A patient-reported outcome measure to identify occurrence and distress of post-surgery symptoms of WOMen with vulvAr Neoplasia (WOMAN-PRO) — A cross sectional study

Patient reported opioid usage following vulvar surgery in gynecologic oncology

Background

There remains a paucity of data for vulvar surgery outcomes in gynecologic oncology in the era of Enhanced Recovery After Surgery (ERAS) ®. As such, the primary objective is to assess the impact of patient and procedural factors on patient reported postoperative opioid usage following vulvar surgery. Secondary objective is to create a tailored opioid prescribing algorithm for this population.

Methods

A retrospective cohort study was performed of patients who underwent vulvar surgery for a gynecologic malignancy between 3/2019-7/2022. Covariates of interest included a history of risk factors for opioid usage, age, anatomic location of the vulvar resection, radicality of surgery, groin dissection, use of postoperative non-steroidal anti-inflammatory drugs (NSAIDs), and complications. Logistic regression models evaluated the effects that sociodemographic characteristics and procedural factors have on opioid usage. Linear regression models were created to determine prescribing guidelines.

Results

A total of 100 patients were included. Following surgery, 35 patients (35 %) were not sent home with an opioid prescription, 39 patients (39 %) reported using at least one opioid pill from their prescription, and 26 patients (26 %) reported not using any opioid pills from their prescription. In the regression models, patient age (p < 0.006) had a significant impact on opioid use, while all other factors did not. Contraindications to NSAIDs did not have a statistically significant impact (p = 0.1) but was deemed clinically meaningful and included in the final model. Proposed opioid prescribing guidelines were created.

Conclusion

In conclusion, most patients after vulvar surgery require little to no opioids. Identifiable preoperative factors can aid providers to manage postoperative pain while minimizing unnecessary opioid prescriptions.

Monitoring Patient-Reported Outcomes in Self-management of Postsurgical Symptoms in Oncology: A Scoping Review

BACKGROUND

Surgery is used widely for cancer treatment, and in most types, after discharge, patients usually report multiple symptoms, which, if not controlled, can put postoperative recovery at risk. Understanding which patient-reported outcomes (PROs) should be monitored could have a significant impact on reducing the symptom burden associated with cancer and its treatment by playing a pivotal role in developing symptom self-management plans and designing tailored approaches to optimize patients' symptom self-management behaviors.

OBJECTIVE

To map the PROs used for patients' postsurgical symptom self-management after hospital discharge following cancer surgery.

INTERVENTIONS/METHODS

Our scoping review process was guided by the steps for conducting scoping reviews recommended by the Joanna Briggs Institute.

RESULTS

The search identified 97 potentially relevant studies, with 27 articles meeting the inclusion criteria. The most frequently assessed and monitored PROs were problems with surgical wounds, more general physical symptoms, psychological functioning outcomes, and quality of life.

CONCLUSIONS

Our results showed an overall uniformity among the PROs selected to be monitored in surgical cancer patients after hospital discharge. Monitoring through electronic platforms is widely used and seems useful to self-manage symptoms and optimize the recovery of cancer patients after discharge following surgery.

IMPLICATIONS FOR PRACTICE

This study provides knowledge about PROs that can be applied in oncologic patients after surgery to self-report their symptoms following discharge.

From existential uncertainty to a new mindset promoting recovery: Exploring the development of uncertainty experience in women with vulvar neoplasia - A qualitative longitudinal study

BACKGROUND

Women with vulvar neoplasia continue to experience uncertainty up to six months post-surgery. Uncertainty in illness is considered a significant psychosocial stressor, that negatively influences symptom distress, self-management strategies and quality of life. According to the Reconceptualized Uncertainty in Illness Theory, the appraisal of uncertainty changes positively over time in chronic illness. We aimed at exploring whether and how the experience of uncertainty develops in women with vulvar neoplasia.

METHODS

We selected a purposive sample of seven women diagnosed with vulvar neoplasia in four Swiss and one Austrian women's clinic. By means of a qualitative longitudinal study, we conducted 30 individual interviews at five points of time during one year after diagnosis. We applied Saldaña's analytical questions for longitudinal qualitative research.

RESULTS

First, participants experienced uncertainty as an existential threat, then an inherent part of their illness, and finally a certainty. Women initially associated the existential threat with a high risk for suffering from severe health deteriorations. Participants that could reduce their individually assessed risk by adopting health promoting behaviors, accepted the remaining uncertainty. From now on they reframed uncertainty into a certainty. This new mindset was based on a belief of promoting recovery and reducing the risk of recurrence.

