Endometriosis of ureter

Chronic Pelvic Puzzle: Navigating Deep Endometriosis with Renal Complications

This case report delves into the intricacies of a challenging clinical scenario involving deep pelvic endometriosis, which manifested with renal complications. Endometriosis, a complex gynecological condition, is explored in this case, highlighting its multifaceted nature. The patient presented with a complex interplay of symptoms, including chronic pelvic pain, urinary tract issues, and severe deep adenomyosis. The diagnostic journey was protracted, emphasizing the need for early recognition and intervention in such cases. A thorough evaluation, including laparoscopic examination and histopathological analysis, revealed the extensive presence of endometriotic lesions in various pelvic and renal structures, ultimately leading to left hydronephrosis. The report underscores the significance of timely diagnosis and surgical intervention to prevent irreversible renal damage. This case provides valuable insights into the management of deep endometriosis with renal involvement and the importance of interdisciplinary collaboration. Understanding the complexities of this condition can aid in improving patient outcomes and enhancing the quality of care provided.

Intrinsic unilateral ureteral endometriosis: A rare case report

INTRODUCTION AND IMPORTANCE

Ureteral endometriosis is a rare disease and it has variable and subtle clinical presentation and often it lead to delayed diagnosis and worse outcome.

CASE PRESENTATION

Here we present a 44-year-old married lady who presented with dull aching right iliac fossa pain. CT urography right moderate hydro-uretero nephrosis with a suspicion of a mass in the lower right ureter. Diagnostic rigid ureteroscopy showed completely intraluminal polypoidal pedunculated right lower ureteral mass with near total occlusion of the lumen, which was excised completely by Ho: Yag laser. Histopathology confirmed pure endometriosis tissue with no ureteral tissue. Follow up showed no recurrence of the mass, however eventually the patient developed deterioration in kidney function due to the long-standing undiscovered obstruction.

CLINICAL DISCUSSION

Ureteral endometriosis can cause silent obstruction for a long time. Surgical intervention has different modalities according to the type of U.E, and it is the appropriate treatment method for U.E causing complete obstruction to preserve kidney function.

CONCLUSION

Ureteral endometriosis is a rare but should be included in the differential diagnosis of premenopausal women with ureteral obstruction of unknown cause. Early intervention is critical for better outcomes.

Isolated Intrinsic Ureteral Endometriosis: A Rare Presentation of Ureteral Obstruction

Intrinsic ureteral endometriosis is a very rare presentation of deep infiltrating endometriosis. It can lead to urinary tract obstruction and loss of renal function. Clinical suspicion and radiologic assessment can aid in preoperative diagnosis and help plan surgical treatment. Herein we report a case of a 29-year-old female who presented with left-sided pelvic and flank pain. Imaging revealed left obstructive uropathy and a left ureteral mass. She underwent laparotomy and resection of the diseased ureter with primary re-anastomosis. Histology confirmed intrinsic ureteral endometriosis. There was subsequently complete resolution on follow-up imaging, with no permanent loss of renal function.

Management of patients with urinary tract endometriosis by gynecologists

Objective

The aim was to report the postoperative outcomes of urinary tract endometriosis (UTE), which is a form of deep, infiltrative endometriosis, and to contribute to the literature by presenting our experience.

Material and Methods

In the present study, patients who underwent surgery for endometriosis at our clinic between 2005 and 2019 and had a final pathological diagnosis of UTE were examined in detail. Patient information was retrospectively retrieved from the medical records. Data obtained pre-, peri-, and postoperatively were analyzed.

Results

Mean age of the 70 patients included, according to the study criteria, was 32.73±7.09 years. Ureteral involvement alone was observed in 49% (n=34) of the patients, bladder involvement alone was observed in 24% (n=17) of the patients, and both bladder and ureteral involvement were observed in 27% (n=19) of the patients. Microscopic hematuria was detected in 16% (n=11) of the patients, whereas preoperative urinary tract findings, such as recurrent urinary tract infections, were detected in 19% patients (n=13). Of the patients, 56% (n=39) were identified with dyspareunia, 56% (n=39) with dysmenorrhea, and 30% (n=21) with pelvic pain. Visual analog scale score was significantly lower after the procedure (p<0.0001).

Conclusion

Although postoperative results were typically considered positive, surgical method performed in deep infiltrative endometriosis should aim to preserve fertility, improve quality of life, and reduce the complication rate to a minimum.

Unilateral Ureteric Endometriosis at the Pelvic Brim Resulting in Complete Loss of Renal Function

Deep infiltrating endometriosis of the urinary tract is rare but can result in ureteric obstruction, hydroureteronephrosis and renal failure. Ureteric endometriosis usually affects the distal third of the left ureter among women of reproductive age. Greater awareness of ureteric endometriosis and a multidisciplinary approach in the management is essential to achieve optimal outcomes. We present an atypical case of right ureteric obstruction due to endometriosis at the pelvic brim resulting in complete loss of renal function and necessitating nephroureterectomy.

Ureteroureteral anastomosis for endometriosis involving the ureter: Case series and literature review

Introduction:

The purpose of this study was to review operative management of endometriosis involving the ureter.

