Platelet-Rich Plasma as Adjuvant Therapy for Recurrent Vesicovaginal Fistula: A Prospective Case Series

Persistent ischiorectal fistula secondary to rectal extrusion of posterior vaginal mesh: Case report

INTRODUCTION AND HYPOTHESIS

Vaginal mesh has been used for years to try to improve the results of pelvic organ prolapse surgery, but current evidence does not confirm this improvement and instead describes serious and frequent adverse events.

CLINICAL CASE

64-year-old patient with rectal extrusion of posterior vaginal mesh placed 8 years earlier, and persistent left ischiorectal fistula refractory to surgery. She required 5 surgeries, carried out jointly between gynecology and general surgery, to solve, firstly, the bilateral perianal abscess secondary to extrusion of the posterior vaginal mesh into the rectum and then the persistent left ischiorectal fistula, despite the removal of the material prosthetic. Finally, the fistula was solved by injection of platelet-rich plasma.

CONCLUSIONS

Vaginal mesh complications often need a multidisciplinary approach, and treatment may require multiple approaches and more than one surgical procedure. In the case of a persistent fistula refractory to surgery, after removing the mesh, non-invasive regenerative therapies that promote vascular growth and tissue regeneration could be considered such as platelet-rich plasma.

Diagnostic and Therapeutic Challenges of Oligosymptomatic Vesicovaginal Fistula in the Complex Case of Endometriosis

Endometriosis is a complex condition causing surgical challenges, sometimes leading to urogynecological complications, the diagnosis and treatment of which are not always obvious. We present a case of a 46-year-old woman with a history of severe endometriosis and adenomyosis who developed an oligosymptomatic vesicovaginal fistula (VVF) as a complication of surgery. The patient's medical history included multiple surgeries for endometriosis, a cesarean section, and a laparoscopic hysterectomy. After the excision of the full-thickness infiltration of the urinary bladder, she experienced postoperative bowel obstruction treated by laparotomy. Subsequent urinary complications of bladder healing were eventually recognized as oligosymptomatic VVF. Symptoms of VVFs may vary, making a diagnosis challenging, especially when the lesion is narrow. Imaging techniques such as cystoscopy and cystography are helpful for diagnosis. The treatment options for VVFs range from surgical repair to conservative methods, like bladder catheterization, hormonal therapy, and platelet-rich plasma (PRP) injections, depending on the lesions' size and location. In this case, the patient's VVF was treated with PRP injections, a low-invasive method in urogynecology. PRP, known for its pleiotropic role, is increasingly used in medicine, including gynecology. The patient's fistula closed after 6 weeks from the PRP session, highlighting the potential of this conservative treatment modality.

Role of platelet-rich plasma in pelvic floor disorders: A systematic review

Background

Management for pelvic floor disorders needs to be improved. Platelet-rich plasma (PRP) offers an innovative treatment in general medical care to promote cell regeneration.

Objective

This review aims to investigate the role of PRP in pelvic floor disorders.

Materials and Methods

6 international databases were accessed using several keywords namely PubMed, Science Direct, Cochrane Library, ProQuest, Google Scholar, and Scopus. The inclusion criteria were articles written in English, published in 10-yr period from 2012 until 2022, and investigated the relevant topic. This systematic review followed PRISMA guideline.

Results

644 articles were found in several databases and 15 articles met the criteria. Management for pelvic floor disorders needs to be improved, but there are still many challenges, such as less effective treatments, risk of recurrence, and postoperative wound healing. PRP offers an innovative treatment in general medical care to promote cell regeneration. A total of 644 articles from the database were found, but 15 studies met the criteria. A total of 600 women with various pelvic floor disorders treated with PRP were analyzed. PRP positively impacts female sexual dysfunction, perineal trauma, vulvovaginal atrophy, stress urinary incontinence, vesicovaginal fistula, perineal rupture, and pelvic organ prolapse. Dosages, preparation techniques, injection techniques, and additive materials are varied. Most studies do not report side effects from the therapy, but the urinary disorder complaints must be paid attention to.

Conclusion

PRP can be used to manage pelvic floor disorders. Future studies should clarify and standardize the dose in each case and how to make PRP produce the best results.

