INNOVATIVE GYN THERAPIES

Innovative therapies in gynecology: The evidence and your practice

OBG Manag. 2021 September;33(9)

References

Preti M, Viera-Baptista P, Digesu GA, et al. The clinical role of LASER for vulvar and vaginal treatments in gynecology and female urology: an ICS/ISSVD best practice consensus document. J Lower Genital Tract Dis. 2019;23:151-160.
Alshiek J, Garcia B, Minassian V, et al. Vaginal energy-based devices: AUGS clinical consensus statement. Female Pelvic Med Reconstr Surg. 2020;26:287-298.
Streicher LF. Vulvar and vaginal fractional CO2 laser treatments for genitourinary syndrome of menopause: NAMS practice pearl. Menopause. 2018;25:571-573.
Gardner AN, Aschkenazi SO. The short-term efficacy and safety of fractional CO2 laser therapy for vulvovaginal symptoms in menopause, breast cancer, and lichen sclerosus. Menopause. 2021; 28:511-516.
Balchander D, Nyirjesy P. Fractionated CO2 laser therapy in recalcitrant lichen sclerosus. J Lower Genital Tract Disease. 2020;24:225-228.
Pieralli A, Fallani MG, Becorpi A, et al. Fractional CO2 laser for vulvovaginal atrophy (VVA) dyspareunia relief in breast cancer survivors. Arch Gynecol Obstet. 2016;294:841-846.
Pieralli A, Bianchi C, Longinotti M, et al. Long-term reliability of fractionated CO2 laser as a treatment of vulvovaginal atrophy (VVA) symptoms. Arch Gynecol Obstet. 2017; 296:973-978.
Sokol ER, Karram MM. Use of novel fractional CO2 laser for the treatment of genitourinary syndrome of menopause: 1-year outcomes. Menopause. 2017;24: 810-814.
Pagano T, Conforti A, Buonfantino C, et al. Effect of rescue fractional microablative CO2 laser on symptoms and sexual dysfunction in women affected by vulvar lichen sclerosus resistant to long-term use of topic corticosteroid: a prospective longitudinal study. Menopause. 2020;27:418-422.
Sindou-Faurie T, Louis-Vahdat C, Oueld Es Cheikh E, et al. Evaluation of the efficacy of fractional CO2 laser in the treatment of vulvar and vaginal menopausal symptoms. Arch Gynecol Obstet. 2021;303:955-963.
Paraiso MFR, Ferrando CA, Sokol ER, at al. A randomized clinical trial comparing vaginal laser therapy to vaginal estrogen therapy in women with genitourinary syndrome of menopause: the VeLVET trial. Menopause. 2019;27:50-56.
Burkett LS, Siddique M, Zeymo A, et al. Clobetasol compared with fractionated carbon dioxide laser for lichen sclerosus: a randomized controlled trial. Obstet Gynecol. 2021;137:968-978.
Mitchell L, Goldstein AT, Heller D, et al. Fractionated carbon dioxide laser for the treatment of vulvar lichen sclerosus: a randomized controlled trial. Obstet Gynecol. 2021;136:979-987.
Kirchin V, Page T, Keegan PE, et al. Urethral injection therapy for urinary incontinence in women. Cochrane Database Syst Rev. 2017;7:CD003881.
Lose G, Mouritsen L, Nielson JB. A new bulking agent (polyacrylamide hydrogel) for treating stress urinary incontinence in women. BJU Int. 2006;98:100-104.
Sokol ER, Karram MM, Dmochowski R. Efficacy and safety of polyacrylamide hydrogel for the treatment of female stress incontinence: a randomized, prospective, multicenter North American study. J Urol. 2014;192:843-849.
Pai A, Al-Singary W. Durability, safety and efficacy of polyacrylamide hydrogel (Bulkamid) in the management of stress and mixed urinary incontinence: three year follow up outcomes. Cent European J Urol. 2015;68:428-433.
Brosche T, Kuhn A, Lobodasch K, et al. Seven-year efficacy and safety outcomes of Bulkamid for the treatment of stress urinary incontinence. Neurourol Urodyn. 2021;40:502-508.
Kasi AD, Pergialiotis V, Perrea DN, et al. Polyacrylamide hydrogel (Bulkamid) for stress urinary incontinence in women: a systematic review of the literature. Int Urogynecol J. 2016;27:367-375.
Vecchioli-Scaldazza CV, Smaali C, Morosetti C, et al. Polyacrylamide hydrogel (Bulkamid) in female patients of 80 or more years with urinary incontinence. Int Braz J Urol. 2014;40:37-43.
Elmelund M, Sokol ER, Darram MM, et al. Patient characteristics that may influence the effect of urethral injection therapy for female stress urinary incontinence. J Urol. 2019;202:125-131.
Sanoulis V, Nikolettos N, Vlahos N. The use of platelet-rich plasma in the gynecological clinical setting: a review. HJOG. 2019;18:55-65.
Fanning J, Murrain L, Flora R, et al. Phase I/II prospective trial of autologous platelet tissue graft in gynecologic surgery. J Minim Invasive Gynecol. 2007;14:633-637.
Runels CE, Melnick H, DeBourbon E, et al. A pilot study of the effect of localized injections of autologous platelet rich plasma (PRP) for the treatment of female sexual dysfunction. J Womens Health Care. 2014;3:4.
Long CY, Lin KL, Shen CR, et al. A pilot study: effectiveness of local injection of autologous platelet-rich plasma in treating women with stress urinary incontinence. Sci Rep. 2021;11:1584.
Matz EJ, Pearlman AM, Terlecki RP. Safety and feasibility of platelet rich fibrin matrix injections for treatment of common urologic conditions. Investig Clin Urol. 2018;59:61-65.
