[Interest of systematic shavings to reduce reoperation in breast-conserving surgery of breast cancer]

OBJECTIVE

The INCa and HAS have developed quality and safety indicators for care specific to breast cancer. Among these, in the conservative surgery of this cancer includes the reoperation rate: target˂10%, alert>20%. The main objective of our study was to evaluate whether the practice of systematic recuts still called "shaving" would meet the objectives of the indicators.

METHODS

Observational, retrospective, single-center study over two years in a regional referral center. Two groups of patients were compared: one with "shaving" and one without (no shaving or oriented shaving).

RESULTS

In total, 381 patients were operated on, including 48 (12.6%) with shaving and 333 (87.4%) without. Revision rates for damaged margins were 18.75% (9/48) in the shaving group which met the quality criterias vs. 23.7% (79/333) which did not satisfy them; P=0.4. Furthermore, the rate of discovery of occult sites on recuts was higher in the shaving group: 22.9% (11/48) vs. 9.9% (33/333); P=0.02. In the shaving group, 10.4% (5/48) of the patients were resected again for damaged margins for the initial cancer vs. 18.6% (62/333) in the group without shaving; P=0.23.

CONCLUSION

Our study confirms the interest of performing "shaving" to meet the requirements of the INCa and HAS quality criteria. The absence of systematic cross-sectioning leads to the risk of not recognizing the existence of occult sites. However, the discovery of occult cancers does not significantly reduce the rate of repeat surgery.

[Efficacy and safety of oral misoprostol 25μg vs. vaginal dinoprostone in induction of labor at term]

OBJECTIVE

To compare the efficacy and safety of oral misoprostol 25μg compared to vaginal dinoprostone in the induction of labor at term.

METHODS

Analytic, retrospective study of patients induced at term by prostaglandins with an unfavorable cervix, over two consecutive periods from 01/01/2019 to 19/02/2020 and from 20/02/2020 to 07/04/2021, within a regional level III university hospital center. We compared the safety and the efficacy between the oral misoprostol Angusta® used since 20/02/2020 and the vaginal dinoprostone previously used in gel or diffuser. The primary endpoint was the rate of vaginal deliveries within 24h. Secondary endpoints were cesarean section rate, indications for cesarean section, uterine contractility abnormalities and neonatal outcomes.

RESULTS

Our study found no difference in terms of efficacy with similar rates of vaginal deliveries within 24h (51.88% vs. 51.25%; P=0.87) and caesarean sections (misoprostol group: 19.42% vs. dinoprostone group: 16.62%; P=0.33). However, the tolerance criteria revealed in the dinoprostone group an increase in tachysystole (misoprostol group: 9.28% vs. dinoprostone group: 16.90%; P=0.003) and acidosis (arterial pH<7.10, misoprostol group: 3.83% vs. dinoprostone group: 9.29%; P=0.006).

CONCLUSION

No difference in efficacy was found between the two induction techniques. Oral misoprostol 25μg seems to be better tolerated from a maternal and fetal point of view.

[Peripartum cardiomyopathy: A review of the literature]

Peripartum cardiomyopathy is a rare and unpredictable pregnancy-related pathology. Idiopathic cardiomyopathy is characterized by a heart failure secondary to left ventricular systolic dysfunction appearing towards the end of pregnancy or in the months following delivery with a non-specific clinic presentation. Through reviewing previous research, our critical literature review wishes to bring a concise and objective summarize for a better understanding of physiopathology, evocative symptoms and knowing of factors influencing prognosis in order to standardize peripartum management. The treatment remains mainly symptomatic but other promising treatments are still in development. In conclusion, early detection and treatment allow a better cardiac function recovery reducing cardiac transplantation.

Obstetrical and neonatal outcomes after successful external cephalic version relative to those after spontaneous cephalic presentations

OBJECTIVE

External cephalic version (ECV) is a procedure during which the fetus is rotated from breech or transversal to cephalic presentation. Our aim was to assess the outcomes of successful ECV in terms of obstetrical and immediate neonatal outcomes relative spontaneous cephalic presentation.

METHODS

We performed a retrospective single-center observational study from January 2007 to December 2017. All included participants benefited from trial of labor with delivery of the fetus in cephalic presentation. They were divided into two groups depending on whether an ECV had been successfully performed or cephalic presentation was spontaneous.

RESULTS

The cephalic presentation after ECV and spontaneous cephalic groups comprised 55 and 244 patients, respectively. The two groups differed significantly in terms of the proportion of induced labor (20 [36.4 %] and 56 [22.9 %], p = 0.04), use of oxytocin during labor (31 [56.4 %] and 100 [49.9 %], p = 0.04), duration of labor (342 ± 183 min and 279 ± 140 min, p = 0.008), spontaneous delivery (38 [69.1 %] and 199 [81.5 %], p = 0.04), intrapartum cesarean section (9 [16.4 %] and 16 [6.6 %], p = 0.02), occiput-posterior variety at birth (20 [36.4 %] and 56 [22.9 %], p = 0.04), and brace umbilical positioning at birth (3 [5.4 %] and 2 [0.8 %], p = 0.04), respectively. There were no significant intergroup differences in terms of APGAR score, cord arterial pH/lactates, or reanimation/intensive care admission.

