The suspended ileal loop for difficult Hartmann's reversal.

BACKGROUND: Hartmann's reversal can be complicated by the presence of dense adhesions in the upper part of the abdominal cavity, difficulties in freeing the splenic flexure with the risk of splenic tears, a lack of sufficient colonic length, the risk of ureteral lesion, or the risk of lesions of the vascular arcade. METHODS: We propose a technique which consists of interposing an adapted segment of ileal loop between the end of the proximal colon and the rectum to restore intestinal continuity. RESULTS: Two patients had Hartmann procedure, the first for a Hinchey stage 4 perforated diverticulitis and the second for a colorectal fistula due to ischemia of the proximal colonic segment. Hartmann's reversal was expected to be difficult, so a suspended ileal loop was used. The outcomes were uneventful, and functional results were satisfactory. CONCLUSIONS: A suspended ileal loop could be used as a salvage procedure in some cases of potentially difficult Hartmann's reversal.

[Botulinium toxin and idiopathic overactive bladder: Multicentric contempory management in Bourgogne]. / Toxine botulique et hyperactivité vésicale idiopathique : évaluation multicentrique des pratiques en Bourgogne.

INTRODUCTION: Since 2014, OnabotulinumtoxinA Botox® (Allergan, Inc., Irvine, USA) represents a new therapeutic option for second-line treatment of idiopathic overactive bladder. The purpose of the current study was to evaluate practices of surgeons using onabotulinium toxin (BoNTA) in this indication. MATERIAL AND METHODS: All urogynecology centers of the country were asked in order to list all patients who were treated since marketing autorisation. Patient symptoms, previous treatments, paraclinic evaluations, data of surgery and the characteristics of the follow up were collected and analyzed. RESULTS: Six centers used BoNTA and five have accepted to participate. Ninety-seven patients have been identified. Sixty-eight first injections (70 %) were carried out with the strict frameworf of the marketing autorisation (urinary frequency, urinary urgency, urinary incontinence). All patients had at least two symptoms. In 69 %, Botulinum toxin was a second-line treatment after the failure of tibial neuromodulation or sacral neuromodulation. Urodynamic evaluation was carried out for 91 % of patients. The search for a post-void residual volume was observed for 59 % of patients during the follow up. CONCLUSION: In our country, BoNTA injections for idiopathic overactive bladder are mainly effected after tibial neuromodulation or sacral neuromodulation failure. Diagnostic, operating and outcome evaluation practices are still very heterogeneous pleading for a greater standardization of this new therapy in this indication. LEVEL OF EVIDENCE: 3.

[The Martius flap in stress urinary incontinence treated by suburethral sling]. / Intérêt du lambeau de Martius (LM) dans l'incontinence urinaire d'effort (IUE) traitée par bandelettes sous-urétrales (BSU).

OBJECTIVE: Study of a series of patients treated with suburethral tapes using the Martius flap technique, for complications or in a preventive way, in order to determine its interest and morbidity. PATIENTS: Eleven female patients treated by suburethral tapes for stress urinary incontinence, for which we described the type of tapes used, their complications, the procedure including Martius flap and the outcomes. RESULTS: Indications of the Martius flap were: three tapes through bladder neck, one through urethra, one uro-vaginal fistula, four loss of substance of the vaginal wall, one peri-urethral fibrosis and one preventive use on irradiated pelvis. Complications were transient postoperative pain and one abscess of the greater lip. In our series, the Martius flap never cured stress urinary incontinence. The placement of a suburethral tape on a Martius flap is feasible but the adjustment is more difficult. CONCLUSION: The Martius flap is efficient in the treatment or prevention of suburethral tapes complications with low morbidity. It allows secondary placement of a suburethral tape with difficult adjustment.

[Plication of suburethral slings as treatment of persisting or recurring stress urinary incontinence]. / Plicature de la bandelette sous-urétrale comme traitement de l'incontinence urinaire d'effort persistante ou récidivante.

OBJECTIVE OF THE STUDY: Feasibility and efficiency study of mesh readjustment in suburethral slings by overcoat plication in case of persisting of recurring stress urinary incontinence in patients with suburethral slings. METHODS: Retrospective and monocentric study including patients that present with a failure or recurring incontinency after suburethral slings surgery. The eligibility was evaluated after a complete clinical and paraclinical statement, proving the recurrence of the incontinence and its mechanism. Surgery consisted in a plication in an overcoat. RESULTS: Nineteen patients were included. The medium delay between initial surgery and the plication was 23.4months (ds=25.5). Results were evaluated subjectively by the MHU questionnaire and objectively by the urodynamic appraisal. The medium survey was 27.2months (ds=37.3). The procedure lasts about 30minutes. According to MHU, 73.7% of patients were cured and for 10.3% the symptoms were lessened. The difference in the MHU score of stress urinary incontinence before and after mesh readjustment was significant (P=0.0005) and get down from 2.31 (ds=0.75) to 0.56 (ds=0.92) as an average. There was no complication during surgery. There were two cases of postoperative acute urinary retention which were reoperated by simply cutting a thread allowing the sling to relax without losing the benefit of the plicature. There was no significant increase in urge incontinence or dysuria. CONCLUSION: The results of this study confirmed the feasibility, the efficiency and the low morbidity of mesh readjustment for the suburethral sling.

