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erbium are conducted using precisely controlled, sequentially packaged bursts of

pulses (SMOOTH

mode) [9, 14]. The “smooth mode pulse,” with a duration of

250ms, consisted of a fast sequence of individual micropulses (300μs) with intra-

pulse intervals of 50ms. In this mode, vaginal mucosa temperatures increased to

60–65°C, without inducing supercial ablation, with an increased vascularization

and a deep collagen remodeling and new collagen synthesis [9, 14]. Thus, the spe-

cically designed sequence of SMOOTH Er:YAG laser pulses can be delivered to

the vaginal tissue in order to achieve controlled heating of the collagen in the deeper

mucosa layers, without ablation or overheating of the mucosa surface, resulting in

the generation of new collagen and an overall improvement of treated tissue tight-

ness and elasticity. VEL usually is associated with a very low incidence of discom-

fort, erythema, edema, and fast recovery rate [14–29].

Specic vaginal probes have been designed to enable a uniform and well-

controlled VEL distribution on the whole length and circumference of the vaginal

canal. As for the rst-generation microablative CO

laser, also for the erbium laser,

we have to underline that the core of the published data was obtained using the spe-

cic SMOOTH erbium in yttrium aluminum-garnet crystal (Er:YAG) technology. The

SMOOTH

mode allowing the use of full beam and patterned handpieces to deliver

Er:YAG laser energy with different uences to the vaginal tissue is a patented and reg-

istered technology which differs from other Er:YAG lasers on the market. Therefore,

the term vaginal erbium laser (VEL) refers to SMOOTH

mode technology.

12.4 Vaginal Erbium Laser

Recent publications suggest that VEL may provide a new noninvasive treatment

with non-ablative, second-generation photothermal vaginal therapy [14–29].

Vaginal laser stimulates profound effects on the vaginal epithelium and lamina pro-

pria [14–16]. Gaspar etal. [15] presented seminal data on the effects of VEL in

comparison to estrogen vaginal administration. Other groups reported the improve-

ment of GSM as well as stress urinary incontinence and initial grades of vaginal

prolapse in VEL-treated patients [14–29].

In a prospective study, the effects of VEL in women with GSM were compared

with another group of women treated with vaginal estriol administration, a stan-

dard treatment of GSM [19]. Signs and symptoms were evaluated subjectively by

the visual analog scale (VAS) and objectively by the vaginal health index (VHIS)

[19]. Three applications of VEL every 30days induced a signicant improvement in

both subjective symptoms of vaginal dryness and dyspareunia and objective evalu-

ation of VHIS.These changes were matching those induced by 3months of vaginal

estriol administration [19]. In both groups the VAS scores for vaginal dryness and

dyspareunia showed a signicant improvement with VEL treatments or 12weeks of

estriol. However, in the estriol group a reduction of efcacy was seen 12weeks after

the end of treatment. Conversely, in the VEL group, the same positive results were

maintained throughout all the study period up to the 6months of follow-up. In that

study [19] the VEL treatment was performed in PMW suffering from GSM with-

out any previous or concomitant treatment with estrogens or even non-hormonal

vaginal creams. Therefore, the effects of VEL seems to be independent from any

12 Laser Treatment forVulvovaginal Atrophy

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pretreatment, suggesting that VEL can be proposed in PMW that cannot be treated

with hormones, as in breast cancer survivors. In fact, in a parallel study [26], it

has been demonstrated that VEL is effective and safe for the treatment of GSM

in postmenopausal breast cancer survivors [26]. In these particular set of patients,

VEL improved both dryness and dyspareunia, inducing a rapid and long-lasting

positive effect on the appearance of vaginal mucosa, up to the 12months after the

VEL treatment [26].

These observations are of relevance, since one of the frequently asked questions

is how long the laser effects can last. This issue was evaluated in a large prospec-

tive, longitudinal study conducted in more than 200 women [28]. The results of

this study indicate that the VEL effects are rapid and long-lasting in PMW suffer-

ing from GSM.Patients were treated with three VEL applications, and follow-up

evaluations were performed up to 24months from the last laser application. Vaginal

dryness and dyspareunia showed a signicant decrease after the rst VEL treatment,

and in the follow-up period, the dryness and dyspareunia values were signicantly

different from baseline values during the follow-up period up to the 12months of

observation. Conversely, the values measured after 18 and 24months from the last

VEL application were not signicantly different anymore from basal values [28].

