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We report an exceptional case of para-cervical pregnancy. Ultrasonography enabled accurate diagnosis after explorative laparoscopy. Treatment was conservative involving methotrexate and surgical ablation of the pregnancy by vaginal approach with a successful outcome.
The prolapse of vaginal stub occurs in about 4% of hysterectomised patients. Suspension of vaginal stub on the ligamentum sacrospinale dextrum is an effective method of the surgical management. The vaginal approach puts increased demands on handiness and orientation in the operation field. Using a proper operation technique and perfect knowledge of the anatomic situation in fossa ischiorectalis can minimize the increased risk of bleeding during the fixation, which results from frequent and varied anastomoses of pelvic vessels. The authors measured several parameters on the group of pelvic girdles of 32 females and found following results: the distance between the base and the apex of spina ischiadica (17.1 mm); the distance between spina ischiadica and the lateral margin of the os sacrum in the axis of central fibres of ligamentum sacrospinale (29.8 mm); the length of axial fibres of ligamentum sacrospinale (37.2 mm); the longest (11.2 mm) and the shortest (1.3 mm) diameter of 15 mm from the top of spina ischiadica. In this site the thickness of muscular layer of musculus coccygeus (3.2 mm) has also been measured. The anatomic study can facilitate the introduction and implementation of more complex surgical techniques.
The uterine and vaginal descent create multidisciplinary issue. Its consequences interfere in gynaecology, urology, geriatrics, general medicine and psychiatry. Collateral symptomatology, pathology of the anatomy, diagnostics, both conservative therapy and surgery are discussed. The author mentions the abdominal and vaginal approach, being most experienced with the latter. Prevention is seen shortening of the labour stress, reduction of chronic elevation of the intraabdominal pressure and use of hormonal replacement therapy in the menopause.
Many women with cerebrospinal fluid shunts are now reaching reproductive age. Clinical management of pregnant patients with hydrocephalus should include preconception counseling and CT scan or MRI. A family pedigree should also be established for counseling on the risk of recurrence of the woman's condition or another neural tube defect. Electrophoresis of acetylcholinesterase in the amniotic fluid can provide the diagnosis of open neural tube defect between 13 and 24 weeks gestation. Shunt malfunction may occur during pregnancy in 50 % of cases. Management requires well-planned, a combined neurosurgical and obstetrical approach. Vaginal delivery is possible in asymptomatic mothers. Cesarean section is recommended for neurologically unstable patients. Prophylactic antibiotics are recommended for labor and delivery to avoid shunt infection. Epidural analgesia is contraindicated in patients with intracranial hypertension. Some complications of complementary treatment for cerebral tumors in childhood are briefly reported.
PURPOSE: To reaffirm the role of MRI in the assessment of the M#159;llerian duct anomalies (MDAs). MATERIAL AND METHODS: Between November 1997 and April 2001, 22 patients, age range 18-40 years (mean 29 years) were investigated with MRI and US. The MRI study was performed with a 0,5 Tesla imager (Vectra, GE Medical System) with body-coil; neither oral nor intravenous contrast was used. We obtained SE T1-weighted, fast STIR with fat suppression and FSE T2-weighted sequences. Sagittal, paracoronal and paraxial images were acquired. The paraxial images were obtained to produce true coronal images of the uterus. In evaluating MDAs, imaging the uterus in its true coronal plane is essential to assess the external fundal contour. US examination was performed with an HDI 3000, ATL, using the trans-vaginal approach. The MDAs were subdivided according to the Buttram and Gibbons classification. RESULTS: There were 22 cases of laparoscopic and hysteroscopic proved anomalies; MRI allowed correct diagnosis of 21 uterine anomalies (accuracy, 95%) whereas U.S. was correct in 20 of 22 cases (accuracy, 92%). The MRI was excellent in depicting the uterine morphology in one case of unicornuate uterus with rudimentary horn non-comunicating with the main cavity and distended by hematometra and associated hematosalpinx. Further-more evaluating composition, thickness and extension of the uterine septum and aspect of the fundal contour, MRI allowed to differentiate definitively between bicornuate uterus and septate uterus. This is a very important distinction to do because it significantly affects patient treatment: a septate uterus requires hysteroscopic septectomy, while a bicornuate uterus does not requires surgical treatment. CONCLUSIONS: Given its characteristics, MRI is a very accurate imaging modality in uterine evaluation and contributes significantly to treatment planning. Although ultrasonography remains the modality of choice for the initial study of patients who are suspected of having a MDAs, we propose, in accordance with many authors in the literature, to reserve MRI imaging for patients with a technically inadequate or indeterminate ultrasound examination.
