Long-Term Improvement in Urinary Incontinence in an Elite Female Athlete Through the Laser Treatment: A Case Report

Unsupervised clustering analysis of treatment strategies for elite female athletes with severe stress urinary incontinence: focusing on competition return and SUI improvement

PURPOSE

To evaluate two primary outcomes in elite female athletes (EFAs) with severe stress urinary incontinence (SUI) 24 months post-intervention: return to elite-level competition and improvement in SUI symptoms. Clustering analysis was conducted to identify subgroups within the patient population and explore treatment efficacy.

METHODS

A retrospective analysis was performed on 183 EFAs with severe SUI who underwent treatments including pelvic floor muscle training (PFMT), vaginal and urethral erbium laser (Fotona Laser), and mid-urethral sling (MUS) surgery. Clustering analysis was conducted using K-means to categorize patients, followed by multivariate regression and Random Forest to determine predictors.

RESULTS

Three distinct clusters were identified. PFMT frequency was the most significant predictor of both return to sports and SUI improvement across clusters. Cluster 0, characterized by younger participants, required interventions like MUS surgery and Fotona Laser for significant improvement. Cluster 2, with high PFMT adherence, showed the best improvement in pad test results (4.9 g) and the highest return to sports rate (85.9%). Fotona Laser was particularly effective in Cluster 2, with 91.3% of patients returning to sports within one year. In contrast, Cluster 1, which included older participants with more severe symptoms, demonstrated the least improvement and lowest return to sports rate (2.8%), likely due to lower PFMT frequency and inconsistent training.

CONCLUSION

Clustering analysis effectively categorized EFAs with SUI, highlighting the critical role of personalized, intensive PFMT in achieving sports return and symptom improvement. Future research should validate findings in larger cohorts and integrate machine learning to refine personalized medicine.

Efficacy and safety of non-ablative ErYAG laser for mild to moderate stress urinary incontinence: a prospective, multicenter, randomized, sham-controlled clinical trial

This study evaluated the efficacy and safety of a non-ablative vaginal Er: YAG laser device in treating stress urinary incontinence (SUI). We conducted a prospective, multicenter, randomized, sham-controlled clinical trial in which women with SUI received either active treatment with Er: YAG laser therapy or sham control with a non-therapeutic handpiece. Patients underwent three treatments spaced one month apart. The primary endpoint measure was the treatment success rate at three months post-treatment. A total of 126 participants with SUI were recruited, with 84 in the active arm and 42 in the sham arm. One participant in the sham arm was excluded due to not using research instruments. The treatment success rate at three months post-treatment was 36.59% in the sham arm and 71.43% in the active arm, with an absolute difference of 34.84% (95% CI: 17.2-52.5%). Incontinence quality of life questionnaire (I-QOL) score and incontinence questionnaire short form (ICIQ-SF) score demonstrated significant improvement in the both arms with no substantial difference between the groups. Non-ablative vaginal ErYAG laser therapy demonstrated a significant improvement in objectively measured SUI symptoms compared to sham treatment. The non-ablative Er: YAG laser therapy seems to be a promising non-surgical treatment option for SUI patients. The limitations of this study are the short follow-up and limited sample size, so additional studies with longer follow-up and larger number of patients are needed to further elucidate the role of this therapy for SUI.

Novel Management of Post-laparoscopic Sacrocolpopexy-Associated Overactive Bladder: A Combined Approach of Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) Mesh Removal and Fotona Laser Therapy

