RESUMO
PURPOSE: Complete mesocolic excision improves lymphadenectomy for right hemicolectomy and respects the embryological planes. However, its effect on cancer-free and overall survival is questioned. Therefore, we aimed to determine the potential benefits of the technique by performing a systematic review of the literature and meta-analysis of the available evidence. METHODS: Web of Science, PubMed/Medline, and Embase were searched on February 22, 2023. Original studies on short- and long-term oncological outcomes of adult patients undergoing right hemicolectomy with complete mesocolic excision as a treatment for primary colon cancer were considered for inclusion. Outcomes were extracted and pooled using a model with random effects. RESULTS: A total of 586 publications were identified through database searching, and 18 from citation searching. Exclusion of 552 articles left 24 articles for inclusion. Meta-analysis showed that complete mesocolic excision increased the lymph node harvest (5 studies, 1479 patients, MD 9.62, 95% CI 5.83-13.41, p > 0.0001, I2 84%), 5-year overall survival (5 studies, 2381 patients, OR 1.88, 95% CI 1.14-3.09, p = 0.01, I2 66%), 5-year disease-free survival (4 studies, 1376 patients, OR 2.21, 95% CI 1.51-3.23, p < 0.0001, I2 0%) and decreased the incidence of local recurrence (4 studies, 818 patients, OR 0.27, 95% CI 0.09-0.79, p = 0.02, I2 0%) when compared to standard right hemicolectomy. Perioperative morbidity was similar between the techniques (8 studies, 3899 patients, OR 1.04, 95% CI 0.89-1.22, p = 0.97, I2 0%). CONCLUSION: Meta-analysis of observational and randomised studies showed that right hemicolectomy with complete mesocolic excision for primary right colon cancer improves oncologic results without increasing morbidity/mortality. These results need to be confirmed by high-quality evidence and randomised trials in selected patients to assess who may benefit from the procedure.
Assuntos
Neoplasias do Colo , Laparoscopia , Mesocolo , Adulto , Humanos , Neoplasias do Colo/patologia , Excisão de Linfonodo/métodos , Linfonodos/patologia , Intervalo Livre de Doença , Colectomia/métodos , Mesocolo/cirurgia , Mesocolo/patologia , Laparoscopia/métodos , Resultado do TratamentoRESUMO
INTRODUCTION: Ventral mesh rectopexy (VMR) is the gold standard for rectal prolapse surgery, but the type of mesh reinforcement is still a matter of debate. The aim of this study was to assess the anatomic and functional results of a single center cohort of patients receiving ventral rectopexy with biological mesh compared to a reference group who had implantation of synthetic mesh. We also assessed the predictive factors for recurrence. PATIENTS AND METHODS: Seventy patients (2015-2021) were included in the biological mesh group and were compared to a reference group of 345 patients operated on with a synthetic mesh (2004-2017). RESULTS: In the biological mesh group, the mean age of patients was 65 years (53-72). The main disorders of the posterior pelvic floor were rectal prolapse (30 cases) or rectocele (37 cases). Two patients had solitary rectal ulcer syndrome and one had internal prolapse. VMR was performed by a laparoscopic approach with robotic assistance in 93%. After a median follow-up of 12 (4.5-23) months, the anatomic recurrence rate was 10%. The median satisfaction score assessed in a telephone interview by a semi-quantitative scale from 0 to 10 was 7. Compared to the synthetic group, neither the morbidity rate (Dindo>2) (0.6% synthetic versus 1.4% biological mesh), nor the recurrence rate (12% synthetic versus 10% biological (ns) with an average interval of 13.5 versus 14 months, respectively) were statistically significantly different. CONCLUSION: VMR with biological mesh represents an alternative to synthetic mesh. Despite its resorbable nature, biological mesh does not seem to increase the risk of recurrence and offers satisfying functional results after a medium term follow-up.