OBJECTIVE: To report our first cases of laparoscopic sacropexy and assess the feasibility and short-term complications. METHODS: We retrospectively studied 77 laparoscopic sacral colpopexies performed from June 1996 to May 1998. Suspension was reinforced with 2 strips of synthetic mesh. Five patients had previously undergone hysterectomy, and 4 others had experienced failure of surgery for prolapse of the uterus. RESULTS: Laparoscopy was performed in 83 women with symptomatic prolapse of the uterus. Six cases required conversion to laparotomy because of technical difficulties. All of the remaining 77 patients underwent laparoscopic sacropexy that included anterior and posterior mesh reinforcement. Subtotal laparoscopic hysterectomy was performed in 60 cases, laparoscopic Burch colposuspension in 74, and levator myorrhaphy via a vaginal approach in 55. Operative time decreased from 292 to 180 minutes as experience was gained. The main operative complications were 1 rectal and 2 bladder injuries. Three patients required reoperations for hematoma or hemorrhage. One patient complained of chronic inflammation of the cervix, and another experienced rejection of the posterior mesh 6 months after the operation. Mean follow-up was 343 days. Three other patients required reoperation, 1 for a third-degree cystocele and 2 for recurrent stress incontinence. CONCLUSION: Laparoscopic sacrocolpopexy is feasible. Operative time and postoperative complications are related to the surgeon's experience but remain comparable to those noted in laparotomy. Long-term assessment is required to confirm the results of this procedure.
Acute puerperal inversion is both rare and serious (1/20000 deliveries in France) and may lead to significant morbidity and mortality. Outcome depends on the degree of uterine bleeding and the presence or not of a state of shock. Acute puerperal inversion occurs at the time of placental delivery. Four stages are usually described by degree of exteriorization of the uterus. The diagnosis is essentially clinical. The predisposing factors are hypotonic uterus, fundal implantation of the placenta and placental acretas. 60% of all cases are caused by precipitous manoeuvres including traction on the cord or improper fundal pressure. Once a diagnosis is made immediate measures must be undertaken to assure clinical stability of the mother. Manuel reinversion of the uterus must be done quickly to avoid a cervical stricture that may form within thirty minutes of the inversion making successful manipulation very difficult. Failure or reoccurrence requires surgical treatment either by abdominal or vaginal approach. We report on two cases: one of complete inversion leading to a hysterectomy in order to control bleeding and a second case of incomplete inversion where repositioning was successful.
A rare case of uterine inversion immediately following delivery is reported. The uterus was successfully repositioned by a combined abdominal and vaginal approach.
A preliminary report is given of a new laparoscopic sterilization technique utilizing silicone rubber rings. A description of the laparoscopic silicone ring applicator and its operative utilization is provided. This technique eliminates the need for thermoenergy to insure tubal destruction and thus removes the cause of intestinal burns. The potential for successful future recannulization procedures should be greater with this procedure. This operation can be performed with a single or double puncture technique; in addition, it can be performed with a suprapubic or vaginal approach. Three hundred one cases have been completed without incurring major problems. No statement can be made at this time about the incidence of failure.
Sterilisation by laparoscopic surgical interruption or occlusion of the Fallopian tubes is briefly reviewed. Fourteen cases of an experimental technique for reversible sterilisation by the insertion, either laparoscopically, at laparotomy, or by the vaginal approach, of a Silastic rod into each oviduct, are described.
OBJECTIVES: We report one case of malakoplakia within a female urethral diverticulum. METHODS: 33-year-old patient who consulted for an asymptomatic vaginal tumor. Physical examination, blood and urine analysis and microbiology tests, as well as urethrocystoscopy and intravenous pyelogram were performed. With the diagnosis of urethral diverticulum we undertook surgical excision through a vaginal approach. RESULTS: Pathology revealed the typical characteristics of malakoplakia within the diverticular lumen. CONCLUSIONS: Malakoplakia is an infrequent inflammatory disease which involves the urinary tract in most cases. Urethra location is exceptional.
OBJECTIVES: To evaluate the efficacy and safety of a porcine biomaterial (Pelvicol) in the transvaginal surgical treatment of urogenital prolapse. MATERIAL AND METHOD: Prospective study from June 2001 to February 2004 based on 132 patients with a mean age of 67.6 +/- 9.89 years presenting major urogenital prolapse: 132 cystoceles and 84 rectoceles with 100% and 63.4% of grade 2 or 3, respectively. Patients were evaluated by questionnaire and clinical examination at 1 month, 6 months, 12 months and 24 months after the operation. Two hundred and sixteen Pelvicol implants were inserted via a vaginal approach: 132 anterior implants and 84 posterior implants. RESULTS: The mean follow-up was 21 months [range: 6-24]. No intraoperative complication was observed. The postoperative complication rate was 11.3% (15/132) including 1 prosthetic exposure with a favourable outcome. After 6 months, 1 recurrence of cystoceles and 1 recurrence of rectoceles were found in 132 patients. Out of the 117 patients followed up for 12 months, 6 presented with grade 2 cystoceles and 1 grade 2 rectoceles. After 24 months, out of the 107 patients evaluated, 18 cystoceles and 9 rectoceles of grade 2 or 3 were found. Globally, 83.1% of patients did not present with grade 2 or 3 recurrences after 24 months. Safety was considered to be good with 10% of moderate pelvic pain and 6% of de novo dyspareunia at 12 months. The overall satisfaction rate was 94%. CONCLUSION: These preliminary results demonstrate an efficacy of 83.1% at 24 months and the good safety of Pelvicol in the transvaginal surgical treatment of urogenital prolapse.
