Pudendal nerve neurolysis outcomes for urogenital and rectal disorders in patients suffering from pudendal nerve entrapment: A systematic review.

PURPOSE: Pudendal neuropathy is an uncommon condition that exhibits several symptoms depending on the site of nerve entrapment. This study aims to evaluate the efficacy of pudendal nerve neurolysis (PNN) in improving lower urinary tract symptoms, anal and/or urinary incontinence, and sexual dysfunctions. MATERIALS AND METHODS: A systematic literature search was performed on 20 May 2023 using Scopus, PubMed, and Embase. Only English and adult papers were included. Meeting abstracts and preclinical studies were excluded. RESULTS: Twenty-one papers were accepted, revealing significant findings in the field. The study identified four primary sites of pudendal nerve entrapment (PNE), with the most prevalent location likely being at the level of the Alcock canal. Voiding symptoms are commonly exhibited in patients with PNE. PNN improved both urgency and voiding symptoms, and urinary and anal incontinence but is less effective in cases of long-standing entrapment. Regarding sexual function, the recovery of the somatic afferent pathway results in an improvement in erectile function early after neurolysis. Complete relief of persistent genital arousal disorder occurs in women, although bilateral PNN is necessary to achieve the efficacy. PNN is associated with low-grade complications. CONCLUSIONS: PNN emerges as a viable option for addressing urinary symptoms, fecal incontinence, erectile dysfunction, and female sexual arousal in patients suffering from PNE with minimal postoperative morbidity.

Fractional CO2 laser for genitourinary syndrome of menopause: evaluating the evidence.

The fractionated CO2 laser has been marketed to women for a variety of gynecologic symptoms and conditions, including the genitourinary syndrome of menopause (GSM). The evidence has been limited, precluding conclusions regarding the efficacy and safety of the therapy. However, data from randomized, controlled trials evaluating this technology for GSM are now available. This Practice Pearl addresses the latest data concerning the use of the fractionated CO2 laser for the treatment of GSM.

Patient-reported sexual function of breast cancer survivors with genitourinary syndrome of menopause after fractional CO2 laser therapy.

OBJECTIVE: The objective of this pilot study was to evaluate the change in sexual function following treatment with fractional CO2 laser therapy in breast cancer (BC) survivors with genitourinary syndrome of menopause (GSM). METHODS: A single-arm feasibility study of BC survivors with symptoms of GSM, including dyspareunia and/or vaginal dryness, was conducted. Participants who received three treatments with fractional CO2 laser and 4-week follow-up were contacted for patient-reported outcomes and adverse events at 12 months. Sexual function was measured using the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale Revised (FSDS-R). Descriptive statistics were calculated for patient demographics and disease characteristics for the set of participants who agreed to long-term follow-up and those who were lost to follow-up. FSFI and FSDS-R scores were summarized at baseline, 4 weeks and 12 months, as well as the change from baseline, and were compared using a Wilcoxon signed rank test. RESULTS: A total of 67 BC survivors enrolled, 59 completed treatments and 4-week follow-up; 39 participated in the 12 month follow-up. The overall FSFI score improved from baseline to 4-week follow-up (median Δ 8.8 [Q1, Q3] (QS) (2.2, 16.7)], P < 0.001). There were improvements at 4 weeks in all domains of the FSFI (P < 0.001 for each) including desire (median Δ 1.2; QS [0.6, 1.8]), arousal (median Δ 1.2; QS [0.3, 2.7]), lubrication (median Δ 1.8 (0, 3.3), orgasm (median Δ 1.2; QS [0, 3.6]), satisfaction (median Δ 1.6 (0.4, 3.2)), and pain (median Δ 1.6 (0, 3.6). The FSDS-R score also improved from baseline to 4-week follow-up (median Δ -10.0; QS [-16, -5] P < 0.001) indicating less sexually related distress. The scores of the FSFI and FSDS-R remained improved at 12 months and there were no serious adverse events reported. CONCLUSIONS: In BC survivors with GSM, the total and individual domain scores of the FSFI and the FSDS-R improved after fractional CO2 laser therapy.

Video Summary:http://links.lww.com/MENO/A711 .

Pilot study of fractional CO2 laser therapy for genitourinary syndrome of menopause in gynecologic cancer survivors.

