EURURO Vol. 71 No. 5

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and disadvantages associated with the surgical techniques
available.
3.3.2.1. TUR surgery. TUR has been proposed for the treatment
of BE even though evidence supporting the efficacy and
safety of this procedure is poor In fact,
this surgical technique does not properly apply to treatment
of this type of lesion from a pathogenic point of view
. Since the nodule develops from the outer layer of the
bladder wall towards the inner layer, complete excision of
the endometriotic lesion is virtually unachievable, exposing
the patient to a high risk of bladder perforation and short-
term recurrence of both symptoms and disease
Therefore, on the basis of the evidence available, TUR should
not be performed for the treatment of BE.
3.3.2.2. Segmental bladder resection. Partial cystectomy is a
bladder-preserving operation for the treatment of BE that
can be performed via laparotomy or
laparoscopy without or with robotic
assistance . This procedure consists of
partial bladder resection for detrusor endometriosis with or
without preventive cystoscopic catheterization of the
ureters. Ureteral cannulation is optional in the case of
surgery for primary BE nodules, which are usually located
on the posterior bladder wall, well above the trigonal area.
The decision to perform ureteral cannulation is mainly
based on the surgeon’s preference and on the distance
between the caudal margin of the endometriotic lesion and
the interureteric ridge (advisable if <2 cm). Conversely,
preventive catheterization is mandatory when treating
recurrent nodules, which may infiltrate down the bladder,
approaching the ureteral meatuses . Partial cystec-
tomy is generally a safe and simple procedure: the bladder
contents are sterile, vesical sutures heal easily because of
rich vascularization, and prolonged urine drainage ( 10 d)
usually prevents fistula formation . Several studies have
shown that partial cystectomy is an effective technique
with excellent long-term results in terms of symptom relief
and recurrence As mentioned earli-
er, complete removal of the lesion is a mandatory aim of the
surgical procedure. Fedele et al reported long-term
outcomes for surgical conservative treatment of BE. Thirty-
three patients with BE of the base were included: one group
(n = 19) underwent partial cystectomy only, while the
second group (n = 14) underwent partial cystectomy plus a
0.5- to 1-cm-deep myometrial resection of the anterior
uterine wall adjacent to the vesical nodule to remove any
adenomyotic focus lying under the vesical lesion. Symptom
recurrence was significantly more frequent among women
in the first group (36.8%) than those in the second group
(7.1%). The type of surgery was the only prognostic factor
associated with a higher risk of BE relapse, and no
significant association was observed for age, previous
surgery for endometriosis, parity, and pregnancy after
operation .
3.3.2.3. Combined cystoscopic and open/laparoscopic/robotic
approach. Different authors have described a combination
of TUR and open/laparoscopic/robotic surgery for BE
. The aim of this double approach is to
overcome the limitations of both surgical techniques
). Open/laparoscopic/robotic excision of endome-
triotic nodules of the bladder may lead to inadvertent
removal of healthy bladder muscle, in particular in the case
of large endometriotic lesions. Hence, this surgical approach
alone increases the risk of postoperative complications and
symptoms due to small bladder volume. Conversely, if
nodule resection is performed only by TUR, the risks of
incomplete removal, of intraoperative bladder perforation
(when attempting to achieve complete nodule removal),
and of relapse are high. Thus, a combination of TUR and
open/laparoscopic/robotic surgery allows complete remov-
al of the endometriotic nodule while sparing most of the
healthy bladder tissue. However, evidence on this topic is
scanty and limited to case reports and case series. In fact,
well-designed (ideally randomized) studies would be very
difficult to perform given the relative rarity of BE and the
high number of patients to be included in a randomized trial
comparing an experimental with the standard procedure.
3.4. Management of BE in patients wishing to conceive
As mentioned earlier, BE is rarely an isolated condition. In
nine out of ten cases, other forms of endometriosis are
concomitant . In practice, disentanglement of the
independent effect of BE on fertility is challenging, if not
impossible. Similarly, evaluation of the benefits of surgical
excision is demanding because surgery for BE is generally
concomitant with treatment for other forms of the disease,
such as adhesions, endometriomas, superficial implants,
and other deep localizations of the disease. It is noteworthy
that there is no strong rationale for hypothesizing a
detrimental impact of BE per se on fertility. Similar to
other deep locations, bladder lesions are buried under
adhesions and the associated inflammation is not expected
to perturb the pelvic milieu. In fact, an independent
detrimental effect of deep invasive endometriotic perito-
neal lesions on fertility has never been demonstrated and
remains debated . Moreover, pelvic steps of the
conception process (ovulation, oocyte pick-up by the tubes,
fertilization, and tubal transport) occur in the posterior
pelvis, and are thus distant from the bladder and BE.
However, deep peritoneal endometriosis is associated with
adenomyosis a condition characterized by
infiltration of the endometrium into the adjacent myome-
trium. Infertility in women with BE may actually be
mediated by this association, considering in particular that
adenomyosismay interferewith fertility Specific
data on fertility treatment in women with BE are extremely
scanty and controversial. We identified only two case
series specifically reporting on pregnancy rates following
surgery for BE and failed to identify any data on
in vitro fertilization (IVF). Specifically, Kovoor et al
reported that five out of ten (50%) infertile women with BE
conceived naturally after the intervention. Soriano et al
observed 16 natural pregnancies out of 42 women
(38%) seeking pregnancy after the intervention. Data on
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