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ABSTRACT: To analyze long-term results and mechanical survival of the artificial urinary sphincter (AUS) AMS 800™ (American Medical Systems, Minnetonka, MN, USA) in women with stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD).
Data were collected prospectively from women treated for SUI at one university hospital between 1987 and 2007. Inclusion criteria was SUI with severe ISD defined by low urodynamic closure pressure and negative continence tests. Endpoints were survival, complications and continence.
A total of 376 AUS were implanted in 344 patients with a median age of 57 years (18-93 years). The median follow-up was 9 years (3-20 years). The 3, 5, and 10 years global device survival were 92, 88.6, and 69.2% respectively. The mean mechanical survival was 176 months (14.7 years). The two main risk factors for decreased AUS survival were the number of previous incontinence surgeries and the presence of neurogenic bladder. The continence rates assessed as full (no leakage) in 85.64% patients, social (some drops but no pad) in 8.78% and incontinence (1 pad or more) in 5.58%.
The study has shown that in patients with ISD, the AUS represents an effective process, durable with an acceptable rate of complication.
Progrès en Urologie 05/2013; 23(6):415-20. · 0.58 Impact Factor
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ABSTRACT: To evaluate the performance of functional MRI (FMRI) performed by general radiologists (GR) in detection of side-specific extracapsular extension (SSECE) prostate cancer (PCa).
We retrospectively analyzed 79 patients who underwent FMRI with pelvic phased array coil before radical prostatectomy (RP) performed at University Hospital (UH) of Nîmes. Twelve GR (including three from UH) interpreted the images during their daily practice. FMRI results were dichotomized as positive or negative and confronted to pathological reports for SSECE and side-specific seminal vesicle invasion (SSSVI), with calculation of diagnostic values. The influence of interval between biopsy and FMRI, diffusion-weighted sequence (DWS) and intensity of FMRI, on the diagnostic performance were assessed by Fisher's exact test.
A SSECE and a SSSVI were observed at FMRI and pathology respectively on 14 (8.8%) and 38 (24.1%) prostate lobes, and on six (3.8%) and seven (4.4%) prostate lobes. The sensitivity, specificity, positive and negative predictive values of FMRI for SSECE were respectively 24%, 96%, 64% and 80%; and for SSSVI were 14%, 97%, 17% and 96% respectively. The time between biopsy and FMRI, intensity of FMRI and DWS, did not influence the sensitivity and specificity of fMRI at Fisher test.
This study found that preoperative prostate FMRI performed by GR has good specificity but poor sensitivity in predicting SSECE on pathological reports.
Progrès en Urologie 03/2013; 23(3):203-9. · 0.58 Impact Factor
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ABSTRACT: With the increase in life expectancy, men's sexual health has become a major concern for elderly couples. Erectile dysfunction (ED) is responsible for a 50 % decrease of sexually active men between 60 and 85. The aim of this study was to identify objective elements to evaluate the influence of age on male sexual health.
Data on the effects of aging on men's sexual health have been explored in Medline and Embase using the MeSH keywords: prostate; sexuality and erectile dysfunction; aging. The articles were selected based on their methodology, relevance, date and language of publication.
ED concerns 64 % of 70 years old patients and up to 77.5 % after 75 years. The screening of this pathology is based on standardized diagnostic tools. The most used of them remains the "International Index of Erectile function" which, in its simplified version with 5 items (IIEF-5 or SHIM), presents at the cutoff score of 21, a sensitivity of 98 %, a specificity of 88 % and a kappa index of 0.82. The ED is often responsible for a decrease in the quality of life for 60 % of elderly couples wishing to pursue sexual activity. Some diagnostic tools, such as the "Self-Esteem And Relationship" (SEAR) questionnaire or the "Sexual Experience Questionnaire" (SEX-Q) assess individual and couple satisfaction. Physiological aging seems to favor erection disorders by the development of an Androgen Deficiency of the Aging Male (ADAM) but pathological aging appears to be primarily responsible. Cardiovascular or neurological diseases and lower urinary tract symptoms (LUTS) are, with the polymedication, modifiable risk factors of ED to systematically screen in elderly subjects.
Many diagnostic tools allow to detect ED and assess the impact on the quality of life of elderly men. The fundamental element of the management of ED is the research of modifiable risk factors including cardiovascular.
Progrès en Urologie 06/2012; 22 Suppl 1:S7-13. · 0.58 Impact Factor
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ABSTRACT: ObjectifL’objectif de cette étude était d’évaluer l’efficacité et la morbidité de la chirurgie vaginale prothétique chez les patientes
présentant une récidive de cystocèle, à distance d’une promontofixation, en comparaison avec une chirurgie vaginale première.
Matériel et méthodeLes dossiers des patientes opérées pour une récidive de cystocèle à distance d’une promontofixation (groupe étudié) ont été
rétrospectivement analysés et comparés aux dossiers des patientes n’ayant pas d’antécédent de promontofixation (groupe témoin).
