Surgical Management of Bladder Endometriosis

INTRODUCTION: Urinary tract endometriosis involving the bladder or ureters is estimated to encompass 1% of women with endometriosis, but in up to 19% to 53% of deep invasive endometriosis cases. The bladder is most commonly involved urinary tract organ. Patients may present with dysuria, urinary frequency, or hematuria along with other classic symptoms of endometriosis. OBJECTIVE: We present a case of surgical management of complex bladder endometriosis and will discuss both surgical principles as well as postoperative management. METHODS: A 28-year-old patient with chronic pelvic pain and chronic dysuria did not have adequate pain relief with hormonal contraceptives and pelvic floor physical therapy. Her preoperative MRI was concerning for deep invasive bladder endometriosis. She consequently underwent a robotic-assisted excision of endometriosis with partial bladder cystectomy and repair. Placement of ureteral stents provided a helpful landmark during dissection. RESULTS: The patient was discharged with a Foley catheter for 3 weeks. Following a reassuring CT urogram, her Foley was removed. Her final pathology revealed a 4.2-cm bladder lesion consistent with endometriosis. She had initial overactive bladder symptoms managed with medications, which improved during her 4-month postoperative course. CONCLUSIONS: Urinary tract endometriosis presents a multitude of difficulties to manage surgically. The power of collaboration between urogynecology and MIGS in the treatment of patients with complex endometriosis is essential. Endometriosis should be completely excised, while balancing the need for preservation of bladder function. Patients should be counseled regarding postoperative expectations for Foley catheter placement as well as overactive bladder symptoms.