During deep endometriosis surgery, bladder and ureter lesions are the most frequent complications.
Bladder lesions. The cystoscopy must be first carried out to assess the location of the endometriosis. If the nodule is close to the ureter, a stent is needed. To prevent lesion to the intramural part of the ureter, it is advisable to enter the bladder at its upper part. To minimize complications, an adequate surgical technique is necessary, a catheter must be placed for 1 to 3 weeks, a large catheter must be placed to drain clots, and control cystoscopy must be achieved before catheter removal. Intraoperative bladder lesions are never a major problem since the bladder wall heals well. Late complications are as follows: vesicovaginal fistula, rare but more frequent after hysterectomy, and the clinical sign is continuous leakage from the vagina, and the treatment is laparoscopy immediately or 50 days after surgery (with, in the last case, treatment with antibiotics until laparoscopic treatment begins). In addition, urinary retention is another late complication, more frequent, especially after resection of large nodules with lateral extension; it is due to parasympathetic nerve injury. Nerve-sparing prevention in endometriosis is not possible; the important thing is not to resect bilaterally. If injury is monolateral, it heals spontaneously in 3 months, rarely longer than 6-12 months.
Ureteral lesions. They occur mainly in cases of hydronephrosis or nodules bigger than 3 centimeters. In case of hydronephrosis, it is necessary to stent the patient before surgery; in all cases, especially when dealing with a nodule, the ureter should be isolated. After surgery a control cystoscopy must be carried out if the ureter works properly. It is important to monitor drain volume and CRP daily. CRP increases on the second day, and decreases on the third day. If CRP increases again, it means there is a complication (infection, ureteral lesion, leakage from rectum). Treatment is immediate laparoscopy with stitch and stent. Another complication is urinoma; symptoms are pain, diarrhea and high temperature. In these cases laparoscopy should be repeated. In case of ureterovaginal fistula, the leakage is intermittent. It usually becomes evident after 1 to 3 weeks. The diagnosis is made by intravenous pyelogram (IVP); treatment is carried out through laparoscopy. In case of unrecognized ureteral transection, there is a late ureteral leak (even after 25 days); ureteral re-anastomosis is the first-line treatment.