Objective To compare differences in the postoperative pregnancy rate in women seeking to conceive and presenting with endometriomas larger than 3 cm in diameter, which were managed by ablation using plasma energy, cystectomy, or simple drainage. Methods A retrospective three-arm comparative study based on prospective collection of data evaluating 363 patients, undergoing endometrioma cystectomy, ablation using plasma energy, or simple drainage. Results In this series, 204 (56.2%) patients underwent endometrioma ablation using plasma energy, 121 (33.3%) received cystectomy, and 38 (10.5%) had a simple drainage. Postoperative follow up was 50 +/- 26 months. Overall postoperative pregnancy rate was 60.3%. The probability of being pregnant after cystectomy, ablation, and drainage was respectively 27%, 32%, and 16% at 12 months, with a statistically significant difference between pregnancy rates among the three arms (P = 0.015). Simple drainage was associated with a probability of conception over 50% after 2 years, mainly based on postoperative assisted reproductive technology. Conclusions We reveal good postoperative pregnancy rate after ablation using plasma energy or cystectomy for endometriomas. Surgical management should be carefully considered in women with endometriomas and pregnancy intention, because the postoperative pregnancy rate may be compared with that observed after first-line assisted reproductive technology management.

Postpartum hemorrhage remains one of the principal causes of maternal mortality in the United States and throughout the world. Its management, which must be multidisciplinary (obstetrics, midwifery, anesthesiology, interventional radiology, and nursing), depends on the speed of both diagnosis and implementation of medical and surgical treatment to control the hemorrhage. The aim of this work is to describe the various techniques of vessel ligation and of uterine compression for controlling and treating severe hemorrhage, and to present the advantages and disadvantages of each. It is not difficult to perform vessel ligation of the uterine arteries: O'Leary's bilateral ligation of the uterine artery, Tsirulnikov's triple ligation, and AbdRabbo's stepwise uterine devascularization (that is, stepwise triple ligation). These procedures are associated with a high success rate (approximately 90%) and a low complication rate. Bilateral ligation of the internal iliac (hypogastric) arteries is more difficult to perform and potentially less effective (approximately 70% effectiveness) than the previously mentioned procedures. Its complication rate is low, but the complications are most often serious. There is no evidence that future fertility or subsequent obstetrical outcomes are impaired by ligation of either the uterine or internal iliac arteries. There are many techniques used for uterine compression sutures, and none has shown clear superiority to another. Uterine compression suture has an effectiveness rate of approximately 75% after failure of medical treatment and approximately 80% as a second-line procedure after unsuccessful vessel ligation. The risk of synechiae after uterine compression suture has not yet been adequately evaluated, but is probably around 5%. The risk of synechiae after uterine compression suture has not yet been adequately evaluated, but probably ranges between 5% and 10%. The methodologic quality of the studies assessing uterine-sparing surgical procedures remains limited, with no comparative studies. Accordingly, no evidence suggests that any one of these methods is better than any other. Accordingly, the choice of surgical technique to control hemorrhage must be guided firstly by the operator's experience. If the hemorrhage continues after a first-line uterine-sparing surgical procedure and the patient remains hemodynamically stable, a second-line procedure can be chosen. Nonetheless, the application of these procedures must not delay the performance of a peripartum hysterectomy in cases of hemodynamic instability.

Study Objective: To assess whether a liberal policy of preventive stoma (LPS) reduces the rate of rectovaginal fistulas in women with excision of deep endometriosis requiring concomitant vaginal and rectal sutures in comparison with a more restrictive policy of preventive stoma (RPS) and to assess the risk factors for rectovaginal fistula. Design: Retrospective before-and-after comparative study. Setting: Two referral centers, one with an LPS and the other with an RPS. Patients: A total of 363 patients with deep endometriosis infiltrating the rectum and the vagina. Interventions: Rectal disc excision or colorectal resection concomitantly with vaginal excision. Measurements and Main Results: Two hundred forty-one and 122 women received surgery at the LPS and RPS centers, respectively. The rate of preventive stomas was 71.4% at the LPS center (n = 172) and 30.3% at the RPS center (N = 37). Rectovaginal fistula was recorded in 31 cases (8.5%): nineteen women were managed at the LPS center, and 12 women underwent surgery at the RPS center. It occurred in, respectively, 9.4%, 10.8%, 10.1%, and 7% of the women managed without and with a stoma at the RPS center and of those managed without and with a stoma at the LPS center (p = .72). The height of the rectal stapled line was significantly lower in the women undergoing a stoma, particularly in those managed at the RPS center (5.4 +/- 1.8 cm). Performing rectal sutures within 8 cm from the anal verge increased the risk of rectovaginal fistula more than 3-fold, independently of stoma creation, surgical procedure carried out on the rectum, size of vaginal infiltration, or associated excision of deep endometriosis involving the pelvic nerves (odds ratio 3.4; 95% confidence interval, 1.3-9.1). Conclusion: No statistically significant differences were found in terms of the risk of rectovaginal fistula between women with rectovaginal endometriosis managed by either an LPS or an RPS; however, these findings need to be confirmed by a randomized trial. (C) 2021 AAGL. All rights reserved.