Materials and methods:

Retrospective case series of three patients undergoing resection of ureteral endometriosis with ureteroureterostomy for endometriosis involving the ureter by minimally invasive gynecologic surgeons between 2007 and 2018 at a large academic medical center in the Northeastern United States. A literature review was conducted to find cases with a similar approach.

Results:

Three cases of ureteral endometriosis surgically managed at our institution with ureteroureteral anastomosis were identified. Ureteral endometriosis was identified preoperatively by hydroureteronephrosis on imaging. Intrinsic ureteral endometriosis was confirmed by pathology in two cases; extrinsic endometriosis was grossly visualized in one case. Operative times ranged from 300 to 387 min. Estimated blood loss ranged from 150 to 250 mL. There were no intraoperative complications. A total of 151 cases with a similar approach were described in the literature. Recurrence of obstructive uropathy occurred in 11 cases.

Conclusion:

Ureteral endometriosis is a rare complication with several management options. Ureterectomy with ureteroureterostomy has been described in the literature and in three cases at our institution with low complication rates and rare stricture formation. This technique can be successful in the management of ureteral endometriosis and warrants further investigation.

Gastrointestinal and Urinary Tract Endometriosis: A Review on the Commonest Locations of Extrapelvic Endometriosis

Extrapelvic endometriosis is a rare entity that presents serious challenges to researchers and clinicians. Endometriotic lesions have been reported in every part of the female human body and in some instances in males. Organs that are close to the uterus are more often affected than distant locations. Extrapelvic endometriosis affects a slightly older population of women than pelvic endometriosis. This might lead to the assumption that it takes several years for pelvic endometriosis to "metastasize" outside the pelvis. All current theories of the pathophysiology of endometriosis apply to some extent to the different types of extrapelvic endometriosis. The gastrointestinal tract is the most common location of extrapelvic endometriosis with the urinary system being the second one. However, since sigmoid colon, rectum, and bladder are pelvic organs, extragenital pelvic endometriosis may be a more suitable definition for endometriotic implants related to these organs than extrapelvic endometriosis. The sigmoid colon is the most commonly involved, followed by the rectum, ileum, appendix, and caecum. Most lesions are confined in the serosal layer; however, deeper lesion can alter bowel function and cause symptoms. Bladder and ureteral involvement are the most common sites concerning the urinary system. Unfortunately, ureteral endometriosis is often asymptomatic leading to silent obstructive uropathy and renal failure. Surgical excision of the endometriotic tissue is the ideal treatment for all types of extrapelvic endometriosis. Adjunctive treatment might be useful in selected cases.

Deep infiltrating ureteral endometriosis with catamenial hydroureteronephrosis: a case report

BACKGROUND

This aim of this case report is to raise awareness of ureteral endometriosis in women of reproductive age with hydronephrosis in the absence of urolithiasis to enable early diagnosis and prevent loss of renal function.

CASE PRESENTATION

A 44-year-old Asian woman presented with a 4-year history of cyclic right flank pain and right hydronephrosis during menstruation. Despite several evaluations by physicians, including gynecologists, the cause of her symptoms was not diagnosed. On transvaginal ultrasonography, the uterus was observed deviated to the right, with a nodular lesion at the right uterosacral ligament, and the right ovary was attached to the uterus with no apparent cystic lesion. Magnetic resonance imaging showed a mass in the right uterine wall and mild wall thickening with delayed enhancement of the right distal ureter. Right ureteral endometriosis was suspected. Diagnostic laparoscopy revealed narrowing of the distal right ureter between the right uterosacral ligament and the right ovary with adhesions caused by deep infiltrating endometriosis. The adhesion bands and infiltrating endometriosis around the right ureter were dissected.

CONCLUSIONS

The nonspecific symptoms of ureteral endometriosis can result in incorrect diagnosis, with renal damage as a result of prolonged hydronephrosis. A high index of suspicion and use of imaging modalities enable earlier diagnosis and preservation of renal function.

Surgical Outcomes of Urinary Tract Deep Infiltrating Endometriosis

OBJECTIVE

To report the outcomes of surgical management of urinary tract endometriosis.

DESIGN

Retrospective study based on prospectively recorded data (NCT02294825) (Canadian Task Force classification II-3).

SETTING

University tertiary referral center.

PATIENTS

Eighty-one women treated for urinary tract endometriosis between July 2009 and December 2015 were included, including 39 with bladder endometriosis, 31 with ureteral endometriosis, and 11 with both ureteral and bladder endometriosis. Owing to bilateral ureteral localization in 8 women, 50 different ureteral procedures were recorded.

INTERVENTION

Procedures performed included resection of bladder endometriosis nodules, advanced ureterolysis, ureteral resection followed by end-to-end anastomosis, and ureteroneocystostomy.

