F. Haab

Anatomie fonctionnelle du plancher pelvien

The pelvic floor is the support of the pelvic visceras. The levator ani muscle (LA) with its two bundles (pubo- and ilio-coccygeus) is the major component of this pelvic floor. LA is formed essentially by type I fibers (with high oxidative capability and presence of slow myosin) as in postural muscles. The aerobic metabolism makes LA susceptible to injury caused by excentric contraction and mitochondrial dysfunction. The innervation of the pelvic floor comes from the 2nd, 3rd, 4th anterior sacral roots; denervation affects pelvic dynamism. Perineum includes the musculofascial structures under the LA: ventrally the striated urethral sphincter and the ischio-cavernous and bulbospongious, caudally the fatty tissue filling the ischioanal fossa. Pelvic fascia covers the muscles; it presents reinforcements: the uterosacral and cardinal ligaments, the arcus tendineus fascia pelvis (ATFP) and the arcus tendineus levator ani (ATLA). The pelvis statics is supported by the combined action of all this anatomical structures anteriorly forming the perineal hammock, medially the uterosacral and cardinal ligaments, posteriorly the rectovaginal fascia and the perineal body. The angles formed by the pelvic visceras with their evacuation ducts participate to the pelvic statics. During the pelvic dynamics the modification of these angles expresses the action of the musculofascial structures.

Prospective, Multidimensional Evaluation of Sexual Disorders in Men after Laser Photovaporization of the Prostate

INTRODUCTIONnA few studies have investigated the impact of photovaporization of the prostate (PVP) on sexual function and were mainly focused on erectile function.nnnAIMSnTo comprehensively evaluate the impact of PVP on sexual function.nnnMETHODSnA prospective evaluation involved sexually active patients needing surgical relief of bladder outlet obstruction due to benign prostatic enlargement in a single center between August 2007 and November 2011. All patients underwent PVP using the GreenLight HPS™ 120W system (AmericanMedicalSystems, Minnetonka, MN, USA).nnnMAIN OUTCOME MEASURESnPatients were evaluated preoperatively and postoperatively by International Prostate Symptom Score (I-PSS), I-PSS question 8, uroflowmetry parameters (maximum urinary flow rate [Qmax ] and postvoid residual [PVR] volume), Danish Prostate Symptom Score Sexual items (DAN-PSSsex), and overall sexual satisfaction using a seven-grade Likert scale. Operative parameters and postoperative complications were also assessed. Preoperative and postoperative values were compared using the Pearson chi-square test and the Wilcoxon paired test. A multivariable model was used to investigate the determinants of variation of global sexual satisfaction.nnnRESULTSnOne hundred and two consecutive patients with 12-month follow-up data were included in the analysis. Urinary parameters (I-PSS, Qmax , and PVR) were significantly improved compared with preoperative values. Compared with baseline, postoperative erection symptom score was not significantly different, whereas ejaculation symptom score was significantly worse. Global DAN-PSSsex score was unchanged, but DAN-PSSsex symptom score was worse (Pu2009=u20090.04) and DAN-PSSsex bother score was significantly improved (Pu2009<u20090.0001). Global sexual satisfaction was significantly improved compared with baseline (Pu2009=u20090.02) and was significantly associated with I-PSS but not with erection and ejaculation score in a multivariable model.nnnCONCLUSIONnEjaculation is the main sexual function impacted by PVP. Despite this, sexual satisfaction and bother due to sexual symptoms were significantly improved, probably due to the positive impact of urinary symptom relief.

