What is the management approach for a bladder Deep Infiltrating Endometriosis (DIE) nodule?

Management of Bladder Deep Infiltrating Endometriosis (DIE) Nodules

Surgical excision via laparoscopic partial cystectomy with simultaneous cystoscopy is the definitive treatment for bladder DIE nodules, offering complete removal while preserving bladder function and minimizing recurrence. 1, 2

Diagnostic Confirmation and Pre-operative Assessment

• Transvaginal ultrasonography with a partially full bladder is the initial imaging modality to identify the nodule size, location, and relationship to surrounding structures 1
• Pelvic MRI should be performed to assess the extent of disease, involvement of the bladder wall layers, proximity to ureteric orifices, and presence of concurrent pelvic endometriosis 3
• Pre-operative cystoscopy helps visualize the intravesical component and determine the distance from ureteric orifices, which is critical for surgical planning 1, 3

Surgical Approach: The Gold Standard

Bimodal visualization using simultaneous laparoscopy and cystoscopy is the optimal surgical technique, as it allows complete resection while avoiding excessive normal bladder wall removal 1, 3

Step-by-Step Surgical Technique:

1. Cystoscopic marking: The urologist identifies and marks the nodule boundaries with a monopolar needle, confirming distance from ureteric orifices 1

2. Laparoscopic marking: The gynecologist marks the external bladder surface corresponding to the cystoscopic markings using bipolar scissors 1

3. Bladder mobilization: Dissect paravesical spaces bilaterally with the bladder partially full, separating it from the uterine isthmus 1

4. Partial cystectomy: Perform full-thickness excision of the marked nodule with a 5mm disease-free margin using monopolar hook or scissors 1, 2

5. Bladder reconstruction: Close the bladder defect in two layers (mucosa and muscularis) using absorbable sutures, typically in a transverse orientation to minimize tension 1

6. Ureteral management: If the nodule is near the uretero-vesical junction, perform ureterolysis and consider ureteral reimplantation with psoas hitch to reduce anastomotic tension 3

Location-Specific Considerations

• Bladder dome lesions (53% of cases): Easier to excise with lower complication risk 2
• Posterior wall/trigone proximity (47% of cases): Requires careful identification of ureteric orifices and potential ureteral stenting 2
• Uretero-vesical junction involvement: May require segmental ureteral resection with reimplantation 3, 4

Critical Intraoperative Techniques

• Bladder filling with methylene blue helps identify the exact depth of infiltration and ensures watertight closure 1
• Stay sutures at lateral bladder angles facilitate exposure and closure 1
• Frozen section analysis should be performed to rule out occult malignancy, particularly adenosarcoma 2

Post-operative Management

• Foley catheter drainage for 14-21 days to allow bladder healing 1, 4
• Ureteral stenting (if ureteral involvement) for 6-8 weeks 3
• 3D CT cystogram at 3 weeks post-operatively to confirm adequate healing before catheter removal 1
• Low-pressure cystoscopy at catheter removal to assess stitch line and rule out residual disease 1

Expected Outcomes and Complications

• Clavien-Dindo grade III complications occur in approximately 8% of bladder endometriosis cases 4
• Recurrence rates are minimal when complete excision with adequate margins is achieved 1, 4
• Symptom resolution (dysmenorrhea, dysuria, chronic pelvic pain) is achieved in the majority of patients 1, 4
• No nephrectomy required in contemporary series when managed by experienced teams 4

Important Caveats

• Multifocal disease is common: 39.1% of DIE cases have multiple lesions, requiring thorough inspection of the entire pelvis 5
• Associated intestinal DIE occurs in 9.9% of cases and is frequently multifocal (39.1%), necessitating complete bowel evaluation 5
• Normal-appearing pelvis does not exclude DIE: Deep infiltrating endometriosis can exist without visible superficial peritoneal disease 3
• Multidisciplinary team approach involving gynecologic surgeons and urologists is essential for optimal outcomes, particularly for complex cases involving the uretero-vesical junction 4

Medical Management is NOT Adequate

Hormonal suppression alone does not address deeply infiltrating bladder endometriosis that has penetrated the detrusor muscle. Surgical excision remains the only definitive treatment that provides both symptom relief and pathologic diagnosis 2, 4