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Transurethral partial cystectomy and laparoscopic reconstruction for the management of bladder endometriosis
CASE REPORT Transurethral partial cystectomy and laparoscopic reconstruction for the management of bladder endometriosis See-Tong Pang, M.D., Ph.D.,a Angel Chao, M.D., Ph.D.,b Chin-Jung Wang, M.D.,b Gigin Lin, M.D.,c and Chyi-Long Lee, M.D., Ph.D.b a
Division of Urology, Department of Surgery, b Department of Obstetrics and Gynecology, and c Department of Radiology, Chang Gung Memorial Hospital, Linkou Medical Center and Chang Gung University College of Medicine, Tao-Yuan, Taiwan
Objective: To report the successful management of bladder endometriosis with laparoscopic and transurethral partial cystectomy. Design: Case report. Setting: Tertiary-care university hospital. Patient(s): A 36-year-old woman with bladder endometriosis. Intervention(s): Combined laparoscopic and transurethral excision of endometriotic lesions and bladder repair. Main Outcome Measure(s): Symptoms remission. Result(s): A hypoestrogenic agent with gonadotropin-releasing hormone (GnRH) agonist was administered for 6 months after the surgery. The patient found to be in good health with normal voiding and full continence during 14 months of regular follow-up evaluations. Conclusion(s): Combined laparoscopy and transurethral resectoscopy can be an alternative treatment to traditional laparotomy in women with bladder endometriosis, especially in those who have simultaneous pelvic endometriosis. (Fertil Steril 2008;90:2014.e1–e3. 2008 by American Society for Reproductive Medicine.) Key Words: Laparoscopy, endometriosis, bladder, transurethral
Endometriosis, defined as the presence of endometriotic glands and stroma outside the uterine cavity, affects 3% to 10% of women between the ages of 20 and 45 years and up to 25% to 35% of infertile women (1). The ovaries are the most frequent extrauterine implant site for endometriosis but other locations throughout the pelvis and even outside the pelvis have been observed (2). Urinary tract involvement has been estimated in 0.3% to 6% of all affected individuals (3, 4). The bladder is the most commonly involved site among the urinary tract structures (5). Treatment of bladder endometriosis (BE) can be medical therapy with antiestrogenic agents or surgical excision. Medical therapy often results in temporary improvement of the symptoms, but relapse may occur (6, 7). Most clinicians believe that surgical excision is the best option (4, 5). Abdominal Received March 2, 2008; revised and accepted April 20, 2008. S-T.P. has nothing to disclose. A.C. has nothing to disclose. C-J.W. has nothing to disclose. G.L. has nothing to disclose. C.-L.L. has nothing to disclose. Supported by a research grant (CMRPG350371) from Chang Gung Memorial Hospital, Taiwan. Reprint requests: Chin-Jung Wang, M.D., Department of Obstetrics and Gynecology, Division of Gynecologic Endoscopy, Chang Gung Memorial Hospital, Linkou Medical Center, 5, Fu-Hsin Street, Kwei-Shan Tao-Yuan, Taiwan (FAX: þ886-3-328-6700; E-mail: wang2260@cgmh. org.tw).
2014.e1
approach with partial cystectomy and bladder reconstruction is the traditional way; pure transurethral resection via resectoscopy is considered to be relatively contraindicated because of the possibility of perforation (4, 6, 7). Complete removal of endometriotic foci is the mainstay for assurance of cure. However, abdominal excision of BE for the sake of eradication of lesions, especially in laparoscopy, may increase the risk of ureteral injury. Thus, for more precise identification of the surgical margin and prevention of injuring ureteral orifices, we report a case of BE treated with combined transurethral and laparoscopic excision followed by laparoscopic bladder reconstruction.
CASE REPORT A 36-year-old woman, gravida 1, para 1, had a 2-year history of worsening lower abdominal pain, dysuria, and hematuria during menses. Her obstetric history revealed a vaginal delivery 10 years ago. She also underwent a laparoscopic conservative treatment with ablation/resection for bilateral ovarian and pelvic endometriosis 3 years ago. A hypoestrogenic agent with gonadotropin-releasing hormone (GnRH) agonist had been prescribed to begin 6 months after her surgery. The
Fertility and Sterility Vol. 90, No. 5, November 2008 Copyright ª2008 American Society for Reproductive Medicine, Published by Elsevier Inc.
