Vesicovaginal fistulas (VVF) are the most commonly acquired fistulas of the urinary tract, but we lack a standardized algorithm for their management. Surgery is the most commonly preferred approach to treat women with primary VVF following benign gynaecologic surgery. To carry out a systematic review and meta-analysis on the effectiveness of operative techniques or conservative treatment for patients with postsurgical VVF. Our secondary objective was to define the surgical time and determine the types of study designs. PubMed, Old Medline, Embase and Cochrane Central Register of Controlled Trials were used as data sources. This systematic review was modelled on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, including a registration number (CRD42012002097). We reviewed 282 full text articles to identify 124 studies for inclusion. In all, 1379/1430 (96.4%) patients were treated surgically. Overall, the transvaginal approach was performed in the majority of patients (39%), followed by a transabdominal/transvesical route (36%), a laparoscopic/robotic approach (15%) and a combined transabdominal-transvaginal approach in 3% of cases. Success rate of conservative treatment was 92.86% (95%CI: 79.54–99.89), 97.98% in surgical cases (95% CI: 96.13–99.29) and 91.63% (95% CI: 87.68–97.03) in patients with prolonged catheter drainage followed by surgery. 79/124 studies (63.7%) provided information for the length of follow-up, but showed a poor reporting standard regarding prognosis. Complications were studied only selectively. Due to the inconsistency of these data it was impossible to analyse them collectively. Although the literature is imprecise and inconsistent, existing studies indicate that operation, mainly through a transvaginal approach, is the most commonly preferred treatment strategy in females with postsurgical VVF. Our data showed no clear odds-on favorite regarding disease management as well as surgical approach and current evidence on the surgical management of VVF does not allow any accurate estimation of success and complication rates. Standardisation of the terminology is required so that VVF can be managed with a proper surgical treatment algorithm based on characteristics of the fistula.

Introduction and hypothesis There is clear evidence of the presence of estradiol receptors (ERs) in the female lower urinary and genital tract. Furthermore, it is a fact that estrogen deficiency after menopause may cause atrophic changes of the urogenital tract as well as various urinary symptoms. Moreover, the effect of hormone replacement therapy (HRT) on urinary incontinence (UI) symptoms as well as pelvic organ prolapse (POP), anal incontinence (AI) and vulvovaginal symptoms (VVS) is still a matter of debate. This committee opinion paper summarizes the best evidence on influence of sex steroids as well as hormonal treatment (local and systemic) in postmenopausal women with pelvic floor disorders. Methods A working subcommittee from the International Urogynecology Association (IUGA) Research and Development Committee was formed. A thorough literature search was conducted and an opinion statement expressed. The literature regarding hormones and pelvic floor disorders was reviewed independently and summarized by the individual members of the sub-committee. Results The majority of studies reported that vaginal estrogen treatment when compared with placebo has more beneficial effects on symptoms and signs of vaginal atrophy including sensation of burning, dyspareunia and UI symptoms. Definitive evidence on local estrogen application and prolapse treatment or prevention is lacking. A statistically significant increase in risk of worsening of UI as well as development of de novo incontinence was observed with estrogen-only or combination systemic HRT. Conclusions In summary, local estrogen seems to be safe and effective in the treatment of VVS and can also improve urinary symptoms in postmenopausal patients with UI, but most of these recommendations correspond to evidence level 2C. The evidence in POP is still scarce but not in favor of benefit. Finally, the duration of local estrogen treatment (LET), optimal dosage, long-term effects and cost-effectiveness compared with current practice are still unknown.

Objectives: To investigate the potential relationship between endogenous sex steroids and presence of stress urinary incontinence ( SUI ). Patients and Methods: A total of 47 peri‐ and postmenopausal women with SUI were matched 1:1 with 47 continent women based on age, menopausal status, body mass index ( BMI ) and parity. Blood samples were drawn from all the women for assessment of oestradiol (E2), follicle‐stimulating hormone, luteinizing hormone, testosterone, androstendion ( AEON ), dehydroepiandrosterone sulphate and sex hormone‐binding globulin with an electrochemiluminescence immunoassay. Results: Women with SUI had significantly lower serum levels of E2 (8.49 ± 7.47 vs 13.09 ± 13.80; P = 0.048) and AEON (0.59 ± 0.41 vs 1.20 ± 0.87; P = 0.033) compared with controls. This difference in E2 levels remained significant after controlling for age, menopausal age, years from menopause, BMI , parity, testosterone and AEON . In addition, hypertension and history of hysterectomy were observed significantly more frequently in the SUI group ( P < 0.001). There was no significant association between hormone levels and degree of SUI ( P > 0.05). Conclusion: The results of the present study indicate that a low E2 level might have a negative impact on the lower urinary tract and continence mechanism and a low E2 level is a possible risk factor for SUI in women.

In contrast to other countries, Austria rarely offers alternative models to medical led-care. In an attempt to improve the facilities, a midwife-led care service was incorporated within the Department of Obstetrics and Fetomaternal Medicine. The aim of the present study was to analyze the maternal and neonatal outcomes of this approach. Over a 10-years period, a total of 2123 low-risk women receiving midwife-led care were studied. Among these women, 148 required obstetric referral. Age- and parity matched low-risk women with spontaneous vaginal birth overseen by an obstetrician-led team were used as controls to ensure comparability of data. Midwife-led care management demonstrated a significant decrease in interventions, including oxytocin use (p < 0.001), medical pain relief (p < 0.001), and artificial rupture of membranes (ARM) (p < 0.01) as well as fewer episiotomies (p < 0.001), as compared with obstetrician-led care. Moreover, no negative effects on maternal or neonatal outcomes were observed. The mean length of the second stage of labor, rate of perineal laceration and APGAR scores did not differ significantly between the study groups (p > 0.05). Maternal age (p < 0.01), head diameter (p < 0.001), birth weight (p < 0.001) and the absence of midwife-led care (p < 0.05) were independent risk factors for perineal trauma. The overall referral rate was low (7%) and was most commonly caused by pathologic cardiotocography (CTG) and prolonged first- and second-stage of labor. Most referred mothers nevertheless had spontaneous deliveries (77%), and there were low rates of vaginal operative deliveries and cesarean sections (vacuum extraction, 16%; cesarean section, 7%). The present study confirmed that midwife-led care confers important benefits and causes no adverse outcomes for mother and child. The favorable obstetrical outcome clearly highlights the importance of the selection of obstetric care, on the basis of previous risk assessment. We therefore fully support the recommendation that midwife-led care be offered to all low-risk women and that mothers should be encouraged to use this option. However, to increase the numbers of midwife-led care deliveries in Austria in the future, it will be necessary to expand this care model and to establish new midwife-led care units within hospital facilities.