X. Deffieux

Vaginal mesh erosion after transvaginal repair of cystocele using Gynemesh or Gynemesh-Soft in 138 women: a comparative study

The objective of this study was to compare mesh erosion after transvaginal repair of cystocele using Gynemesh or Gynemesh-Soft mesh. We retrospectively analyzed 138 consecutive cases of transvaginal repair of cystocele using synthetic mesh. The study endpoint was the pathological evidence of vaginal erosion. Multiple logistic regression was used to determine independent predictors of vaginal erosion. One hundred and thirty eight women (ages 30–83xa0years) with cystocele between October 1999 and October 2004, from a French University Hospital, participated in this study. Cystocele repair was performed in all patients according to the technique of tension-free polypropylene mesh. The median follow-up was 32.1xa0months (range 7.5–59.9) in the Gynemesh group and 7.1xa0months (range 1–21.9) in the Gynemesh-Soft group. Vaginal erosion was reported in 27 (20%) of the patients. Anatomically, the success rate was 95% (131/138). There was no statistically significant difference between the Gynemesh and the Gynemesh-Soft meshes [the rate of vaginal erosion of the mesh was 16% (15/89) vs 24% (12/49), respectively, p=0.39]. Univariate analysis only identified age class as factor significantly associated with the probability of vaginal erosion. Multivariate analysis revealed that age class is an independent predictive factor of vaginal erosion (age > 70xa0years, odds ratio (OR) 3.6, 95% confidence interval (CI) 1.3–9.7, p=0.010). Furthermore cystocele stage > 2 (Baden and Walker classification) is a protective factor against vaginal erosion (OR 0.3, 95% CI 0.1–0.8, p=0.016). Thirteen symptomatic patients (13/27, 48%) necessitated a partial excision of the mesh, associated with a vaginal mucosal closure. Two patients (2/27, 7%) underwent a complete excision of the mesh. The incidence of de novo dyspareunia was 9% in patients with vaginal erosion and 11% in patient without mesh erosion (p=0.85). There was no occurrence of bladder or urethral erosion and no vaginal or pelvic infection. Isolated vaginal erosion of the mesh did not prove to be problematic. Gynemesh-Soft mesh does not decrease the incidence of vaginal erosion. Age > 70xa0years is an independent predictive factor of vaginal erosion. We recommend that mesh placement by vaginal route should be avoided by women with moderate cystocele. Where possible, total hysterectomy and vertical incision should also be avoided. Management of vaginal erosion is simple and is associated with a low rate of morbidity. However, patients should be informed that vaginal erosion of the mesh can occur. A multivariate analysis reveals that the incidence of vaginal erosion is not significantly different between Gynemesh and Gynemesh-Soft meshes. Other factors of erosion are analyzed.

Accuracy of Three-Dimensional Ultrasonography in Differential Diagnosis of Septate and Bicornuate Uterus Compared with Office Hysteroscopy and Pelvic Magnetic Resonance Imaging

STUDY OBJECTIVEnTo estimate the accuracy of 3-dimensional (3-D) ultrasonography in the differential diagnosis of septate and bicornuate uterus compared with office hysteroscopy and pelvic magnetic resonance imaging (MRI).nnnDESIGNnProspective cohort study (Canadian Task Force Classification II-2).nnnSETTINGnUniversity hospital.nnnPATIENTSnThirty-one patients referred with a suspected diagnosis of septate (n = 20) or bicornuate (n = 11) uterus.nnnINTERVENTIONSnAll patients underwent 3-D ultrasonography displaying the rebuilt coronal view of the uterus, office hysteroscopy, and pelvic MRI. Operative hysteroscopic assessment and treatment was performed in case of sonographically diagnosed septate uterus. Bicornuate uterus was confirmed by laparoscopy.nnnMAIN OUTCOMES MEASURESnConcordance between suspected diagnosis with 3-D ultrasonography, hysteroscopy, and pelvic MRI and final diagnosis.nnnRESULTSnA septate uterus was diagnosed with 3-D ultrasonography in 29 patients and bicornuate uterus in 2 patients. Hysteroscopic transcervical section of the uterine septum was achieved in the 29 patients. Bicornuate uterus was laparoscopically confirmed in the 2 patients. Concordance between ultrasonography and operative hysteroscopy or laparoscopy was verified in all 31 cases. Twenty-five uterine septa and 5 bicornuate uteri were diagnosed by hysteroscopy (3 false-positive diagnoses of bicornuate uterus, 1 unfeasible hysteroscopy). Hysteroscopic diagnosis was correct in 27/30 patients. Twenty-four septate uteri and 7 bicornuate uteri were diagnosed by MRI (5 false-positive diagnoses of bicornuate uterus). Two complete septate uteri diagnosed by MRI were finally confirmed as incomplete septate uteri after 3-D ultrasonography and operative hysteroscopy. MRI diagnosis was correct in 24/31 patients.nnnCONCLUSIONnTransvaginal 3-D ultrasonography appears to be extremely accurate for the diagnosis and classification of congenital uterine anomalies, more than office hysteroscopy and MRI. It may conveniently become the only mandatory step in the assessment of the uterine cavity in patients with a suspected septate or bicornuate uterus.

