Géraldine Giraudet

Therapeutic management of uterine fibroid tumors: updated French guidelines

The medical management of symptomatic non-submucosal uterine fibroid tumors (leiomyomas or myomas) is based on the treatment of abnormal uterine bleeding by any of the following: progestogens, a levonorgestrel-releasing intrauterine device, tranexamic acid, nonsteroidal anti-inflammatory drugs, or GnRH analogs. Selective progesterone receptor modulators are currently being evaluated and have recently been approved for fibroid treatment. Neither combined estrogen-progestogen contraception nor hormone treatment of the menopause is contraindicated in women with fibroids. When pregnancy is desired, whether or not infertility is being treated by assisted reproductive technology, hysteroscopic resection in one or two separate procedures of submucosal fibroids less than 4 cm in length is recommended, regardless of whether they are symptomatic. Interstitial, also known as intramural, fibroids have a negative effect on fertility but treating them does not improve fertility. Myomectomy is therefore indicated only for symptomatic fibroids; depending on their size and number, and may be performed by laparoscopy or laparotomy. Physicians must explain to women the potential consequences of myomas and myomectomy on future pregnancy. For perimenopausal women who have been informed of the alternatives and the risks, hysterectomy is the most effective treatment for symptomatic fibroids and is associated with a high rate of patient satisfaction. When possible, the vaginal or laparoscopic routes should be preferred to laparotomy for hysterectomies for fibroids considered typical on imaging. Because uterine artery embolization is an effective treatment with low long-term morbidity, it is an option for symptomatic fibroids in women who do not want to become pregnant, and a validated alternative to myomectomy and hysterectomy that must be offered to patients. Myolysis is under assessment, and research on its use is recommended. Isolated laparoscopic ligation of the uterine arteries is a potential alternative to uterine artery embolization; it also complements myomectomy by reducing intraoperative bleeding. It is possible to use second-generation techniques of endometrial ablation to treat submucosal fibroids in women whose families are complete. Subtotal hysterectomy is a possible alternative to total hysterectomy for fibroid treatment, given that by laparotomy the former has a lower complication rate than the latter, while by laparoscopy, these rates are the same. In each case, the patient is informed about the benefit and risk associated with each therapeutic option.

Impact of laparoscopic sacrocolpopexy learning curve on operative time, perioperative complications and short term results

OBJECTIVE Laparoscopic sacrocolpopexy (LSCP) learning is a challenge for unexperienced surgeons, since complications occurrence and anatomical results could depend from surgeons experience. The aim of this study was to describe LSCP characteristics, perioperative complications and short term anatomical results when LSCP was performed by LSCP-experienced surgeons or trainees. STUDY DESIGN Patients who underwent LSCP in our surgical unit in the last ten years were included. Patients were excluded if laparotomy was performed without any laparoscopic time. Interventions were divided into LSCP experienced surgeons (who had performed at least 30 procedures) and trainees (residents, fellows, and surgeons with less than 30 procedures). Main outcomes were operative time, peroperative complications (included conversions to open or vaginal surgery, bladder and vaginal perforation, epigastric vessels injury and hemorrhage) early postoperative complications, mesh complications and anatomical results at three months. RESULTS 492 patients were included, 108 in the trainee group and 384 in the LSCP-experienced group. Groups were comparable for demographics, preoperative clinical examination and surgery characteristics. Average operative time was significantly higher in trainees group than in LSCP-experienced group (251 versus 178 min (p<0.0001)). There was no difference in open surgery conversion rate (5.6% versus 3.9%, p=0.42) or peroperative complication occurrence (4.7% versus 4.6%, p=0.98). Bladder perforations were more frequent in trainee group but difference was not statistically significant (3.7% versus 1.3%, p=0.11). 98% patients were assessed at three months. Overall anatomical success rate was 94.9%. There was no difference in anatomical failure rate between trainee group and LSCP experienced surgeons group (respectively 4.7% versus 5.2%, p=0.82), neither in mesh complication rate (3.9% versus 2.8%, p=0.77). CONCLUSION LSCP learning in an experimented surgical team induces high operative time, but remains safe for patient.

Use of vaginal mesh for pelvic organ prolapse repair: a literature review

The use of mesh for pelvic organ prolapse repair through the vaginal route has increased during this last decade. The objective is to improve anatomical results (sacropexy with mesh seeming better than traditional surgery) and keep still the advantage of vaginal route. Numbers of cohort series and randomized control trials have been recently published. These works increase our knowledge of advantages and risks of mesh. It has been shown that the use of mesh to treat cystocoele through vaginal route improves anatomical results when compared to traditional surgery. The rate of complications, especially de novo dyspareunia, remains equivalent between the two techniques.

