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The first published reports on the use of laser for cervical pathology date back to 1973. Technical advancements in flexible and rigid laser fibers revolutionized video laser laparoscopy in the 1990s. Fractionated lasers have been used to treat vulvovaginal symptoms associated with genitourinary syndrome of menopause, lichen sclerosus, and urinary incontinence. Review of available data suggests that fractionated lasers can improve both subjective and objective signs of vaginal atrophy and lichen sclerosus, but the evidence is weak because most of the trials are underpowered, are at risk for bias, and lack long-term follow-up. There is no strong evidence to support fractionated laser therapy for urinary incontinence or low-level laser therapy for chronic pelvic pain. Although short-term, single-arm trials suggest benefit of fractionated laser therapy for genitourinary syndrome of menopause, lichen sclerosus, and urinary incontinence, additional adequately powered, prospective, randomized, and longer-term comparative trials are needed before lasers can be recommended for these specific conditions. The purpose of this Clinical Expert Series is to review basic laser biophysics and the mechanism of action for modern fractionated lasers as relevant to the gynecologist. We also summarize safety and effectiveness data for lasers used for some of the most commonly studied gynecologic conditions: the vulvovaginal atrophy component of genitourinary syndrome of menopause, lichen sclerosus, and urinary incontinence.

Objective: To describe composite 30-day postoperative complication rates among patients undergoing hysterectomy during the coronavirus disease 2019 (COVID-19) pandemic and to determine baseline and postoperative mental health symptoms, levels of social support, and socioeconomic status and their association with hysterectomy outcomes., Methods: This multicenter prospective cohort study at eight centers across the United States enrolled patients who underwent minimally invasive hysterectomy for benign indications during the COVID-19 pandemic. Patients completed preoperative and postoperative surveys assessing mental health (PHQ-9 [Patient Health Questionnaire]), social support (MOS-SS [Medical Outcomes Study Social Support Survey]), and socioeconomic status (Hollingshead Index [Hollingshead Four Factor Index of Socioeconomic Status]). Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection rates and 30-day composite complication rates were measured and categorized by Clavien-Dindo Grade. Bivariate associations of survey data on complications were assessed. Logistic regression analyses were used to identify independent predictors of 30-day complications and complication severity., Results: Postoperative complications within 30 days occurred in 67 of 273 (24.5%) patients. Most (88.1%) complications were mild, but eight (11.9%) experienced severe complications. Only three patients (1.1%) tested positive for SARS-CoV-2 infection. There were no differences in complication rates when comparing race and ethnicity, age, or socioeconomic status. Survey responses that indicated more depression and worse support from preoperative to postoperative were seen in patients with severe complications ( P =.008 and P =.09, respectively). Multivariate analysis demonstrated that an increase in support scores was protective against severe complications ( P =.02). Worsening depression scores were associated with more severe complications ( P =.03)., Conclusion: This study showed a high rate of complications (24.5%) among patients who underwent hysterectomy during the COVID-19 pandemic. Lower social support and worse mental health status are associated with worse postoperative outcomes after hysterectomy., Competing Interests: Financial Disclosure Joseph Schaffer reported receiving royalty payments from McGraw-Hill. Margaret Mueller disclosed that her institution received funding from the NIH, she received payment from Butler/Snow and she received educational honoraria from Axonics. Gina Northington disclosed that her institution received funding from NIH/NICHD. She received funding from ABOG and the American Urogynecologic Association. Cheryl Iglesia received payment from UpToDate, the Patty Brisben Foundation Medical Advisory Board, and the Society of Gynecologic Surgeons Executive Board. She is the NICHD PFDN Advisory Board Chair, a US FDA Special Government Employee, and ObGyn Devices panel member. The other authors did not report any potential conflicts of interest., (Copyright © 2024 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Financial Disclosure Cheryl B. Iglesia reports receiving payment from the Society of Gynecologic Surgeons for travel to meetings. She received honoraria for consulting from the NICHD pelvic floor disorders advisory board. She is an advisory board member of Patty Brisben Foundation Medical. She receives payment from UpToDate as a contributor to the OBGmanagement editorial board (USFDA special government employee). Yona Tadir reports receiving payment from Alma Lasers. Jennie Eunsook Choi did not report any potential conflicts of interest.

