Robotic Surgery for Ureteral Endometriosis with End-to-End Anastomosis

Study Objective To demonstrate the technique, landmarks and surgical steps of a robot-assisted end-to-end ureteral anastomosis Design Sequential demonstration of clinical history and surgical approach with narrated video footage. Setting Urinary tract endometriosis occurs in 1–5.5% of women with endometriosis; it involves the bladder in 70–85% of cases and the ureter in 9–23% of the cases. In 90% of patients, ureteral endometriosis (UE) is associated with other sites affected by endometriosis. The diagnosis of UE is difficult since the disease may be clinically silent in 30% of patients, or it may be associated with non- specific symptoms, such as dysmenorrhea, dyspareunia and non- menstrual pelvic pain. Sometimes progressive upper urinary tract obstruction leads lost the kidney function. Patients may temporally benefit from medical therapy, but surgery is needed when ureteral obstruction is present. Surgical options are conservative ureterolysis or radical approaches, such as ureterectomy with end-to-end anastomosis or ureteroneo- cystostomy performed in relation to the type, site and length of ureteral involvement. Patients or Participants A 60-year-old woman with pelvic pain refractory to medical therapy, with a previous MRI showing signs of left pyelocaliceal dilation. Interventions Diagnosis of an endometriotic lesion involving the left ureter with the use of pelvic MRI. Surgical approach with robot-assisted laparoscopy, performing the ureterolysis and an end-to-end ureteral anastomosis. Measurements and Main Results Patient was good after the surgery, showing an important improvement in the pelvic pain. The double J stent was maintained for 30 days and after this period was removed, without complications. The urination remained normal after the removal. Conclusion Ureteral endometriotic lesion cases are challenging due to its requirement of a high skilled surgical treatment. The imaging exams as RMI are extremely important for the surgical planning. The robot-assisted laparoscopy is a great option for the treatment of these cases, but it requires an arduous and specific training and an experienced team, due to its complexity.