[Genital prolapse in young women: a topical issue]. / Le prolapsus génital chez la femme jeune: une question d'actualité.

Genital prolapses usually occurs in the post-menopausal period. Patients under 50 years of age with genital prolapse represent about 25% of candidates for surgical reconstruction in our center. Some of these patients wish to conserve their child-bearing potential and most want to be able to have a normal sex life. Five per cent of these women, all under 35, have isolated hysterocele and a hypertrophic uterine cervix. This article focuses on the etiology, prevention and new surgical treatments of genital prolapse in young women. Etiologies include late age at first pregnancy, chronic lung disease, and perineal damage during delivery. Connective-tissue and collagen disorders predominate before 35 years of age. New surgical procedures include vaginal repair with synthetic mesh. Laparoscopic sacropexy is still the gold standard. Prevention includes non traumatic delivery (Caeseran section), while pelvic floor exercises are mandatory after vaginal delivery.

[Protecting the unborn child. Information needed long before pregnancy]. / Prévention des risques pour l'enfant a naître. Nécessité d'une information bien avant la grossesse.

The unborn child is at risk from several maternal diseases and behaviors, such as smoking (tobacco and cannabis) and alcohol consumption. Other threats come from maternal infections (AIDS, hepatitis, rubella, toxoplasmosis, etc.), certain medicines, obesity, diabetes, etc. Many young women of child-bearing potential are unaware of these risks, and need to be informed well before they conceive. Healthcare professionals must be trained to provide this information, notably during preconceptional consultations. The first examination should take place during the first month of pregnancy (rather than before the third month at present), given the risks of early embryonic and fetal damage. This is not just a question of public health but also a social issue, as the lack of information is most flagrant among the poor. Everything must be done to ensure that all children have the best possible chance of growing up in good health.

[The female urogenital system and high level sports]. / Appareil génital féminin et sport de haut niveau.

High-level competition sports can have a variety of negative effects on the female urogenital apparatus. Perineal trauma is rare and is usually associated with certain sports (impalement or hydrotubation during water-skiing, indurated perineal nodules in racing cyclists, and horse-riders' perineum). Effort incontinence is seen in all sports involving abrupt repeated increases in intra-abdominal pressure that may exceed perineal floor resistance. Sportswomen should be questioned about possible incontinence and be informed of preventive and therapeutic measures.

A biomechanical study of the strength of vaginal tissues. Results on 16 post-menopausal patients presenting with genital prolapse.

AIMS: Measurements of the tensile and bending strength of samples of vaginal tissue collected during corrective surgery of prolapse. MATERIALS AND METHODS: Our measurements were conducted on two samples of vaginal tissue 2 cm x 2 cm collected during surgical correction of prolapse by vaginal route in 16 post-menopausal patients. The samples were collected from posterior vaginal fundus, were orientated, and then fixed on a plate holding the edges and allowing the tissue to be stretched over an orifice of 1 cm. The tensile measurements were made using a suture passed over this distance of 1 cm in one of the two samples by recording the strength curve in order to evaluate the force at rupture of the collagen fibres. The second sample was prepared in the same way and a piston of 1 cm diameter was made to penetrate to determine the strength of breakage of the fibres. The pressure and tensile strength curves were recorded up to rupture of the sample, as was the value of the tissue elongation. RESULTS: There was a great variability in the measurements of maximum strength at rupture of the vaginal samples and in the elongation before rupture of the samples. The mean rupture values in tensile tests were 44 and 59 N in bending with extremes of 12 and 130 N. The values of elongation before rupture of a 10 mm sample were 23 mm in tensile tests and 11 mm in bending tests. There was a great variability of results from one patient to another. There was no relation between the values observed and the patient age. There was a statistical relation between the elongation values of the samples and the maximum force before rupture in both the tensile and bending tests. There was also a relation between the measurement of the maximum force at rupture in bending and in tensile tests although there was no such relation in terms of the values of elongation before rupture. DISCUSSION: There is no published reference concerning the strength at rupture or the tensile strength curves for human vaginal tissues. Vaginal tissues are however commonly used as a suspension component in the vast majority of operations for correcting prolapse or urinary incontinence. These suspensions are made by passing a suture through the thickness of the vaginal tissue. The results that we report do however show that these vaginal tissues are very variable in strength from one patient to another. The same finding was made in terms of the elongation values for the vaginal tissue before rupture. The values in bending tests showed that the highest rupture force values and the greatest mean elongation before rupture were lower than in tensile tests. CONCLUSIONS: These findings could explain some failures of these surgical procedures, which are all based on the tensile strength properties. Finally these results could be included in modelling of the reaction of vaginal tissues to the pressure experienced within the vagina.

[Dynamic MRI in the preoperative management of genital prolapse. A prospective study]. / Place de I'IRM dynamique dans la prise en charge chirurgicale des prolapsus génitaux. Résultats d'une enquête prospective.

Forty-three patients with genital prolapse prospectively underwent blinded pre and postoperative MRI, with dynamic assessment of each compartment. MRI was significantly more accurate than physical examination for the diagnosis of posterior defects (rectocele, enterocele) but not for anterior defects or uterine prolapse (hysterocele, cystocele). Postoperative MRI confirmed the surgical outcome and also identified risk factors for recurrence. MRI was particularly reliable for recurrent prolapse and vault prolapse. The authors consider that dynamic MRI can advantageously replace colpocystodefecography, as it is rapid and well tolerated. Technical improvements should help to understand the role of muscular and fascia lesions.

