Publications by authors named "Lior Lowenstein"

185 Publications

Maintenance Laser Treatment for Vaginal Looseness and Sexual Dysfunction: A Double-blinded Randomized Controlled Trial.

J Sex Med 2022 Jul 18. Epub 2022 Jul 18.

Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel.

Background: Vaginal looseness and decreased sensation during intercourse is prevalent in up to 30%-55% of premenopausal women. The efficacy and safety of CO2 laser have been demonstrated for these indications; however, the effect is temporary, up to 6-12 months. No studies regarding the efficacy and safety of adjuvant laser treatments have been conducted to date.

Aim: To evaluate the efficacy and safety of a single maintenance CO laser treatment in women with vaginal looseness and a concurrent decline in sexual sensation during intercourse.

Methods: This prospective double-blinded randomized controlled trial included premenopausal women who experienced significant temporary improvement in symptoms following previous treatment with CO2 laser due to the abovementioned indications. Participants were randomized to either a single CO2 laser treatment or a single sham treatment.

Outcomes: Treatment efficacy evaluated with the female sexual function index (FSFI) and the vaginal health index (VHI).

Results: Overall, 119 women were included in the study. Mean VHI and FSFI scores were significantly higher in the study group compared to the control group at three months post-treatment (17.34±1.39 vs 12.86±2.23, P = .023 and 30.93±1.79 vs 25.78±1.87, P = .044, respectively). In the study group, both VHI and FSFI returned to baseline at six months post-treatment. The median rate of sexual intercourse per month was increased in the study group at three months post-treatment (8 vs 4, P = .011), and returned to baseline at six months post-treatment.

Clinical Implications: Maintenance laser treatment provides a temporary non-surgical alternative for women with vaginal looseness and associated sexual dysfunction, though treatment effect seems to be limited to less than 6 months, requiring additional maintenance sessions.

Strengths And Limitations: The strengths of the current study include a randomized-sham controlled design. Furthermore, VHI was used as an objective evaluation tool, in addition to the FSFI, and assessment of the rate of sexual intercourse. The homogeneity and the relatively small sample size of the cohort is a limitation, and calls for caution in interpretation of the results, and the use of CO2 laser treatment in different age groups and populations.

Conclusion: A single maintenance laser treatment in women who previously underwent successful treatment with laser is an effective, well-tolerated, and safe procedure for treating symptoms of vaginal looseness and sexual dysfunction, though effects are temporary. Lauterbach R, Aharoni S, Farago N, et al. Maintenance Laser Treatment for Vaginal Looseness and Sexual Dysfunction: A Double-blinded Randomized Controlled Trial. J Sex Med 2022;XX:XXX-XXX.
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http://dx.doi.org/10.1016/j.jsxm.2022.06.010DOI Listing
July 2022

A randomized controlled trial of two techniques of salpingectomy during cesarean section.

Am J Obstet Gynecol MFM 2022 Jul 14:100690. Epub 2022 Jul 14.

Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel.; Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.

Background: Total salpingectomy during benign gynecologic surgery is recommended after completion of childbearing, to reduce the risk for developing ovarian cancer.

Objective: To assess operating time and complication rates of "traditional" salpingectomy, using the "Knot and Cut" technique, compared with bipolar salpingectomy for sterilization at the time of cesarean section.

Study Design: this was a randomized controlled trial. Women undergoing planned cesarean delivery who desired sterilization were randomized to traditional salpingectomy or bipolar salpingectomy. The bipolar salpingectomy was performed using the LigaSure Precise. The primary outcome was the surgical time of the salpingectomy procedure. Secondary outcomes included total cesarean section time and associated bleeding parameters. We estimated that 42 patients would provide 80% power and a two-sided alpha of 0.05 to identify a 10- minute difference in the primary outcome.

Results: 26 women were randomized to bipolar salpingectomy and 25 to traditional salpingectomy. Baseline demographics characteristics were similar between the groups. Six procedures were converted from traditional to bipolar salpingectomy, and two traditional salpingectomies have failed. The surgical time (16.16±9.53 vs. 5.19±3.57 minutes, p<0.001), estimated blood loss (928.08±414.66 ml vs. 677.15±380.42 ml, p=0.029) and need for blood transfusion (20% vs. 0%, p=0.016) were significantly greater in the traditional salpingectomy than the bipolar salpingectomy group. The cesarean section time was similar (88.92±17.87 vs. 88.23±19.85 minutes, p=0.89). Hospitalization time was significantly longer following traditional salpingectomy than bipolar salpingectomy (5.24±2.27 days vs. 3.92±2.01 days, p=0.034).

Conclusion: "Traditional" salpingectomy is associated with longer surgical time, greater blood loss, risk for blood transfusion, and hospitalization time compared to "bipolar" salpingectomy. In practices in which "bipolar" is available, it should be preferred for salpingectomy over alternative methods.
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http://dx.doi.org/10.1016/j.ajogmf.2022.100690DOI Listing
July 2022

Changes in diagnostic sensitivity, incidence and presentation of complete and partial hydatidiform mole over the years.

Eur J Obstet Gynecol Reprod Biol 2022 Jul 25;274:136-141. Epub 2022 May 25.

Department of Obstetrics and Gynecology, Galilee Medical Cente, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel.

Objective: Molar pregnancy is the most common type of gestational trophoblastic disease. Several recent reports have described changes in the clinical representation, the incidence and the diagnostic sensitivity of molar pregnancy. These changes could be due to widespread use of transvaginal ultrasound and beta-hCG testing in the management of routine first-trimester investigations.

Study Design: This is a retrospective study of 144 women diagnosed with partial or complete mole at a regional medical center during 2007-2020. Incidence, demographics, clinical features and diagnostic sensitivity were compared between 2007 and 2014 and 2015-2020, and attempts were made to understand the bases of the changes between the time periods.

Results: Sixty-two moles were diagnosed during 2007-2014 and 82 during 2015-2020. The proportions of complete moles in the respective periods were 65% (40) and 18% (15). From the earlier to the later period, the incidence and proportion of complete moles decreased, and of partial moles, increased. The median gestational age at diagnosis of molar pregnancy was 9.3 weeks. In the later period, women presented less frequently with vaginal bleeding, though this remained the most common presenting symptom. The proportion of women who underwent surgical evacuation of the uterus due to suspected molar pregnancy decreased, as did the proportion of moles that was suspected in ultrasound evaluation (P < 0.001).

Conclusion: The proportion of complete moles decreased between the periods examined. Gestational age at diagnosis was similar to data from 1994 to 2013. Some typical presenting symptoms of molar pregnancy decreased. However, earlier diagnosis of missed abortion can miss diagnoses of molar pregnancy.
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http://dx.doi.org/10.1016/j.ejogrb.2022.05.026DOI Listing
July 2022

Liver stiffness and steatosis in preeclampsia as shown by transient elastography-a prospective cohort study.

Am J Obstet Gynecol 2022 Apr 29. Epub 2022 Apr 29.

Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel; Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel. Electronic address:

Background: Preeclampsia is a multisystem disorder and the leading cause of severe morbidity and death in pregnancy. Liver involvement in preeclampsia ranges from elevated liver enzyme levels to hepatic infarction or rupture. Endothelial dysfunction leads to changes in blood flow and congestion and may be involved in the pathophysiology of preeclampsia. Changes in splanchnic blood flow and portal congestion can lead to altered liver stiffness. Transient elastography is a noninvasive, ultrasound-based technique that measures organ stiffness and steatosis and is therefore widely used in clinical hepatology. Previous studies reported elevated liver stiffness and liver steatosis, as measured by transient elastography, in women with preeclampsia.

Objective: This study followed changes in liver stiffness and steatosis, as measured by transient elastography, from the antepartum period to 1-week postpartum among women with preeclampsia compared with healthy controls and evaluated the association between preeclampsia severity and transient elastography results.

Study Design: This prospective cohort study was conducted from 2017 through 2021. The study group comprised women with preeclampsia, and the control group comprised healthy pregnant women hospitalized for other reasons. All the participants underwent transient elastography either on diagnosis of preeclampsia (study group) or on hospital admission (control group) and again in the postpartum period. Liver stiffness measurements are expressed in kilopascals (kPa) in the range of 2.5 to 75 kPa, and liver steatosis is expressed by controlled attenuation parameter in the range of 100 to 400 dB/m.

Results: The study group comprised 36 women and the control group 37. Liver stiffness scores were significantly elevated in the study when compared with the control group, both in the antepartum period (P<.001) and the postpartum period (P=.025). Liver stiffness scores decreased significantly after delivery in the study and control groups (P<.001 and P=.002, respectively). Liver steatosis scores were higher in the study group than in the control group both in the antepartum and postpartum periods (P<.001 and P<.02, respectively). In the multivariable analysis, the diagnosis of preeclampsia correlated with higher antepartum liver stiffness scores (P=.005). For the study group, postpartum liver stiffness and liver steatosis scores were increased among those with vs those without severe features of preeclampsia (P=.03 and P=.04, respectively) CONCLUSION: Reductions in liver stiffness and steatosis from the antepartum to the postpartum period were documented in both the preeclampsia and control groups. However, both these measures were higher in the preeclampsia group and correlated with preeclampsia severity. Larger studies may be able to determine whether transient elastography can predict the severity of preeclampsia or other related metabolic conditions that correlate with chronic hypertension.
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http://dx.doi.org/10.1016/j.ajog.2022.04.048DOI Listing
April 2022

Clinical implications of the 100-g oral glucose tolerance test in the third trimester.

Arch Gynecol Obstet 2022 Mar 28. Epub 2022 Mar 28.

Department of Obstetrics & Gynecology, Galilee Medical Center, PO Box 21, 22100, Nahariya, Israel.

Purpose:  The clinical implications of gestational diabetes mellitus (GDM) diagnosed in the third trimester are not well established and controversy continues regarding the performance of diagnostic tests beyond 28-week gestation. This study aimed to evaluate the incidence of abnormal third trimester oral glucose tolerance test (OGTT) results in women at high risk and to compare the obstetric and neonatal outcomes with those of women with normal OGTT results.

Methods:  The study included 372 women who completed late (>29 weeks) 100-g OGTT due to suspected fetal macrosomia, polyhydramnios or a personal risk factor for GDM, diagnosed according to the Carpenter & Coustan criteria. Women with only one abnormal OGTT value were diagnosed with GDM by abnormal glucose follow-up and analyzed separately. Obstetric and neonatal outcomes were compared between the GDM and the non-GDM groups.

Results:  GDM was diagnosed in 85/372 (22%) women, including 35 (59.3%) women with one abnormal OGTT value who were later diagnosed with GDM. Of 200 women who had a normal 1-h 50-g glucose challenge test at 24-28 weeks, late GDM was diagnosed in 33 (16.5%). Seventy-six (89.5%) of those with GDM were treated by dietary therapy and 9 (10.5%) by pharmacological therapy. Among women with GDM, large-for-gestational-age fetuses, labor induction and elective cesarean section were more prevalent than for those without GDM. Significant differences were not found between the groups in macrosomia and neonatal outcomes.

Conclusions: The performance of OGTT in women with risk factors during the third trimester should be considered following further prospective trials.
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http://dx.doi.org/10.1007/s00404-022-06520-5DOI Listing
March 2022

The efficacy and safety of a single maintenance laser treatment for stress urinary incontinence: a double-blinded randomized controlled trial.

Int Urogynecol J 2022 Feb 23. Epub 2022 Feb 23.

Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel.

Introduction And Hypothesis: To evaluate the efficacy and safety of a single carbon dioxide (CO) laser maintenance treatment in women previously treated successfully with laser for stress urinary incontinence (SUI), who have demonstrated a decline in treatment effect.

Methods: Women aged 40-70 years who experienced temporary significant improvement in symptoms following CO laser treatments for SUI were randomized to either the treatment group or the sham treatment control group. Cough test results, 1-h pad weights and scores on the Urogenital Distress Inventory (UDI6), the International Consultation of Incontinence Questionnaire (ICIQ-UI) and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) were obtained at baseline and 3 and 6 months.

Results: Of 183 women screened, 131 were included in the final analysis. Demographic characteristics and baseline measures in the outcome tests were similar between the groups. Statistically significant improvements were demonstrated in the study compared to the control group at 3 months post-treatment in positive cough test (44.4% vs. 79.4%, P = 0.002), mean pad weight test (2.3 g ± 1.3 vs. 5.6 ± 1.1, P < 0.001), mean UDI-6(24.7 ± 12.1 vs. 45.1 ± 13.6 SD, P = 0.004), mean ICIQ-UI (16.5 ± 4.3 vs. 10.3 + 3.8, P = 0.003) and mean PISQ-12 (21.3 ± 6.8 vs. 36.6 ± 7.5, P = 0.003). However, values at 6 months post-treatment were similar to those at baseline.

Conclusions: Our results suggest that a single maintenance laser treatment for reducing symptoms of SUI is transiently effective, well tolerated and safe. This treatment modality provides alternative non-surgical therapy for women with SUI.
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http://dx.doi.org/10.1007/s00192-022-05103-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8864590PMC
February 2022

The impact of radiation therapy on vaginal biomechanical properties.

Eur J Obstet Gynecol Reprod Biol 2021 Sep 1;264:36-40. Epub 2021 Jul 1.

Department of Obstetrics and Gynecology, Rambam Health Care Campus, and Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel. Electronic address:

Objective: In women with cervical cancer (CC), treatment with radiation causes changes in vaginal biomechanical properties, anatomy and function. The aims of the current study were to objectively assess effects of radiotherapy (RT) on vaginal elasticity, wall mobility and contraction strength; and to evaluate associations of these changes with sexual function.

Study Design: This prospective cohort study was approved by our Institutional Review Board. Between May 2018 and June 2020, women with CC who were candidates for RT were eligible to participate. Participants underwent vaginal tactile imaging (VTI) evaluation and were asked to fill the Female Sexual Function Index (FSFI) questionnaire at the time of first RT session and at a 6-month post-treatment follow up visit. Women who underwent radical hysterectomy, or had pelvic side-wall, pelvic or distant organ metastasis were not included.

