Rôle de l’échographie dans l’exploration des troubles de la statique pelvienne

The importance of using 3D ultrasound during pelvic organ prolapse surgery in relation to pre- and post-operative quality of life questionnaires

AIM

The main aim of this study is to evaluate the interest of three-dimensional ultrasound perineal in the measurement of the levator hiatus area as an objective reflection of the surgical correction of pelvic organ prolapse (POP). Our hypothesis is that POP surgery decreases the size of the levator hiatus area.

MATERIALS AND METHODS

A longitudinal and prospective study was conducted between April and July 2017 in the Department of Gynaecology & Obstetrics at University Hospital of Angers. Surgery was performed either by laparoscopy (sacrocolpopexy) or vaginal surgery (with or without the use of mesh). All patients were handed an information letter and signed an informed consent before being included in the study. A questionnaire was fullfilled before and one month after surgery. A clinical evaluation using the simplified POP-Q classification and a perineal 3D ultrasound were carried out before and after surgery by the same professional. The levator hiatus area was assessed before and after surgery in order to evaluate the impact of surgery on the levator hiatus area. Simplified POP-Q measurements and responses to PFDI-20 and PFDI-7 questionnaires were also collected.

RESULTS

A total of 18 patients were included in the study and four were excluded. Seven underwent laparoscopic surgery and seven underwent vaginal surgery. The levator hiatus area decreased substantially from 20.87 to 16.55cm² on mean (p=0.0001) at rest. Regarding patient satisfaction, the PFDI-20 score improved after surgery from 89.36 to 37.87 on mean (p=0.006), but the PFIQ-7 score did not reveal any significant changes (p=0.096). For the clinical examination, we used the simplified POP-Q with Ba measurement from 2.3 to -1.92cm (p=0.005) or Bp from -1.5 to -2.46cm, which is not a significant change (p=0.14). Points C (or D in cases with a history of hysterectomy) changed from -3.1 to -6.15cm (p=0.03).

CONCLUSION

The levator hiatus area seems to decrease after POP surgery. 3D ultrasound seems a new and complementary procedure that allowed to evaluate objectively the levator hiatus area and thus the clinical findings of the surgery.

[Severe post-obstetric perineal tears: Medium-term consequences on women's quality of life]

AIMS

To assess the prevalence of anal (AI) and urinary (UI) incontinence at medium term after 3rd and 4th degree anal sphincter tears and their impact on sexuality and women's quality of life.

MATERIAL

It is a case-control, single center study. Sixty-eight primiparous women delivered with severe anal sphincter tear (exposed group) were compared to 136 women without (control group). Questionnaires on anal and urinary incontinence, sexual function and quality of life, using validated scores, were sent between two and five years after the first delivery. Maternal and obstetric data were collected retrospectively on the medical files.

RESULTS

The answer rate was 22.5% (46/204) of which 30.9% (21/68) in the exposed group and 18.4% (25/136) in the unexposed group. In case of severe anal sphincter tear, 57.1% of women reported an AI vs 48% in the control group (P=0.76). The rate of AI for liquid stool was significantly higher in the exposed group (P=0.05). Patients with severe perineal tears reported a greater impact of symptoms on their quality of life but the difference with the control group was not significant.

CONCLUSIONS

The severity of symptoms related to anal sphincter tears is common and underestimated. Preventive measures must be improved in order to maintain women's quality of life.

LEVEL OF EVIDENCE

4.

Diagnosis of bladder cancer from the voided urine specimens using multi-target fluorescence in situ hybridization

The present study aimed to evaluate the diagnostic value of chromosomal analysis by fluorescence in situ hybridization (FISH) for bladder cancer in light of the histological diagnosis. Several valuable observations using FISH technologies in voided urine cells were also reported. The multi-target FISH-containing probes for the centromeres of chromosomes 3, 7 and 17 and the 9p21 locus were applied to cytospin specimens prepared from voided urine. Urine samples from 53 bladder cancer patients and 30 patients with benign alterations were used for this study. The histological observations of surgical resection specimens showed that the specificity and sensitivity for the technique were 100.0 and 88.0%, respectively. Statistical analyses showed that there was no significant correlation between FISH-positive rate and the tumor stage/grade (P<0.05). However, the proportion of tumor cells with genetic abnormalities positively correlated with the tumor stage (P<0.01). Furthermore, the number of abnormal cells in muscle-invasive pT2 was significantly higher than that in non-muscle-invasive pTa, pT1 (P<0.01). Of 50 patients with bladder cancer, polysomies of chromosomes 3, 7 and 17 were detected in 84.0, 48.0 and 78.0% of cases, respectively, and loss of the 9p21 gene was detected in 80.0% of cases. In addition, the detailed results from different urine specimens showed that FISH assay was required. FISH assay for chromosomes 3, 7 and 17 and 9p21 has a high specificity and sensitivity in the detection of bladder cancer and may reduce the necessity for cytoscopy treatment.

Prospective ultrasonographic follow-up of synthetic mesh in cohort of patients after vaginal repair of cystocele

OBJECTIVE

We sought to validate a sequence of ultrasonographic mesh measurements to determine the relevant time points in the postoperative monitoring of mesh size.

METHODS

Mesh was measured preoperatively ex vivo, prior to insertion, in 25 patients scheduled to undergo vaginal repair of cystocele involving insertion of a Ugytex™ transobturating polypropylene mesh. A 2D/3D perineal ultrasound scan was performed at the end of the surgical procedure (D0), then on third day after surgery (D3) and 6 weeks (W6) after the operation. Medio-sagittal view was used to measure mesh total length and the sagittal arc (length between the most distant points of the mesh).

RESULTS

Time-course changes in sagittal arc were marked by a 8% increase on D3 (with respect to D0) and a 20% decrease at W6 (with respect to D3). Mesh total length at W6 on average corresponded to 74% (±20) of mesh total length measured on D3.

CONCLUSION

This study showed the changes in the mesh ultrasonographic measurements following vaginal placement by vaginal route. The D3 ultrasound scan should appear to be suitable as a reference for subsequent ultrasonographic monitoring.