Discussion 121 The aim of this clinical doctoral research was to critically appraise innovative therapies for pelvic floor dysfunctions, that are being introduced to overcome shortcomings of currently available treatment options and that should improve patient reported outcomes. In the first part, we focused on vaginal laser therapy as a novel, minimally invasive treatment option for patients with prolapse and /or urinary incontinence. In the second part, we focused on the evaluation and optimization of sacrocolpopexy, the current gold standard surgical procedure to correct apical prolapse, and explored the potential benefits of incremental modifications of the operation, and alternative procedures. VAGINAL LASER THERAPY AS NON-SURGICAL TREATMENT FOR PROLAPSE AND URINARY INCONTINENCE Alongside with the shortcomings of available conservative treatment options for both prolapse and urinary incontinence, referred to in the introduction of this thesis, two additional incentives have led to a renewed interest for non-surgical treatment modalities. First, since the FDA ruling in 2019, the use of mesh for treating pelvic organ prolapse and stress urinary incontinence, is now nearly everywhere questioned and in some countries even banned, mainly for the fear for graft related complications.213 Second, there has been a shift in patient preferences over time, whereby patients nowadays are willing to accept a slightly lower probability of cure to avoid substantial postoperative pain and possible complications by receiving a less invasive treatment.36 This has created an increased awareness for, yet at the same time a lively debate on the introduction and adoption of new technologies and interventions within our specialty. On July 30th 2018, the FDA issued a warning against the use of energy based devices, including laser.46 Numerous review articles and editorials have followed, urging for greater evidence on the efficacy and safety of vaginal laser application. We performed two assessor-blinded randomized controlled trials comparing vaginal laser therapy to PFE, the current gold standard conservative treatment option for both mild to moderate POP and mild to moderate SUI.79 For both conditions, vaginal laser therapy and PFE improved symptoms to a similar extent on the short term (i.e. four months). At two years after first treatment, more than half of the participants requested for additional treatment, yet an alternative modality. The limited treatment effect of laser therapy questions its widespread promotion as it comes at a huge investment, higher operational cost and requires appropriate training of operators to minimize side effects and to ensure the safety of this intervention. On the other hand, our observations further attenuate earlier safety concerns on vaginal laser therapy. We found that, in line with other studies, this procedure is generally well-tolerated, safe, and the incidence of adverse events is low. The use of laser therapy for POP is still a relatively new approach, with limited available evidence for its efficacy and safety.51 We are aware of only one other RCT performed for this indication:
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