Neto JB. O-Shot: platelets rich plasma in intimate female treatment. J Womens Health Care. 2017;6:5.
Nikolopoulos KI, Pergialiotis V, Perrea D, et al. Restoration of the pubourethral ligament with platelet rich plasma for the treatment of stress urinary incontinence. Med Hypotheses. 2016;90:29-31.
Hersant B, SidAhmed-Mezi M, Belkacemi Y, et al. Efficacy of injecting platelet concentrate combined with hyaluronic acid for the treatment of vulvovaginal atrophy in postmenopausal women with a history of breast cancer: a phase 2 pilot study. Menopause. 2018;25:1124-1130.
Behnia-Willison F, Pour NR, Mohamadi B, et al. Use of platelet-rich plasma for vulvovaginal autoimmune conditions like lichen sclerosus. Plast Reconstr Surg Glob Open. 2016;4:e1124.
Goldstein AT, King M, Runels C, et al. Intradermal injection of autologous platelet-rich plasma for the treatment of vulvar lichen sclerosus. J Am Acad Dermatol. 2017;76:158-160.
Casabona F, Priano V, Vallerino V, et al. New surgical approach to lichen sclerosus of the vulva: the role of adipose-derived mesenchymal cells and platelet-rich plasma in tissue regeneration. Plast Reconstr Surg. 2010;126:210e-211e.
Franic D, Iternica Z, Franic-Ivanisevic M. Platelet-rich plasma (PRP) for the treatment of vulvar lichen sclerosus in a premenopausal woman: a case report. Case Rep Womens Health. 2018;18: e0062.
Posey LK, Runels C. In office surgery and use of platelet rich plasma for the treatment of vulvar lichen sclerosus to alleviate painful sexual intercourse. J Lower Genital Tract Dis. 2017;21(4S):S14.
Stachowicz AM, Hoover ML, Karram MM. Clinical utility of radiofrequency energy for female genitourinary dysfunction: past, present, and future. Int Urogynecol J. 2021;32:1345-1350.
Tadir Y, Gaspar A, Lev-Sagie A, et al. Light and energy based therapeutics for genitourinary syndrome of menopause: consensus and controversies. Lasers Surg Med. 2017;49:137-159.
US Food and Drug Administration. Statement from FDA Commissioner Scott Gottlieb, MD, on efforts to safeguard women’s health from deceptive health claims and significant risks related to devices marketed for use in medical procedures for “vaginal rejuvenation.” https://www.fda.gov/news-events/pressannouncements/statement-fda-commissioner-scott-gottlieb-mdefforts-safeguard-womens-health-deceptive-health-claims. Updated August 2, 2018. Accessed August 13, 2021.
Vicariotto F, Raichi M. Technological evolution in the radiofrequency treatment of vaginal laxity and menopausal vulvo-vaginal atrophy and other genitourinary symptoms: first experiences with a novel dynamic quadripolar device. Minerva Ginecol. 2016;68:225-236.
Kamilos MF, Borrelli CL. New therapeutic option in genitourinary syndrome of menopause: pilot study using microablative fractional radiofrequency. Einstein (Sao Paulo). 2017;15:445-551.
Caruth JC. Evaluation of the safety and efficacy of a novel radiofrequency device for vaginal treatment. Surg Technol Int. 2018;32:145-149.
Shobeiri SA, Kerkhof MH, Minassian VA, et al. IUGA committee opinion: laser-based vaginal devices for treatment of stress urinary incontinence, genitourinary syndrome of menopause, and vaginal laxity. Int Urogynecol J. 2019;30:371-376.
Allan BB, Bell S, Husarek K. Early feasibility study to evaluate the Viveve system for female stress urinary incontinence: interim 6-month report. J Womens Health (Larchmt). 2020;29:383-389.
Leibaschoff G, Izasa PG, Cardona JL, et al. Transcutaneous temperature controlled radiofrequency (TTCRF) for the treatment of menopausal vaginal/genitourinary symptoms. Surg Technol Int. 2016;29:149-159.
Desai SA, Vakil Z, Kroumpouzos G. Transcutaneous temperature-controlled radiofrequency treatment: improvement in female genital appearance, sexual dysfunction, and stress urinary incontinence. Aesthet Surg J. 2021;sjab174. doi: 10.1093/asj/sjab174.
Slongo H, Lunardi AL, Riccetto CL, et al. Microablative radiofrequency versus pelvic floor muscle training for stress urinary incontinence: a randomized controlled trial. Int Urogynecol J. 2021. doi: 10.1007 /s00192-021-04758-2.
Krychman M, Rowan CG, Allan BB, et al. Effect of single-treatment, surface-cooled radiofrequency therapy on vaginal laxity and female sexual function: the VIVEVE I randomized controlled trial. J Sex Med. 2017;14:215-225.
Zerbinati N, Serati M, Origoni M, et al. Microscopic and ultrastructural modifications of postmenopausal atrophic vaginal mucosa after fractional carbon dioxide laser treatment. Lasers Med Sci. 2015;30: 429-436.
Juhasz ML, Korta DZ, Mesinkovska NA. Vaginal rejuvenation: a retrospective review of lasers and radiofrequency devices. Dermatol Surg. 2021;47:489-494.
Sarmento AC, Fernandes FS, Marconi C, et al. Impact of microablative fractional radiofrequency on the vaginal health, microbiota, and cellularity of postmenopausal women. Clinics (Sao Paulo). 2020;75:e1750.

