Excision of Vesicoureteral Junction Endometriosis With Ureteroneocystostomy: Tenets of Surgical Management

Objective: To demonstrate laparoscopic excision of complex urinary tract endometriosis. Design: Narrated surgical video. Setting: Endometriosis of the urinary tract affects 0.3% to 12% of patients with endometriosis [1]. Bladder endometriosis may present with symptoms similar to cystitis, whereas ureteral endometriosis is often asymptomatic and detected incidentally by ureteral obstruction causing hydroureter or compromise of kidney function [2]. Although most cases of ureteral endometriosis are extrinsic and resolved with ureterolysis, intrinsic ureteral endometriosis must be excised entirely to address the underlying cause of stricture [3]. Interventions: We present a 30-year-old G1P0 evaluated in the emergency department for left lower quadrant pain and found on magnetic resonance imaging to have left hydronephrosis with a large nodule invading the bladder at the left ureterovesical junction. After surgical planning with urology and gynecology, the patient underwent laparoscopic excision of bladder endometriosis with left ureterolysis and resection and reimplantation of the left ureter via ureteroneocystostomy. This video highlights: 1. Retroperitoneal dissection with left ureterolysis and development of the paravesical and pararectal avascular spaces to find critical structures (see Figure 1) 2. Temporary ligation of the anterior internal iliac artery to prevent bleeding given marked fibrosis with distortion of anatomy 3. Squeeze technique to palpate the borders of endometriosis and excise the nodule (see Figure 2) 4. Ureteral resection and repair of cystotomy 5. Development of the vesicovaginal space and space of Retzius to increase bladder mobility 6. Reimplantation of the ureter (see Figure 3) After surgery, pathology confirmed endometriosis and the patient recovered well. Conclusion: This video reviews the surgical management of a complicated case of deep infiltrating endometriosis affecting both the bladder and ureter. Successful excision depends on careful multidisciplinary planning, awareness of key anatomic structures, strategies to minimize blood loss, and a proactive approach to protecting the site of repair. Journal of Minimally Invasive Gynecology (2024) 31, 14-16. (c) 2023 AAGL. All rights reserved.