[PROSPERE randomized controlled trial: laparoscopic sacropexy versus vaginal mesh for cystocele POP repair]. / Étude randomisée comparant la promontofixation cœlioscopique à la chirurgie prothétique par voie vaginale pour le traitement des cystocèles : PROSPERE (PROSthetic PElvic organ prolapse REpair).

BACKGROUND: Cystocele is a frequent and invalidating type of genital prolapse in woman. Sacropexy using synthetic mesh is considered the surgical gold standard, and the laparoscopic approach has supplanted the open abdominal route because it offers the same anatomical results with a lower morbidity. The use of mesh through the vaginal route may have many advantages: easiness to perform, shorter operative time and recovery, but may increase morbidity. In France, both laparoscopic sacropexy and vaginal mesh are commonly used to treat cystoceles. The French Haute Autorité de santé (HAS) has highlighted the lack of evaluation of safety assessment for vaginal meshes. METHOD/DESIGN: The main objective of the study is to compare the morbidity of laparoscopic sacropexy with vaginal mesh for cystocele repair. The primary endpoint will be the rate of surgical complications greater or equal to grade 2 of the Clavien-Dindo classification at 1-year follow-up. The secondary aims are to compare the functional results in the medium term (sexuality, urinary and bowel symptoms, pain), the impact on quality of life as well as anatomical results. PROSPERE is a randomized controlled trial conducted in 12 participating French hospitals. 262 patients, aged 45 to 75years old, with cystocele greater or equal to stage 2 of the POP-Q classification (isolated or not) will be included. Exclusion criterias are a previous surgical POP repair, and inability or contra-indication to one or the other technique. We have designed this study to answer the question of the choice between laparoscopic sacropexy and vaginal mesh for the treatment of cystocele. The PROSPERE trial aims to help better determine the indications for one or the other of these techniques, which are currently based on subjective choices or school attitudes. This is the reason why competent authorities have asked for such studies.

[TVT-O treatment of stress urinary incontinence: immediate and one-year results]. / Traitement de l'incontinence urinaire d'effort par bandelette TVT-O: résultats immédiats et à un an.

OBJECTIVE: To compare one-year results between the classic retropupubic (TVT) and the in-out transobturator approaches (TVT-O) of tension-free vaginal tape for the treatment of stress urinary incontinence (SUI). PATIENTS AND METHODS: The first 82 patients operated for SUI by TVT-O in our institution were included in the analysis. Patients were evaluated at 1 and 12 months. The global satisfaction rate was assessed at 12 months by a self-reported questionnaire. Results were compared to those of the first 124 patients operated of SUI by TVT in the same institution and by the same surgeons between 1996 and 1999. RESULTS: Except a younger mean age in the TVT-O group (57 versus 60 years), no other preoperative parameter was significantly different between the TVT and the TVT-O groups. The mean operating time was shorter in the TVT-O group (15 versus 30 minutes, P<0.001). No intraoperative complication occurred. The rate of bladder perforation was significantly lower in the TVT-O group (0 versus 8.8%, P=0.004). The rate of post-voiding residual less than 100 ml was higher in the TVT-O group (88 versus 61%, P<0.001). In the TVT-O group, 40% of patients had postoperative inguinal pain (mean=9 days, range 2-15 days). After 12 months from TVT-O, 85% of patients were completely dry, 6% had de novo over bladder activity, and 93.5% of patients were satisfied with the treatment they received. The 12-month results were not significantly different between the TVT and the TVT-O groups. DISCUSSION AND CONCLUSION: With a follow-up of 12 months, TVT-O is as efficient as TVT and has a lower risk of bladder injury, a cut by half operating time, and less postoperative dysuria.

Anal sphincter injury after forceps delivery: myth or reality? A prospective ultrasound study of 93 females.