Infracoccygeal sacropexy or sacrospinous suspension for uterine or vaginal vault prolapse

To compare infracoccygeal sacropexy (IS) and sacrospinous suspension (SS) for the treatment of uterine or vault prolapse.

Long-term results of tension-free vaginal tape for female urinary incontinence: Follow up over 6 years

Objective:u2003 To describe the long‐term outcome of using tension‐free vaginal tape (TVT) with and without associated procedures.

3D ultrasound to assess the position of tubal sterilization microinserts

BACKGROUNDnThe aim of this study was to assess the diagnostic accuracy of three-dimensional ultrasound (3D-US) for determining the position of Essure microinserts and the success of sterilization by the Essure method.nnnMETHODSnThis retrospective observational study examined the case records of 311 women who underwent hysteroscopic sterilization from October 2002 through October 2008. Imaging with 3D-US or pelvic X-radiography or both was performed 3 months after the procedure to verify device position. Hysterosalpingography (HSG) was performed when a bilateral procedure was not completed because of a history of salpingectomy or blocked tube, when doubt persisted after 3D-US or pelvic radiography, or for comparative purposes in a prospective study. The positions seen on 3D-US were classified in four categories according to a specific scale we devised.nnnRESULTSnThe insertion procedure was completed in 94.2% patients. Only 90.5% underwent imaging verification of the device 3 months afterwards. In all, 227 3D-US, 175 pelvic radiography and 64 HSG imaging procedures were performed. Visualization of the device was possible in 99.6% of the 3D-US images. According to our classification, 3D-US was appropriate for assessing device position for 195 (85.9%) patients. The need for HSG confirmation was significantly lower with 3D-US than radiographic imaging (14.1 versus 26.8%, P = 0.001). 3D-US examinations, compared with the results of HSG as the reference test, had a sensitivity of 100% and a specificity of 76.6%. Neither pregnancy nor early expulsion occurred when 3D-US found that the devices were correctly placed.nnnCONCLUSIONSn3D-US is a simple technique for assessing the position of Essure(®) microinserts, even after concomitant endometrial surgery. The 3D-US classification presented here appears to make it possible to use HSG for back-up confirmation only when the microinsert is found in a very distal position on 3D-US and thus to protect the majority of women from the negative effects of pelvic radiography and HSG.

Assessment of three-dimensional ultrasound examination classification to check the position of the tubal sterilization microinsert

OBJECTIVEnTo assess the accuracy of three-dimensional (3D) ultrasound to determine the position of Essure microinserts.nnnDESIGNnProspective observational study.nnnSETTINGnGynecology department in a teaching hospital.nnnPATIENT(S)nForty women who underwent hysteroscopic sterilization from March through October 2008.nnnINTERVENTION(S)nBoth 3D ultrasound and hysterosalpingography (HSG) were performed 3 months after the procedure to verify device position. Positions seen on 3D ultrasound were classified in four categories: a perfect position (1 + 2 + 3), a proximal position (1 + 2), a distal position (2 + 3), and a very distal position (3-only). MAIN OUTCOME AND MEASURE(S): Microinsert position on 3D ultrasound and correlation with HSG.nnnRESULT(S)nOverall, 93% of the devices for 40 patients were found to have been placed successfully. The final sample comprised 64 Essure devices. HSG showed tubal patency for only three devices, all classified as 3-only. No tubal permeability was noted for the other 61 positions. This 3-only location on 3D ultrasound was statistically associated with a failure of sterilization in comparison with the other locations (3/16 [18%] vs. 0/48 [0%]).nnnCONCLUSION(S)n3D ultrasound is a simple and reproducible technique to assess the position of the Essure microinsert and appears to protect most patients from the negative aspects of pelvic radiography and of HSG. Using the 3D ultrasound classification presented in this study appears to make it possible to use HSG for backup confirmation only when Essure is found to be in the 3-only position on 3D ultrasound.

