Amélie Gervaise

Combined genital prolapse repair reinforced with a polypropylene mesh and tension‐free vaginal tape in women with genital prolapse and stress urinary incontinence: a retrospective case–control study with short‐term follow‐up

Background.  To evaluate the tension‐free vaginal tape (TVT) in both stress urinary incontinence (SUI) and occult SUI as an associated procedure at the time of tension‐free polypropylene mesh repair for the treatment of genitourinary prolapse.

Long-term anatomical and functional assessment of trans-vaginal cystocele repair using a tension-free polypropylene mesh.

We report a case series of 63 women with cystocele who underwent the same trans-vaginal procedure between October 1999 and October 2002. The polypropylene mesh (GyneMesh, Gynecare, Ethicon, France) was placed from the retropubic space to the inferior part of the bladder in a tension-free fashion. Patients were followed up for 24 to 60 months, with a mean follow-up of 37 months. Fifty-five patients returned for follow-up (87.3%). At follow-up, 49 women were anatomically cured (89.1%), five women had stage 2 anterior vaginal wall prolapse (9.1%), and one had a recurrent stage 3 (1.8%). Functional results and sexual function were also investigated. Fifty-three women had significant improvement in their quality of life (96.4%). There were a total of three cases of local pain around a mesh shrinkage (5.5%) and five vaginal erosions of the mesh (9.1%). Four out of 24 patients had dyspareunia (16.7%). In conclusion, the vaginal repair of anterior vaginal wall prolapse reinforced with a polypropylene mesh was efficient at 2 to 5 years follow-up. However, the first generation of polypropylene mesh we used was responsible for high rates of local complications and dyspareunia. Therefore, the polypropylene mesh has to be improved (lower weight) and the technique has to be documented by a randomized controlled trial before we could recommend its use in clinical practice.

Operative transvaginal hydrolaparoscopy for treatment of polycystic ovary syndrome: a new minimally invasive surgery

OBJECTIVE To evaluate a new minimally invasive surgery for treatment of the polycystic ovary syndrome (PCOS) in clomiphene-resistant infertile women. DESIGN Prospective study. SETTING University teaching hospital. PATIENT(S) Thirteen clomiphene citrate-resistant anovulatory women with PCOS. INTERVENTION(S) Operative transvaginal hydrolaparoscopy (THL) using a coaxial bipolar electrode. MAIN OUTCOME MEASURE(S) Feasability, ovulation rate, and pregnancy rate. RESULT(S) Ovarian drilling was performed by THL in all patients; no surgical complications occurred. Mean (+/-SD) duration of follow-up time was 6.3 +/- 3.3 months. Six patients recovered to have regular ovulatory cycles. Six pregnancies occurred; three were spontaneous, two occurred after stimulation and intrauterine insemination, and one occurred after IVF. The cumulative pregnancy rate was 33% at 3 months after THL and 71% at 6 months after THL. No miscarriages occurred. CONCLUSION(S) Transvaginal hydrolaparoscopy with ovarian drilling using bipolar electrosurgery appears to be an alternative minimally invasive in patients with PCOS who are resistant to clomiphene therapy.

Accuracy of Three-Dimensional Ultrasonography in Differential Diagnosis of Septate and Bicornuate Uterus Compared with Office Hysteroscopy and Pelvic Magnetic Resonance Imaging

STUDY OBJECTIVE To estimate the accuracy of 3-dimensional (3-D) ultrasonography in the differential diagnosis of septate and bicornuate uterus compared with office hysteroscopy and pelvic magnetic resonance imaging (MRI). DESIGN Prospective cohort study (Canadian Task Force Classification II-2). SETTING University hospital. PATIENTS Thirty-one patients referred with a suspected diagnosis of septate (n = 20) or bicornuate (n = 11) uterus. INTERVENTIONS All patients underwent 3-D ultrasonography displaying the rebuilt coronal view of the uterus, office hysteroscopy, and pelvic MRI. Operative hysteroscopic assessment and treatment was performed in case of sonographically diagnosed septate uterus. Bicornuate uterus was confirmed by laparoscopy. MAIN OUTCOMES MEASURES Concordance between suspected diagnosis with 3-D ultrasonography, hysteroscopy, and pelvic MRI and final diagnosis. RESULTS A septate uterus was diagnosed with 3-D ultrasonography in 29 patients and bicornuate uterus in 2 patients. Hysteroscopic transcervical section of the uterine septum was achieved in the 29 patients. Bicornuate uterus was laparoscopically confirmed in the 2 patients. Concordance between ultrasonography and operative hysteroscopy or laparoscopy was verified in all 31 cases. Twenty-five uterine septa and 5 bicornuate uteri were diagnosed by hysteroscopy (3 false-positive diagnoses of bicornuate uterus, 1 unfeasible hysteroscopy). Hysteroscopic diagnosis was correct in 27/30 patients. Twenty-four septate uteri and 7 bicornuate uteri were diagnosed by MRI (5 false-positive diagnoses of bicornuate uterus). Two complete septate uteri diagnosed by MRI were finally confirmed as incomplete septate uteri after 3-D ultrasonography and operative hysteroscopy. MRI diagnosis was correct in 24/31 patients. CONCLUSION Transvaginal 3-D ultrasonography appears to be extremely accurate for the diagnosis and classification of congenital uterine anomalies, more than office hysteroscopy and MRI. It may conveniently become the only mandatory step in the assessment of the uterine cavity in patients with a suspected septate or bicornuate uterus.

