Long-term functional stability of sacrospinous ligament-fixation repair of pelvic organ prolapse.

The objective of this study was to evaluate the variation over 5 years of functional discomfort associated with pelvic organ prolapse (POP) repaired by sacrospinous ligament fixation (SLF). A total of 178 women who had undergone SLF from 1992 to 2001. In 2002 and 2008, patients were sent a questionnaire including the pelvic floor distress inventory (PFDI-20); 79 responded and comparison of those data served to evaluate subjective signs at 5 years. This population was divided into two groups: ≤60 and >60 years old, and their 2002-2008 differences were compared. The outcomes were satisfaction, functional results and sexuality. Mean follow-up was 115 (72-173) months. Our results showed the long-term stability of SLF functional outcomes for women >60 years. However, for those≤60 years, functional outcomes and satisfaction had declined at 5 years.

[Pelvic floor disorders four years after first delivery: a comparative study of restrictive versus systematic episiotomy]. / Troubles périnéaux quatre ans après le premier accouchement: comparaison entre épisiotomie restrictive et systématique.

OBJECTIVE: To compare two policies for episiotomy: restrictive and systematic. PATIENTS AND METHODS: It is a quasi-randomised comparative study between two French university hospitals with contrasting episiotomy policies: one using it restrictively and the second routinely. Population included 774 nulliparous women delivered during 1996 of a singleton in cephalic presentation at a term of 37-41 weeks. A questionnaire was mailed four years after delivery. Sample size was calculated to allow showing a 10% difference in the prevalence of urinary incontinence with 80% power. Main outcome measures were urinary incontinence, anal incontinence, perineal pain and pain during intercourse. RESULTS: We received 627 responses (81%), 320 from women delivered under the restrictive policy, 307 from women delivered under the routine policy. In the restrictive group, 186 (49%) deliveries included mediolateral episiotomies and in the routine group, 348 (88%). Four years after the first delivery, the groups did not differ in the prevalence of urinary incontinence (26% versus 32%), perineal pain (6% versus 8%), or pain during intercourse (18% versus 21%). Anal incontinence was less prevalent in the restrictive group (11% versus 16%). The difference was significant for flatus (8% versus 13%) but not for faecal incontinence (3% for both groups). Logistic regression confirmed that a policy of routine episiotomy was associated with a risk of anal incontinence nearly twice as high as the risk associated with a restrictive policy (OR=1.84, 95 % CI :1.05-3.22). DISCUSSION AND CONCLUSION: A policy of routine episiotomy does not protect against urinary or anal incontinence four years after first delivery.

Pelvic floor disorders 4 years after first delivery: a comparative study of restrictive versus systematic episiotomy.

OBJECTIVE: To compare two policies for episiotomy: restrictive and systematic. DESIGN: Quasi-randomised comparative study. SETTING: Two French university hospitals with contrasting policies for episiotomy: one using episiotomy restrictively and the second routinely. POPULATION: Seven hundred and seventy-four nulliparous women delivered during 1996 of a singleton in cephalic presentation at a term of 37-41 weeks. METHODS: A questionnaire was mailed 4 years after delivery. Sample size was calculated to allow us to show a 10% difference in the prevalence of urinary incontinence with 80% power. MAIN OUTCOME MEASURES: Urinary incontinence, anal incontinence, perineal pain, and pain during intercourse. RESULTS: We received 627 responses (81%), 320 from women delivered under the restrictive policy, 307 from women delivered under the routine policy. In the restrictive group, 186 (49%) deliveries included mediolateral episiotomies and in the routine group, 348 (88%). Four years after the first delivery, there was no difference in the prevalence of urinary incontinence (26 versus 32%), perineal pain (6 versus 8%), or pain during intercourse (18 versus 21%) between the two groups. Anal incontinence was less prevalent in the restrictive group (11 versus 16%). The difference was significant for flatus (8 versus 13%) but not for faecal incontinence (3% for both groups). Logistic regression confirmed that a policy of routine episiotomy was associated with a risk of anal incontinence nearly twice as high as the risk associated with a restrictive policy (OR = 1.84, 95% CI: 1.05-3.22). CONCLUSIONS: A policy of routine episiotomy does not protect against urinary or anal incontinence 4 years after first delivery.

Anterior repair using Bologna procedure: long-term results on stress urinary continence.