Results: A total of 25 women with locally advanced CC were included in the final analysis. The mean age was 39 ± 2.7 years, the mean BMI was 24.8 ± 2.2 kg/m and the median parity was 2 (range: 1-5). Following RT, the mean scores for vaginal elasticity and vaginal tightening were significantly lower than at pre-treatment: 11.3 ± 2.5 vs. 28.3 ± 9, P < 0.0001 and 2.6 ± 0.7 vs. 16.7 ± 3, P < 0.0001, respectively. Following RT, significant decreases were demonstrated in vaginal wall mobility and pelvic muscle contraction strength: from 1.77 ± 0.34 to 0.36 ± 0.15, P < 0.0001 and from 2.55 ± 0.48 to 0.52 ± 0.23, P < 0.0001, respectively. Compared to pre-treatment, post-RT vaginal length was significantly shorter (3.30 ± 0.22 vs. 7.64 ± 0.63, P = 0.0023) and sexual intercourse frequency significantly lower: 1 (range 1-2) vs. 2 (range 1-4), P = 0.014). The mean total FSFI score was significantly lower following RT (6.7 ± 1 vs. 14.5 ± 2.7, P < 0.0001).

Conclusions: Women with locally advanced CC who have been treated with RT exhibit persistent vaginal biomechanical changes that compromise sexual activity and result in considerable distress.
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http://dx.doi.org/10.1016/j.ejogrb.2021.06.046DOI Listing
September 2021

Transvaginal Natural Orifice Transluminal Endoscopic Uterosacral Ligament Hysteropexy: An Innovative Approach for Treatment of Uterine Prolapse.

J Minim Invasive Gynecol 2021 11 23;28(11):1818-1819. Epub 2021 Jun 23.

Department of Obstetrics and Gynecology, Rambam Health Care Campus and Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel (all authors). Electronic address:

Study Objective: Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) was previously described as a feasible approach to perform several procedures including hysterectomy followed by uterosacral ligament suspension [1,2]. Approaching the cul-de-sac with vNOTES while the uterus is intact allowing access to the uterosacral ligaments. This enables attainment of apical support by placing sutures on the ligaments, shortening them, and reinforcing their attachment to the cervix. The objective of this video is to demonstrate a surgical technique for vNOTES uterosacral ligament hysteropexy (ULH).

Design: Stepwise demonstration of the technique with narrated video footage. This video report is part of an institutional, investigational review board-approved study.

Setting: Academic tertiary referral center.

Interventions: This video presents our team's vNOTES technique for ULH in a woman aged 37 years (gravida 3 para 3) who presented with pelvic organ prolapse quantification stage 3 symptomatic uterine prolapse. The patient requested uterine prolapse repair surgery while retaining the uterus. After performing a posterior colpotomy and entering the posterior cul-de-sac, the alexis and then the GelPOINT V-path transvaginal access platform (Applied Medical, Rancho Santa Margarita, CA) were placed into the vagina. Three trocars were inserted into the port. We used a 10-mm scope with a 30°-angle view. The instruments included a needle driver and a clinch grasper. The next step was to identify the uterosacral ligamentous structures. Once identified, 2 absorbable vicryl sutures and 1 nonabsorbable Ti-cron suture were placed on each ligament and then secured with large bites into the junctional portion of the uterosacral ligament with the posterior aspect of the cervix. The GelPOINT was then extracted, and the sutures locked in place to shorten the uterosacral ligaments and reinforce their attachment to the cervix. After all the suspensory sutures were tied, cystoscopy was performed to assess ureteral patency. The vaginal incision was then reapproximated in a horizontal manner, using continuous absorbable suture.

Conclusion: vNOTES ULH appears to be feasible in women with uterine prolapse when uterus conservative treatment is desired. Advantages of this technique include good exposure of the ureter, lowering the risk of ureteric injury. In addition, the absence of incisions on the abdomen eliminates the risk of abdominal wound infection and incisional pain and yields a better cosmetic outcome. Further studies are needed to appraise the long-term outcomes and demonstrate the ultimate use of this modality.
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http://dx.doi.org/10.1016/j.jmig.2021.06.010DOI Listing
November 2021

In Vitro Fertilization Entails a High Prevalence of Erectile and Male Sexual Dysfunction: A Prospective Case-Control Study.

J Urol 2021 10 25;206(4):994-1000. Epub 2021 May 25.

Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel.

Purpose: We evaluated the effect of in vitro fertilization (IVF) on sexual function in men, particularly for erectile dysfunction.

Materials And Methods: A prospective case-control study at a tertiary medical center. The study group comprised men of infertile couples that required IVF to conceive. The control group comprised men of couples who conceived spontaneously. The effects of IVF on sexual and erectile function were assessed based on the International Index of Erectile Function (IIEF-15) and the Self-Esteem and Relationship (SEAR) questionnaires. Participants were followed up to 1 year postpartum.

Results: Compared to the control group (378), for the IVF group (356), mean IIEF-15 scores were significantly lower: prior to pregnancy (31.7±4.5 vs 64.4±7.2, p <0.0001), at mid-pregnancy (37.3±5.1 vs 66.4±5.5, p <0.0001) and up to one year postpartum (42.3±4.9 vs 68.6±4.3, p <0.0001). Compared to the control group, in the IVF group, mean SEAR scores were significantly lower at these 3 respective time points (29.9±6.3 vs 66.5±8.3; 34.1±5.8 vs 66.9±7.2; and 40.9±6.7 vs 67.3±5.6; p <0.0001). At the 3 time points, for the IVF compared to the control group, the median monthly sexual intercourse rate was lower; and both the use of phosphodiesterase-5 inhibitor and psychologist/sexologist care were higher.

Conclusions: The prevalence of erectile dysfunction among men participating in IVF in order to conceive is significantly higher compared to couples that conceived spontaneously, thus leading to an extremely high rate of phosphodiesterase-5 inhibitor use.
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http://dx.doi.org/10.1097/JU.0000000000001872DOI Listing
October 2021

Transvaginal natural orifice transluminal endoscopic versus conventional vaginal hysterectomy with uterosacral ligament suspension for apical compartment prolapse.

Eur J Obstet Gynecol Reprod Biol 2021 May 3;260:203-207. Epub 2021 Apr 3.

Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.

Objective: The objective of this study was to compare surgical and short-term postoperative outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) versus conventional vaginal (CV) uterosacral ligament suspension (USLS) surgery.

Study Design: A retrospective cohort study was conducted on 135 patients who underwent hysterectomy with USLS via CV (n = 70) or via vNOTES (n = 65). Patients' baseline characteristics, surgical characteristics, and surgical outcomes were retrieved. The primary outcome was total operative time. Secondary outcomes include intra- and post-operative complications.

Results: Salpingectomy was performed in all vNOTES procedures and in only 27 % of conventional vaginal procedures (p < 0.005). Compared to the conventional vaginal procedures (n = 65), the vNOTES (n = 70) showed lower mean operative time and mean anesthesia time (101.4 ± 22.3 vs 125.5 ± 27.6 min and 141.4 ± 29.6 vs. 174.0 ± 32.9 min, respectively); and slightly longer median hospital stay (3 [range 2-4] vs. 2 [range 2-4] days, p < 0.05). Compared to women who underwent conventional vaginal hysterectomy with USLS, women who underwent vNOTES hysterectomy with USLS had lower incidences of intraoperative complications (6% vs. 18 %, p < 0.05) and intraoperative ureteral obstruction (0% vs. 8%, p < 0.05); and less estimated blood loss (58 ± 68 ml vs. 143 ± 87 ml, p < 0.05).

