Search

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 41 - N° 2 - p. 194-197

Resume Objectifs L’objectif de cette etude etait de mettre en evidence des facteurs statistiquement lies a une evolution perinatale favorable lorsqu’un cerclage cervical avait ete realise en urgence pour incompetence cervicale au deuxieme trimestre de grossesse. Patientes et methodes Il s’agit d’une etude retrospective sur l’evolution des grossesses ayant eu un cerclage en urgence entre 16 et 28 semaines d’amenorrhee (SA), au centre hospitalier universitaire de Clermont-Ferrand sur une periode de 16 ans. Resultats Pour les 32 grossesses cerclees, le taux de survie postnatal a 28 jours etait de 80 %. L’âge gestationnel (AG) moyen a l’accouchement etait de 33,1 SA [18–41,3 SA]. L’accouchement est survenu apres 37 SA dans 39 % des cas. La survie postnatale a 28 jours etait amelioree en l’absence de metrorragies avant ou lors du diagnostic (p = 0,01), lorsque le col n’etait pas efface (p = 0,02), la dilatation cervicale etait de moins de 2 cm (p = 0,002), en l’absence de protrusion des membranes (p = 0,02) et lorsque l’AG etait plus avance au moment du cerclage (p = 0,005). Une expectative de 48 heures entre le diagnostic d’incompetence cervicale et la realisation du cerclage, en l’absence de contractions uterines ou de syndrome inflammatoire biologique, ne permettait pas d’ameliorer de facon significative le devenir perinatal (AG a la naissance [p = 0,1] et taux de survie a j28 [p = 0,3]). Discussion et conclusion L’evolution d’une grossesse apres cerclage en urgence est fonction des conditions cervicales et de l’AG lors de la realisation du geste. Une expectative de 48 heures entre le diagnostic et le cerclage n’ameliore pas le pronostic en l’absence de contractions uterines ou de syndrome inflammatoire.

Resume Objectif L’objectif de cette etude etait d’analyser les resultats de nos trois premieres annees de photocoagulation-laser (PL) et de comparer le devenir perinatal des grossesses gemellaires compliquees d’un syndrome transfuseur-transfuse (STT) avant et apres la mise en place du traitement par PL. Patients et methodes Cette etude retrospective de type avant/apres a ete menee dans un seul centre. Elle comparait le devenir perinatal d’enfants issus de 19 grossesses consecutives compliquees de STT au deuxieme trimestre et traitees par amniodrainages iteratifs (AI), sur une periode de dix ans, a celui d’enfants issus de 49 grossesses consecutives compliquees de STT et traitees par PL, sur une periode de trois ans. Resultats La PL ameliorait de facon significative la survie a la naissance ( p = 0,02) et apres 28 jours de vie ( p = 0,01), sans variation significative des taux de complications neurologiques ( p = 0,5) et cardiologique ( p = 0,3). Le taux de survie du donneur etait significativement augmente par la PL a la naissance ( p = 0,04). Discussion et conclusion Cette etude confirme la superiorite de la PL par rapport a l’AI. Elle montre sa faisabilite par une equipe emergente avec des resultats comparables a ceux d’equipes experimentees.

Resume Objectif Comparer, selon differents delais postoperatoires, l’intensite des douleurs en evaluant differentes techniques utilisant ou non des renforts prothetiques. Patientes et methode Cent trente-deux patientes operees consecutivement d’un prolapsus genital entre 2006 et 2008 par voie vaginale dont la moitie par reparation par tissu autologue et la moitie par renforts prothetique (Prolift™). L’evaluation etait prospective par questionnaire cotant l’echelle visuelle analogique (Eva) de douleur, a j1 postoperatoire, a la sortie du service, au premier mois postoperatoire et a l’evaluation entre le troisieme et le sixieme mois postoperatoire. Les facteurs etudies etaient : l’utilisation de renfort prothetique, l’âge, une cure de prolapsus prealable, la realisation d’une hysterectomie, la realisation d’une sacrospinofixation, l’association d’une bandelette sous-uretrale, le stade POP-Q pre- et postoperatoire. Resultats L’utilisation de renfort prothetique est significativement plus douloureuse le jour de la sortie d’hospitalisation en comparaison a la reparation autologue (Eva a 1,2 ± 1,8 contre 0,5 ± 0,9 ; p = 0,021). Les scores d’Eva des deux groupes n’offrent plus de difference significative a M1 et a M3–6. L’analyse montre que l’hysterectomie influence de maniere significative la survenue de douleurs a j1 postoperatoire, avec une simple tendance pour la sacrospinofixation a j1 ( p = 0,08). Les bandelettes sous-uretrales associees a une reparation autologue sont significativement plus douloureuses a j1 que lorsqu’elles sont associees a une reparation prothetique. Discussion et conclusion Les cures de prolapsus par voie vaginale offrent des suites operatoires peu douloureuses (Eva

