- Email: [email protected]
2414 Endometriosis and the Prevalence of Infectious Agents within the Endometrium and Endo-Cervix
S168
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S98−S231
Virtual Poster Session 3: Endometriosis (9:50 AM − 10:00 AM)
of 1,87cm, and a proximity to the ureters bilaterally. The patient desired possible future fertility. Interventions: Laparoscopic approach for treatment of bladder and uterine lesion. Measurements and Main Results: Laparoscopic surgery identified the limits of the lesion. Nodule affected the round ligament bilaterally, bladder, and uterine serous layer. Both ureters were dissected since iliac bifurcation until uterine vessels. Horizontal incision was performed on the bladder around the lesion until the foley catheter visualization to avoid de ureteral meatus. Vesicouterine space was dissected and an 5cm lesion compromising the uterine serous to the cervix was removed. Yabuki space was recognized during the nodulectomy. Vaginal closure was made primordially followed by the vesical suture using 0 and 2-0 polygactin respectively. Operation was successfully completed. Patient was discharged 5 days later. Foley catheter and prophylactic antibiotic were used for 10 days. Social, urinary and sexual activities with improvement in pain and better quality of life. Conclusion: Urinary tract endometriosis is a rare disease, but when it occurs the bladder is the most affected site. Patients often complain of dysuria, hematuria, and chronic pelvic pain. Partial bladder cystectomy offers complete removal of endometriotic nodule promoting improvement of urinary symptoms and quality of life.
9:50 AM: STATION G 2612 Tumors of the Appendix: Prevalence in Patients with Chronic Pelvic Pain Undergoing Minimally Invasive Excision Surgery with Concomitant Appendectomy for Suspected Endometriosis Farzan Nikou A,1,* Tenzel NS,2 Hua P,3 Pan S,3 Orbuch L,2,4 Orbuch IK2,4. 1Icahn School of Medicine at Mount Sinai, New York, NY; 2 Obstetrics, Gynecology, and Reproductive Science, Mount Sinai Health System, New York, NY; 3Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY; 4Obstetrics and Gynecology, Providence Saint John’s Health Center, Santa Monica, CA *Corresponding author. Study Objective: To determine the prevalence of appendiceal tumors in patients with chronic pelvic pain undergoing excisional surgery. Design: Retrospective chart review. Setting: Two Large Metropolitan Academic Hospitals. Patients or Participants: 135 patients between the ages of 16 to 52 with chronic pelvic pain undergoing minimally invasive excision surgery with concomitant appendectomy for suspected endometriosis from January 2012 to June 2017. Interventions: Medical records and postoperative pathology reports were analyzed for all 135 patients for the presence of appendiceal tumors, presence of endometriosis, and age. Measurements and Main Results: The prevalence of appendiceal tumors in patients with chronic pelvic pain was 3% (95% CI:0.1-5.8%). Of these cases, three were neuroendocrine carcinoid tumors (0.5 cm, 0.6 cm, and 1.1 cm respectively) and one was a low grade appendiceal mucinous neoplasm (LAMN). Two of the patients had biopsy confirmed endometriosis. The biopsy confirmed endometriosis patients had the 0.6 cm neuroendocrine carcinoid tumor and the LAMN, respectively. Patients with and without appendiceal tumors had mean ages of 26.8§7.1 and 32.6§7.6 years, respectively. Conclusion: The 3% prevalence of appendiceal tumors in our sample and the young age of the patients with appendiceal tumors is at odds with the much lower prevalence of appendiceal tumors and much older patient population reported in the literature. This highlights the increased need for research to establish predictive diagnostic criteria for appendiceal tumors and suggests that surgeons consider concomitant appendectomies in patients with chronic pelvic pain. Virtual Poster Session 3: Endometriosis (9:50 AM − 10:00 AM) 9:50 AM: STATION H 1959 Laparoscopic Resection of Bladder and Uterine Cervix Endometriotic Nodule Silveira BBF,1,* Ribeiro HA,1 Oliveira MMV,1 Cervantes GV,2 Souza AC,1 Ribeiro PA1. 1Irmandade da Santa Casa de Miseric ordia de S~ ao Paulo, S~ ao Paulo, Brazil; 2Laparoscopic Surgery and Endometriosis, Irmandade da Santa Casa de Miseric ordia de S~ ao Paulo, S~ ao Paulo, Brazil *Corresponding author. Video Objective: Laparoscopic resection of bladder endometriosis is associated to the benefits of a minimally invasive approach. In this video, we aim to describe the surgical strategy applied in the treatment of anterior compartment deep endometriosis with bladder and uterine cervix infiltration. Setting: Academic and public hospital. Patients: A 37-year-old patient, with dysmenorrhea since the menarche, dysuria and dyspareunia for the last 3 years, without improvement with medical treatment. Complementary exams showed a 2,18cm bladder endometriosis nodule with an extension to cervical and anterior isthmic region
