[Assessment patient's sexuality after prolapse repair using the Elevate™ kit]. / Évaluation de la sexualité des patientes après pose de prothèse Elevate™ pour cure de prolapsus.

OBJECTIVES: The main aim of this study is to present the impact on the sexuality of patients after prolapse repair by a vaginal approach using the Elevate™ kit. Secondary objectives include the evaluation of the quality of life and presentation of anatomical results and complications. MATERIALS AND METHODS: This is a retrospective unicentric study of 177 patients with symptomatic urogenital prolapse, repair from 2009 to 2013, using anterior and/or posterior Elevate™ kit. Assessment sexuality was performed using a validated questionnaire, the PISQ-12. Anatomical outcomes and quality of life were assessed using the classification POP-Q and questionnaires PFDI20 and PFIQ-7 respectively. RESULTS: Response to the questionnaire was 53.1 % with a mean follow-up of 29 months (8-60). Forty-six patients were sexually (49 %) active after the procedure. The average score of postoperative questionnaire PISQ-12 was 34.5/48. De novo dyspareunia rate is 10.8 %. The anatomic success rate was 90 %, the exposure rate was 2.8 % and the retraction rate was 2.2 %. No patient with de novo dyspareunia had postoperative complication. CONCLUSION: The Elevate™ kit is associated with satisfactory functional and anatomical results. De novo dyspareunia rate is "acceptable" compared to the literature data.

[Fertility after hysteroscopic resection of submucosal myoma in infertile women]. / Fertilité après résection hystéroscopique de myomes sous-muqueux chez des patientes infertiles.

OBJECTIVES: Myoma is the most frequent benign uterine tumor and might have a negative impact on fertility. In 5 to 10% of cases, infertility is associated with myoma and in 1 to 3% myoma is the only infertility factor. Even if effect of myomectomy on fertility is controversial, benefit of hysteroscopic myomectomy for submucosal myoma on fertility has already been shown. The aim of this study is to evaluate fertility of infertile women less than 46years old after hysteroscopic resection of submucosal myoma. MATERIAL AND METHODS: This retrospective unicentric study took place in the gynecologic unit of a teaching hospital. All infertile women with a hysteroscopic myomectomy for submucosal myoma between March 2009 and May 2013 were included. A phone questionnaire was conducted to evaluate pregnancy rate, eventual medical assistance, time between submucisal resection and pregnancy and issue of pregnancies. RESULTS: Seventy-one infertile women with a hysteroscopic resection of submucosal myoma were included. Pregnancy rate was 33.8% with 50% of live births, 41.6% of miscarriages and 8.4% of late fetal losses with a mean follow-up of 28.7months. Mean time between hysteroscopic resection and pregnancy was 9.9months. A medical assistance was necessary for 6 women (25% of pregnancy). CONCLUSION: This study reports hysteroscopic resection of submucosal myoma for infertile women. The rate of pregnancy after treatment is 33.8%.

[Treatment of tubal ectopic pregnancy by methotrexate]. / Utilisation du méthotrexate dans les GEU tubaires.

OBJECTIVES: To make a literature analyse about methotrexate as a treatment of tubal ectopic pregnancy. MATERIALS AND METHODS: We made a PubMed research and found articles, randomized control studies, systematic revues and meta-analyses of the Cochrane Database about ectopic pregnancies treated by methotrexate. We made a summary of these articles. RESULTS: Methotrexate can be used as a treatment of tubal ectopic pregnancy with hCG<5000 UI/L and expectative is an option if hCG level is lower than 1500 UI/L. Medical treatment by methotrexate seems to be less effective than surgical salpingotomy but the rate of recurrence and the rate of intra-uterine pregnancy are similar regardless of the treatment chosen. Fertility seems to be the same after treatment by methotrexate. Economically, methotrexate is less expensive than the surgical management (laparoscopy). CONCLUSION: Methotrexate can be used as a treatment of tubal ectopic pregnancies if every criterions of safety are gathered.

[Evidence-based evaluation and expertise of methotrexate off label use in gynaecology and obstetrics: work of the CNGOF]. / États des lieux et expertise de l'usage hors AMM du méthotrexate en gynécologie-obstétrique: travail du CNGOF.

