[Posttraumatic stress disorder and emergency cesarean delivery: Incidence and risk factors]

BACKGROUND

Posttraumatic stress disorder (PTSD) is declared in 3 to 6 % of postpartum women (PP) and up to 18.5 % in cases of complications of pregnancy or childbirth. The objective of this study is to assess the prevalence of PTSD after a red code cesarean section and to identify the risk factors among the prenatal vulnerability factors, the birth alert factors and the maintenance factors in PP.

METHOD

A phone or computerized questionnaire including an Questionnaire de stress immédiat and the Posttraumatic Stress Disorder Checklist for DSM-5 was offered to patients who had a red code cesarean section between 05/12/2015 and 02/28/2021 at the University South Hospital of Reunion Island.

RESULTS

Among the 555 cesarean sections selected, 329 parturients responded. The prevalence of PTSD was 20.1 % and was stable over time. The 2 risk factors found were the negative experience of childbirth and the proven traumatic experience. Prenatal vunerability factors were not found to be statistically significant. Almost 3 in 4 women had not been informed of the risk of cesarean section and more than 1 in 2 women did not have an explanation in PP.

CONCLUSION

Red code cesarean sections cause PTSD in 1 in 5 women. This lasting disorder can last up to 6 years after childbirth. This indicates the seriousness of this disorder and the need to prevent it. The risk of developing it is 4 times greater in the event of a traumatic experience proven in the Questionnaire de stress immédiat. Offering this questionnaire in the maternity could be an important element of secondary prevention. The role of health personnel remains essential.

Evaluation of physicians' practice patterns in France concerning fertility preservation in women with endometriosis

OBJECTIVE

We aim to evaluate the knowledge and physicians' practices concerning fertility preservation in women with endometriosis.

DESIGN

Descriptive, observational, national study using an online self-questionnaire, sent by email to French gynaecologists in October 2019 within 2 months.

RESULTS

We obtained 110 analyzable responses from mainly surgeons (54 %) and reproductive clinicians (19 %) with a good experience (average 15 years of practice). Amongst these practitioners, 91 % seemed aware of latest French recommendations on endometriosis issued in December 2017. The most commonly used surgical techniques for management of endometriomas were intra-peritoneal cystectomy (51 %), vaporization by plasma energy (29 %) and destruction by bipolar coagulation (8.5 %). Preoperative AMH was systematically or often prescribed by 78 % of the practitioners against 37.3 % who did it postoperatively. Furthermore, 74 % also considered and performed fertility preservation strategy to manage endometriosis. It was offered in situations of bilateral or recurrent endometrioma, but only 33 % offered it in unilateral endometrioma cases. In the cases recorded, vitrification of mature oocytes appears to be the most common fertility preservation technique (used by 87 % of the practitioners).

CONCLUSION

We observed in our population of sensitized practitioners a good and adequate knowledge concerning endometriosis physiopathology and recommendations for its management, with good information delivery to women. Operating techniques are adapted although information and education concerning fertility preservation indications seem necessary. The place of multidisciplinary concertation meeting in endometriosis appears essential both for discussion of surgical indications and for fertility preservation possibilities. Creation of dedicated structures should be encouraged.

Implementation of laparoscopy surgery training via simulation in a low-income country

OBJECTIVE

The objective of this study was to evaluate laparoscopy training using pelvitrainers for gynaecological surgeons in a low-income country.

METHODS

The study was carried out in Madagascar from April 2016 to January 2017. The participants were gynaecological surgeons who had not previously performed laparoscopy. Each surgeon was timed to evaluate the execution times of four proposed exercises, based on the fundamentals of laparoscopic surgery (FLS) programme's skills manual, as follows: exercise 1, involving a simple object transfer; exercises 2 and 3, comprising complex object transfers; and exercise 4, a precision cutting exercise. The 8-month training and evaluation programme was divided into different stages, and the four following evaluations were compared: a pretest (T0), assessment at the end of the first training (T1) and auto-evaluation at 2 months (T2) and 8 months (T3).

RESULTS

Eight participants were included. The median time was significantly reduced (P<0.05) at each evaluation for exercises 1, 2 and 4 compared to the pretest. For exercise 3, there was no difference between T0 and T1 (P=0.07). After 8 months of training, all participants progressed in all exercises.

CONCLUSION

Our study showed that it is possible and beneficial to develop a programme for teaching laparoscopic surgery in low-income countries before providing the necessary equipment.

