{"paper_id":"80664a86-8822-4fac-9747-2b1bbc93c96a","body_text":"WWW.KJOG.ORG882\nA SUCCESSFUL CASE OF LAPAROSCOPIC PARTIAL \nCYSTECTOMY FOR BLADDER ENDOMETRIOSIS\nMin Kyoung Kim, MD\n1\n, Yeon Soo Jung, MD\n1\n, Dawn Chung, MD\n1\n, Kang Su Cho, MD\n2\n, Young Sik Choi, MD\n1\n, \nSeok Kyo Seo, MD\n1\n1\nDepartment of Obstetrics and Gynecology, Institute of Women’s Life Medical Science, \n2\nDepartment of Urology, Yonsei University College of Medicine, Seoul, Korea\nEndometriosis is defined as the presence of endometrial tissue (glands and stroma) outside the uterus. About 1% of women with \nendometriosis have urinary tract implantations, and 84% of these cases involve the bladder. Abdominal partial cystectomy has \nbeen reported to treat urinary tract implantations, but laparoscopy has not previously been reported in Korea. We report a case of \nvesical endometriosis that was treated successfully with laparoscopic partial cystectomy.\nKeywords: Endometriosis; Bladder; Laparoscopic partial cystectomy\nReceived: 2012.4.20.   Revised: 2012.8.24.  Accepted: 2012.9.12.\nCorresponding author: Seok Kyo Seo, MD\nDepartment of Obstetrics and Gynecology, Y onsei University \nCollege of Medicine, 50 Y onsei-ro, Seodaemun-gu, Seoul 120-749, \nKorea\nTel: +82-2-2228-2236  Fax: +82-2-2228-2236 \nE-mail: tudeolseo@yuhs.ac\nThis is an Open Access article distributed under the terms of the Creative Commons \nAttribution Non-Commercial License (http://creativecommons.org/licenses/\nby-nc/3.0/) which permits unrestricted non-commercial use, distribution, and \nreproduction in any medium, provided the original work is properly cited.\nCopyright © 2012. Korean Society of Obstetrics and Gynecology \nEndometriosis is the presence of endometrial tissue outside the \nuterus; it is especially common in the pelvic cavity and the peri -\ntoneum. Among the many different implantation sites, bladder \nendometriosis is very rare, occurring in less than 1% of women \nwith endometriosis. For many years, bladder endometriosis has \nbeen treated with abdominal partial cystectomy. Due to its rarity, \nfew studies have been done to develop an improved treatment \nplan. However, since laparoscopy is currently the primary modality \nfor the diagnosis and treatment of endometriosis, a few cases of \nlaparoscopically treated bladder endometriosis have been reported \nabroad [1-3]. Such treatment has yet to be reported in Korea until \nnow; we report a case of bladder endometriosis successfully man -\naged with laparoscopic partial cystectomy.\nCase Report\nPatient: Jung, anonymous, 40-year-old.\nChief complaint: Dysuria during menstruation.\nPara: G0-P0-L0-D0-A0, unmarried.\nMenstrual history:  Menarche, 14-year-old; interval, regular, 28 \ndays; duration, 5–7 days.\nAmount: Moderate; dysmenorrhea (+); visual analogue scale, 7–8.\nPast medical history: Nonspecific.\nFamily history: Mother, hypertension.\nPresent illness:  The patient visited a local hospital in Seoul due \nto dysuria during menstruation. She received six cycles of gonad -\notrophin-releasing hormone (GnRH) agonists, but her symptoms \ndid not improve; thus, she referred to our outpatient clinic on De -\ncember 11, 2010. Base on the results of a computed tomography \n(CT) scan, endometriosis was suspected, with a mass visualized on \nthe posterior wall of the bladder. She was referred to the urology \ndepartment for cystoscopy. The cystoscopy revealed a 3 cm mass \non the posterior wall of the bladder. Transurethral resection of \nbladder was performed (Fig. 1) and the specimens were sent for \nfrozen biopsy. The result was negative, but the final pathologic re-\nsult revealed endometriosis. Therefore, the patient required further \ndiagnostic laparoscopy and laparoscopic partial cystectomy. \nLab: Complete blood count (hemoglobin, 13.2 g/dL; white blood \nCASE REPORT\nKorean J Obstet Gynecol 2012;55(11):882-886\nhttp://dx.doi.org/10.5468/KJOG.2012.55.11.882\npISSN 2233-5188 · eISSN 2233-5196\n\nWWW.KJOG.ORG 883\nMin Kyoung Kim, et al. Bladder endometriosis and laparoscopy\ncell, 6,210/mm\n3\n; platelets, 225,000/mm\n3\n), chemistry, coagulation \ntest, urinanalysis, cancer antigen (CA) 19-9 12.6, and CA 125 \n14.2 were all within normal range.