Objectives To investigate whether ultrasonography coupled with clinical examination can help in understanding the mechanism of recurrence after transvaginal mesh repair of anterior and posterior vaginal wall prolapse. Methods Ninety-one patients who had undergone surgery for anterior and/or posterior vaginal wall prolapse with the Prolift system had a clinical examination and introital/endovaginal two-dimensional ultrasonography a minimum of 1 year later. The retraction of anterior and posterior meshes was estimated relative to the original length of the mesh by transvaginal palpation. Patients with no, moderate (< 50%) or severe (≥ 50%) mesh retraction were compared. Anterior recurrence of prolapse was defined according to the International Continence Society by a Ba value ≥ −1 and posterior recurrence by a Bp value ≥ −1 (where Ba represents the most distal position of the anterior vaginal wall and Bp the most distal position of the posterior vaginal wall). On ultrasonography, two distances were measured in the midsagittal plane: Distance 1, from the distal margin of the anterior mesh to the bladder neck, and Distance 2, from the distal margin of the posterior mesh to the rectoanal junction. Results Seventy-five anterior and 62 posterior meshes were studied at a mean follow-up of 17.9 months. Patients with anterior recurrence presented significantly more often with severe anterior mesh retraction compared with patients without anterior recurrence (5/8 vs. 2/67, P < 0.001) and also had an increased Distance 1 (P < 0.001). Patients with posterior recurrence presented significantly more often with severe posterior mesh retraction compared with patients without posterior recurrence (3/4 vs. 3/58, P < 0.01) and also had an increased Distance 2 (P < 0.01). Conclusions Recurrence of prolapse after transvaginal mesh repair appears to be associated with severe mesh retraction and loss of mesh support on the distal part of the vaginal walls. Copyright © 2010 ISUOG. Published by John Wiley & Sons, Ltd.

L’uterus cicatriciel est devenu le premier motif de cesarienne iterative. Le risque de rupture uterine est estime autour de 0,7 ‰, et environ 600 cesariennes seraient necessaires pour eviter une complication neonatale grave. Parallelement, la morbidite maternelle a augmente par les anomalies d’insertions placentaires, responsables de complications hemorragiques graves. Il convient de discuter avec le couple de la voie d’accouchement en cherchant d’abord a identifier d’emblee toute contre-indication a la voie basse, puis les arguments favorables au succes de celle-ci. En cas de cesarienne prophylactique, on attendra 39 SA pour diminuer la morbidite respiratoire fœtale. En cas de declenchement, il faudra respecter les recommandations de la Haute Autorite de Sante (HAS) et informer la patiente du risque majore de rupture uterine.

Resume Objectif Definir les modalites de realisation et les risques encourus en cas de geste invasif a visee diagnostique (amniocentese/choriocentese) dans un contexte de grossesse gemellaire. Materiel et methodes Une recherche bibliographique PubMed a ete realisee ainsi qu’une consultation de la base de donnees Cochrane et des recommandations de plusieurs societes savantes. Resultats Le risque de perte d’une grossesse gemellaire apres geste invasif apparait un peu plus eleve que celui observe sur singleton soit de l’ordre de 1,5-2% pour une amniocentese realisee apres 15 SA et de l’ordre de 2% pour une choriocentese realisee au premier trimestre (NP3). Le prelevement systematique des deux conceptus n’est pas toujours necessaire. Toutefois la demande du couple peut conduire a le realiser (avis d’expert). Les prelevements ovulaires sur grossesse gemellaire comportent plusieurs risques specifiques : prelevement redondant, permutation des echantillons et mauvaise identification du fœtus atteint en cas de discordance. Pour lutter contre ces risques, il est recommande que le prelevement soit assure par un operateur entraine, sous echoguidage permanent, apres un reperage topographique soigneux consigne dans un schema ou figurent les insertions placentaires et funiculaires (avis d’expert). Si un fœticide selectif est susceptible d’etre pratique, il est fortement recommande que le(s) prelevement(s) initial(aux) soi(en)t realise(s) par la meme equipe medicale (avis d’expert). Pour l’amniocentese, le choix d’inserer deux aiguilles ou une seule est laisse a l’operateur sauf pour les situations d’infection a risque de transmission maternofœtale ou deux ponctions distinctes doivent etre realisees (avis d’expert). Pour la choriocentese, il est imperatif d’avoir recours a un operateur entraine et de realiser le prelevement a proximite de chaque insertion funiculaire (avis d’expert). Conclusion La choriocentese peut etre realisee des le premier trimestre et permet ainsi d’acceder a un resultat et a un eventuel fœticide plus precocement que l’amniocentese. Les deux techniques necessitent une bonne maitrise des gestes invasifs fœtaux pour eviter les risques specifiques dans le contexte de gemellite.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 38 - N° 5 - p. 421-429