Conclusion: vNOTES hysterectomy with USLS is associated with reduced incidence of intraoperative complications, shorter surgical and anesthesia time, and slightly longer hospital stay, compared to the traditional vaginal surgical approach. Post-operative complications during hospital stay were similar and infrequent following the two procedures.
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http://dx.doi.org/10.1016/j.ejogrb.2021.03.040DOI Listing
May 2021

Vaginal Fractional Carbon Dioxide Laser Treatment and Changes in Vaginal Biomechanical Parameters.

Lasers Surg Med 2021 11 9;53(9):1146-1151. Epub 2021 Apr 9.

Department of Obstetrics and Gynecology, Rambam Health Care Campus, Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, 3525408, Israel.

Background And Objectives: Vaginal fractional carbon dioxide (CO ) laser treatment has emerged in the past two decades as a non-surgical option for vaginal tightening. Mounting evidence supports the effectiveness and safety of this treatment for female sexual dysfunction. A newly developed vaginal tactile imaging (VTI) technique accurately evaluates the biomechanical parameters of the female pelvic floor and vagina, including tissue elasticity, pelvic support, and pelvic muscle function in high definition. In the current study, we evaluated changes in objective biomechanical parameters using VTI, following vaginal CO laser treatment for vaginal tightening and sexual dysfunction.

Study Design/materials And Methods: We conducted a prospective cohort between June 2018 and January 2020. Inclusion criteria were vaginal looseness, decreased local sensation during sexual intercourse, and sexual dysfunction. All the participants were treated with a vaginal carbon dioxide laser. They underwent a gynecological evaluation based on the Vaginal Health Index (VHI) and sexual function assessment according to the Female Sexual Function Index (FSFI). Vaginal biomechanical parameters were assessed by VTI. Initial evaluations were performed at the pre-treatment consult visit, 1 week prior to the first treatment and at a 6-month post-treatment follow-up visit.

Results: Twenty-five women were included in the final analysis. Compared with baseline, the post-treatment mean scores for vaginal elasticity and tightening were higher (54.8 ± 5.2 vs. 41.5 ± 6.3, P = 0.0027 and 1.97 ± 0.25 vs. 1.32 ± 0.31, P = 0.0014, respectively). Post-treatment increases were demonstrated in pelvic muscle contraction strength (25.9 ± 3.5 vs. 16.5 ± 4.2, P = 0.0011) and in reflex pelvic muscle contraction (2.93 ± 0.44 vs. 2.12 ± 0.47, P = 0.0022); the mean FSFI and VHI scores were higher following treatment (28.47 ± 1.73 vs. 21.12 ± 1.58, P = 0.036 and 19.15 ± 1.27 vs. 11.6 ± 0.97, P = 0.0032).

Conclusions: The quantification of vaginal biomechanical parameters using VTI technology offers objective evidence of the beneficial effect of vaginal CO laser treatment. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.
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http://dx.doi.org/10.1002/lsm.23405DOI Listing
November 2021

Low-Intensity Shockwave for Treatment of Vestibulodynia: A Randomized Controlled Therapy Trial.

J Sex Med 2021 02 6;18(2):347-352. Epub 2021 Jan 6.

Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion- Israel Institute of Technology, Haifa, Israel.

Background: Provoked vestibulodynia (PVD) is an exhausting pain syndrome that immensely affects quality of sexual life and consequently negatively affects quality of life. Low-intensity shock wave therapy produces physical forces that lead to pain relief.

Aim: The aim of this study was to evaluate the feasibility, safety, and efficacy of low-intensity shockwave therapy in patients with provoked vestibulodynia.

Methods: This is a double-blinded, randomized, sham-controlled, prospective study of 32 women. The treatment protocol included a series of treatments, performed twice a week for 6 weeks. Each treatment consisted of 500 pulses of low intensity shockwaves (0.09 mJmm2) using the Medispec, ED-1000 shockwave generator or sham. Participants were assessed at the baseline, and at 1 and 3 months after completing all treatments.

Outcomes: Pain was assessed by both subjective and objective measures. The primary outcome was a change in dyspareunia, as assessed by scores on the 10-point visual analog scale. Secondary outcome measures were changes in pain threshold and tolerance, assessed by a quantitative validated algometer test, the Wong-Baker pain FACES scale, the Female Sexual Function Index and the Patients' Global Impression of Change scale.

Results: From the baseline to 1 month and 3 months after completion of treatment, visual analog scale scores for dyspareunia decreased (8.0 ± 1.4, 5.7 ± 2.3, and 4.4 ± 2.5, respectively, P < .005). For these respective time points, Wong-Baker scores decreased (4.0 ± 0.6, 2.9 ± 1.2, 2.5 ± 1.3, respectively, P < .05); and total Female Sexual Function Index increased (17.9 ± 6.3, 20.9 ± 6.2, 22.5 ± 8, respectively, P < .002). Pain threshold and tolerance measured by the algometer were increased 3 months after completion of the treatment compared with the baseline (69.8 mmHg ± 11.8 vs 22.9 mmHg ± 9.0, P < .01 and 87.7 mmHg ± 35.7 vs 43.3 mmHg ± 14.7, P < .0001, respectively). No changes were observed in any of the measures assessed in the sham group.

Clinical Implications: We found a new effective treatment for alleviating the most bothersome symptom in PVD, pain during penetration and intercourse. This resulted in improved sexual function.

Strengths & Limitations: The strengths of this study are the randomized controlled design, the correlated subjective questionnaires, and the use of semiquantitative algometer methodology. The limitations are the relative low number of participants in a single center.

Conclusion: For women with PVD, low-intensity shockwave therapy applied at the introitus is a feasible, safe, and effective treatment option that may have a beneficial effect in pain relief and in sexual function. Gruenwald I, Gutzeit O, Petruseva A, et al. Low-Intensity Shockwave for Treatment of Vestibulodynia: A Randomized Controlled Therapy Trial. J Sex Med 2021;18:347-352.
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http://dx.doi.org/10.1016/j.jsxm.2020.11.006DOI Listing
February 2021

The impact of vaginal hysterectomy and uterosacral ligament suspension on vaginal elasticity and sexual function.

Eur J Obstet Gynecol Reprod Biol 2021 Mar 10;258:29-32. Epub 2020 Dec 10.

Department of Obstetrics and Gynecology, Rambam Health Care Campus, and Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.

Objective: Hysterectomy for benign indications has profound effects on both anatomical and physiological pelvic floor and vaginal properties. Vaginal tactile imaging (VTI) enables the quantification of pelvic floor and vaginal biomechanical properties; this enables objective evaluation of various pelvic floor functions. The purposes of this study were to evaluate via VTI, the changes in vaginal elasticity, mobility and strength, before and after hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) and high utero-sacral ligament suspension (USLS); and to assess associations with sexual function. The objective of the current study was to evaluate the effect of these procedures on vaginal elasticity and sexual function.

