A. Bafghi

Multifilament polypropylene mesh for urinary incontinence: 10 cases of infections requiring removal of the sling

One hundred and forty-nine women received a suburethral woven polypropylene mesh insertion for urodynamic stress incontinence. Eleven patients (7.5%) presented between 4 and 17 months after surgery (mean 10 months) with symptoms of retropubic infection. Ten patients required surgical exploration, drainage of the collection and removal of the tape either unilaterally (six) or bilaterally (four). Bacterial cultures were negative in nine women. Following removal of the tape, eight patients reported residual incontinence, either stress leakage (five) or de novo urge incontinence (three). Multifilament polypropylene meshes appear to be more at risk of infection, usually requiring sling removal, which may be related to pore size of the mesh. Our data reinforce the importance of proper evaluation of new surgical procedures by rigorously designed randomised trials with adequate follow up to identify rare but potentially serious complications.Sir, Proposed mechanism for polypropylene tape erosions Repair of damaged connective tissue with implanted mesh is a well-established technique in almost any form of surgery. Any implanted foreign body may cause a foreign body–tissue reaction. Indeed, all ‘tension-free’ vaginal tape operations are based on this principle. An implanted plastic tape irritates the tissues to create a longitudinal deposition of collagen to reinforce the posterior pubourethral ligament,1 the anchoring point for the three-directional muscle forces that facilitate the urethral and bladder neck closure mechanisms.2 Bafghi et al.’s clinical observations of sinus formation were reported in the original animal studies on which all ‘tensionfree tape’ operations are based.1 Woven Mersilene multifilament tapes were implanted as an inverted ‘U’, with both ends lying free in the vagina. Ten of 13 canines developed a suprapubic sinus. Like Bafghi’s patients, all remained afebrile and well, and no significant growth was noted on bacteriological examination. Radioactive Gallium studies showed no evidence of infection. In all cases, the sinus disappeared within 48 hours of vaginal removal of the tapes, accomplished by pulling on the vaginal end. In that study, macrophages were noted in the interstices of the tape. In subsequent human and animal studies on multifilament polypropylene tapes, macrophages were noted surrounding individual microfibrils in spaces less than 5 m.3 These data do not support the ‘pore’ hypothesis, which states that macrophages cannot enter spaces less than 10 m. The experience of the two first authors over 4000 clinical cases confirms this experience: it is unusual to grow significant bacteria in cases of tape rejection, even in cases where a skin sinus is present. Neither Bafghi et al. nor de Boer grew significant bacteria, and there is no mention of bacteria being

Spatula-assisted deliveries: a large cohort of 1065 cases

OBJECTIVE To analyze neonatal and maternal complications of operative vaginal delivery using spatulas. STUDY DESIGN We conducted a retrospective observational study of 1065 consecutive spatula-assisted deliveries at Nice University Hospital from 2003 through 2006, excluding stillbirths and breech deliveries. After univariate analysis, we performed logistic regression analysis to assess risk factors for severe perineal injuries and vaginal lacerations. RESULTS The success rate was 98.2%. Vaginal tears occurred in 23.7% of patients. The rate of third and fourth degree perineal injuries was 6.2%. No severe neonatal complication directly related to extraction was noted. Nulliparity, shoulder dystocia and absence of episiotomy were independently associated with an elevated risk of anal sphincter damage. Nulliparity and absence of episiotomy were significantly and independently associated with an increased incidence of vaginal tears. CONCLUSION Rates of perineal injuries, failure and neonatal complications observed with spatulas were similar to those reported in the literature with other instruments for operative vaginal delivery.

