In Context: Review

Surgical Innovation
2021, Vol. 0(0) 1–8
The Emerging Role on the Use of © The Author(s) 2021
Article reuse guidelines:
Platelet-Rich Plasma Products in the sagepub.com/journals-permissions
DOI: 10.1177/15533506211014848

Management of Urogynaecological journals.sagepub.com/home/sri

Disorders

Anastasia Prodromidou, MD, PhD1, Dimitrios Zacharakis,

MD, PhD1, Stavros Athanasiou, MD, PhD1, Athanasios
Protopapas, MD, PhD1, Lina Michala, MD, PhD1, Nikolaos
Kathopoulis, MD, PhD1, and Themos Grigoriadis,
MD, PhD1

Abstract
Background: The regenerative efficacy of platelet-derived products has been recently investigated in the treatment of
pelvic floor disorders (PFDs). We aimed to synthesize the current evidence of platelet-rich plasma (PRP) products used
in urogynaecological disorders including vaginal atrophy, pelvic organ prolapse (POP), urinary incontinence, vaginal
fistulas and vaginal mesh exposure. Methods: A meticulous search of the currently available literature on the use of PRP
for the management of PFDs was performed using 3 electronic databases. Results: PRP could be a feasible alternative
modality for the management of vaginal atrophy with favourable outcomes in vaginal atrophy parameters and patients’
satisfaction, especially when hormone therapy is contraindicated. In patients with POP, an increase in collagen concen-
tration after PRP application was observed while the use of PRP resulted in improvement of stress urinary incontinence
symptoms. A considerable proportion of vesicovaginal fistulas were treated after application of PRP-based injections.
Conclusions: There is only limited evidence of the use of PRP for PFDs. Platelet-rich plasma appears to be a promising, easy to
apply, cost-effective and feasible alternative therapeutic modality for the management of various urogynaecological dis-
orders. Future randomized trials are needed to confirm the efficacy of PRP in the treatment of urogynaecological disorders.

Keywords
platelet-rich plasma, vaginal atrophy, vaginal rejuvenation, pelvic organ prolapse, vaginal fistula

