Design: Case report illustrated with video.

Setting: Patient under general anesthesia, placed in lithotomy position, with arms alongside the body and legs 80 degrees abducted in adjustable stirrups. One conventional laparoscopic portal was positioned in the iliac fossa, and three robotic portals: one 10mm umbilical and two 5mm on the right and left flanks. The cervix was manipulated with a disposable uterine manipulator.

Patients or Participants: Female, 37-year-old, nulliparous, with dysmenorrhea, dyspareunia and changes in intestinal and urinary habits. On the physical examination, palpable and painful nodules were detected in the left parametrium and retrocervical region. The MRI revealed a large tissue formation in the anterior compartment infiltrated the myometrium and the vesicouterine peritoneum. In the posterior compartment, extensive involvement of the retrocervical and retrouterine region, extending to the anterior wall of the mid-rectum. Also the involvement of the muscular layer of the rectosigmoid, as well as bilateral circumferential ureteral involvement.

Interventions: Laparoscopic excision of foci of deep endometriosis from the rectovaginal septum, bilateral ureters, parametria, vagina, associated with a posterior peritonectomy and parametrectomy, and two intestinal anastomoses.

Measurements and Main Results: The surgery lasted 4h30, with minimal blood loss. The patient's postoperative course was uneventful and was discharged after 4 days. The pathological confirmed endometriosis. In the postoperative follow-up, renal function was monitored.

Conclusion: The use of advanced techniques, such as parametrectomy and posterior peritonectomy, allowed for a more precise and safe dissection of the affected structures, contributing to a successful surgery and a favorable outcome. It is important to highlight the importance of anatomical knowledge, specialized surgical techniques and multidisciplinary approach for the treatment of deep endometriosis and the clinical improvement of the patient.