PURPOSE: The objectives of this study were to evaluate the feasibility and efficacy of fractional CO2 laser therapy in gynecologic cancer survivors. METHODS: This was a pilot, multi-institutional randomized sham-controlled trial of women with gynecologic cancers with dyspareunia and/or vaginal dryness. Participants were randomized to fractional CO2 laser treatment or sham laser treatment. The primary aim was to estimate the proportion of patients who had improvement in symptoms based on the Vaginal Assessment Scale (VAS). Secondary aims included changes in sexual function assessed using the Female Sexual Functioning Index (FSFI) and urinary symptoms assessed using the the Urinary Distress Inventory (UDI-6). RESULTS: Eighteen women participated in the study, ten in the treatment arm and eight in the sham arm. The majority of participants had stage I (n = 11, 61.1 %) or II (n = 3, 16.7 %) endometrial cancer with adenocarcinoma histology (n = 9, 50 %). In total, 15 (83.3 %) of the participants completed all treatments and follow-up visit. There was no difference in the change in the median VAS score from baseline to follow-up. However, there was an improvement in change in the median total FSFI score with treatment compared with sham (Δ 6.5 vs -0.3, p = 0.02). The change in the median UDI-6 score was lower in the treatment arm (Δ -14.6 vs -2.1, p = 0.17), but this was not statistically significant. There were no reported serious adverse events. CONCLUSIONS: Fractional CO2 laser therapy is feasible in gynecologic cancer survivors, with preliminary evidence of safety. In addition, there was preliminary evidence of improvement in sexual function compared with sham treatment. Clinicaltrial.gov Identifier: NCT03372720 (OSU-17261; NCI-2017-02051).

Complications in adulthood for patients with paediatric genitourinary reconstruction.

BACKGROUND: Caring for adults with prior paediatric genitourinary reconstruction remains a challenge for adult providers. Reconstructions typically have occurred decades before; surgical records are not always available and patients and families may be unable to convey procedures performed. Spina bifida (SB) patients are vulnerable to cognitive decline which may compound these challenges. Changes in patient body habitus and loss of function may contribute to problems with previous reconstructions. METHODS: This is a non-systematic review of the literature and represents expert opinion where data are non-existent. This review focuses on the evaluation and management of complications arising from genitourinary reconstruction in congenital neurogenic bladder patients. RESULTS: Common complications experienced by congenital neurogenic bladder patients include recurrent urinary tract infection, incontinence of catheterizable channel and urinary reservoir as well as malignancy as this population ages. Preservation of renal function and prevention of urinary tract infection while optimizing continence are essential guiding principles in the care of these patients. Many of the recommendations, however, are gleaned from available data in the adult spinal cord patient (a more commonly studied population) or the paediatric urologic literature due to limited studies in adult management of such patients. CONCLUSION: Close follow-up and vigilance is warranted to monitor for infectious, mechanical and malignant complications while optimizing preservation of the upper urinary tracts and patient quality of life.

CO2 laser and the genitourinary syndrome of menopause: a randomized sham-controlled trial.

PURPOSE: This study aimed to clarify the efficacy of intravaginal CO2-laser treatment in postmenopausal women with genitourinary syndrome of menopause (GSM). MATERIALS AND METHODS: This double-blind, randomized, sham-controlled trial included postmenopausal women diagnosed with GSM and bothersome dryness and dyspareunia. Treatment consisted of three sessions. Active CO2-laser treatments (active group) were compared to sham treatments (sham group) with the primary endpoints being changes in dryness and dyspareunia intensity, as assessed by the 10-cm visual analog scale. Secondary endpoints were as follows: changes in Female Sexual Function Index (FSFI; total score and all domains), itching, burning, dysuria, and Urogenital Distress Inventory (UDI-6); incidence of symptoms; and presence of adverse events. All outcomes were evaluated at baseline and 4 months post baseline. RESULTS: Fifty-eight women (28 in the active group and 30 in the sham group) were eligible for inclusion. In the active group, dryness, dyspareunia, FSFI (total score), itching, burning, dysuria, and UDI-6 were significantly improved (mean [standard deviation] -5.6 [2.8], -6 [2.6], 12.3 [8.9], -2.9 [2.8], -2.3 [2.8], -0.9 [2.1], and -8.0 [15.3], respectively). In the sham group, dryness, itching, and burning were significantly improved (-1.9 [2], -1.4 [1.9], and -1 [1.9], respectively). All changes were in favor of the active group. After completion of the protocol, the proportion of participants with dryness, dyspareunia, and sexual dysfunction was significantly lower in the active group compared to those in the sham group (all p < 0.005). CONCLUSIONS: CO2 laser could be proposed as an effective alternative treatment for the management of GSM as it is superior to sham treatments.