This case report presents a novel approach for managing overactive bladder (OAB) syndrome following laparoscopic sacrocolpopexy (LSC) using vaginal natural orifice transluminal endoscopic surgery (vNOTES) and Fotona laser therapy. A 73-year-old woman with severe OAB syndrome and pelvic pain after LSC underwent mesh removal via vNOTES. Despite the initial improvement in OAB symptoms, the patient continued to experience persistent urinary issues. Subsequent treatment with Fotona's non-ablative erbium:yttrium-aluminum-garnet (Er:YAG) laser therapy, including Vaginal Erbium Laser (VEL) and Urethral Erbium Laser (UEL), led to the complete resolution of OAB symptoms. The patient's Overactive Bladder Symptom Score (OABSS) significantly improved following combined vNOTES and laser therapy. Follow-up assessments revealed sustained improvements in bladder function and quality of life. This case highlights the potential of combining vNOTES for mesh removal and Fotona laser therapy for managing post-LSC complications, particularly in cases in which mesh-related issues contribute to persistent OAB syndrome. The successful outcome, as evidenced by symptom resolution and improved OABSS, suggests that this approach may offer a viable solution for patients experiencing persistent OAB syndrome following LSC, especially when conventional treatment fails. This report contributes to the limited body of evidence on managing LSC-related OAB syndrome and introduces a promising treatment protocol using Fotona laser therapy, which merits further investigation in larger studies focused on OAB management after pelvic floor surgery.

Efficacy and Safety of Combination Therapy With Vaginal and Urethral Erbium-Doped Yttrium-Aluminum-Garnet (Er:YAG) Laser for Overactive Bladder With Urinary Incontinence

OBJECTIVE

This retrospective cohort study with propensity score (PS) matching aimed to evaluate the efficacy and safety of a combination therapy with vaginal and urethral erbium:yttrium aluminum garnet laser (VEL+UEL) (SP Dynamis; Fotona d.o.o., Ljubljana, Slovenia) in the treatment of overactive bladder with urinary incontinence (OAB-wet).

METHODS

The study included female OAB-wet patients aged 65 and above who were already taking OAB medication. Data obtained from electronic medical records were subjected to propensity score matching. All patients received instructions on pelvic floor exercises and were prescribed an appropriate dose of OAB medication. The VEL+UEL group (n=30) underwent three monthly laser sessions, while the control group (n=30) did not receive the treatment. Clinical outcomes were evaluated using the Overactive Bladder Symptom Score (OABSS), International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), three-day urination diary, and Vaginal Health Index Score (VHIS). Medication usage and adverse events were also assessed. Statistical analysis and R code were performed using the AI chatbot GPT-4.0.

RESULTS

The VEL+UEL group showed significant improvements in OABSS score, ICIQ-SF score, voided volume, daytime frequency, nocturia, and VHIS after 12 months of treatment (p<0.001). Notably, 13.3% of patients transitioned from OAB-wet to OAB-dry. In contrast, the control group did not exhibit significant changes. Medication use was significantly reduced in the VEL+UEL group compared to the control group (p<0.001). No long-term side effects were reported.

CONCLUSION

Combination therapy with VEL+UEL demonstrated efficacy and safety in the treatment of OAB-wet. Improvements in OAB symptoms, voided volume, frequency, nocturia, and vaginal health were observed, with a subset of patients transitioning to OAB-dry. VEL+UEL therapy offers a potential treatment option for OAB-wet, reducing medication use and improving patient outcomes. Further research is warranted to investigate the mechanism, long-term effects, safety, and cost-effectiveness of VEL+UEL therapy.

The Potential of Non-ablative Erbium (YAG) Laser Treatment for Complications After Midurethral Sling Surgery: A Narrative Review

Midurethral sling (MUS) surgery, using tension-free vaginal tape and transobturator tape, has been widely adopted for the treatment of stress urinary incontinence (SUI). However, postoperative complications, including persistent urinary incontinence, mesh exposure, and pain, have become problematic, and surgical treatments for these complications face challenges, such as invasiveness, treatment-resistant cases, and recurrence. This review provides an overview of the current evidence regarding these complications and the potential of vaginal non-ablative erbium (YAG) laser (VEL) treatment as a minimally invasive option with low risk of complications. Studies have suggested the effectiveness of VEL treatment, performed using devices such as IncontiLase (SP Dynamis; Fotona d.o.o., Ljubljana, Slovenia), for persistent urinary incontinence after MUS surgery, pain following mesh removal, and asymptomatic mesh exposure. VEL treatment is expected to be a new treatment option for complications following MUS surgery; however, further large-scale comparative trials are required to verify its efficacy and safety and to establish criteria for its indications. Appropriate assessment of the indications and provision of sufficient information to patients is important when presenting VEL as a treatment option.