Study Design: This prospective cohort study included women who underwent hysterectomy by vNOTES and USLS for the treatment of pelvic organ prolapse (POP). All the women underwent both pre- and postoperative VTI and sexual function evaluation. Vaginal elasticity and wall mobility, and the contraction strength and tone of levator muscles, were measured prior to and 6 months following surgery using VTI.

Results: A total of 23 women, mean age 56.5 years, with stage 3-4 POP participated. Vaginal elasticity increased from 27.3 ± 8.8 to 34.8 ± 12 (P < 0.05) and Female Sexual Function Index (FSFI) scores increased from 22.17 ± 1.62 to 28.66 ± 1.51 (P < 0.05). No correlation was observed between these results. A statistically significant decrease in the mobility of the anterior vaginal wall was demonstrated, from 7.98 ± 10.6 to 0.83 ± 7.5 (P < 0.0001).

Conclusions: VTI showed improvements in vaginal elasticity, mobility and FSFI scores following hysterectomy and POP repair performed by vNOTES.
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http://dx.doi.org/10.1016/j.ejogrb.2020.12.015DOI Listing
March 2021

Robotic Vaginal Natural Orifice Transluminal Endoscopic Hysterectomy for Benign Indications.

J Minim Invasive Gynecol 2021 05 2;28(5):1101-1106. Epub 2020 Nov 2.

Department of Gynecological Oncology and Endoscopy, Imelda Hospital, Bonheiden, Antwerpen, Belgium (Dr. Baekelandt).

Study Objective: The Hominis surgical system is a novel robot-assisted system, designed specifically for robotic vaginal natural orifice transluminal endoscopic surgery (RvNOTES). We presented our experience of the first 30 RvNOTES hysterectomies assessing the feasibility and safety of this technology.

Design: A two-center prospective study.

Setting: Academic tertiary referral centers. The ethics committees approved the study in both centers.

Patients: Thirty women with benign indication for hysterectomy.

Intervention: RvNOTES hysterectomy performed by the Hominis surgical system.

Measurements And Main Results: The primary outcome of the study was the rate of conversion to open or conventional laparoscopic approaches. Secondary outcomes included intra- and postoperative adverse events, operative time, estimated blood loss, length of hospital stay, and 6-week follow-up assessment. A total of 15 women were enrolled at each site. The median age was 59 years (range: 37-79) and the median body mass index was 25.4 kg/m (range: 17.6-40.0). Twenty-four women (80%) had comorbidities. All the procedures were completed successfully without conversion to open abdominal, traditional vaginal, or conventional laparoscopic surgery. No intraoperative complications were observed. Median blood loss and procedure duration were 50 mL (range: 20-400) and 57 minutes (range: 24-88), respectively. Postoperative pain was minimal, with a median visual analog scale of 3 (range: 1-5) for the first 24 hours following surgery. The median hospital stay was 3 days (range: 2-8). According to the treating physicians' evaluations, the vaginal cuff was fully healed in all patients at the 6-week postoperative follow-up visit.

Conclusions: This is the first publication of robot-assisted vaginal hysterectomy using the Hominis surgical system. The positive results of this study show this new technology to be a safe and effective tool for vaginal natural orifice transluminal endoscopic surgery, enabling surgeons to operate vaginally with the known advantages of robotic modality.
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http://dx.doi.org/10.1016/j.jmig.2020.10.021DOI Listing
May 2021

Corrigendum to 'The role of hybrid PET/CT in the evaluation of patients with cervical cancer' [Gynecologic Oncology 100 (2005) 65-69].

Gynecol Oncol 2020 Nov 6;159(2):598. Epub 2020 Sep 6.

Department of Nuclear Radiology, Rambam Medical Center, Haifa, Israel.

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http://dx.doi.org/10.1016/j.ygyno.2020.07.001DOI Listing
November 2020

Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) for omentectomy - A case series.

Surg Oncol 2020 Sep 25;34:186-189. Epub 2020 Apr 25.

Gynecological Oncology and Endoscopy, Imelda Hospital, Bonheiden, Antwerpen, Belgium.

Background And Objective: Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has been applied massively in the gynecological field in recent years. The aim of the current study is to present the surgical technique of vNOTES omentectomy and to evaluate the feasibility of this procedure.

Methods: A case series study of the first 5 vNOTES omentectomy procedures performed for surgical staging of suspicious early stage ovarian cancer, at Rambam Health Care Campus (Israel) and Imelda Hospital (Belgium) between November 2018 and August 2019. Sociodemographic and clinical data were retrieved from patients' electronic charts. Primary points of interest included intra-operative bleeding, length of surgery, length of hospitalization, and surgical complications.

Results: The median age was 61 years (range 50-72), and the median BMI was 27 kg/m (range 23-33). All the operations were carried out to completion through the vaginal GelPOINT, without insertion of an assistant abdominal trocar or conversion to another surgical approach. The median omentectomy time was 45 min (range: 39-52). The median estimated intraoperative blood loss was 150 ml (range: 20-200). The median hospital stay was 2 days (range: 1-3).

Conclusions: vNOTES is a feasible technique for omentectomy in early stage ovarian cancer, with low rates of complications and improved cosmetic results.
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http://dx.doi.org/10.1016/j.suronc.2020.04.018DOI Listing
September 2020

Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) for prophylactic bilateral salpingo-oophorectomy.

Surg Oncol 2020 Dec 6;35:79-80. Epub 2020 Aug 6.

Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.

Background: Prophylactic bilateral salpingo-oophorectomy (BSO) is an important option for reducing the risk of developing ovarian and fallopian tube cancers in women with a hereditary ovarian cancer syndrome. Conventional laparoscopy is generally preferable since it is associated with less morbidity compared to laparotomy. Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is an emerging surgical approach that offers several advantages over conventional laparoscopy including reduced postoperative pain, low rate of surgical site infections, fast patient recuperation and better cosmetic outcome [1-6]. The objective of this video is to demonstrate a surgical technique for vNOTES BSO.

Methods: This is a Stepwise demonstration of the vNOTES for prophylactic BSO with narrated video footage. The diameter of Alexis is 7 cm and we used the GelPOINT V-path transvaginal access platform (Applied Medical, Rancho Santa Margarita, CA).

Results: A 52-year-old carrier of BRCA1 mutation. The patient was selected to be operated on via a vaginal port. The video presents some tips and tricks to aid the surgeon to perform this surgery in a safe and timely manner, using the vaginal GEL POINT system and vNOTES technique.

Conclusions: vNOTES for prophylactic BSO via a vaginal port is a feasible technique with promising cosmetic results. This technique allows surgeon to expose the ureter well and lower the risk of ureteric injury. Additionally, this approach avoids abdominal wall vessels injury associated with the trocar insertion. Currently, as a result of certain technical limitations, such as when performing BSO without a hysterectomy, there has been a tendency to employ the vaginal access less frequently. In this video presentation, we demonstrate the feasibility of laparoscopic BSO via vNOTES whilst leaving the uterus intact.
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http://dx.doi.org/10.1016/j.suronc.2020.07.006DOI Listing
December 2020

Low-intensity extracorporeal shockwave therapy among urologist practitioners: how the opinion of urologists changed between 2016 and 2019.

