Time to revise classification of phyllodes tumors of breast? Results of a French multicentric study

OBJECTIVE: To assess prognostic factors of recurrence of phyllodes tumors (PT) of the breast. METHODS: We performed a retrospective, multicentric cohort study, including all patients who underwent breast surgery for grade 1 (benign), 2 (borderline) or 3 (malignant) PT between 2000 and 2016 in five tertiary University hospitals, diagnosed according to World Health Organisation classification. RESULTS: 230 patients were included: 144 (63%), 60 (26%) and 26 (11%) with grade 1, 2 and 3 PT, respectively. Recurrence occurred in 10 (7%), 7 (12%) and 5 (19%) patients with grade 1, 2 and 3 PT, respectively. In univariate analysis, moderate to severe nuclear stromal pleomorphism (HR 8.00 [95% CI: 1.65-38.73], p < 0.009) was correlated with recurrence in all groups including grade 1 (HR 14.3 [95% CI: 1.29-160], p = 0.031). In multivariate analysis, surgical margin >5 mm, (HR 0.20 [95% CI: 0.06-0.63], p = 0.013) were significantly correlated with less recurrence in all PT grades. For grade 1 PT, there was also significantly less recurrence with surgical margin >5 mm, (HR 0.09 [95% CI: 0.01-0.85], p = 0.047) in multivariate analysis. CONCLUSION: The surgical margin should be at least 5 mm whatever the grade of PT. Moderate to severe nuclear stromal pleomorphism identified a subgroup of grade 1 PT with a higher rate of recurrence. This suggests that the WHO classification could be revised with the introduction of nuclear stromal pleomorphism to tailor PT management

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Prise en charge chirurgicale d’une rétention trophoblastique après grossesse sur cicatrice de césarienne et réparation d’une isthmocèle par cœlioscopie robot-assistée associée à l’hystéroscopie

National audienceJ o u r n a l P r e-p r o o f Prise en charge chirurgicale d'une rétention trophoblastique après grossesse sur cicatrice de césarienne et réparation d'une isthmocèle par coelioscopie robot-assistée associée à l'hystéroscopie. Prise en charge chirurgicale d'une rétention trophoblastique après grossesse sur cicatrice de césarienne et réparation d'une isthmocèle par coelioscopie robot-assistée associée à l'hystéroscopie. Robotic-assisted laparoscopy using hysteroscopy treatment of a residual cesarean scar pregnancy and isthmocele

Intérêt de l’éducation périnéale en rééducation périnéale chez la femme

International audienc

Intérêt de sessions d’éducation périnéale en groupe : satisfaction et amélioration des connaissances des femmes

National audienceINTRODUCTION: Pelvic floor dysfunctions are an important health-care issue however there are no primary prevention programs for perineal health. This study aims to evaluate the impact of perineal education group sessions on women’s urinary and digestive behaviors and their satisfaction with these sessions. MATERIAL: Perineal education sessions were proposed to women working in a gynecology department. Each session covered perineal physiology and anatomy, urinary and digestive physiology as well as risk situations for the pelvic floor. At the beginning and end of the sessions, participants completed a questionnaire on their knowledge about the pelvic floor and questions concerning their satisfaction were asked at the end of the session. A 2-month questionnaire assessed changes in urinary and digestive habits as well as the dissemination of information. RESULTS: One hundred and sixty-three women, average age 38, participated in these sessions; 107 responded at 2 months. The education sessions significantly improved pelvic floor fonctions knowledge. After the sessions, 81.3% of women reported changing their urinary habits and 60.7% their defecatory habits. Participants found the sessions very useful (rating 9.7/10), all participants recommended these sessions to a friend and the dissemination of the information was important. CONCLUSION: Perineal education sessions improve women’s knowledge and limit risky behaviors for the pelvic floor. The satisfaction of women who received information is important and the dissemination of information strong. LEVEL OF EVIDENCE: 4

Lugar de la cirugía asistida por robot en cirugía ginecológica

National audienceEl robot quirúrgico se ha incorporado al arsenal terapéutico quirúrgico en beneficio de las mujeres para el tratamiento de las patologías ginecológicas. No sustituye a la vía vaginal ni a la vía laparoscópica clásica, sino que es complementario de éstas. En cuanto a la cirugía ginecológica oncológica, su lugar parece ser indiscutible para el tratamiento del cáncer de endometrio, al permitir tasas de cirugía mínimamente invasivas del 80% en un sistema sanitario. En cuanto a la patología benigna, permite reducir las laparotomías, sobre todo para las miomectomías y los úteros muy grandes. Para la patología endometriósica, el beneficio no se ha demostrado, pero la mejora de la visión y de la calidad de disección que permite el robot le conferirán sin duda un papel preponderante. Para la promontofijación, el beneficio no se ha demostrado aún, pero el robot permite una estandarización del procedimiento quirúrgico y disminuye las curvas de aprendizaje. El sobrecoste que provoca el robot sigue siendo un problema de salud pública, pero debe sopesarse respecto a las posibilidades que ofrece

