[Management of postpartum anal incontinence: A systematic review]. / Prise en charge de l'incontinence anale du post-partum: revue de la littérature.

AIM: To analyse the prevalence of postpartum anal incontinence, its risk factors, and its management. MATERIALS AND METHODS: A comprehensive systematic review of the literature on PubMed, Medline, Embase and Cochrane using: postpartum anal incontinence, postpartum fecal incontinence, perineal rehabilitation, anal surgery. RESULTS: The prevalence of postpartum anal incontinence varied from 4% (primipare) to 39% (multipare) at 6 weeks postpartum, whereas fecal incontinence can reach respectively 8 to 12% 6 years after delivery. Identified risk factors were: vaginal delivery (OR: 1.32 [95%CI: 1.04-1.68]) compared to cesarean section, instrumental extractions (OR: 1.47 [95%CI: 1.22-1.78]) compared to spontaneous vaginal delivery but it was only with forceps (OR: 1.50 [95%CI: 1.19-1.89]) and not with vaccum (OR: 1.31 [95%CI: 0.97-1.77]). Maternal age over 35 years (OR: 6 [95%CI: 1.85-19.45]), number of births (3 births: OR: 2.91 [95%CI: 1.32-6.41]) and the occurrence of anal-sphincter injury (OR: 2.3 [95%CI: 1.1-5]) were associated with an increased risk of anal incontinence regardless of the type of delivery compared to a group of women without anal incontinence. Perineal rehabilitation should be interpreted with caution because of the lack of randomized controlled trials. A reassessment at 6 months postpartum in order to propose a surgical treatment by sphincteroplasty could be considered if symptoms persist. The results of the sphincteroplasty were satisfactory but with a success rate fading in time (60 to 90% at 6 months against 50 to 40% at 5 and 10 years). CONCLUSION: Postpartum anal incontinence requires special care. Recommendations for the management of postpartum anal incontinence would be useful.

[Mid-uretral retropubic TVT sling procedure complicated by intraoperative cystotomy (bladder injury): Is it possible to avoid postoperative indwelling catheter?]. / Bandelette sous-urétrale TVT rétropubienne compliquée d'une plaie vésicale peropératoire : peut-on se passer du sondage urinaire postoperatoire ?

OBJECTIVE: Retropubic mid-uretral sling (MUS) procedure may be complicated by bladder injury (intraoperative cystotomy). There is no scientific consensus on the length of catheter drainage following bladder injury during MUS procedure: it varies from hours to days. We have made it our policy to immediately remove the catheter. The objective of the current study was to assess the results associated with immediate removal of catheter drainage following intraoperative bladder injury during retropubic MUS procedure. METHODS: Retrospective case-control study. Group 1 (cases): 8 women who have experienced bladder injury during retropubic MUS procedure and group 2 (controls): 32 women (ratio of controls to cases: 4:1). RESULTS: Mean (sd) age, BMI and MUCP were 62(13) vs. 59(10), 25(4) vs. 26(4) and 42(18) vs. 43(16), in group 1 and group 2, respectively (P=0.55, 0.56 and 0.92). Minimum follow-up duration was 12 months. None patient was lost to follow-up in group 1 (cases) and 2 patients were lost to follow-up in group 2 (controls) at 12 months follow-up. No rehospitalization or postoperative complication was noted in both groups. Immediate suprapubic postoperative pain exceeding 30/100 on VAS occurred in 1/8 (12%) and 3/32 (10%), in group 1 and group 2, respectively (P=1.00). Urinary stress incontinence cure rates were not significantly different between the two groups: 8/8 (100%) vs. 28/32 (87%), in group 1 and group 2, respectively (P=0.56). The level of satisfaction was comparable in both groups: PGI-I score was equal to 1(very satisfied) in 6/8 women (75%) and in 24/32 women (75%), in group 1 and group 2, respectively (P=1.00). De novo urgency was observed in 0/8 (0%) vs. 3/32 (10%), in group 1 and group 2, respectively (P=1.00). CONCLUSION: In the current short retrospective series, immediate removal of catheter drainage following intraoperative bladder injury during retropubic MUS procedure was not associated with an increased prevalence of complications. LEVEL OF EVIDENCE: 4.

Prediction of axillary lymph node status in male breast carcinoma.

BACKGROUND: To evaluate whether predictive factors of axillary lymph node metastasis in female breast cancer (BC) are similar in male BC. PATIENTS AND METHODS: From January 1994 to May 2011, we recorded 80 non-metastatic male BC treated at Institut Curie (IC). We analysed the calibration and discrimination performance of two nomograms [IC, Memorian Sloan-Kettering Cancer Center (MSKCC)] originally designed to predict axillary lymph node metastases in female BC. RESULTS: About 55% and 24% of the tumours were pT1 and pT4, respectively. Nearly 46% demonstrated axillary lymph node metastasis. About 99% were oestrogen receptor positive and 94% HER2 negative. Lymph node status was the only significant prognostic factor of overall survival (P = 0.012). The area under curve (AUC) of IC and MSKCC nomograms were 0.66 (95% CI 0.54-0.79) and 0.64 (95% CI 0.52-0.76), respectively. The calibration of these two models was inadequate. CONCLUSIONS: Multi-variate models designed to predict axillary lymph node metastases for female BC were not effective in our male BC series. Our results may be explained by (i) small sample size (ii) different biological determinants influencing axillary metastasis in male BC compared with female BC.

