Spotlight On: Urogynecology/ Vaginal Surgery

This month, we cast a spotlight on articles, SurgeryU videos, and Journal of Minimally Invasive Gynecology (JMIG) article recommendations from the AAGL Urogonecology/Vaginal Surgery (SIG) led by Chair Kate L. Woodburn, MD.

Access to SurgeryU and JMIG are two of the many benefits included in AAGL membership. The SurgeryU library features high-definition surgical videos by experts from around the world. JMIG presents cutting-edge, peer-reviewed research, clinical opinions, and case report articles by the brightest minds in gynecologic surgery.

SurgeryU video and JMIG article recommendations by our SIGs are accessible by AAGL members only. For full access to SurgeryU, JMIG, CME programming, and member-only discounts on meetings, join AAGL today!

Please consider joining the Urogynecology/ Vaginal Surgery SIG this month for our webinar focused on the many causes of bladder pain. This case-based discussion will help participants work through the differential of bladder pain and dysuria and walk away with practical strategies to implement in clinic the next day. We will focus on bladder and vaginal/ vulvar pathology including bladder pain syndrome, recurrent UTI, postoperative complications and vulvar dermatoses.

We also hope to see and meet many of you at AAGL 2026 in Boston during our Postgraduate Course- Urogynecology Call 101: Surviving—and Succeeding—on Urogyn Call. As gynecologic sub-specialty practices continue to grow, many urogynecologist and complex benign gynecology surgeons find themselves sharing patients or cross-covering on call. This PG course will help demystify the nuance of urogynecology practice for the covering CBG surgeon- when it’s an emergency, when it can wait, and why a urine culture is never the wrong thing to order. This course is geared towards fellows and early career physicians but all are welcome to join in our interactive discussions.

About the Author: 
Kate L. Woodburn, MD

Dr. Kate Woodburn is an Assistant Professor and urogynecologist at Atrium Health Wake Forest Baptist, specializing in urogynecology and urology care.

SIG Recommended SurgeryU Video #1: 
Approach to the Laparoscopic Excision of Bladder Endometriosis
By Dong Nguyen, Kristina Arendas, Caitlin Jago, Jeffrey Warren, & Sukhbir Singh

Click Image to View Video

SIG Recommended SurgeryU Video #2:
Surgical Management of Endometriosis of the Bladder and Ureter
By Youssef Yousseff, Michael Neblett, Katherine Anderson, Zaraq Khan

Click Image to View Video

JMIG Article Recommendation #1:

Diagnostic Cystoscopic Findings: A Primer for Gynecology
Sujatha Narayanamoorthy, MD, Brian J. Linder, MD, MS, John B. Gebhart, MD, MS

This article was a good primer for gynecologists to gain experience with abnormal cystoscopy findings which they may encounter incidentally intraoperatively. It highlights findings including mesh erosions as well as lesions concerning for malignancy.

JMIG Article Recommendation #2:

Minimally Invasive Surgery for Excision of Clinically suspected Endometriosis Improves Perception of Lower Urinary Symptoms
Kelly L. Budge, MD, Tamar Yacoel, MD, Kateryna Kolesnikova, MD, Khashayar Shakiba, MD

As many patients who present to either MIGS or URPS may present with a constellation of different pain syndromes, it is important to collaborate between subspecialities for optimal patient care. While deep infiltrating endometriosis/bladder endometriosis is overall rare, this study highlights that patients with pre-existing LUTS had significant reduction in LUTS after surgical excision of endometriosis, even if explanted lesions were not in the urinary tract.

JMIG Article Recommendation #3:

Is the Deep Endometriosis or the Surgery the Cause of Postoperative Bladder Dysfunction?
Rosa Maria Laterza, MD, Stefano Uccella, MD, Maurizio Serati, MD, Rene Wenzl, MD, Alexandra Graf, PhD, Fabio Ghezzi, MD

JMIG Article Recommendation #4:

Intermittent Self-Catheterization for Bladder Dysfunction After Deep Endometriosis Surgery: Duration and Factors that Might Affect the Recovery Process
Sari Boulus, MD, Benjamin Merlot, MD, Isabella Chanavaz-Lacheray, MD, Sandesh Kade, MD, Thomas Dennis, MD, Horace Roman, MD, PhD

When managing patients with deep endometriosis, these two studies highlight the need to discuss voiding dysfunction pre- and post-operatively with patients who are undergoing surgical management of endometriosis. While Laterza et al found an improvement in bladder capacity and decrease in LUTS, Boulus et al notes that there is a subset of patients who may require intermittent self-catheterization. Screening for voiding dysfunction is imperative in the planning stages of surgery.

JMIG Article Recommendations By:
Shirley M Dong, MD

Dr. Shirley Dong, MD is an obstetrician/gynecologist in Columbus, Ohio. She is affiliated with Ohio State University Wexner Medical Center.

Case Report: Urethral Mass

A 64-year-old is referred by her PCP to Urology for microscopic hematuria and recurrent urinary tract infections. Her past medical history is significant for myasthenia gravis, Sjogren’s syndrome and a history of kidney stones. Her surgical history is significant for an appendectomy in her 30s and a prior unknown urinary incontinence procedure, about 3 years prior. She is seen initially by the Nurse Practitioner, who starts the patient on vaginal estrogen and recommends a CT urogram and cystoscopy for further work up. The CT urogram (Images A and B) shows the following:

1. Small bilateral non-obstructing renal calculi, largest ~3.5 mm left kidney. No concerning urothelial or renal parenchymal lesions are identified.

