Long-term functional stability of sacrospinous ligament-fixation repair of pelvic organ prolapse.

The objective of this study was to evaluate the variation over 5 years of functional discomfort associated with pelvic organ prolapse (POP) repaired by sacrospinous ligament fixation (SLF). A total of 178 women who had undergone SLF from 1992 to 2001. In 2002 and 2008, patients were sent a questionnaire including the pelvic floor distress inventory (PFDI-20); 79 responded and comparison of those data served to evaluate subjective signs at 5 years. This population was divided into two groups: ≤60 and >60 years old, and their 2002-2008 differences were compared. The outcomes were satisfaction, functional results and sexuality. Mean follow-up was 115 (72-173) months. Our results showed the long-term stability of SLF functional outcomes for women >60 years. However, for those≤60 years, functional outcomes and satisfaction had declined at 5 years.

Pelvic floor disorders 4 years after first delivery: a comparative study of restrictive versus systematic episiotomy.

OBJECTIVE: To compare two policies for episiotomy: restrictive and systematic. DESIGN: Quasi-randomised comparative study. SETTING: Two French university hospitals with contrasting policies for episiotomy: one using episiotomy restrictively and the second routinely. POPULATION: Seven hundred and seventy-four nulliparous women delivered during 1996 of a singleton in cephalic presentation at a term of 37-41 weeks. METHODS: A questionnaire was mailed 4 years after delivery. Sample size was calculated to allow us to show a 10% difference in the prevalence of urinary incontinence with 80% power. MAIN OUTCOME MEASURES: Urinary incontinence, anal incontinence, perineal pain, and pain during intercourse. RESULTS: We received 627 responses (81%), 320 from women delivered under the restrictive policy, 307 from women delivered under the routine policy. In the restrictive group, 186 (49%) deliveries included mediolateral episiotomies and in the routine group, 348 (88%). Four years after the first delivery, there was no difference in the prevalence of urinary incontinence (26 versus 32%), perineal pain (6 versus 8%), or pain during intercourse (18 versus 21%) between the two groups. Anal incontinence was less prevalent in the restrictive group (11 versus 16%). The difference was significant for flatus (8 versus 13%) but not for faecal incontinence (3% for both groups). Logistic regression confirmed that a policy of routine episiotomy was associated with a risk of anal incontinence nearly twice as high as the risk associated with a restrictive policy (OR = 1.84, 95% CI: 1.05-3.22). CONCLUSIONS: A policy of routine episiotomy does not protect against urinary or anal incontinence 4 years after first delivery.

[Pelvic floor disorders four years after first delivery: a comparative study of restrictive versus systematic episiotomy]. / Troubles périnéaux quatre ans après le premier accouchement: comparaison entre épisiotomie restrictive et systématique.

OBJECTIVE: To compare two policies for episiotomy: restrictive and systematic. PATIENTS AND METHODS: It is a quasi-randomised comparative study between two French university hospitals with contrasting episiotomy policies: one using it restrictively and the second routinely. Population included 774 nulliparous women delivered during 1996 of a singleton in cephalic presentation at a term of 37-41 weeks. A questionnaire was mailed four years after delivery. Sample size was calculated to allow showing a 10% difference in the prevalence of urinary incontinence with 80% power. Main outcome measures were urinary incontinence, anal incontinence, perineal pain and pain during intercourse. RESULTS: We received 627 responses (81%), 320 from women delivered under the restrictive policy, 307 from women delivered under the routine policy. In the restrictive group, 186 (49%) deliveries included mediolateral episiotomies and in the routine group, 348 (88%). Four years after the first delivery, the groups did not differ in the prevalence of urinary incontinence (26% versus 32%), perineal pain (6% versus 8%), or pain during intercourse (18% versus 21%). Anal incontinence was less prevalent in the restrictive group (11% versus 16%). The difference was significant for flatus (8% versus 13%) but not for faecal incontinence (3% for both groups). Logistic regression confirmed that a policy of routine episiotomy was associated with a risk of anal incontinence nearly twice as high as the risk associated with a restrictive policy (OR=1.84, 95 % CI :1.05-3.22). DISCUSSION AND CONCLUSION: A policy of routine episiotomy does not protect against urinary or anal incontinence four years after first delivery.