Impact of hydroxychloroquine on preterm delivery and intrauterine growth restriction in pregnant women with systemic lupus erythematosus: a descriptive cohort study

OBJECTIVE

The aim of this study was to evaluate the effect of hydroxychloroquine (HCQ) on fetal preterm delivery and intrauterine growth restriction (IUGR) in a cohort of pregnant women with systemic lupus erythematosus (SLE).

METHODS

Over an 11-year period (January 1, 2001 to December 31, 2011), all women with SLE and admitted to deliver after 22 weeks of gestation to Bordeaux University Hospital (France), were retrospectively enrolled in the present study. The population was then split into two groups based on the treatment they received: HCQ exposed (HCQ+) versus HCQ non-exposed (HCQ-) group.

RESULTS

118 pregnancies were included, 41 in the HCQ+ group and 77 in the HCQ- group. The rate of adverse fetal outcome was significantly lower in the HCQ+ group (p = 0.001), particularly in terms of preterm delivery, 15.8% versus 44.2% (p = 0.006), and IUGR, 10.5% versus 28.6% (p = 0.03). No adverse outcomes were reported in the HCQ+ group.

CONCLUSION

HCQ reduces neonatal morbidity in women with SLE by significantly decreasing the rate of prematurity and intrauterine growth restriction.

[Male breast cancer: prognostic factors, diagnosis and treatment: a multi-institutional survey of 95 cases]

OBJECTIVES

The optimal treatment for male breast cancer is not known because male breast cancer is a rare disease. It represents as little as 0.6% of all breast cancers and less than 1% of human cancers. The aim was to analyze the clinical, histological and therapeutic characteristics of 95 men cared for breast cancer between 2000 and 2010 in four hospitals, and determine predictors of poor prognosis to improve care of male breast cancer.

METHODS

This study is a multi-institutional survey, retrospective, involving four French institutions: Cancer Institute of the West (ICO), Reunion Island South hospital group, the hospital group of Dax, and the Bergonié Institute. All carcinomas in situ or invasive breast occurred in male patients were included. An analysis of clinical, histological and therapeutic features was performed. Statistical analysis of our study focused on the overall survival of patients and specific method of Kaplan-Meier, enabling search for predictors of poor prognosis.

RESULTS

The mean age was 65 years. Thirty-seven percent of patients were overweight or obese. It was in 88% of cases of palpable tumor whose average size was 26.29mm. Ninety patients, none had a lesion palpable T0, 44% T1 tumors, 38% T2 tumors, 3% had a T3 tumors, and finally 10% T4 tumors. The histological type was the most common invasive ductal carcinoma (87%). He found a similar proportion of patients with or without lymph node involvement. N+ patients, capsular rupture was observed in 29% of cases. Receptor positivity was found, estrogen in 95% of cases and progesterone in 83% of cases. Additional irradiation was performed in 75% of patients and chemotherapy in 37% of patients. Overall survival was 79.2% at five years and 70.8% at ten years. Age, tumor size and histological capsular rupture are factors that significantly influence the overall survival and specific.

CONCLUSION

Male breast cancer is a different pathology of breast cancer in women. The majority of recommendations suggest treating men who are diagnosed with breast cancer, using the guidelines applied to postmenopausal women treatments. There is no study based on male population that has evaluated these treatment modalities in terms of impact on survival. The diagnosis is usually made at later stages, and tumor size is often greater. Histological characteristics also differ. However, the treatment is almost identical.

[Determinants of group B streptococcus maternal colonization and factors related to its vertical perinatal transmission: case-control study]

OBJECTIVES

To investigate the determinants of Group B streptococcus (GBS) maternal colonization, as well as factors associated with its vertical transmission.

PATIENTS AND METHODS

Case-control study on all singletons pregnancies delivered beyond at least 24 weeks of amenorrhoea in Southern Reunion maternities for which GBS screening was known. Multiple logistic regression analysis using 2004-2007 dataset of South Reunion birth registers.