CONCLUSIONS

The long-lasting and oscillating nature of uncertainty should receive attention in supportive oncology care. Uncertainty concerning existential issues is of special importance since it can inhibit a positive development of uncertainty experience.

The Impact of Vulvar Cancer on Psychosocial and Sexual Functioning: A Literature Review

Simple Summary

The diagnostic and therapeutic pathway of vulvar cancer impacts severely on the psychosocial and psychosexual equilibrium of women affected by it. The current literature shows the presence of depressive and anxious symptoms in association with physical, psychological and behavioural alterations in sexuality as well as deterioration of partner relationship. The aim of this article is to highlight the difficulties and challenges faced by women diagnosed and treated for vulvar cancer to provide early recognition and appropriate assistance. By implementing an integrated care model, it should be possible to detect unmet needs and improve the quality of life of these women.

Abstract

Women who are diagnosed and treated for vulvar cancer are at higher risk of psychological distress, sexual dysfunction and dissatisfaction with partner relationships. The aim of this article is to provide a review of the psychological, relational and sexual issues experienced by women with vulvar cancer in order to highlight the importance of this issue and improve the quality of care offered to these patients. A review of the literature was performed using PubMed, CINAHL, PsycINFO, and the Cochrane Library. The results are presented as a narrative synthesis and highlight the massive impact of vulvar cancer: depressive and anxiety symptoms were more frequent in these women, and vulvar cancer may have a negative effect on sexuality from a physical, psychological and behavioural point of view. Factors that may negatively affect these women’s lives are shame, insecurity or difficulties in self-care and daily activities. This review highlights the psychosocial and psychosexual issues faced by women diagnosed and treated for vulvar cancer, although more studies are needed to better investigate this field of interest and to identify strategies to relieve their psychological distress. Care providers should implement an integrated care model to help women with vulvar cancer recognise and address their unmet needs.

Patient reported outcome measures among patients with vulvar cancer at various stages of treatment, recurrence, and survivorship

OBJECTIVE

Our goal was to pragmatically describe patient reported outcomes (PROs) in a typical clinic population of vulvar cancer patients, as prior studies of vulvar cancer PROs have examined clinical trial participants.

METHODS

A prospective PRO program was implemented in the Gynecologic Oncology clinic of a tertiary academic institution in January 2018. Vulvar cancer patients through September 2019 were administered the European Organization for the Research and Treatment of Cancer Quality of life Questionnaire, the Patient Reported Outcome Measurement Information System Instrumental and Emotional Support Scales, and the Functional Assessment of Cancer Therapy-Vulvar questionnaire. Binary logistic regressions were performed to determine adjusted odds ratios for adverse responses to individual questions by insurance, stage, age, time since diagnosis, recurrence, radiation, and surgical radicality.

RESULTS

Seventy vulvar cancer patients responded to PROs (85.4% response rate). Seventy-one percent were > 1 year since diagnosis, 61.4% had stage I disease, and 28.6% recurred. Publicly insured women had less support and worse quality of life (QOL, aOR 4.15, 95% CI 1.00-17.32, p = 0.05). Women who recurred noted more interference with social activities (aOR 4.45, 95% CI 1.28-15.41, p = 0.019) and poorer QOL (aOR 5.22 95% CI 1.51-18.10, p = 0.009). There were no major differences by surgical radicality. Those >1 year since diagnosis experienced less worry (aOR 0.17, 95% CI 0.04-0.63, p = 0.008).

CONCLUSIONS

Surgical radicality does not affect symptoms or QOL in vulvar cancer patients, whereas insurance, recurrence, and time since diagnosis do. This data can improve counseling and awareness of patient characteristics that would benefit from social services referral.

The effect of written information and counselling by an advanced practice nurse on resilience in women with vulvar neoplasia six months after surgical treatment and the influence of social support, recurrence, and age: a secondary analysis of a multicenter randomized controlled trial, WOMAN-PRO II

BACKGROUND

Women with vulvar neoplasia often complain about physical and psychological distress after surgical treatment. Lack of information and support can influence resilience. Whether an information-related intervention through an advanced practice nurse supports resilience and which other factors affect resilience in women with vulvar neoplasia has never been investigated.

