Table of Contents
- Procedure Summary
- Authors
- Youtube Video
- What is Laparoscopic Ureteroneocystotomy for Severe Endometriosis?
- What are the Risks of Laparoscopic Ureteroneocystotomy for Severe Endometriosis?
- Video Transcript
Video Description
Explore a complex laparoscopic ureteroneocystotomy for severe endometriosis involving dual distant ureteral lesions, with detailed steps for safe reconstruction.
Presented By
Affiliations
CHU de Québec Université Laval
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What is Laparoscopic Ureteroneocystotomy for Severe Endometriosis?
Laparoscopic ureteroneocystotomy for severe endometriosis is a complex reconstructive procedure performed when deep infiltrating endometriosis causes obstruction or destruction of the distal ureter. Here’s what it involves:
- Restoration of Pelvic Anatomy: Adhesions are released and normal pelvic landmarks are identified to expose the ureter and bladder.
- Ureterolysis and Disease Excision: The diseased ureter is carefully dissected free and the endometriotic nodule involving the distal ureter and bladder is excised.
- Bladder Mobilization: The bladder is mobilized to create a tension-free site for ureteric re-implantation.
- Cystotomy and Resection: A cystotomy is performed and the diseased ureteric segment is removed.
- Ureteric Re-implantation: The healthy ureter is spatulated and re-implanted into a new opening in the bladder, secured with a double-layer, watertight closure.
- Stent Placement and Protection: A double J stent is placed to maintain ureteral patency and an epiploic flap or peritoneal layer may be interposed to protect the repair.
This stepwise laparoscopic approach allows complete excision of disease while preserving kidney function and minimizing the need for open surgery.
What are the Risks of Laparoscopic Ureteroneocystotomy for Severe Endometriosis?
This advanced procedure carries significant risks that require meticulous technique and postoperative monitoring.
- Ureteral Complications: Stricture, leakage, or obstruction at the re-implantation site may occur despite stent placement.
- Bladder Injury or Leak: Cystotomy closure may fail, leading to urine leakage or fistula formation.
- Bleeding: Dissection around the ureter and bladder can cause hemorrhage from pelvic vessels.
- Infection: Urinary tract infection, pelvic abscess, or sepsis may develop after surgery.
- Adjacent Organ Injury: The bowel, pelvic nerves, or reproductive organs can be inadvertently damaged during extensive dissection.
- Loss of Renal Function: Delayed diagnosis of obstruction or anastomotic failure can result in hydronephrosis and irreversible renal damage.
- Anesthetic and Laparoscopic Risks: Port-site complications, thromboembolism, or anesthetic reactions can occur with prolonged pelvic surgery.
Preoperative imaging, intraoperative stent placement, and careful layered closure help reduce these complications while ensuring durable urinary drainage and effective disease removal.
Video Transcript:
The minimally invasive gynaecologic surgery team at Laval University presents laparoscopic ureteroneocystostomy for severe endometriosis, a challenging case of dual distant lesions. Urinary tract endometriosis is common among women with deep endometriosis, with the bladder being most often affected. The ureter is involved in about 10% of cases. Our team has previously presented a six-step approach for managing these challenging ureteric endometriosis cases.
First, normal pelvic anatomy must be restored. Next, ureterolysis is performed in order to expose the disease. In this case, the endometriotic nodule involved the ureteral vesicle junction and penetrated the bladder transmurally all the way to the mucosa. Excision of the large nodule involving the distal ureter and bladder is performed. Cystotomy is repaired in a two-layer, watertight closure. The bladder and ureter are then mobilised to allow for ureteric re-implantation.
A new double J stent is put in place. Ureteroneocystostomy is then performed. The ureter is spatulated and a new incision is created in the dome of the bladder. The ureter is re-implanted using a double-layer, watertight closure. Finally, an epiploic flap is placed between the vaginal vault and the bladder.
We now present the case of a 35-year-old woman with known endometriosis and desiring fertility. She presented to our centre with severe pain, and was diagnosed with an infected endometrioma. Further investigations revealed a large bladder nodule as well as a left ureteric nodule causing hydronephrosis. We adapted the previously presented stepwise approach to this complex case.
The procedure begins with cystoscopy. An injection of indocyanine green into the ureters. The first laparoscopic step of the procedure is restoration of pelvic anatomy and lysis of adhesions. Once the pelvic structures have been identified and freed up ureterolysis is performed. ICG fluorescence is used to identify the course of the ureter when it is difficult to distinguish because of the disease.
The endometriotic nodule involving the ureter is then excised using cold Metzenbaum scissors. During the dissection, ICG fluorescence is once again used to identify the course of the ureter. Next, the bladder is mobilised. This step is challenging due to the large bladder nodule which is adherent to the uterus. The ureter is also mobilised. It is clipped at its insertion into the bladder and freed up along its length. The procedure continues with excision of the bladder nodule.
Cystotomy repair begins at the medial end, using a running suture. The endometrial nodule and the diseased distal end of the ureter are excised. The ureter is spatulated and then re-implanted into the lateral portion of the existing cystotomy. A double J stent is inserted laparoscopically into the ureter and into the bladder. The ureteric re-implantation is then completed to secure the ureter into the bladder. A second imbricating layer is added to the cystotomy repair and re-implantation site. A watertight closure is ensured at the end of the procedure.
Postoperatively, the patient did well. The Foley catheter remained in place for four weeks as at the two-week mark there was still a small leak on the voiding cystogram. The double J stent remained in place for seven weeks. The patient continued medical suppressive therapy in preparation for IVF.
This case presents the unique challenge of treating dual and separate lesions with the uterus in situ, making ureteric implantation more challenging. In addition, we present an original way of using the lateral portion of the cystotomy for ureteric re-implantation.