Essure® sterilization associated with endometrial ablation

Objective: To evaluate the feasibility and the outcome of Essure® sterilization associated with different techniques of endometrial ablation. Method: Retrospective study conducted among 23 women with confirmed menometrorrhagia and with the desire for or the medical need for permanent tubal sterilization. Patients underwent combined hysteroscopic placement of Essure® and hysteroscopic endometrial resection procedures: ThermaChoice® (n = 14), NovaSure® (n = 4), Hydrothermablator® (n = 2) and endometrial resection using monopolar energy (n = 1), or bipolar energy (n = 2). Results: Fallopian tubes were successfully cannulated bilaterally in 87% of the cases (20/23). No adverse event was reported. Adequate bilateral occlusion was confirmed for all patients (20/20) by 3D ultrasound and pelvic X‐ray at a 3‐month follow‐up. Furthermore, 85% of these patients were satisfied with the results of the procedure, all experiencing a significant reduction in menstrual blood loss (Higham blood loss score). Conclusion: Combining EA and hysteroscopic sterilization seems to be feasible and efficient in patients with menometrorrhagia.

Traitement du prolapsus génital avec mise en place d’une prothèse de polypropylène par voie vaginale: Résultats anatomiques et fonctionnels chez des femmes de moins de 50 ans

OBJECTIVESnWe evaluated the results of surgical insertion of a polypropylene mesh via the vaginal route in young women presenting genital prolapse.nnnMATERIAL AND METHODSnRetrospective study concerning 20 women under age 50 who underwent between July 2000 and December 2003 surgical insertion of an anterior (n=14), posterior (n=3) or double (anterior and posterior) (n=3) polypropylene mesh via the vaginal route. A minimum follow-up of 6 months was required for inclusion in the study. Anatomical results were assessed using the Pelvic Organ Prolapse Quantification (POP-Q) according to ICS (International Continence Society) recommendations. To document the functional results, the patients answered 3 validated self-assessment questionnaires related to pelvic symptoms, sexual behaviors and quality of life.nnnRESULTSnMean follow-up was 21 months (6 to 52 months). A vaginal erosion of the mesh occurred in 2 women (10%). Cystocele recurred in one woman among the 17 patients who had an anterior polypropylene mesh (Gynemesh, Gynecare, Ethicon). Seventeen women were sexually active before the surgical procedure and 19 post-operatively. Among these women, 5 (26%) reported alteration of sexual activity after surgery (with dyspareunia in 4 cases (21%)), and 14 women (74%) reported no changes or improvement in sexual activity.nnnCONCLUSIONnSurgical management of genital prolapse using a polypropylene mesh inserted via the vaginal route has proven its anatomical efficacy in young women. The potential adverse consequences on sexual life would require clinical research concerning the surgical approach (abdominal or vaginal route) and synthetic materials used in prolapse surgery for young women.Resume Objectifs Evaluer chez les femmes jeunes, les resultats a moyen terme des cures de prolapsus par voie vaginale avec mise en place de protheses de polypropylene. Materiels et methodes Etude retrospective portant sur 20 patientes âgees de moins de 50 ans et operees entre juillet 2000 et decembre 2003 d’une cure de prolapsus genital avec mise en place d’une prothese de polypropylene anterieure (n = 14), posterieure (n = 3), ou double (anterieure et posterieure) (n = 3). Les patientes devaient avoir un suivi minimum de 6 mois pour etre eligible dans l’etude. L’evaluation des resultats anatomiques a ete realisee avec la classification POP-Q (Pelvic Organ Prolapse — Quantification) recommandee par l’I.C.S. (International Continence Society). L’evaluation fonctionnelle a ete realisee grâce a des questionnaires de symptomes, de qualite de vie et de sexualite. Resultats Le suivi moyen a ete de 21 mois (de 6 a 52 mois). Le taux d’erosion vaginale avec exposition de prothese a ete de 10 % (2/10). Une seule recidive de cystocele a ete observee parmi les 17 femmes ayant eu la mise en place d’une prothese anterieure de Gynemesh tm (Gynecare

Technique de cerclage cervico-isthmique par voie vaginale avec bandelette de polypropylène: technique de Fernandez: Description et résultats

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 35 - N° 5 - p. 465-471OBJECTIVEnTo assess the efficacy of performing transvaginal cervico-isthmic cerclage using synthetic tape in prevention of preterm labor in high-risk women.nnnPATIENTS AND METHODSnA retrospective analysis of 24 transvaginal cerclages using polypropylene tape performed in women presenting with high risk of preterm delivery: prior histories of pregnancy losses in the second trimester, prior failure of Mac Donalds cerclage and/or absent portio vaginalis of the cervix. Cerclage was performed between 12 and 16 weeks of gestation. A polypropylene tape was placed at the cervicoisthmic junction by vaginal route.nnnRESULTSnThe median age of the patients in this series was 32.1 years (range 22-39 years). No intra-operative complication occurred. The median operating time was 34.9 minutes (+/-5.1) (range 30-45 min). Cesarean delivery was systematically performed in all patients since the cerclage was considered to be definitive. Mean gestational age and birth weight at delivery were respectively 37.1 weeks (+/-1.8) and 2850 g (+/-745). Preterm birth rate was 19% (4/21). Birth at less than 32 weeks occurred in only one patient (4%). In one case, the tape has been removed later because symptomatic vaginal erosion was noted. One neonatal death occurred following amniotic fluid infection at 34 weeks. At the present time, 3 women are at 22, 26 and 26 weeks of gestation with no preterm labor.nnnCONCLUSIONnTransvaginal cerclage using polypropylene tape may be considered as an effective and minimally invasive alternative to transabdominal cervico-isthmic cerclage in women presenting with high risk of preterm delivery.