METHODS

The aims of this study were (a) to analyse whether counselling based on the WOMAN-PRO II program causes a significant improvement in the resilience scores of women with vulvar neoplasia compared to written information and (b) to identify the potential predictors of resilience. A randomized controlled trial was conducted in women with vulvar neoplasia (n = 49) 6 months after surgical treatment in four Swiss hospitals and one Austrian hospital. Analyses of resilience and its predictors were performed using a linear mixed model.

RESULTS

Thirty-six women (intervention I, n = 8; intervention II, n = 28) completed the randomized controlled trial. In total, 13 women (26.5%) dropped out of the trial. The resilience score did not differ significantly between the two interventions three and six months after randomisation (p = 0.759). Age (b = .04, p = 0.001), social support (b = .28, p = 0.009), counselling time (b = .03, p = 0.018) and local recurrence (b = -.56, p = 0.009) were identified as significant predictors of resilience in the linear mixed model analyses.

CONCLUSION

The results indicate that the WOMAN-PRO II program as single intervention does not cause a significant change in the resilience scores of women with vulvar neoplasia 6 months after surgery. Predictors that promote or minimise resilience have been identified and should be considered when developing resilience programs for women with vulvar neoplasia. A repetition of the study with a larger sample size is recommended.

TRIAL REGISTRATION

The WOMAN-PRO II program was registered in ClinicalTrials.gov NCT01986725 on 18 November 2013.

Cancer-Related Distress: Revisiting the Utility of the National Comprehensive Cancer Network Distress Thermometer Problem List in Women With Gynecologic Cancers

PURPOSE

The Distress Thermometer (DT) includes a measure of cancer-related distress and a list of self-reported problems. This study evaluated the utility of the DT problem list in identifying concerns most associated with distress and poorer quality of life (QOL) in survivors of gynecologic cancer.

METHODS

Demographic, clinical, psychosocial functioning, and DT data were described among 355 women participating in a gynecologic cancer cohort. Problems from the DT list were ranked by prevalence, distress, and QOL. Logistic regression models explored factors associated with problems that were common (≥ 25% prevalence) and associated with distress and QOL.

RESULTS

The average age of participants was 59.9 years (standard deviation [SD], 10.8 years). Most participants were non-Hispanic white (97%) and had ovarian (44%) or uterine (42%) cancer. The mean DT score was 2.7 (SD, 2.7); participants reported a mean of 7.3 problems (SD, 5.9 problems). The most common problems were fatigue (53.6%), worry (49.9%), and tingling (46.3%); least common problems were childcare (2.1%), fevers (2.1%), and substance abuse (1.1%). Report of some common problems, including tingling, sleep, memory, skin issues, and appearance, was not associated with large differences in distress or QOL. In contrast, some rarer problems such as childcare, treatment decisions, eating, housing, nausea, and bathing/dressing were associated with worse distress or QOL. Younger age, lower income, and chemotherapy were risk factors across common problems that were associated with worse distress or QOL (fatigue, nervousness, sadness, fears, and pain).

CONCLUSION

The DT problem list did not easily identify concerns most associated with distress and low QOL in patients with gynecologic cancer. Adaptations that enable patients to report their most distressing concerns would enhance clinical utility of this commonly used tool.

["Alone with the taboo" - The social support experienced by women with vulvar neoplasia: a qualitative study]

"Alone with the taboo" - The social support experienced by women with vulvar neoplasia: a qualitative study Abstract.

BACKGROUND

Cancer of the vulva is a gynaecological disease often with relevant impact for these women's daily life. On top of the medical complications, psychological problems might arise as well, due to the impaired quality of life and the withdrawal from social life. We do not know whether and what type of support is given to these patients.

AIM

The qualitative study aimed at describing how the affected women experience the support they receive from their social environment from the time of the diagnosis to six months postoperatively.

METHODS

A qualitative design was used. In a secondary analysis, 20 transcribed interviews from the WOMN-PRO study were analysed by qualitative content analysis according to Mayring.

RESULTS

The findings from the study resulted in four main categories: having a serious disease shows how the patients experience the diagnosis as a shock and are confronted with questions of guilt and taboos. The category feel alone was strongly represented with features of not-speaking out, not looking at it and not-acting. Do it on your own features descriptions of the strategies the women use to get out of their loneliness. In experience help, it is shown that women who try to get in touch with their social environment usually receive support.

