[How I treat a pelvic organ prolapse at the doctor's office]. / Comment je traite un prolapsus uro-génital au cabinet médical.

The use of gynecological pessary to put back up prolapsed organs to their normal position appears to be as effective as surgical management to relieve symptoms related to uro-genital prolapse and restore body image. This millenary device can be used temporarily, awaiting a surgical solution or as a therapeutic test (mimicking the effect of a surgical procedure to predict its functional outcome or identifying a masked urinary incontinence). It can also represent an alternative to surgery (patient choice, women who wish to complete childbearing or who are unsuitable for surgery because of medical comorbidities) and thus can be used in first intention. Pessary can also be used to confirm or deny the responsibility of pelvic organ prolapse for atypical symptomatology as pelvic heaviness or pain. However, this use requires adjuvant treatment. In this paper, we highlight an original effective process not yet published to optimize the tolerance of pessary.

L'utilisation du pessaire gynécologique afin de réintégrer les organes prolabés dans l'enceinte pelvienne est une alternative efficace dans le soulagement des symptômes liés au prolapsus uro-génital et la restauration tant de l'image corporelle que de l'estime de soi. Ce dispositif millénaire peut être utilisé temporairement, dans l'attente d'une intervention chirurgicale, à titre de test thérapeutique préopératoire (prédiction du résultat fonctionnel attendu, identification d'une possible incontinence urinaire masquée par le prolapsus, confirmation de la responsabilité du trouble de la statique pelvienne quant à une symptomatologie inhabituelle à type de pesanteur pelvienne ou de douleurs). Le pessaire peut aussi être considéré en alternative définitive à la chirurgie (choix de la patiente, désir de grossesse, terrain récusant une intervention). Cette alternative nécessite toutefois un traitement adjuvant. Nous mettons en lumière un procédé original, non encore publié, optimisant la tolérance dudit pessaire.

Development of an ovine model for training in vaginal surgery for pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: This aim of this study was to evaluate the feasibility and usefulness of an ovine model for training in vaginal surgery. METHODS: Four senior urogynaecological surgeons and five residents attended five sessions of vaginal surgery for pelvic organ prolapse (POP) in five old multiparous female sheep. Urogynaecological examinations were performed and measurements similar to the POP-Q classification in humans were obtained. Standard POP surgical procedures with and without mesh were performed. A pelvic CT scan was done on one animal and the structures were compared with the pelvic structures in a woman. After the feasibility of vaginal surgery had been established in three cadavers, surgery was performed in two living animals under general anaesthesia and was followed by laparoscopy to explore the internal pelvic anatomy. RESULTS: We found anatomic similarities in the vaginal and pelvic structures between sheep and women. After caudal traction on the cervix, all five sheep had significant POP of stage 3 or 4. We proved the feasibility of all types of vaginal surgery in this animal model: traditional anterior and posterior repair, apex fixation and anterior wall repair with mesh. The video shows the internal pelvic anatomy and different vaginal procedures. CONCLUSION: This study showed that training in vaginal surgery for POP is feasible and useful in an animal model, the ewe, that has vaginal and pelvic structures very similar to those in women.

Total transvaginal mesh (TVM) technique for treatment of pelvic organ prolapse: a 5-year prospective follow-up study.

INTRODUCTION AND HYPOTHESIS: To evaluate clinical effectiveness and complication rates at 5 years following the total Trans Vaginal Mesh (TVM) technique to treat pelvic organ prolapse. METHODS: Prospective, observational, multi-centre study in patients with prolapse of stage II or higher. RESULTS: Of the 90 women enrolled in the study, 82 (91%) were available for the 5-year follow-up period. At the 5-year endpoint, success, defined as no surgical prolapse reintervention and leading edge <-1 (International Continence Society [ICS] criteria) or above the level of the hymen, was 79% and 87% respectively. A composite criterion of success defined as: leading edge above the hymen (<0) and no bulge symptoms and no reintervention for prolapse was met by 90%, 88% and 84% at the 1-, 3-, and 5-year endpoints respectively. Quality of life improvement was sustained over the 5 years. Over the 5-year follow-up period, a total of only 4 patients (5%) required re-intervention for prolapse, while a total of 14 patients (16%) experienced mesh exposure for which 8 resections needed to be performed. Seven exposures were still ongoing at the 5-year endpoint, all asymptomatic. Only 33 out of 61 (54%) sexually active patients at baseline remained so at 5 years. De novo dyspareunia was reported by 10%, but no new cases at the 5-year endpoint. One patient reported de novo unprovoked mild pelvic pain at 5 years, 5 reported pains during pelvic examination only. CONCLUSIONS: Five-year results indicated that TVM provided a stable anatomical repair. Improvements in QOL and associated improvements in prolapse-specific symptoms were sustained. Minimal new morbidity emerged between the 1- and 5-year follow-up.