Introduction effects of growth factors found in platelets.4 To that end,

The term platelet-rich human plasma was firstly described
in 1954 by Kingsley et al. who performed haematological
research on blood coagulation to evaluate thrombocyte
concentration.1 In the surgical field, autologous platelet-
rich plasma (PRP) was firstly introduced in the 80s in
cardiac surgery for the support of autologous transfusions
during heart operation.1,2 Platelet rich is considered the
plasma which contains platelets above the baseline of
more than 1.000.000/μl in every 5 mL of plasma along
with a plethora of cytokines and growth factors.3 More
specifically, growth factors including platelet-derived
growth factor, vascular endothelial growth factor and
transforming growth factor-β and cytokines such as IL-1,
IL-6, IL-8, MMP-9, tumour necrosis factor-a and
interferon-a represent main components of activated
PRP.3 Platelet-rich plasma has many clinical applications
in a wide variety of disorders aiming to enhance tissue
regeneration based on the angiogenetic and restorative
the use of PRP has gained significant popularity in or-
thopaedics and sports medicine specifically for the repair
of ligaments, muscles, cartilage and tendons while ex-
tensive research has been also done in plastic and cosmetic
medicine showing favourable healing outcomes.5 Addi-
tionally, autologous PRP has been also utilized in other
medical fields such as in urology, ophthalmology and as
an experimental cancer treatment due to the regulation of
inflammation and immune process.6 In obstetrics and
1
1st Department of Obstetrics & Gynecology, Medical School, National
and Kapodistrian University of Athens, “Alexandra” Hospital, Athens,
Greece
Corresponding Author:
Anastasia Prodromidou, 1st Department of Obstetrics & Gynecology,
“Alexandra” General Hospital, National and Kapodistrian University of
Athens, Medical School, Lourou 2, Athens 11528, Greece.
Email: a.prodromidou@hotmail.com
2 Surgical Innovation 0(0)
gynaecology, in reports from pilot studies, case reports and
small case series, PRP has been evaluated for the treatment of
cervical ectopy, vulvar dystrophy, premature ovarian failure,
ovarian torsion, assisted reproductive techniques, aesthetic
gynaecology and premature rupture of membranes.7,8
The regenerative efficacy of platelet-derived products
has been also investigated in the treatment of pelvic floor
disorders (PFDs). The aim of the present study was to
synthesize the current evidence of PRP products used in
urogynaecological disorders including vaginal atrophy,
pelvic organ prolapse (POP), urinary incontinence, vag-
inal fistulas and vaginal mesh exposure. Additionally,
special consideration was given to the procedural aspects
of PRP preparation, such as the method of preparation, the
dosage of applications and the post-treatment outcomes.
Methods
A meticulous search of the currently available literature
was performed using 3 electronic databases (PubMed,
Scopus and Google Scholar). The day of the last search
was the 31st of July. Articles that presented outcomes on
the use of PRP for the management of urogynaecological
diseases were assessed, along with the references of the
eligible articles that were retrieved in full text. The fol-
lowing key words were utilized: ‘platelet rich plasma’,
‘PRP’, ‘urogynecology’, ‘vaginal atrophy’, ‘POP’, ‘urinary
incontinence’, ‘vaginal fistula’ and ‘mesh exposure’. All
prospective and retrospective studies (comparative and non-
comparative), case reports and case series that were written
in English language were assessed and critically appraised.
Results
PRP in Vaginal Atrophy
Vaginal atrophy is a condition affecting a significant
proportion of postmenopausal women of approximately
45-47% with significant impact in patients’ quality of
life.9 Local use of hormonal therapy is mainly indicated
for the relief of the vulvo-vaginal symptoms while, re-
cently, the use of non-hormonal therapies and intravaginal
energy devices (such as the intravaginal laser) has shown
favourable outcomes.9 The outcomes of a prospective
phase II pilot study evaluating the efficacy of autologous
PRP combined with hyaluronic acid (HA) for the treat-
ment of vaginal atrophy in 20 postomenopausal breast
cancer survivors were published in 2018 by Hersant
et al.10 Four ml of the mixture of PRP-HA (2 mL of each
ingredient) was injected through mucosal and submucosal
injections into the vestibule and the first 3 cm of the
vaginal wall. A significant increase in mean vaginal health
index scores was noted among pretreatment scores and
scores at 1-, 3- and 6-month follow-up (10.7 ± 2.12 and
16.2 ± 3.9, 18.35 ± 2.7 and 20.75 ± 4.8, respectively,
P < .0001). Moreover, significant improvement was re-
corded in terms of increase in vaginal secretions, elasticity,
moisture rates and decrease in vaginal pH. Similarly,
a significant decrease in the female sexual distress was
observed at 1-, 3- and 6-month follow-up, whereas patients
were reported to be satisfied with the therapy. The afore-
mentioned outcomes indicate the safety and efficacy of
PRP which could be a feasible alternative modality for the
management of vaginal atrophy especially when hormone
therapy is contraindicated. The application of PRP in the
management of vaginal atrophy was also assessed in the
case report by Kim et al. in a 67-year-old woman with
concomitant presence of lichen sclerosus in labia minora
and primary oestrogen therapy failure.11 The patient was
treated with 40cc subcutaneous injections of mixed au-
tologous fat and PRP in the labia majora. A significant
improvement in vaginal pruritus, in irritation and in
macroscopic appearance of the labia majora along with the
patient’s satisfaction with the aesthetic and functional
outcomes was recorded. The main characteristics of the
aforementioned studies are shown in Table 1.
PRP in Vaginal Rejuvenation
Aguilar et al presented a case of application of a combi-
nation of HA and PRP injections as a minimally invasive
approach for vaginoplasty due to vulvo-vaginal laxity.12
More specifically, a 39-year-old primiparous woman with
a history of vaginal delivery who presented with sexual
dysfunction and flatus incontinence received submucosal
posterior vaginal wall and subdermal injections of 16 mL
of mixed PRP and HA. An improvement in symptoms was
recorded 3 months post-injection while a 100% im-
provement of the Sabbatsberg scale score was observed
(15/40 pre therapy vs 30/40 post therapy).
PRP in Pelvic Organ Prolapse
Pelvic organ prolapse has a significant impact in the
quality of life of women with a prevalence of approxi-
mately 5–10%.13 Surgical repair is considered when
conservative modalities such as physiotherapy and pes-
saries have failed to improve symptoms.13 Pelvic organ
prolapse has been associated with significantly decreased
collagen concentration compared to healthy controls.14,15
Therefore, the concept of using PRP for the treatment of
POP was based on the effect of PRP in increasing collagen
concentration of the fibrous connective tissue and pro-
moting wound healing.14 Various protocols and PRP
preparations have been used as supplementary modalities
to surgery in POP repair. More specifically, Einarsson
et al. performed the first pilot study on the intraoperative
use of the autologous platelet gel during anterior col-
porrhaphy in 9 patients with POP.16 Despite the fact that
mean collagen concentration in the biopsy specimen
Table 1. Characteristics of the included studies for the use of PRP in vaginal atrophy.

