[Pelviperineoscopy. Preliminary study of feasibility on cadavers]

OBJECTIVE

The traditional access of perineum for the treatment of the pelvic organ prolapse by vaginal route is probably responsible for the risk of mesh exposure and a longer convalescence. So, endoscopic access to perinemeum needs to be evaluated.

PATIENTS AND METHODS

Feasibility study on cadavers. Details of the procedure: opening of the pararectal space by digital dissection first after incision on the level of the posterior commissure. Introduction of an optical trocart to the level of the perineum incision; dissection of pararectal space with optics and CO(2); individualization of the various elements; installation of a transobturator trocart and a transgluteal trocart; dissection of the rectovaginal septum and visualization of the sacrospinous ligament and pudendal nerve. The measured variables were: operational incidents, possibility of creation of working space, dissection of the rectovaginal septum; finally, visualization of the sacrospinous ligament and pudendal pedicle.

RESULTS

On the 4 studied cadavers, we could carry out a dissection of pelvirectal space in all the cases. On the 8 pararectal fosses, in all the cases we could carry out a cavity of dissection and to open the recto vaginal septum, visualization of the sacrosciatic ligament and pudendal pedicle was possible in 6 cases out of 8. There were one rectal injury, two vaginal injuries and one lesion of the pudendal pedicle.

DISCUSSION AND CONCLUSION

This endoscopic access allows in the majority of cases to see the structures necessary to the realization of a vaginal sacrospinofixation or the installation of posterior mesh without a colpotomy and a traumatic exposure. The incidents are probably due to our inexperience and should disappear in time. The pelvi-perineoscopy is an endoscopic access of perineum which should be evaluated.

Management of placenta accreta: Morbidity and outcome

OBJECTIVE

The aim of the study was to evaluate our results in the management of placenta accreta.

STUDY DESIGN

In a retrospective study we reviewed cases of placenta accreta diagnosed in two university teaching hospitals between 1993 and 2003. For a subgroup of patients a conservative approach was attempted. In this procedure placenta was left in place until spontaneous resorption.

RESULTS

Fifty cases (0.12%) of placenta accreta were observed in 41, 119 deliveries during the study period. Of the 50 cases, 24 patients (48%) were managed by the standard approach and 26 patients (52%) underwent conservative treatment. Additional surgical or medical treatment was performed in 35 of the 50 patients (70%). There was no maternal death. Overall hysterectomy rate was 40%, 10 patients were transferred to intensive care unit (20%), 7 had fever (14%), 5 had endometritis (10%) and 19 patients had blood transfusion (38%). Conservative treatment did not lead to hysterectomy in 21 cases (80.7%) and failed in 5 (19.3%). During the follow-up period, 3 women had successful pregnancy.

CONCLUSION

Analysis of management of placenta accreta shows that for a subgroup of selected patients a conservative approach could preserve subsequent fertility without evident increase in morbidity.

Transvaginal ultrasound measurement of cervical length and efficacy of misoprostol in first-trimester pregnancy failure

OBJECTIVE

The aim of this study was to assess the role of cervical length measurement in predicting successful treatment, by misoprostol administration, of early (first-trimester) pregnancy failure.

METHOD

A prospective study was conducted of all patients who agreed to medical treatment of pregnancy failure. Cervical length and other sonographic variables were measured using pelvic ultrasound before medical treatment began. Measurements were compared between the group with successful medical treatment and the group in whom treatment failed.

RESULTS

In 125 women included in the study, the success rate of misoprostol treatment was 64.8%. There were no significant differences between the groups with successful and failed treatment for cervical length (29.9 +/- 9.3 vs. 30.4 +/- 6.8 mm, P = 0.75), distance between gestational sac and 'virtual' cervical internal os (23.9 +/- 13 vs. 26.6 +/- 13 mm, P = 0.26), crown-rump length (8.7 +/- 9.7 vs. 6.7 +/- 8.6 mm, P = 0.25), or gestational sac diameter (31.3 +/- 14 vs. 30.1 +/- 15 mm, P = 0.73).

CONCLUSION

Cervical length does not predict the success of misoprostol treatment of first-trimester pregnancy failure.

