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The aim of our study was to determine whether nulliparity is a limiting factor for vaginal hysterectomy performed for benign lesions.We conducted a prospective study in 1604 patients who underwent hysterectomy for a benign lesion between 1991 and 1998. We studied a subgroup of this population constituted by 128 nulliparous women, i.e. 8% of the patients.Vaginal hysterectomy was performed at first intention in 54.7% of the cases, after laparoscopic preparation in 14%, and by first intention laparotomy in 31.3% for each type of approach we compared: history of pelvic surgery, duration of the operation, final weight of the uterus, peroperative complications, association or not with adnexectomy in patients aged 45 years or older, frequency of a reduction procedure in the vaginal group and duration of hospitalization.Nulliparity is not a contraindication for vaginal hysterectomy which can be proposed as a first intention procedure, sometimes in association with laparoscopic preparation in case of prior pelvic surgery or concomitant adnexal disorders.

To describe an original technique for transvaginal cystocele repair and to report the anatomical and functional results of the first 47 patients operated by this technique. The operation combines suspension, by six sutures to the tendinous arches of the pelvic fascia, of a vaginal patch measuring 6 to 8 cm long by about 4 cm wide left in contact with the cystocele. The vaginal patch is then buried under the anterior colporraphy suture. Spinal fixation, hysterectomy, levator myorrhaphy or urinary incontinence repair are also performed as necessary.Descriptive retrospective study of 47 patients undergoing transvaginal repair of prolapse between October 1997 and June 1998. All patients presented external prolapse with grade III cystocele, associated with urinary incontinence in 38.3% of cases and hysterocele or vaginal prolapse in 87% of cases. The mean age of the patients was 69 years. The uterus was preserved in two cases, but hysterectomy was performed in the other 45 patients, together with Richter spinal fixation in 44 cases An associated levator myorrhaphy was performed in every case.The mean follow-up was 16.4 months (range: 6 to 26 months) in 46 patients. The cystocele was considered to be cured in 93% of patients, one patient had an asymptomatic grade I cystocele and surgery was unsuccessful in two patients who developed recurrent grade II cystocele.The technique presented here is a curative treatment for grade III cystocele in menopaused women associated with Richter spinal fixation, and prevents the risk of cystocele described after transvaginal treatment of prolapse by spinal fixation alone (10 to 20%). The short-term results are encouraging, but they need to be confirmed by a follow-up of at least 5 years.

Many operative techniques have been proposed for urinary stress incontinence, a common finding in women. The goal of operating solely via a vaginal approach using autologous material has led to the development of a sling technique using a band of vaginal tissue.We described the operative technique and analyzed outcome in the first 35 patients operated with the new vaginal tissue sling technique.Mean duration of the procedure was 35 minutes. The procedure was performed in two cases and thus could be used for prolapsus cure. We had no peroperative complications. Postoperative complications were mainly urine retention (50%) lasting a mean 4.4 days. Transfixation of the bladder was observed late in one case with resection of an intravesicular suture. At mean follow-up of 16.9 months, the success rate was 80% with 68.5% of the patients free of urine leakage. In case of sphincter insufficiency, the success rate was 85.7% (64.3% of the patients were free of leakage). Three of the four patients who had undergone prior Burch colpopexy were cured.Our series demonstrated the feasibility of the new vaginal tissue sling technique. It appears to be an adapted procedure for urinary stress incontinence with sphincter insufficiency and particularly well adapted for low closure pressures and after failure of surgical cure. The final assessment of this technique will require longer follow-up and comparative studies with other methods.

