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Laparoscopic cervical cerclage proved technically feasible and safe for a surgeon trained in laparoscopic suturing methods.

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We present a multidisciplinary approach to the management of a 41-year-old woman who presented with an acute on chronic history of pelvic pain and urinary tract symptoms. The underlying pathology was found to be infiltrative ureteric and vesical endometriosis. The extent of the disease had caused partial ureteric obstruction. The patient subsequently underwent laparoscopic excision of the endometriosis with a laparoscopic extravesical neoureterocystostomy and vesicopsoas hitch, performed by an advanced laparoscopic gynaecologist and a urologist.A 41-year-old multigravid women presented with a 3-month history of right loin pain, dysuria and haematuria. A computed tomography (CT) scan reported a 2.4-cm thickening of the bladder and the patient subsequently underwent cystoscopy and ureteroscopy in May 2005. This showed a 2-to 3-cm endometriotic nodule involving the bladder mucosa near the right ureteric orifice ( Fig. 1) with a 3-cm narrowing of the right ureter. A double-J stent was passed through the right ureter and a laparoscopic excision of this nodule with ureteric reimplantation planned.In May 2001, a laparoscopic vaginal assisted hysterectomy (LAVH) was performed for dysmenorrhoea and menorrhagia. Histology of her uterus showed adenomyosis. Due to persistent pain, a laparoscopy was performed 1 year later and a nodular deposit of endometriosis was seen on the right fundal aspect of the bladder near the ureteric tunnel. A gonadotrophin-releasing hormone analogue was tried but failed to resolve the pain. Cystoscopy performed at the same time demonstrated no endometriotic bladder mucosal involvement. In May 2003 the patient underwent a laparoscopic excision of a 3-to 4-cm endometriotic bladder nodule and opted to have a bilateral salpingo-oophorectomy at the same time. Cystoscopy up to this stage was normal.A four-port laparoscopy was performed with cystoscopy to help define the margins of the lesion from an abdominal and vesical perspective. Retroperitoneal dissection of the ureter from the bladder to about 6 cm above the pelvic brim was performed and the endometriotic ureter transected about 3 cm distal to its vesical insertion, exposing the double-J stent (Figs. 2 and 3). The proximal end of the ureter was examined and found to be free of endometriosis with a good vascular supply. The vagina was dissected free of the bladder to allow for precise resection of the endometriotic nodule. This was then excised using high power density monopolar diathermy. Despite ureteric dissection there was felt to be too much tension to reanastomose the ureter to the bladder and a laparoscopic vesicopsoas hitch was then performed as described below.The anterior abdominal wall peritoneum was retracted vertically down at the level of the median umbilical ligament and opened to access the cave of Retzius. Dissection of the cave of Retzius then allowed adequate mobilization of the bladder toward the right psoas muscle, which had been exposed with careful dissection. Two sutures (1-0 Polyglycol Vicryl) were then used to secure the b...