Standard Approach to Urinary Bladder Endometriosis

Study objective: Urinary endometriosis accounts for 1% of all endometriosis where the bladder is the most affected organ. Although the laparoscopic removal of bladder endometriosis has been demonstrated to be effective in terms of symptom relief with a low recurrence rate, there is no standardized technique. Partial cystectomy allows the complete removal of the disease and is associated with low intra- and postoperative complications. Here we describe a stepwise approach to a rare case of a large endometriosis nodule affecting the trigone of the urinary bladder.

Design: Step-by-step video explanation of a large endometriotic nodule excision (Canadian Task Force classification III).

Setting: IRCAD AMITS - Barretos | Hospital Pio XVI. The video was approved by the local institutional review board.

Patient: A 31-year-old woman.

Intervention: Laparoscopic approach for bladder endometriosis.

Measurements and main results: We present a case of a 31-year-old woman who complained of dysuria and hematuria with a bladder nodule of 3 cm affecting the bladder trigone. Laparoscopic complete excision of the nodule was performed. Laparoscopy began with full inspection of the pelvic and abdominal cavity. Vaginal examination under laparoscopic view helped to determinate the dimensions of the bladder nodule. Strategy consisted of bilateral dissection of the paravesical fossae and the identification of both uterine arteries and ureters. The bladder was slowly dissected from the uterine isthmus and was intentionally opened, thus helping the surgeons to identify the lateral and lower limits of the nodule and its proximity to both ureters. Bilateral double J stents were previously placed to guide the excision and further suture. Once the nodule was removed, the remaining wall consisted of the lower aspect of the trigone, both medial lower parts of the ureter, and the apex of the bladder. Suturing was performed in 2 steps. A simple monofilament interrupted suture was applied vertically at the lower wall between both ureters. The same technique was applied horizontally on the bladder dome. Pressure test demonstrated adequate correction. The patient was discharged 2 days later with a bladder catheter and double J stent. After 15 days, both indwelling catheter and ureteric stent were removed, and patient was submitted to a cystogram where no leakage was found. If a leakage had been found on the cystogram, the bladder should be allowed an additional week of continuous drainage. Early follow-up demonstrated a lower bladder capacity that was resolved within 6 months. After a 1-year follow-up the patient had no symptoms and demonstrated no recurrence. She is now 20 weeks pregnant with no need of assisted reproductive methods.

Conclusion: The technique showed in the video demonstrates the feasibility of a laparoscopic approach for bladder endometriosis. Furthermore, the laparoscopic approach allowed the removal of the large nodule, reducing the risk of small bladder symptoms.