Robotic-assisted resection of parametrial endometriosis with ureterolysis of a medially distorted ureter using indocyanine green and near-infrared fluorescence

Deep infiltrating endometriosis (DIE) is a severe form of endometriosis, with endometriotic implants that can invade several anatomical structures. The urinary tract is the second most common site for deep endometriosis with ureteral endometriosis (UE) the most challenging to manage. Multidisciplinary surgery along with hormonal therapy is the corner stone for the treatment of DIE. Here we describe, with a video, a surgical technique using robotic-assisted surgery along with retrograde injection of indocyanine green (ICG) in the ureter for resection of parametrial endometriosis and ureterolysis using near-infrared fluorescence. The case was a 29-year-old nullipara with a history of severe dysmenorrhea and chronic pelvic pain. The patient was discharged after 48 hrs. The advantages of robotic surgery and the use of ICG in the ureter, in selected cases with UE, enables careful ureterolysis as ICG can even be absorbed in the ureteral mucosa/wall when no stent is left behind during surgery.