Robot-assisted partial cystectomy for bladder endometriosis: dual approach involving cystoscopy and robotic surgery

Bladder endometriosis accounts for 70%–85% cases of urinary tract endometriosis. A high index of suspicion is needed to diagnose this condition as most women have associated pelvic and menstrual complaints. The presence of cyclical haematuria along with tender anterior vaginal wall should alert the gynaecologist or urologist to consider this rare entity. Treatment is medical therapy followed by surgery when needed. Transurethral resection of endometriotic spot is the commonly used approach but to completely excise the endometriotic nodule, bladder resection at the site of nodule is needed along with repair of cut bladder margins. Herein, we describe a dual surgical approach where the margins of the endometriotic spot were delineated and cut using cystoscopy, followed by robotic approach to completely excise the nodule along with bladder repair. Robotic approach seems safer and easier in this complex surgery owing to dense adhesions in such cases.

radiology, urological surgery, haematuria

Bladder endometriosis (BE) is characterised by the presence of endometrial glands and stroma in detrusor muscle; trigone and dome being the most common sites. Bladder is the most frequent type of urinary tract endometriosis seen in almost 70%–85% cases, followed by involvement of ureters in nearly 9%–23%.1 2 We herein describe a case of para 2 live 2 with BE successfully treated with robotic surgery with cystoscopy guidance. Case presentation A 34-year-old para 2 live 2 with previous two caesarean deliveries presented with chronic pelvic pain for last 2 years. She also had cyclical haematuria coinciding with her menstrual cycle for past 8 months. She had history of heavy menstrual bleeding for past 1 year for which she was on oral contraceptive pills for 6 months. On general examination, her vitals were stable. Per abdomen had no organomegaly. On per speculum examination, bluish nodularity was noted in posterior fornix. Per vaginal examination revealed 12 weeks uniformly enlarged and tender uterus with tender thickened area in anterior vaginal wall. Investigations Blood investigations were normal with 8-10RBCs in urine routine microscopy. Urine cytology was negative for malignant cells. Endometrial aspiration showed proliferative endometrium. Ultrasonography showed focal irregular thickening of 26×16 mm in posterior wall of urinary bladder in midline. Records of cystoscopy done in a private hospital showed 3×2 cm endometriotic spot in posterior wall of bladder around 2 cm away from left vesicoureteric orifice. MRI showed findings suggestive of BE as shown in figures 1A, B and 2A, B. Differential diagnosis Since the patient of a reproductive age group presented with chronic pelvic pain and heavy menstrual bleeding, one of the possible diagnosis was endometriosis. This became further evident on finding a bluish nodularity of posterior fornix, tender uterus and tender thickened area in anterior vaginal wall. History of cyclical haematuria in such a case generally suggests bladder mucosal involvement. This working diagnosis was confirmed by MRI findings. Further proof to such an involvement was given by cystoscopy findings done earlier in the course of workup. Treatment After counselling of the patient and considering her symptoms of chronic pelvic pain with deep infiltrating endometriosis (DIE), a decision was taken for hysterectomy with segmental resection of bladder. The patient was not in favour of any sort of further medical treatment. A robotic approach along with transurethral resection (TUR) of endometriotic nodule was planned. Just prior to docking of robotic instruments, cystoscopy was done and bilateral DJ (double J) stenting was done. Endometriotic nodule measuring almost 3 cm was centrally located and was around 2 cm from the ureteric orifice as seen in figure 3A. Transurethral coring around endometriotic nodule was done using needle electrode. The coring was done almost till the bladder serosa without perforating the bladder wall. This was followed by docking of robotic instruments. Intraoperatively, owing to her previous two caesarean deliveries, bladder was seen densely adherent to the anterior surface of uterus in previous uterine scar area. Pouch of Douglas was completely obliterated. Endometriotic spots were also noted in uterosacral ligaments. The bladder was released from the uterus with some difficulty and during this, perforation occurred in the wall of bladder at the site of endometriotic nodule. These peroperative findings have been described in figure 3B–D. The bladder endometriotic nodule was then excised completely along the defect area using the robotic instruments. The peritoneal endometriosis in the pouch of Douglas and the nodules in both uterosacral ligaments were excised. Hysterectomy along with repair of bladder was done. Bladder was repaired in two layers with interposition of appendices epiploicae. The endometriotic nodule was removed from the abdomen through the vault area, which was later closed. After the surgery, a cystoscopy was performed again to check the integrity of the suture and ureteric orifices. The patient also received GnRH (gonadotropin releasing hormone) analogue postsurgery. The duration of hospital stay was 3 days. Urinary catheter was removed after 3 weeks. Outcome and follow-up At 6 weeks follow-up, the patient came for DJ stents removal. The patient was completely satisfied with resolution of her symptoms. Histopathology showed cervical endometriosis with BE.