We retrospectively studied 77 laparoscopic sacral colpopexies performed from June 1996 to May 1998. Suspension was reinforced with two strips of synthetic mesh. Five patients had previously undergone hysterectomy and 4 others had experienced failure of surgery for prolapse of the uterus. Laparoscopy was performed in 83 women with symptomatic prolapse of the uterus. Six cases required conversion to laparotomy because of technical difficulties. All other 77 patients underwent laparoscopic sacropexy using anterior and posterior mesh reinforcement. Subtotal laparoscopic hysterectomy was associated in 60 cases, laparoscopic Burch colposuspension in 74 and levator myorraphy using the vaginal approach in 55. Operative time decreased from 292 to 180 minutes as the surgeon gained experience. The main operative complications were one rectal and two bladder injuries. Three patients required reoperations for haematoma or hemorrhage. One patient complained of chronic inflammation of the cervix and another experienced rejection of the posterior mesh 6 months after the operation. Mean follow up was 343 days. Three other patients required reoperation: one for a 3(rd) degree cystocele and two for recurrent stress incontinence. The conclusion of this study is that laparoscopic sacrocolpopexy is feasible. Operative time and postoperative complications are related to the surgeon's experience but remain comparable to those noted in laparotomy. Long term assessment is required to confirm the results of this procedure.

To reveal the anatomy of arcus tendineus fascia pelvis.and methods. 2 fixed female cadaver pelvises (88 and 66 years old) were dissected.The arcus tendineus fascia pelvis is a fibrous recess of the pelvic fascia which is 10 cm long, laterally to the obturator internus muscle and medially to the peritoneum. It reaches the ischial spine lower and anteriorly to the pubo-vesical ligament. The third posterior part of the arcus tendineus of the pelvic fascia is commun with the posterior part of the arcus tendineus of the levator ani. This third posterior part is like a curve concave anteriorly. This curve is thick and easy to recognize by the palpation. This third posterior curve is 1cm in front of the ischial spine and 2cm in front of the pudendal vessel which took place behind the ischial spine. The vessels of the obturator internus muscle originated from the internal iliac vessel and crossed laterally the median part of the arcus tendineus of the pelvic fascia.Sutures must be placed through the anterior and median part of the arcus tendineus fascia pelvis, in front of the posterior part of the arcus tendineus fascia pelvis to avoid any injury to the pudendal vessels.

Burch colpo-suspension, which is the present gold standard for treatment of stress urinary incontinence, may be performed laparoscopically.The aim of this retrospective study was to report the results of laparoscopic Burch colpo-suspension with a 30-month follow-up and to assess the reason for the unsuccessful results.From 1990 to 1999, 118 patients (mean age: 46 years) were operated on for stress urinary incontinence with laparoscopic colpo-suspension. Urinary incontinence was classified grade 1 (6%), 2 (67%) and 3 (27%). The Burch colpo-suspension was performed through extraperitoneal approach in 51% and transperitoneal in 49%. A genital prolapse was associated in 31% of the patients and treated with sacropexy. A subtotal hysterectomy was performed in 25% of the patients and a vaginal hysterectomy in 46%.Global morbidity rate was 19%, including four cases of bladder injury. With a 30-month follow-up, 76/118 (64.4%) had no more urinary incontinence. Parity, age, previous pelvic surgery, detrusor instability and low urethral closure pressure were not predictive of recurrent stress urinary incontinence after treatment. Associated sacropexy was only correlated with a high risk of failure (P = 0.04). Patients with hysterectomy had significantly better results (72% vs 41.9%) (P = 0.05). Trans- and extraperitoneal techniques had similar results (P = 0.7).With a 30-month follow-up, 64.4% of the patients had satisfactory results with strictly no more stress urinary incontinence. There was no significant difference between the trans- and the extraperitoneal approach. Sacropexy was only associated with a higher rate of failure.

