Évolution des idées sur le traitement chirurgical des prolapsus génitaux

OBJECTIVES

To describe, in view of the new standardization, the technique for urogenital prolapse repair using a one-piece synthetic mesh.

MATERIALS AND METHODS

The history and development steps through which the Tension free Vaginal Mesh (TVM) technique emerged are described. The use of a mesh was prompted by the 20-30% recurrence rate associated with conventional repair techniques. Selection of the type of mesh is discussed. Non-absorbable synthetic meshes have shown their usefulness in visceral surgery. A list of materials along with their respective advantages and inconveniences is reviewed and particular emphasis is put on both the tolerance and erosion issues, the latter being specific to the vaginal route. The TVM Group selected a one-thread polypropylene mesh, Prolene Soft, which seemed the most appropriate for the transvaginal approach of prolapse surgical repair. The prosthesis and its design rationale are described. Full details are given on the consecutive intervention steps and underlying concepts.

RESULTS

The relevant literature is scarce and there is a lack of methodologically sound studies validating the materials and techniques used. After completion of a first step of technique refinement and feasibility assessment involving about 300 surgical interventions, the authors initiated a prospective multicenter study. Clinical outcome assessments using feasibility, complications, and efficacy endpoints will be published after twelve months, three years, and five years of follow-up.

CONCLUSION

Fruitful reasoning led to the development of the TVM technique of complete surgical repair of genital prolapse, which uses a synthetic materiel carefully selected after several tests. All surgeons can apply this technique after a short training period.

Mechanical properties of synthetic implants used in the repair of prolapse and urinary incontinence in women: which is the ideal material?

The authors review the literature concerning all types of synthetics implants used in prolapse repair or the treatment of stress urinary incontinence, and analyze the mechanical properties of and the tolerance to the various products used. Various synthetic implants are also studied, including their advantages and disadvantages, as well as outcome following implantation and tolerance by the host, with respect to the type of product and the type of intervention. A review of current implant products demonstrated that the perfect product does not exist at present. The most promising of theses products for applications in transvaginal surgery to restore pelvic function appears to be the synthetic prostheses made predominantly of polypropylene, which offer mechanical properties of durability and elasticity. Their properties of resistance are undisputed, but it remains to be shown whether they are well tolerated when inserted by the vaginal route. The technical modalities for their use are still under evaluation, which should enable a better identification of the respective indications for these products in prolapse repair and treatment of urinary incontinence by the vaginal route.

Tension-free vaginal tape (TVT) in the treatment of urinary stress incontinence: 3 years experience involving 256 operations

OBJECTIVES

To report the outcome and complications of a series of tension-free vaginal tape (TVT) operations and compare the results with the literature.

MATERIALS AND METHODS

A total of 256 cases with a minimum follow-up time of 3 months (May 1998-September 2001) were included (193 isolated TVT, 23 combined with vaginal hysterectomy and 63 combined with prolapse surgery). These cases included 21% of the patients presenting with mixed incontinence, 14% with sphincter deficiency and 9.8% with recurrent incontinence. The isolated TVT were carried out under local anesthesia an ambulatory procedure, the others were done under spinal anesthesia.

RESULTS

Almost all the patients underwent a clinical check-up after 3 months and 1 year and also underwent urodynamic exploration; they were then questioned by means of a questionnaire after 2 and 3 years. The global cure rate was 90, 91, 83 and 87%, respectively. The authors observed 6.4% of recurrences between 3 months and 1 year and 7.2% between 2 and 3 years. For mixed incontinence at the three first check-ups, the cure rate was 75, 85 and 60%, respectively, with 7.4 and 20% of recurrences between these two intervals. The cure rates of the patients who had presented with sphincter deficiency were 76, 79 and 73%, respectively, with 16% recurrences during the first year. In the case of recurrent incontinence, a cure was obtained in 72 and 71% of cases, with 18% of recurrences. The complications consisted of 5.5% cases of perforated bladder, 0.4% hematomas of the Retropubic space, 3.1% urinary infections, 0.4% urethral injuries, 5.1% transient urine retention, 12.0% de novo urinary urgency and 20% de novo dysuria. It should be noted that half of the pre-operative urgencies had disappeared after the operation. No defective healing and rejection phenomenon was observed.

DISCUSSION

The authors reviewed the results reported in 35 articles, and compare these with their own results. They also reviewed all the complications encountered, account for them and suggested how they can be avoided. There are discrepancies between the various studies, particularly with regard to the complications.