Int J Impot Res 2020 Dec 21;33(8):839-843. Epub 2020 Aug 21.

Urology Section, Department of Surgery, University of Catania, Catania, Italy.

Over the past few years, an increase use of low-intensity shockwave therapy (LISWT) for the treatment of erectile dysfunction (ED) has been observed. However, many controversies in the scientific literature about its efficacy still exist. We aimed to investigate changes in the pattern of usage and attitudes toward LISWT for ED among experts over the last years. A dedicated online survey was sent to delegates at the Congress for the EAU Section of Andrological Urology (ESAU) in Prague from 31st October to 1st November 2019. The survey captured demographic data, professional background, and the experience and personal knowledge about LISWT. The results were compared with a previous survey conducted in 2016 and investigating the same topics in order to assess changes in the knowledge and opinion on LISWT over time. Overall, 172 and 192 questionnaires were available from 2019 and 2016, respectively. Participants in the 2019 survey were 80 (45.7%) urologists, 52 (29.7%) uro-andrologists, and 34 (19.4%) residents in urology, from 30 different countries. Compared to the past, we observed an increase of respondents who were familiar with LISWT (75 vs. 95%; p < 0.0001) and who performed LISWT in their routine practice (38% in 2019 vs. 14% in 2016; p < 0.0001). Conversely, no changes in terms of overall perception of treatment efficacy were registered over time (68% in 2019 vs. 72% in 2016 considered LISWT as an effective treatment, respectively (p = 0.5)). An increased proportion of physicians had suggested a wider application of LISWT, and some even advocated its use in nonvasculogenic ED (33% in 2019 vs. 5.9% in 2016; p < 0.0001). The awareness and clinical application of LISWT for ED have increased over time, despite the lack of robust evidence in terms of effectiveness. Further research on the benefit of LISWT is needed to guide physicians in the therapeutic management of ED patients.
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http://dx.doi.org/10.1038/s41443-020-00347-xDOI Listing
December 2020

Robotic transvaginal natural orifice transluminal endoscopic surgery for bilateral salpingo oophorectomy.

Eur J Obstet Gynecol Reprod Biol X 2020 Jul 23;7:100113. Epub 2020 Jun 23.

Gynecological Oncology and Endoscopy, Imelda Hospital, Bonheiden, Antwerpen, Belgium.

Objectives: The vaginal surgical approach has not become the standard of care, despite its advantages. The Hominis™ Surgical System is a humanoid shaped robot-assisted system that was designed specifically for robotic vaginal natural orifice transluminal endoscopic surgery (RvNOTES). We aimed to present our experience with the first RvNOTES bilateral salpingo-oophorectomy (BSO) performed by the Hominis system.

Study Design: A two-center prospective study of BSO by RvNOTES in women with nonmalignant indications conducted between August and December 2018. Women older than 18 years were offered to participate. Exclusion criteria included a history of abdominal malignancy, pelvic or abdominal irradiation, Crohn's disease, pelvic inflammatory disease, severe infections in the lower abdomen, active diverticulitis, deep infiltrating recto-vaginal endometriosis, and an active vaginal infection. The primary outcome of the study was the rate of conversion to open or laparoscopic approaches. Secondary outcomes included intra- and postoperative adverse events, operative time, estimated blood loss, length of hospital stay, and 6-week follow-up assessment.

Results: Eight women aged 50-70 years with BMI of 19-30 kg/m were recruited. All the procedures were completed successfully without conversions to open surgery. No intraoperative complications were observed. Median blood loss was 10 mL (range: 10-50). The median duration of the procedure was 45 min (range: 38-91), and decreased over the study period. Surgeons' usability assessment was very favorable, with a median of 5 on a 1-5 scale. The median visual analog scale (VAS) score was 1 (range: 1-3).

Conclusions: This is the first documentation of a surgery performed via the vagina using robotic instrumentation developed for this purpose. The disruptive technology of RvNOTES, with its fast learning curve, will make gynecological surgeries accessible to more women.
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http://dx.doi.org/10.1016/j.eurox.2020.100113DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7379144PMC
July 2020

[SAFE SURGICAL PRACTICE IN THE ERA OF COVID-19].

Harefuah 2020 Jun;159(6):458-460

Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.

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June 2020

Feasibility and Learning Curve of Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Hysterectomy and Uterosacral Ligament Suspension in Apical Compartment Prolapse.

Female Pelvic Med Reconstr Surg 2021 01;27(1):e171-e176

Gynecological Oncology and Endoscopy, Imelda Hospital, Bonheiden, Antwerpen, Belgium.

Objective: The aim of this study was to describe our experience with transvaginal natural orifice transluminal endoscopic surgery (vNOTES) uterosacral ligament suspension (USLS) and to evaluate the learning curve of mastering the skills to operate this procedure.

Methods: This is a prospective study of the first 35 vNOTES hysterectomy and USLS surgeries performed between October 2018 and April 2019 at Rambam Health Care Campus (Israel) (n = 26) and Imelda Hospital (Belgium) (n = 9). The primary outcome was surgical time. Secondary outcomes included intraoperative bleeding, length of hospitalization, pain during the first 24 hours postoperative pain, and the need for analgesia, intraoperative, and postoperative adverse events.

Results: The median age was 55 years (range, 40-81). The median operative time was 113 minutes (range, 89-233). For the procedures performed at Rambam, total operative time decreased from the first 13 to the following 13: from 149 minutes (range, 89-233 minutes) to 103 (89-170) (<0.001); Pearson correlation demonstrated a moderate negative significant correlation of surgery duration with surgeon experience (rho = -0.445, P < 0.001). The median estimated blood loss was 30 mL (20-200). The median hospital stay was 2 days (1-3). There were no intraoperative adverse events. The median visual analogue scale score for pain assessment during the first 24 hours after surgery was 1 (range, 1-3).

Conclusions: vNOTES USLS is a feasible procedure that showed marked improvement in surgical performance in a short period, as evidenced by the decrease in surgical time and the low rate of minor associated perioperative complications. Outcomes of long-term follow-up should be investigated.
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http://dx.doi.org/10.1097/SPV.0000000000000875DOI Listing
January 2021

The Efficacy and Safety of CO Laser Treatment for Sexual Function and Vaginal Laxity Improvement in Pre-Menopausal Women.

Lasers Surg Med 2021 02 26;53(2):199-203. Epub 2020 May 26.

Department of Obstetrics and Gynecology, Rambam Health Care Campus, and Ruth and Bruce Rappaport Faculty of Medicine, Hàalia Hàshnia 8, Technion, Haifa, 3109601, Israel.

Background And Objectives: Vaginal laxity lacks standardized diagnosis and severity criteria. It is considered as a subjective complaint that reflects decreased sexual satisfaction due to vaginal loosening. Treatment modalities have included physiotherapy and plastic surgery. Recently, laser treatments have also gained popularity as a means of relieving gynecological complaints such as pelvic organ prolapse, stress urinary incontinence, and genitourinary syndrome of menopause. The aim of the current study was to evaluate the efficacy of CO laser treatment in women for whom a decrease in sexual sensation during intercourse and vaginal loosening were their primary complaints.

