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To compare pelvic organ prolapse (POP) recurrence and morbidity between first and second line sacrocolpopexies. We conducted a retrospective chart review of all laparoscopic or robotic sacrocolpopexies for POP-Q stage ≥ 2, with or without a history of previous prolapse repair, performed with a similar technique between January 2012 and June 2019 in 3 European Gynecologic Surgery Departments. Patients were separated into two groups: first line sacrocolpopexy (FLS) and second line sacrocolpopexy (SLS). Each patient from the SLS group was age-matched with a patient from the FLS group. The primary outcome measure was reoperation procedures for recurrent POP defined as a symptomatic POP-Q stage ≥ 2 POP in at least one vaginal compartment. Secondary outcomes included operative time, intraoperative organ trauma, intraoperative blood loss, postoperative POP recurrence (operated on or not), global reoperation and mesh-related complications. During this period, 332 patients were included. After age-matching, 170 patients were analyzed: 85 patients in the FLS and SLS groups, respectively. After a mean follow-up of 3 years, there was no statistically significant difference between the two groups in terms of recurrent POP (9.4% versus 10.6%, p = 0.7), recurrent POP reoperation (3.5% versus 5.9% p = 0.7), mesh-related reoperation (0% versus 2.4%, p = 0.5), global reoperation (3.5 versus 8.2%, p = 0.3), operative time (198 ± 67 min versus 193 ± 60 min, p = 0.5), intraoperative complications such as organ injury (4.7% versus 7.1%, p = 0.7) and blood loss > 500 mL (2.4% versus 0%, p = 0.5). Patients who underwent a first or a second line sacrocolpopexy seemed to have similar rates of prolapse recurrence and complications. more...

Objective To assess the incidence of serious complications and reoperations for recurrence after surgery for pelvic organ prolapse (POP) and compare the three most common types of repair. Design Prospective cohort study using a registry. Setting Nineteen French surgical centres. Population A total of 2309 women participated between 2017 and 2019. Methods A multivariate analysis including an inverse probability of treatment weighting approach was used to obtain three comparable groups. Main outcome measures Serious complications and subsequent reoperations for POP recurrence. Results The median follow-up time was 17.6 months. Surgeries were native tissue vaginal repairs (n = 504), transvaginal mesh placements (n = 692) and laparoscopic sacropexies with mesh (n = 1113). Serious complications occurred among 52 women (2.3%), and reoperation for POP recurrence was required for 32 women (1.4%). At 1 year the cumulative weighted incidence of serious complications was 1.8% for native tissue vaginal repair, 3.9% for transvaginal mesh and 2.2% for sacropexy, and the rates for reoperation for recurrence of POP were 1.5, 0.7 and 1.1%, respectively. Compared with native tissue vaginal repair, the risk of serious complications was higher in the transvaginal mesh group (weighted hazard ratio, wHR 3.84, 95% CI 2.43-6.08) and the sacropexy group (wHR 2.48, 95% CI 1.45-4.23), whereas the risk of reoperation for prolapse recurrence was lower in both the transvaginal mesh (wHR 0.22, 95% CI 0.13-0.39) and sacropexy (wHR 0.29, 95% CI 0.18-0.47) groups. Conclusions Our results suggest that native tissue vaginal repairs have the lowest risk of serious complications but the highest risk of reoperation for recurrence. These results are useful for informing women and for shared decision making. Tweetable abstract Laparoscopic sacropexy had fewer serious complications than transvaginal mesh and fewer reoperations for recurrence than vaginal repair. more...

The French Department of Health published on October 23, 2020 a decree governing acts associated with mid-urethral sling (MUS) operations. The aim of this study was to evaluate the changes in practice following this new legislation.A cross-sectional study was carried out among French urologists and gynecologists using an online survey to collect changes in practices since the publication of the decree.From January to February 2021, 436 surgeons participated in the survey. Among these surgeons, 87% were aware of the new legislation and 56% of them considered the decree as useless. The order resulted in an increase in working time in 81% of cases. Among these surgeons, 66% of the surgeons worked in tertiary referral centers for the management of incontinence, of which 55% had a multidisciplinary meeting in urogynecology. Among the surgeons, 31% considered this meeting to be useful but 80% considered that it did not lead to any change in surgical indications, even though 33% of complications of BSU were discussed there. In conclusion, 61% of surgeons felt more reluctant to schedule a BSU placement with this new legislation.The majority of questioned surgeons considered the decree as useless. It generated few changes in practices which already respected the law on information, consultation, consent, experience and training. Most urologists and gynecologists are more reluctant to offer MUS after this new legislation.4. more...

