Outcome of laparoscopic ureterolysis for ureteral endometriosis

Laparoscopic ureterolysis and dissection of the paravesical space for deeply scarred adnexal masses

INTRODUCTION

Laparoscopic ureterolysis is a delicate procedure that requires advanced laparoscopic skills.

MATERIALS AND METHODS

We are reporting two cases of laparoscopic hysterectomy and salpingo-oophorectomy with severe adhesions to the pelvic sidewall that required ureterolysis and describing a modified technique suitable for the laparoscopic performance of this procedure.

RESULTS

In more than 15 years of doing laparoscopic ureterolysis to deal with various gynecological cases, we have never had a ureteral injury related to the ureterolysis procedure. There have been uterine artery lacerations, usually when trying to apply clips for uterine artery ligation in which case the artery can be compressed with a clamp until it is reclipped, bipolar-cauterized or suture-ligated using intracorporeal knot tying. However, we did not have a single patient that required open surgery because of these lacerations.

CONCLUSION

Because of the advantage of magnified viewing and laparoscopic dissection techniques which control small vessel bleeding, the laparoscopic route for ureterolysis is far easier to use than its open counterpart once it is learned. Laparoscopy, in addition, offers the added advantages of shorter hospital stay, reduced patient pain, reduced transfusion requirements and far better cosmetic results.

Laparoscopic conservative management of ureteral endometriosis: a survey of eighty patients submitted to ureterolysis

BACKGROUND

this study aims to evaluate the effectiveness and safety of laparoscopic conservative management of ureteral endometriosis.

METHODS

Eighty cases of histologically confirmed endometriosis affecting the ureter, 10 of which with bladder involvement were prospectively studied. In detail, patients were 13 women with ureteral stenosis (7 with hydronephrosis), 32 with circular lesions totally encasing the ureter, and 35 with endometriotic foci on the ureteral wall, but not completely encasing it. They were submitted to laparoscopic ureterolysis with or without partial cystectomy, ureteroneocistostomy. The rate of surgical complications, the recurrence rate, the patients' satisfaction rate was assessed during 22 months (median) follow-up.

RESULTS

Laparoscopic ureterolysis was employed for all patients and set free the ureter from the disease in 95% of cases, whereas ureteroneocystostomy was necessary for 4 patients showing severe stenosis with hydronephrosis, among which 2 had intrinsic endometriosis of the ureteral muscularis. Three post-surgery ureteral fistulae occurred in cases with ureteral involvement longer than 4 cm: two cases were successfully treated placing double J catheter, the third needed ureteroneocistostomy. During follow-up, ureteral endometriosis recurred in 2 patients who consequently underwent ureteroneocystostomy. Most patients expressed high satisfaction rate throughout the whole follow-up period.

CONCLUSION

laparoscopic ureterolysis is effective and well tolerated in most cases of ureteral endometriosis. Ureteroneocystostomy is a better strategy for patients with extended (more than 4 cm) ureteral involvement or with severe stenosis with or without hydronephrosis.

Renal endometriosis presenting with a giant subcapsular hematoma: case report

OBJECTIVE

To describe a case of renal subcapsular hematoma due to renal endometriosis.

DESIGN

Case report.

SETTING

Departments of Urology and Pathology, Baskent University Faculty of Medicine, Ankara, Turkey.

PATIENT(S)

A 46-year-old premenopausal woman was admitted with a left lumbar pain and mass. Ultrasonography and computerized tomography revealed a giant-sized renal subcapsular hematoma.

INTERVENTION(S)

Computerized tomography, percutaneous drainage catheter placement, surgical exploration, and excision of renal capsule.

MAIN OUTCOME MEASURE(S)

None.

RESULT(S)

Histopathologic examination revealed endometriosis located beneath the fibrous renal capsule.

CONCLUSION(S)

Renal capsular endometriosis should be kept in mind among the causes of renal subcapsular hematoma.

Recurrence of endometriosis and its control

BACKGROUND Although surgery is currently the treatment of choice for managing endometriosis, recurrence poses a formidable challenge. To delay or to eliminate the recurrence is presently an unmet medical need in the management of endometriosis. To this end, proposals to investigate patterns of recurrence, to develop biomarkers for recurrence and to carry out biomarker-based intervention have been made. METHODS Publications pertaining to the recurrence of endometriosis and its related yet unaddressed issues were identified through MEDLINE. The reported recurrence rates, risk factors for recurrence, the effects of post-operative medication and causes of recurrence were reviewed and synthesized. In addition, several poorly explored issues such as time hazard function and mechanisms of recurrence were reviewed. Approaches to the development of biomarkers for recurrence and future intervention are discussed. RESULTS The reported recurrence rate was high, estimated as 21.5% at 2 years and 40-50% at 5 years. Few risk factors for recurrence have been consistently identified, and the evidence on the efficacy of the post-operative use of medication was scanty. The investigation on the patterns of recurrence may provide us with new insight into the possible mechanisms of recurrence and its control. The attempt to identify biomarkers for recurrence has started only very recently. CONCLUSIONS Much research is needed to better understand the patterns of recurrence and risk factors, and to develop biomarkers. One top priority is to develop biomarkers for recurrence, which may provide much needed clues to the possible mechanisms underlying recurrence and would allow the identification of patients with high recurrence risk, and permit for targeted intervention.

Management of ureteral endometriosis: areas of controversy

PURPOSE OF REVIEW

In this review we critically evaluate what we know and what we still do not know about pathogenesis, diagnosis and treatment of ureteral endometriosis, highlighting areas of controversy.

RECENT FINDINGS

Recent studies have produced new insights into diagnostic and management options for ureteral endometriosis.

SUMMARY

The diagnosis of ureteral endometriosis entails a high index of suspicion for the disorder. Imaging techniques are of limited value in providing an accurate depiction of extension of ureteral lesions. Preliminary results suggest that magnetic resonance urography is accurate in differentiating between intrinsic and extrinsic forms of ureteral involvement, but further studies are required to define its role in directing better treatment. Current controversies in the treatment of ureteral endometriosis are over whether segmental resection and anastomosis or ureterolysis are indicated, and whether minimal-access procedures are equally effective than their traditional open counterparts. Recent studies suggest that laparoscopic ureterolysis can be an effective treatment option in most patients with ureteral endometriosis but that recurrence rates are not negligible, as suggested in pioneering works. Successful application of laparoscopic surgery, even for procedures that have traditionally necessitated laparotomy, has been reported. Extensive experience with endourological techniques is prerequisite for success.