Vesicovaginal Fistulas: Prevalence, Impact, and Management Challenges

Background and Objectives: Vesicovaginal fistulas (VVFs) are an abnormal communication between the vagina and bladder and the most common type of acquired genital fistulas. This review will address the prevalence, impact, and management challenges of VVFs. Materials and Methods: Epidemiologic studies examining VVFs are considered. In addition, publications addressing the treatment of VVFs are reviewed. Results: VVFs in developing countries are often caused by obstructed labor, while most VVFs in developed countries have iatrogenic causes, such as hysterectomy, radiation therapy, and infection. The reported prevalence of VVFs is approximately 1 in 1000 post-hysterectomy patients and 1 in 1000 deliveries. VVFs affect every aspect of quality of life, including physical, mental, social, and sexual aspects. Prevention of VVFs is essential. Early diagnosis is necessary to reduce morbidity. Nutrition, infection control, and malignancy detection are important considerations during evaluation and treatment. Conservative and surgical treatment options are available; however, these approaches should be customized to the individual patient. The success rate of combined conservative and surgical treatments exceeds 90%. Conclusions: VVFs are considered debilitating and devastating. However, they are preventable and treatable; key factors include the avoidance of prolonged labor, careful performance of gynecologic surgery, and early detection.

The Microcirculation of Vaginal Tissue in Women with Obstetric Vesicovaginal Fistula and Short-Term Effects of Surgical Repair on Microvascular Parameters

OBJECTIVES

The objective of the study was to better understand the extent of the ischemic trauma and the effects of surgical repair on the vaginal microcirculation in patients with obstetric vesicovaginal fistula (VVF).

DESIGN

In this observational study, we evaluated the vaginal microvasculature surrounding VVF using handheld vital microscopy (HVM) before, during, and 2 weeks after surgical VVF repair.

PARTICIPANTS

Seventeen women undergoing VVF repair were included in this study.

SETTING

The study was conducted in the Fistula Care Centre in Lilongwe, Malawi.

METHODS

We used HVM with incident dark-field imaging to non-invasively visualize the microvasculature of the vaginal tissue surrounding fistulas. The primary outcome was the presence of microvascular flow. Secondary outcomes included angioarchitecture, fistula closure (postoperative dye test), and urinary continence (pad weight test).

RESULTS

Microvascular flow was present before, during, and after surgical repair in, respectively, 83.8%, 83.9%, and 93.4% of obtained image sequences. The angioarchitecture was normal in 75.8% of the image sequences before surgery, 69.4% at fistula closure, and 89.1% two weeks after VVF repair. Fourteen (82.4%) patients had a closed fistula after surgical repair.

LIMITATIONS

The study was limited by the lack of a control group and the relatively small sample size.

CONCLUSION

Although the vaginal microcirculation in women with VVF is compromised, extensive ischemic damage is not observed in the tissue surrounding fistulas. This suggests significant regenerative capacity of the vaginal vasculature in young women, or less extensive ischemic damage than presumed. Following surgical repair, we observed improvement of microcirculatory flow and angioarchitecture, suggesting that surgery is a good option for patients with obstetric VVF.

A new conservative treatment approach to vesicovaginal fistula cases: a case report and mini-review of the literature

EINLEITUNG

Eine vesikovaginale Fistel (VVF) ist ein anormaler Weg zwischen der Blase und der Vagina, der es ermöglicht, dass Urin kontinuierlich unbeabsichtigt in die Vagina abfließt. Die Operation ist die am häufigsten bevorzugte Methode zur Behandlung von Frauen, jedoch wird die chirurgische Option für einige Patienten aufgrund der Patientennachfrage und der Kostenanalyse nicht gewählt. Außerdem kann nach einer chirurgischen VVF-Reparatur eine Restharninkontinenz beobachtet werden. In diesem Zustand werden konservative Behandlungsmethoden versucht. Der Erfolg dieser Methoden bleibt jedoch begrenzt. In diesem Sinne ist die Notwendigkeit für ein neues Behandlungsmodell entstanden.

FALLBERICHT

Wir haben einen neuen Ansatz getestet, einschließlich der Injektion von plättchenreichem Plasma in den Fistelgang, und es hat eine kürzere Erholungszeit von 10 Tagen bewirkt, wenn nur die Katheterisierung und die anticholinerge Anwendung berücksichtigt wurden.

SCHLUSSFOLGERUNG

Plättchenreiches Plasma kann vesikovaginale Fisteln behandeln, es hätte die Schließzeit verkürzen können und die Erfolgsrate der Operation erhöhen können, wenn es vor der Operation angewendet wird.