RESULTS

Out of 17,430 women delivered between 1st January 2004 and 31st December 2007, 2911 (16.7%) carried GBS. In a model adjusted on antenatal care, risk groups for GBS carriage were the women indigenous from another island of the Indian Ocean than Reunion (OR: 1.29, CI95%: 1.05-1.57) and obese women (body mass index ≥ 30, OR: 1.19, CI95%: 1.03-1.18). Protective factors included birthplace in mainland France (OR: 0.82, CI95%: 0.69-0.97) and underweight (OR: 0.81; CI95%: 0.69-0. 95). In a model controlling for a composite obstetrical variable delineating the protective roles of C-section and antibioprophylaxis as well as the putative role of meconium-stained fluids (thin, thick or fetid), all previously found in our setting, three key factors were independently associated with GBS vertical mother-to-child transmission: obesity (OR: 1.48, CI95%: 1.05-2.09), fetal tachycardia (OR: 4.92, CI95%: 2.79-8.68) and late preterm birth (35 to 36 wks, OR: 2.14, CI95%: 1.32-3.45).

CONCLUSION

These findings strengthen the putative roles of corpulence and ethnicity in GBS acquisition previously found in the United States, while confirming an authentic role of obesity in its vertical transmission, independently of other classical cofactors lighted by our study.

[Nipple sparing mastectomy: an update]

In order to decrease the psychological impact and the mutilating feeling of surgical treatments of the breast cancer when the mastectomy is indicated, authors described and propose the nipple sparing mastectomy (NSM). The only opposable criticism would be the increase of recurrence rate. The study of the recent literature allows us to make a inventory of fixtures concerning this evolution of the surgical practices whether on a technical, oncological, plastic or psychological plan. This technique is not validated in France and adjuvent therapies as the radiotherapy of the nipple are not validated yet. It seems that the NSM is a safe practice from the carcinologic point of view, while having a positive psychological impact in terms of disease and treatment acceptance. The technique seems possible after an information and selection of the patients and with a respect for technical rules (frozen section, peroperative evaluation of the nipple vitality).

Tissue resistance of the tension-free procedure: What about healing?

The aim of our work was to objectify and quantify the mechanical benefits of healing with regards to tearing meshes off of tissues and maximal resistance after cicatrization. In vivo, we tested the mechanical gain in resistance by healing after implantation of a Prolene mesh. We measured the value of forces when traction was exerted until mobilization at different stages of cicatrization. Resistance increased progressively at the beginning of tissue inclusion. A maximal plateau was reached around the 25th day. It is important to understand the role of sustaining and reinforcement we hope tissue integration of the mesh will play. We can thus adapt procedures to have the best kinetics and maximal resistance of montages. Study of the kinetics and maximal plateau allows us to make the best clinical recommendations.

Prosthetic reinforcements: how to manage bladder injuries?

The aim of this study was to describe our experience in the management of bladder injuries occurring at intervesicovaginal dissection during the tension-free vaginal mesh (TVM) procedure. Seven hundred four patients were treated for prolapse by vaginal route using the TVM procedure. Bladder injury was diagnosed during the procedure in five patients. Polypropylene mesh was placed in the intervesicovaginal space after a careful repair of the bladder injury. Major postoperative complications were not diagnosed during the short-term follow up. We describe the occurrence and treatment of bladder injuries during the dissection phase in the TVM procedure. Such injuries can occur during the dissection. Placing an intervesicovaginal mesh is acceptable if cautious bladder repair is performed.

Choriocarcinome tubaire: à propos d'un cas et revue de la littérature

The authors describe a case report of a tubal choriocarcinoma occurring in women of 32 years old, 2 years after her last pregnancy. The patient was treated by laparoscopic salpingectomy and polychemotherapy. Metastatic pulmonary micronodules were diagnosed at thoraco-abdomino-pelvic tomodensitometry. Patient's recovery was complete with an uneventfull follow-up at 3 years. The association of surgical treatment and chemotherapy used under the guidelines of the FIGO score improves patient's outcome.

[Tissue resistance: what about tension-free?]

OBJECTIVES

The purpose is to quantify objective tissue resistances before healing of prostheses used in pelvic floor surgery.

PATIENTS AND METHODS

We measured tissue resistances offered to five types of meshes by four classical surgical routes. We also tested the incidence of the modification of the width of meshes on tissue resistance. This study was realized on frozen cadavers, by pull on prostheses just after implantation. Tests are realized with a dynamometer and results obtained in Newton.

RESULTS

In the Retzius space, TVT offers a better resistance than IVS or LIFT meshes. We did not bring to the fore a significant difference between four routes for 1 cm wide prosthesis. The increase of width of Prolene meshes improves their resistance in tissues and thus quality of their fixation. We underscore a better resistance of the trans sacrospinous route with regard to the trans muscular one.

