Reoperation rate and outcomes following the placement of polypropylene mesh by the vaginal route for cystocele: very long-term follow-up.

INTRODUCTION AND HYPOTHESIS: The aim was to evaluate the reoperation rate and outcomes in women who underwent transvaginal non-absorbable monofilament polypropylene mesh placement for the treatment of cystocele. METHODS: The retrospective cohort study included 63 patients who underwent transvaginal surgery using a synthetic polypropylene mesh (Gynemesh™) for cystocele. Patients were evaluated using a clinical examination (POP-Q) and validated questionnaires (PGI-I, PFDI-20, PFIQ-7) at 18 years of follow-up (median 18 years [IQR 16-19]). Cumulative death rate was 13 out of 63 (20%) and rate of total loss to follow-up was 21 out of 50 (42%). Finally, among the 63 women who underwent surgery, 29 completed maximum follow-up and 21 underwent a clinical examination. RESULTS: The cumulative reoperation rate was 35% (22 out of 63). Three patients were reoperated on because of recurrence of pelvic organ prolapse. Among the 63 patients initially operated, vaginal mesh exposure occurred in 16 (25%) during follow-up and 11 women (17%) needed a reintervention for vaginal mesh exposure. One patient was reoperated on for bladder mesh exposure. Among the 29 women who completed follow-up, the overall postoperative improvement rate was 93% after 18 years (PGI-I: 1-3). Mean overall satisfaction rate was 80 out of 100. Functional success rate was 76% (22 out of 29) and anatomical success rate was 62% (13 out of 21). The median score of the POP-DI-6 was 4.1 (IQR: 0-11) and the median score of the PFDI-20 was 30.7 (IQR: 13-60) in the 29 women who completed maximum follow-up. CONCLUSION: At very long-term follow-up, the recurrence rate of cystocele following polypropylene mesh placement by the vaginal route remained low and the satisfaction rate was high. However, we found high cumulative reoperation and mesh exposure rates.

Maternal outcome after abdominal packing for uncontrolled postpartum hemorrhage despite peripartum hysterectomy.

BACKGROUND: Intra-abdominal packing is a possible option for persistent bleeding following hysterectomy for postpartum hemorrhage. However, to date, only very limited data about maternal outcome after intra-abdominal packing for surgically uncontrolled hemorrhage following hysterectomy are available. The objective of the current study was to estimate maternal outcome after intra-abdominal packing following unsuccessful peripartum hysterectomy for postpartum hemorrhage. METHODS: A questionnaire was mailed to all maternity units performing more than 850 deliveries per year. Inclusion criteria were: all cases of abdominal packing performed following unsuccessful peripartum hysterectomy for postpartum hemorrhage between 2003 and 2013. The primary outcome was success of intra-abdominal packing, defined as the arrest of hemorrhage with no need of additional procedure. RESULTS: The total number of deliveries during the study period that occurred in the 51 participating centers was 1,430,142. The centers reported a total of 718 (1 per 2000 deliveries) peripartum hysterectomies for PPH and 53 abdominal packings performed after unsuccessful peripartum hysterectomy (about 1 per 14 hysterectomies). A median of 5 [IQR 3-7] pads were used for packing. Abdominal packing was removed after a median of 39.5 hours [IQR 24-48]. The success rate of abdominal packing was 62% (33/53). Among the 20 (38%) women in whom bleeding did not stop following the use of abdominal packing, 6 required a second surgical intervention, 6 a pelvic artery embolization and the 8 other women had "only" further intensive resuscitation and pharmacological treatments. Finally, mortality rate was 24% (13/53). CONCLUSION: Our results suggest that abdominal packing, used for duration of 24 to 48 hours, seems to be an option as an ultimate procedure to control persistent life-threatening postpartum hemorrhage following peripartum hysterectomy.

Bladder injury and success rates following retropubic mid-urethral sling: TVT EXACT™ vs. TVT™.

OBJECTIVE: Although placement of a retropubic mid-urethral slings (MUS) is one of the gold standard surgical treatments for stress urinary incontinence, new devices are poorly evaluated before marketing. We compared TVT-EXACT™ (TVT-E), a new device expected to reduce bladder injuries, with the historically described bottom-to-top TVT™ (TVT). STUDY DESIGN: This retrospective study compared TVT-E (n=49) and TVT (n=49). The main outcomes were the prevalence of complications (bladder injuries, immediate postoperative pain, perioperative complications, etc.) and the short-term success rate (no reported urinary leakage and negative cough test) of both MUSs. RESULTS: Minimum follow-up was 12 months. The characteristics of the two groups were comparable. The prevalence of bladder injury for TVT-E and TVT was 8% and 6%, respectively (p=1). The intensity of immediate postoperative pain (VAS/100) was lower following TVT-E than after TVT (8.0 vs. 15.9, p=0.01). The first post-void residual was increased in the TVT-E group (153.9 vs. 78.9mL, p=0.045), and there were more postoperative bladder outlet obstruction (BOO) symptoms in the TVT-E group (24% vs. 6%, p=0.02). However, there was no difference when considering only de novo BOO (14% vs. 4%, p=0.16). The prevalence of peri- and post-operative complications was equal in the two groups. The success rate was similar at 12 months of follow-up (80 vs. 82%, p=1). CONCLUSION: The prevalence of bladder injury was unchanged with TVT-EXACT™ compared with TVT™, but post-operative pain was decreased. The success rate of both retropubic MUSs was similar at 12 months of follow-up.

