Laparoscopic Management of Genitourinary, GI and Diaphragmatic Endometriosis

Genitourinary Endometriosis

Ureteral involvement has been reported in 1 to 11 percent of women diagnosed with endometriosis. Endometriosis of the urinary tract generally tends to be superficial but can be invasive and cause complete ureteral obstruction. Decreased bladder capacity and stability unresponsive to conventional therapy may result from endometriosis. When bladder symptoms are present a course of danazol may be tried to see the improvement in bladder instability. Clinicians should consider endometriosis in cases of refractory and unexplained urinary complaints.

Genitourinary Endometriosis
Genitourinary Endometriosis

If urinary tract endometriosis is suspected, a complete preoperative evaluation is performed, including an intravenous pyelogram, ultrasound of the kidneys, and routine blood and urine workup. In selected cases of recurrent hematuria, cystoscopy is indicated. Superficial implants over the ureter can be treated by a variation of hydrodissection. Approximately 20 to 30 ml of Ringer’s lactate is injected subperitoneal on the lateral pelvic wall; this elevates the peritoneum and backs it with a bed of fluid to prevent injury at the time of fulguration. The peritoneum is held with an atraumatic grasping forceps and peeled away with the help of a suction irrigation probe. Following hydrodissection of the broad ligaments and the pelvic sidewall, many patients develop swelling of the external genitalia, most likely from the penetration of water through the inguinal canal to the labia major. This swelling resolves in most cases within 1 to 2 hours without sequelae. The incidence of ureteral obstruction by endometriosis is low, and conventional therapy previously consisted of laparotomy followed by resection of the obstructed segment of the ureter. Laparoscopic ureteroureterostomy can be performed under direct laparoscopic observation.

The bladder wall is one of the sites least frequently involved with endometriosis. If the lesions are superficial, hydrodissection and vaporization are adequate for removal. Using hydrodissection, the areolar tissue between the serosa and muscularis beneath the implants is dissected. The lesion is circumcised with the laser and fluid is injected into the resulting defect. The lesion is grasped with forceps and dissected with the help of either sharp or electrosurgical dissection. Traction allows the small blood vessels supplying the surrounding tissue to be coagulated as the lesion is resected. Frequent irrigation is necessary to remove char, ascertain the depth of vaporization, and ensure that the lesion does not involve the muscularis and the mucosa. Endometriosis extending to the muscularis but without mucosal involvement can be treated laparoscopically and any residual or deeper lesions may be treated successfully with postoperative hormonal therapy. When endometriosis involves full bladder wall thickness, the lesion is excised and the bladder may be reconstructed laparoscopically.

Gastrointestinal Endometriosis

Gastrointestinal endometriosis is believed to be involved in 3 to 37 percent of women suffering from endometriosis. Endometriosis can involve rectovaginal septum, rectosigmoid colon, between the small intestine and anal canal. The symptoms are lower abdominal pain, backache, dysmenorrhea, dyspareunia, diarrhea, constipation, and tenesmus. Occasionally rectal bleeding is also noticed. Typically these symptoms occur cyclically at or about the time of menstruation. Surgical intervention is necessary to dissect and resect the infiltrating bowel endometriosis. Intestinal endometriosis involves the rectum and sigmoid colon in 76 percent of cases, the appendix in 18 percent, and the cecum in 5 percent. Appendiceal lesion requires an appendectomy. In cases of severe disease of the bowel wall, resection and anastomosis are done laparoscopically. In cases of cul-de-sac endometriosis, because ureter is lateral to the uterosacral ligament, surgeons should try to separate between them. If the dissection is extended laterally to the uterosacral ligament the ipsilateral ureter should be identified by opening the overlying peritoneum and stressing it to the area of the lesion. The ureter, uterine artery, and vein should be identified and bipolar forceps or titanium clips must be used if bleeding starts.

Diaphragmatic Endometriosis

Endometriosis sometimes affects diaphragm also. In these cases, pleuritic shoulder or upper abdominal pain is present at the time of menses. Laparoscopy is an excellent modality to diagnose and treat diaphragmatic endometriosis. Follow- up medical treatment is necessary because extensive surgery can rupture the diaphragm. Bilateral oophorectomy is promising and further intervention may not be necessary. Three cannulas are required in the upper quadrant according to the site of the lesion on the diaphragm. The liver retractor is used by one port and lesions are removed using hydrodissection and vaporization or excision. If an injury to diaphragm happens it should be repaired with a 4-0 PDS. Cardiopulmonary resuscitation may be necessary after surgery.

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