Strategies for Laparoscopic Excision of Endometriomas Involving the Bladder

INTRODUCTION: Bladder endometriosis is the presentation of abnormal endometrial glands and stroma in the detrusor muscle of the bladder. Although generally considered a relatively rare phenomenon affecting only about 1% of women with endometriosis, patients diagnosed with deep infiltrating endometriosis are more likely to have involvement of the urinary tract and especially the bladder. Ultimately, bladder endometriosis is diagnosed with histology. However, imaging modalities such as pelvic ultrasound and MRI have been instrumental in helping to make this diagnosis and improving surgical planning. MRI has been shown to be more effective at detecting and characterizing bladder endometriosis lesions, especially for smaller deep endometriosis lesions. Overall, these cases can present as a surgical challenge depending on the extent of disease, the patient’s anatomy, and the location of the lesion. OBJECTIVE: The objectives of this video are to describe bladder endometriosis, to present two cases of bladder endometriosis with significant involvement of the bladder wall, and to demonstrate strategies for laparoscopic excision of deeply infiltrating endometriosis of the bladder. METHODS: Two cases demonstrating the laparoscopic excision of bladder endometriomas in the setting of deep infiltrating endometriosis. RESULTS: Describing strategies for laparoscopic excision of bladder endometriosis including optimizing exposure by dissecting integral peri-bladder surgical planes (i.e., paravaginal and vesicovaginal spaces and the space of Retzius), using suture to tag the lesion to provide additional tension and traction, minimizing bleeding by injecting the lesion with diluted vasopressin, and using layer-by-layer dissection approach to minimize resection of healthy bladder tissue. CONCLUSIONS: Bladder endometriomas are a rare but impactful phenomenon associated with severe endometriosis. Removing bladder endometriomas laparoscopically requires excellent exposure, a strong understanding of pelvic anatomy, and careful surgical technique to ensure the complete resection of the lesion without compromising healthy tissue.