[Guidelines for the surgical treatment of female urinary stress incontinence in women using the suburethral sling]. / Recommandations concernant la prise en charge des complications des bandelettes sous-urétrales.

The complications of suburethral slings are rare but varied. The operative complications result most often from errors in surgical technique. Intraoperative cystoscopy is required when implanting a retropubic sling to diagnose vesical transfixion intraoperatively. Functional complications are the most frequent. They require a true diagnostic strategy before proposing treatment adapted to the patient. The first examination should be an endoscopic urethrovesical exploration to eliminate vesicourethral transfixion by the suburethral slings. Acute postoperative retention most often stems from surgical relaxation of the suburethral slings during the immediate postoperative period. Dysuria is more easily reversed if it is treated early with resection or ablation of the suburethral slings. De novo urge incontinence has many etiologies : infection, urethral obstruction, more rarely cystocele, and idiopathic causes. With recurrent stress incontinence after suburethral slings, management will depend on anamnesis, as well as the clinical and urodynamic workups. The treatment could involve the sling (second suburethral sling, kinking of the suburethral sling); however, another therapeutic alternative will have to be suggested relatively early (artificial sphincter, ACT balloons, etc.). The recommended use of the large-mesh knitted monofilament polypropylene suburethral sling has considerably reduced the risk of infectious complications related to the prosthetic material. In case of vaginal erosion, prosthesis infection must be eliminated, which requires removing the sling. Simple erosion can be treated with partial resection of the exposed sling and vaginal suture. Many nonabsorbant palliative treatments have been reported, often with small series. They can be grouped into three types: extra-urethral occlusive devices, intra-urethral obstructive devices, and intravaginal support devices. The use of a pessary or other vaginal devices can be proposed, in particular with associated prolapse, which can be used when leakage is very occasional (sport, etc.) or in women who cannot have any other treatment.

[Synthesis of the guidelines for the treatment of non-neurological urinary incontinence in women]. / Synthèse des recommandations pour le traitement de l'incontinence urinaire féminine non neurologique.

The last two decades have brought about new medical and surgical treatments revolutionizing care for non-neurological urinary incontinence in women. Many studies, often randomized prospective studies with sufficient follow-up, have validated the therapeutic choices and shown them not to be part of a fad or marketing pressures. The French Association of Urology (L'Association Française d'Urologie), through its Committee on Women's Urology and Pelviperineology (Comité d'Urologie et de Pelvipérinéologie de la Femme), proposes its recommendations. These were established by an expert group of specialists (urologists, gynecologists, and physical therapists), based on a review of the literature but taking into account the daily practices in academic and private practice settings. Between evidence-based medicine and reality in the field, these recommendations attempt to propose realistic and applicable strategies.

[Description and results of a prospective study on a new physiotherapy method in the management of postprostatectomy urinary incontinence]. / Description et résultat d'une étude prospective portant sur une nouvelle méthode de kinésithérapie dans la prise en charge de l'incontinence urinaire postprostatectomie.

OBJECTIVE: Prospective evaluation of the short-, medium- and long-term efficacy of the "ABDO-MG concept" technique in the rehabilitation of urinary incontinence following radical prostatectomy (abdominal or laparoscopic approach). METHODOLOGY: Fifty-three patients suffering from clinical urinary stress or triple incontinence (pure stress incontinence, incontinence due to bladder instability or sphincteric insufficiency) took part in the study. Rehabilitation treatment, begun six weeks before the operation, continued during the immediate postoperative period, at home and at the physiotherapist's office for three to 12 months until the urinary incontinence had disappeared or was considered to be minimal and acceptable, therefore tolerated. The exercises were performed according to a strict protocol defined by the inventor of the concept, involving expiration into a specific end-piece (called "sound end-piece") and connection with an abdominal neurostimulator for which the current is triggered and maintained by the sound of the patient's breathing into the sound end-piece. The efficacy of this concept was confirmed by a comparative trial before and during rehabilitation and then at the end of treatment. There was triple monitoring: evaluation by LFT noting, for each breath, the flowrate/volume curve and FEV1/s, clinical abdominal testing with monitoring of abdominal movement both vertically and horizontally during coughing and a "pad test" at home, assessing the quantity of nocturnal and diurnal urinary leakage relative to each patient's activity. RESULTS: The results were meaningful and significant. The improvement of the flowrate/volume curve and FEV1/s varied between 1.4436 and 1.1209 L. Abdominal testing showed constant positive evolution in the correction of abdominal incompetence under stress (test improved by one point on a negative graduation of -1 to -3). The home "pad test" confirmed a highly significant result with leakage virtually disappearing, sometimes falling from nearly 800 cc to just a few drops at the end of treatment. The subjective results were marked by the improvement in various dysfunctions within the context of abdominal incompetence increased by the abdominal surgery. CONCLUSION: This prospective study was the first to provide an evaluation of the abdominal motor score and the relationship between expiration thrust and pelviperitoneal protection.