2. Small cystic structure associated with the urethra, most suggestive of a urethral diverticulum.

3. Hepatic steatosis. Small scattered hepatic cysts.

Image A- CT Urogram

Image B- CT Urogram

The radiologists recommend MRI pelvis with and without contrast to better characterize the urethral lesion. The below images are obtained (Images C, D, E) and are read as a multiloculated complex urethral diverticulum. The patient was then referred to Urogynecology for further evaluation. Office cystoscopy and pelvic exam were then performed with the following findings:

Urethra: normal without strictures, without scarring, no concern for diverticulum.

Bladder: Normal without lesions.

Ureteral orifices were seen bilaterally

Pelvic Exam- Urethra and urethral meatus midline, Negative caruncle, negative for tenderness, discharge, masses. Positive CST, Negative hypermobile

Image C- MRI Pelvis

Image D- MRI Pelvis

Image E- MRI Pelvis

So, imaging suggests a large urethral diverticulum, but office evaluation was all normal- what is going on?

Urethral bulking is an office or OR-based minimally invasive procedure for stress urinary incontinence. The procedure has been around for years and in the mid 1990’s the first FDA urethral bulking product was brought to market. Since then, the procedure has gone through many iterations with different materials used including PAHG (Bulkamid™), calcium hydroxyapatite (Coaptite™), pyrolytic carbon (Durasphere™), and polydimethylsilaxone (Macroplastique™). Urethral bulking works through augmentation of mucosal coaptation, increasing urethral resistance and decreasing stress urinary incontinence. While not as effective or as durable as mesh mid-urethral slings, urethral bulking is a good choice for women with less severe incontinence, who want minimal/ no recovery time, who desire non-mesh-based procedures or who are not candidates for mesh mid-urethral slings. The most common adverse events after urethral bulking are injection site pain and urinary tract infection. More rare risks include urinary retention, bleeding, bulking agent reaction, and granuloma or abscess formation.

On pelvic imaging, urethral bulking may often mimic the cystic structures of urethral diverticulum, such as was seen in this patient (Images F, G). Evidence of urethral bulking may not be present on cystoscopy and would not be appreciated on pelvic exam. Understanding the patient’s history is critical for both the evaluating physician and the radiology team.

Image F- comparing the patient imaging with urethral bulking

Image G- comparing the patient imaging with urethral bulking

About the Author: 

About the Author: 
Kate L. Woodburn, MD

Dr. Kate Woodburn is an Assistant Professor and urogynecologist at Atrium Health Wake Forest Baptist, specializing in urogynecology and urology care.

A Point-Based Calculator to Predict Prolapse Surgery Recurrence

Recurrence after pelvic organ prolapse (POP) surgery is common, yet telling an individual patient her personal risk before surgery remains difficult. Established point-based tools such as the Caprini score for venous thromboembolism, CHA2DS2-VASc for stroke show how a handful of routine variables can stratify risk at the bedside. We set out to build the equivalent for prolapse recurrence: a simple, preoperative score any surgeon could calculate in clinic.

Developing the POP-PREDICT Score

Using data from 752 women across four prospective trials (2017–2024), with a 27.9% composite recurrence rate, we developed the POP-PREDICT Score (See Image 1). From more than 20 candidate variables, logistic regression with backward stepwise selection guided by the Akaike Information Criterion identified four independent predictors: surgical approach (colpocleisis, sacrocolpopexy, or native tissue repair), the preoperative Ba point on POP-Q, genital hiatus size, and hormonal status. Each coefficient was scaled proportionally into integer points (the method behind the Caprini and Framingham scores) producing a 0-to-7-point scale.

The score stratifies patients into three tiers: low risk (0–2 points, ~8–17% recurrence), moderate (3–4 points, ~21–28%), and high (5–7 points, ~40–45%). Discrimination was modest but clinically meaningful (area under the curve, 0.67) and held on internal five-fold cross-validation (0.64) and external leave-one-dataset-out validation (0.55–0.66), indicating the model generalizes beyond its development cohort. Colpocleisis candidates, whose recurrence is very low, fall outside the model and should be counseled separately.

A Tool for the Point of Care

To make the score usable in clinic, we built a free, interactive online calculator. The clinician enters four inputs and immediately sees the predicted recurrence risk and category, which update in real time as any variable changes. making individualized, shared counseling concrete during the visit. The full calculation takes under 30 seconds and requires no proprietary software.

We view this pilot as a starting point. The precision of any risk model grows with the breadth and volume of data behind it, and the greatest opportunity now is collaborative: incorporating prospective outcomes from centers worldwide will refine both the recurrence estimates and the variable selection over time. We warmly invite local and international colleagues with prospective POP outcomes data to contribute. The calculator is freely available at POP-PREDICT Score — Prolapse Recurrence Risk Calculator, and we welcome feedback (and data!) from the AAGL community as we continue to strengthen it.

References:

1. Jonsdottir G, Beermann M, Lanz E, et al. Ultrasound guided microwave ablation
treatment of uterine fibroids: clinical response and patient acceptability. Acta Obstet
Gynecol Scand. 2025;104(2):350–356. doi:10.1111/aogs.15041

2. Tinelli A, Morciano A, Sparic R, et al. Artificial intelligence and uterine fibroids: a
useful combination for diagnosis and treatment. J Clin Med. 2025;14(10):3454.
doi:10.3390/jcm14103454

About the Author: 
Amr El Haraki, MD
Marie Sullivan, MD

Dr. Sullivan is a URPS Fellow at Atrium Health Wake Forest Baptist in Winston-Salem, North Carolina, pursuing advanced training in female pelvic medicine and reconstructive surgery.