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COMPLICATIONS
The complications of the surgical treatment of rectovaginal and bowel endometriosis may include urinary retention caused
by denervation of the bladder at the time of colorectal resection, bladder dysfunction, formation of a rectovaginal fistula,
bowel anastomotic leakage, and abscess formation.
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KEY REFERENCES
1. Chapron C, Fauconnier A, Vieira M, et al. Anatomical distribution of deeply infiltrating endometriosis: surgical implications
and proposition for a classification. Hum Reprod. 2003:18:157–161.
2. Kopelman D, King L, Nezhat C. Laparoscopic management of intestinal endometriosis. Chapter 10.4. In: Nezhat’s Video-
Assisted and Robotic-Assisted Laparoscopy and Hysteroscopy with DVD. 4th ed. Cambridge University Press, New
York, NY; 2013:303–312.
3. Remorgida V, Ferrero S, Fulcheri E, et al. Bowel endometriosis: presentation, diagnosis, and treatment. Obstet Gynecol
Surv. 2007;62(7):461–470.
4. Markham SM, Welling DR, Larsen KS, et al. Endometriosis of the rectum treated with a long-term GnRH agonist and
surgery. N Y State J Med. 1991;91:69–71.
5. Ferrero S, Camerini G, Seracchioli R, et al. Letrozole combined with norethisterone acetate compared with norethisterone
acetate alone in the treatment of pain symptoms caused by endometriosis. Hum Reprod. 2009;24:3033–3041.
6. Chapron C, Vieira M, Chopin N, et al. Accuracy of rectal endoscopic ultrasonography and magnetic resonance imaging in
the diagnosis of rectal involvement for patients presenting with deeply infiltrating endometriosis. Ultrasound Obstet
Gynecol. 2004;24:175–179.
7. Vercellini P, Crosignani PG, Abbiati A, et al. The effect of surgery for symptomatic endometriosis: the other side of the
story. Hum Reprod Update. 2009;15:177–188.
8. Nezhat C, Nezhat FR. Safe laser endoscopic excision or vaporization of peritoneal endometriosis. Fertil Steril.
1989;52(1):149–151.
9. Nezhat C, Nezhat F, Pennington E, et al. Laparoscopic disk excision and primary repair of the anterior rectal wall for the
treatment of full-thickness bowel endometriosis. Surg Endosc. 1994;8(6):682–685.
10. Nezhat F, Nezhat C, Pennington E, et al. Laparoscopic segmental resection for infiltrating endometriosis of the
rectosigmoid colon: a preliminary report. Surg Laparosc Endosc. 1992;2(3):212–216.
11. Mohr C, Nezhat FR, Nezhat CH, et al. Fertility considerations in laparoscopic treatment of Infiltrative bowel
endometriosis. JSLS. 2005; 9(1)16–24.
12. Nezhat C Nezhat F, Ambroze W, et al. Laparoscopic repair of small bowel and colon. A report of 26 cases. Surg Endosc.
1993;7:88–89.
13. Nezhat C, Nezhat F, Pennington E. Laparoscopic treatment of infiltrative rectosigmoid colon and rectovaginal septum
endometriosis by the technique of videolaparoscopy and the CO
2
laser. Br J Obstet Gynaecol. 1992;99(8):664–667.
14. Remorgida V, Ragni N, Ferrero S, et al. The involvement of the interstitial Cajal cells and the enteric nervous system in
bowel endometriosis. Hum Reprod. 2005;20(1):264–271.
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Chapter 6.4
Excision of Endometriosis: Segmental Bladder Resection
Azade h Nezhat, Cam ran Nezhat
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GENERAL PRINCIPLES
Definition
The genitourinary system is involved in about 1% to 2% of endometriosis cases.
1
The bladder is most commonly involved,
followed by ureter and kidney, with a ratio of 40:5:1 or with the respective prevalence of 85%, 10%, and 4%.
2,3
Symptoms of bladder endometriosis include suprapubic pressure, dysuria, urgency, frequency, and hematuria. These are
often, but not always, concurrent with menstruation.
Bladder endometriosis may be extrinsic, involving the bladder serosa, or intrinsic, involving the detrusor muscle. Intrinsic
disease is far more likely to be symptomatic.
Fifty percent of patients with bladder endometriosis will have a tender anterior vaginal wall and palpable pelvic mass on
physical exam. Ninety percent will have an abnormal cystoscopy with endometriotic lesions, visible within the bladder
mucosa.
4,5
The combined cystoscopic and laparoscopic approach is needed for definitive surgical resection.
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Differential Diagnosis
Urinary tract infection, interstitial cystitis, and bladder malignances should be ruled out.
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Nonoperative Management
Treatment of genitourinary endometriosis depends in part on the extent of disease, both within the genitourinary system and
in other locations, as well as future fertility desires of the patient.
Medical management includes oral contraceptive pills (OCPs), progestins, danazol, and gonadotropin-releasing hormone
(GnRH) therapy.
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IMAGING AND OTHER DIAGNOSTICS
Bladder lesions may also sometimes be seen on ultrasound, magnetic resonance imaging (MRI), or as a filling defect on a
cystogram.
Cystoscopically, bladder lesions appear as solitary submucosal lesions that are slightly raised with surrounding mucosal
edema in the absence of concomitant cystitis or infection.
Transurethral biopsy or resection may be inadequate for histologic diagnosis because of the submucosal nature of the lesion.
Extravesically, the lesion can be identified by laparoscopy and direct biopsy.
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SURGICAL MANAGEMENT
Surgical management is preferred in intrinsic disease of the bladder, due to high rate of recurrence with medical
management.
6–8
Shaving off the endometriotic lesion extending to the muscularis but without mucosal involvement can be treated
laparoscopically, and any residual or deeper lesions may be treated successfully with postoperative hormone therapy.
9
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Positioning
The patient is in the dorsal lithotomy position with access to the perineum and vagina. The thighs are not flexed so that the
suprapubic and lateral trocars may be maneuvered. Nasogastric tube is placed before procedure. Proper alignment of head
and neck is crucial. The location of fingers, toes, face, and chest should be observed for any unintentional pressure. The
blood pressure cuff is then placed on the right arm and placed high enough that it is away from the ulnar nerve. The eyes
are covered with tape, in order to avoid any corneal abrasions. When securing the arm, ensure the oxygen saturation probe
is free and able to be moved, should there be a need. The arm is secure and the fingers are visualized. The fingers should
always be visible when positioning the patient on the bed. The buttocks are hanging 2 to 3 in. off the table. A warming
blanket device may be placed just beneath the breast line.
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Procedures and Techniques (Video 6.4.1 )
This procedure requires an umbilical incision to accommodate the video camera and laser laparoscope, in addition to three
accessory trocars (two lateral 5-mm trocars and one 5-mm suprapubic trocar).
Bilateral ureteral stents are placed.
The bladder is mobilized superiorly with monopolar cautery and careful dissection. Extensive dissection is required to
develop the vesicovaginal space.
Cystotomy is performed under concurrent laparoscopic and cystoscopy visualization, in close proximity to the lesion.
The lesion is carefully everted. The lesion is excised sharply to prevent compromise of blood supply and facilitate healing.
The ureteral stents are visualized and the lesion is excised in it entirely with good margins.
The cystotomy is closed with full thickness V-lock sutures in running fashion, the efficacy of which has recently been
demonstrated in the urologic literature.
10,11
Upon closure, the cystoscopy is again performed, ensuring bladder wall integrity and lack of ureteral compromise.
A portion of the omentum is brought down over the bladder incisions to prevent fistula formation.
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