Safety and efficacy of non-ablative CO2 laser treatment of vulvo-vaginal atrophy in women with history of breast cancer.

PURPOSE: Breast cancer survivors (BCS) suffer severe vulvo-vaginal atrophy (VVA) and some of the most effective therapies are contraindicated. In literature we have no data about the non-ablative CO2 laser on these women. The aim of this study was to examine its efficacy, safety and acceptability in BCS. MATERIALS AND METHODS: The enrolled women underwent 3 sessions of laser therapy (t0, t1, t2) and a one-month follow up examination (t3). At each time point we measured objective signs of VVA via VHI (Vaginal Health Index) and VuHI (Vulvar Health Index) and subjective parameters (Dryness, Burning, Itching, Dysuria) via visual analog scales (VAS). In sexually active women we evaluated the sexual function with FSFI (Female Sexual Function Index), FSDS (Female Sexual Distress Score) scores and MENQOL (menopause quality of life questionnaire). RESULTS: We enrolled 26 BCS. The mean VHI, VuVHI, dryness and burning VAS scores improved significantly and this improvement was not influenced by the initial VVA grade. MENQOL sexual domain, Lubrication, Orgasm and Pain domains and FSFI total score improved significantly, while Desire, Arousal and Satisfaction domains of FSFI and FSDS did not. At t0 women using Aromatase Inhibitors suffered more severe vaginal dryness than women using Tamoxifen or no therapy, but the three subgroups improved without differences. No adverse event and minimum discomfort were reported. CONCLUSIONS: The non-ablative CO2 laser is a safe and effective treatment of VVA and has positive effects on sexual function in BCS regardless the use of adjuvant therapies and the initial grade of VVA.

Single institution experience of cloacal malformation.

INTRODUCTION: The aim of this study is to report on the outcomes of patients born with cloacal malformation, managed at a single institution more than the last 28 years. The focus of this study is the long term renal and colorectal outcomes. METHODS: Patients were identified from the departmental database from 1994 to 2021. The medical records and operative notes were retrospectively reviewed. RESULTS: Twenty-one patients fulfilled the inclusion criteria. Eleven long common channel (LCC) and ten short common channel (SCC) cloacae patients were identified. Median age at the time of primary reconstruction was 11 months in both groups. In the LCC group, seven (63.6%) patients underwent a Total Urogenital Mobilisation (TUM), and 4 (36.4%) required a vaginal replacement. 6/11 (54.5%) of patients required drainage of a hydrocolpos. In the SCC group, four patients required a TUM, two patients underwent mobilisation of the rectum and vagina alone, and three underwent rectal mobilisation alone. Two patients have required renal transplant for congenital renal dysplasia, and two have developed chronic renal failure associated with the sequalae of vesicoureteric reflux. Eleven (52.3%) of the patients manage their bowels with an antegrade continent enema (ACE), and two of the LCC cloaca are defunctioned with a colostomy. Clean intermittent catheterisation is performed by 12 (57%) of the patients, either per urethra or via a Mitrofanoff channel. CONCLUSION: The urinary and faecal continence are the main challenges in the management of cloaca patients. Many require surgical intervention to achieve social continence. LEVEL OF EVIDENCE: Level IV.

A novel bilateral anterior sacrospinous hysteropexy technique for apical pelvic organ prolapse repair via the vaginal route: a cohort study.

BACKGROUND: Uterine-preserving techniques are becoming increasingly popular in the last decade. This investigation evaluates a novel hysteropexy technique using a mesh in sling-alike configuration [Splentis (Promedon, Argentina)] which is attached anteriorly to the cervix and suspended to the sacrospinous ligaments bilaterally via the vaginal route in women undergoing surgery for uterine prolapse. METHODS: This was a single-center cohort study, evaluating women who underwent transvaginal hysteropexy with Splentis for primary uterine descent. Data have been collected prospectively as part of the quality assurance system. Primary endpoint was treatment success, defined as a combined endpoint including the absence of a vaginal bulge symptom and no retreatment of apical prolapse. A validated questionnaire to evaluate quality-of-life and prolapse symptoms was utilized. Descriptive analysis was applied. Wilcoxon signed-rank test was performed to compare paired samples. The significance level was set at 5%. RESULTS: A total of 103 women with a median age of 68.0 [IQR 11.5] years with a median apical POP-Q stage of 3 were included. The median surgery time was 22 [IQR 12] minutes and no intraoperative complication occurred. After a median follow-up time of 17 months, treatment success was achieved in 91 (89.2%) patients and quality of life and patient report outcomes improved significantly (p < 0.001). Mesh exposure occurred in 3 (2.9%) patients. Of these, two patients required surgical revision, and one patient was treated conservatively. One patient required partial mesh removal due to dyspareunia. CONCLUSION: Bilateral sacrospinous hysteropexy with Splentis offers an efficacious and safe alternative for apical compartment repair, incorporating the advantages of pelvic floor reconstruction via the vaginal route.