Hydrogel urethral bulking

Urethral bulking agents have been used for 5 decades in the treatment of stress urinary incontinence (SUI) in women. Unlike midurethral slings, in which many medical device companies use the same implant material (microporous, monofilament polypropylene mesh), the material for bulking agents has varied greatly. A 2017 Cochrane review of urethral bulking listed these agents used for this indication: autologous fat, carbon beads, calcium hydroxylapatite, ethylene vinyl alcohol copolymer, glutaraldehyde cross-linked bovine collagen, hyaluronic acid with dextranomer, porcine dermal implant, polytetrafluoroethylene, and silicone particles.¹⁴ These agents can be injected through a transurethral or periurethral technique. The review failed to find superiority of one material or injection technique over another.

New bulking agent available

In January 2020, the FDA approved the premarket application for a new bulking agent. This new agent is a permanently implanted, nonresorbable hydrogel that consists of cross-linked polyacrylamide (2.5%) and water (97.5%). It is intended to be used with a transurethral bulking system that includes a rotatable sheath and two 23-guage needles; a total of 1.5 to 2.0 mL of the hydrogel is injected in 3 locations in the proximal urethra per session. Patients may undergo an additional 2 sessions, if needed, at least 4 weeks after the previous session.

Polyacrylamide hydrogel has been used as a bulking agent in cosmetic and ophthalmic surgery for many years, and it was first approved for medical use in Europe in 2001. The initial European data on its use as a urethral bulking agent was published in 2006.¹⁵ The first North American data came in 2014 from a multicenter, randomized trial that compared polyacrylamide hydrogel with collagen gel.¹⁶ This investigation followed 345 women for 12 months and concluded that the safety and efficacy of polyacrylamide hydrogel was not inferior to collagen, with a little over half of both cohorts demonstrating a 50% or greater decrease in incontinence episodes.

