Identification of a group with high risk of postoperative complications after deep bowel endometriosis surgery: a retrospective study on 164 patients

PURPOSE

Identify a group with a high risk of postoperative complications after deep bowel endometriosis surgery.

METHODS

We conducted a retrospective study on patients treated from 2012 to 2018 in two departments of gynecological surgery at the Toulouse University Hospital, France. The postoperative complications were evaluated in relation to the surgical management, associated with or without non-digestive surgical procedures, initial disease and patient's characteristics.

RESULTS

164 patients were included. A postoperative complication occurred in 37.8% (n = 62) of the cases and required a secondary surgery in 18.3% (n = 30) of the cases. In the univariate analysis, the risk of postoperative complications increased significantly in the presence of segmental resection, disease progression, and associated urinary tract procedure or vaginal incision. In the multivariate analysis, the risk of overall postoperative complications was associated with the surgical management (p = 0.013 and 0.017) and particularly in the presence of segmental resection [Odds Ratio (OR): 20.87; CI 95% (1.96-221.79)]. The risk of rectovaginal fistula increased in the presence of segmental resection [OR: 22.71; CI 95% (2.74-188.01)] as well as in vaginal incision [OR: 19.67; CI 95% (2.43-159.18); p = 0.005].

CONCLUSION

The risk of overall postoperative complications and rectovaginal fistula in particular increases significantly in the presence of vaginal incision, segmental resection and urinary tract procedures after deep bowel endometriosis surgery.

[Evolution of clinical practices in the surgical management of pelvic organ prolapse in a "vaginalist" team over the period 2010-2015: A paradigm shift towards pluripotency]

OBJECTIVES

To determine whether the 2011 FDA alert and French Guidelines have impacted the routine surgical practice in the management of pelvic organ prolapse in a "vaginalist" team over the period 2010-2015.

METHODS

Retrospective study involving all patients undergoing surgical management of anterior and/or apical symptomatic pelvic organ prolapse during the civil years 2010 and 2015. Both naive and relapsed prolapses were eligible.

RESULTS

Overall, 338 patients were included: 187 in 2010 and 151 in 2015. Among patients with naive prolapse, we observed a significant increase in the number of laparoscopic sacrocolpopexies (11.1% in 2010 versus 34.4% in 2015, P=0.001) and a significant decline in the use of native tissue repair (67.6% in 2010 versus 39% in 2015, P=0.001). While the number of transvaginal meshes did not decline over the study period, their indications displayed a significant evolution towards a restricted use to advanced stages. We did not observe any difference regarding the treatment of recurred pelvic organ prolapse. Vaginal route remained the preferred approach in this indication.

CONCLUSION

In our "vaginalist" team, routine practice has significantly evolved over the period 2010-2015, resulting in a diversification of the healthcare offer. This paradigm shift towards pluripotency is mandatory, since patients' preference should also drive the choice of both surgical route and technique.

Anatomical study of the inferior vesical artery: is it specific to the male sex?

PURPOSE

The aim of our study was to clarify the origin of the inferior vesical artery and determine its existence in women.

METHODS

This descriptive study is based on 25 dissections (6 male and 19 female cadavers). We dissected the internal iliac artery and its branches from the iliac bifurcation, bilaterally and comparatively. Each arterial branch supplying the bladder was identified and dissected as far as the bladder.

RESULTS

In total, 50 topographies of the bladder vascularization were visualised. The inferior vesical artery was observed in 92% of the male subjects and in 47.4% of the female subjects. In the male cadavers, it arose from the internal iliac artery in 72.7% of cases and from the umbilical artery in 27.3% of cases. In the female cadavers, it arose from a common trunk with the umbilical artery and the uterine artery in 33.3% of cases and directly from the umbilical artery in 33.3% with one terminal branch supplying the upper part of the vagina. In two female subjects, the inferior vesical artery arose from the first segment of the uterine artery (22.2%), and in one subject from the obturator artery (11.1%).