[Pelvic floor rehabilitation for female urinary incontinence: mechanisms of action]. / Mécanismes d'action de la rééducation périnéale pour l'incontinence urinaire de la femme.

OBJECTIVE: To analyze the proven mechanisms of action of pelvic rehabilitation in women presenting with urinary incontinence. METHODS: Review of literature (PubMed, Embase, Cochrane Database) using following keywords: female; urinary incontinence; overactive bladder syndrome; stress urinary incontinence; bladder training; bladder diary; pelvic floor muscle training; pelvic floor rehabilitation; physiotherapy; cognitive therapies. Among 2906 articles (animal and anatomical studies have been excluded); 66 have been selected because they focused on the evaluation of the pathophysiological mechanisms of pelvic floor rehabilitation concerning female urinary incontinence. RESULTS: Studies on pelvic floor muscles training exercises showed a significant increase in the force of contraction of these muscles and it was correlated with improved scores of urinary incontinence and pad test (coefficient of correlation r ranged from 0.23 to 0.34) for women presenting with stress urinary incontinence. These studies have not observed an increase in the maximum urethral closure pressure (MUCP) or correction of urethral hypermobility related with the improvement of incontinence after rehabilitation sessions. Studies concerning pelvic floor stimulation observed an increase in the force of contraction of pelvic floor muscles after rehabilitation and a decrease in the intensity of detrusor contractions without changing the MUCP. There is very little data on the precise mechanisms of action of biofeedback and cognitive behavioral therapy. CONCLUSION: In studies that objectively evaluated the mechanisms of action of pelvic rehabilitation, it was observed that pelvic floor muscles voluntary exercises and electrostimulation resulted an increase in force of contraction of these muscles without changing the MUCP.

[Hysteroscopic morcellation versus bipolar resection for endometrial polyp removal]. / Morcellement hystéroscopique versus résection à l'anse bipolaire pour les polypes endométriaux.

OBJECTIVE: The treatment of endometrial polyps is based on hysteroscopic resection. The aim of the current study was to compare the results associated with hysteroscopic morcellation and those observed with bipolar loop resection. PATIENTS AND METHODS: A single-center observational retrospective comparative study was performed, including 25 patients who underwent hysteroscopic resection of endometrial polyps from January 2012 to December 2013. The mean size of polyp was 9.2 mm in the group compared to 12.5mm in the resection group loop (P=0.06). RESULTS: Twelve patients underwent resection of the polyp morcellation with MyoSure(®) and 13 with bipolar resection loop Versapoint(®) 24F. The mean operative time was 16 minutes in morcellation group and 17 minutes in the bipolar resection group (P=0.76). Complete removal was achieved in 100% of cases in morcellation group and in bipolar loop resection. Regarding intraoperative and postoperative complications, no complication was observed in the two groups. DISCUSSION AND CONCLUSION: Results associated with hysteroscopic morcellation and bipolar loop resection seen to be comparable.

Influence of auto-cross-linked hyaluronic acid gel on pregnancy rate and hysteroscopic outcomes following surgical removal of intra-uterine adhesions.

OBJECTIVE: To determine the effect of the use of auto-cross-linked hyaluronic acid (ACP) gel following hysteroscopic surgery on the prevention of intra-uterine adhesions (IUAs) and the pregnancy rate. STUDY DESIGN: An observational retrospective study of 90 patients who underwent hysteroscopic removal of IUAs was conducted between 2008 and 2013 at a tertiary university care centre. Thirty-two patients received ACP gel during hysteroscopic removal of IUAs, and the remaining 58 patients did not receive ACP gel. Controls were matched to cases according to infertility and severity of IUAs using the American Society for Reproductive Medicine (ASRM) score. Four to six weeks after surgery, patients underwent diagnostic hysteroscopy to determine the re-occurrence of IUAs or the presence of adhesions. The patients were contacted by telephone to answer a questionnaire concerning their fertility. The main outcomes were pregnancy rate and postoperative IUAs. RESULTS: Pregnancy (viable or not) rates were not influenced by the use of ACP gel. The viable pregnancy rate was eight of 24 (33.3%) in the ACP gel group and 12 of 49 (24.5%) in the control group (p=0.427). The mean interval between surgery and pregnancy was 11.8 [standard deviation (SD) 10.5] months in the ACP group compared with 13.4 (SD 14.1) months in the control group (p=0.744). The mean ASRM score after surgery (hysteroscopic diagnosis at 4-6 weeks postoperatively) was equivalent in the two groups: 2.7 (SD 3.0) in the ACP gel group vs 2.6 (SD 3.2) in the control group (p=0.854). The mean follow-up was 45.2 months (interquartile range 33.2-52.7), with a loss to follow-up of 25% in the ACP gel group compared with 15.5% in the control group (p=0.817). CONCLUSION: Application of ACP gel did not prevent recurrence of IUAs and was not associated with an increased pregnancy rate. ACP gel should be used with caution pending assessment in a randomized control trial in a larger population.