Type of
Type gynaecological
Prodromidou et al

Year; of disorder/ Assessed Dose of PRP

author study Country procedure Inclusion criteria parameters PRP preparation technique injection Injected areas

2018; Phase France Vulvo-vaginal >18 years; history of VHI score>15; RegenKit BCT-HA (a sterile, 4 mL of PRP-HA Into the vestibule and the
Hersant II laxity/PRP-HA hormone-dependent vaginal pH; nonpyrogenic tube designed (2 mL PRP mixed 1st 3 cm of the posterior
pilot injections breast cancer in efficacy of for use in preparing with 2 mL HA) vagina and 2 cm posterior
PS remission >5 years treatment; sexual a mixture of PRP and HA (.1 mL/point) wall of the introitus using
after surgery; VHI<15; quality; pain (VAS (40 mg [2% w/v] of non- Injections every a speculum or by laterally
no vulvo-vaginal score) cross-linked HA per tube, 5 mm with 27G opening the vaginal walls
inflammation or 1550 KDa)); centrifugation calibre needle and with the fingers
infection; no history 1500 g for 5 minutes a 1-mL syringe
of recurrent vaginal
herpes; no lichen
sclerosus; no history
or genital cancer
2017; Kim CR Korea Vaginal atrophy N/A Postoperative Double spin centrifugation 40cc autologous fat Subcutaneous layer of the
and lichen photographs with SmartPrep APC-30 4cc mixed with PRP labia majora aseptically
sclerosus/filling of PRP derived from 30cc into 1cc syringes via 4 ports
with autologous of autologous PRP
fat and PRP
2016; CR France Vaginal laxity- N/A Sabbatsberg sexual RegenKit BCT-HA 3 sterile 4 mL of PRP-HA 16 mL of fat cells in the
Aguilar sexual self-rating scale tubes (4 mL/tube). Each (2 mL PRP mixed posterior vaginal wall (2
dysfunction/ contained a gel of HA, and with 2 mL HA) linear anteroposterior
vaginoplasty + inert cell-selector gel, tractus) and 10 mL PRP-
PRP with HA a liquid anticoagulant and HA in the perineal raphe
allowed the preparation of (episiotomy scar) in the
4 mL of PRP–HA mixture; vestibular fossa and in the
centrifugation: 1500 g for labium minus and majus
5 minutes (cellular elements
settle on the surface)
manual homogenization
PRP and HA; harvesting fat
with Coleman’s technique
centrifuged at 1500 g for
1 minute

