[Fibroma: surgical myomectomy or embolization or GnRH analogs? Does myomectomy by laparoscopy have a justifiable place in the therapeutic strategy today?].
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Adolescent↗
Biomedical subjects
J B Dubuisson
Publications and source records attributed to J B Dubuisson.
Laparoscopically assisted vaginal management of deep endometriosis infiltrating the rectovaginal septum.
BACKGROUND: Two aims: 1) To assess the results of laparoscopically assisted vaginal management of deep endometriosis infiltrating the rectovaginal septum (RVS); 2) to pinpoint the differences between this procedure and that used for deep endometriotic lesions located on the uterosacral ligaments (USL). METHODS: Descriptive retrospective study. Twenty-nine consecutive patients operated for deep endometriosis infiltrating the RVS were included in this series. RESULTS: One patient only (3.5%) presented a major complication of the recto-vaginal fistula type. After a one step reoperation under anesthesia, the post operative history was uncomplicated and no sequelae are to be deplored. With respect to dysmenorrhea (DM), deep dyspareunia (DP) and chronic pelvic pain (CPP), there was an improvement in respectively 91.7% (22 patients), 100% (24 patients) and 92.9% (13 patients) of cases. For each of these 3 symptoms the median score according to the visual analog scale was significantly lower after the operation (for DM: 7.6+/-2.0 versus 1.7+/-2.6; for DP 7.5+/-1.9 versus 0.5+/-1.1; for CPP 5.9+/-2.8 versus 1.4+/-3.2) (p<0.0001). CONCLUSIONS: These results demonstrate that provided the surgeon is highly skilled in laparoscopy, operative laparoscopy is efficient for the treatment of patients presenting painful symptoms related to deep endometriotic infiltrating the RVS. From the technical point of view the rectum must be freed, leaving the deep endometriotic nodule attached to the posterior wall of the vagina. Resection of the whole lesion requires the posterior wall of the vagina to be resected, whereas ureterolysis is often unnecessary. So for lesions located on the RVS the vagina is opened systematically, unlike the situation when resecting deep endometriotic lesions infiltrating the USL. Deep pelvic endometriosis is not synonymous with endometriosis of the RVS. Lesions truly infiltrating the RVS represent only a small proportion of all deep endometriosis lesions.
Adult↗
[Management of endometriosis ovarian cysts].
The efficacy of medical treatment as unique treatment for endometrioma is not demonstrated. Operative laparoscopic management is the gold standard for surgical treatment. There is no indication to prescribe preoperatively medical treatment before cystectomy. Post-operative administration of low-dose cyclic oral contraceptive does not significantly affect long-term recurrence rate of endometriosis after surgical treatment. In cases of infertility, management of endometriomas is controversial. Recurrent ovarian surgery is not recommended.
Contraceptives, Oral, Combined↗
Total hysterectomy for benign pathologies: direct costs comparison between laparoscopic and abdominal hysterectomy.
OBJECTIVES: The aim of this study is a direct costs comparison between laparoscopic and abdominal total hysterectomy when theses procedures are indicated for benign pathologies. STUDY DESIGN: To this end we compared the direct costs of total laparoscopic hysterectomy (TLH) calculated from a series of 105 patients with that obtained for a comparable series of 30 patients who underwent hysterectomy by laparotomy. RESULTS: The direct costs of total hysterectomy for a benign pathology by laparoscopic surgery and laparotomy are comparable (respectively 7693 French francs (FF) and 7759 FF). Whatever the type of operation the cost for staff represents 60% of the total cost. Expenditure for staff during the operation represents 41.0% of the total cost of TLH (3154 FF/7693 FF) whereas it represents only 31.0% of the cost of the operation when carried out by laparotomy (2406 FF/7759 FF) (P<0.0001). Inversely the expenditure due to staff during the post operative phase represents 24.1% of the total cost of the operation when laparotomy is used (1875 FF/7759 FF) and only 13.4% of the cost of the operation by laparoscopic surgery (1029 FF/7693 FF) (P<0.0001). When the operation uses laparoscopic surgery the increase in expenditure during the surgical act is compensated by the statistically significant shortening in the hospital stay. Expenditure connected with the laparoscopic surgery equipment is minimal compared to the costs connected with the staff. CONCLUSION: Provided that TLH is carried out with reusable laparoscopic surgery equipment, by skilled surgeons working in suitable hospital structures making the particularly heavy investment in laparoscopic surgery equipment economically viable, TLH is an economically viable technique as an alternative to laparotomy.
