7489 Conjunction of Cystoscopy and Robotic-Assisted Bladder Trigone Endometriosis Nodule Removal with Ureteral Preservation

Abstract

<h3>Study Objective</h3> Demonstrate tips for successful execution of robotic-assisted resection of large bladder trigone endometriosis nodule while preserving the ureters. <h3>Design</h3> Stepwise demonstration with narrated video footage. <h3>Setting</h3> An academic-tertiary-care hospital. <h3>Patients or Participants</h3> 36-year-old G0 with symptomatic full-thickness ill-defined nodule located in the posterior wall and trigone of the urinary bladder with anterior cul-de-sac endometriosis. <h3>Interventions</h3> Cystoscopy was first performed, and 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 robotic instruments were docked, and inspection of the pelvic space conducted. The peritoneum lateral to the bladder bilaterally was incised to better define the edges of the bladder. Bilateral distal ureters were dissected out circumferentially and the dissection was carried distally. Flexible cystoscopy with Firefly technology was then utilized to define precise location and extent of the trigonal nodule in effort to minimize removal of uninvolved bladder tissue and preserve ureters. Using cystoscopic-guidance, the dissection was first carried through the serosal and muscular layers, and once the circumference of the nodule had been defined, we proceeded with the mucosal layer. The bladder lumen was entered, and the nodule meticulously excised to avoid injury to the intramural ureters as the dissection was carried distally. Bilateral ureters were preserved despite the close proximity to ureteral orifices and also maintain enough bladder tissue for bladder closure. Once resection was completed, running 3-0 V-loc sutures were utilized in 2-layer closure. <h3>Measurements and Main Results</h3> Patient was discharged in one-day with Foley catheter and ureteral stents with minimal pain. Cystogram at 10 days postop was negative for leak and Foley catheter was removed. <h3>Conclusion</h3> Robotic-assisted resection of bladder trigone endometriosis with cystoscopic guidance offers the most precise and delicate dissection of large bladder trigone endometriosis nodules, thus providing optimal bladder trigone and ureteral preservation.