Introduction/BackgroundThe DESKTOP III trial has demonstrated a significant survival benefit in AGO-score positive patients who underwent complete cytoreduction at 1st relapse compared to those treated with chemotherapy alone. The question whether eligible patients who missed the opportunity of potentially life prolonging surgery at 1st relapse would benefit from surgery at the time of their second relapse, remains open.MethodologyWe evaluated separately the patients who were randomized in the standard, non-surgical arm of the DESKTOP III trial who then subsequently underwent cytoreductive surgery at a subsequent relapse at investigator’s discretion.ResultsThe median progression-free survival (PFS) counted from randomization of 201 patients in the control arm of DESKTOP III was 14.0 months. 171 (85%) had progressive or relapsing disease and 32 of 171 (19%) underwent cytoreductive surgery. Patients’ median age at this subsequent surgery was 63 years (range: 46 – 78). Complete tumor resection was achieved in 19 patients (60%), while 5 (16%) had postoperative residual disease (n=8 missing data). Sixteen patients (50%) commenced systemic treatment within 90 days from surgery, as documented. Thirty- and 90-day surgical mortality rates were 1 (3%) and 2 (6%), respectively. Within a postoperative median follow-up time of 43.8 months, 12 (38%) deaths were reported. Median overall survival after surgery (OS) was 54.0 months. One- and 2-year OS rates were 91% and 84%, respectively.ConclusionCytoreductive surgery for subsequent ovarian cancer relapse appears feasible and with low mortality in selected patients who received non-surgical treatment at 1st relapse despite a positive AGO -score. Surgery could be considered as an option in carefully selected patients also later in their journey within a specialized gynecological cancer setting.

Study Objective: To assess the risk of low anterior resection syndrome (LARS) between women managed by either disk excision or rectal resection for low rectal endometriosis. Design: Retrospective study of a prospective database. Setting: University hospital. Patients: One hundred seventy-two patients managed by disk excision or rectal resection for deep endometriosis infiltrating the rectum <7 cm from the anal verge. Interventions: Rectal disk excision and/or segmental resection using transanal staplers. Measurements and Main Results: One hundred eight patients (62.8%) were treated by disk excision (group D) and 64 (37.2%) by rectal resection (group R). All patients answered the LARS score questionnaire. Follow-up was 33.3 +/- 22 months for group D (range 12-108 months) and 37.3 +/- 22.1 months (range 12-96 months) for group R (p = .25). The rates of rectovaginal fistula and pelvis abscess requiring radiologic drainage and surgery in the D and R groups were, respectively, 7.4% and 8.3% vs 7.8% and 9.3%. The rate of women with normal bowel movements postoperatively was higher in group D (61.1% vs 42.8%, p = .05). Women enrolled in group R reported higher frequency of stools (p <.001), clustering of stools (p = .02), and fecal urgency (p = .05). Regression logistic model revealed 2 independent risk factors for minor/major LARS: performing low rectal resection (adjusted odds ratio 2.28; 95% confidence interval, 1.1-4.7) and presenting with bladder atony requiring self-catheterization beyond postoperative day 7 (adjusted odds ratio 2.52; 95% confidence interval, 1.1-5.8). Conclusion: The probability of normal bowel movements is higher after disk excision than after low rectal resection in women with deep endometriosis infiltrating the low rectum. (C) 2021 AAGL. All rights reserved.

