Évolution des symptômes attribués aux Implants Essure® après retrait par hystérectomie vaginale ou salpingectomie bilatérale par coelioscopie avec cornuectomie

Thèse présentée sous la forme d'une "Thèse Article"Introduction : les implants intra-tubaires Essure® ont été utilisés comme méthode de stérilisation définitive de 2001 à 2017. Ils ont été utilisés pour plus de 750 000 procédures. Des effets indésirables gynécologiques ou non ont été rapportés par des patientes. L’objectif de l’étude est d’évaluer la résolution des symptômes attribués aux implants intra-tubaires de type Essure® après leur retrait chirurgical.Méthodes : étude rétrospective monocentrique. Les patientes ayant bénéficié d’un retrait chirurgical des implants Essure® entre janvier 2017 et avril 2019 ont été inclues. Le retrait a été réalisé par salpingectomie bilatérale avec cornuectomie par cœlioscopie ou par hystérectomie vaginale. Les symptômes ont été évalués en préopératoire, 4 à 8 semaines après le retrait (évaluation précoce) et 6 à 24 mois après le retrait (évaluation plus tardive). Résultats : quatre-vingt-dix patientes ont bénéficié d’un retrait chirurgical des implants Essure®. Cinquante-deux hystérectomies vaginales et trente-cinq salpingectomies par cœlioscopie ont été réalisées. Les principaux symptômes rapportés sont des douleurs pelviennes (70%), de l’asthénie (66,7%) et des méno-métrorragies (53,3%). Un mois après la chirurgie, 46,7% des patientes ont une résolution complète des symptômes et 51,1% une résolution partielle. Le taux de résolution complète n’est pas significativement différent entre la salpingectomie coelioscopique et l’hysterectomie vaginale (51,5% versus 42,3%) (p=0,23). A 24 mois, les résultats s’améliorent avec 83,3% de résolution complète.Conclusion : l’ablation chirurgicale semble efficace pour traiter la majorité des patientes présentant des symptômes attribués aux implants intra-tubaires de type Essure®. L’hystérectomie vaginale et la salpingectomie par cœlioscopie avec cornuectomie semblent être équivalentes dans la résolution des symptômes lors de l’évaluation précoce et plus tardive

Minithoracotomy versus sternotomy in mitral valve surgery: meta-analysis from recent matched and randomized studies

Abstract Background There is still ongoing debate about the benefits of mini-thoracotomy (MTH) approach in mitral valve surgery in comparison with complete sternotomy (STER). This study aims to update the current evidence with mortality as primary end point. Methods The MEDLINE and EMBASE databases were searched through June 2022. Two randomized studies and 16 propensity score matched studies published from 2011 to 2022 were included with a total of 12,997 patients operated on from 2005 (MTH: 6467, STER: 6530). Data regarding early mortality, stroke, reoperation for bleeding, new renal failure, new onset of atrial fibrillation, need of blood transfusion, prolonged ventilation, wound infection, time-related outcomes (cross clamp time, cardiopulmonary bypass time, ventilation time, length of intensive care unit stay, length of hospital stay), midterm mortality and reoperation, and costs were extracted and submitted to a meta-analysis using weighted random effects modeling. Results The incidence of early mortality, stroke, reoperation for bleeding and prolonged ventilation were similar, all in the absence of heterogeneity. However, the sub-group analysis showed a significant OR in favor of MTH when robotic enhancement was used. New renal failure (OR 1.67, 95% CI 1.06–2.62, p = 0.03), new onset of atrial fibrillation (OR 1.31, 95% CI 1.15–1.51, p = 0.001) and the need of blood transfusion (OR 1.77, 95% CI 1.39–2.27, p = 0.001) were significantly lower in MTH group. Regarding time-related outcomes, there was evidence for important heterogeneity of treatment effect among the studies. Operative times were longer in MTH: differences in means were 20.7 min for cross clamp time (95% CI 14.9–26.4, p = 0.001), 36.8 min for CPB time (95% CI 29.8–43.9, p = 0.001) and 37.7 min for total operative time (95% CI 19.6–55.8, p < 0.001). There was no significant difference in ventilation duration; however, the differences in means showed significantly shorter ICU stay and hospital stay after MTH compared to STER: − 0.6 days (95% CI − 1.1/− 0.21, p = 0.001) and − 1.88 days (95% CI − 2.72/− 1.05, p = 0.001) respectively, leading to a significant lower hospital cost after MTH compared to STER with difference in means − 4528 US$ (95% CI − 8725/− 326, p = 0.03). The mid-term mortality was significantly higher after STER compared to MTH: OR = 1.50, 1.09–2.308 (95% CI), p = 0.01; the rate of mid-term reoperation was reported similar in MTH and STER: OR = 0.76, 0.50–1.15 (95% CI), p = 0.19. Conclusions The present meta-analysis confirms that the MTH approach for mitral valve disease remains associated with prolonged operative times, but it is beneficial in terms of reduced postoperative complications (renal failure, atrial fibrillation, blood transfusion, wound infection), length of stay in ICU and in hospitalization, with finally a reduction in global cost. MTH approach appears associated with a significant reduction of postoperative mortality that must be confirmed by large randomized study