Les patientes des deux groupes ont été opérées par l’implantation vaginale d’une prothèse de polypropylène de type 1. L’évaluation
préopératoire comprenait les antécédents, un examen clinique urogynécologique et une stadification du prolapsus selon la classification
de POP-Q, un bilan urodynamique et une évaluation des symptômes et de la qualité de vie. Les complications per- et postopératoires
ont été systématiquement enregistrées. Les gestes associés, comme l’hystérectomie vaginale, la sacrospinofixation, la cure
de rectocèle et la cure d’incontinence urinaire par bandelette sous-urétrale, ont été rapportés. Après l’opération, les patientes
ont été revues à six semaines, à six mois, à un an et à deux ans, avec un examen clinique urogynécologique, une stadification
du prolapsus selon la classification de POP-Q et une évaluation des symptômes et de la qualité de vie. Afin de compléter le
suivi, les patientes non revues en consultation ont été contactées par téléphone pour connaître les symptômes de prolapsus,
la satisfaction et les complications tardives. Le succès objectif a été défini par l’absence de récidive anatomique de cystocèle
(point Ba < −1) au dernier suivi.
RésultatsSoixante-cinq patientes ont été incluses (32 dans le groupe étudié et 33 dans le groupe témoin). Dans le groupe étudié, une
patiente est décédée d’un cancer et deux ont été perdues de vue, laissant 29/32 patientes pour l’analyse. Dans le groupe témoin,
trois patientes ont été exclues en raison d’un antécédent de chirurgie vaginale et une a été perdue de vue, laissant 29/33
patientes pour l’analyse. Dans le groupe étudié, 17/29 patientes ont été opérées par une prothèse transobturatrice à quatre
bras (Ugytex®, Sofradim-Covidien) et 12/29 par une autre prothèse de polypropylène de type 1 (Polyform®, Boston Scientific)
fixée bilatéralement aux arcs tendineux du fascia pelvien et aux ligaments sacroépineux à l’aide du Capio® (Boston Scientific).
Dans le groupe témoin, 20/29 patientes ont été opérées par la même prothèse transobturatrice à quatre bras, et 9/29 par la
même prothèse fixée bilatéralement aux arcs tendineux du fascia pelvien et aux ligaments sacroépineux. Les caractéristiques
cliniques et démographiques initiales étaient similaires dans les deux groupes, en dehors des antécédents de chirurgie pelvienne
(cure de prolapsus, hystérectomie, cure d’incontinence urinaire) plus fréquents dans le groupe étudié. Les gestes associés
(sacrospinofixation, cure de rectocèle, cure d’incontinence urinaire) étaient plus fréquents dans le groupe témoin. Avec un
recul moyen de 22 ± 12 mois dans le groupe étudié et de 23 ± 14 mois dans le groupe témoin, les taux de succès objectifs sur
la cystocèle ont été de 25/29 (86,2 %) et de 28/29 (93,1 %) [p > 0,05]. Bien que toutes les patientes fussent satisfaites du résultat de la chirurgie, une patiente dans chaque groupe a
présenté une récidive apicale, et 7/20 (35 %) patientes du groupe étudié ont présenté une décompensation du compartiment postérieur.
L’évaluation postopératoire des symptômes et de la qualité de vie était similaire dans les deux groupes. Le taux de dyspareunie
de novo était de 1/8 (12,5 %) et de 2/13 (15,4 %) dans le groupe étudié et dans le groupe témoin respectivement (p > 0,05). Le taux global de complications était de 6/29 (20,7 %) et de 5/29 (17,2 %) dans le groupe étudié et dans le groupe
témoin respectivement (p > 0,05), incluant une coudure urétérale (3,4 %) dans le groupe étudié et de 1/29 (3,4 %) érosion vaginale ayant nécessité
une réopération dans chaque groupe.
ConclusionLa chirurgie vaginale prothétique est une stratégie valide chez une patiente présentant une cystocèle récidivée après promontofixation.
ObjectiveThe aims of this study were to evaluate the efficacy and safety of vaginal surgery using mesh in women with recurrent anterior
vaginal wall prolapse after abdominal sacrocolpopexy, in comparison with primary repair.
Material and methodsPatients operated for recurrent anterior vaginal wall prolapse after abdominal sacrocolpopexy (study group) were retrospectively
analyzed and compared with patients operated for anterior vaginal wall prolapse as primary repair (control group). All patients
have been operated with an anterior type 1 polypropylene mesh. Preoperative evaluation included history, POP-Q classification
and symptoms and quality of life questionnaires. Intra- and post-operative complications were recorded. Associated procedures,
such as vaginal hysterectomy, sacrospinous fixation, posterior repair and sub-urethral sling, were also reported. After surgery,
patients were seen at 6 weeks, 6 months, one and two years, using POP-Q classification, satisfaction index and symptoms and
quality of life questionnaires. To complete follow-up, patients who were not seen recently had phone interviews on POP symptoms,
satisfaction and late complications. Objective success was defined by the absence of anatomical recurrence of anterior vaginal
wall prolapse (Ba < −1) at last follow-up.