Long-term results of tension-free vaginal tape for female urinary incontinence: Follow up over 6 years

Objective:  To describe the long‐term outcome of using tension‐free vaginal tape (TVT) with and without associated procedures.

Fertility after Ovarian Drilling by Transvaginal Fertiloscopy for Treatment of Polycystic Ovary Syndrome

STUDY OBJECTIVE To evaluate fertiloscopy ovarian drilling with bipolar energy in women with clomiphene citrate-resistant polycystic ovary syndrome (PCOS). DESIGN Prospective study (Canadian Task Force classification II). SETTING University teaching hospital and private clinic. PATIENTS Eighty women with clomiphene citrate-resistant PCOS. INTERVENTION Operative transvaginal fertiloscopy with a coaxial bipolar electrode. MEASUREMENTS AND MAIN RESULTS During a mean follow-up of 18.1 months (+/- 6.4), 73 women (91%) recovered regular and ovulatory cycles. The cumulative pregnancy rate was 60% (44/73) for spontaneous and stimulated cycles, with 39.7% (29/73) imputed to drilling alone. The mean time to conceive was 3.9 months (range 1-11.8). There were eight miscarriages (18%), and no ectopic pregnancies or multiple pregnancy. No complications occurred. CONCLUSION Ovarian drilling by transvaginal fertiloscopy with bipolar electrosurgery appears to be an effective minimally invasive procedure in patients with PCOS resistant to clomiphene citrate.

Predictors of success in methotrexate treatment of women with unruptured tubal pregnancies

The use of methotrexate (MTX) for the treatment of tubal ectopic pregnancy (EP) has become common practice, although the factors associated with a favorable outcome are not totally clear. The aim of this study was to investigate the predictors of successful MTX treatment.

Assessment of three-dimensional ultrasound examination classification to check the position of the tubal sterilization microinsert

OBJECTIVE To assess the accuracy of three-dimensional (3D) ultrasound to determine the position of Essure microinserts. DESIGN Prospective observational study. SETTING Gynecology department in a teaching hospital. PATIENT(S) Forty women who underwent hysteroscopic sterilization from March through October 2008. INTERVENTION(S) Both 3D ultrasound and hysterosalpingography (HSG) were performed 3 months after the procedure to verify device position. Positions seen on 3D ultrasound were classified in four categories: a perfect position (1 + 2 + 3), a proximal position (1 + 2), a distal position (2 + 3), and a very distal position (3-only). MAIN OUTCOME AND MEASURE(S): Microinsert position on 3D ultrasound and correlation with HSG. RESULT(S) Overall, 93% of the devices for 40 patients were found to have been placed successfully. The final sample comprised 64 Essure devices. HSG showed tubal patency for only three devices, all classified as 3-only. No tubal permeability was noted for the other 61 positions. This 3-only location on 3D ultrasound was statistically associated with a failure of sterilization in comparison with the other locations (3/16 [18%] vs. 0/48 [0%]). CONCLUSION(S) 3D ultrasound is a simple and reproducible technique to assess the position of the Essure microinsert and appears to protect most patients from the negative aspects of pelvic radiography and of HSG. Using the 3D ultrasound classification presented in this study appears to make it possible to use HSG for backup confirmation only when Essure is found to be in the 3-only position on 3D ultrasound.

Essure® sterilization associated with endometrial ablation

Objective: To evaluate the feasibility and the outcome of Essure® sterilization associated with different techniques of endometrial ablation. Method: Retrospective study conducted among 23 women with confirmed menometrorrhagia and with the desire for or the medical need for permanent tubal sterilization. Patients underwent combined hysteroscopic placement of Essure® and hysteroscopic endometrial resection procedures: ThermaChoice® (n = 14), NovaSure® (n = 4), Hydrothermablator® (n = 2) and endometrial resection using monopolar energy (n = 1), or bipolar energy (n = 2). Results: Fallopian tubes were successfully cannulated bilaterally in 87% of the cases (20/23). No adverse event was reported. Adequate bilateral occlusion was confirmed for all patients (20/20) by 3D ultrasound and pelvic X‐ray at a 3‐month follow‐up. Furthermore, 85% of these patients were satisfied with the results of the procedure, all experiencing a significant reduction in menstrual blood loss (Higham blood loss score). Conclusion: Combining EA and hysteroscopic sterilization seems to be feasible and efficient in patients with menometrorrhagia.

Hysteroscopic Management of Residual Trophoblastic Tissue and Reproductive Outcome: A Pilot Study

We report on the feasibility, efficiency, and reproductive outcomes of hysteroscopic resection of late residual trophoblastic tissue in 50 patients in an observational study over 6 years. Complete evacuation of the uterus was achieved in all patients by hysteroscopy. The median operative time was 21 (15-30) min. Only one surgical complication was registered: a uterine perforation in a patient with previous metroplasty. Hysteroscopic resection of persistent trophoblastic tissue seems to be a safe and efficient procedure that could be proposed as an alternative to conventional non-selective blind curettage. We would also recommend systematic second-look hysteroscopy to asess the exact prevalence of post-procedure intrauterine adhesions.