Characterization of the adverse effects of nicotine on placental development: in vivo and in vitro studies.

In utero exposure to nicotine is associated with increased risk of numerous adverse fetal and neonatal outcomes, which suggests that it acts directly to affect placental development and the establishment of the fetomaternal circulation (FC). This study used both in vivo [Wistar rats treated with 1 mg/kg nicotine from 2 wk prior to mating until gestational day (GD) 15] and in vitro (RCHO-1 cell line; treated with 10(-9) to 10(-3)M nicotine) models to examine the effects of nicotine on these pathways. At GD 15, control and treated placentas were examined for the impact of nicotine on 1) trophoblast invasion, proliferation, and degree of hypoxia, 2) labyrinth vascularization, 3) expression of key genes of placental development, and 4) expression of placental angiogenic factors. The RCHO-1 cell line was used to determine the direct effects of nicotine on trophoblast differentiation. Our in vivo experiments show that nicotine inhibits trophoblast interstitial invasion, increases placental hypoxia, downregulates labyrinth vascularization as well as key transcription factors Hand1 and GCM1, and decreases local and circulating EG-VEGF, a key placental angiogenic factor. The in vitro experiments confirmed the inhibitory effects of nicotine on the trophoblast migration, invasion, and differentiation processes and demonstrated that those effects are most likely due to a dysregulation in the expression of nicotine receptors and a decrease in MMP9 activity. Taken together, these data suggest that adverse effects of maternal smoking on pregnancy outcome are due in part to direct and endocrine effects of nicotine on the main processes of placental development and establishment of FC.

Endocrine gland-derived endothelial growth factor (EG-VEGF) is a potential novel regulator of human parturition.

EG-VEGF is an angiogenic factor that we identified as a new placental growth factor during human pregnancy. EG-VEGF is also expressed in the mouse fetal membrane (FM) by the end of gestation, suggesting a local role for this protein in the mechanism of parturition. However, injection of EG-VEGF to gravid mice did not induce labor, suggesting a different role for EG-VEGF in parturition. Here, we searched for its role in the FM in relation to human parturition. Human pregnant sera and total FM, chorion, and amnion were collected during the second and third trimesters from preterm no labor, term no labor, and term labor patients. Primary human chorion trophoblast and FM explants cultures were also used. We demonstrate that circulating EG-VEGF increased toward term and significantly decreased at the time of labor. EG-VEGF production was higher in the FM compared to placentas matched for gestational age. Within the FM, the chorion was the main source of EG-VEGF. EG-VEGF receptors, PROKR1 and PROKR2, were differentially expressed within the FM with increased expression toward term and an abrupt decrease with the onset of labor. In chorion trophoblast and FM explants collected from nonlaboring patients, EG-VEGF decreased metalloproteinase-2 and -9 activities and increased PGDH (prostaglandin-metabolizing enzyme) expression. Altogether these data demonstrate that EG-VEGF is a new cytokine that acts locally to ensure FM protection in late pregnancy. Its fine contribution to the initiation of human labor is exhibited by the abrupt decrease in its levels as well as a reduction in its receptors.

EG-VEGF controls placental growth and survival in normal and pathological pregnancies: case of fetal growth restriction (FGR).

Identifiable causes of fetal growth restriction (FGR) account for 30 % of cases, but the remainders are idiopathic and are frequently associated with placental dysfunction. We have shown that the angiogenic factor endocrine gland-derived VEGF (EG-VEGF) and its receptors, prokineticin receptor 1 (PROKR1) and 2, (1) are abundantly expressed in human placenta, (2) are up-regulated by hypoxia, (3) control trophoblast invasion, and that EG-VEGF circulating levels are the highest during the first trimester of pregnancy, the period of important placental growth. These findings suggest that EG-VEGF/PROKR1 and 2 might be involved in normal and FGR placental development. To test this hypothesis, we used placental explants, primary trophoblast cultures, and placental and serum samples collected from FGR and age-matched control women. Our results show that (1) EG-VEGF increases trophoblast proliferation ([(3)H]-thymidine incorporation and Ki67-staining) via the homeobox-gene, HLX (2) the proliferative effect involves PROKR1 but not PROKR2, (3) EG-VEGF does not affect syncytium formation (measurement of syncytin 1 and 2 and ß hCG production) (4) EG-VEGF increases the vascularization of the placental villi and insures their survival, (5) EG-VEGF, PROKR1, and PROKR2 mRNA and protein levels are significantly elevated in FGR placentas, and (6) EG-VEGF circulating levels are significantly higher in FGR patients. Altogether, our results identify EG-VEGF as a new placental growth factor acting during the first trimester of pregnancy, established its mechanism of action, and provide evidence for its deregulation in FGR. We propose that EG-VEGF/PROKR1 and 2 increases occur in FGR as a compensatory mechanism to insure proper pregnancy progress.