CONCLUSION

This minimally invasive operation should be further assessed so that it can demonstrate its effectiveness, and become the "Gold standard". Randomized studies are awaited with this in view.

[Complications of urinary incontinence surgery: 800 procedures]

OBJECTIVE

To present the complications of urinary incontinence surgery through our experience over 13 years with 800 procedures in continuous practice. These complications were compared to those of the literature for the same type of procedure.

STUDY DESIGN

From January 1988 to September 2001, 800 procedures were performed in the same hospital in the gynecology unit. The procedures were: Bologna (91 cases), laparotomic Burch (83 cases), laparoscopic Burch (62 cases), Pereyra (112 cases), Stamey (8 cases), Ingelman-Sundberg (27 cases), Mouchel (40 cases), autograft sling (22 cases), mesh sling: small size (62 cases), large size (12 cases) et TVT (tension free vaginal tape) (281 cases). These procedures were performed alone in 475 cases (125 cases with hysterectomy for other reason), and in 325 cases associated with prolapse surgery. The complications were noted during the hospitalization and at the control at 3 months and 1 year. We only noted the complications attributable to the different procedures.

RESULTS

Bladder injuries are found in 3.5% (0 to 6%), hemorrhage in 1% (0 to 3.8%), urinary infection in 4.5% (0 to 11.3%), fever at 48 hours in 1.5% (0 to 9.7%), momentary urine retention in 17% (1.6 to 64.5%), de novo dysuria in 10.9% (0 to 35.5%), de novo urge in 6.9% (0 to 11%). For the other complications, which were less frequent or more procedure-specific, we noted: subcutaneous emphysema in 1.6% of the laparoscopic Burch procedures, cutting thread in 4.8% of the laparoscopic Burch procedures and 2.7% in Pereyra, rejection of prosthetic mesh in 9% of the large slings, 14% with the small sling and 28.2% with the Mouchel procedure, a wound abscess in 3.8% of the Bologna procedures, 1.2% of laparotomic Burch procedures. The percentage of women who had at least one complication was a minimum of 18% for TVT and a maximum of 62.9% for small synthetic sling. In summary, 32% of the patients presented at least one complication. Overall, we noted urinary complications in 41% of the patients, which accounted for 81% of the complications.

DISCUSSION

We reviewed more than 100 references concerning complications of the procedures performed in these patients. "Blind" procedures gave more bladder injuries, slings more dysuria and urine retention and procedures using mesh gave more pool healing or rejection especially with the old materials. A particular place must be made for the TVT, recent procedure, which is widely studied. We reviewed 35 references explaining complications of TVT or proposing preventions measures.

CONCLUSION

There are many complications of urinary incontinence surgery, but the majority is quickly resolved without consequence. The only after-effects are dysuria which are the most often slow micturition, and urge which are a real problem, sometimes leading to sling removal.

[Development of better tolerated prosthetic materials: applications in gynecological surgery]

Meshes have come to be widely used for surgical repair of the dysfunctional pelvic floor. The problem to date has been mesh intolerance. History. The first meshes were made with silver filigrees or stainless steel. Non-metallic and non-absorbable synthetic prostheses include nylon, silastic, polytetrafluoroethylene as well as expansive polyester and polypropylene forms. Most of the absorbable prostheses are made of polyglycolic acid and polyglactine 910. Classification. Four groups of biomaterials can be described according to pore size. Mechanical and biological properties. The mechanical properties of meshes have been tested industrially for resistance, pliability, elasticity and ductile qualities. These properties depend on type of tissue structure (woven or knitted) and the type of fiber used (mono and multi-filaments). The goal is to obtain a "silent" material, i.e. a material which does not trigger a host tissue reaction. Introducing the foreign body induces a "scarring" response. This fibroblastic reaction replaces the inflammatory reaction, leading to progressive colonization of the prosthesis. The major risk is infection caused by a disturbance of the inflammatory phase and bacterial development. Bacteria can be trapped in fibrotic tissue, with the risk of delayed infection. Immunological reactions may have an additive effect. These problems are not encountered with absorbable meshes. An ideal implant material must: not undergo physical modification by tissue fluids, be chemically inert, not trigger inflammatory or foreign body cell response in body tissues, be noncarcinogenic and nonallergenic, be capable of resisting mechanical stress and sterilization, and be able to be manufactured in the necessary shape. Polyester, polypropylene and expansive polytetrafluoroethylene fulfill these criteria. The ideal mesh. Eleven criteria are proposed. Complications for hernia repair. Infection and seroma are the most frequent complications with micro-porous meshes. Macro-porous meshes can cause erosive phenomena and adhesions. Retraction of synthetic tissues is observed in 20 to 30% of cases. Meshes in gynecology. In gynecology surgery, meshes made their first appearance in trans-abdominal sacrocolpopexy and slings. A detailed review of complications found in 32 articles studying slings and 22 studying sacrocolpopexy with approximately 10 types of meshes shows that intolerance of slings has oscillated between 1% with Prolene and 31% with Gore-Tex; for abdominal sacrocolpopexy the rate was between 1.7% with Prolene and 20% with Teflon. Rejection phenomena appear during the first year and are proportional to the surface area of the synthetic tissue and the proximity of the vaginal scar. New materials have been proposed over the last ten years for prolapse surgery, notably for cystocele, which accounts for 70% of all repair procedures. Nearly fifteen studies have reported a level of intolerance reaching 6%, the large majority of the meshes used being Prolene meshes. Our personal experience with 87 repair procedures has led us to the conclusion that Prolene is the most adapted mesh, allowing free tension between the bladder and the anterior vaginal wall.

