Comparison of urethral sling surgery and non-ablative vaginal Erbium:YAG laser treatment in 327 patients with stress urinary incontinence: a case-matching analysis

Efficacy and Safety of Combination Therapy With Vaginal and Urethral Erbium-Doped Yttrium-Aluminum-Garnet (Er:YAG) Laser for Overactive Bladder With Urinary Incontinence

OBJECTIVE

This retrospective cohort study with propensity score (PS) matching aimed to evaluate the efficacy and safety of a combination therapy with vaginal and urethral erbium:yttrium aluminum garnet laser (VEL+UEL) (SP Dynamis; Fotona d.o.o., Ljubljana, Slovenia) in the treatment of overactive bladder with urinary incontinence (OAB-wet).

METHODS

The study included female OAB-wet patients aged 65 and above who were already taking OAB medication. Data obtained from electronic medical records were subjected to propensity score matching. All patients received instructions on pelvic floor exercises and were prescribed an appropriate dose of OAB medication. The VEL+UEL group (n=30) underwent three monthly laser sessions, while the control group (n=30) did not receive the treatment. Clinical outcomes were evaluated using the Overactive Bladder Symptom Score (OABSS), International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), three-day urination diary, and Vaginal Health Index Score (VHIS). Medication usage and adverse events were also assessed. Statistical analysis and R code were performed using the AI chatbot GPT-4.0.

RESULTS

The VEL+UEL group showed significant improvements in OABSS score, ICIQ-SF score, voided volume, daytime frequency, nocturia, and VHIS after 12 months of treatment (p<0.001). Notably, 13.3% of patients transitioned from OAB-wet to OAB-dry. In contrast, the control group did not exhibit significant changes. Medication use was significantly reduced in the VEL+UEL group compared to the control group (p<0.001). No long-term side effects were reported.

CONCLUSION

Combination therapy with VEL+UEL demonstrated efficacy and safety in the treatment of OAB-wet. Improvements in OAB symptoms, voided volume, frequency, nocturia, and vaginal health were observed, with a subset of patients transitioning to OAB-dry. VEL+UEL therapy offers a potential treatment option for OAB-wet, reducing medication use and improving patient outcomes. Further research is warranted to investigate the mechanism, long-term effects, safety, and cost-effectiveness of VEL+UEL therapy.

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.

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

OBJECTIVE

To evaluate the efficacy and safety of non-ablative vaginal Er:YAG laser device in stress urinary incontinence (SUI) treatment.

METHODS

We conducted a multicenter blinded randomized sham-controlled trial in which women with urodynamic SUI were randomization to active arm using Er:YAG laser therapy, and sham arm using sham handpiece. Patients received two treatments 1 month apart. The primary outcomes measure was 1 h pad weight test measured at 6 months. Secondary outcomes were durability of treatment success at 12 months, and questionnaires for assessment of SUI severity (ICIQ-UI SF), sexual function (PISQ-12) and HRQoL (KHQ), and incidence and severity of device related adverse events and pain (VAS).

RESULTS

A total of 110 participants with SUI were recruited; 73 in the active arm and 37 in the sham arm. Two participants were excluded; one was assigned the wrong treatment and one withdrew their consent. Treatment success was observed in 36% of the sham arm and 59% of the active arm; in the latter, odds of achieving treatment success were more than three-fold higher (OR 3.63, 95% CI: 1.3-11.2, P = 0.02). HRQoL by KHQ showed significant improvement in the active versus the sham arm (OR 0.36, 95% CI: 0.15-0.87, P = 0.003). Similarly, subjective patient assessment of general and sexual function improvement with PISQ-12 and PGI-I showed superior effect over sham (OR 2.8, 95% CI: 1.2-7.0, P = 0.02 and OR 0.13, 95% CI: 0.05-0.36, P < 0.001, respectively).

CONCLUSION

Non-ablative vaginal Er:YAG laser therapy significantly improves SUI symptoms versus sham treatment. Er:YAG laser therapy should be considered as a non-surgical treatment option for SUI patients.

Management of mixed urinary incontinence: IUGA committee opinion

INTRODUCTION AND HYPOTHESIS

Mixed urinary incontinence (MUI) is defined by the International Urogynecology Association (IUGA) and International Continence Society as the complaint of involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing or coughing. It therefore implies the coexistence of both stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). MUI is a heterogeneous diagnosis that requires an assessment of its individual components of SUI and UUI. Management requires an individualised approach to the symptom components. The aim of this review is to identify the assessment/investigations and management options for MUI.

