E. Werbrouck

Medium term outcome of laparoscopic sacrocolpopexy with xenografts compared to synthetic grafts

PURPOSE We compared the medium term anatomical and subjective outcome, and graft related complications after sacrocolpopexy for apical vaginal prolapse using xenogenic or polypropylene grafts. MATERIALS AND METHODS We prospectively studied 50 consecutive patients who underwent laparoscopic sacrocolpopexy with porcine grafts of small intestinal submucosa (21) or dermal collagen (29). We compared these patients to 100 consecutive controls in whom polypropylene was used, and underwent surgery before (50) or after (50) the cases. The primary outcome was anatomical cure (stage I or less at any compartment). Secondary outcomes were graft related complications, subjective cure and quality of life evaluated by clinical examination, standardized interview and prolapse specific questionnaire, respectively. RESULTS At study closure 129 (86%) patients were available for functional evaluation and 104 (67%) were available for anatomical evaluation. Mean postoperative followup (+/-33 months) and baseline characteristics except age were comparable. The overall anatomical failure rate was comparable (49% vs 34%, p = 0.053) but failures at the vault (21% vs 3%, p <0.01) and posterior compartment (36% vs 19%, p <0.05) were more frequent in the xenograft group. There were 6 reoperations including secondary laparoscopic sacrocolpopexy (5) and cystocele repair (1), all confined to the xenograft group (p <0.01). Graft related complications were equally frequent (11%) in the xenograft and polypropylene groups. The reoperation rate for graft related complications was not different (xenograft 3% vs controls 11%, p = 0.20). There were no differences in functional outcome and quality of life between xenografts and controls. CONCLUSIONS While overall anatomical failure was comparable, sacrocolpopexy using xenograft was associated with more apical failures and reoperations for prolapse than with polypropylene without differences in functional outcome. The use of xenografts did not decrease the number of graft related complications.

Persistence of polypropylene mesh anisotropy after implantation: an experimental study

Please cite this paper as: Ozog Y, Konstantinovic M, Werbrouck E, De Ridder D, Mazza E, Deprest J. Persistence of polypropylene mesh anisotropy after implantation: an experimental study. BJOG 2011; DOI: 10.1111/j.1471‐0528.2011.03018.x.

Combined biaxial and uniaxial mechanical characterization of prosthetic meshes in a rabbit model

The present experimental study is aimed at a combined uniaxial and biaxial mechanical characterization of the deformation behavior of two types of prosthetic meshes, SPMM (heavy-weight) and Gynemesh M (light-weight, partly absorbable), after integration in the host tissue. Explants from a full-thickness-abdominal-wall-defect-rabbit-model were tested in the two loading conditions. Corresponding protocols and data analysis procedures for biaxial inflation tests and uniaxial tensile tests were developed. Biaxial responses were observed to be by factor 2-4 stiffer compared to corresponding uniaxial experiments, depending on the material tested. In biaxial loading conditions, SPMM explants were stiffest. Gynemesh M explants and native tissue were similarly compliant at low membrane tensions (<5N/cm) (abdominal wall: 40±23N/cm, Gynemesh M: 59±44N/cm, SPMM: 145±36N/cm). At high membrane tensions (>5N/cm), there were distinct differences in the stiffness of the three groups, SPMM explants being the stiffest, followed by Gynemesh M explants and native tissue being the most compliant. In uniaxial loading conditions, the two explants were similarly stiff and distinctly stiffer than native tissue at low membrane tensions (<5N/cm) (abdominal wall: 9±1N/cm, Gynemesh M: 21±5N/cm, and SPMM: 24±5N/cm). At high membrane tension (>5N/cm), differences between all groups vanished. Biaxial and uniaxial tests yield different results with respect to the mechanical behavior of mesh explants. These findings demonstrate that an evaluation of the mechanical biocompatibility of prosthetic meshes should be based on an experimental configuration (uniaxial or biaxial tension) which reproduces the expected in vivo conditions of mechanical loading and deformation.