Revisiting the role of hCG: new regulation of the angiogenic factor EG-VEGF and its receptors.

Endocrine gland-derived vascular endothelial growth factor (EG-VEGF) is an angiogenic factor reported to be specific for endocrine tissues, including the placenta. Its biological activity is mediated via two G protein-coupled receptors, prokineticin receptor 1 (PROKR1) and prokineticin receptor 2 (PROKR2). We have recently shown that (i) EG-VEGF expression peaks between the 8th and 11th weeks of gestation, (ii) its mRNA and protein levels are up-regulated by hypoxia, (iii) EG-VEGF is a negative regulator of trophoblast invasion and (iv) its circulating levels are increased in preeclampsia (PE), the most threatening pathology of pregnancy. Here, we investigated the regulation of the expression of EG-VEGF and its receptors by hCG, a key pregnancy hormone that is also deregulated in PE. During the first trimester of pregnancy, hCG and EG-VEGF exhibit the same pattern of expression, suggesting that EG-VEGF is potentially regulated by hCG. Both placental explants (PEX) and primary cultures of trophoblasts from the first trimester of pregnancy were used to investigate this hypothesis. Our results show that (i) LHCGR, the hCG receptor, is expressed both in cyto- and syncytiotrophoblasts, (ii) hCG increases EG-VEGF, PROKR1 and PROKR2 mRNA and protein expression in a dose- and time-dependent manner, (iii) hCG increases the release of EG-VEGF from PEX conditioned media, (iv) hCG effects are transcriptional and post-transcriptional and (v) the hCG effects are mediated by cAMP via cAMP response elements present in the EG-VEGF promoter region. Altogether, these results demonstrate a new role for hCG in the regulation of EG-VEGF and its receptors, an emerging regulatory system in placental development.

[Efficacy and safety of oral misoprostol 25µg vs. vaginal dinoprostone in induction of labor at term]. / Efficacité et tolérance du misoprostol oral 25µg vs dinoprostone vaginale dans le déclenchement du travail à terme.

OBJECTIVE: To compare the efficacy and safety of oral misoprostol 25µg compared to vaginal dinoprostone in the induction of labor at term. METHODS: Analytic, retrospective study of patients induced at term by prostaglandins with an unfavorable cervix, over two consecutive periods from 01/01/2019 to 19/02/2020 and from 20/02/2020 to 07/04/2021, within a regional level III university hospital center. We compared the safety and the efficacy between the oral misoprostol Angusta® used since 20/02/2020 and the vaginal dinoprostone previously used in gel or diffuser. The primary endpoint was the rate of vaginal deliveries within 24h. Secondary endpoints were cesarean section rate, indications for cesarean section, uterine contractility abnormalities and neonatal outcomes. RESULTS: Our study found no difference in terms of efficacy with similar rates of vaginal deliveries within 24h (51.88% vs. 51.25%; P=0.87) and caesarean sections (misoprostol group: 19.42% vs. dinoprostone group: 16.62%; P=0.33). However, the tolerance criteria revealed in the dinoprostone group an increase in tachysystole (misoprostol group: 9.28% vs. dinoprostone group: 16.90%; P=0.003) and acidosis (arterial pH<7.10, misoprostol group: 3.83% vs. dinoprostone group: 9.29%; P=0.006). CONCLUSION: No difference in efficacy was found between the two induction techniques. Oral misoprostol 25µg seems to be better tolerated from a maternal and fetal point of view.