DISCUSSION AND CONCLUSION

The increase of resistance is bound to the increase of the contact area between the prosthesis and the tissues. This increase of resistance should be taken into account in prolapse surgery: constraints are stronger than for stress incontinence. The posterior arms of meshes have to measure more than 1 cm wide and be set up through the sacrospinous ligament rather than through the elevator muscles. The type of knitting of prostheses is important and influences the resistance in tissues in the immediate postoperative time. Manufacturers should be interested in conceiving specific meshes for the tension-free fixation, with special and adapted mechanical properties.

Évaluation IRM des chirurgies du prolapsus

OBJECTIVE

To bring to the fore the differences in terms of anatomical restoration between the abdominal and vaginal approach of pelvic floor repair. We compared the short-term anatomical results of the sacropexy and the sacrospinous fixation and paravaginal repair.

PATIENTS AND METHODS

Magnetic Resonance Imagery (MRI) allowed us to obtain a reproducible and objective comparison of location of the various pelvic organs. Forty-three patients benefited from a MRI a pre- and postoperative evaluation according to the position of organs with regard to the pubo-coccygeal line. We noted cystocele, hysterocele or enterocele when the bladder, the uterine cervix, or the Douglas' cul-de-sac came under this line during efforts of push. We measured length modifications and lateral and anteroposterior vaginal axis.

RESULTS

After the surgery, we noted that all pelvic organs were found above the reference line. On the other hand, bladders are significantly situated less high after vaginal pelvic floor repair. There is no postoperative difference as regards of the vaginal wall location. The lengths and vaginal axis are comparable in pre- and postoperative evaluation.

DISCUSSION AND CONCLUSION

In our study, the anatomical results of pelvic floor repair performed by vaginal or abdominal route are short-term comparable and the vaginal approach is not responsible for decrease of length or vaginal reorientation. Standardized and longer term evaluated, the MRI can represent an objective and reproducible help to the staging of pelvic floor dysfunction.

Traitement chirurgical du prolapsus génital chez les femmes âgées de plus de 80 ans

OBJECTIVES

The aim of this study was to assess the morbidity and the effectiveness of the vaginal surgical treatment for women over 80 years of age with genital prolapse.

MATERIALS AND METHODS

All the women over 80 years operated in our institution between 1996 and 2003 were reviewed retrospectively. We examined the risk and the effectiveness of this surgery.

RESULTS

Forty-eight women underwent surgery during this period. No colpocleisis was performed. The most frequent surgery was a combination of vaginal patch plastron, Richter's spinous fixation and posterior perineorrhaphy. No major intra- or post-operative complication occurred. One woman required blood transfusion. The most frequent postoperative complication was voiding difficulties (12%), which had disappeared 3 months later. A partial stenosis of a left ureter with ureterohydronephrosis occurred, requiring endoscopic dilatation. At 3 months, anatomic and functional outcome was good in 92% of women. The number of patients lost to follow-up at one year was to large to draw any conclusion.

CONCLUSION

Complete transvaginal surgical treatment is a safe procedure for elderly women which provides good short-term effectiveness.

Les malformations artério-veineuses intra-utérines

Intra-uterine arteriovenous malformations are a possible etiology of persistent metrorrhagia especially in the event of a history of miscarriages, cornuale pregnancy, molar pregnancy or gravidic trophoblastic diseases. We report 4 cases of patients having an intra-uterine arteriovenous malformation. The diagnosis of such lesions calls upon first intention Doppler echography. This diagnosis is confirmed thereafter by angiography. The first intention treatment is embolization which can save time if carried out at the same time as the angiography. This treatment is rapid and final, enabling the patients to have other pregnancies later on. An echographic follow-up, according to a schedule which remains to be defined, is necessary in order to check the good involution of this type of vascular malformation.

[Haemostatic hysterectomies in developing countries: A vital act. Prospective study in a reference Nigerian maternity]

OBJECTIVE

The purpose of our prospective study was to determine the frequency, the main indications and difficulties of coverage of the peripartum haemostatic hysterectomy in a developing country. The secondary purpose was to assess the maternal forecast and suggest suited management and to estimate the necessary material and human means to reduce the incidence of this surgery.

PATIENTS AND METHODS

We realized a forward-looking monocentric study in the Issaka Gazobi maternity of Niamey, between January 1st, 2003 and December 31st, 2003.

