ENDOMETRIOSIS AND UROGYNECOLOGY

Endometriosis is a chronic, estrogen-dependent inflammatory disease characterized by the presence of endometrial-like tissue outside the uterus. It affects approximately 10-20% of women, predominantly during reproductive years, and most commonly presents with pelvic pain and infertility. Deep infiltrating endometriosis (DIE), the most severe form of the disease, is defined by the invasion of endometriotic lesions more than 5 mm below the peritoneal surface. DIE frequently involves pelvic structures such as the uterosacral ligaments, rectovaginal septum, bladder, ureters, and bowel, resulting in complex clinical manifestations. Urogynecological involvement occurs in approximately 6% of DIE cases, with the bladder and ureters being the most commonly affected organs. Such involvement may lead to symptoms including dysuria, hematuria, pelvic pain, hydronephrosis, and even loss of renal function. Transvaginal ultrasonography is the first-line imaging modality, but magnetic resonance imaging (MRI) is preferred for the evaluation of deep pelvic lesions. In recent years, artificial intelligence (AI)-assisted imaging analysis systems have enhanced the accuracy and standardization of lesion detection, contributing significantly to diagnostic precision and surgical planning. Surgical treatment must be individualized based on the anatomical extent and organ involvement of the disease. Surgical options include ureterolysis, segmental ureteral resection, or ureteroneocystostomy for ureteral involvement, and lesion excision or partial cystectomy for bladder endometriosis. Compared to traditional 2D laparoscopy, 3D laparoscopic systems provide superior depth perception and tissue differentiation, particularly benefiting nerve-sparing dissections. Techniques such as the Negrar approach, which emphasize preservation of pelvic autonomic nerves, reduce the risk of postoperative complications and improve functional outcomes. Postoperative follow-up is essential to monitor renal function and detect recurrence. Adjunctive medical therapy with GnRH analogues or progestins may help reduce recurrence rates. Literature reports postoperative symptomatic improvement in 80-95% of patients undergoing bladder surgery for endometriosis. The integration of multidisciplinary management and advanced technologies in the diagnosis, treatment, and follow-up of DIE is essential to ensure optimal surgical outcomes, patient safety, and long-term quality of life.

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