Laparoscopic Nerve Sparing Technique for Bladder Endometriosis Infiltrating the Anterior Parametrium

Abstract

Study Objective The purpose of this video is to demonstrate the Nerve Sparing (NS) technique for resection of infiltrating endometriosis on the upper part of the trigone, which extends to the left anterior parametric (deep portion of the vesicouterine ligament). Design The NS technique for resection of an endometriotic lesion infiltrating the anterior parametrium aims at preserving the anterior efferent bundles (vesical nerve), which transmit the parasympathetic stimuli for the contraction of the detrusor muscle (motor nerve). Setting Cystoscopy was used to determine the exact location of the lesion in relation to the trigone and ureteral openings. The laparoscopic procedure was performed with a 3D camera. Patients or Participants A 38-year-old patient presented with cyclic urinary pain. MRI showed a 3.0 cm endometriotic lesion located on the upper part of the trigone, close to the ureteral opening and extending to the deep portion of the vesicouterine ligament. The lesion was palpable upon vaginal touch. Interventions The vesicocervical and vesicovaginal spaces were dissected and the endometriotic lesion was individualized. The left vesicouterine ligament was isolated and the structures were individualized. The vesical arteries (superior, middle and inferior) were dissected and the first two were sectioned. The uterine artery and the ureter were individualized and isolated through dissection and sectioning of the intraligamentous connective tissue, thus, separating them from the infiltrative lesion. The lesion was removed and the bladder was sutured. The left anterior efferent bundles, coming from the inferior hypogastric plexus and originating from S2-S3-S4 (Pelvic Splancnic Nerves), were identified and preserved. Measurements and Main Results There were no intraoperative complications. After 1 year the patient remains asymptomatic. MRI in the 3rd postoperative month showed absence of endometriotic lesion. Conclusion The Laparoscopic Nerve Sparing technique is safe and effective to treat bladder endometriosis infiltrating the anterior parametrium.