Laparoscopic resection of deep endometriotic nodule for pelvic pain, left hydronephrosis and renal function impairment

Renal function impairment is a rare condition when associated with endometriosis. This video shows the laparoscopic resection of a deep endometriotic nodule for pelvic pain, left hydronephrosis and renal function impairment. The left kidney has an almost silent pattern on scintigraphy. The therapeutic strategy consists of freeing the obstacle caused by the endometriotic nodule, placement of a double J (JJ) catheter and monitoring for renal function in the postoperative follow-up. Further laparoscopic nephrectomy is to be discussed if the renal function is not improved.

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Laparoscopic resection of deep endometriotic nodule for pelvic pain, left hydronephrosis and renal function impairment

Authors

A Wattiez, J Nassif, I Miranda-Mendoza, J Marescaux

Abstract

Renal function impairment is a rare condition when associated with endometriosis. This video shows the laparoscopic resection of a deep endometriotic nodule for pelvic pain, left hydronephrosis and renal function impairment. The left kidney has an almost silent pattern on scintigraphy. The therapeutic strategy consists of freeing the obstacle caused by the endometriotic nodule, placement of a double J (JJ) catheter and monitoring for renal function in the postoperative follow-up. Further laparoscopic nephrectomy is to be discussed if the renal function is not improved.

Classification

complex cases

Keywords

Laparoscopic resection, deep endometriotic nodule, pelvic pain, left hydronephrosis, renal function impairment

Media type

Surgical video

Duration

07'56''

Publication

2009-03

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E-publication

WeBSurg.com, Mar 2009;9(03).
URL: http://www.websurg.com/doi-vd01en2536.htm

Laparoscopic resection of deep endometriotic nodule for pelvic pain, left hydronephrosis and renal function impairment

1. Exploration and exposure 00'23''

The patient has a left ovarian simple functional cyst and a right endometrioma. We start the procedure by freeing the sigmoid colon from its physiological attachment. Carbon dioxide will guide us to find the good dissection spaces. One must not use irrigation at this moment, since it makes our planes loose. We pay attention not to pass in the retroperitoneal space. Once we are in the good dissection plane, we do not have bleeding. The left ovarian cyst is drained for exposure purposes.

2. Identification of the left ureter 01'25''

The dilated left ureter is clearly identified once we pass in the retroperitoneal space. We dissect the ureter while trying to preserve the ureteral blood supply as much as possible. Energy use next to the ureter should be done with care, since ureteral damage can occur not only intraoperatively but also by secondary ischemia and necrosis. We continue our dissection until we find the stenotic ureter.

3. Excision of the endometriotic nodule 02'31''

We then begin to excise the nodule surrounding the stenotic ureter and causing an obstacle to urine flow. The tissues are very inflammatory at this level and bleeding easily occurs. Careful hemostasis should be carried out during all this dissection since a good view of the surgical field is mandatory because of the proximity of many important structures such as the ureter, pelvic nerves and uterine vessels.

4. Freeing the stenotic ureter and double J catheter placement 04'45''

After removing the endometriotic nodule, we begin to free the stenotic part of the left ureter. We place a double J catheter laparoscopically while performing at the same time a cystoscopy to be able to assist the good placement of the catheter. We introduce the double J catheter and push it with atraumatic graspers. Once the JJ catheter is in place, we excise the stenotic part of the ureter.

5. Excision of the stenotic ureter and ureteral re-anastomosis 05'33''

After excising the stenotic part of the ureter, we proceed to a ureteral re-anastomosis. Although ureteral re-implantation to the urinary bladder is still an option, we know from our experience that re-anastomosis is also associated with good results. We suture with Monocryl 4/0 absorbable sutures. Two to 4 stitches are generally sufficient.

6. Excision of right endometrioma 06'18''

The right endometrioma is then excised. After drainage of the cyst, we pull the inner surface of the endometrioma in order to evert the ovary. We make a small incision and we can easily identify a cleavage plane that we follow until we dissect all the cyst’s wall. Once achieved, the cystectomy is followed by a meticulous hemostasis of the ovary.

7. Final aspect of the left ureter 07'27''

As we can see, the left ureter has a decreased diameter when compared to the one it had at the beginning of the intervention. The therapeutic strategy consists of freeing the obstacle caused by the endometriotic nodule, placement of a double J catheter and monitoring for renal function in the postoperative follow-up. Further laparoscopic nephrectomy is to be discussed if the renal function is not ameliorated.