Shiga toxin-producing and attaching and effacing Escherichia coli in cats and dogs in a high hemolytic uremic syndrome incidence region in Argentina

Shiga toxin-producing Escherichia coli (STEC), responsible for the hemolytic uremic syndrome, is an endemic pathogen in Argentina. We studied the prevalence of STEC in fecal samples from cats and dogs of Buenos Aires city and suburbs. Cultures were used for screening stx1/stx2 and rfbO157 by multiplex PCR. All E. coli-positive colonies for these genes were further characterized for the eae gene and for serotypes. In dogs, 17 (3.7%), 19 (4.2%) and 34 (7.5%) of samples were positive for stx2, stx1 and rfb, respectively. In cats, six (4.0%) of the samples were positive for stx2, three (2.0%) for stx1 and four (2.7%) for rfbO157. In 18 (4.0%) of the dog samples, a bacteriological diagnosis was obtained by isolation. The percentage of positive isolates corresponding to the rfbO157 and to the stx2 genotypes were 2.9% and 1.1%, respectively. In four of the cat samples, the bacteriological diagnosis for stx2 (2.6% prevalence of STEC) was confirmed. Although these data suggest that the high infection index of STEC in children in Argentina does not seem to be due mainly to the role of cats and dogs, there are some strains with virulence genes in common for humans and their domestic animals.

[Uterine artery embolisation to treat severe haemorrhage following legal abortion]

The aim of this paper is to present a case of hemorrhagic complication following a legal abortion treated with uterine embolisation. A 45-year-old woman, with a history of one caesarean section and seven legal induced abortions, requested legal induced abortion at 12 weeks of amenorrhea. Legal induced abortion was performed as a day case using vacuum aspiration with a plastic cannula under general anaesthesia. Severe haemorrhage, with an estimated blood loss of 800 ml, occurred during the procedure. Bleeding was not related to cervical laceration, incomplete abortion, or uterine perforation. Surgical conservative procedures and intravenous use of sulprostone (Nalador) failed to control haemorrhage. The patient underwent uterine artery embolisation with Curaspon, a porcine-derived gelfoam, used for the temporary occlusion of the visceral arteries. Successful hemostasis was obtained. The patient presented no complication related to the procedure. Severe haemorrhage following legal induced procedure is rarely reported. Emergency arterial embolisation may offer an effective modality of treatment.

[Comparative evaluation of the Joel-Cohen cesarean section versus the transrectal incision]

OBJECTIVE

The aim of this study was to compare the Joel-Cohen method for cesarean section to the traditional transrectal incision.

METHOD

Fifty-two patients requiring a caesarean section were enrolled in this prospective study. Overall morbidity and post-operative pain was assessed. Four surgeons participated to this study, each included 13 patients. The main judgement criterion was post-operative pain on the first day.

RESULTS

Post-operative pain on the first day was less important (50 vs 23% p=0.04) in Joel-Cohen's. This method was shorter compared to the transrectal incision (33.6+6.4 min vs 51.2+8 min p<0.0001). There was no difference in overall morbidity between the two groups.

CONCLUSION

Joel-Cohen's method decrease post-operative pain and is a shorter procedure compared to the transrectal incision.

In situ methotrexate injection for treatment of recurrent endometriotic cysts

OBJECTIVE

Ovarian endometrioma recurrence is frequent. Conventional treatment of ovarian endometrioma is by surgical cystectomy. We proposed an alternative medical treatment for recurrent ovarian endometrioma: cyst aspiration followed by in situ methotrexate injection.

STUDY DESIGN

From January 2002 to May 2003, 14 patients with recurrent homolateral ovarian endometrioma underwent transvaginal ultrasound guided cyst puncture and aspiration followed by methotrexate injection, whilst under general anasthesia. Recurrence rate during follow up was evaluated.

RESULTS

No complication was reported. After a mean follow up of 20+/-5 month (min: 13, max: 29), four recurrences were diagnosed (28.6%). Two asymptomatic recurrences were not treated and two painful recurrences underwent a second cyst drainage with methotrexate injection.