STUDY QUESTION: What are the risk factors and prevalence of bowel fistula following surgical management of deep endometriosis infiltrating the rectosigmoid and how can it be managed? SUMMARY ANSWER: In patients managed for deep endometriosis of the rectosigmoid, risk of fistula is increased by bowel opening during both segmental colorectal resection and disc excision and rectovaginal fistula repair is more challenging than for bowel leakage. WHAT IS KNOWN ALREADY: Bowel fistula is known to be a severe complication of colorectal endometriosis surgery; however, there is little available data on its prevalence in large series or on specific management. STUDY DESIGN, SIZE, DURATION: A retrospective study employing data prospectively recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis (CIRENDO) from June 2009 to May 2019, in three tertiary referral centres. PARTICIPANTS/MATERIALS, SETTING, METHODS: One thousand one hundred and two patients presenting with deep endometriosis infiltrating the rectosigmoid, who were managed by shaving, disc excision or colorectal resection. The prevalence of bowel fistula was assessed, and factors related to the complication and its surgical management. MAIN RESULTS AND THE ROLE OF CHANCE: Of 1102 patients enrolled in the study, 52.5% had a past history of gynaecological surgery and 52.7% had unsuccessfully attempted to conceive for over 12 months. Digestive tract subocclusion/occlusion was recorded in 12.7%, hydronephrosis in 4.5% and baseline severe bladder dysfunction in 1.5%. An exclusive laparoscopic approach was carried out in 96.8% of patients. Rectal shaving was performed in 31.9%, disc excision in 23.1%, colorectal resection in 35.8% and combined disc excision and sigmoid colon resection in 2.9%. For various reasons, the nodule was not completely removed in 6.4%, while in 7.2% of cases complementary procedures on the ileum, caecum and right colon were required. Parametrium excision was performed in 7.8%, dissection and excision of sacral roots in 4%, and surgery for ureteral endometriosis in 11.9%. Diverting stoma was performed in 21.8%. Thirty-seven patients presented with bowel fistulae (3.4%) of whom23 (62.2%) were found to have rectovaginal fistulae and 14 (37.8%) leakage. Logistic regression model showed rectal lumen opening to increase risk of fistula when compared with shaving, regardless of nodule size: adjusted odds ratio (95% CI) for disc excision, colorectal resection and association of disc excision thorn segmental resection was 6.8 (1.9-23.8), 4.8 (1.4-16.9) and 11 (2.1-58.6), respectively. Repair of 23 rectovaginal fistulae required 1, 2, 3 or 4 additional surgical procedures in 12 (52.2%), 8 (34.8%), 2 (8.7%) and 1 patient (4.3%), respectively. Repair of leakage in 14 patients required 1 procedure (stoma) in 12 cases (85.7%) and a second procedure (colorectal resection) in 2 cases (14.3%). All patients, excepted five women managed by delayed coloanal anastomosis, underwent a supplementary surgical procedure for stoma repair. The period of time required for diverting stoma following repair of rectovaginal fistulae was significantly longer than for repair of leakages (median values 10 and 5 months, respectively, P = 0.008) LIMITATIONS, REASONS FOR CAUTION: The main limits relate to the heterogeneity of techniques used in removal of rectosigmoid nodules and repairing fistulae, the lack of accurate information about the level of nodules, the small number of centres and that a majority of patients were managed by one surgeon. WIDER IMPLICATIONS OF THE FINDINGS: Deep endometriosis infiltrating the rectosigmoid can be managed laparoscopically with a relatively low risk of bowel fistula. When the type of bowel procedure can be chosen, performance of shaving instead of disc excision or colorectal resection is suggested considering the lower risk of bowel fistula. Rectovaginal fistula repair is more challenging than for bowel leakage and may require up to four additional surgical procedures.

Study Objective To assess the postoperative probabilities of pregnancy in patients with deep infiltrating endometriosis (DIE) and ≥2 previous in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) failures. Design Retrospective study using data prospectively recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis (CIRENDO) database. Setting University tertiary referral center. Patients Infertile patients under the age of 43 years, having undergone ≥2 previous IVF or ICSI failures, who were surgically managed for DIE. Interventions Complete excision of DIE. Measurements and Main Results The pregnancy rate after surgery was assessed. One hundred and four infertile patients had surgery in 7 different centers participating in the database. Seventy-seven women intended to get pregnant postoperatively. Four patients who got pregnant by oocyte donation were excluded, resulting in a sample of 73 women. The mean patient age was 31.9 years (standard deviation [SD], 4.1), and the mean length of history of infertility was 48.4 months (SD, 26.5). Stage III and IV endometriosis were recorded in 83.6% of patients. The mean postoperative follow-up was 46.6 months (SD, 20.5). The postoperative pregnancy rate was 43.8% with a mean time from surgery to pregnancy of 11.1 months. 21.8% of pregnancies were spontaneous, 31.2% were obtained by IVF, 21.8% by frozen embryo transfer, 18.7% by IVF-ICSI, and 3.1% by intrauterine insemination. Multivariate analysis revealed that ovarian surgery, age ≥35 years old, and stage II endometriosis was associated with the probability of conception. Conclusion Infertile women with ≥2 IVF-ICSI failures may be referred for surgery as it appears related to reasonable postoperative pregnancy rates, particularly when endometriomas surgery is either not required or not performed. Surgery for DIE does not routinely delay conception, as it usually occurs during the year following surgery.

