Outcome of laparoscopic ureterolysis for ureteral endometriosis

Systematic use of intraureteral indocyanine green: a game changer in endometriosis surgery. A proof-of-concept study

BACKGROUND

Endometriosis of the distal segment of the uterosacral ligament may lead to a displaced ureter in the surgical field and must be identified before safe disease excision can be carried out. The aim of this study is to investigate the benefit of the systematic use of preoperative intraureteral indocyanine green (ICG) fluorescence injection in patients undergoing endometriosis surgery.

METHOD

In this proof-of-concept, monocentric, observational, cohort study data were prospectively collected and retrospectively analyzed. Patients underwent laparoscopic surgery for deep infiltrating endometriosis with suspected ureteral involvement between January 2022 and December 2023. Using the propensity score matching (PSM) in a 1:1 matching ratio, patients who underwent preoperative ICG injection were compared with those who did not in terms of ureterolysis length and duration, and operative time.

RESULTS

The mean length of ureterolysis was shorter in the ICG group compared to the non-ICG group (p < 0.001). The ICG group also had shorter ureterolysis duration (p < 0.001) and operative time (p = 0.02). No complications were reported at mean 6.8-month follow-up visit.

CONCLUSIONS

The systematic use of intraureteral ICG prior to uterosacral ligaments endometriosis surgery may be safe and could assist in reducing the length of ureterolysis and operative time. Larger prospective studies are needed to confirm our findings.

Keep your attention closer to the ureters: Ureterolysis in deep endometriosis surgery

Endometriosis surgery involving the ureter poses significant challenges requiring meticulous surgical techniques and vigilant postoperative care. This chapter addresses key aspects of ureterolysis techniques, intraoperative management of ureteral injuries, and postoperative care in the context of endometriosis surgery. Ureterolysis methods aim to isolate and mobilize the ureter while preserving its vascularity. Cold instruments and careful dissection are recommended to prevent thermal injury during surgery. Intraoperative tools such as indocyanine green (ICG) show promise in assessing for vascular compromise. Over half of ureteral injuries are detected postoperatively, necessitating a high index of suspicion. Optimal postoperative care in the case of ureteral injury involves Foley catheterization for decompression, ureteral stenting, and meticulous follow-ups to monitor healing and renal function. While advances have been made in surgical techniques and diagnostic tools, gaps persist in preoperative imaging optimization and predictive models for identifying at-risk patients. This chapter aims to bridge existing knowledge gaps, optimize surgical practices, and enhance the overall care and outcomes of patients undergoing endometriosis surgery involving the ureter.

Are ureterolysis for deep endometriosis really all the same? An anatomical classification proposal for ureterolysis: A single-center experience

OBJECTIVE

Ureteral endometriosis has an incidence of 0.1% to 1%. The type of surgery required is either conservative (ureterolysis) or radical treatment, depending on the degree of ureter infiltration. The incidence of intraoperative and postoperative complications is heterogeneous. Thus, the aim of the current study was to propose a classification of ureterolysis based on the anatomical structure of the ureter and differing complication rates with procedures.

METHODS

A total of 139 ureterolysis procedures were included in the study. Patients were divided into three groups according to the depth of ureterolysis required. Differences were recorded across the three types of ureterolysis in terms of intraoperative and postoperative complications.

RESULTS

The incidence of ureteral fistula was reported in 0.7% of cases, with postoperative ureteral stenosis in 2% of type 2 ureterolysis. In the case of type 3 ureterolysis, after conservative procedures, 52.9% of patients required an ureteroneocystostomy to solve the ureteral stenosis.

CONCLUSION

The risk of ureteral injury and ureteroneocystostomy after conservative procedures appears to be associated with type 3 ureterolysis, probably due to excessive devascularization, secondary to the incision of adventitia. Obviously, these data should be confirmed through a prospective study of a larger number, but our proposed classification can provide the basis for making data from future studies more comparable.

