Risk factors for postoperative pain after cystocele repair with mesh.

INTRODUCTION AND HYPOTHESIS: Prolapse is a common condition seen in women and its therapeutical management consists first and foremost of surgery. Postoperative pain is one of the most common side effects seen after surgery. The objective of this study was to identify risk factors for postoperative pain after cystocele repair with mesh. METHODS: This is a secondary analysis of the multicenter randomized trial PROSPERE, which compared cystocele repair with mesh according to the vaginal or laparoscopic approach. The presence of postoperative pain was assessed by a pain-specific self-reported questionnaire (Questionnaire de Baudelocque). The statistical analysis is based on the Wilcoxon, Chi-squared, and Fisher's tests. RESULTS: The prevalence of postoperative pain (pain persisting more than 6 months) was 39% (80 out of 205, 95% CI 32.4-46.1), with 6.3% (13 out of 205) of chronic pain reports. Preoperative pain was the only statistically significant risk factor OR = 2.32 (p = 0,007; 95% CI 1.24-4.36). CONCLUSIONS: Surgeons must be careful with preoperative painful prolapse and should inform their patient of the risk of developing postoperative chronic pain.

Long-term outcomes of primary cystocele repair by transvaginal mesh surgery versus laparoscopic mesh sacropexy: extended follow up of the PROSPERE multicentre randomised trial.

OBJECTIVE: To compare the effectiveness and safety of laparoscopic sacropexy (LS) and transvaginal mesh (TVM) at 4 years. DESIGN: Extended follow up of a randomised trial. SETTING: Eleven centres. POPULATION: Women with cystocele stage ≥2 (pelvic organ prolapse quantification [POP-Q], aged 45-75 years without previous prolapse surgery. METHODS: Synthetic non-absorbable mesh placed in the vesicovaginal space and sutured to the promontory (LS) or maintained by arms through pelvic ligaments and/or muscles (TVM). MAIN OUTCOME MEASURES: Functional outcomes (pelvic floor distress inventory [PFDI-20] as primary outcome); anatomical assessment (POP-Q), composite outcome of success; re-interventions for complications. RESULTS: A total of 220 out of 262 randomised patients have been followed at 4 years. PFDI-20 significantly improved in both groups and was better (but below the minimal clinically important difference) after LS (mean difference -7.2 points; 95% CI -14.0 to -0.05; P = 0.029). The improvement in quality of life and the success rate (LS 70%, 61-81% versus TVM 71%, 62-81%; hazard ratio 0.92, 95% CI 0.55-1.54; P = 0.75) were similar. POP-Q measurements did not differ, except for point C (LS -57 mm versus TVM -48 mm, P = 0.0093). The grade III or higher complication rate was lower after LS (2%, 0-4.7%) than after TVM (8.7%, 3.4-13.7%; hazard ratio 4.6, 95% CI 1.007-21.0, P = 0.049)). CONCLUSIONS: Both techniques provided improvement and similar success rates. LS had a better benefit-harm balance with fewer re-interventions due to complications. TVM remains an option when LS is not feasible. TWEETABLE ABSTRACT: At 4 years, Laparoscopic Sacropexy (LS) had a better benefit-harm balance with fewer re-interventions due to complications than Trans-Vaginal Mesh (TVM).

Serious complications and recurrences after pelvic organ prolapse surgery for 2309 women in the VIGI-MESH registry.

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.

Complications after pelvic floor repair surgery (with and without mesh): short-term incidence after 1873 inclusions in the French VIGI-MESH registry.

OBJECTIVE: To assess the short-term incidence of serious complications of surgery for urinary incontinence or pelvic organ prolapse. DESIGN: Prospective longitudinal cohort study using a surgical registry. SETTING: Thirteen public hospitals in France. POPULATION: A cohort of 1873 women undergoing surgery between February 2017 and August 2018. METHODS: Preliminary analysis of serious complications after a mean follow-up of 7 months (0-18 months), according to type of surgery. Surgeons reported procedures and complications, which were verified by the hospitals' information systems. MAIN OUTCOME MEASURES: Serious complication requiring discontinuation of the procedure or subsequent surgical intervention, life-threatening complication requiring resuscitation, or death. RESULTS: Fifty-two women (2.8%, 95% CI 2.1-3.6%) experienced a serious complication either during surgery, requiring the discontinuation of the procedure, or during the first months of follow-up, necessitating a subsequent reoperation. One woman also required resuscitation; no women died. Of 811 midurethral slings (MUSs), 11 were removed in part or totally (1.4%, 0.7-2.3%), as were two of 391 transvaginal meshes (0.5%, 0.1-1.6%), and four of 611 laparoscopically placed mesh implants (0.7%, 0.2-1.5%). The incidence of serious complications 6 months after the surgical procedure was estimated to be around 3.5% (2.0-5.0%) after MUS alone, 7.0% (2.8-11.3%) after MUS with prolapse surgery, 1.7% (0.0-3.8%) after vaginal native tissue repair, 2.8% (0.9-4.6%) after transvaginal mesh, and 1.0% (0.1-1.9%) after laparoscopy with mesh. CONCLUSIONS: Early serious complications are relatively rare. Monitoring must be continued and expanded to assess the long-term risk associated with mesh use and to identify its risk factors. TWEETABLE ABSTRACT: Short-term serious complications are rare after surgery for urinary incontinence or pelvic organ prolapse, even with mesh.