[Peripartum cardiomyopathy: A review of the literature]. / Cardiomyopathie du péripartum : une revue de la littérature.

Peripartum cardiomyopathy is a rare and unpredictable pregnancy-related pathology. Idiopathic cardiomyopathy is characterized by a heart failure secondary to left ventricular systolic dysfunction appearing towards the end of pregnancy or in the months following delivery with a non-specific clinic presentation. Through reviewing previous research, our critical literature review wishes to bring a concise and objective summarize for a better understanding of physiopathology, evocative symptoms and knowing of factors influencing prognosis in order to standardize peripartum management. The treatment remains mainly symptomatic but other promising treatments are still in development. In conclusion, early detection and treatment allow a better cardiac function recovery reducing cardiac transplantation.

[Interest of systematic shavings to reduce reoperation in breast-conserving surgery of breast cancer]. / Intérêt des recoupes systématiques pour éviter les réinterventions dans la chirurgie conservatrice du cancer du sein.

OBJECTIVE: The INCa and HAS have developed quality and safety indicators for care specific to breast cancer. Among these, in the conservative surgery of this cancer includes the reoperation rate: target˂10%, alert>20%. The main objective of our study was to evaluate whether the practice of systematic recuts still called "shaving" would meet the objectives of the indicators. METHODS: Observational, retrospective, single-center study over two years in a regional referral center. Two groups of patients were compared: one with "shaving" and one without (no shaving or oriented shaving). RESULTS: In total, 381 patients were operated on, including 48 (12.6%) with shaving and 333 (87.4%) without. Revision rates for damaged margins were 18.75% (9/48) in the shaving group which met the quality criterias vs. 23.7% (79/333) which did not satisfy them; P=0.4. Furthermore, the rate of discovery of occult sites on recuts was higher in the shaving group: 22.9% (11/48) vs. 9.9% (33/333); P=0.02. In the shaving group, 10.4% (5/48) of the patients were resected again for damaged margins for the initial cancer vs. 18.6% (62/333) in the group without shaving; P=0.23. CONCLUSION: Our study confirms the interest of performing "shaving" to meet the requirements of the INCa and HAS quality criteria. The absence of systematic cross-sectioning leads to the risk of not recognizing the existence of occult sites. However, the discovery of occult cancers does not significantly reduce the rate of repeat surgery.

Obstetrical and neonatal outcomes after successful external cephalic version relative to those after spontaneous cephalic presentations.

OBJECTIVE: External cephalic version (ECV) is a procedure during which the fetus is rotated from breech or transversal to cephalic presentation. Our aim was to assess the outcomes of successful ECV in terms of obstetrical and immediate neonatal outcomes relative spontaneous cephalic presentation. METHODS: We performed a retrospective single-center observational study from January 2007 to December 2017. All included participants benefited from trial of labor with delivery of the fetus in cephalic presentation. They were divided into two groups depending on whether an ECV had been successfully performed or cephalic presentation was spontaneous. RESULTS: The cephalic presentation after ECV and spontaneous cephalic groups comprised 55 and 244 patients, respectively. The two groups differed significantly in terms of the proportion of induced labor (20 [36.4 %] and 56 [22.9 %], p = 0.04), use of oxytocin during labor (31 [56.4 %] and 100 [49.9 %], p = 0.04), duration of labor (342 ± 183 min and 279 ± 140 min, p = 0.008), spontaneous delivery (38 [69.1 %] and 199 [81.5 %], p = 0.04), intrapartum cesarean section (9 [16.4 %] and 16 [6.6 %], p = 0.02), occiput-posterior variety at birth (20 [36.4 %] and 56 [22.9 %], p = 0.04), and brace umbilical positioning at birth (3 [5.4 %] and 2 [0.8 %], p = 0.04), respectively. There were no significant intergroup differences in terms of APGAR score, cord arterial pH/lactates, or reanimation/intensive care admission. CONCLUSION: A successful ECV does not seem to guaranty an identical labor progress and obstetrical outcome as spontaneous cephalic presentations. Immediate neonatal state, on the other hand, seems unaffected by a history of ECV.

