Posts in category: Artigos

The aim of this paper is to present a novel laser technology utilizing the erbium YAG laser for various minimally invasive, non-surgical procedures in gynecology.

Non-ablative, thermal-only SMOOTH-mode erbium pulses are used to produce vaginal collagen hyperthermia, followed by collagen remodeling and the synthesis of new collagen fibers, resulting in improved vaginal tissue tightness and elasticity.

This erbium laser technology is used for treatments of vaginal laxity, stress urinary incontinence, pelvic organ prolapse and vaginal atrophy. In the period from 2010 to 2014, several clinical studies covering all four indications were conducted with the aim to prove the efficacy and safety of this novel technology. An overview is presented of the results of these studies where several objective as well as subjective assessment tools were used.

The results have shown that SMOOTH-mode erbium laser seems to be an effective and safe method for treating vaginal laxity, stress urinary incontinence, pelvic organ prolapses and vaginal atrophy.

In this best practice document, we propose recommendations for the use of LASER for gynaecologic and urologic conditions such as vulvovaginal atrophy, urinary incontinence, vulvodynia and lichen sclerosus based on a thorough literature review. Most of the available studies are limited by their design; for example they lack a control group, patients are not randomized, follow up is short term, series are small, LASER is not compared with standard treatments, and most studies are industry sponsored.

Due to these limitations, the level of evidence for the use of LASER in the treatment of these conditions remains low and does not allow for definitive recommendations for its use in routine clinical practice.

Histological evidence is commonly reported as proof of tissue regeneration following LASER treatment. However, the histological changes noted can also be consistent with reparative changes after a thermal injury rather than necessarily representing regeneration or restoration of function.

The use of LASER in women with vulvodynia or lichen sclerosus should not be recommended in routine clinical practice. There is no biological plausibility or safety data on its use on this population of women.
The available clinical studies do not present convincing data regarding the efficacy of LASER for the treatment of vaginal atrophy or urinary incontinence. Also, while short-term complications seem to be uncommon, data concerning long-term outcomes are lacking.

Therefore, at this point, LASER is not recommended for routine treatment of the aforementioned conditions unless part of well-designed clinical trials or with special arrangements for clinical governance, consent and audit.

In the last decade, there has been an ever-growing user demand for minimally invasive procedures for treating symptoms of pelvic floor dysfunction. Some of the most promising treatments were developed using energy-based devices, such as lasers (Erbium:YAG and CO2) and radiofrequency.

The FotonaSMOOTHVR non-ablative thermal-only Er:YAG technology1 (Fotona, Ljubljana, Slovenia) has been specially developed for minimally invasive intravaginal treatments. Four different treatment protocols that incorporate non-ablative thermal-only Er:YAG technology have been developed and
clinically validated for the following indications: stress urinary incontinence (SUI)2, vaginal laxity/vaginal relaxation syndrome3, genitourinary syndrome of menopause (GSM)/vulvovaginal atrophy (VVA)4, and pelvic organ prolapse (POP)5.

The non-ablative thermal-only Er:YAG technology works by creating rapid sequential heat pulses that are transferred deeper into mucosa (up to 500 mm), without overheating the tissue surface. As a result of this precisely controlled heating, the temperature in the vaginal wall increases to approximately 65
C, the optimal temperature that allows the shorteningof the collagen fibrils without irreversible denaturation
of their structure6. Shortening of the collagen fibrils leads to contraction and shortening of the irradiated mucosal tissue.

Sintomas relacionados com a atrofia vulvovaginal apresentam um impacto negativo sobre aqualidade de vida de até 50% das mulheres na pós-menopausa. No entanto, algumas recu-sam o uso de estrogênios, que é a terapia eficaz padrão, devido à publicidade negativa nosúltimos anos e à disponibilidade de outras terapias opcionais.

Esta revisão avaliou a eficá-cia de tratamentos hormonais, fitoterápicos de uso oral ou tópico para aliviar os sintomasda atrofia vaginal em mulheres na pós-menopausa.

Foram avaliados estudos do Medline,Scopus e Cochrane Central Register de Ensaios Controlados com as palavras-chaves vagina,postmenopause, isoflavones, estrogen, syndrome genitourinária, vulvovaginal atrophy, clinical appli-cations. Estudos de revisão e ensaios clínicos randomizados foram incluídos neste estudo.Os dados mostraram que os estrogênios de uso sistêmico ou local são os mais indicados,as isoflavonas só mostraram efeitos positivos quando de uso local.

Alguns tratamentos não hormonais, como hidratantes, lubrificantes e o uso de laser vaginal, também são indicados. Outra possibilidade de tratamento é o os pemifeno, um modulador de receptor hormonal seletivo (SERM) na dispareunia e na atrofia vulvovaginal. Assim, o uso de opcões é benéfico para mulheres com risco de neoplasia relacionada aos estrogênios.