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Retroperitoneal fibrosis (RPF) is a rare fibro-inflammatory condition characterized by abnormal tissue growth around the abdominal aorta and iliac arteries, usually encasing adjacent structures like the ureters. Its etiology remains most of the time idiopathic, but secondary causes, including malignancies and medication use, account for a minority of cases. This review aims to consolidate recent advancements in understanding RPF, focusing on its pathophysiology, diagnosis, and treatment. Literature search was conducted using databases like PubMed, with emphasis on recent publications. Biomarkers such as elevated CRP levels and imaging techniques like CT scans and MRI play pivotal roles in diagnosis and monitoring. Medical management primarily revolves around corticosteroids, with adjunctive therapies like tamoxifen and immunosuppressants showing promise. Surgical intervention, typically ureterolysis, becomes necessary in cases of urinary tract obstruction. This review studies the importance of a comprehensive approach to RPF management, integrating medical and surgical modalities for optimal patient outcomes.

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BACKGROUND: Endometriosis of the distal segment of the uterosacral ligament may lead to a displaced ureter in the surgical field and must be identified before safe disease excision can be carried out. The aim of this study is to investigate the benefit of the systematic use of preoperative intraureteral indocyanine green (ICG) fluorescence injection in patients undergoing endometriosis surgery. METHOD: In this proof-of-concept, monocentric, observational, cohort study data were prospectively collected and retrospectively analyzed. Patients underwent laparoscopic surgery for deep infiltrating endometriosis with suspected ureteral involvement between January 2022 and December 2023. Using the propensity score matching (PSM) in a 1:1 matching ratio, patients who underwent preoperative ICG injection were compared with those who did not in terms of ureterolysis length and duration, and operative time. RESULTS: The mean length of ureterolysis was shorter in the ICG group compared to the non-ICG group (p < 0.001). The ICG group also had shorter ureterolysis duration (p < 0.001) and operative time (p = 0.02). No complications were reported at mean 6.8-month follow-up visit. CONCLUSIONS: The systematic use of intraureteral ICG prior to uterosacral ligaments endometriosis surgery may be safe and could assist in reducing the length of ureterolysis and operative time. Larger prospective studies are needed to confirm our findings.

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BACKGROUND: Varicocele embolization, a minimally invasive treatment for symptomatic varicoceles, carries a rare risk of complications like ureteral obstruction and hydronephrosis. This case report documents such a case to raise awareness of these potential complications and showcase minimally invasive surgical management as a successful solution. CASE SUMMARY: A 35-year-old male presented with flank pain and hematuria following varicocele embolization. Imaging confirmed left ureteral obstruction and hydronephrosis. Laparoscopic ureterolysis successfully removed the embolization coil and repaired the ureter, resolving the patient's symptoms. Follow-up at six months and two years showed sustained improvement. CONCLUSION: Minimally invasive surgery offers an effective treatment option for rare complications like ureteral obstruction arising from varicocele embolization.

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Endometriosis surgery involving the ureter poses significant challenges requiring meticulous surgical techniques and vigilant postoperative care. This chapter addresses key aspects of ureterolysis techniques, intraoperative management of ureteral injuries, and postoperative care in the context of endometriosis surgery. Ureterolysis methods aim to isolate and mobilize the ureter while preserving its vascularity. Cold instruments and careful dissection are recommended to prevent thermal injury during surgery. Intraoperative tools such as indocyanine green (ICG) show promise in assessing for vascular compromise. Over half of ureteral injuries are detected postoperatively, necessitating a high index of suspicion. Optimal postoperative care in the case of ureteral injury involves Foley catheterization for decompression, ureteral stenting, and meticulous follow-ups to monitor healing and renal function. While advances have been made in surgical techniques and diagnostic tools, gaps persist in preoperative imaging optimization and predictive models for identifying at-risk patients. This chapter aims to bridge existing knowledge gaps, optimize surgical practices, and enhance the overall care and outcomes of patients undergoing endometriosis surgery involving the ureter.