Folinic acid, 5-fluorouracil bolus and infusion and mitoxantrone with or without cyclophosphamide in metastatic breast cancer.

60 patients with metastatic breast cancer were entered in a phase II study using folinic acid, 5-fluorouracil bolus and infusion and mitoxantrone with or without cyclophosphamide. 47 had measurable visceral metastases and 13 had exclusively bone metastases. 36 had received previous adjuvant or metastatic treatment (33/36 with anthracycline-based regimens). Overall response rate in visceral metastatic patients was 57.1% [95% confidence interval (CI) 35.4-78.8%]; 45.5% and 70% in previously and non-previously treated patients, respectively; duration of response was 9 and 13 months, respectively. 10 out 13 patients with exclusive bone metastases improved for a median time of 18 months. Median survival was 22 months for the 60 patients; 18 and 31 months for previously and non-previously treated patients, respectively. Cyclophosphamide was scheduled only in the absence of nadir grade 4 neutropenia. However, this toxicity occurred in the first 7 patients. For this reason, we chose to avoid cyclophosphamide in patients over 60 years, or with a performance status of 1-2, or who had received previous chemotherapy. Overall, cyclophosphamide was stopped due to nadir grade 4 neutropenia in 17/24 patients for whom this drug was planned. When mitoxantrone, 5-fluorouracil and folinic acid were used at the doses scheduled, the addition of cyclophosphamide appeared feasible in only about 25% of the patients. Furthermore, survival was identical for patients receiving or not receiving cyclophosphamide. Therefore, cyclophosphamide does not contribute substantially to this regimen. This study confirms the value of folinic acid, 5-fluorouracil and mitoxantrone in metastatic breast cancer.

Sequential cisplatin-doxorubicin, early debulking surgery and intraperitoneal chemotherapy in advanced ovarian cancer. Groupe d'Etude et de Recherche sur les Cancers de l'Ovaire et Digestifs (GERCOD).

40 patients with advanced ovarian cancer were treated with immediate debulking followed by sequential cisplatin and doxorubicin every 4 weeks, followed by second-look laparotomy (SLL). Six courses were given when residual disease (RD) was under 2 cm. When RD was over 2 cm, three courses were followed by early debulking and six more courses before SLL. Immediate debulking was optimal in 15 patients (38%) and early debulking in an additional 15 (38%). Pathological complete responses (34 evaluable cases) were observed in 14 cases (41%), partial response in 13 (38%), stable disease in 3 (9%) and progression in 5 (15%). Toxicity was mainly haematological. 11 patients with negative SLL and 15 with RD under 2 cm received intraperitoneal cisplatin 200 mg/m2 alone or with cytarabine. Median survival was 45 months: 58 months for RD under 2 cm at initial laparotomy and 31 months for RD over 2 cm. Median survival was 46 months when early debulking was successful. 5 year disease-free survival was only 16%. However, this multimodal treatment offers prolonged survival, especially in patients optimally debulked either at initial laparotomy or at early debulking surgery.

Survival with intraperitoneal cisplatin in advanced ovarian cancer after second-look laparotomy.

We studied survival in 36 patients with Stage III/IV ovarian cancer who received intraperitoneal high-dose cisplatin (200 mg/m2) alone or in combination with cytarabine (2 g), after intravenous (i.v.) cisplatin-based chemotherapy followed by second-look laparotomy. Complete responders were scheduled for three courses of IP chemotherapy, and others for six. Eight patients (22%) did not complete treatment (6 catheter failures and 2 renal failures). Peritoneal cytology remained positive in 6 patients (17%). Median overall and progression-free survival after second-look laparotomy were 44 and 37 months, respectively, for 13 complete responders to i.v. chemotherapy; 24 months and 11 months for patients with residual tumors less than 2 cm (17 cases); 15 and 12 months with tumors greater than 2 cm (6 cases). There was a significant difference in overall (p = 0.05) and progression-free (p = 0.001) survival between complete responders to i.v. chemotherapy and patients whose tumor was less than 2 cm. We find no evidence that high-dose cisplatin-based intraperitoneal chemotherapy given after second-look laparotomy will enhance survival in advanced ovarian cancer with zero or minimal residual disease.