It is noteworthy that 73.6% of them (n=151) reported that the VEL treatment was

effective for 12–18months [28]. Only 8 patients (3.9%) afrmed that the treatment

was not effective in reducing GSM symptoms, while total of 174 (84.9%) patients

decided to repeat the VEL procedure [28].

Thus, this large longitudinal study [28] can be of help in setting the timing of

when a repeated laser procedure(s) can be offered. The positive action on VEL ther-

motherapy may last at least 1year, and it can be suggested that 12months could be

a therapeutic window for the vast majority of women. Therefore, a new VEL pro-

cedure could be indicated every 12months. In this view, the use of a non-ablative

laser such as VEL with the smooth mode is particularly appropriate in younger

women suffering from GSM in which we can imagine many laser procedure during

their lifetime. Thus, VEL is appropriate for women that cannot or do not want to be

treated with hormones, such as breast cancer survivors, often young and sometimes

premenopausal before cancer treatment. In addition VEL can be of help in women

who do not accept long-term use of moisturizing and lubricants for the interferences

with sexuality.

This study [

28] demonstrates that the large majority of patients were satised,

as demonstrated by the high percentage (85%) that chooses to repeat the treatment.

The possible difference in the outcomes of VEL treatment with or without estrogen

or other non-hormonal pretreatment or the current use of other therapies is a matter

of future randomized studies.

12.5 Conclusions

In conclusion, although data from large randomized trials are not available, the

results from a large number of observational studies are encouraging (Table12.1).

The effect of laser treatment is comparable to that exerted by local hormone

M. Gambacciani

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209

treatment in postmenopausal women suffering from GSM.Cohort prospective long-

term studies show that the second-generation VEL-Smooth

procedure is effective

and intrinsically safe, if applied with the appropriate parameters, and no serious

adverse effects were ever reported. Thus, VEL-Smooth

for vaginal functional res-

toration can be seen as an effective, noninvasive ambulatory procedure for the treat-

ment of GSM.VEL-Smooth

can increase our armamentarium in order to offer a

new, long-term therapeutic option, to improve the quality of life, allowing women to

choose, considering the limits and the balance between benets and risks associated

with each therapeutic approach.

References

1. Portman DJ, Gass MLS, on behalf of the Vulvovaginal Atrophy Conference Panel.

Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from

the International Society for the Study of Women’s Sexual Health and the North American

Menopause Society. Climacteric. 2014;17(5):557–63.

2. Management of symptomatic vulvovaginal atrophy: 2013 position statement of the North

American Menopause Society. Menopause. 2013;20:888–902.

3. Stuenkel CA, Davis SR, Gompel A, Lumsden MA, Murad MH, Pinkerton JV, Santen

RJ.Treatment of symptoms of the menopause: an Endocrine Society clinical practice guide-

line. J Clin Endocrinol Metab. 2015;100(11):3975–4011.

4. Palacios S, Castelo-Branco C, Currie H, Mijatovic V, etal. Update on management of genito-

urinary syndrome of menopause: a practical guide. Maturitas. 2015;82:307–12.

5. Gambacciani M, Biglia N, Cagnacci A, Caruso S, Cicinelli E, DE Leo V, DI Carlo C, Farris

M, Gambera A, Guaschino S, Lanzone A, Paoletti AM, Russo N, Vicariotto F, Villa P,

Volpe A, Italian Menopause Society (SIM). Menopause and hormone replacement ther-

apy: the 2017 recommendations of the Italian Menopause Society. Minerva Ginecol.

2018;70(1):27–34.

6. Bachmann GA, Komi JO.Ospemifene effectively treats vulvovaginal atrophy in postmeno-

pausal women: results from a pivotal phase 3 study. Menopause. 2010;17(3):480–6.

7. Portman DJ, Bachmann GA, Simon JA.Ospemifene, a novel selective estrogen receptor mod-

ulator for treating dyspareunia associated with postmenopausal vulvar and vaginal atrophy.

Menopause. 2013;20(6):623–30.

8. Portman D, Palacios S, Nappi RE, Mueck AO.Ospemifene, a non-oestrogen selective oes-

trogen receptor modulator for the treatment of vaginal dryness associated with postmeno-

pausal vulvar and vaginal atrophy: a randomised, placebo-controlled, phase III trial. Maturitas.

