Should we perform cervix removal during hysterectomy for benign uterine disease? Clinical practice guidelines from the French College of Gynecologists and Obstetricians (CNGOF).

OBJECTIVE: To provide guidelines from the French College of Obstetricians and Gynecologists (CNGOF), based on the best evidence available, concerning subtotal or total hysterectomy, for benign disease. METHODS: The CNGOF has decided to adopt the AGREE II and GRADE systems for grading scientific evidence. Each recommendation for practice was allocated a grade, which depends on the quality of evidence (QE) (clinical practice guidelines). RESULTS: Conservation of the uterine cervix is associated with an increased risk of cervical cancer (0.05 to 0.27%) and an increased risk of reoperation for cervical bleeding (QE: high). Uterine cervix removal is associated with a moderate (about 11 min) increase in operative time when hysterectomy is performed by the open abdominal route (laparotomy), but is not associated with longer operative time when the hysterectomy is performed by laparoscopy (QE: moderate). Removal of the uterine cervix is not associated with increased prevalence of short-term follow-up complications (blood transfusion, ureteral or bladder injury) (QE: low) or of long-term follow-up complications (pelvic organ prolapse, sexual disorders, urinary incontinence (QE: moderate). CONCLUSION: Removal of the uterine cervix is recommended for hysterectomy in women presenting with benign uterine disease (Recommendation: STRONG [GRADE 1-]; the level of evidence was considered to be sufficient and the risk-benefit balance was considered to be favorable).

Should we perform cervix removal during hysterectomy for benign uterine disease? Clinical practice guidelines from the French College of Gynecologists and Obstetricians (CNGOF)

To provide guidelines from the French College of Obstetricians and Gynecologists (CNGOF), based on the best evidence available, concerning subtotal or total hysterectomy, for benign disease. The CNGOF has decided to adopt the AGREE II and GRADE systems for grading scientific evidence. Each recommendation for practice was allocated a grade, which depends on the quality of evidence (QE) (clinical practice guidelines). Conservation of the uterine cervix is associated with an increased risk of cervical cancer (0.05 to 0.27%) and an increased risk of reoperation for cervical bleeding (QE: high). Uterine cervix removal is associated with a moderate (about 11 min) increase in operative time when hysterectomy is performed by the open abdominal route (laparotomy), but is not associated with longer operative time when the hysterectomy is performed by laparoscopy (QE: moderate). Removal of the uterine cervix is not associated with increased prevalence of short-term follow-up complications (blood transfusion, ureteral or bladder injury) (QE: low) or of long-term follow-up complications (pelvic organ prolapse, sexual disorders, urinary incontinence (QE: moderate). Removal of the uterine cervix is recommended for hysterectomy in women presenting with benign uterine disease (Recommendation: STRONG [GRADE 1-]; the level of evidence was considered to be sufficient and the risk-benefit balance was considered to be favorable).

Diastasis of the rectus abdominis muscles in postpartum: Concordance of patient and clinician evaluations, prevalence, associated pelvic floor symptoms and quality of life.

OBJECTIVES: The main objective was to assess the reliability of the patient's measurement of diastasis. The secondary aims were the estimation postpartum diastasis prevalence, of diastasis-associated pelvic floor symptoms and quality of life immediately after childbirth and at 3-6 months postpartum. STUDY DESIGN: Using a prospective observational design, women who gave birth in a French university hospital were eligible. After a learning phase, both clinician and patient conducted a clinical evaluation of diastasis. Then, patients were asked to complete the HerQLes, the FPFQ and a general questionnaire. Three to 6 months later, patients completed the same questionnaires online and performed a clinical evaluation of diastasis at home, as learned previously. RESULTS: Of 253 patients included in the study, 139 (54.9 %) completed the questionnaires at 3-6 months of follow-up. There was good correlation between clinician and patient evaluations of diastasis (kappa coefficient 0.76 [95 % CI, 0.5-0.7]). Immediately after childbirth, 210 (83 %) of the women presented diastasis including 116/210 (55 %) cases of severe diastasis and 51 (42 %) of those had persistent diastasis at 3-6 months of follow-up. Cesarean section (p = 0.05) and multiparity (p = 0.04) were factors of persistent diastasis. Severe diastasis had a significant impact on quality of life (HerQLes score) at birth (p = 0.001) and at 3-6 months (p = 0.01), but no effect on pelvic floor symptoms according the FPFQ. The occurrence and severity of diastasis did not significantly impact lumbar or pubic symphysis pain. Furthermore, the aesthetic discomfort felt by patients was significantly increased by the presence of diastasis on a numerical scale at 3-6 months (p = 0.03). CONCLUSION: Good agreement between clinician and patient evaluations of postpartum diastasis indicated that the evaluation method is reliable. Persistent diastasis was associated with impaired quality of life.