Assuntos
Laparoscopia , Distúrbios do Assoalho Pélvico , Prolapso Retal , Feminino , Humanos , Pessoa de Meia-Idade , Idoso , Prolapso Retal/cirurgia , Distúrbios do Assoalho Pélvico/cirurgia , Telas Cirúrgicas , Laparoscopia/métodos , Resultado do Tratamento , Reto/cirurgiaRESUMO
Twenty-seven experts under the aegis of the French Association of Surgery (AFC) offer this reference system with formalized recommendations concerning the performance of right colectomy by robotic approach (RRC). For RRC, experts suggest patient installation in the so-called "classic" or "suprapubic" setup. For patients undergoing right colectomy for a benign pathology or cancer, RRC provides no significant benefit in terms of intra-operative blood loss, intra-operative complications or conversion rate to laparotomy compared to laparoscopy. At the same time, RRC is associated with significantly longer operating times. Data from the literature are insufficient to define whether the robot facilitates the performance of an intra-abdominal anastomosis, but the robotic approach is more frequently associated with an intra-abdominal anastomosis than the laparoscopic approach. Experts also suggest that RRC offers a benefit in terms of post-operative morbidity compared to right colectomy by laparotomy. No benefit is retained in terms of mortality, duration of hospital stay, histological results, overall survival or disease-free survival in RRC performed for cancer. In addition, RRC should not be performed based on the cost/benefit ratio, since RRC is associated with significantly higher costs than laparoscopy and laparotomy. Future research in the field of RRC should consider the evaluation of patient-targeted parameters such as pain or quality of life and the technical advantages of the robot for complex procedural steps, as well as surgical and oncological results.
Assuntos
Neoplasias do Colo , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Colectomia/métodos , Neoplasias do Colo/cirurgia , Humanos , Laparoscopia/métodos , Tempo de Internação , Duração da Cirurgia , Qualidade de Vida , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/métodos , Resultado do TratamentoRESUMO
INTRODUCTION: Sacral neuromodulation (SNM) aims to improve anorectal function in patients with disorders of anal continence and rectal emptying. The mechanism of action of SNM is not well known, and its indications are still under evaluation. We report the functional results and morbidity of a prospective cohort treated between 2002 and 2019. RESULTS: A total of 284 patients (of 423 tested) had implantation of a SNM. Five patients (1.8%) were lost to follow-up. Among those who had implantation, the indications for SNM were anal incontinence (n=376), refractory constipation (n=17), anterior resection syndrome (n=13), solitary rectal ulcer syndrome (n=7), and chronic inflammatory bowel disease (IBD) (n=10). The morbidity rate was 2.7% (Dindo-Clavien>2), 33 patients (11%) required explantation for infection (n=5), pain (n=2), inefficacy (n=24) or other reasons (rectal cancer) (n=3). It was necessary to change the stimulator in 68 patients (24%) during the follow-up period. Regarding the group of patients with anal incontinence, functional results showed improvement of the incontinence score in 40% and of quality of life in 25% after a mean follow-up of 55months. CONCLUSION: SNM constitutes a mini-invasive treatment associated with low morbidity. Its' efficacy in anal incontinence makes it a priority approach. Other indications are still under evaluation; while results are promising, they are highly variable.
Assuntos
Terapia por Estimulação Elétrica , Incontinência Fecal , Doenças Retais , Humanos , Estudos Prospectivos , Qualidade de Vida , Resultado do Tratamento , Incontinência Fecal/terapia , Doenças Retais/terapia , SacroAssuntos
Fístula Anastomótica/diagnóstico , Neoplasias Retais/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Fístula Anastomótica/sangue , Fístula Anastomótica/terapia , Biomarcadores/sangue , Proteína C-Reativa/análise , Intervalo Livre de Doença , Diagnóstico Precoce , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Retais/mortalidade , Reto/cirurgia , Análise de SobrevidaRESUMO
Obstetrical anal sphincter injuries (OASI), formerly referred to as "complete" or "incomplete" perineal tears, are a frequent complication of childbirth. They can lead to intestinal consequences (anal incontinence, ano-genital fistula) or sexual consequences (dyspareunia, genital pain). The complexity of management of OASI lies in the multi-factorial nature of these consequences but also in the frequently lengthy interval before their appearance, often long after childbirth. Indeed, while 2.4% of women in childbirth develop OASI, up to 61% of them will present with anal incontinence15 to 25 years after childbirth. Immediate or delayed repair of the sphincter and perineum within a few hours of injury is therefore the rule, but there is no consensus on longer-term management. The patient must be educated on preventive actions (avoidance of pushing or straining, regularization of stool transit, muscle strengthening, etc.). Early detection of anal incontinence leads to prompt management, which is more effective. This review aims to synthesize the information necessary to provide clear and up-to-date patient information on OASI (risk factors and prevalence), the management of OASI, and the management of eventual complications in the setting of dedicated specialty consultations. Dedicated "post-OASI" consultations by a specialist in ano-perineal pathologies could therefore become a first step in the development of care for women, particularly by removing the "shameful" nature of the symptoms.