2014;78(2):91–8.

9. Tadir Y, Gaspar A, Lev-Sagie A, etal. Light and energy based therapeutics for genitourinary

syndrome of menopause: consensus and controversies. Lasers Surg Med. 2017;49(2):137–59.

10. Gambacciani M, Palacios S.Laser therapy for the restoration of vaginal function. Maturitas.

2017;99:10–5.

11. Gaspar A, Addamo G, Brandi H.Vaginal fractional CO2 laser: a minimally invasive option for

vaginal rejuvenation. Am J Cosmet Surg. 2011;28:156–62.

Table 12.1

Vaginal erbium

laser (VEL) treatment for the

genitourinary syndrome

(GSM) of menopause: key

points

• VEL is a noninvasive, ambulatory procedure

•

VEL is effective in the treatment of GSM

•

The results are rapid and long-lasting

•

The clinical effects are comparable to local estrogen

treatment

•

VEL is intrinsically safe and can be repeated every year

12 Laser Treatment forVulvovaginal Atrophy

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210

12. Salvatore S, Nappi RE, Zerbinati N, etal. A 12-weeks treatment with fractional CO2 laser for

vulvovaginal atrophy: a pilot study. Climacteric. 2014;17(4):363–9.

13. Salvatore S, Nappi RE, Parma M, etal. Sexual function after fractional microablative CO2laser

in women with vulvovaginal atrophy. Climacteric. 2015;18:219–25.

14. Vizintin Z, Lukac M, Kazic M, Tettamanti M. Erbium laser in gynecology. Climacteric.

2015;18(suppl 1):4–8.

15. Gaspar A. Comparison of new minimally invasive Er:YAG laser treatment and hormonal

replacement therapy in the treatment of vaginal atrophy. Climacteric. 2014;17(Suppl

1):48–108.

16. Lapii GA, Yakovleva AY, Neimark AI. Structural reorganization of the vaginal mucosa in

stress urinary incontinence under conditions of Er:YAG laser treatment. Bull Exp Biol Med.

2017;162:510–4.

17. Gambacciani M, Levancini M.Short-term effect of vaginal erbium laser on the genitourinary

syndrome of menopause. Minerva Ginecol. 2015;67(2):97–102.

18. Gambacciani M, Levancini M.Vaginal erbium laser: the second generation thermotherapy for

the genitourinary syndrome of menopause (GSM) in breast cancer survivors. A preliminary

report of a pilot study. It J Gynaecol Obstet. 2015;27:15–7.

19. Gambacciani M, Levancini M, Cervigni M.Vaginal erbium laser: the second-generation ther-

motherapy for the genitourinary syndrome of menopause. Climacteric. 2015;18:757–63.

20. Fistonić N, Fistonić I, Lukanovič A, FindriGuštek Š, SortaBilajacTurina I, Franić D. First

assessment of short-term efcacy of Er:YAG laser treatment on stress urinary incontinence in

women: prospective cohort study. Climacteric. 2015;18:37–42.

21. Lee MS.Treatment of vaginal relaxation syndrome with an erbium: YAG laser using 90° and

360° scanning scopes: a pilot study & short-term results. Laser Ther. 2014;23:129–38.

22. Ogrinc UB, Senčar S, Lenasi H.Novel minimally invasive laser treatment of urinary inconti-

nence in women. Lasers Surg Med. 2015;47(9):689–97.

23. Pardo JI, Solà VR, Morales AA.Treatment of female stress urinary incontinence with erbium-

YAG laser in non-ablative mode. Eur J Obstet Gynecol Reprod Biol. 2016;204:1–4.

24. Fistonic N, Fistonic I, Findri-Gustek S, Bilajac Turina I, Kristoc I, Franic D.Minimally inva-

sive, non-ablative Er:YAG laser treatment of stress urinary incontinence in women—a pilot

study. Lasers Med Sci. 2016;31:635–43.

25. Gambacciani M, Torelli MG, Martella L, etal. Rationale and design for the vaginal erbium

laser academy study (VELAS): an international multicenter observational study on genito-

urinary syndrome of menopause and stress urinary incontinence. Climacteric. 2015;18(Suppl

1):43–8.