Adult↗
[Major vascular complications from gynecologic laparoscopy].
OBJECTIVE: To specify the circumstances of occurence, the means of diagnosis, the risk factors and the means of prevention for major vascular injuries (MVI) during gynecologic laparoscopic procedure. STUDY DESIGN: Retrospective case review study of 24 patients. RESULTS: Twenty-four patients with 31 MVI were identified. The average age of the patients was 32.8 +/- 10.6 years and the mean body index mass was 22.4 +/- 4.0 kg/m2. Three of four of the MVI occurred during the setting-up phase of laparoscopy (19 cases; 79.2%). In five cases (20.8%) MVI occurred during the laparoscopic surgical procedure. Fifteen of the MVI occurring during the set up phase were secondary to insertion of the umbilical trocar and four to insertion of the needle used to create the pneumoperitoneum. A minimum of six MVI secondary to insertion of the umbilical trocar were observed with disposable trocars. In every case diagnosis was performed during the laparoscopic procedure. Five patients (20.8%) died and three others (12.5%) presented serious complications (phlebitis (one case); ischemia (two cases) with a reoperation for one patient). CONCLUSION: MVI are rare but serious complications of gynecologic laparoscopy. Prevention relies on the surgeon's experience and strict respect of the safety rules. In the vast majority of cases, it is necessary to convert to laparotomy immediately, calling in a vascular surgeon.
Adult↗
Rectosigmoid endometriosis: endoscopic ultrasound features and clinical implications.
BACKGROUND AND STUDY AIMS: The main area of the gastrointestinal tract affected by deep pelvic endometriosis is the rectosigmoid colon in 3-37% of cases. Due to the risk of infiltration and the clinical symptoms of endometriosis, with pain and infertility, the condition may require surgical resection. Preoperative imaging diagnosis of rectosigmoid involvement is therefore important. Rectal endoscopic ultrasonography (EUS), which is already used for the staging of anorectal carcinoma and submucosal lesions, may be a promising technique for this indication. The present study was conducted in order to describe the endosonographic appearance of rectosigmoid endometriosis, and to define the potential relevance of the technique to the choice of resection method. PATIENTS AND METHODS: Between 1993 and 1997, 46 women (mean age 31) with deep pelvic endometriosis underwent imaging investigations and surgical resection. The clinical and imaging findings, and the surgical and histological features identified--mainly with regard to infiltration of the rectal wall--were compared retrospectively. The impact of the EUS findings on the decision on whether or not to carry out resection, either by laparoscopy or open abdominal surgery, was also examined. RESULTS: When there was deep pelvic endometriosis with suspected rectal wall infiltration, EUS showed normal anatomy in nine patients, endometriotic lesions without rectal wall infiltration in 12, and typical rectal infiltration in 25. The lesions were confirmed by the surgical findings during therapeutic laparoscopy (n = 22) and laparotomy (n = 25), as well as by clinical follow-up. Rectal wall infiltration, demonstrated in all cases using EUS, had initially been suspected on the basis of clinical examinations, rectoscopy, barium enema, computed tomography, and magnetic resonance imaging in 62%, 50%, 33%, 67% and 66% of cases, respectively. CONCLUSIONS: EUS is a simple and noninvasive technique capable of correctly diagnosing rectal wall infiltration in deep pelvic endometriosis. It may be helpful in determining the choice between laparoscopy and laparotomy when complete resection is indicated.
Adult↗
Ureteral injuries after laparoscopic hysterectomy.
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Female↗
Pregnancy outcome and deliveries following laparoscopic myomectomy.
