Jean-Philippe Lucot

Transvaginal mesh technique for pelvic organ prolapse repair: mesh exposure management and risk factors

Prosthetic reinforcement in the surgical repair of pelvic prolapse by the vaginal approach is not devoid of tolerability-related problems such as vaginal erosion. The purposes of our study are to define the risk factors for exposure of the mesh material, to describe advances and to recommend a therapeutic strategy. Two hundred and seventy-seven patients undergoing surgery due to pelvic prolapse with transvaginal mesh technique were included in a continuous, retrospective study between January 2002 and December 2003. Thirty-four cases of mesh exposure were observed within the 2 months following surgery, which represents an incidence of 12.27%. All the patients were medically treated, nine of whom were found to have completely healed during the check-up performed at 2 months. In contrast, 25 patients required partial mesh exeresis. Risk factors of erosion were concomitant hysterectomy [OR=5.17 (p=10−3)] and inverted T colpotomy [OR=6.06 (p=10−2)]. Two technical guidelines can be defined from this study as regards the surgical procedure required in order to limit mesh exposure via the vaginal route. The uterus must be preserved, and the number and extent of colpotomies needed to insert the mesh must be limited.

Epithelial–mesenchymal transition in ovarian cancer

Ovarian cancer is a highly metastatic disease and the leading cause of death from gynecologic malignancy. Hence, and understanding of the molecular changes associated with ovarian cancer metastasis could lead to the identification of targets for novel therapeutic interventions. The conversion of an epithelial cell to a mesenchymal cell plays a key role both in the embryonic development and cancer invasion and metastasis. Cells undergoing epithelial-mesenchymal transition (EMT) lose their epithelial morphology, reorganize their cytoskeleton and acquire a motile phenotype through the up- and down-regulation of several molecules including tight and adherent junctions proteins and mesenchymal markers. EMT is believed to be governed by signals from the neoplastic microenvironment including a variety of cytokines and growth factors. In ovarian cancer EMT is induced by transforming growth factor-beta (TGF-beta), epidermal growth factor (EGF), hepatocyte growth factor (HGF) and endothelin-1 (ET-1). Alterations in these cellular pathways candidate them as useful target for ovarian cancer treatment.

Les prothèses synthétiques dans la cure de prolapsus génitaux par la voie vaginale : bilan en 2005

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 35 - N° 5 - p. 429-454

TVT Secur™ : étude prospective et suivi à un an de 154 patientes

OBJECTIVES To evaluate the efficacy and complications of this new sub-urethral tape procedure with a follow up of 12 months. MATERIALS AND METHODS Prospective, multicenter study of 154 patients operated for stress urinary incontinence with the TVT Secur. Patients were operated between 24 July 2006 and 18 December 2007 and were all controlled at 2 months and 118 at 1 year. No associated surgical procedure was performed. RESULTS One hundred five patients had pure stress incontinence with 12 of them presenting an intrinsic sphincter deficient. Forty-nine had a mixed urinary incontinence with 12 of them having ISD. Preoperatively, 69 patients complained of urgency and 12 of micturation disorder. Anaesthesia was local for 97 patients (63%). Per operative complications were five hemorrhages, one bladder injury, one vaginal wound, 21 patients had post-void residual volume (100 to 200ml) and one groin pain. We noted two exposed tapes, one granuloma, one ITU and seven lateral vaginal bands. Among the patients with urge at baseline, 61.2% were cured at 2 months and 75.5% at 1 year. De novo urge appeared in 12.8% at 2 months and 12.3% at 1 year. De novo micturation disorder was found in 9.5% at 2 months and 3.7% at 1 year. The cured patients at 1 year were 70.3%, improved 11% and fails 18.7%. The cured rate remains same between 2 months and 1 year. The improved patients (24%) at 2 months remain 11% at 1 year. The recurrence rate was 12,8% at 1 year. CONCLUSION The results are inferior to TVT or TVT-O procedures. We probably must selected the patients for this procedure.

