Publication
Chapron C, Fauconnier A, Goffinet F, Bréart G, Dubuisson JB
• 05/2002
BACKGROUND: Laparoscopic surgery presents a large number of advantages over laparotomy. The goal of this work was to check whether these benefits outweigh any greater risk of complications. METHODS: The study design was a meta-analysis of published data from prospective randomized clinical trials (RCT). For the period 1966 to June 2000 we searched Medline and Cochrane Controlled Trial Registers and asked the investigators for further details. Meta-analysis was carried out with the Cochrane review manager software RevMan 4.1. RESULTS: A total of 27 prospective RCT including 3611 women (1809 treated by operative laparoscopy and 1802 treated by laparotomy) were enrolled in the meta-analysis. The overall risk of complications was significantly lower for patients operated by laparoscopic surgery [relative risk (RR) 0.59; 95% confidence interval (CI) 0.50-0.70]. There was no statistically significant difference concerning the risk of major complications with respect to the approach used (RR 1.0; 95% CI 0.60-1.65). The risk of minor complications was significantly lower for patients operated by laparoscopic surgery (RR 0.55; 95% CI 0.45-0.66). Concerning the risks of readmission, second procedure and blood transfusion, there was no difference between the two groups. Identical results were found when we performed a sensitivity analysis including or excluding studies according to the methodological score. Subgroup analysis according to how serious the surgery was (minor, major, advanced) showed a significant increase in the risk of transfusion for advanced procedures performed by laparotomy. CONCLUSIONS: Laparoscopic surgery is not inherently dangerous for patients presenting benign gynaecological pathologies. The potential risk of complications should no longer be advanced as an argument against using laparoscopic surgery rather than laparotomy for an operation when the indication allows the choice.
Publication
Chapron C, Dubuisson JB, Pansini V, Vieira M, Fauconnier A, Barakat H, Dousset B
• 05/2002
STUDY OBJECTIVE: To determine whether routine clinical examination is sufficient for the diagnosis and establishing the location of deeply infiltrating endometriosis (DIE). DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. Patients. One hundred sixty women with histologically proved deeply infiltrating endometriosis. MEASUREMENTS AND MAIN RESULTS: Speculum examination allowed endometriotic lesions to be viewed in only 14.4% (23) of patients, and a classic, painful, spheric nodule was palpated in only 43.1% (69). Results of routine clinical examination varied significantly with location of DIE. Whereas a nodule was found in 80.0% (24) of patients with vaginal endometriosis, this rate dropped to only 35.3% (6) and 33.3% (34) in those with DIE of the digestive tract and uterosacral ligaments, respectively (p <0.0001). CONCLUSION: High locations of DIE lesions at the level of uterosacral ligaments, bottom of the pouch of Douglas, and upper one-third of the posterior vaginal wall explain why results of routine clinical examination are so poor. The term -'deep endometriosis infiltrating the rectovaginal septum-' is generally incorrect in the true anatomic sense.
Publication
Dubuisson JB, Jacob S, Chapron C, Fauconnier A, Decuypere F, Dubernard G
• 02/2002
We report our experience with a new technique to treat genital prolapse: the laparoscopic lateral suspension with two meshes. This is a prospective longitudinal study of 47 women with genital prolapse. With a mean follow-up of 15.2 +/- 10 months (1-39), the anatomical result was perfect in 78.7% of the cases (37 patients). From the functional point of view, 89.3% were satisfied (42 patients). These good preliminary results need to be confirmed by other extensive studies.
Publication
Balleyguier C, Chapron C, Dubuisson JB, Kinkel K, Fauconnier A, Vieira M, Hélénon O, Menu Y
• 02/2002
STUDY OBJECTIVE: To take recent progress in magnetic resonance imaging (MRI) into account to determine its accuracy compared with that of transvaginal ultrasonography (TVUS) in diagnosing bladder endometriosis. DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: Twelve women with histologically proved bladder endometriosis. INTERVENTION: Magnetic resonance imaging with body and endocavitary coils and TVUS. MEASUREMENTS AND MAIN RESULTS: Although TVUS was normal in four patients, MRI enabled endometriotic lesions to be detected in all patients. Magnetic resonance imaging with endocavitary coil established the existence of deep infiltration in three patients when muscularis involvement was not visible with the body coil. In seven women MRI determined how far deep posterior endometriotic lesions extended, whereas with TVUS this was impossible to see. Conclusion. MRI had advantages over TVUS in diagnosing small lesions of associated posterior deep endometriotic lesions. The endocavitary coil gave better results than the phased-array coil for diagnosing deep infiltration. These results are important in that they help guide surgical management.
Publication
Chapron C, Dubuisson JB, Fauconnier A, Vieira M
• 11/2001
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.
Publication
Doridot V, Dubuisson JB, Chapron C, Fauconnier A, BabakiFard K
• 11/2001
STUDY OBJECTIVE: To assess recurrence of leiomyomata after laparoscopic myomectomy (LM) and evaluate predictive factors of recurrence. DESIGN: Observational study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: One hundred ninety-six women. INTERVENTION: Laparoscopic myomectomy with mean follow-up of 47 months. MEASUREMENTS AND RESULTS: Myoma recurrence included recurrence of initial symptomatology before LM, recurrence at clinical examination, and appearance of a myoma 2 cm or larger on ultrasound examination. Recurrence was observed in 45 patients (22.9%). The mean time before recurrence was 42 months (range 4-95 mo). Eight women (4.08%) required reoperation. The cumulative recurrence risk was 12.7% at 2 years and 16.7% at 5 years. Predictive factors for recurrence were number of myomas and nulliparity. CONCLUSION: According to our results, the cumulative rate of myoma recurrence within 5 years appears greater after LM than after laparotomy. However, this should not lead us to reject laparoscopy, which has many advantages compared with laparotomy, in particular its low morbidity.