Virtual Poster Session 3: Endometriosis (9:50 AM − 10:00 AM) 9:50 AM: STATION I 2196 Vulvar Vestibulectomy with Vaginal Advancement Flap for Neuroproliferative Vulvodynia Wu CZ,1,* Goldstein A,2 Klebanoff J,3 Moawad GN4. 1Minimally Invasive Gynecologic Surgery, George Washington University Hospital, Washington DC, DC; 2George Washington University Hospital, Washington DC, DC; 3George Washington University, Washington, DC; 4 The George Washington University, Washington, DC *Corresponding author. Video Objective: To demonstrate the surgical technique and steps of a vulvar vestibulectomy procedure used for management of neuroproliferative vulvodynia. Setting: A patient with lifelong vulvar pain and dyspareunia diagnosed with neuroproliferative vulvodynia seeking surgical management at a large academic center. Interventions: Vulvodynia is a common, but under recognized, cause of pain in women. In neuroproliferative vulvodynia, there is a higher density of nociceptors in the vestibule that cause both allodynia and hyperalgesia. Though medical management options are available, surgical management through vestibulectomy removes the affected mucosa with the associated nociceptors, and can more effectively alleviate pain for these women. Conclusion: For patients with neuroproliferative vulvodynia, surgical management with removal of the vulvar vestibule is a safe and effective treatment method. Virtual Poster Session 3: Endometriosis (9:50 AM − 10:00 AM) 9:50 AM: STATION J 2414 Endometriosis and the Prevalence of Infectious Agents within the Endometrium and Endo-Cervix Hilgers SJ,1,2 Roberts A3,*. 1Obstetrics & Gynecology; 2Reproductive Robotic Surgery Program, Houston Methodist Hospital, Houston, TX; 3 Obstetrics & Gynecology Residency Program, Houston Methodist Hospital, Houston, TX *Corresponding author. Study Objective: The presence of endometriosis has been shown to be strongly associated with chronic endometritis, and, furthermore, chronic endometritis has been associated with infectious agents in the endometrial
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S98−S231
S169
cavity (73% in published data). We planned to evaluate the prevalence of infectious agents within in the endometrial cavity and endo-cervix when endometriosis is present. Design: Retrospective review of all patients that underwent diagnostic laparoscopy, diagnostic hysteroscopy, and the collection of sterile endometrial/endo-cervical cultures during surgical evaluation for suspected endometriosis and chronic endometritis. Setting: Referral center for reproductive medicine and surgery in an academic medical center. Patients or Participants: All patients diagnosed with endometriosis at the time of laparoscopy who underwent collection of endometrial/endo-cervical cultures from 2016 − 2018 (N=97). Interventions: N/A. Measurements and Main Results: Sterile endometrial/endo-cervical cultures were collected, per standardized protocol, prior to preparation of the vagina. Aerobic/anaerobic cultures; PCR for mycoplasma/ureaplasma/gonorrhea/chlamydia; viral cultures; and yeast cultures were performed. In patients diagnosed with endometriosis at the time of laparoscopy, 70% tested positive for an infectious agent on endometrial/endo-cervical culture. Organisms were found in 65% of individuals diagnosed laparoscopically with mild endometriosis (American Society for Reproductive Medicine Revised Classification of Endometriosis “ASRM Classification” Stage 1-2), and 75% diagnosed with severe endometriosis (ASRM Classification Stage 3-4). Gram positive organisms were the most common infectious agent cultured at 72%, and were primarily E. Faecalis (31%), Lactobacillus (17%), and Group B Strep (15%). Gram negative organisms (18%) were primarily E. coli (10%). Less commonly, yeasts (13%), anaerobes (3%), and ureaplasma (1%) were found. No gonorrhea, chlamydia, mycoplasma, or viruses were detected. No significant correlation was found between severity of endometriosis and prevalence of any single organism. Conclusion: For individuals with endometriosis, regardless of severity, the presence of infectious organisms in the endometrium and endo-cervix is similar to published data on chronic infectious endometritis.