A history of cesareans is a risk factor in vaginal hysterectomies.

AIMS: This study describes the characteristics and per- and postoperative frequencies of complications in vaginal hysterectomies for benign lesions in patients with a history of cesareans. We compare these figures with the frequency of complications in vaginal hysterectomies without a history of such operations. PATIENTS AND METHODS: Over a period of 8 years we studied all the hysterectomies for benign lesions (963) conducted at the Hospital Jeanne de Flandre in Lille and at the Paul Gellé maternity clinic at Roubaix. During that time 76.94% of the hysterectomies were conducted exclusively by the vaginal route (n = 741), 10.1% (n = 98) were by the laparoscopic-assisted vaginal route, and 12.9% (n = 124) by the pure abdominal route. We selected the hysterectomies conducted by the pure vaginal route from this series. We compared two subgroups of patients that were subjected to hysterectomy by the vaginal route: patients with a history of cesarean section and those never having had cesarean delivery. In each of these groups we recorded the characteristics of the population and compared the peroperative and postoperative data of the hysterectomies. We gave special attention to peroperative complications such as bladder or digestive tract wounds and hemorrhages. We used analysis of variance tests to compare means and chi2-tests and Fisher's exact tests for comparisons of numbers. A probability of p < 0.05 was adopted as the limit of significance. RESULTS: The two populations were comparable in terms of age, weight, height, parity and history of pelvic surgery causing adhesions. There was a significant difference in the number of annexectomies between the two populations. The frequency of peroperative reductions in the uterine volume was also similar in the two vaginal hysterectomy groups. We were unable to find any significant difference in uterine weight or in the operating or hospitalization time. The frequency of hemorrhages was significantly higher in the patients with a history of cesareans. The number of injuries to the bladder and intestines was higher in the patients with a history of cesareans but not significant for the bowel injuries. We compared the cumulative frequency of complications in the group of hysterectomies with a previous history of cesareans and the group without a history of cesarean section. In our patients with a history of cesareans, we recorded 13 peroperative complications out of 71 hysterectomies (18.3%). In the group of hysterectomies without history of cesareans, we recorded 24 complications out of 670 (3.58%). There was a significant difference between the cumulative frequency of complications in the two populations of patients in favor of the subgroup without past cesarean scarring (p < 0.0001). CONCLUSION: In vaginal hysterectomy, a history of single or multiple cesareans increases the peroperative risk for hysterectomies by the vaginal route. The surgeon must take into account the history of cesareans and be attentive to the previous operating time of the bladder and uterine region especially at the time of opening the anterior peritoneal cul de sac. Nevertheless, uterine scarring as a sequel to cesareans must not be a contraindication for the vaginal route.

Mechanical properties of synthetic implants used in the repair of prolapse and urinary incontinence in women: which is the ideal material?

The authors review the literature concerning all types of synthetics implants used in prolapse repair or the treatment of stress urinary incontinence, and analyze the mechanical properties of and the tolerance to the various products used. Various synthetic implants are also studied, including their advantages and disadvantages, as well as outcome following implantation and tolerance by the host, with respect to the type of product and the type of intervention. A review of current implant products demonstrated that the perfect product does not exist at present. The most promising of theses products for applications in transvaginal surgery to restore pelvic function appears to be the synthetic prostheses made predominantly of polypropylene, which offer mechanical properties of durability and elasticity. Their properties of resistance are undisputed, but it remains to be shown whether they are well tolerated when inserted by the vaginal route. The technical modalities for their use are still under evaluation, which should enable a better identification of the respective indications for these products in prolapse repair and treatment of urinary incontinence by the vaginal route.

[Surgical cure of stress urinary incontinence with vaginal tissue sling: technique, results, indications]. / Cure chirurgicale de l'incontinence urinaire d'effort par fronde de tissu vaginal: technique, résultats, indications.

OBJECTIVES: Describe a new surgical technique of sling procedure using a vaginal sling and report complications and mid-term functional results. According to these results, it's necessary to discuss the best indications. MATERIAL AND METHODS: Retrospective study of the first 75 patients operated for urinary stress incontinence. RESULTS: The average age of patients was 56 (30-90). Preoperative complications have been rare with only one bladder injury (1.3%). Postoperative complications have been more frequent and the most of them was caused by 76% of urine retention lasting a mean of 14 days and 44% of urinary infections. 20% of the patients have presented secondary dysuria and/or urinary urgency. 4 patients (5.3%) have presented a vaginal mucocele between 9 and 32 months after the operation. At mean follow-up of 25.1 months, the success rate was 70.6%, with 61.3% of patients who have been cured and 9.3% which was improved. In case of severe sphincter insufficiency, the success rate was 80%. Success rate was 30% when the vaginal sling was the only procedure and 66.1% when it was associated to another vaginal procedure (p = 0.006) as vaginal hysterectomy or sacro-spinous suspension. CONCLUSION: This original surgical technique for cure of urinary stress incontinence is inexpensive and easy to learn. It can be associated to other operations by vaginal way. The realization of this procedure under regional anaesthesia should enable to warn urine retention which is the mean postoperative complication. The success rate of this series is cheerful because it takes into account any patients no selected and operated on the learning phase of the technique. The best results of this technique are urinary stress incontinence associated with vaginal surgery for genital prolapse. The final assessment of this surgical technique will be require longer follow-up and comparative studies with other procedures on an elevated number of patients.