Indications de l’abord vaginal en chirurgie urologique: à propos de 30 cas

Buts: Presenter les variables epidemiologiques des patientes qui ont ete operees par voie vaginale, presenter les pathologies en cause et leur prise en charge. Patientes et methodes: Etude retrospective portant sur les patientes operees par voie vaginale entre novembre 2005 et novembre 2010 au Centre Hospitalier Regional de Louga pour des pathologies du bas appareil urogenital. Les renseignements concernant l’epidemiologie, les pathologies, le type d’intervention, les complications et resultats ont ete obtenus de l’exploitation des dossiers. Resultats: Trente (30) patientes etaient concernees par cette etude dont une operee a deux reprises. L’âge moyen etait de 42,17 ans (extremes de 20 ans a 70 ans) avec un ecart type de 15,06. La parite moyenne etait de 4,06 (extremes de 1 a 10). Il a ete note 22 cas de prolapsus genito-urinaire (PGU) tous exteriorises, 6 cas de fistule vesico-vaginale (FVV), un cas de metastase peri-uretrale d’un choriocarcinome gestationnel et un cas de diverticule uretral lithiasique. Les composantes des PGU etaient : cystoceles (21 cas dont 11 cas isoles), hysteroceles (11 cas) et rectoceles (3 cas). Trois cas de PGU etaient associes a une incontinence urinaire d’effort (IUE). Toutes les patientes ont ete operees sans pose de renfort prothetique. Les interventions ont consistees en : une triple intervention perineale (TIP) associee a une hysterectomie totale (11 cas dont 7 cas avec annexectomie bilaterale), une cure des cystoceles isolees avec colpoperineorraphie posterieure (11 cas). Les IUE (3 cas) ont ete corrigees selon Marion-Kelly. Toutes les FVV ont ete traitees par dedoublement puis fermeture en plan separe avec interposition d’un lambeau de Martius dans 5 cas. Le diverticule uretral a ete reseque totalement apres ablation des calculs. La metastase peri-uretrale du choriocarcinome gestationnel a egalement ete resequee et la perte de substance comblee par un lambeau de Martius. Il y a eu une transfusion dans 5 cas de TIP avec hysterectomie totale. Une breche vesico-vaginale a ete constatee apres hysterectomie et a ete resolue par simple drainage vesical. Aucun deces n’a ete constate. Le taux de satisfaction des patientes etait de 86,66% avec un recul de 6 mois. Nous avons enregistre un echec et deux patientes ont ete perdues de vue. Mots Cles:  Prolapsus genital; Fistule vesico-vaginale; Incontinence urinaire; Chirurgie urologique; Chirurgie vaginale English Title:  Indications of urological surgery by vagina route: A series of 30 cases English Abstract Objectives: To report the epidemiological features of patients operated by vaginal route, the patients’ pathologies and management. Patients and methods: From November 2005 to November 2010 in the department of Urology of the regional hospital center of Louga, all the patients who have been operated by vaginal route for genito urinary disease were included in this study. All data were obtained by review of medical records and registers. Results: The study included 30 patients; one patient had two operations. The mean age was 42.17 years (range 20–70 years), SD 15.06. The mean parity was 4.06 (range 1–10). We noted 22 cases of external genito-urinary prolapse, 6 cases of vesico-vaginal fistula, one case of peri-urethral metastasis of gestational trophoblastic disease, one case of urethral diverticulum with calculi. The different constituents of genito-urinary prolapse were: cystoceles (21 cases, 11 of which were isolated), hysteroceles (11 cases) and rectoceles (3 cases). Three cases of genito-urinary prolapse were associated with stress urinary incontinence. All patients were treated without prosthesis placement. The procedures were: triple perineum operation with total hysterectomy (11 cases, 7 of which had annexectomy), repair of cystocele with posterior colpoperineorraphy (11 cases). Stress urinary incontinences (3 cases) was treated by Marion–Kelly technique. The vesico-vaginal fistulas were treated by splitting in two and closure the vesico-vaginal wall with interposition of Martius flap in five cases. The diverticulectomy was done for the urethral diverticulum. The peri-urethral metastasis of gestational trophoblastic disease was resected and the loss of substance repaired by using a Martius flap. Five patients who had triple perineum operation with total hysterectomy were transfused. A vesical injury observed was managed by vesical drainage. No mortality was noted. The satisfaction rate was 86.66%. We noted one failure and two patients were not seen during the follow period. Conclusion: The urological surgery by vaginal route is mainly practiced for genito-urinary prolapses in our institution. This surgery has many advantages concerning the cost, the morbidity and the convalescence. The question about using prosthesis reinforcement in certain cases, in certain countries makes that, the urological surgery without prosthesis will continue for many years. Keywords:  Genital prolapse; Vesico-vaginal fistula; Urinary incontinence; Urological surgery; Vaginal surgery