Pelvic floor disorders can involve all three parts of the pelvic floor, and must be managed holistically. They are often associated with one another, because they all involve an imbalance between counterbalancing forces, namely abdominal pressure on the one hand and mooring forces on the other hand. The mooring forces consist of 1) the visceral ligaments, which are fibrous cellular condensations around vessels and nerves, connecting the pelvic wall to the organs; 2) the endopelvic fascia; and 3) the pelvic muscles, including the levator ani. The physical examination must be both functional and anatomical, in order to detect obvious and occult disorders of the three parts of the pelvic floor. When physical examination is inadequate, standard radiography or MRI may be used. Radiographic explorations include colpocystography and defecography. The first is carried out in the standing position with a "blocked" perineum, and the second is performed in the defecation position with a "relaxed" perineum. Treatment must take into account dysfunctions, incontinence, and ptosis of the three parts. The author discusses the various examinations and treatments (by the abdominal or vaginal approach), based on published data and personal experience. The choice of treatment always depends on the patient's age, anatomical defects and functional disorders, and the surgeon's expertise
Döppler study of the uterine arteries investigates the utero-placental vascular bed. It can be used to identify a population at risk of vascular complications, in particular retroplacental hematoma. This type of study is indicated when there is a history of a vascular problem during pregnancy, as well as following the onset during pregnancy of hypertension, pre-eclampsia, delayed intrauterine growth or thrombocytopenia. The measurement technique avoids neighbouring vessels. An abdominal or vaginal approach may be used. The quality of the signal recorded and compliance with practical technical aspects enable long term prediction of the course of the pregnancy and the organisation of appropriate obstetric monitoring.
The authors review 903 cases of vesicovaginal fistulae, either simple or complicated by ureteral destruction, which were gathered over 21 years. They firstly sum up their classification for the various types of fistulae and/or ureteral destruction. This classification is used as a base for the indications of the various methods of treatment. In uncomplicated vesicovaginal fistulae, healing is obtained in 96.8% of all cases, most often through a vaginal approach. Radiation and repeated recurrence account for most failures. Out of the 82 cases of ureteral destruction, only degrees I, II and III are amenable to reconstruction. This is associated to normal continence in 56% of all cases, owing to the systematic use of autosphincterotomy, for which the technique is described in this article. Whether complicated or not, vesicovaginal fistulae must be treated by an experienced specialist, as experience only guarantees that the communication will be closed and normal continence restored.
Since 1975 a total of 55 patients with vesicovaginal fistulas have undergone surgery at the Clinic of Urology, University of Saarland, Homburg/Saar. A majority (55%) of the cases were complicated. In 9 cases supravesical urinary diversion was necessary. Successful closure of the fistula was achieved in 45 patients (81.8%); only in one case is the fistula still present. In 5 patients with uncomplicated fistulas successful closure was accomplished by a vaginal approach. In the presence of complications, e.g., previous radiotherapy or accompanying lesions of the ureter or rectum, a transvesical/transabdominal approach was preferred; surgery was successful in 93.3% of such cases.
The technical details are described for preparing and carrying out plasty of the ventral medial portion of the elevator ani. These are essential for a successful outcome of this stage of Lahodny's procedure for the surgical treatment of female urinary incontinence and descensus vaginae using an exclusively vaginal approach.
Description of a new technique for urethral support which complies with the usual criteria for the efficacy of a surgical cure for stress incontinence without having any of its disadvantages. Presentation of the results, postoperative complications and of the potential role of endovaginal echography in preoperative assessment and follow up. The method can be characterized by: its safety, thanks to the vaginal approach across an operative field the size of a postage stamp, ensuring an uncomplicated postoperative period and a short stay in hospital; its accuracy in suburethral support provided by a strip of expanded polytetrafluoroethylene (Gore-tex soft tissue patch), 30 mm by 10 mm, fixed at the ends to the public insertion of the pubococcygeal tract of the levator muscles, and by its median part to the vesicourethral junction: it is of unrivalled precision, thanks to the peroperative use of an urethrometer which is introduced into the urethra to a certain determined length, either by the application of the formula: urethral length = functional length + 8 mm or, better, from a knowledge of the anatomical length measured between the meatus and the origin of the sphincteral zone during prior endovaginal echography; its efficacy, since the results are stable over time and are obtained without dysuria. These characteristics should make it a first line treatment in the therapeutic arsenal for stress incontinence.