Introduction > Non endometrioid endometrial cancer ore infrequent and have poor prognosis. The aim of the study was to evaluate non endometrioid endometrial cancer managment by evaluating endometrial cancer guidelines application. Materials and methods > This multicentric retrospective study enrolled non endometrioid endometrial cancer between January 2009 to December 2019. Analyses adapted at lost French guidelines opplicated corresponding of year management. Results > Seventy-four non endometrioid endometrial cancer analysed in 10 centers: 34 corcinosarcoma (45,9 %), 29 serous carcinoma (39,2 %), 9 clear cells carcinoma (12,2 %) and 2 undifferentiated carcinoma (2,7 %). For initial management, endometrial cancer guidelines applicated to 45,9 %. First reason of initial guidelines "non-application" was lock of surgical lymph node stadification (57,1 %). For adjuvant management, endometrial cancer guidelines applicated to 38.7 %. First reason of adjuvant guidelines "non-application" was lack lymph node stadification to complete staging when it previously incompletly operated (67,6 %). Discussion > Non endometrioid endometrial cancer guidelines applicability is difficult. This explicated by high age and comorbidity when surgical lymph node stadification is necessary. Using new staging technic will allow target management and better select lymph node staging indication.

Background: Even though preventive stoma is unlikely to ensure primary healing in women with juxtaposed rectal and vaginal sutures, it may be considered, in selected patients at risk of rectovaginal fistula, to reduce fistula related complications. Objective: To assess whether a generalized use of preventive stoma reduces the rate of rectovaginal fistula in women with excision of deep endometriosis requiring concomitant vaginal and rectal sutures. Study Design: Retrospective comparative study including 363 patients with deep endometriosis infiltrating the rectum and the vagina. They were managed by either rectal disk excision or colorectal resection, concomitantly with vaginal excision, in two centers (Rouen and Bordeaux) each following differing policies concerning the use of stoma. The prevalence of rectovaginal fistula was assessed, and risk factors analysed. Results: 241 and 122 women received surgery in respectively Rouen and Bordeaux. The rate of preventive stoma was 71.4% in Rouen (N=172) and 30.3% in Bordeaux (N=37). Rectovaginal fistula were recorded in 31 cases (8.5%): 19 women in Rouen and 12 women in Bordeaux. Performing rectal sutures less than 8 cm above the anal verge increased the risk of rectovaginal fistula more than 3-fold, independently of other risk factors (OR 3.4, 95%CI 1.3-9.1). Conclusions: No statistically significant differences were found in terms of risk of rectovaginal fistula between women with rectovaginal endometriosis managed respectively by a generalized or restrictive use of preventive stoma. A higher risk of rectovaginal fistula independently related to a low rectal stapled line, less than 8 cm above the anal verge.