0015-0282/08/$34.00 doi:10.1016/j.fertnstert.2008.04.045
FIGURE 1
FIGURE 2
Cystoscopic view of bladder endometriosis.
Laparoscopic view of bladder endometriosis (arrow) between uterine body and urinary bladder.
Pang. Endoscopic treatment of bladder endometriosis. Fertil Steril 2008.
Pang. Endoscopic treatment of bladder endometriosis. Fertil Steril 2008.
endometriotic deposits did not involve her urinary bladder or ureter at that time. A urologist (S-T.P.) was consulted for this patient’s lower urinary tract symptoms, and a cystoscopy revealed a 3-cm solid mass, slightly raised with a hyperemic appearance, surrounded by a congestive and edematous halo at the dome of the bladder (Fig. 1). The remainder of her bladder was visibly normal, as was its capacity. Computed tomography scans disclosed a round mass between the uterine body and urinary bladder. After a discussion of treatment options, the patient underwent a combined transurethral and laparoscopic partial cystectomy performed simultaneously by surgeons from the urology and gynecology departments, followed by a laparoscopic bladder repair. Under general anesthesia, the patient was placed in the dorsolithotomy Trendelenburg position with both legs protected by elastic bandages. Video-laparoscopy was performed with a 5-mm principal trocar introduced through the umbilicus. Three ancillary 5-mm cannulas were placed under laparoscopic visualization: one cannula in the left lower quadrant lateral to the inferior epigastric arteries, one 5 mm cannula in the right lower abdomen at the paramedian line at the level of the umbilicus, and the other 3-mm cannula in the right lower quadrant. The pelvic cavity was inspected systematically, and multiple endometrial deposits on the anterior abdominal wall and peritoneum were identified and destroyed by using electrodesiccation. The anterior cul-de-sac was dissected using the unipolar scissors to separate the bladder from the uterus. The bladder endometrioma was readily visible as it protruded from the dome of the bladder (Fig. 2). A 24F resectoscope with a Collings knife was used to cut full-thickness through the bladder and circumferentially excise the endometrioma. Fertility and Sterility
Ureteric stents were cystoscopically inserted for identification and avoidance of ureteric orifice damage. This procedure was observed laparoscopically to prevent adjacent organ injury. Once the endometrioma was completely excised, a 4 4 cm opening was created at the bladder dome. A Foley catheter was placed in the bladder. The endometrioma was removed through posterior colpotomy. The bladder defect was closed in two layers in a running fashion with 3-0 absorbable polyglactin 910 sutures (Vicryl, Ethicon Inc, Somerville, NJ) laparoscopically. The repair was tested by instilling 150 mL of methylene blue diluted in normal saline into the bladder, and no leaks were observed. A suction drain (Jackson-Pratt drain) was introduced through a 5-mm access site. The total operative time was 90 minutes with 30 mL of blood loss. Histopathologic evaluation confirmed transmural bladderwall endometriosis. The patient’s cystogram on postoperative day 7 was normal with a 350 mL volume, and the Foley catheter was removed. The patient was discharged on the eighth postoperative day after an uneventful recovery. A 6-month course of GnRH agonist administration was prescribed immediately after surgery. The patient was in good health with normal voiding and full continence during 14 months of regular follow-up evaluations.