[Contribution of array CGH in the management of fetal nuchal translucency]. / L'apport de l'ACPA dans la prise en charge des hyperclartés nucales.

OBJECTIVES: Increased nuchal translucency and cystic hygroma have a neonatal prognosis, when the karyotype is normal, which depends on the findings during the medical follow-up. Array comparative genomic hybridization (aCGH) has been systematically included in this follow-up by prenatal diagnosis teams. There are no guidelines and little information on the advantages of carrying out this test systematically. The aim of our study is to evaluate the contribution of the aCGH in the medical follow-up. METHODS: Fifty-one patients were included during 18 months and followed till the end of their pregnancy in prenatal diagnosis centers in Brest and Amiens. Inclusion criterion was a nuchal translucency above 3,5mm on the first trimester ultrasound. A fetal DNA ChromoQuant and aCGH analysis on chorionic villi sampling, and an ultrasound at 18 weeks of gestation were performed during the follow-up. RESULTS: The aCGH was decisive in only 2 cases. The ultrasound at 18 weeks gestation seemed to be more sensible in the detection of an abnormality. When the aCGH relieved an abnormality, the ultrasound permitted already to detect the presence of a deformity. In 10 cases, the aCGH could not be interpreted on the chorionic villi sampling. In 9 cases, an amniocentesis was performed in order to obtain this result. CONCLUSION: Given the results of this study, the aCGH was rarely determinant or decisive on the realization of a therapeutic abortion. These elements make us reflect on the necessity of maintaining this test before 14 weeks of gestation or propose it as a second-line test after the ultrasound shows signs at 18weeks of gestation.

[Suburethral sling procedures for stress urinary incontinence]. / Bandelettes sous-urétrales et incontinence urinaire d'effort.

The rational of the surgical treatment of female stress urinary incontinence has changed over the past few years. The techniques of colposuspension have been replaced by the suburethral slings, retropubic initially with the TVT, recreating a backboard between the urethra and the vaginal anterior wall. Nevertheless with overall cure rates of 69% to 88%, in periods beyond 5 years, the colposuspension still remains the reference (high-grade scientific evidence). Based on observational studies (low quality scientific evidence), with generally a short follow-up, the results of the TVT appear similar. More recently, the suburethral transobturator tape (TOT) was introduced to reduce the complications of the TVT. It is thus difficult to currently have an objective idea of the effectiveness of the TOT compared to the TVT, even if the first impressions, with respect to the TOT, are rather favourable. Furthermore the TOT technique itself and the biomaterials used, have continued to evolve. In fact, if the complications of these two kinds of suburethral slings are different: bladder perforation for the TVT, prosthetic erosion for the TOT, in contrast, in the future, their indications could be different. Therefore the TVT appears more effective in presence of intrinsic sphincter deficiency with urethral hypermobility.

Management of breech and twin labor during registrarship: A two-year prospective, observational study.

INTRODUCTION: Breech presentation and twin pregnancy are regarded as stressful situations for medical staff. This stress is often associated with an increased likelihood of intervention during labor - especially when the on-shift obstetrician lacks experience. MATERIAL AND METHODS: We performed a 2-year prospective, observational study of cesarean section (CSDs) and assisted vaginal (AVDs) deliveries in a tertiary maternity unit for attempted vaginal deliveries of breech presentations and twin pregnancies. The obstetric management decisions taken by a group of four registrars were compared with those taken by a group of 11 experienced obstetricians. Changes over time in practice were also monitored. RESULTS: Registrars managed 66 and 52 breech presentations and twin pregnancies respectively (30 and 27 in the experienced group). Groups' neonatal outcomes were similar. There were no intergroup differences in proportions of CSDs for either breech presentations (25 [37.5%] vs. 15 [50%] in the registrar and experienced groups, respectively; P=0.26) or twin pregnancies (11 [21.1%] vs. 6 [22.2%], respectively; P=0.91) or in proportion of AVDs for twin pregnancies (41 [78.8%] vs. 21 [77.8%], respectively; P=0.91). Proportions of CSDs for breech presentation and AVDs for twin pregnancies did not change over time in either group. However, proportion of CSDs for twin pregnancies increased over time in the registrar group (P=0.004). DISCUSSION: Well-trained registrars appeared to have acquired the skills required to safely manage an obstetric ward; this pleads to maintain clinical practice during residency to preserve low CSD and AVD rates.