26. Gambacciani M, Levancini M.Vaginal erbium laser as second generation thermotherapy for

the genitourinary syndrome of menopause: a pilot study in breast cancer survivors. Menopause.

2017;24(3):316–9.

27. Gaspar A, Brandi H, Gomez V, Luque D.Efcacy of erbium:YAG laser treatment compared to

topical estriol treatment for symptoms of genitourinary syndrome of menopause. Laser Surg

Med. 2017;49:160–8.

28. Gambacciani M, Levancini M, Russo E, Vacca L, Simoncini T, Cervigni M.Long-term effects

of vaginal erbium laser in the treatment of genitourinary syndrome of menopause. Climacteric.

2018;21(2):148–52.

29. Blaganje M, Šcepanovic D, Žgur L, Verdenik I, Pajk F, Lukanovic A.Non-ablative Er:YAG

laser therapy effect on stress urinary incontinence related to quality of life and sexual function:

a randomized controlled trial. Eur J Obstet Gynecol Reprod Biol. 2018;224:153–8.

M. Gambacciani

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211

F. R. Pérez-López (ed.), Postmenopausal Diseases and Disorders,

https://doi.org/10.1007/978-3-030-13936-0_13

I. Fistonić (*)

Institute for Women’s Health, Zagreb, Croatia

e-mail: ivan.stonic@zg.t-com.hr

N. Fistonić

Ob/Gyn Department, University Hospital Merkur, Zagreb, Croatia

Laser Treatments inFemale Urinary

Incontinence

IvanFistonić andNikolaFistonić

Abbreviations

BMI Body mass index

CRC Collagen Remodeling Capacity

Er:YAG Erbium:yttrium-aluminum-garnet

FSFI Female sexual function index

GSM Genitourinary syndrome of menopause

ICIQ-UI SF International Consultation on Incontinence Questionnaire-Urinary

Incontinence Short Form

ISD Intrinsic sphincter deciency

ISI Incontinence Severity Index

LUTS Lower urinary tract symptoms

MUS Mid-urethral sling

OAB Overactive bladder

OABSS Overactive Bladder Symptoms Score Questionnaire

PISQ12 Pelvic Organ Prolapse/Urinary Incontinence Sexual Function

Questionnaire

POP Pelvic organ prolapse

QoL Quality of life

RTD Residual thermal damage

SUI Stress urinary incontinence

UCP Urethral closure pressure

UI Urinary incontinence

VEL Vaginal erbium laser

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13.1 Introduction

A wide spectrum of treatments for stress urinary incontinence (SUI) include non-

invasive (pelvic oor muscle training, weight reduction, laser interventions), mini-

mally invasive (bulking methods), less invasive (sling and mesh), and invasive

surgical procedures. Less invasive operative techniques are relatively effective but

are still related to >15% complications (bleeding, erosions, urethral injury, infec-

tion, chronic pain, and urine retention) [1], while conventional surgery relates to

anesthesia risks and high recurrence rates (25%) [2].

The association between pelvic organ prolapse (POP) and SUI with collagen is

well established. The expression levels of Type I and Type III collagen are signi-

cantly lower in patients with POP and SUI when compared to the controls (p<0.01)

[3], and pubocervical fasciae of incontinent women have a lower collagen content [4].

Postmenopausal hormonal deciency with increased degradation of collagen reserve

is a possible explanation for the failure of many surgical procedures aimed at correct-

ing prolapse/incontinence with a frequent recurrence of symptoms [5].

Contemporary scientic and technological breakthroughs have led to better clin-

ical outcomes with less invasive procedures with shorter recovery times and lower

implicated costs. In this sense, recent evidence supports laser treatment as an alter-

native and effective intervention for SUI [6].

13.2 Mode ofLaser Action andProtocol forIts Use forStress

Urinary Incontinence

Pulsed laser photothermal energy can improve collagen structure and initiate neo-

collagenesis in the skin [7] and pelvic oor with nearby tissue as well [8]. An

increase in temperature breaks up intermolecular cross-links and stabilizes the col-

lagen triple-helix structure, thus resulting in the shortening of collagen bers with

consequent neocollagenesis, elastogenesis, neoangiogenesis, and increased bro-

blast pool. In addition, morphometry showed an increase of the volume density of

blood capillaries and the thickness of the epithelial layer [9].