bleeding. While PU indicated adnexal abnormalities in 25% of patients (hydrosalpinx, ovarian cysts or endometrioma), BPE only identified 1 case, for a detection rate of 20%. PU identified myomas in 80% of the cases, while BPE detected only 5 cases, for a detection rate of 31%. Although the size and location of myomas were mostly undetermined by BPE, it did accurately assess uterine size in 80% of the cases. Conclusion: BPE offers little clinical utility in diagnosing gynecologic problems in symptomatic women. A full prospective study of a large number of patients is in progress to further validate these results.
Virtual Poster Session 3: Endometriosis (9:50 AM − 10:00 AM) 9:50 AM: STATION K 2948 Prospective, Single-Blinded Pilot Study: Bimanual Pelvic Examination Versus Pelvic Ultrasound Results in Symptomatic Women Touchan F,1,* Mamik M,2 Sarfoh V,2 Mackoul P,2 Danilyants N,3 van der Does L,1 Haworth L1. 1Research, The Center for Innovative GYN Care, Rockville, MD; 2The Center for Innovative GYN Care, Rockville, MD; 3cigc, Rockville, MD *Corresponding author. Study Objective: To compare the results of bimanual pelvic exam (BPE) to Pelvic Ultrasound (PU) in symptomatic women. The American College of Physicians reported that 35% of women may experience pain, discomfort, embarrassment, or anxiety during a pelvic exam. This may serve as a barrier for women to seek medical care, which could potentially delay diagnosis. While prior studies show lack of evidence for routine BPE in asymptomatic women, its use in symptomatic women may also be limited. Design: Prospective single-blinded pilot study. Setting: Free-standing ambulatory surgery center serving the Washington, DC area. Patients or Participants: Women, 18 years or older, with BMI < 40, presenting for evaluation of symptomatic gynecologic problems. Interventions: BPE was performed by an experienced gynecologist blinded to the patient’s previous ultrasound results. The sonographer was also blinded to BPE results. Measurements and Main Results: A total of 20 patients were evaluated, 45% for abnormal uterine bleeding, 60% for pelvic pain or dysmenorrhea, 25% for infertility or pregnancy losses, and 15% for post-menopausal
Virtual Poster Session 3: Endometriosis (9:50 AM − 10:00 AM) 9:50 AM: STATION L 1901 Obliterated Rectovaginal Space Dissection Gupta N*. Minimally Invasive Gynecologic Surgery, Jackson Madison County General Hospital, Jackson, TN *Corresponding author. Video Objective: Show dissection techniques in a completely obliterated cul-de sac. Setting: Stage 4 Endometriosis patient. Interventions: Robotic assisted excision of endometriosis, hysterectomy and restoration of normal anatomy. Conclusion: Stage 4 Endometriosis causes frozen pelvis and complete distortion of normal anatomy. Restoration of normal anatomy and excision of endometriosis is the goal of surgery in such patients whether or not hysterectomy is performed. It is essential to restore the normal anatomy and identify the key structures before undertaking hysterectomy to avoid inadvertent injuries and also to provide symptomatic relief to the patient. Deeply infiltrative fibrotic endometriosis infiltrates through rectovaginal space and causes complete obliteration of the cul-de sac, displacement of ureters, distorted pelvic