Rate of re-interventions after transvaginal pelvic organ prolapse repair using partially absorbable mesh: 20 months median follow-up outcomes

OBJECTIVE To report our experience regarding the use of partially absorbable mesh, evaluating the nature and rate of re-intervention after transvaginal pelvic organ prolapse repair. MATERIALS AND METHODS We retrospectively collected data on 269 consecutive patients who underwent partially absorbable mesh repair between January 2009 and January 2011. Data were obtained from our hospital medical records and we phoned patients to check if they had surgery in another hospital since then. RESULTS 250 patients were included, with a median follow-up duration of 20 months (range 8-34 months). The global rate of re-interventions was 8%. The main indications were mesh exposure (2%), prolapse recurrence (1.2%), and urinary complications such as de novo stress urinary incontinence (4.8%). Afterwards, we compared these data with those previously obtained in our centre with non-absorbable mesh. CONCLUSION Our study shows that the use of a partially absorbable mesh is efficient and reliable with relatively low rates of re-intervention. According to the available literature data, a partially absorbable mesh does not seem to give advantages in comparison with classic non-absorbable mesh regarding rates of re-intervention.

Multiparous Ewe as a Model for Teaching Vaginal Hysterectomy Techniques

BACKGROUND Despite being linked to improving patient outcomes and limiting costs, the use of vaginal hysterectomy is on the wane. Although a combination of reasons might explain this trend, one cause is a lack of practical training. An appropriate teaching model must therefore be devised. Currently, only low-fidelity simulators exist. Ewes provide an appropriate model for pelvic anatomy and are well-suited for testing vaginal mesh properties. This article sets out a vaginal hysterectomy procedure for use as an education and training model. METHOD A multiparous ewe was the model. Surgery was performed under general anesthesia. The ewe was in a lithotomy position resembling that assumed by women on the operating table. EXPERIENCE Two vaginal hysterectomies were performed on two ewes, following every step precisely as if the model were human. Each surgical step of vaginal hysterectomy performed on the ewe and on a woman were compared side by side. We identified that all surgical steps were particularly similar. The main limitations of this model are costs (

Identification of sexually transmitted bacteria in tubo-ovarian abscesses through nucleic acid amplification

500/procedure), logistic problems (housing large animals), and public opposition to animal training models. CONCLUSION The ewe appears to be an appropriate model for teaching and training of vaginal hysterectomy.

Does sacrocolpopexy present heterogeneity in its surgical technique? A systematic review

Tubo-ovarian abscess (TOA) consists of a purulent collection involving the fallopian tube, ovary, and, occasionally, other adjacent pelvic organs. TOA is clinically interrelated with pelvic inflammatory diseases (PID) and noncollected infection of the uterus, fallopian tubes, and other reproductive

Long-term (8.5 years) analysis of the type and rate of reoperation after transvaginal mesh repair (Prolift®) in 349 patients

Sacrocolpopexy (SCP) is an extensively studied and highly efficacious treatment for female pelvic organ prolapse (POP). We aimed to analyze the technical steps for performance of a SCP among all RCTs in the literature that compared it with different procedures, or that studied different routes for performing SCP.

The anatomy of the sacral promontory: How to avoid complications of the sacrocolpopexy procedure

OBJECTIVE Polypropylene meshes have specific complications, and in 2016 the Food and Drug Administration required a Premarket Approval for their use in pelvic prolapse repair, as there was a lack of long-term data. Our objectives were to determine the long-term reoperation rates and type in our patients after transvaginal mesh repair and to study their risk factors. STUDY DESIGN We were able to follow up with 349 patients from a single University Hospital, with phone calls, after a median time of 8,5 years. The 8.5-year reoperation rates were derived from Kaplan-Meier survival curves. RESULTS Our global, long-term reoperation rate, including mesh complications, prolapse recurrence and urinary incontinence after a median follow-up of 8.5 years, was 14.5%. The mesh-related complication rate (including mesh exposures, infections, and retractions requiring surgery) was 4.3%, the urinary incontinence rate was 5.7%. The prolapse recurrence rate was 7.2%; mainly found with posterior mesh only (18.5% of reoperations). For total Prolift, the reoperation rate for prolapse recurrence was only 4%. Moreover, 867% of the patients who had an anterior Prolift only or a posterior Prolift only and who were re-operated for prolapse recurrence showed recurrence exclusively in another compartment. In bivariate analysis, only the posterior mesh type was significantly associated with prolapse recurrence versus total meshes. CONCLUSION Despite their market withdrawal, the transvaginal meshes are a safe and efficient option for pelvic organ prolapse surgical management. Low rates of mesh complications can be achieved with cautious dissection and adequate training of surgeons.

Feasibility and benefits of the ewe as a model for vaginal surgery training

Because of problems with vaginal meshes and the high rate of recurrences of native tissue repair, more and more surgeons treat pelvic organ prolapse with laparoscopic sacrocolpopexy. This surgery requires skilled surgeons. The first step of sacrocolpopexy is the dissection of tissues in front of the sacral promontory to reach the anterior longitudinal ligament. Some complications can occur during this dissection and the attachment of the mesh. This step is dangerous for surgeons because of the proximity of vessels, nerves, and ureters. The lack of knowledge of anatomy can lead to severe complications such as vascular, ureteral, or nerve injuries. These complications can be life-threatening. To show anatomic concerns when surgeons dissect and affix the mesh on the anterior longitudinal ligament, we have developed a video of the promontory anatomy. By reviewing anatomic articles about vessels, nerves, and ureters in this localization, we propose an educational tool to increase the anatomic knowledge to avoid severe complications. In this video, we show an alternative location for dissection and graft fixation when the surgeon believes that mesh cannot be fixed safely on the anterior surface of S1, as currently recommended.