CONCLUSIONS

In situ methotrexate injection is a simple, effective and an interesting alternative to surgical treatment in women with recurrent homolateral ovarian endometrioma.

[Vaginoscopic hysteroscopy]

Vaginoscopic hysteroscopy permits to avoid several painful gestures of classical office hysteroscopy. The aim of this article is to describe the advantages such vaginoscopic approach. Six studies were thus selected, dealing with vaginoscopic hysteroscopy. The diameter of the hysteroscope, always a rigid one, was between 3.5 and 5 mm, and CO(2) or saline infusions were indifferently used. Failure rate is inferior to 5%. One study, comparing pain induced by vaginoscopic versus classical hysteroscopy, concluded that vaginoscopic approach was less painful.

Value of laparoscopic assistance for vaginal hysterectomy with prophylactic bilateral oophorectomy

OBJECTIVE

This study was undertaken to compare morbidity for women undergoing laparoscopy-assisted vaginal hysterectomy with bilateral oophorectomy (LAVHO) and vaginal hysterectomy with bilateral oophorectomy without laparoscopic assistance (VHO).

STUDY DESIGN

Between April 1, 2002, and February 1, 2004, a prospective randomized study at Marseille University Hospital (La Conception) included 48 patients who underwent a hysterectomy with prophylactic bilateral oophorectomy for benign uterine conditions. These patients were allocated to 2 groups (LAVHO vs VHO). The study variables were duration of surgery and of hospitalization and surgical and postoperative complications.

RESULTS

There was no significant difference in the duration of surgery between the LAVHO and VHO groups (100.2 +/- 27.9 vs 83.9 +/- 34.6, P = .08). The rate of complications was significantly higher in the LAVHO group (13/24 [54.1%] vs 6/24 [25%], P = .039).

CONCLUSION

The overall complication rate was higher with LAVHO than VHO. It thus appears that laparoscopic assistance is not useful in performing vaginal hysterectomies with prophylactic bilateral oophorectomies in patients without other related disorders (endometriosis, adhesions, adnexal anomalies).

Immediate complications of tension-free vaginal tape (TVT): results of a French survey

BACKGROUND

The aim was to evaluate morbidity following operation using tension-free vaginal tape (TVT).

METHODS

Between June 2002 and June 2003, a questionnaire was sent to French gynecologists and urologists. Participants reported the number of TVT procedures performed before January 2002, number of minor or major pre- and post-operative complications.

RESULTS

The questionnaire was returned by 92 participants (21 urologists and 71 gynecologists) who reported 12,280 TVT procedures (median: 100, minimum: 5, maximum: 2100). Overall, 901 preoperative bladder injuries were reported (7.34%). For 809 patients (6.59%), complete post-operative urinary retention requiring catheterization was noted. There were 26 cases of vaginal defect healing (0.21%). Retropubic or vulvovaginal hematoma was reported for 39 patients (0.32%). Ten major organ injuries were reported (0.08%): one obturator nerve injury, three bowel perforations, four vessel injuries and two ureteral injuries.

CONCLUSION

The risk of major complications following the use of tension-free vaginal tape is low. However, these potential complications require experienced surgeons for the practice of tension-free vaginal tape.

[Cervical ripening using misoprostol before hysteroscopy]

Cervical ripening with misoprostol is performed before office or operative hysteroscopy. Aim of this review is to evaluate benefits of cervical ripening with misoprostol before hysteroscopy . Ten studies were selected concerning office or operative hysteroscopy. Cervical ripening with misoprostol seems to be not useful for office hysteroscopy performed with minihysteroscope. Interest of misoprostol in menopausal women with traditional office hysteroscope is debatable. Risk of cervical tear during operative hysteroscopy seems to be reducing with misoprostol. However, interest of misoprostol was not found in all studies. Data were not sufficient to determine adequate dose of misoprostol, time and mode of administration. However, vaginal administration is preferable.

Risk of bladder injury during vaginal hysterectomy in women with a previous cesarean section

OBJECTIVE

To determine the risk of bladder injury during vaginal hysterectomy in women with a previous cesarean section.