Les carcinomes de l'endomètre de type 2 sont des cancers peu fréquents et de mauvais pronostique. Il existe très peu d'étude analysant leur prise en charge. L'objectif de l'étude était d'étudier la prise en charge des carcinomes de type 2 dans nos centres en évaluant l'application des recommandations. Il s'agit d'une étude multicentrique rétrospective enregistrant les cancers de l'endomètre de type 2 pris en charge de janvier 2009 à décembre 2019. Les analyses ont été adaptées aux dernières recommandations françaises appliquées par rapport à l'année de prise en charge. Soixante-quatorze carcinomes de type 2 ont été analysés dans dix centres: 34 carcinosarcomes (45,9 %), 29 carcinomes séreux (39,2 %), neuf carcinomes à cellules claires (12,2 %) et deux carcinomes indifférenciés (2,7 %). Lors de la prise en charge initiale, les recommandations étaient appliquées dans 45,9 % des cas. Le principal motif de non-application des recommandations était la non-réalisation d'une stadification ganglionnaire chirurgicale pour 20 patientes (57,1 %). Lors de la prise en charge adjuvante, les recommandations étaient appliquées dans 37,8 % des cas. Le principal motif de non-application des recommandations était la non-réalisation d'une restadification ganglionnaire chirurgicale ou radiologique pour 25 patientes (67,6 %). L'applicabilité des recommandations pour la prise en charge des carcinomes de type 2 reste difficile en raison de l'âge élevé et des comorbidités des patientes notamment pour la réalisation d'une stadification chirurgicale ganglionnaire pelvienne et lombo-aortique. L'utilisation de nouvelles techniques de stadification permettrait de mieux sélectionner les indications de curages ganglionnaires. Non endometrioid endometrial cancer are infrequent and have poor prognosis. The aim of the study was to evaluate non endometrioid endometrial cancer managment by evaluating endometrial cancer guidelines application. This multicentric retrospective study enrolled non endometrioid endometrial cancer between January 2009 to December 2019. Analyses adapted at last French guidelines applicated corresponding of year management. Seventy-four non endometrioid endometrial cancer analysed in 10 centers: 34 carcinosarcoma (45,9 %), 29 serous carcinoma (39,2 %), 9 clear cells carcinoma (12,2 %) and 2 undifferentiated carcinoma (2,7 %). For initial management, endometrial cancer guidelines applicated to 45,9 %. First reason of initial guidelines « non-application » was lack of surgical lymph node stadification (57,1 %). For adjuvant management, endometrial cancer guidelines applicated to 38.7 %. First reason of adjuvant guidelines « non-application » was lack lymph node stadification to complete staging when it previously incompletly operated (67,6 %). Non endometrioid endometrial cancer guidelines applicability is difficult. This explicated by high age and comorbidity when surgical lymph node stadification is necessary. Using new staging technic will allow target management and better select lymph node staging indication.

BACKGROUND:Sterility is a major late effect of radiotherapy and chemotherapy treatments. Iatrogenic sterility is often permanent and greatly impacts long-term quality of life. Ovarian tissue cryopreservation (OTC) performed before gonadotoxic treatments with subsequent autograft is a method of fertility preservation available for girls and women. Its application in prepubertal girls is of particular value as it is the only possible approach in this patient group. In addition, it does not require a delay in cancer therapy and no ovarian stimulation is needed.OBJECTIVE:The primary aim of this protocol is to help increase the implementation of ovarian tissue autografting in France. Knowledge is still lacking regarding the efficacy of ovarian transplantation in restoring ovarian function and regarding the safety of this procedure, especially the risk of cancer cell reseeding in certain types of cancer. A secondary aim of this study is to generate data to improve our understanding of these two essential aspects.METHODS:The DATOR (Development of Ovarian Tissue Autograft in Order to Restore Ovarian Function) study is ongoing in 17 university hospitals. The DATOR protocol includes the autograft of ovarian cortex fragments. Candidates are identified from an observational prospective cohort (called the Prospective Cohort of Patients Candidates for Ovarian Tissue Autograft [PERIDATOR]) of patients who have undergone OTC. Enrollment in the study is initiated at the patient's request and must be validated by the center's multidisciplinary team and by the study steering committee. The DATOR study begins with a total medical checkup. Ovarian tissue qualification and residual disease detection, if required, are performed.RESULTS:The study is ongoing. Currently, 38 patients have provided informed consent and have been entered into the DATOR study. Graft has been performed for 34 of these patients. An interim analysis was conducted on the first 25 patients for whom the period of at least 1 year posttransplantation was achieved. Out of these 25 patients, 11 women succeeded in becoming pregnant (pregnancy rate=44% [11/25]; delivery rate=40% [10/25]). Among these, 6 women conceived twice, and 1 pregnancy led to a miscarriage.CONCLUSIONS:Our preliminary analysis appears to be coherent with the accumulating body of evidence indicating the potential utility of ovarian tissue autograft for patients with premature ovarian failure. All these elements justify the pursuit of our study.TRIAL REGISTRATION:ClinicalTrials.gov NCT02846064; https://clinicaltrials.gov/ct2/show/NCT02846064.INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID):DERR1-10.2196/12944.