Surgical removal of essure® micro inserts by vaginal hysterectomy or laparoscopic salpingectomy with cornuectomy: Case series and follow up survey about device-attributed symptoms resolution

International audienceIntroduction: Inserts Essure® were used as a definitive sterilization method from 2001 to 2017. They have been used for more than 750,000 procedures. Gynecological or extra gynaecological adverse events have been reported by patients. The objective of the study is to evaluate the resolution of symptoms attributed to Essure® micro-inserts after surgical removal.Methods: Monocentric retrospective study. Patients who had surgical removal of Essure® micro-inserts between January 2017 and April 2019 were included. The removal was performed by bilateral salpingectomy with cornuectomy by laparoscopy or vaginal hysterectomy. Symptoms were reported preoperatively, 4-8 weeks after withdrawal (early assessment) and 6-24 months after withdrawal (later assessment).Results: Ninety patients had a surgical removal of Essure® micro-inserts. Fifty-two vaginal hysterectomies and thirty-five laparoscopic salpingectomies were performed. The main symptoms reported are pelvic pain (70 %), fatigue (66.7 %) and heavy bleeding menstruations (53.3 %). One month after surgery, 46.7 % of patients have a major improvement of symptoms and 51.1 % a partial resolution. The major improvement rate is not significantly different between laparoscopic salpingectomy and vaginal hysterectomy (51.5 % versus 42.3 %) (p = 0.23). At 24 months, results improved with 83.3 % major improvement.Conclusion: Surgical removal may be effective for treating most women with attributed device symptoms. Vaginal hysterectomy and laparoscopic salpingectomy with cornuectomy seem to have an equivalent rate for the resolution of extra-gynecological symptoms

A Lost Balloon—The Interest of a Systematic Ultrasonographyafter a Postabortion Hemorrhage

International audienceNo abstract availabl

A Lost Balloon—The Interest of a Systematic Ultrasonographyafter a Postabortion Hemorrhage

International audienceNo abstract availabl

vNOTES for Ovarian Drilling: A New Minimal Invasive Technique

International audienceStudy Objective: To show a new mini-invasive surgical technique of ovarian drilling and fertility workup using transvaginal natural orifice transluminal endoscopic surgery (vNOTES). Design: Stepwise demonstration of the technique with narrated video footage. Setting: Ovarian drilling is a surgical technique for patients with dysovulatory polycystic ovary syndrome. The aim of this technique is to destroy 5% to 10% of the ovarian cortex to restore spontaneous ovulation. Drilling is proposed as a second-line treatment in case of failure of treatments with clomid, metformin, or letrozole. The Cochrane 2020 review shows that drilling has the same pregnancy rate as the other second-line treatment: stimulation with gonadotropins [1]. After ovarian drilling, the results show 80% of spontaneous ovulation within 3 months and 50% of spontaneous pregnancy within a year; these results are effective in the long term [2]. The techniques used until now were either classic laparoscopy or transvaginal hydrolaparoscopy, which is currently not feasible owing to the cessation of the kit [3,4]. We present to you a new surgical technique: ovarian drilling by vNOTES. This new technique is minimally invasive, without scarring on the abdomen, and very well tolerated. It allows simultaneous ovarian drilling and fertility workup with assessment of tubal patency and uterine cavity by hysteroscopy. It is recommended to use bipolar energy to reduce ovarian lesions and limit the risk of adhesion [5]. Interventions: Transvaginal laparoscopic ovarian drilling is a minimally invasive surgical technique using a vNOTES kit from Applied Medical (Rancho Santa Margarita, CA), a hysteroscope of 5 mm with an operating channel from Delmont Imaging (La Ciotat, France), and a bipolar spring electrode, Versapoint from Olympus (Hamburg, Germany). The key steps to perform this surgery are as follows: 1. Perform a diagnostic hysteroscopy with vaginoscopy 2. Perform a posterior colpotomy 3. Introduce the Alexis retractor into the Douglas and place the GelPOINT with 2 sleeves 4. Introduce the hysteroscope into the pelvic cavity with serum saline, using a pressure of approximately 150 mm Hg 5. Drill approximately 10 holes on each ovary using the bipolar electrode 6. Explore the pelvic cavity with the possibility of performing a blue test for tubal patency 7. Suture the posterior vagina Conclusion: Ovarian drilling is a surgical treatment proposed after the failure of first-line treatments in polycystic ovary syndrome to obtain long-term spontaneous ovulations. The development of minimally invasive techniques such as vNOTES will highlight this treatment and allow it to be performed easily and with minimal adverse effects on patients, especially in bariatric women for whom the vNOTES technique provides easier access to their pelvic cavity than abdominal laparoscopy

