Influence of auto-cross-linked hyaluronic acid gel on pregnancy rate and hysteroscopic outcomes following surgical removal of intra-uterine adhesions.

OBJECTIVE: To determine the effect of the use of auto-cross-linked hyaluronic acid (ACP) gel following hysteroscopic surgery on the prevention of intra-uterine adhesions (IUAs) and the pregnancy rate. STUDY DESIGN: An observational retrospective study of 90 patients who underwent hysteroscopic removal of IUAs was conducted between 2008 and 2013 at a tertiary university care centre. Thirty-two patients received ACP gel during hysteroscopic removal of IUAs, and the remaining 58 patients did not receive ACP gel. Controls were matched to cases according to infertility and severity of IUAs using the American Society for Reproductive Medicine (ASRM) score. Four to six weeks after surgery, patients underwent diagnostic hysteroscopy to determine the re-occurrence of IUAs or the presence of adhesions. The patients were contacted by telephone to answer a questionnaire concerning their fertility. The main outcomes were pregnancy rate and postoperative IUAs. RESULTS: Pregnancy (viable or not) rates were not influenced by the use of ACP gel. The viable pregnancy rate was eight of 24 (33.3%) in the ACP gel group and 12 of 49 (24.5%) in the control group (p=0.427). The mean interval between surgery and pregnancy was 11.8 [standard deviation (SD) 10.5] months in the ACP group compared with 13.4 (SD 14.1) months in the control group (p=0.744). The mean ASRM score after surgery (hysteroscopic diagnosis at 4-6 weeks postoperatively) was equivalent in the two groups: 2.7 (SD 3.0) in the ACP gel group vs 2.6 (SD 3.2) in the control group (p=0.854). The mean follow-up was 45.2 months (interquartile range 33.2-52.7), with a loss to follow-up of 25% in the ACP gel group compared with 15.5% in the control group (p=0.817). CONCLUSION: Application of ACP gel did not prevent recurrence of IUAs and was not associated with an increased pregnancy rate. ACP gel should be used with caution pending assessment in a randomized control trial in a larger population.

[Management of third and fourth degree perineal tears: A systematic review]. / Prise en charge des périnées complets (déchirure périnéale stade 3 et 4) : revue de la littérature.

This was a comprehensive literature review using Pubmed, Medline, Embase and Cochrane, whose aim was to analyse the prevalence of anal sphincter injuries, their risk factors, their management and their functional prognosis. The prevalence of 3rd and 4th degree perineal tears varies between studies from 2.95% regardless the parity to 25% in nulliparous women. Twenty-eight percent to 48% of these lacerations were clinically occult. Perineal tears were associated with (multivariate analysis) forceps (6.021 [IC 95% 1.23-19.45]), nulliparity (OR 9.8 [IC 95% 3.6-26.2]), gestational age over 42 SA (OR 2.5 [IC 95% 1-6.2]), fundal pressure (OR 4.6 [IC 95% 2.3-7.9]), midline episiotomy (OR 5.5 [IC 95% 1.4-18.7]) or fetal weight in interval of 250g (OR 1.3 [IC 95% 1.1-1.6]). There was no difference between the sphincter repair techniques. Post-partum laxative use showed less painful bowel motion and earlier postnatal discharge. Data concerning rehabilitation were contradictory. The rate of anal incontinence 6 months after vaginal delivery were 3.6% following third degree of perineal tear and 30.8% in case of fourth degree of perineal tear. Thirty years after anal sphincter disruption, the prevalence of fecal incontinence reached 6.9%.

[Management of postpartum anal incontinence: A systematic review]. / Prise en charge de l'incontinence anale du post-partum: revue de la littérature.