RESULTS

3255 deliveries took place, and 41 peripartum haemostatic hysterectomies for post-partum haemorrhage were realized (ie 1.26%). The mean age of our patients was 32.76. The multiparous (more than 5 children) were most often concerned. The majority of patients had benefited from an in utero transfer. 31 patients presented an active bleeding, 11 were in a state of shock during the admittance. The main indications of hysterectomies were represented by an abruptio haematoma, uterine inertia, a rupture of the uterus, a wound of the genital field, 1 placenta accreta with uterine inversion. In a third part of the cases a disseminated intravascular coagulation was associated to the clinical picture. The hysterectomy was subtotal in most of the cases. Finally, the rate of maternal death is high in our series.

DISCUSSION AND CONCLUSION

Prevention of post-partum haemostatic haemorrhage and new therapeutic strategies are essential to reduce the rate of haemostatic hysterectomy in our regions, and improve the coverage of this pathology. However, it is a vital surgery which must be technically mastered.

Les prothèses synthétiques dans la cure de prolapsus génitaux par la voie vaginale : bilan en 2005

Since 1996, prosthetic meshes have become increasingly popular for transvaginal surgical cure of genital prolapse. In light of the growing number of proposed techniques and materials we reviewed the experience of the pioneers in order to provide surgeons with the most objective information available. We reviewed the literature indexed in Meline/PubMed and Current Contents retaining all work concerning resorbable and non-resorbable meshes. For the larger class of non-resorbable meshes we also reviewed articles by category of material, each type of mesh being carefully defined: different compositions of polypropylene, polyester, composite meshes and also insertion kits. Resorbable meshes were evaluated in two randomized studies which did not demonstrate better results than with simple folding known to have a high rate of recurrence. For polypropylene meshes, Marlex was studied in six trials which demonstrated a high rate of cure at one year but also a high rate of erosion which reached 25%. Use of Atrium was mentioned in three studies with a 6 to 12% recurrence rate and an erosion rate nearly reaching 20%. The majority of studies used Prolene and Gynemesh. Seventeen authors reported their experience, generally reviewing retrospective series, with recurrence rates of less than 10% for follow-up periods rarely greater than two years. A large variety of forms and sizes have been used, hindering comparisons. The rate of erosion was also quite variable, as high as 45%, demonstrating the need for a precise definition of erosion. Only recently have authors shown interest in the impact of prosthetic meshes on quality of life and sexual activity. An improvement is generally noted for defecation but the rate of dyspareunia has reached as high as 60%. Here again grades of prosthetic retraction should be better defined. Proposed to improve these phenomena, soft Prolene recently used by several authors does not appear to fulfil expectations. Since 2005, several precut polypropylene meshes have been proposed with an insertion kit. The Prolift kit has been followed prospectively in 100 patients undergoing regular surveillance. Surgipro has been used sporadically in small series but follow-up is still too short for proper assessment. Polyester meshes (Mersilene and Paritex) have been presented by three authors who have found them useful but reports have been vague concerning results and complications. Polytetrafluoroethylene has not been evaluated for transvaginal surgery, probably because of the poor tolerance of suburetral bands. For composite meshes, Vypro has been used by four authors who noted about 10% erosion but with a short follow-up insufficient to draw conclusions about the functional and anatomic outcome. Surfaced meshes, advocated for transvaginal treatments, have been studied in only two reports. Plevitex is a polypropylene mesh coated with collagen; another polyester composite with polyglactin 910. The rate of dyspareunia varied from 14 to 24%. Other composites with antiadherents or antiseptics are also proposed for transvaginal insertion but have not been studied. This work demonstrated the lack of sufficient evidence from prospective randomized trials and the lack of standardized techniques to draw any definite conclusions. While evidence is being accumulated on the lower rate of recurrence for anterior compartment prolapse, the lack of data on the rate of complications and patient quality of life is unacceptable for this functional surgery. We still have reservations about widespread use of synthetic meshes. A special chapter is detailed in appendix on post-operative complications. These new specific complications call to a new semiology, with a classification in 4 types and under-types, proposed by authors. Type 1: defects of healing. Type 2: the infection of the graft. Type 3: the shrinkage of the mesh. Type 4: erosions. Authors detail the symptoms of these 4 types as well as the prevention and the treatment of these complications.