Bulky fibroid and pregnancy: myomectomy is possible during pregnancy.

When bulky fibroids are discovered during pregnancy, they can become acutely complicated. The question of their resection thus arises. The authors report a case of a woman who was diagnosed at eight weeks' gestation by ultrasound and then by MRI, with a uterine fibroma measuring 22x12x15 cm.

Management of Complications of Prosthetic Mid-urethral Tape Surgery for Stress Urinary Incontinence in Women.

OBJECTIVE: To propose guidelines for the management of complications of prosthetic mid-urethral tape surgery for stress urinary incontinence in women. METHODS: These guidelines are based on an exhaustive literature review on retropubic and trans-obturator mid-urethral tape complications. The expert panel rated the level of evidence of each study, summarized literature for the treatment of each complication, and proposed guidelines. RESULTS: Management of these complications is complex and the first treatment is crucial to offer the best functional result to the patient. We propose a standardized approach and guidelines for the management of complications to help physicians to early identify a surgical complication, offer adequate treatment for each complication and provide clear and appropriate information to patients. We detailed management of intraoperative complications as follows: bladder, urethral, vaginal, visceral, and vascular injury; short-term post-operative complications are the following: bleeding/hematoma, voiding dysfunction, pain, infection; and long-term post-operative complications are the following: chronic voiding dysfunction, de novo overactive bladder syndrome, chronic pain, dyspareunia, vaginal, bladder, and urethral tape erosion. CONCLUSION: These guidelines may help physicians to improve management of prosthetic mid-urethral sling complications that may occur following stress urinary incontinence surgery.

Value of dynamic contrast-enhanced MRI for tissue characterization of ovarian teratomas: correlation with histopathology.

AIM: To analyse the value of double contrast-enhanced (DCE) magnetic resonance imaging (MRI) in addition to conventional MRI to characterize ovarian teratomas subtypes with histological correlation. MATERIALS AND METHODS: From January 2005 to December 2008, 38 women undergoing MRI and subsequent resection of ovarian teratomas were identified [40 mature cystic teratomas (MCT), two struma ovarii, three immature teratomas]. MRI images were analysed blindly by two radiologists according to morphological and vascular abnormalities. An experienced histopathologist reviewed all slides to determine the presence and histological composition of Rokitansky protuberances. RESULTS: Thirty-one MCT (77%) had at least one small, regular Rokitansky protuberance presenting at an acute angle with the cyst wall. Ten out of 31 MCT did not display any enhancement on contrast-enhanced MRI related to sebaceous glands, adipose lobules, keratin, and pilosebaceous adnexa at histology. Three different time-intensity curve (TIC), types 1, 2, and 3, were related to presence of smooth muscular cells and fibrous, neuroglial, or thyroid tissue, respectively, found at histology of MCT. Type 3 TIC was also present in one struma ovarii and two immature teratomas. CONCLUSION: TIC types are related to the specific content of the solid tissue of ovarian teratomas but cannot be used to differentiate benign and malignant ovarian teratomas.

[TVT Secur: prospective study and follow up at 1 year about 154 patients]. / TVT Secur : étude prospective et suivi à un an de 154 patientes.