The aim of this retrospective study was to demonstrate the feasibility of laparoscopic Jamain-Letessier procedure and to report its results.Between August 1993 and September 1997, 19 patients (mean age: 29.7 years, range: 20-39 years) with painful uterine retroversion were operated on according to a laparoscopic Jamain-Letessier procedure. A preoperative pessary test was performed in 15 patients. The procedure included suture of the uterosacral ligaments to the midline and resection of the pouch of Douglas, followed by peritoneal suture.The pessary test was positive in 14 of the 15 patients. Mean operating time was 2 hours. There was no conversion to laparotomy. Postoperative urinary tract infection was observed in 3 cases. Mean postoperative hospital stay was 2.5 days. With a mean 3-year follow-up, 15 patients were completely pain-free and 2 patients were partially pain-free. The 14 patients with a positive pessary test obtained a good result.The pessary test is necessary for selection of patients. The Jalmain-Letessier procedure is easily performed laparoscopically and is associated with a low morbidity. With a mean 3-year follow-up, good results were obtained in 17 out of 19 patients (89%) and all patients with a positive pessary test obtained a good result.

Although hysterectomy for benign disorders is a routine and usually well-tolerated procedure, complications do occur, and the resulting morbidity rates are not negligible. The aim of this prospective study was to report perioperative and early postoperative complications observed after hysterectomy, regardless of the route or the operator.Between March 31, 1991 and December 14, 1998, 1,604 patients (mean age: 46.5 +/- 8.1 years) underwent an hysterectomy for benign disorders. Perioperative and early postoperative complications, in the 1,248 vaginal hysterectomies (77.9%), 190 laparoscopically-assisted vaginal hysterectomies (11.9%) and 166 abdominal hysterectomies (10.2%) were noticed in each group and compared.None of the patients died in this series. Lesions on the urinary tract included 15 bladder injuries (0.9%) and 1 ureter injury (0.06%) without significant difference between routes. There were 9 (0.6%) intestinal injuries, with a significant increase when laparotomy was performed (2.4%). In 45 patients (2.8%), bleeding exceeded 500 mL: and vaginal hysterectomy caused significantly fewer cases of heavy bleeding (2%, p0.001) than either laparotomy (6.7%) or laparoscopy (5.3%). The overall reoperating rate was 0.8% and this does not differ with the type of the procedure.Peri- and early postoperative complications after hysterectomy for benign disorders are not a rare event. In order to control complications and decrease the morbidity, a high-risk population should be defined based on the patients' history of pelvic surgery and endometriosis, on their parity and the size of their uterus. For these patients, the most appropriate route should be preferred and complications should be assessed using different tests and subsequently treated during the same procedure.

HPV types are carcinogenic in cervical cancer. This view is supported by epidemiological and biological evidence. Knowledges of HPV gene expression, of natural history of cervical HPV infection and neoplasia and of tumoral antigenic expression have lead to develop two strategies for vaccine development: 1-Prophylactic vaccines of HPV infections. 2-Therapeutic vaccines aimed to control the tumor growth and even to cure the patient. After an update of natural history of cervical HPV infection, the different target of vaccine strategies. The first published trials will be presented.

We describe a new surgical technique (the vaginal plastron) for the treatment of cystocele by the vaginal route. The technique is based on bladder support by a vaginal strip, isolated from the anterior colpocele, left attached to the bladder, associated with a suspension of this strip by its fixation to the tendinous arch of the pelvic fascia by six lateral sutures (3 on each side of the plastron). Proposed as a curative treatment of cystocele and combined with the Richter fixation, the plastron provides a surgical solution to the problem of cystocele relapse arising after vaginal treatment of prolapse by sacro-spino-fixation alone (10 to 20% according to Richter).

In this presentation, we attract attention to the disadvantage of using synthetic material in functional surgery of prolapse and urinary incontinence.Two hundred eighty seven vaginal operations using synthetic material (Gore Tex, Dacron and Lyodura) were followed. The operations were: Mouchel procedure (127 cases), small slings (118 cases), large slings (11 cases), Stamey procedure (8 cases) and patch for paravaginal repair (23 cases). These operations were performed from 01/01/89 to 31/12/95.Mean follow-up at study end was 49 months. The intolerance phenomenon, leading to rejection, occurred between 1 and 72 months. The Mouchel procedure gave a rejection rate of 28.3% versus 9.3% for the slings (p0.001). Dacron was better tolerated (rejection rate at 19.3%) than Gore tex (rejection rate at 30.2%), p0.05.The substratum of the intolerance process would have two explanations (infection and foreign body reaction) for the early and late rejections. We suggest that the synthetic tissue tolerance is proportional to the exposed surface and to the distance which separates it from the vaginal scar. The ideal synthetic mesh material for pelvic surgery has yet to be developed.

