Pfeuti, Courtney K.

Purpose of review To synthesize the current literature regarding the evaluation and management of genitourinary fistula in women. Recent findings Genitourinary fistula are aberrant communications between the urinary tract and genital tract that present with urinary leakage per the vagina. Initial management often involves conservative measures, such as urethral catheter or ureteral stent placement, progressing to surgical repair when needed. Key surgical principles include a tension-free, watertight closure with well-vascularized tissue including tissue interposition as appropriate, and postoperative urinary drainage. When surgical management of vesicovaginal fistula is necessary, a transvaginal repair is the most common. Other minimally invasive approaches are increasing and result in similarly high success rates with lower patient morbidity compared to open abdominal surgeries. The initial management of ureterovaginal fistula commonly includes ureteral stent placement. When not feasible or in persistent fistula, laparoscopic and robotic surgical repair with ureteral reconstruction offers high success rates with lower morbidity than an open approach. Summary Successful management of genitourinary fistula ranges from conservative urinary tract drainage to surgical interventions based on etiology, location, and complexity. Approaches to repair are shifting toward less invasive procedures. With optimal technique and surgical planning, high success rates can be achieved, particularly in primary repairs.

ABSTRACT Aims To discuss the use of urodynamic testing for female stress urinary incontinence and provide a narrative review of the current evidence regarding the utility of urodynamics across the spectrum of clinical presentations. Methods A nonsystemic, extensive literature review via PubMed was performed on the use of urodynamics for female stress urinary incontinence. Results Findings from several large multicenter trials and subsequent secondary analyses have significantly influenced treatment patterns away from the routine use of urodynamics in female patients with uncomplicated stress urinary incontinence. Much of the current literature focuses on selected patients with uncomplicated stress urinary incontinence that are subsequently treated with midurethral sling placement. These studies comprise the foundational evidence supporting multiple national and international guidelines on the topic. In uncomplicated patients, these guidelines do not support the routine use of urodynamics. However, in more complicated presentations, urodynamic studies are more often valuable for diagnosis and management. Conclusions Routine use of urodynamic testing is not currently recommended in guidelines for evaluating uncomplicated female stress urinary incontinence. It is important to recognize that much of the evidence supporting these recommendations is derived from a select population of uncomplicated patients, which may limit generalizability to more complex cases. In such cases, urodynamic testing may be more useful to guide diagnosis and management, though further research is needed to identify which findings have the greatest impact on clinical outcomes.

Importance Exposure to the surgical management of obstetric anal sphincter injuries (OASIS) is limited during obstetrics training. Objectives The objective of this study was to quantify residents' exposure to OASI repair during 4-year obstetrics and gynecology (OBGYN) residency and examine temporal trends over a 16-year period. Study Design This was a retrospective cohort study of residents' exposure to OASIS at a community academic hospital from 2007 to 2022. Individuals with documented OASIS (third- or fourth-degree laceration) by International Classification of Diseases, Ninth and Tenth Revisions, codes during vaginal delivery (VD), spontaneous vaginal delivery (SVD), or operative vaginal delivery (OVD), were included. Delivery rates and OBGYN resident positions were examined. Temporal trends in OASIS were analyzed in 4-year epoch to determine average resident exposure during OBGYN residency. Results During the 16-year study period, there were 103,234 deliveries (62% VD, 4% OVD, 34% cesarean delivery). Among VDs, there were 2,344 (3.4%) OASIS with 88.5% classified as third-degree and 11.5% as fourth degree. The OASI rate decreased from 4.2% (2007–2010) to 2.9% (2019–2022), whereas OBGYN residents increased by 49% (67 to 99; P < 0.001). Average resident exposure to OASIS decreased from 11 (2007–2010) to 5 (2019–2022; P = 0.55). Subclassification revealed that residents were exposed to 5 third-degree repairs and less than 1 fourth-degree repair, on average, during 2019–2022. Conclusions During 4 years of training, average resident exposure was to 7 OASIS, 6 third degree, and 1 fourth degree. Limited exposure to OASIS during residency may be detrimental, as surgical treatment is a complicated yet essential obstetric procedure that carries significant risk of patient morbidity and potential long-term sequelae. Therefore, reliance on supplementation with simulation may improve surgeon competence in OASI management.

Importance Racial and ethnic disparities exist in urogynecologic surgery; however, literature identifying specific disparities after sling operations for stress incontinence are limited. Objective The objective of this study was to evaluate racial and ethnic disparities in surgical complications within 30 days of midurethral sling operations. Study Design This retrospective cohort study identified women who underwent an isolated midurethral sling operation between 2014 and 2021 using the American College of Surgeons National Surgical Quality Improvement Program database. Women were stratified by racial and ethnic category to assess the primary outcome, 30-day surgical complications, and the secondary outcome, comparison of urinary tract infections (UTIs). Results There were 20,066 patients included. Mean age and body mass index were 53.9 years and 30.8, respectively. More Black or African American women had diabetes and hypertension, and more American Indian or Alaska Native women used tobacco. The only difference in 30-day complications was stroke/cerebrovascular accident, which occurred in only 1 Asian, Native Hawaiian or other Pacific Islander patient (0.1%, P < 0.0001). The most frequent complication was UTI (3.3%). Black or African American women were significantly less likely to have a diagnosis of UTI than non-Hispanic White (P = 0.04), Hispanic White (P = 0.03), and American Indian or Alaska Native women (P = 0.04). Conclusions Surgical complications within 30 days of sling operations are rare. No clinically significant racial and ethnic differences in serious complications were observed. Urinary tract infection diagnoses were lower among Black or African American women than in non-Hispanic White, Hispanic White, and American Indian or Alaska Native women despite a greater comorbidity burden. No known biologic reason exists to explain lower UTI rates in this population; therefore, this finding may represent a disparity in diagnosis and treatment.