MEASUREMENTS AND MAIN RESULTS

The main outcome measure was the outcome of the surgical management of urinary tract endometriosis. Fifty women presented with deep infiltrating endometriosis (DIE) of the bladder and underwent either full-thickness excision of the nodule (70%) or excision of the bladder wall without opening of the bladder (30%). Ureteral lesions were treated by ureterolysis in 78% of the patients and by primary segmental resection in 22%. No patient required nephrectomy. Histological analysis revealed intrinsic ureteral endometriosis in 54.5% of cases. Clavien-Dindo grade III complications were present in 16% of the patients who underwent surgery for ureteral nodules and in 8% of those who underwent surgery for bladder endometriosis. Overall delayed postoperative outcomes were favorable regarding urinary symptoms and fertility. Patients were followed up for a minimum of 12 months and a maximum of 7 years postoperatively, with no recorded recurrences.

CONCLUSION

Surgical outcomes of urinary tract endometriosis are generally satisfactory; however, the risk of postoperative complications should be taken into consideration. Therefore, all such procedures should be managed by an experienced multidisciplinary team.

[A CASE OF URETERAL ENDOMETRIOSIS]

A 49-year-old woman was admitted to our hospital due to macroscopic hematuria. Contrast-enhanced computed tomography revealed left hydronephrosis, a tumor at her left ureter, pseudoaneurysm and ovarian cystoma. Prior to the operation, the tumorous lesion was considered as left ureteral cancer without metastasis (cT4N0M0; stage IV). Left nephroureterectomy was performed. After the surgery, pathological examination revealed that this lesion was extrinsic endometriosis originating from the ureter.We here report this case of ureteral endometriosis that presented with atypical clinical findings along with a review of the literature.

[Retroperitoneal endometriosis : When a rare form of endometriosis becomes a urological disease]

BACKGROUND

Retroperitoneal endometriosis is a common benign disease, which requires an interdisciplinary approach. In the clinical practice diagnosis is often delayed for years after onset of the unspecific symptoms so that increased awareness is necessary for detection of the presence of the disease.

OBJECTIVE

This article provides a description of the disease including the symptoms and pathogenesis, an introduction to the complexity of diagnostic investigations and the current therapy recommendations.

MATERIAL AND METHODS

Comparison of current therapy recommendations according to the guidelines under consideration of individual studies and background research. Assessment of studies and the accompanying interpretations with the intention of presenting an introduction to the topic with therapy recommendations.

RESULTS

From a urological point of view retroperitoneal endometriosis is a benign disease affecting the ureters and urinary bladder. Involvement of the ureters leading to hydronephrosis caused by ureteral compression represents an absolute indication for therapy. Recurrent macrohematuria can also necessitate treatment. Treatment includes surgical excision of the focal point of endometriosis as the first line therapy. Various operative procedures and access routes are available but when possible a minimally invasive procedure should be used. A second line drug therapy is also possible.

CONCLUSION

Surgical excision of a clinically significant focus of endometriosis is the gold standard for therapy. This procedure should take place in a specialized center within an interdisciplinary consensus. Due to the fact that endometriosis is primarily a benign disease, medical clarification for the patient concerning the benefits and risks of therapy is absolutely necessary. An individual therapy concept under consideration of factors, such as the specific clinical relevance and psychological stress is recommended and in close cooperation with the patient.

Fertility rates, course of pregnancy and perinatal outcomes after laparoscopic ureterolysis for deep endometriosis: A long-term follow-up study

We evaluated fertility rates, pregnancy course and maternal/neonatal outcomes following laparoscopic ureterolysis for deep endometriosis. Data about women who underwent laparoscopic excision of ureteral endometriosis were analysed. After exclusion of women who underwent hysterectomy/bilateral adnexectomy at initial surgery, and those lost-to-follow-up or with follow-up <1 year, a total of 61 patients were included. Of them, 36 (59%) wished to conceive after surgery. Twenty women became pregnant: nine (45%) of them after assisted reproductive technologies. Twenty-six pregnancies were observed with four (15.6%) miscarriages. Median gestational week at delivery was 38 weeks + 2 days (range, 33 + 1-41 + 6), with three (13.6%) and two (9%) deliveries before 37 and 34 weeks, respectively. Nine caesarean sections were performed (40.9%). Fertility rates after laparoscopic ureterolysis are comparable to those of other women operated for other forms of deep endometriosis. Apart from a higher risk of caesarean and preterm birth, the course of pregnancy and peripartum outcomes appear encouraging.

Complex abdominopelvic endometriosis: the radiologist's perspective

Endometriosis is a multifocal gynecological disorder affecting approximately 6%-10% of women during their reproductive years (Giudice and Kao in: Lancet 364:1789-1799, 2004). Presenting symptomatology often relates to the anatomical structures involved. Given the complexity of both the management and pain control of patients with complex endometriosis, the British Society of Gynaecological Endoscopy has issued guidelines on the establishment of a multidisciplinary team approach to these cases (http://www.bsge.org.uk/ec-requirements-BSGE-accredited-endometriosis-centre.php). The ovaries are the most common site affected, but the gastrointestinal, genitourinary tract, chest and other soft tissues are not infrequently involved. Less well-recognized features of the disease include the deep infiltrative form of endometriosis, malignant transformation and decidualization of endometriomas under progesterone. In this pictorial essay, we will discuss the clinical presentation and review the imaging features of these complex and under appreciated forms of endometriotic disease.

