Robotic Resection of Deep Infiltrating Pelvic Sidewall Endometriosis and Concomitant Nephrectomy

Abstract

Study Objective To demonstrate a surgical video wherein deep infiltrating endometriosis (DIE) was resected off the left pelvic sidewall. Design Step-by-step video demonstration of DIE resection from the external iliac vessels and the ureter. Setting Academic tertiary referral center. Patients or Participants 41-year-old female with history of endometriosis, presented with pelvic pain and left lower extremity swelling. Abdominal and pelvic imaging revealed extensive left pelvic sidewall fibrosis, resulting in compression of the external iliac vein, hydroureter and renal atrophy. Further urologic workup showed minimal to no residual function of the left kidney. Interventions Patient was taken to the operating room for resection of sidewall endometriosis and concomitant nephrectomy. Exploration of the peritoneal cavity showed that endometriosis was confined to the pelvis, heavily involving the left pelvic sidewall. The left retroperitoneum was entered and avascular spaces were elaborated. The left hydroureter and IP ligament were identified above the pelvic brim, as well as the common iliac vessels. Once proximal and distal access to the external iliac vessels were obtained, the majority of DIE was resected off the vessels. Complete resection of sidewall DIE would have led to vascular injury; therefore, the decision was made to proceed with debulking of fibrosis off the vessel surface and the remainder of the lesions inferior to the external iliac vessels. Given inability to salvage distal left ureter and non-functional kidney, concomitant left nephrectomy was performed. Measurements and Main Results The procedure and post-operative course were uncomplicated. There was significant improvement in patient's pelvic pain and lower extremity swelling. One month after surgery, she underwent balloon angioplasty and stenting of left external iliac vein to attain complete patency of the vein. Conclusion Long-standing DIE can lead to vascular compression and unsalvageable renal obstruction, which requires a multidisciplinary team approach in order to address this multisystem disease.