Combined cystoscopic and laparoscopic approach in deep endometriosis of the bladder

Study objective: To report the combined cystoscopic and laparoscopic approach in deep endometriosis with full-thickness infiltration of the bladder.

Design: Video (Canadian Task Force classification III).

Setting: University hospital.

Patient: A 34-year-old nulliparous woman with a large (35-mm) endometriosis nodule infiltrating the bladder and deep endometriosis of the rectum and sigmoid colon.

Intervention: The urologic surgeon performed cystoscopy, identified the limits of mucosal involvement, and incised the muscular layer up to fat tissues surrounding the bladder. The gynecologic surgeon identified and followed the circular incision, and completed full-thickness resection of the bladder wall. Surgical technique reports in anonymous patients are exempt from ethical approval by the institutional review board.

Measurements and main results: The patient's functional outcome was uneventful. Laparoscopic resection of large endometriotic nodules of the bladder per se may lead to inadvertent removal of healthy bladder muscle. Thus it increases the risk of postoperative complications and symptoms due to small bladder volume. Conversely, if resection of the nodule is performed only cystoscopically, it probably would not be completely removed. We routinely combine the 2 approaches because this enables complete resection of the endometriotic nodule. It not only averts the risk of excessive removal of healthy bladder muscle but also leaves no disease behind.

Conclusions: On the basis of our experience, we propose the combined cystoscopic and laparoscopic approach in managing large endometriotic nodules with full-thickness infiltration of the bladder.