Medical treatment of ureteral obstruction associated with ovarian remnants and/or endometriosis: report of three cases and review of the literature

STUDY OBJECTIVE

Experience with low-dose intermittent danazol or prolonged gonadotropin-releasing hormone agonist (GnRH-a) with and without add-back therapy in endometriosis-associated ureteral obstruction.

DESIGN

Retrospective case series (Canadian Task Force classification II-2).

SETTING

University-affiliated teaching hospital.

PATIENTS

Three women with endometriosis-associated ureteral obstruction.

INTERVENTION

The regimen of GnRH-a alone or with add-back included (1) leuprolide acetate 3.75 mg intramuscularly monthly; (2) micronized 17α-estradiol 1 mg/day by mouth; (3) pulsed norethinedrone 0.35 mg/day by mouth, 2 days on and/or 2 days off; and (4) letrozole 2.5 mg by mouth for the first 5 days of the first GnRH-a injection. Danazol, 100 mg/day by mouth, was prescribed as a regimen of 3 months on, 3 months off, for 4 years.

MEASUREMENTS AND MAIN RESULTS

The first case was a 50-year-old woman, gravida 3, para 3, body mass index (BMI) 27 kg/m(2), with multiple surgeries, including hysterectomy and bilateral salpingo-oophorectomy (HBSO), and history of a stroke. She presented with right-sided pain and hydro-uretero-nephrosis. Magnetic resonance imaging identified a right adnexal cyst (4.5 × 3.4 × 2.4 cm). She was treated with leuprolide acetate monthly injections and a ureteric stent. The cyst, pain, and hydro-uretero-nephrosis resolved after 12 months. The second case was a 45-year-old woman, G2P2, BMI 28 kg/m(2) with multiple surgeries, including HBSO. She presented with left-sided pelvic pain. Ultrasound identified a left adnexal cyst and hydronephrosis. After 3 months of leuprolide acetate and add-back therapy, the cyst, pain, and hydronephrosis resolved. The third case was a 46-year-old woman, G2P2, BMI 25 kg/m(2), who presented with left flank and pelvic pain. Magnetic resonance imaging indicated moderate left hydronephrosis and left adnexal pelvic side-wall involvement with possible endometriosis. Due to many previous surgeries, this patient was a high-risk surgical candidate, and therefore, she was offered medical therapy. After a normal serum liver and lipid profile, she was started on danazol, 100 mg/day for 3 months. After 3 months of therapy, there was complete resolution of the patient's hydronephrosis and pain. She was then advised to continue with a 3-month on, 3-month off regimen. She discontinued the danazol and remained asymptomatic with no recurrence of hydronephrosis at 3 years.

CONCLUSIONS

Low-dose intermittent danazol or GnRH-a alone or with add-back, may be effective long-term therapies in endometriosis-associated ureteral obstruction when surgery is contraindicated, refused, or difficult to perform.

Endoureterotomy is not a sufficient treatment for intrinsic ureteral endometriosis

Aim

To investigate whether intrinsic ureteral endometriosis could be managed by laser endoureterotomy.

Material and methods

We studied retrospectively 6 patients with intrinsic ureteral endometriosis who underwent laser endoureterotomy and reviewed their clinical data. Pathological sections of them have also been studied by immunohistochemistry for expressional levels of oestrogen (ER) and progesterone (PR) receptors. Ten sections of normal endometrium were included as a control.

Results

Five patients had recurrence of ureteral stricture within 6 months postoperatively despite hormonal therapy for 3 to 6 months. One patient had recurrence 8 months after endoureterotomy. Two patients had secondary surgery for ureteroureterostomy and pathology confirmed recurrence of endometriosis. Immunohistochemistry revealed decreased ER and PR expression compared to the control.

Conclusions

Endoureterotomy with hormonal therapy may not be suitable for ureteral endometriosis due to inadequate cutting and expressional change of ER and PR.

Urinary tract endometriosis

Urinary endometriosis is a rare diagnosis which is becoming much more common at referral centres. The bladder and the pelvic ureter are the sites that can be affected, each posing to the urologist and gynecologist some specific diagnostic and therapeutic difficulties. Bladder endometriosis, indeed, usually causes lower urinary tract symptoms, has a typical appearance at imaging and can be an isolated presentation; ureteral location, at the contrary, often presents with a vague or aspecific symptomatology and is often associated to other pelvic locations, so that a careful evaluation of the urinary tract, preferably with NMR, is mandatory for severe pelvic endometriosis, also in the absence of symptoms. The treatment of bladder presentation is partial cystectomy, preferably via a laparoscopic approach, while ureteral endometriosis can require different surgical solutions, from ureterolysis to ureteral reimplantation, open, laparoscopic or robot-assisted, basing on its extent and on the need of additional procedures for other locations.