PURPOSE: This study was designed to estimate the prevalence of anal sphincter injury after forceps delivery in a large population of females managed by trained obstetricians in a French hospital and to identify factors predictive for anal sphincter injury. METHODS: We performed a prospective study of healthy females older than 18 years with no history of anal incontinence, anorectal abnormalities, or anorectal surgery after their first vaginal delivery. All females were interviewed using a standardized questionnaire concerning intestinal transit and continence status. Physical examination and endoanal ultrasonography were performed after delivery. RESULTS: Between November 1999 and November 2000, 93 females were included in the study after their first forceps delivery. Eleven patients (11.8 percent) had a partial defect involving the external sphincter, visible on ultrasonography. One patient (1.1 percent) had a partial defect of external sphincter with complete defect of internal sphincter (sequelae of primary repair of a third-degree perineal tear). Seventeen patients (18.2 percent) had flatus incontinence, and four patients (4.3 percent) had liquid stool incontinence. A high daily number of stools was significantly associated with sphincter defect visible on ultrasonography (P=0.02). The development of anal incontinence was not related to sphincter defect on ultrasonography. There was a strong association between perineal tear and sphincter defect visible on ultrasonography (odds ratio, 4.5 (range, 1.2-16.7)). CONCLUSIONS: Anal sphincter injury after forceps delivery was identified in <13 percent of our large population of healthy females. Our study does not confirm previous observations that anal sphincter injury is common after forceps delivery; previously published studies may have overestimated the prevalence of this condition. The only factor with significant predictive value for anal sphincter injury was perineal tear. Anal endosonography should be recommended after obstetric perineal tear.

Classical and nerve-sparing radical hysterectomy: an evaluation of the risk of injury to the autonomous pelvic nerves.

Radical hysterectomy represents the treatment of choice for FIGO stage IA2-IIA cervical cancer. It is associated with several serious complications such as urinary and anorectal dysfunction due to surgical trauma to the autonomous nervous system. In order to determine those surgical steps involving the risk of nerve injury during both classical and nerve-sparing radical hysterectomy, we investigated the relationships between pelvic fascial, vascular and nervous structures in a large series of embalmed and fresh female cadavers. We showed that the extent of potential denervation after classical radical hysterectomy is directly correlated with the radicality of the operation. The surgical steps that carry a high risk of nerve injury are the resection of the uterosacral and vesicouterine ligaments and of the paracervix. A nerve-sparing approach to radical hysterectomy for cervical cancer is feasible if specific resection limits, such as the deep uterine vein, are carefully identified and respected. However, a nerve-sparing surgical effort should be balanced with the oncological priorities of removal of disease and all its potential routes of local spread.

[Schistosomiasis: an unusual cause of breast microcalcifications]. / La bilharziose: une cause exceptionnelle de microcalcifications mammaires.

We report a unusual case of mammary schistosomiasis revealed by breast microcalcifications. This localisation of schistosomiasis is exceptional but should be suspected in women who come from endemic areas. Other cases previously reported in the literature are also described.

[Genital actinomycosis. Diagnostic and therapeutic difficulties. Report of three cases]. / Actinomycose génitale. Difficultés diagnostiques et thérapeutiques. A propos de trois cas.

Genital actinomycosis is a rare bacterial infection affecting women of child-bearing age, which is sometimes related to the use of an IUD or an intra-vaginal pessary. Nevertheless, this relationship is at best tenous and actinomycosis is not the only bacterial infection caused by IUD use. Genital actinomycosis often occurs as a pelvic tumour which is sometimes difficult to correctly diagnose and consequently treat accordingly. Rapid diagnosis is essential in order to avoid any irreparable tissue damage. Treatment of this condition consists of a combination of antibiotics and surgery to achieve complete recovery. Three cases are described.

[Surgical treatment of genito-urinary prolapse by abdominal approach with promotofixation and setting of an anterior subvesical prosthesis combined with retropubic colpopexia: anatomical and functional results in 104 patients]. / Traitement chirurgcal des prolapsus génito-urinaires par voie abdominale avec promontofixation et mise en place d'une prothèse antérieure sous-vésicale associées à une colpopexie rétropubienne: résultats anatomiques et fonctionnels chez 104 patientes.

A homogeneous series of 104 patients with genito-urinary prolapse or urinary incontinence is reported. Surgical treatment combined promotofixation with (n = 45) or without (n = 59) subtotal hysterectomy, retropubic colpopexia and in certain cases posterior colpoperineorraphia with myorraphia of the levator ani (n = 28). Anatomic results were excellent for bladder and uterine ptosis. Moderate results were obtained for rectoceles and procedures involving the posterior perineum. A rectovaginal prosthesis or complete repair of the rectovaginal wall appeared to be required to improve results for rectoceles. Urine function was good for urinary incontinence: 91% success. Results depended on the pressure of the uretral closure. A complete urodynamic work-up is required prior to surgery in case of sphincter failure. Poor results were also related to excessive posterior traction which can open the cervico-uretral angle. Treatment of genito-urinary prolapse with promotofixation in combination with retropubic colpopexia is a reliable reproducible technique which gives excellent long-term results if excessive promontory traction is avoided and if, in certain cases, the rectovaginal wall is repaired or a prosthesis implanted when maximum uretral closure pressure is weak.