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OBJECTIVE: To evaluate ureteral involvement using transvaginal sonography (TVS) regarding the distortion of the course of the ureters caused by deep endometriosis (DE), which can facilitate predicting the need for ureterolysis during surgery, even in the absence of ureteral stenosis or dilatation. METHODS: This is a single-center, observational, retrospective pilot study of 88 consecutive patients who later underwent surgery for DE that used ultrasound preoperative diagnosis of ureteral medial deviation of one or both ureters between January 2019 and January 2022. At TVS, the course of the ureter was considered medialized if, in longitudinal and transversal section, any distance was detectable between the ureter and the cervix at the point where the ureter crosses the uterine artery. The primary end point was to determine sensitivity, specificity, and positive and negative predictive values of "ureteral medial deviation" diagnosed using TVS, in order to predict the need for ureterolysis. RESULTS: Our series included 88 women with a median age of 39 (interquartile range 33-43) years. Ureteral medialization showed a relatively low false-positive rate (10.9%), with a specificity of 89.1% (95% confidence interval [CI] 81.4%-96.7%) and a sensitivity of 86.6% (95% CI 80.3%-92.9%), along with a high positive predictive value of 93.3% (95% CI 88.4%-98.1%), and a lower negative predictive value of 79.1% (95% CI 69.8%-88.5%), respectively. CONCLUSIONS: This study introduced a new ultrasound sign with a high degree of accuracy to predict ureterolysis and this may have positive implications in the management and surgical planning of patients with ureteral endometriosis.

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STUDY OBJECTIVE: The main objective is to describe the feasibility and report a single-center experience of a standardized laparoscopic modified radical hysterectomy technique among patients with severe endometriosis and pouch of Douglas obliteration. DESIGN: A single-center case series of laparoscopic modified radical hysterectomy performed at the Poissy Hospital between December 2012 and May 2021. SETTINGS: Single-center, gynecology unit (level III) with a focus on endometriosis. PATIENTS: Patients with severe endometriosis (stage 4 American Fertility Society) and pouch of Douglas obliteration. MEASUREMENTS AND MAIN RESULTS: Fifty-two patients with severe endometriosis underwent the surgical procedure. Of these patients, 23.1% underwent a rectal shaving (n = 12), 1.9% a discoid resection (n = 1), and 17.3% a rectal resection (n = 9), including a protective ileostomy in 1 case. Ureterolysis was performed on 82.7% of patients (n = 43). The average hospital stay was 3.3 days. Seven patients required intermittent self-catheterization (13.5%). Minor complications (Clavien-Dindo grade 1 and 2) occurred in 25.9% of the patients and severe complications in 3.8% of them (Clavien-Dindo grade 3, no grade 4). Two patients (3.8%) were reoperated: one for a postoperative occipital alopecia (balding) and the other for vaginal dehiscence with evisceration. Approximately 50 patients (96.2%) had a complete resection of endometriosis. The median follow-up was 14 months (interquartile range, 6-23 mo) with 94.3% of them improved (much and very much) and 3.8% minimally improved. CONCLUSION: In our experience, laparoscopic modified radical hysterectomy is a reliable procedure with a low rate of severe complications. This technique needs to be assessed by other surgeons and others centers across the country and abroad, to determine the likelihood of it succeeding.

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BACKGROUND: Ureterolysis represents the surgical treatment for retroperitoneal fibrosis. The aim of the study was to review the outcomes of patients who had undergone radical hysterectomy and radiotherapy for cervical cancer that later developed retroperitoneal fibrosis, for whom 3D laparoscopic ureterolysis was performed in our department and to review current published studies. METHODS: We present a series of cases consisting of 6 patients with secondary retroperitoneal fibrosis. In all cases, the intervention was performed by the same surgeon from the Oncological Institute "Prof. Dr. Ion Chiricuța" Cluj-Napoca, Romania. We carried out a literature review, searching in the PubMed and MEDLINE studies published between 2000 and 2021 relevant to the matter and a total of 12 papers were selected. We reviewed the functional outcomes of patients that underwent minimally invasive ureterolysis. RESULTS: 3D laparoscopic ureterolysis was performed in 6 patients. Mean operative time was 166 minutes and mean blood loss was 203 mL. No surgery required conversion. Five patients showed good functional results after ureteral stent removal. In one case, the patient developed acute pyelonephritis and the ureteral stents were kept. CONCLUSIONS: Laparoscopic ureterolysis for retroperitoneal fibrosis secondary to operated and radiation-treated cervical cancer represents one of the most complex and challenging surgeries in the urological field. From personal experience we conclude that in oncological centers with vast experience in laparoscopy this minimally invasive approach is feasible and safe. Published data, even though scarce, strengthens our results and the need for this surgery in patients with retroperitoneal fibrosis with urological impact. The laparoscopic approach comes with good functional results and with the advantages of faster post-operative recovery comparing to open surgery and comparable results with the precision and dexterity offered by the robotic approach, but with lower economic burden.

