Bladder endometriosis with trigone involvement: tips 'n tricks

This video demonstrates a partial cystectomy technique in a 26-year-old patient with a symptomatic bladder endometriotic nodule, localized proximal to the ureteral ostia. It is complemented with previous, intraoperative and six-week postoperative cystoscopies.

Create account

Browse the WORLD

Virtual University

Google translate

Summary
Chapters
Your comments
Ask the Experts

You need to log in to watch this media!

Click here to log in.

Bladder endometriosis with trigone involvement: tips 'n tricks

Authors

AM Furtado Lima, P Trompoukis, J Nassif, B Gabriel, A Wattiez

Abstract

This video demonstrates a partial cystectomy technique in a 26-year-old patient with a symptomatic bladder endometriotic nodule, localized proximal to the ureteral ostia. It is complemented with previous, intraoperative and six-week postoperative cystoscopies.

Classification

tips and tricks

Media type

Surgical video

Duration

08'20''

Publication

2011-02

Popular

Favorites

Favorites Media

Audio

Subtitles

E-publication

WeBSurg.com, Feb 2011;11(02).
URL: http://www.websurg.com/doi-vd01en2997.htm

Bladder endometriosis with trigone involvement: tips 'n tricks

1. Introduction 00'10''

This is the case of a 26-year-old patient, with primary infertility, dysmenorrhea, dyspareunia, dysuria and dyschezia. MRI shows an endometriotic nodule localized in the bladder, described to be of approximately 2cm in diameter. UroMRI shows integrity of the ureters, with no dilatation. As the endometriotic lesion is close to the inter-ureteric ridge, the surgery must be planned accordingly, using double J catheters.

2. Cystoscopy - positioning of double J catheters 00'56''

This endometriotic nodule is located in the bladder base, or fundus, and not in the apex of the bladder, which makes this surgery more challenging.

3. Surgical dissection 01'06''

The procedure is started with the adhesiolysis between the anterior uterine wall and the vesicouterine fold of the peritoneum. The vesicouterine space is dissected under the inferior limit of Deep Infiltrative Endometriosis (DIE).

4. Nodule resection 01'52''

The disease is surrounded using a monopolar hook. It is important not to go too low because interfering with trigone can cause bladder instability. The nodule is suspended by the assistant. The surgeon tries to identify the limit between healthy soft tissue and the fibrotic tissue. The opening of the bladder is determinant to guide the excision of the nodule. The urine collecting bag becomes inflated as the air escapes from the bladder opening. In this case, a 4.5 x 2.5 x 2cm nodule is excised with proved histological endometriosis. The bladder mucosa is not involved. The removal of the nodule has to be as radical as possible leaving the healthy tissue behind.

5. Closure of the defect - bladder suturing 04'27''

There are many different ways of suturing the bladder defect: after the ureters have been identified and the bladder mucosa has been examined again, the bladder is closed with several interrupted or continuous, intracorporeal or extracorporeal knots or in one or two layers. The suture must be adapted to the defect. In this case, the surgeon uses a 3/0 monocryl. Six separate stitches are placed longitudinally to gain some distance from the ureteral orifices. Separate stitches are used to start the transverse closure and to reduce tension between the two walls of the bladder. The left aspect is closed with a continuous suture. Once the cystotomy has been closed, the bladder is tested for leaks with retrograde filling. In this case, a cystoscopy is simultaneously performed. The suture is reinforced in the left angle with an extracorporeal knot. The right aspect is then sutured with separate stitches, tailoring the technique to the needs. In this stage, any leakage can be corrected. It is important to balance between a small leakage and over suturing with the risk of affecting the ureters.

6. Cystoscopy 07'32''

Here the cystoscopy and the proximity of the ureteral meata can be seen. The patient is discharged with a vesical catheter and double J catheters as well.

7. Follow-up 07'43''

Four weeks later, the Foley catheter is removed after the exclusion of leakage with a retrograde cystography, which confirmed a good compliance with contrast, without wall anomalies.

8. Outcome-end 07'56''

Double J catheters were removed six weeks after the surgical procedure, under cystoscopic control. The patient recovered completely and got pregnant after a cycle of assisted reproduction.