2934 Minimally Invasive Treatment of Bladder Deep Endometriosis and Isthmocele

Abstract

Video Objective To demonstrate the endoscopic management of bladder endometriosis and isthmocele. Setting Bladder endometriosis, defined by the presence of detrusor muscle layer invasion, affect around 1%-2% of womens. In nowadays, laparoscopic partial cystectomy is the gold standard surgical treatment. By other hand, the isthmocele is a defect of the anterior wall of the cervical canal at the site of the previous C-section, and affect around 0.6% of women's. It will be symptomatic in about 30% of the cases with AUB as the main presentation. Laparoscopic treatment report between 59%-90% of symptom control, and will be choose when overlying myometrial mantle is less than 3mm and/or 50% of total myometrial thickness. Due the invasive nature of endometriosis, added to the inflammatory response following the c-section heal, it is not surprising that both pathologies could be anatomically closer. A 37 years old patient, with clinical history of dysuria, cyclic hematuria and post-menstrual spotting. Ultrasound evidence a 29 millimeter hypo-echogenic nodule at the bladder dome plus a 12mm isthmocele, with overlying miometrial mantle of 7mm. Interventions Hysteroscopic isthmoplasty was done using a mini-resectoscope including the treatment of both caudal and cranial edges and resection of all the diverticular mucosal hyperplasia. Posteriorly, laparoscopic partial cystectomy was done. Under general anesthesia, the patient was placed in 0 degrees dorsal decubitus with her arms alongside her body. Operative set-up include 15mmhg pneumoperitoneum and four trocars: a 10mm trocar at the umbilicus for a zero-degree laparoscope; a 5mm trocar in the right and left iliac fossa; and a 12mm trocar in the suprapubic area. Using mechanical, electrical and ultrasonic energy, partial cystectomy followed by two layer closure was done. During final chromotubation, massive leakage was noted coming from the isthmic area. Complementary laparoscopic resection and closure was done. Histopathological result show no cleavage plane between isthmus area and bladder endometriosis tissue. Conclusion Full endoscopic treatment of bladder endometriosis and Isthmocele is feasible, safe and effective in experienced hands. In this patient, procedure was uneventful, without any intra or pos-operative complications.