Objective: To compare the rates of health care utilization (office messages or calls, office visits, and emergency department [ED] visits) and postoperative complications within 30 days after surgery between patients with successful voiding trials on postoperative day 0 and those with unsuccessful voiding trials on postoperative day 0 and between patients with successful and unsuccessful voiding trials on postoperative day 1. Secondary objectives were to identify risk factors for unsuccessful voiding trials on postoperative days 0 and 1 and to explore the feasibility of catheter self-discontinuation by assessing for any complications associated with at-home catheter self-discontinuation on postoperative day 1., Methods: This study was a prospective observational cohort study of women undergoing outpatient urogynecologic or minimally invasive gynecologic surgery for benign indications at one academic practice from August 2021 to January 2022. Enrolled patients with unsuccessful immediate postoperative voiding trials on postoperative day 0 performed catheter self-discontinuation by cutting their catheter tubing per instructions at 6 am on postoperative day 1 and recording their voided volumes over the subsequent 6 hours. Patients who voided less than 150 mL underwent a repeat voiding trial in the office. Demographics, medical history, perioperative outcomes, and number of postoperative office calls or visits and ED visits within 30 days were collected., Results: Of the 140 patients who met inclusion criteria, 50 patients (35.7%) had unsuccessful voiding trials on postoperative day 0, and 48 of these 50 (96%) performed catheter self-discontinuation on postoperative day 1. Two patients did not perform catheter self-discontinuation on postoperative day 1: One had her catheter removed in the ED on postoperative day 0 during an ED visit for pain control, and the other performed catheter self-discontinuation off protocol at home on postoperative day 0. There were no adverse events associated with at-home postoperative day 1 catheter self-discontinuation. Of the 48 patients who performed catheter self-discontinuation on postoperative day 1, 81.3% (95% CI 68.1-89.8%) had successful postoperative day 1 at-home voiding trials, and 94.5% (95% CI 83.1-98.6%) of those with successful voiding trials did not require additional catheterization. Patients with unsuccessful postoperative day 0 voiding trials had more office calls and messages (3 vs 2, P <.001) and those with unsuccessful postoperative day 1 voiding trials attended more office visits (2 vs 1, P <.001) compared with those with successful postoperative day 0 or 1 voiding trials, respectively. There was no difference in ED visits or postoperative complications between patients with successful voiding trials on postoperative day 0 or 1 and those with unsuccessful voiding trials on postoperative day 0 or 1. Patients with unsuccessful postoperative day 0 voiding trials were older and more likely to have undergone vaginal hysterectomy or prolapse repair than those with successful postoperative day 0 voiding trials. Patients with unsuccessful postoperative day 1 voiding trials were older than those with successful postoperative day 1 voiding trials., Conclusion: Catheter self-discontinuation is a feasible alternative to in-office voiding trials on postoperative day 1 after advanced benign gynecologic and urogynecologic surgery, with low rates of subsequent retention and no adverse events seen in our pilot study., Competing Interests: Financial Disclosure Cheryl B. Iglesia reported the following: Executive Board SGS Editorial Board Urogynecology, OBGManagement Special Govt Employee US FDA chair, NICHD PFDN Advisory Board Medical Advisory board: Patty Brisben Foundation, Healthy Women Foundation, Foundation for Female Health Awareness. The other authors did not report any potential conflicts of interest., (Copyright © 2023 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To compare 6-month safety and efficacy outcomes of fractionated CO2 laser (laser) with topical clobetasol propionate (steroid) for treatment of symptomatic vulvar lichen sclerosus., Methods: We conducted a single-center randomized controlled trial that compared fractionated CO2 laser with steroid treatment for patients with biopsy-proven lichen sclerosus. Randomization was stratified by prior clobetasol propionate use. The primary outcome was mean change in Skindex-29 score at 6 months. A total sample size of 52 participants were recruited to detect a mean difference of 16 points on the Skindex-29 (SD±22) with 80% power, based on a one-sided two-sample t test with α=0.05, accounting for 10% attrition. Secondary outcomes included validated subjective and objective measures. Intention-to-treat, per protocol, and regression analysis based on prior steroid exposure were performed., Results: From October 2015 to July 2018, 202 women were screened, 52 were randomized, and 