Ann-Sophie Page

VELPOP 35 is that we powered for subjective improvement rather than physician measured anatomical cure (POP-Q). Clearly, the former is much stricter, but in our view, for a condition like POP, certainly when treated conservatively, of less importance.75 At closer look, part of Athanasiou’s study population reported subjective improvement (PGI > 3) after laser (53% (8/15)) yet not when they were assigned to watchful waiting (0% (0/15)). Additional data on laser treatment for POP is limited to two observational studies that suggest treatment benefit of laser.57,59 However, next to the limitations of the study design, both trials report on completely different study populations, and report on anatomical rather than subjective outcomes. Ogrinc et al. prospectively studied patients with GSM who also had concomitant mild POP. Mikic et al. retrospectively studied patients who had a combination of stress urinary incontinence and also presented with an anterior wall prolapse . Overall, we believe that the aforementioned observational studies contribute little to the current body of evidence. Patient safety is always the first priority. In that respect, there is an abundance of studies in a variety of patient populations, that show that vaginal laser therapy is generally well-tolerated, safe, and the incidence of adverse events is low.76 Conversely, in terms of treatment effect for the management of bothersome POP, data is limited and the findings are contradictory. Therefore, this study is an important addition. Although not-inferior, the limited treatment effect of laser therapy questions its widespread use as it comes at a higher cost and requires appropriate training of operators to minimize side effects and to ensure the safety of this intervention. Further trials may focus on the place of laser alongside and in combination with other conservative therapies, including the use of a pessary and lifestyle changes. If such studies confirm our findings, identifying specific subgroups of women who might benefit more from any conservative therapy would be of interest, yet then still health-technology assessment studies would need to follow.

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