Since these initial studies, 3-year¹⁷ and 7-year safety and efficacy data¹⁸ have been reported, with reassuring findings, but both studies experienced significant attrition of the original group of patients. The most commonly reported adverse events associated with the procedure are pain at the injection site (4%–14%) and urinary tract infection (3%–7%); transient urinary retention rates range in incidence from 1.5% to 15%.¹⁹

Short procedure, long-term results

Given that a urethral bulking procedure can be done in less than 10 minutes in the office under local analgesia, this treatment may lend itself to use in more brittle patient populations. One study of women aged 80 or older showed a greater than 50% decrease in the number of daily pads used for up to 2 years after initial injection.²⁰ Another study found the greatest treatment success in women aged 60 years or older with fewer than 2.5 episodes of SUI per day.²¹

Platelet-rich plasma therapy

Platelet-rich plasma (PRP) therapy has been used in multiple disciplines for more than 2 decades as a treatment to regenerate damaged tissue, particularly in sports medicine for treating tendonitis as well as in plastic surgery, gynecology, urology, and ophthalmology, and good outcomes have been demonstrated with no serious adverse effects. PRP is a natural product in which high levels of platelets are concentrated through centrifugation with bioactive growth factors, including platelet-derived growth factor (PDGF), transforming growth factor-beta (TGF-β), vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), fibroblast growth factor (FGF), and insulin growth factor (IGF).²² The activated platelets are then injected autologously back into the patient’s tissue. This process releases activated growth factors that accelerate tissue healing by stimulating the number of reparative cells to create collagen production, angiogenesis, and neurogenesis while fighting infection and downregulating the autoimmune system.

Continue to: Uses for PRP in gynecology...

