Crépin G

Mechanical properties of synthetic implants used in the repair of prolapse and urinary incontinence in women: which is the ideal material?

The authors review the literature concerning all types of synthetics implants used in prolapse repair or the treatment of stress urinary incontinence, and analyze the mechanical properties of and the tolerance to the various products used. Various synthetic implants are also studied, including their advantages and disadvantages, as well as outcome following implantation and tolerance by the host, with respect to the type of product and the type of intervention. A review of current implant products demonstrated that the perfect product does not exist at present. The most promising of theses products for applications in transvaginal surgery to restore pelvic function appears to be the synthetic prostheses made predominantly of polypropylene, which offer mechanical properties of durability and elasticity. Their properties of resistance are undisputed, but it remains to be shown whether they are well tolerated when inserted by the vaginal route. The technical modalities for their use are still under evaluation, which should enable a better identification of the respective indications for these products in prolapse repair and treatment of urinary incontinence by the vaginal route.

A biomechanical study of the strength of vaginal tissues. Results on 16 post-menopausal patients presenting with genital prolapse.

AIMS Measurements of the tensile and bending strength of samples of vaginal tissue collected during corrective surgery of prolapse. MATERIALS AND METHODS Our measurements were conducted on two samples of vaginal tissue 2 cm x 2 cm collected during surgical correction of prolapse by vaginal route in 16 post-menopausal patients. The samples were collected from posterior vaginal fundus, were orientated, and then fixed on a plate holding the edges and allowing the tissue to be stretched over an orifice of 1 cm. The tensile measurements were made using a suture passed over this distance of 1 cm in one of the two samples by recording the strength curve in order to evaluate the force at rupture of the collagen fibres. The second sample was prepared in the same way and a piston of 1 cm diameter was made to penetrate to determine the strength of breakage of the fibres. The pressure and tensile strength curves were recorded up to rupture of the sample, as was the value of the tissue elongation. RESULTS There was a great variability in the measurements of maximum strength at rupture of the vaginal samples and in the elongation before rupture of the samples. The mean rupture values in tensile tests were 44 and 59 N in bending with extremes of 12 and 130 N. The values of elongation before rupture of a 10 mm sample were 23 mm in tensile tests and 11 mm in bending tests. There was a great variability of results from one patient to another. There was no relation between the values observed and the patient age. There was a statistical relation between the elongation values of the samples and the maximum force before rupture in both the tensile and bending tests. There was also a relation between the measurement of the maximum force at rupture in bending and in tensile tests although there was no such relation in terms of the values of elongation before rupture. DISCUSSION There is no published reference concerning the strength at rupture or the tensile strength curves for human vaginal tissues. Vaginal tissues are however commonly used as a suspension component in the vast majority of operations for correcting prolapse or urinary incontinence. These suspensions are made by passing a suture through the thickness of the vaginal tissue. The results that we report do however show that these vaginal tissues are very variable in strength from one patient to another. The same finding was made in terms of the elongation values for the vaginal tissue before rupture. The values in bending tests showed that the highest rupture force values and the greatest mean elongation before rupture were lower than in tensile tests. CONCLUSIONS These findings could explain some failures of these surgical procedures, which are all based on the tensile strength properties. Finally these results could be included in modelling of the reaction of vaginal tissues to the pressure experienced within the vagina.

A history of cesareans is a risk factor in vaginal hysterectomies

Aims.  This study describes the characteristics and per‐ and postoperative frequencies of complications in vaginal hysterectomies for benign lesions in patients with a history of cesareans. We compare these figures with the frequency of complications in vaginal hysterectomies without a history of such operations.

The feasibility of vaginal hysterectomy

OBJECTIVE To assess the feasibility of vaginal hysterectomy for benign uterine disease and to assess how frequently laparoscopic assistance is necessary. METHODS A prospective series of 806 hysterectomies for benign disease of the uterus without prolapse which were performed in our institution from 1 March 1991 to 28 February 1994 is discussed. The report is an evaluation of a planned approach for hysterectomy. Vaginal hysterectomy was performed whenever possible-laparoscopic hysterectomy was indicated for adnexal pathology, known or anticipated significant pelvic adhesions and for a narrow vaginal access with a moderately enlarged uterus-abdominal hysterectomy was chosen when both laparoscopic and vaginal surgery were judged to be impossible. RESULTS Vaginal hysterectomy was performed in 80.6% of patients. Laparoscopic assistance was needed in 9.4% of cases. The need for laparotomy was reduced to 10% with an acceptable pre- or postoperative complications rate.