Intravenous sulprostone and uterine scarring based upon 22 cases of therapeutic abortion during 2nd and 3rd trimesters of pregnancy.

A preliminary study in 22 patients with uterine scarring was undertaken using sulprostone by intravenous infusion when therapeutic abortion was deemed necessary during the 2nd and 3rd trimesters of pregnancy. The dosage used was 500 micrograms by slow infusion lasting 10 h. There were no cases of ruptured uterus. Adverse reactions were absent. Results were satisfactory. Mean induction-expulsion duration: 11 h. Expulsion rate in 24 h: 63%. With strict monitoring and in a specialized center, this technique may be suggested when a late therapeutic abortion with a scarred uterus is indicated.

Therapeutic abortion during the 2nd and 3rd trimesters of pregnancy using a synthetic derivative of prostaglandin E2, sulprostone, administrated intravenously. Based upon 182 cases.

OBJECTIVE: The purpose of the study is to assess the efficacy of and adverse events linked to the use of intravenous sulprostone during the 2nd or 3rd trimesters of pregnancy for therapeutic abortion. STUDY DESIGN: One hundred eighty-two patients (70 nulliparous, 112 multiparous) were hospitalized for therapeutic abortion. The route of administration was invariably intravenous and one single dose of sulprostone was used: 1000 micrograms of sulprostone diluted in 1 l of isotonic saline solution given as a 10-h infusion. RESULT: Expulsion within the first 24 h was obtained in 70% of cases with a mean induction-expulsion interval of 14 h. In three cases, laparotomy was required for hemorrhagic syndromes. CONCLUSION: Intravenous sulprostone enable evacuation of uterine contents with minimal adverse reaction. Attention should nevertheless be drawn to the existence of hemorrhagic syndromes.

Hysteroscopic diagnosis of ectopic pregnancy.

Although vaginal ultrasonography combined with plasma beta-hCG determination can provide a reliable diagnosis and location of ectopic pregnancy, the results can be difficult to interpret in the early stages when hCG levels are low. Hysteroscopy can be used in such cases to differentiate between ectopic pregnancy and non-viable uterine pregnancy when viable uterine pregnancy has been ruled out. General anaesthesia and laparoscopy are avoided. We performed 60 hysteroscopic procedures between January 1989 and December 1990 in patients with suspected ectopic pregnancies. The pregnancy had been located by means of vaginal ultrasonography in every case in which the hCG was above 1500 IU/ml and in 36% of cases in which the beta-hCG was below this level. Hysteroscopy was hindered by metrorrhagia in three cases and was inconclusive in one, necessitating laparoscopy. Diagnosis was possible in all the remaining cases, as follows: ectopic pregnancy in 41 cases, with an empty uterus and occasional bleeding from an ostium; non-viable uterine pregnancy in 18 cases, with the presence of material within the cavity. Hysteroscopy therefore confirmed the diagnosis in 55% of the cases and was itself diagnostic in a further 43% of cases. Its sensitivity for the diagnosis of ectopic pregnancy was 100% and its specificity 95%. We propose a diagnostic decision tree.

[Surgical treatment of genitourinary prolapse by the abdominal approach. Apropos of a series of 232 cases]. / Traitement chirurgical des prolapsus génito-urinaires par voie abdominale. A propos d'une série de 232 cas.

Two hundred and thirty two patients with genitourinary prolapse were operated via an abdominal incision between 1981 and 1994. The technique consisted of retroperitoneal promontofixation, systematically associated with a retropubic colposuspension, levator myorrhaphy, Douglassectomy and uterosacral ligamentoplasty. The mean age of operated patients was 52.57 years (30-85 years), the mean follow-up was 17.8 months (1-105). 65 patients (27.7%) had a history of foetal macrosomy, 125 women (53.4%) were delivered without forceps or expression, and 2 patients (0.8%) had never procreated. The main presenting complaint was prolapse in 197 patients (84.4%), while 140 patients complained of urinary incontinence (60.3%). A urodynamic assessment was systematically performed before the operation and revealed defective transmission in 160 cases (71%); sphincter incompetence in 62 cases (62/228 cases, i.e. 27%); a combination of sphincter incompetence and defective transmission in 40 cases (17.7%). The results were assessed in terms of anatomical and functional parameters. The anatomical results revealed 21 recurrences, the majority of which were posterior recurrences, and the functional results were marked by urinary functional disorders such as urinary incontinence (30%), urgent micturition (14%) and dyspareunia (21%).