References

Preti M, Viera-Baptista P, Digesu GA, et al. The clinical role of LASER for vulvar and vaginal treatments in gynecology and female urology: an ICS/ISSVD best practice consensus document. J Lower Genital Tract Dis. 2019;23:151-160.
Alshiek J, Garcia B, Minassian V, et al. Vaginal energy-based devices: AUGS clinical consensus statement. Female Pelvic Med Reconstr Surg. 2020;26:287-298.
Streicher LF. Vulvar and vaginal fractional CO2 laser treatments for genitourinary syndrome of menopause: NAMS practice pearl. Menopause. 2018;25:571-573.
Gardner AN, Aschkenazi SO. The short-term efficacy and safety of fractional CO2 laser therapy for vulvovaginal symptoms in menopause, breast cancer, and lichen sclerosus. Menopause. 2021; 28:511-516.
Balchander D, Nyirjesy P. Fractionated CO2 laser therapy in recalcitrant lichen sclerosus. J Lower Genital Tract Disease. 2020;24:225-228.
Pieralli A, Fallani MG, Becorpi A, et al. Fractional CO2 laser for vulvovaginal atrophy (VVA) dyspareunia relief in breast cancer survivors. Arch Gynecol Obstet. 2016;294:841-846.
Pieralli A, Bianchi C, Longinotti M, et al. Long-term reliability of fractionated CO2 laser as a treatment of vulvovaginal atrophy (VVA) symptoms. Arch Gynecol Obstet. 2017; 296:973-978.
Sokol ER, Karram MM. Use of novel fractional CO2 laser for the treatment of genitourinary syndrome of menopause: 1-year outcomes. Menopause. 2017;24: 810-814.
Pagano T, Conforti A, Buonfantino C, et al. Effect of rescue fractional microablative CO2 laser on symptoms and sexual dysfunction in women affected by vulvar lichen sclerosus resistant to long-term use of topic corticosteroid: a prospective longitudinal study. Menopause. 2020;27:418-422.
Sindou-Faurie T, Louis-Vahdat C, Oueld Es Cheikh E, et al. Evaluation of the efficacy of fractional CO2 laser in the treatment of vulvar and vaginal menopausal symptoms. Arch Gynecol Obstet. 2021;303:955-963.
Paraiso MFR, Ferrando CA, Sokol ER, at al. A randomized clinical trial comparing vaginal laser therapy to vaginal estrogen therapy in women with genitourinary syndrome of menopause: the VeLVET trial. Menopause. 2019;27:50-56.
Burkett LS, Siddique M, Zeymo A, et al. Clobetasol compared with fractionated carbon dioxide laser for lichen sclerosus: a randomized controlled trial. Obstet Gynecol. 2021;137:968-978.
Mitchell L, Goldstein AT, Heller D, et al. Fractionated carbon dioxide laser for the treatment of vulvar lichen sclerosus: a randomized controlled trial. Obstet Gynecol. 2021;136:979-987.
Kirchin V, Page T, Keegan PE, et al. Urethral injection therapy for urinary incontinence in women. Cochrane Database Syst Rev. 2017;7:CD003881.
Lose G, Mouritsen L, Nielson JB. A new bulking agent (polyacrylamide hydrogel) for treating stress urinary incontinence in women. BJU Int. 2006;98:100-104.
Sokol ER, Karram MM, Dmochowski R. Efficacy and safety of polyacrylamide hydrogel for the treatment of female stress incontinence: a randomized, prospective, multicenter North American study. J Urol. 2014;192:843-849.
Pai A, Al-Singary W. Durability, safety and efficacy of polyacrylamide hydrogel (Bulkamid) in the management of stress and mixed urinary incontinence: three year follow up outcomes. Cent European J Urol. 2015;68:428-433.
Brosche T, Kuhn A, Lobodasch K, et al. Seven-year efficacy and safety outcomes of Bulkamid for the treatment of stress urinary incontinence. Neurourol Urodyn. 2021;40:502-508.
Kasi AD, Pergialiotis V, Perrea DN, et al. Polyacrylamide hydrogel (Bulkamid) for stress urinary incontinence in women: a systematic review of the literature. Int Urogynecol J. 2016;27:367-375.
Vecchioli-Scaldazza CV, Smaali C, Morosetti C, et al. Polyacrylamide hydrogel (Bulkamid) in female patients of 80 or more years with urinary incontinence. Int Braz J Urol. 2014;40:37-43.
Elmelund M, Sokol ER, Darram MM, et al. Patient characteristics that may influence the effect of urethral injection therapy for female stress urinary incontinence. J Urol. 2019;202:125-131.
Sanoulis V, Nikolettos N, Vlahos N. The use of platelet-rich plasma in the gynecological clinical setting: a review. HJOG. 2019;18:55-65.
Fanning J, Murrain L, Flora R, et al. Phase I/II prospective trial of autologous platelet tissue graft in gynecologic surgery. J Minim Invasive Gynecol. 2007;14:633-637.
Runels CE, Melnick H, DeBourbon E, et al. A pilot study of the effect of localized injections of autologous platelet rich plasma (PRP) for the treatment of female sexual dysfunction. J Womens Health Care. 2014;3:4.
Long CY, Lin KL, Shen CR, et al. A pilot study: effectiveness of local injection of autologous platelet-rich plasma in treating women with stress urinary incontinence. Sci Rep. 2021;11:1584.
Matz EJ, Pearlman AM, Terlecki RP. Safety and feasibility of platelet rich fibrin matrix injections for treatment of common urologic conditions. Investig Clin Urol. 2018;59:61-65.
Neto JB. O-Shot: platelets rich plasma in intimate female treatment. J Womens Health Care. 2017;6:5.