The aim of our study was to compare the morbidity and long-term efficacy after laparoscopic sacrocolpopexy with and without robotic assistance.We conducted a retrospective chart review of all laparoscopic or robotic sacrocolpopexies for POP-Q stage 2-4 vaginal prolapse performed between September 2015 and October 2018 in 2 Gynecologic Surgery Departments of France. Patients were separated into two groups: a laparoscopic sacrocolpopexy group (LS) and a robotic-assisted sacrocolpopexy group (RAS). The primary outcome measure was reoperation procedures for recurrent pelvic organ prolapse (POP).Two hundred and fourteen patients were included, 160 patients (75%) in the LS group and 54 patients (25%) in the RAS group. After a mean follow-up of 32.8 months, reoperation rate for recurrent POP and the recurrent POP rate were greater in the RAS group (9.2% versus 1.2%, p = 0.01 and 25.9% versus 7.5%, p = 0.0003, respectively). No significant difference was found in terms of immediate intraoperative (3.1% versus 1.8%, p = 1) and postoperative complications (1.9% versus 1.8%, p = 1). On comparing the 2 groups by bivariate analysis, RAS significantly increased the odds of reoperation for POP recurrence (OR = 7.8 CI 95% [1.5-41.6], p = 0.02) and the odds of global reoperation (OR = 3.8 CI 95% [1.4-10.4], p = 0.0095). Similarly, multivariate logistic analysis showed that RAS increased the risks of global reoperation (OR = 3.8 CI 95% [1.3-10.6], p = 0.01) after controlling high-grade prolapse.Robotic sacrocolpopexy does not appear to give long-term clinical benefits. Recurrent POP and reoperation procedures seem to be more frequent in case of robotic-assisted surgery. more...

Background The development of the activities of medication conciliation (CM) at admission and discharge have reduced medication errors. Due to the lack of time and adequate tools, CM information is rarely transmitted to patients or community health professionals (CHP). In our hospital, since July 2017, a pharmaceutical letter (PL) of hospital discharge is edited from CM data and integrated into the patient’s computerised record. This PL is given and explained to the patient and transmitted to CHP (general practioner (GP), pharmacist, rehabilitation centre). Purpose The objective of this study was to assess the satisfaction of PL transmission to CHP and patients. Material and methods We conducted this prospective study in two internal medicine units from July 2017 to February 2017. This study using data regarding two internal medicine units (44 beds) were collected from July 2017 to February 2018. The PL and a satisfaction questionnaire were explained and given to the patient, and sent (email, regular mail or fax) to the pharmacy, the GP and/or the medical centre. The questionnaire included 10 questions, satisfaction scales from 0 (not at all satisfied) to 10 (very satisfied). Results Two-hundred and six patients were included: sex ratio M/F=0.6, mean age 72 years’ old and average length of stay of 13 days. Respectively 112 (54%), 112 (54%), 143 (69%) and 66 (32%) PL were given and explained to patients, sent to pharmacies, doctors and others health centres. The response rates for the questionnaires were respectively 53% (59) for patients, 39% (44) for pharmacies, 5% (seven) for GP and 9% (seven) for others centres. Overall satisfaction was 8.6±2.1 for patients, 9.3±0.9 for pharmacies, 8.2±2.3 for GPs and 8.7±1.7 for other centres. According to the patients, the explanations of PL significantly improved the knowledge of their treatments (7.9±2.3 versus 9.7±0.9, p Conclusion According to these results, we observed a very positive overall satisfaction, on the one hand of patients, and on the other, of CHP. References and/or acknowledgements https://www.ncbi.nlm.nih.gov/pubmed/28007439 No conflict of interest. more...

The aim of this work was to issue clinical practice guidelines on antibiotic prophylaxis in urodynamics (urodynamic studies, UDS).Clinical practice guidelines were provided using a formal consensus method. Guidelines proposals were drew up by a multidisciplinary experts group (pilot group = steering group), then rated by a panel of 12 experts (rating group) using a formal consensus method, and then peer reviewed by a reviewing/reading group of experts (different from the rating group).Urine (bacterial) culture with antimicrobial susceptibility testing is recommended for all patients before UDS (strong agreement). In patients with no neurologic disease, the risk factors for tract urinary infection (UTI) after UDS are age70 years, recurrent UTI, and post-void residual volume100ml. In patients with neurologic disease, the risk factors for UTI after UDS are recurrent UTI, vesicoureteral reflux, and intermicturition pressure40cmHThese new guidelines should help to harmonize clinical practice and limit exposure to antibiotics.4. more...