Is the Deep Endometriosis or the Surgery the Cause of Postoperative Bladder Dysfunction?

STUDY OBJECTIVE

To assess if deep endometriosis surgery affects the bladder function.

DESIGN

Prospective multicenter observational study (Canadian Task Force classification II-2).

SETTING

Academic researches centers.

PATIENTS

Thirty-two patients with diagnosis of deep endometriosis requiring surgery.

INTERVENTIONS

Women were evaluated with urodynamic studies, ICIQ-UI SF and ICIQ-OAB questionnaires before and 3 months after surgery.

MEASUREMENTS AND MAIN RESULTS

The main outcome measure was the impact of deep endometriosis surgery on urodynamic parameters. All cystomanometric parameters showed an improvement postoperatively: in particular, the first desire to void (120 vs 204 ml, p<0.001) and the bladder capacity (358 vs 409 ml, p=0.011) increased significantly after surgery. Of the uroflow parameters, the maximal voiding flow improved significantly postoperatively (19 vs 25 ml/sec, p=0.026). The ICIQ-UI SF (2.5 vs 0, p=0.0005) and ICIQ-OAB (4.3 vs 1.2, p<0.001) questionnaires showed a significant postoperative improvement too.

CONCLUSIONS

Our data show that in a selected population of patients with DE (not requiring bowel or urethral resection), the bladder function improves after surgery, both during filling and on voiding urodynamic phases. Postoperatively, patients with DE become aware of bladder filling later, have a higher bladder capacity and have a higher maximal flow. The postoperative urodynamic results are corroborated by the improved scores on the bladder questionnaires.

Clinical practice guidelines for the treatment of extragenital endometriosis in Japan, 2018

The aim of this publication is to disseminate the clinical practice guidelines for the treatment of intestinal, bladder/ureteral, thoracic and umbilical endometriosis, already published in Japanese, to non-Japanese speakers. For developing the original Japanese guidelines, the clinical practice guideline committee was formed by the research team for extragenital endometriosis, which is part of the research program of intractable disease of the Japanese Ministry of Health, Labor and Welfare. The clinical practice guideline committee formulated eight clinical questions for the treatment of extragenital endometriosis, which were intestinal, bladder/ureteral, thoracic and umbilical endometriosis. The committee performed a systematic review of the literature to provide responses to clinical questions and developed clinical guidelines for extragenital endometriosis, according to the process proposed by the Medical Information Network Distribution Service. The recommendation level was determined using modified Delphi methods. The clinical practice guidelines were officially approved by the Japan Society of Obstetrics and Gynecology and the Japan Society of Endometriosis. This English version was translated from the Japanese version.

Feasibility and safety of cryoablation on the porcine ureter using a new balloon cryoprobe

Cryoablation, as a well-characterized technology, has multifarious clinical applications. But few are reported on ureteral endometriosis. Thus, we examined the feasibility and safety of cryotherapy with a novel balloon cryoprobe on ureter in a live porcine model. During the freezing and thawing cycle, temperature was recorded in different parts of the ureter in real-time. Two-minute cryoablation could induce necrosis within range in 1 cm diameter on serosa layer. The temperature respectively dropped to -136.5 °C, -96.1 °C and -17.5 °C at the cryotherapy center, 1 cm and 1.5 cm from center on serosal side. The ureters were harvested immediately, 2 weeks or 3 months after cryotherapy. No perforation, stricture, adhesions, or hydronephrosis was observed. Histopathologic representations of ureters after cryoablation indicated that full thickness necroses of ureters were seen in all samples. The results demonstrated ureteral cryoablation using a novel balloon probe was feasible, safe, and effective. These findings provided us reference before cryoablation could be applied in clinical practice in treating ureteral endometriosis.