Abbreviations: CS = case report; HA = hyaluronic acid; N/A = not available; PS = prospective; PRP = platelet-rich plasma; VAS = visual analogue scale; VHI = vaginal health index.
3
4 Surgical Innovation 0(0)
increased 3 months postoperatively when compared to
baseline (9.04 μg/mg vs 9.58 μg/mg, respectively), this
did not reach statistical significance (P = .63).16 At 3-
month follow-up, there was a significant improvement at
Aa and Ba points (P = .01) and remained significant only
for Aa point at 20-month follow-up (P = .04).16 The
subjective patients’ satisfaction with a scale from 1 to 5
reached a mean of 4.1 and 4.3 at the interval of 3 and
20 months, respectively, while subjective and objective
failure rates were 12.5% and 66.7%, respectively.16
Similarly, Gorlero et al evaluated the efficacy of
platelet-rich fibrin (PRF) with the use of the Vivostat
system in 10 patients who had vaginal surgical procedures
due to prolapse recurrence.17 The authors observed an
anatomical success rate of 80%, while patients reported
100% improve in symptoms and 20% increment in sexual
activity.17 Based on the aforementioned outcomes, the
authors propose the application of the PRF system as
optimal treatment for patients at risk of recurrence or
erosion.17 The aspects of PRP products preparation and
application for each study are shown in Table 2.
PRP in Urinary Incontinence
The need of avoiding transvaginal synthetic implants in
the management of stress urinary incontinence (SUI) led
to the investigation of less-invasive techniques, such as
the transvaginal laser18 showing safety and feasibility of
this treatment option in improving SUI symptoms.18 The
first study to evaluate the use of PRP and CO2 laser in the
management of women with SUI was a prospective pilot
study by Behnia-Wilson et al.19 Platelet-rich plasma was
prepared with the RegenPRP method and was injected in
the periurethral region and into the lower one-third of the
anterior vagina.19 From a total of 62 women with age range
from 32 to 86 years, a significant proportion reported im-
provement of SUI symptoms both at 3-month and 12–24-
month follow-up compared to baseline (66%, n = 41/62, P <
.001 and 62%, n = 23/37, P < .001, respectively). Addi-
tionally, urge incontinence, urgency, urine leakage–related
quality of life and bladder function were significantly im-
proved at 3 months and 12-24 month after therapy with CO2
and PRP (P < .02 and P < .03, respectively). Similarly, Matz
et al. reported a case of a woman with SUI who received
transurethral injection of activated PRP and noted 50%
decrease in pad usage.20 Finally, an animal experimental
study by Nikolopoulos et al in rats showed that PRP ap-
plication into a transected pubourethral ligament restored
leak point pressure 1 and 2 months following injection,
which could result in improvement of SUI.21
PRP in Vaginal Fistulas
The role of PRP has also been investigated for the
management of vesicovaginal fistulas (VVF). Shirvan
et al. assessed the effect of concomitant PRP injections
in the tissue around the fistula and PRF glue interposi-
tioned into the VVF tract in 12 patients with iatrogenic
VVF.22 The proportion of patients with complete dryness
post-injection and normal cystography and physical ex-
amination after 3 months was 91.67% (n = 11/12). A
respective improvement was observed in 11 patients with
regard to International Consultation on Incontinence
Questionnaire-Urinary Incontinence (ICIQ-UI) and In-
ternational Consultation on Incontinence Questionnaire-
Quality of Life (ICIQ-QOL) scores.22 The features of PRP
preparation and application are shown in Table 3. Ad-
ditionally, Streit-Cleckliewicz et al. applied PRP around
the fistula of 16 patients at an interval of 6–8 weeks before
performance of the Latzko procedure for the repair of
VVF.23 One patient (1/16) was cured after PRP injection
and did not require surgery. No adverse events were
detected; while for the remaining patients, complete
dryness and absence of urinary complications were re-
corded during the follow-up period, indicating the safety
and efficacy of the combined therapy with PRP and
surgery.
PRP in Mesh Extrusion
In literature, the prevalence of vaginal mesh exposure
following sacrocolpopexy for the treatment of apical
prolapse ranges between 2% and 8% often requiring
surgery, especially in symptomatic cases.24,25 Current
evidence is conflicting with regard to the optimal treat-
ment of mesh extrusion after sacrocolpopexy, although
surgical removal of the exposed mesh should be con-
sidered when conservative management with local oes-
trogens fail.26 Castellani et al. presented their initial
experience in 3 symptomatic women with vaginal mesh
exposure following abdominal sacrocolpopexy, who were
treated with endoscopic mesh excision with resectoscope
followed by application of PRP on the resected surface
and of PRP-gel injection around it at the same surgery.27 A
complete re-epithelization was recorded 6 months post-
operatively and relief of preoperative symptoms and no
prolapse were noted at 1-year follow-up.27 Furthermore,
based on the outcomes of animal experimental studies,
coating of polypropylene meshes with PRP seems
promising in preventing exposure and enhancing re-
covery. More specifically, Parizzi et al. reported a de-
creased inflammatory infiltration at 30 days and increased
collagen III concentration at 90 days in the histologic
specimen of PRP-coated meshes which were implanted in
the vaginal mucosa of 15 rabbits.28 On the contrary,
Belebecha et al. found reduced levels of myeloperoxidase
and N-acetylglucosamide activities as well as decreased
oxidative stress and elevated antioxidant levels without
difference in inflammatory cells in the specimen of rabbits
with PRP-coated polypropylene mesh compared to those
Table 2. Characteristics of the included studies for the use of PRP in POP.

Type of gynaecologic
Year; author Type of study Country disorder/treatment Inclusion criteria Assessed parameters PRP preparation Dose of PRP Type of application

2015; Medel In vitro Canada POP/12 weeks after N/A Attachment of POP Regen ACR-C kit 8 mL Coat in 200 μL Coating of 5 × 5mm
Prodromidou et al

POP repair human vaginal whole blood PRP squares of

samples from 6 fibroblast to 2 meshes collected into EDTA- absorbable
patients collected coated tube polyglactin mesh
to obtain PRP centrifuge for (5 samples) and
5 minutes at 1500 g; nonabsorbable
collection of the polypropylene mesh
supernatant (4 mL) (5 samples) into
200 μL PRP
2012; PS observational Italy Recurrent POP (≥II stage); high ICS POP grading system; PRF-Vivostat system 120 mL blood, Constant spraying
Gorlero symptomatic POP risk for recurrence; P-QoL questionnaire (on-site PRF 6 mL direct to the surgical
(≥II stage)/anterior high risk for erosion results pre- and preparation and autologous site for 7 minutes;
posterior or apical with graft materials postoperatively; lower application) sealant (1 mL PRF polymerized
repair + PRF and high anaesthetic urinary tract, bowel, polymerization of of PRF covers into a white gel
and bleeding risk for sexual and prolapse fibrin activated by 3–4 cm)
IP and PO symptoms; QOL; simple pH change (no
complications with Vancouver scar scale enzymatic reaction)
traditional for pigmentation,
reconstructive pliability, height and
procedures; previous vascularity; anatomical
vaginal hysterectomy successful of the
POP surgery without prolapse repair
graft materials
2009; Pilot USA Anterior POP/ Anterior prolapse RNA of specimen pre- 52 mL of whole blood N/A APG application after
Einarsson standard anterior (cystocele); age and PO (6-mm punch in 8 mL of plication of the
repair + APG: <55 years; no biopsy); POP-Q (pre-, anticoagulant pubocervical fascia
(thrombin-rich previous corrective 3-, 18- and 23-month dextrose-A solution and before closure
serum and platelet- surgery; no age PO); objective and Centrifuge PRP was of the vaginal
rich plasma) punch <18 years; no subjective recurrence; drawn up into epithelium; closure
biopsy taken from emergent surgery; no subjective patients a syringe with added of vaginal epithelium
the anterior wall at participation in other satisfaction (from 1-5) glass fibres to start with a running
the beginning of research studies; no clotting. Once a clot absorbable suture
the surgery known iv drug users; had formed, the
willingness to resulting thrombin-
complete 3-month rich serum was
follow-up expressed out
through a filter into
a new syringe

Abbreviations: APG = autologous platelet gel; PS = prospective; ICS = international continence society; IP = intraoperative; PO = postoperative; POP = pelvic organ prolapse; PRF = platelet-rich fibrin; QOL =
quality of life; PRP = platelet-rich plasma.
5
6 Surgical Innovation 0(0)

Table 3. Characteristics of the included studies for the use of PRP in vaginal fistulas.

Type of
Type gynaecologic
of disorder/ Assessed Type of
Year; author study Country treatment Inclusion criteria parameters PRP preparation application

2019; Streit- PS-CS Poland Recurrent Recurrent VVF after Assessment of 150–180 mL whole 4–6 ml PRP
Cieckiewicz VVF/PRP at least 1 previous patients’ status blood collected transvaginal
injection and failed attempt; no by releasing into sodium injection in 15
surgery after supplementary 150 mL citrate tubes- patients and via
6–8 weeks radio- methylene centrifugation cystoscopy in 1
chemotherapy blue dye into (Arthrex Angel patient in 4-5
bladder before System kit) 4- points around
discharge 6 mL of PRP the edges of
the fistula
2013; Shirvan CS Iran VVF/PRP-PRFP True incontinence Subjective 60 mL whole blood 2 mL PRP around
around and and diagnosed VVF; symptoms; collected in 9 mL the fistula,
into the VVF no genital or urinary ICIQ-UI and citrate phosphate 5 mL mixture
tract system infection or ICIQ-UI at dextrose buffer; of PRFP with
malignancies; no baseline and centrifugation at thrombin-
presence of VVF for after 10 days 2000 g for calcium
<1 month; ability for and 1, 3 and 2 minutes (1st) injected into
lithotomy position; 6 months after and 4000 g for the tract within
no urolithiasis; no catheter 8 minutes (2nd). 5 minutes to
vaginal prolapse; no removal Production of form a clot
neuromuscular 4 mL of PRP.
disorders; no 2 mL of PRP
uncontrolled DM; mixed with 2 mL
no pregnancy; no fibrinogen
radiation treatment concentrate
to the urethra or (PRFP). 4 mL
adjacent structures; PRFP mixed with
no use medications 1 mL thrombin-
for UI; physical and calcium solution
mental ability to form rich
fibrin glue