[Management of third and fourth degree perineal tears: A systematic review]. / Prise en charge des périnées complets (déchirure périnéale stade 3 et 4) : revue de la littérature.

This was a comprehensive literature review using Pubmed, Medline, Embase and Cochrane, whose aim was to analyse the prevalence of anal sphincter injuries, their risk factors, their management and their functional prognosis. The prevalence of 3rd and 4th degree perineal tears varies between studies from 2.95% regardless the parity to 25% in nulliparous women. Twenty-eight percent to 48% of these lacerations were clinically occult. Perineal tears were associated with (multivariate analysis) forceps (6.021 [IC 95% 1.23-19.45]), nulliparity (OR 9.8 [IC 95% 3.6-26.2]), gestational age over 42 SA (OR 2.5 [IC 95% 1-6.2]), fundal pressure (OR 4.6 [IC 95% 2.3-7.9]), midline episiotomy (OR 5.5 [IC 95% 1.4-18.7]) or fetal weight in interval of 250g (OR 1.3 [IC 95% 1.1-1.6]). There was no difference between the sphincter repair techniques. Post-partum laxative use showed less painful bowel motion and earlier postnatal discharge. Data concerning rehabilitation were contradictory. The rate of anal incontinence 6 months after vaginal delivery were 3.6% following third degree of perineal tear and 30.8% in case of fourth degree of perineal tear. Thirty years after anal sphincter disruption, the prevalence of fecal incontinence reached 6.9%.

[Operative hysteroscopy for myoma removal: Morcellation versus bipolar loop resection]. / Hystéroscopie opératoire pour fibrome : morcellement versus résection à l'anse bipolaire.

OBJECTIVE: To evaluate the results associated with hysteroscopic morcellation for submucous myomas removal, and to compare with those observed associated with bipolar loop resection. MATERIELS AND METHODS: A retrospective comparative study was conducted in two universitary centers from January 2012 to December 2013. A total of 83 patients, who presented with submucous myomas type 0,1 and 2, were included. The number of myomas type 0,1 was 36 (71 %) and 15 (29 %) myomas type 2 in morcellation group versus 44 (59 %) myomas type 0,1 and 31 (41 %) type 2 in electrosurgical resection group (P=0.17). Hysteroscopic morcellation or electrosurgical resection with bipolar loop for removal submucous myomas were performed. RESULTS: Thirty-four patients underwent hysteroscopic morcellation using MyoSure(®), and 49 had hysteroscopic resection using Versapoint-24F(®) bipolar loop. The mean operative duration was 30minutes in morcellation group, compared to 31minutes in bipolar resection group (P=0.98). Complete myoma removal was achieved in 22 (64 %) patients in morcellation group, and in 34 (69 %) in bipolar resection group (P=0.65). There were no difference in the occuring of adverse events between the two. The prevalence of postoperative intra-uterine adherence was 10 % in morcellation group and 13.8 % in bipolar resection group (P=0.69). CONCLUSION: In the current short comparative series, hysteroscopic morcellation and bipolar loop resection were associated with comparable results for removal of submucous myomas.

[Complications of presumed benign ovarian tumors]. / Complications des tumeurs ovariennes présumées bénignes.

The main risk factor of adnexal torsion is a previous adnexal torsion (LE3). There is no clinical, biological or radiological sign that may exclude the diagnosis of adnexal torsion (LE3). The presence of flow at color Doppler imaging does not allow exclusion of the diagnosis (LE2). An emergent laparoscopy is recommended for adnexal untwisting (Grade B), except in postmenopausal women where oophorectomy is recommended (grade C). A persistent black color of the adnexa after untwisting is not an indication for systematic oophorectomy (grade C), since a functional recovery is possible (LE3). Ovariopexy is not routinely recommended following adnexal untwisting (grade C). The clinical signs of intra-cystic hemorrhage and those of rupture of the corpus luteum are not specific (LE4). MRI is not recommended to confirm the diagnosis of intra-cystic hemorrhage (grade C). Malignant transformation of an ovarian cyst is very rare. The presence of a benign ovarian cyst is not associated with an increased risk of ovarian cancer at long-term follow-up (LE2). For these women, an ultrasound follow-up is not recommended (grade C). Dermoid ovarian cyst containing nerve tissue can trigger the production of pathogenic auto-antibody-anti-NMDA, leading to encephalitis. A high proportion of thyroid tissue in a mature teratoma (struma ovarii) may cause hyperthyroidism.