Vaginal symptoms in women who are affected by gynecologic cancer.

PURPOSE OF REVIEW: Pelvic floor disorders are common among gynecologic cancer survivors. With improvements in survivorship, quality of life conditions in these women need greater attention and care. This review focuses specifically on vulvovaginal symptoms, which are common and have a negative impact on sexual health and quality of life in women affected by gynecologic cancer. RECENT FINDINGS: We review publications on treatment-specific sexual health outcomes, screening and treatment of vulvovaginal symptoms and sexual pain, and surgical management options. Recent evidence regarding the safety of concomitant prolapse repair at the time of surgery for gynecologic malignancies and CO2 laser therapy is discussed and areas needing further research and innovation are highlighted. SUMMARY: Pelvic floor disorders, including vaginal and sexual health concerns, are common in women affected by gynecologic cancer due to both common risk factors and as a side effects of cancer treatment. Gynecologists play a critical role in screening, treatment, and collaboration with other specialists to provide comprehensive care for these women throughout their lifetime.

A Novel Injection Technique for Extended-Release Local Anesthetic After Posterior Colporrhaphy and Perineorrhaphy: A Randomized Controlled Study.

OBJECTIVES: To evaluate the effect of vaginal intraoperative infiltration of liposomal bupivacaine on vaginal pain among patients undergoing posterior colporrhaphy and perineorrhaphy. METHODS: This was a randomized, placebo-controlled trial offered to women undergoing posterior colporrhaphy and perineorrhaphy with concomitant pelvic reconstructive procedures. Liposomal bupivacaine or normal saline placebo (30 mL) was injected into the posterior vaginal compartment and perineal body in 2- to 3-mL increments, using a systematic technique. All participants received 10-mL 0.25% bupivacaine with epinephrine prior to incision. Perioperative care was standardized. The primary outcome was vaginal pain as measured by a visual analog scale. RESULTS: One hundred twenty-six women were screened, and 72 were included. Demographic characteristics were similar. Median visual analog scale was not different at any time point (P = 0.81). There were no differences in secondary outcomes, including narcotic use (37.5 vs 37.5 mg morphine equivalents, P = 0.51; placebo vs liposomal bupivacaine), time to first opioid (68 vs 89.5 minutes, P = 0.56), antiemetic doses (3 vs 2, P = 0.07), hospital length of stay (24 vs 21.9 hours, P = 0.98), length of stay in postanesthesia care unit (93 vs 100 minutes, P = 0.32), proportion of patients who had a bowel movement within the first 3 postoperative days (65.7 vs 59.5% P = 0.36), or successful voiding trials (45.7 vs 59.5%, P = 0.24). There were no differences in patient satisfaction or postoperative adverse events. CONCLUSIONS: In this study of pelvic reconstructive surgeries with posterior colporrhaphy and perineorrhaphy, there were no differences in pain scores or any secondary outcomes between liposomal bupivacaine and placebo injected into the posterior vaginal compartment.

Vaginal necrosis: A rare late toxicity after radiation therapy.

Vaginal necrosis is a late radiation tissue injury with serious morbidity complications. It is rare, and its incidence is not well assessed in prospective trials. Patient comorbidities and radiation dose can significantly increase the risk. As treatment of gynecologic malignancies often involve a multidisciplinary approach, timely diagnosis and appropriate management by physicians of the team are crucial. Untreated vaginal necrosis can lead to infection, hemorrhage, necrosis-related fistulation to the bladder or rectum, perforation, and death. In this review, we describe the pathophysiology of vaginal necrosis, its clinical course, and management options.