[French language validation of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire - IUGA revised (PISQ-IR)]. / Validation linguistique en français du Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire - Révisé IUGA (PISQ-IR).

OBJECTIVES: To report a linguistically validated French version of the PISQ-IR (the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire IUGA-Revised). METHODS: PISQ-IR is a valid, reliable, and responsive measure of sexual function in both sexually active or inactive women with pelvic floor disorders. Validation process was performed according the IUGA guidelines. The French version of the PISQ-IR was developed after two independent translations (English>French), one back translation (French>English), cognitive debriefing with a sample of 25 women with pelvic floor disorders attending the gynecologic clinic in the university hospital of Nîmes and a critical review by experts in the field of urogynecology and sexuality. RESULTS: The PISQ-IR is a self-administered questionnaire, which overcomes some shortcomings of the initial version. Questionnaire includes 20 questions, the first one to clarify sexual activity: part 1 of the questionnaire is for non-sexually active women and contains 5 questions and the second part is for sexually active women and contains 12 or 14 questions depending on whether or not the women has a partner. CONCLUSION: This paper reports the linguistically validated French version of the PISQ-IR. Psychometric validation of the French PISQ-IR is currently ongoing and when completed, the scoring system will be shortly published in addition to the definitive version of the questionnaire.

Prenatal diagnosis of lobar bronchial atresia.

We report three cases of fetal lobar bronchial atresia referred to our Fetal Medicine Center during the mid-trimester of pregnancy over the last 15 years. Lobar bronchial atresia can mimic a main stem bronchial atresia on mid-trimester ultrasound examination as it induces extensive lobar enlargement, major mediastinal shift and eversion of the diaphragm. It was associated with severe pulmonary hypoplasia in all three cases, even though polyhydramnios and ascites were absent in two. Termination of pregnancy was performed at parental request after extensive counseling in each of the cases and necropsy confirmed one or two enlarged lung lobes leading to major compression of the remaining lobe(s) of the ipsilateral lung, the contralateral lung and the heart. No other anomalies were observed and the karyotype was normal in all cases.

Transvaginal mesh repair of anterior and posterior vaginal wall prolapse: a clinical and ultrasonographic study.

OBJECTIVES: To investigate whether ultrasonography coupled with clinical examination can help in understanding the mechanism of recurrence after transvaginal mesh repair of anterior and posterior vaginal wall prolapse. METHODS: Ninety-one patients who had undergone surgery for anterior and/or posterior vaginal wall prolapse with the Prolift system had a clinical examination and introital/endovaginal two-dimensional ultrasonography a minimum of 1 year later. The retraction of anterior and posterior meshes was estimated relative to the original length of the mesh by transvaginal palpation. Patients with no, moderate (< 50%) or severe (> or = 50%) mesh retraction were compared. Anterior recurrence of prolapse was defined according to the International Continence Society by a Ba value > or = -1 and posterior recurrence by a Bp value > or = -1 (where Ba represents the most distal position of the anterior vaginal wall and Bp the most distal position of the posterior vaginal wall). On ultrasonography, two distances were measured in the midsagittal plane: Distance 1, from the distal margin of the anterior mesh to the bladder neck, and Distance 2, from the distal margin of the posterior mesh to the rectoanal junction. RESULTS: Seventy-five anterior and 62 posterior meshes were studied at a mean follow-up of 17.9 months. Patients with anterior recurrence presented significantly more often with severe anterior mesh retraction compared with patients without anterior recurrence (5/8 vs. 2/67, P < 0.001) and also had an increased Distance 1 (P < 0.001). Patients with posterior recurrence presented significantly more often with severe posterior mesh retraction compared with patients without posterior recurrence (3/4 vs. 3/58, P < 0.01) and also had an increased Distance 2 (P < 0.01). CONCLUSIONS: Recurrence of prolapse after transvaginal mesh repair appears to be associated with severe mesh retraction and loss of mesh support on the distal part of the vaginal walls.