Nongynecological endometriosis presenting as an acute abdomen

Endometriosis is a highly prevalent disease that affects up to 10 % of menstruating women. Patients commonly present with pelvic pain or infertility, although the range of clinical symptoms varies widely. Affected women may be asymptomatic or experience mild, moderate, or severe pain that fluctuates with hormonal cycles. Patients who suffer extreme pain may seek immediate care and present to the emergency department with clinical signs of an acute abdomen. In the case of patients without a prior history of endometriosis, the differential diagnosis is broad and making the correct clinical and radiologic diagnosis in the emergency setting can be challenging. In some cases, the diagnosis is only made after surgical or histopathological analysis. Prompt and accurate clinical and radiological evaluation is necessary because complications of endometriosis, such as bowel obstruction and appendicitis, may require immediate surgical intervention. This pictorial essay analyzes nongynecological manifestations of endometriosis that may have a clinical presentation of an acute abdominal emergency. Atypical clinical presentations and unusual sites and complications of endometriosis are discussed, as well as the differential diagnostic considerations. The radiologic features of endometriosis are shown on multiple modalities, including computed tomography, magnetic resonance imaging, and ultrasound.

Urinary tract endometriosis: Review of 19 cases

AIM

The aim of our study was to evaluate the treatment outcomes of medical and surgical management of urinary tract endometriosis.

MATERIALS AND METHODS

Urinary tract endometriosis patients enrolled between Jan 2006 and May 2010 were retrospectively reviewed. Preoperative datas (mode of presentation, diagnosis, imaging), intraoperative findings (location and size of lesion), postoperative histopathology and follow-up were recorded and results were analyzed and the success rate of different modalities of treatment was calculated.

RESULTS

In our study, of nineteen patients, nine had vesical involvement and ten had ureteric involvement. Among the vesical group, the success rate of transurethral resection followed by injection leuproide was 60% (3/5), while among the partial cystectomy group, the success rate was 100%. Among patients with ureteric involvement, success rate of distal ureterectomy and reimplantation was 100%, laparoscopic ureterolysis with Double J stenting followed by injection leuprolide was 75% while that of Gonadotropin- releasing hormone (GnRh) analogue alone was 67%.

CONCLUSION

One should have a high index of suspicion with irritative voiding symptoms with or without hematuria, with negative urine culture, in all premenopausal women to diagnose urinary tract endometriosis. Partial cystectomy is a better alternative to transurethral resection followed by GnRh analogue in vesical endometriosis. Approach to the ureter must be individualised depending upon the severity of disease and dilatation of the upper tract to maximise the preservation of renal function.

Endometriosis - morphology, clinical presentations and molecular pathology

Endometriosis is found predominantly in women of childbearing age. The prevalence of endometriosis is difficult to determine accurately. Laparoscopy or surgery is required for the definitive diagnosis. The most common symptoms are dysmenorrhea, dyspareunia, and low back pain that worsen during menses. Endometriosis occurring shortly after menarche has been frequently reported. Endometriosis has been described in a few cases at the umbilicus, even without prior history of abdominal surgery. It has been described in various atypical sites such as the fallopian tubes, bowel, liver, thorax, and even in the extremities. The most commonly affected areas in decreasing order of frequency in the gastrointestinal tract are the recto-sigmoid colon, appendix, cecum, and distal ileum. The prevalence of appendiceal endometriosis is 2.8%. Malignant transformation is a well-described, although rare (<1% of cases), complication of endometriosis. Approximately 75% of these tumors arise from endometriosis of the ovary. Other less common sites include the rectovaginal septum, rectum, and sigmoid colon. Unopposed estrogens therapy may play a role in the development of such tumors. A more recent survey of 27 malignancies associated with endometriosis found that 17 (62%) were in the ovary, 3 (11%) in the vagina, 2 (7%) each in the fallopian tube or mesosalpinx, pelvic sidewall, and colon, and 1 (4%) in the parametrium. Two cases of cerebral endometriosis and a case of endometriosis presenting as a cystic mass in the cerebellar vermis has been described. Treatment for endometriosis can be expectant, medical, or surgical depending on the severity of symptoms and the patient's desire to maintain or restore fertility.

Robotic-assisted laparoscopic management of ureteral endometriosis

This report describes 2 cases of ureteral obstruction secondary to endometriosis managed with robotic-assisted laparoscopic partial ureterectomy and ureteroneocystostomy.

Endometriosis is the leading cause of female pelvic pain and infertility and affects approximately 10% of women. Lesions involve the urinary tract in up to 6% of cases with ureteral involvement in a smaller subset of .08% to 1%. Multiple authors describe open and laparoscopic approaches to management of ureteral endometriosis; howeve, this report describes 2 cases of ureteral obstruction secondary to endometriosis managed with robotic-assisted laparoscopic partial ureterectomy and ureteroneocystostomy.

Laparoscopic ureteroneocystostomy and vesicopsoas hitch for infiltrative ureteral endometriosis

The aim of the study was to assess the safety and efficacy of laparoscopic treatment of distal infiltrative ureteral endometriosis with segmental ureteral resection, ureteroneocystostomy, and vesicopsoas hitch. We performed a retrospective analysis of perioperative data and looked at follow-up outcomes of patients with deep endometriosis with ureteral involvement treated by laparoscopic vesicopsoas hitch. Six patients were treated for left ureteral endometriosis in the study period. Four of those were diagnosed during previous laparoscopies. A ureteroneocystostomy (Lich-Gregoir reimplantation procedure) with vesicopsoas hitch was fashioned laparoscopically in all cases, and a double-J stent was applied intraoperatively. There were no intraoperative or postoperative complications and no cases of extravasation of contrast at cystogram one week after surgery. The median follow-up time was 38 months (range 12-56). All patients had normal renal ultrasound or intravenous pyelogram results at one year follow-up. This study confirmed that laparoscopic ureteroneocystostomy and vesicopsoas hitch is a safe and effective option in the management of distal ureteral endometriosis. In view of the small size of this series, multicenter studies are needed to confirm these conclusions.