OBJECTIVES: To evaluate the efficacy and complications of this new sub-urethral tape procedure with a follow up of 12 months. MATERIALS AND METHODS: Prospective, multicenter study of 154 patients operated for stress urinary incontinence with the TVT Secur. Patients were operated between 24 July 2006 and 18 December 2007 and were all controlled at 2 months and 118 at 1 year. No associated surgical procedure was performed. RESULTS: One hundred five patients had pure stress incontinence with 12 of them presenting an intrinsic sphincter deficient. Forty-nine had a mixed urinary incontinence with 12 of them having ISD. Preoperatively, 69 patients complained of urgency and 12 of micturation disorder. Anaesthesia was local for 97 patients (63%). Per operative complications were five hemorrhages, one bladder injury, one vaginal wound, 21 patients had post-void residual volume (100 to 200ml) and one groin pain. We noted two exposed tapes, one granuloma, one ITU and seven lateral vaginal bands. Among the patients with urge at baseline, 61.2% were cured at 2 months and 75.5% at 1 year. De novo urge appeared in 12.8% at 2 months and 12.3% at 1 year. De novo micturation disorder was found in 9.5% at 2 months and 3.7% at 1 year. The cured patients at 1 year were 70.3%, improved 11% and fails 18.7%. The cured rate remains same between 2 months and 1 year. The improved patients (24%) at 2 months remain 11% at 1 year. The recurrence rate was 12,8% at 1 year. CONCLUSION: The results are inferior to TVT or TVT-O procedures. We probably must selected the patients for this procedure.

[Should a hysterectomy be carried at the same time as surgery for a prolapse by vaginal route?]. / Faut-il faire une hystérectomie au cours de la chirurgie du prolapsus par voie vaginale?

Classically hysterectomy is done during vaginal surgery for prolapse. But the anatomical and physiopathological facts would be in favour of uterus or cervix preservation. Uterine preservation do not modify the anatomical results of prolapse surgery. If a mesh is used, uterine or cervix preservation reduce the chance for a vaginal erosion. The sexual consequences, aside the narrow vaginal tube, are more psychological than objectively proved. The wish of pregnancy in young patient must leads to conservative procedures with sacrofixation (Richter or Richardson) better than cervix ablation (Manchester procedure). Further uterine or ovarian pathologies are as rare as to justify hysterectomy or annexectomy, the patient must be aware of a regular gynecological exam. Hysterectomy implies more bleeding, more hospital stay, more cost. So hysterectomy during vaginal surgery for prolapse would indicate for major hysterocele or in case of concomitant uterine pathology.

[Extra uterine leiomyomatosis: Review of the literature]. / La léiomyomatose extra-utérine : revue de la littérature.

Extra-uterine leiomyomatosis is a rare pathology defined by the presence of benign smooth uterine muscle cells in unusual localizations, including different entities. It mainly affects premenopausal women with a medical history of uterine myoma with or without surgical treatment. Three main types are discribed: intraveinous leiomyomatosis, benign metastatisizing leiomyoma and leiomyomatosis peritonealis disseminata. The diagnosis may be complex with many differential diagnosis, and relies on histology. The treatment depends on multiple factors such as age, localization, size, symptoms and associated comorbidities. It is based on surgical resection and hormonal privation, surgical (adnexectomy) or medical (hormonotherapy). There is a high risk of recurrence. Some malignant evolutions have been reported, mostly leiomyosarcoma following peritoneal disseminated leiomyomatosis. Long term follow-up of these patients is mandatory. A particular manifestation of extra-uterine leiomyomatosis is the hereditary leiomyomatosis and renal cell carcinoma (HLRCC) syndrome. It is an autosomal dominant disorder which confers an increased risk of cutaneous and uterine leiomyomas and renal cell cancer, with a poor prognosis due to the urologic tumor.

[Treatment of genital prolapse in young women: sacrohysteropexy or vaginal route?]. / Traitement du prolapsus génital chez la femme jeune : voie vaginale ou voie coelioscopique ?

Even if genital prolapse does particularly affect the elder woman, we often have to face a surgical demand with conservation of the uterus from a patient less than 50 years. Before making the decision of treating a non life-threatening symptom by a specific surgical technique, it is important to ask who should be operated and when. Then, the route of the surgery has to be chosen considering that the woman wants to preserve her fertility. In the past decade, some surgical acts, like the sacrohysteropexy, were known as having poorer results if the women got pregnant. Thus, if there was a persistent childbearing desire, more interventions allowing pregnancy (like the Manchester's or the Richardson's procedures) were preferred. Nowadays, the sacrohysteropexy is considered as the gold standard technique, but one question is coming out: could we substitute this traditional surgery by a vaginal repair with meshes? Despite the big diversity of the so-called "sacrohysteropexy", we think that it remains the first choice technique to cure a young woman. Vaginal meshes have too high a rate of morbidity (especially on sexual activity) to be considered as the best surgical treatment. But this question could probably find another answer in the future, when all the studies about the component of the meshes will be finished.

