Total laparoscopic bladder resection in the management of deep endometriosis: “take it or leave it.” Radicality versus persistence

  • Marcello Ceccaroni
  • Roberto Clarizia
  • Matteo CeccarelloEmail author
  • Paola De Mitri
  • Giovanni Roviglione
  • Daniele Mautone
  • Giuseppe Caleffi
  • Alberto Molinari
  • Giacomo Ruffo
  • Stefano Cavalleri
Original Article



Bladder endometriosis (BE) is the most common external site of deep-infiltrating endometriosis (DIE) affecting the urinary tract. Frequently associated with other DIE lesions, it can be strongly related to a ventral spread of adenomyosis. Possible symptoms are urinary frequency, tenesmus and hematuria, and they are frequently related to DIE of the posterior and lateral compartment. Hormonal therapy can be used in non-symptomatic patients; conversely, in other cases surgical treatment is the management of choice.


Retrospective cohort study of a series of consecutive patients treated between September 2004 and December 2017 in a tertiary care referral center. Only full-thickness detrusor involvement was considered as BE. All patients underwent laparoscopic bladder resection with concomitant radical excision of DIE.


BE was found in 264 patients and was associated with simultaneous bowel DIE requiring bowel resection in 140 patients (53%). Twenty-five patients (9.5%) had associated obstructive ureteral signs requiring ureteroneocystostomy. Mean hospital stay and time of catheter removal were 9.7 and 9.1 days, respectively. Postoperative major complications (< 28 days) were observed in 19 patients (7.2%). Follow-up was performed at 1, 6 and 12 months after surgery, with a 2.3% recurrence rate observed.


Laparoscopic partial cystectomy for BE is a feasible and safe technique, and experienced laparoscopic surgeons should consider it the gold standard treatment. Surgical eradication leads to excellent surgical outcomes in terms of reduction of symptoms and recurrence rates, considering the need to maintain an adenomyotic uterus for fertility purposes.


Bladder endometriosis Laparoscopic cystectomy Bladder suturing Deep-infiltrating endometriosis Segmental bowel resection 