In the absence of contraindication, methotrexate by intramuscular unique injection of 1mg/kg or 50mg/m(2) is the medical treatment recommended for tubal ectopic pregnancy (EP; LE1). It can be renewed once, at the same dose, according to hCG rates decrease. The pretherapeutic biological assessment contains blood cells numeration, renal and hepatic function. Methotrexate therapy constitutes an alternative conservative treatment to laparoscopic salpingotomy for non-complicated tubal EP (LE1) with hCG level <5000 UI/L (LE2). When the rates of hCG are <1000 UI and or presented a spontaneous decreasing kinetics, the simple prospect (LE2) is preferred. It is recommended to use intramuscular methotrexate in case of surgical conservative treatment failure or more prematurely if the follow-up is not possible (LE3). Except in particular cases there is no indication to use methotrexate in local injection under sonographic control in usual tubal EP (LE2). The use of in situ injection methotrexate is an option to handle the cervical, interstitial or on caesareans scar pregnancies (LE2). In front of a persistent undetermined location pregnancy, after more than 10 days of survey, in an asymptomatic woman and/or at rate of hCG >2000 UI/L, the systematic treatment by methotrexate is an option. The methotrexate is not indicated for first trimester termination of pregnancy or miscarriage neither in placentas accreta nor in association with other treatments such myfegine or potassium.

Overview and expert assessment of off-label use of misoprostol in obstetrics and gynaecology: review and report by the Collège national des gynécologues obstétriciens français.

The literature suggests that misoprostol can be offered to patients for off-label use as it has reasonable efficacy, risk/benefit ratio, tolerance and patient satisfaction, according to the criteria for evidence-based medicine. Both the vaginal and sublingual routes are more effective than the oral route for first-trimester cervical dilatation. Vaginal misoprostol 800µg, repeated if necessary after 24 or 48h, is a possible alternative for management after early pregnancy failure. However, misoprostol has not been demonstrated to be useful for the evacuation of an incomplete miscarriage, except for cervical dilatation before vacuum aspiration. Oral mifepristone 200mg, followed 24-48h later by vaginal, sublingual or buccal misoprostol 800µg (followed 3-4h later, if necessary, by misoprostol 400µg) is a less efficacious but less aggressive alternative to vacuum aspiration for elective or medically-indicated first-trimester terminations; this alternative becomes increasingly less effective as gestational age increases. In the second trimester, vaginal misoprostol 800-2400µg in 24h, 24-48h after at least 200mg of mifepristone, is an alternative to surgery, sulprostone and gemeprost. Data for the third trimester are sparse. For women with an unripe cervix and an unscarred uterus, vaginal misoprostol 25µg every 3-6h is an alternative to prostaglandin E2 for cervical ripening at term for a live fetus. When oxytocin is unavailable, misoprostol can be used after delivery for prevention (sublingual misoprostol 600µg) and treatment (sublingual misoprostol 800µg) of postpartum haemorrhage. The use of misoprostol to promote cervical dilatation before diagnostic hysteroscopy or surgical procedures is beneficial for premenopausal women but not for postmenopausal women. Nonetheless, in view of the side effects of misoprostol, its use as a first-line treatment is not indicated, and it should be reserved for difficult cases. Misoprostol is not useful for placing or removing the types of intra-uterine devices used in Europe, regardless of parity.

[Use of misoprostol in gynaecology]. / Utilisation en gynécologie du misoprostol (hors AMM).

OBJECTIVES: To assess the interest of misoprostol in gynaecology and particularly for cervical priming. METHOD: Research in PubMed in English and French about misoprostol and its use in gynaecology. RESULTS: We summarized the results of 3 meta-analyses, randomized controlled trials and literature review. Results show that misoprostol did not scientifically prove a benefit for cervical priming before hysteroscopy or before intra-uterine device (IUD). Results are the same with post-menopausal or nulliparous women. It did not lead either to lower the complications but increase adverse effects. CONCLUSION: It is not indicated to use misoprostol for cervical priming in gynaecology.

[Interest of a thrombin and fibrinogen combipatch in preventing breast cancer seroma after lymph node dissection]. / Intérêt d'un combipatch de thrombine et de fibrinogène dans la prévention des lymphocèles après curage axillaire.

OBJECTIVE: To evaluate the effect of combipatch TachoSil(®) in the prevention of seromas after axillary dissection in local breast cancer. PATIENTS ET MÉTHODES: A retrospective, case-control study conducted between January 2007 and December 2009, in two departments of Obstetrics and Gynecology of the AP-HP. Sixty-six patients (45 in the control group and 22 in the group TachoSil(®)) who have undergone an axillary dissection alone, with establishment of a redon or with lumpectomy, were included. The total amount of lymph drained during the stay, the number of days of drainage, duration of hospitalization, the number of lymphoceles and the number of retrievals performed at the waning of hospitalization were collected. RESULTS: The population was similar in age, body mass index (BMI), clinical and pathological data. There was no significant difference in terms of total volume of lymph drained (268.2 ± 220.7 mL without TachoSil(®) and 228.6 ± 128.8 mL with TachoSil(®), P = 0.89) and the number of days of drainage (3.9 ± 1.6 days without TachoSil(®) and 3.1 ± 0.9 days with TachoSil(®), P = 0.10). The duration of hospitalization was significantly higher in the group TachoSil(®) (5 ± 1.6 days with TachoSil(®) and 3.8 ± 1.1 days without TachoSil(®), P = 0.006). CONCLUSION: This study shows no benefit of combipatch (TachoSil(®)) in prevention of seromas after axillary lymph node dissection. A randomized study with large effective is necessary.