Bilateral plication of the puborectal muscles: A new surgical concept for treating vulvar widening.

OBJECTIVES: This study describe a new myorraphy technique by bilateral plication of the puborectalis bundles (PRP) of the levator ani muscle to treat vulvovaginal widening. The aim of this work was to report our preliminary experience in terms of morbidity and results (anatomical and functional) in the short and medium term. MATERIALS AND METHODS: This single centre retrospective study concerned 69 women who underwent PRP between January 2011 and December 2014. The main criterion for judging success was the GH before and after surgery (Genital Hiatus in the POP-Q classification: Pelvic Organ Prolapse Quantification System). The secondary criteria were the quality of sexual intercourse and the morbidity. RESULTS: The average GH post-surgery was 31, 35 and 35mm at 6 weeks, 6 and 12 months respectively compared to 65±5mm preoperatively (P<0.00001). Among the 27 patients who were sexually active prior to surgery, 18.52% deemed the quality of sexual intercourse satisfactory. After surgery, more than 88% of the patients observed an improvement (P<0.00001). After the surgery the reported rate of minor complications was under 3%. CONCLUSION: This preliminary study of PRP confirms the feasibility of the procedure, its low morbidity and the stability of the anatomical outcomes at 12 months.

Determinants of promoter-specific activity by glucocorticoid receptor.

Glucocorticoid receptor (GR) is expressed at essentially equal levels in almost all tissues and cell types. Remarkably, glucocorticoids themselves regulate transcription in vivo in both a promoter- and tissue-specific manner. Thus, specific systems must be in place to regulate receptor action within certain cells and at certain promoters. To address two specific aspects of these systems, we have analyzed promoter-specific activity of GR using two different, well studied promoters (termed simple and composite promoters) from which GR activates transcription. The simple promoter depends only on the receptor for glucocorticoid-responsive transcriptional activation, while GR activity at the composite promoter depends on additional transcription factors. We have compared the action of several GR ligands at these promoters and demonstrate fundamental differences in the activities of these ligands on receptor activity. Furthermore, these compounds induce unique conformational changes in receptor, resulting in promoter-specific receptor function. We have identified critical amino acid residues within GR which, when mutated, genetically distinguish the action of GR at these promoters. Taken together, the data indicate that the presence of only the receptor and the ligand is not sufficient to allow activation of transcription. An additional system of regulation influences receptor action in both a tissue- and promoter-selective fashion, suggesting that multiple, regulated surfaces of the receptor respond to the cellular environment and determine the spectrum of GR activities. These functional surfaces may be induced or regulated by ligand binding, by the DNA sequence to which receptor is bound, or by the nonreceptor factors resident at the promoter or in the tissue.

[Surgery for female stress urinary incontinence with transobturator tape]. / Traitement chirurgical de l'incontinence urinaire d'effort de la femme par bandelette transobturatrice.

The aim of suburethral transobturator suspension is to cure the women stress urinary incontinence. The concept underlying this apparatus is based on several points: it reproduces the urethral fascia; it complies with Delancey's concept; it consists of a tension-free band through the soft structures of the obturator fossa; it is a perineal surgery. This surgery needs specific devices: a synthetic tape and a specific tool to introduce it, the tunnelling device. Respecting some technical landmarks are mandatory to ensure successful intervention: the vaginal incision must include all the thickness of the vaginal wall; the trans-obturated endpoint must be located at the level of the mid urethra; the tunnelling device must have a close contact with the ischiopubic bone; the finger inside the incision protects the urethra and drives the tunnelling device inside the vaginal incision.

Hydrazinonaphthalene and azonaphthalene thrombopoietin mimics are nonpeptidyl promoters of megakaryocytopoiesis.

