LAUSR

OBJECTIVE To demonstrate how to treat bladder and ureteral deep pelvic endometriosis using a laparoscopic approach with partial cystectomy and resection and end-to-end anastomosis of the ureter. DESIGN A step-by-step explanation of the surgery using video, approved by the local Institutional Review Board. SETTING University Hospital of Strasbourg, France. A 27-year-old nulliparous woman with severe endometriosis stage 4 (AFS-R score >40) of the bladder and left ureter. On pelvic MRI, we found left uretero-hydronephrosis induced by a 17mm endometriosis nodule. A JJ probe was placed on the left ureter before the surgery because of the dilatation of the ureter and the decreased of renal function. INTERVENTIONS During the exploration, we found an abdominal cavity free of adhesion. There was an endometriosis implant in the bladder in front of the uterus and a large nodule of the left uterosacral ligament that was compressing the ureter. In the first step, we made a section of the round ligament, to perform anterior ureterolysis and progressive dissection of the nodule surrounding the ureter. Once the nodule was resected, a tight stenosis was observed at about 1 cm from the bladder. The vesico-uterine and the vesico-vaginal spaces were then dissected to pass under the nodule to the vagina. We opened the dome of the bladder with the thunderbeatTM (Olympus) and dissected the bladder to remove the transfixing nodule while staying away from the ureters. The closure of the bladder was performed by 2 lateral sutures and by a running suture of braided suture (V-LocTM) 2-0 with a good tightness checked by a blue test. Ureteral resection was performed around the JJ probe in place to remove the stenotic zone, then we performed a end-to-end anastomosis of the ureter by 4 sutures of monofilament (MonocrylTM) 4 -0 with a good anatomical result. Finally an omentoplasty was fixed around the ureter by 2-0 monofilament suture (MonocrylTM). Post operative course was uneventful. Foley catheter was let in place 10 days and JJ probe was removed 6 weeks later. Operative time was 140 minutes. The step-by-step explanation technique was simple with minimal operative difficulty and low rate of morbidity. CONCLUSION This video shows how deep urinary endometriosis can be performed laparoscopically. Mastering suturing is essential to avoid complications.