Three months after hysteroscopic sterilisation with EssureThis retrospective study examined patients who underwent birth control EssureOne hundred and thirty-four patients were tested, of which 60 (44.8%) using a single X-ray and 74 (55.2%) using a combination of X-ray and ultrasound. We note that the combined X-ray/ultrasound test reduces significantly the number of HSG performed (26.7% versus 12.2%, P=0.04).Compared to a single X-ray, the combination of X-ray and ultrasound enables to significantly limit the use of HSG. more...

Providing clinical practice guidelines for first surgical treatment of female pelvic organ prolapse.Systematic literature review, level of evidence rating, external proofreading, and grading of recommendations by 5 French academic societies: Association française d'urologie, Collège national des gynécologues et obstétriciens français, Société interdisciplinaire d'urodynamique et de pelvi-périnéologie, Société nationale française de coloproctologie, and Société de chirurgie gynécologique et pelvienne.It is useful to evaluate symptoms, their impact, women's expectations, and to describe the prolapse prior to surgery (Grade C). In the absence of any spontaneous or occult urinary sign, there is no reason to perform urodynamics (Grade C). When a sacrocolpopexy is indicated, laparoscopy is recommended (Grade B). A bowel preparation before vaginal (Grade B) or abdominal surgery (Grade C) is not recommended. There is no argument to systematically use a rectovaginal mesh to prevent rectocele (Grade C). The use of a vesicovaginal mesh by vaginal route should be discussed taking into account an uncertain long-term risk-benefit ratio (Grade B). Levator myorrhaphy is not recommended as a first-line rectocele treatment (Grade C). There is no indication for a vaginal mesh as a first-line rectocele treatment (Grade C). There is no reason to systematically perform a hysterectomy during prolapse repair (Grade C). It is possible to not treat stress incontinence at the time of prolapse repair, if the woman is advised of the possibility of a 2-step surgical treatment (Grade C). Clinical practice guidelines. © 2016 Published by Elsevier Masson SAS. more...

Rectovaginal fistula requires a complex management because it has an important psychological impact associated with impaired quality of life of patients. Thus, the aim of our study was to evaluate the improvement of the quality of life of patients after surgical management.This is a retrospective study. We included patients operated between 2009 and 2014 for the treatment of a rectovaginal fistula, whose data were available and who agreed to answer a questionnaire. We evaluated the satisfaction of short-term and long-term patients on the answer to the basic PFDI-20 and PFIQ-7 questionnaires. We then evaluated whether there was an improvement in symptoms and quality of life after surgery.Nine patients were included but only 4 patients completed the PFDI-20 and PFIQ-7 questionnaires. Fistula was secondary to either surgical intervention (44%, n=4) or complicated perineal tear (44%, n=4) or unknown cause (11%, n=1). After surgery, we found the short term a significant decrease in stool incontinence, as there was no stool incontinence (0/5) in the postoperative period, while preoperatively 55% (5/9) (P=0.03). Postoperatively, 33% (3/9) of the patients had genital discomfort and 44% (4/9) had gas incontinence compared to 0% preoperatively (P=0.2 and P=0.6). There appears to be an improvement in pelvic static disorders after surgical management. However, we found a slight improvement in nauseous leucorrhoea in the immediate postoperative period, as the prevalence decreased from 33% (3/9) preoperatively to 22% (2/9) postoperatively (P0.9). In the long term, we observed an improvement in the sensation of perineal heaviness and gas incontinence because only 25% (1/4) of the 75% (3/4) preoperative patients still showed slight discomfort (P=0.5). The quality of life and the emotional state of the patients were no altered postoperatively. Indeed, preoperatively, 50% (2/4) of the patients reported anxiety compared to 0% (0/4) postoperatively (P=0.4). Similarly, 75% (3/4) complained of a decrease in their quality of life (social, sports, etc.) preoperatively compared with 0% (0/4) postoperatively (P0.9).A simple surgical management of rectovaginal fistulas would allow a significant decrease in stool incontinence and improved quality of life and their emotional state, which confirms the beneficial effect of this therapeutic strategy.4. more...

Resume La chirurgie gynecologique cœlioscopique assistee par robot s’est largement developpee ces dernieres annees. La litterature disponible sur ce sujet ne cesse de s’enrichir. L’objectif de cet article est de faire le point sur les principales indications du robot en chirurgie gynecologique et d’offrir un etat des lieux des principaux articles traitant de l’utilisation du robot, tant dans le domaine de la pathologie benigne qu’en cancerologie. more...