CONCLUSION

A successful ECV does not seem to guaranty an identical labor progress and obstetrical outcome as spontaneous cephalic presentations. Immediate neonatal state, on the other hand, seems unaffected by a history of ECV.

Management of breech and twin labor during registrarship: A two-year prospective, observational study

INTRODUCTION

Breech presentation and twin pregnancy are regarded as stressful situations for medical staff. This stress is often associated with an increased likelihood of intervention during labor - especially when the on-shift obstetrician lacks experience.

MATERIAL AND METHODS

We performed a 2-year prospective, observational study of cesarean section (CSDs) and assisted vaginal (AVDs) deliveries in a tertiary maternity unit for attempted vaginal deliveries of breech presentations and twin pregnancies. The obstetric management decisions taken by a group of four registrars were compared with those taken by a group of 11 experienced obstetricians. Changes over time in practice were also monitored.

RESULTS

Registrars managed 66 and 52 breech presentations and twin pregnancies respectively (30 and 27 in the experienced group). Groups' neonatal outcomes were similar. There were no intergroup differences in proportions of CSDs for either breech presentations (25 [37.5%] vs. 15 [50%] in the registrar and experienced groups, respectively; P=0.26) or twin pregnancies (11 [21.1%] vs. 6 [22.2%], respectively; P=0.91) or in proportion of AVDs for twin pregnancies (41 [78.8%] vs. 21 [77.8%], respectively; P=0.91). Proportions of CSDs for breech presentation and AVDs for twin pregnancies did not change over time in either group. However, proportion of CSDs for twin pregnancies increased over time in the registrar group (P=0.004).

DISCUSSION

Well-trained registrars appeared to have acquired the skills required to safely manage an obstetric ward; this pleads to maintain clinical practice during residency to preserve low CSD and AVD rates.

The impact of using electrical impedance spectroscopy (ZedScan) on the performance of colposcopy in diagnosing high grade squamous lesions of the cervix

OBJECTIVES

To determine the efficacy of colposcopy plus ZedScan, which measures changes in tissue electrical impedance, for detecting intraepithelial high-grade lesions compared to colposcopy alone.

METHODS

A prospective study conducted at a university hospital colposcopy clinic. Patients referred following abnormal cervical cytology or colposcopic follow up were examined by colposcopy plus ZedScan to assess the cervix. The results of ZedScan directed and colposcopically directed biopsies were compared.

RESULTS

Ninety-one patients were included in this study. The median age was 33 years. Eighty (88%) were referred with abnormal cytology; LSIL 45%, ASCUS 27%, ACS-H 8%, HSIL 7%, AGC 1% and 12% follow-up postconisation or colposcopic follow up. Colposcopy alone detected 18 high-grade lesions with 64 women undergoing biopsy with a total of 115 biopsies being taken with a sensitivity of 60% and NPV estimated at 81.7%. ZedScan with colposcopy increased the detection of high-grade lesions by 47.3%, identifying 27 high-grade lesions and one case of invasive cancer. Sensitivity was 93.1% and NPV estimated at 91.3%. A combination of normal colposcopy practice and ZedScan had a sensitivity and NPV of 100%.

CONCLUSION

ZedScan used in conjunction with the colposcopy improves sensitivity in detecting high-grade lesions at the expense of a moderate increase in the number of biopsies.

Impact of anaesthesia mode on evaluation of LEEP specimen dimensions

OBJECTIVES

To study the influence of anaesthesia (local by cervical block vs. general or spinal anaesthesia) on height and volume of resection specimens in case of conization treatment for cervical intraepithelial neoplasia (CIN).

METHODS

Prospective observational study of all patients who underwent a first treatment by loop electrosurgical excision procedure (LEEP) for CIN. Height of fresh resection specimens was first measured by the operator and then by the pathologist after formaldehyde fixation. Volume of fresh specimens was measured in a measuring cylinder by fluid displacement.

RESULTS

One hundred patients were included and 35% of LEEP were performed under local anaesthesia. There was a significant difference in height of specimens depending on anaesthesia mode: after fixation, the average height was 11.2mm in the general or spinal anaesthesia group vs. 8.8mm in the local anaesthesia group (P=0.002). There was also a difference in terms of volume depending on anaesthesia mode: 1.6mL in local anaesthesia group vs. 2.3mm in general and spinal anaesthesia group (P=0.01).

CONCLUSIONS

Anaesthesia mode has an impact on height and volume of LEEP specimens. In our experience, local anaesthesia could reduce LEEP specimen height.

[Indications of primary cesarean deliveries in a regional teaching hospital and reasonable strategies for reducing them]

OBJECTIVES

To characterize the indications of primary cesarean sections and discuss the various possibilities to reduce them.

MATERIALS AND METHODS

Retrospective study, carried out over a period of 1 year in a university hospital having a level 3 perinatal activity, including the 499 primary cesarean sections of 2013. Two groups were defined by parity: nulliparous patients (group 1) and multiparous patients who had never previously been delivered by cesarean section (group 2). We have assessed the indication of every primary cesarean section and health status of newborns in each group.