Prise en charge des mutilations génitales féminines de type III

Resume Les mutilations genitales feminines correspondent a l’ablation partielle ou totale des organes genitaux externes de la femme et/ou la lesion des organes genitaux feminins non therapeutiques. Dans certaines regions d’Afrique ou du Moyen-Orient, cette pratique est courante. La migration des femmes africaines en Europe ces dix dernieres annees a importe ce probleme dans notre pays. Elles se regroupent en 4 types. Le 3e type ou l’infibulation est l’excision partielle ou totale des organes genitaux externes et suture/retrecissement de l’orifice vaginal. Cette mutilation peut s’associer a des complications uro-gynecologiques et obstetricales specifiques. Le kyste dermoide clitoridien est la complication la plus frequente. Sur le plan obstetrical, l’infibulation rend impossible une surveillance rigoureuse du travail. Elle peut etre a l’origine d’une prolongation de la duree de travail et de complications perineales lors de l’expulsion. La prise en charge therapeutique repose sur la desinfibulation chirurgicale decrite par Gabbar. Elle doit etre proposee de maniere prophylactique, en antenatal afin de permettre un accouchement par voie basse. Le but de cet article est de presenter notre experience sur la prise en charge des mutilations genitales feminines.

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.

Prise en charge des expositions de prothèse après cure de prolapsus génitaux par voie vaginale

Resume Introduction Le renforcement prothetique dans la cure chirurgicale des troubles de la statique pelvienne est actuellement en plein essor. Cette technique n’est pas sans poser des problemes de tolerance ; en effet, un nombre non negligeable d’exposition de prothese est a deplorer. L’exposition de prothese est la complication la plus frequemment rencontree, elle est aussi appelee erosion ou granulome. Son mecanisme est un defaut de cicatrisation. Elle est a differencier de phenomene infectieux majeur tel qu’une cellulite pelvienne. Objectifs Le but de notre etude etait de definir le devenir et la meilleure prise en charge des patientes presentant ces expositions de materiel prothetique. Materiels et methodes Notre etude descriptive et retrospective sur 24 mois a permis de colliger 34 dossiers de janvier 2002 a decembre 2003. Ces patientes ont beneficie d’une cure de prolapsus par renforcement prothetique par voie vaginale qui s’est compliquee d’une exposition de prothese. L’intervention pratiquee, intitulee TVM (Tension free Vaginal Mesh), comprend la pose sans fixation d’une prothese synthetique dans les espaces de decollement vesico-vaginal et/ou recto-vaginal. Resultats Le siege de l’exposition a ete 33 fois sur 34 en regard de la cicatrice de la colpotomie anterieure (97,06 %). La prise en charge de ces expositions s’est faite en deux temps, tout d’abord on a utilise un traitement antibiotique local. Ce traitement a suffi pour guerir 9 patientes (26,47 %). En cas d’echec, une intervention de resection partielle de la prothese a ete pratiquee en ambulatoire ou durant une courte hospitalisation de 24 heures. Cette resection unique a suffi pour 20 patientes (88 %). Deux patientes ont necessite une deuxieme intervention d’excision de prothese (8 %) et une patiente a necessite 3 retraits (4 %). Il est a noter qu’une patiente, a l’occasion de la resection partielle de prothese, a presente une fistule vesico-vaginale. Cet evenement nous impose de recommander la pratique, en peroperatoire, d’un test au bleu ou d’une cystoscopie. Conclusion Dans le cadre de cette chirurgie, il est important de surveiller attentivement l’apparition d’une exposition de prothese. Il est necessaire ensuite de realiser une prise en charge en 2 temps. Tout d’abord, il faut commencer par un traitement medical local, antibiotique ou œstrogenique. Puis en cas d’echec, un traitement chirurgical de retrait partiel de la prothese se justifie. Il faut enfin recommander la plus grande prudence lors de l’exerese d’une partie de prothese en realisant un controle de la vessie.

