Patrick Madelenat

Are sphincter defects the cause of anal incontinence after vaginal delivery? Results of a prospective study.

PURPOSE: Anal incontinence affects approximately 10 percent of adult females. Damage to the anal sphincters has been considered as the cause of anal incontinence after childbirth in the sole prospective study so far available. The aims of the present study were to determine prospectively the incidence of anal incontinence and anal sphincter damage after childbirth and their relationship with obstetric parameters. METHODS: We studied 259 consecutive females six weeks before and eight weeks after delivery. They were asked to fill in a questionnaire assessing fecal incontinence. Anal endosonography (7–10 MHz) was then performed. Two independent observers analyzed internal and external anal sphincters. RESULTS: A total of 233 patients (90 percent) were assessed, of whom 31 had cesarean section.De novo sphincter defects were observed in 16.7 percent (14 percent external, 1.7 percent internal, and 1 percent both) in the postpartum period only after vaginal delivery. These disruptions occurred with the same incidence after the first and the second childbirth. Independent risk factors (odds ratio; 95 percent confidence interval) for sphincter defect were forceps (12; 4–20), perineal tears (16; 9–25), episiotomy (6.6; 5–17), and parity (8.8; 4–19) as revealed by multivariate analyses. The overall rate of anal incontinence was 9 percent and independent risk factors (odds ratio; 95 percent confidence interval) involved forceps (4.5; 1.5–13), perineal tears (3.9; 1.4–10.9), sphincter defect (5.5; 5–15), and prolonged labor (3.4; 1–11). Among these patients only 45 percent had sphincter defects. CONCLUSION: Anal incontinence after delivery is multifactorial, and anal sphincter defects account for only 45 percent of them. Primiparous and secundiparous patients have the same risk factors for sphincter disruption and anal incontinence. Because external anal sphincter disruptions are more frequent than internal anal sphincter damage, surgical repair should be discussed in symptomatic patients.

Expression of cadherins in benign, borderline, and malignant ovarian epithelial tumors: A clinicopathologic study of 60 cases

We have analyzed the expression of E- and N-cadherins in benign, borderline, and maligant ovarian tumors, and we have correlated the pattern of cadherin expression with the standard clinicopathological parameters. An immunohistochemical technique has been applied to formalin-fixed, paraffin-embedded samples of 20 benign cystic tumors, 20 borderline tumors, and 20 cancers. Expression of E- and N-cadherins immunostaining were compared with the histological type, degree of histological differentiation, International Federation of Gynecology and Obstetrics (FIGO) stage, presence of ascites, occurrence of recurrence, and survival. E-cadherin was homogeneosuly expressed in benign tumors but was heterogeneously expressed or undetectable in most borderline and malignant tumors. In contrast, N-cadherin was detected in most benign and borderline tumors but was absent or heterogeneous in most carcinomas. The difference of expression of E-cadherin and N-cadherin between the three groups of ovarian tumors was statistically significant (respectively, P = .03 and P < .001). In ovarian carcinoma, patients with negative E-cadherin staining present a significantly shorter survival. No correlation was found between cadherin expression and clinicopathological parameters in borderline tumors. Our results suggest that alterations in E-cadherin and N-cadherin expressions are differentially involved in ovarian carcinogenesis and may have diagnostic and prognostic values.

Dienogest is as effective as triptorelin in the treatment of endometriosis after laparoscopic surgery: results of a prospective, multicenter, randomized study

OBJECTIVE To compare the efficacy of Dienogest versus Decapeptyl at 3.75 mg as consolidation therapy for surgery in the treatment of endometriosis. DESIGN Multicenter, open, randomized, parallel-group clinical trial. SETTING Volunteer patients in an academic research environment. PATIENT(S) Women with grade 2, 3, and 4 (</=70) endometriosis at initial laparoscopy. INTERVENTION(S) We provided 16 weeks of treatment with Dienogest, 1 mg tablet daily; or with Decapeptyl, 3.75 mg IM injection every 4 weeks. MAIN OUTCOME MEASURE(S) A change in the patients Revised American Fertility Society score at the post-treatment laparoscopy. RESULT(S) From June 1994 to July 1998, 142 patients were enrolled in the trial. After exclusion for major protocol deviations, 59 patients were included in the Dienogest group and 61 in the Decapeptyl group. This study group was comparable to the first inclusion group. The patient demographic and clinical characteristics, median duration of endometriosis, Revised American Fertility Society scores, and Visual Analogic Squale (VAS) scores were comparable in both groups. Statistical analysis of efficacy was not significantly different between the two groups. Adverse events were reported by 87.7% of patients in the Dienogest group and 85.1% in the Decapeptyl group. Neither treatment affected patient body weight or vital signs. CONCLUSION(S) Dienogest is as effective as Decapeptyl for consolidation therapy after surgery for the treatment of endometriosis. The safety profile of dienogest differed from Decapeptyl (3.75 mg). Dienogest constitutes a new therapeutic alternative to the GnRH analogues.