[Acute per-partum feto-fetal transfusion. A case study on two sets of twins]

Description of acute per-partum feto-fetal transfusion. The risk of twin-twin transfusion syndrome in monochorionic twin pregnancies is well known. This pathology starts in the second trimester and has a chronic course. Acute per-partum feto-fetal transfusion seems to be less frequent and has not been studied. In the study, we described two cases of acute per-partum feto-fetal transfusion. The outcomes of the pregnancies were as follows: following a successful delivery, the first set of twins presented hypovolemic shock at birth due to an acute anemia. The second set of twins was polyglobulic, but otherwise healthy at birth. The risk of hypovolemic shock seems to be unpredictable, even if the pregnancy is monitored. Obstetricians and pediatricians must keep this pathology in mind when dealing with this kind of pregnancy. Moreover, it would be interesting to obtain systematically a full blood count of each set of twins of monochorionic pregnancies, in order to detect every case of feto-oetal transfusion.

Prise en charge de la grossesse extra-utérine dans les pays en voie de développement : exemple d'une maternité de référence au Niger

OBJECTIVE

We report 143 cases of ectopic pregnancy (EP) treated in the Issaka-Gazobi maternity of Niamey between January 1st, 1999 and April 30th, 2001 (28 months). The objective of this study was to estimate the epidemiological, diagnostic and therapeutic aspects to propose actions, which could lead to the improvement of the prognosis of EP.

PATIENTS AND METHODS

The frequency of ectopic pregnancy was 2.32% in our study. The patients were young and pregnant for the second or third time. Frequently we observed previous sexually contagious infections and/or abortions. More than 70% of the patients were admitted for a complicated stage of EP.

RESULTS

The culdocentesis allowed to evoke the diagnosis in more than 80% of the cases. It is a simple gesture, which makes it possible to make the diagnosis of EP and which should be taught and practised in maternities of the developing countries. The pelvic ultrasonography and the laparoscopy allowed the diagnosis in the other cases. The tubal localization was the most frequent, cervical and abdominal pregnancies were found. The surgical treatment conducted by laparotomy was conservative in 11.9% and radical in 87.4% of the cases. The mortality rate was still 0.70%.

DISCUSSION AND CONCLUSION

Prevention of the sexually contagious infections and medical management of abortions are important to reduce the risks of ectopic pregnancies. Education of the patients, living far from the maternity, is also necessary to obtain more precocious consultation in case of pregnancy in order to improve the prognosis of EP.

A biomechanical model of the pelvic cavity: first steps

The surgical treatments of genital prolapsus are still empirical and poorly valued. We plan to achieve a method for the objective assessment of the troubles of the pelvic statics and of the various surgical strategies. The methodology considers 3 axes: building a 3D mechanical model of the pelvic cavity, mechanical characterization of the concerned organic tissues, in-vivo measurement of the intravaginal pressures. The MRI images are acquired according 3 orientations (sagittal, axial and coronal); the organs (bladder, vagina and rectum) are manually outlined and their 3D shape is then rebuilt. Uniaxial tensile tests are initially developed on animal samples before being applied to peroperative human samples. In-vivo measurements of the intravaginal pressures are made thanks to a set of 8 strain gauges specially designed. We show results obtained on 2 patients with a different rank of prolapsus. These first steps will be continued by a more detailed geometry of the organs and a characterization of healthy tissues. Dynamic behaviour of the mechanical stresses will also be investigated.

Traumatismes crâniens obstétricaux spontanés : mythe ou réalité ?

In spite of the fact that there are many articles considering that intrauterine depressed skull fractures are caused essentially by instrumental extraction, literature is scarce about spontaneous foetal head injuries. Here, we report the case of two depressed skull fractures and one of linear fracture not associated with any known trauma during the pregnancy or delivery. The etiological process leading to the idiopathic character of such lesions, the aetiology, the treatment and the prognostic will be discussed. The forensic problem raised by such cases is very important.

Métastase ovarienne d'un mélanome malin : à propos d'un cas

The diagnosis of malignant melanoma metastatic to the ovary is rare. The primary lesion can be followed by metastasis site after few years. We describe the case of a 31 year-old woman who presented an acute pelvic pain in relation with a right ovarian cyst. This patient presented many metastatic melanoma few years ago. The ovarian metastatic diagnosis is strongly suspected by the use of preoperative magnetic resonance imaging. The operating piece immunohistochemical studies demonstrated the positivity for S-100 protein, HMB-45 and negativity for keratin in cytoplasm cells. The surgical treatment (right salpingo-oophorectomy) would be followed by chemotherapy. The patient had a good postoperative recovery. She is in good health at six months.