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Background: Ureterolysis represents the surgical treatment for retroperitoneal fibrosis. The aim of the study was to review the outcomes of patients who had undergone radical hysterectomy and radiotherapy for cervical cancer that later developed retroperitoneal fibrosis, for whom 3D laparoscopic ureterolysis was performed in our department and to review current published studies. Methods: We present a series of cases consisting of 6 patients with secondary retroperitoneal fibrosis. In all cases, the intervention was performed by the same surgeon from the Oncological Institute “Prof. Dr. Ion Chiricuț㔠Cluj-Napoca, Romania. We carried out a literature review, searching in the PubMed and MEDLINE studies published between 2000 and 2021 relevant to the matter and a total of 12 papers were selected. We reviewed the functional outcomes of patients that underwent minimally invasive ureterolysis. Results: 3D laparoscopic ureterolysis was performed in 6 patients. Mean operative time was 166 minutes and mean blood loss was 203 mL. No surgery required conversion. Five patients showed good functional results after ureteral stent removal. In one case, the patient developed acute pyelonephritis and the ureteral stents were kept. Conclusions: Laparoscopic ureterolysis for retroperitoneal fibrosis secondary to operated and radiation-treated cervical cancer represents one of the most complex and challenging surgeries in the urological field (AU)

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OBJECTIVE: Ureteral endometriosis has an incidence of 0.1% to 1%. The type of surgery required is either conservative (ureterolysis) or radical treatment, depending on the degree of ureter infiltration. The incidence of intraoperative and postoperative complications is heterogeneous. Thus, the aim of the current study was to propose a classification of ureterolysis based on the anatomical structure of the ureter and differing complication rates with procedures. METHODS: A total of 139 ureterolysis procedures were included in the study. Patients were divided into three groups according to the depth of ureterolysis required. Differences were recorded across the three types of ureterolysis in terms of intraoperative and postoperative complications. RESULTS: The incidence of ureteral fistula was reported in 0.7% of cases, with postoperative ureteral stenosis in 2% of type 2 ureterolysis. In the case of type 3 ureterolysis, after conservative procedures, 52.9% of patients required an ureteroneocystostomy to solve the ureteral stenosis. CONCLUSION: The risk of ureteral injury and ureteroneocystostomy after conservative procedures appears to be associated with type 3 ureterolysis, probably due to excessive devascularization, secondary to the incision of adventitia. Obviously, these data should be confirmed through a prospective study of a larger number, but our proposed classification can provide the basis for making data from future studies more comparable.

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Excision of deep infiltrating endometriosis has to be complete to prevent symptomatic recurrences but with more complications. The patients with obliterated Douglas space who wish a definitive treatment for their pain require a more complex hysterectomy to remove all the lesions. Laparoscopic modified radical hysterectomy may allow to perform safely this surgery following 9 steps. The dissection is standardized according to anatomical landmarks. The key steps are: extrafascial dissection of uterine pedicle by opening the pararectal spaces and paravesical space, nerve sparing, ureterolysis if needed, the retrograde dissection of rectovaginal space and the rectal step if needed. The rectal step depends on depth of rectal infiltration and on the number of nodules (rectal shaving, disc excision or rectal resection). This standardized procedure could help surgeons to achieve a complex radical surgery for patients with endometriosis and obliterated Douglas space.