RESULTS

Groups 1 and 2 respectively included 369 and 130 patients. The cesarean section rate in 2013 was 24.7% with a primary cesarean section rate of 17%. Seventy-four percent of the primary caesarean deliveries were performed on nulliparous women and 26% on multiparous (P<0.001). Sixty-three percent of the primary caesarean deliveries were performed on nulliparous women with a singleton fetus in cephalic presentation. The most common indications for primary cesarean delivery were non-reassuring fetal heart rate tracing (47.1%), failure to progress (24.8%) for which nulliparous women were more involved (29% vs. 13%, P<0.001) and fetal malpresentation (9.6%).

CONCLUSION

Further analysis of fetal heart rate during labor, a larger use of second line means to evaluate the fetal status during labor, using 6cm as the cut off for active labor, and encouraging vaginal operative delivery constitute the best way to decrease the primary cesarean section rate.

[Introducing a daily obstetric audit: A solution to reduce the cesarean section rate?]

OBJECTIVE

To evaluate the impact of a medical audit assessing the accuracy of caesarean indications on the final caesarean section rate of an obstetrics department.

MATERIAL AND METHOD

Comparative observational study conducted in a regional university teaching hospital on the two first quadrimester periods of 2013. During the first quadrimester, there was no cesarean section audit introduced for the daily reports meetings, while an audit was introduced during the second quadrimester. The caesarean rate and the instrumental delivery rate on both quadrimesters were compared.

RESULTS

In the first quadrimester period, there were 248 caesarean sections for 947 deliveries (26.2%), while in the second quadrimester period, there were 246 for 1033 deliveries (23.8%), P=0.014. The emergency caesarean rate decreased from 19.6 to 16.7%, P=0.02 in the second quadrimester period while the instrumental delivery rate increased from 14.4 to 17.2%, P=0.0004. Mothers and children's health was not modified between the two periods.

CONCLUSION

In our experience, the introduction of a daily obstetric audit of the caesarean indications is effective to decrease the emergency caesarean section rate and it encourages us to be active in the first like in the second part of the labor.

[The urinary bladder is an uncommon site of metastasis from breast cancer]

Bladder metastasis of breast origin are rare. Lobular carcinoma is the most frequent histological subtype of the primary tumor. This secondary location can be the only one or can be associated with other locations. The prognosis is poor. The period between primary breast tumor and the development of bladder metastasis is variable. Herein is reported the case of a 68-year-old woman presenting with irritative disorders. Urological examination was performed and made the diagnosis. When having a history of breast cancer, the occurrence of urinary symptoms require radiographics and a cystoscopy.

[Which prostheses to use in mesh sacrocolpopexy? Experimental and clinical study]

BACKGROUND

Sacrocolpopexy is the standard surgical treatment of genital prolapse of the upper vaginal wall. Nowadays, the laparotomy approach is progressively supplanted by the laparoscopic procedure for the same anatomical results. About sacrocolpopexy, to date it still remains details of the technique, which differ with surgical teams maintaining controversy. Among them, the choice of the meshes certainly creates debate.

OBJECTIVES

To state the basic physicochemical principles which are necessary for surgeons to select the most suitable prosthetic material to obtain the most beneficial anatomic and functional outcomes for patients.

MATERIAL AND METHODS

The concepts of prosthetic biocompatibility, strength, shrinkage, deformation and elasticity are discussed. They are illustrated by experimental animal references and also human clinical references.

RESULTS

Macroporous polypropylene and polyester prostheses (pore size>1 mm) are properly integrated. Collagen prosthetic coating improves tissue integration. Absorbable and nonabsorbable ultralight prostheses expose patients to a high risk of recurrence. Multifilament polyester wide pore-side prostheses have less retraction and are more flexible than monofilament polypropylene prostheses.

DISCUSSION AND CONCLUSION

The prosthetic cut-off weight below which the mesh does not offer any guarantee of strength is not precisely known. Moreover, the benefit of weight reduction is not proved. Currently, heavy weight multifilament polyester prostheses with wide pore size, more than 1mm, appear to be the most appropriate meshes for sacrocolpopexy without vaginal incision.

Characterization of the adverse effects of nicotine on placental development: in vivo and in vitro studies

In utero exposure to nicotine is associated with increased risk of numerous adverse fetal and neonatal outcomes, which suggests that it acts directly to affect placental development and the establishment of the fetomaternal circulation (FC). This study used both in vivo [Wistar rats treated with 1 mg/kg nicotine from 2 wk prior to mating until gestational day (GD) 15] and in vitro (RCHO-1 cell line; treated with 10(-9) to 10(-3)M nicotine) models to examine the effects of nicotine on these pathways. At GD 15, control and treated placentas were examined for the impact of nicotine on 1) trophoblast invasion, proliferation, and degree of hypoxia, 2) labyrinth vascularization, 3) expression of key genes of placental development, and 4) expression of placental angiogenic factors. The RCHO-1 cell line was used to determine the direct effects of nicotine on trophoblast differentiation. Our in vivo experiments show that nicotine inhibits trophoblast interstitial invasion, increases placental hypoxia, downregulates labyrinth vascularization as well as key transcription factors Hand1 and GCM1, and decreases local and circulating EG-VEGF, a key placental angiogenic factor. The in vitro experiments confirmed the inhibitory effects of nicotine on the trophoblast migration, invasion, and differentiation processes and demonstrated that those effects are most likely due to a dysregulation in the expression of nicotine receptors and a decrease in MMP9 activity. Taken together, these data suggest that adverse effects of maternal smoking on pregnancy outcome are due in part to direct and endocrine effects of nicotine on the main processes of placental development and establishment of FC.