Nikolopoulos KI, Pergialiotis V, Perrea D, et al. Restoration of the pubourethral ligament with platelet rich plasma for the treatment of stress urinary incontinence. Med Hypotheses. 2016;90:29-31.
Hersant B, SidAhmed-Mezi M, Belkacemi Y, et al. Efficacy of injecting platelet concentrate combined with hyaluronic acid for the treatment of vulvovaginal atrophy in postmenopausal women with a history of breast cancer: a phase 2 pilot study. Menopause. 2018;25:1124-1130.
Behnia-Willison F, Pour NR, Mohamadi B, et al. Use of platelet-rich plasma for vulvovaginal autoimmune conditions like lichen sclerosus. Plast Reconstr Surg Glob Open. 2016;4:e1124.
Goldstein AT, King M, Runels C, et al. Intradermal injection of autologous platelet-rich plasma for the treatment of vulvar lichen sclerosus. J Am Acad Dermatol. 2017;76:158-160.
Casabona F, Priano V, Vallerino V, et al. New surgical approach to lichen sclerosus of the vulva: the role of adipose-derived mesenchymal cells and platelet-rich plasma in tissue regeneration. Plast Reconstr Surg. 2010;126:210e-211e.
Franic D, Iternica Z, Franic-Ivanisevic M. Platelet-rich plasma (PRP) for the treatment of vulvar lichen sclerosus in a premenopausal woman: a case report. Case Rep Womens Health. 2018;18: e0062.
Posey LK, Runels C. In office surgery and use of platelet rich plasma for the treatment of vulvar lichen sclerosus to alleviate painful sexual intercourse. J Lower Genital Tract Dis. 2017;21(4S):S14.
Stachowicz AM, Hoover ML, Karram MM. Clinical utility of radiofrequency energy for female genitourinary dysfunction: past, present, and future. Int Urogynecol J. 2021;32:1345-1350.
Tadir Y, Gaspar A, Lev-Sagie A, et al. Light and energy based therapeutics for genitourinary syndrome of menopause: consensus and controversies. Lasers Surg Med. 2017;49:137-159.
US Food and Drug Administration. Statement from FDA Commissioner Scott Gottlieb, MD, on efforts to safeguard women’s health from deceptive health claims and significant risks related to devices marketed for use in medical procedures for “vaginal rejuvenation.” https://www.fda.gov/news-events/pressannouncements/statement-fda-commissioner-scott-gottlieb-mdefforts-safeguard-womens-health-deceptive-health-claims. Updated August 2, 2018. Accessed August 13, 2021.
Vicariotto F, Raichi M. Technological evolution in the radiofrequency treatment of vaginal laxity and menopausal vulvo-vaginal atrophy and other genitourinary symptoms: first experiences with a novel dynamic quadripolar device. Minerva Ginecol. 2016;68:225-236.
Kamilos MF, Borrelli CL. New therapeutic option in genitourinary syndrome of menopause: pilot study using microablative fractional radiofrequency. Einstein (Sao Paulo). 2017;15:445-551.
Caruth JC. Evaluation of the safety and efficacy of a novel radiofrequency device for vaginal treatment. Surg Technol Int. 2018;32:145-149.
Shobeiri SA, Kerkhof MH, Minassian VA, et al. IUGA committee opinion: laser-based vaginal devices for treatment of stress urinary incontinence, genitourinary syndrome of menopause, and vaginal laxity. Int Urogynecol J. 2019;30:371-376.
Allan BB, Bell S, Husarek K. Early feasibility study to evaluate the Viveve system for female stress urinary incontinence: interim 6-month report. J Womens Health (Larchmt). 2020;29:383-389.
Leibaschoff G, Izasa PG, Cardona JL, et al. Transcutaneous temperature controlled radiofrequency (TTCRF) for the treatment of menopausal vaginal/genitourinary symptoms. Surg Technol Int. 2016;29:149-159.
Desai SA, Vakil Z, Kroumpouzos G. Transcutaneous temperature-controlled radiofrequency treatment: improvement in female genital appearance, sexual dysfunction, and stress urinary incontinence. Aesthet Surg J. 2021;sjab174. doi: 10.1093/asj/sjab174.
Slongo H, Lunardi AL, Riccetto CL, et al. Microablative radiofrequency versus pelvic floor muscle training for stress urinary incontinence: a randomized controlled trial. Int Urogynecol J. 2021. doi: 10.1007 /s00192-021-04758-2.
Krychman M, Rowan CG, Allan BB, et al. Effect of single-treatment, surface-cooled radiofrequency therapy on vaginal laxity and female sexual function: the VIVEVE I randomized controlled trial. J Sex Med. 2017;14:215-225.
Zerbinati N, Serati M, Origoni M, et al. Microscopic and ultrastructural modifications of postmenopausal atrophic vaginal mucosa after fractional carbon dioxide laser treatment. Lasers Med Sci. 2015;30: 429-436.
Juhasz ML, Korta DZ, Mesinkovska NA. Vaginal rejuvenation: a retrospective review of lasers and radiofrequency devices. Dermatol Surg. 2021;47:489-494.
Sarmento AC, Fernandes FS, Marconi C, et al. Impact of microablative fractional radiofrequency on the vaginal health, microbiota, and cellularity of postmenopausal women. Clinics (Sao Paulo). 2020;75:e1750.

Innovative therapies in gynecology: The evidence and your practice

References

Hydrogel urethral bulking

New bulking agent available

Short procedure, long-term results

Platelet-rich plasma therapy

Pages

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