Surgical management of pelvic organ prolapse in women: how to choose the best approach.

Although benign, pelvic organ prolapse is a real public health problem, affecting mostly women above sixty-five. Eighty-year-old women have an 11.1% lifetime risk of undergoing surgery for prolapse or stress urinary incontinence and 29% will need a second procedure. Surgical approach may be abdominal (sacrocolpopexy by laparotomy, laparoscopy or robot-assisted) or vaginal (autologous, or prosthetic reinforcement). In addition to anatomical correction, surgical objectives include: improvement of the patient's quality of life, prolapse symptoms relief, normal urinary, digestive and sexual functions and especially, avoiding iatrogenic sequelae. Thus, the choice of the surgical approach does not only depend upon the site and the severity of the prolapse. Urogynecological surgeons should take into consideration the patient's expectations and life style, her age--a determinant factor in deciding upon the best approach -, and her relapse risk factors. They should master both approaches, and the management of surgical complications. Therefore, an apprenticeship in a reference pelviperineology center is a must. In addition, surgeons should be aware of and consider contraindications to each procedure, for instance contraindications to transvaginal prosthesis reinforcement like risk factors of bad healing or infection. Urogynecology specialists have to take into consideration known anatomical and functional results of each technique as cited in the medical literature and act in accordance with international recommendations. The surgery's main objective is to ameliorate the patient's discomfort and her quality of life without causing iatrogenic dysfunctional symptoms (urinary, digestive, sexual). The pelvic organ prolapse being a benign pathology, the patient's satisfaction is the main marker of the procedure success. In short, regarding the surgical management of pelvic organ prolapse in women the answer to the question How to choose the best approach? is not binary. It depends on several factors, and regardless of the choice, it must

[From the open approach to laparoscopy. Background, rationale, technique]. / La promontofixation: de la voie ouverte a la coelioscopie. Historique, rationnel, technique.

Genital prolapse is a frequent functional pathology in women. Its surgical treatment depends specially upon the suspension and fixation of the vaginal vault. Thus, sacrocolpopexy has become a gold standard technique to correct genital prolapse. Laparoscopy is a procedure resulting in less bleeding and decreased hospital stay than open sacrocolpopexy and is presently the approach of choice. Its objective and subjective correction rates are > 90%. Some authors proposed a dual abdominal and perineal approach to help fixing the posterior mesh and repairing the perineal body. Robotics is the actual surgeons' gadget.Its results are similar to laparoscopic sacrocolpopexy albeit a higher cost and a longer operating time. The ideal mesh is monofilamentous with large pores. Sacrocolpopexy consists in fixing two meshes, one on the anterior vaginal wall and one on the posterior vaginal wall, on the anterior sacral ligament, without tension for the posterior mesh, with or without subtotal hysterectomy, and with closure of the peritoneum at the end. In the case of associated stress urinary incontinence, proved on the clinical exam or urodynamical exam, appropriate surgical treatment is done with sacrocolpopexy. In the near future, robotics will replace laparoscopy when costs will be reduced and medical staff well trained to perform robotic or robot-assisted sacrocolpopexy.

Spontaneous detorsion of the ovary: can it be diagnosed by MRI?

PURPOSE: To determine whether recent progress in imaging has made it possible to diagnose spontaneous detorsion, which is an accepted concept in the gynecological literature but until now has been a presumptive diagnosis that could not be confirmed because of the lack of imaging proof. MATERIALS AND METHODS: We searched for patients who had a diagnosis of spontaneous detorsion on MRI between January 2000 and January 2003, and selected only patients who met a selection of strict criteria, including mainly enlargement and hyperintensity of ovarian stroma on T2-weighted (T2W) images, clinical findings compatible with torsion and detorsion, and return of the stroma to normal size on follow-up examinations. Other signs of torsion, such as tubal thickening, were appreciated but not mandatory. Clinical follow-up for at least three years was available. RESULTS: Four patients met the study criteria. No stabilizing procedure was performed in the ovaries. One patient recurred and lost her ovary. CONCLUSION: The diagnosis of torsion followed by spontaneous detorsion was made with high probability in a selected number of patients. The clinical management of such patients remains a matter of debate. Laparoscopy with oophoropexy would be useful for young patients in whom close follow-up cannot be achieved.

Extraovarian cystadenomas: ultrasound and MR findings in 7 cases.

OBJECTIVE: To describe the ultrasound and MR appearance of paraovarian cystadenomas. METHODS: We reviewed retrospectively the radiologic findings in 7 patients with surgically proven paraovarian cystic neoplasms, including 6 serous cystadenomas and 1 borderline seromucinous cystadenoma. All had ultrasound and 4 had MR preoperatively. RESULTS: On ultrasound, the ipsilateral ovary was visualized in six cases, in contact with the cyst in five and separate from it in one. On MR, the ovary and the cyst were visible in four cases, in contact in three and separate in one. Internal papillary excrescences, present at pathology in all cysts, were seen in five on ultrasound and in four on MR. CONCLUSION: Although the extraovarian location of these neoplasms is difficult to determine preoperatively by ultrasound and MR, these imaging modalities are more reliable in predicting the histology of these rare lesions and differentiating them from simple paraovarian cysts.