Ureteral endometriosis with obstructive uropathy

Endometriosis is a common disease, but ureteral involvement is rare. The symptoms and signs of ureteral endometriosis mimic those of ureteral malignancy. This case report describes a woman who presented with chronic back pain for 5 years. Imaging studies showed a right small contracted kidney with hydronephrosis and a bladder tumor. Endometriosis of the right lower ureter was ultimately diagnosed. The patient was healthy without recurrence during follow-up. It is difficult to differentiate between ureteral endometriosis and malignancy; in fact, renal loss may occur before diagnosis. Ureteral endometriosis should be considered for women with ureteral obstruction manifesting as chronic backache.

Obstructive uropathy associated with primary ureteral endometrioma: case report and review of the literature

We report the case of a 56-year-old postmenopausal woman who presented with incidental left hydronephrosis during an investigation for a gastrointestinal complaint. The patient denied any history of flank pain or hematuria. Contrast-enhanced computed tomography revealed severe right-sided ureterohydronephrosis as well as renal atrophy. The contralateral kidney was normal, as was the patient's overall renal function. A retrograde ureterogram demonstrated complete ureteral obstruction 4 cm proximal to the ureterovesical junction. Subsequent ureteroscopy revealed a polypoid mass completely occupying the ureteral lumen, of which the biopsies demonstrated inconclusive atypical urothelial changes. The patient underwent a laparoscopic nephrectomy with open dissection of the distal ureter. The patient recovered well postoperatively. Final pathology revealed a benign obstructing endometrioma without evidence of invasion from periureteral tissue. This appears to be the first reported case of asymptomatic primary ureteral endometrioma with secondary renal atrophy. Earlier investigation and treatment may have allowed for renal preservation earlier in the course of the disease.

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.

Surgical management of bilateral ureteral endometriosis

Ureteral endometriosis is a rare disease that typically is unilateral. Endometriosis involving both ureters and surgical management after hormone therapy failure has seldom been described. We describe a patient with bilateral ureteral endometriosis who underwent ureteroneocystostomy with psoas hitches of both ureters. A 33-year-old woman with advanced endometriosis and recurrent pyelonephritis was found to have high-grade bilateral ureteral obstruction at the pelvic inlet from ureteral endometriosis. The patient subsequently underwent a supracervical hysterectomy with bilateral salpingo-oophorectomy, ureterolysis, and ureteroneocystostomy with psoas hitches and ureteral stent placements. Surgical therapy is reserved for advanced disease with the optimal choice being a ureteral reimplantation with a psoas hitch. The key operative point for a successful psoas hitch ureteral reimplantation is completely mobilizing the bladder anteriorly and laterally.

Treatment of urinary tract endometriosis

Endometriosis involving the urinary tract, although infrequent, can have significant impact on patients' symptoms, response to treatment, and urologic function. The purpose of this article is to review the epidemiology, pathophysiology, diagnosis, and management of endometriosis that affects the urinary tract.

Obstruction urétérale d’origine endométriosique

Endometriosis frequently affects women with genital activity and exceptionally involves the urinary tract, and the ureter in particular. From a case report of a female consulting for renal colic pain related to an intrinsic-type pelvic ureteral endometriosis, we report the difficulty in diagnosing this pseudotumoral obstruction and finding therapeutic options with a review of the literature. Ureteral endometriosis is marked by non-specific symptoms liable to delay preoperative diagnosis with a risk of deterioration of renal function due to the obstruction. Regarding the therapeutic approach, the surgical treatment associated or not with GNRH agonists seems best.

Outcome of laparoscopic ureterolysis for ureteral endometriosis

OBJECTIVE

To evaluate the adequacy of laparoscopic ureterolysis as a primary treatment option for ureteral endometriosis.

DESIGN

Prospective collaborative cohort study.

SETTING

Gynecologic departments of three university hospitals.

PATIENT(S)

Women with ureteral endometriosis exhibiting moderate-to-severe hydronephrosis on preoperative intravenous pyelography.

INTERVENTION(S)

Laparoscopic ureterolysis.

MAIN OUTCOME MEASURE(S)

Cure rate, disesase recurrence.

RESULT(S)

Thirty-three patients underwent laparoscopic ureterolysis during the study period. Bilateral involvement of ureters was found in 4 (12.1%) cases. In women with unilateral lesions the left ureter was more frequently affected (24/29 vs. 5/29). Ureteral involvement was associated with uterosacral ligaments endometriosis in 65.5% (22/34) of cases. No inadvertent ureteral injuries occurred during ureterolysis. A partial wall resection of the ureter was necessary in one case and a segmental ureteral resection with vescicopsoas hitch was required in a women with intrinsic ureteral endometriosis. The median (range) follow-up time was 16 months (range: 3-53 months). Thirty-two patients (96.7%) had a patent ureter on the 3-month postoperative intravenous pyelography. The recurrence rate of ureteral lesions was 12.1% (4/33).