AIM: To analyse the prevalence of postpartum anal incontinence, its risk factors, and its management. MATERIALS AND METHODS: A comprehensive systematic review of the literature on PubMed, Medline, Embase and Cochrane using: postpartum anal incontinence, postpartum fecal incontinence, perineal rehabilitation, anal surgery. RESULTS: The prevalence of postpartum anal incontinence varied from 4% (primipare) to 39% (multipare) at 6 weeks postpartum, whereas fecal incontinence can reach respectively 8 to 12% 6 years after delivery. Identified risk factors were: vaginal delivery (OR: 1.32 [95%CI: 1.04-1.68]) compared to cesarean section, instrumental extractions (OR: 1.47 [95%CI: 1.22-1.78]) compared to spontaneous vaginal delivery but it was only with forceps (OR: 1.50 [95%CI: 1.19-1.89]) and not with vaccum (OR: 1.31 [95%CI: 0.97-1.77]). Maternal age over 35 years (OR: 6 [95%CI: 1.85-19.45]), number of births (3 births: OR: 2.91 [95%CI: 1.32-6.41]) and the occurrence of anal-sphincter injury (OR: 2.3 [95%CI: 1.1-5]) were associated with an increased risk of anal incontinence regardless of the type of delivery compared to a group of women without anal incontinence. Perineal rehabilitation should be interpreted with caution because of the lack of randomized controlled trials. A reassessment at 6 months postpartum in order to propose a surgical treatment by sphincteroplasty could be considered if symptoms persist. The results of the sphincteroplasty were satisfactory but with a success rate fading in time (60 to 90% at 6 months against 50 to 40% at 5 and 10 years). CONCLUSION: Postpartum anal incontinence requires special care. Recommendations for the management of postpartum anal incontinence would be useful.

[Hysteroscopic morcellation versus bipolar resection for endometrial polyp removal]. / Morcellement hystéroscopique versus résection à l'anse bipolaire pour les polypes endométriaux.

OBJECTIVE: The treatment of endometrial polyps is based on hysteroscopic resection. The aim of the current study was to compare the results associated with hysteroscopic morcellation and those observed with bipolar loop resection. PATIENTS AND METHODS: A single-center observational retrospective comparative study was performed, including 25 patients who underwent hysteroscopic resection of endometrial polyps from January 2012 to December 2013. The mean size of polyp was 9.2 mm in the group compared to 12.5mm in the resection group loop (P=0.06). RESULTS: Twelve patients underwent resection of the polyp morcellation with MyoSure(®) and 13 with bipolar resection loop Versapoint(®) 24F. The mean operative time was 16 minutes in morcellation group and 17 minutes in the bipolar resection group (P=0.76). Complete removal was achieved in 100% of cases in morcellation group and in bipolar loop resection. Regarding intraoperative and postoperative complications, no complication was observed in the two groups. DISCUSSION AND CONCLUSION: Results associated with hysteroscopic morcellation and bipolar loop resection seen to be comparable.

[Operative hysteroscopy for myoma removal: Morcellation versus bipolar loop resection]. / Hystéroscopie opératoire pour fibrome : morcellement versus résection à l'anse bipolaire.

OBJECTIVE: To evaluate the results associated with hysteroscopic morcellation for submucous myomas removal, and to compare with those observed associated with bipolar loop resection. MATERIELS AND METHODS: A retrospective comparative study was conducted in two universitary centers from January 2012 to December 2013. A total of 83 patients, who presented with submucous myomas type 0,1 and 2, were included. The number of myomas type 0,1 was 36 (71 %) and 15 (29 %) myomas type 2 in morcellation group versus 44 (59 %) myomas type 0,1 and 31 (41 %) type 2 in electrosurgical resection group (P=0.17). Hysteroscopic morcellation or electrosurgical resection with bipolar loop for removal submucous myomas were performed. RESULTS: Thirty-four patients underwent hysteroscopic morcellation using MyoSure(®), and 49 had hysteroscopic resection using Versapoint-24F(®) bipolar loop. The mean operative duration was 30minutes in morcellation group, compared to 31minutes in bipolar resection group (P=0.98). Complete myoma removal was achieved in 22 (64 %) patients in morcellation group, and in 34 (69 %) in bipolar resection group (P=0.65). There were no difference in the occuring of adverse events between the two. The prevalence of postoperative intra-uterine adherence was 10 % in morcellation group and 13.8 % in bipolar resection group (P=0.69). CONCLUSION: In the current short comparative series, hysteroscopic morcellation and bipolar loop resection were associated with comparable results for removal of submucous myomas.