ResultsThe study included 65 implanted patients (32 in the study group and 33 in the control group). In the study group, one patient
died from a cancer and two were lost to followup, leaving 29/32 patients available for analysis. In the control group, three
patients have previously undergone vaginal surgery and one was lost to follow-up, leaving 29/33 patients available. In the
study group, 17/29 patients underwent a transobturator four arms mesh (Ugytex®, Sofradim-Covidien), and 12/29 under went another
operation — type 1 polypropylene mesh (Polyform®, Boston Scientific) fixed bilaterally to the arcus tendineus fascia pelvis
and to the sacrospinous ligament using the Capio® (Boston Scientific). In the control group, 20/29 patients underwent the
transobturator four arms mesh, and 9/29 underwent the mesh fixed bilaterally to the arcus tendineus fascia pelvis and to the
sacrospinous ligament operation. Demographic and clinical characteristics at baseline were similar in both groups, except
for previous POP surgery, previous hysterectomy and previous SUI surgery, more frequent in the study group. Associated procedures
(sacrospinous fixation, posterior repair and sub-urethral sling) were more frequent in the control group.With a mean follow-up
time of 22 ± 12 months in the study group and 23 ± 14 months in the control group, objective success on the anterior compartment
were 25/29 (86.2%) and 28/29 (93.1%), respectively (P > 0.05). Although all patients were satisfied with results of surgery, one patient in each group had a recurrence of apical
defect (P > 0.05), no patient in the control group had a recurrence of posterior compartment prolapse (P > 0.05), and 7/20 (35%) patients in the study group had de novo posterior compartment prolapse (P < 0.05). Postoperative symptoms and quality of life evaluation were similar in both groups. De novo dyspareunia occurred
in1/8 (12.5%) and 2/13 (15.4%) patients, in the study and the control group, respectively (P > 0.05). Overall rates of complications were 6/29 (20.7%) and 5/29 (17.2%), in the study and the control group (P > 0.05), respectively, including one ureteral kinking (3.4%) in the study group and 1/29 (3.4%) rate of vaginal erosion,
which has necessitated re-operation in each group.
ConclusionVaginal surgery using mesh is a valid option in women with recurrent anterior vaginal wall prolapse after abdominal sacrocolpopexy.
Mots clésChirurgie vaginale–Prolapsus récidivé–Promontofoxation–Prothèse
KeywordsVaginal Surgery–Recurrent prolapse–Sacrocolpopexy–Mesh
Pelvi-périnéologie 05/2012; 6(2):89-96. · 0.07 Impact Factor
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ABSTRACT: ObjectifsComparer les résultats anatomiques, fonctionnels et la morbidité de deux stratégies chirurgicales du traitement associé des
prolapsus de l’étage antérieur et moyen à savoir les prothèses sous-vésicales transobturatrices (TO) de type Ugytex® (Sofradim-Covidien)
associées à une sacrospinofixation postérieure unilatérale (« technique de Richter ») comparées aux prothèses sous-vésicales
fixées à l’arc tendineux du fascia pelvien (ATFP) de type Polyform® et Pinnacle® (Boston Scientific) associées à une sacrospinofixation
antérieure bilatérale (SSFa) à l’aide du dispositif Capio®. L’hypothèse de départ était une efficacité supérieure de la sacrospinofixation
antérieure bilatérale dans la prise en charge des prolapsus complexes avec cystocèle prédominante.
Matériel et méthodesQuatre-vingt-cinq patientes opérées consécutivement d’un prolapsus génito-urinaire entre mars 2005 et mars 2009 ont été incluses
dans une étude monocentrique rétrospective comparative (groupe TO-Richter, n = 41; groupe ATFP-SSFa, n = 44). Les caractéristiques initiales des patientes étaient similaires dans les deux groupes en dehors des antécédents chirurgicaux
de prolapsus (17 patientes [38 %] dans le groupe ATFP-SSFa et quatre patientes [10 %] dans le groupe TO-Richter avec p = 0,002). Toutes les patientes présentaient un prolapsus de l’étage antérieur de stade supérieur ou égal à 2 et de l’étage
moyen de stade supérieur ou égal à 1 selon la classification POP-Q. Les gestes associés ont été: plicatures prérectales (18
[40%] dans le groupe ATFP-SSFa vs 32 [78%] dans le groupe TO-Richter, p = 0,005), bandelettes sous-urétrales (17 [39,8 %] dans le groupeATFP-SSFa vs 19 [46%] dans le groupe TO-Richter). Les résultats
anatomiques et fonctionnels ont été évalués et comparés dans les deux groupes.
RésultatsLe recul moyen est de 11,5 mois dans le groupe ATFP-SSFa et de 22,7 mois dans le groupe TO-Richter (p = 0,011). Le taux de succès anatomique sur l’étage antérieur (stade < 2) est de 40/44 (90,1 %) pour le groupe ATFP-SSFa et
de 32/41 (78 %) dans le groupe TO-Richter (p = 0,1). Le taux de succès anatomique sur l’étage moyen (stade postopératoire < stade préopératoire) est de 43/44 (98 %) dans
le groupe ATFP-SSFa et de 37/41 (90 %) pour le groupe TO-Richter (p = 0,19). Le taux de succès global (c’est-à-dire à la fois
sur l’étage antérieur et moyen) est de 39/44 (88,6 %) dans le groupe ATFP-SSFa et de 29/41 (70 %) dans le groupe TO-Richter
(p = 0,033). Le taux de décompensation de l’étage postérieur est de 7/26 (27 %) dans le groupe ATFP-SSFa et de 1/9 (11 %) dans
le groupe TO-Richter (p = 0,65). Les complications opératoires sont marquées par: hématomes (2 [4,6 %] vs 1 [2,4 %], p = 1); érosions (3 [7 %] vs 1 [2,4 %], p = 0,80); complications urétérales (4 [9 %] vs 0 p = 0,12); infection de prothèse sévère compliquée de fistule vésicovaginale (1 [2,3 %] vs 0, p = 1). Le taux de dyspareunie de novo est élevé dans les deux groupes (2/10 [20 %] vs 2/7 [28 %]). Au total, huit patientes
(18,2 %) ont été réopérées dans le groupe ATFP-SSFa vs 4 (9,7 %) dans le groupe TO-Richter, p = 0,14).