Application of platelet-rich plasma in spinal surgery

With the aging of the population and changes in lifestyle, the incidence of spine-related diseases is increasing, which has become a major global public health problem; this results in a huge economic burden on the family and society. Spinal diseases and complications can lead to loss of motor, sensory, and autonomic functions. Therefore, it is necessary to identify effective treatment strategies. Currently, the treatment of spine-related diseases includes conservative, surgical, and minimally invasive interventional therapies. However, these treatment methods have several drawbacks such as drug tolerance and dependence, adjacent spondylosis, secondary surgery, infection, nerve injury, dural rupture, nonunion, and pseudoarthrosis. Further, it is more challenging to promote the regeneration of the interstitial disc and restore its biomechanical properties. Therefore, clinicians urgently need to identify methods that can limit disease progression or cure diseases at the etiological level. Platelet-rich plasma (PRP), a platelet-rich form of plasma extracted from venous blood, is a blood-derived product. Alpha granules contain a large number of cytokines, such as platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), epidermal growth factor, platelet factor 4 (PF-4), insulin-like growth factor-1 (IGF-1), and transforming growth factor-β (TGF-β). These growth factors allow stem cell proliferation and angiogenesis, promote bone regeneration, improve the local microenvironment, and enhance tissue regeneration capacity and functional recovery. This review describes the application of PRP in the treatment of spine-related diseases and discusses the clinical application of PRP in spinal surgery.

Platelet-Rich Plasma: A Promising Regenerative Therapy in Gynecological Disorders

Platelet-rich plasma (PRP) could be understood as a special preparation of plasma in which the concentration of platelet is immensely high. This rationale for plasma use has been in the medical science for many years with plenty of success in various fields where it was inculcated, bringing dramatically favorable and better outcomes in terms of disease management and prognosis. PRP has been widely used in orthopedics from the very beginning, but in the past few years its use has been extended to other fields too, such as obstetrics and gynecology. From the very onset of the introduction of platelet-rich plasma in gynecology, there had been constant research being carried out all around the globe in order to scientifically prove and confirm its exact role in the management of gynecological problems. Regenerative medicine in gynecology was among the first areas where the platelet-rich plasma was implemented and has substantially given great results, which encouraged further extensive research to be carried out in other spectrums of gynecology. The implications of such great struggles ultimately gave way to evidence suggesting the importance of platelet-rich plasma in managing gynecological disorders like Asherman’s syndrome, urinary incontinence, genital fistulas, thin endometrium, etc. This review article collectively summarizes the various use of platelet-rich plasma in gynecology.

Treatment of bronchial anastomotic fistula using autologous platelet-rich plasma post lung transplantation

BACKGROUND

Bronchial anastomotic dehiscence is considered one of the most catastrophic early airway complications post-transplant. The presence of a partial dehiscence can also cause further complications such as a fistula between the bronchus and the pleural membrane. Platelet-rich plasma (PRP) is known to significantly enhance the healing process and is being used in the treatment of various conditions, however, so far, there are no reports of the use of PRP in the treatment of bronchial anastomotic dehiscence fistula.

CASE PRESENTATION

We present a 37-year-old male, with non-cystic fibrosis bronchiectasis underwent bilateral lung transplantation. The patient developed partial dehiscence of the right bronchial anastomosis that was complicated by a small bronchopleural fistula. Two bronchoscopic applications of autologous platelet-rich plasma were carried out. Follow-up a few weeks later showed complete closure and healing of the fistula.

CONCLUSIONS

This case report suggests that the treatment of post-lung transplant small bronchial anastomotic partial dehiscence fistula with PRP is safe and effective.

Joint Report on Terminology for Cosmetic Gynecology

INTRODUCTION AND HYPOTHESIS

The current terminology used to describe cosmetic gynecologic procedures includes many nondescriptive, trademarked, or informal names, which contributes to substantial ambiguity about their aims and specific techniques. The development of clear, uniform descriptive terminology for cosmetic gynecology is needed for patients, researchers, and practitioners across multiple specialties.

METHODS

This document was developed from a collaboration of selected members from the International Urogynecological Association (IUGA) and the American Urogynecologic Society (AUGS). Wide-ranging literature reviews were performed to identify the breadth of currently used terms and tools for measuring efficacy and safety. After extensive internal review the adoption of each definition was ratified by group consensus.

RESULTS

A terminology report for elective cosmetic gynecology procedures, anatomical classification, outcome metrics, and reporting of complications has been developed. This document seeks to provide clear descriptive guidance for patients, researchers, and practitioners across multiple specialties. This document will be subject to internal review by IUGA and AUGS to incorporate and adopt evidence-based changes in the field.

CONCLUSIONS

A consensus-based document establishing clear terminology for cosmetic gynecology procedures has been created. Use of these terms should be encouraged to provide clarity to patients seeking these procedures and to facilitate future research to establish the safety and efficacy of these procedures.