Pathological Insights on Polypropylene Mesh Complications From Laparoscopic Sacrocolpopexy: A Case Series

Background The use of polypropylene mesh in laparoscopic sacrocolpopexy (LSC) is a common treatment for pelvic organ prolapse (POP). Despite its widespread application, postoperative complications such as mesh pain and infection sometimes necessitate the removal of the mesh. However, it remains unclear in which cases mesh removal is warranted. Our research focused on the pathological changes at the sacral fixation point of the mesh. We sought to evaluate the pathological alterations of the sacral mesh removed through an innovative approach of transvaginal natural orifice transluminal endoscopic surgery (vNOTES). Methods This retrospective study included nine patients who underwent mesh removal surgery at the Yokosuka Urogynecology and Urology Clinic in 2023. Extraction surgery was performed using vNOTES with the GelPoint Access Platform (Applied Medical JAPAN HEADQUARTERS, Tokyo, Japan). Non-ablative Erbium YAG and Neodymium YAG lasers (RenovaLase, SP Dynamis; Fotona d.o.o., Ljubljana, Slovenia) were utilized for persistent stress urinary incontinence, fecal incontinence, vaginal erosion, and bleeding after surgery. Patients were categorized based on mesh fixation conditions, including unintended mesh overlap (Group I), excessive traction (Group II), and signs of mesh aging (Group III). This categorization helped to understand the distinct pathological outcomes associated with each condition. Results Pathological findings from the mesh removed via vNOTES varied significantly across the groups. In Group I, characteristic large vacuole formation and accumulation of atypical giant cells were observed, attributed to mesh overlap. Group II presented with vacuole formation, fiber degradation, and tissue destruction as a result of excessive mesh traction. In Group III, the aging of the mesh was marked by cracks in the surrounding tissues and granuloma formation. These detailed observations provide crucial insights into the underlying causes of mesh-related pain and other complications, highlighting the complexity of bodily responses to mesh implants. Conclusion This study demonstrated the effectiveness of vNOTES for polypropylene mesh removal in patients with post-LSC complications, resulting in significant pain reduction. Pathological analysis revealed that mesh-related issues stem from the surgical techniques, mesh properties, and long-term bodily reactions. These findings provide valuable insights for improving mesh design and POP treatment strategies. Despite the technical challenges, vNOTES is recommended for mesh removal in patients with pain. Additionally, the combination of UEL, VEL, targeted laser irradiation, AEL, and Nd:YAG laser treatments showed promising results in managing post-mesh removal complications such as stress urinary incontinence, vaginal erosion, bleeding, and fecal incontinence, offering hope for improved patient outcomes.

Non-ablative Erbium (YAG) and Neodymium (YAG) Laser Treatment for Anal Incontinence and Vaginal Atrophy: A Case Study

In this case study, a 68-year-old woman with anal incontinence (AI) and vaginal atrophy (VVA), who did not respond to traditional treatments such as pelvic floor exercises or hormone therapy, underwent three sessions of laser treatment using RenovaLase (SP Dynamis; Fotona d.o.o., Ljubljana, Slovenia), which employs non-ablative Erbium:YAG and Neodymium:YAG lasers. Significant improvements were observed in the VVA symptoms, with AI being resolved. The Vaginal Health Index Score increased from 7 points at the initial assessment to 18 points at 12 months after treatment. Similarly, the Cleveland Clinic Florida Fecal Incontinence Score and St. Mark's Incontinence Score, initially at 4 points each, improved to 0 points, indicating resolution of incontinence symptoms. MRI results demonstrated vascular enhancement and growth in the anal sphincter, with the thickness of the internal anal sphincter slightly increasing from initial measurements to a maximum of 0.36 cm, and improvements in resting and squeeze pressures from 42 mmHg to 110 mmHg, respectively. These findings underscore the effectiveness of RenovaLase® laser treatment for VVA and AI symptoms, offering a novel option for pelvic floor health management in postmenopausal women, especially those resistant to the use of artificial devices for anal improvement. In the environment of hormonal decline after menopause, the atrophy of pelvic vessels leads to reduced blood flow. This situation, where a noticeable lack of blood flow occurs during pretreatment of the pelvic vessels, is addressed by laser treatment. This phenomenon has been named "re-canalization." This case suggests the potential of this therapy as an alternative for patients resistant to conventional methods involving the insertion of devices into the anus to improve fecal incontinence. Further research is needed to explore its potential benefits.