Uterine rupture after myomectomy by laparotomy is not a common occurrence. Some case reports of uterine rupture after laparoscopic myomectomy (LM) raise the question of the quality of the uterine scar produced when this technique is performed. In order to assess the outcome of pregnancies and deliveries after LM and to assess the risk of uterine rupture, we performed an observational study. Questionnaires were mailed to all women who had had LM for at least one intramural or subserosal myoma of more than 20 mm diameter and who were aged <45 years. Ninety-eight patients became pregnant at least once after LM, giving a total of 145 pregnancies. Among the 100 patients who had delivery, there were three cases of spontaneous uterine rupture. Because only one of these uterine ruptures occurred on the LM scar, the risk of uterine rupture was 1.0% (95% CI 0.0-5. 5%). Seventy-two patients (72.0%) had trials of labour. Of these, 58 (80.6%) were delivered vaginally. There was no uterine rupture during the trials of labour. Spontaneous uterine rupture seems to be rare after LM. This risk should not deter the use of LM if needed. When performing LM, particular care must be given to the uterine closure.
Adult↗
Prognostic factors of reproductive outcome after myomectomy in infertile patients.
The objective of this study was to identify the prognostic factors for conception after myomectomy carried out in cases of infertility. A total of 91 infertile patients presenting at least one subserous or intramural myoma measuring >2 cm underwent myomectomy. The characteristics of the patients, myomata and associated infertility factors were collected in a uniform and systematic way. A postal questionnaire was sent to patients. For each of the various factors studied, the specific cumulative probability of spontaneous intrauterine conception was estimated using the Kaplan-Meier method. Multiple regression analysis was then carried out using Cox's proportional hazards model. The cumulative probability of spontaneous intrauterine conception at 2 years follow-up was 44% (95% confidence interval: 32-56%). The cumulative probability of conception was less after removal of a posterior or intramural myoma, after a sutured hysterotomy, and when accompanied by a male factor, associated tubal or ovulation pathology. The cumulative probability of conception was greater after ablation of myomata responsible for menometrorrhagia. The size, deforming effect on the cavity and age played no role in our sample. Our results indirectly suggest that post myomectomy adhesions could have an adverse effect on fertility. Myomata responsible for menometrorrhagia are also the cause of infertility. In the presence of an associated male, tubal or ovulatory factor, the results were poor and it was not possible to determine if a myomectomy should be performed in these cases in order to enhance fertility.
Adult↗
Reproductive outcome after laparoscopic myomectomy in infertile women.
OBJECTIVE: To assess reproductive outcome after laparoscopic myomectomies for interstitial and/or subserosal myomas in infertile women with or without associated infertility factors. STUDY DESIGN: In this observational study, 91 women with infertility for one year and at least one interstitial and/or subserosal myoma > 20 mm were treated with laparoscopic myomectomy. All patients were mailed questions about fertility and pregnancy outcome. Cumulative pregnancy rates were calculated by the Kaplan-Meier method. The log rank test and Cox's model were used for comparing the spontaneous pregnancy rate in patients with and without associated infertility factors. RESULTS: The mean age of the patients was 35 +/- 4 years. The mean duration of infertility was 44 +/- 33 months. Twenty-five patients (27.5%) had no associated infertility factors, and 66 (72.5%) had one or more. The mean size of the largest myomas was 45 +/- 19 mm. The mean number of myomas removed was 2.0 +/- 1.4. Eighty-six patients had laparoscopic myomectomy (94.5%), and five had laparoscopically assisted myomectomy (5.5%). There were no conversions to laparotomy. Ten patients were lost to follow-up (11.0%). Among the 91 patients treated surgically, 81 (89.0%) of them were evaluated. Forty-three (53.1%) conceived, resulting in a total of 51 pregnancies. The two-year overall cumulative conception rate was 51.2% (95% confidence interval [CI], 39.2-63.2%). The two-year spontaneous pregnancy rate was 43.9% (95% CI, 32.1-55.7%). This rate was 69.9% (95% CI, 50.3-89.5%) for patients with no associated factors and 31.5% (95% CI, 18.4-44.6%) for patients with associated factors (P < .001). This result was not affected by adjusting for age or duration of infertility. CONCLUSION: Laparoscopic myomectomy seems to be a good procedure for patients with myomas and no other infertility factors. In cases with associated infertility factors, the need for myomectomy has to be studied.
Adult↗
[Laparoscopy and bladder endometriosis].