Update: The Clinical Role of Vaginal Lasers for the Treatment of the Genitourinary Syndrome of Menopause.

OBJECTIVE: To educate providers on the emergence of vaginal lasers for the treatment of the genitourinary syndrome of menopause (GSM) and discuss the peer-reviewed literature regarding their use. MATERIALS AND METHODS: A search of literature databases (PubMed and Medline) was performed for publications in February 2020. Keywords included genitourinary syndrome of menopause, urinary incontinence, overactive bladder, urgency, urinary tract infections, atrophy, laser, and vaginal. We reviewed the available published literature, identifying articles, guidance, and society statements on the use vaginal laser therapies. RESULTS: The literature regarding vaginal laser therapy in the treatment of the GSM is primarily limited to prospective case series with small numbers and short-term follow-up. Nevertheless, these studies have demonstrated reductions in genitourinary syndrome of menopause symptoms. High quality data describing the safety, benefits, and appropriate use of vaginal laser therapy is lacking. CONCLUSION: Vaginal laser treatment for the GSM is of interest as it provides patients with a nonhormonal treatment option. Further research to better outline the indications, efficacy, safety, and applications of this technology is needed before supporting its universal use for the management of the GSM.

Nerve-sparing in Gynecologic Surgery: A Perspective.

OBJECTIVE: To provide a perspective on nerve-sparing (NS) surgery in gynecology. DATA SOURCES: Literature review, English language. METHODS OF STUDY SELECTION: Systematic reviews and meta-analyses studies were selected for review for oncology; comparative studies were selected for endometriosis, and 1 comparative and 1 prospective study were chosen for sacrocolpopexy. TABULATION, INTEGRATION, AND RESULTS: Two tables summarize the results of systematic reviews and meta-analyses in oncology. Oncology, endometriosis, and urogynecology sections. Primary benefit of NS technique is decreased bladder dysfunction, and, to a lesser degree, vaginal and rectal dysfunc. CONCLUSION: NS is preferable to conventional surgery for benign and malignant conditions to reduce postoperative bladder, rectal, and vaginal dysfunction.

Sexual function after vaginal erbium laser: the results of a large, multicentric, prospective study.

The aim of this multicentric, prospective study was to evaluate the effects of vaginal erbium laser (VEL-SMOOTH®) on sexual function in postmenopausal women suffering from the genitourinary syndrome of menopause (GSM). This study was performed on an outpatient basis without anesthesia or drug use before or after the intervention, using an erbium laser (XS Fotona Smooth®, Fotona, Ljubljana, Slovenia) in 1081 postmenopausal women (age 54.3 ± 3.9 years) treated with up to three laser applications every 30 days. Patients were assessed using the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale-Revised (FSDS-R). No adverse events were recorded during the study. The FSDS-R scores (n = 554), from basal values of 25.5 ± 3.5, were 11.5 ± 3.0, 10.5 ± 3.5 and 11.5 ± 3.5 at the 4-, 12- and 24-week follow-ups, respectively (p < 0.01 vs. corresponding basal values). Individual FSFI domain scores (n = 569) significantly (p < 0.001) increased after VEL-SMOOTH® treatment and remained significantly higher up to the 24th week after the end of treatment. The total scores, from basal values of 15.5 ± 1.5, were 27.5 ± 2.5, 27.6 ± 2.7and 27.0 ± 3.5 at the 4-, 12- and 24-week follow-ups, respectively (p < 0.01 vs. corresponding basal values). Albeit not randomized, this large, prospective study shows that VEL-SMOOTH® treatment may improve sexual function in postmenopausal women suffering from GSM.