[Pyelovenous fistula revealed by repeated thromboembolic events after emergency peripartum hysterectomy]

We report the case of a 51-year old woman presenting pyelovenous fistula revealed by recurrent and serious thromboembolic events after ureteral ligation during emergency peripartum hysterectomy. Imaging reported a complete left ureteral obstruction, a fistula between the upper calix and the left renal vein and a renal function preserved. Uretero-vesical reimplantation was performed. The patient was well doing after 12 months. The authors wonder if pyelovenous fistula is responsible for prothrombotic state and maintaining renal function.

[A comparative study between two procedures of TVT retropubic mid-urethral sling placement for treatment of female stress urinary incontinence]

OBJECTIVE

To evaluate complications and functional outcomes at 1 year and more of a modified Tension-free Vaginal Tape (TVT) technique from that of classic TVT.

PATIENTS AND METHODS

Retrospective study comparing the two techniques. For the modified TVT technique, a peri-urethrovesical hydrodissection was performed. An 18-gauge hollow needle, in which a thread was introduced, was used as an ancillary for the placement of the sling. The sling was secured to the thread and then positioned with it. Bladder filling objectified perforations. An absorbable suture around the sling allowed its descent if necessary.

RESULTS

One hundred and eighteen procedures were performed (54 classic TVT and 64 modified TVT). For the standard TVT and the modified TVT, the vesico-urethral perforation rates were respectively 7.4% and 1.5% (P<0.05), those of reoperations for pulling the sling downward 11.1% and 1.5% (P<0.05). A 1 year and more, healing and satisfaction rates were respectively 83.3% and 79.2% for the standard TVT versus 88.2% and 90% for the modified TVT (NS). The dissatisfaction rate was lower for the modified TVT (P<0.05).

CONCLUSION

By modifying the placement of the classic TVT, it is possible to reduce its complications while maintaining its efficacy.

[Ovarian cryopreservation: evaluation of two surgical procedures]

OBJECTIVES

To evaluate various surgical techniques for partial oophorectomy cryopreservation. To evaluate the consequences of prior exposure to cytotoxic therapy on the quality of the ovary removed.

PATIENTS AND METHODS

Single center retrospective observational study over 4 years of women who had ovarian cryopreservation surgery for chemotherapy or radiotherapy which were at high risk of premature ovarian failure. Several techniques have been proposed: partial oophorectomy with clamping of the vascular gonadal pedicle (indirect tissue sample) without clamping (direct tissue sample) and partial oophorectomy with an automatic stapler. Ovarian tissue was immediately prepared for cryopreservation in the operating theatre. The whole sample was divided into small slices. For each ovary, a count of small slices was made. Additionally, one slice was examined to determine the presence of primordial follicles.

RESULTS

Ovary was successfully removed and cryopreserved in 13 patients. Two bleeding events occurred with the direct technique, without consequences for patients. The number of fragments obtained between indirect and direct techniques was respectively 19 vs 15, P=0.18; the number of primordial follicles was 38 vs 36, P=0.87. The automatic stapler consumed too much ovarian tissue to be interesting. There were fewer fragments, 15 vs 20, P<0.05 and primordial follicles, 35 vs 40, P=0.65, after a first cycle of chemotherapy.

DISCUSSION AND CONCLUSION

The vascular clamping technique is safer but with no difference in the quality of the sample tissue. One cycle of chemotherapy has a pejorative impact on the quality of the sample tissue.

[Interstitial pregnancy: experience at Rouen's hospital]

OBJECTIVE

Presenting our experience concerning interstitial pregnancies (IP) surgical management and to evaluate our patients' subsequent long-term fertility.

PATIENTS AND METHOD

Twenty patients underwent surgical treatment of IP in our department over 15 years. In this retrospective study, we present symptoms that led to diagnosis, treatments, fertility and obstetrical outcome.

RESULTS

Mean gestational age at diagnosis was 8SA, with a median BHCG rate of 7411 IU/L, and a patient mean age of 30 years. Ninety percent of patients had at least one risk factor for ectopic pregnancy. Pain or bleeding were the most common symptoms at admission, 4 patients were admitted in an hypovolemic shock status. Location of the interstitial ectopic pregnancy was discovered during surgery in 45 % of cases. Six patients had a large hemoperitoneum bigger than 1L, 5 patients had an IP of uterine stump after salpingectomy for a previous ectopic pregnancy. The most used surgical technique was in 60 % of cases the excision by Endo GIA stapling(®) with salpingectomy. Regarding fertility, 12 patients wished pregnancy in the aftermath of the intervention, 10 had at least one pregnancy, among them there is an ectopic contralateral ampullary pregnancy, and a contralateral recurrence of interstitial pregnancy. Four patients were delivered by cesarean section and 4 patients were delivered vaginally, some several times. No uterine rupture occured.

