DIE. Rectal nodule. Ureteral nodule. Bowel resection. Ureteroneocystostomy.

38-year-old patient, nulliparous, known with deep pelvic endometriosis, is admitted to our department for surgical treatment. Symptoms: severe dysmenorheea and dyspareunia and disorders of the bowel movements (constipation).

Patient had a previous open surgery for endometrioma - left adnexectomy.

Both ureters are stented due to bilateral hydronephrosis.

MRI examination

 - adherential lesions that distorts the pelvic anatomy, between the uterus, rectum, recto-sigmoid, appendix and bilateral LUS

 - pseudonodular lesion that excentrically infiltrates and stenoses the rectum and the recto-sigmoid junction, starting from about 100 mm of OAE, on a length of 30 mm and a thickness of 14 mm

 - pseudonodular lesion that infiltrates the posterior wall of the uterus, cervix and vagina - 40/10 mm

 - infiltration of the uterosacral ligaments bilaterally and both parameters

 - adherential-infiltrative lesions involving the right adnexa, ileum, right USL, right round ligament, right pelvic ureter, internal iliac vessels

 - endometriotic lesions: retrouterin and retrocervical, rectum, recto-sigmoid, sigmoid colon

Deep infiltrating endometriosis - stage 4 rASF, Enzian 2A2B1B3CFAFUFO.

Exploratory laparoscopy - frozen pelvis - uterus, right adnexa, sigmoid colon, superior rectum, middle rectum, both ureters (intrinsec right ureteral endometriosis).

After dissecting the sigmoid colon, superior/middle rectum, both pelvic ureters, pararectal spaces, recto-vaginal space, I practiced:

• excision of both parameters - endometriotic infiltrates
• excision of the right ureteral node (approx. 25 mm) - right ureteroneocystostomy
• recto-sigmoid resection with end-to-end intracorporeal mechanical anastomosis