ConclusionDans cette série comparative, les deux techniques s’accompagnent d’un taux élevé de complications et de réinterventions, bien
qu’il s’agissait d’opérateurs entraînés à la chirurgie prothétique vaginale. La sacrospinofixation antérieure pourrait avoir
un intérêt, mais celui-ci reste à évaluer au regard d’un taux de complications important.
Hypothesis/aims of studyTo compare anatomical and functional results of two different surgical strategies in the combined treatment of anterior vaginal
wall and vault prolapse: a transobturator (TO) mesh (Ugytex® Sofradim-Covidien) associated with a posterior sacrospinous ligament
suspension (pSLS) compared with an arcus- anchored (AA) mesh (Polyform® or Pinnacle®, Boston Scientific) associated with a
bilateral anterior sacrospinous ligament suspension (aSLS) using the Capio® needle driver. Our hypothesis was that the second
strategy (AA mesh + aSLS) could be more efficient for anterior wall reconstruction, restoring a more physiological vaginal
axis than the posterior approach.
Study design, materials and methodsEighty-five women operated for a complex POP were included between March 2005 and March 2009 in a monocentric retrospective
and comparative study (group TO/pSLS N = 41; group AA/aSLS N = 44). All patients had at least a POP-Q stage 2 anterior vaginal wall prolapse with Ba point ≥ +1 and a stage 2 vault prolapse
with C point ≥ −1. Associated procedures were: site- specific rectocele repair (18 [40%] in the AA/aSLS group vs 32 [78%]
in the TO/pSLS group (P = 0.005)). In the post- operative period, anatomical and functional results were evaluated and compared between groups. Post-
operative anatomical success was defined by a stage 0 or 1 cystocele for the anterior compartment and by a post- operative
vault prolapse stage inferior to the preoperative one for the medium compartment.
ResultsThe baseline patient characteristics were similar in both groups, except for the history of prolapse surgery (17 patients
[38%] in the AA/aSLS group vs four patients [10%] in the TO/pSLS group (P = 0.002)). The average follow- up was 11.5 ± 8.1 months in the AA/aSLS group and 22.7 ± 16.1 months in the TO/pSLS group
(P = 0.011). Anatomical success rate on the anterior compartment was 40/44 (90.1%) in the AA/aSLS group vs 32/41 (78%) in the
TO/pSLS group (P = 0.1). Anatomical success rate on the vaginal vault was 43/44 (98%) in the AA/aSLS group vs 37/41 (90%) in the TO/pSLS group
(P = 0.19). Total anatomical success on either anterior compartment and vaginal vault was 39/44 (88.6%) in the AA/aSLS group
vs 29/41 (70%) in the TO/pSLS group (P = 0.033). De novo prolapse rate on the untreated posterior compartment was 7/26 (27%) in the AA/aSLS group vs 1/9 (11%) in
the TO/pSLS group (P = 0.65). Operative complications are represented by: haematomas (2 [4.6%] vs 1 [2.4%]); vaginal erosions (3 [7%] vs 1 [2.4%]);
ureteral kinking (4 [9%] vs 0); severe mesh infection with vesico- vaginal fistula (1 [2.3%] vs 0). De novo dyspareunia rate
is similar in both groups (2/10 [20%] vs 2/7 [28%]). In total, 8 patients (18.2%) were reoperated in the AA/aSLS group vs
3 (7.3%) in the TO/pSLS group.
Concluding messageIn this comparative series, both techniques have a high rate of complications and reoperations, although they were performed
by trained operators in vaginal prosthetic surgery. The bilateral anterior sacrospinous ligament fixation shows promising
results, but needs reevaluation because of the high rate of complications
Mots clésSacrospinofixation antérieure bilatérale–Prothèse sous-vésicale–Décompensation postérieure–Complications urétérales
KeywordsBilateral anterior sacrospinous ligament suspension–Anterior vaginal vault prolapse–Ureteral kinking
Pelvi-périnéologie 04/2012; 6(3):145-155. · 0.07 Impact Factor
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ABSTRACT: ButÉvaluer l’efficacité et la tolérance à court terme du traitement de l’incontinence urinaire d’effort (IUE) après prostatectomie
totale par prothèse sous-urétrale transobturatrice Advance®.
Matériel et méthodeIl s’agit d’une étude prospective unicentrique menée chez 21 patients opérés entre septembre 2007 et mars 2008 avec une bandelette
sous-urétrale de type Advance® (polypropylène, voie transobturatrice de dehors en dedans). L’âge moyen était de 69 ans (extrêmes:
60 à 77 ans). Le délai moyen entre la prostatectomie et la cure d’incontinence était de 39,38 mois (extrêmes: 10–100 mois).
