Surgical Evaluation and Management of Concomitant Anterior and Posterior Deep Infiltrating Endometriosis

Abstract

Study Objective The objective of this video is to present the evaluation and management of a patient who presents with concomitant anterior and posterior compartment deep infiltrating endometriosis. Design Surgical Video. Setting The operating room. Patients or Participants We present the case of a 34-year-old G0 female who was referred for evaluation and management of biopsy proven bladder endometriosis. The patient reported a long-standing history of chronic pelvic pain, dyspareunia, dysmenorrhea, cyclic hematuria and cyclic dyschezia as well. Of note, she had failed 2 IVF cycles. On pelvic examination, the patient was noted to have a fixed uterus with a scarred posterior cul-de-sac with significant nodularity. Although the patient had known bladder endometriosis, her history and physical exam findings were suggestive of possible rectosigmoid involvement as well. The patient then underwent further evaluation with imaging including a transvaginal ultrasound and pelvic MRI. The transvaginal ultrasound demonstrated hypoechoic nodules in the anterior and posterior compartments, highly suggestive of deep infiltrating endometriosis. The MRI demonstrated anterior compartment disease transmurally invading the urinary bladder as well as posterior disease as well. Given these findings, the patient underwent preoperative planning with a multidisciplinary team including Gynecologic surgery, Urology, and Colorectal surgery. Interventions Definitive surgical management. Measurements and Main Results The patient underwent a cystoscopy, bilateral ureteric stenting, cystectomy, and excision of endometriosis. In the post operative period, the patient underwent a retrograde cystogram which demonstrated no leakage at the site of repair. Her symptoms improved significantly and she is now attempting to conceive. Conclusion A thorough pre-operative evaluation of patients with deep infiltrating endometriosis is of utmost importance. Although the patient was referred for bladder endometriosis, she was incidentally found to have significant posterior compartment disease. As a result, she underwent surgical planning with a multidisciplinary team, which ultimately allowed for the best patient outcome. The objective of this video is to present the evaluation and management of a patient who presents with concomitant anterior and posterior compartment deep infiltrating endometriosis. Surgical Video. The operating room. We present the case of a 34-year-old G0 female who was referred for evaluation and management of biopsy proven bladder endometriosis. The patient reported a long-standing history of chronic pelvic pain, dyspareunia, dysmenorrhea, cyclic hematuria and cyclic dyschezia as well. Of note, she had failed 2 IVF cycles. On pelvic examination, the patient was noted to have a fixed uterus with a scarred posterior cul-de-sac with significant nodularity. Although the patient had known bladder endometriosis, her history and physical exam findings were suggestive of possible rectosigmoid involvement as well. The patient then underwent further evaluation with imaging including a transvaginal ultrasound and pelvic MRI. The transvaginal ultrasound demonstrated hypoechoic nodules in the anterior and posterior compartments, highly suggestive of deep infiltrating endometriosis. The MRI demonstrated anterior compartment disease transmurally invading the urinary bladder as well as posterior disease as well. Given these findings, the patient underwent preoperative planning with a multidisciplinary team including Gynecologic surgery, Urology, and Colorectal surgery. Definitive surgical management. The patient underwent a cystoscopy, bilateral ureteric stenting, cystectomy, and excision of endometriosis. In the post operative period, the patient underwent a retrograde cystogram which demonstrated no leakage at the site of repair. Her symptoms improved significantly and she is now attempting to conceive. A thorough pre-operative evaluation of patients with deep infiltrating endometriosis is of utmost importance. Although the patient was referred for bladder endometriosis, she was incidentally found to have significant posterior compartment disease. As a result, she underwent surgical planning with a multidisciplinary team, which ultimately allowed for the best patient outcome.