The aim of this study was to describe the prognostic factors and long-term results on stress urinary continence of the Bologna procedure for bladder neck suspension in women undergoing vaginal repair for large cystocele. This was a cohort study and questionnaire-based outcomes analysis. Subjects were 218 women operated on between 1982 and 1992. Their mean age was 66 years. The Bologna vaginal wall sling was associated with vaginal hysterectomy in 199 cases and with posterior colporrhaphy in 202 cases. Median follow-up was 69 months. Of the 218 patients, 182 were continent at stress (83%). The risk factors were low urethral pressure (<30 cmH(2)O, RR = 2.42), severity of preoperative stress urinary incontinence (RR = 2.01 for grade I, 4.03 for grade II and 8.10 for grade III), and an exteriorized cystocele (RR = 0.45). We concluded that the Bologna procedure allows bladder neck suspension during vaginal repair of cystocele, with good results on future continence.

Intravenous chemotherapy, early debulking surgery, and consolidation intraperitoneal chemotherapy in advanced ovarian carcinoma.

OBJECTIVE: The efficacy of a cisplatin-anthracycline combination, early debulking surgery, and intraperitoneal chemotherapy has been demonstrated through separate studies. We evaluated a multimodal treatment strategy integrating these therapeutic options. METHODS: Women with stage III or IV ovarian carcinoma received six cycles of cisplatin/epirubicin alternating with leucovorin and 5-fluorouracil. Patients with a residual disease (RD) measuring more than 2 cm after the initial laparotomy underwent an early debulking surgery after the first three cycles of chemotherapy. A second-look laparotomy (SLL) was performed after six cycles of intravenous chemotherapy. Intraperitoneal chemotherapy with cisplatin, VP16, and mitoxantrone was then administered in patients with no or RD < 2 cm after SLL. RESULTS: A total of 87 patients were included. After initial laparotomy, 11 patients (12%) had no macroscopic residual disease, 38 (44%) had a RD < or =2 cm, and 38 (44%) had a RD > 2 cm. After early debulking surgery, an additional 18 patients (21%) had a RD < 2 cm. Seventy-five patients were evaluable for response to intravenous chemotherapy: the overall response rate was 80%, and 30 patients achieved a pathological complete response (40%). Eight percent of the patients had stable disease and 12% had a progression. Sixty-eight patients received intraperitoneal chemotherapy after second-look laparotomy. With a 72-month median follow-up, median overall survival and progression-free survival were, respectively, 37 and 19 months. Five-year survival was 41%. CONCLUSION: The prognosis of patients with advanced ovarian carcinoma may be improved by a sequential treatment strategy including intravenous chemotherapy, early debulking surgery, and intraperitoneal chemotherapy.

Results of transurethral injection of silicone micro-implants for females with intrinsic sphincter deficiency.

PURPOSE: We evaluated the medium term efficiency of silicone micro-implants injected in women with intrinsic sphincter deficiency. MATERIALS AND METHODS: A total of 21 women with intrinsic sphincter deficiency underwent transurethral injection of silicone micro-implants between August 1996 and February 1997. Each patient was assessed preoperatively by questionnaire, physical examination and urodynamic study. The results were evaluated by questionnaire at 1 month, and 1 and 2 years after silicone injection. The outcome was classified as dry in all circumstances, improved or failure. RESULTS: All patients (median age 68 years, range 46 to 83) had undergone previous anti-incontinence or prolapse surgeries. At 1 month 2 patients (10%) were dry and 9 (42%) were improved, and treatment failed in 10 (48%). At 1 year (median 16 months, range 14 to 22) 2 cases (10%) were classified as dry, 8 (38%) improved and 11 (52%) failures. At last followup (median 31 months, range 24 to 34) 4 cases (19%) were classified as dry, 6 (29%) improved and 11 (52%) failures. None of the 6 patients with bladder neck hypermobility was dry. CONCLUSIONS: Our results of silicone transurethral injection are disappointing but comparable to other bulking agents without a time dependent decrease in efficiency. The use of silicone micro-implants is an alternative for the treatment of intrinsic sphincter deficiency in patients without bladder neck hypermobility and in whom the sling procedure has failed.

[Ureteral endometriosis: three cases. Diagnostic and therapeutic management. Literature review]. / Endométriose urétérale: à propos de 3 cas. Conduite diagnostique et thérapeutique. Revue de la littérature.

Ureteral endometriosis is a rare but serious entity because of its insidious evolution which can lead to the loss of kidney function. Three cases are reported: two patients have received a medical and endoscopic management and the third one has undergone a surgical procedure. According to the literature, the authors suggest a diagnostic and therapeutic tree.

[Surgical treatment of genitourinary prolapse by the abdominal approach. Apropos of a series of 232 cases]. / Traitement chirurgical des prolapsus génito-urinaires par voie abdominale. A propos d'une série de 232 cas.