An alternative technique in surgical correction of anterior compartment prolapse; Iliococcygeal fixation of the pubocervical fascia by native tissue repair.

AIM: To present 'bilateral iliococcygeal fixation of the pubocervical fascia' as an alternative vaginal surgical technique for anterior compartment repair with native tissue and the surgical outcomes of 30 cases. MATERIALS-METHODS: The consecutive 30 cases who admitted to urogynecology clinic with anterior vaginal prolapse/cystocele and underwent anterior compartment repair by bilateral iliococcgeal fixation of the pubocervical fascia by native tissue were included to the study. All cases attended to the postoperative follow-up visits at the sixth and the twelfth months. RESULTS: There were no major or minor intraoperative complications. Overall, in 28 (93.3 %) patients surgical success was achieved at the postoperative 12th month when it was defined as the maximum descent of the anterior segment was proximal to the hymen. During the study period, none of the patients requested or admitted for re-treatment for anterior compartment prolapse. Subjective cure that was assessed by the absence of bulge symptoms was achieved in 29 cases (96.7 %) at first year follow-up. Lower urinary tract symptoms (LUTS) were found to be significantly lower at the first-year postoperative visit compared to pre-operative evaluation. A clinically significant improvement in the quality of life parameters were also noted (mean PFIQ-7 scores = 8.5, 5.6 and 50.8, respectively). CONCLUSION: Bilateral iliococcygeal fixation of the pubocervical fascia seems to be effective in surgical correction of anterior vaginal prolapse according to our post-operative follow-up results. It is an easy to learn procedure with low complication rates and associated with high patient satisfaction.

Vaginal posterior isthmic sling: A report of 53 cases.

INTRODUCTION: Sacrospinofixation is used for fundic vaginal vault's prolapse or to prevent mid-level or posterior prolapse. It can lead to complications such as dyspareunia, chronic pain, and quality of life impairment. Anchoring a posterior isthmic sling to the two sacrospinous ligaments is an alternative to classic Richter's sacrospinofixation. Objective of this study is to report the first cases of vaginal posterior isthmic slings. METHODS: This study is retrospective and unicentric. It includes women who had posterior isthmic sling at the time of a surgery with a mesh for anterior prolapse by vaginal way between 2010 and 2016 in the gynecologic department of a teaching hospital. Report of efficacy and tolerance was performed. RESULTS: Between 2010 and 2016, 53 women were included with a posterior isthmic sling and a mesh for an anterior prolapse. POP-Q evolution during the follow-up in the posterior isthmic sling group assess of a good efficacy of the sling. Four women (7.5%) required second surgery in 28 months following initial surgery (only 1 for excision). Four women (7.5%) had a prolapse recurrence in a mean time of 30 months without recurrent surgery. Women's satisfaction level was high (8.0/10 [7,1-8,8]). CONCLUSION: Efficacy and tolerance of the posterior isthmic sling seems good. It might then be an option for mid-level prolapses in case of vaginal surgery with mesh for anterior prolapse. A non-inferiority trial should be performed to be able to conclude on the place of this alternative to Richter's sacrospinofixation.

Preoperative Bowel Preparation in Minimally Invasive and Vaginal Gynecologic Surgery.

Bowel preparation traditionally refers to the removal of bowel contents via mechanical cleansing measures. Although it has been a common practice for more than 70 years, its use is based mostly on expert opinion rather than solid evidence. Mechanical bowel preparation in minimally invasive and vaginal gynecologic surgery is strongly debated, since many studies have not confirmed its effectiveness, neither in reducing postoperative infectious morbidity nor in improving surgeons' performance. A comprehensive search of Medline/PubMed and the Cochrane Library Database was conducted, for related articles up to June 2019, including terms such as "mechanical bowel preparation," "vaginal surgery," "minimally invasive," and "gynecology." We aimed to determine the best practice regarding bowel preparation before these surgical approaches. In previous studies, bowel preparation was evaluated only via mechanical measures. The identified randomized trials in laparoscopic approach and in vaginal surgery were 8 and 4, respectively. Most of them compare different types of preparation, with patients being separated into groups of oral laxatives, rectal measures (enema), low residue diet, and fasting. The outcomes of interest are the quality of the surgical field, postoperative infectious complications, length of hospital stay, and patients' comfort during the whole procedure. The results are almost identical regardless of the procedure's type. Routine administration of bowel preparation seems to offer no advantage to any of the objectives mentioned above. Taking into consideration the fact that in most gynecologic cases there is minimal probability of bowel intraluminal entry and, thus, low surgical site infection rates, most scientific societies have issued guidelines against the use of any bowel preparation regimen before laparoscopic or vaginal surgery. Nonetheless, surgeons still do not use a specific pattern and continue ordering them. However, according to recent evidence, preoperative bowel preparation of any type should be omitted prior to minimally invasive and vaginal gynecologic surgeries.

