Laparoscopic Ureterolysis in the Setting of Endometriosis

Abstract

Study Objective This video presentation will review the medial and lateral approaches to ureter identification and illustrate surgical techniques to perform a laparoscopic ureterolysis in cases of endometriosis and retroperitoneal fibrosis. Design Stepwise demonstration of advanced laparoscopic surgical techniques with narrated video footage. Setting Ureteral identification is crucial in the setting of advanced endometriosis when performing a laparoscopic hysterectomy. Retroperitoneal fibrosis as a result of endometriosis can make ureterolysis challenging. Associated risks can include ureteral transection with improper identification in the retroperitoneum, unrecognized or delayed thermal injury to the ureter due to aggressive electrocautery use or incomplete resection of endometriosis surrounding the ureter. Patients or Participants Two patients with endometriosis requiring ureterolysis who underwent laparoscopic hysterectomy. Interventions Identification of the ureter and laparoscopic ureterolysis can be safely performed in the setting of endometriosis with several key strategies: 1. Use of the medial and lateral approaches to ureter identification, which may be facilitated by the placement of a preoperative ureteral stent when dense retroperitoneal fibrosis is present 2. Minimizing risk of thermal injury by use of directed blunt dissection with the “open and spread” and “hook” techniques 3. Use of reliable anatomic landmarks such as the medial umbilical ligament and development of the paravesical and pararectal spaces to aid in retroperitoneal dissection 4. Meticulous attention to hemostasis to include control of both small vessels in retroperitoneal aerolar tissue and ligation of the uterine artery at the origin to maintain adequate visualization Measurements and Main Results N/A Conclusion In patients with advanced endometriosis, ureterolysis is often necessary given extensive retroperitoneal fibrosis and inherent risk of ureteral injury. An intimate knowledge of anatomic landmarks, directed blunt and sharp dissection techniques, judicious use of cautery and careful hemostasis may allow for safe and effective completion of a laparoscopic ureterolysis in complex cases.