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 40 - N° 8 - p. 693-696

Introduction Le prolapsus rectal touche essentiellement la femme âgee et coexiste frequemment avec les prolapsus genitaux. Il est responsable de symptomes digestifs invalidants. Un de ses traitements est la rectopexie par voie haute. La voie d’abord vaginale semble moins invasive et serait preferable chez les patientes âgees. more...

Introduction La preparation de medicaments radiopharmaceutiques (MRP) requiere une demarche qualite rigoureuse (BPP 2007) sous la responsabilite du radiopharmacien. La qualification du personnel, initiale et periodique, concernant les bonnes pratiques de preparation, d’hygiene et de radioprotection s’inscrit dans cette demarche. En matiere de radioprotection, la radiocontamination dans l’enceinte blindee, faible mais frequente, est controlee avec le radiocontaminometre, qui ne permet pas une localisation precise. Objectifs Dans ce travail, nous presentons un test de simulation de radiocontamination avec une solution de fluoresceine, en vue de la formation et de la qualification du personnel. L’utilisation de fluoresceine permet d’identifier et de localiser les situations et gestes a l’origine de radiocontamination. Materiels Fluoresceine : fluoresceine sodique, diluee a 10 % (NaCl 0,9 %), placee dans un flacon d’elution pour simuler un eluat de 99mTcO4− ou un precurseur. Materiel utilise : flacons et seringues de routine dans leur protection blindee. Methode Le test est realise en binome (operateur/controleur). Le mode operatoire detaille les gestes a realiser, similaires aux preparations de routine : prelevement et dilution de l’eluat, injection dans le flacon de la trousse, prelevement de 5 seringues (5 × 0,5 mL qsp 1 mL). A l’issue du test, la presence de fluorescence sur le plan de travail et l’ensemble du materiel est relevee sous lumiere UV. Une brumisation d’eau finale permet d’augmenter la sensibilite de detection par dilution des microgouttelettes de fluoresceine. Une grille d’evaluation est etablie avec un score de 0 a 15 patients pour 10 localisations, cotees a 1 ou 2 points. Le test est reussi si le score est Resultats Dans ce premier travail, 5 tests ont ete realises et reussis avec un score moyen de 2/15. Les principales zones radiocontaminees sont le champ de travail et les doigts des gants. Sur les gants, cette radiocontamination due a des microgouttelettes n’apparait qu’apres brumisation dans 3 cas sur 5. Discussion Notre test a la fluoresceine permet la mise en evidence de radiocontamination, en particulier celle due aux microgouttelettes. La dilution de l’eluat a partir d’un Ecoflac® est identifiee comme l’etape a risque. Au-dela de la qualification initiale et annuelle, ce test se revele tres utile pour la formation hors et dans l’enceinte blindee et permet a chacun d’optimiser ses gestes. more...

Vingt et un pour cent des femmes souffrent de dyspareunies. Certaines interventions gynecologiques, notamment dans le domaine de la statique pelvienne, sont pourvoyeuses de dyspareunies. Nous avons effectue une revue de la litterature afin d’evaluer le caractere dyspareuniant des principales interventions de gynecologie non cancerologiques. L’hysterectomie, la cure d’incontinence urinaire par colposuspension selon Burch ou par mise en place d’une fronde sous-uretrale de type TVT n’entrainent pas ou peu de dyspareunies. Parmi les techniques chirurgicales de traitement des prolapsus genitaux sans utilisation de biomateriaux, la colporraphie posterieure est celle la plus souvent associee a une augmentation du taux de dyspareunies (26 % de dyspareunies postoperatoires selon Weber et al.). La promontofixation (8,7 % de dyspareunies postoperatoires selon Nieminen et al.) semble entrainer un peu moins de dyspareunies que la colposuspension selon la technique de Richter (entre 9 et 16 % selon les etudes), sans qu’il y ait de difference concernant les dyspareunies de novo. Les techniques utilisant des biomateriaux entrainent plus de dyspareunies (de 15 a 69 % selon les etudes). Cependant, l’amelioration des materiaux semble prometteuse (12,8 % de dyspareunies de novo dans une serie recente). more...