Study Design/materials And Methods: For this prospective study, women with reported vaginal laxity and decreased sensation during intercourse were recruited from the Sexual Dysfunction Clinic in our health care campus. Each participant received three outpatient treatments with laser therapy, according to the same protocol. Treatment efficacy was assessed by changes in the Vaginal Health Index (VHI) and Female Sexual Function Index (FSFI).

Results: Overall, 84 pre-menopause women, with a mean age of 47.7 years, were included in the study. Mean VHI and FSFI were increased significantly at 3 months post-treatment and decreased again at 6 months post-treatment: 11.8 ± 1.6, 13.5 ± 1.1, and 11.8 ± 1.2, respectively, P = 0.013; and 21.3 ± 1.7, 29.9 ± 1.6, and 22.5 ± 1.8, respectively, P = 0.022. The rate of sexual intercourse doubled during the period of maximal treatment effect (P < 0.0001).

Conclusions: CO laser treatment has both a statistically and clinically significant effect on participants' complaints and sex-life, which wanes by 6 months post-treatment. Laser therapy seems to be safe in the short term, with no serious adverse events reported in the current study. Further studies are warranted to determine the long-term safety and the efficacy of maintenance laser treatments. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.
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http://dx.doi.org/10.1002/lsm.23263DOI Listing
February 2021

Laser-Based Devices for Female Genitourinary Indications: Position Statements From the European Society for Sexual Medicine (ESSM).

J Sex Med 2020 05 20;17(5):841-848. Epub 2020 Mar 20.

Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel.

Background: Laser-based technologies have been commercially marketed as "wonder treatments" without a sufficient and adequate body of evidence. In addition, on July 30, 2018, the U.S. Food and Drug Administration issued a warning regarding the safety of the use of laser-based devices for the following indications: vaginal "rejuvenation" or cosmetic vaginal procedures, vaginal conditions and symptoms related to menopause, urinary incontinence, and sexual function.

Aim: To perform a thorough review of the available literature regarding laser-based vaginal devices for the treatment of female genitourinary indications and summarize the results in several short statements according to the level of evidence.

Methods: A comprehensive review of the literature regarding laser treatments for gynecological indications was performed based on several databases. Eligible were studies that included at least 15 patients.

Outcomes: Several aspects, including preclinical data, have been investigated. For each topic covered, data on laser-based devices were analyzed.

Results: Despite the high heterogeneity of studies and its limitations, the committee released several statements regarding the use of laser-based devices for genitourinary indications.

Clinical Implications: Available data in the clinical setting are still poor, and the impact of these technologies on vaginal symptoms and signs has not been clearly established.

Strengths & Limitations: All studies have been evaluated by a panel of experts providing recommendations for clinical practice.

Conclusion: It is too early in the evolution and research of laser-based devices to make decisive recommendations regarding vaginal treatments. There is grave need to carry out randomized controlled trials with proper design for safety reasons, possible harm, and short-/long-term benefits for the different indications studied.
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http://dx.doi.org/10.1016/j.jsxm.2020.02.013DOI Listing
May 2020

Laparoscopic sacrocolpopexy complication: Ilio-femoral deep vein thrombosis.

Eur J Obstet Gynecol Reprod Biol 2020 Apr 26;247:270-271. Epub 2020 Feb 26.

Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.

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http://dx.doi.org/10.1016/j.ejogrb.2020.02.040DOI Listing
April 2020

Radiofrequency-Based Devices for Female Genito-Urinary Indications: Position Statements From the European Society of Sexual Medicine.

J Sex Med 2020 03;17(3):393-399

Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel.

Introduction: Radiofrequency (RF)-based treatment has been introduced as an esthetic alternative treatment for various medical indications without the scientific backup of a satisfactory body of evidence. Furthermore, the United States Food and Drug Administration issued a warning regarding the safety of energy-based technologies for indications such as vaginal "rejuvenation," cosmetic vaginal treatment, vaginal conditions related to menopause, and symptoms of urinary incontinence and sexual function on July 30, 2018.

Aim: To perform a thorough review of the existing literature regarding RF-based vaginal devices for the treatment of female genitourinary indications and summarize the evidence available in a few short statements.

Methods: A thorough review of the literature regarding RF treatments for gynecological indications was performed based on several databases. Studies that included at least 15 patients were eligible for analysis.

Main Outcome Measure: Efficacy of RF devices for different genitourinary indications.

Results: Although a high level of heterogeneity of studies poses a serious challenge, the committee reached a decision on several statements related to the use of RF-based devices for genitourinary indications.

Clinical Implications: RF-based vaginal treatments have not been studied thoroughly enough in order to establish decisive recommendations regarding their safety and efficacy.

Strength & Limitations: These position statements have been established by a group of experts. The lack of strong evidence makes it difficult to give decisive recommendations.

Conclusions: Further randomized controlled trials with proper methodology and design are required to establish both benefits and possible harm these treatments may have in both short and long term for all the different indications studied. Otero JR, Lauterbach R, Aversa A, et al. Radiofrequency-Based Devices for Female Genito-Urinary Indications: Position Statements From the European Society of Sexual Medicine. J Sex Med 2020;17:393-399.
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http://dx.doi.org/10.1016/j.jsxm.2019.12.015DOI Listing
March 2020

Transvaginal Natural Orifice Transluminal Endoscopic (vNOTES) Hysterectomy Learning Curve: Feasibility in the Hands of Skilled Gynecologists.

Isr Med Assoc J 2020 Jan;22(1):13-16

Department of Obstetrics and Gynecology, Rambam Health Care Campus, affiliated with Rappaport Faculty of Medicine, Technion, Haifa, Israel.

Background: During Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) the surgeon operates exclusively through a single vaginal entry point, leaving no external scarring.

Objectives: To evaluate the learning curve of vNOTES hysterectomy by experienced gynecologists based on surgical times and short-term outcomes.

Methods: A retrospective study was conducted of the first 25 vNOTES hysterectomy surgeries performed from July to December 2018 at Rambam Health Care Campus by a single surgeon. The primary outcome was hysterectomy time. Secondary outcomes included intra-operative bleeding, length of hospitalization, postoperative pain, and need for analgesia. Socio-demographic and clinical data were retrieved from patient electronic medical charts.

Results: Median age was 64.5 years (range 40-79). Median hysterectomy time was 38 minutes (range 30-49) from the first cut until completion. Comparisons between median hysterectomy time in the first 10 hysterectomies and in the 15 subsequent procedures demonstrated a significant decrease in median total time: 45 minutes (range 41-49) vs. 32 minutes (range 30-38), respectively (P = 0.024). The median estimated intraoperative blood loss decreased from 100 ml (range 70-200) in the first 10 hysterectomies to 40 ml (range 20-100) in the subsequent procedures (P = 0.011).

Conclusions: vNOTES hysterectomy is feasible by an experienced gynecologist, with an exponential improvement in surgical performance in a short period as expressed by the improvement in hysterectomy time, low complication rates, negligible blood loss, minimal post-surgical pain, fast recovery, and short hospitalization. vNOTES allows easier and safer access to adnexal removal compared to conventional vaginal surgery.
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January 2020

How Does Myofascial Physical Therapy Attenuate Pain in Chronic Pelvic Pain Syndrome?