Assuntos
Incontinência Fecal , Lacerações , Canal Anal , Parto Obstétrico , Incontinência Fecal/epidemiologia , Incontinência Fecal/etiologia , Incontinência Fecal/terapia , Feminino , Humanos , Lacerações/etiologia , Lacerações/terapia , Períneo/lesões , GravidezRESUMO
Rectocele is defined as a hernia of the rectum with protrusion of the anterior rectal wall through the posterior wall of the vagina. This condition occurs commonly, with an estimated prevalence of 30-50% of women over age 50. The symptomatology that leads to consultation is variable but consists predominantly of anorectal and/or gynecological complaints such as dyschezia, requiring digital disimpaction maneuvers, pelvic heaviness, anal incontinence, or dyspareunia. Rectocele may be isolated or associated with other disorders of pelvic stasis involving cystocele and uterine prolapse. Complementary exams (dynamic imaging and anorectal manometry) are essential before deciding on the surgical management of this condition. The indications for surgical management of rectocele are based on the intensity of symptoms and the resulting deterioration in quality of life, and surgery should be discussed after failure of medical treatment. Different approaches are possible, although there is currently no real consensus in the literature. The initial approach depends on the type of rectocele: if it involves the low or mid rectum or is isolated, an approach from below (transanal, transperineal, or transvaginal approach) can be proposed, while, in the presence of a high rectocele and/or associated with various disorders of pelvic stasis, transabdominal rectopexy is more suitable.
Assuntos
Qualidade de Vida , Retocele , Constipação Intestinal , Feminino , Humanos , Pessoa de Meia-Idade , Retocele/cirurgia , Reto , VaginaRESUMO
BACKGROUND AND AIMS: Few prospective data exist on outcomes of surgery in Crohn's disease [CD] complicated by an intra-abdominal abscess after resolution of this abscess by antibiotics optionally combined with drainage. METHODS: From 2013 to 2015, all patients undergoing elective surgery for CD after successful non-operative management of an intra-abdominal abscess [Abscess-CD group] were selected from a nationwide multicentre prospective cohort. Resolution of the abscess had to be computed tomography/magnetic resonance-proven prior to surgery. Abscess-CD group patients were 1:1 matched to uncomplicated CD [Non-Penetrating-CD group] using a propensity score. Postoperative results and long-term outcomes were compared between the two groups. RESULTS: Among 592 patients included in the registry, 63 [11%] fulfilled the inclusion criteria. The abscess measured 37â ±â 20 mm and was primarily managed with antibiotics combined with drainage in 14 patients and nutritional support in 45 patients. At surgery, a residual fluid collection was found in 16 patients [25%]. Systemic steroids within 3 months before surgery [pâ =â 0.013] and the absence of preoperative enteral support [pâ =â 0.001] were identified as the two significant risk factors for the persistence of a fluid collection. After propensity score matching, there was no significant difference between the Abscess-CD and Non-Penetrating-CD groups in the rates of primary anastomosis [84% vs 90% respectively, pâ =â 0.283], overall [28% vs 15% respectively, pâ =â 0.077] and severe postoperative morbidity [7% vs 7% respectively, pâ =â 1.000]. One-year recurrence rates for endoscopic recurrence were 41% in the Abscess-CD and 51% in the Non-Penetrating-CD group [pâ =â 0.159]. CONCLUSIONS: Surgery after successful non-operative management of intra-abdominal abscess complicating CD provides good early and long-term outcomes.