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 36 - N° 8 - p. 799-806

Resume Nous presentons un nouveau dispositif destine a la mesure simultanee de pressions en huit points de la cavite vaginale. Ce nouvel instrument permet la mesure in vivo des pressions intravaginales chez des patientes porteuses de prolapsus. L'objectif est de permettre d'enregistrer les variations de la pression intravaginale au cours des epreuves d'effort classiquement pratiquees lors de l'exploration des prolapsus. Un corps cylindrique en polyethylene haute densite est equipe de huit jauges de contraintes miniatures et relie a une chaine de mesures permettant la calibration, la visualisation en temps reel et l'enregistrement des donnees dans un format universel. Sa fixation rigide a la table d'examen permet a la fois de s'adapter a l'anatomie de chaque patiente et de s'affranchir du biais apporte par le maintien manuel. Une calibration metrologique a ete entreprise : elle a permis d'etablir un etalonnage et une caracterisation technique precis de cet instrument de mesure, a l'aide notamment d'un fantome physique de la cavite pelvienne. Des mesures preliminaires in vivo ont complete cette etude : elles illustrent la faisabilite de la methode et la tres bonne tolerance de l'instrumentation. Notre etude montre l'interet que pourrait avoir ce type d'exploration fonctionnelle dans une prise en charge plus personnalisee des patientes. more...

Analysis of litigation in gynecological surgery in the French university hospital of Lille.It is a longitudinal and retrospective study. We collected all cases of complaints between November 1997 and August 2015 concerning the department of gynecological surgery, university hospital of Lille. Medical data were obtained using electronic medical record and hospital's legal unit gave data about the complaints.Forty cases were identified during the reporting period. Thirty-three records concerned medical injuries and seven cases failing to provide information or lack of communication. Eleven complaints were reviewed by the French "commission de conciliation et d'indemnisation". Five cases were brought to administrative court. Finally, Lille high court examined two records. Most of complaints concerned perforation during endoscopic procedures, nosocomial infections and forgotten foreign bodies. It was not observed any increasing number of complaints during the whole period. It was noticed a decreasing number of legal action in favor of "commission de conciliation et d'indemnisation".This study evaluated specifically litigation in gynecological surgery. It is necessary to conduct this type of study so as to improve medical care and to provide information for practitioner about consequences of their exercise. more...

Resume Nous souhaitons discuter de l’importance de l’imagerie par resonance magnetique en complement de l’examen clinique dans le cadre du bilan pre- et postoperatoire dans l’etude du prolapsus uterovaginal et notamment du compartiment posterieur (rectocele, elytrocele). L’amelioration notable, obtenue en IRM (cliches statiques et dynamiques dans les 3 plans de l’espace) a permis une correlation clinicoradiologique plus precise sur l’exploration des prolapsus. Nous rapportons une observation clinique dans laquelle l’IRM pre- et postoperatoire peut apporter une evaluation plus fiable que le seul examen clinique. more...

Resume Buts. – A travers 8 cas d'endometrioses vesicales ou ureterales, nous analysons les symptomes permettant d'evoquer le diagnostic et nous etudions les possibilites therapeutiques. Materiels et methodes. – Nous avons recense retrospectivement les cas d'endometrioses vesicales et/ou ureterales sur une periode de 11 ans (novembre 1989–juillet 2000), ayant eu soit un geste ureteral chirurgical (reimplantation, suture sur sonde) soit un geste d'exerese vesicale. Resultats. – Sur 8 dossiers selectionnes, trois comportaient des atteintes vesicales et cinq des lesions ureterales. La seule complication postoperatoire etait un reflux vesico-ureteral apres reimplantation ureterale sur une vessie psoique. Aucune recidive constatee sur l'arbre urinaire. Conclusion. – Les lesions d'endometrioses ureterales ou vesicales symptomatiques justifient un traitement par resection chirurgicale. Les atteintes vesicales peuvent dans la majorite des cas etre traitees par cœliochirurgie lorsqu'elles sont isolees. Les lesions d'endometrioses ureterales mettent en jeu le pronostic fonctionnel renal. Dans un premier temps, une ureterolyse percœlioscopique ou un geste de dilatation par ureteroscopie, associee a un traitement medical, peut etre tentee sous couvert d'une surveillance rapprochee. En cas de persistance ou de recidive le geste d'exerese est indique. more...

Pelvic floor disorders are frequent and source of symptoms which can be invalidating for patients. Between them, hedrocele is a pathology often unknown and clinically difficult to diagnose. It is a herniation of fat pad, small bowel or sigmoid colon in the recto-uterine pouch (cul-de-sac of Douglas) exercising a mass effect on the anterior wall of the rectum. Pelvic magnetic resonance imaging with morphological sequences and dynamic sequences in thrust can be very useful, allowing a comprehensive study of pelvic floor dysfunction and confirming the complete diagnosis, especially before surgery. We suggest you some examples to illustrate this pathology in order to emphasize the importance of its diagnosis, especially preoperative. A better understanding of this pelvic floor dysfunction would improve the care of patients. more...