High-throughput screening for the induction of a luciferase reporter gene in a thrombopoietin (TPO)-responsive cell line resulted in the identification of 4-diazo-3-hydroxy-1-naphthalenesulfonic acids as TPO mimics. Modification of the core structure and adjustment of unwanted functionality resulted in the development of (5-oxo-1,5-dihydropyrazol-4-ylidene)hydrazines which exhibited efficacies equivalent to those of TPO in several cell-based assays designed to measure thrombopoietic activity. Furthermore, these compounds elicited biochemical responses in TPO-receptor-expressing cells similar to those in TPO itself, including kinase activation and protein phosphorylation. Potencies for the best compounds were high for such low molecular weight compounds (MW < 500) with EC(50) values in the region of 1-20 nM.

Regulation of voltage-dependent Ca2+ channels of neuronal cells by chronic changes in membrane potential.

The regulation of voltage-dependent Ca2+ channels by chronic changes in membrane potential was studied by measuring the binding of [3H]nitrendipine to membranes from PC12 pheochromocytoma cells. Depolarization of the cells by elevation of extracellular K+ caused up to a 45% loss of [3H]nitrendipine binding sites within 4 days without any change in Kd. Repolarization of the cells caused a return to control binding within 1-2 days, showing that either decreases or increases in membrane potential can cause reversible changes in [3H]nitrendipine binding sites.

Cardiovascular effects of 1-methyl-4-(1-naphthylvinyl)piperidine hydrochloride.

1-Methyl-4-(1-naphthylvinyl)piperidine (B-120) produced a dose related decrease in blood pressure in cats. B-120 did not alter the cardiovascular response to acetylcholine or vagal stimulation. It did not affect the response of the nictitating membrane to both pre- and post-ganglionic stimulation. In isolated cortical synaptosomes, B-120 decreased calcium flux below basal levels. Thus, the blockade of calcium channels appeared to be related to the production of hypotension and may be the mechanism by which B-120 protected against organophosphate toxicity.

[Intra-muscular injections and post-injectional paralysis. 18 cases]. / Intra-musculaires et paralysies post-injectionnelles. A propos de 18 cas.

The study of 264 lower limbs paralysis recorded from 1988 to 1990 in 6 Physiotherapy Centers in Madagascar showed that 66% has received prior intra-muscular injections. Among those, 10.2% could be diagnosed as post injectional paralysis and quinine was responsible in 73%. Defining a national policy on the use of the intra-muscular injections, training medical workers and improving the access to oral and intra-rectal drugs could help to decrease the frequency of those complications spirochetes and other infections (43).

[Transobturator urethral suspension: mini-invasive procedure in the treatment of stress urinary incontinence in women]. / La bandelette trans-obturatrice: un procédé mini-invasif pour traiter l'incontinence urinaire d'effort de la femme.

Transobturator tape is an artificial tape designed for urethral suspension to treat female stress urinary incontinence. This tape has two original features: its non-woven polypropylene structure is coated with silicone on the urethral surface in order to limit retraction of polypropylene and to establish a barrier to extension of periurethral fibrosis. transmuscular insertion, through the obturator and puborectalis muscles, reproduces the natural suspension fascia of the urethra while preserving the retropubic space. A preliminary study (40 implantations) confirmed the feasibility of this operation, the low morbidity (one complication: sepsis) and the encouraging results between 3 and 12 months; in the treatment of isolated incontinence (16 patients), no postoperative dysuria has been observed; 15 patients are totally continent and 1 patient is improved; in the treatment of prolapse associated with frank or potential incontinence (24 patients), transient postoperative dysuria was observed in 4 cases, with no postoperative incontinence.

[Pelvic organ prolapse-surgical technique (POP-ST): a classification of techniques of mesh augmented repairs for pelvic organ prolapse by vaginal route]. / Proposition d'une classification des techniques chirurgicales de cure de prolapsus (pelvic organ prolapse-surgical technique [POP-ST]) avec mise en place d'une prothèse par voie transvaginale.

OBJECTIVE: The aim of this study was to propose a classification of surgical techniques for treatment of prolapse by vaginal route using prosthetic reinforcements and to relate the evaluation of surgeons involved in the care of surgical patients. METHODS: A literature review was conducted searching for all articles relating novel technique of surgical management of patients with use of prosthetic reinforcements vaginally. The classification was made from descriptions found and then assessed by questionnaires filled out by surgeons. RESULTS: The classification takes account of all the techniques available today and can integrate new. Among the surgeons, 56.5% (13/23) found that the POP-ST is adapted to reflect the reality and variety of techniques and 60.8% (14/23) will be ready for daily use. CONCLUSION: A classification covering all the techniques put them at risk of a final tool too complex for routine use. The simplification would make it more usable but limited the comprehensiveness and evolutionary. Only 23 surgeons returned the questionnaire. A larger sample would be desirable. The POP-ST is the first classification of this type. We believe that it would assess the new techniques to better understand the complications.