Tous les patients avaient une incontinence modérée, définie par l’usage de trois à quatre protections par jour (n = 20), ou sévère (plus de cinq protections par jour; n = 1). Aucun d’entre eux n’était incontinent au repos. L’objectif principal était d’évaluer l’efficacité du traitement à court
terme (absence totale de fuite et de troubles mictionnels). L’objectif secondaire était l’étude de la tolérance postopératoire
immédiate et des complications périopératoires.
RésultatsL’intervention, d’une durée moyenne de 44,28 minutes (extrêmes: 30 à 70 minutes), n’a pas altéré la débitmétrie ou la vidange
vésicale. Aucune complication per- ou postopératoire précoce n’était mise en évidence. À un mois, sept patients étaient secs,
11 patients étaient améliorés (dix incontinences légères et une incontinence modérée). Le traitement était inefficace chez
trois patients, notamment en cas d’incontinence sévère. À trois mois, sept patients étaient secs, dix patients étaient améliorés
(six incontinences légères et quatre modérées). Le traitement était inefficace chez quatre patients.
ConclusionLe traitement d’une IUE après prostatectomie totale par bandelette sous-obturatrice Advance® a été aisé et n’a pas entraîné
d’obstruction vésicale significative. Les résultats à court terme ont été encourageants. Les facteurs prédictifs d’échec et
la pérennité des résultats restent à valider à plus long terme dans des études multicentriques.
The objectives of the study were to evaluate the efficacy and safety of the Advance® procedure, using a transobturator tape,
in the treatment of male urinary stress incontinence after radical prostatectomy. Twenty-one consecutive patients (60 to 77
years old), operated between September 2007 and March 2008, were included in this monocentric prospective study. The Advance®
system is a minimally invasive procedure marked by AMS. in which a polypropylene tape is placed underneath the bulbomembranous
urethra via a transobturator route (outside - in procedure). The time between radical prostatectomy and the Advance® procedure
range from 10 to 100 months (39.4). Most patients (20/21) presented moderate urinary incontinence (3 to 4 pads/day). Only
one patient had severe urinary incontinence (>4 pads/day). No patient had leakage at rest. The mean time of the procedure
was 45 minutes (range 30 to 70). No perioperative complications were observed. The three months postoperative evaluation showed
improvement in 17 patients (80%) with seven patients completely dry (33%) and six patients significantly improved (mild urinary
incontinence (28.5%). The four other patients improved with moderate incontinence and treatment was ineffective on four patients.
No patient had any postoperative complications. Especially, there were no dysuria, evaluated by max flow rate and residual
volume. In conclusion, these preliminary results show, with a short follow-up, that Advance® procedure seems to be an efficient,
simple and well-tolerated procedure.
Mots clésIncontinence urinaire–Prostatectomie–Bandelette sous-urétrale (Advance®)
KeywordsUrinary incontinence–Prostatectomy–Sub-urethral tape (Advance®)
Pelvi-périnéologie 04/2012; 5(4):216-221. · 0.07 Impact Factor
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ABSTRACT: Le prolapsus utérin (hystéroptose) correspond à la descente de l’utérus dans la cavité vaginale puis à l’extérieur de l’orifice
vulvaire. Cette pathologie fréquente est principalement due à la défaillance du système de suspension utérine par les ligaments
utérosacrés. La recherche d’une pathologie utérine ou cervicale associée doit être systématique (échographie, frottis), ainsi
que la recherche d’un autre trouble de la statique pelvienne au niveau de l’étage antérieur (cystocèle) ou postérieur (rectocèle).
Le bilan des fonctions vésicosphinctérienne et anorectale, et notamment la recherche d’une incontinence urinaire ou anale,
doit également être réalisé avant traitement. L’utilisation d’un pessaire doit être proposée avant la chirurgie, y compris
chez les femmes jeunes, en raison de son efficacité relative et de son innocuité. Le traitement chirurgical est le traitement
de référence du prolapsus utérin, mais il n’est indiqué que pour les prolapsus symptomatiques. La promontofixation reste actuellement
le gold standard de la chirurgie réparatrice du prolapsus utérin. La promontofixation est plus efficace et entraînerait moins de dyspareunies
que la sacrospinofixation par voie vaginale (intervention de Richter). L’abord cœlioscopique donne des résultats comparables
à l’abord par laparotomie et représente actuellement la technique de choix. Chez les femmes âgées, la chirurgie vaginale présente
des avantages incontestables, et la sacrospinofixation est alors la technique de référence. La réalisation d’une hystérectomie
associée à la suspension du fond vaginal n’apporte pas de bénéfice en termes de correction du trouble de la statique pelvienne
par rapport à la sacrospinofixation avec conservation utérine (intervention de Richardson). La sacropexie infracoccygienne
(technique « IVS postérieur ») est aussi efficace que la sacrospinofixation à moyen terme, avec une réduction des douleurs
postopératoires précoces et du taux de récidive de cystocèle.
