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.

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.

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.

Vaginally inserted herbs causing vesico-vaginal fistula and vaginal stenosis.

A 32-year-old woman developed a vesico-vaginal fistula and vaginal stenosis following insertion of herbs into her vagina by a traditional doctor to "melt" her uterine myomata. She underwent successful trans-abdominal repair of her fistula and passive dilatation of her vagina was recommended for the vaginal stenosis. The emerging importance of traditional treatments as a cause of vesico-vaginal fistula is highlighted. The role of quality improvement through research and strict regulation to maximise the benefits of traditional treatment and minimise complications is also emphasised.

Local anesthesia with sedation for vaginal reconstructive surgery.

To evaluate local anesthesia with sedation for vaginal reconstructive surgery. All cases of vaginal surgery performed by the primary author for correction of pelvic organ prolapse with and without urinary incontinence between February 2000 and October 2004 were identified. From the medical record, data on age, duration of surgery, amount of local anesthetic used, estimated blood loss, hospital stay, urinary retention, and need for conversion to general anesthesia were recorded. Among 127 potential candidates, 98 (77.2%) opted for local with sedation. These cases included 18 anterior colporrhaphies, 47 posterior colporrhaphies with perineoplasties, 9 enterocele repairs, 32 total colpocleises, and 9 LeFort procedures. Tension-free vaginal tape (TVT) were concomitantly placed in 37 of the cases; 121 TVT-only cases done under local were not included. No cases were converted to general anesthesia. Surgical time ranged from 20 to 195 min (mean 99 min). Most patients were discharged within 24 h of surgery. Traditionally, local anesthesia with sedation has been reserved for superficial vaginal procedures. However, it can be successfully employed for more invasive vaginal reconstructive surgeries. Duration of surgery and patient acceptance have not been limiting factors. The advantages of local anesthesia include minimal interference with homeostasis and rapid recovery with patients often bypassing the recovery unit.

The LANN technique to reduce postoperative functional morbidity in laparoscopic radical pelvic surgery.

BACKGROUND: We investigated the feasibility and advantages of introducing Laparoscopic Neuro-Navigation (LANN) into the field of laparoscopic gynecologic radical pelvic surgery. STUDY DESIGN: In a prospective pilot study, 261 consecutive patients underwent laparoscopic radical pelvic surgery for cervical cancer or deep infiltrating endometriosis of the parametria. During the procedure, dissection and electrostimulation, and consequently, sparing of the pelvic parasympathetic nerves by transection of the parametria, were performed. Postoperative bladder dysfunction was documented. RESULTS: Laparoscopic dissection and electrostimulation of the pelvic splanchnic nerves were feasible in all patients without any complications, and the rate of postoperative bladder dysfunction was considerably reduced, to less than 1% of the patients. CONCLUSIONS: The parasympathetic nerve-sparing method using the Laparoscopic Neuro-Navigation technique in laparoscopic radical pelvic gynecologic surgery is a feasible and reproducible technique that preserves postoperative bladder function.

[Rectovaginal septum endometriosis: a disease with specific diagnosis and treatment]. / Endometriose de septo retovaginal: doença de diagnóstico e tratamento específicos.

BACKGROUND: The involvement of the rectovaginal septum, of rectum and sigmoid by endometriosis leads to intense symptoms as dysmenorrhea, pelvic pain, deep dyspareunia, tenesmus and hematochezia in young and middle aged women during periods. The diagnosis can be made by tipycal history and vaginal examination, rectal examination, barium enema, proctoscopy and so on. The indications of operation include severe clinic symptoms and failed conservative therapy. The treatment of choice for this type of endometriosis is the surgical resection of affected tissue, in order to relieve patient symptoms, and avoid disease progression. The correct assessment as to the presence and extension of the endometriosis-affected sites such as the rectum, uterosacral ligaments and rectovaginal septum is extremely important to provide better results with the surgical treatment of endometriosis. AIM: To describe the main aspects related to rectovaginal septum endometriosis and offer the general surgeon some information about this enigmatic disease. CONCLUSION: Rectovaginal septum endometriosis is a frequent disease, with specific diagnosis and treatment.

Interposition of fallopian salpinges in the treatment of sigmoidovaginal fistula, secondary to vaginal hysterectomy with failure of previous repair.

A 50-year-old woman, para 4, suffering from uterine fibromatosis and recurrent menometrorrhagia, underwent vaginal hysterectomy with preservation of salpinges. About 15 days after surgery, hydrosoluble contrast enema showed sigmoidovaginal fistula; after about two months there was failure of surgery repair by the rectal endoscopic technique. A month later, we performed repair surgery by the abdominal approach interposing fallopian salpinges between the sigmoid and the vagina. About two months later, a enema showed absence of fistula and today the women is free from disease.

[Vaginal-sigmoid fistula caused by diverticular disease]. / Fistola vagino-sigmoidea come consequenza di malattia diverticolare.

A case of a 66 years old patient suffering from a sigmoido-vaginal fistula and diverticulosis, previously treated with a total laparohysterectomy, is reported. Retrograde studies demonstrated the presence of fistula, whereas colonoscopy and barium enema failed. After laparotomy and an appropriate bowel preparation, surgery was restricted to the bowel resection and anastomosis, whereas the vaginal defect was not closed.

[Anorectal traumas by impalement in children. Apropos of 3 cases]. / Les traumatismes ano-rectaux par empalement chez l'enfant. A propos de trois observations.

Traumatic impalement is an exceptional cause of anorectal lesions in the child. The clinical diagnosis is sometimes difficult and associated lesions raise the problem of the most appropriate exploratory examination. Based on our experience with three cases, we would emphasize the usefulness of hydrosoluble enema study prudently performed by the surgeon during the preoperative work-up. The precise localization of the lesions must be obtained with careful emergency exploration before repair. Treatment of the trauma includes lavage, drainage and sometimes colostomy. Antibiotics must always be prescribed. Early complications are dominated by infection and long-term sequellae, requiring a long follow-up.

Prognostic variables in treating vaginismus.

Twenty-three patients with vaginismus were seen in a Sexual Dysfunction Program over five years. Twenty of these patients continued in therapy and had successful outcomes. Length of therapy was analyzed and seen to be related to the following factors: duration of the dysfunction, and patient's conception of the etiology of the problem, history of previous attempts at operative treatment, motivational factors, the husband's degree of acceptance of the unconsummated marriage, previous organic abnormalities, extent of sexual knowledge, fear of sexually transmitted diseases, parental attitudes regarding sex, and the patient's attitude toward her genitalia. Follow-up of one to four years has revealed maintenance of sexual functioning in 95% of the couples. The three patients who dropped out and were considered failures all had had previous operative therapy and would not relinquish the idea that there was an anatomic abnormality causing their dysfunction. The method of therapy is reviewed.