Fistules entérogénitales d'origine digestive bénigne : À propos de trois cas

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 35 - N° 7 - p. 720-724Fistulas between the female genital tract and the digestive tract occur after obstetrical, oncological, or post-operative complications. We report herein 3 rare cases of enterogenital fistulas: one colouterine fistula and one colotubal fistula in a patient with diverticulitis, and one ileovaginal fistula in a patient with Crohns disease. Vaginal discharge was frequent and incited patients to consult a gynecologist. Better knowledge of enterogenital fistulas is necessary to enable earlier diagnosis and apply specific treatment. The incidence of colovaginal fistulas is increasing in diverticular disease because of increased prevalences of hysterectomies and diverticular disease.

Un motif de consultation surprenant : la perception de fils sortant par l’anus: À propos d’une complication rare de la pose de DIU

Resume La perforation rectale par une migration de sterilet est une complication rare qui necessite d’etre parfaitement connue des praticiens du fait de ses particularites therapeutiques qui peuvent associer des examens endoscopiques a une prise en charge chirurgicale.

Évaluation selon l’âge de la technique TVT

OBJECTIVE: To compare efficacy and long-term morbidity of the TVT between patients younger than 70 years and patients older than 70 years. METHOD: Retrospective monocentric study from January 2000 to May 2001. A postal questionnaire was sent to patients to evaluate their satisfaction and their functional status after surgery. RESULTS: The study included 154 patients, and 137 (89%) answered the questionnaire. Seventy-two were less than 70 years old (52.5%) and 65 were more than 70 years old (47.5%). The satisfaction rate in the total population was 88.3%. Amongst the patients younger than 70 years, 97.5% were cured or improved, versus 78.5% of the oldest patients (p=0.001). The study within age groups showed that the satisfaction rate between 70-74 years was higher (92.6%) than in the total population and lower after 75 years (66.7%). This difference is linked to the rates of de novo and persistent urge incontinence, which increase after 75 years. CONCLUSION: The TVT seems to be a good treatment for urinary incontinence in women younger than 75 years. Patients should be warned that preoperative urge incontinence may persist after surgery.

Découverte fortuite d’une tumeur vésicale au cours d’une opération de TVT

Resume La generalisation du TVT ( tension-free vaginal tape ) lors de ces dix dernieres annees, nous mettra probablement face a des pathologies qui necessiteront un traitement par voie trans-uretrale. On rapporte un cas de tumeur vesicale decouvert pendant une cystoscopie peroperatoire d’une operation de TVT et qui a necessite plusieurs resections par voie trans-uretrale. Ces resections ne semblent pas influencer ni la qualite de la resection, ni l’efficacite de la bandelette.

Multifilament polypropylene vaginal erosion: infection or foreign body–tissue reaction?

Sir, Our experience of suburethral tapes is that monofilament prostheses are rigid, which is why we have favoured multifilament prostheses. As Richardson et al. point out, these prostheses are less elastic and therefore can be inserted tension free more easily. However, we rapidly observed postoperative vaginal erosions (on average 9 months) worth reporting to the BJOG readers to discuss their aetiologies: are these erosions infections or foreign body–tissue reaction? Infection is the first aetiologic factor that has to be considered when foreign material placed in the tissues causes complications. Indeed, the main risk factor associated with such biomaterial is infection. The degree of risk depends on the nature of prosthesis and its manufacturing type.1 Thus, in vitro studies show that polypropylene multifilament tapes are more prone to infections than polypropylene monofilament tapes.1 Moreover, late infections prior to slime production are well known in other specialties such as orthopaedics.2 Patients presenting with this type of infection often present with an abscess, as is the case in our series, without any prior symptoms of infection. We think, as do Richardson et al., that foreign body–tissue reaction can probably account for all the erosions we observed. However, such a theory has first to be tested by in vivo or in vitro studies rather than speculating that they are due to a simple mistake in operative technique. For comparison, we have studied a further 313 patients to assess the efficacity and the complications of monofilament and multifilament polypropylene tapes, inserted by the same surgeons with the same technique in the same operating room.3 That study showed a 9% erosion rate for multifilament prostheses compared with 0% for monofilament prostheses.3 Moreover, multifilament prostheses appear to be less