CONCLUSION(S)

Our findings suggest that a conservative laparoscopic approach is an effective treatment option in most patients with ureteral endometriosis exhibiting moderate-to-severe hydronephrosis.

Clinical Aspects and Surgical Treatment of Urinary Tract Endometriosis: Our Experience with 31 Cases

OBJECTIVES

To present and discuss clinical and surgical management of urologic endometriosis.

METHODS

Retrospective review of a database on surgical patients with endometriosis.

RESULTS

Thirty-one patients (incidence, 2.6%; mean age, 33.1 yr) were affected by urologic endometriosis (bladder, 12; ureter, 15; both, 4). Bladder endometriosis was revealed by symptoms related to menses and showed a typical endoscopic picture, whereas ureteral involvement had a nonspecific or silent symptomatology. All patients affected by bladder endometriosis and undergoing transurethral resection (2 cases) developed a bladder recurrence; a ureteral recurrence was observed in two of six patients submitted to laparoscopic ureterolysis and in one of two patients submitted to ureterectomy with ureteroureterostomy. Conversely, no relapses were observed among the 14 patients who had partial cystectomy or the 9 who had ureterectomy and ureterocystoneostomy. Finally, two patients underwent nephrectomy due to end-stage renal atrophy.

CONCLUSIONS

Cystoscopy is advisable in women with pelvic endometriosis with lower urinary tract symptoms; the upper urinary tract should be evaluated in all patients with pelvic endometriosis to exclude asymptomatic ureteral involvement. Partial cystectomy gives the best results when used to treat bladder endometriosis. Ureterolysis can be successful only in case of limited ureteral involvement with no urinary obstruction, whereas terminal ureterectomy and ureterocystoneostomy should be preferred in case of obstructive ureteral endometriosis.

Endoscopic Diagnosis and Management of Ureteral Endometriosis

It is estimated that 1% of patients with endometriosis have involvement of the urinary tract, with the bladder being the most common location. Ureteral endometriosis is a rare entity, and the majority of cases are found at exploratory laparotomy for extensive involvement of the pelvic organs. Obstruction of the ureter may be caused by extrinsic or intrinsic disease, with the extrinsic form occurring four times as often. Progressive ureteral obstruction can be insidious in onset and ultimately lead to renal failure. Hormone therapy has had variable success, and open surgery has been the mainstay of treatment. Only one case of ureteral endometriosis, both intrinsic and extrinsic, diagnosed at ureteroscopy has been reported previously. We present a case of ureteral obstruction secondary to isolated intrinsic endometriosis diagnosed at ureteroscopy and treated endoscopically with holmium laser ablation and leuprolide therapy.

Ureteral endometriosis: the role of magnetic resonance imaging

In six women out of 792 who underwent magnetic resonance imaging (MRI) for management of deep infiltrating endometriosis (DIE), ureteral involvement was suspected. Ureteral endometriosis was identified as a hypointense nodule on T2- weighted images and hyperintense foci on T1-weighted images. Magnetic resonance urography detected obstruction and hydronephrosis in half the women. Detection with MRI of periureteral involvement (extrinsic endometriosis) in four women rather than ureteral wall lesions (intrinsic endometriosis) in two women is an original finding from this series. Magnetic resonance imaging features were correlated and matched with intraoperative and pathologic findings. Magnetic resonance imaging is a useful preoperative tool for the diagnosis and assessment of ureteral endometriosis in rare cases when such lesions have been suspected.

A Rare Case Report about an Extrinsic Ureteral Endometriosis

Endometriosis represents extrauterine nonneoplastic endometrial tissue. Involvement of the genitourinary tract has been reported at an incidence of about 1.2% and ureteral endometriosis is a rare entity. There are two major pathological types of ureteral endometriosis extrinsic and intrinsic. Here, we describe a case report about an ureteral endometriosis extrinsic with double collecting system and complete ureteral duplication.

Diffused Pelvic Endometriosis to the Ureter and Rectal: Multidisciplinary Approach

Endometriosis functionally causes lesions, nodules or active bulges to numerous organs. Is the second most common pelvic pathology in woman and strikes the 10–20% of the women in the pre-menopausal epoch (40–45 years) and the interest of the urinary apparatus is 1–11%. Rare to renal level, it mostly strikes the bladder and in smaller measure the ureters and the uretera with a relationship 40/5/1. Ureteral location is common extrinsic, deriving for contiguity of the ovarian endometriosis adherent or of the peritoneum or of the uterus-sacred ligament; rare the ureteral intrinsic endometriosis, primitively located in the organ wall. Our therapeutic orientation is surgical, especially in the cases of wide endometriosis or when the tissue has had a cicatrizial involution with absence of answer to the hormonal therapy.