side walls and perirectal fossas. The dissection is started by identifying the ureters on each side, develop normal space between the ureter and colon as well as between the rectum and uterosacral ligaments. The instinct is to tackle the midline but a minimally invasive gynecologic surgeon should know that the correct approach is in developing the spaces laterally before dissecting in the midline. Virtual Poster Session 3: Endometriosis (9:50 AM − 10:00 AM) 9:50 AM: STATION M 2133 Bilateral Ureteral Endometriosis - an Indolent, Aggressive and Dangerous Condition Fernandes LFC,1,* Xavier GE,2 Bassi MA3. 1Obstetrics and Gynecology, Faculty of Medicine of University of S~ ao Paulo, S~ ao Paulo, Brazil; 2 Urology, Faculty of Medicine of University of S~ ao Paulo, S~ ao Paulo, Brazil; 3Gynecology, Faculty of Medicine of University of S~ ao Paulo, S~ ao Paulo, Brazil *Corresponding author. Video Objective: Describe an unusual bilateral ureteral reimplantation due to endometriosis and a flowchart of a conservative decision making. Setting: Deep infiltrating endometriosis (DIE) involving the ureter has an incidence of 0.1 − 1%, normally affecting the lower third of its segment, up to 4 cm above the vesicoureteric junction. Bilateral ureteral involvement happens in 9% of the cases. The absence of specific symptoms makes its diagnostic challenging. Lumbar pain takes place when its involvement is complicated by a marked obstruction, with an impaired renal function. Decompressive surgery is mandatory. The necessity of ureteroneocystostomy increases along with the severity of hydronephrosis, accounting for 62% of the ureteral decompressive procedures. Even though, bilateral ureteroneocystostomy is a rare procedure, not trespassing 6% of ureteral reimplantations.
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S98−S231
Virtual Poster Session 3: Endometriosis (9:50 AM − 10:00 AM)
of 1,87cm, and a proximity to the ureters bilaterally. The patient desired possible future fertility. Interventions: Laparoscopic approach for treatment of bladder and uterine lesion. Measurements and Main Results: Laparoscopic surgery identified the limits of the lesion. Nodule affected the round ligament bilaterally, bladder, and uterine serous layer. Both ureters were dissected since iliac bifurcation until uterine vessels. Horizontal incision was performed on the bladder around the lesion until the foley catheter visualization to avoid de ureteral meatus. Vesicouterine space was dissected and an 5cm lesion compromising the uterine serous to the cervix was removed. Yabuki space was recognized during the nodulectomy. Vaginal closure was made primordially followed by the vesical suture using 0 and 2-0 polygactin respectively. Operation was successfully completed. Patient was discharged 5 days later. Foley catheter and prophylactic antibiotic were used for 10 days. Social, urinary and sexual activities with improvement in pain and better quality of life. Conclusion: Urinary tract endometriosis is a rare disease, but when it occurs the bladder is the most affected site. Patients often complain of dysuria, hematuria, and chronic pelvic pain. Partial bladder cystectomy offers complete removal of endometriotic nodule promoting improvement of urinary symptoms and quality of life.