[Early debulking surgery after chemotherapy in advanced cancer of the ovary]. / La cytoréduction chirurgicale précoce après chimiothérapie dans le cancer de l'ovaire avancé. GEROD. Groupe d'Etude et de Recherche sur les Cancers de l'Ovaire et Digestifs.

The main prognostic factor in advanced ovarian cancer is the volume of residual disease after the initial laparotomy. Early debulking surgery after several cycles of chemotherapy, before the emergence of resistant cell lines, could improve the prognosis of patients with bulky residual disease. This study concerns patients with advanced ovarian cancer entered into three prospective trials including IV cisplatin and anthracycline-based chemotherapy, early debulking surgery after three cycles of chemotherapy in case of initial residual disease superior 2 cm and intraperitoneal consolidation chemotherapy. Among 160 patients with stage III or IV, 80 (50%) had at least a residual tumor of more than 2 cm in diameter. Early debulking surgery was effectively performed in 54 patients (67.5%), leaving 39 patients with no residue over 2 cm. Twenty-one patients had no macroscopic residual disease. The median survival of all patients with initial residual disease over 2 cm was 23 months. Patients with no macroscopic residual disease at early debulking surgery had a median survival of 44 months. Early debulking surgery appears useful in advanced ovarian cancer with bulky residual disease. The objective of this operation is to achieve no macroscopic residual lesion.

[Ophthalmologic pathology in the pregnant woman]. / Pathologie ophtalmologique de la femme enceinte.

Literature review and report of personal cases concerning the ocular physiopathological problems of pregnant women. Are studied especially chorioretinal perturbations: surgical and medical retinal detachment, diabetic retinopathy, choroiditis with pseudohistoplasmosis and toxoplasmosis. Are also studied the variations of the visual acuity, ocular tumors and pituitary tumors.

[Chronic inflammatory bowel disease and pregnancy]. / Maladies inflammatoires chroniques intestinales et grossesse.

The authors have looked out the obstetric history of 13 young women who were suffering from ulcerative colitis or Crohn's disease between the years 1978 and 1982 and who had 25 pregnancies. This study made it possible to analyse the influence of these pathological conditions on the evolution of pregnancy as well as the effect of pregnancy on the evolution of the disease. The different therapeutic treatments that have to be given for these diseases, such as medical treatment using Sulphasalazine, enemata, corticosteroids and Azathioprin, or surgical treatments have been examined in their relationship with pregnancy. The results that have been obtained confirm those to be found in the literature in the sense that the two conditions are independent of one another and therapy for the pregnancy as well as for the bowel disease can be continued without too much consideration for the effect of the one condition on the other.

[Urethral instability]. / L'instabilité urétrale.

This study was carried out on 121 sets of records of uretrocystomanometry and 25 records of uretrocystomanometry combined with dynamic sphincterometry. The patients consulted us either for stress incontinenceor urgency incontinence. The mean age was 41 years. The urethra was considered to be unstable when variations in pressure reached 20 cm of water or higher. There are four different types of instability described and these correspond to different urodynamic pictures. The treatments that have been proposed resulted from the different aetiologies that we have been proposed resulted from the different aetiologies that we have worked out. Some of these cases are due to an inadequate perineal floor. This has been shown by changes in striated urethral sphincter behaviour and in the improvement that can be brought about by re-education of the levator and muscles.

[A case of post partum gonococcal arthritis]. / A propos d'un cas de polyarthrite gonococcique du post-partum.

The authors report a case of gonorrhoea occurring immediately after delivery, characterized by acute inflammatory polyarthritis. The diagnosis was made from swabs taken from the lochia that were cultured on enriched media. The outcome of the disease treated with penicillin was good after 48 hours. The new-born's state of health after swabs take from the nostrils were positive was satisfactory all the time. A review of the literature shows how rare these conditions are, how serious they can sometimes be, and the management that should be undertaken in order to prevent complications occurring.

[Delivery of black African women in France]. / L'accouchement de la femme d'Afrique noire en France.

