"Robot-assisted partial cystectomy for deep infiltrating endometriosis of the bladder with the Hugo RAS system".: PRECIS: Robotic-assisted laparoscopy for bladder endometriosis is a feasible procedure, able to reproduce all surgical steps without critical errors or complications requiring a change in surgical planning

OBJECTIVE

Involvement of the lower urinary tract is found in 0.2-2.5% of all deep infiltrating endometriosis (DIE)1,2. The bladder is the most affected organ with a prevalence of up to 80% of cases3. Patients with bladder endometriosis are often symptomatic (dysuria, hyperactive bladder, recurrent urinary tract infections and hematuria). Surgery is the gold standard treatment for this condition when medical therapy fails1,2. Several studies have shown the feasibility, effectiveness, and safety of the laparoscopic approach4 but data about robotic-assisted approach are missing in literature. Currently, novel platforms are entering the market and the Hugo™RAS(Medtronic, Minneapolis, USA) is a new system(HRS) consisting of an open console with 3D-HD screen and a multi-modular bedside units. Even if some series are already available for radical cystectomies for oncologic purposes5, a full description of DIE surgery performed with HRS is still lacking. Aim of this video-article is to show our technique and surgical setup to carry out a complex case of anterior compartment DIE.

DESIGN

A step-by-step explanation of surgical technique with narrated video footage.

SETTING

Tertiary Level Academic Hospital "IRCCS Azienda Ospedaliero - Universitaria di Bologna" Bologna, Italy.

INTERVENTION

A 36-year-old nulliparous woman affected by DE was referred to our center due to severe dyspareunia, dysuria with hematuria and post-voiding pain not responsive to oral progestins. The preoperative work up consisted of a gynecological examination, pelvic ultrasound and MRI that showed the presence of an endometriotic nodule of the bladder base. All possible therapeutic strategies and related complications have been discussed with the patient before the signature of the informed consent. To carry out the procedure a "straight" port placement in a "compact" docking configuration6 was installed. After developing the paravesical spaces bilaterally, the bladder nodule was approached in a latero-medial direction then a partial cystectomy with macroscopical free margins was performed. A double layer horizontal running suture with barbed thread was used to repair the bladder wall.

CONCLUSION

To the best of our knowledge, this is the first case of bladder endometriotic nodule excision perfomed with HRS. We explained our technique and robotic set-up to successfully manage a compelx case of DIE of the bladder.

Clinical Significance of a Pain Scoring System for Deep Endometriosis by Pelvic Examination: Pain Score

Endometriosis-associated pain is an essential factor in deciding surgical indications of endometriosis. However, there is no quantitative method to diagnose the intensity of local pain in endometriosis (especially deep endometriosis). This study aims to examine the clinical significance of the pain score, a preoperative diagnostic scoring system for endometriotic pain that can be performed only with pelvic examination, devised for the above purpose. The data from 131 patients from a previous study were included and evaluated using the pain score. This score measures the pain intensity in each of the seven areas of the uterus and its surroundings via a pelvic examination using a numeric rating scale (NRS) which contains 10 points. The maximum value was then defined as the max pain score. This study investigated the relationship between the pain score and clinical symptoms of endometriosis or endometriotic lesions related to deep endometriosis. The preoperative max pain score was 5.93 ± 2.6, which significantly decreased to 3.08 ± 2.0 postoperatively (p = 7.70 × 10^-20). Regarding preoperative pain scores for each area, those of the uterine cervix, pouch of Douglas, and left and right uterosacral ligament areas were high (4.52, 4.04, 3.75, and 3.63, respectively). All scores decreased significantly after surgery (2.02, 1.88, 1.75, and 1.75, respectively). The correlations between the max pain score and dysmenorrhea, dyspareunia, perimenstrual dyschezia (pain with defecation), and chronic pelvic pain were 0.329, 0.453, 0.253, and 0.239, respectively, and were strongest with dyspareunia. Regarding the pain score of each area, the combination of the pain score of the pouch of Douglas area and the VAS score of dyspareunia showed the strongest correlation (0.379). The max pain score in the group with deep endometriosis (endometrial nodules) was 7.07 ± 2.4, which was significantly higher than the 4.97 ± 2.3 score obtained in the group without (p = 1.71 × 10^-6). The pain score can indicate the intensity of endometriotic pain, especially dyspareunia. A local high value of this score could suggest the presence of deep endometriosis, depicted as endometriotic nodules at that site. Therefore, this method could help develop surgical strategies for deep endometriosis.