Partial cystectomy is in the great majority of the cases the treatment of choice for patients with bladder endometriosis. The aim is to assess the methods, indications and results of operative laparoscopy for patients presenting with bladder endometriosis. We perform a descriptive retrospective study of 13 cases. All patients presenting with bladder endometriosis infiltrating the bladder muscularis between January 1, 1993 and June 30, 1998 were included in this series. It was possible to treat bladder endometriosis in all the patients by performing a laparoscopic partial cystectomy. With an average follow-up of 29.3 +/- 24.6 months (range 4-77) the results are satisfactory. Neither peri- nor postoperative complications were observed. The patients experienced an improvement in their condition, with complete disappearance of the urinary symptoms in every case. No recurrence of the functional urological symptoms occurred. Provided the surgeons are skilled and the lesions require no ureteral reimplantation, operative laparoscopy is a valid alternative to laparotomy for partial cystectomy.
Cystectomy↗
[Treatment of ectopic pregnancy in 2000].
Operative laparoscopy is currently the best treatment for pregnancy (EP). As with laparotomy, laparoscopic treatment of EP can be either conservative (salpingotomy or radical (salpingectomy). After conservative laparoscopic treatment, failures are diagnosed by monitoring the drop in beta-hCG levels. Fertility results after laparoscopic treatment of EP are comparable with those observed after similar treatment by laparotomy. Better knowledge o the risk factors of EP, development of hCG assays using serum progesterone and high resolution sonography using vaginal probes allow early diagnosis of EP and a nonsurgical approach in more than 30% of cases. When inclusion criteria are strict, methotrexate administered by local injection or systemically (1mg/kg) in a single dose or in combination with mifepristone gives a 90 to 95% success rate. Whatever treatment protocol is used, fertility prognosis after EP is not correlated to the features of EP but depends mainly on patient age and past history.
Chorionic Gonadotropin, beta Subunit, Human↗
[Total hysterectomy: laparoscopy or vaginal route? Arguments in favor of laparoscopy].
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Female↗
[Comparison of endoscopic ultrasound and magnetic resonance imaging in severe pelvic endometriosis].
UNLABELLED: Deep pelvic endometriosis may lead to severe pain, the treatment of which may require complete surgical resection of lesions. Digestive infiltration is a difficult therapeutic problem. Preoperative diagnosis is difficult and digestive infiltration may remain unknown with incomplete resection and sometimes repeated surgery. Both magnetic resonance imaging (MRI) and endoscopic ultrasonography are able to detect rectosigmoid infiltration but their usefulness in the preoperative staging is still to be evaluated. The aim of this work was to evaluate and compare both techniques in the preoperative detection of deep pelvic endometriosis, particularly digestive infiltration. PATIENTS AND METHODS: From 1996 to 1998, 48 women with painful deep pelvic endometriosis had preoperative imaging exploration with endoscopic ultrasonography and MRI, and were operated on in order to attempt complete endometriosis resection. Patients were proposed for laparoscopic resection if endoscopic ultrasonography and/or MRI did not reveal digestive infiltration or for open resection if endoscopic ultrasonography and/or MRI were positive for digestive infiltration. RESULTS: Endoscopic ultrasonography and/or MRI led to suspicion of digestive endometriosis in 16 patients. Surgical resection was performed in 12 and digestive wall invasion was histologically demonstrated. At final follow-up, all patients had a dramatic decrease of their symptoms. The remaining 4 patients refused digestive resection and had only laparoscopic gynecologic resection. Infiltration although not histologically proven was very likely both on operative findings and clinical evolution. Digestive infiltration was preoperatively excluded in the 32 other patients. All had a laparoscopic treatment without digestive resection and pain diminished in all patients. In the 12 patients group who had digestive resection, digestive infiltration was correctly diagnosed by endoscopic ultrasonography in all cases (no false negative) whereas MRI, even with the use of endocoil antenna, led to correct diagnosis in 8 out of 12 cases. When endoscopic ultrasonography was negative for digestive infiltration, laparoscopic resection of lesions at surgery appeared complete in all cases. For the 16 patients with presumed digestive infiltration, sensitivity of endoscopic ultrasonography and MRI was 100 and 75% respectively, with a 100% specificity in both cases. MRI appeared very accurate for the detection of ovarian endometriotic locations. MRI was more sensitive but less specific than endoscopic ultrasonography for the diagnosis of isolated endometriotic recto-vaginal septum and utero-sacral ligaments lesions. CONCLUSION: Endoscopic ultrasonography was the best technique for the diagnosis of digestive endometriotic infiltration, which complicates the therapeutic strategy. MRI, however, allows more complete staging of other pelvic endometriotic lesions.