A large number of operations have been proposed for the treatment of female urinary stress incontinence, but no consensus has been reached about a possible reference technique. The objective of our study was to analyse the quality of the methodology and results of randomized prospective studies comparing various surgical techniques for urinary stress incontinence since 1978. The statistical methodology of most of these studies was far from perfect. They usually compared colposuspension and support techniques, while sling techniques were only rarely studied. Most surgical techniques give a similar short-term success rate, which declines with time. In the long-term, the Burch technique is superior to the other techniques with which it has been compared.

The aim of this study was to assess the factors of success in abdominal colposacropexy (CSP) procedures.We performed 271 consecutive CSP between 1986 and 1997 (mean age: 48.8 years +/- 11.1). We reviewed 217 patients (80.1%). Mean duration of follow-up was 5.5 years (1-136 months). We performed: 18 CSP with Goretex mesh, 3 with resorbable mesh and 196 with Mersilene; 179 CSP with posterior colporraphy and 38 without; 208 CSP with culdoplasty (Moschowitz's procedure) and 9 without; 182 CSP with anterior and posterior meshes, 26 with posterior mesh only and 9 with anterior mesh only.97.7% (212/217) of patients were cured for prolapse. 58% (125/217) had urinary stress incontinence totally cured and 82% (178/217) had urinary stress incontinence improved. Rejected grafts were 16.7% (3/18) with Goretex mesh and 1.1% with Mersilene mesh (p = 0.004). Recurrent prolapses were 1.1% (2/196) with CSP with posterior colporrhaphy and 7.9% (3/38) in CSP without (p = 0.009; OR = 0.14, CI = 0.02-0.86); 4/208 with CSP with culdoplasty and 1/9 with CSP without (p = 0.04; OR = 0.17, CI = 0.02-1.58). Recurrent stress incontinence was observed in 4/9 cases with CSP with anterior mesh only and 28/182 with CSP with anterior and posterior meshes (p = 0.03; OR = 0.34, CI = 0.12-0.97).CSP must use anterior and posterior Mersilene mesh. The CSP must be systematically combined with posterior colporraphy and culdoplasty (Moschcowitz's procedure).

Vaginal hysterectomy is an advantageous surgical technique as compared with abdominal hysterectomy: operating time is shorter, it is safer and hospitalization stay and recovery time are shorter. However in France, 2/3 of all hysterectomies are still performed by laparotomy. Would the vaginal approach be reasonable if a difficult hysterectomy is expected? The purpose of our study was to compare the per- and postoperative complications and the period following vaginal hysterectomy versus the abdominal route in patients with a large uterus.Forty-nine vaginal hysterectomies were compared retrospectively with 22 abdominal hysterectomies for fibroma during the period from 01.01.91 to 31.12.95. Uterine weight in all cases was between 500 to 1,000 g.The average uterine weight was significantly different between the vaginal and the abdominal groups (644 g vs 747 g, p = 0.02). Operating time, pre- and postoperative complications and analgesic use were not significantly different between the two groups. Operative bleeding was significantly higher in the abdominal group than in the vaginal group (659 ml vs. 359 ml, p = 0.006), as well as hemoglobin loss (2.49 vs. 1.82, p = 0.04). There was also a statistical difference between the vaginal group and the abdominal groups in terms of hospital stay (4 d vs. 6 d respectively, p = 0.0002).Vaginal hysterectomy with morcellation is advantageous in comparison with abdominal hysterectomy even when the uterine weight is over 500 g, since it offers better post-operative comfort than laparotomy without endangering the patients. The main contraindications for the vaginal route are uterus beyond the ombilicus and vaginal atresia. Excepting these cases, the indication for the vaginal approach depends on the patient's past surgical history, uterine mobility and vaginal access. In more difficult cases, these factors are assessed under anesthesia.

