Bruno Occelli

The vaginal patch plastron for vaginal cure of cystocele. Preliminary results for 47 patients.

OBJECTIVE We describe a new surgical technique (the vaginal plastron) for the treatment of cystocele by the vaginal route. The technique is based on bladder support by a vaginal strip (6-8cm in length and 4cm in width), isolated from the anterior colpocele, left attached to the bladder, associated with a suspension of this strip by its fixation to the tendinous arch of the pelvic fascia by six lateral sutures (three on each side of the plastron). The vaginal plastron is then covered by tucking it under the anterior colporraphy. STUDY DESIGN We evaluated the short-term functional and anatomical results of the first 47 patients to have undergone this treatment between October 1997 and June 1998. The average age of the patients was 69 years. Cystoceles were associated with urinary stress incontinence in 38.3% of cases, with hysterocele or prolapse of the vaginal dome in 87.2% of cases, with an elytrocele in 19.1% of cases and a rectocele in 70.2% of cases. Of the 45 patients having had a hysterectomy combined with the vaginal plastron or in their past history, 44 (99.77%) had a Richter sacro-spino-fixation and 17 (38%) had a Campbell procedure combined with the vaginal plastron. All patients underwent a posterior perineorraphy with myorraphy of the elevators. RESULTS Average follow-up was 16.4 months with extremes of 6-26 months and concerned 46 patients (one patient was unavailable). Ninety-three percent of the cystoceles were considered treated. One case of imperfect anatomical outcome was noted (persistence of stage 1 cystocele in one patient) together with two other cases of failure of the treatment of cystocele (relapse to stage 2 cystocele). CONCLUSION Proposed as a curative treatment of cystocele and combined with the Richter fixation, the plastron provides a surgical solution to the problem of cystocele relapse arising after vaginal treatment of prolapse by sacro-spino-fixation alone (10-20% according to Richter). Short-term results are encouraging, however, medium- to long-term results (36-60 months) are necessary in order confirm the usefulness of this surgical technique.

Anatomic study of arcus tendineus fasciae pelvis

OBJECTIVE To describe the anatomy of the arcus tendineus fasciae pelvis. MATERIAL AND METHODS Two fixed female cadaver pelvises (88 and 66 years old) were dissected. RESULTS The arcus tendineus fasciae pelvis is a 10-cm-long fibrous thickening of the pelvic fascia which is medial to the obturator internus muscle and lateral to the peritoneum. It is inserted on the ischiatic spine and courses downward and anteriorly to the pubovesical ligament. The posterior third of the arcus tendineus fasciae pelvis is fused with the posterior third of the arcus tendineus musculus levatoris ani, forming a curve with upward and anterior concavity. This portion of the arcus tendineus is thick and easy to recognise upon palpation. It is located 1cm slightly above and anterior to the ischiatic spine and 2 cm from of the pudendal vessels, which course around the posterior inferior margin of the ischiatic spine. The superior margin of the median part of the arcus tendineus fasciae pelvis is crossed laterally by vessels for the obturator internus muscle arising from the internal iliac vessels. CONCLUSION In genital prolapse cure, sutures must be placed through the anterior or median parts of the arcus tendineus fasciae pelvis. In any case, they must remain anterior to the posterior part of the arcus tendineus fasciae pelvis to avoid injury to the pudendal vessels.

Causes of Failure of Abdominal Colposacropexy for the Treatment of Genital and Vaginal Vault Prolapse

The goal of this study was to assess factors associated with the failure of abdominal colposacropexy. Between 1986 and 1997, 217 colposacropexies were performed (mean patient age 49.9 years ± 11.2; average follow-up 5.5 years, range 1-136 months). Synthetic mesh placement consisted of 182 anterior and posterior attachments, 9 anterior only and 26 posterior only. One hundred ninety-six procedures were performed using Mersilene as the graft material, 18 with Gore-Tex, and 3 with absorbable material. A total of 179 posterior colporraphies and 208 culdoplasties (Moschowitzs procedure) were performed. The anatomical and functional results for prolapse showed a treatment success rate of 97.7% (212/217). Fifty-eight percent (125/217) of the patients were totally continent in the long term (no postoperative incontinence). Eight-two percent (178/217) of patients were classified as having been successfully treated and/or having improved condition following the surgical procedure (postoperative incontinence was les...

