Uterine conservation despite severe sepsis in a case of placenta accreta first treated conservatively: 3-month delayed successful removal of the placenta.

OBJECTIVE: To report a case of successful delayed removal of a placenta accreta first treated conservatively. Secondary infectious complications can occur after conservative management in cases of placenta accreta, most often leading to hysterectomy. DESIGN: Case report. SETTING: A French teaching hospital. PATIENT(S): A 33-year-old woman. INTERVENTION(S): A healthy 33-year-old woman underwent Cesarean section for her first pregnancy. Diagnosis of placenta accreta was made at ultrasound scanning for her second pregnancy. She was first treated conservatively. Hysterectomy was planned 3 months after conservative treatment because of sepsis attributed to uterine retention. (Hysterotomy was first realized.)-?? MAIN OUTCOME MEASURE(S): Uterine conservation. RESULT(S): The placenta was easily and successfully removed with no subsequent bleeding. The uterus was sutured and conserved. CONCLUSION(S): In cases of delayed sepsis because of uterine retention after conservative treatment for placenta accreta, when medical treatment remains unsuccessful, manual removal of the placenta should be attempted. This approach might allow improved uterine conservation rates in women with placenta accreta treated conservatively.

[Sentinel node biopsy in vulvar cancer]. / La technique du ganglion sentinelle dans le cancer de la vulve : état des lieux.

In vulvar cancer, lymph node status is a major prognostic factor. Currently, the reference regarding nodal exploration is the groin lymphadenectomy responsible for a significant morbidity. The sentinel node technique in breast cancer has become a standard of care. This technique has been studied for fifteen years in vulvar cancer, on small numbers because of its low incidence. There is not yet consensus about its use in practice. This article is a focus on this technology, its feasibility and the benefits of sentinel node detection applied to vulvar cancer.

[Impact of surgical access on staging of early borderline and invasive tumors of the ovary]. / Effet de la voie d'abord sur la stadification chirurgicale des lésions ovariennes frontières et des cancers à un stade précoce.

The objectives were to evaluate the impact of the surgical approach on the staging of borderline tumors and early-stage malignancies of the ovary. We retrospectively reviewed cases of borderline and invasive ovarian tumors stages Ia through Ic treated surgically between January 1, 1985 and December 31, 2001. We compared the rates of potentially harmful procedures according to the surgical approach. The quality of surgical staging was assessed by examining each required procedure and by determining a score. The influence of variables related to patient characteristics, preoperative workup, and initial surgery on staging quality was tested by univariate analysis. Variables independently associated with staging quality were entered in a logistic regression model. SPPS 7.5 and STATA 8 software was used for statistical tests. Of 118 patients with borderline tumors, 48 (41 %) underwent laparoscopic surgery, 54 (45 %) laparotomy, and 16 (14 %) laparoscopy converted to laparotomy. Surgery was conservative in 57 % of cases overall ; this proportion was significantly greater with laparoscopy than with laparotomy (p < 0.05) and in younger women (p < 0.001). Intraoperative tumor rupture occurred in 9 % of patients, with no significant difference across surgical approaches (p = 0.1). Bag extraction was used in 19 (40 %) of 48 laparoscopically treated patients. Staging was incomplete in 73 % of patients. By univariate analysis, bilateral adnexectomy and, to a lesser extent, age > 44 years, laparotomy, hysterectomy, and treatment after 1995 predicted at least partial staging. Factors independently associated with at least partial staging in the multivariate model were treatment after 1995, bilateral adnexectomy, and hysterectomy. Of 178 patients with invasive tumors, 34 underwent laparoscopic surgery, 114 laparotomy, and 30 conversion from laparoscopy to laparotomy. The laparotomy group was characterized by significantly older patient age and larger tumors, compared to the laparoscopy group. Staging was often inadequate after initial surgery, most notably with low rates of paraaortic lymphadenectomy (0 % in the laparoscopy group, 18 % in the laparotomy group, and 33 % in the conversion group). Staging is often less complete with laparoscopy than with laparotomy. In patients with invasive cancer, inadequate initial staging is common, most notably when laparoscopy is used. The surgeons training seems of major importance.

Impact of surgical approach on the management of macroscopic early ovarian borderline tumors.

OBJECTIVE: The aim of this study was to evaluate the impact of the surgical approach on the management and outcomes of patients with early borderline ovarian tumors (BOTs). MATERIAL AND METHODS: We retrospectively reviewed the medical charts of patients with stage Ia to Ic BOT treated surgically between January 1, 1985, and December 31, 2001. We compared patients initially managed by laparoscopy vs. laparotomy in terms of potentially harmful procedures and quality of staging. RESULTS: Of the 118 included patients, 48 (41%) had laparoscopy for initial surgery, 54 (45%) had laparotomy, and 16 (14%) had conversion from laparoscopy to laparotomy. Conservative treatment (57% of patients) was more common with laparoscopy (vs. laparotomy, P < 0.05) and in women older than 44 years (vs. younger than 44 years, P < 0.001). Intraoperative tumor rupture occurred in 9% of patients and was not associated with the surgical approach (P = 0.1). Bag extraction was used in 19 (40%) of the 48 laparoscopy patients. Staging was incomplete in 73% of patients overall. By univariate analysis, better quality of staging was associated with bilateral adnexectomy, age >44 years, laparotomy, hysterectomy, and treatment after 1995. By multivariate analysis, bilateral adnexectomy or hysterectomy was associated with better staging. Mean follow-up was 40 months, during which recurrence and survival rates were similar in the laparoscopy and laparotomy groups. CONCLUSION: Staging of macroscopic early stage BOTs was better in patients requiring radical surgery. After adjustment on disease severity, type of surgical access was not related to staging quality.