[Comparison of different types of ovarian wound closure in rats. Role of biological glue]. / Comparaison de différents types de "fermeture" de l'ovaire chez la rate. Place de la colle biologique.

Three techniques for closing the ovary have been compared. The test was carried out on 30 rats' ovaries. After the ovary had been cut with scissors it was closed with rapid acting Tissucol (a biological glue) or closed with interrupted stitches of 10/0 Vicryl, or left to close by itself. Sixty days later the ovaries were looked at macroscopically and histologically. The macroscopic score was established according to the presence of adhesions, the size of the ovary, the presence of cysts; and the histological score was carried out according to the presence of granulomatous macrophage lesions, the degree of fibrosis and the existence of germ cell cysts. The results were identifically the same as far as these five different criteria were concerned. All the same, Tissucol brought about less fibrosis and less atrophy of the ovary. Tissucol, therefore, is a good alternative for suturing the ovary as compared with stitching or no formal closure after the removal of ovarian cysts, particularly laparoscopically.

[Tubal bilharziasis]. / Bilharzoise tubaire.

We report a case of tubular bilharziosis discovered on a surgical specimen after salpingectomy. Tubular bilharziosis is not exceptional in endemic zones but is rarely found in Europe. The species most often isolated is Schistosoma haematobium. Contamination occurs via vascular anastomoses between the bladder and the genital organs. Bilharziosis has been shown to be a cause of extra-uterine pregnancy although its effect on fertility is yet to be established.

[The reliability of study methods of the endometrium. A comparative study of 178 patients]. / Fiabilité des méthodes d'exploration de l'endomètre. Etude comparative chez 178 patientes.

OBJECTIVE: To compare the reliability of different methods for investigating the endometrium. DESIGN: A prospective study from November 1990 to October 1991. SETTING: Department of surgery and gynaecology Diaconesses Hospital, Paris. SUBJECTS AND INTERVENTIONS: In a total of 178 symptomatic patients, hysteroscopy with curettage in a day-centre under general anesthesia was performed. Before this operation, 79 women had had endometrial cytology, 98 women had had endometrial biopsy with the endometrial Pipelle, 112 women had ultrasonography and 120 women hysterography. MAIN OUTCOME MEASURES: Endometrial cytology and biopsy, ultrasonography, hysterography and hysteroscopy were correlated with curettage. RESULTS: the Pipelle's diagnostic accuracy appeared better than that of cytology. The hysteroscopic diagnosis agreed with the histologic diagnosis showed by the curettage except for atypical hyperplasia. The positive predictive value for identifying endometrial atrophy with ultrasonography is 100%. A vaginal ultrasonographic examination showing an endometrial thickness of < or = 5 mm can be used to exclude endometrial carcinoma as the cause of post menopausal bleeding. CONCLUSIONS: The combination of hysteroscopy and endometrial biopsy is the diagnostic method of choice for the endometrium. It is possible to avoid some useless curettages for diagnosis in women with abnormal uterine bleeding.

[Diagnosis and treatment of epithelial cancer of the ovary. Apropos of 102 cases]. / Réflexions sur le diagnostic et le traitement des cancers épithéliaux de l'ovaire. A propos de 102 cas.

This is a retrospective study including 102 cases records of female patients presenting with epithelial carcinoma of the ovary. Survival, as in the other series, depended upon the stage of the cancer at the time of diagnosis, mean survival rates being 77.1, 57.7, 26.6 and 19.3 for stages I, II, III and IV respectively. However, most of all, survival was related to the quantity of remanent tumoral tissue following the initial laparotomy. The 5-year survival rates were 84%, 42% and 10% when there was no residual tumor, when the latter measured less than 2 cm, and more than 2 cm, respectively. In contradistinction to what is generally found in such studies, the diagnosis here was established at earlier stages, since 53% of the cases of interest were female patients with stage I or II carcinoma. The chief argument, therefore, is based on the methods of early diagnosis and, judging from what is generally admitted in literature, on the place of extended surgery.

[Complications of abdominal hysterectomy for benign gynecologic lesions. Apropos of 1,000 cases]. / Complications de l'hystérectomie abdominale pour lésions gynécologiques bénignes. A propos de 1 000 cas.