Fertility after hysteroscopic myomectomy: effect of intramural myomas associated

OBJECTIVE The aims of this retrospective study were to evaluate the subsequent fertility and outcome of pregnancies after hysteroscopic myomectomy according to (a) the characteristics of submucous myomas and (b) the association with intramural myomas. MATERIALS AND METHODS From July 1994 to June 1997, 119 patients had hysteroscopic myomectomy including 31 infertile women. Among these 31 patients, the mean number of removed myomas by hysteroscopy was 1.4 (range 1-4) and the mean diameter of fibroid was 20 mm (range 10 to 50). RESULTS Eleven out of 31 women (35.5%) became pregnant. Thirteen pregnancies were observed including nine term deliveries, three miscarriages and one premature labor at 24 weeks of amenorrhea. A difference in delivery rate was found between patients with one submucous myoma resected and those with two or more (p=0.02). No difference in pregnancy and in delivery rates was observed according to size and location of submucous myomas. In contrast, in patients without intramural myomas, the delivery rate (p<0.03) was significantly greater and the delay of conception (p=0.05) was significantly shorter than those found in patients with intramural myomas. CONCLUSION Our study suggest that fertility after hysteroscopic myomectomy depend on (a) the number of submucous myomas resected and (b) the association with intramural fibroids.

Anal fissure and thrombosed external hemorrhoids before and after delivery.

AbstractPURPOSE: Thrombosed external hemorrhoids and anal fissures are common and are responsible for severe discomfort during childbirth. However, the real incidence of these lesions is unknown. The aim of our study was to evaluate their incidence and the risk factors for these lesions during childbirth. METHODS: A prospective study with proctologic examination during the last 3 months of pregnancy and after delivery (within 2 months) was performed in 165 consecutive pregnant females. RESULTS: Fifteen females (9.1 percent) with anal lesions (13 thrombosed external hemorrhoids and 2 anal fissures) were observed during pregnancy. Fifty-eight females (35.2 percent) with anal lesions (33 thrombosed external hemorrhoids and 25 anal fissures) were observed during the postpartum period. Ninety-one percent of thrombosed external hemorrhoids were observed during the first day after delivery, whereas anal fissures were distributed, with no peak, over the two months after delivery. The 2 independent risk factors for anal lesions (among obstetric, baby’s, and mother’s information) were dyschezia, with a 5.7 odds ratio (95 percent confidence interval, 2.7–12), and late delivery, with a 1.4 odds ratio (95 percent confidence interval, 1.05–1.9). Furthermore, many thrombosed external hemorrhoids were observed after superficial perineal tears and heavier babies (P < 0.05). Only 1 of the 33 patients with thrombosed external hemorrhoids who were observed underwent a cesarean section. CONCLUSION: One third of females have thrombosed external hemorrhoids or anal fissures in the postpartum period. The most important risk factor is dyschezia. Traumatic delivery appears to be associated with thrombosed external hemorrhoids.

Alternative to surgery of treatment of unruptured interstitial pregnancy: 15 cases of medical treatment.

OBJECTIVE To evaluate medical treatment of interstitial pregnancy. METHODS This series was a retrospective study of medical treatment of interstitial pregnancies which was managed in two French Departments of Obstetrics and Gynecology (Bichat public Hospital. Paris and A. Béclère public Hospital, Clamart, France). Fifteen patients with clear evidence of an unruptured interstitial pregnancy were treated by injection of methotrexate (MTX) or potassium chloride (KCL) without surgery since January 1988. The diagnosis was established either by sonography and laparoscopic confirmation in eight cases or by only transvaginal ultrasound in seven cases. Three out of 15 cases in this series, had a heterotopic pregnancy who were treated by transvaginal ultrasound-guided injection of KCL. Others received systemic MTX injection in four cases, and local MTX injection in eight cases under either laparoscopy or transvaginal ultrasound guidance. Four different protocols of MTX (Ledertrexate) administration was performed in this series with time: at the beginning of our experience, MTX1 protocol, 15 mg i.m. daily for 5 days was used; and after MTX2 protocol, 1 mg/kg body weight i.m. daily for 4 days; MTX3 protocol, 1 mg/kg body weight intratubal associated with 1 mg/kg body weight i.m. daily for 3 days; and now MTX4 protocol, only intratubal 1 mg/kg body weight is especially used. The success was defined as declining serum human chorionic gonadotropin (hCG) to undetectable levels, and no further surgical management was required. Outcome of subsequent fertility was also evaluated. RESULTS Complete resolution was obtained in 13 (86.6%) out of 15 interstitial pregnancies. Two out of 15 patients, with medical treatments failure required secondary surgery. No severe side effects of medical treatment were observed. Follow-up hysterosalpingography was performed in 12 patients showing 91.7% tubal patency on the side of interstitial pregnancy. Outcome of intra-uterine pregnancy of the three patients who had heterotopic gestation, was two miscarriages and one delivery at term. Out of the other 12 patients in this series, nine became pregnant within 1 year: eight pregnancies at term, and one induced abortion. At present, among the last three patients, two have no desire to conceive. CONCLUSION Our results suggest that unruptured interstitial pregnancies now can be managed with local MTX administration of 1 mg/kg body weight under transvaginal ultrasound or under laparoscopy procedure. This approach is particularly attractive in these patients, where the only alternative to therapy is laparotomy with cornual resection.