Resume La sexualite est un parametre important de la qualite de vie des patientes. Elle peut etre alteree par un prolapsus et/ou une incontinence urinaire mais aussi etre modifiee par la chirurgie reparatrice elle-meme. Les dysfonctions sexuelles secondaires a nos interventions ont longtemps ete peu documentees mais des questionnaires specifiques et valides ont ete developpes qui permettent une meilleure evaluation des resultats de la chirurgie du prolapsus et/ou de l’incontinence sur la sexualite. Cet article propose une mise au point des resultats disponibles dans la litterature et aborde notamment les consequences sexuelles de la chirurgie avec renforcement prothetique qui restent aujourd’hui une des preoccupations majeures des chirurgiens urogynecologues notamment vaginalistes.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 38 - N° 1 - p. 11-41

La chirurgie sexuelle garde une reputation sulfureuse, hesitant souvent entre chirurgie fonctionnelle et simple chirurgie esthetique. Les demandes sont neanmoins croissantes et les techniques proposees nombreuses. Si certaines sont validees et semblent legitimes et efficaces chez des femmes genees et honnetement selectionnees (nymphoplastie, correction d’une beance vulvaire, refection d’hymen), d’autres sont beaucoup plus contestables, ne reposant sur aucun fondement scientifique et abusant trop souvent de la fragilite de certaines femmes ou exploitant une «fausse image» de normalite esthetique (rajeunissement vaginal, ampliation du point G). Quel que soit le type de prise en charge proposee, il est, de toute facon, essentiel de prendre en compte la dimension psychologique.

La laparoscopia es una estrategia quirurgica moderna minimamente invasiva que ofrece numerosas ventajas respecto a la laparotomia. Tiene peculiaridades y limitaciones que hay que conocer bien para poder llevarla a cabo en las mejores condiciones y prevenir las complicaciones que le son propias. Ademas, la cirugia laparoscopica depende en gran medida del material y de la tecnologia que utiliza. Este entorno especial necesita un aprendizaje adecuado por parte del cirujano.

From the literature, the crucial knowledge were drawn among endometriosis related infertility. Endometriosis is an important factor of infertility in minimal or light stages and a major one in mild or moderate stages. Thus, a laparoscopy must be performed to confirm endometriosis when suggestive clinical or biological signs exist. In absence of them, laparoscopy can be delayed after intra-uterine inseminations (IUI). The first line treatment is laparoscopic surgery. Its efficacy is proven. It is useless to prescribe a post-operative medical treatment (GnRH analogues). Surgery leads to 25 to 40% of deliveries. It is dependant on age, infertility duration, tubo-ovarian adhesion and tubes involvement. But, surgery can be avoided and the patient is directly referred to In Vitro Fertilization (IVF) when the lesions extension is so important that surgery exposes to complications or when there is a permanent other indication for IVF (severe male infertility). When infertility persists 6 to 12 months after surgery and without patent recurrence, ovulation stimulations and IUI are performed as the second line treatment. After IUI failure, or in case of recurrence, IVF must be applied. A second surgery is not recommended. The IVF results are not impaired by the presence of endometriosis and even of endometriomas. Thus, it is useless to operate again endometriosis before IVF. In opposition, in severe stages or in cases of recurrence, a pre-IVF medical treatment (GnRH analogues) improves the results. IVF do not increased the risk of endometriosis acute growth. In case of infertility and pain, infertility is considered as the first target. But medical treatment can be prescribed between the IVF attempts.

