19: Resection of endometriotic bladder nodule causing cyclic dysuria

Abstract

To review the presentation of bladder endometriosis and highlight strategies and techniques for safe and efficient surgical resection of an endometriotic bladder nodule. Bladder endometriosis has a prevalence of 19-53% in women with deep-infiltrating endometriosis and can present with dysuria, urinary frequency, and hematuria. When conservative management of these symptoms fails, surgical resection may be necessary. Preoperative magnetic-resonance imaging is imperative for surgical planning as it best delineates the relationship of the nodule to other important anatomic structures, such as the ureters. Intraoperative ureteral stent placement further highlights the position of the ureters. Back-filling the bladder with sterile saline during the procedure defines its borders and helps avoid inadvertent damage. Development of the vesicouterine space and the space of Retzius ensures a tension-free closure of the bladder. A combined cystoscopic and laparoscopic approach is paramount to minimizing the amount of bladder tissue removed. Quick bursts of energy with an advanced bipolar device, such as the Enseal bipolar device, allows for hemostasis while minimizing thermal injury to the bladder mucosa. Closure is performed in two layers. The first layer reapproximates the bladder mucosa, and the second imbricating layer reinforces the closure and maintains a water-tight seal. Back-filling the bladder with sterile saline must be performed upon completion of the repair to confirm a water-tight closure. Conservative management of symptomatic bladder endometriosis may not be successful, and surgical resection may be required. This video presents several strategies and techniques for resection of an endometriotic bladder nodule in a safe and efficient manner, which is important given the prevalence of bladder endometriosis in women with deep-infiltrating endometriosis.