[Recurrence of stress urinary incontinence after tension-free vaginal tape and childbirth]. / Récidive d'incontinence urinaire d'effort après bandelette sous-urétrale et accouchement.

Retropubic or transobturator insertions of suburethral tapes are the new gold standard surgical procedure for female stress urinary incontinence. Some women of childbearing age can be treated by a suburethral tape. There are at present no sufficient data to recommend a mode of delivery rather than another in these patients. We report the case of a young woman, cured of her urinary incontinence by a suburethral tape. A recurrence occurred after childbirth by vaginal route. A second suburethral tape made it possible to restore the continence. The patient became again pregnant. A preventive caesarean section was quite as ineffective to preserve the continence.

[Prosthetic repair of genito-urinary prolapses by the transobturateur infracoccygeal hammock technique: medium-term results]. / Correction prothétique des prolapsus génito-urinaires selon la technique du hamac transobturateur infracoccygien: résultats à moyen terme.

OBJECTIVES: The aim of this study was to evaluate the anatomical and functional medium-term efficacy and possible complications of vaginal prosthetic surgery with transobturator and infracoccygeal support to treat genital urinary prolapse. MATERIAL AND METHOD: A prospective and monocentre study was conducted, from February 2002 till February 2005. All the patients with or without stress urinary incontinence (SUI), who presented either a recurrent prolapse, either a voluminous genital prolapse of stage 3 or 4 notably a dominant cystocele, either a post-hysterectomy vaginal vault prolapse or even a prolapse of lesser importance but in a context of obesity, were operated according to the transobturator infracoccygeal sling technique. RESULTS: One hundred and three patients with a mean age of 65+/-11 years (41-84) were enrolled, with once on two SUI. Thirty percent of the patients had recurrent prolapse and 44% post-hysterectomy vaginal vault prolapse. With a mean follow-up of 32+/-13 months (12-53), the success rate of the technique was estimated to be 97% anatomically (three failures) and 89% in terms of urinary symptoms (69% of patients were cured, 20% were improved and 11% failed). Quality of life of the patients was sharply improved and their degree of satisfaction was high. Sexuality of the population which was limited here (44% of active patients) did not seem very modified by surgery. Complications were represented by a case of urinary retention observed with a secondarily pelvic haematoma, a low rectal injury without consequence, three blood transfusions. Three patients developed de novo overactive bladder. The prostheses exposure rate was 16%, once requiring on two one re-intervention. Prostheses were perceived during the postoperative evaluation by the examiner for 43% of the patients. But examination was painful only in 9,7% of the cases. CONCLUSION: Combined treatment of vaginal prolapse and associated urinary incontinence is possible by the use of a single transvaginal prosthesis. The medium-term anatomical and functional results are very good. The results on continence are good and a subsequent specific procedure is always possible in the case of failure or insufficient improvement. The prostheses exposure rate is similar to that observed with synthetic transvaginal prostheses. The exact tolerance of vaginal prosthetic repair of the prolapse of young women being this day an unknown, we remain careful on the extension of the indications of this technique in this category of population.

[Management of pregnancies after adjustable gastric banding]. / Prise en charge des grossesses après anneau gastrique ajustable.