Innovations in surgery to perform an ovarian drilling

International audienceBackground: Ovarian drilling is a surgical technique for patients with dysovulatory polycystic ovarian syndrome. It is proposed as a second-line treatment in case of failure of medical treatment with Clomiphene citrate, Metformin or Letrozole. The 2020 Cochrane study comparing gonadotrophin stimulation and drilling has found the same pregnancy rate in both cases. The literature review concludes that 50% of spontaneous ovulation occurs in the first three months after drilling and 80% of pregnancy occurs in the following year. Ovarian drilling has also an impact on androgen excess and metabolic syndrome. Aims: To update on the different surgical techniques to perform an ovarian drilling: surgical approach, energy used, operative risks. Techniques: The objective of an ovarian drilling is to destroy 5% of the ovarian stroma. It is recommended to perform 8 to 10 perforations in each ovary with bipolar energy. Laser C02 and monopolar energy can be used but increase the risk of adhesion. The surgical approach is actually laparoscopic. Abdominal laparoscopy or transvaginal laparoscopy by vNOTES can be performed. The advantage of the second one is to provide an easier access to the pelvic cavity in case of obesity and patient have no abdominal scare. Both laparoscopic approaches allow an evaluation of tubal patency and adhesiolysis or fimbrioplasty. That it's not the case of an alternative technique: the fertiloscopy, due to coaxial instrumentation in spite of less rate of post-operative adhesions. Operative risks are abdominal adhesions, damage to neighboring organs and due to the general anesthesia. Conclusion: Different surgical techniques exist to perform an ovarian drilling. The surgeon can choose the one that he masters best and that will involve the least risk for the patient. It is recommended to use bipolar energy

Vaginal cervicoisthmic cerclage for cervical incompetence in pregnant women: Fernandez’s technique in 8 steps

Video objective: To demonstrate that surgical technique of vaginal cervicoisthmic cerclage must be performed in women with history of cervical incompetence with more than two late miscarriages before 24 weeks or premature deliveries before 28 weeks and after prior failure of preventive Mc Donald cerclage. In this video, the authors describe the complete procedure in 8 steps to standardize and facilitate the procedure in a simple and safe way during pregnancy.&nbsp;Design: Step-by-step video demonstration of the surgical technique.Setting: Tertiary Center for University Hospital

Successful IVF pregnancy despite inadequate ovarian steroidogenesis due to congenital lipoid adrenal hyperplasia (CLAH): a case report

International audienceSteroidogenic acute regulatory protein (StAR) mutations are the most frequent aetiologies of congenital lipoid adrenal hyperplasia (CLAH). Phenotypes may vary, and puberty may be absent in affected individuals. To date, only two pregnancies have been described in 46,XX CLAH patients with StAR mutations; these patients exhibited ovarian steroidogenesis along with spontaneous puberty and menarche and normal menses. The patient described here presented with CLAH caused by the homozygous (unreported, 1 bp) deletion c.719del in the StAR gene, which was diagnosed after acute adrenal insufficiency when the patient was 10 days old. The patient did not undergo spontaneous puberty, so puberty was induced by HRT when the patient was 13 years old. At the age of 25 years, the patient was referred to our reproductive unit because she desired to conceive. An initial cycle of clomiphene, stimulation produced follicular growth with two mature follicles measuring 18 and 15 mm, respectively, but the plasma oestradiol levels remained low (18 pg/ml) and the endometrium was thin (3 mm). Pregnancy was finally achieved after ovarian stimulation, IVF and transfer of frozen-thawed embryos after endometrial preparation with HRT. A normal female child was delivered following a 40 weeks' uneventful pregnancy. We therefore report the first IVF pregnancy achieved in a 46,XX CLAH patient homozygous for a StAR mutation, with inadequate ovarian steroidogenesis and no spontaneous puberty

Asherman Syndrome after Uterine Artery Embolization: A Cohort Study about Surgery Management and Fertility Outcomes

International audienceStudy Objective: To study the severity of intrauterine adhesions (IUA) after uterine arterial embolization and to evaluate fertility, pregnancy, and obstetrical outcomes after hysteroscopic treatment. Design: Retrospective cohort. Setting: French University Hospital. Patients: Thirty-three patients under the age of 40 years who were treated by uterine artery embolization with nonabsorbable microparticles between 2010 and 2020 for symptomatic fibroids or adenomyosis, or postpartum hemorrhage. Interventions: All patients had a diagnosis of IUA after embolization. All patients desired future fertility. IUA was treated with operative hysteroscopy. Measurements and Main Results: Severity of IUA, number of operative hysteroscopies performed to obtain a normal cavity shape, pregnancy rate, and obstetrical outcomes. Of our 33 patients, 81.8% had severe IUA (state IV et V according to the European Society of Gynecological Endoscopy or state III according to the American fertility society classification). To restore fertility potential, an average of 3.4 operative hysteroscopies had to be performed [CI 95% (2.56–4.16)]. We reported a very low rate of pregnancy (8/33, 24%). Obstetrical outcomes reported are 50% of premature birth and 62.5% of delivery hemorrhage partly due to 37.5% of placenta accreta. We also reported 2 neonatal deaths. Conclusion: IUA after uterine embolization is severe, and more difficult to treat than other synechiae, probably related to endometrial necrosis. Pregnancy and obstetrical outcomes have shown a low pregnancy rate, an increased risk of preterm delivery, a high risk of placental disorders, and very severe postpartum hemorrhage. Those results have to alert gynecologists and radiologists to the use of uterine arterial embolization in women who desire future fertility