Defining a Uterine Extraction Score based on a Volume/Access Ratio in Total Hysterectomy: a retrospective cohort study.

Background: Regardless of the technique used, extraction of the uterus is a crucial step in hysterectomy. There is currently no scoring system to predict its feasibility. Objectives: Our main objective was to determine a predictive score of uterine extraction feasibility to optimise surgical planning of total hysterectomy. As secondary objectives, we examined the correlation between uterine volume predicted by preoperative ultrasound and the final weight of the surgical specimen and analysed the impact of the uterine extraction modality on operative and hospitalisation times. Materials and Methods: We defined a Uterine Extraction Score (UES) based on the ratio between uterine sizes and vaginal access. This score was retrospectively applied to a cohort of 178 patients who were hysterectomised for benign conditions between January 2019 and December 2022. Main outcome measures: The UES allows identification of three groups of decreasing feasibility of vaginal extraction, symbolised by traffic light colours: green - vaginal extraction without morcellation, orange -vaginal extraction with morcellation, red - abdominal morcellation by mini-laparotomy or primary laparotomy. Results: The results show that the UES--predicted, and the observed routes of extraction concord in 92% of cases. There is a strong correlation between estimated volume and final uterine weight. Uterine morcellation lengthens the operative time and the hospital stay. Conclusions: The UES seems to be a reliable tool to predict the route of uterine extraction in total hysterectomy. What is new?: The development of a new scoring system empowers surgeons with decisive information to enhance perioperative outcomes.

Practice of laparoscopic prolapse surgery in Europe - ESGE Survey.

Sacrocolpopexy is considered as the "gold standard" for management of women with apical prolapse. Numerous technical variants are being practiced. The first aim of this survey was to determine the habits of practice of laparoscopic sacrocolpopexy (LSCP) in Europe. The second aim was to determine whether surgeons who perform laparoscopic pelvic organ prolapse (POP) repair are familiar with the practice of alternative techniques and with mesh-less laparoscopic treatment of prolapse. The questionnaire was designed by the Urogynaecology Special Interest Group of the European Society for Gynaecological Endoscopy (ESGE). All ESGE-members were invited by email to respond to this survey consisting of 54 questions divided in different categories. Following review of ESGE member's responses, we have highlighted the great heterogeneity concerning the practice of LSCP and important variability in performance of concomitant surgeries. Alternative techniques are rarely used in practice. Furthermore, the lack of standardisation of the many surgical steps of a laparoscopic sacrocolpopexy is mainly due to the lack of evidence. There is a need for training and teaching in both standard and newer innovative techniques as well as the reporting of medium and long-term outcomes of both standard laparoscopic sacrocolpopexy and any of its alternatives.

[Third- and fourth-degree post-delivery perineal tears : retrospective analysis and management adaptation]. / Les déchirures périnéales des 3ème et 4ème degrés post-accouchement : analyse rétrospective et adaptation de la prise en charge.

Third- and fourth-degree perineal tears are injuries involving the anal sphincter that occur during vaginal delivery. Their prevalence is between 0.25 and 6 %, which highlights the variability of obstetrical practice among different countries. This type of tear can lead to short- and long-term complications for the mothers, affecting their quality of life. Therefore, it seems essential that their management should be optimal. In this study, we analyzed the records of all women who suffered from an obstetric anal sphincter injury between January 2015 and January 2021. During this period, out of 11222 vaginal deliveries, 61 records (0.54%) were retained. Maternal, fetal, and delivery-related risk factors were studied and were mostly similar to those found in the literature. However, the treatment of these lesions was very heterogeneous among patients and lacked standardization. A better management of these tears through the establishment of a decision algorithm would potentially reduce the long-term morbidity.

Les déchirures périnéales des troisième et quatrième degrés sont des lésions entreprenant le sphincter anal et survenant lors de l'accouchement par voie vaginale. Leur prévalence est comprise entre 0,25 et 6 %, ce qui souligne la variabilité de la pratique obstétricale selon les pays. Ce type de lésion peut entraîner des complications à court et long termes pour les patientes, affectant leur qualité de vie. Dès lors, il semble essentiel que leur prise en charge soit optimale. Dans cette étude rétrospective monocentrique, les dossiers des femmes ayant présenté une lésion obstétricale du sphincter anal entre janvier 2015 et janvier 2021 ont été analysés. Durant cette période, sur 11.222 accouchements par voie basse, 61 dossiers (0,54 %) ont été retenus. Les facteurs de risque maternels, fœtaux et liés à l'accouchement ont été étudiés et sont majoritairement similaires à ceux retrouvés dans la littérature. En revanche, la prise en charge de ces lésions était très hétérogène parmi les patientes, avec un manque de standardisation. Une meilleure gestion de ces déchirures via l'instauration d'un algorithme décisionnel permettrait potentiellement d'en diminuer la morbidité à long terme.

[Recovery after gynaecological surgery in French-speaking Belgium : survey and recommendation of the GGOLFB surgical working group]. / Convalescence après chirurgie gynécologique en Belgique francophone : sondage et recommandations du groupe de travail de chirurgie du Groupement des Gynécologues et Obstétriciens de Langue Française de Belgique.

Since the introduction of laparoscopy and mini-invasive techniques, gynaecological surgery has largely evolved. However, post-operative recommendations still remain very restrictive with poor evidence from literature. The survey, performed by the GGOLFB surgical working group, shows that the post-operative advices to the patients are very heterogeneous for the sick leave period as for more specific advices like the period of disallowance of sexual intercourse, bathing and weightlifting. It is nevertheless fundamental to prescribe clear and precise advices to patients, from the first pre-operative consultation on, which will substantially improve the perception of their recovery and promote a return to their normal activity under good conditions. It is not necessary to be too restrictive concerning certain activities in the post-operative period, neither to give too long periods of work incapacity because it may have a negative impact on their quality of life. This survey and the data from literature helped our surgical taskforce group to propose and develop harmonised recommendations on recovery and work incapacity after gynaecological surgery, taking into account the actual surgical practice in 2020.