The authors present a retrospective study of 1,000 total abdominal hysterectomies performed between 1969 and 1975, and they report the main complications. Early complications are dominated by: rare thrombo-embolic accidents (2.2%) since the advent of prophylactic heparin therapy; infectious complications, dominated by the abscess of the abdominal wall and asymptomatic urinary infections, and for which simple measures prevent resorting to prophylactic antibiotherapy. The role of the hysterectomy seems minimal in the occurrence of a prolapse or a stress-related urinary incontinence: prolapses after hysterectomy (1.4%) seem more related to tissue aging than to the procedure which modifies very little the supporting system of the pelvis. A post-operative urinary incontinence is, most of the time, the result of an incomplete pre-operative work-up: failure to recognize a potential stress-related incontinence, or an incontinence secondary to an unstable bladder. Prolapse and incontinence must always be treated independently. In the psychological and sexual repercussion, age, ovariectomy and the distress related to the procedure, involving the heart of womanhood, seem to be the most important factors.

[Surgical technic for the excision of subclinical radiologic anomalies of the breast]. / Technique chirurgicale pour l'exérèse des anomalies radiologiques infracliniques du sein.

Routine mammography screening can detect radiologically evident but subclinical breast anomalies. Insofar as these anomalies can correspond to carcinoma, either in situ or invasive, surgeons are increasingly forced to operate on non-palpable breast lesions. A regulated and strict surgical technic is necessary to ensure exeresis of a radiologically detected focus, while avoiding sufficient adjacent healthy parenchyma and thus reducing the esthetic prejudice to a minimum. Technical artifices are described to assist compliance with these imperatives. First, the periareolar incision is chosen, as a principle, for its cosmetic qualities. Insofar as it provides an often limited approach it can be extended radially. The latter is concealed during closure without major alteration to the areola. Second, the radiating exeresis assists detection and is safer. It also provides glandular reconstruction of good esthetic quality and facilitates follow up surveillance.

Influence of the timing of physiotherapy upon the lymphatic complications of axillary dissection for breast cancer.

A prospective randomized study was carried out to discover the influence of the timing of shoulder physiotherapy after-axillary dissection for breast cancer upon the incidence and duration of lymphatic fluid production and seroma after these operations. Sixty-eight patients underwent a modified radical mastectomy, 31 were submitted to early physiotherapy and 37 to delayed physiotherapy after removal of the suction drainage. In 32 patients this surgery was conservative of the breast; in 16 the physiotherapy was early and in 16 delayed. The shoulder was left free when the physiotherapy was delayed. The mean volume of lymphatic fluid produced after these 100 axillary dissections was 437 cc (range: 50 to 800 cc) with a mean duration of 6.3 days (range: 2 to 11 days). There was a linear relation between the volume and the duration of the lymphatic fluid production. This volume was significantly higher in radical mastectomy than in conservative procedures (486 cc vs 333 cc - p less than 0.02). There was no significant difference in the production of lymphatic fluid with early or delayed physiotherapy, whatever the group of patients: radical or conservative surgery - age - number of excised lymph nodes - lymph node involvement. Five seromas occurred in patients with delayed physiotherapy. Delaying physiotherapy after axillary dissection for breast cancer does not seem to reduce the incidence of lymphatic complication, but the use of a conservative procedure rather than a modified radical mastectomy seems to be able to do so.

[Injuries of the thoracic duct during neck surgery]. / Plaies opératoires du canal thoracique au cou.

Although rarely published, operative injuries to thoracic duct in neck are by no means exceptional, and can occur during all types of surgery to lower cervical and supraclavicular regions. A case is reported and used as a basis for an analysis of diagnostic means and therapeutic possibilities of injuries detected during operation or those developing manifestations at a later stage. In the case reported, long-term medical treatment resulted in arrest of lymphorrhea within 37 days.

[Value of lumbo-aortic curettage in stage I and IIA tubal cancers]. / Intérêt du curage lombo-aortique dans les cancers tubaires stades I et IIA.

Results of a 7-year follow-up review of a patient with intratubal cancer and lumbo-aortic glands invasion are reported. The highly lympholytic character of these tumors and the existence of elective lumbo-aortic lymph node metastases suggest that surgery should include routine bilateral lumbo-aortic curettage in tubal cancer, particularly stages I and IIA. As well as providing improved assessment of degree of extension of the disease it can also avoid the frequently poorly tolerated abdominopelvic radiotherapy.