Our patient is a 28-year-old para-2002 with complaints of non-cyclical pelvic pain for one year. Physical examination revealed a palpable mass in the anterior bladder wall. Previous history included chronic pelvic pain, two prior cesarean deliveries, and a diagnostic laparoscopy one year prior revealing endometriosis affecting the cul-de-sac and utero-sacral ligaments. Pre-procedure cystoscopy revealed a mass in the anterior wall of the bladder that was infiltrating the mucosa. Ureter stents were placed bilaterally prior to the procedure. Upon evaluation, the bladder was severely adherent to the lower uterine segment and the cervix. We start the case by mobilizing the bladder away from the lower uterine segment. A combination of sharp dissection with cutting current of the robotic scissors and blunt dissection is used to separate the adhesions. Downward traction is placed on the uterus in order to help identify the tissue plane. In cases where there are dense anterior adhesions, it can be useful to approach and mobilize the bladder flap laterally, as demonstrated, in order to better identify a tissue plane and facilitate dissection. We now approach from the right side and continue mobilizing the bladder from the lower uterine segment. We now proceed with cystotomy using cutting current. It is important to enter at a point that is away from the orifice of the ureter. The next steps involve excision of the endometriotic nodule. Traction is placed on the nodule and cutting current with the robotic scissors is used for dissection. It is crucial to maintain knowledge of the location of both ureter orifices during this procedure. We circumferentially dissect around the nodule. Again we check the location of both orifices. Pre-procedure placement of stents in the ureter is crucial for maintaining safety during this procedure. We now dissect the inferior portion of the nodule. Fine adhesions between the bladder and anterior cervix are bluntly mobilized. Sharp dissection with cutting current is now used to mobilize the remaining adhesions. We now continue to circumferentially excise the nodule. It is mobilized from its final attachments to the bladder. The nodule is placed in an endoscopic bag prior to removal. We now proceed to repair the cystotomy incision in two layers. We introduce an ovicular suture. We first start by securing the angle. For the first layer, we make sure to incorporate the bladder mucosa with each bite of suture. The first layer of closure is accomplished using a continuous suture technique that incorporates the bladder mucosa with each bite of suture as demonstrated. This technique was continued in order to close the first layer. After closing the first layer, a second ovicular suture was introduced. A second layer using a continuous suture technique was done to imbricate the first layer forming a watertight seal. Final pathology was consistent with the deeply invading endometriotic nodule that was invading the bladder mucosa. All remaining endometriotic lesions were removed. The patient did well post-op without any complications or sequelae. Post-procedure cystoscopy confirmed excision of the lesion, a watertight seal, and patency of both urethral orifices. A cystogram done two weeks post-op showed complete healing of the bladder. At six weeks and three months follow-up, the patient was doing well with no complaints of pain. Thank you for your attention to our video.

chronic pelvic pain

endometriosis

robotic surgery

bladder endometriotic nodule

ureter stents