DISCUSSION AND CONCLUSION

Interstitial pregnancy is a rare ectopic pregnancy. Its diagnosis is difficult and may involve maternal life-threatening and fertility. In subsequent pregnancies, the clinician has to be careful concerning the risks of interstitial pregnancy recurrence and uterine rupture.

EG-VEGF controls placental growth and survival in normal and pathological pregnancies: case of fetal growth restriction (FGR)

Identifiable causes of fetal growth restriction (FGR) account for 30 % of cases, but the remainders are idiopathic and are frequently associated with placental dysfunction. We have shown that the angiogenic factor endocrine gland-derived VEGF (EG-VEGF) and its receptors, prokineticin receptor 1 (PROKR1) and 2, (1) are abundantly expressed in human placenta, (2) are up-regulated by hypoxia, (3) control trophoblast invasion, and that EG-VEGF circulating levels are the highest during the first trimester of pregnancy, the period of important placental growth. These findings suggest that EG-VEGF/PROKR1 and 2 might be involved in normal and FGR placental development. To test this hypothesis, we used placental explants, primary trophoblast cultures, and placental and serum samples collected from FGR and age-matched control women. Our results show that (1) EG-VEGF increases trophoblast proliferation ([(3)H]-thymidine incorporation and Ki67-staining) via the homeobox-gene, HLX (2) the proliferative effect involves PROKR1 but not PROKR2, (3) EG-VEGF does not affect syncytium formation (measurement of syncytin 1 and 2 and β hCG production) (4) EG-VEGF increases the vascularization of the placental villi and insures their survival, (5) EG-VEGF, PROKR1, and PROKR2 mRNA and protein levels are significantly elevated in FGR placentas, and (6) EG-VEGF circulating levels are significantly higher in FGR patients. Altogether, our results identify EG-VEGF as a new placental growth factor acting during the first trimester of pregnancy, established its mechanism of action, and provide evidence for its deregulation in FGR. We propose that EG-VEGF/PROKR1 and 2 increases occur in FGR as a compensatory mechanism to insure proper pregnancy progress.

[Fetal heart rate variability and clozapine treatment]

We report the 2 cases of schizophrenic patients with clozapine treatment and particularly, we underlined a reduced variability and low short-term variability, whereas biophysical ultrasound score, Dopplers and perception of fetal movements were acceptable and comfortable concerning the fetal vitality. Our aim is to show the limits of the analyzed fetal heart rate under clozapine. So, we may change our observation of fetus in chronic suffering that is usually mainly made with an informatics analysis of pregnants under clozapine.

[Giant ectopic peritoneal and omental deciduosis mimicking a peritoneal carcinomatosis]

Ectopic decidual reaction of the peritoneum and the omentum is rare. It is usually an incidental finding during caesarean section and it could mimick macroscopically peritoneal carcinomatosis or tuberculosis. Histology is very important to make diagnosis. Ectopic decidual reaction is physiological, with an excellent prognosis and spontaneous resolution. We report one case of ectopic peritoneal and omental deciduosis of the peritoneum and discovered incidently during caesarian section. Definitive diagnosis was done by immunohistological examination. A laparoscopy four months later showed complete and spontaneous regression of all lesions.

[Prospective evaluation of an intravaginal electrical stimulation in the treatment of women with pure genuine stress urinary incontinence]

OBJECTIVES

To study the objective and subjective effectiveness of transvaginal electrical stimulation for treatment of female pure genuine stress incontinence.

PATIENTS AND METHODS

This was a multicenter prospective trial including 207 patients with genuine stress incontinence who used the stimulator for 10 weeks. Similar pre-treatment and post-treatment assessments included both validated symptom severity index and health-related quality of life.

RESULTS

Objective evaluation showed a significant improvement in 65.7% of subjects with stress incontinence. All domains of quality of life improved significantly after treatment (P=0.0001) and rate of satisfactory was 84.7%. There were no statistical differences between the two stimulators.

DISCUSSION AND CONCLUSION

Pelvic floor electrical stimulation seems to be effective in treating female genuine stress incontinence and could be considered first-line therapy.