Pain and bleeding pattern related to levonorgestrel intrauterine system (LNG-IUS) insertion

OBJECTIVE To investigate whether the pattern or pain or bleeding during levonorgestrel intrauterine system (LNG-IUS) insertion and in the first 6 weeks thereafter is altered by LNG-IUS malposition. STUDY DESIGN Prospective cohort of 413 women undergoing LNG-IUS insertion or replacement. A first questionnaire on pain perception was completed by the women immediately after insertion. In a second questionnaire the women were asked to record pain in the 3 days following insertion and both pain and bleeding from 4 to 6 weeks after insertion. Six weeks after insertion a 2D- and 3D-ultrasound examination was performed to evaluate the position of the LNG-IUS and of the uterus. RESULTS Parity was inversely related to pain at insertion, in the first 3 days and at 4-6 weeks. LNG-IUS insertion was less painful in the postpartum period. Women who had had a LNG-IUS as prior contraceptive method reported a higher percentage of amenorrhea at 4-6 weeks. The position of the LNG-IUS or of the uterus did not influence the pain scores or the bleeding pattern. The fact that the LNG-IUS arms appeared embedded in the uterine wall on coronal 3D-volume reconstruction did not influence pain or the bleeding pattern. CONCLUSIONS Because neither pain nor bleeding is a reliable predictor of LNG-IUS position, we suggest an ultrasound examination to confirm correct LNG-IUS placement in all patients at about 6 weeks after insertion.

OC08.01: Differentiation of uterine pathology by transvaginal elastography: preliminary results

Objectives: Fetoscopic SLP improves outcome in TTTS by promoting resolution of cardiovascular (CV) manifestations. The time course and pattern of disease regression is unknown. We sought to investigate the nature of CV disease regression after SLP by analysis of individual cardiovascular elements through application of the CHOP score for TTTS. Methods: The CHOP score is a fetal echo derived system for detailed CV characterization of TTTS. Elements of the Score include 4 domains in the recipient: 1) ventricular characteristics of dilation, hypertrophy, systolic dysfunction, 2) atrioventricular valve (AV) regurgitation, 3) diastolic properties of Doppler AV inflow (double or single peak), ductus venosus, and umbilical venous flow, 4) right ventricular outflow tract obstruction (RVOTO) as assessed by pulmonary artery measuring smaller than aorta or pulmonary stenosis/atresia; and in the donor, evaluation of umbilical artery diastolic flow. In 32 twin pairs individual elements of the Score as well as myocardial performance indices (MPI) were measured at 1 day and 1 week after SLP and compared to pre-op values using paired t-test. Results: Overall score was unchanged at 1 day (pre-op 6.6 + 4.0 vs. 6.0 + 3.8, P = NS) but significantly improved by 1 week (4.2 + 4.1, P < 0.001) after SLP. At 1 day, there was no improvement in systolic or diastolic parameters and AV regurgitation worsened, however there was slight improvement in RVOTO (P < 0.05) and recipient RV and LV MPI (P = 0.02). At 1 week, improvements in ventricular dilation (P = 0.01), hypertrophy (P = 0.01) and all of the diastolic parameters were noted, with further improvement in RVOTO (P = 0.002) and recipient RV and LV MPI (P < 0.01). Systolic performance and AV regurgitation did not improve. Conclusions: Minimal improvement is seen 1 day after SLP, however diastolic CV elements, but not systolic, improve substantially at 1 week. Acute diastolic relaxation of the recipient right ventricle after SLP may improve filling and result in an increase in pulmonary artery diameter.

OC17.01: The association of patients' characteristics and bleeding pattern with uterine intracavitary pathology

Objectives: To describe the sonographic and clinical findings in a cohort of fetuses with commissural anomalies. To compare between US, MRI and autopsy findings. Methods: Retrospective review of all the cases with commissural anomalies diagnosed between January 1989–May 2010. Results: 176 cases of commissural anomalies were identified. The number of cases diagnosed rose from a mean of 1.25/year during 1989–2000 to 15.8/year during 2001–2010. The mean gestational age was 26.5 ± 4.7 weeks (range 15–38). Agenesis of the corpus callosum (ACC) was diagnosed in 47%, dysgenesis of the corpus callosum (DCC) in 46%, cavum septi pellucidi (CSP) anomalies in 5% and pericallosal lipoma in 2%. Associated anomalies were present in 122 (69%) and included anomalies of: central nervous system (104), musculoskeletal (29), genitourinary (17), cardiac (14), dysmorphic features (24), gastrointestinal (5), and miscellaneous (12). Colpocephaly was evident in 71 (40%) cases. MRI was performed in 79 (45%) cases; added new information but did not modify management in 10; and was not conclusive in 7 cases. Autopsy were performed in 65 cases out of 119 (78%) terminated pregnancies. There was a case of IUFD, 53 (30%) children were delivered but 5 died. Out of the 48 livebirths there were 13 with ACC, 22 with DCC, 4 with lipoma and 9 with CSP anomalies. Overall 27 of them are developing normally, 10 suffer from mild to moderate developmental delay, 5 form severe developmental delay and 6 have not yet been evaluated. Conclusions: Fetal commissural anomalies can be diagnosed reliably by the sonographic examination. The correlation between US, MRI and autopsy findings is high. MRI has only a marginal role in diagnosis but contributes to reassure the patients. Prognosis is highly dependent on the presence of associated anomalies.