[Sexual outcome after pelvic reconstructive surgery]. / Impact de la chirurgie réparatrice pelvienne sur la sexualité

Sexual well-being is an important parameter of women's health and quality of live. Sexual disorders may occur in women with pelvic organ prolapse and/or stress urinary incontinence and also after pelvic reconstructive surgery. Sexual dysfunction after POP or SUI surgery has been poorly documented but new condition specific questionnaires have been developed to help us to better evaluate such consequences. This paper reports available data and highlights more specifically consequences of surgery with mesh reinforcement which is, currently, an important issue particularly when performing by vaginal approach.

[What about transvaginal mesh repair of pelvic organ prolapse? Review of the literature since the HAS (French Health Authorities) report]. / Quoi de neuf depuis le rapport de la HAS? Bilan de deux ans d'évaluation des implants de renfort prothétique dans le traitement des prolapsus par voie vaginale.

The French Health Authorities' (HAS) report of November 2006 concluded that the use of mesh at the time of transvaginal repair of pelvic organ prolapse (POP) should be limited to clinical research. This review intends to analyse and comment the recent data on this topic. A review on PubMed, on a personal database and actualisation until May 2008 has been performed choosing French or English language series concerning prolapse surgery with mesh disposed by the vaginal route. It includes six randomised controlled trials comparing transvaginal repair of POP with or without mesh: four about cystocele, one about rectocele and one about apical prolapse. Both surgical techniques and recurrence criteria are poorly standardised. The four randomised trials focusing on cystocele repair support the anatomical superiority of techniques using mesh, with similar functional results with or without mesh reinforcement. In the other indications, the results remain unclear or controversial. According to the randomised trials, the complications rate, except mesh exposure, is similar with and without mesh. However there are some specific complications when using mesh, such as mesh infection, mesh exposure or shrinkage and visceral extrusion. We recommend using vaginal reinforcement mesh with specific care in selected patients and we suggest some guidelines to be proposed for consensus at concerned French scientific societies.

[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.

[Patients' satisfaction and perinatal network: a preliminary report]. / Pré-étude sur la satisfaction des femmes au sein d'un réseau de santé périnatale.

OBJECTIVES: The objective of this work was to determine the principal axes for measuring the satisfaction of women transferred within a perinatal network. MATERIAL AND METHODS: We began with two successive qualitative sociological approaches (18 semi-structured interviews of women and of couples in 2004 and 2006-2007) and one quantitative approach (questionnaire survey of 583 women hospitalized in 15 of the 16 maternity units in the Auvergne network during a two-week period in 2004). RESULTS: The qualitative surveys show that the procedures at arrival at the new establishment and the feeling of consistency that they did or did not induce, the identification of the participants, an understanding of their role, and the objectives of the new examinations were all important dimensions. During hospitalization, explanations of who does what and the consistency of the information provided also played a role in this satisfaction. The quantitative survey (participation rate=89%) showed that 77% of the women were aware of the possibility of an in utero transfer. Nonetheless, most of them had very little information about the network. CONCLUSION: It is possible to identify specific themes associated with women's satisfaction about in utero transfers that are useful for constructing a questionnaire that must, in turn, be validated.

[How to manage multicompartment pelvic organe prolapse?]. / La prise en charge des prolapsus multicompartimentaux par voie vaginale?

Repair of pelvic organ prolapse by vaginal route may use native tissues or meshes, which have been in extensive use over the last decades. Traditional surgery, and particularly sacrospinous fixation, has been proven to be effective with long term follow-up with well-known specific risks that could be avoided by skilled surgeons on condition that he observes basic vaginal surgery rules. This surgery is still recommended as first choice in patients over 70 years old with high-grade prolapse. Nevertheless recurrence rate after high-grade cystocele repair using native tissues as been reported between 30 and 50% depending on the technique used. Mesh repair and particularly the use of mesh kits is a valid option in case of prolapse with cystocele behind the hymen, specifically in case of paravaginal defect. Meshes use is licit in patients with prolapse recurrence as well. In contrast, spread use of transvaginal meshes in young patients with grade 3 or 4 prolapse whom tissues have a poor quality, has to be considered very carefully because of the lack of knowledge about long term results and sexual outcome.