Two hundred and thirty two patients with genitourinary prolapse were operated via an abdominal incision between 1981 and 1994. The technique consisted of retroperitoneal promontofixation, systematically associated with a retropubic colposuspension, levator myorrhaphy, Douglassectomy and uterosacral ligamentoplasty. The mean age of operated patients was 52.57 years (30-85 years), the mean follow-up was 17.8 months (1-105). 65 patients (27.7%) had a history of foetal macrosomy, 125 women (53.4%) were delivered without forceps or expression, and 2 patients (0.8%) had never procreated. The main presenting complaint was prolapse in 197 patients (84.4%), while 140 patients complained of urinary incontinence (60.3%). A urodynamic assessment was systematically performed before the operation and revealed defective transmission in 160 cases (71%); sphincter incompetence in 62 cases (62/228 cases, i.e. 27%); a combination of sphincter incompetence and defective transmission in 40 cases (17.7%). The results were assessed in terms of anatomical and functional parameters. The anatomical results revealed 21 recurrences, the majority of which were posterior recurrences, and the functional results were marked by urinary functional disorders such as urinary incontinence (30%), urgent micturition (14%) and dyspareunia (21%).

[Incisional hernia after surgical laparoscopy: a case of hepatic ligament incarceration and review of the literature]. / Hernie incisionnelle après coelioscopie chirurgicale: à propos d'un cas d'incarcération du ligament suspenseur du foie et revue de la littérature.

The authors report a case of incisonal hernia occurring 5 years after laparoscopic treatment of extra-uterine pregnancy. This involved incarceration of the hepatic suspensor ligament during insertion of a 10 mm umbilical trocard. Laparoscopy permitted diagnosis and treatment of the hernia. Parietal complications after laparoscopy usually concern epigastric vascular lesions, infections at trocard sites, and residual abdominal wall pain. Incisonal umbilical and extra-umbilical hernias, described for the first time in 1968, are highly unusual complications, with an incidence of 21/100,000 in the Mintz study. The hernia sac usually contains omentum or small intestine. The present observation alems to be the first case of incarceration of the hepatic suspensor ligament in an umbilical trocard. This observation is remarkable not only for the hernia sac contents but also for the delay between laparoscopy and the occurrence of the umbilical hernia.

[Early debulking surgery after chemotherapy in advanced cancer of the ovary]. / La cytoréduction chirurgicale précoce après chimiothérapie dans le cancer de l'ovaire avancé. GEROD. Groupe d'Etude et de Recherche sur les Cancers de l'Ovaire et Digestifs.

The main prognostic factor in advanced ovarian cancer is the volume of residual disease after the initial laparotomy. Early debulking surgery after several cycles of chemotherapy, before the emergence of resistant cell lines, could improve the prognosis of patients with bulky residual disease. This study concerns patients with advanced ovarian cancer entered into three prospective trials including IV cisplatin and anthracycline-based chemotherapy, early debulking surgery after three cycles of chemotherapy in case of initial residual disease superior 2 cm and intraperitoneal consolidation chemotherapy. Among 160 patients with stage III or IV, 80 (50%) had at least a residual tumor of more than 2 cm in diameter. Early debulking surgery was effectively performed in 54 patients (67.5%), leaving 39 patients with no residue over 2 cm. Twenty-one patients had no macroscopic residual disease. The median survival of all patients with initial residual disease over 2 cm was 23 months. Patients with no macroscopic residual disease at early debulking surgery had a median survival of 44 months. Early debulking surgery appears useful in advanced ovarian cancer with bulky residual disease. The objective of this operation is to achieve no macroscopic residual lesion.

[Postpartum hemorrhage. Current management]. / Hémorragie de la délivrance. Prise en charge actuelle.

Post-partum haemorrhage is one of the major worldwide causes of maternal mortality. Better knowledge of risk factors should limit its incidence and short term hazards. In case of excessive bleeding, classical therapeutic means continue to be of major importance. If unsuccessful, modern methods including injections of prostaglandins, vascular ligations, and arterial embolization, should be employed, preserving future fertility.

[Surgical indications in female urinary incontinence]. / Indications chirurgicales de l'incontinence urinaire féminine.

In addition to artificial urinary sphincters, the surgical management of female urinary incontinence includes many surgical procedures of the bladder neck: its retropubic placement within the confines of abdominal pressure, posterior support preventing effort opening or the reduction of its diameter. Whatever the surgical procedure, surgical indications depend on discomfort and patient desire after complete assessment to evaluate risk of failure and postoperative complications. Choice of a technique depends on the surgeon's individual preference; success rate varies from 50 to 80% after 5 years follow-up.

[Locoregional recurrences of breast cancer]. / Récidives loco-régionales de cancers du sein.