Histological findings after non-ablative Er:YAG laser therapy in women with severe vaginal atrophy.

Objective: The aim of this study was to evaluate the effect of non-ablative erbium vaginal laser treatment on vaginal mucosa tissue affected by severe atrophy.Methods: Ten patients with severe genitourinary syndrome of menopause were treated with two sessions of the non-ablative erbium-doped yttrium aluminium garnet laser (Er:YAG laser) separated by 4 weeks. Vaginal biopsies were performed before and 3 months after the second treatment. The improvement in vaginal atrophy was assessed using multiple measuring tools before and 6 months after the treatment. The degree of patients' satisfaction was also assessed.Results: Microscopic examination showed significant changes in the main structural components of the vaginal wall mucosa after two non-ablative Er:YAG laser sessions. The epithelial thickness increased from 45 µm (10-106 µm) to 153 µm (97-244 µm) measured 3 months after the final laser treatment. Vaginal atrophy improved in all patients by all measured outcomes. The degree of patient satisfaction was very high (3.6 on the Likert four-point scale). No adverse events or complications were observed in any of the sessions. Conclusion: The non-ablative Er:YAG laser seems to be a safe and effective method to increase epithelial thickness of the vaginal mucosa in patients with severe vaginal atrophy.

Safety of vaginal erbium laser: A review of 113,000 patients treated in the past 8 years.

Background: Energy-based devices are becoming a popular option for minimally invasive vaginal procedures. The aim of this study was to obtain information on the frequency of occurrence of adverse effects (AEs) related to vaginal erbium laser (VEL™) treatment.Materials and methods: The global survey was conducted among practitioners using the non-ablative VEL™ (Fotona, Ljubljana, Slovenia). Users were invited to provide the number of patients treated with VEL™ and the number of observed laser-related AEs.Results: The survey was conducted from August 2018 to April 2019. Responses from 535 practitioners were collected, with a total of 113,174 patients treated in the period from 2012 to 2019. Out of 535 respondents, 160 (30%) shared detailed information about the indications they treated in a population of 62,727 patients, whereas 188 (35%) respondents provided information on the frequency of AEs observed in their treated population of 43,095 patients. All observed AEs were mild to moderate, transient and appeared with low frequencies.Conclusions: Minimally invasive thermal-only laser treatment using the non-ablative VEL™ procedures appears to be safe and the incidence of AEs is low.

Lasers in the era of evidence-based medicine.

Transvaginal laser therapies are being increasingly used for a variety of indications, particularly genitourinary syndrome of the menopause and stress urinary incontinence. This article reviews the current data pertaining to the place of these devices in current clinical practice. Whilst there has been a rapid increase in the number of publications over the last few years, many of the studies are of small numbers, short duration, and poor quality and are device-sponsored. The evidence suggests that vaginal laser therapy with either the erbium-doped yttrium aluminum garnet laser (FotonaSmooth®) or the CO2 laser (MonaLisa Touch®) is an effective intervention for the relief of symptoms of vulvovaginal atrophy in symptomatic women. The benefits of three laser treatments appear to last for at least 12 months and the procedure is generally well tolerated, with transient minor discomfort being the most common adverse event. Whilst the vaginal laser certainly has the potential to be an alternative treatment to vaginal estrogens for those groups of women, such as breast cancer patients, who cannot take them, there are still many unanswered questions about the role of vaginal laser therapy in clinical practice, particularly in relation to standard conservative management. The place of vaginal laser therapy in other conditions such as stress urinary incontinence is less clear. The outcomes from several ongoing randomized trials should help to answer some of these questions. In the meantime, the use of vaginal laser devices should be confined to clinical trials.

Machine learning in the optimization of robotics in the operative field.