Publication
Chapron C, Pierre F, Querleu D, Dubuisson JB
• 09/2001
In the field of surgery the development of operative laparoscopy has been one of the most important steps forward over the past fifteen years. This technique has become the surgical treatment of choice for a number of indications in gynaecology. The advantages of laparoscopy as compared with laparotomy are weil known, and assessment of the risk of complications is essential. A multicentric study was carried out in seven top French centres for laparoscopic gynaecological surgery. This series runs over a period of nine years and covers 29,966 diagnostic and operative laparoscopies. The risk of complications has been assessed according to the complexity of the laparoscopic procedure in question. The means of diagnosis and treatment of the complications have been analysed together with the importance of the surgeon's degree of experience. The mortality rate is 3.33 per hundred thousand laparoscopies. The overall complication rate is 4.64 per thousand laparoscopies (139 cases). The rate of complications requiring laparotomy is 3.20 per thousand (96 cases). The complication rate is significantly correlated with the complexity of the laparoscopic procedure (p = 0.0001). One out of three complications (34.1%; 43 cases) occurred while setting up for laparoscopy, and one out of four complications (28.6%) were not diagnosed during the operation. As new indications for laparoscopic surgery in gynaecology have appeared, there has been a parallel and statistically significant increase in the rate of urological complications (p = 0.001). Increased experience of the surgeons has had three consequences: a statistically significant drop in the number of bowel injuries (p = 0.0003), a drop in the rate of complications requiring laparotomy for those laparoscopic surgical procedures which are weil-defined (p = 0.01) and a change in the way complications are treated, with a significant increase in the proportion of incidents treated by laparoscopy (p = 0.0001). Laparoscopic surgery is a reliable technique. The risk of complications exists whatever the indication for laparoscopy. None of the phases in the operation must be neglected. The risk of accidents being overlooked means that the methods for postoperative follow-up must be adapted, bearing in mind the shorter hospital stay. The part played by the surgeon's experience raises the major problem of practitioner training.
Publication
Dubuisson JB, Chapron C, Fauconnier A, BabakiFard K
• 09/2001
The appearance of uterine myomas has been linked to infertility. It has been suggested that surgical management of myomas by laparoscopic myomectomy improves fertility rates in these group of patients. In this paper we initially describe specific aspects of the surgical technique of laparoscopic myomectomy including the set-up, precise technique for hysteroromy, enucleation of the myoma, suturing of the uterus, and extraction of the myoma. We detail recent findings that demonstrate improved fertility rates in women undergoing laparoscopic myomectomy. We recommend that, when criteria for selection of patients is strictly adhered to and patients present with no other associated infertility, laparoscopic myomectomy be used to increase the implantation rate.
Publication
Chapron C, Dubuisson JB
• 09/2001
Deep endometriosis is defined as an endometriotic lesion that penetrates the retroperitoneal space for a distance of > or =5 mm. Deep endometriosis is extremely active, occurs in phase with eutopic endometrium, evolves progressively with age, and is most often located in the pouch of Douglas, the rectovaginal septum, the uterosacral ligaments, and occasionally in the uterovesical fold. These lesions are associated with pelvic pain, the intensity of which is proportional to the depth of penetration. It is clear that choice of treatment depends on the location of the endometriotic lesion. In this paper we describe our methods for the initial diagnosis and subsequent treatment of deep endometriosis. These include consultation and clinical examination protocols, use of rectal endoscopic ultrasonography (EUS), magnetic resonance imaging (MRI), and transvaginal ultrasonography techniques in diagnosis and surgical treatment approaches.
Publication
Dubuisson JB, Fauconnier A, Fourchotte V, BabakiFard K, Coste J, Chapron C
• 08/2001
BACKGROUND: Laparoscopic myomectomy (LM) has some advantages over laparotomy; however, it is reputed to be technically difficult, and the risk of conversion to laparotomy might be an obstacle in using this procedure. The aim of this study was to identify the pre-operative factors affecting the risk of conversion to an open procedure (either laparoscopic assisted myomectomy or laparotomy), and to develop a simple prediction model based on available pre-operative data with the use of multiple logistic regression. METHODS: A total of 426 women presenting with a subserous or intramural myoma measuring 20 mm or more underwent LM between March 1989 and October 1999. Of these patients, 378 had successful LM. Forty eight patients [11.3%, 95% confidence interval (CI) 8.3--14.3] had a conversion to an open procedure. A total of 265 women had adequate pre-operative ultrasonography (US) and were used for the analysis. RESULTS: The best prediction model included four pre-operative factors that were found to be independently related to the risk of conversion: size > or = 50 mm at US (adjusted OR = 10.3; 95% CI = 2.8--37.9), intramural type (adjusted OR = 4.3; 95% CI = 1.3--14.5), anterior location (adjusted OR = 3.4; 95% CI = 1.3-9.0) and pre-operative use of gonadotrophin-releasing hormone (GnRH) agonists (adjusted OR = 5.4; 95% CI = 2.0--14.2). The regression coefficients were then scaled and rounded to integers to provide an estimate of the risk for conversion. For a given patient with selected characteristics the predicted risk varied from 0--73%. CONCLUSIONS: This prediction model provides a useful tool that enables multiple criteria to be taken into account simultaneously to help select cases for LM. GnRH agonists should been used only in selected cases. US evaluation is essential before performing LM.