OBJECTIVES: To report our experience of the association adjustable gastric banding and pregnancy. To define a management for a such association. MATERIALS AND METHODS: Retrospective and descriptive study on two centers over a 3-year follow-up of pregnancies begun with a Lap-Band gastric banding placed by laparoscopic way. RESULTS: Twenty-one pregnancies, 22 newborns resulting from 18 women were identified. Eleven patients were hospitalized. The motive of the hospitalization was severe epigastralgia for four patients requiring three deflations for mechanical complication. No case of preeclampsia was identified. Seven bands were deflated. In the group of the deflated bands, the mean maternal weight gain was 19 vs 10 kg (P=0.008), the mean birth weight was 3700 vs 3204 g (P=0.09) with a rate of fetal macrosomia increased, 50 vs 29% (P=0.038). The difference between the rates of cesarean delivery was not significant (NS) between the two groups. The childbirth term was appreciably the same, 39.4 vs 38.6 weeks of gestation (NS). The only case of gestational diabetes was found in the deflated band group. Three intrauterine growth restrictions whose one fetal death occurred in the not deflated band group. CONCLUSION: Results obtained were comparable to those of the literature. This series confirms that adjustable gastric banding limits the usual complications of the morbid obesity during pregnancy. It is generally well tolerated and must not be thus deflated by principle, but only on symptoms. That will be a total dysphagia, severe epigastric pains, vomiting after the first trimester of pregnancy or an intrauterine growth restriction.

The impact of using electrical impedance spectroscopy (ZedScan) on the performance of colposcopy in diagnosing high grade squamous lesions of the cervix.

OBJECTIVES: To determine the efficacy of colposcopy plus ZedScan, which measures changes in tissue electrical impedance, for detecting intraepithelial high-grade lesions compared to colposcopy alone. METHODS: A prospective study conducted at a university hospital colposcopy clinic. Patients referred following abnormal cervical cytology or colposcopic follow up were examined by colposcopy plus ZedScan to assess the cervix. The results of ZedScan directed and colposcopically directed biopsies were compared. RESULTS: Ninety-one patients were included in this study. The median age was 33 years. Eighty (88%) were referred with abnormal cytology; LSIL 45%, ASCUS 27%, ACS-H 8%, HSIL 7%, AGC 1% and 12% follow-up postconisation or colposcopic follow up. Colposcopy alone detected 18 high-grade lesions with 64 women undergoing biopsy with a total of 115 biopsies being taken with a sensitivity of 60% and NPV estimated at 81.7%. ZedScan with colposcopy increased the detection of high-grade lesions by 47.3%, identifying 27 high-grade lesions and one case of invasive cancer. Sensitivity was 93.1% and NPV estimated at 91.3%. A combination of normal colposcopy practice and ZedScan had a sensitivity and NPV of 100%. CONCLUSION: ZedScan used in conjunction with the colposcopy improves sensitivity in detecting high-grade lesions at the expense of a moderate increase in the number of biopsies.

Impact of anaesthesia mode on evaluation of LEEP specimen dimensions.

OBJECTIVES: To study the influence of anaesthesia (local by cervical block vs. general or spinal anaesthesia) on height and volume of resection specimens in case of conization treatment for cervical intraepithelial neoplasia (CIN). METHODS: Prospective observational study of all patients who underwent a first treatment by loop electrosurgical excision procedure (LEEP) for CIN. Height of fresh resection specimens was first measured by the operator and then by the pathologist after formaldehyde fixation. Volume of fresh specimens was measured in a measuring cylinder by fluid displacement. RESULTS: One hundred patients were included and 35% of LEEP were performed under local anaesthesia. There was a significant difference in height of specimens depending on anaesthesia mode: after fixation, the average height was 11.2mm in the general or spinal anaesthesia group vs. 8.8mm in the local anaesthesia group (P=0.002). There was also a difference in terms of volume depending on anaesthesia mode: 1.6mL in local anaesthesia group vs. 2.3mm in general and spinal anaesthesia group (P=0.01). CONCLUSIONS: Anaesthesia mode has an impact on height and volume of LEEP specimens. In our experience, local anaesthesia could reduce LEEP specimen height.

Preservation of Malassezia pachydermatis using skimmed milk as cryoprotective agent.