Compliance with ethical standards

Conflicts of interest



  1. 1.
    Koninckx PR, Ussia A, Adamyan L, Wattiez A, Donnez J. Deep endometriosis: definition, diagnosis, and treatment. Fertil Steril. 2012;98:564–71.CrossRefGoogle Scholar
  2. 2.
    Nezhat C, Falik R, McKinney S, King LP. Pathophysiology and management of urinary tract endometriosis. Nat Rev Urol. 2017;14(6):359–72.CrossRefGoogle Scholar
  3. 3.
    Vercellini P, Meschia M, De Giorgio O, Panazza S, Cortesi I, Crosignani PG. Bladder detrusor endometriosis: clinical and pathogenetic implications. J Urol. 1996;155:770–1.CrossRefGoogle Scholar
  4. 4.
    Somigliana E, Vercellini P, Gattei U, Chopin N, Chiodo I, Chapron C. Bladder endometriosis: getting closer and closer to the unifying metastatic hypothesis. Fertil Steril. 2007;87:1287–90.CrossRefGoogle Scholar
  5. 5.
    Donnez J, Spada F, Squifflet J, Nisolle M. Bladder endometriosis must be considered as bladder adenomyosis. Fertil Steril. 2000;74:1175–81.CrossRefGoogle Scholar
  6. 6.
    Donnez J, Van Langendonckt A, Casanas Roux F, Van Gossum JP, Pirard C, Jadoul P, et al. Current thinking on the pathogenesis of endometriosis. Gynecol Obstet Investig. 2002;54:52–62.CrossRefGoogle Scholar
  7. 7.
    Chapron C, Chopin N, Borghese B, Foulot H, Dousset B, Vacher Lavenu MC, et al. Deeply infiltrating endometriosis: pathogenetic implications of the anatomical distribution. Hum Reprod. 2006;21:1839–45.CrossRefGoogle Scholar
  8. 8.
    Mettler L, Gaikwad V, Riebe B, Schollmeyer T. Bladder endometriosis: possibility of treatment by laparoscopy. JSLS. 2008;12:162–5.Google Scholar
  9. 9.
    Villa G, Mabrouk M, Guerrini M, Mignemi G, Montanari G, Fabbri E, et al. Relationship between site and size of bladder endometriotic nodules and severity of dysuria. J Minim Invasive Gynecol. 2007;14:628–32.CrossRefGoogle Scholar
  10. 10.
    Roberti Maggiore UL, Ferrero S, Candiani M, Somigliana E, Viganò P, Vercellini P. Bladder endometriosis: a systematic review of pathogenesis, diagnosis, treatment, impact on fertility, and risk of malignant transformation. Eur Urol. 2017;71:790–817.CrossRefGoogle Scholar
  11. 11.
    Vercellini P, Buggio L, Berlanda N, Barbara G, Somigliana E, Bosari S. Estrogen-progestins and progestins for the management of endometriosis. Fertil Steril. 2016;106:1552–71.CrossRefGoogle Scholar
  12. 12.
    Chapron C, Bourret A, Chopin N, Dousset B, Leconte M, Amsellem Ouazana D, et al. Surgery for bladder endometriosis: long-term results and concomitant management of associated posterior deep lesions. Hum Reprod. 2010;25:884–9.CrossRefGoogle Scholar
  13. 13.
    Dubuisson JB, Chapron C, Aubriot FX, Osman M, Zerbib M. Pregnancy after laparoscopic partial cystectomy for bladder endometriosis. Hum Reprod. 1994;9:730–2.CrossRefGoogle Scholar
  14. 14.
    Ceccaroni M, Pontrelli G, Scioscia M, Ruffo G, Bruni F, Minelli L. Nerve-sparing laparoscopic radical excision of deep endometriosis with rectal and parametrial resection. J Minim Invasive Gynecol. 2010;17:14–5.CrossRefGoogle Scholar
  15. 15.
    Ceccaroni M, Clarizia R, Bruni F, et al. Nerve-sparing laparoscopic eradication of deep endometriosis with segmental rectal and parametrial resection: the Negrar method. A single center, prospective, clinical trial. Surg Endosc. 2012;26:2029–45.CrossRefGoogle Scholar
  16. 16.
    Joseph J, Hitendra RH. Patel. Retroperitoneal robotic and laparoscopic surgery, Springer 2011.Google Scholar
  17. 17.
    Testut L. Appareil urogenital, Peritoine. In: Latarget A. Traité d’anatomie humaine. 8th edn revue par, G Doin et Cie Editeurs, Paris. 1931.Google Scholar
  18. 18.
    Scarperi S, Pontrelli G, Campana C, Steinkasserer M, Ercoli A, Minelli L, Bergamini V, Ceccaroni M. Laparoscopic radiofrequency thermal ablation for uterine adenomyosis. JSLS. 2015;19(4).Google Scholar
  19. 19.
