Endometriosis is a chronic gynecological condition characterized by the presence of endometrial glands and stroma outside the uterine cavity. While most cases involve the pelvic peritoneum and ovaries, extragenital locations can occur. Among these, urinary tract endometriosis is rare, affecting 1–2% of women with endometriosis. Within the urinary tract, the bladder is the most commonly affected organ, accounting for nearly 85% of cases. A bladder endometrioma, also known as bladder endometriosis, presents significant diagnostic and therapeutic challenges.

With advances in minimally invasive surgery, laparoscopic management has emerged as the preferred approach, offering precision in diagnosis, excision of lesions, and restoration of normal bladder anatomy with minimal morbidity.

Pathophysiology and Clinical Presentation

Bladder endometriomas are usually secondary to deep infiltrating endometriosis. Endometrial tissue infiltrates the detrusor muscle, leading to localized nodules or masses within the bladder wall. In many cases, lesions are associated with previous pelvic surgery, especially cesarean sections, where implantation may occur in the bladder dome.

Common symptoms include:

Cyclical dysuria (painful urination during menstruation).

Hematuria coinciding with menses.

Suprapubic pain or pelvic discomfort.

Irritative voiding symptoms such as frequency and urgency.

Occasionally, asymptomatic lesions discovered incidentally during imaging.

Delayed diagnosis is common because symptoms often mimic urinary tract infections or interstitial cystitis.

Diagnostic Workup

A structured evaluation is essential for diagnosis and surgical planning:

Ultrasonography: Transvaginal and transabdominal ultrasound can identify bladder wall thickening or nodules.

MRI: Provides excellent soft tissue detail and defines the extent of infiltration into bladder and surrounding structures.

Cystoscopy: Direct visualization of endometriotic nodules within the bladder mucosa; biopsies can be taken if required.

Urinalysis and Cytology: Useful to rule out infection or malignancy but nonspecific for endometriosis.

Role of Laparoscopy

Laparoscopy is considered the gold standard for both diagnosis and treatment of bladder endometrioma. It allows direct visualization of pelvic structures, precise excision of endometriotic lesions, and simultaneous management of associated pelvic endometriosis.

The goals of laparoscopic management are:

Complete excision of bladder lesion to relieve symptoms and prevent recurrence.

Restoration of bladder integrity and function.

Preservation of fertility and quality of life.

Laparoscopic Surgical Technique
Patient Preparation

Preoperative imaging and cystoscopic assessment.

Bowel preparation may be advised if rectovaginal endometriosis is suspected.

Ureteric stents may be placed prophylactically if lesions are close to the ureteric orifices.

Port Placement

Typically, a standard four-port laparoscopic setup is used.

A 10 mm umbilical port for the laparoscope and three 5 mm working ports are placed in the lower abdomen.

Dissection

Adhesiolysis is often required as bladder endometriomas are commonly associated with pelvic adhesions.

The vesicouterine peritoneum is opened, and the bladder is dissected downward from the uterus and cervix.

Excision of Bladder Lesion

The nodule is carefully excised with adequate margins, including involved bladder wall.

Depending on lesion depth, either partial thickness (shaving technique) or full-thickness bladder excision is performed.

Full-thickness excision requires opening of the bladder cavity.

Bladder Repair

Following excision, the bladder is sutured in two layers using absorbable sutures.

Integrity of repair is confirmed intraoperatively by filling the bladder with saline or methylene blue.

Catheterization

A Foley catheter is left in situ for 7–14 days to allow proper healing of the bladder.

Management of Associated Lesions

Frequently, bladder endometrioma coexists with ovarian or rectovaginal endometriosis, which can be treated in the same laparoscopic session.

Postoperative Care

Catheter Care: Continuous bladder drainage until healing is confirmed.

Analgesia and Antibiotics: Given as per protocol.

Follow-up Cystography: May be performed before catheter removal to check for leaks.

Hormonal Suppression: Postoperative medical therapy with GnRH analogs, oral contraceptives, or progestins may reduce recurrence.

Outcomes and Prognosis

Laparoscopic excision of bladder endometrioma provides significant symptom relief and improved quality of life. Studies demonstrate:

High success rates with low recurrence when complete excision is achieved.

Preservation of bladder function in most patients.

Symptomatic improvement in dysuria, hematuria, and pelvic pain.

Fertility outcomes are favorable, especially when coexisting pelvic endometriosis is addressed.

Complications are rare but may include bladder leak, fistula formation, or ureteric injury, all of which can be minimized with meticulous surgical technique.

Advantages of Laparoscopy

Magnified view enabling precise dissection.

Minimally invasive with faster recovery.

Reduced postoperative pain and hospital stay.

Simultaneous management of widespread pelvic endometriosis.

Superior cosmetic outcomes.

Conclusion

Laparoscopic management of bladder endometrioma represents the standard of care in modern gynecology. It combines accurate diagnosis with definitive treatment in a minimally invasive manner. By ensuring complete excision of the lesion and careful bladder reconstruction, laparoscopy achieves excellent symptomatic relief, low recurrence rates, and preservation of bladder function. With proper preoperative planning, skilled surgical expertise, and postoperative follow-up, patients with bladder endometrioma can expect significant improvement in both quality of life and reproductive potential.