\nAbdominopelvic CT: This was taken on December 13, 2010, \nshowing a 3.1×1.6 cm-sized heterogeneous enhancing lesion on \nthe posterior wall of the bladder (Fig. 2). On December 22, the fol-\nlow-up CT showed that the lesion had decreased in size to 2.8×1.4 \ncm.\nPelvic magnetic resonance imaging (MRI):  Focal wall thickening \nat the posterior wall of the bladder was noted, showing low signal \nintensity with high SI spots on T2WI (weighed image) and T1WI. \nCompared to the normal bladder wall, there was mild enhance -\nment. A benign bladder tumor, rather than endometriosis, was \nsuspected, and a differential diagnosis from leiomyoma, heman -\ngioma, or neurofibroma was needed using the tissue biopsy from \npartial cystectomy.\nIntraoperative findings: Under general anesthesia, diagnostic \nlaparoscopy was done on March 28, 2011. Severe pelvic adhe -\nsions, including the rectum, the posterior vesical wall, and the \nuterus, were noted (Fig. 3). The bladder endometriosis was de -\nFig. 1. (A) Cystoscopy reveals dark elevated lesions on the posterior wall of the bladder. (B) Resection of the lesions. (C) Resection in progress. (D)  \nFinal resectied lesions.\nA  B\nC  D\nFig. 2. Magnetic resonance imaging image revealing focal wall thicken -\ning at the posterior wall of bladder, and low signal intensity (SI) with high \nSI spots on T2WI and T1WI. The arrow indicates the lesion. \n\nWWW.KJOG.ORG884\nKJOG  Vol. 55, No. 11, 2012\ntected as a lesion of 1 cm that augmented to 3 cm on traction. \nThe lesion was attached by well-vascularized dense adhesions to \nthe uterine serosa. Further endometriotic lesions were seen on \nthe bilateral sacrouterine ligament, the left part of the cul-de-sac \ninfiltrating the rectum, and the sigmoid colon (endometriosis stage \nIII). The uterus and both ovaries were grossly normal. On the right \nsalpinx, a paratubal cyst of around 1×2 cm was found. The cyst \nwas removed and a biopsy was done. The posterior vesical wall le-\nsion was then marked by resectoscope, and prophylactic bilateral \nureteral stent insertion was done. Laparoscopic partial cystectomy \nand adhesiolysis were done. All procedures were performed by Dr. \nKS Cho, a medical doctor from the urology department, with the \nassistance of gynecologists. Initially the vesicouterine peritoneal \nfold was opened transversely and the bladder was mobilized off \nthe cervix and the upper vagina with sharp dissection to the level \nof the trigone. The scarred endometrial implant was then freed \nusing Harmonic scalpel and scissors to excise the portion of blad -\nder that was involved with endometriosis, together with the area \nof fibrotic bladder around it. This full thickness bladder resection \ncame within 1 cm of the right ureteral orifice and extended into \nthe right side of the trigone. The bladder was closed in three lay -\ners, using interrupted sutures with #3-0 and #2-0 Vicryl and a \nthird running suture with #3-0 Vicryl. Closure was tested by instil -\nlation of methylene blue (150 mL). In addition, Interceed was left \nintraabdominally for adhesion prophylaxis. This turned out to have \nboundaries similar to the previous cystoscopically marked regions. \nThe specimens were sent to the pathology department for frozen \nbiopsy and the result was negative for malignancy. However, the \nfinal pathologic report revealed bladder endometriosis and a \nsimple paratubal cyst on the right salpingeal lesion. \nPostoperative status: The patient was discharged four days af -\nter surgery with the Foley catheter in situ.  