Robot-assisted laparoscopic ureteral reconstruction for ureter endometriosis: Case series and literature review

BACKGROUND

The aim of this report was to review experience from a single hospital in treating ureteral obstruction related to endometriosis with robot-assisted laparoscopic ureteral reconstruction.

METHODS

This retrospective analysis study (Canadian Task Force classification II-3) was conducted at an academic tertiary hospital. Five female patients with hydronephrosis without significant elevation of serum creatinine levels were enrolled. Ureteral endometriosis with obstruction was suspected on radiological images. Previous treatment with double-J stenting with or without medical treatment had failed in all of the patients. We performed robot-assisted laparoscopic segmental resection for ureteral endometriosis and reconstructed the ureter through ureteroureterostomy (RUU) or ureteroneocystostomy (RUC). The involved ureters included left lower ureter in three patients and right lower ureter in two patients. RUU was performed in four patients and RUC in one patient. All of the operations were completed smoothly without complications.

RESULTS

All ureteral endometrioses were successfully resected, and follow-up sonography or intravenous pyelography showed resolution of hydronephrosis in all of the patients.

CONCLUSION

Our experience proves the feasibility and efficacy of a robot-assisted approach for this rare situation with good outcomes.

Recurrent endometriosis: a battle against an unknown enemy

Recurrence of endometriosis after conservative surgery is not an uncommon finding. There is no uniformity, however, on what the term 'recurrence' means. Recurrence is variously defined in the literature as the relapse of pain, clinical or instrumental detection of an endometriotic lesion, repeat rise in CA 125 levels, or evidence of recurrence found during repeat surgery. Consequently, the reported recurrence rate varies widely (0-89%) in the different series, depending on its definition and the type of study performed. As endometriosis recurrence seems to be an indeterminate enemy, we set out to examine exactly what we were fighting in our everyday battle. In this narrative review, we aimed to seek an answer to questions related to endometriosis recurrence, some of which are often asked by our patients.

Ureteral endometriosis: a systematic review of epidemiology, pathogenesis, diagnosis, treatment, risk of malignant transformation and fertility

BACKGROUND

The ureter is the second most common site affected by urinary tract endometriosis, after the bladder. Optimal strategies in the diagnosis and treatment of ureteral endometriosis (UE) are not yet well defined.

OBJECTIVE AND RATIONALE

The aim of this study was to systematically review evidence regarding the epidemiology, pathophysiology, diagnosis, medical and surgical treatment, impact on fertility and risk of malignant transformation of UE.

SEARCH METHODS

A systematic literature review, by searching the MEDLINE and PUBMED database until April 2018, was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement and was registered in the PROSPERO registry (www.crd.york.ac.uk/PROSPERO CRD42017060065). A total of 67 articles were selected to be included in this review.

OUTCOMES

The involvement of the ureter by endometriosis is often asymptomatic or leads to non-specific symptoms. When the diagnosis is delayed, UE may lead to persistent hydronephrosis and eventually loss of renal function. Ultrasonography is the first-line technique for the assessment of UE; alternatively, magnetic resonance imaging provides an evaluation of ureteral type involvement. The surgical treatment of UE aims to relieve ureteral obstruction and avoid disease recurrence. It includes conservative ureterolysis or radical approaches, such as ureterectomy with end-to-end anastomosis or ureteroneocystostomy performed in relation to the type of ureteral involvement. Fertility and pregnancy outcomes are in line with those observed after surgical treatment of deep infiltrating endometriosis (DIE). Current evidence does not support the potential risk of malignant transformation of UE.

WIDER IMPLICATIONS

In this article, we review available evidence on ureteral endometriosis, providing a useful tool to guide physicians in the management of this disease. Diagnosis and management of UE remain a challenge. In relation to the degree of ureteral involvement and the association with other DIE implants, the surgical approach should be planned and carried out in an interdisciplinary collaboration between gynecologist and urologist.