Comparaison des adhérences postopératoires après lymphadénectomies para-aortiques par laparotomie avec versus sans Intergel : Étude expérimentale animale

INTRODUCTION Advanced cancers of the cervix are treated by external radiotherapy within range limits which depend on the para-aortic ganglion metastases found during surgical staging. The presence of postoperative intraperitoneal adhesions increases the risk of postradical enteritis. The aim of this study is to investigate the efficacy of an anti-adhesive substance (Intergel) undergoing para-aortic lymphadenectomy by laparotomy. MATERIALS AND METHODS We conduced a prospective, randomized study on 60 pigs divided into 2 groups (with and without Intergel) undergoing para-aortic lymphadenectomy by laparotomy to compare the efficacy of an anti-adhesive substance using an adhesion scoring system based on density and surface area in question. RESULTS There was no difference between the 2 groups in terms of duration of surgery, number of ganglia removed, postoperative mortality and per and postoperative morbidity, especially the adhesion process. CONCLUSION Administration of an anti-adhesive substance such as Intergel does not reduce the adhesion process after para-aortic lymphadenectomy in animals. However, perhaps we can not interpret these results because of the too much quantity of anti-adhesive substance for the animal weight, and because of the too precocious control.Resume Introduction Les cancers evolues du col uterin sont traites par radiotherapie externe dont les limites du champ varient suivant l’existence de metastases ganglionnaires para-aortiques recherchees lors d’un staging chirurgical. La presence d’adherences intraperitoneales postoperatoires augmente le risque d’enterite post-radique. Le but de cette etude est d’etudier l’efficacite d’une substance antiadhesiogene (Intergel) apres des lymphadenectomies para-aortiques par laparotomies. Materiel et methode Nous avons realise une etude prospective et randomisee sur 60 porcs, repartis en 2 groupes de curages para-aortiques par laparotomie (avec ou sans Intergel) comparant l’efficacite d’une substance antiadhesiogene par un score adherentiel associant densite et surface d’occupation. Resultats Il n’y a eu aucune difference statistiquement significative entre les 2 groupes concernant la duree operatoire, le nombre de ganglions preleves, la mortalite postoperatoire et la morbidite per- et postoperatoire notamment le processus adherentiel. Conclusion L’administration d’une substance anti-adhesiogene de type Intergel ne permet pas de reduire le processus adherentiel apres curage para-aortique chez l’animal. Toutefois, la quantite de produit utilisee etait peut-etre trop elevee pour le poids des animaux, et la date du controle des adherences etait peut-etre trop precoce pour permettre l’interpretation des resultats.

Modified vaginal hysterectomy with or without laparoscopic nerve-sparing dissection: A comparative study

