Laparoscopic Ureteroneocystotomy for Severe Endometriosis: Challenging Case of Dual Distant Lesions скачать в хорошем качестве

Laparoscopic Ureteroneocystotomy for Severe Endometriosis: Challenging Case of Dual Distant Lesions

This video from the minimally invasive gynaecologic surgery team at Laval University demonstrates a laparoscopic ureteroneocystostomy for severe endometriosis, highlighting a challenging case of dual distant lesions. Urinary tract endometriosis is common among women with deep disease, most often affecting the bladder, while the ureter is involved in about 10% of cases. The team follows a previously described six-step approach for managing ureteric endometriosis. First, normal pelvic anatomy is restored. Ureterolysis is then performed to expose the diseased segment. In this case, a large endometriotic nodule involved the ureterovesical junction and penetrated the bladder transmurally to the mucosa. The nodule affecting the distal ureter and bladder is excised, and the cystotomy is repaired with a two-layer, watertight closure. The bladder and ureter are mobilised to allow ureteric re-implantation. A new double-J stent is placed, the ureter is spatulated, and a new incision is made in the dome of the bladder. Ureteroneocystostomy is completed with a double-layer, watertight closure, and an epiploic flap is placed between the vaginal vault and the bladder. The patient is a 35-year-old woman with known endometriosis who desired fertility. She presented with severe pain and was diagnosed with an infected endometrioma. Imaging revealed a large bladder nodule and a left ureteric nodule causing hydronephrosis. The team adapted their stepwise approach to this complex case. The procedure begins with cystoscopy and injection of indocyanine green into the ureters. Laparoscopically, pelvic anatomy is restored and adhesions are lysed. Ureterolysis follows, with ICG fluorescence used to trace the ureter where disease obscures landmarks. The ureteric nodule is excised using cold Metzenbaum scissors, again guided by ICG. The bladder is mobilised, a challenging step because the large bladder nodule is adherent to the uterus. The ureter is mobilised, clipped at its insertion, and freed along its length. The bladder nodule is then excised. Cystotomy repair begins at the medial end with a running suture. The diseased distal ureter is excised, the ureter is spatulated, and re-implantation is performed into the lateral portion of the cystotomy. A double-J stent is inserted laparoscopically into the ureter and bladder. The re-implantation is secured and a second imbricating layer is added for a watertight closure. Postoperatively, the patient recovered well. The Foley catheter remained for four weeks because a small leak persisted on a two-week voiding cystogram. The double-J stent was removed after seven weeks. She continued medical suppressive therapy in preparation for IVF. This case demonstrates the complexity of treating dual, separate lesions with the uterus in situ, which makes ureteric implantation more challenging. It also illustrates an original method of using the lateral portion of the cystotomy for ureteric re-implantation.