Successful management of ureteric endometriosis by laparoscopic ureterolysis - A review and report of three further cases

Objective

To review articles highlighting the effectiveness of conservative laparoscopic ureterolysis as a primary treatment option in patients with ureteric endometriosis and to report on a further three cases.

Patients and methods

PubMed, EMBASE, Cochrane database were searched to identify articles reporting cases of laparoscopic management of ureteric endometriosis and, in particular management by ureterolysis. We further described three new cases of ureteric endometriosis managed at our institute.

Results

The present study illustrates the significance of laparoscopic ureterolysis in the management of patients with ureteric endometriosis. In our cases, a systematic surgical approach was followed in order to perform complete but careful excision of the all visible endometriotic implants. During follow-up successful treatment was established by relief of hydroureteronephrosis by ultrasonographic evaluation.

Conclusion

Considering the risk of loss of renal function and due to the nonspecific symptoms, a prompt clinical suspicion and thorough preoperative assessment can potentially help in the diagnosis. We conclude that laparoscopic ureterolysis is a minimally invasive technique with low complication and recurrence rates. It is a suitable option as a primary approach for selected patients with ureteric endometriosis, if done in a systematic step-by-step approach.

[Urinary tract involvement by endometriosis. Techniques and outcomes of surgical management: CNGOF-HAS Endometriosis Guidelines]

Urinary tract involvement by endometriosis is reported in 1% of endometriosis patients (NP3). Consequences range from pelvic pain for bladder localizations to silent kidney loss in case of chronic ureteral obstruction (NP3). The feasibility of laparoscopic management was widely proven (NP3) and may reduce hospital stay length (NP4). Radical surgery with partial cystectomy for bladder localizations was shown to significantly and durably reduce pain symptoms with low risk of a severe postoperative complications (NP3). Medical hormonal treatment also shows short-term reduction of pain symptoms (NP4). Transureteral resection of bladder endometriosis nodule is not recommended (grade C) because of a high postoperative recurrence rate (NP4). Given a high risk of silent kidney loss, it is recommended that patients with ureteral involvement by endometriosis are managed by a multidisciplinary team considering urinary and potential extra-urinary localizations of endometriosis (grade C). No recommendation can be made on which technique to prefer between conservative (ureterolysis) or radical surgical techniques or on benefit and length of ureteral stents in case of ureteral involvement. Surgical management of bladder and ureteral localizations of endometriosis do not seem to be associated with altered or improved postoperative fertility (NP4). Since late postoperative ureteral anastomosis stenosis were reported with silent kidney loss, repeated postoperative imaging monitoring is justified (expert opinion).

Laparoscopic surgery with urinary tract reconstruction and bowel endometriosis resection for deep infiltrating endometriosis

Deep infiltrating endometriosis (DIE) is the most severe form of endometriosis. It causes chronic pelvic pain, severe dysmenorrhea, deep dyspareunia, dyschezia, and dysuria, markedly impairing the quality of life of women of reproductive age. A number of randomized controlled trials on surgical and medical treatments to reduce the pain associated with endometriosis have been reported, but few have focused on this in DIE. DIE causes not only pain but also functional invasion to the urinary organs and bowel, such as hydronephrosis and bowel stenosis. In addition to DIE resection, surgical treatment involves adhesion separation as well as resection and reconstruction of the urinary organs and bowel; high-level skills are required. The severity of DIE should be evaluated preoperatively as accurately as possible. Using ENZIAN in conjunction with the AFS (The revised American Fertility Society classification of endometriosis) classification makes a more detailed assessment of DIE possible. The operative procedures used for laparoscopic resection of urinary DIE and reconstruction of the urinary organs are chosen based on the type of lesion (intrinsic/extrinsic) and length of stenosis. In addition to ureteroneocystostomy, the psoas bladder hitch and Boari bladder flap procedures are applied when necessary to extend the urinary tract. Bowel resection for bowel endometriosis is classified into classic segmental resection and conservative approaches (shaving/discoid). When these procedures are employed, it is advisable to work in consultation with urologists and gastroenterologists and to inform the patients of the associated risks and outcomes. Furthermore, postoperative medication is essential because it is difficult to conduct repeated surgeries.