METHODS

A working subcommittee from the IUGA Research & Development (R&D) Committee was created and volunteers invited from the IUGA membership. A literature review was performed to provide guidance focused on the recommended assessment and management of MUI. The document was then evaluated by the entire IUGA R&D Committee and IUGA Board of Directors and revisions made. The final document represents the IUGA R&D Committee Opinion.

RESULTS

The R&D Committee MUI opinion paper provides guidance on the assessment and management of women with MUI and summarises the evidence-based recommendations.

CONCLUSIONS

Mixed urinary incontinence is a complex problem and successful management requires alleviation of both the stress and urge components. Care should be individualised based on patient preferences. Further research is needed to guide patients in setting goals and to determine which component of MUI to treat first. The evidence for many of the surgical/procedural treatment options for MUI are limited and needs to be explored in more detail.

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.

SUI in postmenopausal women: advantages of an intraurethral + intravaginal Er:YAG laser

OBJECTIVE

This study aimed to compare the efficacy of concomitant application of an intraurethral (IU) + intravaginal (IV) non-ablative Erbium (Er):YAG laser with IV application in improving the symptoms of stress urinary incontinence (SUI) in women.

METHODS

This observational retrospective cohort study included 122 patients with SUI, 60 women in the IU + IV laser arm and 62 in the IV laser arm. The primary outcome was the International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form score at entry and at 3, 6 and 12 months from baseline.

RESULTS

Demographic characteristics were comparable in both arms. Significant improvement in SUI symptoms was seen 3 months after the intervention and was sustained until the end of month 12 in both arms. The women who had severe SUI symptoms initially showed greater improvement. A higher number of women who initially had mild to moderate SUI symptoms were dry after treatment. Patients treated with IU + IV Er:YAG laser showed significant improvement in SUI symptoms compared to IV laser only, especially at postmenopausal state (p = 0.003).

CONCLUSIONS

The Er:YAG laser appears to be an efficient treatment method for SUI. Concomitant application of an IU + IV Er:YAG laser is more effective in relieving SUI symptoms at postmenopausal state.

Efficacy and safety of intraurethral Erbium:YAG laser treatment in women with stress urinary incontinence following failed intravaginal laser therapy: a retrospective study

Urinary incontinence (UI) is a prevalent condition affecting 25-45% of women and is linked to factors such as menopause, parity, high body mass index, and radical pelvic surgery. Among the three types of UI, stress incontinence (SUI) is the most common, accounting for almost 50% of cases, followed by urgency and overflow incontinence. UI has been found to be associated with reduced quality of life and mental stress. Non-invasive laser treatment is the safest and most effective option for managing SUI, with intraurethral Erbium SMOOTHTM laser treatment holding promise for patients experiencing SUI even after undergoing previous failed intravaginal Erbium:YAG laser treatment. The study recruited 93 female patients with mild to moderate SUI who had received two courses of intravaginal Erbium:YAG laser between January 2015 and June 2018. Of these, 22 patients (23%) who continued to experience SUI after a four-week interval for a second intravaginal Erbium:YAG laser were selected for intraurethral laser treatment in January 2019. The efficacy of the treatment was evaluated by comparing the pre- and post-treatment ICIQ-UI SF score. The urethral length was measured before the procedure. The main procedure involved delivering non-ablative laser energy using Erbium SMOOTHTM technology 2940 nm via a 4-mm cannula with personalized length and fluence was 1.5 J/cm. The 22 female patients with persistent SUI received intraurethral Erbium:YAG laser treatment. Their average age was 47.5 years, with an average of 2 parities and a mean body mass index of 20.97. All patients completed the ICIQ-SF questionnaire before and 3 months after the procedure. Of the patients, 77% reported improvement in symptoms, with 6 reporting strong improvement and 11 reporting improvement. The treatment was well-tolerated, with mild and transient adverse effects such as urinary infection in 1 patient (4.5%) and mild pain in 7 patients (31.8%). Intraurethral laser treatment may be helpful for Taiwanese women with persistent SUI after vaginal laser treatment. However, patients with prior pelvic surgery or pelvic organ prolapse history may limit the efficacy of intraurethral laser. Additional research is necessary to comprehensively investigate the advantages of intraurethral laser therapy. However, using intraurethral Erbium SMOOTHTM laser treatments to rejuvenate tissues and enhance structural support could be a promising avenue for managing stress urinary incontinence in Taiwanese women.

Comparison of Er:YAG and CO2 laser therapy for women with stress urinary incontinence

OBJECTIVE

To compare the effectiveness of Er:YAG and CO2 laser therapies for treating female stress urinary incontinence (SUI).

METHODS

This retrospective study included 139 women who were divided into four groups: group 1 received two therapy sessions with the Er:YAG laser, group 2 received two therapy sessions with the CO2 laser, group 3 received one therapy session with the Er:YAG laser, and group 4 received one therapy session with the CO2 laser. Patients completed three questionnaires to assess SUI symptom severity at baseline, 1 month, and 3 months after laser therapy.