[Complications of presumed benign ovarian tumors]. / Complications des tumeurs ovariennes présumées bénignes.

The main risk factor of adnexal torsion is a previous adnexal torsion (LE3). There is no clinical, biological or radiological sign that may exclude the diagnosis of adnexal torsion (LE3). The presence of flow at color Doppler imaging does not allow exclusion of the diagnosis (LE2). An emergent laparoscopy is recommended for adnexal untwisting (Grade B), except in postmenopausal women where oophorectomy is recommended (grade C). A persistent black color of the adnexa after untwisting is not an indication for systematic oophorectomy (grade C), since a functional recovery is possible (LE3). Ovariopexy is not routinely recommended following adnexal untwisting (grade C). The clinical signs of intra-cystic hemorrhage and those of rupture of the corpus luteum are not specific (LE4). MRI is not recommended to confirm the diagnosis of intra-cystic hemorrhage (grade C). Malignant transformation of an ovarian cyst is very rare. The presence of a benign ovarian cyst is not associated with an increased risk of ovarian cancer at long-term follow-up (LE2). For these women, an ultrasound follow-up is not recommended (grade C). Dermoid ovarian cyst containing nerve tissue can trigger the production of pathogenic auto-antibody-anti-NMDA, leading to encephalitis. A high proportion of thyroid tissue in a mature teratoma (struma ovarii) may cause hyperthyroidism.

[Pelvic floor rehabilitation for female urinary incontinence: mechanisms of action]. / Mécanismes d'action de la rééducation périnéale pour l'incontinence urinaire de la femme.

OBJECTIVE: To analyze the proven mechanisms of action of pelvic rehabilitation in women presenting with urinary incontinence. METHODS: Review of literature (PubMed, Embase, Cochrane Database) using following keywords: female; urinary incontinence; overactive bladder syndrome; stress urinary incontinence; bladder training; bladder diary; pelvic floor muscle training; pelvic floor rehabilitation; physiotherapy; cognitive therapies. Among 2906 articles (animal and anatomical studies have been excluded); 66 have been selected because they focused on the evaluation of the pathophysiological mechanisms of pelvic floor rehabilitation concerning female urinary incontinence. RESULTS: Studies on pelvic floor muscles training exercises showed a significant increase in the force of contraction of these muscles and it was correlated with improved scores of urinary incontinence and pad test (coefficient of correlation r ranged from 0.23 to 0.34) for women presenting with stress urinary incontinence. These studies have not observed an increase in the maximum urethral closure pressure (MUCP) or correction of urethral hypermobility related with the improvement of incontinence after rehabilitation sessions. Studies concerning pelvic floor stimulation observed an increase in the force of contraction of pelvic floor muscles after rehabilitation and a decrease in the intensity of detrusor contractions without changing the MUCP. There is very little data on the precise mechanisms of action of biofeedback and cognitive behavioral therapy. CONCLUSION: In studies that objectively evaluated the mechanisms of action of pelvic rehabilitation, it was observed that pelvic floor muscles voluntary exercises and electrostimulation resulted an increase in force of contraction of these muscles without changing the MUCP.

[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.

[Pregnancy and postpartum of women with mid-urethral sling procedure: a review of the literature]. / Grossesse et post-partum des patientes porteuses de bandelette sous-urétrale: revue de la littérature.

OBJECTIVE: To realize a review of literature to observe the impact of pregnancy and delivery in patients who underwent mid-urethral sling procedure for stress urinary incontinence (SUI), in order to provide recommendations on the route of delivery. MATERIAL AND METHODS: Literature review from 1995 to 2012 on the database Pubmed/Medline including only studies involving pregnant women with mid-urethral sling procedure. RESULTS: Of the 35 published cases, 14 % of patients had a recurrence of SUI symptoms during pregnancy. Nineteen percent of patients who underwent a c-section had SUI symptoms in the immediate postpartum period, against 33 % of patients with vaginal deliveries (P=0.56). In the follow-up of delivery (>3 months), there was a persistent SUI in 20 % (7/34) of patients: 12.5 % (2/16) of women who underwent a c-section and 27.7 % (5/18) of women who had a vaginal delivery (P=0.75). CONCLUSION: Although c-section seems to slightly decrease the risk of recurrence of SUI comparing to the vaginal route, we do not recommend to propose a systematic elective c-section in these patients because of its morbidity and mortality and the possibility of repeat mid-urethral sling procedure.

