Étude cas-témoin comparant l'hystérectomie par voie vaginale à l'hystérectomie vNOTES : thèse présentée pour le diplôme d'État de docteur en médecine, diplôme d'État, mention diplôme d'études spécialisées en gynécologie-obstétrique

Médecine (gynécologie-obstétrique)En cas d’hystérectomie sans geste associé, il est recommandé de préférer la voie vaginale ou coelioscopique. Au cours des dernières années s’est développée une nouvelle voie d’abord : la voie vaginale coelio-assistée (vNOTES). L’objectif de cette étude était de comparer l’hystérectomie par voie vaginale (HV) et par vNOTES, en particulier en terme de douleur post opératoire à H6 en vue d’une chirurgie ambulatoire. Nous avons réalisé une étude monocentrique rétrospective cas-témoins comparant 38 HV à 38 vNOTES. Les patientes ont été appariées en un pour un suivant l’âge, l’IMC, le nombre d’accouchement voie basse, le nombre de césarienne et le poids de l’utérus. Le critère de jugement principal était les douleurs à six heures post opératoires mesurées par EVA. Les critères de jugements secondaires concernaient les douleurs à 1, 2 et 12 heures, les complications per et post opératoires, le recours aux morphiniques en post opératoire, le taux de conversion, la durée d’hospitalisation et le taux de reprise chirurgicale. Nos résultats montrent une diminution significative de la douleur à 6 heures post opératoire ainsi qu’une tendance à la diminution de la douleur à 1 heure post opératoire et du recours aux morphiniques. Il n’y a pas de différences portant sur les complications sévères, les douleurs à H2 et H12, la durée d’hospitalisation, le taux de reprise chirurgicale et le taux de conversion. La durée opératoire est significativement plus élevée dans le groupe vNOTES. Ce résultat est à pondérer par la learning curve en cours d’étude avec un plateau atteint entre 20 et 30 patientes opérées. L’hystérectomie par vNOTES semble diminuer les douleurs post opératoire sans augmenter le risque de complications sévères. Sa place reste toutefois à définir et d’autres études avec de plus grands effectifs semblent nécessaires pour confirmer ses avantagesIn case of hysterectomy without associated procedure, it is recommended to prefer the vaginal or laparoscopic route. In recent years, a new approach has developed: the coelio-assisted vaginal approach (vNOTES). The objective of this study was to compare vaginal hysterectomy (HV) and vNOTES, in particular in terms of postoperative pain at 6 hours post surgery. We performed a single-center, retrospective case-control study comparing 38 HV to 38 vNOTES. Patients were matched one for one according to age, BMI, number of vaginal deliveries, number of cesarean sections and uterine weight. The primary endpoint was pain six hours postoperatively measured by VAS. The secondary endpoints concerned pain at 1, 2 and 12 hours, intra and postoperative complications, use of opioids postoperatively, the conversion rate, the length of hospitalization and the rate of surgical revision. Our results show a significant reduction in pain at 6 hours postoperatively as well as a tendency to decrease in pain at 1 hour postoperative and in the use of opioids. There are no differences regarding severe complications, pain at H2 and H12, length of hospitalization, revision rate and conversion rate. The operating time is significantly higher in the vNOTES group. This result is to be weighted by the learning curve during the study with a pic reached between 20 and 30 patients operated on. vNOTES hysterectomy seems to reduce postoperative pain without increasing the risk of severe complications. However, its place remains to be defined and other studies with larger numbers seem necessary to confirm its advantage

Adherence to European ovarian cancer guidelines and impact on survival: a French multicenter study (FRANCOGYN)

International audienceOBJECTIVE: The primary objective of the study was to validate the European Society for Medical Oncology (ESMO)-European Society of Gynecologic Oncology (ESGO) ovarian cancer guideline as a method of assessing quality of care, and to identify patient characteristics predictive of non-adherence to European guideline care. The secondary objectives were to analyze the evolution of practices over the years and to evaluate heterogeneity between centers. METHODS: This retrospective multicenter cohort study of invasive epithelial ovarian cancer reported to the FRANCOGYN database included data from 12 French centers between January 2000 and February 2017. The main outcome was adherence to ESMO-ESGO guidelines, defined by recommended surgical procedures according to the International Federation of Gynecology and Obstetrics (FIGO) stage and appropriate chemotherapy. Mixed multivariable logistic regression analysis with a random center effect was performed to estimate the probability of adherence to the guidelines. Survival analysis was carried out using the Kaplan-Meier method and a mixed Cox proportional hazards model. RESULTS: 1463 patients were included in the study. Overall, 317 (30%) patients received complete guideline adherent care. Patients received appropriate surgical treatment in 69% of cases, while adequate chemotherapy was administered to 44% of patients. Both patient demographics and disease characteristics were significantly associated with the likelihood of receiving guideline adherent care, such as age, performance status, FIGO stage, and initial burden of disease. In univariate and multivariate survival analysis, adherence to the guidelines was a statistically significant and independent predictor of decreased overall survival. Patients receiving suboptimal care experienced an increased risk of death of more than 100% compared with those treated according to the guidelines (hazard ratio 2.14, 95% confidence interval 1.32 to 3.47, p<0.01). In both models, a significant random center effect was observed, confirming the heterogeneity between centers (p<0.001). CONCLUSIONS: Adherence to ESMO-ESGO guidelines in ovarian cancer was associated with a higher overall survival and may be a useful method of assessing quality of care