Exposition prothétique après mise en place d’une prothèse par voie vaginale pour cure de cystocèle

Resume Objectif Rapporter notre experience du traitement des defauts de cicatrisation et erosions vaginales des protheses synthetiques sous vesicales mises en place pour traiter les cystoceles, et determiner leurs consequences fonctionnelles. Materiel et methode Etude retrospective de 34 cas d’erosion vaginale apres mise en place d’une prothese sous vesicale de polypropylene (GynemeshTM ou Gynemesh-SoftTM). Nous avons etudie les resultats de la prise en charge medicale et chirurgicale de ces patientes. Nous avons egalement compare les consequences fonctionnelles chez ces 34 patientes ayant eu une exposition prothetique avec 111 femmes ayant eu une intervention identique mais qui ne s’etait pas compliquee d’une exposition prothetique. Resultats Parmi les 34 erosions, 23 (68 %) ont fait l’objet d’un traitement medical avec des estrogenes et des antiseptiques locaux par ovules de Colposeptine© (Chlorquinaldol + Promestriene). Parmi elles, 12 (52 %) sont restees stables, 6 (26 %) ont diminue et 5 (22 %) ont disparu (re-epithelialisation complete) dans un delai 2 a 9 mois. Dix-neuf patientes ont eu une exerese partielle (n = 18) ou complete (n = 1) de la prothese exposee, associee a une suture vaginale, sous anesthesie generale. La duree d’intervention a ete de 15 a 40 minutes pour les excisions partielles. Cette procedure a ete un succes dans 14 cas (77 %). Quatre patientes ont necessite une deuxieme reprise chirurgicale en raison d’une recidive de l’exposition. Les dyspareunies etaient aussi frequentes dans les 2 groupes (12 % chez les femmes ayant presente une exposition et 11 % chez celles n’en n’ayant pas eu (p = 0,81)), de meme que les urgenturies (8 % versus 9 %, p = 0,95) ou les symptomes de dysurie (8 % versus 10 %, p = 0,81). Conclusion Le traitement des expositions prothetiques vaginales est en general simple et associe a un faible taux de morbidite. Les patientes doivent toutefois etre prevenues de ces risques.OBJECTIVEnTo describe management of vaginal mesh erosion following transvaginal repair of acystocele by placement of a polypropylene mesh.nnnMATERIALS AND METHODnRetrospective analysis of 34 consecutive cases of vaginal mesh erosion following transvaginal repair of cystocele using synthetic mesh (Gynemesh or Gynemesh-Soft). We have analyzed the results of both medical and surgical management of this complication. Furthermore, we also assessed sexual and urinary morbidity in women with mesh erosion (n = 34) and in women who had undergone the same procedure but without mesh erosion (n = 111).nnnRESULTSnAmong the 34 patients with vaginal mesh erosion, 23 (68%) have undergone local therapy using Colposeptine (Chlorquinaldol + Promestriène). In 12 (52%) cases no modification of the surface of the erosion was observed. In 6 (26%) cases, a decrease of the surface of the mesh erosion was observed. In 5 (22%) cases the mesh erosion had completely disappeared, with a follow-up of 2 to 9 months. Nineteen symptomatic patients (19/32, 59%) required partial (n = 18) or complete (n = 1) excision of the mesh, associated with vaginal mucosal closure, under general anaesthesia. Duration of operation ranged from 15 to 40 minutes for partial excision of the mesh. This procedure was successful in 14 cases (77%). Four women required repeated resection of the mesh because of recurrence. The incidence of de novo dyspareunia was 12% in patients with vaginal mesh erosion, and 11% in patients without mesh erosion (p = 0.81). The incidence of urge urinary symptoms and voiding dysfunction symptoms was respectively 8% versus 9% (p = 0.95), and 8% versus 10% (p = 0.81) in the 2 groups.nnnCONCLUSIONnManagement of vaginal mesh erosion is simple and is associated with a low rate of morbidity. However, patients should be informed that vaginal erosion of the mesh can occur.