[Widespread of clinical practice guidelines, concerning urinary incontinence in women]. / Diffusion des recommandations pour la pratique clinique concernant l'incontinence urinaire de la femme.

OBJECTIVE: Recommendations for good clinical practice concerning the treatment of urinary incontinence in women are available from the HAS (Haute Autorité de santé or French National Authority for Health), the Collège national des gynécologues obstétriciens français (French national college of gynaecologists and obstetricians) and Association française des urologues (French association of urologists). We wanted to conduct the first investigation of these recommendations to primary care physicians (GPs) and gynaecologists in the cities located in the same area of health. METHODS: A questionnaire was sent to GPs and gynaecologists (French administrative divisions 78 and 92), with questions on the recommendations, as well as the methods of dissemination of these recommendations. Response rate: 22%. RESULTS: A total of 72 questionnaires were usable from 51 (71%) GPs and 21 (29%) gynaecologists. Of these, 76% of gynecologists and 47% of GPs were aware of recommendations from the HAS for clinical practice for urinary incontinence in women (P=0.04). Only 56% of doctors prescribed a urinalysis (dipstick or bacteriological urinalysis) and evaluated the residual urine in women seeking care for symptoms of urinary incontinence. Training for one or two days was the most desirable/popular method of dissemination of the recommendations (30 out of 72 doctors), followed by journals such as Prescrire, then the mailing and forms provided by the HAS, especially when combined with office visits from a representative of the HAS. CONCLUSION: This study provided an interesting perspective on the knowledge, dissemination and application of recommendations for good clinical practice concerning urinary incontinence in women.

[Metastasis to the breast from non mammary metastasis. Clinical, radiological characteristics and diagnostic process. A report of two cases and a review of literature]. / Métastases au niveau des seins de tumeurs extramammaires. Caractéristiques cliniques, radiologiques et démarche diagnostique. A propos de deux cas et revue de la littérature.

The metastatic involvement of the breast from non-mammary neoplasms is a relatively rare condition: 0.5 to 6% of the breast cancers. All cancers can give breast metastases, several months after the discovery of the primitive tumor or in 25% of the cases in being the first sign. Their clinical and radiological presentation polymorphic installation a problem of differential diagnosis between benign tumor, like the fibroadenomas on the one hand, and malignant tumors of other share. The presence of multiple, bilateral round tumors, superficial without the traditional signs of malignity which one meets with the primitive tumors: irregular margins, spiculations, microcalcifications, posterior cone of shadow is evocative diagnosis. The IRM finds the criteria of malignity specific to the primitive tumor. Pathologic examination completed with immunohistochemical tests is a key point for diagnosis. The search for a primitive tumor is essential, in particular for neuroendocrine carcinoma, stromal sarcoma, and the angiosarcoma which can be primitive tumors of the breast. Treatment is therefore modified, taking into consideration the treatment and prognosis of the primary disease.

Cyclic activated sludge technology--recent operating experience with a 90,000 p.e. plant in Germany.

Cyclic activated sludge technology was selected for the Potsdam Wastewater Treatment Plant (90,000 p.e.). The cyclic activated sludge facility comprises four modules integrated into two circular basins. Construction was commenced in February 1998 with seeding of the plant for start up taking place in October 1998. Process performance has been met since Spring 1999 at 80-90% of design load. In order to optimize start-up procedures, respiration rates were used as a guidance for process stabilization and online process optimization during normal operation. Operation for co-current nitrification denitrification provided an ammonia removal of 1.1 mg NH4-N/g MLSS.h (15 degrees C) and a corresponding nitrate respiration rate of 0.85 mg NO3-N/g MLSS.h under aerated conditions. Enhanced biological phosphorus removal generated an effluent mean total phosphorus concentration of 0.38 mg/L without precipitant addition.