Bruno Deval

Body Mass Index and Outcome of Tension-Free Vaginal Tape

OBJECTIVES To assess the effectiveness of tension-free vaginal tape (TVT) in women with high body mass indices (BMIs). METHODS Thirty-eight consecutive patients with BMIs exceeding 30 who underwent tension-free vaginal tape were compared with 149 consecutive patients with BMIs of 30 or less who underwent the same procedure. Body mass index was calculated pre-operatively and at follow-up. Women were classified as being of normal weight (BMI 20-25), overweight (BMI 26-30), or obese (BMI >30). Patient characteristics, operative and post-operative complications, reported continence rates were analyzed according to BMI. RESULTS There were no significant differences between groups in terms of age, parity, menopausal status, previous surgery, type and degree of incontinence. Estimated blood loss, operative times, bladder injuries, post-operative urgency and voiding disorders did not differ significantly between women with high BMIs and those with low BMIs. Women with BMIs exceeding 30 had a significantly higher incidence of post-operative urge urinary incontinence (17.9 versus 3.4 and 6.4% p = 0.02) without any effects on the objective and subjective cure rates (82 versus 88.7 and 93% p = 0.1, 71.7 versus 72.1 and 74% p = 0.9). CONCLUSION We did not find pre-operative obesity to be a risk factor for failure of tension-free vaginal tape.

A French Multicenter Clinical Trial of SPARC for Stress Urinary Incontinence

OBJECTIVE To evaluate the safety and efficacy of the SPARC procedure in women with genuine stress urinary incontinence. METHODS We conducted a prospective multicenter trial of a suprapubic approach to suburethral polypropylene (SPARC) taping for the treatment of genuine stress urinary incontinence. Between June 2001 and June 2002, 104 consecutive women (mean age 58.7 years) underwent SPARC in three centers. All the women had urethral hypermobility preoperatively. Detrusor instability was ruled out by cystometry. The women were evaluated 1, 3, 6 and 12 months postoperatively. The objective cure rate was evaluated by clinical and urodynamic examination, and the subjective cure rate was assessed using the Kings and Bristol questionnaire. RESULTS The mean follow-up time was 11.9+/-1.9 months (range 8 to 20 months). The mean operating time was 30 min (25-50 min). Most of the patients received general anesthesia (48%). The overall complication rate was 44.2% (46/104). The perioperative complication rate was 10.5%, including 11 bladder injuries. A significant difference in the bladder injury rate was observed between women with and without previous incontinence surgery (respectively 4/11, 36.3% versus 7/93, 7.5%; p<0.001). No hemorrhaging occurred. The early postoperative complication rate was 22.1%. The main complication was voiding disorders (11 patients), which necessitated intermittent self-catheterization for less than 15 days (1.3+/-1.1 days, range 1 to 10 days). The late postoperative complication rate was 11.5%, including de novo urge symptoms in 12 women. The objective cure rate was 90.4%. No difference was found between patients with genuine stress incontinence and those with mixed incontinence. The subjective cure rate was 72%. The objective and subjective cure rates differed significantly (p<0.05). The subjective cure rate among patients with de novo urge symptoms was 58%. CONCLUSION The SPARC procedure is a safe and effective treatment for women with stress urinary incontinence, despite a high incidence of de novo urge symptoms.

Lidocaine spray and outpatient hysteroscopy : Randomized placebo-controlled trial

Objective To assess the efficacy of lidocaine spray during outpatient hysteroscopy for reducing procedure-related pain and to identify risk factors for discomfort. Methods One hundred twenty-one women were assigned randomly to have application of lidocaine spray or placebo to the uterine cervix during outpatient hysteroscopy. The main outcome measure was pain during hysteroscopy, assessed on a visual analog scale. Results There was no statistically significant difference between study and control groups in mean age, rate of nulliparity, postmenopausal state, need for cervical dilation, or percentage of women who used hormone replacement therapy. Indications for diagnostic hysteroscopy were similar between groups. Women in the lidocaine group had statistically significantly less pain during the procedure than women in the placebo group (2.2 ± 1.9 and 3.7 ± 2.5, respectively; P < .001). Women with abnormal uterine findings (submucous myoma, endometrial polyps, or intrauterine adhesions) had significantly higher pain scores than women with normal cavities (2.2 ± 1.9 and 3.2 ± 2.4, respectively; P < .002). Aerosol anesthesia and normal uterine findings were independently associated with less pain. No procedure had to be abandoned because of excessive pain or complications, and no women required hospitalization. Conclusion Women treated with lidocaine spray had significantly less pain. Uterine cavity abnormality might be associated with a higher degree of pain during hysteroscopy.

Results of tension-free vaginal tape in patients with or without vaginal hysterectomy

OBJECTIVE To assess complications and cure rates of tension-free vaginal tape (TVT) procedure performed with or without vaginal hysterectomy. STUDY DESIGN Retrospective comparison of 41 women with urinary incontinence treated by a TVT procedure alone and 40 combined with vaginal hysterectomy. Objective cure was evaluated by clinical and urodynamic examination and by the contilife questionnaire. All patients were operated under regional anesthesia. RESULTS The two groups were similar in age, parity, menopausal status and type and severity of incontinence. There was no difference in overall complication rates. In the TVT-hysterectomy group, there was a trend towards more bladder perforation (P=0.09). Post-operative urinary flow was lower in the TVT-hysterectomy group: 14 versus 24 ml/pc (P=0.02). The mean follow-up was similar: 23 and 25 months, respectively. No difference in objective and subjective cure rates was found between TVT group and TVT-hysterectomy group: 97.6% versus 92.5% and 68.3% versus 75%, respectively. CONCLUSION TVT is a safe and effective surgical treatment of urinary incontinence. The association of the procedure with vaginal hysterectomy gave similar short-term objective and subjective cure rates than TVT technique alone.

