# Bladder Endometriosis as Part of Complex Pelvic Deep Endometriosis: Surgical Challenges and Outcomes in a Reference Center

## TL;DR

This paper explores the surgical management of bladder endometriosis, highlighting the challenges and outcomes in a specialized center.

## Contribution

The study provides insights into the surgical techniques and outcomes for complex bladder endometriosis cases managed by a bi-disciplinary team.

## Key findings

- Bladder endometriosis often coexists with involvement of other pelvic organs.
- Laparoscopic surgery is feasible and effective for managing complex bladder endometriosis.
- Postoperative complications are linked to disease complexity but remain low with specialized care.

## Abstract

Objective: To analyze multiple aspects of advanced bladder endometriosis surgery, based on the experience of an endometriosis reference center. Methods: This retrospective/prospective study included 80 consecutive patients with deep bladder endometriosis treated with laparoscopic surgery. Results: In 96.3% of cases, bladder endometriosis coexisted with other organ involvement: bowel (87.5%), uterus (61.3%), and ureters (37.5%); isolated bladder lesions occurred in 3.7%. Full-thickness bladder infiltration occurred in 36.4% of patients, and 71.8% had a history of surgery. The most frequent preoperative symptoms related to multiorgan involvement were dysmenorrhea (88.7%), dyschezia (75.0%), and dyspareunia (55.7%). Dysuria (55.7%), pollakiuria (17.9%), and urinary urgency (9.0%) were also reported. Shaving was performed in 45.0% of cases, resection in 40.0%, skinning in 15.0%, with two rare cases requiring bladder augmentation with bowel insert. Of all multiorgan surgeries (96.3% of cases), the most complex 30% were performed by a bi-disciplinary team of gynecologists and urologists. Postoperative complications occurred in 8 patients (10%) and were significantly associated with larger lesions, full-thickness infiltration, trigonum involvement, multiple organs opened, and prior surgery. Conclusions: Laparoscopic management of bladder endometriosis is feasible and effective, even in complex cases. Postoperative complications were linked to disease complexity but remained low, likely due to protective techniques used by the reference team. Optimal outcomes for the most difficult cases are more likely when procedures are performed by a bi-disciplinary team involving both oncological gynecologists specialized in deep endometriosis surgery and urologists. Given the heterogeneous clinical profiles of bladder endometriosis, treatment should be carried out in specialized centers where individualized surgical strategies can be implemented.