CONCLUSIONS

Patients have a high demand for information concerning the disease and its possible impacts on their daily life as well as emotional and practical support from their families / partners and especially from health professionals. We recommend designating someone who acts throughout the whole treatment process as a mediator and a person of trust.

Vulvar field resection based on ontogenetic cancer field theory for surgical treatment of vulvar carcinoma: a single-centre, single-group, prospective trial

BACKGROUND

The incidence of vulvar cancer is increasing, but surgical treatment-the current standard of care-often leads to unsatisfactory outcomes, especially in patients with node-positive disease. Preliminary results at our centre showed that locoregional spread of vulvar carcinoma occurs within tissue domains defined by stepwise embryonic and fetal development (ontogenetic cancer fields and associated lymph node regions). We propose that clinical translation of these insights into practice could improve outcomes of surgical treatment of vulvar cancer.

METHODS

We did a single-centre prospective trial at the University of Leipzig's Cancer Center. Eligible patients were aged 18 years or older, had ontogenetic stage 1-3b histologically proven primary carcinoma of the vulva, and had not undergone previous surgical or radiotherapy treatment for vulvar cancer or any other major perineal or pelvic disease. In view of staged morphogenesis of the vulva from the cloacal membrane endoderm at Carnegie stage 11 to adulthood, we defined the tissue domains of tumour spread according to the theory of ontogenetic cancer fields. On the basis of ontogenetic staging, patients were treated locally with partial, total, or extended vulvar field resection; regionally with therapeutic inguinopelvic lymph node dissection; and anatomical reconstruction without adjuvant radiotherapy. The primary endpoints were recurrence-free survival, disease-specific survival, and early postoperative complications. Analysis of tumour spread and early postoperative surgical complications was done by intention to treat (ie, all patients were included), whereas outcome analyses were done per protocol. This ongoing trial is registered with the German Clinical Trials Register, number DRKS00013358.

FINDINGS

Between March 1, 2009, and June 8, 2017, 97 consecutive patients were included in the study, of whom 94 were treated per protocol with vulvar field resection, therapeutic inguinopelvic lymph node dissection, and anatomical reconstruction without adjuvant radiotherapy. 46 patients had moderate or severe postoperative complications, especially infectious perineal and inguinal wound dehiscence. 3-year recurrence-free survival in all patients was 85·1% (95% CI 76·9-93·3), and 3-year disease-specific survival was 86·0% (78·2-93·8).

INTERPRETATION

Our results support the theory of ontogenetic cancer fields for vulvar carcinoma, accord with our previous findings in cervical cancer, and suggest the general applicability of the theory. Application of the concept of cancer field resection could improve outcomes in patients with vulvar carcinoma, but needs to be investigated further in multicentre randomised controlled trials.

FUNDING

Leipzig School of Radical Pelvic Surgery and Gynecologic Oncology Research Foundation.

Effectiveness, structure, and content of nurse counseling in gynecologic oncology: a systematic review

BACKGROUND

Gynecological pre-cancer and gynecological cancers are considerable diseases in women throughout the world. The disease and treatment lead to numerous biopsychosocial issues. To improve the outcomes of affected women, several counseling interventions have been tested thus far in nursing research. These interventions target different endpoints and are composed of various structural and content components. The purpose of this research was to systematically review the effectiveness of nurse counseling on any patient outcomes tested so far in gynecologic oncology before, during and after treatment and to explore structure and content components.

METHODS

Experimental, quasi-experimental, and pre-experimental studies assessing the effectiveness of nurse counseling in women with gynecological neoplasia were searched for in PubMed®, CINAHL®, PsychINFO®, Cochrane®, and EMBASE®. Reference lists were hand-searched and relevant authors were contacted. Moreover, the evidence level and methodological quality of the included studies were assessed. Afterwards, the effect of nurse counseling on each identified patient outcome was narratively analyzed. To identify the structural and content components of the included interventions, a structured content analysis was performed. Finally, it was determined which components were associated with favorable outcomes within the included studies.

RESULTS

Seven experimental and three pre-experimental studies, reporting the effects of 11 interventions on a total of 588 participants, were eligible. No study investigated women with pre-cancer. Three studies had a high, five a moderate, and two a low methodological quality. Positive effects were found on quality of life, symptoms, and healthcare utilization. Eight structural components and four content components composed of various sub-components were identified and linked to specific effects.