    Ceccaroni M, Ceccarello M, Caleffi G, Clarizia R, Scarperi S, Pastorello M, Molinari A, Ruffo G, Cavalleri S. Total laparoscopic ureteroneocystostomy for ureteral endometriosis: a single-center experience of 160 consecutive patients. J Minim Invasive Gynecol, 2019.Google Scholar
  20. 20.
    Bergmark K, Avall-Lundqvist E, Dickman PW, Henningson L, Steineck G. Vaginal changes and sexuality in women with a history of cervical cancer. N Engl J Med. 1999;340:1383–9.CrossRefGoogle Scholar
  21. 21.
    Diagnostic and Statistical Manual of Mental Disorders, 4th ed., American Psychiatric Association, Washington D.C. 2000.Google Scholar
  22. 22.
    The World Health Organization quality of life instruments. 1997.Google Scholar
  23. 23.
    Ceccaroni M, Roviglione G, Spagnolo E, Casadio P, Clarizia R, Peiretti M, et al. Pelvic dysfunctions and quality of life after nerve-sparing radical hysterectomy: a multicenter comparative study. Anticancer Res. 2012;32(2):581–8.Google Scholar
  24. 24.
    American Society for Reproductive Medicine. Revised American society for reproductive medicine classification of endometriosis. 1996.Google Scholar
  25. 25.
    Mitropoulos D, Artibani W, Graefen M, Remzi M, Rouprêt M, Truss M, et al. Reporting and grading of complications after urologic surgical procedures: an ad hoc EAU guidelines panel assessment and recommendations. Eur Urol. 2012;61(2):341–9.CrossRefGoogle Scholar
  26. 26.
    Scioscia M, Bruni F, Ceccaroni M, Steinkasserer M, Stepniewska A, Minelli L. Distribution of endometriotic lesions in endometriosis stage IV supports the menstrual reflux theory and requires specific preoperative assessment and therapy. Acta Obstet Gynecol Scand. 2011;90:136–9.CrossRefGoogle Scholar
  27. 27.
    Maccagnano C, Pellucchi F, Rocchini L, Ghezzi M, Scattoni V, Montorsi F, et al. Diagnosis and treatment of bladder endometriosis: state of the art. Urol Int. 2012;89(3):249–58.CrossRefGoogle Scholar
  28. 28.
    Abrao MS, Dias JA Jr, Bellelis P, Podgaec S, Bautzer CR, Gromatsky C. Endometriosis of the ureter and bladder are not associated diseases. Fertil Steril. 2009;91(5):1662–7.CrossRefGoogle Scholar
  29. 29.
    Vercellini P, Pisacreta A, Pesole A, Vincentini S, Stellato G, Crosignan PG. Is ureteral endometriosis an asymmetric disease? BJOG. 2000;4:559–61.CrossRefGoogle Scholar
  30. 30.
    Schonman R, Dotan Z, Weintraub AY, Bibi G, Eisenberg VH, Seidman DS, et al. Deep endometriosis inflicting the bladder: long-term outcomes of surgical management. Arch Gynecol Obstet. 2013;288(6):1323–8.CrossRefGoogle Scholar
  31. 31.
    Kovoor E, Nassif J, Miranda-Mendoza I, Wattiez A. Endometriosis of bladder: outcomes after laparoscopic surgery. J Minim Invasive Gynecol. 2010;17(5):600–4.CrossRefGoogle Scholar
  32. 32.
    Sánchez Merino JM, Guillán Maquieira C, García Alonso J. The treatment of bladder endometriosis. Arch Esp Urol. 2005;58:189–94.Google Scholar
  33. 33.
    Vignali M, Bianchi S, Candiani M, Spadaccini G, Oggioni G, Busacca M. Surgical treatment of deep endometriosis and risk of recurrence. J Minim Invasive Gynecol. 2005;12:508–13 1990; 13: 227-236.CrossRefGoogle Scholar

Copyright information

© The International Urogynecological Association 2019

Authors and Affiliations

  • Marcello Ceccaroni
    • 1
  • Roberto Clarizia
    • 1
  • Matteo Ceccarello
    • 1
    Email author
  • Paola De Mitri
    • 1
  • Giovanni Roviglione
    • 1
  • Daniele Mautone
    • 1
  • Giuseppe Caleffi
    • 2
  • Alberto Molinari
    • 2
  • Giacomo Ruffo
    • 3
  • Stefano Cavalleri
    • 2
  1. 1.Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical AnatomyIRCCS “Sacro Cuore-Don Calabria” HospitalVeronaItaly
  2. 2.Department of UrologyIRCCS “Sacro Cuore-Don Calabria” HospitalVeronaItaly
  3. 3.Department of General SurgeryIRCSS “Sacro Cuore-Don Calabria” HospitalVeronaItaly

Personalised recommendations