Perineal prevention and protection in obstetrics: CNGOF clinical practice guidelines.

INTRODUCTION: The objective of these clinical practice guidelines was to analyse all of the interventions during pregnancy and childbirth that might prevent obstetric anal sphincter injuries (OASIS) and postnatal pelvic floor symptoms. MATERIAL AND METHODS: These guidelines were developed in accordance with the methods prescribed by the French Health Authority (HAS). RESULTS: A prenatal clinical examination of the perineum is recommended for women with a history of Crohn's disease, OASIS, genital mutilation, or perianal lesions (professional consensus). Just after delivery, a perineal examination is recommended to check for OASIS (Grade B); if there is doubt about the diagnosis, a second opinion should be requested (Grade C). In case of OASIS, the injuries (including their severity) and the technique for their repair should be described in detail (Grade C). Perineal massage during pregnancy must be encouraged among women who want it (Grade B). No intervention conducted before the start of the active phase of the second stage of labour has been shown to be effective in reducing the risk of perineal injury. The crowning of the baby's head should be manually controlled and the posterior perineum manually supported to reduce the risk of OASIS (Grade C). The performance of an episiotomy during normal deliveries is not recommended to reduce the risk of OASIS (Grade A). In instrumental deliveries, episiotomy may be indicated to avoid OASIS (Grade C). When an episiotomy is performed, a mediolateral incision is recommended (Grade B). The indication for episiotomy should be explained to the woman, and she should consent before its performance. Advising women to have a caesarean delivery for primary prevention of postnatal urinary or anal incontinence is not recommended (Grade B). During pregnancy and again in the labour room, obstetrics professionals should focus on the woman's expectations and inform her about the modes of delivery.

[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.

[The gynecological pessary: Is it really a device of another age, a fig leaf?] / Le pessaire gynécologique: est-ce vraiment un dispositif d'un autre âge, un cache-misère?

OBJECTIVES: The use of pessary to put back up prolapsed organs to their normal position dates back prior to several millennia. This work aims to discuss its place in our clinical practice through an updated bibliographic review and emphasizes a hands-on approach to pessary fitting and management in terms of indication, pessary type selection, device' size, insertion, removal, follow-up visits and care. METHODS: A review of the literature, in the light of the latest publications and recommendations of French and international learned societies, as well as our own experience, were analyzed. RESULTS: This device appears to be as effective as surgical management to relieve symptoms related to urogenital prolapse and restore body image. It can be used temporarily, awaiting a surgical solution or as a therapeutic test (mimicking the effect of a surgical procedure to predict its functional outcome or identifying a masked urinary incontinence). It can also represent an alternative to surgery (patient choice, women who wish to complete childbearing or who are unsuitable for surgery because of medical comorbidities) and thus can be used in first intention. However, despite its moderate cost and its harmlessness, this device remains somewhat little known as regards the practical modalities of its use, which, moreover, appear not consensual. CONCLUSION: A guide intended for the attention of the patients as well as a film relating to the practical modalities of the device' use were elaborated to improve the knowledge of both professionals and users in order to optimize and secure the care pathway.

[Perineal prevention and protection in obstetrics: CNGOF Clinical Practice Guidelines (short version)]. / Prévention et protection périnéale en obstétrique : Recommandations pour la Pratique Clinique du CNGOF (texte court).