Carcinome à petites cellules de l'ovaire hypercalcémiant révélé par un épisode de pancréatite aiguë : à propos d'un cas

Small cell carcinoma of the ovary of the hypercalcemic type is a rare tumour, usually lethal and occurring almost exclusively in young patients. In the majority of described cases, signs of this lesion were revealed by the associated hypercalcemia or by virtue of the physical tumour bulk alone. We report the first case of ovarian small cell carcinoma of the hypercalcemic revealed by a severe acute pancreatitis in a 19-year-old patient.

Prise en charge des mutilations génitales féminines de type III

Female genital mutilation (FGM) consists in a non-therapeutic removal of part or all of the external genitalia and /or injury to the external genitalia. This practice in common in a few African countries and in Middle East. Mass immigration of African women to Europe in the past decade has brought the problems of FGM to these countries. There are four types of FGM. Many early (hemorrhage, infectious) and/or late (uro-gynecologic and obstetric) complications can be associated. The dermoid clitoridia cyst is the most frequently complication. Rigorous obstetrical labor monitoring is not possible. Therefore labor is longer and there are many delivery complications. The treatment is based on Gabbar's deinfibulation surgery which can be proposed when there are uro-gynecologic complications, or during pregnancy and labor. This method can lead to spontaneous vaginal delivery without perineal trauma. The aim of this article was to share our experience and inform obstetrician-gynecologists about FGM.

Étude objective de résistance des ligaments pelviens utilisés dans les cures de prolapsus et d'incontinence urinaire d'effort

OBJECTIVE

Underline the objective strength of the pelvic ligaments.

PATIENTS AND METHODS

Twenty nine human female pelvis cadavers, whose storage conditions differed, were used in our study. In each cadaver we dissected all the ligaments used in pelvic surgery. A subjective clinical evaluation of the ligament properties was performed by visual observation as well as by finger palpation. Ligaments were classified into three groups in terms of thickness and apparent strength following finger palpation, high, doubtful and low apparent quality ligaments. Then a suture taking the entire ligament switched the ligaments and a force was applied on the vagina axis until tearing. The device used for strength measurement during traction was a Samson type force gauge, which was developed for the purpose of our study. Results were given in Newtons.

RESULTS

We found a great variability in the values obtained at tearing with maximal values at 200 newtons and minimal at 22. Individually measured, ligament strength varied between individuals, and for a same patient between the type of ligaments and the side. The pre-vertebral ligament was on average the strongest. For bilateral ligaments, there was no difference between the left and right side. The iliopectineal ligament was statistically significantly stronger than sacrospinous and arcus tendineus of pelvic fascia. There was a correlation between subjective evaluation and objective strength measurements.

DISCUSSION AND CONCLUSION

We performed the only study of the strength of pelvic ligaments at tearing. These are, however, routinely used in the cure of prolapse and urinary incontinence. Our results show that there is a great variability in strength between individuals, and for a same patient between the types of ligaments and side. These observations could explain some of the surgical intervention failures and demonstrate the importance of per-operative strength evaluation. Per-operative subjective evaluation on strength is related to objective measurements and could be used to determine the type of ligaments to be used for surgical assembly suspension.

L'antécédent de césarienne est un facteur de risque opératoire de l'hystérectomie vaginale

OBJECTIVE

We describe the intra and postoperative frequency of complications in vaginal hysterectomies for benign disorders in patients with a history of caesarean section.

PATIENTS AND METHODS

Since 1996, 963 hysterectomies have been performed in our institution. 76.94% were performed exclusively by vaginal route (n = 741), 10.1% (n = 98) were by laparoscopic-assisted vaginal route and 12.9%, by pure abdominal route. We compared two groups of patients who underwent vaginal hysterectomy, with or without history of caesarean section. In each group we recorded the characteristics of the population and compared the intra and postoperative data, such as bladder or digestive tract wounds and haemorrhages. We used analysis of variance tests to compare means, chi2-tests and Fisher's exact tests for comparisons of numbers. A probability of P < 0.05 was adopted as the limit of significance.