CONCLUSION

Continuous evaluation is needed to study these replacement materials which should in theory, improve the rate of recurrence, which is at present 20% with classic procedures not using a mesh.

[Hysterectomy for benign lesions in the north of France: epidemiology and postoperative events]

OBJECTIVE

We conducted an inquiry on hysterectomy practices in gynecology and obstetric units of general hospitals in the north of France (North and Picardy regions) focusing on procedures made for benign lesions of non-prolapsed uteri.

MATERIAL

and methods: Two studies supported this inquiry. The first was a retrospective study in 1997 concerning 21 gynecology and obstetric units in general hospitals among the 24 units belonging to the general hospital network in the North and Picardy regions. The series included 1293 hysterectomies for benign lesions on non-prolapsed uteri, accounting for 68.6% of all hysterectomies performed during the study period. Surgical route, indications and duration of hospital stay were recorded. The second study was a prospective study conducted in 1998 in 9 voluntary units among the 24 units in the hospital network. This study included 423 hysterectomies and recorded techniques, indications, and complications as well as late complications and social and psycho-sexual impact assessed during a telephone interview at 3 months. The 5 University Hospitals in the North, Picardy and Champagne regions also participated in the inquiry and provided data on 191 hysterectomies performed during a three-month period.

RESULTS

Twenty-seven hysterectomies were performed per year and per operator. The main indications for hysterectomy were, for the two studies respectively: fibroid uterus 66.7% and 60%, menstrual disorders 13.8% and 27.2%, endometriosis 10.6% and 5%, and hyperplasia of the endometrium 3.9% and 5%. Surgical routes recorded in the second study were: vaginal 64.8%, abdominal 30.5%, vaginal laparoscopy 4.7%. Reductions were performed to facilitate vaginal hysterectomy in 25% of the cases. The vaginal route was used for adnexectomy in 30% of the cases. The rate of peroperative complications were observed in 3 - 4.8% of the vaginal, 4.8 - 10.7% of the abdominal and 15% of the laparoscopic vaginal hysterectomies. Bleeding was reported in 0.4% and 9.3% of the vaginal and abdominal hysterectomies respectively (p<0.001). The rate of postoperative complications was 0.8 - 4.9%, 1.6 - 19.4%, and 5% for vaginal, abdominal and vaginal laparoscopic hysterectomies respectively. Duration of convalescence was 4.4 weeks for vaginal and 6.1 weeks for abdominal (p<0.00001) and 5.3 weeks for vaginal laparoscopic procedures. The quality of sexual intercourse was improved in 30% of the patients irrespective of the surgical rout but was found to be deteriorated in 20% of those who had laparoscopic vaginal hysterectomy.

DISCUSSION

It is difficult to ascertain the exact number of hysterectomies performed in France. The computerized information system currently in use in France (PMSI) should provide interesting data. Reports from North America, Great Britain and the Scandinavian countries have found comparable data. Complication rate, duration of hospitalization and social impact are in favor of vaginal hysterectomy.

[Comparison of the Bologna and Ingelman-Sundberg procedures for stress incontinence associated with genital prolapse: ten-year follow-up of a prospective randomized study]

OBJECTIVE

Our purpose was to evaluate and compare the long-term results of the Bologna and the Ingelman-Sundberg procedures for the treatment of stress urinary incontinence in women with genital prolapse.