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STUDY OBJECTIVE: To explore the use of indocyanine green (ICG) in highlighting ureteral anatomical landmarks for the successful and safe execution of robotic-assisted transvaginal NOTES hysterectomy with resection of deeply infiltrated endometriosis. DESIGN: Stepwise demonstration with narrated video footage. SETTING: An academic tertiary care hospital. Our patient is a 38-year-old G4P1031 with a symptomatic enlarged uterus secondary to adenomyosis and uterine myomas, dense adhesions between the posterior uterus, and left uterosacral ligament. INTERVENTIONS: Stage IV endometriosis with obliterated cul-de-sac is a challenging procedure in the surgical management of endometriosis. Ureterolysis is the key step to performing this surgery successfully and safely; however, the routine dissection of ureters from the sacral promontory level to the uterine artery is challenging in obliterated cul-de-sacs with pelvic side wall adhesions with the proximal ureter at greatest risk [1-4]. Using the ICG firefly technique allowed us to rapidly identify and safely dissect the ureter through robotic transabdominal endometriosis surgery [5,6]. The angle of approach in transvaginal NOTES surgery for hysterectomy with obliterated cul-de-sac endometriosis leads to far more difficulty in identifying the ureter at the beginning of surgery [3]. Therefore, an obliterated cul-de-sac was associated with a potentially increased risk of ureteral injury and bowel injury. We used ICG to help identify the ureter at the beginning of the case leading to reducing the risk of surgical complication, in which the concept of ureterolysis from the level of the uterine artery to the bifurcation of common iliac vessels in vNOTES surgery will be referred to as "vNOTES retrograde ureterolysis." With the cystoscope in place, a ureteral catheter was inserted into the right ureter and 5 cc of ICG was injected, and the same procedure was done on the left [1,5]. Bovie electrosurgical device was used to incise circumferentially around the cervix. The bladder was dissected off the pubovesical cervical fascia anteriorly and posteriorly with a combination of the Bovie as well as blunt and sharp dissection. Bilateral uterosacral and cardinal ligaments, as well as uterine arteries, were then clamped, transected with Mayo scissors, and secured. Entry into the anterior cul-de-sac was completed, and a stitch using 0 vicryl was used to tag the anterior peritoneum to the anterior vaginal cuff. Posterior entry was attempted unsuccessfully. The Gelpoint mini device was then placed, and the Da Vinci XI robot was docked. Bilateral ureters were identified and dissected out of bilateral pelvic sidewalls using the firefly mode at the level of the uterine artery. The ureters were easily dissected away from the uterus. The left broad ligament was then cauterized and transected using the vessel sealer. The plane between the uterus and the rectum was identified laterally, and the rectum was taken down from the uterus from the right to the left side. Bilateral broad ligaments were then cauterized and transected using the vessel sealer, followed by cauterization and transection of the round ligaments, utero-ovarian ligaments, and mesosalpinx bilaterally. The vaginal cuff angles were secured with a figure-of-eight stitch of 0 vicryl, and the vaginal cuff was then closed in a running fashion with 0 V-Loc. The patient was discharged in one day with reports of minimal pain (Videos 1-3). CONCLUSION: Robotic-assisted NOTES hysterectomy with deeply infiltrated endometriosis resection is feasible and safe with ICG-assisted ureteral labeling in a case of obliterated cul-de-sac. The unique green color labeling of ureters offers a prominent landmark in assisting the ureteral dissection while avoiding ureteral and bowel injury, resulting in the possibility of using vNOTES surgery in challenging cases.

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INTRODUCTION: Idiopathic retroperitoneal fibrosis is a known cause of obstructive uropathy. Ureterolysis is done when medical management fails or the presentation is at an advanced stage. Conventionally ureterolysis without omental wrap has been considered incomplete. Our Institute has experience of laparoscopic or robotic ureterolysis with intraperitonealization of the ureter alone and no other adjunctive procedure. This study retrospectively assesses the result of the procedure with patients presenting with varying severity of disease. METHODS: From 2008, all patients who underwent laparoscopic or robotic ureterolysis were analyzed retrospectively for pre-operative management, operative findings, and post operative outcomes. RESULTS: We operated and released nine renal units in seven patients. Two of the nine cases were performed robotically completely and the rest was performed by laparoscopic approach. Median follow up was 60 months. All patients documented resolution of symptoms. The mean post-operative creatinine at 1 year was significantly decreased to 1.47 ± 0.49 mg/dl in comparison to preoperative creatinine (p < 0.05). The postoperative mean ESR decreased significantly from a preoperative value of 58.2 ± 19.41 mm to 15.8 ± 17.23. The nuclear scan revealed unobstructed drainage and radiological imaging revealed resolution of hydronephrosis and fibrosis in all. The mean GFR on the nuclear scan after 3 and 12 months of surgery was 36.3 ± 4.33 and 40 ± 3.77, respectively. Thus, there was significant increase noted in GFR at 3 and 12 months in comparison to preoperative GFR (p < 0.05). CONCLUSION: Laparoscopic/robotic ureterolysis with intraperitonealization alone is secure and durable procedure for idiopathic retroperitoneal fibrosis needing surgical release.