Two years after the French guidelines, the objective was to assess the feasibility and efficiency of ultrasound-guided trans-vaginal drainage of tubo-ovarian abscesses (TOA) and to study the responsible germs.All the patients with a larger abscess than 20mm were included prospectively from May 2011 to July 2014 in the university hospital of Lille.Sixty-nine drainages were performed among 50 patients. Success rate was 94%. No complication occurred. One germ was found in 55% of patients, the TOA was polymicrobian in 20% of cases.Ultrasound-guided trans-vaginal drainage of TOA is safe and effective with more than 90% of success rate. more...

Systematically review literature on the efficacy and tolerability of botulinum toxin A (onabotulinumtoxineA, BOTOX(®), Allergan, CA, USA) in refractory idiopathic overactive bladder (iOAB) METHODS: Pubmed search on the efficacy, toxicity and adverse events of onabotulinumtoxinA in clinical trials only with level 1 and 2 evidence.Eleven controlled randomised trials have been selected, of which 3 phase III trials. The studies published data of 1008 patients with refractory iOAB treated with onabotulinumtoxineA. In the phase II and III trials, doses from 50 U to 300 U have been evaluated; more than half of the patients (n = 676) with 100 U. In the 2 main phase III trials, onabotulinumtoxinA has demonstrated to be more efficient compared to placebo on continence, symptoms and quality of live (QoL). Urodynamic results, reported in the phase II trials, demonstrated higher changes compared to placebo only from dose 100 U on, although not always significant. Adverse events (urinary retention, dysuria, urinary tract infection) were easily treated and did not influence patient's QoL.Intradetrusor injections of onabotulinumtoxinA (BOTOX(®)), a minimally-invasive procedure, seem to be efficient and well tolerated in the treatment of refractory iOAB. more...

Botulinum toxin-A detrusor injections are now approved for use (extension of marketing authorization) in the management of refractory idiopathic overactive bladder. The goal of the current study was to study the value and efficacy of this therapy.A literature review was performed on Medline, Embase and Cochrane databases, using the following keywords: botulinum toxin; overactive bladder syndrome; urinary incontinence; detrusor injection.The recommended first step dose is 50 units of BOTOX(©) (dose selected for tolerance assessment). However, the cure rates for urge incontinence are greater with 100 units. Before proposing an injection, it is recommended to ensure the feasibility and acceptability of self-catheterisation by the patient, because of the risk of urinary retention (6%). The administration of BOTOX(©) comprises an intra-detrusor injection using a cystoscope, performed under local anesthesia. Clinical improvement is generally observed in the first two weeks after the injection. Patients should be considered for reinjection when the clinical effect of the previous injection has diminished, approximately 6-9 months after the first injection. An injection of 100 units may be considered when the clinical benefit of the 50-unit injection is not satisfactory concerning incontinence symptoms.Botulinum toxin detrusor injections may be offered to women who develop refractory OAB. more...

Resume La colposuspension selon Burch, qui est la technique de reference dans le traitement de l’incontinence urinaire d’effort peut etre realisee par voie cœlioscopique. But de l’etude : Cette etude retrospective avait pour but de rapporter les resultats de la colposuspension cœlioscopique selon Burch avec un recul moyen de 30 mois et de rechercher les facteurs d’echec. Patientes et methode : Entre 1990 et 1999, 118 patientes (âge moyen : 46 ans) ont ete operees pour une incontinence urinaire d’effort par colposuspension cœlioscopique. Il s’agissait d’une incontinence de grade 1 (6 %), 2 (67 %) et 3 (27 %). L’operation de Burch a ete realisee par voie preperitoneale dans 51 % des cas et par voie transperitoneale dans 49 % des cas. Un prolapsus genital etait associe dans 31 % des cas et a ete traite par sacropexie. Une hysterectomie subtotale a ete associee dans 25 % des cas et une hysterectomie vaginale dans 46 % des cas. Resultats : Le taux global de complications a ete de 19 % (dont quatre plaies vesicales). Avec un recul moyen de 30 mois, 76/118 (64,4 %) etaient gueries de leur incontinence avec absence complete de fuite urinaire. La parite, l’âge, les antecedents de chirurgie pelvienne, la pression de cloture basse n’etaient pas des facteurs de recidive. Seule l’association d’une sacropexie est apparue comme un facteur de risque d’echec ( p = 0,04). Les patientes ayant eu une hysterectomie ont eu un taux de succes plus eleve que les autres : 72 % contre 41,9 % ( p = 0,05). Les voies trans- ou extraperitoneales ont donne des resultats comparables ( p = 0,7). Conclusion : Avec un recul moyen de 30 mois, 64,4 % des patientes n’avaient plus aucune fuite urinaire. Les resultats sont comparables par voie trans- ou extraperitoneale. Le seul facteur d’echec mis en evidence est l’association d’une sacropexie au traitement de l’incontinence urinaire. more...