Revisiting the role of hCG: new regulation of the angiogenic factor EG-VEGF and its receptors

Endocrine gland-derived vascular endothelial growth factor (EG-VEGF) is an angiogenic factor reported to be specific for endocrine tissues, including the placenta. Its biological activity is mediated via two G protein-coupled receptors, prokineticin receptor 1 (PROKR1) and prokineticin receptor 2 (PROKR2). We have recently shown that (i) EG-VEGF expression peaks between the 8th and 11th weeks of gestation, (ii) its mRNA and protein levels are up-regulated by hypoxia, (iii) EG-VEGF is a negative regulator of trophoblast invasion and (iv) its circulating levels are increased in preeclampsia (PE), the most threatening pathology of pregnancy. Here, we investigated the regulation of the expression of EG-VEGF and its receptors by hCG, a key pregnancy hormone that is also deregulated in PE. During the first trimester of pregnancy, hCG and EG-VEGF exhibit the same pattern of expression, suggesting that EG-VEGF is potentially regulated by hCG. Both placental explants (PEX) and primary cultures of trophoblasts from the first trimester of pregnancy were used to investigate this hypothesis. Our results show that (i) LHCGR, the hCG receptor, is expressed both in cyto- and syncytiotrophoblasts, (ii) hCG increases EG-VEGF, PROKR1 and PROKR2 mRNA and protein expression in a dose- and time-dependent manner, (iii) hCG increases the release of EG-VEGF from PEX conditioned media, (iv) hCG effects are transcriptional and post-transcriptional and (v) the hCG effects are mediated by cAMP via cAMP response elements present in the EG-VEGF promoter region. Altogether, these results demonstrate a new role for hCG in the regulation of EG-VEGF and its receptors, an emerging regulatory system in placental development.

Prise en charge des grossesses après anneau gastrique ajustable

OBJECTIVES

To report our experience of the association adjustable gastric banding and pregnancy. To define a management for a such association.

MATERIALS AND METHODS

Retrospective and descriptive study on two centers over a 3-year follow-up of pregnancies begun with a Lap-Band gastric banding placed by laparoscopic way.

RESULTS

Twenty-one pregnancies, 22 newborns resulting from 18 women were identified. Eleven patients were hospitalized. The motive of the hospitalization was severe epigastralgia for four patients requiring three deflations for mechanical complication. No case of preeclampsia was identified. Seven bands were deflated. In the group of the deflated bands, the mean maternal weight gain was 19 vs 10 kg (P=0.008), the mean birth weight was 3700 vs 3204 g (P=0.09) with a rate of fetal macrosomia increased, 50 vs 29% (P=0.038). The difference between the rates of cesarean delivery was not significant (NS) between the two groups. The childbirth term was appreciably the same, 39.4 vs 38.6 weeks of gestation (NS). The only case of gestational diabetes was found in the deflated band group. Three intrauterine growth restrictions whose one fetal death occurred in the not deflated band group.

CONCLUSION

Results obtained were comparable to those of the literature. This series confirms that adjustable gastric banding limits the usual complications of the morbid obesity during pregnancy. It is generally well tolerated and must not be thus deflated by principle, but only on symptoms. That will be a total dysphagia, severe epigastric pains, vomiting after the first trimester of pregnancy or an intrauterine growth restriction.

[Recurrence of stress urinary incontinence after tension-free vaginal tape and childbirth]

Retropubic or transobturator insertions of suburethral tapes are the new gold standard surgical procedure for female stress urinary incontinence. Some women of childbearing age can be treated by a suburethral tape. There are at present no sufficient data to recommend a mode of delivery rather than another in these patients. We report the case of a young woman, cured of her urinary incontinence by a suburethral tape. A recurrence occurred after childbirth by vaginal route. A second suburethral tape made it possible to restore the continence. The patient became again pregnant. A preventive caesarean section was quite as ineffective to preserve the continence.

Correction prothétique des prolapsus génito-urinaires selon la technique du hamac transobturateur infracoccygien: résultats à moyen terme

OBJECTIVES

The aim of this study was to evaluate the anatomical and functional medium-term efficacy and possible complications of vaginal prosthetic surgery with transobturator and infracoccygeal support to treat genital urinary prolapse.

MATERIAL AND METHOD

A prospective and monocentre study was conducted, from February 2002 till February 2005. All the patients with or without stress urinary incontinence (SUI), who presented either a recurrent prolapse, either a voluminous genital prolapse of stage 3 or 4 notably a dominant cystocele, either a post-hysterectomy vaginal vault prolapse or even a prolapse of lesser importance but in a context of obesity, were operated according to the transobturator infracoccygeal sling technique.

RESULTS

One hundred and three patients with a mean age of 65+/-11 years (41-84) were enrolled, with once on two SUI. Thirty percent of the patients had recurrent prolapse and 44% post-hysterectomy vaginal vault prolapse. With a mean follow-up of 32+/-13 months (12-53), the success rate of the technique was estimated to be 97% anatomically (three failures) and 89% in terms of urinary symptoms (69% of patients were cured, 20% were improved and 11% failed). Quality of life of the patients was sharply improved and their degree of satisfaction was high. Sexuality of the population which was limited here (44% of active patients) did not seem very modified by surgery. Complications were represented by a case of urinary retention observed with a secondarily pelvic haematoma, a low rectal injury without consequence, three blood transfusions. Three patients developed de novo overactive bladder. The prostheses exposure rate was 16%, once requiring on two one re-intervention. Prostheses were perceived during the postoperative evaluation by the examiner for 43% of the patients. But examination was painful only in 9,7% of the cases.