Adenomyosis is a frequent pathology of the uterus for women over 40. Difficult to diagnose, adenomyosis can be responsible of pelvic pain and menorrhagia. Association with infertility is a rare event and the responsibility of adenomyosis is difficult to prove. A medical treatment with LHRH agonist can be propose to improve fertility in case of patent adenomyosis.

The aim of this study was to compare the results of open retropubic (OC) and laparoscopic (LC) colposuspension to the Cooper's ligament (Burch operation). We matched retrospectively 72 LC and OC according to their ages, the type of associated operations and the clinical stages of their urinary incontinence. We excluded associated prolapsus, previous surgical procedure for urinary incontinence, maximal urethral closure pressure lower than 30 cms of water and instability of the detrusor. We estimated the comparability of our two series about the other criteria which have an effect upon the post operative results in literature. The mean follow up was 17 months for LC and 46 months for OC. LC operative time was longer than (Mean: LC: 89 minutes, OC: 42 minutes), women considered LC less aching than OC. They needed less postoperative analgesia, mostly given only just the day of the procedure. LC length of hospitalization and return to normal activity was shorter than OC (Mean: LC: 3 days--OC: 6, 7 days; LC: 15 days--OC: 21 days). The graphs of the subjective cure and improvement rates made according to the Kaplan-Meier method could be compared with the log rank test. (Cure after one year: LC 79%, OC 69%--Improvement after one year: LC 85%, OC 82%--Cure after two years: LC 68%--OC 64%--Improvement after two years: LC 80%--OC 75%).

To evaluate the predictive value of postoperative urodynamic assessment on the apparition or the resurgence of genuine stress incontinence after a surgical procedure for genitourinary prolapse.103 patients operated on for prolapse, with or without an associated surgical procedure for genuine stress incontinence. A review of the results of the urodynamic assessment carried out during the early post operative period was effected.77.7% of the patients had an associated procedure for stress incontinence during surgery for prolapse. An urodynamic abnormality such as intrinsic sphincter deficiency and/or transmission ratio default was noted in 83.3% of the women who demonstrated incontinency during postoperative assessment, and in 76.7% of the patients without any problem of continence. During long term follow up, only 41.7% of the women who were incontinent shared intrinsic sphincter deficiency, and an abnormal cytometric parameter was noted in 74.4% of continent patients. 86% of the patients who were incontinent in the early postoperative period will remain so, whatever the result of the cystometric evaluation.Our results show that there is no correlation between the various cystometric parameters evaluated during the postoperative period, and the symptoms described by the patients. The absence of abnormal urodynamic assessment cannot consistently predict normal bladder function. Only postoperative symptoms can be considered to be predictive of a satisfactory surgical cure.

Since the beginning of the nineties, we have seen an increase in the use of operative hysteroscopy in the surgical treatment of women with dysfunctional uterine bleeding. The aim of this article is to show that these new techniques are surgical acts subject to complications, failures, morbidity and indeed mortality. It seems therefore reasonable to ask whether vaginal hysterectomy represents a good alternative to endometrial ablation. We think so both in terms of functional or clinical results, and cost or quality of life. The endometrial ablation should be reserved to women who have strictly dysfunctional pathologies. In all cases, the difficulty in the diagnosis of adenomyosis, the high rate of failure of endometrial ablation, the degradation of its results with time and finally the better quality of life after hysterectomy must be exposed clearly to all patients. It will be with full knowledge of the facts, that women will be able to choose between radical surgical treatment represented by hysterectomy and so-called conservative surgical treatments.