Management of the complications of the synthetic slings.

Purpose of review The aim of this article is to review the last years literature on the management of vaginal erosion and obturator abscess with suburethral tapes in the treatment of female urinary incontinence. Recent findings During the past decade suburethral tapes have been approved in Europe for minimally invasive treatment of stress urinary incontinence. Consensus is, however, lacking regarding the material best suited for this surgery. Although the success rates with synthetic materials have been, in general, good, the risk of vaginal extrusion and urethral erosion is considerably greater, ranging from 0.2 to 22%. We report diagnosis and management of complications occurring after this procedure. The presenting symptoms, physical findings, diagnostic procedures, surgical treatments, and outcomes are analyzed. Pain, vaginal discharge, bleeding, recurrent urinary tract infections, and/or persistent stress urinary incontinence are suspected symptoms of vaginal erosion. All vaginal erosions are usually detected by physical examination; in cases of suspected pelvic abscess, magnetic resonance imaging is performed. Total tape removal is recommended in the majority of cases; however, patients have recurrence of incontinence. Summary Urogenital tract erosion and pelvic abscess are significant complications of suburethral tape; immediate symptom relief is expected after removal of the eroded sling.

Vaginal and laparoscopic myomectomy for large posterior myomas: results of a pilot study.

OBJECTIVE To evaluate the feasibility and complications of vaginal and laparoscopic myomectomy, and analgesic drug consumption. METHODS We conducted a pilot study involving 24 women with single, large (>5cm) symptomatic posterior uterine leiomyomas. Twelve women underwent vaginal myomectomy and 12 laparoscopic myomectomy. The main outcome measures were the operating time, peri- and post-operative complications, and analgesic drug consumption. RESULTS There was no difference in mean age, the rate of nulliparity, and the mean size of myomas between the two groups. The mean operating time was shorter in the vaginal group (96+/-38min versus 166+/-78min; P<0.01). There was no difference in mean blood loss or fibroid weight between the two groups. One of the 12 patients in the vaginal myomectomy group required laparoscopic conversion for an inaccessible fundal myoma. Post-operative morphine consumption was lower in the vaginal group (37.2+/-64mg versus 150.8+/-42mg; P<0.003). No post-operative complications occurred in either group. Gas and stool recovery, the length of hospital stay, and the time required to return to normal activity were similar in the two groups. CONCLUSION Vaginal myomectomy is feasible and safe, and was associated with a shorter operating time and lower morphine consumption than laparoscopic myomectomy.

Results of recto-vaginal fistula repair: retrospective analysis of 48 cases

OBJECTIVE To evaluate the long-term outcome of the Musset technique of recto-vaginal fistula (RVF) repair. STUDY DESIGN During the years 1992-1998, 48 women underwent recto-vaginal fistula repair. A retrospective study in a university tertiary referral center was conducted. RESULTS The main etiologies were obstetrical trauma (25), local infection (11), inflammatory disease (7), and post surgery (3). Thirty women (63%) had a previous fistula repair failure. The mean+/-S.D. fistula diameter was 1.4+/-1.0, and in 40% of the patients the fistula diameter was >2.5cm. In 19 cases (39.6%) there was a complete opening of the perineum and anal sphincter. Gas and stool incontinence before the operation were noted in 85 and 75% of the patients, respectively. Successful anatomic results were achieved in all patients. Five patients were re-operated due to gas and stool incontinence, and all but one had satisfactory anatomic and functional satisfactory results. The success rates in women with Crohns disease and with a previous RVF repair failure were 100 and 98%, respectively. No major intra or postoperative complications were noted. CONCLUSION The Musset procedure provide excellent anatomic and functional results and women with Crohns disease or previous RVF repair have comparable long-term results.

Obturator abscess after transobturator tape for stress urinary incontinence.

BACKGROUND: A transobturator tape is a nonwoven, thermally bonded polypropylene tape recently approved in Europe for minimally invasive treatment of stress urinary incontinence. CASE: Three cases of obturator abscess after transobturator tape procedures are reported. Patients presented with groin pain and vaginal discharge, and physical examination showed vaginal erosions. Magnetic resonance imaging confirmed the obturator abscess. All patients had complete sling removal and were treated with antibiotics. The organism responsible for the obturator abscess was Bacteroides fragilis in all three cases, suggesting that the infection occurred through a vaginal erosion. CONCLUSION: Persistent painful or irritating symptoms after suburethral tape procedures may be due to a vaginal erosion that can be associated with an obturator abscess. Appropriate evaluation and treatment result in marked symptomatic improvement, although stress incontinence may recur.

Vaginal hysterectomy for benign disorders in obese women: a prospective study.

Objective  To compare the morbidity of vaginal hysterectomy in obese and non‐obese women in a single institution.

Anesthesia for breast cancer surgery in the elderly

Anesthesia for breast cancer surgery in the elderly requires a specific approach, taking into account physiological and psychological alterations secondary to aging. Breast surgery is a low specific risk surgery, and perioperative risk is mainly dependent of the presence and severity of co-morbidity. It may be reduced by careful evaluation and stabilization of concurrent diseases, at best done through a multidisciplinary approach. In view of anesthetic technique adjustment to medical condition, most geriatric patients may undergo breast cancer surgery with a low incidence of perioperative complications.