This article presents an investigation of a series of 95 patients who have undergone laparoscopically assisted radical vaginal hysterectomy at the University of Lille since 1991. In 1996, this technique was modified to include laparoscopic paracervical lymphadenectomy. This change in technique presents the opportunity to study the results of this procedure in 47 women who did, and 48 women who did not, undergo paracervical dissection at the time of modified radical vaginal hysterectomy. Paracervical lymphatic dissection is performed between the anterior and posterior faces of the cardinal ligament. Dissection continues from the superior edge to the lateral rectal ligament and pelvic floor while carefully avoiding the vaginal and inferior vesical arteries, deep uterine veins, vaginal and vesical veins, and hypogastric plexus. After exposure of the cardinal ligament, a 2 cm X 1.5 cm portion is excised to facilitate removal of the cellular tissue surrounding the pudendal and gluteal vessels and the lumbosacral trunk. The average length of follow up was 41 months for the women who did not and 26 months for those who did undergo paracervical dissection. Sixty of the 95 patients, including 28 in the group without and 32 in the group with paracervical lymphadenectomy, were available to complete a questionnaire concerning the impact of their surgery on incontinence and urogenital symptoms. There were no differences in the clinical characteristics or operative data of the two groups. Tumors were less than 2 cm in size in 43 women without and 38 with paracervical dissection. Similar numbers of interiliac nodes (18 and 19) were removed from both groups of patients. The women who underwent paracervical lymphadenectomy had an average of six nodes removed, although no nodes were present at all in some cases. Only one positive node was found, this in one patient whose tumor was larger than 2.5 cm. The women who underwent paracervical lymphatic dissection had significantly longer periods of postoperative urinary retention compared with those who did not. However, long-term urologic results were similar in both groups. Fourteen percent of the women who did not and 12.5% of those who did undergo paracervical dissection reported no long-term urinary symptoms. Thirty-five percent (n = 21) of all patients had continued dysuria, with no patient requiring catheterization and 11 women having only occasional symptoms. Stress incontinence was reported by 59% (n = 35) of the total group. Four women experienced permanent incontinence, and 31 had mild or moderate symptoms requiring one or two pads per day. Nocturnal polyuria and urgency were each reported by 57% of patients. Seven women were awakened three times per night and 29 got up one or two times. Urgency symptoms ranged from less than one episode a day for 16 patients, one a day for 10 patients, more than once a day for three women. Among the patients who had received radiation therapy, the distribution of urinary symptoms was similar to those who had not. Only 1 of the 81 women whose tumor size was less than 2 cm had a recurrence. She was from the group without paracervical dissection and had no known risk factors. In comparison, 6 of the 14 women with tumors greater than 2 cm experienced a recurrence. Of the 12 patients with tumors ranging from 2.0 cm to 3.9 cm, there were three in the group without and one in the group with paracervical lymphadenectomy who recurred. Both of the women with tumor 4 cm or greater recurred.

Positive Margins After Conization and Risk of Persistent Lesion

OBJECTIVE The aim of this study was to investigate a method to reduce the frequency of uterine reoperation with no persistent lesion and to identify factors predictive of persistent or recurrent lesions. MATERIALS AND METHODS Of 505 conizations performed by the same surgeon, 71 had positive margins (average patient age = 35.7 +/- 7.7 years). The patients underwent either immediate reoperation or monitoring with a Pap smear and colposcopy. RESULTS Histologic assessment of the cervical cone after conization showed positive margins in 14.1% of cases [endocervical and exocervical margins affected in 50 of 505 (9.9%) and 21 of 505 (4.2%) cases, respectively]. Of 59 of these patients (83.1%) who underwent follow-up monitoring over an average of 35.2 months (range: 2.6-180. 8), 12 patients (average age: 40.8 +/- 6.4 years) underwent immediate hysterectomy and 47 (average age 34.0 +/- 7.4 years) benefited from monitoring first [secondary discovery of 19 persistent lesions within 6 months and 9 recurrences within 18 months on average (range: 8.8-48 months)]. Of the 9 patients with recurrent lesions, 7 underwent reintervention and 2 monitoring. Of the 19 patients with persistent lesions, 18 underwent reintervention and 1 monitoring. Normal histology was observed in 29.4% of patients undergoing secondary reoperation for an abnormal smear compared with 66.7% of patients undergoing immediate reoperation (P = 0.04). Severity of lesion and age of patients could not be used to predict the incidence of a persistent or recurring lesion. Seventy-nine percent of conizations had positive endocervical margins in patients with a recurring or persistent lesion compared with 48% in patients with normal follow-up (P = 0.03). CONCLUSION Cytology and colposcopy follow-up in cases of positive conization margins may help to establish justification for the choice of reoperation, thereby limiting morbidity following repeated surgery.