Assuntos
Abscesso Abdominal/terapia , Doença de Crohn/cirurgia , Abscesso Abdominal/etiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Estudos de Coortes , Doença de Crohn/complicações , Drenagem , Procedimentos Cirúrgicos Eletivos , Feminino , França , Humanos , Masculino , Análise por Pareamento , Pessoa de Meia-Idade , Apoio Nutricional , Recidiva , Adulto JovemRESUMO
INTRODUCTION: Pelvic and perineal pain after genital prolapse surgery is a serious and frequent post-operative complication which diagnosis and therapeutic management can be complex. MATERIALS ET METHODS: A literature review was carried out on the Pubmed database using the following words and MeSH : genital prolapse, pain, dyspareunia, genital prolapse and pain, genital prolapse and dyspareunia, genital prolapse and surgery, pain and surgery. RESULTS: Among the 133 articles found, 74 were selected. Post-operative chronic pelvic pain persisting more than 3 months after surgery according to the International Association for the Study of Pain. It can be nociceptive, neuropathic or dysfunctional. Its diagnosis is mainly clinical. Its incidence is estimated between 1% and 50% and the risk factors are young age, the presence of comorbidities, history of prolapse surgery, severe prolapse, preoperative pain, invasive surgical approach, simultaneous placement of several meshes, less operator experience, increased operative time and early post-operative pain. The vaginal approach can cause a change in compliance and vaginal length as well as injury to the pudendal, sciatic and obturator nerves and in some cases lead to myofascial pelvic pain syndrome, whereas the laparoscopic approach can lead to parietal nerve damage. Therapeutic management is multidisciplinary and complex. CONCLUSION: Pelvic pain after genital prolapse surgery is still obscure to this day.
Assuntos
Prolapso de Órgão Pélvico/cirurgia , Dor Pélvica/etiologia , Períneo , Complicações Pós-Operatórias/etiologia , Humanos , ReoperaçãoRESUMO
AIM OF THE STUDY: Right colonic Diverticulitis (RD) is rare in Europe; few studies have focused on it and its management is not standardised. The aim of this study was to analyse the clinical presentation (complicated, uncomplicated), acute phase management and long-term outcome of RD in western countries. PATIENTS AND METHODS: From 2003 to 2017, 93 consecutive patients who presented with RD were retrospectively included at 11 French Hospital Centres. RESULTS: The study population consisted of two groups: Uncomplicated Right Diverticulitis (URD) group (63.5%, (n=59)) and Complicated Right Diverticulitis (CRD) group (36.5%, [n=34]). 84.7% (n=50/59) of URD were treated conservatively. 41.2% (n=14/34) of patients with CRD had emergency surgery (mostly laparotomy) for Hinchey III peritonitis, clinical intolerance or hemodynamic instability. Altogether 5.2% (n=2/34) patients with CRD had surgery after a cooling off period (initially abscess). The overall rate of severe postoperative complications was low (8%). Recurrence rate was low and comparable in both groups: 6.8% (n=4/59) for URD and 8.8% (n=3/34) for CRD, all recurrences occurred in the same locations with an uncomplicated form, 42.9% (n=3/7) of them had elective laparoscopic surgery and the rest were conservatively treated. Median follow up was 33.2 months. CONCLUSION: Conservative treatment can be proposed safely and efficiently for URD and for selected patients with CRD. Surgery should be reserved for unstable patients or patients with severe forms of complicated diverticulitis in emergency.
