Combined Cystoscopic-Abdominal Versus Abdominal-Only Route for Complete Excision of Large Deep Endometriosis Nodules Infiltrating the Supratrigonal Area of the Bladder: A Comparative Study.

STUDY OBJECTIVE: Surgical excision of large deep endometriosis nodules infiltrating the bladder may be challenging, particularly when the nodule limits are close to the trigone and ureteral orifice. Bladder nodules have classically been approached abdominally. However, combining a cystoscopic with an abdominal approach may help to better identify the mucosal borders of the lesion to ensure complete excision without unnecessary resection of healthy bladder. This study aimed to compare classical excision of large bladder nodules by abdominal route with a combined cystoscopic-abdominal approach. DESIGN: Retrospective comparative study on data prospectively recorded in a database. Patients were managed from September 2009 to June 2022. SETTING: Two tertiary referral endometriosis centers. PATIENTS: A total of 175 patients with deep endometriosis infiltrating the bladder more than 2 cm undergoing surgical excision of bladder nodules. INTERVENTIONS: Excision of bladder nodules by either abdominal or combined cystoscopic-abdominal approaches. MEASUREMENTS AND MAIN RESULTS: A total of 141 women (80.6%) were managed by abdominal route and 34 women (19.4%) underwent a combined cystoscopic-abdominal approach. In 99.4% of patients, the approach was minimally invasive. Patients with nodules requiring the combined approach had a lower American Fertility Society revised score and endometriosis stage and less associated digestive tract nodules, but larger bladder nodules. They were less frequently associated with colorectal resection and preventive stoma. Operative time was comparable. The rate of early postoperative complications was comparable (8.8% vs 22%), as were the rates of ureteral fistula (2.2% vs 2.9%), bladder fistula (2.2% vs 0), and vesicovaginal fistula (0.7% vs 2.9%). CONCLUSION: In our opinion, the combined cystoscopic-abdominal approach is useful in patients with large bladder nodules with limits close to the trigone and ureteral orifice. These large deep bladder nodules seemed paradoxically associated to less nodules on the digestive tract, resulting in an overall comparable total operative time and complication rate.

Surgical Outcomes of Urinary Tract Deep Infiltrating Endometriosis.

OBJECTIVE: To report the outcomes of surgical management of urinary tract endometriosis. DESIGN: Retrospective study based on prospectively recorded data (NCT02294825) (Canadian Task Force classification II-3). SETTING: University tertiary referral center. PATIENTS: Eighty-one women treated for urinary tract endometriosis between July 2009 and December 2015 were included, including 39 with bladder endometriosis, 31 with ureteral endometriosis, and 11 with both ureteral and bladder endometriosis. Owing to bilateral ureteral localization in 8 women, 50 different ureteral procedures were recorded. INTERVENTION: Procedures performed included resection of bladder endometriosis nodules, advanced ureterolysis, ureteral resection followed by end-to-end anastomosis, and ureteroneocystostomy. MEASUREMENTS AND MAIN RESULTS: The main outcome measure was the outcome of the surgical management of urinary tract endometriosis. Fifty women presented with deep infiltrating endometriosis (DIE) of the bladder and underwent either full-thickness excision of the nodule (70%) or excision of the bladder wall without opening of the bladder (30%). Ureteral lesions were treated by ureterolysis in 78% of the patients and by primary segmental resection in 22%. No patient required nephrectomy. Histological analysis revealed intrinsic ureteral endometriosis in 54.5% of cases. Clavien-Dindo grade III complications were present in 16% of the patients who underwent surgery for ureteral nodules and in 8% of those who underwent surgery for bladder endometriosis. Overall delayed postoperative outcomes were favorable regarding urinary symptoms and fertility. Patients were followed up for a minimum of 12 months and a maximum of 7 years postoperatively, with no recorded recurrences. CONCLUSION: Surgical outcomes of urinary tract endometriosis are generally satisfactory; however, the risk of postoperative complications should be taken into consideration. Therefore, all such procedures should be managed by an experienced multidisciplinary team.

Combined cystoscopic and laparoscopic approach in deep endometriosis of the bladder.

STUDY OBJECTIVE: To report the combined cystoscopic and laparoscopic approach in deep endometriosis with full-thickness infiltration of the bladder. DESIGN: Video (Canadian Task Force classification III). SETTING: University hospital. PATIENT: A 34-year-old nulliparous woman with a large (35-mm) endometriosis nodule infiltrating the bladder and deep endometriosis of the rectum and sigmoid colon. INTERVENTION: The urologic surgeon performed cystoscopy, identified the limits of mucosal involvement, and incised the muscular layer up to fat tissues surrounding the bladder. The gynecologic surgeon identified and followed the circular incision, and completed full-thickness resection of the bladder wall. Surgical technique reports in anonymous patients are exempt from ethical approval by the institutional review board. MEASUREMENTS AND MAIN RESULTS: The patient's functional outcome was uneventful. Laparoscopic resection of large endometriotic nodules of the bladder per se may lead to inadvertent removal of healthy bladder muscle. Thus it increases the risk of postoperative complications and symptoms due to small bladder volume. Conversely, if resection of the nodule is performed only cystoscopically, it probably would not be completely removed. We routinely combine the 2 approaches because this enables complete resection of the endometriotic nodule. It not only averts the risk of excessive removal of healthy bladder muscle but also leaves no disease behind. CONCLUSIONS: On the basis of our experience, we propose the combined cystoscopic and laparoscopic approach in managing large endometriotic nodules with full-thickness infiltration of the bladder.

[A rare entity: cystadenoma of the prostate]. / Une entité rare: le cystadénome de prostate.

The authors report the case of a 40-year-old man with cystadenoma of the prostate. This rare disease is difficult to diagnose despite a complete radiological assessment (transrectal and bladder ultrasound and MRI of pelvis). Only histological examination of the operative specimen demonstrated absence of malignancy. However, follow-up is required in view of the risk of recurrence of this prostatic lesion.