Incidence and risk factors for reoperation of surgically treated pelvic organ prolapse

Introduction and hypothesis  

The objective of our study was to estimate the incidence and to identify the risk factors for reoperation of surgically treated pelvic organ prolapse (POP).     

Lateral Incisional Hernia After Renal Transplantation: A Comparative Study

Background

Because of the lack of published data and the relative rarity of lateral incisional hernias (LIHs), especially after renal transplantation, mesh repair of LIH remains a challenge for surgeons. The aim of the present study was to evaluate the outcomes of LIH treated by mesh repair after renal transplantation.

Methods

All consecutive patients who had undergone LIH mesh repair after renal transplantation were compared with patients who had undergone LIH mesh repair without renal transplantation. Demographic data, incisional hernia characteristics, operative data, and postoperative outcomes were prospectively recorded. Early complications and recurrence rates were evaluated.

Results

Altogether, 112 patients were treated for LIH with mesh repair. Among these patients, 61 (54.4 %) underwent LIH after renal transplantation. The early complications were similar for the patients with and without renal transplantation (24.5 vs. 23.5 %, respectively; p = 0.896). The recurrence rates also were similar for the patients with and without renal transplantation (9.8 vs. 9.8 %, respectively; p = 1).

Conclusions

Mesh graft repair is feasible in patients with LIH after renal transplantation. Postoperative complications and recurrences were not more frequent in renal transplantation patients than in those without renal transplantation.     

Prognostic factors of reproductive outcome after myomectomy in infertile patients

The objective of this study was to identify the prognostic factors for conception after myomectomy carried out in cases of infertility. A total of 91 infertile patients presenting at least one subserous or intramural myoma measuring >2 cm underwent myomectomy. The characteristics of the patients, myomata and associated infertility factors were collected in a uniform and systematic way. A postal questionnaire was sent to patients. For each of the various factors studied, the specific cumulative probability of spontaneous intrauterine conception was estimated using the Kaplan-Meier method. Multiple regression analysis was then carried out using Cox's proportional hazards model. The cumulative probability of spontaneous intrauterine conception at 2 years follow-up was 44% (95% confidence interval: 32-56%). The cumulative probability of conception was less after removal of a posterior or intramural myoma, after a sutured hysterotomy, and when accompanied by a male factor, associated tubal or ovulation pathology. The cumulative probability of conception was greater after ablation of myomata responsible for menometrorrhagia. The size, deforming effect on the cavity and age played no role in our sample. Our results indirectly suggest that post myomectomy adhesions could have an adverse effect on fertility. Myomata responsible for menometrorrhagia are also the cause of infertility. In the presence of an associated male, tubal or ovulatory factor, the results were poor and it was not possible to determine if a myomectomy should be performed in these cases in order to enhance fertility.     

Recurrence of leiomyomata after myomectomy

Abdominal myomectomy (by laparotomy or by laparoscopy) enables all the myomata to be excised while maintaining reproductive function. The actual risk of recurrence after abdominal myomectomy is difficult to assess because of methodological problems. Studies using life-table analysis find a cumulative risk of clinically significant recurrence of approximately 10% at 5 years for myomectomy by laparotomy. This risk probably underestimates the true prevalence of myomata as assessed by systematic ultrasound investigation. After laparoscopic myomectomy there appears to be a greater risk of recurrence. In one third of cases, recurrence becomes the reason for a hysterectomy. The risk of recurrence increases when there is more than one myoma. The use of gonadotrophin-releasing hormone agonists preoperatively could increase the risk of recurrence. Persistence or recurrence of the myoma thus reduces the chances of conception or taking a pregnancy full term after the myomectomy. It is essential to obtain the most complete exeresis possible in order to reduce the risk of recurrence to a minimum. However, it is inevitable that small, undetectable nuclei will remain within the myometrium whatever approach is used (laparoscopy or laparotomy). It would be an advantage to know what the growth factors are and how to identify groups at high risk of recurrence so that the treatment strategies could be better adapted and appropriate prophylactic methods developed.     