CONCLUSION

Combined treatment of vaginal prolapse and associated urinary incontinence is possible by the use of a single transvaginal prosthesis. The medium-term anatomical and functional results are very good. The results on continence are good and a subsequent specific procedure is always possible in the case of failure or insufficient improvement. The prostheses exposure rate is similar to that observed with synthetic transvaginal prostheses. The exact tolerance of vaginal prosthetic repair of the prolapse of young women being this day an unknown, we remain careful on the extension of the indications of this technique in this category of population.

Rupture utérine obstétricale après hystéroscopie opératoire

The aim of this study was to attempt to identify factors predictive of uterine rupture following operative hysteroscopy. A MEDLINE and EMBASE search (1980 to April 2006) using the keywords "hysteroscopy", "uterine rupture" and "pregnancy" was performed with no limitations of languages. 18 cases of uterine rupture following operative hysteroscopy were retrieved. Hysteroscopic metroplasty (uterine septa and synechiae) was involved in 16 (89%) cases. Hysteroscopic resection was performed with monopolar current cutting, rigid scissors and laser in respectively 14 (78%), 3 (16.5%) and 1 (5.5%) cases. Uterine perforation occurred in 10 (55.5%) cases. The interval between hysteroscopy and subsequent pregnancies varied from 1 month to 5 years with an average delay of 16 months. Uterine rupture occurred between 19 and 41 weeks, with no labour in 12 (66.5%) cases. Four fetal and one maternal deaths followed uterine rupture. Hysteroscopic metroplasty may expose patients to an increased risk of uterine rupture in subsequent pregnancy. Uterine perforation and/or the use of current monopolar section during operative hysteroscopy increase this risk. Uncomplicated hysteroscopic resection of submucous myomas and endometrial polyps do not alter obstetrical outcome. Considering hysteroscopic metroplasty, the use of coaxial bipolar electrode should be preferred.

Prolapsus isolé de l'étage postérieur posthystérectomie : résultats préliminaires d'une technique utilisant les voies vaginales et transobturatrice basses

OBJECTIVE

The aim of this study is the description and anatomical and functional outcome assessment of a novel surgical procedure, based on rectovaginal fascia defect repair with polypropylene mesh using the tension-free transobturator and infracoccygeal route based on the integral theory developed by Petros.

MATERIALS AND METHOD

Prospective, consecutive and single centre study performed between February 2003 and April 2005. Inclusion criteria were symptomatic posthysterectomy stage three to four regarding posterior compartment prolapse according to the Baden and Walker classification, with no anterior and/or apical prolapse. Principles and description of this new surgical procedure are described.

RESULTS

Fourteen patients, with a mean age of 63.5 years and a mean body mass index of 29.2, were included in the study. All the patients had previous hysterectomy, 64.3% reported at least one previous surgery for pelvic organ prolapse, 44.5% reported at least one reoperation. All patients complained of rectocele and/or enterocele stage three. No perioperative or postoperative complication occurred. With a median follow-up of 13 months (range 3-32.9), no recurrence and no anterior or apical compartment prolapse occurred. No vaginal erosion an infection of the mesh was observed. The mean level of subjective satisfaction was 9.23 on a visual analogical scale (0-very disappointed, 10-very satisfied).

CONCLUSION

This new surgical procedure is effective and safe for the repair of posthysterectomy large posterior compartment prolapse. A long-term follow-up is required to confirm these promising results.

Hémorragie retardée post-conisation et faux anévrisme du pédicule utérin

We report a case of delayed post-conization hemorrhage induced by the rupture of a uterine artery false aneurysm. Cold knife conization of the cervix was the main cause of the false aneurysm. To our knowledge, this is the first case reported. Angiography enabled the diagnosis and the treatment by embolization of the lesion. A less aggressive technique than a scalpel, perhaps with a diathermic loop, could help to prevent this type of complication.

Résultats à trois ans de la prise en charge d'une incontinence urinaire d'effort avec pression de clôture urétrale basse par fronde sous-urétrale TVT

OBJECTIVE

The aim of this study was to assess, with long-term outcome, the effectiveness of TVT for stress urinary incontinence (SUI) with low maximum urethral closure pressure (MUCP) and to identify predicting factors for failure in this case.

PATIENTS AND METHODS

This is a bicentric retrospective study including women who underwent a TVT procedure for grade 3-SUI according to the Ingelman-Sundberg's scale. All patients had a low MCUP defined by PCUM < 30 or by the formula 110-the age+/-20% cmH2O. Urethral hypermobility was defined on physical examination and urodynamic investigations. TVT was the only operation performed. Patients were assessed at three months then at longer term with an average follow-up of three years and ever less than one year.