BACKGROUND:Two surgical approaches usually are used in the surgical management of deep infiltrating endometriosis of the rectum: the radical approach that mainly is based on colorectal resection and the conservative or symptom-guided approach that prioritizes conservation of the rectum. There are no data available that compare long-term functional digestive outcomes of 1 approach to the other. OBJECTIVE:The purpose of this study was to compare long-term digestive outcomes in women who were treated by either rectal shaving or colorectal resection for deep endometriosis infiltrating the rectum. STUDY DESIGN:A retrospective comparative study was performed. All women who were treated with surgery for deep endometriosis infiltrating the rectum by either shaving or colorectal resection at the University Hospital of Rouen from January 2005 to January 2010 were enrolled. Follow-up evaluation was carried out for a minimum of 5 years. Postoperative evaluation of digestive symptoms was performed by 4 standardized gastrointestinal questionnaires: the Gastrointestinal Quality of Life Index, the Knowles-Eccersley-Scott-Symptom score for constipation, the Wexner score for anal continence, and the Bristol Stool Score. Symptoms that were related to endometriosis, fertility, and disease recurrence were obtained from a specific questionnaire. RESULTS:A total of 77 women were included. Three women were lost to follow up (3.9%), and 3 were treated by disc excision (3.9%). The mean follow-up time was 80±19 months. Forty-six women underwent conservative rectal shaving, and 25 women underwent colorectal resection. Patient characteristics and the severity of the disease were comparable in both groups. Patients who were treated by rectal shaving had significantly better Gastrointestinal Quality of Life Index values, lower Knowles-Eccersley-Scott-Symptom scores for postoperative constipation, and better anal continence. No statistically significant differences were revealed for postoperative pelvic pain. Rectal recurrence occurred in 8.7% of patients who were treated by conservative surgery: 4.3% underwent secondary colorectal resection and 4.3% were treated secondarily by rectal shaving. Consequently, avoiding a recurrence for merely 1 patient would have required 11 patients to undergo colorectal resection instead of shaving. CONCLUSION:Our data suggest that, in patients who are treated for rectal endometriosis, colorectal resection does not improve long-term postoperative functional outcomes when compared with rectal shaving.

Objectives. - Every year 3 millions of young women had undergone female genital mutilation. The psychological, identical and sexual consequences, as well as the treatment were described only recently. After a sociodemographic and cultural reminder, we analyze the anatomical, psychological, identital, and functional results of the reconstructive surgery.Patients and methods. - We conducted a retrospective monocentric study. Thirty women were included in our series. All the patients operated according to the technique of Pierre Foldes were contacted again, to estimate their motivations for this surgery and study the results on femininity, anatomy, psychology and functionality of this intervention.Results. - Twenty-six women were able to be estimated in the long term. Their main motivation was in 77% of the cases the research for a feminine identity. We compared the pre- and postoperative results, as well as different predefined under groups. The results shown a significant improvement between the pre- and the postoperative estimation for each of the items. The patients indicate an improvement: anatomical in 96% of the cases, for identity in 88% of the cases, psychological in 96% of the cases, and for sexuality in 88% of the cases.Discussion and conclusion. - This technique allows an improvement for anatomy and functionality but also for physical image, well-being and feminity. (C) 2016 Elsevier Masson SAS. All rights reserved.

Study Objective: To compare the probability of postoperative pregnancy in infertile women with ovarian endometrioma larger than 3 cm in diameter, managed by either ablation using plasma energy or cystectomy.Design: A multicentric case-control study (Canadian Task Force classification II-2).Setting: Six surgical departments, affiliated with 4 university hospitals and 2 private facilities.Patients: One hundred four infertile patients with ovarian endometrioma larger than 3 cm.Interventions: Endometrioma ablation using plasma energy was performed in 64 patients (61.5%) and cystectomy in 40 patients (38.5%).Measurements, and Main Results: Patients were enrolled in the CIRENDO prospective cohort database (NCT02294825) from June 2009 to June 2014 and managed in 6 different facilities. The minimum length of follow-up was 1 year. Postoperative probabilities of pregnancy in patietns and control subjects were estimated using the Kaplan-Meier method with 95% confidence intervals (CIs) and compared using the log-rank test. The Cox model was used to assess independent predictive factors for pregnancy. Patients managed by plasma energy were significantly older than patients managed by cystectomy, had significantly higher overall revised American Fertility Society (rAFS) score, and had higher rate of Douglas pouch obliteration, deep endometriosis, and colorectal localizations. After a mean follow-up of 35.3 +/- 17.5 months (range, 12-60), fertility outcomes were comparable between the groups. The probability of pregnancy at 24 and 36 months after surgery in plasma energy and cystectomy groups was, respectively, 61.3% (95% CI, 48.2%-74.4%) versus 69.3% (95% CI, 54.5%-83%) and 84.4% (95% CI, 72%-93.4%) versus 78.3% (95% CI, 63.8%-90%). The Cox's model revealed that the type of surgical procedure on ovarian endometrioma had no statistically significant impact on the probability of pregnancy, after adjustment for women's age, bilateral cysts larger than 3 cm, colorectal endometriosis, and rAFS stage of endometriosis.Conclusion: Postoperative pregnancy rates were comparable after management of ovarian endometrioma by either ablation using plasma energy or cystectomy despite an overall higher rate of unfavorable fertility predictive factors in women managed by ablation. (C) 2016 AAGL. All rights reserved.

