[Multicentric prospective randomized study evaluating the interest of intravaginal electro-stimulation at home for urinary incontinence after prior perineal reeducation. Interim analysis]

OBJECTIVES

Perineal reeducation of stress urinary incontinence is beneficial in 80% of cases. However, patients have to perform self-retraining exercises of the perineal muscles at home, in order to maintain the benefit of the physiotherapy. The aim of this study is to assess the benefit of GYNEFFIK(®), a perineal electro-stimulator, during this home-care phase.

PATIENTS AND METHODS

Women with stress urinary incontinence (UI) or with mixed UI (composed predominantly of stress UI) that responded to physiotherapy were included in this study in two parallel groups. The groups followed a self-reeducation program, with or without GYNEFFIK(®) electro-stimulation sessions. The comparison of the two groups was based on the rate of women for whom the benefit of the initial perineal reeducation was maintained (defined as non-worsening ICIQ and Ditrovie scales' score).

RESULTS

According to the protocol, an interim analysis was performed on 95 patients (i.e. almost half of the expected sample size) who had had at least one evaluation under treatment, among which 44 patients had finished the study. The therapeutic benefit of the initial perineal reeducation was maintained in 87.8% of the GYNEFFIK(®) patient group, while it was maintained in 52.2% (P=0.0001) in the usual care group (i.e. who did not use electro-stimulation).

DISCUSSION AND CONCLUSION

Likewise, patient had a more favorable subjective impression when using GYNEFFIK(®) (83.7% versus 60.0% in the usual care group) as they felt that they improved during the study. In the GYNEFFIK(®) group, no increase in symptoms was reported, whereas almost one out of five patients in the usual care group felt that their condition had worsened.

[Interest of 3D ultrasound in the follow-up of tubal sterilizations: case report of a rare tubal perforation]

The Essure™ system's effectiveness is based on the follow-up at three months. The challenge is to find a minimally invasive imaging technique to locate the devices. Therefore, many authors recommend three-dimensional ultrasound in first-line. We report here an exceptional case of tubal perforation for which ultrasound failed to diagnose. Until then, only three cases have been reported in the literature, noting the difficulty to diagnose this complication. Indeed, although ultrasound is described as reliable, reproducible and non-radiating, it is a dynamic examination, operator dependent, exposing to the risk of misinterpretation.

[Cervical screening: toward a new paradigm?]

OBJECTIVES

Analysis of the trials which compare the virologic testing (HPV testing) and the cytology in the cervical screening.

MATERIAL AND METHODS

The MedLine database was consulted using the Keywords: "cervical screening", "pap smear", "liquid based cytology", "HPV testing", "adults", "adolescents", "cervical intraepithelial neoplasia (CIN)", "uterine cervix cancer". Articles were selected according their concern about the debate of the uterine cervix cancer screening in France.

RESULTS

The HPV testing seems interesting allowing a decreasing delay in the diagnosis of CIN (more diagnosis of CIN2+ in the first round and less during the second one). But, when the two rounds are added, the number of CIN2+ are identical in the two arms (cytology and HPV testing) in all the trials (except the Italian NTCC trial). A negative HPV testing protects the women much longer than cytology can do: a delay of five years between two rounds seems ideal. The HPV testing alone increases the detection rate of cervical lesions, which could regress spontaneously and may induce an overtreatment, especially in the youngest population: a triage is necessary and the cytology appears to be the best way to select the candidates for colposcopy in case of positive HPV testing and cytology. The HPV infection presents some particularities in adolescent females: for this reason, the HPV testing should not be used in this special population. In vaccinated women, a consensus for the screening is necessary.

CONCLUSION

The health care providers in France have to understand the characteristics of the HPV testing: its advantages compared to the cytologic screening are only evident in case of an organization of the screening in France and even in Europe.

[Interest of selective lymphadenectomy in patients with vulvar cancer]

Vulvar cancer represents approximately 4% of all gynecologic malignancies and the most important prognosis factor in this cancer is the status of the regional lymph nodes. The radical inguinal lymphadenectomy, associated or not with radiotherapy, is accompanied by high morbidity, which can affect 50% of the patients. The sentinel node detection appears now to be feasible in patients with vulvar carcinoma, in order to reduce the morbidity of inguinal lymphadenectomy. But contrary to breast cancer, the learning curve is not easy to obtain because of the low number of cases. That is why we have described the procedure of selective lymphadenectomy. The aim of this technique is to remove the blue and/or marked inguinal lymph node and any other palpable lymph node, without a real radical inguinal lymphadenectomy. Thus, since November 2003, 4 procedures have been performed in total. With the lymphoscintigraphy, we identified 17 marked lymph node and we finally obtained 28 lymph nodes after surgery, with only one metastatic lymph node. There was no complication after our procedure. Selective lymphadenectomy appears to be a new procedure which may reduce the morbidity of usual inguinal lymphadenectomy.

