Bladder Endometriosis: Management by Cystoscopic and Laparoscopic Approaches

STUDY OBJECTIVE: Endometriosis of the urinary system accounts for less than 1% of all endometriosis, wherein bladder endometriosis is the most common. Bladder endometriosis is defined as endometriosis infiltrating the detrusor muscle and represents 85% of urinary tract endometriosis [1,2]. Segmental bladder resection/partial cystectomy is the bladder-preserving surgery and offers the complete removal of bladder endometriotic nodules [3,4]. Laparoscopic/robotic excision increases the chances of complete removal of nodules but may lead to inadvertent removal of excess bladder wall and increase the risk of complications, especially in cases of large lesions in close proximity to ureteric orifices. Thus, simultaneous laparoscopy and cystoscopy offers the most effective way of complete resection of bladder endometriotic nodules, relieving symptoms and minimizing intraoperative and postoperative complications and recurrence rates in patients [5-11]. This article with accompanying video describes the systematic approach and step-by-step surgical excision of a bladder endometriotic nodule in a patient with frozen pelvis. DESIGN: Step-by-step surgical excision of a bladder endometriotic nodule by simultaneous cystoscopy and laparoscopy. (Canadain Task Force classification: level III) SETTING: Jyoti Hospital and Minimum Invasive Surgery Center, Ahmedabad, India. PATIENT: A 41-year-old women, P2L2, presented with cyclical dysmenorrhea, dysuria, and chronic pelvic pain. Informed consent was obtained from the patient, and the local institutional board provided the approval. INTERVENTION: Simultaneous cystoscopy and laparoscopy. MEASUREMENTS AND MAIN RESULTS: A preoperative assessment was done with transvaginal ultrasonography with a partially full bladder that showed an intravesical 3-cm endometriotic nodule along with chocolate cysts of the ovary and adenomyosis of the uterus. A simultaneous cystoscopy by a urologist and laparoscopy by a gynecologist was performed. On cystoscopy the nodule was seen away from both the ureteric orifices. The nodule was marked cystoscopically with a monopolar needle and laparoscopically with bipolar scissors. Laparoscopy began with a full inspection of the abdomen, pelvis, and adhesions. Dissection started from the left round ligament, and both paravesical spaces were dissected gently, keeping the bladder partially full. Good uterine manipulation helped to delineate vaginal fornices during dissection. Dissection continued over the isthmus, and bladder was gently separated from the isthmus. The bladder was partially filled with methylene blue and intentionally cut opened to excise the demarcated bladder nodule with a monopolar hook, taking a disease-free margin of 5 mm [12]. Two stay sutures were taken at both the lateral angles of the bladder, and suture ends were brought outside the abdomen to facilitate closure of the bladder transversely. After mobilization of the bladder, both uterine vascular bundles were desiccated with bipolar and laparoscopic hysterectomy. Vaginal closure was done away from bladder stitches. The patient was discharged on day 3 with catheter and DJ stents. On day 21, 3-dimensional computed tomography cystogram showed adequate bladder volume. Catheter and DJ stents were removed, low-pressure cystoscopy showed a smooth stitch line with mucosa over it and no residual endometriosis. The patient was found to have no symptoms at the 2-year follow up. CONCLUSION: The video demonstrates the feasibility of simultaneous laparoscopic and cystoscopic approach for excision of a bladder endometriotic nodule. Marking the nodule by simultaneous cystoscopy and laparoscopy before excision helps in removing the disease completely and avoiding unnecessary normal bladder wall excision, thus reducing the risk of recurrence and resultant small bladder symptoms.