Management of leiomyomata

Uterine myoma is the benign tumour with which the general publicis most familiar. Indeed, because it is extremely frequent andhas such an effect on women’s genital life, it is a subjectof preoccupation for public health. Although there was littlechange in conservative management for over a century after Atleedescribed the first myomectomy by laparotomy in 1844 (reportedin Brown et al., 1956), since the end of the 1970s several newtechniques have been proposed as alternatives to myomectomyby laparotomy: hysteroscopic myomectomy, laparoscopic myomectomy,myolysis, uterine artery embolization, and treatment with gonadotrophin-releasinghormone (GnRH) agonists. Renewed interest is also being shownin abstention from therapy. These new approaches are the subjectof considerable enthusiasm because they enable patients to betreated while keeping the constraints and sequelae of treatmentto a minimum. These minimally invasive therapies are in linewith the present attitude of ‘reduced therapy’ forthe management of myoma. Integration of these new techniquesinto everyday practice does raise certain questions, however. Firstly, many of the new techniques are still in the assessmentstage, which poses the problem of their efficiency and sideeffects compared with myomectomy via laparotomy. Given thatconservative treatment affects the whole reproductive life ofthe woman concerned, it is essential to have data on the longterm results with these techniques, especially with respectto fertility, subsequent pelvic adhesions and the outcome ofpregnancies after the treatment. Secondly, these new techniques are not being spread evenly amongthe centres, which results in a different scheme of managementdepending on where the patients consult. Moreover certain techniquessuch as laparoscopic myomectomy or uterine artery embolizationrequire skilled surgeons which raises the problem of trainingand regular practice. Another aspect concerns the need for specializedand expensive equipment for these new techniques (interventionalradiology, laparoscopic surgery equipment). Altogether thereis a very clear need to establish a ranking for the variousapproaches to conservative management of uterine leimyomataaccording to their cost, feasibility and facilities required. The third point is that the new possibilities afforded by theseminimally invasive techniques require the strategy for managementand indications to be modified. The decision for surgery affectsthe long-term future of reproductive function, with potentialbeneficial effects (cure of symptoms, improvement in fertility)together with risks (adhesions, synechia, uterine scars, ‘iatrogenichysterectomy’). At present the indications are foundedon empirical reasoning and common sense (large myomata, deformingthe cavity, etc) but the relationships between the anatomopathologicalcharacteristics of the myomata and the symptoms are still veryvague, in particular with respect to infertility and pain. Onthe other hand, renewed interest in abstention from therapyrequires a more thorough knowledge of the natural history ofthe disease, especially in the long term, in patients who havemyomata but receive no treatment. The prospects for the future of conservative management of uterineleimyomata will be governed inevitably by the contribution offundamental research. Our understanding of the processes leadingto tumorigenesis and growth of uterine myomata is still patchy.Recent epidemiological studies have identified some interestingleads, such as the protective role of tobacco, genetic, nutritional,and hormonal factors for which the physiopathology still needsto be clarified at molecular level. This type of research couldmodify profoundly the management of this pathology by allowingprevention or an early, non-invasive cure.     

Tubal causes of ectopic pregnancy

141 patients with tubal pregnancies underwent complete salpingectomy in the department of obstetrics and gynecology at Port Royal, Paris between January 1, 1977-January 31, 1984. Usually, a tubal pregnancy occurs in the affected tube. Ampullary pregnancy (88%) is the result, in 95% of the cases, of ampullary pathology. Isthmic pregnancy (12%) is probably due, in every case, to a pathology of the isthmus which is generally associated with ampullary disease. In these cases, too, chronic salpingitis is usually the reason while endometriosis is very rare. The high rate of reoccurrence after conservative surgery results from the high rate of initial tubal alterations. (author's modified)     

Experimental study of the permeability of the fallopian tubes in the rabbit after division of the isthmus and microsurgical anastomosis (author's transl)]

The poor results of traditional reconstructive surgery of the Fallopian tubes have led the authors to try the possibilities of microsurgery in tubal sterility. The experimental animal chosen was the rabbit owing to its similarities with the Fallopian tube in women. After division of the isthumus, the tube was repermeabilised with a 10.0 single nylon thread under the operating microscope. A series of 11 rabbits were then coupled one mont after the operation. The pregnancy rate was 55%. This figure was much better than those obtained in the literature by non-microsurgical technics. One may hope to improve the results further by less traumatic surgery, better asepsis, and better control of fertility.