Douleur postopératoire après hystérectomie par voie vaginale selon la méthode d'hémostase utilisée: thermofusion ou suture aux fils

OBJECTIVES

The purpose of the study was to compare the postoperative pain of patients who had a hysterectomy through vaginal route according to the process of binding: wire or electrosurgical bipolar vessel sealing.

PATIENTS AND METHODS

Retrospective study carried out in the 60 last patients who underwent a hysterectomy by vaginal route for a benign pathology in the gynaecological service of surgery of the CHI Poissy-Saint-Germain-en-Laye until March 2006. Among these patients, 32 had profited from a binding by wire and 28 of the electrosurgical bipolar vessel sealing. The studied criteria were the post-operative pain, total morphine consumption and the durations of the analgesic treatment, the hospitalisation and intervention time.

RESULTS

The postoperative pain in the first 24 hours was twice lower using thermofusion; it was valid in immediate post-operative period and after 24 hours. In addition, total morphine consumption was also significantly lower using thermofusion.

DISCUSSION AND CONCLUSION

This pilot study shows that the electrosurgical bipolar vessel sealing allows a reduction in the pain into the immediate postoperative period. Other prospective and randomised studies would allow it and conclude on the duration of hospitalisation, the quality of life from the patients and the cost in terms of public health.

Facteurs de risque des expositions prothétiques après cure de prolapsus génital par voie vaginale

OBJECTIVES

Prosthetic reinforcement in the surgical repair of pelvic prolapse by the vaginal approach is currently on the increase. However, this technique is not without tolerance-related problems. The most frequently described complication is prosthesis exposure, including erosion and delayed healing. It is independent of a granuloma and a major infection as pelvic cellulitis. Its mechanism is associated with defective vaginal healing. The purpose of our study is to define the risk factors for exposure of the prosthetic material.

PATIENTS AND METHODS

Two hundred and seventy-seven medical records relating to patients undergoing surgery due to pelvic prolapse were included in our study. The treatment of genital prolapse was managed via the vaginal approach with polypropylene mesh. This is a continuous, retrospective study conducted over a period of 24 months.

RESULTS

Thirty-four cases of prosthesis exposure were observed in the 2 months following surgery, which represents an incidence of 12.27%. The risk factors are concomitant hysterectomy [odds ratio 5.17 (P = 0.001)] and inverted T colpotomy [odds ratio 6.06 (P = 0.01)]. The protective factors are preservation of the uterus and the performance of a minor colpotomy in patients who had already undergone a hysterectomy or in those whose uterus had been preserved [odds ratio 5.16 (P = 0.0001)].

DISCUSSION AND CONCLUSION

In our study, we have only found risk factors of operative protocol. In fact, other information as age, menopause status or medical history of the patient is not significant. The uterus must be preserved and the number and extent of colpotomies needed to insert the prosthesis must be limited.

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

INTRODUCTION

Prosthetic reinforcement by the vaginal approach for surgical repair of pelvic prolapse is experiencing increasing popularity despite problems with tolerance. The most frequently described complication is prosthesis exposure, also known as erosion or granuloma. The mechanism is associated with defective vaginal healing and is independent of major infection such as pelvic cellulitis.

OBJECTIVES

The purpose of our study was to define the course of this complication and the best therapeutic strategy for patients with prosthesis exposure.

MATERIALS AND METHOD

Our continuous and retrospective study conducted over a period of 24 months between January 2002 and December 2003 recorded 34 files. These patients underwent prosthetic treatment via the vaginal approach of genital prolapse associated with prosthesis exposure. The procedure, known as TVM (Tension free Vaginal Mesh), involves the insertion without fixing of a synthetic prosthesis in areas of bladder-vagina and rectum-vagina detachment.

RESULTS

In 33 cases out of 34, the exposure site was located on the anterior colpotomy scar (97%). These prosthesis exposures were managed in two stages, using antiseptic treatment first. This treatment cured 9 patients (26.47%). In the event of failure, a procedure was carried out under brief general anesthesia on an outpatient basis or during a 24-hour hospital stay. This single resection was sufficient for 20 patients (88%). Two patients nevertheless required a second removal procedure (8%) and one patient a third procedure (4%). To notice, one patient presented with a bladder-vagina fistula after resection. This observation of a bladder-vagina fistula following partial removal led us to recommend a blue test and/or cystoscopy as routine practice for each procedure.

CONCLUSION

With this new vaginal approach for prolapse repair, it is important to monitor prosthesis exposure. To manage exposures, it is necessary to begin with antiseptic or estrogenic treatment. In the event of failure, a partial resection is warranted. We recommend careful prosthesis resection and systematic verification of the bladder.

Molecular cloning and expression of two distinct human N-acetylgalactosamine 4-O-sulfotransferases that transfer sulfate to GalNAc beta 1-->4GlcNAc beta 1-->R in both N- and O-glycans

Recently, cDNAs encoding human chondroitin 4-O-sulfotransferase-1 and -2 (C4ST-1 and C4ST-2) were cloned based on their similarity to HNK-1 sulfotransferase (HNK-1ST) (Hiraoka, N., Nakagawa, H., Ong, E., Akama, T.O., Fukuda, M.N., and Fukuda, M. [2000] Molecular cloning and expression of two distinct human chondroitin 4-O-sulfotransferases that belong to the HNK-1 sulfotransferase gene family. J. Biol. Chem., 275, 20188--20196). In the present study, we identified two additional novel sulfotransferases by searching the expression sequence tag and genomic DNA database for enzymes similar to C4ST-1 and C4ST-2. These newly cloned enzymes, termed GalNAc4ST-1 and GalNAc4ST-2, belong to the HNK-1ST gene family having 40--42% identity with C4ST-1. GalNAc4ST-1 and -2 do not add sulfate to HNK-1 precursor glycans, chondroitin, or desulfated dermatan sulfate. Instead, both enzymes can transfer sulfate to the 4-position of GalNAc in the context of GalNAc beta 1-->4GlcNAc beta 1-->R attached to both N-linked and core 2 branched O-linked oligosaccharides. GalNAc4ST-1 and -2 transcripts are highly expressed in the pituitary gland and trachea, respectively, and GalNAc4ST-1 and -2 transcripts are reciprocally expressed in other tissues as well. Moreover, both enzymes can transfer sulfate to lutropin, a pituitary glycoprotein hormone. These combined results indicate that GalNAc4ST-1 and -2 play critical roles in forming sulfo-->4GalNAc beta 1-->4GlcNAc beta 1-->R in both N-glycans and O-glycans in a tissue-specific manner.