From 1992 to 1995, 1565 laparoscopic operations were performed in Roubaix. We report on six complications.To compare this figure with these of the French collaborative study done from 1987 to 1991 by seven departments known for their laparoscopic activity, including Roubaix.The trends are good. The rate of injuries was stable in spite of increasingly complex procedures. The largest portion of visceral and even vascular injuries were repaired by laparoscopy reducing by the same amount use of laparotomy.Strict adherence to safety guidelines and specific training of surgeons reduce the need of laparotomy for laparoscopic complication.

The use of laparoscopy in the management of gynaecological malignancies has significantly increased over the last 5 years. Patients with cervical, vaginal, endometrial and ovarian cancer can be managed laparoscopically either for staging or for treating. The feasibility of procedures through the laparoscope (such as hysterectomies, bilateral oophorectomies, pelvic and para aortic lymphadenectomies, omentectomies, colostomies, bowel resections, oophoropexies, radical hysterectomies and ovarian cancer debulking) has been demonstrated by skilled gynaecologists. Many of these procedures have been heralded as avant garde ‘surgical standards’ without appropriate evaluation of efficacy, effectiveness and efficiency. Larger series of patients have now replaced case reports to try to answer the numerous unanswered questions regarding the value of these procedures. Several prospective trials were begun to compare laparotomy and laparoscopy. If the results of these trials confirm the hope, laparoscopic management of gynaecological malignancies will leave the limited club of specialists to become a widely used technique. But the patients will benefit from laparoscopic procedures only when in the hands of well-trained surgeons.

We report three cases of caudal regression syndrome diagnosed in utero. Caudal regression syndrome (CRS) is a rare condition associating vertebral agenesia and urinary and digestive tract malformations. Pathogenesis is not clear but, as in our three cases, the CRS is often associated with poorly controlled maternal diabetes. Antenatal ultrasound examinations may reveal the disease in major forms with a non-viable foetus. In our 3 cases, a femoral "V" was associated with sudden interruption of the spine. Minor forms may not be recognized until childhood. Prognosis depends essentially on the extent of spinal involvement and associated malformations. Sirenomelus was considered for many years to be the most severe form of caudal regression, but recently acquired evidence suggests that these two conditions are separate entities.

We report a case of acute toxoplasmosis during the first trimester of pregnancy in which antenatal diagnosis was negative. Except for non-specific signs of liver failure, assessment by repeated ultrasound scans, testing of fetal blood for toxoplasmic specific antibodies and competitive PCR to isolate the parasite, had ruled out fetal infection. In spite of early treatment with spiramycin, and although the infant was assumed to be non-contaminated, severe hydrocephalus was noted at 3 and half months of life, arising soon after therapy had been stopped. This case focuses attention on the problem of the shortcomings of the diagnostic techniques currently used, and leads us to question our practical course of action. Several questions are thus raised: how reliable are indirect signs of fetal compromise, what is the real sensitivity of the PCR test and how useful are repeated amniocentesis and inoculation of the amniotic fluid to mice.

Hysterectomy is a common gynaecological operation in Europe. Although the advantages of new minimally invasive procedures seem obvious, prospective randomised trials are essential for proper appraisal. We reviewed all randomised studies about routes for hysterectomy and comparison of conservative or radical surgery. This study points out the many deficiencies of such studies. Referred conclusions are then open to criticism. We concluded that new prospective studies should be performed, adapted to social, cultural and economic conditions in Europe.

Our purpose was to assess etiological factors in enterocele and to compare abdominal sacral colpopexy with mesh and resection of the cul-de-sac of Douglas to transvaginal sacrospinous colpopexy.A retrospective study, for 20 years, concerned 134 patients clinically proved enterocele confirmed during the operation.Etiological factors were: multiparity, perineal tear, foetal macrosomia, instrumental extractions, antecedents of gynaecologic operations, tissular and constitutional factors. The analysis of the anatomical and functional results did not distinguish between the two surgical procedures, each with its proper indications.For patients 60 years old or older, we propose the transvaginal sacrospinous colpopexy. Before 50 years, we prefer abdominal sacral colpopexy with mesh. Between 50 and 60 years, each case must be examined with the health status of the patients.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 33 - N° 7 - p. 559-560