51 completed a 6-month follow-up. No significant difference was found in baseline demographics, symptoms, and physician assessment scores. There was greater improvement in the Skindex-29 score in the laser arm at 6-months (10.9 point effect size, 95% CI 3.42-18.41; P=.007). Overall, 89% (23/27) of patients in the laser group rated symptoms as being "better or much better" compared with 62% (13/24) of patients in the steroid group, P=.07. More patients (81%, 21/27) were "satisfied or very satisfied" with laser treatment compared with steroid treatment (41%, 9/24); P=.01. After stratification for previous steroid use, the significant change of Skindex-29 score was only seen in the previously exposed group. There was one adverse event in each group: minor burning and blistering at the laser site and reactivation of genital herpes 1 week after starting steroid., Conclusion: Fractionated CO2 laser treatment showed significant improvement in subjective symptoms and objective measures compared with clobetasol propionate, without serious safety or adverse events at 6 months., Clinical Trial Registration: ClinicalTrials.gov, NCT02573883., Competing Interests: Financial Disclosure Robert E. Gutman has received royalties from UpToDate, a research grant from Boston Scientific and SAB, and has been a J&J expert witness on a sling class-action lawsuit defense. Amy J. Park is a speaker for Allergan and receives honoraria from UpToDate. Cheryl B. Iglesia receives honorarium from UpToDate, is special government employee and consultant to USFDA ObGyn Devices panel 2011–2017, and served on five panels, now ad hoc, received research support from the Foundation for Female Health awareness, and National Vulvodynia Foundation made payable to MedStar Health Research Institute. The other authors did not report any potential conflicts of interest., (Copyright © 2021 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Cystourethroscopy can be performed by obstetrician-gynecologists for diagnostic and occasional operative indications. Intraoperative use of cystourethroscopy to confirm urinary tract (urethral, bladder, and ureteral) integrity is one of the most important indications, because these findings can greatly affect patient care. This monograph provides an overview of appropriate instrumentation and technique for cystourethroscopy in women with normal anatomy. Also, it depicts benign and malignant lesions of the urethra and bladder and shows examples of intraoperative abnormalities, such as incidental bladder or urethral penetration, and nonpatent ureters, foreign body erosion, or fistula-related complications. Clinical vignettes outline differential diagnoses and management of common cystourethroscopic findings., (Copyright © 2021 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To assess whether there is any association between the implantation of synthetic polypropylene mesh slings for the treatment of stress urinary incontinence (SUI) and risk of cancer., Methods: We performed a nationwide cohort study based on the general female population in Sweden. All women entered the observational period as unexposed on January 1, 1997, and contributed person-time as unexposed unless they underwent a midurethral sling procedure for SUI, after which they contributed person-time as exposed until first occurrence of any cancer, death, emigration, or end of the observational period (December 31, 2009). Occurrence of primary cancer was ascertained from the Cancer Register. Hazard ratios (HRs) with 95% CIs were calculated by Cox proportional hazards regression., Results: The final study population included 5,385,186 women, including 20,905 exposed, encompassing a total of 44,012,936 person-years at risk. Other than an inverse association with rectal cancer (HR 0.5, 95% CI 0.3-0.8), there were no significant differences in risk between exposed and unexposed women for pelvic organ cancers including ovarian (HR 0.8, 95% CI 0.5-1.2), endometrial (HR 1.1, 95% CI 0.8-1.4), cervical (HR 0.4, 95% CI 0.2-1.0), bladder, and urethra (HR 0.7, 95% CI 0.4-1.2). No significant association was observed between exposed women and primary cancer in any organ system when compared with unexposed women. The relative risk for cancer after exposure showed little variation over time except for an inverse overall correlation within the first 4 years of surgery (HR 0.7, 95% CI 0.7-0.8). The incidence rates per 100,000 person-years (95% CIs) for exposed vs unexposed women were 20.5 (14.3-29.5) vs 21.0 (20.6-21.5) for rectal cancer, 25.5 (18.4-35.3) vs 19.8 (19.4-20.2) for ovarian cancer, 65.0 (53.0-79.8) vs 33.1 (32.6-33.7) for endometrial cancer, 5.7 (2.8-11.3) vs 11.9 (11.6-12.2) for cervical cancer, and 19.1 (13.1-27.8) vs 13.3 (13.0-13.7) for bladder and urethra cancer., Conclusion: Our results suggest that midurethral polypropylene sling surgery for SUI is not associated with an increased cancer risk later in life.