CONCLUSIONS

The current evidence base is fragmented and inconsistent. More well-designed, large-scale studies including women with pre-cancer are warranted. Most convincing evidence indicates that nurse counseling can improve symptom distress. Components associated with the most trustworthy effects include nurses with an academic education; repeated and individual consultations during and after active treatment; structured, tailored, interdisciplinary orientated, and theoretically based counseling concepts; specific materials; comprehensive symptom management; and utilization of healthcare services. Healthcare providers and researchers can use the findings of this review for the systematic development of nurse counseling in gynecologic oncology.

The impact of written information and counseling (WOMAN-PRO II Program) on symptom outcomes in women with vulvar neoplasia: A multicenter randomized controlled phase II study

OBJECTIVE

To determine whether written information and/or counseling based on the WOMAN-PRO II Program decreases symptom prevalence in women with vulvar neoplasia by a clinically relevant degree, and to explore the differences between the 2 interventions in symptom prevalence, symptom distress prevalence, and symptom experience.

METHODS

A multicenter randomized controlled parallel-group phase II trial with 2 interventions provided to patients after the initial diagnosis was performed in Austria and Switzerland. Women randomized to written information received a predefined set of leaflets concerning wound care and available healthcare services. Women allocated to counseling were additionally provided with 5 consultations by an Advanced Practice Nurse (APN) between the initial diagnosis and 6months post-surgery that focused on symptom management, utilization of healthcare services, and health-related decision-making. Symptom outcomes were simultaneously measured 5 times to the counseling time points.

RESULTS

A total of 49 women with vulvar neoplasia participated in the study. Symptom prevalence decreased in women with counseling by a clinically relevant degree, but not in women with written information. Sporadically, significant differences between the 2 interventions could be observed in individual items, but not in the total scales or subscales of the symptom outcomes.

CONCLUSIONS

The results indicate that counseling may reduce symptom prevalence in women with vulvar neoplasia by a clinically relevant extent. The observed group differences between the 2 interventions slightly favor counseling over written information. The results justify testing the benefit of counseling thoroughly in a comparative phase III trial.

Recommendations for symptom management in women with vulvar neoplasms after surgical treatment: An evidence-based guideline

PURPOSE

To develop an evidence-based guideline for nurses and other health care professionals involved in pre- and postsurgical care of women with vulvar cancer (VC) or vulvar intraepithelial neoplasia (VIN).

METHODS

This evidence-based guideline was developed according to six domains of the methodological framework AGREE II. Literature research with focus on cancer care, symptom management and self-management/counselling was conducted from April to August 2013 in the databases CINAHL, Cochrane Library, PsycINFO, PubMed as well as in 14 international guideline databases. Interdisciplinary experts (n = 14) were involved in the development of the guideline from December 2013 to January 2014. This guideline is currently tested in the WOMAN-PRO II RCT (Clinical Trial No: NCT01986725).

RESULTS

For the definition of recommendations, five guidelines, one meta-analysis, two systematic reviews and two randomized controlled trials were included. In total, 24 recommendations were formulated to answer 22 clinical questions based on patients' perspective and experts' opinion. Evidence ranged from 3.5 to 5 (3.5 = weak evidence and/or clinical relevance, 5 = best evidence and/or clinical relevance). The recommendations were subsumed under different themes regarding physical, psychological and psychosocial aspects.

CONCLUSIONS

The clinical practice guideline developed in this study firstly provides recommendations for symptom management issues focusing on self-management interventions for women with VC or VIN. As an interdisciplinary guideline it should be used in addition to the existing medical guideline in the German speaking context.

Perceived Health-Related Quality of Life in Women With Vulvar Neoplasia: A Cross Sectional Study

Objective

The aim of the study was to determine health-related quality of life (HRQoL) of women with surgically treated vulvar intraepithelial neoplasia (VIN) and vulvar cancer (VC) during the first week after hospital discharge. Further objectives were to investigate differences between women with VIN and VC as well as to examine whether correlations exist between women’s symptom experience and HRQoL.

Methods

This cross-sectional study was conducted in 8 hospitals in Germany and Switzerland. Women with VIN and VC rated HRQoL with the validated German Short-Form 36. Differences between HRQoL in women with VIN and VC were tested with Wilcoxon rank-sum score. The WOMen with vulvAr Neoplasia (WOMAN) - Patient reported Outcome (PRO) self-report instrument was used to measure women’s symptom experience. Correlations between symptoms and HRQoL were calculated using Spearman correlation coefficient.