PATIENTS AND METHODS

Forty-seven women underwent surgery at the gynecologic division at Dunkirk Hospital, France between January 1989 and August 1990. All patients presented a genital prolapse with a cystocele of at least degree 2 associated with urinary stress incontinence. The subjects were randomly allocated to one of the two procedures. In the clinical incontinence group (28 patients), 12 procedures were Bologna operations and 16 were Ingelman-Sundberg operations. In the potential incontinence group (19 patients), 11 procedures were Bologna operations and 8 were Ingelman-Sundberg operations. Physical examination and urodynamic explorations were performed preoperatively, and 3 months and 1 year postoperatively. A questionnaire was sent to all participating women during the tenth year of follow-up. We obtained 46 answers.

RESULTS

Mean follow-up was 9.7 years. The result of the 1-year postoperative evaluation has been previously published. At 1 year, complete cure was achieved in 91.7% of the patients who underwent the Bologna procedure and 93.7% in those who had the Ingelman-Sundberg procedure. At 10 years, the cure rate was 72.7% and 56.2% (p<0.05) respectively. After the first year, the decline in cure rate was twice as fast with the Ingelman-Sundberg procedure than with the Bologna operation.

CONCLUSION

The longevity of the Bologna procedure is greater than that of the Ingelman-Sundberg procedure. Recovery rate declines by 20% in 9 years. All results of urinary stress incontinence surgery were good after the first year. One has to wait 5 to 10 years before reliable informative results can be obtained. This fact should be taken into consideration before accepting to use of new procedures.

Tolerance of synthetic tissues in touch with vaginal scars: review to the point of 287 cases

With an experience of 287 vaginal way operations using synthetic material, the authors make a review about the tolerance of the tissues. Three tissues were used (polytetrafluoroethylene, Dacron and Lyodura). The procedures are: Mouchel, big and small slings, Stamey and para vaginal refect procedures. At 30 months, the tolerance is 70% for Mouchel and 90% for sling procedures. The rejection rate with Dacron is globally 19.3% vs. 30.3% for Gore Tex . The authors describe materials' history, clinical symptoms and histopathologic signs of the intolerance. They think that the synthetic tissue tolerance is proportional to the exhibit surface and to the distance which separates it from the scar. The substratum of the intolerance process answers with two explanations: infection and foreign body reaction. Different theories are explained. Infection can be an ethiologic factor in early rejection. With rigid material, a small ulcer is formed and serves as a nidus for an ascending infection. Foreign material acts as an adjuvant by decreasing the number of bacteria necessary to produce an infection. The tissue reaction may be an immune response to Dacron, a delayed hypersensitivity reaction, or a graft vs. host antigen-antibody reaction. The ideal synthetic mesh material for pelvic surgery has yet to be developed.

[Tolerance of synthetic tissues and vaginal surgery. Report of 287 cases]

OBJECTIVE

In this presentation, we attract attention to the disadvantage of using synthetic material in functional surgery of prolapse and urinary incontinence.

PATIENTS AND METHODS

Two hundred eighty seven vaginal operations using synthetic material (Gore Tex, Dacron and Lyodura) were followed. The operations were: Mouchel procedure (127 cases), small slings (118 cases), large slings (11 cases), Stamey procedure (8 cases) and patch for paravaginal repair (23 cases). These operations were performed from 01/01/89 to 31/12/95.

RESULTS

Mean follow-up at study end was 49 months. The intolerance phenomenon, leading to rejection, occurred between 1 and 72 months. The Mouchel procedure gave a rejection rate of 28.3% versus 9.3% for the slings (p < 0.001). Dacron was better tolerated (rejection rate at 19.3%) than Gore tex (rejection rate at 30.2%), p < 0.05.

CONCLUSION

The substratum of the intolerance process would have two explanations (infection and foreign body reaction) for the early and late rejections. We suggest that the synthetic tissue tolerance is proportional to the exposed surface and to the distance which separates it from the vaginal scar. The ideal synthetic mesh material for pelvic surgery has yet to be developed.