OP26.08: Preoperative ultrasound measurements of genital hiatus are not different between patients with and without de novo recurrence after anterior vaginal repair

on examination. Latency between age at first vaginal delivery and presentation was 32.6 years (0–72.6). There was a strong association between levator avulsion and symptoms and signs of prolapse (all P < 0.001). Patients with avulsion were not shown to present earlier, regardless of symptoms. On multivariable logistic regression, the relationship between symptoms/signs of FPOP and latency was nonlinear and was treated as a binary variable (<=20, > 20 years). However, latency was not an effect modifier of the relationship between avulsion and symptoms/signs of FPOP. Conclusions: We have found no evidence for the hypothesis that levator trauma leads to earlier presentation of women with symptoms and/ or signs of prolapse.

OP26.03: Transperineal ultrasound and clinical examination for pelvic organ prolapse correlate better if both are performed in a one stop clinic

cases and persistent incontinence despite successful fistula closure. Patients were examined supine and after voiding if bladder volume was over 50 ml. Volume datasets were obtained on coughing, on maximal Valsalva and pelvic floor muscle contraction. Results: Women were seen prior to (n = 22) or after VVF repair (n = 73). Mean age was 29.5 (16–65), mean parity was 2.7 (range, 0–11). Two patients had only delivered by C/S. Only 2 patients had a significant cystocele (stage 2), 3 a uterine prolapse stage 2 and 13 a rectocele stage 2. Levator dimensions on Valsalva were obtained in 92/95 women. Mean hiatal area on Valsalva was 18.8 cm2 (range, 7.7–45.9), and only 6/92 (7%) fulfilled the criteria for ballooning (hiatal distension >=25 cm2). A levator avulsion as defined on tomographic ultrasound was diagnosed in 27 cases (28%), of which 11 were bilateral. There was a reflex contraction of the levator ani observed on coughing in all but two patients. A levator contraction on request could be obtained in all but 6 women. Conclusions: Abnormal levator function and anatomy in patients with VVF is not uncommon, but no more so than in unselected urogynecological patients in the developed world. There was no evidence of permanent denervation of the levator ani.

OP07.04: The value of fluid instillation sonography in women under 40 years of age

Results: Mean age (±SD) was 49 years ±14. Sensibility (%), specificity (%), positive and negative LR were 96, 97, 30.9 and 0.04 for endometrial polyp, respectively; 85, 97, 24.9 and 0.16 for endometrial hyperplasia, respectively; 90, 99, 280.4 and 0.09 for endometrial cancer, respectively. Conclusions: Saline contrast sonohysterography with endometrial sampling performed by using the 14Fr bioptic intrauterine catheter showed to be accurate and efficacious in the triage of patients with AUB, showing to be a diagnostic test. Failed cases and inadequate samples should undergo hysteroscopy.

OP07.02: The added value of fluid instillation sonography in women with a total endometrial thickness ⩽ 5 mm at transvaginal ultrasound

Results: Mean age (±SD) was 49 years ±14. Sensibility (%), specificity (%), positive and negative LR were 96, 97, 30.9 and 0.04 for endometrial polyp, respectively; 85, 97, 24.9 and 0.16 for endometrial hyperplasia, respectively; 90, 99, 280.4 and 0.09 for endometrial cancer, respectively. Conclusions: Saline contrast sonohysterography with endometrial sampling performed by using the 14Fr bioptic intrauterine catheter showed to be accurate and efficacious in the triage of patients with AUB, showing to be a diagnostic test. Failed cases and inadequate samples should undergo hysteroscopy.