Abbreviations: CS = case series; ICIQ-UI = international consultation on incontinence questionnaire-urinary incontinence; ICIQ-QOL = international
consultation on incontinence questionnaire-quality of life; PS = prospective; PRP = platelet-rich plasma; VVF = vesicovaginal fistula.

with uncoated polypropylene mesh.29 Finally, an in vitro
study by Medel et al. demonstrated the beneficial effect of
PRP in enhancing the cell attachment to the surface of
both Vicryl and Restorelle meshes compared to no PRP-
coated meshes as proved by light microscopic evaluation
(9875 ± 996 vs 1006 ± 84 cells/cm2, 9.8 times increase
and 3724 ± 407 vs 649 ± 53 cells/cm2, 5.7 times increase,
respectively).30 Thus, the application of PRP could lead to
decreased complications related to meshes through the
potential effect of PRP to enhance attachment of meshes
to adjacent tissues.
Future Perspectives
Ongoing Studies
A recently assigned randomized controlled trial aimed to
evaluate the outcomes after application of either high-
intensity focused ultrasound or PRF in patients with SUI
(NCT04144829). A total of 200 women aged from 18 to
60 years are expected to be randomized and included
while the PRF will be applied through 3 injections of
a total of 2 mL under the urethra produced after a 5-minute
centrifugation of autologous patients’ whole blood.
Similarly, the study group by Long et al. will assess the
efficacy of 3 sessions of monthly 3 ml-PRP applications
injected into anterior vaginal wall, external urethral
sphincter and endopelvic fascia in 20 women with SUI
(NCT04279210). Additionally, a pilot study designed by
Meningaud et al. will evaluate the efficacy of submucosal
injections with a combination of PRP and HA in the vulva,
posterior vaginal wall and the perineum in 20 patients
with vaginal atrophy (NCT02966925).
Limitations
The accumulation on the currently available knowledge
on the use of PRP products in pelvic disorders and in
Prodromidou et al
pelvic reconstructive surgery is limited by the wide
variety of PRP preparations, as well as ways of appli-
cation. More specifically as shown in Tables 1-3, there is
significant discrepancy among the included studies in the
preparation kits and equipment used, in the amount of
collected blood sample, the technical aspects of prepa-
ration (centrifugation aspects), type of application, ac-
tivation method as well as the potential mixture with
other healing agents and the application as main or
adjacent treatment strategy even for the management of
the same disease.
Conclusion
Current evidence of the use of PRP for PFDs appears to be
a promising, easy to apply, cost-effective and feasible
alternative therapeutic modality for the management of
urogynaecological disorders. No major side effects were
recorded despite the fact our outcomes are restricted by
the limited number of the currently available studies.
Consequently, based on the promising results of the use of
PRP, we acknowledge that further larger randomized trials
are needed to confirm the efficacy of PRP in the treatment
of urogynaecological disorders.
Author Contributions
Study conception and design: Anastasia Prodromidou and
Themos Grigoriadis.
Acquisition of data: Anastasia Prodromidou, Dimitrios Za-
charakis and Nikolaos Kathopoulis.
Analysis and interpretation of data: Anastasia Prodromidou,
Dimitrios Zacharakis, Lina Michala, Athanasios Protopapas and
Stavros Athanasiou.
Study supervision: Themos Grigoriadis, Athanasios Protopapas
and Stavros Athanasiou.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship and/or publication of this article.
ORCID iDs
Anastasia Prodromidou  https://orcid.org/0000-0002-4250-
1853
Nikolaos Kathopoulis  https://orcid.org/0000-0002-0031-
809X
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