DISCUSSION The symptoms caused by endometriosis in the bladder usually vary based on the location and size of the lesion as well as the phase of the menstrual cycle. Similar to our patient, most lesions affect the bladder dome and base (6). Though some women are asymptomatic, the condition 2014.e2
usually manifests as hematuria, dysuria, and suprapubic pain and discomfort (6–9). Westney et al. (9) found that 70% of their patients presenting with BE had symptoms that were identical to those of interstitial cystitis. The urethral syndrome may worsen during menstrual periods, and the pain can be more severe when the lesion is deeper into the detrusor muscle and of larger diameter (10). Because the urinary symptoms may be similar to those of interstitial cystitis or cystitis, these conditions should be included in the differential diagnosis. Just as the symptoms of BE present to clinicians in a variety of ways, imaging studies of BE may disclose the mass but otherwise be nonspecific (6). Cystoscopy can provide the most cost-effective examination (4–6). The presentation of endometriosis varies over the menstrual cycle; the lesions are more obvious and congestive during menstruation. Therefore, the optimal time for performing a cystoscopy may be the days around and during menstruation. A patient history of previous treatment for endometriosis and the concomitant existence of other forms of pelvic endometriosis are common (6, 11). Somigliana et al. (11) reported that 58.6% of 58 women with large bladder endometriotic nodules had combined superficial peritoneal implants, ovarian endometriomas, adhesions, and deep peritoneal endometriosis. A multidisciplinary approach is required to completely destroy coexisting abdominal endometriosis foci in one surgery. Despite at least three different theories to explain the pathogenic mechanism of BE (11), the common point of these has been that the direction of invasion is from the serosal surface of bladder toward mucosa (12, 13). That is, perforation will be inevitable via transurethral resection for transmural disease. Abdominal removal of BE followed by bladder repair is therefore the popular therapeutic option. Nevertheless, cystoscopy can easily identify the intralumenal lesions and the orifices of the ureter; thus, transurethral resection facilitates the procedures, provides assurance of complete removal of affected tissues, and avoids ureteral injury. Patients undergoing laparoscopic surgery experience shorter hospitalization, a smaller incision, less adhesion formation, and faster recovery compared with patients who have undergone traditional abdominal surgery. Due to these advantages, the majority of the gynecologic surgeries can be accomplished laparoscopically. Combined transurethral partial cystectomy and laparoscopic reconstruction for the management of bladder endometriosis and coexisting abdominal endometriosis fits into the trend for minimally invasive surgery.
2014.e3
Pang et al.
Sener et al. (8) reported a similar case where surgery was performed with the aid of the da Vinci robot (Intuitive Surgical, Sunnyvale, CA). Compared with standard laparoscopy, robot-assisted laparoscopy has a better instrument range of motion that can improve suturing techniques. However, the longer set-up time and greater expense limits its use in developing countries. In conclusion, BE is rare, and it usually coexists with other forms of abdominal endometriosis. Multidisciplinary cooperation is required to achieve complete excision of the lesions. A combined transurethral and laparoscopic approach, which can provide good results with minimal invasion, is an alternative for experienced hands.
REFERENCES 1. Olive DL, Schwartz LB. Endometriosis. N Engl J Med 1993;328: 1759–69. 2. Jenkins S, Olive DL, Haney AF. Endometriosis: pathogenetic implications of the anatomic distribution. Obstet Gynecol 1986;67:335–8. 3. Chapron C, Fauconnier A, Vieira M, Barakat H, Dousset B, Pansini V, et al. Anatomical distribution of deeply infiltrating endometriosis: surgical implications and proposition for a classification. Hum Reprod 2003;18:157–61. 4. Comiter CV. Endometriosis of the urinary tract. Urol Clin North Am 2002;29:625–35. 5. Shook TE, Nyberg LM. Endometriosis of the urinary tract. Urology 1988;31:1–6. 6. Pastor-Navarro H, Gimenez-Bachs JM, Donate-Moreno MJ, PastorGuzman JM, Ruız-Mondejar R, Atienzar-Tobarra M, et al. Update on the diagnosis and treatment of bladder endometriosis. Int Urogynecol J Pelvic Floor Dysfunct 2007;18:949–54. 7. Gustilo-Ashby AM, Paraiso MF. Treatment of urinary tract endometriosis. J Minim Invasive Gynecol 2006;13:559–65. 8. Sener A, Chew BH, Duvdevani M, Brock GB, Vilos GA, Pautler SE. Combined transurethral and laparoscopic partial cystectomy and robotassisted bladder repair for the treatment of bladder endometrioma. J Minim Invasive Gynecol 2006;13:245–8. 9. Westney OL, Amundsen CL, McGuire EJ. Bladder endometriosis: conservative management. J Urol 2000;163:1814–7. 10. Villa G, Mabrouk M, Guerrini M, Miqnemi G, Montanari G, Fabbri E, et al. Relationship between site and size of bladder endometriotic nodules and severity of dysuria. J Minim Invasive Gynecol 2007;14: 628–32. 11. Somigliana E, Vercellini P, Gattei U, Chopin N, Chiodo I, Chapron C. Bladder endometriosis: getting closer and closer to the unifying metastatic hypothesis. Fertil Steril 2007;87:1287–90. 12. Gajda M, Tyloch J, Tyloch F, Skok Z, Sujkowska R, Krakowiak J. Endometriosis of the urinary bladder. Int Urol Nephrol 1999;31:39–44. 13. Nezhat CH, Malik S, Osias J, Nezhat F, Nezhat C. Laparoscopic management of 15 patients with infiltrating endometriosis of the bladder and a case of primary intravesical endometrioid adenosarcoma. Fertil Steril 2002;78:872–5.
