Lateral-to-Medial Approach for Lateral Parametrial Endometriosis with Ureteral Entrapment: A Step-By-Step Technique

Abstract

Study Objective

To demonstrate a step-by-step lateral-to-medial approach for the surgical treatment of lateral parametrial endometriosis with ureteral entrapment, emphasizing key anatomical landmarks and technical strategies for safe ureteral release and en bloc excision.

Design

Surgical video presentation of a case of deep infiltrating endometriosis involving the lateral parametrium, with detailed anatomical dissection and ureteral management.

Setting

Tertiary referral center for endometriosis surgery. The patient was positioned in dorsal lithotomy with Trendelenburg tilt. A laparoscopic approach was performed with the surgeon on the patient’s left. High-definition imaging and ergonomic instrumentation enabled meticulous dissection.

Patients or Participants

A 45-year-old female with chronic pelvic pain, severe right renal colic, recurrent urinary tract infections, and sciatica. Preoperative assessment revealed a non-functioning left kidney and suspected ureteral entrapment. Informed consent was obtained for the procedure and video use.

Interventions

Peritoneal opening was initiated over the psoas muscle to access the pelvic sidewall. Dissection followed the umbilical artery to develop medial and lateral paravesical spaces and expose branches of the internal iliac artery. Obturator vessels and nerve were isolated, and the lumbosacral trunk identified. After uterine artery ligation, the ureter was released from the fibrotic parametrium. Due to absent renal function, distal ureteral ligation and nephrectomy were performed.

Measurements and Primary Results

Key anatomical structures were clearly visualized, including the superior gluteal artery, middle rectal artery, lumbosacral trunk, and hypogastric fascia. The lateral-to-medial approach enabled complete and safe ureteral liberation. No intraoperative complications occurred, and the patient was discharged on postoperative day four.

Conclusion

The lateral-to-medial approach is a feasible and effective technique for treating lateral parametrial endometriosis with ureteral entrapment. It offers enhanced visualization of critical anatomical structures, potentially reducing risks of ureteral injury or bleeding. Further studies are needed to assess its broader applicability.