9:50 AM: STATION G 2612 Tumors of the Appendix: Prevalence in Patients with Chronic Pelvic Pain Undergoing Minimally Invasive Excision Surgery with Concomitant Appendectomy for Suspected Endometriosis Farzan Nikou A,1,* Tenzel NS,2 Hua P,3 Pan S,3 Orbuch L,2,4 Orbuch IK2,4. 1Icahn School of Medicine at Mount Sinai, New York, NY; 2 Obstetrics, Gynecology, and Reproductive Science, Mount Sinai Health System, New York, NY; 3Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY; 4Obstetrics and Gynecology, Providence Saint John’s Health Center, Santa Monica, CA *Corresponding author. Study Objective: To determine the prevalence of appendiceal tumors in patients with chronic pelvic pain undergoing excisional surgery. Design: Retrospective chart review. Setting: Two Large Metropolitan Academic Hospitals. Patients or Participants: 135 patients between the ages of 16 to 52 with chronic pelvic pain undergoing minimally invasive excision surgery with concomitant appendectomy for suspected endometriosis from January 2012 to June 2017. Interventions: Medical records and postoperative pathology reports were analyzed for all 135 patients for the presence of appendiceal tumors, presence of endometriosis, and age. Measurements and Main Results: The prevalence of appendiceal tumors in patients with chronic pelvic pain was 3% (95% CI:0.1-5.8%). Of these cases, three were neuroendocrine carcinoid tumors (0.5 cm, 0.6 cm, and 1.1 cm respectively) and one was a low grade appendiceal mucinous neoplasm (LAMN). Two of the patients had biopsy confirmed endometriosis. The biopsy confirmed endometriosis patients had the 0.6 cm neuroendocrine carcinoid tumor and the LAMN, respectively. Patients with and without appendiceal tumors had mean ages of 26.8§7.1 and 32.6§7.6 years, respectively. Conclusion: The 3% prevalence of appendiceal tumors in our sample and the young age of the patients with appendiceal tumors is at odds with the much lower prevalence of appendiceal tumors and much older patient population reported in the literature. This highlights the increased need for research to establish predictive diagnostic criteria for appendiceal tumors and suggests that surgeons consider concomitant appendectomies in patients with chronic pelvic pain. Virtual Poster Session 3: Endometriosis (9:50 AM − 10:00 AM) 9:50 AM: STATION H 1959 Laparoscopic Resection of Bladder and Uterine Cervix Endometriotic Nodule Silveira BBF,1,* Ribeiro HA,1 Oliveira MMV,1 Cervantes GV,2 Souza AC,1 Ribeiro PA1. 1Irmandade da Santa Casa de Miseric ordia de S~ ao Paulo, S~ ao Paulo, Brazil; 2Laparoscopic Surgery and Endometriosis, Irmandade da Santa Casa de Miseric ordia de S~ ao Paulo, S~ ao Paulo, Brazil *Corresponding author. Video Objective: Laparoscopic resection of bladder endometriosis is associated to the benefits of a minimally invasive approach. In this video, we aim to describe the surgical strategy applied in the treatment of anterior compartment deep endometriosis with bladder and uterine cervix infiltration. Setting: Academic and public hospital. Patients: A 37-year-old patient, with dysmenorrhea since the menarche, dysuria and dyspareunia for the last 3 years, without improvement with medical treatment. Complementary exams showed a 2,18cm bladder endometriosis nodule with an extension to cervical and anterior isthmic region
Virtual Poster Session 3: Endometriosis (9:50 AM − 10:00 AM) 9:50 AM: STATION I 2196 Vulvar Vestibulectomy with Vaginal Advancement Flap for Neuroproliferative Vulvodynia Wu CZ,1,* Goldstein A,2 Klebanoff J,3 Moawad GN4. 