Introduction
Deeply infiltrating endometriosis (DIE) is a highly invasive form of endometriosis which is defined arbitrarily as endometriosis infiltrating the peritoneum by more than 5mm. When this disease affects the bladder, the endometriotic lesion infiltrates the detrusor muscle to partial or full thickness. When medical therapy for such a lesion is declined or fails, surgical excision is the most effective management option.
We present a case series and surgical video of a combined laparoscopic and cystoscopic excision of deeply infiltrating endometriosis of the bladder.
Methods
A case series of all patients undergoing combined laparoscopic and cystoscopic excision of bladder DIE in a single tertiary centre over a 5-year period. Information documented included patient demographic data, symptomatology, operative details, length of admission and intra- and post-operative complications.
A representative surgical video was recorded of a patient undergoing combined laparoscopic and cystoscopic excision of an endometriotic bladder nodule.
Case Description:Surgical Video
A 36 year-old, P0 presented with a 12-month history of sudden onset cyclical dysuria and haematuria, on a background of longstanding dysmenorrhea.
Tertiary level transvaginal-ultrasound scan demonstrated adenomyosis, tethered ovaries, and a 25mm endometriotic bladder nodule extending through the bladder wall. Concurrent MRI demonstrated a 25mm heterogeneous mass postero-superiorly within the urinary bladder. The upper renal tracts were normal.
The patient declined medical management and elected to undergo surgical management as first line therapy. Following detailed consent, she underwent combined laparoscopic and cystoscopic excision of the bladder nodule. A urologist outlined the lesion cystoscopically and the gynaecologist excised it laparoscopically and then sutured the defect laparoscopically. The procedure and post-operative course were uneventful. On post-operative review at 8 weeks, the patient described complete resolution of urinary symptoms. Histopathological analysis of the excised specimen confirmed endometriosis.
[A surgical video demonstrating the procedure will be embedded into the final presentation, along with a detailed discussion of the method used].
Results
Six patients underwent combined laparoscopic and cystoscopic excision of deeply infiltrating bladder endometriosis during the study period. All patients underwent pre-operative tertiary-level pelvic ultrasound scan and MRI, and imaging findings correlated closely with intra-operative findings. Average length of post-operative stay was 3 days. There were no intra operative complications and 4 post-operative complications, all urinary tract infections. All patients described complete resolution of urinary symptoms at post-operative review.
Conclusion
We conclude that laparoscopic and cystoscopic partial cystectomy for excision of deeply infiltrating bladder endometriosis is a safe and feasible procedure within our institution.