Vaginal erbium laser treatment for stress urinary incontinence: A multicenter randomized sham-controlled clinical trial

Hyaluronic acid and erbium laser for the treatment of genitourinary syndrome of menopause

OBJECTIVE

This study aimed to evaluate the effect of the vaginal erbium laser (VEL) in association with vaginal hyaluronic acid (HA) in postmenopausal women suffering from genitourinary syndrome of menopause (GSM).

METHODS

One hundred sexually active postmenopausal women were selected and divided into three groups using a block randomization method; 10 women declined to participate. The remaining women received three laser applications at 30-day intervals; 22 women dropped out for personal reasons or protocol violations. Group 1 (n = 25) received VEL treatment (XS Fotona Smooth®; Fotona, Slovenia) alone; Group 2 (n = 22) received daily vaginal HA tablets for 10 days after VEL treatment, followed by a twice a week administration during the follow-up period; and Group 3 (n = 21) received daily HA tablets for 10 days before the first VEL treatment and for 10 days after each laser application, followed by a twice a week administration for the follow-up period. Vaginal dryness and dyspareunia were assessed at the screening visit, before VEL treatment, after 1 and 3 months from the last laser treatment, using the visual analog scale. Data were analyzed using one-way analysis of variance and a linear mixed model for repeated measures. The post-hoc test for the interaction between time and treatment was performed using Bonferroni correction.

RESULTS

A significant (p < 0.001) improvement in both vaginal dryness and superficial dyspareunia was evident, with greater (p < 0.001) improvement in Group 2 and Group 3.

CONCLUSIONS

The results suggest that vaginal HA administration can improve the VEL effects on GSM in postmenopausal women.

Exploring the Impact of Non-Ablative Erbium Laser Therapy on Recurrent Vaginal Candidiasis

OBJECTIVES

To assess the effect of non-ablative Er:YAG laser therapy on the symptoms and microbiological conditions of women with recurrent vulvovaginal candidiasis (RVVC).

MATERIALS AND METHODS

One hundred and sixty-seven women (mean age 34.1 ± 8.57 years) participated in this cohort study. Women diagnosed with RVVC received four vaginal laser therapies within 4 months. At baseline, 3 months, and 9 months after the last laser therapy microbiological assessment, improvement of five bothersome symptoms related to vaginal infection (burning, itching, dyspareunia, dysuria, and abnormal discharge), and the safety of the laser therapy and overall patient satisfaction were assessed.

RESULTS

Non-ablative vaginal Er:YAG laser therapy resulted in improvements of all bothersome symptoms and was statistically significant at 3 and 9 months following the therapy. A complete resolution in symptoms (VAS = 0) was observed in 38%-74% of women, depending on the symptom. Nine months after therapy, the prevalence of Candida albicans dropped from 80% to 30%, and a complete elimination of pathogens was detected in 64% of the women. The laser therapy appeared to be effective in the elimination of non-albicans Candida species. A total of 86% of the patients reported being satisfied or very satisfied with the therapy. Only minor and transient adverse effects were recorded during the study.

CONCLUSION

Non-ablative vaginal Er:YAG laser therapy proved to be a promising treatment for RVVC in women. The effect was achieved by improving their vaginal health by lowering the load of pathogenic yeast and by promoting the restoration of a favorable environment for normal microflora.

Double-blind randomized controlled trial of Er: YAG vaginal laser to treat female stress urinary incontinence

BACKGROUND

Stress urinary incontinence affects approximately 40% of adult females and is often treated surgically. Minimally invasive vaginal laser therapy to treat stress urinary incontinence has become widely available, but the efficacy of this novel therapy is unclear.

OBJECTIVE

This study aimed to determine the efficacy of erbium-doped yttrium aluminum garnet laser as a therapy for stress urinary incontinence.

STUDY DESIGN

This was a double-blind randomized sham-controlled trial with 6-week and 6-month follow-ups at a single tertiary hospital setting with 144 adult female patients with symptomatic stress urinary incontinence. Each participant received 2 vaginal laser therapies 6 weeks apart, with patients randomized to either laser or sham. The primary outcome was patients' subjective reporting of no urinary incontinence at 6 months after treatment on question 3 of the International Consultation on Incontinence Questionnaire-Short Form. The secondary outcomes included objective measures of urine loss with 24-hour pad tests, 3 incontinence symptom questionnaires (Urogenital Distress Inventory-6, Incontinence Impact Questionnaire-7, and International Consultation on Incontinence Questionnaire-Short Form), 1 quality-of-life questionnaire (King's Health Questionnaire), and 1 sexual function questionnaire (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire).

RESULTS

Of 263 individuals approached, 76 of 144 individuals were randomized to the laser treatment group, and 68 of 144 individuals were randomized to the sham treatment group. There was no difference in the reported cure rate and the primary outcome at 6 months after treatment between the groups (laser treatment group: 0.0136; 95% confidence interval, 0.0006-0.0811; sham treatment group: 0.0000; 95% confidence interval, 0.0000-0.0666). Apart from a statistically significant difference noted at 6 weeks after treatment in 1 of 3 incontinence questionnaires and 3 of 9 domains of the quality-of-life questionnaire, there were no other significant differences in our subjective or objective measures between the 2 groups at 6 weeks and 6 months after treatment.

CONCLUSION

Er: YAG laser was no more effective than sham for curing or improving female stress urinary incontinence at 6 months.

European Board and College of Obstetrics and Gynaecology (EBCOG) position statement on the use of laser vaginal devices for treatment of genitourinary syndrome of menopause, vaginal laxity, pelvic organ prolapse and stress urinary incontinence

One in three women will experience pelvic floor disorders in her lifetime and nearly 60 percent of postmenopausal women are affected by vaginal dryness. Conservative management is recommended as first line treatment for pelvic organ prolapse and stress urinary incontinence. Also, vaginal estrogens are often prescribed for symptomatic vaginal atrophy. Lasers have been used in cosmetic industry for connective tissue remodeling and repair of skin. Their use in the last decade for treating genitourinary symptoms of menopause, pelvic organ prolapse and stress urinary incontinence has gained popularity but there is lack of robust evidence to support its use in routine practice. The European Board and College of Obstetrics and Gynaecology calls for high quality evidence with patient related outcome measures before adopting to routine clinical practice.

Navigating Treatment Choices for Stress and Urgency Urinary Incontinence Using Graph Theory in Discrete Mathematics

In this study, we propose a method for navigating the choice of treatment for stress urinary incontinence (SUI) and urgency urinary incontinence (UUI) using graph theory in discrete mathematics. Our previous study accumulated data from 150 patients who underwent tension-free vaginal tape (TVT), transobturator tape (TOT), and vaginal non-ablation Erbium YAG laser (VEL) surgeries between 2014 and 2016. Network diagrams were created using this data. The treatments TVT, TOT, and VEL, along with patient characteristics (1-hour pad test: 1-hrPadTest, Overactive Bladder Symptom Score: OABSS), were represented as nodes and edges in the network diagram. We then employed a heuristic function to select the optimal treatment method for the patients with SUI and UUI. This process enables medical professionals to easily navigate the data for patients with both SUI and UUI concerns by calculating the shortest path connecting the 1-hrPadTest and OABSS. These results, which are consistent with those of previous studies, suggest that VEL is the optimal treatment. Unlike previous studies that employed statistical knowledge that is challenging for patients to understand, our study aids patients in visually comprehending and developing a customized treatment plan. This approach introduces a novel perspective for clinical decision-making in the treatment of urinary incontinence. To the best of our knowledge, this is the first study to apply discrete mathematics to patient decision-making for urinary incontinence treatment.

The Treatment Selection for a 36-Year-Old Woman With Stress Urinary Incontinence Using a Discrete Mathematical Approach: A Case Report

This case report describes the treatment selection process for a 36-year-old woman with stress urinary incontinence (SUI) and an overactive bladder (OAB) who desired pregnancy. The patient had comorbidities of hypertension and type 2 diabetes, which required consideration to improve her quality of life and reproductive health. A recently developed decision support tool using a discrete mathematical approach was used to select a treatment method tailored to the patient's individual situation. The analysis determined that vaginal erbium laser (VEL) treatment (Renovalase SP Dynamis Fotona d.o.o, Ljubljana, Slovenia) was the most suitable for this patient. VEL treatment significantly improved both SUI and OAB and changing antihypertensive medication eliminated nocturia. This case suggests the potential application of graph theory in treatment selection for SUI patients.

Innovative decision making tools using discrete mathematics for stress urinary incontinence treatment

In this study, we applied graph theory to clinical decision-making for Stress Urinary Incontinence (SUI) treatment. Utilizing discrete mathematics, we developed a system to visually understand the shortest path to the desired treatment outcomes by considering various patient variables. Focusing on women aged 35-50, we examined the effectiveness of Tension-free Vaginal Tape (TVT) surgery and Vaginal Erbium Laser (VEL) treatment for over 15 years. The TVT group consisted of 102 patients who underwent surgery using either the Advantage Fit mid-urethral sling system (Boston Scientific Co., MA, USA) or the GYNECARE TVT retropubic system (Ethicon Inc., NJ, USA). The VEL group included 113 patients treated with a non-ablative Erbium: YAG laser (FotonaSmooth™ XS; Fotona d.o.o., Ljubljana, Slovenia), and there were 112 patients in the control group. We constructed a network diagram analyzing the correlations between health, demographic factors, treatment methods, and patient outcomes. By calculating the shortest path using heuristic functions, we identified significant correlations and treatment effects. This approach supports patient decision making by choosing between TVT and VEL treatments based on individual objectives. Our findings provide new insights into SUI treatment, highlighting the value of a data-driven personalized approach for clinical decision-making. This interdisciplinary study bridges the gap between mathematics and medicine, demonstrating the importance of a data-centric approach in clinical decisions.

