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

Renal Endometriosis Mimics Renal Cell Carcinoma in a Hypoplastic Kidney: A Case Report

Renal endometriosis is a rare disorder of cases of urinary tract endometriosis. A 42-year-old woman presented at our outpatient department with an incidental painless mass on her left hypoplastic kidney revealed on an abdominal ultrasound. Abdominal and pelvic examinations revealed no abnormal findings. A computed tomography (CT) scan revealed an anterolateral slightly enhanced left renal mass that measured 1.2 cm in diameter. Furthermore, CT did not reveal any evidence of abdominal or thoracic metastasis. There are a few case reports in the literature of tumors in specimens from patients who underwent nephrectomy for hypoplastic kidneys, but discriminating between benign and malignant masses is difficult unless a nephrectomy is performed. Given the radiological findings and the impaired function of the hypoplastic kidney, laparoscopic radical nephrectomy was recommended. The procedure was performed under general anesthesia without intraoperative or postoperative complications. Microscopic examination revealed several findings consistent with a diagnosis of renal endometriosis. The patient had no symptoms at her last follow-up visit. This case highlights that renal endometriosis can mimic renal cell carcinoma and awareness of this entity should be raised, as it can be asymptomatic, especially when located in a hypoplastic kidney.

Urological procedures performed by gynecologists: Activity profile in a gynecological surgery department, 10-year observation cohort

INTRODUCTION

The proximity of the urinary tract to the female genital tract explains its possible involvement in pelvic gynaecological cancer or deep endometriosis. Surgical treatment is aimed at improving overall survival and recurrence-free survival of patients, as well as restoring normal anatomy and functional integrity depending on the pathology. These operations are accompanied by significant post-operative complications. Thus, the urological procedures performed must be rigorously justified, and the different resection and reconstruction techniques adapted to the pathology and the level of infiltration.

OBJECTIVE

To describe the activity profile, over the last ten years, of a gynaecological surgery department in terms of urological procedures in the management of patients with deep endometriosis and pelvic carcinology.

STUDY DESIGN

This is a monocentric retrospective observational study, including all patients who underwent a urological procedure by a gynaecological surgeon only, as part of the management of pelvic gynaecological cancers or deep endometriosis, at the University Hospital Centre (CHU) of Strasbourg, between January 1st 2010 and April 31st 2021. The variables studied were early postoperative complications, the rate of surgical reintervention, operating time, length of hospital stay, the need for peri-operative drainage or transfusion, and post-operative functional disorders.

RESULTS

A total of 86 patients were included, 27 in the pelvic gynaecological cancer group and 59 in the deep endometriosis group. 61.6% of patients received uretero-vesical catheterization, 60.5% partial cystectomy, 10.5% psoic bladder ureteral reimplantation, and 3.5% trans-ileal Bricker skin ureterostomy. The mean operating time was 316 min in the pelvic gynaecological cancer group and 198.9 min in the deep endometriosis group. The average hospital stay was 11.5 days, 22.3 days for patients treated for pelvic cancer and 6.3 days for those treated for endometriosis. The rate of minor post-operative complications was 8.2% of cases, and major post-operative complications 17.4% of cases, the majority of which were in the gynecological cancer group. There were no cases of intra- or early post-operative death. Early postoperative urinary complications affected 14.0% of the total patients, mostly in the gynaecological cancer group with 33.3% of patients, but only 5.1% of patients in the deep endometriosis group. The total reoperation rate within 60 days postoperatively was 15.1%, 40.7% for patients treated for gynaecological cancer and 3.4% for those treated for deep pelvic endometriosis. The rate of reoperations for urinary complications was 11.6% of total patients, or 76.9% of total reoperations. 15 patients received labile blood products intra- or postoperatively, 11 in the pelvic gynaecological cancer group and 4 in the endometriosis group.

CONCLUSION

Our overall results appear comparable to those reported in the literature and are particularly satisfactory in terms of post-operative complications after partial cystectomy in the management of deep endometriosis compared to other gynaecological departments. This work encourages us to continue and improve the training of gynaecological surgeons in terms of multidisciplinary surgical procedures, including urological ones, to obtain a global vision of the pathology and to allow an optimal quality of care for the patients.

Improvement of Post-Operative Quality of Life in Patients 2 Years after Minimally Invasive Surgery for Pain and Deep Infiltrating Endometriosis

This study addressed the improvement in the quality of life of patients 2 years after minimally invasive surgery for painful deep infiltrating endometriosis (DIE), evaluated with EHP-5 (Endometriosis Health Profile-5) scores and the intensity of dysmenorrhea and dyspareunia. This was a retrospective study, performed in a referral centre for endometriosis, between January 2010 and January 2019. EHP-5 scores were complete for 54 patients, and two subgroups were analysed: classic laparoscopy (CL) vs. robotic laparoscopy (RL), and conservative surgery (ConservS) vs. total surgery (TS). There was an important decrease in 2-year post-operative EHP-5 scores in the global population (pre-op: 61.36 (42.18−68.75) and 2-year post-op: 20.45 (0−38.06); p < 0.001). The Visual Analogic Scale (VAS) was also lower for dysmenorrhea (pre-op: 8 (7−9.75) vs. 2-year post-op: 3 (2−5.25); p < 0.001) and dyspareunia (pre-op: 6 (3.1−8.9) vs. 2-year post-op: 3 (0−6); p < 0.001). In the subgroup analysis, EHP-5 scores were improved in the RL group (pre-op: 65.9 (59.09−71.02) vs. 2-year post-op: 11.4 (0−38.06); p < 0.001) and the CL group (pre-op: 50 (34.65−68.18) vs. 2-year post-op: 27.27 (14.20−40.90); p < 0.001), with a slight advantage for RL (p = 0.04), and the same improvements were found for ConservS (pre-op: 61.4 (38.06−71.59) vs. 2-year post-op: 22.7 (11.93−38.07); p < 0.001) and TS groups (pre-op: 61.59 (51.70−68.75) vs. 2-year post-op: 13.63 (0−44.30); p < 0.001). Minimally invasive surgery improved the quality of life for DIE patients 2 years after surgery, and conservative surgery showed comparable results to total surgery.