1Minimally Invasive Gynecologic Surgery, George Washington University Hospital, Washington DC, DC; 2George Washington University Hospital, Washington DC, DC; 3George Washington University, Washington, DC; 4 The George Washington University, Washington, DC *Corresponding author. Video Objective: To demonstrate the surgical technique and steps of a vulvar vestibulectomy procedure used for management of neuroproliferative vulvodynia. Setting: A patient with lifelong vulvar pain and dyspareunia diagnosed with neuroproliferative vulvodynia seeking surgical management at a large academic center. Interventions: Vulvodynia is a common, but under recognized, cause of pain in women. In neuroproliferative vulvodynia, there is a higher density of nociceptors in the vestibule that cause both allodynia and hyperalgesia. Though medical management options are available, surgical management through vestibulectomy removes the affected mucosa with the associated nociceptors, and can more effectively alleviate pain for these women. Conclusion: For patients with neuroproliferative vulvodynia, surgical management with removal of the vulvar vestibule is a safe and effective treatment method. Virtual Poster Session 3: Endometriosis (9:50 AM − 10:00 AM) 9:50 AM: STATION J 2414 Endometriosis and the Prevalence of Infectious Agents within the Endometrium and Endo-Cervix Hilgers SJ,1,2 Roberts A3,*. 1Obstetrics & Gynecology; 2Reproductive Robotic Surgery Program, Houston Methodist Hospital, Houston, TX; 3 Obstetrics & Gynecology Residency Program, Houston Methodist Hospital, Houston, TX *Corresponding author. Study Objective: The presence of endometriosis has been shown to be strongly associated with chronic endometritis, and, furthermore, chronic endometritis has been associated with infectious agents in the endometrial
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S98−S231
S169
cavity (73% in published data). We planned to evaluate the prevalence of infectious agents within in the endometrial cavity and endo-cervix when endometriosis is present. Design: Retrospective review of all patients that underwent diagnostic laparoscopy, diagnostic hysteroscopy, and the collection of sterile endometrial/endo-cervical cultures during surgical evaluation for suspected endometriosis and chronic endometritis. Setting: Referral center for reproductive medicine and surgery in an academic medical center. Patients or Participants: All patients diagnosed with endometriosis at the time of laparoscopy who underwent collection of endometrial/endo-cervical cultures from 2016 − 2018 (N=97). Interventions: N/A. Measurements and Main Results: Sterile endometrial/endo-cervical cultures were collected, per standardized protocol, prior to preparation of the vagina. Aerobic/anaerobic cultures; PCR for mycoplasma/ureaplasma/gonorrhea/chlamydia; viral cultures; and yeast cultures were performed. In patients diagnosed with endometriosis at the time of laparoscopy, 70% tested positive for an infectious agent on endometrial/endo-cervical culture. Organisms were found in 65% of individuals diagnosed laparoscopically with mild endometriosis (American Society for Reproductive Medicine Revised Classification of Endometriosis “ASRM Classification” Stage 1-2), and 75% diagnosed with severe endometriosis (ASRM Classification Stage 3-4). Gram positive organisms were the most common infectious agent cultured at 72%, and were primarily E. Faecalis (31%), Lactobacillus (17%), and Group B Strep (15%). Gram negative organisms (18%) were primarily E. coli (10%). Less commonly, yeasts (13%), anaerobes (3%), and ureaplasma (1%) were found. No gonorrhea, chlamydia, mycoplasma, or viruses were detected. No significant correlation was found between severity of endometriosis and prevalence of any single organism. Conclusion: For individuals with endometriosis, regardless of severity, the presence of infectious organisms in the endometrium and endo-cervix is similar to published data on chronic infectious endometritis.
bleeding. While PU indicated adnexal abnormalities in 25% of patients (hydrosalpinx, ovarian cysts or endometrioma), BPE only identified 1 case, for a detection rate of 20%. PU identified myomas in 80% of the cases, while BPE detected only 5 cases, for a detection rate of 31%. Although the size and location of myomas were mostly undetermined by BPE, it did accurately assess uterine size in 80% of the cases. Conclusion: BPE offers little clinical utility in diagnosing gynecologic problems in symptomatic women. A full prospective study of a large number of patients is in progress to further validate these results.