Comparison of open retropubic and laparoscopic colposuspension for treatment of stress urinary incontinence

The aim of this study was to compare the results of open retropubic (OC) and laparoscopic (LC) colposuspension to the Coopers ligament (Burch operation). We matched retrospectively 72 LC and OC subjects according to their ages, the type of associated operations and the clinical stages of their urinary incontinence. We excluded associated prolapsus, previous surgical procedure for urinary incontinence, maximal urethral closure pressure lower than 30 cm of water, and instability of the detrusor. We estimated the comparability of our two series for other criteria which have an effect upon the postoperative results in the literature. The mean follow-up was 17 months for LC and 46 months for OC. LC operative time was longer than OC (mean: LC, 89 min; OC, 42 min), women considered LC less painful than OC. They needed less postoperative analgesia, mostly given only just the day of the procedure. LC length of hospitalization and return to normal activity was shorter than OC (mean: LC, 3 days; OC, 6.7 days; LC, 15 days; OC, 21 days). The graphs of the subjective cure and improvement rates made according to the Kaplan-Meier method could be compared with the log rank test (cure after 1 year: LC 79%; OC 69%; improvement after 1 year: LC 85%; OC 82%; cure after 2 years: LC 68%; OC 64%; improvement after 2 years: LC 80%; OC 75%).

Long-term results of the Burch procedure combined with abdominal sacrocolpopexy for treatment of vault prolapse

The aim of the study was to determine the long-term results of Burch procedures combined with vault prolapse repair by abdominal sacrocolpopexy. Between 1986 and 1997 82 women (mean age 46.0 years, range 27–79) underwent sacrocolpopexy combined with a Burch procedure. All patients presented with urinary incontinence and vault prolapse. The surgery consisted of a Burch procedure using non-absorbable suture material, and abdominal sacrocolpopexy with a non-absorbable mesh. The mesh was placed anteriorly and posteriorly in 66 cases, posteriorly (rectovaginal) in 12, and anteriorly (vesicovaginal) in 4. Additional procedures included hysterectomy (34 cases), enterocele repair (79 cases), and posterior repair with perineorrhaphy (65 cases). Failure was defined as the presence of persistent or worsened postoperative stress urinary incontinence (SUI). At a mean follow-up of 86 months (range 24–133) 34% (28/82) of patients were dry, and another 46% (38/82) were improved compared to their preoperative status. The postoperative SUI rate (persistent, worsened) after the placement of a single anterior mesh (4 failures out of 4) was higher than the postoperative SUI rate after combined meshes (41 failures out of 66) (log rank P = 0.05). All the patients with a history of prior surgery had worsened or persistent stress urinary incontinence (7/7), but 63% (47/75) of those with no prior surgery for stress urinary incontinence had worsened or persistent stress urinary incontinence (log rank P = 0.01). One case of recurrent rectocele was observed (after 20 months) and treated by transvaginal Richter sacrospinous fixation. At a mean follow up of 7 years, the Burch procedure combined with abdominal sacrocolpopexy appears to be less effective than previously published long-term results for the Burch procedure alone.

Folate status during pregnancy: relationship with alcohol consumption, other maternal risk factors and pregnancy outcome

This study was designed to identify the factors affecting folate status in pregnant women and to explore the relationship between folate status and alcohol consumption during pregnancy. For this purpose, 347 French women were recruited during 1985-1986 on their first visit to the antenatal clinic at Roubaix Hospital (northern France). Alcohol consumption was ascertained by a standardized interview. Folate status assessment was available for 246 pregnant women who were not given folate supplementation. Average folate levels during pregnancy were lower among young women and smokers. Serum folate values diminished with the educational level, and red cell folate values increased with high parity. Unexpectedly, high red cell folate values were strongly related with high alcohol consumption after adjustment for the maternal risk factors associated with alcohol consumption and folate status. This was probably because in the Roubaix region where the study was conducted women consume mostly beer, which contains folates. Pregnancy outcome was not related to folate levels; birthweight was negatively associated with alcohol consumption during the first trimester of pregnancy.

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.

Long term complications of vaginal hysterectomy: a case control study.

OBJECTIVE Our purpose was to evaluate the long term sequelae after vaginal hysterectomy. STUDY DESIGN A retrospective case control study to evaluate the long term complications after vaginal hysterectomy compared with control patients who had during the same period undergone cholecystectomy for benign pathology. Excluded were hysterectomies during which adnexectomy or treatment of prolapse, stress incontinence or genital cancer was also effected. We selected 221 patients who had undergone simple vaginal hysterectomy and 232 where cholecystectomy had been performed. The questionnaire listed 149 questions that dealt with matching characteristics and queries relating to symptoms. RESULTS 117 questionnaires suitable for analysis were received from the patients in the hysterectomy group and 95 from the cholecystectomy group. After the matching process 61 patients who had a simple vaginal hysterectomy and 58 who had undergone cholecystectomy were selected. After simple vaginal hysterectomy there was a significant worsening of all urinary problems, of digestive problems and sexual intercourse. After cholecystectomy there is also an increase in the severity of most symptoms surveyed. CONCLUSION Many long-term complications following hysterectomy cannot be attributed to the intervention. Vaginal hysterectomy should not be considered as being responsible for major complications appearing during the first 4 years of follow-up.

Rejection of stapled prosthetic mesh after laparoscopic sacropexy.

Abstract: We report the first case of rejection of prosthetic mesh after laparoscopic sacropexy using a Roticulator stapler. The risk of this complication is extremely low if simple precautions are observed. Our experience suggests that the use of staples to attach the mesh to the vaginal apex should be avoided. At the end of the procedure a careful assessment should be made to ensure that the vaginal wall is intact and not penetrated by staples.