PURPOSE OF REVIEW: The increasing use of robotics in urologic surgery facilitates collection of 'big data'. Machine learning enables computers to infer patterns from large datasets. This review aims to highlight recent findings and applications of machine learning in robotic-assisted urologic surgery. RECENT FINDINGS: Machine learning has been used in surgical performance assessment and skill training, surgical candidate selection, and autonomous surgery. Autonomous segmentation and classification of surgical data have been explored, which serves as the stepping-stone for providing real-time surgical assessment and ultimately, improve surgical safety and quality. Predictive machine learning models have been created to guide appropriate surgical candidate selection, whereas intraoperative machine learning algorithms have been designed to provide 3-D augmented reality and real-time surgical margin checks. Reinforcement-learning strategies have been utilized in autonomous robotic surgery, and the combination of expert demonstrations and trial-and-error learning by the robot itself is a promising approach towards autonomy. SUMMARY: Robot-assisted urologic surgery coupled with machine learning is a burgeoning area of study that demonstrates exciting potential. However, further validation and clinical trials are required to ensure the safety and efficacy of incorporating machine learning into surgical practice.

A new treatment of genito-urinary post-menopausal atrophy with autologous micro-fragmented fat tissue: a thirty-six months follow up case series.

OBJECTIVE: Genitourinary atrophy is a menopausal pathological change determined by the definitive drop of ovarian hormones' production that can impact heavily on the health status of women, with important direct and indirect social costs. Unfortunately, available treatments are only symptomatic, and they are not able to reverse the atrophy and other related symptoms. Regenerative medicine, with single local injection of autologous micro-fractured fat tissue, could represent a viable new solution for these patients as it not only helps to relieve symptoms, but it also counteracts the mechanisms that lead to the menopausal genitourinary atrophy. The objective of this paper is to evaluate the long-term effectiveness of micro-fractured fat vulvar injection for genito-urinary atrophy in patients, affected by severe genitourinary atrophy (at least 4 symptoms lasting for at least 4 years). PATIENTS AND METHODS: We present a case series of 35 patients followed for 36 months to evaluate the effectiveness and safety of a single subcutaneous vulvar injection of autologous micro-fragmented fat tissue (MFAT). RESULTS: We have not observed any adverse effects in any patients. All symptoms, and especially pelvic pain and dyspareunia, improved in almost half of patients within 3 months. Ninety-nine percent of patients recovered completely from all symptoms after 9-12 months, reporting no relapse of the symptoms up to the third year of follow up. CONCLUSIONS: Our case series is the first case series, evaluating the long-term (3 years) safety and effectiveness of micro-fragmented adipose tissue graft for urogenital atrophy.

Evaluation of genitourinary fistulas in pelvic malignancies with etiopathologic correlation: role of cross sectional imaging in detection and management.

OBJECTIVE: Genitourinary fistulas in pelvic malignancies are abnormal communications occurring due to either locally advanced tumours invading the surrounding organs or post-therapeutic complications of malignancies. In this article we review and describe the role of cross-sectional imaging findings in the management of genitourinary fistulas in pelvic malignancies. METHODS: A retrospective study, for the period January 2012 to December 2018, was undertaken in patients with pelvic malignancies having genitourinary fistulas. The cross-sectional (CT and MRI) imaging findings in various types of fistulas were reviewed and correlated with the primary malignancy and the underlying etiopathology. RESULTS: Genitourinary fistulas were observed in 71 patients (6 males, 65 females). 11 types of fistulas were identified in carcinomas of cervix, rectum, ovary, urinary bladder, sigmoid colon, vault, endometrium and prostate. The commonest were rectovaginal and vesicovaginal fistulas. 13 patients had multiple fistulas. The sensitivity, specificity, positive and negative predictive values of CT and MRI are 98%, 100%, 66%, 98% and 95%, 25%, 88% and 50% respectively. Contrast-enhanced CT with oral and rectal contrast is more sensitive and specific than MRI in the evaluation of genitourinary fistulas. CONCLUSION: Imaging findings significantly influence the management and outcome of genitourinary fistulas in pelvic malignancies. Contrast-enhanced CT is the imaging modality of choice in the evaluation of pelvic fistulas associated with malignancies and MRI is complimentary to it. ADVANCES IN KNOWLEDGE: To our knowledge, this study is the first of its kind wherein the mean duration of occurrence of fistulas in pelvic malignancies is correlated with the underlying etiopathology.

Use of a shaving technique for surgical management of partial ureteral obstruction due to endometriosis.