RESULTS

A total of 60 women 30 to 78 years old (mean age 55) were so operated. More than third of them (38%) had already been operated for incontinence. Thirty-eight percent had SUI without urethral hypermobility. Thirty percent presented bladder overactivity. The short-term evaluation found that, out of 58 patients, 70,6% cured, 10,3% improved and 18,9% classified as failure. The long-term evaluation, concerning 44 patients, found that 57% remained cured, 16% improved and 27% were classified as failure. Bladder overactivity was cured or improved in more than half of the cases (60%). Ten percent of de novo urgencies were noted, all of which persisted later on. For all that, as much as two thirds of these patients were satisfied with the TVT. Mean age of patients classified as failure, was higher (65 years). Previous SUI surgery did not modify the results. When the MUCP was < 20 cmH2O, success was present only one time out of two. The absence of urethral hypermobility decreased to a significant degree the probability of cure (38 vs. 82,6%, P < 0.01), and more still when bladder overactivity was associated (16,6 vs. 66,6%, P < 0.01). Postoperative voiding troubles constituted a pejorative factor for success of surgery.

DISCUSSION AND CONCLUSION

Even if results of TVT with low MCUP are worse, they do not remain less appreciable. When we confront the benefits awaited with this technique compared to the usually described complications, TVT must represent the first treatment of this indication.

[Malignant transformation of abdominal wall endometriosis: a new case report]

Cancer arising in abdominal wall endometriosis is a rare event, hindering diagnosis and making management uncertain. A cesarean section scar is generally at the origin of the disease. We report the case of a 45-year-old woman, with a past medical history of cesarean deliveries, complaining of a repeat abdominal wall endometriosis which transformed into a clear-cell carcinoma. Outcome was rapidly fatal. Compared with endometriosis-associated ovarian carcinoma, the prognosis of this abdominal scar complication is poor. In the literature, survival rate reaches only 57% after a short follow-up of 20 months. Clear-cell carcinoma is the most common histological subtype, followed by endometrioid carcinoma. Radical surgery is the main treatment. Good technique and proper care during cesarean section may help in preventing this endometriosis complication.

Cystocèle et incontinence urinaire d'effort : évaluation d'un traitement global par monoprothèse

OBJECTIVES

The aim of this study is to evaluate the effectiveness and the potential complications in the short and medium terms of the transobturator and infracoccygeal hammock, a surgical technique suggested to treat in one sole operating time, by vaginal way, cystocele and stress urinary incontinence.

PATIENTS AND METHODS

From February 2002 till August 2004, 45 patients aged 66+/-11 years on average, presenting a stage 3 or stage 4 cystocele associated with stress urinary incontinence (proven for 40 of them and masked by the prolapse itself for the other five) benefited from this new surgical procedure.

RESULTS

With a mean follow-up of 31+/-9 months, the success rate of the technique is estimated at 98% on the anatomical aspect (one single failure) and at 91% on the urinary aspect (73% of the patients were cured, 18% improved and 9% in failure). No patient presented urinary retention except one with an infected pelvic hematoma requiring its evacuation and the partial ablation of the prosthesis. Postvoid residual volume at discharge was 83 ml. Two patients developed de novo bladder overactivity. Unfortunately we had to regret nearly 18% of exposed prosthesis. This result should be improved by the exclusive use of polypropylene monofilament prosthesis with broad meshes, weak weights and by reduced vaginal scars.

DISCUSSION AND CONCLUSION

Total treatment by monoprosthesis of cystoceles with associated stress urinary incontinence constitutes an interesting prospect for some high-risk genital urinary prolapses for anatomical repetition or post-operative dysvoiding. Patients with recurrent failures of prolapse surgical cure, those with a large cystocele or by extension with a complete prolapse of the three floors, and even those with a post-hysterectomy prolapse have perhaps found a durable solution with their problem.

Idées pour faire progresser le TVT

Because of the bladder injuries risk and subsequent increase of the intervention time due to the bladder integrity checking, many surgeons have abandoned TVT. Based on a demonstrative clinical case, we report a simple, fast and effective method meant to minimize the risk of bladder injuries and to wonder about the mandatory bladder checking by cystoscopy during the TVT sling installation. An infiltration of 1% Xylocaïne half diluted is carried out in the area laterally to the urethra and the bladder, through vaginal and pubic ways. A 360 ml blue of methylene solution bladder filling may show quickly and safely a bladder injuries occurrence, either a true transfixion or an under mucous route. Using this procedure, TVT technique could be no more dangerous or longer than the TOT technique.

Prise en charge chirurgicale des hémorragies sévères du post-partum

Surgical management of an intractable postpartum haemorrhage after failure of medical and obstetric measures is not limited to the emergency peripartum hysterectomy. Uterine atony and abnormal placental insertions are the major causes of primary postpartum haemorrhages. Involving mostly young women, having few or no child, before with a healthy uterus, in first intention conservative option is recommended. The simplest methods must be known and be applied. It will be essentially progressive uterine arteries' ligation, which can be adapted to the majority of situations. Internal iliac arteries' ligation is a little less effective and technically more difficult to carry out. It remains interesting in obstetrical traumatic hurts, which do not concern the uterus. New and easier surgical methods, such as uterine compression or hemostatic suturing techniques have been described for which we lack experience. The quality of the result depends of the length of intervention and the cause of the bleeding. Nevertheless the main cause of failure with conservative treatments is placenta accreta. In case of failure of a conservative treatment, it would be dangerous to multiply techniques. Emergency peripartum hysterectomy then should remain the choice procedure.