La chirurgie gynécologique a fortement évolué depuis l'introduction de la laparoscopie et le développement de la chirurgie mini-invasive. Les recommandations post-opératoires sont souvent assez restrictives, avec peu d'évidence dans la littérature sur le bien-fondé de ces limitations. Notre sondage auprès des gynécologues francophones de Belgique montre que les consignes post-opératoires délivrées aux patientes sont très hétérogènes, aussi bien pour les durées d'incapacité de travail que pour des consignes plus spécifiques sur la durée d'absence de port de charges, de bains et de rapports sexuels. Il est pourtant fondamental de délivrer aux patientes des consignes précises, dès la consultation préopératoire, afin d'améliorer le vécu de leur convalescence et favoriser un retour aux activités dans de bonnes conditions. Il n'est pas non plus nécessaire d'être trop restrictif dans la reprise de certaines activités en postopératoire ni de recommander des incapacités de travail trop longues car elle peuvent avoir un impact négatif sur la qualité de vie des patientes. Au regard du sondage et de la revue des données de la littérature, notre groupe de travail propose des recommandations harmonisées sur la convalescence et l'incapacité de travail après chirurgie gynécologique, tenant compte des pratiques chirurgicales recommandées en 2020.

Use of methotrexate in the treatment of ectopic pregnancies: a retrospective single center study.

INTRODUCTION: The aim of this study was to evaluate the efficacy of methotrexate (MTX) in the treatment of ectopic pregnancies. We identified predictive factors of success or failure and compared our results with previous studies to make recommendations for its use. MATERIAL AND METHODS: A cohort of 61 patients from a single center was retrospectively analyzed. Inclusion criteria were a diagnosis of ectopic pregnancy and treatment with a single-dose injection of MTX. The need to perform surgery despite MTX was defined as treatment failure while needing a second MTX injection was not. RESULTS: In our cohort, MTX demonstrated a success rate of 80%. This rate rose to 84% when patients with human Chorionic Gonadotropin (hCG ) > 5,000 IU/L were excluded. Twenty percent underwent surgery for pain, increased mass size and/or suboptimal hCG kinetics. Low hCG levels on days 0, 4 and 7 as well as the absence of pain, metrorrhagia and hemoperitoneum were predictive of success. MTX was also efficient in the treatment of persisting pregnancies of unknown location (PUL). CONCLUSION: Our results are consistent with previous studies and emphasize the fact that MTX is less effective above a certain level of hCG. We obtained a cut-off value of 2439 IU/L with a sensitivity of 66.7% and a specificity of 93.9%. MTX should not be used when hCG is higher than 5,000 IU/L and laparoscopic surgery should be performed. Our results bring additional data about the efficacy of MTX in the management of persisting pregnancies of unknown location.

[Do we need to perform systematic supracervical hysterectomy during laparoscopic sacrocolpopexy?] / Doit-on réaliser systématiquement une hystérectomie subtotale dans le cadre d'une promontofixation cœlioscopique ?

OBJECTIVE: To evaluate the place of subtotal hysterectomy during laparoscopic sacrocolpopexy. METHODS: This retrospective observational study includes patients undergoing laparoscopic sacrocolpopexy between November 2010 and March 2015 at the Centre Hospitalier Régional de la Citadelle, Liège, Belgium. Patient characteristics, medical and surgical history were collected. Clinical data, operative and intraoperative complications were analyzed. The postoperative results were collected at 6 weeks, 4 months and then every year with a clinical and anatomical evaluation by POP-Q (Pelvic Organ Prolapse - Quantification). RESULTS: Ninety-four patients were included in the study. Sixty-four patients (68.1%) underwent sacrocolpopexy with subtotal hysterectomy, 12 patients (12.7%) had sacrocolpopexy with uterine preservation, 16 patients (17%) had a clinical history of hysterectomy and 2 patients (2.2%) have had sacrocolpopexy with total hysterectomy. The mean age of the patients was 61±20 years, parity 2±2 and BMI 25.2±7.32. The objective success rate, defined by a stage of POP-Q<2, was 93.75% in the sacrocolpopexy group with subtotal hysterectomy vs. 66.7% in the sacrocolpopexy group with uterine preservation (P=0.019). The subjective success rates were 98.4% and 83% respectively (P=0.063ns). CONCLUSION: Sacrocolpopexy offers good anatomical results, with better objective and subjective success rates when associated with a subtotal hysterectomy. The decision of hysterectomy should consider the risk/benefit balance and the patient's preferences.

Vaginocutaneous fistula and buttock abscess formation 7 years after polypropylene transobturator tape insertion.

Surgical treatment for stress urinary incontinence (SUI) using transobturator tape insertion is widely accepted. However, several postoperative complications were reported in the literature including infections, abscess and fistula formation. Here, we report a case of 57-year-old female who presented with abscess and left vaginocutaneous buttock fistula 7 years after transobturator polypropylene tape insertion. Treatment included abscess drainage with dissection of the fistulous tract and removal of the left arm of the transobturator tape along with antibiotic coverage. Sinus drainage stopped after 3 days. Stress urinary incontinence did not recur. Suspicion of fistula formation should rise in patients presenting with bothersome vaginal or cutaneous discharge after transobturator tape insertion. This case is particular since it describes a fistula complication with polypropylene tape, which is unusual with this type of tapes. Treatment of such complication should always consist of surgical removal of the mesh to allow closure of the fistulous tract.