Accuracy of transvaginal ultrasound and magnetic resonance imaging for diagnosis of deep endometriosis in bladder and ureter: a meta-analysis

This meta-analysis aimed to determine the accuracy of transvaginal ultrasound (TVS) and pelvic magnetic resonance imaging (MRI) in diagnosing urinary tract endometriosis (UTE). A comprehensive search of the Pubmed and Embase was conducted between January 1989 and June 2020. Studies that described the accuracy of MRI or TVS for the diagnosis of UTE using surgical data as the reference standard were included. Of the 913 citations identified, 23 studies were analysed. For detection of endometriosis in bladder endometriosis (BE), the overall pooled sensitivities of TVS and MRI were 72% and 68% respectively, and their specificities were 99% and 100% respectively. For detection of endometriosis in the ureteral endometriosis (UE), the overall pooled sensitivities of TVS and MRI were 97% and 87% respectively, and their specificities were both 100%. In conclusion, both TVS and MRI provide good accuracy with specific strong points in diagnosing UTE and seem useful first-line methods from a clinical perspective. Besides, pelvic MRI and TVS are more accurate for predicting UTE localised in the ureter than bladder, especially in terms of sensitivity.IMPACT STATEMENTWhat is already known on this subject? Previous studies have confirmed high diagnostic value of transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) on bladder endometriosis (BE) respectively. However, high heterogeneity was found for both sensitivity and specificity and no meta-analysis has yet been performed to test the diagnostic value of TVS and MRI for ureteral endometriosis (UE).What the results of this study add? In this meta-analysis, we firstly confirmed high diagnostic value of TVS and MRI on UE respectively. For detection of UE, the overall pooled sensitivities of TVS and MRI were 97% and 87% respectively, and their specificities were both 100%.What the implications are of these findings for clinical practice and/or further research? Early preoperative diagnosis and accurate understanding of the widespread distribution of endometriosis are prerequisites for radical surgical in UTE. In the present study, we updated the previous results on the accuracy of TVS and MRI for the diagnosis of BE and firstly confirmed high diagnostic value of TVS and MRI on UE. Both TVS and MRI provide good accuracy with specific strong points in diagnosing UTE and seem useful first-line methods from a clinical perspective.

Renal Endometriosis Mimicking Cystic Renal Tumor: Case Report and Literature Review

Background: Endometriosis mainly affects female pelvic tissues and organs, and the presence of endometriosis in the kidney is extremely rare.

Case Presentation: We report a case of a 48-year-old woman who presented with intermittent hematuria. She was found to have a cystic mass on renal ultrasonography, and contrast-enhanced computed tomography (CT) showed slight enhancement of the cystic wall and septa. These findings were indicative of cystic renal tumor. The patient subsequently underwent partial right nephrectomy. Histopathology revealed endometriosis of the right renal parenchyma. The patient recovered well and had no evidence of a recurrent renal mass at the 3 months' follow up.

Conclusion: The possibility of renal endometriosis should be considered in a female patient with a cystic renal mass and clinical symptoms related to the menstrual cycle.

Case report and surgical video presentation: Combined laparoscopic and cystoscopic partial bladder cystectomy for excision of deeply infiltrating endometriosis

Introduction

Whilst endometriosis is a relatively common condition, deeply infiltrating endometriosis (DIE) of the bladder is less so, and when medical treatment fails, surgical management is an effective option. We present a case report and surgical video of a patient undergoing combined laparoscopic and cystoscopic excision of deeply infiltrating endometriosis of the bladder.

Design

Case report (Canadian Task Force Classification III) and step-by-step explanation of the surgery using video. Exemption was granted from the local institutional review board.

Presentation of case

We present a case report and surgical video of a 36-year-old nulliparous patient presenting with a 12-month history of sudden onset cyclical dysuria and haematuria. Imaging demonstrated a deeply infiltrating endometriotic nodule involving the bladder. The patient underwent a combined laparoscopic and cystoscopic excision of deeply infiltrating endometriosis of the bladder. The procedure was uneventful and the patient progressed to a full recovery.

Discussion

DIE is a highly invasive form of endometriosis which is defined arbitrarily as endometriosis infiltrating beneath the peritoneum by 5mm or greater. When medical therapy is declined or fails, surgical excision by partial cystectomy would appear to be the most effective management option. A combination of cystoscopy and laparoscopy has been shown to be a safe and feasible procedure, with a low rate of complications. It represents the ideal way by which to identify the resection limits for complete excision of the lesion, and allows for optimal repair of the bladder defect.

Conclusion

Combined laparoscopic and cystoscopic partial cystectomy for excision of deeply infiltrating bladder endometriosis is a safe and feasible procedure in our institution.

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A case of surgical management of deeply infiltrating endometriosis of the bladder is reported.

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Combined cystoscopic and laparoscopic excision can be performed for the treatment of this form of endometriosis.

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This approach is safe, feasible and has a low rate of complications in the current literature.