E. Faivre

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.

Vaginal Myomectomy: Literature Review

The objective of this literature review was to evaluate the results obtained at vaginal myomectomy. The databases consulted were Medline, Cochrane Library, National Guideline Clearinghouse, and Health Technology Assessment Database. Keywords used for research were colpotomy, myomectomy, and vaginal myomectomy, and then abdominal myomectomy, laparoscopic-assisted vaginal myomectomy, and laparoscopic myomectomy. Eight case series and 2 case reports were analyzed, and included 372 patients. Reported rates of conversion to laparotomy during the operation ranged from 0% to 17.6%. The most frequently described risk factors for conversion to laparotomy were location of the myoma in the fundus and a large volume of myoma to be extracted, although no maximum threshold size can be defined. Performing laparoscopy first does not seem to limit the risk. Reported rates of transfusion during the operation ranged from 0% to 40%. Several cases of pelvic abscess have been described, with reported frequency of 2.2% to 5.7%. Authors mentioned the role of the vaginal drain that is inserted at the end of the procedure. No specific studies have been performed on long-term effectiveness, postoperative adhesions, integrity of the scar, or subsequent fertility. There are no good controlled studies of this technique. Feasibility seems to be acceptable, although the risk of pelvic infection in the postoperative period may be increased. Long-term effectiveness and safety were not assessed. A vaginal approach may be considered an alternative to laparotomy or laparoscopy in surgery to treat accessible myomas, and seems to be the simplest method.

Technique de cerclage cervico-isthmique par voie vaginale avec bandelette de polypropylène: technique de Fernandez: Description et résultats

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 35 - N° 5 - p. 465-471OBJECTIVE To assess the efficacy of performing transvaginal cervico-isthmic cerclage using synthetic tape in prevention of preterm labor in high-risk women. PATIENTS AND METHODS A retrospective analysis of 24 transvaginal cerclages using polypropylene tape performed in women presenting with high risk of preterm delivery: prior histories of pregnancy losses in the second trimester, prior failure of Mac Donalds cerclage and/or absent portio vaginalis of the cervix. Cerclage was performed between 12 and 16 weeks of gestation. A polypropylene tape was placed at the cervicoisthmic junction by vaginal route. RESULTS The median age of the patients in this series was 32.1 years (range 22-39 years). No intra-operative complication occurred. The median operating time was 34.9 minutes (+/-5.1) (range 30-45 min). Cesarean delivery was systematically performed in all patients since the cerclage was considered to be definitive. Mean gestational age and birth weight at delivery were respectively 37.1 weeks (+/-1.8) and 2850 g (+/-745). Preterm birth rate was 19% (4/21). Birth at less than 32 weeks occurred in only one patient (4%). In one case, the tape has been removed later because symptomatic vaginal erosion was noted. One neonatal death occurred following amniotic fluid infection at 34 weeks. At the present time, 3 women are at 22, 26 and 26 weeks of gestation with no preterm labor. CONCLUSION Transvaginal cerclage using polypropylene tape may be considered as an effective and minimally invasive alternative to transabdominal cervico-isthmic cerclage in women presenting with high risk of preterm delivery.

Infracoccygeal sacropexy for uterovaginal prolapse

To report on the efficacy and safety of infracoccygeal sacropexy for the treatment of uterovaginal prolapse.

Le cerclage du col utérin en 2008

Cervical cerclage is a common surgical technique that has been used for more than 50 years to prevent preterm deliveries and in the management of a threatened second trimester loss. However, it remains one of the most controversial interventions in obstetrics and this is probably due to difficulties in diagnosing cervical insufficiency, which is based on a history of recurrent second trimester loss or early preterm delivery following painless cervical dilatation in the absence of contractions or bleeding. This article reviews in 2008 the current literature regarding the efficacy of elective cerclage, ultrasound-indicated cerclage, emergency cerclage, and cervico-isthmic cerclage for singletons and multiple pregnancies.

Diffusion des recommandations pour la pratique clinique concernant l'incontinence urinaire de la femme

OBJECTIVE Recommendations for good clinical practice concerning the treatment of urinary incontinence in women are available from the HAS (Haute Autorité de santé or French National Authority for Health), the Collège national des gynécologues obstétriciens français (French national college of gynaecologists and obstetricians) and Association française des urologues (French association of urologists). We wanted to conduct the first investigation of these recommendations to primary care physicians (GPs) and gynaecologists in the cities located in the same area of health. METHODS A questionnaire was sent to GPs and gynaecologists (French administrative divisions 78 and 92), with questions on the recommendations, as well as the methods of dissemination of these recommendations. Response rate: 22%. RESULTS A total of 72 questionnaires were usable from 51 (71%) GPs and 21 (29%) gynaecologists. Of these, 76% of gynecologists and 47% of GPs were aware of recommendations from the HAS for clinical practice for urinary incontinence in women (P=0.04). Only 56% of doctors prescribed a urinalysis (dipstick or bacteriological urinalysis) and evaluated the residual urine in women seeking care for symptoms of urinary incontinence. Training for one or two days was the most desirable/popular method of dissemination of the recommendations (30 out of 72 doctors), followed by journals such as Prescrire, then the mailing and forms provided by the HAS, especially when combined with office visits from a representative of the HAS. CONCLUSION This study provided an interesting perspective on the knowledge, dissemination and application of recommendations for good clinical practice concerning urinary incontinence in women.