[Impact of the diastasis of the rectus abdominis muscles on the pelvic-perineal symptoms: Review of the literature]. / Impact du diastasis des muscles droits de l'abdomen sur les symptômes pelvi-périnéaux : revue de la littérature.

INTRODUCTION: The diastasis of the rectus abdominis muscles is common during pregnancy and post-partum. OBJECTIVE: To determine the prevalence of this pathology, methods of diagnosis, association with pelvic-perineal disorders and therapies that may be proposed. METHODS: Review of Pubmed, Medline, Embase and Cochrane literature using the following words and MeSH: diastasis, diastasis and pregnancy, diastasis of the rectus abdominis muscle, increase of the inter-recti distance. RESULTS: Among the 124 articles found, 61 were selected. Ultrasound seems to be the exam of choice both in terms of feasibility and reproducibility for the diagnosis of this pathology (intra-class correlation coefficients (ICC) high 0.81 to 0.94). The risk factors identified vary from one study to another: heavy load bearing (OR=2.18 (95 % CI 1.05 to 4.52) P=0.04), weight gain. Studies are discordant regarding the association between diastasis and low back pain (RR=1.39 (95 % CI 0.91-2.14), P=0.17), urinary incontinence (RR=0.86 (95 % CI 0.55-1.33) P>0.65) and prolapse (OR=2.25 (95 % CI 1.51-3.37) P<0.001), but the diastasis seems to play a role in the alteration of the quality of life for these patients. CONCLUSION: Knowledge about risk factors, consequences of diastasis and management is still limited today. It is therefore necessary to establish prospective studies on larger numbers in order to improve knowledge on the diastasis of the rectus abdominis muscles.

Assessment of different pre and intra-operative strategies to predict the actual ESMO risk group and to establish the appropriate indication of lymphadenectomy in endometrial cancer.

PURPOSE OF INVESTIGATION: The objective of this study was to evaluate the best pre- and intra-operative strategy to determine the European Society for Medical Oncology (ESMO) risk group. MATERIALS AND METHODS: Retrospective study on patients supported for endometrial cancer between 2006 and 2011. Twelve algorithms, integrating endometrial biopsy for histological type and tumour grade, and ultrasound and/or magnetic resonance imaging (MRI)±intra-operative examination for determination of myometrial invasion, were built. The diagnostic values of each algorithm to predict high- and low-risk group were calculated. RESULTS: During the study period, 159 patients were operated for endometrial cancer. On these 159 patients, 103 met the inclusion criteria. For the prediction of high-risk group, the best algorithm was endometrial biopsy and ultrasound, combined with MRI in case of myometrial invasion <50%±intra-operative examination in case of myometrial invasion <50% on MRI. For the prediction of low-risk group, the 2 best algorithms were endometrial biopsy and ultrasound or MRI, combined with MRI or ultrasound in case of myometrial invasion <50% and intra-operative examination in case of discrepancy between both exams. There was no internal or external validation. CONCLUSION: Our study suggests that the best strategy to predict actual ESMO risk group is endometrial biopsy and transvaginal ultrasound±MRI and intra-operative examination in case of myometrial invasion <50% on ultrasound.

Fluid Shear Stress Promotes Placental Growth Factor Upregulation in Human Syncytiotrophoblast Through the cAMP-PKA Signaling Pathway.

The effects of fluid shear stress (FSS) on the human syncytiotrophoblast and its biological functions have never been studied. During pregnancy, the syncytiotrophoblast is the main source of placental growth factor (PlGF), a proangiogenic factor involved in the placental angiogenesis and the vascular adaptation to pregnancy. The role of FSS in regulating PlGF expression in syncytiotrophoblasts is unknown. We investigated the impact of FSS on the production and secretion of the PlGF by the human syncytiotrophoblasts in primary cell culture. Laminar and continuous FSS (1 dyn cm-2) was applied to human syncytiotrophoblasts cultured in a parallel-plate flow chambers. Secreted levels of PlGF, sFlt-1 (soluble fms-like tyrosin kinase-1), and prostaglandin E2 were tested by immunologic assay. PlGF levels of mRNA and intracellular protein were examined by RT-PCR and Western blot, respectively. Intracellular cAMP levels were examined by time-resolved fluorescence resonance energy transfer cAMP accumulation assay. Production of cAMP and PlGF secretion was significantly increased in FSS conditions compared with static conditions. Western blot analysis of cell extracts exposed to FSS showed an increased phosphorylation of protein kinase A substrates and cAMP response element-binding protein on serine 133. FSS-induced phosphorylation of cAMP response element-binding protein and upregulation of PlGF were prevented by inhibition of protein kinase A with H89 (3 µmol/L). FSS also triggers intracellular calcium flux, which increases the synthesis and release of prostaglandin E2. The enhanced intracellular cAMP in FSS conditions was blocked by COX1/COX2 (cyclooxygenase) inhibitors, suggesting that the increase in prostaglandin E2 production could activate the cAMP/protein kinase A pathway in an autocrine/paracrine fashion. FSS activates the cAMP/protein kinase A pathway leading to upregulation of PlGF in human syncytiotrophoblast.

