Laparoscopic promontofixation: Where to stop the anterior dissection?

BACKGROUND: Laparoscopic promontofixation is the gold standard to treat apical defects but the dissection of the anterior compartment is variable since based on surgical judgment only. We therefore evaluate the placement of the anterior mesh using an ultrasonographic measurement after promontofixation. DESIGN: A prospective cohort study (Canadian Task Force Classification II-1) was conducted between January 2015 and September 2015. 63 women that underwent a promontofixation for prolapse were included. Pelvic floor descent was evaluated with POP-Q. The distance between the bladder neck, and the anterior mesh was measured by ultrasound at the end of surgery. The placement of the mesh was subsequently correlated to the anatomical repair 1 month after surgery, and the occurrence of de novo symptoms as stress urinary incontinence. RESULTS: Ultrasound permitted to measure the distance between bladder neck and Mesh (BMD = Bladder neck-Mesh Distance) in all patients with variation between repeated measurements ranging for 0.6 to 1.2 mm. The BMD was highly variable from 0 to 13 mm (mean ±â€¯SD; 5.3 ±â€¯3.1 mm). The BMD inversely correlated with the difference between C (P = 0.01) and Bp (P = 0.04) after and before surgery respectively, with the complication rate (P = 0.01) but not with the difference of Ba. A BMD of more than 6 mm predicted the absence of postoperative de novo symptoms. De novo" stress urinary incontinence occurred in 23.8%. CONCLUSION: BMD can be accurately measured by ultrasound. BMD predicts the apical repair but not the anterior repair. A short BMD predicted postoperative de novo stress urinary incontinence.

Trends in the rate of invasive procedures after the addition of the intrauterine tamponade test to a protocol for management of severe postpartum hemorrhage.

OBJECTIVE: The purpose of this study was to investigate changes in invasive procedure rates after the addition of intrauterine balloon tamponade as an initial second-line therapy to our protocol for the management of severe postpartum hemorrhage. STUDY DESIGN: We compared the outcomes of all patients with postpartum hemorrhage that was unresponsive to prostaglandin during 2 equal periods, before (first period) and after (second period) the introduction of a balloon tamponade protocol. RESULTS: During the second period, 43 women had uterine tamponade with a Bakri balloon as their initial second-line therapy (after vaginal delivery, 31; after caesarean delivery, 12). The global success rate was 86% (37/43 women). Among patients who delivered vaginally, the rates of arterial embolization (8.2% vs 2.3% in the first and second period; P = .006; odds ratio, 0.26; 95% confidence interval, 0.09-0.72) and conservative surgical procedures (5.1% vs 1.4%, in the first and second period; P = .029; odds ratio, 0.26; 95% confidence interval, 0.07-0.95) were significantly lower after the uterine tamponade test was added to our protocol. CONCLUSION: Intrauterine balloon tamponade is an attractive adjunctive strategy for the achievement of hemostasis in intractable hemorrhages and prevention of the need for invasive procedures.

Anorectal symptoms before and after laparoscopic sacrocolpoperineopexy for pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: To evaluate changes in anorectal symptoms before and after pelvic organ prolapse (POP) surgery, using laparoscopic sacrocolpoperineopexy. METHODS: Preoperative and postoperative anorectal symptoms, colorectal-anal distress inventory (CRADI) and colorectal-anal impact questionnaire (CRAIQ) scores were prospectively compared from 90 consecutive women undergoing laparoscopic sacrocolpoperineopexy. RESULTS: After a median follow-up of 30.7 months, laparoscopic surgery significantly worsened CRADI (p = 0.02) with no effect on CRAIQ (p = 0.37) scores. Post-operative and de novo straining (27%) and the need for digital assistance (17%) were the most frequent anorectal symptoms. No correlation was found between laparoscopic surgery and anorectal symptoms after multivariate analysis (OR = 2.45[95% confidence interval 0.99-6.05], p = 0.05). CONCLUSION: Anorectal symptoms are not improved after POP surgery by laparoscopic sacrocolpoperineopexy.

Four-year functional results of the suburethral sling procedure for stress urinary incontinence: a French prospective randomized multicentre study comparing the retropubic and transobturator routes.

PURPOSE: To evaluate long-term (over 4 years) functional outcomes and quality of life of transobturator (TOR) and retropubic (RPR) routes in the cure of stress urinary incontinence (SUI). METHODS: Prospective, randomized multicentre study involving 88 women with SUI from March 2004 to May 2005 (RPR group (n = 42), TOR group (n = 46)). Long-term functional results and quality of life were evaluated using validated questionnaires and compared with those observed at the first year. RESULTS: Eight patients (19%) in the RPR group and 9 patients (19.5%) in the TOR group were lost to follow-up (NS). The mean follow-up in the RPR and the TOR groups was 52.7 months and 53.1 months, respectively. In intention to treat, the success rate at 4 years was 64.3% in the RPR group and 69.5% in the TOR group (NS). At 4 years, no significant differences in the IIQ scores were observed in either group compared to the preoperative scores with no difference between the groups (RPR group: 32 vs. 14.9 (NS), TOR group: 25.7 vs. 21.4 (NS)). Compared to 1 year UDIQ and IIQ scores, a decrease in quality of life was observed for both groups at 4 years (RPR group: 4.7 vs. 34 (P < 0.0001) and 2.6 vs. 14.9 (P < 0.001), TOR group: 1.2 vs. 38.7 (P < 0.0001) and 0 vs. 21.4 (P < 0.0001)) without difference between the groups. CONCLUSIONS: This study shows similar relatively high long-term success rates for both the RPR and TOR procedures. Patients should be informed about a possible time-dependent alteration in functional results.