Stérilisation tubaire par voie hystéroscopique : faisabilité et évaluation à un an

OBJECTIVES

Hysteroscopic flexible micro-insert (Essure) is an ambulatory improvement of fallopian tube sterilization, which is a deliberated suppression of fertility. The aim of this study was an evaluation of feasibility (learning curve) and the first year outcome of this method.

PATIENTS AND METHODS

This prospective study, carried out between February 2002 and March 2003, included patients who were matching with manufacturer recommendations. One surgeon only realized all the device placements.

RESULTS

Fifty patients were included (one year follow-up). Mean age was 41 (+/-3.3), mean parity was 2.7 (+/-0.8). Mean time needed for device placement was 26 minutes (+/-6.5) and was reduced with increased experience. Six failures of placement (12%) were related, because of submucus leiomyomas, proximal tubal stenotic disease or too retroverted uterus. Only 5 patients (11,4%) described intensive pelvic pain during the placement. The only case of device expulsion benefited from a successful second placement. The one-year follow-up showed no significant difference of body weight increasing, duration or quantity of menstruation, neither significant pelvic pain nor vaginal bleeding. Tolerance was rated at least at "somewhat satisfied". There have been no pregnancies reported in 670 woman-months of effectiveness.

DISCUSSION AND CONCLUSION

Our results agree in any point with those of larger studies. We think that hysteroscopy micro-insert placement is not only reserved to specialized centers but also to any gynecologist who is used to performing hysteroscopy because of its feasibility.

Enquête Propause : profil de patientes traitées par progestatif en périménopause

Progestins are widely used in France for treatment of perimenopause.

OBJECTIVES

To evaluate the real use of progestins in daily practice.

MATERIAL AND METHODS

A transverse epidemiological survey conducted between May and June 1998, by 284 gynecologists representative of French private practitioner gynecologists, who selected the first 4 patients treated with progestins for perimenopause.

RESULTS

For 887 observations collected, the most frequent indications of prescription were: functional disorders of perimenopause (57%), mastalgia (47%), premenstruel syndrome (38%), endometrial pathology (29%) and ovulation inhibition (28%). Multiple reasons were present in 81% of patients: when progestin was prescribed more than 10 days per cycle, breast pathologies were the most frequent indication and the length of treatment was more than one year; when progestin was prescribed 10 days per cycle, isolated menstrual irregularities (without breast or endometrium pathology) predominated and the length of treatment was one year or less. The most widely used progestin classes were pregnanes and norpregnanes; there was an estrogene co-prescription in 17% of cases, more frequently in women with perimenopause disorders.

CONCLUSION

We found the following pattern for progestin prescription in perimenopause: 10-day prescription for one-third of the women, 11 to 15 days for one-third, and 20 days per cycle for one-third. We thus observe some differences with recommended use. This difference is observed either with the initial prescription or with symptom-related dose adaptation.

[Fertilization in vitro: ovulation induction and oocyte harvest]

In vitro fertilization, the pregnancy rate obtained by transfer of embryo increases with the number of embryos transferred. For this reason, ovarian follicles are made to multiply and mature by means of various therapeutic patterns which stimulate ovulation. The conventional treatments with gonadotropins administered alone or combined with clomifene citrate have been superseded by GnR analogues-gonadotropin combinations. The effects of treatment are monitored by ovarian ultrasonography and by repeated measurements of serum oestradiol levels. This enables the HMG dosage to be adjusted and the injection of HCG, which completes follicular maturation, to be given at the right time. The oocytes, initially collected by coelioscopy, are now usually collected by transvaginal aspiration under ultrasonic guidance.

[Electromicroscopy of the nerve structures in human myometrium at term (author's transl)]

The authors describe the ultrastructure of myelinated and nonmyelinated nerve fibres as seen in human myometrium at the end of pregnancy. The nerve ending looks degenerate and is found in close contact with a structure that is probably muscular. This ultrastructural appearance corresponds to the quantitative levels of noradrenaline found in the tissues at the end of pregnancy which show that the uterus becomes depleted of catecholamines.