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BACKGROUND: The aim of this study was to investigate the long-term effects of ureteral stenting and the exact timing of stent removal in favor of surgery in patients with idiopathic retroperitoneal fibrosis (IRF). SUMMARY: Medline research terms of "idiopathic retroperitoneal fibrosis" AND " medical therapy" OR "ureteral stenting" OR "surgical treatment" were done. Systematic reviews and observational and clinical studies were analyzed to obtain indication regarding the objective of the study for a narrative review. Ninety-two papers were analyzed. The treatment of IRF includes the monitoring of retroperitoneal fibrotic process spread and the prevention of abdominal organs entrapment. Treatment of ureteral obstruction includes medical therapy and ureteral stenting (US) or percutaneous nephrostomy (PNS) to overcome the worsening of renal function. Up to now, the timing of US or PNS removal is not yet clear, both for the complexity of evaluating the efficacy of the medical therapy and demonstrating the resolution of obstructive nephropathy. Moreover, it is not yet clear if the long-term ureteral stent placement or PNS is able to maintain an efficient renal function. Ureterolysis with a laparoscopic robot-assisted approach is now considered as an ultimate treatment for ureteral obstruction, limiting the progression of kidney impairment and improving the quality of life of patients, although nephrologists are generally abdicant regarding the potential switch toward the surgical approach. KEY MESSAGES: Prospective studies regarding the long-term effects of US on the renal function impairment in patients with IRF should be structured to obtain adequate information on the exact timing for the surgical approach.

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STUDY OBJECTIVE: To develop a model, including clinical features and ultrasound findings, to predict the need for ureterolysis (i.e., dissection of the ureter) during laparoscopy for endometriosis. DESIGN: A retrospective observational study of patients who had undergone transvaginal ultrasound (TVS) according to the International Deep Endometriosis Analysis consensus and subsequent laparoscopy ± excision of endometriosis between January 2017 and February 2021 was conducted. SETTING: Sydney Medical School Nepean, University of Sydney, Nepean Hospital, and Blue Mountains Hospital, New South Wales, Australia. PATIENTS/PARTICIPANT: 177 patients. INTERVENTION: The demographic, clinical, TVS, and intraoperative data were extracted through electronic clinical records. MEASUREMENTS AND MAIN RESULTS: Multicategorical decision-tree and baseline models were built to choose the variables most correlated to the outcome under study. Receiver operating characteristic analysis was performed on the binary classification. Based on our results, we selected the variables performing with significant statistical differences (p <.05). During the study period, 177 consecutive patients were recruited and divided into 2 subgroups, ureterolysis (51.4%) and nonureterolysis (48.6%). Ureterolysis was noted in 87.5% of patients in which the left ovary was immobile (p <.001) and in 82.5% in which the right ovary was fixed (p <.001). For patients with right uterosacral ligament (USL) deep endometriosis (DE), ureterolysis was performed in 96.2% patients (p <.001) and 64.6% (p = .043) for left USL DE. Among patients with bowel DE, the proportion of patients undergoing ureterolysis was 95.5% (p <.001). The prognostic variables used in the final model to predict ureterolysis included dyschezia, absence of ovarian mobility, presence of right or left USL DE, and presence of bowel DE on TVS. According to the developed model, the baseline risk for performing ureterolysis is 20% in our sample. The overall model performance demonstrated an area under the receiver operating characteristic curve 0.82. CONCLUSION: Our study demonstrates that it is possible to predict the need for ureterolysis with clinical and sonographic data. Furthermore, patients presenting with a combination of the variables of our model (dyschezia, ovarian immobility, USL, and bowel DE lesions) have a high risk of ureterolysis. In contrast, patients without these features have a low risk (approximately 20%) of needing ureterolysis.