Objective: To estimate the prevalence of auditory vaginal air passage among women with and without pelvic organ prolapse (POP) in a population with pelvic floor disorders., Methods: This prospective cohort study included women with urinary incontinence and POP who sought consultation at a single center from January 2012 to August 2013. Women with rectovaginal fistula, prior surgery for POP or incontinence, and current pregnancy were excluded. Participants completed a nonvalidated questionnaire about auditory vaginal air passage, also known as vaginal wind. The subset who had pelvic reconstructive surgery completed the same questionnaire 6 months postoperatively. Baseline demographic and clinical characteristics and preoperative and postoperative POP quantification data were collected., Results: One hundred thirty-two women were approached for participation, of whom 110 (83%) completed baseline study questionnaires. Of these 110, 59 had POP and 51 had normal pelvic support. The mean age was 55±12 years. Sixty-nine percent (76/110, 95% confidence interval [CI] 60-78%) experienced vaginal wind an average of 2.1±8.7 times weekly. There was no difference in the prevalence of vaginal wind between women with and without POP. Women with vaginal wind were younger than those without vaginal wind (mean age 52±12 years compared with 62±11 years, P<.001). The majority with vaginal wind experienced symptoms during intercourse (65/75 [87%], 95% CI 77-93%) and were at least somewhat bothered by it (49/76 [64%], 95% CI 53-75%), but only 22% (17/76, 95% CI 14-33%) reported a negative effect on quality of life., Conclusion: Vaginal wind is common among women with pelvic floor disorders but is not associated with POP., Level of Evidence: II.

Objective: To present the 3-year outcomes of a double-blind, multicenter, randomized trial comparing vaginal prolapse repair with and without mesh., Methods: This was a planned final analysis of women with Pelvic Organ Prolapse Quantification (POP-Q) stage 2-4 prolapse randomized to traditional vaginal prolapse surgery without mesh and vaginal colpopexy repair with mesh. We evaluated anatomic, symptomatic, and combined cure rates for those with at least 3-year validated quality-of-life questionnaires and 2- or 3-year postoperative blinded POP-Q examination. Participants undergoing reoperation for recurrent prolapse were removed for anatomic and subjective outcomes analysis and considered failures for combined outcomes analysis., Results: Sixty-five women were enrolled (33 mesh, 32 no mesh) before the study was prematurely halted as a result of a 15.6% mesh exposure rate. At 3 years, 51 of 65 (78%) had quality-of-life questionnaires (25 mesh, 26 no mesh) and 41 (63%) had examinations. Three participants died, three required reoperation for recurrent prolapse (all in mesh group), and eight were lost to follow-up. No differences were observed between groups at 3 years for prolapse stage or individual prolapse points. Stage improved for each group (90% and 86%) from baseline to 3 years (P<.01). Symptomatic improvement was observed with no differences in scores between groups. Cure rates did not differ between groups using a variety of definitions, and anatomic cure was lowest for the anterior compartment., Conclusion: There was no difference in 3-year cure rates when comparing patients undergoing traditional vaginal prolapse surgery without mesh with those undergoing vaginal colpopexy repair with mesh., Clinical Trial Registration: Clinicaltrials.gov, www.clinicaltrials.gov, NCT00475540., Level of Evidence: : I.