Results

Women with VIN and VC (n = 65) reported lower HRQoL in physical aspects (Physical Component Summary [PCS], 34.9) than that in mental aspects (Mental Component Summary, 40.5). Women with VC had lower HRQoL than women with VIN, as manifested by significant differences concerning the dimensions of “physical functioning” and “role-physical.” “Difficulties in daily life” as a distressing symptom correlated with MCS and PCS. Wound-related symptoms correlated with PCS and psychosocial symptoms/issues with MCS.

Conclusions

Analysis showed that women with vulvar neoplasia reported lower HRQoL in the physical and mental dimensions 1 week after discharge than comparable studies referring to months or years after surgery. Health-related quality of life is influenced by physical impairment because physical symptoms are prevalent 1 week after discharge. Patient education should focus on symptom management in an early postsurgical phase to enhance women’s HRQoL.

Clinical application of sartorius tendon transposition during radical vulvectomy: a case control study of 58 cases at a single institution

Objective

The aim of this study was to investigate the clinical effects of sartorius tendon transposition versus sartorius transposition during bilateral inguinal lymphadenectomy of radical vulvectomy.

Methods

A total of 58 vulvar cancer patients who had surgery from May 2007 to October 2013, in which 30 patients received sartorius transposition and 28 patients received sartorius tendon transposition. All patients were matched by age, body mass index, stage, histology, and grade. Intraoperative variables and postoperative complications, recurrence, progression-free survival (PFS), and overall survival (OS) and postoperative life quality were compared and analyzed.

Results

No significant differences were found at median surgical times and amounts of bleeding (p=0.316 and p=0.249, respectively), neither at the incidences of groin cellulitis and lymphocele (p=0.673 and p=0.473, respectively), but the recovery times of the inguinal wounds were shorter (p=0.026) and the incidences of wound break and chronic lymphedema were significantly decreased in the tendon transposition group (p=0.012 and p=0.022, respectively). Postoperative quality of life in tendon transposition group was significantly improved as indicated by the EORTC QLQ-C30 questionnaire. Recurrences were similar (p=0.346) and no significant differences were found at PFS and OS (p=0.990 and p=0.683, respectively).

Conclusion

Compared to sartorius transposition, sartorius tendon transposition during inguinal lymphadenectomy led to improved patient recovery, reduced postoperative complications, and improved life quality without compromising the outcomes.

Surgical interventions for high-grade vulval intraepithelial neoplasia

BACKGROUND

This is an updated version of an original Cochrane review published in The Cochrane Library, 2011, Issue 1.Vulval intraepithelial neoplasia (VIN) is a pre-malignant condition of the vulval skin. This uncommon chronic skin condition of the vulva is associated with a high risk of recurrence and the potential to progress to vulval cancer. The condition is complicated by its multicentric and multifocal nature. The incidence of this condition appears to be rising, particularly in the younger age group. There is a lack of consensus on the optimal surgical treatment method. However, the rationale for the surgical treatment of VIN has been to treat the symptoms and exclude any underlying malignancy, with the continued aim of preserving the vulval anatomy and function. Repeated treatments affect local cosmesis and cause psychosexual morbidity, thus impacting he individual's quality of life.

OBJECTIVES

To evaluate the effectiveness and safety of surgical interventions in women with high-grade VIN.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group Trials Register and the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 11,2013 and MEDLINE and EMBASE up to December 2013. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies, and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared surgical interventions in adult women diagnosed with high-grade VIN.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias.

MAIN RESULTS

We identified one RCT, including 30 women, that met our inclusion criteria; this trial reported data on carbon dioxide (CO2) laser surgery versus cavitational ultrasonic surgical aspiration (CUSA). There were no statistically significant differences in the risks of disease recurrence after one year of follow-up, pain, scarring, dysuria or burning, adhesions, infection, abnormal discharge or eschar between women who underwent CO2 laser surgery and those who received CUSA. The trial lacked statistical power due to the small number of women in each group and the low number of observed events, but was at low risk of bias.

AUTHORS' CONCLUSIONS

The included trial lacked statistical power due to the small number of women in each group and the low number of observed events. The absence of reliable evidence regarding the effectiveness and safety of the two surgical techniques for the management of VIN therefore precludes any definitive guidance or recommendations for clinical practice.