[Surgical therapeutic management for menorrhagia]. / Thérapeutique chirurgicale des pathologies fonctionnelles.

In patients with dysfunctionnal uterine bleeding, endometrial hypertrophy or endometrial hyperplasia without atypie, the curettage is the only surgical conservative treatment which allows preservation of fertility. Its efficacy is limited to about 50%. In women without wish for further childbearing, endometrial destruction techniques are effective with high satisfaction levels. Second generation devices should be preferred because they are as effective as first generation techniques, but are easier and faster to perform with less complications. There is no indication for systematic use of pre operative thinning agents. Endometrial destruction techniques are an alternative to hysterectomy that should be offered to women with heavy menstrual bleeding, because there are shorter operation time and hospital stay, earlier recovery and reduced post operative complications. The possibility of further surgery should however be discussed pre-operatively. In case of hysterectomy, abdominal route is not recommended, and vaginal or laparoscopic routes are preferred.

[TVT Secur: more and more minimally invasive. Preliminary prospective study of 110 cases]. / TVT Secur: de plus en plus minimal invasif. Etude préliminaire prospective sur 110 cas.

OBJECTIVES: To present a new minimal invasive suburethral tape device derivative of the classic TVT, to describe the technique of laying, to evaluate complications and results to short term. MATERIALS AND METHODS: Prospective multicentric study of 110 patients presenting a stress urinary incontinence and benefiting from the laying of TVT Secur without associated operation. The tape is identical to that old-fashioned retropubic and obturator TVT, smaller, laying in "U" or in "hammock" without orifice of exit, to avoid complications due to crossed spaces of the other techniques. The device and the technique of laying are described by authors. The originality of the TVT Secur resides in the mechanism of insertion of the tape to a metallic divice. All patients have been controlled at two months and complications with notably pains (quotation VAS) as well as objective results have been reported. RESULTS: Pure and isolated stress urinary incontinence for 71 patients, mixed incontinence for 39 and sphincter deficient for 23. Preoperative urgency for 49 patients and dysuria for 10 of them. The method "hammock" has been used in 85.5% of cases. The type of anaesthesia has been pure local for 69.1% (0 to 98.8% for the different centers) with an average operative time of 8'30". Under local anaesthesia, the average per operative pain was quoted 2.8/10, and 0.7 at the end of intervention. Peroperative complications have revealed a wound of bladder, a vaginal wound and four bleeding of more than 100ml. In immediate continuations a total retention yielding to 24h and 13 postmicturition residual between 100 and 200ml have been mentioned. At two months, authors have observed the following: de novo urgency in 19.6%, de novo dysuria in 13.2%, one tape exposition, one granuloma, one urinary infection and seven perceptible lateral cords without pain. Thirteen patients have signalled to have had moderated pains on a duration of four to 30 days. Early objective results are globally 70.4% of dry patients (83% for pure isolated SUI, 72.2% for SUI with deficient sphincter, 50% for mixed incontinence). The pure local anaesthesia was recommended by 98% of patients. CONCLUSION: The diminution of complications ahead not to be made to the detriment of results, it is necessary to envisage multicentric studies with standardized modifications. The indications of this new device will have to be defined.

About a case of traumatic separation of the cervix from the uterine corpus, diagnosed in a context of infertility.

This article reports a case of cervico-isthmic disjunction unnoticed during childhood, diagnosed in a context of primary infertility and endometriosis, and surgically treated. It is an uncommon condition. The diagnosis is most often made as part of an assessment of primary amenorrhea in a young woman with a history of severe pelvic trauma. It is suspected after imaging assessment and confirmed intraoperatively. The treatment consists in an anastomosis between the cervix and the uterine body, after individualizing these two structures, around a drain guiding healing. After this surgery, multiple pregnancies have been successfully carried out.

[Tubal choriocarcinoma: a case report and review of the literature]. / Choriocarcinome tubaire: à propos d'un cas et revue de la littérature.

The authors describe a case report of a tubal choriocarcinoma occurring in women of 32 years old, 2 years after her last pregnancy. The patient was treated by laparoscopic salpingectomy and polychemotherapy. Metastatic pulmonary micronodules were diagnosed at thoraco-abdomino-pelvic tomodensitometry. Patient's recovery was complete with an uneventfull follow-up at 3 years. The association of surgical treatment and chemotherapy used under the guidelines of the FIGO score improves patient's outcome.

Outpatient vaginal hysterectomy: Comparison of conventional suture ligature versus electrosurgical bipolar vessel sealing.