Hydronephrosis due to ureteral endometriosis treated by transperitoneal laparoscopic ureterolysis

Ureteral obstruction secondary to endometriosis is relatively uncommon. We present a 43-year-old multiparous woman who suffered from periodic left loin pain in the terminal period of her menstruation. Excretory urogram demonstrated left hydronephrosis and hydroureter and obstruction of the lower left ureter just inferior to the left sacroiliac joint without urolithiasis. An enhanced computed tomography scan showed soft tissue density mass around the left ureter at the level of the stenosis. She underwent transperitoneal laparoscopic ureterolysis and adhesiotomy of the left ureter under the diagnosis of ureteral endometriosis. Because blueberry spots were clearly observed on the pelvic brim, the fibrous tissue surrounded the ureter was removed with peritoneal bleeding spots. Histological examination of the surrounding tissue confirmed the ectopic endometriosis. Even though retroperitoneoscopy is frequently used for ureteral lesion, transperitoneal laparoscopy has an advantage for resection of ectopic endometriosis surrounding the ureter.

Surgical treatment of ureteral obstruction from endometriosis: our experience with thirteen cases

Endometriosis is a biologically benign albeit aggressive pathology marked by high local recurrences. Ureteral involvement accounts for only a minority of cases (0.1-0.4%) with often non-specific symptoms at clinical presentation and difficult preoperative diagnosis. Thirteen cases of severe ureteral endometriosis (i.e. causing significant obstruction to the urinary flow) were observed and surgically treated, out of 17 ureteral units affected (three cases of bilateral involvement, one case of complete pyeloureteral duplicity). The initial symptomatology was acute and related to ureteral obstruction in eight cases, silent and non-specific in the other five; a presumptive diagnosis was made only for the seven patients (53.9%) with a positive medical history for pelvic (and in two cases also ureteral) endometriosis. Preoperative drainage of urine proved necessary for eight patients due to the complete functional exclusion of the excretory axis. One patient (7.7%) underwent nephrectomy due to renal atrophy. Segmental ureteral resection and termino-terminal anastomosis were performed in two patients, while seven patients underwent segmental ureterectomy and ureterocystoneostomy, with bladder psoas hitching in four cases and vesical flap according to Casati-Boari in one case. All three cases of bilateral involvement were treated by bilateral segmental ureterectomy and trans-uretero-uretero-cystoneostomy with bladder psoas hitching. Following histological examination, all patients were diagnosed with active ureteral endometriosis, which was found to be intrinsic in five cases (38.5%) and extrinsic in the other eight. One of the two patients that had undergone ureterectomy and termino-terminal anastomosis had to undergo ureteral resection and ureterocystoneostomy 22 months later due to relapsing endometriosis-induced stenosis. Conversely, no ureteral endometriosis relapses occurred in the remaining 12 patients within the mean follow-up time of 41.1 months (range 6-91). Ureteral endometriosis is marked by non-specific symptoms, making preoperative diagnosis often difficult. Therefore, an ultrasound or urographic examination of the urinary tract in case of pelvic endometriosis is absolutely essential. In our experience, terminal ureterectomy with ureterocystoneostomy has provided long-term favourable results as extended ureteral resection can be performed and continuity of the urinary tract can be restored without resorting to the distal pelvic ureter, which is often affected by the disease besides being more subject to relapses.

Surgical management of endometriosis

The efficacy of medical and surgical treatment of endometriosis-associated infertility and pelvic pain is a source of ongoing controversy. Complete resolution of endometriosis is not yet possible and current therapy has three main objectives: (1) to reduce pain; (2) to increase the possibility of pregnancy; and (3) to delay recurrence for as long as possible. It is possible that a consensus will never be reached on the optimal treatment of minimal and mild endometriosis. In case of moderate and severe endometriosis-associated infertility, the combined approach (operative laparoscopy with a gonadotropin-releasing hormone (GnRH) agonist) should be considered as 'first-line' treatment. The mean pregnancy rate of 50% reported in the literature following surgery provides scientific proof that operative treatment should first be undertaken to give our patients the best chance of conceiving naturally. In case of rectovaginal adenomyotic nodules, surgery must be considered as first-line therapy, medical therapy being relatively in-efficacious.

Ureteral endometriosis

PURPOSE

This review discusses the pathophysiology, presentation, and different minimally invasive medical and surgical treatment options for ureteral endometriosis.

MATERIALS AND METHODS

A comprehensive literature review of reports on the diagnosis and management of ureteral endometriosis was performed using MEDLINE.

RESULTS

Ureteral endometriosis is a rare disease. Most cases present with silent obstruction, as opposed to cyclical hematuria. The diagnosis of ureteral endometriosis requires a high index of suspicion. A variety of diagnostic tests can help identify the extent of disease and the degree of renal function on the side of ureteral involvement.

CONCLUSIONS

Ureteral endometriosis can be treated with hormones or surgical intervention. While surgery is reserved for hormone refractory cases and obstruction associated with extensive scarring, the majority of cases can be managed with hormones only. A combination of hormones and surgery is also effective. Surveillance for obstructive uropathy with periodic noninvasive monitoring of kidney function is currently recommended for all patients with endometriosis.