The new etiology and surgical therapy of stress urinary incontinence in women.

OBJECTIVES: To determine the subjective and objective cure rate of a urethral stabilization procedure (USP) for stress urinary incontinence (SUI) in women; to describe this new surgical intervention; to record its potential complications; to establish the SUI etiology. STUDY DESIGN: The author conducted a prospective case series study in ambulatory settings and under local anesthesia. Thirty-four consecutive women with uncomplicated SUI subjected to USP, which was performed by reconstructing site-specific defects within the urethral stabilizing mechanism (USM) and using no surgical slings, meshes or absorbable sutures. The paravaginal defect(s) was repaired by transvaginal approach. The endopelvic fascia was sharply separated from the ventral perineal membrane (VPM) just above the anterior urethral meatus. The vestibular bulbs sharply dissected from VPM and advance upwards. The VPM defect(s) reconstructed and vestibular bulbs placed back to the original location. The access to the peri- and the para-urethral region was created by making a lateral vertical incision, aside from the lateral urethral meatus and defects were repaired. The suburethral transverse incision was made beneath the urethral meatus and the stratum-by-stratum surgical dissection conducted until the lateral vaginourethral ligament is visualized bilaterally. The defect(s) within the vaginourethral ligaments was surgically reconstructed, and the vaginal wall repaired. The primary outcome measured subjective and objective cure rates, and the secondary outcome measured the occurrence of potential complications. The five-year postoperative follow-up was conducted. RESULTS: Two out of thirty-four patients dropped-out from the study. The USP performed without difficulties, and no severe complication observed. One-subject developed superficial wound separation (3.1 %) and one-subject (3.1 %) developed urinary urge incontinence at the 5-postoperative-year. At 60-month follow-up subjective and objective cure rates were a 92 % and an 88 % respectively. CONCLUSIONS: The urethral stabilization procedure yields a high degree of subjective and objective cure rates without severe complications and is a well-tolerated operation by women. The urethral stabilization procedure is a simple, easy to implement, and reproducible method for uncomplicated stress urinary incontinence in women. Site-specific defects within the urethral stabilizing mechanism constitute the etiology of the stress urinary incontinence in women.

Rationale and design for fractional microablative CO2 laser versus photothermal non-ablative erbium:YAG laser for the management of genitourinary syndrome of menopause: a non-inferiority, single-blind randomized controlled trial.

Genitourinary syndrome of menopause (GSM) is a common condition affecting up to 50% of postmenopausal women and up to 70% of postmenopausal breast cancer survivors. GSM is a chronic condition with a significant impact on sexual health and quality of life. The mainstay of treatment has been with symptomatic relief using topical emollients or lubricants. Second-line treatment is with topical vaginal estrogens to restore the physiology of the vaginal epithelium. For some, the latter is not suitable or acceptable. Newer treatments with ospemifene and vaginal lasers have now been introduced. The two main types of laser currently used for the treatment of GSM are the fractional microablative CO2 laser and the non-ablative photothermal erbium:YAG laser. We present a study protocol for a multicenter, prospective, non-inferiority, single-blinded, randomized controlled trial comparing the fractional microablative CO2 laser versus the photothermal non-ablative erbium:YAG laser for the management of GSM. We will recruit 88 postmenopausal women across two sites who will be randomized to one of the two laser groups. Participants will all have GSM symptoms and a Vaginal Health Index Score < 15. All participants will receive an active treatment. Each participant will receive three applications of vaginal laser 1 month apart and will be followed up at 1 month, 6 months, and 12 months. Our primary outcomes will look at all changes of GSM symptoms (dryness, dyspareunia, itching, burning, dysuria, frequency, urgency), urinary incontinence (if present), and overall sexual satisfaction. Both subjective and objective means will be used to assess participants. The findings of this trial have the potential to allow clinicians and women suffering from GSM to make an informed decision when opting for a specific laser type. The trial will add to the current growing body of evidence for the safe use of vaginal lasers in GSM as an alternative treatment. We hope this trial will provide robust and long-term data for the safe use of both lasers.

