Robotic-Assisted Laparoscopic Excision of Deep Infiltrating Endometriosis with Concomitant Left Ureteroneocystostomy

Abstract

<h3>Study Objective</h3> To describe the surgical techniques employed to effectively excise deep infiltrating endometriosis involving the ureters and to highlight the successful re-implantation of the left ureter. <h3>Design</h3> Video presentation. <h3>Setting</h3> Academic tertiary care center. <h3>Patients or Participants</h3> This is the case of a 45-year-old G1P1001 patient with a history of chronic pelvic pain and endometriosis. She underwent previous exploratory laparotomy due to endometriosis. Her symptoms however recurred and worsened to the point where she started experiencing left flank pain. A CT scan revealed moderate left hydroureteronephrosis to the level of the left adnexa. MRI findings confirmed the left ureter to be encased by pelvic endometriosis causing significant extrinsic compression. <h3>Interventions</h3> Intra-operatively, deep infiltrating endometriosis was noted involving the posterior cul-de-sac, bilateral uterosacral ligaments, with retroperitoneal fibrosis involving bilateral ureters. Retroperitoneal dissection was performed using a medial approach thus identifying the ureters bilaterally. Careful and extensive dissection was then carried out, excising the fibrotic endometriotic nodule from the ureters. The left hydroureter was transected at its most distal and narrowed portion by the urology team. The proximal end for re-implantation was then spatulated. The bladder was mobilized, and a tension free re-implantation was successfully completed after placing a double pig-tail stent in a retrograde fashion. A water-tight re-anastomosis was confirmed. <h3>Measurements and Main Results</h3> The patient recovered well from her procedure and had significant improvement in her pain symptoms when she was reviewed at her postoperative visit. <h3>Conclusion</h3> Despite its incessant, recalcitrant nature, endometriosis affecting the ureters can be effectively resected. Laparoscopic ureteroneocystostomy for ureteral endometriosis is safe, feasible, and can achieve good surgical outcomes leading to effective control of patient's symptoms as was noted in this case.