The Er:YAG laser SMOOTH

mode beam (Fotona, Slovenia) is strongly absorbed

in water which is the major constituent of human soft tissue. Precisely controlled

sequences of non-ablative Er:YAG laser pulses are delivered to the intravaginal

mucous tissue in order to achieve controlled heating of the collagen in the deeper

mucosa layers (lamina propria), without ablation and overheating of the mucosa sur-

face, so avoiding the risk of perforation with accidental lesions of the urethra, blad-

der, or rectum. Recommended parameters are laser spot size of 7mm, frequency of

1.6Hz, and uence (laser energy emitted per unit area) of 6.0 J/cm

. Mechanical

pull of the deeper tissue layers following shrinkage of the upper, photothermally

processed tissue layers further contributes to the tightening effect [10]. No general

anesthesia is needed. The lower vaginal third and introitus can be covered with a thin

layer of anesthetic cream. Treatment regimen consists of three sessions 3–4weeks

apart. When the process of neocollagenesis is well on its way, and assuming the

I. Fistonić and N. Fistonić

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patient Collagen Remodeling Capacity (CRC) was not fully reached during the rst

session, with the second and third session, some previously not affected collagen

bers are additionally captured. Minor side effects include sensation of warmth,

increased vaginal discharge, and rarely transient urge urinary incontinence [11].

laser system MonaLisa Touch

(DEKA, Florence, Italy) intravaginal ther-

apy is delivered once a month for 3 consecutive months. Recommended settings

[12, 13] of the microablative fractional CO

laser (MFCO

-Laser) are as follows:

D-pulse mode, dot power 40W, dwell time 1000μs, and dot spacing 1000μm for

the treatment of the vaginal canal and the dot power 24W, dwell time, 400μs, and

dot spacing 1000μm for the treatment of the vaginal introitus. The procedure is

performed in the outpatient setting and does not require any specic preparation

or anesthesia. Patients are recommended to avoid coital sexual activity for at least

3days after each laser application as mild inammatory reaction may last up to

48h.

13.3 Stress Urinary Incontinence (SUI)

The rst pilot study regarding Er:YAG laser for the treatment of female SUI

started on September 20, 2009 [14]. The degree of incontinence and its impact on

quality of life were assessed with the International Consultation on Incontinence

Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) [15] tool, where a

maximum score of 21 represents permanent incontinence.

The inclusion criteria for entering the study were ahistory of vaginal delivery,

SUI, normal cell cytology, negative urine culture, and a vaginal canal, introitus,

and vestibule free of injuries and bleeding. The exclusion criteria were severe pro-

lapse and damage of the rectovaginal fascia, urge incontinence, severe neurologi-

cal conditions associated with incontinence (multiple sclerosis, spinal cord injury,

stroke, Parkinson’s disease), neurogenic bladder, insulin-dependent diabetes mel-

litus, current urinary tract infection, hematuria, age <18 and >70years, pregnancy,

less than 24weeks after vaginal delivery, body mass index (BMI) >30kg/m

, intake

of photosensitive drugs, injury and/or active infection in the area to be treated, and

undiagnosed vaginal bleeding.

At the rst follow-up measurement (1month after the intervention), the number

of those with an ICIQ-UI score=0 increased from zero to 17/52 (42.3% continent).

At the second follow-up measurement, 2–6months after the intervention, 18/47

(38.3% continent) had an ICIQ-UI score=0 (Fig.13.1). From the baseline to the

second follow-up, a total of 34/47 (72.3%) of participants experienced improve-

ment, whereas 11/47 (23.4%) experienced no change in the ICIQ-UI score, and two

(4.3%) experienced worsening of symptoms. No major adverse events throughout

the course of laser treatment and the follow-up period were noticed or reported. The

rare mild reported symptoms such as slight edema, vaginal discharge, and transient

urgency vanished spontaneously after 8days.

Ogrinc etal. published a study of 175 women with newly diagnosed SUI (66%)

and mixed urinary incontinence (MUI, 34%) [16]. Patients were treated according

13 Laser Treatments inFemale Urinary Incontinence

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214

to the uniform Er:YAG laser protocol. Follow-ups were performed at 2, 6, and

12months after procedure. Results were based on the Incontinence Severity Index

(ISI) and the reduction in ICIQ-UI SF scores. One year after laser treatment, 77%

of the SUI patients and only 34% of mixed UI remained continent. No difference in

efcacy was noted between pre- and postmenopausal patients.