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BACKGROUND: Ureteral trauma recognized in the operating theater is managed, for the most part, at the same surgical procedure oftentimes with urologic consultation. A delayed urine leak presents unique problems in that direct access to the site of the leak is not possible except by a reoperative procedure. METHODS: In patients who develop delayed urine leakage following cancer surgery, the leakage may be controlled by the collaborative efforts of a urologist and interventional radiologist. Success depends on placement of a nephroureteral stent by the rendezvous procedure. RESULTS: The sequence of procedures to reestablish ureteral continuity following a delayed leak are important in the successful placement of a nephroureteral stent. In the first methodology, through a percutaneous nephrostomy, a guidewire is placed in the ureter and down to the ureteral defect. The guidewire is then recovered and advanced into the bladder using a ureteroscope and grasping forceps. A nephroureteral stent is placed over the guidewire to bridge the gap and stent the ureteral defect. In the second methodology, the urologist passed a guidewire into the distal ureter, out of the ureteral defect, and into the free peritoneal space. Under fluoroscopic control, the wire loop must snare the ureteral guidewire and pull it out at the percutaneous nephrostomy. The nephroureteral stent is passed over the ureteral wire into the bladder. CONCLUSIONS: Two different methodologies were described to complete the rendezvous procedure. It can be successful a large percentage of the time with a delayed ureteral leakage. Success requires a combined interventional radiology and urologic procedure.

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OBJECTIVES: To determine whether ovarian fixation at transvaginal ultrasound (TVU) is a marker for a need for laparoscopic pelvic sidewall surgery (ie, ureterolysis or dissection of adhesions involving the pelvic sidewall). The relationship between ovarian immobility at TVU with respect to endometriosis staging using the revised American Fertility Society (r-AFS) classification was also evaluated. METHODS: Retrospective diagnostic accuracy study was performed in a tertiary referral hospital and two private hospitals. Sixty-six women with pelvic pain underwent detailed TVU preoperatively followed by laparoscopic endometriosis surgery. TVU ovarian mobility findings (ie, mobile versus fixed ovary) were compared to surgical findings, the need for laparoscopic pelvic sidewall surgery and r-AFS score (I-IV). RESULTS: Complete ultrasound and surgical data were available for 66 of 77 (86%) women. Twenty-six of 66 (40%) had isolated superficial peritoneal endometriosis, 15 of 66 (23%) had ovarian endometrioma (OE), 13 of 66 (20%) had pelvic deep endometriosis (DE). Twenty-seven of 66 (41%) had ovarian fixation at TVU. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of ovarian fixation at TVU for the prediction of need for laparoscopic pelvic sidewall surgery was 71%, 61%, 86%, 85%, and 62%, respectively (P = .0002). Ovarian fixation at TVU was significantly associated with the presence of ipsilateral OE, pouch of Douglas obliteration, pelvic DE nodules, and r-AFS stage III/IV (moderate/severe) endometriosis (all P-values <.05). CONCLUSIONS: Ovarian fixation at TVU appears to be a marker for moderate/severe endometriosis and the need for laparoscopic pelvic sidewall surgery. This sign may be a valuable "red flag" for identifying women at increased risk of requiring an advanced laparoscopic surgeon, and in turn, improve surgical planning.

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STUDY OBJECTIVE: To present a procedure to reduce the occurrence of intraoperative capsule rupture in presumed clinically early-stage ovarian cancer with adhesions to the abdominal wall. DESIGN: Stepwise presentation of the procedure with narrated video footage. SETTING: The occurrence of intraoperative capsule rupture exerts a negative effect on the prognosis of early-stage ovarian cancer [1,2]. Thus, it is important to reduce intraoperative capsule rupture to improve the oncologic outcome of such patients. In this video we describe a laparoscopic procedure to minimize the risk of intraoperative capsule rupture in presumed clinically early-stage ovarian cancer with adhesions to the abdominal wall. A 52-year-old woman was referred from a local clinic for a 6 × 6 × 4-cm left ovarian mass and a 7 × 6 × 6-cm right ovarian mass. Her serum cancer antigen 125 level was 214.4U/mL. Pelvic magnetic resonance imaging and positron emission tomographic/computed tomographic imaging showed no evidence of metastatic diseases or lymph node involvement. A diagnosis of ovarian malignancy was suspected. INTERVENTIONS: Laparoscopic evaluation suggested that the right adnexa was adhered to the right abdominal wall and there was no evidence of tumor seeding in the peritoneal cavity. We collected the peritoneal lavage fluid. Since pelvic adhesiolysis between the right adnexa and the abdominal wall may increase the occurrence of intraoperative capsule rupture of the ovarian tumor, leading to a worse clinical outcome, we decided to remove both the right adnexa as well as the adhered peritoneum. The key steps of the procedure are summarized as follows. First, the utero-ovarian ligament and tubal isthmus were coagulated and excised. Second, the pelvic peritoneum was excised, and the infundibulo-pelvic ligament and ureter were identified and mobilized. Third, the infundibulo-pelvic ligament was coagulated and excised. Fourth, the pelvic peritoneum which was adhered to the right adnexa was dissected off the ureter and excised. Then, the resected right adnexa as well as the adhered peritoneum were collected in a disposable pocket and removed to avoid further contamination. Adenocarcinoma was diagnosed by frozen section evaluation. So, surgical staging was performed laparoscopically, and consisted of hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissection, omentectomy, and random peritoneal biopsies from the pelvis, paracolic gutters, and undersurfaces of the diaphragm. Final pathologic reports showed ovarian clear cell carcinoma with involvement of both ovaries and the adhered peritoneum. CONCLUSION: Our method is effective for intact removal of the involved adnexa without rupture and the adhered pelvic peritoneum with potential for tumor seeding.