Endoscopic treatment of bladder endometriosis
Vol. 90, No. 5, November 2008
Division of Urology, Department of Surgery, b Department of Obstetrics and Gynecology, and c Department of Radiology, Chang Gung Memorial Hospital, Linkou Medical Center and Chang Gung University College of Medicine, Tao-Yuan, Taiwan
Objective: To report the successful management of bladder endometriosis with laparoscopic and transurethral partial cystectomy. Design: Case report. Setting: Tertiary-care university hospital. Patient(s): A 36-year-old woman with bladder endometriosis. Intervention(s): Combined laparoscopic and transurethral excision of endometriotic lesions and bladder repair. Main Outcome Measure(s): Symptoms remission. Result(s): A hypoestrogenic agent with gonadotropin-releasing hormone (GnRH) agonist was administered for 6 months after the surgery. The patient found to be in good health with normal voiding and full continence during 14 months of regular follow-up evaluations. Conclusion(s): Combined laparoscopy and transurethral resectoscopy can be an alternative treatment to traditional laparotomy in women with bladder endometriosis, especially in those who have simultaneous pelvic endometriosis. (Fertil Steril 2008;90:2014.e1–e3. 2008 by American Society for Reproductive Medicine.) Key Words: Laparoscopy, endometriosis, bladder, transurethral
Endometriosis, defined as the presence of endometriotic glands and stroma outside the uterine cavity, affects 3% to 10% of women between the ages of 20 and 45 years and up to 25% to 35% of infertile women (1). The ovaries are the most frequent extrauterine implant site for endometriosis but other locations throughout the pelvis and even outside the pelvis have been observed (2). Urinary tract involvement has been estimated in 0.3% to 6% of all affected individuals (3, 4). The bladder is the most commonly involved site among the urinary tract structures (5). Treatment of bladder endometriosis (BE) can be medical therapy with antiestrogenic agents or surgical excision. Medical therapy often results in temporary improvement of the symptoms, but relapse may occur (6, 7). Most clinicians believe that surgical excision is the best option (4, 5). Abdominal Received March 2, 2008; revised and accepted April 20, 2008. S-T.P. has nothing to disclose. A.C. has nothing to disclose. C-J.W. has nothing to disclose. G.L. has nothing to disclose. C.-L.L. has nothing to disclose. Supported by a research grant (CMRPG350371) from Chang Gung Memorial Hospital, Taiwan. Reprint requests: Chin-Jung Wang, M.D., Department of Obstetrics and Gynecology, Division of Gynecologic Endoscopy, Chang Gung Memorial Hospital, Linkou Medical Center, 5, Fu-Hsin Street, Kwei-Shan Tao-Yuan, Taiwan (FAX: þ886-3-328-6700; E-mail: wang2260@cgmh. org.tw).
2014.e1
approach with partial cystectomy and bladder reconstruction is the traditional way; pure transurethral resection via resectoscopy is considered to be relatively contraindicated because of the possibility of perforation (4, 6, 7). Complete removal of endometriotic foci is the mainstay for assurance of cure. However, abdominal excision of BE for the sake of eradication of lesions, especially in laparoscopy, may increase the risk of ureteral injury. Thus, for more precise identification of the surgical margin and prevention of injuring ureteral orifices, we report a case of BE treated with combined transurethral and laparoscopic excision followed by laparoscopic bladder reconstruction.
CASE REPORT A 36-year-old woman, gravida 1, para 1, had a 2-year history of worsening lower abdominal pain, dysuria, and hematuria during menses. Her obstetric history revealed a vaginal delivery 10 years ago. She also underwent a laparoscopic conservative treatment with ablation/resection for bilateral ovarian and pelvic endometriosis 3 years ago. A hypoestrogenic agent with gonadotropin-releasing hormone (GnRH) agonist had been prescribed to begin 6 months after her surgery. The
Fertility and Sterility Vol. 90, No. 5, November 2008 Copyright ª2008 American Society for Reproductive Medicine, Published by Elsevier Inc.
0015-0282/08/$34.00 doi:10.1016/j.fertnstert.2008.04.045
FIGURE 1
FIGURE 2
Cystoscopic view of bladder endometriosis.
Laparoscopic view of bladder endometriosis (arrow) between uterine body and urinary bladder.
Pang. Endoscopic treatment of bladder endometriosis. Fertil Steril 2008.
Pang. Endoscopic treatment of bladder endometriosis. Fertil Steril 2008.
endometriotic deposits did not involve her urinary bladder or ureter at that time. A urologist (S-T.P.) was consulted for this patient’s lower urinary tract symptoms, and a cystoscopy revealed a 3-cm solid mass, slightly raised with a hyperemic appearance, surrounded by a congestive and edematous halo at the dome of the bladder (Fig. 1). The remainder of her bladder was visibly normal, as was its capacity. Computed tomography scans disclosed a round mass between the uterine body and urinary bladder. After a discussion of treatment options, the patient underwent a combined transurethral and laparoscopic partial cystectomy performed simultaneously by surgeons from the urology and gynecology departments, followed by a laparoscopic bladder repair. Under general anesthesia, the patient was placed in the dorsolithotomy Trendelenburg position with both legs protected by elastic bandages. Video-laparoscopy was performed with a 5-mm principal trocar introduced through the umbilicus. Three ancillary 5-mm cannulas were placed under laparoscopic visualization: one cannula in the left lower quadrant lateral to the inferior epigastric arteries, one 5 mm cannula in the right lower abdomen at the paramedian line at the level of the umbilicus, and the other 3-mm cannula in the right lower quadrant. The pelvic cavity was inspected systematically, and multiple endometrial deposits on the anterior abdominal wall and peritoneum were identified and destroyed by using electrodesiccation. The anterior cul-de-sac was dissected using the unipolar scissors to separate the bladder from the uterus. The bladder endometrioma was readily visible as it protruded from the dome of the bladder (Fig. 2). A 24F resectoscope with a Collings knife was used to cut full-thickness through the bladder and circumferentially excise the endometrioma. Fertility and Sterility
Ureteric stents were cystoscopically inserted for identification and avoidance of ureteric orifice damage. This procedure was observed laparoscopically to prevent adjacent organ injury. Once the endometrioma was completely excised, a 4 4 cm opening was created at the bladder dome. A Foley catheter was placed in the bladder. The endometrioma was removed through posterior colpotomy. The bladder defect was closed in two layers in a running fashion with 3-0 absorbable polyglactin 910 sutures (Vicryl, Ethicon Inc, Somerville, NJ) laparoscopically. The repair was tested by instilling 150 mL of methylene blue diluted in normal saline into the bladder, and no leaks were observed. A suction drain (Jackson-Pratt drain) was introduced through a 5-mm access site. The total operative time was 90 minutes with 30 mL of blood loss. Histopathologic evaluation confirmed transmural bladderwall endometriosis. The patient’s cystogram on postoperative day 7 was normal with a 350 mL volume, and the Foley catheter was removed. The patient was discharged on the eighth postoperative day after an uneventful recovery. A 6-month course of GnRH agonist administration was prescribed immediately after surgery. The patient was in good health with normal voiding and full continence during 14 months of regular follow-up evaluations.
DISCUSSION The symptoms caused by endometriosis in the bladder usually vary based on the location and size of the lesion as well as the phase of the menstrual cycle. Similar to our patient, most lesions affect the bladder dome and base (6). Though some women are asymptomatic, the condition 2014.e2
usually manifests as hematuria, dysuria, and suprapubic pain and discomfort (6–9). Westney et al. (9) found that 70% of their patients presenting with BE had symptoms that were identical to those of interstitial cystitis. The urethral syndrome may worsen during menstrual periods, and the pain can be more severe when the lesion is deeper into the detrusor muscle and of larger diameter (10). Because the urinary symptoms may be similar to those of interstitial cystitis or cystitis, these conditions should be included in the differential diagnosis. Just as the symptoms of BE present to clinicians in a variety of ways, imaging studies of BE may disclose the mass but otherwise be nonspecific (6). Cystoscopy can provide the most cost-effective examination (4–6). The presentation of endometriosis varies over the menstrual cycle; the lesions are more obvious and congestive during menstruation. Therefore, the optimal time for performing a cystoscopy may be the days around and during menstruation. A patient history of previous treatment for endometriosis and the concomitant existence of other forms of pelvic endometriosis are common (6, 11). Somigliana et al. (11) reported that 58.6% of 58 women with large bladder endometriotic nodules had combined superficial peritoneal implants, ovarian endometriomas, adhesions, and deep peritoneal endometriosis. A multidisciplinary approach is required to completely destroy coexisting abdominal endometriosis foci in one surgery. Despite at least three different theories to explain the pathogenic mechanism of BE (11), the common point of these has been that the direction of invasion is from the serosal surface of bladder toward mucosa (12, 13). That is, perforation will be inevitable via transurethral resection for transmural disease. Abdominal removal of BE followed by bladder repair is therefore the popular therapeutic option. Nevertheless, cystoscopy can easily identify the intralumenal lesions and the orifices of the ureter; thus, transurethral resection facilitates the procedures, provides assurance of complete removal of affected tissues, and avoids ureteral injury. Patients undergoing laparoscopic surgery experience shorter hospitalization, a smaller incision, less adhesion formation, and faster recovery compared with patients who have undergone traditional abdominal surgery. Due to these advantages, the majority of the gynecologic surgeries can be accomplished laparoscopically. Combined transurethral partial cystectomy and laparoscopic reconstruction for the management of bladder endometriosis and coexisting abdominal endometriosis fits into the trend for minimally invasive surgery.
2014.e3
Pang et al.
Sener et al. (8) reported a similar case where surgery was performed with the aid of the da Vinci robot (Intuitive Surgical, Sunnyvale, CA). Compared with standard laparoscopy, robot-assisted laparoscopy has a better instrument range of motion that can improve suturing techniques. However, the longer set-up time and greater expense limits its use in developing countries. In conclusion, BE is rare, and it usually coexists with other forms of abdominal endometriosis. Multidisciplinary cooperation is required to achieve complete excision of the lesions. A combined transurethral and laparoscopic approach, which can provide good results with minimal invasion, is an alternative for experienced hands.
REFERENCES 1. Olive DL, Schwartz LB. Endometriosis. N Engl J Med 1993;328: 1759–69. 2. Jenkins S, Olive DL, Haney AF. Endometriosis: pathogenetic implications of the anatomic distribution. Obstet Gynecol 1986;67:335–8. 3. Chapron C, Fauconnier A, Vieira M, Barakat H, Dousset B, Pansini V, et al. Anatomical distribution of deeply infiltrating endometriosis: surgical implications and proposition for a classification. Hum Reprod 2003;18:157–61. 4. Comiter CV. Endometriosis of the urinary tract. Urol Clin North Am 2002;29:625–35. 5. Shook TE, Nyberg LM. Endometriosis of the urinary tract. Urology 1988;31:1–6. 6. Pastor-Navarro H, Gimenez-Bachs JM, Donate-Moreno MJ, PastorGuzman JM, Ruız-Mondejar R, Atienzar-Tobarra M, et al. Update on the diagnosis and treatment of bladder endometriosis. Int Urogynecol J Pelvic Floor Dysfunct 2007;18:949–54. 7. Gustilo-Ashby AM, Paraiso MF. Treatment of urinary tract endometriosis. J Minim Invasive Gynecol 2006;13:559–65. 8. Sener A, Chew BH, Duvdevani M, Brock GB, Vilos GA, Pautler SE. Combined transurethral and laparoscopic partial cystectomy and robotassisted bladder repair for the treatment of bladder endometrioma. J Minim Invasive Gynecol 2006;13:245–8. 9. Westney OL, Amundsen CL, McGuire EJ. Bladder endometriosis: conservative management. J Urol 2000;163:1814–7. 10. Villa G, Mabrouk M, Guerrini M, Miqnemi G, Montanari G, Fabbri E, et al. Relationship between site and size of bladder endometriotic nodules and severity of dysuria. J Minim Invasive Gynecol 2007;14: 628–32. 11. Somigliana E, Vercellini P, Gattei U, Chopin N, Chiodo I, Chapron C. Bladder endometriosis: getting closer and closer to the unifying metastatic hypothesis. Fertil Steril 2007;87:1287–90. 12. Gajda M, Tyloch J, Tyloch F, Skok Z, Sujkowska R, Krakowiak J. Endometriosis of the urinary bladder. Int Urol Nephrol 1999;31:39–44. 13. Nezhat CH, Malik S, Osias J, Nezhat F, Nezhat C. Laparoscopic management of 15 patients with infiltrating endometriosis of the bladder and a case of primary intravesical endometrioid adenosarcoma. Fertil Steril 2002;78:872–5.
Endoscopic treatment of bladder endometriosis
Vol. 90, No. 5, November 2008