Placental growth factor (PlGF) and sFlt-1 during pregnancy: physiology, assay and interest in preeclampsia.

The placental growth factor (PlGF) and its soluble receptor (sFlt-1) are circulating angiogenic factors. During pregnancy these factors are released by the placenta into the maternal circulation. Preeclampsia affects 2-7% of pregnant women according to their risk factors and is characterized by high blood pressure and the onset of de novo proteinuria in the second half of pregnancy. Alterations of the sFlt-1/PlGF ratio in preeclampsia correlate with the diagnosis and adverse outcomes, particularly when the disease presents prematurely (<34 weeks). These factors can be assayed in maternal blood and measuring the sFlt-1/PlGF ratio is now available. We propose in this work to update the knowledge of these two molecules, describe their roles and evolution during normal pregnancy and preeclampsia, and finally to focus on the available assays.

[Postpartum pelvic floor disorders]. / Troubles pelvi-périnéaux du post-partum. Fréquents et à rechercher systématiquement à l'interrogatoire.

Postpartum pelvic floor disorders. Postpartum pelvic floor disorders are frequent but most of the time, decrease spontaneously. Even if 40% of pregnant women suffer from urinary incontinence, 85% of them are cured 3 months after delivery. In case of persistent urinary incontinence, postpartum rehabilitation improves short-term urinary incontinence. Six weeks after delivery 4% to 39% women suffer from anal incontinence. Most of the time anal symptoms decrease spontaneously. Postpartum rehabilitation seems to improve short-term anal incontinence. 15 to 20% of pregnant women have a genital prolapse stage 2 during the third trimester and 20 to 50% in the immediate postpartum. Even if most of the women (90%) have genital prolapse (stage 1 for most of them) one year after delivery, only 10% are bothered. Expectative management with a clinical evaluation 12 months after delivery is sufficient. In case of persistent symptoms, pelvic floor rehabilitation can be proposed.

Troubles pelvi-périnéaux du post-partum. Les troubles pelvi-périnéaux du post-partum sont fréquents mais régressent spontanément la plupart du temps. L'incontinence urinaire dont la prévalence est proche de 40 % au cours de la grossesse régresse spontanément dans 85 % des cas à 3 mois du post-partum. En cas de persistance des symptômes, la rééducation périnéale semble améliorer les symptômes au moins à court terme. L'incontinence anale, dont la prévalence varie de 4 à 39 % à 6 semaines du post-partum régresse aussi spontanément la plupart du temps. La rééducation périnéale semble également être efficace à court mais pas à long terme. La prévalence des prolapsus de stade 2 est de 15 à 20 % au 3e trimestre de grossesse et elle varie de 20 à 50 % dans le post-partum immédiat. Même si la majorité des patientes (90 %) ont encore une petite composante de prolapsus à 1 an, seules 10 % en sont gênées. L'expectative avec une réévaluation de la gêne à 1 an du post-partum semble être préférable et, en cas de persistance des symptômes, une rééducation périnéale est alors préconisée.

Satisfaction, quality of life and lumbar pain following laparoscopic sacrocolpopexy: suture vs. tackers.

OBJECTIVE: To compare the operative results and rate of complications, in particular dorsolumbar pain, following laparoscopic sacrocolpopexy (LS) using sutures or tackers. STUDY DESIGN: A case-control study: LS using tackers (n=35, tacker group) compared with LS using sutures (n=65, suture group). In addition to clinical evaluation of prolapse, all patients were evaluated for urinary incontinence (ICIQ-SF), dorsolumbar pain, overall quality of life (SF-36 score), and overall improvement in symptoms (PGI-I), one year after LS. RESULTS: The patient characteristics (age, initial stage of prolapse,…) were comparable in the two groups, as was operating time (240 vs. 210min, p=0.18). There was no significant between-group difference in terms of anatomical correction (median post-operative ICS stage: 0 in both groups, p=0.26) or post-operative complication rates. The incidence of de novo low back pain appearing after LS was equivalent in both groups (50% vs. 25%, in the tacker and suture groups, respectively, p=0.11). However, there was a significant difference in lumbar pain intensity evaluated using the visual analog scale (4 (IQR 0-6.5) vs. 0 (IQR 0-4) in the tacker and suture groups, respectively; p=0.01), and in post-operative quality of life, which was better in patients in the suture group according to all the questionnaires. CONCLUSION: Our study suggests that the use of tackers for prosthesis fixation to the promontory does not increase the incidence of post-operative dorsolumbar pain, but may increase its intensity and decrease quality of life.