Chapter 5 122 Athanasiou et al randomised women with symptomatic stage 2 or 3 prolapse between Er:YAG laser and watchful waiting, and did not report any objective nor subjective improvement over a four month period in either group.58 Vaginal laser therapy for SUI has been studied more extensively over the past years, possibly due to the concerns about the use of synthetic midurethral slings and as a consequence the promotion of energy based devices as a potential treatment option for SUI. Recently, six RCTs comparing vaginal laser therapy to sham procedures have been published with conflicting results. 83-88 All but one of these studies87 were incorporated in a meta-analysis on 577 patients, reporting “no efficacy of energy-based therapy over placebo intervention for the management of SUI, either in terms of subjective or objective outcomes”.95 To our knowledge, alongside with our study, only one other RCT compared vaginal laser therapy with PFE for SUI, reporting similar findings.82 This has actually been echoed in a recent position statement of the European Board and College of Obstetricians & Gynaecologists.49 Conversely, all studies confirm the safety of laser, which is in line with previously published data.50,76,96 Implications for clinical practice: Although the use of lasers in urogynaecology has increased in recent years, current evidence does not support its wide implementation in routine practice. Implications for further research: Given the inconsistency of study results, a rigorous meta-analysis of available studies using individual patient data would be welcomed. Further optimization of the therapy through preclinical studies, like animal models, would be appropriate. From a clinical viewpoint, further trials should determine the place of laser alongside and/or in combination with other conservative therapies, including the use of a pessary and lifestyle changes, because there is still a clinical need for effective conservative therapies. Identifying specific subgroups of women who might benefit more from any conservative therapy would be of interest. Each health system will have do its local health-economic analysis, to determine a justified price for laser application that health insurance or patients may want to pay. SURGICAL TREATMENT OF PROLAPSE AND URINARY INCONTINENCE Contemporary evidence strongly supports sacrocolpopexy as the gold standard procedure for surgical repair of apical prolapse. This is based on superior rates of decreased patient awareness of prolapse, anatomical success, and a lower need for repeat surgeries, when compared to vaginal apical support procedures.214,215 However, patient-reported quality of life outcome measures are essential to favorize one surgical intervention over another. When using this as an endpoint,
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