INTRODUCTION: The objective of these clinical practice guidelines was to analyse all of the interventions during pregnancy and childbirth that might prevent obstetric anal sphincter injuries (OASIS) and postnatal pelvic floor symptoms. MATERIAL AND METHODS: These guidelines were developed in accordance with the methods prescribed by the French Health Authority (HAS). RESULTS: A prenatal clinical examination of the perineum is recommended for women with a history of Crohn's disease, OASIS, genital mutilation, or perianal lesions (professional consensus). Just after delivery, a perineal examination is recommended to check for OASIS (Grade B); if there is doubt about the diagnosis, a second opinion should be requested (GradeC). In case of OASIS, the injuries (including their severity) and the technique for their repair should be described in detail (GradeC). Perineal massage during pregnancy must be encouraged among women who want it (Grade B). No intervention conducted before the start of the active phase of the second stage of labour has been shown to be effective in reducing the risk of perineal injury. The crowning of the baby's head should be manually controlled and the posterior perineum manually supported to reduce the risk of OASIS (GradeC). The performance of an episiotomy during normal deliveries is not recommended to reduce the risk of OASIS (Grade A). In instrumental deliveries, episiotomy may be indicated to avoid OASIS (GradeC). When an episiotomy is performed, a mediolateral incision is recommended (Grade B). The indication for episiotomy should be explained to the woman, and she should consent before its performance. Advising women to have a caesarean delivery for primary prevention of postnatal urinary or anal incontinence is not recommended (Grade B). During pregnancy and again in the labour room, obstetrics professionals should focus on the woman's expectations and inform her about the modes of delivery.

Long-term results of tension-free vaginal tape (TVT) for the treatment of female urinary stress incontinence.

OBJECTIVES: Prospective evaluation of outcome and complications over a 5-year period post-treatment of urinary stress incontinence by TVT, and comparison of our results with the reference studies. MATERIALS AND METHODS: About 94 patients were treated for urinary stress incontinence only by one TVT procedure (single surgical procedure), between April 1997 and December 1998; 68% of patients presented pure urinary stress incontinence and 32% mixed incontinence. We found also a 25.5% rate of sphincter deficiency (UCP < 20 cm H(2)O) in this cohort. Patients were evaluated after 5 years: 52 complete evaluations (clinical, flow measurement with measurement of post-mictional residue, 24h PAD-test, quality of life questionnaire), 30 complete telephone interviews, 12 lost to follow-up (2 patients deceased). RESULTS: About 87% of the patients had a 5-year follow-up. The success rate was 79.2% overall (84.5% for the pure urinary stress incontinence and 67% for the mixed incontinence cases), and 72.2% for the cases of associated sphincter deficiency. We had only a 13% rate of patients lost to follow-up. More than half of the urinary urgency cases were treated successfully, however with a less satisfactory outcome in cases of bladder instability. The urodynamic exploration appeared to reveal that TVT caused dysuria: 52% of patients had a maximum flowrate below 15 ml/s, but the quality of life was improved, with a 95% rate of satisfaction without functional problems. We observed no late complications such as vaginal erosion or rejection of the prolene; the de novo syndrome was rare, with 8.5% of urinary frequency, 6% of urinary urgency and only 5.7% of invalidating dysuria. We saw no cases of pelvic floor disease after TVT treatment. DISCUSSION: Our casuistry results are comparable with the reference studies by Scandinavian authors, Rezapour and Ulmsten, confirming the long-term success of the TVT procedure. Concerning the apparently elevated rates of post-TVT dysuria found by urodynamic exploration, a distinction has to be drawn between post-TVT urinary problems (frequent but oligosymptomatic), and true, severe dysuria (rare). However, "dysuria" in the broad sense did not affect the patients' quality of life, and is a reminder of the absolute necessity of meticulous compliance with the correct surgical techniques. CONCLUSION: Treatment of urinary incontinence by TVT is a reliable, mini-invasive, reproducible technique, almost suitable for outpatients, with no serious complications; it is inexpensive and very successful, including in complicated cases such as sphincter deficiency. All the recent data confirms, with this 5-year follow-up, that the TVT procedure is comparable to the previously gold standard, the Burch colposuspension.

[Management of gestational hypertriglyceridemia by plasmapheresis]. / Prise en charge d'une hypertriglycéridémie gravidique par plasmaphérèse.

We report a case of unexpected severe hypertriglyceridemia (140N) diagnosed at 33 weeks during a second gestation. The risk of acute pancreatitis indicated plasmapheresis (three procedures) with reduction of hypertriglyceridemia (6N) and no impact on fetal well-being. Immediate recurrence led to induction of labour at 34 weeks. Spontaneous regression occurred after delivery. We demonstrated reduced lipoprotein lipase activity with no mutation for apolipoprotein E, nor lipoprotein lipase in favour of a potential pregnancy-induced inhibitor of lipoprotein degradation.