Resume But de l’etude : Le but de ce travail retrospectif etait de demontrer la faisabilite de l’intervention de Jamain et Letessier par laparoscopie, et de rapporter ses resultats. Patientes et methodes : Entre aout 1993 et septembre 1997, 19 patientes (âge moyen : 29,7 ans, extremes : 20–39 ans) ayant une retroversion uterine symptomatique ont ete operees selon la technique de Jamain et Letessier realisee par voie cœlioscopique. L’intervention a ete precedee d’un test au pessaire dans 15 cas. Elle a consiste en une suture des ligaments uterosacres sur la ligne mediane et une resection du peritoine du cul-de-sac de Douglas suivie de peritonisation. Resultats : Le test au pessaire a ete positif 14 fois sur 15. L’intervention a dure en moyenne deux heures. Il n’y a pas eu de conversion. Dans les suites operatoires, il y a eu une infection urinaire dans trois cas et une retention aigue d’urine passagere dans trois cas. La duree d’hospitalisation postoperatoire a ete de deux jours et demi. Avec un recul moyen de trois ans, il y avait une disparition complete des douleurs dans 15 cas et une amelioration des douleurs dans deux cas. Les 14 patientes qui avaient un test au pessaire positif ont toutes eu un bon resultat. Conclusion : Le test au pessaire est indispensable pour selectionner les indications operatoires. L’operation de Jamain et Letessier est facilement realisable sous cœlioscopie. Sa morbidite est faible. Avec un recul moyen de trois ans, il y a 17 succes sur 19, soit 89 %, et 100 % de succes chez les patientes qui avaient un test au pessaire positif. more...

Resume Objectifs : Comme tout acte chirurgical, l’hysterectomie pour lesion benigne est grevee d’une morbidite non negligeable. Le but de cette etude prospective etait de rapporter les complications per- et postoperatoires observees, toutes voies d’abord confondues et quel que soit l’operateur. Patientes et methodes : Entre le 31 mars 1991 et le 14 decembre 1998, 1 604 patientes ont ete operees d’une hysterectomie pour lesion benigne. Les complications urinaires, digestives et hemorragiques, survenues au cours, ou au decours des 1 248 hysterectomies vaginales (77,9 %), des 190 hysterectomies cœliovaginales (11,9 %) et des 166 hysterectomies abdominales (10,2 %), ont ete comparees. Resultats : Il y a eu 15 plaies de vessie (0,9 %) et une plaie ureterale (0,06 %), sans difference significative entre les trois voies d’abord. Il y a eu neuf plaies digestives (0,6 %), avec une difference significative en defaveur de la voie abdominale (p = 0,02). Il y a eu dans 45 cas sur 1 604 (2,8 %), une hemorragie peroperatoire superieure a 500 mL, avec un avantage significatif (p Conclusion : Les complications per- et postoperatoires precoces lors des hysterectomies pour lesions benignes ne sont pas rares. Pour diminuer la morbidite de cette intervention, il est important de definir une population a risque en fonction des antecedents de chirurgie pelvienne ou d’endometriose, de la parite et du volume uterin, et de choisir la voie d’abord la plus appropriee. Ces complications doivent etre reconnues au cours de l’operation et traitees dans le meme temps et par la meme voie d’abord. more...

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 35 - N° 5 - p. 425-427

To report the setting-up of a new educational program in the teaching of female pelvic and breast examinations and to investigate and compare the views and experience of undergraduate medical students and teachers on the program.Prospective evaluation of the teaching program through completion of a satisfaction questionnaire including items related to the educational value of the session by the students and the teachers.The educational program included an online preparation for the session, 3 workshops on training models (breast examination, pelvic examination, cervical snear procedure) and a video clip. In total, 419 (80.6%) of 520 second study year students (and 15 [50%] of 30 teachers [13 doctors and 17 midwifes] responded to the questionnaire). The students and the teachers were either very satisfied (56.6% and 13.4%, respectively) or satisfied (43.2% and 86.6%, respectively). On average, 89.7% of students wanted more lessons of this type and all teachers felt these useful or very useful training for students.Teaching sessions for pelvic and breast examination, which make combined use of videos and training models, are associated with a high degree of satisfaction from teachers and students in their second student's year. more...

