Cystoscopic-guided Robotic Resection of Bladder Trigone Endometriosis Nodule with Ureteral Preservation

Abstract

To demonstrate tips and tricks for the successful execution of robotic-assisted resection of a large bladder trigone endometriosis nodule while preserving the ureters. Stepwise demonstration with narrated video footage. An academic tertiary care hospital. Our patient is a 36-year-old G0P0 with a symptomatic full-thickness ill-defined nodule located in the posterior wall and trigone of the urinary bladder with anterior cul-de-sac endometriosis. 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]. Robotic-assisted resection of bladder trigone endometriosis with cystoscopic guidance may offer a precise and delicate dissection of large bladder trigone endometriomas, thus possibly providing optimal bladder trigone and ureteral preservation.