Objective: To compare rates of de novo dyspareunia in women with and without vaginal dilator use after posterior colporrhaphy., Methods: This randomized controlled trial included sexually active patients with prolapse and no bothersome baseline dyspareunia undergoing posterior colporrhaphy. Patients were randomized to daily vaginal dilator use from postoperative weeks 4 through 8 or to no dilator use. Pelvic organ prolapse quantification examination and vaginal caliber were measured at baseline, 8 weeks, and 6 months postoperatively. Sexual function was evaluated at baseline, 3 months, and 6 months postoperatively using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire-12. Participants completed a Patient Global Impression of Improvement at 3 months and 6 months postoperatively., Results: Sixty patients were randomized: 30 in the dilator group and 30 in the control group. There were no differences in baseline characteristics and postoperative vaginal caliber between groups. At 3 months, 9.5% of patients reported de novo dyspareunia in the dilator group compared with 19.2% of control patients (P=.44). At 6 months, 12.5% of patients in the dilator group reported de novo dyspareunia compared with 3.8% of control patients (P=.34). There was a 13% loss-to-follow-up rate, and therefore we did not meet appropriate power to detect a difference. There were no differences in overall sexual function or Patient Global Impression of Improvement scores between groups at 3 months and 6 months., Conclusion: There were no significant differences in de novo dyspareunia rates, overall postoperative sexual function scores, or global improvement scores between those using vaginal dilators compared with control patients.

Objective: To compare the efficacy of a single-incision mini-sling, placed in the "U" position, with tension-free vaginal tape (TVT) in the treatment of stress urinary incontinence., Methods: Women with urodynamic stress incontinence with or without genital prolapse were randomized to receive a mini-sling or TVT (N=263). Those randomized to the mini-sling received two "sham" suprapubic incisions to facilitate blinding. The primary outcome was subjective cure (absence of any urinary incontinence or retreatment) as assessed at 1 year. This trial was a noninferiority study design., Results: Participants receiving the mini-sling were less likely to have a bladder injury (0.8% compared with 4.8%; P=.0.46), more likely to be discharged without a catheter (78.5% compared with 63%; P=.008), and had less pain for postoperative days 1-3. One year after surgery, the rate of cure was similar between treatment groups (mini-sling 55.8% compared with TVT 60.6%; mean difference, 4.8%; 95% confidence interval, -16.7 to +7.2); however, this did not meet our predefined noninferiority criteria of -12%. Incontinence severity at 1 year was greater with the mini-sling than with TVT (mean severity score ± SD: 2.2±2.7 compared with 1.5±1.9; P=.015), resulting predominantly from a higher proportion of participants with "severe" incontinence postoperatively (16% compared with 5%; P=.025)., Conclusion: The mini-sling placed in the "U" position results in similar subjective cure rates to TVT 1 year after surgery but postoperative incontinence severity is greater with the mini-sling than with TVT., Level of Evidence: I.