Objective. - To assess the feasibility of deep endometriosis surgery using robotic assistance, benefits and limits of this approach. Method. - Case-series study enrolling patients managed for deep infiltrating endometriosis (DIE) using robotic assistance in our department between September 2011 and March 2014 (NCT02294825). Self-questionnaires including pain and digestive symptoms were filled in pre-operatively and 1 year after surgery. Results. - Thirty-five patients were enrolled in the series. They represented 54% of patients managed for gynecological disease by laparoscopic route with robotic assistance during the study period, and 14% of patients managed for deep endometriosis in our department. Followup averaged 24 +/- 8 months, and no patient was lost to follow-up. Thirty-two patients had rectal involvement: rectal shaving was performed in 25 patients, disc excision in 3 and colorectal resection in 4. Three patients had bladder resection. Thirteen patients presented with deep endometriosis of the ureters: ureterolysis was performed in 11 of them, and resection of the ureter followed by reimplantation into the bladder in 2 patients. One major complication(Clavien IIIb) was recorded in a patient presenting with necrosis of the right ureter on postoperative day 5. Nine patients tried to conceive after surgery and 8 have already become pregnant (88.9%). One year after surgery, self-questionnaires revealed a significant decrease in pain symptoms and significant improvement in several item values of gastrointestinal standardized questionnaires. Conclusions. - Surgical management of DIE is feasible using robotic assistance. However, data available in the literature and our own experience do not definitively support the hypothesis of the superiority of robotic assistance in the management of DIE. (C) 2015 Elsevier Masson SAS. All rights reserved.

Study ObjectiveTo report the combined cystoscopic and laparoscopic approach in deep endometriosis with full-thickness infiltration of the bladder.DesignVideo (Canadian Task Force classification III).SettingUniversity hospital.PatientA 34-year-old nulliparous woman with a large (35-mm) endometriosis nodule infiltrating the bladder and deep endometriosis of the rectum and sigmoid colon.InterventionThe urologic surgeon performed cystoscopy, identified the limits of mucosal involvement, and incised the muscular layer up to fat tissues surrounding the bladder. The gynecologic surgeon identified and followed the circular incision, and completed full-thickness resection of the bladder wall. Surgical technique reports in anonymous patients are exempt from ethical approval by the institutional review board.Measurements and Main ResultsThe patient's functional outcome was uneventful. Laparoscopic resection of large endometriotic nodules of the bladder per se may lead to inadvertent removal of healthy bladder muscle. Thus it increases the risk of postoperative complications and symptoms due to small bladder volume. Conversely, if resection of the nodule is performed only cystoscopically, it probably would not be completely removed. We routinely combine the 2 approaches because this enables complete resection of the endometriotic nodule. It not only averts the risk of excessive removal of healthy bladder muscle but also leaves no disease behind.ConclusionsOn the basis of our experience, we propose the combined cystoscopic and laparoscopic approach in managing large endometriotic nodules with full-thickness infiltration of the bladder.

