Systematic Laparoscopic Excision and Reconstruction of Bladder Endometriosis With Deep Myometrial Infiltration: A Step-by-Step Surgical Technique and Educational Case Report.

Bladder deep endometriosis is an uncommon but clinically significant phenotype of deep infiltrating endometriosis (DIE), and the coexistence of full-thickness detrusor disease with deep myometrial infiltration of the anterior uterine wall is infrequently documented in a stepwise, reproducible surgical format. We describe a case of a 30-year-old nulligravid female with two years of infertility, cyclical pelvic pain since menarche, severe urinary urgency, dysuria, and persistent microscopic haematuria, in whom magnetic resonance imaging demonstrated an hourglass-shaped fibrotic nodule of the anterior compartment with 16 mm involvement of the bladder dome and 18 mm of myometrial infiltration. Notably, preoperative cystoscopic biopsy had been reported as interstitial cystitis, underscoring the well-recognised tendency of superficially sampled detrusor lesions to be misclassified because endometriosis progresses from the serosa towards the mucosa. The patient was treated by a systematic laparoscopic transmural excision and layered reconstruction. The technique is presented as a teaching framework organised around the mastery of avascular pelvic spaces: development of the prevesical (Retzius) and paravesical spaces, restoration of the vesicouterine plane, retroperitoneal identification and lateral mobilisation of both ureters, complete transmural resection of the bladder nodule together with the infiltrated myometrium while preserving the ureteric orifices, and tension-free two-layer closure of the bladder and uterine wall with barbed (self-anchoring) suture, followed by an intravesical methylene-blue test to confirm a watertight repair. The procedure was completed without intraoperative or postoperative complications, with histological confirmation of endometriosis in both the detrusor and the myometrium. At 12 months of follow-up, the patient had complete resolution of urinary and pain symptoms, with all visual analogue scale (VAS) scores reduced to zero and free histological resection margins. We discuss the anatomical rationale, the diagnostic pitfalls, the correlation with infertility, and the available comparative evidence, and we summarise practical, transferable surgical tips intended to make complete excision safe and reproducible for surgeons developing experience in urinary tract endometriosis.