Assuntos
Tratamento Conservador , Doença Diverticular do Colo/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Colo Ascendente , Tratamento Conservador/estatística & dados numéricos , Doença Diverticular do Colo/complicações , Doença Diverticular do Colo/diagnóstico , Doença Diverticular do Colo/cirurgia , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Tratamento de Emergência/efeitos adversos , Tratamento de Emergência/métodos , Europa (Continente) , Feminino , França , Humanos , Laparoscopia , Laparotomia/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Recidiva , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
PURPOSE: To assess the impact of a simple flap closing procedure by Karydakis flap (KF) after pilonidal sinus excision on the costs and healing time as compared to routine lay-open technique. METHOD: Out of 44 consecutive patients operated on for pilonidal excision (November 2013-March 2015), 17 had a Karydakis flap and 27 a lay-open procedure. For each patient, the length of stay, the operating time (OT), the time needed for complete healing and postoperative care resources were recorded. The global costs included OT, nursing care quantity, and modalities until complete scar healing. RESULTS: One reoperation in the lay-open group was necessary during the follow-up (8±5months). No recurrence occurred. Postoperative morbidity was similar in both groups. Results showed that KF global cost was inferior as compared to lay-open technique (941±178 vs. 1601±399; P=0.0001), KF healed faster (32±17 vs. 59±22days; P=0.0001), whereas OT was longer in KF group (16±7 vs. 25±4min; P=0.001). CONCLUSION: KF allows a faster healing time and a 41% lower cost than lay-open technique. Preferential use of KF rather than lay-open procedure could allow a significant health cost saving.
Assuntos
Redução de Custos , Procedimentos Cirúrgicos Dermatológicos/métodos , Seio Pilonidal/cirurgia , Retalhos Cirúrgicos/economia , Retalhos Cirúrgicos/transplante , Cicatrização/fisiologia , Distribuição de Qui-Quadrado , Estudos de Coortes , Análise Custo-Benefício , Procedimentos Cirúrgicos Dermatológicos/economia , Feminino , França , Hospitais Universitários , Humanos , Masculino , Análise Multivariada , Assistência Perioperatória/economia , Estudos Retrospectivos , Medição de Risco , Resultado do Tratamento , Técnicas de Fechamento de FerimentosAssuntos
Neurilemoma/diagnóstico por imagem , Neurilemoma/cirurgia , Neoplasias Retroperitoneais/diagnóstico por imagem , Neoplasias Retroperitoneais/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Cirurgia Vídeoassistida/métodos , Adulto , Perda Sanguínea Cirúrgica/fisiopatologia , Feminino , Seguimentos , Humanos , Imageamento por Ressonância Magnética/métodos , Duração da Cirurgia , Tomografia Computadorizada por Raios X/métodos , Resultado do TratamentoAssuntos
Cirurgia Colorretal , Ginecologia , Comunicação Interdisciplinar , Obstetrícia , Prolapso de Órgão Pélvico/cirurgia , Procedimentos Cirúrgicos Operatórios/normas , Urologia , Adulto , Cirurgia Colorretal/métodos , Cirurgia Colorretal/organização & administração , Cirurgia Colorretal/normas , Feminino , França , Ginecologia/métodos , Ginecologia/organização & administração , Ginecologia/normas , Humanos , Obstetrícia/métodos , Obstetrícia/organização & administração , Obstetrícia/normas , Prolapso de Órgão Pélvico/patologia , Pelve/cirurgia , Períneo/cirurgia , Padrões de Prática Médica/normas , Sociedades Médicas/normas , Procedimentos Cirúrgicos Operatórios/métodos , Urodinâmica , Urologia/métodos , Urologia/organização & administração , Urologia/normasRESUMO
AIM: Poor functional results, such as faecal incontinence (FI), low anterior resection syndrome (LARS) or high stool frequency, can occur after colorectal resections, including proctocolectomy with ileal pouch-anal anastomosis (IPAA), rectal resection and left hemicolectomy. Management of such patients is problematic, and some case reports have demonstrated the effectiveness of sacral nerve stimulation (SNS) in these situations. Our aim was to analyse the effectiveness of SNS on poor functional results and on quality of life in patients after treatment with different types of colorectal resection. METHOD: At five university hospitals from 2006 to 2014, patients with poor functional results after rectal resection, IPAA or left hemicolectomy underwent a staged SNS implant procedure. Failure was defined by the absence or insufficient improvement (< 50%) of FI episodes. RESULTS: SNS for bowel dysfunction was performed in 16 patients after rectal resection with coloanal anastomosis, left hemicolectomy with colorectal anastomosis or IPAA. Two (13%) cases of primary failure were observed after the percutaneous stimulation test. Median frequency of stool, FI episodes and urgency were significantly improved in 14 patients. Wexner and LARS scores were also significantly improved for 14 patients. When we compared results according to the type of colorectal surgery (IPAA, rectal resection or left hemicolectomy), median frequencies of stool and urgency, Wexner and LARS scores were still significantly improved. Overall success rate was 75% (12/16 patients) in intention-to-treat analysis and 86% (12/14 patients with permanent electrode) in per-protocol analysis. CONCLUSION: SNS seems to improve bowel dysfunction following rectal resection, left hemicolectomy or IPAA.
