Stepwise demonstration with narrated video footage.
SETTING: Urinary tract
endometriosis is a rare entity occurring in 1% of women with
endometriosis and may involve the bladder and/or the ureters [1]. Bladder
endometriosis (BE) frequently coexists with
endometriosis in other locations such as the ovaries or peritoneum. Frequently seen
lower urinary tract symptoms of BE include
hematuria, frequency, and
dysuria [2]. Previous literature has demonstrated the feasibility of a laparoscopic approach to BE in the trigone. However, there has yet to be any publications investigating the feasibility of robotic resection of bladder trigone
endometriosis [3]. Cystoscopy was first performed, and the large mid-trigonal
endometriosis nodule was noted to be extending within millimeters of the ureteral orifices. Bilateral ureteral orifices were identified, and double-J ureteral
stents were sequentially guided up to the kidneys. The peritoneum lateral to the bladder bilaterally was incised to better define the edges of the bladder. Next, bilateral distal ureters were dissected out circumferentially, and the dissection was carried distally to the posterior bladder wall. Flexible cystoscopy with Firefly technology was then utilized to define the precise location and extent of the trigonal nodule to minimize removal of uninvolved bladder tissue and preserve the ureters. Using cystoscopic guidance, the dissection was first carried through the serosal and muscular layers, and once the circumference of the nodule had been clearly defined, we proceeded with the mucosal layer. The bladder lumen was entered, and the nodule was meticulously excised to avoid injury to the intramural ureters as the dissection was carried distally. We were able to preserve bilateral ureters despite the close proximity to ureteral orifices and also maintain enough bladder tissue for bladder closure. Once the resection of the trigonal nodule was completed, running 3-0 V-loc
sutures were utilized in a 2-layer closure. The patient was discharged in 1 day with a Foley
catheter and ureteral
stents with reports of minimal
pain. A cystogram
at 10 days after the surgery was negative for leak, and the Foley
catheter was removed. The ureteral
stents were subsequently removed at 6 weeks after the surgery, and follow-up renal ultrasound demonstrated no
hydronephrosis.
Tips and tricks: (1) Utilizing robotic assistance in conjunction with cystoscopy
aids the surgeon in precisely defining the boundaries of an
endometriosis nodule and ureteral identification. (2) The precise dissection permitted by
robotic-assisted surgery leads to greater tissue preservation of the bladder with complete
endometriosis resection [4-6]. (3) Three-dimensional visualization provides depth of tissue analysis, which allows the surgeon to delicately dissect several centimeters of intramural ureter in the bladder wall and trigone. (4) Cystoscopy with Firefly technology guidance permits more precise localization compared with white light during dissection of the bladder nodule [7,8]. (5) The articulating instrumentation in the robotic surgical platform enables fine suturing technique [9,10].
CONCLUSION: