1. Preoperative preparation
a. The surgeon examines old operative reports.
b. An intravenous pyelogram (IVP) is recommended when there is severe and extensive endometriosis and selectively in other situations.
c. Cleansing enemas or a formal bowel preparation are recommended the day before surgery.
2. Excision of endometriosis at the level of the left ovary2: Endometriotic plaques overlying or invading the ureter are often associated with endometriomas of the ovary.
a. The course of the left ureter must be explored and defined before adhesiolysis is attempted.
b. The surgeon elevates the peritoneum lateral to the ureter with a toothed forceps and incises (with scissors or CO2 laser) for a distance of 2 cm to expose the ureter and the endometriosis.
c. The surgeon separates the ureter from surrounding tissues, using blunt aquadissection and perpendicular and parallel spreading with a blunt dissecting forceps.
d. With the ureter exposed, the ovarian adhesions are placed on ten-sion and the initial incision is made with scissors or a CO2 laser. Gentle blunt aquadissection with the suction irrigator usually completes the ovariolysis.
e. The ovarian endometrioma(s) is excised to improve surgical exposure.
f. The peritoneal incision is extended lateral to the endometriotic plaque.
g. The surgeon grasps the lateral margin of the endometriotic plaque with a pair of toothed forceps and reflects it medially.
h. The endometriotic plaque is dissected with aquadissection and blunt spreading forceps, cutting the peritoneum and dense adhesion bands to the muscularis of the ureter with scissors or a harmonic scalpel.
i. Caution must be exercised so that the dense adhesion bands do not tent the ureter. This dissection may be tedious and time consuming. The surgeon should be gentle and persistent, avoiding impulsive moves and rough dissection.
j. Hemoclips or fine bipolar forceps can be used for hemostasis. The surgeon excises the endometriosis.
k. The surgeon examines the ureter. Additional ureterolysis is performed if needed.
l. The peritoneal wounds are left open to heal.
3. Excision of endometriosis at level of the left uterosacral ligaments2: Medial displacement of the ureter adjacent to the uterosacral ligament may occur as a congenital anomaly or from contraction of deep fibrotic endometriosis in the uterosacral or broad ligament. Dissection of the ureter must be performed very carefully to avoid brisk bleeding from the extensive venous network in the cardinal ligament and from the uterine artery. The retroperitoneal approach is recommended.
a. The peritoneum is incised lateral to the ureter 2 cm from the cardinal ligament, and the incision is extended caudally.
b. The ureter is dissected free with aquadissection ana perpendicular and parallel spreading with a blunt dissecting forceps, until it can be displaced laterally with a blunt probe.
c. Hemostasis is applied with clips or bipolar coagulation. If bipolar coagulation is necessary to control bleeding, the power density must be kept low to prevent the lateral spread of thermal energy, but it must be sufficient for hemostasis.
d. With the ureter displaced laterally, the surgeon grasps the endometriosis with a pair of toothed forceps and maintains constant medial traction.
e. Excision with hemostasis is facilitated by use of the harmonic scalpel. Scissors dissection may require hemostasis with hemoclips or bipolar electrocoagulation.
f. To prevent or control bleeding or hematoma formation in the broad ligament, the uterine artery must be ligated. The paravesical and pararectal spaces must be opened and developed. The surgeon identifies the external iliac vein and artery, the internal iliac artery, the uterine artery, and the ureter. The surgeon displaces the yireter medially out of harm’s way and ligates the uterine artery with clips, bipolar electrocoagulation, or ligature.
4. Dissection of left-frozen-pelvis: In some cases of extensive endometriosis (greater than RAFS stage IV-70), the left tube and ovary are irrecoverably damaged, trapped by obliterative, adhesive disease between the sigmoid colon and the pelvic wall. The left-frozen-pelvis may be a complication of previous conservative surgery. The ureter is particularly at risk for ligation or transection. The experienced pelvic endosurgeon may attempt retroperitoneal dissection and left salpingo-oophorectomy; however, the prudent course in most cases is to gain access to the pelvis by laparotomy.
5. Dissection of frozen pelvis and frozen ureter: When the pelvic anatomy is totally distorted by obliterative endometriotic disease and the ureters are firmly embedded in endometriosis, laparotomy is recommended as the only mode of access. The surgical team (gynecologist, colorectal surgeon, and urologist) should be prepared for bowel resection as well as resection of the ureter(s) and implantation into the bladder.
PREOPERATIVE URETERAL CATHETERS
Surgery for severe and extensive endometriosis is often more challenging than surgery for malignancy. Deeply invasive disease combined with dense, obliterative adhesions so distort pelvic anatomy that dissection is long, tedious, and bloody. Ureteral catheters facilitate identification of the ureters and should be used in such cases, This gives the urologist an opportunity to meet the patient, read the detailed preoperative note, and perform a cystoscopy and insert the ureteral catheters. If a urologic problem arises, the urologist comes to the operating table prepared.
A detailed discussion of detection and intraoperative repair of ureteral injuries, as well as the diagnosis and treatment of unrecognized ureteral injuries and unsuccessful ureteral repairs, is beyond the scope of this chapter. Detailed information is readily available.5