On April 7, 2011, she \ncame back to the hospital for a check-up; the cystography showed \nno dye extravasation from the bladder and the bilateral ureteral \nstents were in place. On April 21, 2011, the 24th postoperative \nday, her Foley catheter and the ureteral stents were removed. Her \nbone mineral density levels were within normal limits and she was \neligible for three postoperative cycles of GnRH agonists followed \nby 6 months of oral progesterone therapy. With this surgical and \nmedical treatment combination, she had no complications during \nthe 12-month post-surgical follow-up. \nDiscussion\nBladder endometriosis is a rare entity that involves the detrusor \nmuscle and often affects the vesical wall transmurally [4]. There \nare a number of explanationhs regarding the pathogenesis of this \ndisease, and the implantation of regurgitated endometrial cells is \nthe most accepted theory. The bladder constitutes a privileged tar-\nget for the implantation because it is located in the anterior cul-\nde-sac, which is a dependent portion of the pelvic cavity. The fact \nthat bladder endometriosis is usually not observed in women with \na retroverted uterus (because no dependent anterior cul-de-sac is \npresent) supports this theory [5]. \nIt is important to suspect vesical endometriosis when a patient has \ncatamenial urinary symptoms, such as frequency, urgency, pain -\nful micturition, or vesical tenesmus. Symptoms usually appear to \noverlap with those of urinary tract infections, overactive bladder, \ninterstitial cystitis and other similar diseases in women in which \ndiagnosis is often delayed [6]. \nSeveral imaging studies are used for diagnosis, and pelvic ultraso -\nnography can be the initial approach. The disease entity is viewed \nas a heterogeneous, hyperechoic, intraluminal, and usually coni -\ncal vegetation, which protrudes from the posterior vesical wall or \nthe dome. MRI and CT scans may confirm the ultrasonographical \nFig. 3. Laparoscopic findings show severe pelvic adhesions including the uterus, and rectum (endometriosis stage III).\n\nWWW.KJOG.ORG 885\nMin Kyoung Kim, et al. Bladder endometriosis and laparoscopy\nfindings, but they are not known to add much more different or \nprecise information to ultrasonography and cystoscopy [7,8]. \nIn this case, using the cystoscopic approach, a solid mass with a \nhyperemic appearance and typical bluish, slightly raised cysts were \nseen on the surface. Biopsy of the lesion and the pathologic find -\ning of the endometrial glands confirmed the diagnosis. But even if \nthe results were negative, the diagnosis is not excluded. Transure-\nthral resection is usually not recommended as a definite treatment \nbecause attempting to completely eradicate the transmural lesion \nmay perforate the bladder [9]. \nBladder endometriosis has two treatment options: medical and \nsurgical. Surgical treatment is the definitive treatment for endome-\ntriosis since medical treatment is considered to be palliative and \nthe recurrence rate is higher when the treatment is discontinued. \nHowever, because the main goal of treating bladder endometriosis \nis controlling symptoms, medical treatment is also highly effective \nand it is not always necessary to perform surgery. In this case, the \npatient was initially on a medical therapy (six cycles of GnRH ago -\nnists), but she experienced no symptom improvement. As we can \nlearn from this case, when treatment is not satisfactory, physicians \nshould consider the next option–surgical