Traitements pharmacologiques de l’hyperactivité vésicale idiopathique : revue de la littérature

OBJECTIVEnTo depict the recent advances in the field of pharmacological treatment of idiopathic overactive bladder (iOAB).nnnMETHODSnA literature search was conducted, using the PubMed/Medline database. Articles were included if published as full papers, after 2008 and before September 2012, and focused on recent pharmacologic treatment options for iOAB management. Publications having the highest level of evidence have been analyzed to summarize the available evidence, prioritizing the treatments available in France.nnnRESULTSnSome meta-analyses have been published between 2008 and 2012, gathering information about 82 level 1 evidence studies about efficacy and safety of anticholinergics. According to the most recent meta-analysis, anticholinergics have proved their efficacy for iOAB management, reducing the number of micturitions per day by up to 1.59, the number of incontinence episodes per day by up to 0.7, the number of urgency episodes by up to 1.7, the number of urgency incontinence episodes by up to 2.25, and the number of nocturnal voids by up to 0.24. Safety profile was good, especially for solifenacin and fesoterodine, supported by strong scientific evidence. However, data were limited to short-term follow-up, with no anticholinergic drug superior to another. Few data were available about observance, risk factors for failure and results in specific populations. Anticholinergics can be used safely for management of lower urinary tract symptoms in men, but their role is still to be determined. Data about innovative drugs were still preliminary.nnnCONCLUSIONSnAnticholinergics are a valuable option for management of iOAB, and have a growing role in management of lower urinary tract symptoms in men without bladder outlet obstruction.

Place des explorations électrophysiologiques dans la prise en charge des prolapsus urogénitaux

Isolated pelvic organ prolapse or together with urinary or fecal incontinence are frequently associated with peripheral neuropathy. This peripheral neuropathy could be seen as the cause or sometimes the consequence of the prolapse itself. Most of the studies have looked at the relationships between neuropathy and fecal incontinence. However, concerning urogenital prolapses, it seems that any peripheral denervation would lead to an exacerbation of the prolapse due to the weakness of the pelvic floor. Electromyography and electrophysiological tests are the only options to demonstrate objectively the peripheral neuropathy associated with pelvic organ prolapse. Those tests should not be performed systematically but only if there is any clinical suspicion of an underlying neuropathy.

Traitement chirurgical du prolapsus par promontofixation par laparotomie: Principes techniques et résultats

UNLABELLEDnAbdominal sacrofixation is the gold standard for the treatment of the prolapse. There are many ways to do it: technical, meshes, dissection, fixation of the mesh, associated procedures. Laparotomy is the classical procedure for sacrofixation. The basis of sacrofixation is to dissect the weak vesicovaginal and rectovaginal fascias and to replace with meshes spread out on the entire dissected surface.nnnPROCEDUREnSuprapubic abdominal incision, dissection of the anterior vertebral ligament on the right of the promontory, dissection of the vesicovaginal and rectovaginal spaces; meshes are fixed anteriorly on the vagina, posteriorly on the levator ani and uterosacral ligaments. The peritoneum on the meshes is carefully closed to avoid later ileus.nnnRESULTSnRedux is globally 10% (74-98%); the redux occur in the two years. Meshes exposure, spondilodiscitis, ileus are uncommon. In comparison with the vaginal procedures, there is less redux, less dyspareunia. But the drawbacks are postoperative pains, scars, eventration, low dissection difficult and some contraindications to the abdominal sacrofixation: respiratory insufficiency, morbid obesity, multi-operated abdomen, ascitis, aortoiliac aneurysms.

Le cloisonnement vaginal : indications, technique et résultats

The aim of this review was to summarize recent published data about indications, surgical technique and results of colpocleisis. We conducted a literature search on Medline using PubMed from 1990 to 2008. Anatomical and functional results were assessed for each selected study according to the age and the morbidity of the surgical procedure. As the colpocleisis was complete or partial, anatomic success rates were reported near 100 % with a follow-up ranged from one month to six years. Colpocleisis is an effective procedure for treatment of advanced pelvic organ prolapse in selected patient who no longer desire preservation of coital function. Concomitant anti-incontinence procedure is not associated with increased postoperative morbidity. However, preoperative urodynamics remain to be established for an optimal management of urinary incontinence.