AIM OF THE STUDY: To determine the characteristics of 51 cases of isolated local regional breast cancer recurrence. METHODS: Retrospective study from 1980 to 1992, survival calculated according to Kaplan-Meier and log-rank test. RESULTS: Twenty-five patients had had a conservative treatment of her primary tumour, 26 had been treated by modified radical mastectomy. Local regional recurrence rate was 9%: 44% of recurrences after lumpectomy and 43% of recurrences after mastectomy occurred within 2 years after the initial treatment. Site of local regional recurrence was chest wall only (16 cases), breast only (15 cases) or axillary or supraclavicular node with or without chest wall or breast involvement (20 cases). The actuarial 5-year survival rate after recurrence is 54%. It depends on the time to recurrence (40% if time to recurrence was less than 2 years, 68% if more than 2 years, p < 0.10), on initial node involvement (36% for N+, 71% for N-, p < 0.15) and on the site of recurrence (chest wall: 43%; breast: 48%; regional node: 12%, p < 0.10). CONCLUSION: Like in the literature, severe recurrences are early recurrences, lymph node recurrences and recurrences following a primary tumour with involved axillary nodes.

[Immature teratoma of the ovary. Apropos of 3 cases. Review of the literature and an evaluation]. / Tératome immature de l'ovaire. A propos de trois observations. Revue de la littérature et mise au point.

Immature teratoma of the ovary is a rare tumour (1% of cancer of the ovary) usually seen in adolescents or young women. It is a malignant tumour derived from an abnormal germ-cell which undergoes meiotic division. The diagnosis is based on the pathological examination which reveals immature tissue derived from two or three types of embryonic tissue (endo-, meso- and ectoderm). Intraperitoneal dissemination occurs and immature or mature recurrence is observed. The prognosis was particularly severe before the use of polychemotherapy which has also made conservative surgery possible. At the present time, the consensus is to reduce the duration of the chemotherapy with a regular clinical and laboratory (tumour markers, aFP) monitory. A second look laparotomy verifies successful treatment.

Intravenous sulprostone and uterine scarring based upon 22 cases of therapeutic abortion during 2nd and 3rd trimesters of pregnancy.

A preliminary study in 22 patients with uterine scarring was undertaken using sulprostone by intravenous infusion when therapeutic abortion was deemed necessary during the 2nd and 3rd trimesters of pregnancy. The dosage used was 500 micrograms by slow infusion lasting 10 h. There were no cases of ruptured uterus. Adverse reactions were absent. Results were satisfactory. Mean induction-expulsion duration: 11 h. Expulsion rate in 24 h: 63%. With strict monitoring and in a specialized center, this technique may be suggested when a late therapeutic abortion with a scarred uterus is indicated.

Therapeutic abortion during the 2nd and 3rd trimesters of pregnancy using a synthetic derivative of prostaglandin E2, sulprostone, administrated intravenously. Based upon 182 cases.

OBJECTIVE: The purpose of the study is to assess the efficacy of and adverse events linked to the use of intravenous sulprostone during the 2nd or 3rd trimesters of pregnancy for therapeutic abortion. STUDY DESIGN: One hundred eighty-two patients (70 nulliparous, 112 multiparous) were hospitalized for therapeutic abortion. The route of administration was invariably intravenous and one single dose of sulprostone was used: 1000 micrograms of sulprostone diluted in 1 l of isotonic saline solution given as a 10-h infusion. RESULT: Expulsion within the first 24 h was obtained in 70% of cases with a mean induction-expulsion interval of 14 h. In three cases, laparotomy was required for hemorrhagic syndromes. CONCLUSION: Intravenous sulprostone enable evacuation of uterine contents with minimal adverse reaction. Attention should nevertheless be drawn to the existence of hemorrhagic syndromes.

[Postpartum perineal rehabilitation by early electrostimulation at home. Preliminary study]. / Rééducation périnéale du post-partum par électrostimulation précoce à domicile. Etude préliminaire.

The authors report a preliminary trial of post-partum perineal physiotherapy by functional electric stimulation at home starting from Day 15. Fifteen primipara used the technique. Perineal muscle testing and urodynamic investigations took place before Perineal muscle testing and urodynamic investigations took place before and after physiotherapy. Testing of the levators showed complete recovery in 20 p. cent of cases and partial in 80 p. cent. Urodynamic results showed a significant increase in resting urethral pressure. Acceptability of physiotherapy was perfect. The early start offered the twin advantages of better muscular recovery and easier motivation of the patient. Physiotherapy at home enabled these women, already busy, to carry out their perineal physiotherapy with minimum difficulty.