eradication. \nIn the past, abdominal surgery was the treatment of choice, but \ndue to improvements in laparoscopic technology, laparoscopic \npartial cystectomy is becoming the new standard of treatment for \nbladder endometriosis. It has several advantages, such as allow -\ning enhanced visualization of the pelvic anatomy for the adequate \nexcision of all lesions, less bleeding, shortened operative time \nand hospital stay, a major reduction in postoperative pain, and \ndecreased risk of postoperative morbidity [10]. Concomitant cys -\ntoscopy can be useful for better defining the margins of the endo -\nmetriotic lesion to be resected, as demonstrated in this case [11]. \nIn conclusion, when patients with bladder endometriosis do \nnot experience satisfying effects with medical therapy, clinicians \nshould move on to further evaluation and surgical treatment when \nit is needed. Further, with today’s developing laparoscopic skills, \nwe need to be up-to-date in treating even the rare cases, such as \nbladder endometriosis, with laparoscopy. There are a few cases re-\nported to have been successfully treated with laparoscopic partial \ncystectomy around the world, but none were previously reported \nin Korea. Thus, we report one case in which a patient was satisfied \nwith the result of laparoscopic partial cystectomy.\nReferences\n  1. Prager M, Wilson T, Krüger K, Ebert AD. Laparoscopic extramu-\ncosal partial bladder resection in a patient with symptomatic \ndeep-infiltrating endometriosis of the bladder. J Minim Inva -\nsive Gynecol 2012;19:113-7.\n  2. Kovoor E, Nassif J, Miranda-Mendoza I, Wattiez A. Endometri-\nosis of bladder: outcomes after laparoscopic surgery. J Minim \nInvasive Gynecol 2010;17:600-4.\n  3. Walid MS, Heaton RL. Laparoscopic partial cystectomy for \nbladder endometriosis. Arch Gynecol Obstet 2009;280:131-5.\n  4. Berlanda N, Vercellini P , Carmignani L, Aimi G, Amicarelli F , Fe-\ndele L. Ureteral and vesical endometriosis. Two different clini -\ncal entities sharing the same pathogenesis. Obstet Gynecol \nSurv 2009;64:830-42.\n  5. Vercellini P , Frontino G, Pisacreta A, De Giorgi O, Cattaneo M, \nCrosignani PG. The pathogenesis of bladder detrusor endome-\ntriosis. Am J Obstet Gynecol 2002;187:538-42.\n  6. Bogart LM, Berry SH, Clemens JQ. Symptoms of interstitial cys-\ntitis, painful bladder syndrome and similar diseases in women: \na systematic review. J Urol 2007;177:450-6.\n  7. Balleyguier C, Chapron C, Dubuisson JB, Kinkel K, Fauconnier \nA, Vieira M, et al. Comparison of magnetic resonance imaging \nand transvaginal ultrasonography in diagnosing bladder endo-\nmetriosis. J Am Assoc Gynecol Laparosc 2002;9:15-23.\n  8. Kinkel K, Frei KA, Balleyguier C, Chapron C. Diagnosis of en -\ndometriosis with imaging: a review. Eur Radiol 2006;16:285-98.\n  9. Aldridge KW, Burns JR, Singh B. Vesical endometriosis: a re -\nview and 2 case reports. J Urol 1985;134:539-41.\n10. Granese R, Candiani M, Perino A, Venezia R, Cucinella G. Blad-\nder endometriosis: laparoscopic treatment and follow-up. Eur \nJ Obstet Gynecol Reprod Biol 2008;140:114-7.\n11. Seracchioli R, Mannini D, Colombo FM, Vianello F , Reggiani A, \nVenturoli S. Cystoscopy-assisted laparoscopic resection of ex -\ntramucosal bladder endometriosis. J Endourol 2002;16:663-6.\n\nWWW.KJOG.ORG886\nKJOG  Vol. 55, No. 11, 2012\n복강경하 부분방광절제술을 시행한 방광 자궁내막증 1예\n연세대학교 의과대학 1산부인과학교실, 2비뇨기과학교실\n김민경1, 정연수1, 정다은1, 조강수2, 최영식1, 서석교1\n  자궁내막증은 자궁외에 자궁내막 조직이 존재하는 것을 의미한다. 자궁내막증 여성의 약 1%가 요로계 자궁내막증을 가지고 있으며, 그 \n중 84%는 방광이 포함된다. 과거에는 방광 자궁내막증은 개복하 부분방광절제술로 치료되고 있었으며, 국내에서는 아직 복강경술로 치\n료한 증례가 보고되지 않았다. 저자는 복강경하 부분방광절제술로 방광 자궁내막증 환자를 성공적으로 치료한 1예를 경험하였기에 보고\n하는 바이다. \n중심단어: 자궁내막증, 방광, 복강경하 부분방광절제술","source_license":"CC0","license_restricted":false}