indicated. Performing a prompt myomectomy avoids the need for hysterectomy, preserving future fertility. CONCLUSION: Pregnancy is possible following uterine sparing treatment of pyomyoma.

Impact of Laparoscopic Surgical Management of Deep Endometriosis on Pregnancy Rate.

STUDY OBJECTIVE: To evaluate the impact of laparoscopic excision of lesions on deep endometriosis-related infertility. DESIGN: Retrospective study. SETTING: Endometriosis tertiary referral center (Canadian Task Force II-2). PATIENTS: A group of 115 patients who had undergone laparoscopic surgery for infertility with histologic confirmation of deep endometriosis. INTERVENTIONS: Patient medical records and operative reports were reviewed. Telephone interviews were conducted for long-term follow-up of fertility outcomes. MEASUREMENTS AND MAIN RESULTS: Evaluation of fertility outcome after laparoscopic treatment of deep endometriosis by spontaneous conception and by assisted reproductive technology (ART) correlated with lesion number, size, and location (anterior, posterolateral, pouch of Douglas, and multiple locations). After a mean follow-up of 22 months the overall pregnancy rate was 54.78% (n = 63) with a live-birth rate of 42.6% (n = 49). Among those patients given the chance to conceive spontaneously (n = 70), the overall pregnancy rate was 60% (n = 42): 38.5% (n = 27) spontaneously and 21.4% (n = 15) by ART. The removal of multiple lesions was associated with a higher pregnancy rate after surgery. When comparing isolated lesion size and disease location, there was no difference in pregnancy rate. Furthermore, those patients who underwent surgical eradication of the disease for the first time had a higher pregnancy rate (odds ratio, 4.18). CONCLUSION: This study demonstrates that laparoscopic excision of deep endometriosis enhances pregnancy rate, by both spontaneous conception and ART. First surgical treatment of multiple lesions was associated with higher pregnancy rates, whereas isolated lesions influenced the pregnancy rate irrespective of their location and size.

First report of granulomatous mastitis associated with Sjögren's syndrome.

Granulomatous mastitis is a rare and often considered as idiopathic disease. However, clinical examination and thorough diagnostic investigations have to be carried out in order to identify cases that are secondary to infections or systemic diseases since these forms may be cured with appropriate etiologic treatment. To the best of our knowledge, this report is the first to describe the association of granulomatous mastitis with Sjögren's syndrome. We discuss the clinical, pathological and therapeutic implications of this association.

[Contribution of microCT structural imaging to preclinical evaluation of hepatocellular carcinoma chemotherapeutics on orthotopic graft in ACI rats]. / Apport de l'imagerie structurale par micro scanner X dans l'évaluation pré-clinique de chimiothérapies du carcinome hépatocellulaire sur greffe orthotopique chez le rat ACI.

Animal experimentation is a prerequisite for preclinical evaluation of treatments such as chemotherapy. It's strictly regulated with the purpose of reducing the number of experimental animal as well as their pain. Small animal imaging should provide a painless longitudinal follow up of tumor progression on a single animal. The aim of the study is to validate small animal imaging by microscanner (µscan) in longitudinal follow up of a hepatocellular carcinoma (HCC) and to demonstrate its interest for in vivo evaluation of tumor response to different therapeutics. An HCC model achieved by orthotopic graft of the MH3924A cell line in ACI rats was followed using a Imtek/Siemens microscanner (µscan) with contrast agents (Fenestra(®) LC/VC). The procedures giving the optimal enhancement of the liver as well as a reliable determination of tumor volumes by µscan were validated. Three protocols for therapeutic assessment through µscan longitudinal follow up were performed. Each consisted in three groups testing a chemotherapy (gemcitabine, gemcitabine-oxaliplatine or sorafenib) versus two control groups (placebo and doxorubicine). Comparison was done on tumor volumes, median and actual survivals. There was a significant correlation between tumor volumes measured by µscan and autopsy. Treatment by sorafenib, at the contrary of gemcitabine alone or with oxaliplatine, resulted in a significant reduction in tumor volumes and prolongation of actuarial survival. These results are consistent with available clinical data for these diverse therapeutics. In conclusion, small animal imaging with µscan is a non-invasive, reliable, and reproducible method for preclinical evaluation of antitumor agents.