Uterine prolapse is an intra-vaginal or extra-vulvae uterine descent. That frequent pathology is mainly due to the weakness
of the uterosacral complex suspension system. Preoperatively, cervical cytology and ultrasound should be performed looking
for an associated uterine pathology, and other pelvic floor disorders should be systematically checked. A pessary should be
proposed before surgery, even for young women, because of its relative efficacy and safety. Surgical treatment is still the
reference management, but is only indicated for symptomatic cases. Abdominal sacrocolpopexy is currently the gold standard
for uterine suspension. Sacrocolpopexy is more efficient than vaginal sacrospinous suspension (Richter procedure), with a
decreased rate of postoperative dyspareunia. Laparoscopic approach seems to be as efficient as open abdominal surgery, and
is currently recommended as the first line. On elderly, vaginal reconstructive surgery has well known advantages. For the
vaginal route, sacrospinous suspension is the reference technique. Sacrospinous suspension with uterine conservation (Richardson
procedure) is as efficient as sacrospinous suspension associated with hysterectomy. Infracoccygeal sacropexy (“posterior IVS”
procedure) is as efficient as sacrospinous suspension at medium-term, with a decreased rate of early postoperative pain and
cystocele recurrence.
Pelvi-périnéologie 04/2012; 4(3):218-225. · 0.07 Impact Factor
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ABSTRACT: Estimate the feasibility and the results of the realization in consultation of a flexible videocystoscopy in blue light preceded by an instillation of Hexvix(®) (GE Healthcare) for the initial diagnosis or the surveillance of vesicals tumors (VT). The objective of this study was to compare the number of hurts seen in white light and in blue light, and to estimate in which percentage of case the use of the Hexvix(®) in consultation modified the care.
Thirty consecutive patients (26 men and four women) were estimated prospectively by vesical videofibroscopy in blue light (Wolf's PD videofibroscope) realized 1 hour after an endovesical instillation of Hexvix(®). All the examinations were realized in external consultation under local anesthetic by xylocaine gel: 23 (76.6%) patients within the framework of a surveillance of VT and seven (23.4%) for the diagnosis of a hematuria with normal echography. When a suspect hurt or a VT was discovered, the patients benefited from an endoscopic resection under anesthesia with new cystoscopy in blue light.
Suspect hurts were revealed in 10 out of 30 patients, five in white and blue light, five in blue light only. Among the five only visible hurts in blue light, three were urothelial tumors (any pTa of bottom-rank, less of 5 mm) and two non-specific hurts. No CIS's hurt was revealed during this study. The fibroscopy in blue light allowed to diagnose invisible hurts in white light in three patients (10%) and has modified the care of five patients (16.7%). The duration of the cystoscopy was on average of 9.5 minutes. The tolerance of the examination was good and no complication arose.
The use of the flexible videocystoscopy in blue light +Hexvix(®) has allowed to improve the rate of detection of VT. Except CIS's hurts, this improvement was bound to the diagnosis of little aggressive small-sized VT. The indications must be specified by studies of bigger scale and a medical economic evaluation.
Progrès en Urologie 03/2012; 22(3):172-7. · 0.58 Impact Factor
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ABSTRACT: Assessment of the Peyronie's disease (PD) is clinical in absence of validated questionnaire or of para-clinical standardized test. The international index of erectile function (IIEF) and Lue's score are used for the clinical evaluation. Penile dynamic duplex ultrasound (PDU) was considered in the 2010 recommendations as "useful but not necessary test". The objective of this study was to estimate the utility of the scores and of the PDU in the diagnostic and in the therapeutic decision at the patients suffering from a PD.
Twenty-one patients were included in this forward-looking single-center study over 12 months. All the patients had a clinical examination with photos, an evaluation using the IIEF-5 and the Lue's score and a PDU.
The average age was of 57.7 years (34-77) with an average evolution duration of 38.9 months. IIEF-5 was not adapted to the assessment of the preoperative erectile function of the PD because the questions 3 to 5 were modified by the penil deformity. The result of Lue's score did not seem to us to have interest in the therapeutic decision because it is not recommended to operate a patient in evolution. Plaques were classified according to ultrasonographic patterns : presence of hyperechoic or/and calcified lesion. The application of relevant differential ultrasound criteria turned out delicate. The PDU found abnormalities of the vascular flows for 61.9 % of the patients. Nine patients were operated and PDU modified the surgical gesture for two of them.
The search for objective criteria of evaluation of the PD is essential, but those currently proposed, clinical or ultrasound seemed to us a little adapted or difficult to apply.
Progrès en Urologie 02/2012; 22(2):113-9. · 0.58 Impact Factor
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ABSTRACT: To evaluate the risk of occurrence of de novo stress urinary incontinence (SUI) after sacral colpopexy (SCP).
In all, 57 women with no concomitant or occult SUI, had a SCP for urogenital prolapse between January 2006 and October 2009. Some data from their medical charts (age, body mass index, past medical history, maximum urethral closure pressure, bladder neck hypermobility) were reviewed retrospectively and statistically analyzed to assess the association between these factors and de novo SUI.
With a median follow-up of 16 months, four patients (7.3%) developed de novo SUI 1 year postoperative and which required the wearing of pads defensively, three of which were significantly improved after pelviperineal rehabilitation, however only one patient: 1.8% required the establishment of a sub-urethral tape 8 months after the surgical correction of prolapse. No statistically significant association has been established despite a P<0.01 between the sphincter deficiency (SD) and de novo SUI because of a sample too small inferior to five, however predictive values for PPV and NPV, the MUCP was 43 and 2.2%.
The results of this study were consistent with the literature data, the risk to our patients to develop de novo SUI requiring secondly anti-incontinence procedure was lower: 7.3% but could become more important: 43% if preoperative SD. Patients should always be informed before surgery as it cannot be predicted.