OBJECTIVE: The aim of our study was to evaluate the feasibility of vaginal hysterectomy in an ambulatory care system and the best way to perform it between conventional and bipolar vessel sealing system ligatures. PATIENTS AND METHODS: This was a prospective study of 32 patients with vaginal hysterectomy at Lille University Hospital between December 2013 and May 2015. Two surgical techniques were compared: conventional suture ligature (CSL) and electrosurgical bipolar vessel sealing (BVS). Patients stayed in classical hospitalization but were managed how if they were in an ambulatory unit to evaluate their capacity to come back home the same evening of the surgery. The evaluation of same-day discharge was based on Post Anesthetic Discharge Scoring System (PADSS) score?9/10 and Visual Analogic Scale (VAS) score?4/10. Other data collected were: operative time, uterus weight, peroperative bleeding, PADSS score at the 8th postoperative hour, VAS score at the 4th, 6th, 8th, 12th and 24th postoperative hours, the presence of postoperative nausea/vomiting and rehospitalization. RESULTS: In the BVS group, 93.8% of patients validated the combined score (PADSS+VAS) on the evening of the intervention against 50% of patients in the CSL group (P<0.05). Hundred percent of BVS group patients were discharged on the day after surgery against 87.5% in the CSL group. The VAS was significantly lower in the BVS group at the 8th (1.4), 12th (1.2) and 24th (1.3) postoperative hours. Operative time was significantly shorter in the BVS group. We found more events such as nausea/vomiting in the CSL group. CONCLUSION: Vaginal hysterectomy is feasible in an ambulatory care system most of times. By reducing postoperative pain, electrosurgical bipolar vessel sealing would promote outpatient hospitalization.

Efficacy and complications in the surgical treatment of stress urinary incontinence by insertion of a silicone-coated polyester tape (Lift).

OBJECTIVES: To evaluate the efficacy and safety of a surgical treatment for stress urinary incontinence by implantation of a silicone-coated polyester tape (Lift). MATERIALS AND METHODS: This retrospective study included 72 female patients having had a suburethral silicone-coated polyester tape inserted as treatment for stress urinary incontinence, combined or not with pelvic surgery. We recorded the patient's characteristics, the surgical procedure, the short and long-term results and complications. RESULTS: Seventy-two patients were operated, 60 of whom were fully evaluated. The average follow-up was 17 months. On 48 patients (80%) the treatment was successful, 3 (5%) were improved, and 9 (15%) were regarded as a failure. Dysuria occurred in six (10%) patients, five were de novo, and one was persistent. Ten patients (16.6%) presented de novo urge incontinence. The main complication was a higher rate of severe infections, accompanied by defective healing (4, i.e. 6.7%). CONCLUSION: The procedure using a silicone-coated polyester tape seems to be efficient, but insufficiently secure. This higher rejection rate leads us to prefer other synthetic materials proved to be better tolerated.

[Subsequent pregnancy following uterine artery embolization for interstitial pregnancy]. / Conservation de la fertilité après embolisation sélective d'une grossesse cornuale.

Subsequent pregnancy following an interstitial pregnancy is rare. The risk of uterine rupture may be increased in this situation. Uterine selective embolization has been proposed as an effective treatment. However, no further pregnancy has ever been described after this method of management. We are reporting a case of subsequent pregnancy following interstitial pregnancy managed by embolization. The pregnancy was uneventful. A healthy male infant was delivered by C-section. This case supports the hypothesis that selective embolization for interstitial pregnancy may respect fertility. However, as actual risk of uterine rupture in subsequent pregnancies remains unknown, a C-section is advised.

[Management of endometriosis of the urinary tract]. / Prise en charge de l'endométriose urinaire.

Endometriosis of the urinary tract (bladder and/or ureter) is rare and concerns 1-2% of cases of endometriosis. Surgical management is usually mandatory. Rate of peri operative morbidity is low. There is a risk of functional (dysuria, chronic hypogastric pains, imperiosity) and anatomical recurrences (0-15 and 0-10% respectively). Surgical treatment of bladder and/or ureteral endometriosis requires informed consent of patients and multidisciplinary management.

[The HELLP syndrome: diagnosis and therapeutic burden]. / Le HELLP syndrome: diagnostic et prise en charge thérapeutique.

Management of HELLP syndrome is still controversial. In order to improve maternal and foetal prognosis, 2 approaches are usually considered: immediate termination of pregnancy (risk of foetal complications related to prematurity) or conservative treatment (maternal risk of complications related to hematologic disorders). Choice of treatment needs to be taken after evaluation of the maternal and fetal risk/benefit ratio.