DIE is the most severe variety of endometriosis seen in almost 1% women of childbearing age.3 It is characterised as endometriotic implants penetrating more than 5 mm of peritoneum. Common sites of DIE are pouch of Douglas, uterosacral ligaments, broad ligaments, bladder and ureter. Urinary tract endometriosis is rare with reported incidence being 0.3%–12% among all women affected by endometriosis.4–7 BE generally affects women of reproductive age group. BE can be primary or secondary, based on the origin. Primary BE occur spontaneously whereas secondary BE is an iatrogenic lesion occurring after pelvic surgeries like caesarean section or hysterectomy.8 Clinical presentation of BE varies considerably depending on the size and location of the lesion. Dysuria, frequency and bladder pain are the common symptoms related to BE. Dysuria has been seen in 21%–69% of patients with BE.1 Haematuria is less frequent presentation as BE rarely infiltrates the mucosal layer.1 Menouria (haematuria coinciding with menstruation) is seen in 20%–25% of cases when mucosa is affected.9 In our case, the women had cyclical haematuria coinciding with her menses owing to the bladder mucosa involvement. Diagnosis is both clinical and radiological. Vaginal examination has almost 100% accuracy in detecting BE.10 The presence of painful nodule or thickening in anterior vaginal wall points to BE. Ultrasonography helps to identify the exact site and size of the lesion. MRI can differentiate BE from malignancy if there is suspicion. Cystoscopy is an outpatient diagnostic procedure; it further adds to delineation of the distance of endometriotic nodule from ureteric orifices thereby guiding the surgical approach. Medical therapy should be the first-line approach for treating DIE as they are safe and efficacious. Hormonal therapy remains the mainstay of treatment. But desmoplastic reaction within detrusor resulting from repetitive bleeding and resorption of menstrual debris might lead to suboptimal response to medical therapy. This was probably the reason of failed response in our case. Surgery is done in cases of failed medical therapy. TUR and segmental bladder resection are the commonly performed procedures. Combination of TUR along with partial cystectomy (open/laparoscopic/robotic) has been previously done.11 In our case also, this double approach was used. The aim of this double approach was to overcome the difficulties encountered with single approach. Use of TUR alone may result in possibility of leaving some endometriotic tissue in situ leading to recurrence and relapse of symptoms. Open/laparoscopic/robotic approach alone can at times result in advertent removal of excess bladder tissue. As this was a case of DIE in the setting of previous two abdominal surgeries, we did cystoscopy with bilateral ureteric stenting to demarcate the margins of endometriotic nodule and its location from ureteric orifices. Under cystoscopy guidance, coring in around the endometriotic nodule was done. This was followed by robot-assisted partial cystectomy and primary repair of bladder defect. Robotic hysterectomy was also done considering chronic pelvic pain with enlarged uterus after patient counselling. Patient’s perspective. I came to this hospital with persistent and non-resolving pelvic pain despite taking multiple analgesics and hormonal pills. The blood in urine everytime I had periods was very much bothersome. The doctors in this hospital did an MRI scan and said that the disease which is of benign nature has invaded my bladder wall. I was counselled that I might need a urinary diversion procedure in case a majority of bladder wall needs to be removed in order to excise entire disease. After already having a failed medical treatment I consented for the surgery. I was satisfied that the surgery was done robotically as my postoperative recovery was very smooth. I am relieved of my pain and have no urinary complaints with a fairly regular menstrual cycle. Learning points. Symptoms of bladder endometriosis (BE) often overlap with common urological problems, hence a high index of suspicion is needed in women of reproductive age presenting with lower urinary tract symptoms like cyclical haematuria. Such cases should be managed by a team of gynaecologists and urologists as they usually have associated gynaecological symptoms. Transurethral resection and segmental bladder resection are the commonly performed procedures for BE. With the advent of robotic surgery, it has now become easier to perform such complex surgeries with better postoperative recovery. Preoperative DJ stenting of ureters prevents ureteric injury and with demarcation of bladder endometrioma under cystoscopy guidance further makes the surgery easier and safer. Footnotes Contributors: AB and RM managed the case. PS assisted with diagnosis. SK along with AB and RM operated the case. AB and RM prepared and revised the manuscript. All authors accepted the final version of the manuscript. Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Competing interests: None declared. Provenance and peer review: Not commissioned; externally peer reviewed. Ethics statements Patient consent for publication Obtained.