OBJECTIVE: To illustrate the surgical management of advanced endometriosis causing extrinsic ureteral compression. DESIGN: Video description of the case, demonstration of the surgical technique, reevaluation at 14-year follow-up, and review of urogenital endometriosis. Patient provided consent for the video recording and publication. This surgical report with no identifying patient data was exempt from Institutional Review Board approval. SETTING: Tertiary referral center. PATIENT(S): A 42-year-old nulligravida with a known history of endometriosis presented with persistent pelvic pain and no other specific symptoms. She had previously undergone a diagnostic laparoscopy demonstrating advanced endometriosis involving multiple organs, including the urinary tract. She was referred to us for further surgical management. Preoperative intravenous pyelogram showed partial obstruction and constriction of a long portion of the midpelvic and distal left ureter with proximal hydroureter, consistent with extrinsic ureteral compression. INTERVENTION(S): The patient underwent operative video laparoscopy using a multipuncture technique, with enterolysis, extensive left ureterolysis, shaving of periureteral constrictive fibrosis and endometriosis, cystoscopy, and placement of left ureteral stent. MAIN OUTCOME MEASURE(S): There was extensive endometriosis and fibrotic adhesions involving the left pelvic sidewall. Proximal hydroureter was noted to the pelvic inlet secondary to severe periureteral fibrosis from the pelvic brim to the bladder meatus, with significant narrowing of the pelvic ureter. The endometriosis was resected using hydrodissection and shaving with a carbon dioxide laser. Histopathologic evaluation of the resection specimens confirmed endometriosis. RESULT(S): An intravenous pyelogram performed 4 weeks postoperatively revealed ureteral patency and resolving hydroureter, and her ureteral stent was removed. Annual renal ultrasounds for the subsequent 2 years were normal. Fourteen years later, she remained asymptomatic on no suppressive treatment. A follow-up intravenous pyelogram was performed and showed a normal urinary tract with bilateral ureteral patency and no recurrent strictures or hydroureter. CONCLUSION(S): In selected cases, conservative shaving of periureteral fibrotic endometriosis avoids ureteral resection and has acceptable outcomes.

Effectiveness of CO2 laser on urogenital syndrome in women with a previous gynecological neoplasia: a multicentric study.

BACKGROUND: Many women diagnosed with gynecological cancers undergo adjuvant therapy, which may lead to transient or permanent menopause that ultimately leads to urogenital syndrome and vulvovaginal atrophy. Studies advise against the use of estrogen in women with a history of hormone-dependent cancer. One alternative is vaginal microablative fractional CO2 laser, which promotes tissue regeneration through the production of collagen and elastic fibers. OBJECTIVE: To evaluate the effectiveness of CO2 laser in the treatment of urogenital syndrome-in particular, symptomatic vulvovaginal atrophy in women who have survived gynecological cancers. METHODS: A retrospective study was carried out, including all patients with a history of gynecological cancers and vulvovaginal atrophy who underwent CO2 laser treatment between November 2012 and February 2018 in four Italian centers. The study was approved by the local ethics committee of each participating institution. The inclusion criteria were women aged between 18 and 75; Eastern Cooperative Oncology Group performance status <2; and history of breast, ovarian, cervical, or uterus cancer. Patients had to have vulvovaginal atrophy and at least one of the following symptoms of urogenital syndrome: vaginal dryness, dyspareunia, vaginal introitus pain, burning, or itching. Three applications were administered at baseline, 30 days, and 60 days. All patients were evaluated before the first laser session, at each session, and 4 weeks after the last session. In particular, patients were asked to indicate the intensity of symptoms before the first session and 4 weeks after the last session, using Visual Analog Scale (VAS) scoring from 0 ('no discomfort') to 10 ('maximum discomfort'). RESULTS: A total of 1213 patients underwent CO2 laser treatment and of these, 1048 were excluded because they did not meet the inclusion criteria in the analysis. Finally, a total of 165 patients were included in the study. The mean age at the time of treatment was 53 years (range 31-73). Dryness improved by 66%, dyspareunia improved by 59%, burning improved by 66%, pain at introitus improved by 54%, and itching improved by 54%. The side effects were evaluated as pain greater than VAS score 6 during and after the treatment period. No side effects were seen in any sessions. CONCLUSIONS: Fractional microablative CO2 laser therapy offers an effective strategy in the management of the symptoms of genitourinary syndrome in post-menopausal women and in survivors of gynecological cancer.