Assuntos
Colectomia/efeitos adversos , Doenças Funcionais do Colo/terapia , Plexo Lombossacral , Complicações Pós-Operatórias , Estimulação Elétrica Nervosa Transcutânea/métodos , Adulto , Idoso , Anastomose Cirúrgica/efeitos adversos , Colo/cirurgia , Doenças Funcionais do Colo/etiologia , Feminino , Humanos , Análise de Intenção de Tratamento , Masculino , Pessoa de Meia-Idade , Reto/cirurgia , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE: Develop guidelines for surgery for primary pelvic organ prolapse (POP). METHODS: Literature review, establishment of levels of evidence, external review, and grading of recommendations by 5 French academic societies: Association Française d'Urologie, Collège National des Gynécologues et Obstétriciens Français, Société Interdisciplinaire d'Urodynamique et de Pelvi-Périnéologie, Société Nationale Française de Colo-proctologie, and Société de Chirurgie Gynécologique et Pelvienne. RESULTS: It is useful to evaluate symptoms, their impact, women's expectations, and to describe the prolapse prior to surgery (grade C). In the absence of any spontaneous or occult urinary sign, there is no reason to perform urodynamics (grade C). When a sacrocolpopexy is indicated, laparoscopy is recommended (grade B). A bowel preparation before vaginal (grade B) or abdominal surgery (grade C) is not recommended. There is no argument to systematically use a rectovaginal mesh to prevent rectocele (grade C). The use of a vesicovaginal mesh by vaginal route should be discussed taking into account an uncertain long-term risk-benefit ratio (grade B). Levator myorrhaphy is not recommended as a first-line rectocele treatment (grade C). There is no indication for a vaginal mesh as a first-line rectocele treatment (grade C). There is no reason to systematically perform a hysterectomy during prolapse repair (grade C). It is possible to not treat stress incontinence at the time of prolapse repair, if the woman is advised of the possibility of a 2-step surgical treatment (grade C).
Assuntos
Procedimentos Cirúrgicos em Ginecologia/normas , Prolapso de Órgão Pélvico/cirurgia , Guias de Prática Clínica como Assunto/normas , Feminino , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Prolapso de Órgão Pélvico/diagnósticoRESUMO
Postoperative ileus (POI) is a major focus of concern for surgeons because it increases duration of hospitalization, cost of care, and postoperative morbidity. The definition of POI is relatively consensual albeit with a variable definition of interval to resolution ranging from 2 to 7 days for different authors. This variation, however, leads to non-reproducibility of studies and difficulties in interpreting the results. Certain risk factors for POI, such as male gender, advanced age and major blood loss, have been repeatedly described in the literature. Understanding of the pathophysiology of POI has helped combat and prevent its occurrence. But despite preventive and therapeutic efforts arising from such knowledge, 10 to 30% of patients still develop POI after abdominal surgery. In France, pharmacological prevention is limited by the unavailability of effective drugs. Perioperative nutrition is very important, as well as limitation of preoperative fasting to 6 hours for solid food and 2 hours for liquids, and virtually no fasting in the postoperative period. Coffee and chewing gum also play a preventive role for POI. The advent of laparoscopy has led to a significant improvement in the recovery of gastrointestinal function. Enhanced recovery programs, grouping together all measures for prevention or cure of POI by addressing the mechanisms of POI, has reduced the duration of hospitalization, morbidity and interval to resumption of transit.
