Complex Ureteral, Vaginal, and Bladder Endometriosis Excision and Ureteroneocystostomy: Robotic Approach

INTRODUCTION: Urinary tract endometriosis accounts for 1–2% of surgically diagnosed endometriosis. This challenging condition can lead to significant morbidity, including ureteral obstruction and compromised renal function. Effective management requires a multidisciplinary approach and advanced surgical techniques to ensure complete excision and optimal patient outcomes. OBJECTIVE: The objective of this video is to demonstrate a step-by-step robotic approach for excising complex ureteral and bladder endometriosis. It also aims to demonstrate the technique of ureteroneocystostomy with a psoas hitch and Boari flap for ureteral reconstruction. METHODS: A 44-year-old patient with a history of endometriosis and chronic pelvic pain presented with left hydroureteronephrosis and impaired renal function due to ureteral obstruction. Decision was made to perform a robotic excision of endometriosis. The procedure involved ureterolysis, excision of the bladder and vaginal endometriotic nodules, partial vaginectomy, and ureteroneocystostomy with psoas hitch and Boari flap reconstruction. RESULTS: The complete excision of endometriosis was achieved without complications. The ureteroneocystostomy was successfully performed with a tension-free anastomosis, and the bladder was confirmed to be watertight upon distention. CONCLUSIONS: Robotic excision of complex ureteral and bladder endometriosis, combined with ureteroneocystostomy using a psoas hitch and Boari flap, is a safe and effective approach for managing deep infiltrating urinary tract endometriosis. Key surgical principles, such as complete ureterolysis, adequate hemostasis, precise dissection, and multidisciplinary collaboration, are critical for successful outcomes.