RESULTS

Urinary incontinence symptoms significantly improved in groups 1 and 2 at both the 1- and 3-month follow-up evaluations compared to the baseline (p < 0.001). Symptoms improved after one therapy session in groups 3 and 4 at the 3-month follow-up (p < 0.001). The Er:YAG laser was more effective than the CO2 laser in improving SUI symptoms (Urogenital Distress Inventory 6 and Incontinence Impact Questionnaire 7) 3 months after treatment, regardless of the number of sessions. Both Er:YAG and CO2 laser therapies were found to be effective in reducing symptoms associated with an overactive bladder, as demonstrated by improvements in overactive bladder symptom scores. Two sessions of laser therapy were more effective than one.

CONCLUSION

Vaginal laser therapy could be an effective alternative treatment for mild to moderate SUI. The Er:YAG laser was more effective than CO2 laser therapy, with results lasting for at least 3 months. However, further large-scale, randomized, controlled trials are needed to confirm our findings.

Long-Term Improvement in Urinary Incontinence in an Elite Female Athlete Through the Laser Treatment: A Case Report

Stress urinary incontinence (SUI) is increasing in elite female athletes (EFAs), affecting competition results and quality of life. Pelvic floor muscle training (PFMT) is the first-line treatment for SUI, and surgery is generally performed when PFMT is insufficient. However, in EFA, there are few cases in which surgery is performed and fewer reports. Therefore, there is no known general treatment strategy for EFA with SUI. In our study, a 23-year-old track-and-field medalist with severe SUI was successfully treated with a vaginal and urethral erbium-doped yttrium aluminum garnet laser (VEL + UEL). After 12 treatments over one year, urinary incontinence decreased from 300 mL or more in the 400 m track run before treatment to 0 mL. She did not experience any more problems during running or competition. There was no recurrence of SUI for three years, and the urethral pressure profile examination confirmed improvement. MRIs showed that the left puborectalis muscle was absent from the first visit. The urethra was oval with an anteroposterior outer diameter of 10 mm and a transverse outer diameter of 13 mm before treatment. However, after three years of treatment, both anteroposterior and transverse diameters became circular, measuring 11 mm. Vaginal wall thickness increased from 8 to 12 mm at the center of the height of the urethra, making it possible to support the urethra, and pretreated adipose tissue space between the urethra and vagina disappeared. It was noted that the uneven and fragile urethra/vagina, the presence of adipose tissue space, and the absence of the left puborectalis muscle may have been the cause of the SUI. One year of VEL + UEL treatment resulted in long-term improvement of SUI; MRI showed changes in the urethra and vagina.

The evidence behind the use of LASER for genitourinary syndrome of menopause, vulvovaginal atrophy, urinary incontinence and lichen sclerosus: A state-of-the-art review

In recent years, LASER has been introduced as a minimally invasive treatment for a broad range of vaginal and vulvar symptoms and diseases. However, the efficacy and safety of vaginal and vulvar LASER has continuously been questioned. The aim of this study is to create an overview of the current literature and discuss the controversies within the use of LASER for genitourinary syndrome of menopause, vulvovaginal atrophy, urinary incontinence and lichen sclerosus. A search string was built in PubMed. The search was commenced on August 25, 2021 and closed on October 27, 2021. Two authors screened the studies in Covidence for inclusion according to the eligibility criteria in the protocol. The data were extracted from the studies and are reported in both text and tables. This review included 114 papers, of which 15 were randomized controlled trials (RCTs). The effect of LASER as a vaginal treatment was investigated for genitourinary syndrome of menopause in 36 studies (six RCTs), vulvovaginal atrophy in 34 studies (four RCTs) and urinary incontinence in 30 studies (two RCTs). Ten studies (three RCTs) investigated the effect of vulvar treatment for lichen sclerosus. Half of the included RCTs, irrespective of indication, did not find a significant difference in improvement in women treated with vaginal CO₂ or Er:YAG LASER compared with their respective controls. However, most non-comparative studies reported significant improvement after exposure to vaginal or vulvar LASER across all indications. Included studies generally had a short follow-up period and only a single RCT followed their participants for more than 6 months post treatment. Adverse events were reported as mild and transient and 99 studies including 51 094 patients provided information of no serious adverse events. In conclusion, this review found that the effect of vaginal and vulvar LASER decreases with higher study quality where potential biases have been eliminated. We therefore stress that all patients who are treated with vaginal or vulvar LASER should be carefully monitored and that LASER for those indications as a treatment should be kept on a research level until further high-quality evidence is available.