- 1.Gabriel B, Nassif J, Trompoukis P, et al. Prevalence and management of urinary tract endometriosis: a clinical case series. Urology 2011;78:1269–74. 10.1016/j.urology.2011.07.1403 [DOI] [PubMed] [Google Scholar] - 2.Abeshouse BS, Abeshouse G. Endometriosis of the urinary tract: a review of the literature and a report of four cases of vesical endometriosis. J Int Coll Surg 1960;34:43–63. [PubMed] [Google Scholar] - 3.Koninckx PR, Ussia A, Adamyan L, et al. Deep endometriosis: definition, diagnosis, and treatment. Fertil Steril 2012;98:564–71. 10.1016/j.fertnstert.2012.07.1061 [DOI] [PubMed] [Google Scholar] - 4.Gustilo-Ashby AM, Paraiso MFR. Treatment of urinary tract endometriosis. J Minim Invasive Gynecol 2006;13:559–65. 10.1016/j.jmig.2006.07.012 [DOI] [PubMed] [Google Scholar] - 5.Donnez J, Spada F, Squifflet J, et al. Bladder endometriosis must be considered as bladder adenomyosis. Fertil Steril 2000;74:1175–81. 10.1016/S0015-0282(00)01584-3 [DOI] [PubMed] [Google Scholar] - 6.Douglas C, Rotimi O. Extragenital endometriosis--a clinicopathological review of a Glasgow hospital experience with case illustrations. J Obstet Gynaecol 2004;24:804–8. 10.1080/01443610400009568 [DOI] [PubMed] [Google Scholar] - 7.Chapron C, Fauconnier A, Vieira M, et al. Anatomical distribution of deeply infiltrating endometriosis: surgical implications and proposition for a classification. Hum Reprod 2003;18:157–61. 10.1093/humrep/deg009 [DOI] [PubMed] [Google Scholar] - 8.Leone Roberti Maggiore U, Ferrero S, Candiani M, et al. Bladder endometriosis: a systematic review of pathogenesis, diagnosis, treatment, impact on fertility, and risk of malignant transformation. Eur Urol 2017;71:790–807. 10.1016/j.eururo.2016.12.015 [DOI] [PubMed] [Google Scholar] - 9.Westney OL, Amundsen CL, McGuire EJ. Bladder endometriosis: conservative management. J Urol 2000;163:1814–7. 10.1016/S0022-5347(05)67550-7 [DOI] [PubMed] [Google Scholar] - 10.Hudelist G, Oberwinkler KH, Singer CF, et al. Combination of transvaginal sonography and clinical examination for preoperative diagnosis of pelvic endometriosis. Hum Reprod 2009;24:1018–24. 10.1093/humrep/dep013 [DOI] [PubMed] [Google Scholar] - 11.Supermainam S, Koh ET. Laparoscopic partial bladder cystectomy for bladder endometriosis: a combined cystoscopic and laparoscopic approach. J Minim Invasive Gynecol 2020;27:575–6. 10.1016/j.jmig.2019.06.020 [DOI] [PubMed] [Google Scholar]