"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

Renato Seracchioli; Stefano Ferla; Pierandrea DE Benedetti; Agnese Virgilio; Antonio Raffone; Diego Raimondo

doi:10.1016/j.jmig.2024.04.012

"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

J Minim Invasive Gynecol. 2024 Apr 19:S1553-4650(24)00174-2. doi: 10.1016/j.jmig.2024.04.012. Online ahead of print.

Authors

Renato Seracchioli¹, Stefano Ferla², Pierandrea DE Benedetti¹, Agnese Virgilio¹, Antonio Raffone³, Diego Raimondo⁴

Affiliations

¹ Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero - Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy.
² Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero - Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy. Electronic address: stefano.ferla2@studio.unibo.it.
³ Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy; Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, 80131 Naples, Italy.
⁴ Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero - Universitaria di Bologna, Bologna, Italy.

PMID: 38643963
DOI: 10.1016/j.jmig.2024.04.012

Abstract

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.

Keywords: endometriotic nodule; hematuria; minimally invasive surgery; robotic surgery; urinary endometriosis.