Robot-assisted ureteral reconstruction - current status and future directions

Robotic surgery in the treatment in certain urological diseases has become a mainstay. With the increasing use of the robotic platform, some surgeries which were historically performed open have transitioned to a minimally invasive technique. Recently, the robotic approach has become more utilized for ureteral reconstruction. In this article, the authors review the surgical techniques for a number of major ureteral reconstuctive surgeries and briefly discuss the outcomes reported in the literature.

Laparoscopic ureteroneocystostomy for mid and lower ureteric strictures: Experience from a tertiary center

Purpose:

The purpose of this study is to evaluate our experience of laparoscopic ureteroneocystostomy for mid and lower ureteral stricture in a tertiary center in North India.

Materials and Methods:

A total of 20 laparoscopic ureteroneocystostomy were performed with or without bladder flap procedures in 20 patients (13 females and 7 males) with various etiologies such as ureteric stricture, ureterovaginal fistula, endometriosis, and distal ureteric tumor at our hospital in a time frame from August 2013 to January 2017. Eight cases each presented after laparoscopic/open hysterectomy and postureterorenoscopic stone removal while two cases each presented secondary to endometriosis and distal ureteric tumor. Simple laparoscopic ureteroneocystostomy in 4, psoas hitch in 9, and Boari flap was done in 7 cases.

Results:

The mean patient age was 44.2 years (range 19–65), mean surgical time was 184.25 min (115–250 min.), mean amount of bleeding was 153.25 mL (90–250 mL), and mean hospital stay was 3.05 days (2–7 days). Female-to-male ratio was 1.3:0.7. There was one conversion to open during laparoscopic Boari reimplant because of inadvertent injury to external iliac vein. The mean follow-up was 22.35 months (6–45). All the patients were asymptomatic with the resolution of hydronephrosis on ultrasound and without any significant obstruction on renal scan.

Conclusions:

Laparoscopic ureteroneocystostomy with or without bladder flap (Boari) provides good functional outcomes with excellent success rates and minimal morbidity comparable to open surgery in patients with ureteric stricture.

Bladder and Ureteral Dysfunction Leading to Hydronephrosis and Hydroureteronephrosis in Adults

Chronic non-stone-related hydronephrosis from supravesical or bladder dysfunction in adults is often detected incidentally. This study aims to review the literature regarding supravesical obstruction or bladder dysfunction leading to bilateral hydronephrosis in adults and to develop an algorithm to identify patients at risk of renal failure. Cross-sectional studies, retrospective and prospective cohorts, clinical trials, and systematic reviews from 1980 to 2017 were included. From 8115 articles screened, 39 met the inclusion criteria. Despite the lack of studies addressing this issue, this review brings up a rational evidence-based algorithm to diagnose and manage adults with bilateral hydronephrosis due to supravesical or bladder disease or dysfunction.

Ureteral endometriosis: A systematic literature review

Introduction:

Ureteral endometriosis is a rare disease affecting women of childbearing age which presents with nonspecific symptoms and it may result in severe morbidity. The aim of this study was to review evidence about incidence, pathogenesis, clinical presentation, diagnosis, and management of ureteral endometriosis.

Materials and Methods:

PubMed Central database was searched to identify studies reporting cases of ureteral endometriosis. “Ureter” or “Ureteral” and “Endometriosis” were used as key words. Database was searched for articles published since 1996, in English without restrictions regarding the study design.

Results:

From 420 studies obtained through database search, 104 articles were finally included in this review, including a total of 1384 patients with ureteral endometriosis. Data regarding age, location, pathological findings, and interventions were extracted. Mean patients' age was 38.6 years, whereas the therapeutic arsenal included hormonal, endoscopic, and/or surgical treatment.