To describe perinatal and pediatric outcome after selective feticide for complicated monochorionic twin pregnancy.We reviewed all consecutive cases of umbilical cord occlusion performed for complicated monochorionic twin pregnancy over a 16-year period. Pediatric follow-up was based on medical records and updated by phone calls to the parents.Thirty procedures were performed. Indications were: twin-to-twin transfusion syndrome (TTTS) progressing despite serial amniodrainage (n=12) ; twin reversed arterial perfusion (n=9) ; selective growth restriction (n=5) ; severe discordant structural anomalies (n=4). Mean gestational age at procedure was 21.8±3.1gestational weeks (GW) and 31.8±4.8 GW at birth. Overall survival rate was 87%, i.e. 83%, 100%, 60% and 100% for each indication, respectively. Mean pediatric follow-up was 5years (range: 6months to 15years). Medical charts and parents declared normal development in 88% of surviving children, i.e. 67%, 100%, 100%, and 100% for each indication. Cross-comparison between the four groups revealed that in the TTTS group, gestational age at procedure was more advanced (P=0.01) while delivery was slightly earlier (P=0.1), and pediatric development was poorer (P=0.02).Pediatric outcome after selective feticide appeared to be poorer for TTTS progressing despite serial amniodrainage than for other indications.

To assess postoperative pain after POP surgery by vaginal approach with and without mesh.One hundred and thirty-two consecutives patients operated on for POP (POP-Q ≥ 2) were enrolled. Surgical procedure was a traditional repair without mesh in 66 women and a mesh repair (Prolift) in 66 women. Postoperative pain was prospectively assessed by autoadministred questionnaires including analog visual scale. Pain scores were recorded 1 day after surgery (D1), at discharge, at 1 month follow-up (M1) and at 3 to 6 months follow-up (M3-6). We focused specially on mesh repair, age, previous prolapse procedure, hysterectomy, sacrospinofixation, transobturator sling, pre- and postoperative POP-Q score.At discharge, pain score was significantly higher in the mesh group (1.2 ± 1.8 versus 0.5 ± 0.9, P=0.021). Pain score were low (VAS3) and similar in the two groups with or without mesh at M1 and M3-6 follow-up. When focusing on associated factors, hysterectomy as a significant higher pain score at day 1, transobturator slings associated to traditional repair are more painful at D1 versus associated to mesh repair, sacrospinofixation has only a statistical tendency (P=0.08) more painful at D1.Pain score are low after both traditional or mesh repair by vaginal route. Mesh repair, hysterectomy and sacrospinofixation are more painful only in the first days after surgery. Our study supports the theory that transvaginal mesh procedure allows a quick return to normal life.

The objective of this study was to identify factors associated with favourable perinatal outcome after emergency cervical cerclage during mid-trimester of pregnancy.This is a retrospective study of all cases who underwent emergency cervical cerclage between 16 to 28 weeks of gestation (WG) over a period of 16 years in a University Hospital.Among the 32 cases, the postnatal survival rate (day 28) was 80%. Delivery occurred at a mean gestational age of 33.1 WG [18-41.3 WG] and after 37 WG in 39% of cases. The perinatal outcome was improved by absence of bleeding (P=0.01), unripened cervix (P=0.02), cervical dilatation below 2 cm (P=0.002), no protruding membranes (P=0.02) and more advanced gestational age at the procedure (P=0.005). When no uterine contraction and no maternal blood inflammation were observed at admission, an expectancy of 48 hours before the procedure did not improve significantly perinatal outcome (gestational age at birth and survival rate [P=0.1 and P=0.3 respectively]).Perinatal outcome after emergency cerclage depends on cervical status and gestational age at procedure. It is not influenced by an expectancy of 48 hours before intervention for patients with no uterine contraction and no maternal blood inflammation at admission.

Our objective was to report perinatal outcome during the first three years of an emerging centre for laser photocoagulation in twin-twin transfusion syndrome (TTTS) and to compare with outcome observed earlier in the same centre when management consisted in recurrent amniodrainage.We conducted a single centre retrospective study. We compared perinatal outcome of 19 consecutive cases of mid trimester TTTS managed by amniodrainage over a 10-year period with 49 cases of TTTS managed by laser photocoagulation over a 3-year period.Laser photocoagulation increased survival rate at birth (P=0.02) and at postnatal day 28 (P=0.01). Neurologic and cardiologic complications did not differ significantly (P=0.5 and P=0.3 respectively). We observed a significant increase in survival of the donor after laser coagulation at birth (P=0.04).Our study demonstrated better outcome after laser photocoagulation. Early results of an emerging centre appeared comparable to those of more experienced centres.