The African population is a specific entity. It is younger, the women have more babies and the pelvis is frequently narrow. Caesarean section for a narrow pelvis should be considered very carefully in this population, while the idea of feto-pelvic disproportion has to be a clinical one. Radiological pelvimetry and the use of Magnin's diagram play no part in deciding which way to deliver the women.

[Stress urinary incontinence in women. Epidemiologic inquiry. Apropos of 500 cases]. / L'incontinence urinaire d'effort chez la femme. Enquête épidémiologique. A propos de 500 cas.

Nearly 50% of women in Tunisia have urinary incontinence, and 30% of these are highly embarassed. This condition is under-estimated in Tunisia by doctors in as far as its functional effects are concerned because the country has other diseases which are more urgent and take priority. Stress incontinence causing invalidism is very frequent: 31.4%. The principal factors that lead to it are home delivery, multiparity, menopause and large babies. There are two frequent associated conditions: incontinence during pregnancy and cystocoele. A contribution is made by the clinical diagnosis, but if investigations stop there a definite diagnosis cannot be made and therefore there is a risk of failure of treatment. In fact the treatment should be according to the cause: it is medical when are purely urinary troubles and surgical or physiotherapeutic when there is true stress incontinence. The best treatment would be to prevent the condition by good obstetrics and this by better methods of delivering the babies.

[Treatment of acute non-chlamydial salpingitis. Study of the efficacy and tolerance of a single-therapy antibiotic: Augmentin]. / Traitement des salpingites aiguës non chlamydiennes. Etude de l'efficacité et de la tolérance d'un antibiotique en monothérapie: l'Augmentin.

An open randomised comparative trial of the efficacy and safety of Augmentin as against the triple therapy of penicillin-gentamicin-metronidazole in acute salpingitis was conducted in forty women admitted to hospital. Laparoscopy was performed routinely to confirm the diagnosis. The two groups of patients were comparable as to age and clinical and biological symptoms and the severity of the salpingitis (grade I to IV, with the presence or absence of Fitz-Hugh-Curtis syndrome). Treatment was started immediately after the laparoscopy, first by parental route until the patient had been apyrexic for 48 hours. Oral follow-up was then commenced. Twenty women received Augmentin and twenty the triple antibiotic therapy. Specimens for bacteriological study were obtained before treatment (culture of the urine, culture from the IUD and from the cervix, and swabs were taken laparoscopically). This made it possible to identify aerobic and anaerobic organisms. (The gonococcus was found more often in the group treated with triple antibiotics). On discharge, cures had been obtained in 12 women and 6 more were responding out of the Augmentin group. Out of the triple therapy group 8 were cured and 10 were responding. There was one failure in each group (persisting fever). Long-term assessment was carried out in the out-patients three weeks after discharge. 11 out of the 13 reviewed in the Augmentin group and 8 out of the 14 in the triple therapy group were considered as definitely cured. The clinical safety of both treatments was good. These results demonstrate that Augmentin is as effective as the combined therapy in treating acute salpingitis and with the added advantage of its easy use and lower cost.

[Pregnancy and injuries in traffic. Apropos of a case]. / Grossesse et traumatisme de la voie publique. A propos d'un cas.

6.9% of women involved in accidents are pregnant. It is difficult to calculate all the fetal and maternal lesions that occur under these conditions. We are reporting a case of a 27-year-old primipara who had internal bleeding with shock without a precise aetiology. Very heavy vaginal bleeding occurred on the third day after admission so that a Caesarean had to be carried out in order to preserve the health of the mother and of the baby. Several complications can follow road traffic accidents in pregnant woman. The worst is usually fetal death and its mechanism is discussed. More frequently occurring, however, are fetal distress that threaten premature labour. Some lesions that are not lethal, such as bone fractures, can affect the long-term outlook for the pregnancy.

[Bi-parietal diameter of the black African child]. / Le diamètre bi-pariétal de l'enfant noir africain.

The authors have made a growth cure of the bi-parietal diameter of the African infant using observations taken on 350 African women who were followed up and delivered in their department. Over all these curves of growth are smaller than the reference curves used in France. This study is a first contribution to the understanding of the mechanics of obstetrics in the African woman.