Conclusions:

Ureteral endometriosis represents a diagnostic and therapeutic challenge for the clinicians and high clinical suspicion is needed to identify it.

Ureteral Endometriosis and Silent Renal Loss: A Retrospective Study

Objective

To present six cases of ureteral endometriosis with renal loss managed by a multidisciplinary minimally invasive approach.

Introduction

Severe ureteral endometriosis can potentially lead to urinary tract obstruction and silent loss of renal function. Nephrectomy should be considered and may be performed by a multidisciplinary minimally invasive approach.

Material and methods

Retrospective observational study of patients with deep endometriosis with ureteral involvement and consequently loss of renal function who underwent laparoscopic nephrectomy between April 2009 and April 2016 in a tertiary care university hospital. The clinical presentation, imaging characteristics, surgical findings, surgical procedures, operative time, blood loss, postoperative analgesic administration, mean hospital stay and recurrence rates were analyzed.

Results

The mean age of patients was 28 years (range 26 to 40). Mean overall operative time for the laparoscopic procedures was 382 minutes (range 310 to 705). Mean blood loss was 200 cc and there were no intraoperative complications in our series with no need to laparotomy conversion. Mean overall hospital stay was 157 hours (range 48 to 364). Regarding complications, a case of pyelonephritis and one of urinary retention were registered, the latter requiring bladder neurostimulation 2 years after surgery. All women remain asymptomatic in follow-up.

Conclusions

In ureteral deep endometriosis, nephrectomy should be considered for significant renal functional impairment associated with persistent ureterohydronephrosis and renal parenchymal atrophy. It may be performed by laparoscopy with minimal morbidity, minimal postoperative discomfort, and a short hospital stay.

Ureteral Endometriosis: Preoperative Risk Factors Predicting Extensive Urologic Surgical Intervention

OBJECTIVE

To identify risk factors for urologic reconstruction during surgery for endometriosis.

PATIENTS AND METHODS

We retrospectively identified patients in a surgical pathology database undergoing surgery for endometriosis at our institution from 2010 to 2015 and subsequently identified those patients with ureteral involvement. Patients were categorized as requiring minimal urologic surgery (eg, ureterolysis only) or more extensive urologic surgery (eg, ureteral reimplant). All patients were undergoing surgery for endometriosis, and preoperative risk factors were then identified to predict the need for intraoperative extensive urologic surgery.

RESULTS

Of 386 women undergoing surgery for endometriosis, 82 (21%) women required a surgical procedure on the ureter. Fifteen of these 82 patients (18.3%) with ureteral involvement required urologic surgical expertise in the form of either ureteral reimplantation with or without psoas hitch, or ureterolysis with ureteral stenting or omental wrap. The remaining 67 underwent ureterolysis alone or no intervention. The presence of flank pain, any urinary symptom, or hydronephrosis on preoperative imaging was a significant predictor of the need for major urologic intervention.

CONCLUSION

In patients with endometriosis undergoing surgery who complain of flank pain, any urinary symptom, or have hydronephrosis on preoperative imaging, one should have a high suspicion for needing to perform urologic reconstruction during surgery. Planning for this additional operation can afford the opportunity for appropriate urologic consultation and patient counseling.

[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.

Deep infiltrating endometriosis affecting the urinary tract-surgical treatment and fertility outcomes in 2004-2013