Incompatibility Mechanism Between Radix Paeoniae Alba and Veratrum nigrum Focusing on Estrogen-Estrogen Receptor Pathway in Immature/Ovariectomized Mice.

Radix paeoniae alba (RPA) and Veratrum nigrum (VN) L. belong to the 18 incompatible medicaments and have been prohibited for thousands of years in China. Previous studies focused on the chemical constituents that induced the toxicological response of the two agents, but this study offers preliminary insight into the pharmacodynamics and mechanism on estrogenic activity, which is responsible for their incompatibility. We undertook a characterization of the interaction on estrogenic activity of RPA and VN using in vivo models of immature and ovariectomized (OVX) mice and in vitro studies focused on estrogen receptor (ER) pathway for further mechanism. VN disturbed the estrogenic efficacy of RPA in promoting development of uterus and vagina in immature mice, and reversing the atrophy of reproductive tissues in OVX mice by decreasing the increase of serum estrogen level and upregulation of ER expression in reproductive tissues by treatment with RPA. Besides, VN antagonized the estrogenic efficacy of RPA in stimulating the binding with ERα and ERß, increasing ERα/ß-estrogen response element (ERE) luciferase reporter gene expression and promoting MCF-7 cell viability. This study provided evidence that VN antagonized the estrogenic efficacy of RPA by decreasing the up-regulations of estrogen biosynthesis in circulation and ERs in target tissues caused by RPA, and through ER-ERE-dependent pathway.

Long-term effects of vaginal erbium laser in the treatment of genitourinary syndrome of menopause.

OBJECTIVES: To evaluate the long-term efficacy of a second generation of vaginal laser treatment, the vaginal erbium laser, as a non-ablative photothermal therapy for the management of genitourinary syndrome of menopause. METHODS: The study was performed using an erbium laser crystal yttrium-aluminum-garnet (XS Fotona Smooth™, Fotona, Ljubljana, Slovenia) with a wavelength of 2940 nm. Postmenopausal women (n = 205) were treated with three laser applications at 30-day intervals. Symptoms were assessed before and after treatment throughout 24 months, using the subjective visual analog scale (VAS) and the objective vaginal health index score (VHIS). In addition, postmenopausal women suffering from stress urinary incontinence were evaluated with the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF). RESULTS: Vaginal erbium laser treatment induced a significant (p < 0.01) decrease in VAS for both vaginal dryness and dyspareunia, as well an increase in VHIS (p < 0.01) up to the 12th month after the last laser treatment. The values returned to levels similar to the baseline after 18 and 24 months. In addition, vaginal erbium laser treatment improved mild-moderate stress urinary incontinence in 114 postmenopausal women. Less than 3% of patients discontinued treatment due to adverse events. CONCLUSIONS: These results suggest that vaginal erbium laser may be effective and safe for the treatment of genitourinary syndrome of menopause.

[Cylindric Abdominoperineal Rectum Exstirpation with Partial Vulvar and Vaginal Resection as well as Perineal and Vaginal Defect Reconstruction by a Vertical Rectus Abdominis Myocutaneous (VRAM) Flap]. / Zylindrische abdominoperineale Rektumexstirpation mit partieller Vulva- und Vaginaresektion sowie perinealer und vaginaler Defektrekonstruktion durch einen vertikalen Rectus-abdominis-Muskel-Haut-Lappen (VRAM-Lappen).