Objective: To present 3-month outcomes of a double-blind, multicenter randomized controlled trial comparing traditional vaginal prolapse surgery without mesh with vaginal surgery with mesh., Methods: Women with pelvic organ prolapse quantification prolapse stages 2-4 were randomized to vaginal colpopexy repair with mesh or traditional vaginal colpopexy without mesh. The primary outcome measure was objective treatment success (pelvic organ prolapse quantification stage 1 or lower) at 3 months. Secondary outcome measures included quality-of-life variables and complication rates., Results: Sixty-five women were recruited from January 2007 to August 2009, when the study was halted due to predetermined stopping criteria for vaginal mesh erosion at a median follow-up of 9.7 months (range, 2.4-26.7 months). Thirty-two women underwent mesh colpopexy (24 anterior mesh, eight total mesh), and 33 women had vaginal colpopexies without mesh (primarily uterosacral ligament suspension) and concurrent colporrhaphy. There were no statistically significant baseline differences between the mesh and no-mesh groups with respect to demographics, menopausal status, and race. Analysis of the mesh and no-mesh women found no difference with respect to overall recurrence (mesh: 19 [59.4%] compared with no mesh: 24 [70.4%], P=.28). There were five (15.6%) vaginal mesh erosions. Two cystotomies and one blood transfusion occurred in the mesh group only. Subjective cure of bulge symptoms was noted in 93.3% of mesh patients and 100% of no-mesh patients. Furthermore, subjective quality-of-life measurements did not differ between the two groups at baseline or 3 months postoperatively., Conclusion: At 3 months, there is a high vaginal mesh erosion rate (15.6%) with no difference in overall objective and subjective cure rates. This study questions the value of additive synthetic polypropylene mesh for vaginal prolapse repairs., Clinical Trial Registration: Clinicaltrials.gov, www.clinicaltrials.gov, NCT00475540., Level of Evidence: I.

Objective: To evaluate the relationship between change in weight and pelvic organ prolapse (POP) progression/regression in women during a 5-year period., Methods: Postmenopausal women with uteri (N=16,608), ages 50 to 79, who were enrolled in the Women's Health Initiative (WHI) Estrogen plus Progestin Clinical Trial between 1993 and 1998 were included in this secondary analysis. Baseline pelvic examination, repeated annually, assessed uterine prolapse, cystocele, and rectocele using the WHI Prolapse Classification System. Statistical analyses included univariate and multiple logistic regression methods., Results: During the 5-year time period, the majority of women (9,251, 55.7%) gained weight (mean 4.43 kg, +/-5.95 kg), and the overall rate of prolapse (WHI Prolapse Classification System: grades 1-3) increased from 40.9% at baseline to 43.8% at year 5 of evaluation. Controlling for age, parity, race, and other health/physical variables, being overweight (body mass index [BMI] between 25 and 29.9) or obese (BMI of at least 30) at baseline was associated with progression in cystocele, rectocele, and uterine prolapse compared with women with healthy BMIs (BMI is calculated as weight (kg)/[height (m)]). Specifically, the risk of prolapse progression in overweight and obese women as compared with the participants with healthy BMIs increased by 32% and 48% for cystocele, by 37% and 58% for rectocele, and by 43% and 69% for uterine prolapse, respectively. Adjusting for women with prolapse at baseline and baseline BMI, a 10% weight change was associated with minimal change in overall POP. Specifically, a 10% weight loss was associated with a borderline worsening of uterine prolapse (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.88-0.97) and a minimal regression of cystocele (OR 1.03, 95% CI 1.00-1.05) and rectocele (OR 1.04, 95% CI 1.01-1.07)., Conclusion: Being overweight or obese is associated with progression of POP. Weight loss does not appear to be significantly associated with regression of POP, suggesting that damage to the pelvic floor related to weight gain might be irreversible., Level of Evidence: II.

Background: The Burch retropubic urethropexy for the repair of stress urinary incontinence can be performed laparoscopically. Advances in laparoscopic technique have led some surgeons to perform this procedure with hernia mesh and surgical tacks., Case: A postmenopausal woman presented with complaints of lower abdominal pain, dyspareunia, dysuria, and urinary urgency and frequency after a laparoscopic Burch and paravaginal repair. Bimanual examination revealed tenderness over the pelvic floor muscles and anterior vaginal wall. Exploratory laparotomy revealed dense fibrous adhesions in the space of Retzius along with mesh, permanent suture, and 13 helical tacks., Conclusion: Laparoscopic procedures that use hernia mesh fastened with surgical tacks should not be used in the vagina or surrounding structures.