Progrès en Urologie 10/2011; 21(9):631-5. · 0.58 Impact Factor
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ABSTRACT: To assess feasibility and results of mid-urethral sling placement for stress urinary incontinence (SUI) in adult women after transurethral injection therapy failure.
Eleven patients were operated on for a mid-urethral sling placement after at least one transurethral injection therapy, from January 2005 to February 2008. Injections were performed for moderate non-daily SUI, or according to patient willingness, or for SUI surgical history. Mean age at the time of surgery was 59.9 years (range: 33 to 84).
Mean operative time, including control cystoscopy time during TVT placement, was 26 minutes (20-35). There were no peri-operative complications, nor problems for dissection or tape placement. At a mean follow-up of 9.9 months (5-20), 9/11 (81%) patients were dry with no lower urinary tract disorders.
SUI treatment by mid-urethral sling after transurethral injections failure is feasible not bothered by the injected material and effective at short-term.
Gynécologie Obstétrique & Fertilité 10/2010; 38(11):710-3. · 0.52 Impact Factor
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ABSTRACT: Estimate the urinary impact of vaginal occlusion without mid-urethral sling in the elderly with vault vaginal prolapse and stress urinary incontinence.
Retrospective case series of 22 women who underwent a vaginal closure between May 2005 and April 2009. Postoperating evaluation of the impact on the urinary tract of this surgery and of the satisfaction of the patients to a phone investigation.
Seventeen patients with mean age 80 years answered the phone questionnaire. With a mean follow up of 23.9 months, the rate of satisfaction amounts to 88%. The rate of recurrence is 11%. Urge incontinence decreases from 36 to 24% and there is no stress urinary incontinence postoperatively.
Colpocleisis is a surgical technique which meets high rates of satisfaction and which seems effective in the treatment of urinary incontinence associated with vaginal vault prolapse in the elderly.
Journal de Gynécologie Obstétrique et Biologie de la Reproduction 06/2010; 39(4):318-24. · 0.42 Impact Factor
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ABSTRACT: The objective of this survey was to describe medical reasons disclosed by men over 18 years old when visiting an urologist, to estimate the prevalence of male sexual dysfunction (MSD) including erectile dysfunction (ED) and to describe treatment options for ED.
This survey was performed, with Urology French Association (AFU) partnership, in 150 urological clinics, sample representative of urologists in France regarding age, geographical distribution and practice. The survey was proposed to all adults' men consulting a participating urologist the defined day (Tuesday the 19th of June 2007 or an imminent day). A total of 1848 (92.5%) patients agreed to participate; analysis was performed on 1740 patients. Information related to urological disorders, sexual dysfunctions, their treatment and their impact on the patient's life were gathered by a patient auto-questionnaire. Erectile dysfunction was assessed through the single question of John B. McKinlay.
Among patients (mean age 63+/-14 years), 68% (IC95%=[65.2%; 70.7%]) had ED (44% severe); 25% were treated (of which 2/3 with IPDE5 alone or in association). Male sexual dysfunction was the first reason for visiting urologists (14%) following prostatic diseases (62%). About 60% of the patients had already talked about their ED to a physician, who was an urologist in 44.6% of cases. The perspective of living the rest of their life with this trouble was "unacceptable" for 21.1% of patients with ED and "fairly acceptable" for 34.4%.
This first survey in French urologists' community emphasizes the high prevalence male sexual dysfunctions for inpatients visiting their urologists. Despite declared urologists' interest for male sexual dysfunction, the discrepancy between the high prevalence of ED and the low rate of patients consulting for this condition probably explains the low rate of patients using treatments.
Progrès en Urologie 12/2009; 19(11):830-8. · 0.58 Impact Factor
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ABSTRACT: The prevalence of pelvic organ prolapse (POP) varies between 2.9 and 11.4% in questionnaire-based studies and from 31.8 to 97.7% according to the ICS Pelvic Organ Prolapse Classification (POPQ) anatomical classifications. The cumulative incidence of surgery for POP is as high as 70% in women more than 70-year-old. Aging is significantly associated with the prevalence and severity of POP. Pelvic disorders are a health economic challenge for the future due to the longer life expectancy of women and to an increasing demand for a better quality of life. Identification of risk factors will be critical in order to develop strategies to prevent the disease and limitate the need for surgical intervention.
Progrès en Urologie 12/2009; 19(13):907-15. · 0.58 Impact Factor
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ABSTRACT: The pelvic floor is the support of the pelvic visceras. The levator ani muscle (LA) with its two bundles (pubo- and ilio-coccygeus) is the major component of this pelvic floor. LA is formed essentially by type I fibers (with high oxidative capability and presence of slow myosin) as in postural muscles. The aerobic metabolism makes LA susceptible to injury caused by excentric contraction and mitochondrial dysfunction. The innervation of the pelvic floor comes from the 2nd, 3rd, 4th anterior sacral roots; denervation affects pelvic dynamism. Perineum includes the musculofascial structures under the LA: ventrally the striated urethral sphincter and the ischio-cavernous and bulbospongious, caudally the fatty tissue filling the ischioanal fossa. Pelvic fascia covers the muscles; it presents reinforcements: the uterosacral and cardinal ligaments, the arcus tendineus fascia pelvis (ATFP) and the arcus tendineus levator ani (ATLA). The pelvis statics is supported by the combined action of all this anatomical structures anteriorly forming the perineal "hammock", medially the uterosacral and cardinal ligaments, posteriorly the rectovaginal fascia and the perineal body. The angles formed by the pelvic visceras with their evacuation ducts participate to the pelvic statics. During the pelvic dynamics the modification of these angles expresses the action of the musculofascial structures.
