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Letter to editor: “Vaginal Er:YAG laser application in the menopausal ewe model: a randomised estrogen and sham-controlled trial “Cheng-Yang Hsu1, Ching-Hu Wu1, Cheng-Yu Long1, 21 Department of Obstetrics and Gynecology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan2 Department of Obstetrics and Gynecology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, TaiwanRunning head: Two prospective for this promising experimentWords Count: 315Corresponding Author:Dr. Cheng-Yu Long, MD, PhD, Department of Obstetrics and Gynaecology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, 100, Shih-Chuan 1st Rd, Kaohsiung 80708, TaiwanE-mail: [email protected] Editor-in Chief:We read with great interest with recent publication in BJOG by Mackova et al. (1) This study describe effects of non-ablative erbium-doped: yttrium-aluminium-garnet (Er:YAG) laser on vaginal atrophy induced by iatrogenic menopause in the ewe. The ewes were randomized to three groups: vaginal Er:YAG laser application, estrogen replacement, and sham groups.In the estrogen replacement group of ewes, an estrogen implant was inserted under the skin in the inguinal region. The result showed increase in epithelia thickness in vaginal biopsies and it was significantly higher compared with the laser application and sham groups. In all groups, the lamina propria did not showed any significant differences. Also the autopsy showed the uterus of estrogen-exposed ewes weighted more.We would like to humbly comment the vaginal estrogen use and laser application in genitourinary syndrome of menopause.The vaginal estrogen application was given twice a week with the cream in currently practice of female who suffered from genitourinary syndrome of menopause (GSM). Firstly, the vaginal estrogen application was given twice a week with the cream in clinical practice of female who suffered from GSM. The administration showed improvement of the symptoms while no significant change in serum estrogen level. (2) The estrogen implant in the ewe experiment continues to release estrogen and caused sustained estrogen effect in the ewe and caused gaining weight of uterus, which was very different with our clinical practice of intermittent vaginal cream use.Second, the application in this study is Er:YAG laser, with the the lesser wave length: 2940 nm. While the CO2 laser had much longer wave length 10600 nm and had deeper effect in not only vaginal epithelium but also lamina propia. (3) Therefore the vascularization effects of lamina propia may be obvious noticeably.We thought these 2 flaws could be revised to make the ewe experiment more accurate and similar to current management in women with GSM.ReferencesMackova KA-OX, Mazzer AM, Mori Da Cunha MA-O, Hajkova Hympanova LA-O, Urbankova IA-O, Kastelein AA-O, et al. Vaginal Er:YAG laser application in the menopausal ewe model: a randomised estrogen and sham-controlled trial. BJOG . 2021 May;128(6):1087-1096.Long CY, Liu CM, Hsu SC, Wu CH, Wang CL, Tsai EM. A randomized comparative study of the effects of oral and topical estrogen therapy on the vaginal vascularization and sexual function in hysterectomized postmenopausal women. Menopause . Sep-Oct 2006;13(5):737-43.Bhide AA, Khullar V, Swift S, Digesu GA. The use of laser in urogynaecology. Int Urogynecol J . 2019 May;30(5):683-692.

Dear Editor, We really appreciate MN van IJsselmuiden et al. for their efforts in conducting the first ever multicenter randomized controlled trial to compare laparoscopic sacrohysteropexy (LSH) with sacrospinous hysteropexy (SSHP).1 However, I have some questions regarding the methodology and results of this trial. What are the reasons for including patients with histories of previous pelvic floor or prolapse surgery in the exclusion criteria? Would randomly and equally allocating these patients into two surgical groups affect the study result or design? Nevertheless, we are really interested in the conduct of anterior or posterior colporrhaphy through the laparoscopic method.Patients presented with anterior vaginal wall prolapse are higher in number: POP-Q stage- Aa or Ba > 0 (LSH group:81%; SSHP group:72.6%) than those presented with apical prolapse (LSH group:46.6%; SSHP:45.6%) in Table 1. The majority of study population appears to have combined anterior and apical compartment prolapse rather than apical prolapse alone. Furthermore, Table 2 shows that the overall anterior compartment failure rates are 50.9% and 56.9% in the LSH and SSHP groups, respectively, in a 1 year follow-up interval. The failure rate is extraordinarily high compared with that in a previous study.2 Hysteropexy surgery is beneficial for patients with apical prolapse. It is not beneficial for patients with combined anterior and apical compartment prolapse with prominent cystocele. Most patients are satisfied with the 1 year surgical results and would recommend surgery to someone else (LSH: 87.7%; SSHP: 89.7%) despite the high recurrence rate of anterior wall prolapse in a 1 year follow-up.In the statistical