Objective: To analyze multiple aspects of advanced bladder endometriosis surgery, based on the experience of an endometriosis reference center. Methods: This retrospective/prospective study included 80 consecutive patients with deep bladder endometriosis treated with laparoscopic surgery. Results: In 96.3% of cases, bladder endometriosis coexisted with other organ involvement: bowel (87.5%), uterus (61.3%), and ureters (37.5%); isolated bladder lesions occurred in 3.7%. Full-thickness bladder infiltration occurred in 36.4% of patients, and 71.8% had a history of surgery. The most frequent preoperative symptoms related to multiorgan involvement were dysmenorrhea (88.7%), dyschezia (75.0%), and dyspareunia (55.7%). Dysuria (55.7%), pollakiuria (17.9%), and urinary urgency (9.0%) were also reported. Shaving was performed in 45.0% of cases, resection in 40.0%, skinning in 15.0%, with two rare cases requiring bladder augmentation with bowel insert. Of all multiorgan surgeries (96.3% of cases), the most complex 30% were performed by a bi-disciplinary team of gynecologists and urologists. Postoperative complications occurred in 8 patients (10%) and were significantly associated with larger lesions, full-thickness infiltration, trigonum involvement, multiple organs opened, and prior surgery. Conclusions: Laparoscopic management of bladder endometriosis is feasible and effective, even in complex cases. Postoperative complications were linked to disease complexity but remained low, likely due to protective techniques used by the reference team. Optimal outcomes for the most difficult cases are more likely when procedures are performed by a bi-disciplinary team involving both oncological gynecologists specialized in deep endometriosis surgery and urologists. Given the heterogeneous clinical profiles of bladder endometriosis, treatment should be carried out in specialized centers where individualized surgical strategies can be implemented.

Background: Bowel surgery is a key component of advanced deep endometriosis management, with anastomotic leakage representing the most serious postoperative complication. This study aimed to identify risk factors for dehiscence after lower colorectal anastomosis and to determine effective preventive measures. Methods: This retrospective/prospective study included 425 consecutive patients aged 37.7 ± 6.0 years with laparoscopical bowel resection due to multiorgan complex deep endometriosis. All bowel surgeries were performed with use of indocyanine green (ICG). Many technical aspects of surgery and preventive procedures were analyzed which could impact leakage risk of surgery. Results: Endometriotic nodules were resected with segmental bowel resection (n = 294; 69.8%), discoid bowel resection (n = 84; 20.0%), and shaving procedure (n = 43; 10.2%). A total of 12 dehiscence events occurred (2.8%), including intraperitoneal leakage (n = 1; 0.2%), rectovaginal fistula (RVF) (n = 10; 2.3%), and rectoureteral fistula (n = 1; 0.2%); no rectovesical fistulas were observed. RVF developed only following segmental resections. Protective measures used during lower bowel procedures included fibrin glue (n = 375; 88.2%), omental flaps (n = 86; 20.2%), reinforcing sutures (n = 33; 7.8%), protective stomas (n = 25; 5.9%), and ghost stomas (n = 14; 3.3%). Among patients who developed RVFs, 90% had no protective stoma, and these cases were predominantly associated with low (from 6 to <8 cm; n = 4/77; 5.2%) and very low (from 5 to <6 cm; n = 4/10; 40%) anastomoses. In very low anastomoses (n = 4), 1 RVF occurred despite a protective stoma but there existed other strong risk factors, such as levator ani infiltration and vagina opening, whereas 3 others RVF developed in patients without a protective stoma. Notably, in ultra-low anastomoses (<5 cm), protective stomas prevented the anastomosis in 100%, and no fistula was observed (n = 3). The following factors were associated with the increased rate of RVF: segmental resection (p = 0.0355), low and very low anastomosis (p = 0.0010), lateral infiltration of the levator (p < 0.0001), concomitant hysterectomy or vaginal opening (p = 0.051), and prolonged operative time (p = 0.0010), Clostridioides difficile infection (p = 0.0001). Conclusions: RVFs occurred mainly after segmental resection (no other type of bowel resection), with very low anastomosis (5–6 cm from anal verge), in patients with levator ani infiltration and concomitant vaginal or uterine surgery; in such situations, discoid resection is the safer option. Despite the complexity of procedures, preventive strategies maintained a low overall RVF rate; no RVFs occurred in ultra low anastomoses (<5), indicating effective prevention with protective stomas.