The aim of this study was to assess the lurning curve of young residents for vacuum extraction.All vacuum extractions performed in our department by five residents (or =5th semester) during a study period of nine months were systematically supervised by a senior who fulfilled an assessment questionnaire from which was calculated a score reflecting the quality of the extraction.Fifty-four vacuum extractions were assessed with a mean of 10.8+/-2.9 (range, 10-13) procedures by resident. We compared the group including the six first procedures performed by each resident (group 1, n = 30) with the group including the following procedures (group 2, n = 24). We observed in the group 2 compared to the group 1, a significant improvement of the scores mean (12.3+/-5.4 vs 8.4+/-6.2, p = 0.016) and a significant reduction of the need for manual assistance by the senior (12.5% vs 40%, p = 0.034).We report a method for the learning and assessment of vacuum extraction feasible at "the bed" of the patient. This approach allows to observe a significant progression of the resident for the technique of vacuum extraction on a dozen of procedures.

Sexual well-being is an important parameter of women's health and quality of live. Sexual disorders may occur in women with pelvic organ prolapse and/or stress urinary incontinence and also after pelvic reconstructive surgery. Sexual dysfunction after POP or SUI surgery has been poorly documented but new condition specific questionnaires have been developed to help us to better evaluate such consequences. This paper reports available data and highlights more specifically consequences of surgery with mesh reinforcement which is, currently, an important issue particularly when performing by vaginal approach.

The French Health Authorities' (HAS) report of November 2006 concluded that the use of mesh at the time of transvaginal repair of pelvic organ prolapse (POP) should be limited to clinical research. This review intends to analyse and comment the recent data on this topic. A review on PubMed, on a personal database and actualisation until May 2008 has been performed choosing French or English language series concerning prolapse surgery with mesh disposed by the vaginal route. It includes six randomised controlled trials comparing transvaginal repair of POP with or without mesh: four about cystocele, one about rectocele and one about apical prolapse. Both surgical techniques and recurrence criteria are poorly standardised. The four randomised trials focusing on cystocele repair support the anatomical superiority of techniques using mesh, with similar functional results with or without mesh reinforcement. In the other indications, the results remain unclear or controversial. According to the randomised trials, the complications rate, except mesh exposure, is similar with and without mesh. However there are some specific complications when using mesh, such as mesh infection, mesh exposure or shrinkage and visceral extrusion. We recommend using vaginal reinforcement mesh with specific care in selected patients and we suggest some guidelines to be proposed for consensus at concerned French scientific societies.

Urethral erosion (UE) is an uncommon but potentially severe complication after suburethral synthetic slings. We aimed to identify the risk factors and diagnostic modalities of UE and also functional outcome after UE surgical management. We retrospectively analyzed eight cases of UE managed in our department between 1997 and 2007. The main presumptive risk factors of UE were excessive sling tensioning (six of eight) and postoperative urethral dilation (four of eight). The most frequent symptoms included voiding difficulties (five of eight), storage symptoms (three of eight), pain (three of eight), and recurrent stress incontinence (three of eight). UE diagnosis was accessible to introital ultrasound (five of five) and confirmed by urethroscopy (eight of eight). Surgical management was performed in seven cases and included transvaginal sling removal with urethral repair (two of seven), endoscopic transurethral sling resection (four of seven), and combined approach (one of seven). All the approaches provided good functional outcomes. Transurethral endoscopy is a mini-invasive treatment of UE and should be tried first in selected cases.

From the literature, the crucial knowledge were drawn among endometriosis related infertility. Endometriosis is an important factor of infertility in minimal or light stages and a major one in mild or moderate stages. Thus, a laparoscopy must be performed to confirm endometriosis when suggestive clinical or biological signs exist. In absence of them, laparoscopy can be delayed after intra-uterine inseminations (IUI). The first line treatment is laparoscopic surgery. Its efficacy is proven. It is useless to prescribe a post-operative medical treatment (GnRH analogues). Surgery leads to 25 to 40% of deliveries. It is dependant on age, infertility duration, tubo-ovarian adhesion and tubes involvement. But, surgery can be avoided and the patient is directly referred to In Vitro Fertilization (IVF) when the lesions extension is so important that surgery exposes to complications or when there is a permanent other indication for IVF (severe male infertility). When infertility persists 6 to 12 months after surgery and without patent recurrence, ovulation stimulations and IUI are performed as the second line treatment. After IUI failure, or in case of recurrence, IVF must be applied. A second surgery is not recommended. The IVF results are not impaired by the presence of endometriosis and even of endometriomas. Thus, it is useless to operate again endometriosis before IVF. In opposition, in severe stages or in cases of recurrence, a pre-IVF medical treatment (GnRH analogues) improves the results. IVF do not increased the risk of endometriosis acute growth. In case of infertility and pain, infertility is considered as the first target. But medical treatment can be prescribed between the IVF attempts.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 38 - N° 2 - p. 186-187