Adnexal Diseases↗
[Surgical treatment of endometriosis].
The treatment of first intention for endometriosis must be surgery. In cases of infertility the surgical treatment of choice is laparoscopic surgery, maybe in conjunction with the medical treatment and possibly followed-up by a second-look. When there is pelvic pain, the treatment relies on complete exeresis of the endometriotic lesions. In this context, laparoscopic surgery is as efficient as laparotomy for dealing with ovarian endometriomas, deep endometriosis infiltrating the uterosacral ligaments, the rectovaginal septum and the bladder. However, in the majority of cases bowel endometriosis is still an indication to operate by laparotomy.
Adnexal Diseases↗
Operative management of deep endometriosis infiltrating the uterosacral ligaments.
STUDY OBJECTIVE: To describe and assess the efficacy of laparoscopic surgical treatment for patients with pain and deep endometriosis located on the uterosacral ligaments. DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: One hundred ten consecutive women with deep endometriosis infiltrating uterosacral ligaments. INTERVENTION: Operative laparoscopic management of endometriosis. MEASUREMENTS AND MAIN RESULTS: Improvement was reported in 82.3% (70/85) of patients with severe dysmenorrhea and was considered satisfactory in 82.8% (58/70). Improvement also occurred in 88.2% (75/85) of women with deep dyspareunia, and was considered satisfactory in 88.0% (66/75). CONCLUSION: Provided the surgeon is highly skilled in laparoscopy, operative laparoscopy is efficient for the treatment of painful symptoms related to deep endometriosis infiltrating uterosacral ligaments. (J Am Assoc Gynecol Laparosc 6(1):31-37, 1999)
Adolescent↗
Hysterectomy techniques used for benign pathologies: results of a French multicentre study.
The objective of this study was to assess the techniques by which hysterectomies are carried out and to determine the rate of total laparoscopic hysterectomy (TLH). A transversal multicentre study was conducted in 23 gynaecology and obstetrics departments of French University Hospital Centres. The study population comprised only those patients for whom hysterectomy was indicated for benign disease without genital prolapse or urinary stress incontinence. Whereas the rates of performance of hysterectomy by laparotomy and by the vaginal route are comparable [respectively 40.0% (94 patients) and 46.8% (110 patients)], the rate of performance of TLH is only 13.2% (31 patients). All 23 centres (100%) carried out hysterectomy by laparotomy and 21 centres (91.3%) carried out vaginal hysterectomy; however, only nine centres (39.1%) carried out TLH. Only seven centres (30.4%) performed all three types of operation. Of the eight centres whose rate of vaginal hysterectomy was >60%, six (75%) did not carry out TLH. The study suggests that the usage of the TLH technique appears to be limited. The extent of surgical training is a major factor in the choice of technique for hysterectomy.
Adult↗
Fertility after laparoscopic management of deep endometriosis infiltrating the uterosacral ligaments.
The aim of this study was to evaluate fertility outcome after laparoscopic management of deep endometriosis infiltrating the uterosacral ligaments (USL). From January 1993 to December 1996, 30 patients who presented with no other infertility factors were treated using laparoscopic surgery. The overall rate of intrauterine pregnancy (IUP) was 50.0% (15 patients). Only one of these 15 pregnancies was obtained using in-vitro fertilization techniques (IVF). The cumulative IUP rate for the 14 pregnancies which occurred spontaneously was 48.5% at 12 months (95% confidence interval 28.3-68.7). The rate of spontaneous pregnancies was not significantly correlated with the revised American Fertility Society (rAFS) classification. The rate of IUP was 47.0% (eight cases) for patients with stage I or II endometriosis and 46.1% (six cases) for the patients presenting stage III or IV endometriosis (not significant). These encouraging preliminary results show that in a context of infertility it is reasonable to associate classic treatment for endometriosis (e.g. lysis, i.p. cystectomy, biopolar coagulation of superficial peritoneal endometriotic lesions) with resection of deep endometriotic lesions infiltrating the USL. Apart from the benefit with respect to the pain symptoms from which these patients suffer, it is possible to use laparoscopic surgery with substantial retroperitoneal dissection and enable half of the patients to become pregnant. These results also raise the question of the influence of deep endometriotic lesions on infertility.
Adult↗