This study evaluated the effect of skimmed milk as a cryoprotectant for the maintenance and long-term preservation of 70 Malassezia pachydermatis strains. An initial suspension of each strain was prepared in sterile distilled water with skimmed milk. The most effective method was cryopreservation that ensured 100% viability for 2years.

[Ideas to make the TVT progress]. / Idées pour faire progresser le TVT.

Because of the bladder injuries risk and subsequent increase of the intervention time due to the bladder integrity checking, many surgeons have abandoned TVT. Based on a demonstrative clinical case, we report a simple, fast and effective method meant to minimize the risk of bladder injuries and to wonder about the mandatory bladder checking by cystoscopy during the TVT sling installation. An infiltration of 1% Xylocaïne half diluted is carried out in the area laterally to the urethra and the bladder, through vaginal and pubic ways. A 360 ml blue of methylene solution bladder filling may show quickly and safely a bladder injuries occurrence, either a true transfixion or an under mucous route. Using this procedure, TVT technique could be no more dangerous or longer than the TOT technique.

[Place of surgery in the management of gestational trophoblastic tumors]. / Place de la chirurgie dans la prise en charge des tumeurs trophoblastiques gestationnelles.

Gestational trophoblastic tumors are authentic malignant tumors of the conception. They are mostly chemosensitive. For young women, the place of the surgery seems now restricted and more and more codified. Hysterectomy keeps a certain interest for women who do not wish to preserve their fertility. Hysterectomy limits then the complications of chemotherapy. It optimizes the chances of recovery without recurrence. If chemotherapy must nevertheless be carried out, hysterectomy decreases the necessary number of cures to obtain complete remission of the disease. Surgery is also indispensable to chemoresistant tumors. It allows exeresis of localized residual sites or isolated metastases. Other indications for surgery include uncontrollable vaginal or intra-abdominal bleedings and placental site trophoblastic tumors.

[Three-year outcomes of the tension-free vaginal tape procedure for treatment of female stress urinary incontinence with low urethral closure pressure]. / Résultats à trois ans de la prise en charge d'une incontinence urinaire d'effort avec pression de clôture urétrale basse par fronde sous-urétrale TVT.

OBJECTIVE: The aim of this study was to assess, with long-term outcome, the effectiveness of TVT for stress urinary incontinence (SUI) with low maximum urethral closure pressure (MUCP) and to identify predicting factors for failure in this case. PATIENTS AND METHODS: This is a bicentric retrospective study including women who underwent a TVT procedure for grade 3-SUI according to the Ingelman-Sundberg's scale. All patients had a low MCUP defined by PCUM < 30 or by the formula 110-the age+/-20% cmH2O. Urethral hypermobility was defined on physical examination and urodynamic investigations. TVT was the only operation performed. Patients were assessed at three months then at longer term with an average follow-up of three years and ever less than one year. RESULTS: A total of 60 women 30 to 78 years old (mean age 55) were so operated. More than third of them (38%) had already been operated for incontinence. Thirty-eight percent had SUI without urethral hypermobility. Thirty percent presented bladder overactivity. The short-term evaluation found that, out of 58 patients, 70,6% cured, 10,3% improved and 18,9% classified as failure. The long-term evaluation, concerning 44 patients, found that 57% remained cured, 16% improved and 27% were classified as failure. Bladder overactivity was cured or improved in more than half of the cases (60%). Ten percent of de novo urgencies were noted, all of which persisted later on. For all that, as much as two thirds of these patients were satisfied with the TVT. Mean age of patients classified as failure, was higher (65 years). Previous SUI surgery did not modify the results. When the MUCP was < 20 cmH2O, success was present only one time out of two. The absence of urethral hypermobility decreased to a significant degree the probability of cure (38 vs. 82,6%, P < 0.01), and more still when bladder overactivity was associated (16,6 vs. 66,6%, P < 0.01). Postoperative voiding troubles constituted a pejorative factor for success of surgery. DISCUSSION AND CONCLUSION: Even if results of TVT with low MCUP are worse, they do not remain less appreciable. When we confront the benefits awaited with this technique compared to the usually described complications, TVT must represent the first treatment of this indication.