Joint Report on Terminology for Cosmetic Gynecology

INTRODUCTION AND HYPOTHESIS

The current terminology used to describe cosmetic gynecologic procedures includes many nondescriptive, trademarked, or informal names, which contributes to substantial ambiguity about their aims and specific techniques. The development of clear, uniform descriptive terminology for cosmetic gynecology is needed for patients, researchers, and practitioners across multiple specialties.

METHODS

This document was developed from a collaboration of selected members from the International Urogynecological Association (IUGA) and the American Urogynecologic Society (AUGS). Wide-ranging literature reviews were performed to identify the breadth of currently used terms and tools for measuring efficacy and safety. After extensive internal review the adoption of each definition was ratified by group consensus.

RESULTS

A terminology report for elective cosmetic gynecology procedures, anatomical classification, outcome metrics, and reporting of complications has been developed. This document seeks to provide clear descriptive guidance for patients, researchers, and practitioners across multiple specialties. This document will be subject to internal review by IUGA and AUGS to incorporate and adopt evidence-based changes in the field.

CONCLUSIONS

A consensus-based document establishing clear terminology for cosmetic gynecology procedures has been created. Use of these terms should be encouraged to provide clarity to patients seeking these procedures and to facilitate future research to establish the safety and efficacy of these procedures.

Platelet Rich Plasma in Gynecology-Discovering Undiscovered-Review

Regenerative medicine combines elements of tissue engineering and molecular biology aiming to support the regeneration and repair processes of damaged tissues, cells and organs. The most commonly used preparation in regenerative medicine is platelet rich plasma (PRP) containing numerous growth factors present in platelet granularities. This therapy is increasingly used in various fields of medicine. This article is a review of literature on the use of PRP in gynecology and obstetrics. There is no doubt that the released growth factors and proteins have a beneficial effect on wound healing and regeneration processes. So far, its widest application is in reproductive medicine, especially in cases of thin endometrium, Asherman’s syndrome, or premature ovarian failure (POF) but also in wound healing and lower urinary tract symptoms (LUTS), such as urinary incontinence or recurrent genitourinary fistula auxiliary treatment. Further research is, however, needed to confirm the effectiveness and the possibility of its application in many other disorders.

A Novel Technique Combining Human Acellular Dermal Matrix (HADM) and Enriched Platelet Therapy (EPT) for the Treatment of Vaginal Laxity: A Single-Arm, Observational Study

BACKGROUND

There is a paucity of knowledge about cosmetic vaginal tightening procedures; therefore, the present study aimed to describe the clinical effects of a novel combination technique of human acellular dermal matrix (HADM) and enriched platelet therapy (EPT) for the treatment of vaginal laxity.

METHODS

This single-arm, observational study was conducted on 52 patients with grade II to III vaginal relaxation. HADM biological band (U-shaped) was implanted in these patients by submucosal puncture in vagina under anesthesia. This was followed by thrice administration of EPT injection, once at the time surgery followed by each dose at a time interval of one month. Patients were followed up for a period of 6 months based on Female Sexual Function Index (FSFI) and Vaginal Health Index (VHI) scores. Patient satisfaction was measured using Visual Analogue Score (VAS).

RESULTS

About 52 women with median age of 39 years were included in the study. The average time reported to complete HADM surgery was reported as 27 minutes. Following implantation, it was found that labia minora was significantly closed and perineal length was increased from 1.5 to 2.2 cm. Moreover, there was improvement in elasticity, contractility and lubricity of vaginal mucosa. The sexual function scores from pre- to post-surgery were significantly increased (7.95 vs. 30.09; p value: <0.001). The mean VHI score also increased significantly after 6 months of treatment (mean ± S.D. before vs after treatment: 11.2 ± 3.3 vs. 19.6 ± 4.1, P < 0.0001). The mean VAS after surgery was 1.61 ± 0.31. About 96% of the patients did not feel any pain after treatment at 6-month follow-up. No adverse effects were reported in this study.

CONCLUSIONS

These findings supported that combination treatment with HADM and EPT was safe and associated with both improved vaginal laxity and sexual function. These results may provide a novel surgical technique for this prevalent and undertreated condition.