Fertilité après myomectomie par laparotomie pour les femmes de plus de 38 ans

OBJECTIVES Uterine fibroids is the most common benign pathology during reproductive age. Fibroids are implicated as a possible cause of infertility. The mechanism of infertility may depend on the size and the location of the fibroids and remain unclear. Myomectomy is performed in case of symptomatic patients who want to preserve their reproductive potential or in case of infertile patients. There are few data concerning fertility following abdominal myomectomy in patients over the age of 38. PATIENTS AND METHODS Retrospective study of a case series. Assessment of reproductive outcome after abdominal myomectomy among patients older than 38 years. RESULTS Abdominal myomectomy was performed on 34 patients aged over 38 during. Among these patients, 25 (74%) were contacted and 15 (60%) tried to obtain a pregnancy. Seven patients (46%) needed a new intervention. Five patients (33%) required intra-uterine insemination or in vitro fertilization and embryo transfer postoperatively. Three patients obtained a pregnancy and two (13%) had a delivery. All pregnancies were obtained spontaneously. None infertile or nulliparous woman before surgery became pregnant postoperatively. CONCLUSION After 38 years old, nulliparity and infertility before abdominal myomectomy seem to be a factor of poor prognostic to become pregnant after surgery.

Vesico-vaginal wall myoma mimicking genital prolapse

A 37-year-old woman (para 2) presented with a 1-year history of deteriorating sensation of exteriorized genital prolapse, with no rectal or urinary complaints. There were no symptoms of voiding dysfunction or stress urinary incontinence. The patients general medical history was unremarkable. Although the patient was referred for anterior genital prolapse (pelvic organ prolapse quantification [POP-Q] Ba at +1), clinical examination revealed a mobile 3 cm mass located in the vesico-vaginal wall. During straining (Valsalva maneuver), the most distal portion of the anterior vaginal wall prolapse was 1 cm below the plane of the hymen (Fig. 1). There was no rectocele, enterocele or significant uterovaginal prolapse (POP-Q Bp at −4; C at −6). On examination the patient had a soft and non-tender abdomen and normal external genitalia. Positive-pressure cystourethrography and cystourethroscopy showed no urethral

Incontinencia urinaria de la mujer

El diagnostico de incontinencia urinaria (IU) es clinico: la anamnesis diferencia una incontinencia urinaria de esfuerzo (IUE), una incontinencia urinaria de urgencia (IUU) (hiperactividad vesical) y una incontinencia urinaria mixta (IUM). Esta distincion es esencial, porque las estrategias terapeuticas son diferentes. La fisiopatologia es compleja y multifactorial. Es cierto que el embarazo, el parto, la edad, un cierto grado de predisposicion genetica tisular y el sobrepeso son factores de riesgo demostrados, pero todavia no se conocen los mecanismos precisos que conducen a la genesis de uno u otro tipo de incontinencia. Aparte de los raros casos en que se sospecha una enfermedad organica subyacente (neurologica o uroginecologica) y despues de haber descartado una infeccion urinaria y un residuo posmiccional, puede proponerse un tratamiento de primera linea sin exploracion urodinamica previa. En la IUE, se recomienda la reeducacion (ejercicios de contraccion voluntaria de los musculos perineales) de entrada, en ocasiones asociada a una reduccion ponderal. En la hiperactividad vesical, la reeducacion (tecnicas conductuales, ejercicios de contraccion muscular y electroestimulacion) y los anticolinergicos (con o sin estrogenos topicos despues de la menopausia) constituyen los tratamientos de primera linea, en ocasiones asociados a una reduccion ponderal. En caso de fracaso de un tratamiento de primera linea, esta indicada una exploracion urodinamica. En la IUE, tras el fracaso de la reeducacion, se propone una intervencion quirurgica con colocacion de un cabestrillo suburetral (CSU). En caso de fracaso, se discuten otras alternativas: inyecciones/balones parauretrales y esfinter artificial. En la hiperactividad vesical, en caso de fracaso de los anticolinergicos, se puede proponer a la paciente una neuromodulacion (sacra o del ciatico popliteo interno) o inyecciones intradetrusorianas de toxina botulinica. Sea cual sea el tipo de incontinencia, se puede proponer a las mujeres que presentan una IU durante el embarazo o en el posparto una reeducacion, que se ha mostrado eficaz en estas dos indicaciones. En cambio, esta reeducacion no parece tener un efecto protector de larga duracion.