Progrès en Urologie 12/2009; 19(13):916-25. · 0.58 Impact Factor
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ABSTRACT: The physiopathology of urogenital prolapse is multifactorial, a combination of the interaction between constitutional and acquired factors resulting in the weakening of perineal support. Genetic modifications contribute to the occurrence of prolapse (proof level 2). Differences relating to types of collagen and their proportions, the construction of smooth muscle fibres and nervous structures, have been described between women with and without prolapse. But the relationship of cause and effect is not always clear. It would appear that the reduction in the expression of the elastine gene and the perturbation of metabolism may be at the origin of the cause of a prolapse. However, the intense activity of tissue remodeling is probably the consequence of biomechanical pressure born by the prolapse. Muscular or neuropathic lesions of the levator ani have been widely researched and documented. In the case of prolapse, these were isolated exceptions and most often associated with dehiscence of support tissue.
Progrès en Urologie 12/2009; 19(13):926-31. · 0.58 Impact Factor
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ABSTRACT: Numerous epidemiological studies in recent years have involved the search for the principal risk factors of genitourinary prolapse. Although it has been agreed for a long time that vaginal delivery increases the risk of prolapse (proof level 1), on the other hand, the Cesarian section cannot be considered a completely effective preventative method (proof level 2). The pregnancy itself is a risk factor for prolapse (proof level 2). Certain obstetrical conditions contribute to the alterations of the perineal floor muscle: a foetus weighing more than four kilos, the use of instruments at birth (proof level 3). If the risk of prolapse increases with age, intrication with hormonal factors is important (proof level 2). The role of hormonal replacement therapy remains controversial. Antecedent pelvic surgery has also been identified as a risk factor (proof level 2). Other varying acquired factors have been documented. Obesity (BMI and abdominal perimeter), professional activity and intense physical activity (proof level 3), as well as constipation, increase the risk of prolapse. More thorough research into these varying factors is necessary in order to be able to argue for measures of prevention, obstetrical techniques having already evolved to ensure minimal damage to the perineal structure.
Progrès en Urologie 12/2009; 19(13):932-8. · 0.58 Impact Factor
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ABSTRACT: Physical examination is still very contributing in the evaluation of female pelvic organ prolapse. Related symptoms do predict neither the severity nor the location of the prolapse. The accuracy and the reliability of the physical examination are high for the anterior and middle compartments but insufficient for the evaluation of the posterior compartment, which should include imaging and manometric tests. The physical examination does not show any difference between morning and afternoon and its reliability is independent of the examiner particularly if performed in the patient standing.
Progrès en Urologie 12/2009; 19(13):939-43. · 0.58 Impact Factor
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ABSTRACT: Dynamic ultrasound, especially perineal and introital, allows the appreciation of the prolapses (cystoptosis, bladder neck and urethral mobility,enterocele, rectocele). It remains, however, clearly more limited in the precise study of posterior colpoceles, and especially in anorectal disorders, than colpocystodefecography or dynamic MRI. Endoanal ultrasound is the first line morphological examination of the anal sphincter. Perineal and introital ultrasound examinations are useful to appreciate certain complications with suburethral tape and pelvic mesh. For an appreciaton of the morphology of the pelvis and post-mictional residual, the ultrasound remains the first line examination. Pelvic and endovaginal ultrasounds should be systematic, in the absence of MRI, in the presurgical assessment of a prolapse: checks for an ovarian lesion or endrometrial cancer (obesity being a risk factor in the menopaused woman), evaluation of uterine volume in the younger woman.
Progrès en Urologie 12/2009; 19(13):947-52. · 0.58 Impact Factor
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ABSTRACT: Colpocystodefecography (CCD) and dynamic MRI with defecography (MRId) permit an alternation between filling and emptying the hollow organs and the maximum abdominal strain offered by the defecation. The application in imaging of these two principles reveal the masked or underestimated prolapses at the time of the physical examination. Rigorous application of the technique guarantees almost equivalent results from the two examinations. The CCD provides voiding views and improved analysis of the anorectal pathology (intussusceptions, anismus) but involves radiation and a more invasive examination. MRId has the advantage of providing continuous visibility of the peritoneal compartment, and a multiplanar representation, enabling an examination of the morphology of the pelvic organs and of the supporting structures, but with the disadvantage of still necessitating a supine examination, resulting sometimes in an incomplete evacuation. The normal and abnormal results (cystoptosis, vaginal vault prolapse, enterocele, anorectal intussuception, rectocele, descending perineum, urinary and fecal incontinence) and the respective advantages and the limits of the various imaging methods are detailed. Morphological and dynamic imaging are essential complementary tools to the physical examination, especially when a precise anatomic assessment is required to understand the functional complaint or when a reintervention is needed.
Progrès en Urologie 12/2009; 19(13):953-69. · 0.58 Impact Factor