Urinary tract endometriosis (UTE) is a rare form of deep infiltrating endometriosis. We studied the operative treatment of UTE and evaluated postoperative recurrences and fertility outcomes. This is a retrospective cohort study of 53 women who underwent operative treatment for UTE in 2004–2013 at Helsinki University Hospital, and were followed-up until the end of 2014. The data were gathered from the hospital’s electronic database. The main outcome measures were complications, reoperations, postoperative pregnancies, and deliveries. Preoperative diagnosis was accurate in 72 % with bladder endometriosis and in 93 % with ureteral disease. Thirty-one (58 %) of the 53 operations were performed via laparoscopy. Postoperative complications requiring re-intervention occurred in five cases (9 %). Five reoperations were performed in four cases due to endometriosis recurrence, only two due to recurrence of UTE (4 %). Twenty-eight women wished for pregnancy; 18 (64 %) of them conceived. Infertility treatment was needed in 20 (71 %) cases. Twelve (75 %) women delivered via cesarean section; intraoperative difficulties occurred in ten (83 %). The complication rate with UTE operations is acceptable and recurrences are rare. Infertility is common, but 57 % of those who wished for a child succeeded. A majority of the deliveries involved unplanned and complicated cesarean section.

Employing Laparoscopic Surgery for Endometriosis

Endometriosis is a chronic, multifactorial disease, which can impact significantly on a women's quality of life. It is associated with pelvic pain, dyspareunia and intestinal disorders, and can lead to infertility. The use of laparoscopic surgery in the management of endometriosis is well documented; however, the optimal management of women with deep infiltrating disease remains controversial. This review describes the different surgical strategies for the treatment of endometriosis.

Isolated ureteric endometriosis presenting as a ureteric tumor

A 32 year old lady presented with recurrent left flank pain for 4 weeks and chronic lower back pain. CT without contrast showed no stones and mild left hydronephrosis. CT of the spine suggested an inflammatory process at L5-S1 vertebra. The diagnosis was supported by a bone scan. Incidentally, the scan showed nonfunctioning left kidney. Diuretic renography confirmed poor perfusion and no excretion. A retrograde study showed narrowing of the ureter at the pelvic brim. Ureteroscopy showed a papillary mass in the lumen of the ureter from which multiple cold cup biopsies were taken. The pathology however was not conclusive. A robotic nephroureterectomy was carried out. Definitive pathology showed intrinsic endometriosis of the ureter. We conclude that endometriosis should be considered in the differential diagnosis of unexplained ureteric obstruction and ureteric lumen filling defects in young women.

Laparoscopic management of moderate: Severe endometriosis

OBJECTIVES:

To assess the feasibility of laparoscopic surgery in cases of moderate-severe endometriosis.

MATERIALS AND METHODS:

A prospective study was carried out in a tertiary centre over a period of 2 years. Moderate to severe endometriosis was defined by revised American fertility society (rAFS) classification (41 patients). Various procedures were done to provide symptomatic relief. Feasibility of laparoscopic surgery and various patient parameters were analysed.

RESULTS:

Various procedures like adhesiolysis in POD, excision of endometriomas, resection of endometriotic nodules in the recto-vaginal septum, ureterolysis and total laparoscopic hysterectomy with/ without oophorectomy were done. Majority of patients underwent cystectomy for endometriomas (53.6%) or adhesiolysis with excision of endometriotic nodule (36.5%). Total laparoscopic hysterectomy with or without ooperectomy was done in 31.7% patients. Of the total 9 patients with primary infertility and moderate-severe endometriosis, 5 patients (55.5%) conceived after surgery.

CONCLUSION:

There is good evidence that in experienced hands laparoscopic surgery helps in long-term symptomatic relief, improves pregnancy rates and reduces recurrence of disease with largely avoiding complications.

Outcomes of surgical management of deep infiltrating endometriosis of the ureter and urinary bladder

Conservative surgery can be proposed for cases of urinary tract endometriosis associated with postoperative amenorrhea; however, there is a risk of concomitant colorectal surgery and postoperative complications.

Objectives:

To report the outcomes of surgical management of urinary tract endometriosis and discuss the choice between conservative and radical surgery.

Materials and Methods:

We reviewed data concerning women managed for ureteral or bladder deep infiltrating endometriosis in 5 surgical departments participating in the CIRENDO prospective database. Preoperative data, surgical procedure data, and postoperative outcomes were analyzed.