Expression of cadherins and CD44 isoforms in human endometrium and peritoneal endometriosis

Background.  To evaluate (a) cadherins and CD44 expression in normal endometrium and in peritoneal endometriosis, and (b) to correlate, their expressions with clinicopathological parameters.

Treatment of unruptured tubal pregnancy by local injection of methotrexate under transvaginal sonographic control

Seventeen unruptured tubal gestations were managed on an outpatient basis using local methotrexate (MTX) injection. A single 50-mg dose of MTX was injected into the gestational sac under transvaginal sonographic control. Follow-up included serial assays of the beta-subunit of human chorionic gonadotropin (beta-hCG), clinical and sonographic evaluation. Resolution was obtained in 13 out of 17 patients. The regression curve between days after treatment versus beta-hCG (y = 82.2 - 10.8x + 0.37x2) demonstrated a significant negative correlation (R2 = 0.77; R = 0.88; P less than or equal to 0.02). The mean beta-hCG level on day 15 was 3.2% +/- 3.1% of the initial value. Laparoscopy was performed in 4 patients. Pathological findings suggested that resolution was underway in these four cases despite a slow decline in beta-hCG. No systemic side effects were observed in any of the 17 patients. Long-term follow-up is needed to evaluate tubal patency and reproductive outcome. Our experience suggests that local injection of MTX may be an effective alternative for the treatment of unruptured ectopic pregnancy.

Management and outcome of borderline ovarian tumors incidentally discovered at or after laparoscopy

BACKGROUND To evaluate in a series of patients with borderline ovarian tumors the clinical findings and the outcome after laparoscopic management. METHODS Retrospective study of 25 patients with borderline ovarian tumors first treated by laparoscopic approach. RESULTS Thirteen patients had mucinous tumors and 12 had serous tumors. Twenty-one patients had ultrasound examination which detected 24 ovarian cysts including multilocular cysts in 50% of cases and unilocular sonolucent cysts in 25% of cases. The serum CA 125 and CA 199 levels were elevated in 30.7% and 23% respectively. Among the 25 patients first treated by laparoscopic approach, 24 had stage I disease: six of them had cystectomy, seven unilateral salpingo-oophorectomy, two bilateral salpingo-oophorectomy and two laparoscopic hysterectomy with bilateral salpingo-oophorectomy. Seven patients had laparoconversion for presumption of ovarian cancer (5) and failure of laparoscopic procedure (2). One patient with stage III disease had laparoscopic biopsies and subsequent laparotomy. Among the 25 patients, 15 had conservative treatment and 10 had radical treatment. Three recurrences occurred after cystectomy. The mean follow-up was 41 months. Twenty-three patients were alive without evidence of disease, one died of intercurrent disease and one patient was lost to follow-up. CONCLUSION Our data suggest that the laparoscopic approach to borderline ovarian tumors is possible in early stage disease but associated with a high risk of recurrence after cystectomy.

Determinants of pregnancy rate and obstetric outcome after laparoscopic myomectomy for infertility

Abstract Objective: To determine the effect of myomectomy on infertility and to assess the factors influencing reproductive outcome. Design: Retrospective study. Setting: Tertiary care center. Patient(s): One hundred and three infertile women with uterine leiomyoma who had had infertility >2 years and a follow-up time >12 months were enrolled. Follow-up was complete for 88 patients, including 28 (31.8%) with primary infertility and 44 (50%) with unexplained infertility. The mean (±SD) age of the patients was 36.1 ± 2.1 years. Intervention(s): Laparoscopic myomectomy. Main Outcome Measure(s): Pregnancy rate according to patient and fibroid characteristics. Result(s): Forty-two patients became pregnant (40.7%). The mean (±SD) delay in conception was 7.5 ± 2.6 months. Nearly 80% of the women conceived spontaneously. Of 44 pregnancies in 42 women, 36 live newborns were delivered. No dehiscence of uterine scar occurred. The pregnancy rate was significantly higher in women P Conclusion(s): Fertility and pregnancy after laparoscopic myomectomy depend primarily on patient age, duration of infertility before myomectomy, and existence of associated infertility factors.