Pain Res Manag 2019 12;2019:6091257. Epub 2019 Dec 12.

Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel.

Background: Chronic pelvic pain syndrome (CPPS) is a multifactorial disorder comprising structural and functional muscular abnormalities, a dysfunctional pain system, and psychological distress. Myofascial physical Therapy (MPT) that is targeted at improving pelvic muscle functioning is considered a first line nonpharmacological treatment for CPPS, although the precise mechanisms that lead to symptoms alleviation have not yet been elucidated.

Purpose: This longitudinal study aimed to examine the local and systemic effects of MPT intervention, including biopsychophysiological processes, among CPPS patients.

Methods: The study included 50 CPPS women. Morphologic assessment of the levator ani and quantitative sensory testing of the pain system were applied alongside with evaluation of pain-related psychological factors using designated questionnaires. All measures were evaluated both before and after MPT in 39 patients. The long-term effects of MPT were evaluated by clinical pain reports obtained at 3 and 9 months following MPT that were compared with a nontreated group of 11 untreated CPPS women.

Results: Along with an improvement in the clinical pain intensity ( = 0.001) and sensitivity to experimental pain tests ( = 0.001) following MPT, the results also indicate that MPT has anatomical, psychological, and social therapeutic effects ( = 0.04; = 0.001; = 0.01, respectively). Furthermore, clinical pain evaluation at 3 and 9 months after MPT revealed a significant improvement in women who received treatment ( = 0.001).

Conclusions: The findings of this pilot study suggest multisystemic (direct and indirect anatomical, neurophysiological, and psychological) effects of MPT on the multifactorial pain disorder of CPPS and therefore place MPT as a mechanism-based intervention.
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http://dx.doi.org/10.1155/2019/6091257DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6930783PMC
April 2020

How Does Myofascial Physical Therapy Attenuate Pain in Chronic Pelvic Pain Syndrome?

Pain Res Manag 2019 12;2019:6091257. Epub 2019 Dec 12.

Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel.

Background: Chronic pelvic pain syndrome (CPPS) is a multifactorial disorder comprising structural and functional muscular abnormalities, a dysfunctional pain system, and psychological distress. Myofascial physical Therapy (MPT) that is targeted at improving pelvic muscle functioning is considered a first line nonpharmacological treatment for CPPS, although the precise mechanisms that lead to symptoms alleviation have not yet been elucidated.

Purpose: This longitudinal study aimed to examine the local and systemic effects of MPT intervention, including biopsychophysiological processes, among CPPS patients.

Methods: The study included 50 CPPS women. Morphologic assessment of the levator ani and quantitative sensory testing of the pain system were applied alongside with evaluation of pain-related psychological factors using designated questionnaires. All measures were evaluated both before and after MPT in 39 patients. The long-term effects of MPT were evaluated by clinical pain reports obtained at 3 and 9 months following MPT that were compared with a nontreated group of 11 untreated CPPS women.

Results: Along with an improvement in the clinical pain intensity ( = 0.001) and sensitivity to experimental pain tests ( = 0.001) following MPT, the results also indicate that MPT has anatomical, psychological, and social therapeutic effects ( = 0.04; = 0.001; = 0.01, respectively). Furthermore, clinical pain evaluation at 3 and 9 months after MPT revealed a significant improvement in women who received treatment ( = 0.001).

Conclusions: The findings of this pilot study suggest multisystemic (direct and indirect anatomical, neurophysiological, and psychological) effects of MPT on the multifactorial pain disorder of CPPS and therefore place MPT as a mechanism-based intervention.
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http://dx.doi.org/10.1155/2019/6091257DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6930783PMC
April 2020

The safety and efficacy of CO laser in the treatment of stress urinary incontinence.

Int Urogynecol J 2020 08 18;31(8):1691-1696. Epub 2019 Dec 18.

Department of Obstetrics and Gynecology, Rambam Health Care Campus, and Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.

Introduction And Hypothesis: Conservative treatment is recommended as first-line therapy for stress urinary incontinence (SUI). We hypothesized that CO laser treatment would demonstrate safety and efficacy for women with SUI.

Methods: A prospective, open-label, cohort study of 33 women (mean age 43 years) referred from a continence clinic after urologist/urogynecologist assessment, with a verified stress urinary incontinence diagnosis based on urodynamic testing. The participants completed three outpatient treatments with laser therapy and were subsequently evaluated at 1, 3 and 6 months. The independent t and chi-square tests were used to assess changes in sanitary pad usage and SUI symptoms.

Results: Sanitary pad usage decreased from a median of 12 per day at baseline to 7 at 1-3 months post-treatment (P < 0.0001) and returned to 12 at 6 months post-treatment. Scores on the Urogenital Distress Inventory and the International Consultation of Incontinence Questionnaire decreased (improved) significantly at 1-3 months post-treatment: from 45 ± 2 and 16 ± 4, respectively, to 29.3 ± 14.7 and 8.15 ± 3.1, respectively (P < 0.0001). The scores returned to levels similar to baseline at 6 months after treatment. Participants reported mild and transient side effects, with significant improvement in quality of life.

Conclusions: Laser therapy can be an optional conservative treatment for women who seek minimally invasive non-surgical treatment for the management of SUI. No serious adverse effects were reported though the sample size was not large, a possible limitation of the study. Further large randomized control trials are needed to appraise the efficacy and safety of laser therapy for stress urinary incontinence and to demonstrate the ultimate utility of this modality.
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http://dx.doi.org/10.1007/s00192-019-04204-4DOI Listing
August 2020

Postpartum Female Sexual Function: Risk Factors for Postpartum Sexual Dysfunction.

Sex Med 2020 Mar 16;8(1):8-13. Epub 2019 Dec 16.

Department of Obstetrics and Gynecology, Rambam Medical Center, Haifa, Israel. Electronic address:

Introduction: Women's sexual health is a vital and important part of life at any age. In particular, pregnancy and childbirth bring biological, psychological, and social changes which may influence sexual health. It has been shown that sexual function declines during pregnancy and does not return to its baseline levels during the postpartum period. Despite the complexity and significance of this subject, health providers often neglect sexual aspects during pregnancy and postpartum.

Aim: We believe that clarifying the risk factors will help open conversations and improvements in sexual function.

Methods: In this review, we focus on how postpartum sexual function is affected by mode of delivery, perineal trauma during delivery, episiotomy, and lactation.

Concclusions: We conclude that the mode of delivery has no significant effect on short- and long-term postpartum sexual function. On the other hand, 3rd and 4th degree tears are strongly associated with postpartum sexual dysfunction. We found that episiotomy does not adversely affect sexual function, and lactation has a slightly negative effect. We believe that shedding light on this topic will lead to a better understanding for pregnant and postpartum women and the obstetrician. Further studies may elucidate more useful treatment approaches. Ola Gutzeit, Gali Levy, Lior Lowenstein. Postpartum Female Sexual Function: Risk Factors for Postpartum Sexual Dysfunction. Sex Med 2019;8:8-13.
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http://dx.doi.org/10.1016/j.esxm.2019.10.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7042171PMC
March 2020
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