Results:

Data from 30 women pooled in the database showed 15 women presenting with ureteral endometriosis, 14 women with bladder nodules, and 1 with both types of lesions. Ureterolysis was performed in 14 cases; the ureter was satisfactorily freed in 10 of these. In 4 women over 40 years old, who were undergoing definitive amenorrhea, moderate postoperative ureteral stenosis was tolerated and later improved in 3 cases, while the fourth underwent secondary ureteral resection and ureterocystoneostomy. Primary ureterectomy was carried out in 4 women. Two cases of intrinsic ureteral endometriosis were found in 5 ureter specimens. Four complications were related to surgical procedures on ureteral nodules, and 2 complications followed the removal of bladder endometriosis. Delayed postoperative outcomes were favorable with a significant improvement in painful symptoms and an absence of unpleasant urinary complaints, except for one patient with prolonged bladder denervation.

Conclusion:

Conservative surgery, in association with postoperative amenorrhea, can be proposed in a majority of cases of urinary tract endometriosis. Although the outcomes are generally favorable, the risk of postoperative complications should not be overlooked, as surgery tends to be performed in conjunction with other complex procedures such as colorectal surgery.

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.

Robot-assisted laparoscopic ureterolysis: case report and literature review of the minimally invasive surgical approach

Results of this study suggest that robotic-assisted laparoscopic ureterolysis is a safe and effective procedure for patients with idiopathic retroperitoneal fibrosis.

Objectives:

To evaluate our case of robot-assisted ureterolysis (RU), describe our surgical technique, and review the literature on minimally invasive ureterolysis.

Methods:

One patient managed with robot-assisted ureterolysis for idiopathic retroperitoneal fibrosis was identified. The chart was analyzed for demographics, operative parameters, and immediate postoperative outcome. The surgical technique was assessed and modified. Lastly, a review of the published literature on ureterolysis managed with minimally invasive surgery was performed.

Results:

One patient underwent robot-assisted ureterolysis at our institution in 2 separate settings. Operative time (OR) decreased from 279 minutes to 191 minutes. Estimated blood loss (EBL) was less than 50mL. The patient has been free of symptoms and both renal units are unobstructed. According to the published literature, 302 renal units underwent successful laparoscopic ureterolysis (LU), and 6 renal units underwent RU. There were 9 open conversions (all in LU). Mean OR in LU was 248 minutes for unilateral and 386 minutes for bilateral cases. In RU, mean OR was 220 minutes for unilateral and 390 minutes for bilateral cases. EBL averaged 200mL in LU and 30 mL in RU.

Conclusions:

Our data reveal that robot-assisted ureterolysis is safe and feasible. Published data demonstrate the advantages of minimally invasive surgery.

Management of ureteric endometriosis associated with hydronephrosis: An Australian case series of 13 patients

Background

Hydronephrosis is a rare but serious manifestation of ureteric endometriosis.

Findings

One hundred and twenty-six women underwent ureterolysis for ureteric endometriosis betweeen and October 1996 and June 2009. Thirteen of the 126 women were identified as having ureteric obstruction at the time of their procedure and were included in the case series. The median age was 39.5 (30 - 63). Chronic pelvic pain was the most common presenting symptom (53.8%). The point of ureteric obstruction was noted to occur most commonly at a small segment of distal left ureter, where it is crossed by the uterine artery (54%). Seven of the 13 women (53.8%) were successfully managed with ureterolysis only. Three of the 13 women (21.3%) underwent ureterolysis and placement of a double J ureteric stent. Three of the 13 (21.3%) required a segmental ureteric resection. There was one incidence of inadvertent thermal ureteric injury which was managed with a ureteric stent. In all cases the hydronephrosis had resolved at six months follow up.

Conclusions

Our findings support the growing body of literature supporting ureterolysis as the optimal treatment for ureteric endometriosis causing moderate to severe ureteric obstruction.