Présenter notre expérience sur la prise en charge chirurgicale des grossesses interstitielles (GI) et évaluer la fertilité ultérieure de nos patientes à long terme. Vingt patientes ont été opérées dans notre service d’une grossesse interstitielle sur une période de 15 ans. Dans ce travail rétrospectif nous présentons : la symptomatologie ayant amené au diagnostic, les traitements réalisés, la fertilité et le devenir obstétrical ultérieur. L’âge gestationnel moyen du diagnostic était de 8 SA, le taux de Bhcg médian était de 7411 IU/L, l’âge moyen des patientes était de 30 ans. 90 % des patientes présentaient au moins 1 facteur de risque de grossesse ectopique. Les douleurs ou métrorragies étaient les symptômes les plus fréquents à l’admission ; 4 patientes ont été admises en choc hypovolémique. La localisation interstitielle de cette grossesse ectopique a été découverte en peropératoire dans 45 % des cas. Six patientes avaient un hémopéritoine volumineux supérieur à 1 L, 5 patientes présentaient une GI sur moignon utérin après salpingectomie pour GEU. La technique chirurgicale employée le plus souvent a été 60 % d’excisions par agrafage Endo GIA® avec salpingectomie antégrade. Concernant la fertilité, 12 patientes souhaitaient une grossesse dans les suites de l’intervention, 10 ont eu au moins 1 grossesse, parmi elles on note 1 grossesse extra-utérine ampullaire controlatérale, et 1 récidive de grossesse interstitielle controlatérale. Quatre patientes ont accouché par césarienne et 4 patientes ont accouché par voie basse, certaines plusieurs fois. Aucune rupture utérine n’a été répertoriée. La grossesse interstitielle est une grossesse ectopique rare, de diagnostic difficile qui peut mettre en jeu le pronostic vital ainsi que la fertilité maternelle. Lors des grossesses ultérieures le clinicien se méfiera des risques de récidive de grossesse interstitielle et de rupture utérine. Presenting our experience concerning interstitial pregnancies (IP) surgical management and to evaluate our patients’ subsequent long-term fertility. Twenty patients underwent surgical treatment of IP in our department over 15 years. In this retrospective study, we present symptoms that led to diagnosis, treatments, fertility and obstetrical outcome. Mean gestational age at diagnosis was 8 SA, with a median BHCG rate of 7411 IU/L, and a patient mean age of 30 years. Ninety percent of patients had at least one risk factor for ectopic pregnancy. Pain or bleeding were the most common symptoms at admission, 4 patients were admitted in an hypovolemic shock status. Location of the interstitial ectopic pregnancy was discovered during surgery in 45 % of cases. Six patients had a large hemoperitoneum bigger than 1 L, 5 patients had an IP of uterine stump after salpingectomy for a previous ectopic pregnancy. The most used surgical technique was in 60 % of cases the excision by Endo GIA stapling® with salpingectomy. Regarding fertility, 12 patients wished pregnancy in the aftermath of the intervention, 10 had at least one pregnancy, among them there is an ectopic contralateral ampullary pregnancy, and a contralateral recurrence of interstitial pregnancy. Four patients were delivered by cesarean section and 4 patients were delivered vaginally, some several times. No uterine rupture occured. Interstitial pregnancy is a rare ectopic pregnancy. Its diagnosis is difficult and may involve maternal life-threatening and fertility. In subsequent pregnancies, the clinician has to be careful concerning the risks of interstitial pregnancy recurrence and uterine rupture.

Objective. - Presenting our experience concerning interstitial pregnancies (IP) surgical management and to evaluate our patients' subsequent long-term fertility.Patients and method. - Twenty patients underwent surgical treatment of IP in our department over 15 years. In this retrospective study, we present symptoms that led to diagnosis, treatments, fertility and obstetrical outcome.Results. - Mean gestational age at diagnosis was 8 SA, with a median BHCG rate of 7411 IU/L, and a patient mean age of 30 years. Ninety percent of patients had at least one risk factor for ectopic pregnancy. Pain or bleeding were the most common symptoms at admission, 4 patients were admitted in an hypovolemic shock status. Location of the interstitial ectopic pregnancy was discovered during surgery in 45 % of cases. Six patients had a large hemoperitoneum bigger than 1 L, 5 patients had an IP of uterine stump after salpingectomy for a previous ectopic pregnancy. The most used surgical technique was in 60 % of cases the excision by Endo GIA stapling with salpingectomy. Regarding fertility, 12 patients wished pregnancy in the aftermath of the intervention, 10 had at least one pregnancy, among them there is an ectopic contralateral ampullary pregnancy, and a contralateral recurrence of interstitial pregnancy. Four patients were delivered by cesarean section and 4 patients were delivered vaginally, some several times. No uterine rupture occured.Discussion and conclusion. - Interstitial pregnancy is a rare ectopic pregnancy. Its diagnosis is difficult and may involve maternal life-threatening and fertility. In subsequent pregnancies, the clinician has to be careful concerning the risks of interstitial pregnancy recurrence and uterine rupture. (C) 2013 Published by Elsevier Masson SAS.