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STUDY OBJECTIVE: To describe the surgical management and risks of postoperative complications of patients with urinary tract endometriosis in France in 2017. DESIGN: Multicenter retrospective cohort pilot study. SETTING: Departments of gynecology at 31 expert endometriosis centers. PATIENTS: All women managed surgically for urinary tract endometriosis from January 1, 2017, to December 31, 2017. We distinguished patients with isolated bladder endometriosis or isolated ureteral endometriosis (IUE) from those with endometriosis in both locations (mixed locations [ML]). INTERVENTIONS: Surgeons belonging to the French Colorectal Infiltrating Endometriosis Study (FRIENDS) group enrolled patients who filled a 24-item questionnaire on the day of the inclusion and 3 months later. Data were collected on operative routes, surgical management, and postoperative complications according to the Clavien-Dindo classification in a single anonymized database. MEASUREMENTS AND MAIN RESULTS: A total of 232 patients from 31 centers were included. Isolated bladder endometriosis was found in 82 patients (35.3%), IUE in 126 patients (54.4%), and ML in 24 patients (10.3%). Surgery was performed by laparoscopy, laparotomy, or robot-assisted laparoscopy in 74.1%, 11.2%, and 14.7% of the cases, respectively. Among the 150 ureteral lesions (IUE and ML), 114 were managed with ureterolysis (76%), 28 with ureteral resection (18.7%), 4 with nephrectomy (2.7%), and 23 with cystectomy (15.3%). Concerning bladder endometriosis, a partial cystectomy was performed in 94.3% of the cases. We reported 61 postoperative complications (26.3%): 44 low-grade complications according to the Clavien-Dindo classification (18%), 16 grade III complications (7%), and 1 grade IV complication (peritonitis). CONCLUSION: The surgical management of ureteral and bladder endometriosis is usually feasible and safe through laparoscopic surgery. Ureteral resection, when necessary, is more strongly associated with laparotomy and with more complications than other procedures. Prospective controlled studies are still mandatory to assess the best surgical management for patients.

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STUDY OBJECTIVE: To describe a novel technique for temporary ovarian suspension using the Carter-Thomason CloseSure system (CooperSurgical, Inc., Trumbull, CT). DESIGN: A narrated, stepwise in vivo demonstration of surgical technique. SETTING: Academic tertiary care hospital (University of Louisville Hospital, Louisville, KY). INTERVENTIONS: Laparoscopic temporary ovarian suspension using the Carter-Thomason CloseSure system for improved exposure of deep pelvis during a laparoscopic excision of deep pelvic endometriosis (including demonstration of previously used techniques at this institution). CONCLUSION: We have developed and used this technique at our institution for the last several years, reviewing 20 cases between August 2018 and September 2019, with improved intraoperative visualization and no observed intraoperative or postoperative complications. This technique has replaced the use of other forms of ovarian suspension at our institution owing to the accessibility of the device, stability of the suspension, and ease of the procedure. The Carter-Thomason technique of ovarian suspension provides excellent retraction of ovarian tissue to provide improved views of the deep pelvis, with ease of use and low cost.

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