Tumeurs phyllodes du sein: À propos de 8 patientes

INTRODUCTION Phyllodes tumors of breast are rare and usually benign. These are histologically fibro-epithelial tumors similar to fibroadenomas. Histological confirmation on the operative specimen is required to establish the diagnosis and histological pronostic of phyllode tumors. MATERIALS AND METHODS We reviewed 8 cases of phyllodes tumors and the literature to report the circumstances of occurrence of these tumors, and their specific clinical diagnosis, therapeutic, prognostic features. RESULTS 62.5% of patients were nulliparous. The mean age at diagnosis was 33.4 years. Mean tumor size was 3.75 cm. Tumours predominated on the right side (87.5%) and upper-outer quadrant (62.5%). Imaging findings were helpful for diagnosis. Aspiration cytology demonstrated the phyllode tumor in 43% of patients. Wide tumorectomy was performed in seven patients. One patient underwent mastectomy and radiotherapy and chemotherapy. The recurrence rate (37.5%) justifies wide margin excision. There were no deaths in our series. DISCUSSION and conclusion. These results together with those reported in the literature show that the loco-regional and general spread depends on margin surgery.Resume Introduction Les tumeurs phyllodes du sein sont rares. Elles sont le plus souvent benignes. Histologiquement, elles correspondent a une tumeur fibro-epitheliale s’apparentant au fibro-adenome. Le diagnostic de tumeur phyllode et l’histopronostic sont etablis lors de l’analyse anatomo-pathologique de la piece operatoire. Materiel et methodes Nous souhaitons, a travers notre etude portant sur 8 cas de tumeurs phyllodes et une revue de la litterature, relater les circonstances de survenue de ces tumeurs, ainsi que leurs caracteristiques cliniques, para-cliniques, pronostiques et therapeutiques. Resultats 62,5 % des patientes sont nullipares. L’âge moyen de survenue est de 33,4 ans. La taille de la tumeur est en moyenne de 3,75 cm, avec une localisation surtout au niveau du sein droit (87,5 %) et dans le quadrant supero-externe (62,5 %). L’imagerie peut nous orienter vers le diagnostic. La cytoponction peut evoquer la presence d’une tumeur phyllode dans 43 % des cas. Le traitement chirurgical consiste en une tumorectomie elargie pour 7 patientes. Une patiente a beneficie d’une mastectomie d’emblee et d’un traitement par radiotherapie et chimiotherapie. Le suivi a 24 mois montre un taux de recidive (37,5 %) justifiant la realisation d’une exerese elargie. Aucun deces n’est a deplorer dans notre etude. Discussion et conclusion Ces resultats ont ete compares a ceux de la litterature. L’existence d’une extension loco-regionale et generale semble correle aux marges chirurgicales de l’exerese.

Traitement chirurgical du prolapsus génital chez les femmes âgées de plus de 80 ans: À propos de 48 patientes opérées par voie vagnile

OBJECTIVES The aim of this study was to assess the morbidity and the effectiveness of the vaginal surgical treatment for women over 80 years of age with genital prolapse. MATERIALS AND METHODS All the women over 80 years operated in our institution between 1996 and 2003 were reviewed retrospectively. We examined the risk and the effectiveness of this surgery. RESULTS Forty-eight women underwent surgery during this period. No colpocleisis was performed. The most frequent surgery was a combination of vaginal patch plastron, Richters spinous fixation and posterior perineorrhaphy. No major intra- or post-operative complication occurred. One woman required blood transfusion. The most frequent postoperative complication was voiding difficulties (12%), which had disappeared 3 months later. A partial stenosis of a left ureter with ureterohydronephrosis occurred, requiring endoscopic dilatation. At 3 months, anatomic and functional outcome was good in 92% of women. The number of patients lost to follow-up at one year was to large to draw any conclusion. CONCLUSION Complete transvaginal surgical treatment is a safe procedure for elderly women which provides good short-term effectiveness.

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.