RESULTS

The frequency of haemorrhages was significantly higher in the patients with a history of caesareans. Bladder and intestine injury rates are significantly higher in the previous caesarean section group, but not significant for the bowel injuries. We compared the cumulative frequency of complications between the two groups. In the group with previous caesarean section, we recorded 18.3% of intra operative complications. In the group without history of caesarean section, we recorded 3.58% of complications. There is a significant difference between the cumulative frequency of complications in the two populations of patients in favour of the sub group without a history of caesarean scar (P < 0.0001).

DISCUSSION AND CONCLUSION

A history of single or multiple previous caesarean section increases the intra operative risk in vaginal hysterectomies. The surgeon must take into account the history of caesarean section and be attentive to the previous operating time of the bladder and uterine region especially at the time of opening the anterior peritoneal cul-de-sac. Nevertheless, uterine scarring as a sequel to caesareans must not be a contraindication to the vaginal route.

[Promontofixation procedure: use of non-absorbable sutures or Tackers?]

AIM

Description and evaluation of ligamentopexy techniques using strings and spiral staples.

MATERIAL AND METHODS

We first describe the ligamentopexy procedure using non-absorbable sutures before comparing this technique to the use of Tacker type staples. We describe the advantages and disadvantages of this procedure in terms of surgical technique, secondary complications and biomechanical strength.

RESULTS

For our team, recommendable attitude is to use non-absorbable sutures for the fixation to the prevertebral ligament. The main advantages of the use of staples are the ease and facility for learning the technique. The risk of spondylodiscitis is rare but enhanced by the deeper penetration of the staples into the intervertebral discs. In terms of resistanc, promontofixation using sutures is much stronger compared to staples.

CONCLUSION

The use of sutures for promontofixation, in laparoscopy, is preferred to the utilization of staples type Tacker. These staples should be used when there is a risk of needle stitches for the patient.

Long-term results of the Burch procedure combined with abdominal sacrocolpopexy for treatment of vault prolapse

The aim of the study was to determine the long-term results of Burch procedures combined with vault prolapse repair by abdominal sacrocolpopexy. Between 1986 and 1997 82 women (mean age 46.0 years, range 27-79) underwent sacrocolpopexy combined with a Burch procedure. All patients presented with urinary incontinence and vault prolapse. The surgery consisted of a Burch procedure using non-absorbable suture material, and abdominal sacrocolpopexy with a non-absorbable mesh. The mesh was placed anteriorly and posteriorly in 66 cases, posteriorly (rectovaginal) in 12, and anteriorly (vesicovaginal) in 4. Additional procedures included hysterectomy (34 cases), enterocele repair (79 cases), and posterior repair with perineorrhaphy (65 cases). Failure was defined as the presence of persistent or worsened postoperative stress urinary incontinence (SUI). At a mean follow-up of 86 months (range 24-133) 34% (28/82) of patients were dry, and another 46% (38/82) were improved compared to their preoperative status. The postoperative SUI rate (persistent, worsened) after the placement of a single anterior mesh (4 failures out of 4) was higher than the postoperative SUI rate after combined meshes (41 failures out of 66) (log rank P = 0.05). All the patients with a history of prior surgery had worsened or persistent stress urinary incontinence (7/7), but 63% (47/75) of those with no prior surgery for stress urinary incontinence had worsened or persistent stress urinary incontinence (log rank P = 0.01). One case of recurrent rectocele was observed (after 20 months) and treated by transvaginal Richter sacrospinous fixation. At a mean follow up of 7 years, the Burch procedure combined with abdominal sacrocolpopexy appears to be less effective than previously published long-term results for the Burch procedure alone.

[Mechanical properties of biological or synthetic implants used to treat genital prolapse and stress incontinence in women : what is the ideal material?]

INTRODUCTION

Many surgical techniques proposed for genital prolapse or stress incontinence use prosthetic material to reinforce native tissues. Most of the synthetic meshes used have been designed for hernia repair.

MATERIAL AND METHOD

We study the biomechanical properties of human Alloderm or animals tissues like Pelvicol and of synthetic resorbable and permanent meshes. We report the results from the literature. We report the results of a personal study of the biomechanical properties of synthetic meshes.

RESULTS

The literature on biomechanical properties of biological or synthetic meshes and their evolution after implantation is sparse. Biogyn ITY or Prolène are the only meshes without spatial orientation. Their resistance to rupture and mechanical properties are variable and seem poor for Biogyn W8 et Mersuture.

DISCUSSION

Reviewing the literature we discuss the ideal properties for synthetic meshes used for cure of genital prolapse.