In another study [17], using the same Er:YAG protocol for SUI, urodynamic

studies, pad testing, lower urinary tract symptoms (LUTS), and sexual function

were assessed before and after treatment. The authors concluded that the procedure

for mild SUI was effective at 6-month follow-up, but was not for the patients with

an initial pad weight >10g. Moreover, it improved LUTS, quality of life (QoL),

and sexual function. Urodynamic values did not differ across the timeline. The

authors speculate that this paradox originates from tighter and more elastic colla-

gen that acts as a “hammock,” preventing urine leakage and reducing pad weights.

Although procedure follow-up was only up to the sixth month, authors summarize

that IncontiLase™ should not replace mid-urethral sling (MUS) surgery as the stan-

dard therapy for SUI patients who fail to improve following rst-line therapy. In

addition, authors stress that the injection of bulking agents has been reported to have

a cure rate of 53–73.2%, which is better than the cure rate of 39.3% they achieved

at a 6-month follow-up with IncontiLase™. In conclusion authors admit that, based

on its minimally invasive nature and the lack of signicant adverse effects, the

IncontiLase™ procedure may be used as an alternative therapy for mild SUI cases.

In a long-term, 24-month follow-up study [18] of 114 postmenopausal

women suffering from SUI, the vaginal erbium laser (VEL) treatment induced a

very sev

ere

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

Percentage of participants

severe

moderate

mild

no UI

Baseline 1st month 2-nd-6th month

Severity of UI

Fig. 13.1 Kloving’s categories of ICIQ-UI SF score severity at the baseline and follow-up visits.

ICIQ-UI International Consultation on Incontinence Questionnaire-Urinary Incontinence Short

Form, UI urinary incontinence. Reproduced with permission from Fistonic et al. [14]

I. Fistonić and N. Fistonić

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signicant decrease of baseline ICIQ-SF scores of 12.2±2.5. The ICIQ-UI SF

scores remained signicantly (p<0.01) lower than basal values 1 (4.8±1.8), 3

(6.2±1.9), 6 (7.0±2.3), and 12 (8.0±1.8) months after the last VEL application.

Scores after 18 (9.3±2.7) and 24 (9.9±2.8) months from the last VEL applica-

tion were, however, not signicantly different from the baseline values. This study

shows for the rst time that VEL treatment signicantly improves thegenitouri-

nary syndrome of menopause (GSM) at 12months after the last laser application,

while the effects decrease afterward. The study conrms that VEL is effective in

the treatment of GSM, with clinical effects similar to those exerted by established

local therapies.

Several other observational studies in which Er:YAG was used for mild to mod-

erate SUI also showed improvement of SUI symptoms [19–21].Up to date, there is

only one patient-blinded randomized controlled trial for SUI [22] consisting of 114

women patients receiving a single-session ofnon-ablative thermal-only Er:YAG

laser treatment. This study reported improvement of SUI symptoms, QoL (ICIQ-UI

SF), and sexual function (PISQ12 and FSFI) in premenopausal parous women. A

21.4% (12/56) of the laser group patients were continent 3months after treatment

according to ICIQ-UI SF (score = 0) in comparison to only 3.6% (2/56) conti-

nence in the sham control group. Covariates age, BMI, and parity had no signicant

effect on the outcome. All pelvic oor muscle variables, derived from perineometry

studies (duration and maximum pressure), showed a signicant improvement in the

laser group but not in the sham control group.

Carbon (CO

) laser has been used for the treament ofGSM, particularly focusing

on the vulvovaginal atrophy segment [8]. To date, very few studies regarding CO

laser treatment of SUI have been published.

Isaza etal. [23] used the SmartXide2 V2LR fractional microablative CO

laser

system (MonaLisa Touch™; Deka, Florence, Italy) in a prospective study of 161

postmenopausal women suffering from mild SUI.Patients received four sessions

30–45days apart. SUI was evaluated using the 1-h pad test and the ICIQ-UI SF at

the baseline and at 12, 24, and 36months of follow-up. Basal ICIQ-UI SF score

(14.34±2.65) signicantly decreased 12 (7.09±1.1, p<0.001), 24 (7.49±0.94,

p<0.001), and 36months (6.76±0.82, p<0.001) of follow up. The 1-h pad test

reduced from 9.89± 0.57 g at the baseline to 3.52 ± 1.89 g, 3.55 ±1.88 g, and

3.72±2.05g at 12, 24, and 36months, respectively (all p<0.001). Histology ana-

lyzed pretreatment and 6weeks after the rst treatment showed essentially thicker

epithelium with a higher population of intermediate and supercial cell shedding.