The Potential of Non-ablative Erbium (YAG) Laser Treatment for Complications After Midurethral Sling Surgery: A Narrative Review

Midurethral sling (MUS) surgery, using tension-free vaginal tape and transobturator tape, has been widely adopted for the treatment of stress urinary incontinence (SUI). However, postoperative complications, including persistent urinary incontinence, mesh exposure, and pain, have become problematic, and surgical treatments for these complications face challenges, such as invasiveness, treatment-resistant cases, and recurrence. This review provides an overview of the current evidence regarding these complications and the potential of vaginal non-ablative erbium (YAG) laser (VEL) treatment as a minimally invasive option with low risk of complications. Studies have suggested the effectiveness of VEL treatment, performed using devices such as IncontiLase (SP Dynamis; Fotona d.o.o., Ljubljana, Slovenia), for persistent urinary incontinence after MUS surgery, pain following mesh removal, and asymptomatic mesh exposure. VEL treatment is expected to be a new treatment option for complications following MUS surgery; however, further large-scale comparative trials are required to verify its efficacy and safety and to establish criteria for its indications. Appropriate assessment of the indications and provision of sufficient information to patients is important when presenting VEL as a treatment option.

Current Treatment of Stress Urinary Incontinence by Bulking Agents and Laser Therapy-An Update

Stress urinary incontinence (SUI) affects around 20% of women. In addition to the established suburethral sling insertion, two less invasive approaches are of interest today: urethral bulking agents and vaginal laser therapy. This review discusses articles through December 2023 identified by a PubMed literature search using the keywords "incontinence" and "bulking" or "laser". Although the two approaches are less effective than sling insertions, there are specific conditions in which one or the other technique is more advantageous. Injecting bulking agents into the urethra only takes some minutes and works without general anesthesia. The method is particularly suited for elderly, frail, or obese patients with multiple comorbidities, but is also applicable for all patients and in combination with other therapies. Generally, the safety profile is good but differs between bulking materials. Two laser types-the Erbium:YAG laser with SMOOTH-mode and the fractional ablative CO2 laser-deliver heat into the tissue to induce tissue tightening and regeneration. Intravaginal laser therapy improves mild to moderate SUI, while studies describe how intraurethral laser therapy is also beneficial for severe SUI. Young women between childbirths, as well as postmenopausal women, may benefit from laser therapy. The method is safe, can be performed on an outpatient basis, and does not require any artificial material.

Mesh Extraction Surgery and Laser Treatment for Pain After Mid-Urethral Sling Surgery: A Case Series

Stress urinary incontinence (SUI) is the leakage of urine due to abdominal pressure. The primary surgical approach involves the insertion of a mid-urethral sling (MUS) with a mesh, which can occasionally lead to post-operative pain. To address complications, MUS removal is often necessary. We hypothesize that a non-ablative erbium:yttrium aluminum garnet (Er:YAG) laser combined with vagina (vaginal erbium laser (VEL)) and urethra (urethra erbium laser (UEL)) treatments could be a post-MUS removal option. A study involving laser treatment started in 2016 for women with recurrent SUI one year after MUS removal who were not affected by pelvic floor muscle exercises and who did not wish to have MUS reinsertion or urethral injection treatment. Five patients (mean age, 54.5 ± 9.35 years) were enrolled, all receiving laser therapy. The visual analog scale (VAS) was used to assess pain as a primary endpoint, and the one-hour pad test was performed for SUI as a secondary endpoint. The mean pain VAS score changed from 8.57 ± 0.69 to 2.29 ± 1.50 (p = 0.00002) after MUS removal. Furthermore, the VAS score was 0 (p = 0.0034) after VEL + UEL. SUI changed from 4.42 ± 2.9 g on the one-hour pad test during MUS insertion to 66.7 ± 39.0 (p = 0.005) after removal. However, after the VEL + UEL treatment, it was 3.71 ± 5.25 g (p = 0.0035). The pathological tissue collected from the five patients at the time of MUS removal surgery had vacuolization in the part where the artificial material was present in the specimen, with foreign-body giant cells proliferated around it. One year after the MUS removal, mucous membrane regeneration was poor, and tissue thickness was thin. One year after the VEL + UEL treatment, the tissue had normalized mucosa, and there was no inflammation. Our study suggests MUS extraction and VEL + UEL as viable options for treating MUS pain in women.