Robotic Approach to Ectopic Endometriosis in a Patient with Duplicated Ureters

Abstract

<h3>Study Objective</h3> To demonstrate a minimally invasive approach to excision of ectopic urinary tract endometriosis in a patient with an anomalous duplicated left renal collecting system. <h3>Design</h3> Case report surgical video. <h3>Setting</h3> Single center academic institution. <h3>Patients or Participants</h3> A 45-year-old female with a history of endometriosis with prior robotic hysterectomy and left salpingo-oophorectomy presented with worsening urge incontinence, flank and pelvic pain. Patient was referred after evaluation revealed a mass adjacent to the left ureterovaginal junction and bladder trigone. <h3>Interventions</h3> Initial cystoscopy revealed a left non-intrusive bladder mass near the left ureteral orifices. A 2 cm firm, fixed nodule in the left fornix of the vagina was excised. Endometriosis was confirmed on frozen section. Upon laparoscopic entry, anatomy was noted to be distorted due to extensive scarring in the left pelvic sidewall including the vaginal cuff and bladder. The posterior cul-de-sac, pararectal, and paravesical spaces were then dissected open, allowing for visualization of the intersigmoid recess and the double ureters encased in scar tissue. After creating two small windows to open the peritoneum, continued dissection proceeded laterally along the pelvic sidewall. En bloc endometriosis was noted on the left infundibulopelvic ligament, vaginal cuff, bladder, and ureters. The scarred peritoneum was excised by encircling the affected areas. Concomitant ureteral dissection ensued with simultaneous removal of endometriotic nodules at the vaginal cuff and ureterovaginal junction. The patient then had an uncomplicated right salpingo-oophorectomy. <h3>Measurements and Main Results</h3> The patient was discharged home on postoperative day one and had an overall uncomplicated postoperative course. Final pathology was consistent with endometriosis. At her post-operative appointment, the patient experienced complete resolution of her symptoms. <h3>Conclusion</h3> In a patient with a known history of endometriosis and a newfound bladder mass, ectopic endometriosis should be considered. Robotic surgical excision is an appropriate minimally invasive approach after adequate preparation.