STUDY DESIGN

Analysis of selected studies found through a MEDLINE search from 1980 to 2003.

RESULTS

Four comparative studies (women with or without a previous cesarean section) were selected and analyzed. Risk of bladder injury was significantly increased in only 1 study. Analysis of cumulative data did not find a significant difference (8 of 430 [1.86%] vs. 11 of 1,227 [0.89%], p = 0.12).

CONCLUSION

The risk of bladder injury during vaginal hysterectomy does not seem to be increased in women with a previous cesarean section.

Transvaginal sonographic evaluation of cervix length after cervical conization

OBJECTIVE

The purpose of this study was to evaluate transvaginal sonographic cervical length before and after cervical conization for squamous intraepithelial lesions.

METHODS

Between November 2002 and October 2004, all women undergoing conization by either cold-knife conization or a loop electrosurgical excision procedure for squamous intraepithelial lesions were prospectively enrolled in this study. Cervical length was measured by transvaginal sonography (TVS) before and after conization.

RESULTS

A total of 48 women were studied before and after a mean of 7 days after conization. Complete excision was achieved in 41 patients, and endocervical margins were involved in 7 patients. Mean TVS cervical length was significantly shorter after than before conization (mean +/- SD, 22.7 +/- 6.9 versus 26.7 +/- 8.1 mm; P < .001). The correlation coefficient between cone specimen length and postoperative length was r = 0.75 (P < .001). Mean TVS cervical lengths were 24.3 +/- 6.7 mm in the group of women who underwent a loop electrosurgical excision procedure and 20.7 +/- 9.4 mm in the group of women who underwent cold-knife conization (P = .13).

CONCLUSIONS

Transvaginal sonographic measurement of cervical length after conization is well correlated with cone specimen length.

Influence of clinical and ultrasound factors on the efficacy of misoprostol in first trimester pregnancy failure

An observational study including 276 patients with early pregnancy failure was performed to evaluate the clinical and ultrasound factors influencing the efficacy of misoprostol in the treatment of first trimester pregnancy failure. Gestational age did not influence the efficacy of this treatment and the success rate was inversely proportional to parity.

Résultats de la sacro-spino-fixation dans le traitement des prolapsus après hystérectomie

OBJECTIVE

To evaluate results of sacrospinous ligament fixation in the treatment of posthysterectomy prolapse.

PATIENTS AND METHODS

Between September 1990 and September 2002, 92 women (mean age 64.8 years, range 45 to 92 years) underwent sacrospinous ligament fixation following total hysterectomy (82.6%) or subtotal hysterectomy (17.4%); 96.7% had a menopausal status, and 21.7% used hormone replacement therapy. 48.9% of the patients had a history of surgery for prolapse (and/or urinary incontinence), and 21.7% had associated symptoms of stress urinary incontinence. In all cases, sacrospinous ligament fixation was performed under visual control using conventional stitch. Sacrospinous ligament fixation was combined with the following procedures: anterior vaginal repair (n=31), additional incontinence surgery (n=11), cervical amputation (n=11), levator myorrhaphy (n=61). Main outcome measures were intraoperative complications, postoperative complications, anatomic and functional outcome.

RESULTS

Complications were represented by 1 vaginal hematoma (related to sacrospinous fixation), 1 bladder injury, 1 ureteral injury, 3 acute urinary retentions. With a mean follow-up of 47 months (range: 12-156), 12 patients (13.5%) had failure of sacrospinous ligament fixation and 9 required additional procedures, during the first year of follow-up. 14 patients (15.7%) had postoperative cystocele, with 1 case of third-degree cystocele treated with sub-bladder prosthesis by the vaginal route.

CONCLUSION

We noted low rates of major complications and sacrospinous ligament fixation in posthysterectomy prolapse appears to give satisfactory long-term results.

Laparoscopic removal of a remaining myoma after vaginal hysterectomy: A case report

We report on an uncommon postoperative complication of vaginal hysterectomy--a remaining myoma--diagnosed and treated by laparoscopy. This procedure was performed for a remaining myoma 3 months after vaginal hysterectomy for fibroid uterus. Laparoscopy may be helpful to diagnose and treat this complication.