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 33 - N° 7 - p. 652-654

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 33 - N° 6-C1 - p. 531-533

Steinert's disease or myotonic dystrophy is a heredo-degenerative neuroendocrinal dystrophy. It is an autosomal dominant disorder. The arising of a congenital myotonic dystrophy of one of the new-born children of the maternity hospital enabled to diagnose the Steinert's disease of his mother. A review of the international literature enabled us to recall its interactions with pregnancy. There is an aggravation of myotonia and multiple obstetric complications such as miscarriage, premature onset of labor, polyhydramnios, stillbirth, difficulties during the evacuation, atonic postpartum hemorrhage, anesthetic-accidents. The congenital variant of myotonic dystrophy (6 to 30% of the cases) is a severe disease with a high mortality. It is only seen in the offspring of mothers who themselves have myotonic dystrophy. The myotonic dystrophy gene has been isolated and the mutation-causing myotonic dystrophy was found to result from a series of trinucleotide (CTG) repeats located in the 3' untranslated region of the gene. The direct diagnosis is henceforth possible both on the fetus and parents. Steinert's disease and its association with pregnancy are rare, especially when the affected parent has hypogonadism. The diagnosis of the congenital form is difficult because of the mother is unaware of the disorder. Family and personal history may give hints: hydramnios, appearance delay and reduced fetal movements, and the association at birth of generalized hypotonia with neonatal respiratory distress.

In the French region Nord-Pas-de-Calais a Public Health action was undertaken in order to set up a training program for neonatal resuscitation for the maternity-hospitals personnel. The incidence and severity of meconium aspiration among the population of children admitted to the neonatal intensive care unit of Lille University Hospital during two 15 month-periods of time, before and after the training, were compared. The number of neonates who presented with meconium aspiration decreased from 54 during the first period to 9 during the second, i.e. from 7.2 to 1.3% with respect to the total number of hospitalized patients (p less than 0.001). On the contrary, the number of deaths did not decrease significantly. This regression of the meconium aspiration gives evidence for an improved quality of care at birth. Even if training is not the only factor, this evolution gives argument in favour of the efficacy of such actions.

The authors report a case of twins conjoined at the umbilicus and diagnosed by ultrasound after 19 weeks of amenorrhoea in whom an assessment in utero was carried out using magnetic resonance imaging after the patient had been curarized. A review of the literature on this very difficult problem of conjoined twins has given us the possibility to assess the diagnostic measures as well as the prognosis of this pathology. In particular we point out the results that can be obtained using MRI in utero during the second and third trimesters of the pregnancy.

Objectifs Presenter le protocole d’exploration des troubles de la statique pelvienne du service et en illustrer les pathologies les plus frequemment rencontrees dans notre pratique en tenant compte des donnees recentes de la litterature. Materiels et methodes Protocole : etude morphologique du pelvis et des muscles du plancher pelvien, etude dynamique des trois compartiments pelviens a l’aide de sequence ultra-rapide sur une IRM 1.5 tesla. Travail a visee didactique illustrant les differents troubles de la statique pelvienne : cystocele (cervico-cystoptose, trigonoptose), hysterocele, peritoneocele (avec ou sans enterocele), rectocele (sous levatorienne, retentionniste), prolapsus rectal interne ou intussusception, perinee descendant et complications post-operatoires. Etude musculaire morphologique et dynamique du plancher pelvien. Resultats L’IRM permet un bilan lesionnel precis des troubles de la statique pelvienne. La presentation consiste en un rappel anatomique, semiologique et une illustration de tous les types de pathologies rencontrees au sein du service. En fin d’expose des cas cliniques sont presentes sous forme de quiz. Conclusion L’IRM morphologique et dynamique est une aide precieuse pour le clinicien lui permettant d’adapter au mieux la prise en charge therapeutique.