Implantation d’un programme de chirurgie robotique gynécologique : leçons à retenir des 100 premières procédures

International audienceIntroduction: The objective of this work is to report the first 6 months of a robotic program in a surgical gynecological team, trained in advanced laparoscopy, in terms of operating times, complication rate, analgesic consumption and average duration of hospitalization.Methods: This is a prospective observational study, intended to treat.Results: During the study period, 98 women underwent laparoscopic robot assisted surgery. The average BMI was 27.2 kg/m2 (± 7). Malignant diseases accounted for 41% of operative indications. Comparing the first 30 procedures to the last 30 procedures, there is a significant decrease in docking times: 14.7 min (± 7.0) vs 8.9 min (± 5.0), P = 0.009. There is also a trend towards a decrease in operative times for hysterectomy: 151.9 min (± 56.2) vs 113 min (± 51.4), P = 0.08. The rates of complications were not significantly different at the beginning and end of inclusion during the study (10.0% vs 16.7%).Conclusion: The implementation of a robotic surgery program in a gynecological surgery department does not lead to an increase in complications for the patients, including for the first procedures. The learning curve mainly allows a reduction in the robot's installation time.Introduction: L’objectif de ce travail est de rapporter les 6 premiers mois d’un programme robotique dans une équipe chirurgicale gynécologique, rodée à la cœlioscopie avancée, en termes de durées opératoires, taux de complications, consommation d’antalgiques et durée moyenne d’hospitalisation.Méthodes: Il s’agit d’une étude observationnelle prospective, en intention de traiter.Résultats: Sur la période de l’étude, 98 femmes ont été opérées par cœlioscopie robot assistée. L’IMC moyen était de 27,2 kg/m2 (± 7). Les pathologies malignes représentaient 41 % des indications opératoires. En comparant les 30 premières procédures aux 30 dernières procédures ; on observe une diminution significative des temps de docking avec l’expérience : 14,7 min (± 7.0) vs 8,9 min (± 5.0), p = 0,009. On observe également une tendance à une diminution des temps opératoires pour l’hystérectomie simple : 151,9 min (± 56,2) vs 113 min (± 51,4), p = 0,08. Les taux de complications ne sont pas significativement différents en début et en fin d’expérience au cours de l’étude (10,0 % vs 16,7 %).Conclusion: La mise en place d’un programme de chirurgie robotique dans un service de chirurgie gynécologique n’entraine pas une augmentation des complications pour les patientes, y compris pour les premières procédures. La courbe d’apprentissage permet surtout une diminution des temps d’installation du robot

Anatomía clínica del aparato genital femenino

National audienceEs indispensable conocer la anatomía pélvica femenina para tratar mejor a las pacientes. Sin embargo, esta anatomía presenta muchos aspectos difíciles. Se distinguen dos regiones principales: intraperitoneal y subperitoneal. Sólo los ovarios son intraperitoneales. El resto del aparato genital femenino está revestido por peritoneo pélvico visceral. El conocimiento de la región subperitoneal es un elemento importante para el cirujano. Este espacio puede compararse con un botellero donde los elementos nobles deben preservarse absolutamente durante la cirugía. Contiene un tejido conjuntivo abundante, vasos, ganglios linfáticos y nervios. El parametrio y el paracérvix son zonas clave de la región subperitoneal. El hilo conductor de la pelvis es el uréter pélvico. El objetivo de este artículo es ofrecer claves para comprender mejor la anatomía pélvica femenina, detallando sus regiones y sus principales elementos

A prospective study of the frequency of severe pain and predictive factors in women undergoing first-trimester surgical abortion under local anaesthesia

International audienceObjective - To determine the frequency of severe pain among women and to identify the associated predictive factors during first-trimester surgical abortion under local anaesthesia (LA).Study design - A prospective cohort study from November 2013 to January 2014 at the Department of Gynecology and Obstetrics, Rennes, France. The study population was composed of one hundred and ninety-four patients who underwent an elective first-trimester surgical abortion under LA. In an anonymized questionnaire, the participants were asked to self-record their perceived pain level 30 min after the completion of the procedure using a 10 cm visual analogue scale (VAS). The main outcome measure was the frequency of severe pain among women, defined as VAS ≥ 7. Secondary outcome measure was the risk factor(s) for severe pain.Results - Severe pain (i.e. VAS ≥ 7) was experienced by 46% (95% CI: 39%-53%) of the population. Multivariate analysis confirmed that >10 weeks of gestation (OR: 2.530 [95% CI: 1.1-5.81], p = .0287) and having 0 or 1 child (OR: 5.206 [95% CI: 1.87-14.49], p = .0016) were significant independent factors of severe pain.Conclusion - Nearly half of the women experienced severe pain. More than 10 weeks of gestation and parity were predictive factors of severe pain. These findings should be useful in counselling women undergoing surgical abortion under LA.<br