Resume Objectif Determiner les indications et contre-indications de la chirurgie prothetique du prolapsus par voie vaginale. Patientes et methode Revue de la litterature et cotation de propositions selon une methode inspiree des recommandations par consensus formalise. Resultats Avant une intervention chirurgicale pour prolapsus genital, la patiente doit etre informee des differentes techniques existantes (chirurgie abdominale et vaginale, avec et sans prothese), des raisons pour lesquelles le chirurgien lui propose la mise en place d’une prothese synthetique et egalement des autres traitements non chirurgicaux du prolapsus (reeducation et pessaire). L’intervention doit etre precedee d’une evaluation des symptomes pelviens, urinaires, digestifs et sexuels, ainsi que de la gene occasionnee. Pour le traitement chirurgical de la cystocele par voie vaginale, l’utilisation d’une prothese inter-vesico-vaginale n’est pas justifiee de maniere systematique. Elle doit etre discutee au cas par cas compte tenu du rapport benefice/risque incertain sur le long terme. Chez les patientes ayant une cystocele recidivee, la mise en place d’une prothese inter-vesico-vaginale est une option raisonnable pour reduire le risque de nouvelle recidive. En dehors de quelques situations particulieres (rectocele recidivee), la mise en place par voie vaginale d’une prothese inter-recto-vaginale n’est pas justifiee en premiere intention. En cas de prolapsus isole de l’etage moyen, la fixation du fond vaginal ou de l’uterus par l’intermediaire de bras prothetiques synthetiques par voie vaginale n’est pas justifiee en premiere intention. Conclusion Le chirurgien devra mettre en œuvre les mesures preventives etablies qui permettent de diminuer le risque de complication. more...

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.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. more...

Resume La fistule peritoneo-vaginale est une complication rare de l'hysterectomie. Nous presentons le cas d'une fistule developpee chez une patiente presentant des douleurs pelviennes et des leucorrhees persistantes 6 mois apres une hysterectomie vaginale. L'abord cœlioscopique avec epreuve au bleu intravaginal a permis de mettre en evidence la fistule peritoneo-vaginale. L'abord vaginal a permis sa fermeture et l'amendement des symptomes. Nous avons revu a travers la litterature, les symptomes revelateurs, les diagnostics differentiels, ainsi que la prise en charge de cette pathologie. more...

To evaluate the educational interest of a workshop on diagnosis and repair of obstetric anal sphincter injuries (OASIS). To evaluate the theoretical and anatomical knowledge of OASIS repair by French residents in obstetrics and gynecology.The workshop was composed of slides, video of repair and training using cadaveric sow's anal sphincters. All subjects were tested with a questionnaire before and after the course.Thirty residents participated. Classification of OASIS was known by 13.3% of the residents before the training versus 93.3% after the workshop (P0.001). Initially, only 6.7% correctly classified operative procedures of OASIS versus 86.7% after the workshop (P0.001). Per pre-test, 90% of residents did not know how to identify the internal anal sphincter (IAS) versus 3% at post-test (P0.001). Seventy percent of trainees correctly identified the external anal sphincter (EAS) at the beginning of training. Before the course, no resident knew the repair of the IAS and only one third knew the technical repair of the EAS. After the workshop, the theoretical knowledge of EAS and IAS repair were acquired by all (P0.001).Structured hands-on training improves significantly the knowledge of OASIS diagnosis and repair. more...

More and more perimenopausal and menopausal women seek an alternative to hysterectomy because they desire future pregnancy or wish to retain their uteri even if they have completed childbearing. Myomectomy may be an option. We can't know the evolution of leiomyomas. Hysteroscopic myomectomy is the treatment of submucous fibromas. Recurrence and subsequent surgery occurs in 16 to 21 % of cases. Intramural and subserousal myomas can be treated by myomectomy. Myomectomy should be performed laparoscopically because of shorter hospital stay, faster recovery and reduced postoperative pain. Second surgery is needed in 4-16 % of patients. If hysterectomy is performed, it should be by vaginal or laparoscopic route. There is no difference in perioperative morbidity between hysterectomy and myomectomy. Intra- and postoperative complications are similar between myomectomy and hysterectomy. Hysterectomy may be prefered if there is risk factor of malignancy or if the fibroma is discovered or has a rapid growth after menopause. more...