Introduction Patients with low rectal cancer or anal cancer undergoing abdominoperineal excision (APE) benefit from extended surgery and the subsequent avoidance of surgical "waisting" at the level of the puborectalis muscle. The method of cylindrical APE was introduced by T. Holm and led to a reduction of intraoperative perforations and involvement of circumferential resection margins, and subsequently reduced the risk of local recurrence. The use of myocutaneous flaps reduces perineal wound complications, which occur in up to 60% of patients with primary closure of perineal defects, especially following neoadjuvant radiochemotherapy. Flaps obliterate pelvic dead space, recruit well-vascularised tissue into irradiated regions, facilitate wound closure and allow for vaginal and perineal reconstructions. This video shows the technique of extended cylindrical APE with partial vulvar and vaginal resection and subsequent reconstruction of the posterior vaginal wall and the pelvic floor defect by a vertical rectus abdominis myocutaneous (VRAM) flap. Indication Locally advanced anal cancer with infiltration and fistula to the posterior vaginal wall without metastatic spread following neoadjuvant radiochemotherapy. Procedure Extended cylindric APE with partial vulvar and vaginal resection, construction of a descending colostomy with parastomal intraperitoneal onlay mesh augmentation, pelvic reconstruction with a VRAM flap and inlay mesh augmentation of the anterior rectus sheath. Conclusion From the oncological point of view, extralevator APE is superior to standard surgery. The use of myocutaneous flaps improves postoperative wound healing and quality of life.

Age Is Just a Number: WPATH-Affiliated Surgeons' Experiences and Attitudes Toward Vaginoplasty in Transgender Females Under 18 Years of Age in the United States.

BACKGROUND: A rising number of female-affirmed transgender adolescents are being treated with gonadotropin-releasing hormone analogues and subsequently cross-sex hormones at early or mid-puberty, with vaginoplasty as the presumed final step in their physical transition. But, despite the minimum age of 18 years defining eligibility to undergo this irreversible procedure, anecdotal reports have shown that vaginoplasties are being performed on minors by surgeons in the United States, thereby contravening the World Professional Association for Transgender Health (WPATH) standards of care (SOC). AIM: To explore surgeons' attitudes toward ethical guidelines in the SOC; any professional experiences of performing vaginoplasty on transgender minors; views of surgical risks, benefits, and harm reduction measures; and perceptions of future challenges and concerns in this area of surgical practice. METHODS: A qualitative semistructured interview approach was used to collect data from 13 male and 7 female surgeons who perform transgender vaginoplasty in the United States. OUTCOMES: Professional experiences and attitudes toward vaginoplasty in transgender minors were analyzed using the constant comparative method applied to 20 individual interview transcripts. RESULTS: While there was close agreement concerning surgical techniques, proper patient selection, and predictive elements of postoperative success, attitudes toward the SOC and the reliance on the guidelines varied. The sole practitioner model is gradually giving way to a more holistic team approach, with patient responsibility dispersed among different professionals. Different approaches to surgical training, professional standards, and fellowship programs were suggested. Several participants expressed a need for centralized data collection, patient tracking, and increased involvement of the WPATH as a sponsor of studies in this emergent population. CLINICAL IMPLICATIONS: Drawing on surgeons' attitudes and experiences is essential for the development of standards and practices. A more precise and transparent view of this surgical procedure will be essential in contributing to the updated version 8 of the WPATH SOC. STRENGTHS AND LIMITATIONS: The abundant data elicited from the interviews address several meaningful research questions, most importantly patient selection criteria, surgical methods, and issues critical to the future of the profession. Nevertheless, the limited sample might not be representative of the surgical cadre at large, particularly when exploring experiences and attitudes toward vaginoplasty in minors. A larger participant pool representing WPATH-affiliated surgeons outside the United States would improve the generalizability of the study. CONCLUSION: Taken together, the study and its findings make a significant contribution to the planned revision of the WPATH SOC. Milrod C, Karasic DH. Age Is Just a Number: WPATH-Affiliated Surgeons' Experiences and Attitudes Toward Vaginoplasty in Transgender Females Under 18 Years of Age in the United States. J Sex Med 2017;14:624-634.

Vaginal erbium laser as second-generation thermotherapy for the genitourinary syndrome of menopause: a pilot study in breast cancer survivors.