[Postpartum pelvic floor disorders]. / Troubles pelvi-périnéaux du post-partum. Fréquents et à rechercher systématiquement à l'interrogatoire.

Postpartum pelvic floor disorders. Postpartum pelvic floor disorders are frequent but most of the time, decrease spontaneously. Even if 40% of pregnant women suffer from urinary incontinence, 85% of them are cured 3 months after delivery. In case of persistent urinary incontinence, postpartum rehabilitation improves short-term urinary incontinence. Six weeks after delivery 4% to 39% women suffer from anal incontinence. Most of the time anal symptoms decrease spontaneously. Postpartum rehabilitation seems to improve short-term anal incontinence. 15 to 20% of pregnant women have a genital prolapse stage 2 during the third trimester and 20 to 50% in the immediate postpartum. Even if most of the women (90%) have genital prolapse (stage 1 for most of them) one year after delivery, only 10% are bothered. Expectative management with a clinical evaluation 12 months after delivery is sufficient. In case of persistent symptoms, pelvic floor rehabilitation can be proposed.

Troubles pelvi-périnéaux du post-partum. Les troubles pelvi-périnéaux du post-partum sont fréquents mais régressent spontanément la plupart du temps. L'incontinence urinaire dont la prévalence est proche de 40 % au cours de la grossesse régresse spontanément dans 85 % des cas à 3 mois du post-partum. En cas de persistance des symptômes, la rééducation périnéale semble améliorer les symptômes au moins à court terme. L'incontinence anale, dont la prévalence varie de 4 à 39 % à 6 semaines du post-partum régresse aussi spontanément la plupart du temps. La rééducation périnéale semble également être efficace à court mais pas à long terme. La prévalence des prolapsus de stade 2 est de 15 à 20 % au 3e trimestre de grossesse et elle varie de 20 à 50 % dans le post-partum immédiat. Même si la majorité des patientes (90 %) ont encore une petite composante de prolapsus à 1 an, seules 10 % en sont gênées. L'expectative avec une réévaluation de la gêne à 1 an du post-partum semble être préférable et, en cas de persistance des symptômes, une rééducation périnéale est alors préconisée.

Surgical treatment: Myomectomy and hysterectomy; Endoscopy: A major advancement.

Uterine fibroids affect 25% of women worldwide. Symptomatic women can be treated by either medical or surgical treatment. Development of endoscopic surgery has widely changed the management of myoma. Currently, although laparoscopic or laparoscopic robot-assisted myomectomies or hysterectomies are common, there has been no consensual guideline concerning the surgical techniques, operative route, and usefulness of preoperative treatment. Hysteroscopy management is a major advancement avoiding invasive surgery. This study deals with a literature review concerning surgical management of fibroids.

Outcomes of laparoscopic sacropexy in women over 70: A comparative study.

OBJECTIVE: Precise data are lacking concerning laparoscopic sacropexy in the elderly population. The purpose of this study was to compare the outcomes and complications associated with laparoscopic sacropexy (colpopexy or hysteropexy) in women aged under 70 and 70 or over. STUDY DESIGN: Retrospective review of data on patients who underwent laparoscopic sacropexy in two tertiary centers. Peri- and postoperative complications were recorded and described using the IUGA classification. Surgery was considered successful if the patient was symptomatically satisfied or very satisfied and if the POP-Q (Pelvic Organ Prolapse-Quantification) stage score at the follow-up visit was below stage 2 for all compartments. RESULTS: Among the 191 women studied, 47 (24.6%) were aged 70 or more. According to the ICS/IUGA classification of POP complications, perioperative and postoperative complication rates were similar in the older versus younger groups (bladder injuries (0 vs. 1.39%, p=1) (4A T1 S2), rectal injuries (0% vs. 0.69%, p=1) (5BT1S5), vaginal injuries (2.13% vs. 0%, p=0.246) (2A T1 S1)). No laparotomy conversion was required in either group. At two months of follow-up, the success rate was 97.9% and 95.1% in the older and younger groups, respectively (p=0.68). At 24 months of follow-up, the overall reoperation rate was 12.8% for the older group versus 11.8% in the younger group (p=0.80). CONCLUSIONS: Our findings suggest that laparoscopic sacropexy is a valid option in elderly women presenting with genital prolapse.

Malignant transformation of abdominal wall endometriosis: case report and literature review.

In recent years we have seen an increase in the frequency of cesarean sections. We present a case report of an endometrioid adenocarcinoma arising from abdominal wall endometriosis in a patient with a history of cesarean sections and describe its diagnostic and therapeutic management.