LEVEL OF EVIDENCE IV

Therapeutic Study This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Materials Selection for the Injection into Vaginal Wall for Treatment of Vaginal Atrophy

Vaginal atrophy caused by the aging process and perineal trauma has a negative impact on women. A new vaginal atrophy treatment is injection of materials into the vaginal wall, including platelet-rich plasma (PRP), autogenous fat graft (AFG), hyaluronic acid (HA), botulinum toxin (BTX), and collagen, but to date their efficacy has not been reviewed. Vaginal wall injection is available only for mild cases of vaginal atrophy or as an adjunct to vaginal surgery. PRP is used mainly to restore vaginal function, and multiple injections are needed to achieve good results in vaginal atrophy. HA, AFG, and collagen are used mainly to augment the vaginal wall. BTX injection can inhibit vaginal muscle spasm and reduce pain during sexual intercourse in patients with vaginismus. Injection of most of these materials into vaginal wall is effective and relatively safe. Vascular embolisms are the most serious complication of vaginal injection and should be prevented. In addition, there has been no randomized double-blind placebo-controlled trial or discussion of methods to avoid serious complications resulting from vaginal injection. Therefore, further studies of the injection of materials into the vaginal wall to treat vaginal atrophy are required, and the procedures should be standardized to benefit more patients.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Radiation-Induced Recurrent Vesicovaginal Fistula-Treatment with Adjuvant Platelet-Rich Plasma Injection and Martius Flap Placement-Case Report and Review of Literature

Vesicovaginal fistula is the non-physiological connection between the urinary bladder and vagina. This results in continuous urine leakage. In developed countries, the prevalence of this condition is low and affects (mainly) women with a history of gynaecological procedures or radiotherapy. The aim of this study was to present the therapeutic process of a patient with radiation-induced, recurrent vesicovaginal fistula. The thirty-eight-year-old patient underwent radical hysterectomy with follow-up radiotherapy due to cervical cancer. Five years after the therapy, she was diagnosed with vesicovaginal fistula. After two unsuccessful Latzko procedures and two adjuvant platelet-rich plasma injections, a third Latzko reconstructive surgery was performed with additional transposition of the Martius flap—with successful closure of the fistula.

The Emerging Role on the Use of Platelet-Rich Plasma Products in the Management of Urogynaecological Disorders

Background: The regenerative efficacy of platelet-derived products has been recently investigated in the treatment of pelvic floor disorders (PFDs). We aimed to synthesize the current evidence of platelet-rich plasma (PRP) products used in urogynaecological disorders including vaginal atrophy, pelvic organ prolapse (POP), urinary incontinence, vaginal fistulas and vaginal mesh exposure. Methods: A meticulous search of the currently available literature on the use of PRP for the management of PFDs was performed using 3 electronic databases. Results: PRP could be a feasible alternative modality for the management of vaginal atrophy with favourable outcomes in vaginal atrophy parameters and patients' satisfaction, especially when hormone therapy is contraindicated. In patients with POP, an increase in collagen concentration after PRP application was observed while the use of PRP resulted in improvement of stress urinary incontinence symptoms. A considerable proportion of vesicovaginal fistulas were treated after application of PRP-based injections. Conclusions: There is only limited evidence of the use of PRP for PFDs. Platelet-rich plasma appears to be a promising, easy to apply, cost-effective and feasible alternative therapeutic modality for the management of various urogynaecological disorders. Future randomized trials are needed to confirm the efficacy of PRP in the treatment of urogynaecological disorders.

Predictive value of classification systems and single fistula-related factors in surgical management of vesicovaginal fistula

AIMS

The aim of this study was to find the most clinically useful vesicovaginal fistula (VVF) classification system or single fistula-related factor, which would be helpful in determining the most proper management leading to successful treatment.

METHODS

Between 2018 and 2020, 30 patients were diagnosed with VVF and underwent the Latzko procedure. Nineteen patients, after previously failed surgery, were injected with platelet-rich-plasma (PRP) before a final attempt to close VVF. Patients with primary VVF were included into the surgery only group and patients with secondary VVF were included into PRP and surgery group. Each patient was classified according to 13 different classification systems.

RESULTS

Statistical evaluation revealed some significant differences between the patients who required PRP injection and repeated surgery, compared with patients who were successfully treated at first surgery but only with Lawson, Waaldijk, Arrowsmith, and Tafesse classifications. Patients who succeded with the fistula closure after the first surgical procedure had significantly higher body mass index (BMI) when compared with patients who required PRP injection prior surgical procedure (30.9 vs. 25.7, respectively; p < .05).

CONCLUSIONS

None of the classification systems allows to precisely predict VVF surgery outcome. There are several factors such as previous surgery, lack of urethral involvement, lack of circumferential defect which might suggest that PRP injection would help to preserve watertightness of the closure. The most important finding is that overweight is the most positive predicting demographic feature of surgical success. Thus we may conclude that Martius flap technique should be taken into consideration in patients with low BMI.