OBJECTIVE: The aim of this study was to evaluate the efficacy and acceptability of a second generation of vaginal laser treatment, the vaginal erbium laser, as a nonablative photothermal therapy for the management of genitourinary syndrome of menopause in postmenopausal breast cancer survivors. METHODS: The study was performed using an erbium laser crystal yttrium-aluminum-garnet (XS Fotona Smooth, Fotona, Ljubljana, Slovenia) with a wavelength of 2,940 nm. Forty-three postmenopausal breast cancer survivors were treated with three laser applications every 30 days. Symptoms were assessed before the treatment and after 1, 3, 6, 12, and 18 months, using two methods, subjective Visual Analog Scale (VAS) and objective Vaginal Health Index Score (VHIS). The procedures were performed on an outpatient basis without anesthesia or drug use before or after the intervention. RESULTS: From baseline values of 8.5 ±â€Š1.0 cm, vaginal dryness VAS scores were 4.4 ±â€Š1.2 cm after the third treatment and 5.5 ±â€Š1.5 cm 12 months after the treatment (P < 0.01 vs basal values), whereas they were 7.5 ±â€Š1.8 cm after 18 months from the last laser application (NS vs basal values). From baseline values of 7.5 ±â€Š1.5 cm, dyspareunia VAS values decreased to 4.2 ±â€Š0.9 cm after the third treatment and 5.1 ±â€Š1.8 cm 12 months from the last laser application (P < 0.01 vs basal values), whereas they were 6.5 ±â€Š1.8 cm after 18 months from the last laser application (NS vs basal values). VHIS, from baseline values of 8.1 ±â€Š1.3, was 21.0 ±â€Š1.4 after the third treatment and 18 ±â€Š1.8 12 months from the last laser application (P < 0.01 vs basal values), whereas they were 14.8 ±â€Š1.5 cm after 18 months from the last laser application (NS vs basal values). No adverse events were recorded during the study. CONCLUSIONS: This study suggests that the vaginal erbium laser is effective and safe for the treatment of genitourinary syndrome of menopause in breast cancer survivors.

Randomized controlled trial of postoperative belladonna and opium rectal suppositories in vaginal surgery.

BACKGROUND: After vaginal surgery, oral and parenteral narcotics are used commonly for pain relief, and their use may exacerbate the incidence of sedation, nausea, and vomiting, which ultimately delays convalescence. Previous studies have demonstrated that rectal analgesia after surgery results in lower pain scores and less intravenous morphine consumption. Belladonna and opium rectal suppositories may be used to relieve pain and minimize side effects; however, their efficacy has not been confirmed. OBJECTIVE: We aimed to evaluate the use of belladonna and opium suppositories for pain reduction in vaginal surgery. MATERIALS AND METHODS: A prospective, randomized, double-blind, placebo-controlled trial that used belladonna and opium suppositories after inpatient or outpatient vaginal surgery was conducted. Vaginal surgery was defined as (1) vaginal hysterectomy with uterosacral ligament suspension or (2) posthysterectomy prolapse repair that included uterosacral ligament suspension and/or colporrhaphy. Belladonna and opium 16A (16.2/60 mg) or placebo suppositories were administered rectally immediately after surgery and every 8 hours for a total of 3 doses. Patient-reported pain data were collected with the use of a visual analog scale (at 2, 4, 12, and 20 hours postoperatively. Opiate use was measured and converted into parenteral morphine equivalents. The primary outcome was pain, and secondary outcomes included pain medication, antiemetic medication, and a quality of recovery questionnaire. Adverse effects were surveyed at 24 hours and 7 days. Concomitant procedures for urinary incontinence or pelvic organ prolapse did not preclude enrollment. RESULTS: Ninety women were randomly assigned consecutively at a single institution under the care of a fellowship-trained surgeon group. Demographics did not differ among the groups with mean age of 55 years, procedure time of 97 minutes, and prolapse at 51%. Postoperative pain scores were equivalent among both groups at each time interval. The belladonna and opium group used a mean of 57 mg morphine compared with 66 mg for placebo (P=.43) in 24 hours. Patient satisfaction with recovery was similar (P=.59). Antiemetic and ketorolac use were comparable among groups. Subgroup analyses of patients with prolapse and patients <50 years old did not reveal differences in pain scores. The use of belladonna and opium suppositories was uncomplicated, and adverse effects, which included constipation and urinary retention, were similar among groups. CONCLUSION: Belladonna and opium suppositories are safe for use after vaginal surgery. Belladonna and opium suppositories did not reveal lower pain or substantially lower narcotic use. Further investigation may be warranted to identify a population that may benefit optimally from belladonna and opium use.