Assuntos
Íleus/etiologia , Complicações Pós-Operatórias , Humanos , Íleus/epidemiologia , Íleus/fisiopatologia , Íleus/terapia , Incidência , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/terapia , Fatores de RiscoRESUMO
Bladder exstrophy is a rare malformation. Ureteral diversion, such as ureterosigmoidostomy or a neorectal bladder, has been described. When the patients reach adulthood, cancer may arise in these reconstructions. Our aim was to perform a systematic review (all languages) of the published literature on neoplasia after urinary diversion and suggested management in cases of cancer. PubMed and Cochrane library were searched for relevant articles published within the last 20 years. All identified articles were reviewed for inclusion. Carcinoma occurring in the bladder and unreconstructed exstrophy were excluded. Out of 47 articles found, 12 matched our search criteria. The outcomes of 23 patients (including 2 from the authors' institution) were reported. Twenty-two patients with adenocarcinoma and 1 with carcinoid tumour were identified. Median age at urinary diversion was 3 (range 1-13) years. There were 20 ureterosigmoidostomies and 2 neorectal bladders. Cancer was diagnosed subsequently at a median of 31 (range 5-55) years after urinary diversion still in place (n = 18) or 21 years (range 1-30) after incomplete excision of ureteric stump when re-diverted (n = 5). The long-term outcomes of 15 patients were available. Ten died due to colorectal adenocarcinoma, and 5 were disease-free at 3 years. Patients with enteric diversion for bladder exstrophy, including those with subsequent reconstruction, are at risk of adenocarcinoma during adulthood. It is important to provide adequate surveillance. If lesions suggestive of carcinoma are seen, complete excision of the receptive bowel and urinary diversion are mandatory.
Assuntos
Extrofia Vesical/cirurgia , Carcinoma/epidemiologia , Neoplasias Colorretais/epidemiologia , Colostomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Ureterostomia/efeitos adversos , Derivação Urinária/efeitos adversos , Adenocarcinoma/epidemiologia , Adenocarcinoma/etiologia , Adolescente , Adulto , Carcinoma/etiologia , Criança , Pré-Escolar , Colo Sigmoide/cirurgia , Neoplasias Colorretais/etiologia , Colostomia/métodos , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Ureterostomia/métodos , Bexiga Urinária/cirurgia , Derivação Urinária/métodos , Adulto JovemRESUMO
OBJECTIVE: Providing clinical practice guidelines for first surgical treatment of female pelvic organ prolapse. METHODS: Systematic literature review, level of evidence rating, external proofreading, and grading of recommendations by 5 French academic societies: Association française d'urologie, Collège national des gynécologues et obstétriciens français, Société interdisciplinaire d'urodynamique et de pelvi-périnéologie, Société nationale française de coloproctologie, and Société de chirurgie gynécologique et pelvienne. RESULTS: It is useful to evaluate symptoms, their impact, women's expectations, and to describe the prolapse prior to surgery (Grade C). In the absence of any spontaneous or occult urinary sign, there is no reason to perform urodynamics (Grade C). When a sacrocolpopexy is indicated, laparoscopy is recommended (Grade B). A bowel preparation before vaginal (Grade B) or abdominal surgery (Grade C) is not recommended. There is no argument to systematically use a rectovaginal mesh to prevent rectocele (Grade C). The use of a vesicovaginal mesh by vaginal route should be discussed taking into account an uncertain long-term risk-benefit ratio (Grade B). Levator myorrhaphy is not recommended as a first-line rectocele treatment (Grade C). There is no indication for a vaginal mesh as a first-line rectocele treatment (Grade C). There is no reason to systematically perform a hysterectomy during prolapse repair (Grade C). It is possible to not treat stress incontinence at the time of prolapse repair, if the woman is advised of the possibility of a 2-step surgical treatment (Grade C). Clinical practice guidelines. © 2016 Published by Elsevier Masson SAS.