Virtual Poster Session 3: Endometriosis (9:50 AM − 10:00 AM) 9:50 AM: STATION K 2948 Prospective, Single-Blinded Pilot Study: Bimanual Pelvic Examination Versus Pelvic Ultrasound Results in Symptomatic Women Touchan F,1,* Mamik M,2 Sarfoh V,2 Mackoul P,2 Danilyants N,3 van der Does L,1 Haworth L1. 1Research, The Center for Innovative GYN Care, Rockville, MD; 2The Center for Innovative GYN Care, Rockville, MD; 3cigc, Rockville, MD *Corresponding author. Study Objective: To compare the results of bimanual pelvic exam (BPE) to Pelvic Ultrasound (PU) in symptomatic women. The American College of Physicians reported that 35% of women may experience pain, discomfort, embarrassment, or anxiety during a pelvic exam. This may serve as a barrier for women to seek medical care, which could potentially delay diagnosis. While prior studies show lack of evidence for routine BPE in asymptomatic women, its use in symptomatic women may also be limited. Design: Prospective single-blinded pilot study. Setting: Free-standing ambulatory surgery center serving the Washington, DC area. Patients or Participants: Women, 18 years or older, with BMI < 40, presenting for evaluation of symptomatic gynecologic problems. Interventions: BPE was performed by an experienced gynecologist blinded to the patient’s previous ultrasound results. The sonographer was also blinded to BPE results. Measurements and Main Results: A total of 20 patients were evaluated, 45% for abnormal uterine bleeding, 60% for pelvic pain or dysmenorrhea, 25% for infertility or pregnancy losses, and 15% for post-menopausal
Virtual Poster Session 3: Endometriosis (9:50 AM − 10:00 AM) 9:50 AM: STATION L 1901 Obliterated Rectovaginal Space Dissection Gupta N*. Minimally Invasive Gynecologic Surgery, Jackson Madison County General Hospital, Jackson, TN *Corresponding author. Video Objective: Show dissection techniques in a completely obliterated cul-de sac. Setting: Stage 4 Endometriosis patient. Interventions: Robotic assisted excision of endometriosis, hysterectomy and restoration of normal anatomy. Conclusion: Stage 4 Endometriosis causes frozen pelvis and complete distortion of normal anatomy. Restoration of normal anatomy and excision of endometriosis is the goal of surgery in such patients whether or not hysterectomy is performed. It is essential to restore the normal anatomy and identify the key structures before undertaking hysterectomy to avoid inadvertent injuries and also to provide symptomatic relief to the patient. Deeply infiltrative fibrotic endometriosis infiltrates through rectovaginal space and causes complete obliteration of the cul-de sac, displacement of ureters, distorted pelvic side walls and perirectal fossas. The dissection is started by identifying the ureters on each side, develop normal space between the ureter and colon as well as between the rectum and uterosacral ligaments. The instinct is to tackle the midline but a minimally invasive gynecologic surgeon should know that the correct approach is in developing the spaces laterally before dissecting in the midline. Virtual Poster Session 3: Endometriosis (9:50 AM − 10:00 AM) 9:50 AM: STATION M 2133 Bilateral Ureteral Endometriosis - an Indolent, Aggressive and Dangerous Condition Fernandes LFC,1,* Xavier GE,2 Bassi MA3. 1Obstetrics and Gynecology, Faculty of Medicine of University of S~ ao Paulo, S~ ao Paulo, Brazil; 2 Urology, Faculty of Medicine of University of S~ ao Paulo, S~ ao Paulo, Brazil; 3Gynecology, Faculty of Medicine of University of S~ ao Paulo, S~ ao Paulo, Brazil *Corresponding author. Video Objective: Describe an unusual bilateral ureteral reimplantation due to endometriosis and a flowchart of a conservative decision making. Setting: Deep infiltrating endometriosis (DIE) involving the ureter has an incidence of 0.1 − 1%, normally affecting the lower third of its segment, up to 4 cm above the vesicoureteric junction. Bilateral ureteral involvement happens in 9% of the cases. The absence of specific symptoms makes its diagnostic challenging. Lumbar pain takes place when its involvement is complicated by a marked obstruction, with an impaired renal function. Decompressive surgery is mandatory. The necessity of ureteroneocystostomy increases along with the severity of hydronephrosis, accounting for 62% of the ureteral decompressive procedures. Even though, bilateral ureteroneocystostomy is a rare procedure, not trespassing 6% of ureteral reimplantations.