Nevertheless, such multiple ablative vaginal treatments raise concerns regarding the

possibility of vaginal scarring and infection, which can be reduced with the use of

a non-ablative treatment [22].

The prospective observational study regarding the efcacy of fractional CO

laser in postmenopausal women with moderate to severe clinical signs of GSM [24]

showed signicant improvement of dyspareunia, dryness, burning, itching, dysuria,

urgency, and SUI scores assessed by standard questionnaires. Participants received

intravaginal therapy, once a month for 3 consecutive months, with a CO

laser system

13 Laser Treatments inFemale Urinary Incontinence

https://t.me/med1917

216

(MonaLisa Touch

, DEKA, Florence, Italy). As a secondary outcome, authors noted

that urinary symptoms improved, as scores of the urinary and QoL questionnaires

signicantly decreased. ICIQ-UI SF at the baseline was 8.1± 5.6 vs. 3.4±4.3 at

the 3rdmonthof follow-up. All participants showed a >5-point improvement in the

King’s Health Questionnaire (KHQ) score, which includes psychometric aspects of

urinary incontinence. Despite this,authors concluded that factors predictive of ideal

laser therapy candidates were not identied. Considering predictive, preven-

tive, and personalized medicine (PPPM) current goal is not only to predict the risk

of an adverse clinical event but also benets [25]. A recent study [26] identied

predictors for the segment of patients achieving optimal short termEr:YAG laser

treatment outcomes. The best results after Er:YAG laser treatment of SUI should be

expected in younger women (<47.5years) with a body mass index of <23.3, average

newborn birth weight of >3.6kg, ICIQ-UI at a baseline of <10, and a perineometer

squeeze duration at a baseline of >3.51s.

However, despite the rigorous selection of patients, in a certain group, laser

treatment will not succeed. Namely, SUI is not only induced by urethral hypermo-

bility, as a result of weakening or disruption of the pelvic oor musculature and/

or pubourethral ligament, but also due to the weakening of the urethral sphinc-

ter, resulting in more severe intrinsic sphincter deciency (ISD) [27]. The ure-

thral sphincter function depends on the muscular component; the rhabdosphincter,

extending along 60–70% of the urethra length; and the mucosal or intrinsic com-

ponent, extending across the urethra and contributing to urethral closure [28].

Gaspar etal. [29, 30] hypothesized that by targeting the mucosal component of the

urethral sphincter, urethral coaptation ability would be able to increase. Authors

used the novel Er:YAG intraurethral cannula (IntraLase™, Fotona, Slovenia).

As assessed by a questionnaire addressing QoL (ICIQ-UI SF) and the 1-h pad

test, therapeutic efcacy was measured at 3 and 6 months after the procedure.

ICIQ-SF scores improved by an average of 64% at 3 months and by 40% at

6months. The 1-h pad test showed a reduction of the quantity of leaked urine by

59% at 3months and by 42% at 6months.

Patel [31] enrolled women whose urodynamic studies showed a maximal ure-

thral closure pressure (UCP) of less than 40cm H

O.Subjects received three frac-

tional CO

laser treatments 4weeks apart. Three months posttreatment, urodynamic

reevaluation showed an increase in maximal UCP from 19 to 33cm H

O atpretreat-

ment to 45–73cm H

Oposttreatment.

13.4 Overactive Bladder

Perino etal. [32] analyzed the effect of CO

laser treatment in postmenopausal

women with overactive bladder (OAB) symptoms (≥8 times micturition/24h)

and ≥1 symptoms of GSM (itching, burning, reduced lubrication, supercial

and/or severe dyspareunia) in the previous 3 months. OAB symptoms were

assessed using the validated Overactive Bladder Questionnaire Short Form

(OAB-Q SF). Results at 1-month follow-up after the third laser session indicated

I. Fistonić and N. Fistonić

https://t.me/med1917

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