Postoperative anatomic and quality-of-life outcomes after vaginal sacrocolporectopexy for vaginal vault prolapse.

OBJECTIVE: To assess anatomic outcome and quality of life (QOL) after vaginal sacrocolporectopexy among patients with pelvic organ prolapse. METHODS: A noncomparative observational study was conducted at Hanover Medical School, Germany, among patients who underwent vaginal sacrocolporectopexy for uterine or vaginal vault prolapse between May 1, 2006, and October 31, 2012. A validated German version of the Prolapse QOL (P-QOL) questionnaire was sent to eligible patients; respondents were invited for follow-up examination. RESULTS: Overall, 128 patients were enrolled. Concomitant hysterectomy was performed among 82 (64.1%) patients, anterior colporrhaphy among 105 (82.0%), and posterior colporrhaphy among 58 (45.3%). After a mean interval of 26.5 months (range 1.0-81.3 months), seven patients exhibited recurrent vaginal vault prolapse of at least stage 2, giving a success rate of 92.3% (95% confidence interval 85.9%-96.5%). The P-QOL scores were either low (<40) or very low (<20), indicating high QOL. Regarding symptoms related to pelvic organ prolapse, patients reported little or no impact on QOL after vaginal sacrocolporectopexy. CONCLUSION: Vaginal sacrocolporectopexy seemed safe and feasible, leading to anatomically correct fixation of the vaginal apex, high anatomic success rates, and good QOL. This procedure might be considered as an alternative to laparoscopic or abdominal sacrocolpopexy.

[Acquired caustic vagina stenosis: Surgical outcomes of 21 cases]. / Rétrécissements du vagin d'origine caustique. À propos de 21 plasties.

OBJECTIVE: To document epidemiology, causes, anatomical varieties and surgical management outcomes of caustic acquired vagina stenosis. METHODOLOGY: Retrospective study of 21 patients involved from 1996 to 2012 at the department of obstetrics and gynecology of Yopougon's teaching hospital in Abidjan, Côte d'Ivoire. Vaginal stenosis due to genital malformation, vaginal irradiation of pelvic tumours, repair of bladder and vaginal fistulae or intersexual disorders were excluded. RESULTS: The prevalence was 0.14/1000 admissions, mean age was 32.1 years, mean gravidity was 1.76 and mean parity was 1.1. Vaginal stenosis seat and extent were variable and 100 % had a caustic origin by use of traditional medicine vaginal pessaire. Of the patients, 95.2 % underwent surgical treatment followed by several dilations sessions with glass dilators. Successful surgical outcome allowing coitus was achieved in 47.6 % of cases with 52.4 % failure. CONCLUSION: Acquired caustic vagina stenosis are frequently occurring and are a public health problem related to ignorance. Health education and establishment of expert centers with exchange of experiences in West Africa should be able to improve surgical outcomes.

[Effects of Electric Stimulation and Biofeedback for Pelvic Floor Muscle Exercise in Women with Vaginal Rejuvenation Women].

PURPOSE: The purpose of this study was to investigate the effects of pelvic floor muscle exercise using electric stimulation and biofeedback on maximum pressure of vaginal contraction, vaginal contraction duration and sexual function in women who have had vaginal rejuvenation. METHODS: The research design was a non-equivalent control group non-synchronized design study. Participants in this study were women who had vaginal rejuvenation at C obstetrics and gynecology hospital. The 15 participants in the experimental group were given pelvic floor muscle exercise using electric stimulation and biofeedback and the 15 participants in the control group received self pelvic floor muscle exercise. RESULTS: For maximum pressure of vaginal contraction, the experimental group showed a statistically significant increase compared to than the control group (t=5.96, p<.001). For vaginal contraction duration, the experimental group also showed a statistically significant increase compared to the control group (t=3.23, p=.003). For women's sexual function, the experimental group showed a significant increase when compared to the control group in total sexual function scores (t=3.41, p=.002). CONCLUSION: The results indicate that pelvic floor muscle exercise with electric stimulation and biofeedback after vaginal rejuvenation is effective in strengthening vaginal contraction pressure, vaginal contraction and that it also positively functions to increase women's sexual function.