The Impact of Laparoscopic Surgery on Vaginal Hysterectomy

The development of laparoscopic surgery may be used either to replace (laparoscopic hysterectomy, LH) or to extend the indications (laparoscopically assisted vaginal hysterectomy, LAVH) of the vaginal route. A 2-year (March 1991-March 1993) prospective study of the impact of laparoscopic surgery has been carried out by a group of surgeons experienced in both vaginal and laparoscopic surgery. The design of the study protocol was as follows: use the vaginal route whenever possible; select LH in women with very narrow vaginal access or LAVH to improve the feasibility and safety of vaginal hysterectomy in case of adnexal disease; and select laparotomy only when both laparoscopic and vaginal surgery are impossible. Women with genital prolapse or pelvic relaxation were excluded as well as women with invasive malignant disease of the genital tract. Four hundred twenty-eight patients were included. Abdominal hysterectomy was used in only 44 cases (10.3%), including 4 cases of failure of the vaginal technique. Vaginal hysterectomy was completed without laparoscopic assistance in 339 (79.2%) of cases. LAVH was performed in 45 cases (10.5%), LH in 0. Laparoscopic surgery is an efficient modality for the vaginal surgeon in the presence of adnexal disease, but does not replace the less expensive, quicker and probably safer vaginal hysterectomy.

Comparison of the Bologna and Ingelman-Sundberg procedures for stress incontinence associated with genital prolapse: prospective randomized study

It is difficult to make a choice among the many surgical procedures designed for the correction of stress urinary incontinence by the vaginal route because their results have not been correctly compared. The Bologna (B) operation uses two flaps from the anterior vaginal wall that are anchored to the abdominal wall; the Ingelman-Sundberg (IS) operation is a suburethral sling made from two transplants from the pubococcygeus muscle. A prospective randomized study has been carried out in order to compare these two procedures. A selection of cases has been based upon the presence of genuine or potential stress incontinence, genital prolapse and available tissues (anterior vaginal wall excess and palpable pubococcygeus muscles) for both procedures. No significant difference was noted for clinical results (91.7% and 93.7% of patients cured by the B and IS operations, respectively) or for transmission rate gain at 3 months and 1 year. Maximum urethral closing pressure was maintained in both treatment arms. No significant postoperative complication or persistent dysuria occurred. The Bologna procedure is best indicated in case of frank anterior vaginal excess, and the Ingelman-Sundberg procedure when strong anterior parts of pubococcygeus muscles are available. Both are excellent in the cure of stress incontinence associated with genital prolapse.

[Meconium fluid. Significance and management]

The authors have tried to determine the significance of meconial fluid by studying 3 groups: a first group (MF) representing the meconial fluid observed at he beginning, the second group where the meconial fluid was observed secondarily (SMF) and a third group which is the reference group (RG). The presence of meconial fluid is an ominous sign and an element of prognosis of fetal distress. Meconial fluid at the beginning may be present physiologically, but there are authentic pathological cases with a markedly decreased residual Apgar at 5 minutes. In addition, the perinatal mortality is 4 times higher. In the group with secondary meconial fluid, it is more of an obstetrical emergency. Distress occurs on a healthy fetus along with labor. The signs are occurring with abnormalities of the fetal heart rhythm which do not aggravate the prognosis. These data are confirmed with the study of the pH at the cord. The risk of meconial fluid is inhalation and its complications. The authors conclude by insisting of the need for nasopharyngeal aspirations soon as the fetal head is delivered.

[Communicating uteri. Study and review of the literature. Apropos of 11 cases]

The authors are reporting 11 communicating uteri's cases. This class of uterine malformation present 1 a 2% of the malformation. They report Musset's classification and Toaff too. The Musset's type 2 is more frequent. After a summary of diagnostic, the authors describe the treatment during and outside the pregnancy.

[Low transverse laparotomy with rectus abdominus section in gynecology and obstetrics. Apropos of 1,000 cases]

The authors report 1,000 cases (357 cesarean sections, 230 hysterectomies for benign lesions, 157 conservative utero-adnexal procedures, 128 tubal plasties, 58 prolapse or incontinence procedures, 70 cancers) ,of laparotomies performed according to the technique described by Mouchel in 1980, i.e. strictly supra-pubic and transverse, from skin to peritoneum, including section of the rectus abdominis. This incision enables to perform in ideal technical conditions, with a minimal complication rate (3 hematomas, 2 incisional hernias for 1,000), and satisfactory esthetic results, almost all of the gynecological and obstetrical surgical procedures (90% of two among the authors' practice). The only contra-indications are, except for cases of previous median laparotomy, ovarian tumors. Neither the high risk of infection, nor obesity, extended hysterectomy, nor fetal distress, represent contra-indications, which is a definite advantage over the Pfannenstiel incision. As compared with the median incision which at some time offered similar results, the esthetics and mainly the strength of the abdominal wall are markedly superior.