CONCLUSIONS

The inferior vesical artery is not specific to the male sex. The contradictions found in the literature of this artery are due to the variations observed in pelvic vascularization and to the close connections between vaginal and bladder vascularisation in women. However, surgeons should consider these variations, to prevent bladder devascularization by non-selective ligation.

Persistent and moderate hypercalcemia related to an ovarian clear cell adenocarcinoma: Pre- and postoperative parathyroid hormone related-peptide and 1,25-dihydroxyvitamin D3 levels

OBJECTIVE

To evaluate the role of PTH-related peptide (PTH-rP) and 1,25-dihyhydroxyvitamin D3 in a case of hypercalcemia related to an ovarian adenocarcinoma.

DESIGN

We report a case of humoral hypercalcemia in a patient aged 74 yr with a clear cell adenocarcinoma of the right ovary at an early stage of its development (stage T1aN0M0) revealed by moderate and persistent hypercalcemia (variable level between 2.7 and 3.2 mmol/l without any treatment) over six months.

METHODS

PTH-rP and 1,25-dihydroxyvitamin D3 were measured in blood samples taken before and after hysterectomy and bilateral salpingooophorectomy and in blood samples taken intraoperatively from the right ovarian vein and a peripheral vein.

RESULTS

High levels of plasma PTH-rP and 1,25-dihydroxyvitamin D3 concomitant with high serum calcium and low PTH levels were found before surgery, which was followed by normalisation of all parameters studied. A concentration gradient was found regarding plasma PTHrP (right ovarian vein 60.4 pmol/l, peripheral vein 4.5 pmol/l), not 1,25-dihydroxyvitamin D3.

CONCLUSION

1) moderate and persistent hypercalcemia can be observed at an early stage of an ovarian carcinoma; 2) the gradient of PTH-rP concentration between the samples taken from the right ovarian vein and a peripheral vein provides evidence for a direct secretion of PTH-rP by the ovarian tumor; 3) the increased 1,25-dihydroxyvitamin D3 level is not related to a direct ovarian production, but is a consequence of PTH-rP secretion.

[Anterolateral hysteropexy via abdominal approach. Results and indications. Apropos of a series of 92 patients]

Of the possible surgical techniques for the treatment of genito-urinary prolapses, abdominal suspension is reserved for young patients in whom retention of sexual function is desirable. Fixation to the sacral promontory is the reference method but has some contraindications. Anterolateral suspension of the uterine isthmus to the anterior superior iliac spines by a strip of non-absorbable mesh, as described by Kapandji, is then a good alternative. We report our results with this technique over an 8-year period in 92 patients. Mean follow-up was 5 years. There was no intraoperative mortality nor major complications. Anatomical results were satisfactory in 87% of cases at 5 years, with however 4 reoperations for total recurrent prolapse, of which one was posterior. Functional results showed two cases of deep dyspareunia and 12% post-operative stress urinary incontinence, of gradual onset. In conclusion, anterolateral hysteropexy associated with removal of the pouch of Douglas is a reliable procedure with no particular danger. It can be a good alternative to fixation to the sacram promontory when the latter is contraindicated or dangerous.

Hypercalcemia and breast cancer related to parathormone-like secretion by liver metastases

A premenopausal woman developed hypercalcemia 30 months after treatment for infiltrating breast cancer. After bone metastases had been excluded, primary hyperparathyroidism was suspected. A parathyroid adenoma was removed and histologically confirmed. Hypercalcemia, associated with low plasma phosphate and severely depressed plasma parathormone (PTH) levels, persisted. Further investigations showed liver metastases from the primary breast cancer and also secretion of a PTH-like substance. Antitumoral treatment was effective on the liver metastases and also normalized calcemia and the PTH-like substance, demonstrating the existence of a paraneoplastic syndrome related to the secretion of a PTH-like substance by disseminated liver metastases of primary breast cancer.