Traitement chirurgical du prolapsus par voie haute et incontinence urinaire d'effort associée

Stress urinary incontinence is often associated with prolapse. The suburethral tapes have modified the indication for a preventive treatment of incontinence. The tapes are necessary in case of patent or masked incontinence, discussed in case of potential incontinence. The diagnosis of incontinence is done on questions to the patient, clinical exam, more than in urodynamic study. There is no absolute sign allowing to predict postoperative incontinence after surgery for prolapse. A continent woman can be incontinent postoperatively. If a potential incontinence is treated in the same as the prolapse, the patient must be informed of risk of obstruction and/or urgency.

Facteurs de risque et prévention des prolapsus génito-urinairesRisk factors and prevention of genitourinary prolapse

Numerous epidemiological studies in recent years have involved the search for the principal risk factors of genitourinary prolapse. Although it has been agreed for a long time that vaginal delivery increases the risk of prolapse (proof level 1), on the other hand, the Cesarian section cannot be considered a completely effective preventative method (proof level 2). The pregnancy itself is a risk factor for prolapse (proof level 2). Certain obstetrical conditions contribute to the alterations of the perineal floor muscle: a foetus weighing more than four kilos, the use of instruments at birth (proof level 3). If the risk of prolapse increases with age, intrication with hormonal factors is important (proof level 2). The role of hormonal replacement therapy remains controversial. Antecedent pelvic surgery has also been identified as a risk factor (proof level 2). Other varying acquired factors have been documented. Obesity (BMI and abdominal perimeter), professional activity and intense physical activity (proof level 3), as well as constipation, increase the risk of prolapse. More thorough research into these varying factors is necessary in order to be able to argue for measures of prevention, obstetrical techniques having already evolved to ensure minimal damage to the perineal structure.

[Surgical treatment of prolapse using laparoscopic promontofixation: technical principles and results].

UNLABELLEDnAbdominal sacrofixation is the gold standard for the treatment of the prolapse. There are many ways to do it: technical, meshes, dissection, fixation of the mesh, associated procedures. Laparotomy is the classical procedure for sacrofixation. The basis of sacrofixation is to dissect the weak vesicovaginal and rectovaginal fascias and to replace with meshes spread out on the entire dissected surface.nnnPROCEDUREnSuprapubic abdominal incision, dissection of the anterior vertebral ligament on the right of the promontory, dissection of the vesicovaginal and rectovaginal spaces; meshes are fixed anteriorly on the vagina, posteriorly on the levator ani and uterosacral ligaments. The peritoneum on the meshes is carefully closed to avoid later ileus.nnnRESULTSnRedux is globally 10% (74-98%); the redux occur in the two years. Meshes exposure, spondilodiscitis, ileus are uncommon. In comparison with the vaginal procedures, there is less redux, less dyspareunia. But the drawbacks are postoperative pains, scars, eventration, low dissection difficult and some contraindications to the abdominal sacrofixation: respiratory insufficiency, morbid obesity, multi-operated abdomen, ascitis, aortoiliac aneurysms.

Place de l’hystérectomie lors de la cure de prolapsus par promontofixation

In the past, hysterectomy was routinely performed at the time of pelvic organ prolapse repair. Nowadays, in patients with abnormal uterus (fibroma, dysplasia...), hysterectomy should be performed at the time of surgery. In contrast, in young women especially with desire of childbearing, uterus preservation is the best choice. But there is still a debate in postmenopausal patients with normal uterus and POP. There is currently no argument for choosing hysterectomy or uterus preservation at the time of POP repair in regard of the anatomical results for the middle as well as the anterior and posterior compartments. But it has been proven that hysterectomy increased the perioperative morbidity. Subtotal hysterectomy decreases this morbidity and result in a decreased rate of mesh erosion. To date, literature is not conclusive about the impact of hysterectomy on lower urinary tract symptoms. Patients counselling is important before hysterectomy with adequate information about potential psychosexual consequences of such procedure. At least, if uterus preservation, patients must be aware of the risk of malignant diseases (cervix or endometrial carcinoma) even if the risk is low in case of a good screening preoperatively.