Assuntos
Procedimentos Cirúrgicos em Ginecologia/normas , Prolapso de Órgão Pélvico/cirurgia , Feminino , Procedimentos Cirúrgicos em Ginecologia/métodos , HumanosRESUMO
INTRODUCTION: Open sacrocolpopexy have demonstrated its efficiency in surgical treatment of pelvic organ prolapse with an important backward on a large number of patients. Laparoscopic sacrocolpopexy reproduced the same surgical technique with reduced morbidity and may benefits from the recent development of robotic. Numerous technical variants have been developped around the original procedure but results seems not ever equivalent. Our objectives are to establish practical recommendations issues from the data of the litterature on the various technical aspects of this technique. METHODS: This work leans on an exhaustive lecture of the literature concerning meta analyses, randomized tries, registers, controlled studies and the largest non controlled studies published on the subject. Recommendations were developed by a multidisciplinary workgroup then reread and amended by an also multidisciplinary group of proofreaders (urologists, gynecologists, gastroenterologists and surgeons). The methodology follows at best the recommendations of the HAS with a scientific argument for every question (accompanied with the level of proof, NP) and the recommendations, the officers (In, B, C and agreement of experts) and validated at the end of the phase of review. RESULTS: Surgical treatment of uro-genital prolapse by abdominal route classically associated hystero and anterior vaginopexy on the sacral ligament with a synthethic mesh. There are no argument to systematically associated a posterior vaginopexy to prevent secondary rectocele (level C). The consensual indication of laparoscopic rectopexy is represented by symptomatic rectal prolapse, the anatomical and functional results of which are the best estimated (level C). The surgical treatment of rectocele, elytrocele and enterocele with a posterior vaginopexy is not well estimated (level 3). Thus, it is not possible to conclude on the results of a posterior vaginal fixation with a mesh in these indications (AP). In the absence of colpocèle, the interest brought by the posterior vaginal mesh is not established (level 3). There is no comparative studies which allows to conclude on the type and mode of fixation of the prostheses of sacrocolpopexy. We would only report the most common practices without other conclusion. The anterior mesh is usually fixed upper on the anterior part of uterus cervix and lower on the anterior vaginal wall. These fixations are most of the time made by suture and on the promontory with non absorbable suture. The great majority of the authors recommend to make a peritonisation of prostheses to limit the risk of post-operative occlusion. It is now recommended to use only 2 kind of not absorbable prostheses: type I (macroporous polypropylene) or type III (polyester) and not to use any more prostheses type II (PTFE, Silicone) (level C) because of a high rate of mesh erosion: PTFE (9 %) or Silicone (19%) (level 3). Biological prostheses are no more recommended, because of short and medium-term lower anatomical results (level B). Anatomical and functional results are not stastistically differents between laparotomy and coelioscopy (NP1) but the comparison of tong-term results between both ways is not yet established. Coelioscopy allows significant reduction of blood losses, hospital stay and return to normal activity (level 1). Furthemore, there is a higher level of post-operative complications in laparotomy (level 1). When sacrocolpopexy is indicated, coelioscopy is thus recommended (level B). During coelioscopic sacrocolpopexy, anatomical and functional result have not shown any significance difference when using or no a robotics assistance but real randomised studies does not exist (level 2). In comparison to coelioscopy, robotic seems not to improve post-operative consequences and not to decrease the rate of complications of sacrocolpopexy (level 3). Robotic assistance cannot be yet recommended when a coelioscopic sacrocolpopexy is indicated (rank B). CONCUSION: Sacrocolpopexy using not absorbable meshes allows to cure pelvic organ prolapses with very good results with few complications in terms of prothetic exposure and infection and thus is now considered as the referent prothetic surgical technique in this indication. Thus, it seems very important to establish clear recommendations on the numerous operating technical variants which developed around the original technique. © 2016 Published by Elsevier Masson SAS.