INTRODUCTION: Deep infiltrating endometriosis (DIE) with bladder involvement is one of the most common features of urinary tract endometriosis, accounting for 70–85% of the cases. It causes severe dysuria, urinary urgency, and pelvic pain, making it particularly challenging to diagnose, manage, or treat. Recent studies have highlighted the value of enhanced preoperative imaging, such as transvaginal ultrasound and MRI (magnetic resonance imaging), in facilitating the precise mapping of bladder lesions and allowing for targeted, minimally invasive excisions. Preoperative imaging additionally allows for optimal surgical planning and patient counseling. Postoperative outcomes are promising, with over 90% of patients reporting symptom relief after laparoscopic bladder endometriosis surgery, including complete resolution of dysuria in one study. Crucially, these interventions significantly improve quality of life by alleviating pain and restoring daily function. Collectively, such advances underscore a commitment to innovation, adaptability, and broader access in gynecologic surgical care. OBJECTIVE: The aim of this video is to highlight the preoperative strategy and surgical tactics for the excision of a large bladder endometrioma. METHODS: We present the case of a 29-year-old with cyclic, progressively worsening pelvic pain and urinary symptoms mimicking recurrent infections. Cystoscopy revealed a 3-cm lesion on the bladder dome. Pelvic magnetic resonance confirmed the lesion's involvement of both the bladder and the anterior uterine wall. Given the lesion’s complexity and location, a robotic-assisted approach was proposed to enhance surgical visualization, precision, and safety. RESULTS: A robotic-assisted laparoscopy was performed. The initial step involved a meticulous inspection of the abdomen and pelvis to identify key anatomical landmarks. A large endometriotic nodule was visualized over the bladder dome. The retroperitoneum was dissected to lateralize the ureter and prevent unintended injury. With the ureter clearly identified, a safe dissection of the vesicouterine space was carried out, separating the bladder from the uterus. Care was taken to minimize dissection within the bladder wall. The nodule had penetrated the full thickness of the bladder, involving the mucosa, similar to what was demonstrated at the preoperative images. The implant was mobilized and completely excised. Both ureteral orifices were identified. To reduce tension on the suture line, the prevesical space was dissected, allowing for bladder mobilization. A two-layer closure was performed. The bladder was filled with saline to test for leakage, which was negative. The specimen was sent for pathological evaluation. The patient recovered well postoperatively, with substantial improvement in urinary symptoms. Pathology confirmed endometriosis in all the specimens. CONCLUSIONS: This case demonstrates the importance of having a strategic plan to treat challenging endometriosis cases. Preoperative strategies, including imaging diagnosis and disease mapping, are essential to guide surgical planning and patient counseling. Robotic technology associated with surgical tactics and anatomical knowledge offers a safe and precise procedure, optimizing patient care.Figure 1Figure 2
Mori et al. (Fri,) studied this question.