[PROSPERE randomized controlled trial: laparoscopic sacropexy versus vaginal mesh for cystocele POP repair]. / Étude randomisée comparant la promontofixation cœlioscopique à la chirurgie prothétique par voie vaginale pour le traitement des cystocèles : PROSPERE (PROSthetic PElvic organ prolapse REpair).

BACKGROUND: Cystocele is a frequent and invalidating type of genital prolapse in woman. Sacropexy using synthetic mesh is considered the surgical gold standard, and the laparoscopic approach has supplanted the open abdominal route because it offers the same anatomical results with a lower morbidity. The use of mesh through the vaginal route may have many advantages: easiness to perform, shorter operative time and recovery, but may increase morbidity. In France, both laparoscopic sacropexy and vaginal mesh are commonly used to treat cystoceles. The French Haute Autorité de santé (HAS) has highlighted the lack of evaluation of safety assessment for vaginal meshes. METHOD/DESIGN: The main objective of the study is to compare the morbidity of laparoscopic sacropexy with vaginal mesh for cystocele repair. The primary endpoint will be the rate of surgical complications greater or equal to grade 2 of the Clavien-Dindo classification at 1-year follow-up. The secondary aims are to compare the functional results in the medium term (sexuality, urinary and bowel symptoms, pain), the impact on quality of life as well as anatomical results. PROSPERE is a randomized controlled trial conducted in 12 participating French hospitals. 262 patients, aged 45 to 75years old, with cystocele greater or equal to stage 2 of the POP-Q classification (isolated or not) will be included. Exclusion criterias are a previous surgical POP repair, and inability or contra-indication to one or the other technique. We have designed this study to answer the question of the choice between laparoscopic sacropexy and vaginal mesh for the treatment of cystocele. The PROSPERE trial aims to help better determine the indications for one or the other of these techniques, which are currently based on subjective choices or school attitudes. This is the reason why competent authorities have asked for such studies.

[Urinary incontinence and menopause]. / Incontinence urinaire et ménopause.

PURPOSE: The aim of this review was to examine the relationship between menopause and urinary incontinence (UI). MATERIAL: Our work is based on a review of the literature on the epidemiology of UI in women and the effects of hormone therapy on symptoms of urinary leakage. A search of the Medline database between January 2000 and April 2012 was performed by crossing the keywords "urinary incontinence, stress urinary incontinence (SUI), urge incontinence, over active bladder, menopause, estrogen therapy". RESULTS: Twenty-nine articles over the 482 articles were initialy selected. The UI was a common symptom during menopause, with a prevalence of 15 to 30% and an annual incidence of 5 to 10%. The association between UI and menopause was controversial. Indeed, although underpinned by pathophysiological mechanisms such as the sensitivity of tissues of the urogenital sinus to estrogen, the epidemiological data available were contradictory and should be interpreted, if possible, depending on the type of UI. Thus, it remained difficult to distinguish the effect of menopause of the aging. The effects of estrogen on IU differed depending on the route of administration and of the type of UI. Randomized trials showed that oral administration of estrogen after menopause increased the occurrence of UI or SUI. However a vaginal administration of estrogen improved urge urinary incontinence (UUI) and overactive bladder. CONCLUSION: The data of this review were consistent with the French and European guidelines.

[Surgical management of intrauterine adhesions: is benefice bigger than risk?]. / Synéchie utérine: le jeu chirurgical en vaut-il la chandelle?

Management of intrauterine synechiae in a context of infertility remains a challenge, in spite of hysteroscopic microsurgery progress. There is no published prospective study to be used as a guideline. Anatomic, but most of all functional prognosis are directly correlated to the severity of adhesions and the number of surgical procedures required to complete treatment. Complications during surgery are not infrequent, but are well known and often benign. Obstetrical complications are much less frequent but often severe (abnormal placentation, uterine rupture). Recurrences are common enough to impose a systematic second-look diagnostic hysteroscopy. However, the benefit gained by the recovery of fertility (either spontaneous or not) remains superior, in my opinion, to the risks of the surgical management.