Combined cystoscopic-abdominal vs. abdominal only route for complete excision of large deep endometriosis nodules infiltrating the supratrigonal area of the bladder: a comparative study

STUDY OBJECTIVE:Surgical excision of large deep endometriosis nodules infiltrating the bladder may be challenging, particularly when the nodule limits are close to the trigone and ureteral orifice. Bladder nodules have classically been approached abdominally. However, combining a cystoscopic with an abdominal approach may help to better identify the mucosal borders of the lesion to ensure complete excision without unnecessary resection of healthy bladder. The aim of our study was to compare classical excision of large bladder nodules by abdominal route with a combined cystoscopic-abdominal approach. DESIGN:Retrospective comparative study on data prospectively recorded in a database. Patients were managed from September 2009 to June 2022. SETTING:Two tertiary referral endometriosis centres PATIENTS: 175 patients with deep endometriosis infiltrating the bladder more than 2 cm undergoing surgical excision of bladder nodules. INTERVENTIONS:Excision of bladder nodules by either abdominal or combined cystoscopic-abdominal approaches. MEASUREMENT AND MAIN RESULTS:141 women (80.6%) were managed by abdominal route and 34 women (19.4%) underwent a combined cystoscopic-abdominal approach. In 99.4% of patients the approach was minimally invasive. Patients with nodules requiring the combined approach had a lower American Fertility Score (AFSr) score and endometriosis stage, less associated digestive tract nodules, but larger bladder nodules. They were less frequently associated with colorectal resection and preventive stoma. Operative time was comparable. The rate of early postoperative complications was comparable (8.8% vs 22%), as were the rates of ureteral fistula (2.2% vs 2.9%), bladder fistula (2.2% vs 0) and vesico-vaginal fistula (0.7% vs 2.9%). CONCLUSIONS:In our opinion, the combined cystoscopic-abdominal approach is useful in patients with large bladder nodules with limits close to the trigone and ureteral orifice. These large deep bladder nodules appeared paradoxically associated to less nodules on the digestive tract, resulting in an overall comparable total operative time and complication rate.