analysis section, additional anterior vaginal wall repairs are significantly higher in the SSHP group than those in the LSH group (SSHP: n = 61, 98.4%; LSH: n = 55, 85.9%, P = 0.010). I would like to know how this small number difference (61 − 55 = 6) in these groups can cause significant difference in P value and how this P value is calculated. This trial assumes a failure rate of 3% on the basis of the outcomes of SSHP in a previous prospective study. However, the data population is relatively small, and the non-inferiority margin was set at 10%.The primary outcome is defined as a composite outcome of the surgical failure of the apical compartment after 12 months of follow-up and as the recurrence of uterine prolapse (POP-Q ≥ stage 2). Surgical success is defined as the absence of prolapse beyond the hymen. In the POP-Q stage system, POP-Q stage 2 is defined as the most distal prolapse between 1 cm above and 1 cm beyond the hymen.3 The most prominent prolapse, which descends beyond hymen, is the stage 2 prolapse. It elicits clinical controversy and conflicts with regard to the definitions of surgical failure and success. We hope that this letter will deliver the message that precise preoperative patient selection and study design are crucial, as they may have substantial impacts on clinical outcomes and treatment success.Min-syuan Huang,2, 3 Zi-Xi Loo,1Kun- Ling Lin,1, 2 Cheng-Yu Long1, 21 Department of Obstetrics and Gynecology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan2 Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan3 Department of Obstetrics and Gynecology, Kuo General Hospital, Tainan, Taiwan

Dear Editor, We really appreciate MN van Ijsselmuiden et al. for their efforts in conducting the first ever multicentre randomized controlled trial to compare laparoscopic sacrohysteropexy (LSH) versus sacrospinous hysteropexy (SSHP) .1 It has raised my queries and questions regarding the methodology and results of this trial. I would like to know the reasons to include the patients with history of previous pelvic floor or prolapse surgery in the exclusion criteria. If those above patients were randomly allocated into two surgical group equally, would it have impacts over the study result or design? Moreover, we are really interested and keen to know how to perform the anterior colporrhaphy and posterior colporrhaphy though laparoscopic method as mentioned in the article.There are more patients presented with anterior vaginal wall prolapse: POP-Q stage- Aa or Ba > 0 (LSH group:81%; SSHP group:72.6%) when compared to apical prolapse (LSH group:46.6%; SSHP:45.6%) in Table 1. It seems that the majority of study population had combined anterior and apical compartment prolapse but not with solely apical prolapse. Furthermore, Table 2 showed that overall anterior compartment failure rates are 50.9% and 56.9% in LSH group and SSHP group respectively in 1-year follow-up interval. The failure rate is extraordinarily high compared with previous study.2 Hysteropexy surgeries are useful to treat patients with sorely apical prolapse but not with patients with combine anterior and apical compartment prolapse with prominent cystocele. In controversy, a large majority were satisfied with the one year surgical results and would recommend the surgery to someone else (LSH: 87.7%; SSHP: 89.7%) even though there was a high recurrence rate of anterior wall prolapse in one year follow-up.In the statistical analysis section, there were significantly more additional anterior vaginal wall repairs in the SSHP group compared to LSH group (SSHP: n = 61, 98.4%; LSH: n = 55, 85.9%, P = 0.010). I would like to know how this small number difference (61-55=6) in these two groups can cause significant difference in P value and how to calculate this P value. This trial assumes a failure rate of 3% based on outcomes of SSHP in a previous prospective study. However, the data population is relatively small while the non-inferiority margin was set at 10%.The primary outcome is defined as a composite outcome of surgical failure of the apical compartment at 12 months’ follow-up, defined as recurrence of uterine prolapse (POP-Q ≥ stage 2). Surgical success was defined as no prolapse beyond the hymen. According to POP-Q stage system, POP-Q stage 2 is defined as most distal prolapse is between 1 cm above and 1 cm beyond hymen.3 The most prominent prolapse which descends beyond hymen would be also considered as stage 2 prolapse. It elicits clinical controversy and conflicts in the definition between surgical failure and success. We hope that this letter will deliver the message that precise preoperative patient selection and study design are crucial as they may have critical impacts over clinical outcomes and treatment success.Min-syuan Huang,2, 3 Zi-Xi Loo,1Kun- Ling Lin,1, 2 Cheng-Yu Long1, 21. Department of Obstetrics and Gynecology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan2. Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan3. Department of Obstetrics and Gynecology, Kuo General Hospital, Tainan, Taiwan