Mesh Extraction Surgery and Laser Treatment for Pain After Mid-Urethral Sling Surgery: A Case Series

Stress urinary incontinence (SUI) is the leakage of urine due to abdominal pressure. The primary surgical approach involves the insertion of a mid-urethral sling (MUS) with a mesh, which can occasionally lead to post-operative pain. To address complications, MUS removal is often necessary. We hypothesize that a non-ablative erbium:yttrium aluminum garnet (Er:YAG) laser combined with vagina (vaginal erbium laser (VEL)) and urethra (urethra erbium laser (UEL)) treatments could be a post-MUS removal option. A study involving laser treatment started in 2016 for women with recurrent SUI one year after MUS removal who were not affected by pelvic floor muscle exercises and who did not wish to have MUS reinsertion or urethral injection treatment. Five patients (mean age, 54.5 ± 9.35 years) were enrolled, all receiving laser therapy. The visual analog scale (VAS) was used to assess pain as a primary endpoint, and the one-hour pad test was performed for SUI as a secondary endpoint. The mean pain VAS score changed from 8.57 ± 0.69 to 2.29 ± 1.50 (p = 0.00002) after MUS removal. Furthermore, the VAS score was 0 (p = 0.0034) after VEL + UEL. SUI changed from 4.42 ± 2.9 g on the one-hour pad test during MUS insertion to 66.7 ± 39.0 (p = 0.005) after removal. However, after the VEL + UEL treatment, it was 3.71 ± 5.25 g (p = 0.0035). The pathological tissue collected from the five patients at the time of MUS removal surgery had vacuolization in the part where the artificial material was present in the specimen, with foreign-body giant cells proliferated around it. One year after the MUS removal, mucous membrane regeneration was poor, and tissue thickness was thin. One year after the VEL + UEL treatment, the tissue had normalized mucosa, and there was no inflammation. Our study suggests MUS extraction and VEL + UEL as viable options for treating MUS pain in women.

Analysis of Predictive Factors for Return to Sports in Female Athletes With Stress Urinary Incontinence

Introduction This study aimed to identify predictive factors for successful return to sports among elite female athletes (EFAs) experiencing stress urinary incontinence (SUI). We used machine learning to analyze these predictors. Methods This study was conducted at Yokosuka Urogynecology and Urology Clinic, located in Yokosuka City, Kanagawa, Japan. A total of 153 EFAs with postpartum SUI were included in this retrospective cohort study. Information regarding the frequency of pelvic floor muscle training (PFMT), treatment approaches, rates of return to sports after one year, and one-hour pad test (1HrPadtest) at three months were collected. Results At three months, 26.8% of the EFAs improved in SUI; after one year, 28.1% returned to their respective sports successfully. The equation for predicting return to sports (logit(p)) involved several factors: (a) serum total testosterone, (b) PFMT frequency per week, (c) 1HrPadtest at three months, and (d) vaginal erbium-doped yttrium aluminum garnet laser (VEL) + urethral EL (UEL) treatment. The equation was as follows: -126 - 0.07276a + 25.98b - 1.947c - 25.32d, with a logit(p) cutoff point at 0.5. The optimal cutoff values and the four influential factors were determined through a receiver operating characteristic (ROC) analysis and the random forest model, respectively. Conclusions For EFAs with severe SUI to successfully return to their sports activities, the PFMT frequency was paramount. Patients who exhibited unsatisfactory results in the 1HrPadtest at the three-month mark benefited from the VEL+UEL treatment. Serum total testosterone proved to be an effective discerning criterion.