Pathophysiology and management of urinary tract endometriosis

Bioelectronics for electrical stimulation: materials, devices and biomedical applications

Bioelectronics is a hot research topic, yet an important tool, as it facilitates the creation of advanced medical devices that interact with biological systems to effectively diagnose, monitor and treat a broad spectrum of health conditions. Electrical stimulation (ES) is a pivotal technique in bioelectronics, offering a precise, non-pharmacological means to modulate and control biological processes across molecular, cellular, tissue, and organ levels. This method holds the potential to restore or enhance physiological functions compromised by diseases or injuries by integrating sophisticated electrical signals, device interfaces, and designs tailored to specific biological mechanisms. This review explains the mechanisms by which ES influences cellular behaviors, introduces the essential stimulation principles, discusses the performance requirements for optimal ES systems, and highlights the representative applications. From this review, we can realize the potential of ES based bioelectronics in therapy, regenerative medicine and rehabilitation engineering technologies, ranging from tissue engineering to neurological technologies, and the modulation of cardiovascular and cognitive functions. This review underscores the versatility of ES in various biomedical contexts and emphasizes the need to adapt to complex biological and clinical landscapes it addresses.

Combined Cystoscopic-Abdominal Versus Abdominal-Only Route for Complete Excision of Large Deep Endometriosis Nodules Infiltrating the Supratrigonal Area of the Bladder: A Comparative Study

STUDY OBJECTIVE

Surgical excision of large deep endometriosis nodules infiltrating the bladder may be challenging, particularly when the nodule limits are close to the trigone and ureteral orifice. Bladder nodules have classically been approached abdominally. However, combining a cystoscopic with an abdominal approach may help to better identify the mucosal borders of the lesion to ensure complete excision without unnecessary resection of healthy bladder. This study aimed to compare classical excision of large bladder nodules by abdominal route with a combined cystoscopic-abdominal approach.

DESIGN

Retrospective comparative study on data prospectively recorded in a database. Patients were managed from September 2009 to June 2022.

SETTING

Two tertiary referral endometriosis centers.

PATIENTS

A total of 175 patients with deep endometriosis infiltrating the bladder more than 2 cm undergoing surgical excision of bladder nodules.

INTERVENTIONS

Excision of bladder nodules by either abdominal or combined cystoscopic-abdominal approaches.

MEASUREMENTS AND MAIN RESULTS

A total of 141 women (80.6%) were managed by abdominal route and 34 women (19.4%) underwent a combined cystoscopic-abdominal approach. In 99.4% of patients, the approach was minimally invasive. Patients with nodules requiring the combined approach had a lower American Fertility Society revised score and endometriosis stage and less associated digestive tract nodules, but larger bladder nodules. They were less frequently associated with colorectal resection and preventive stoma. Operative time was comparable. The rate of early postoperative complications was comparable (8.8% vs 22%), as were the rates of ureteral fistula (2.2% vs 2.9%), bladder fistula (2.2% vs 0), and vesicovaginal fistula (0.7% vs 2.9%).

CONCLUSION

In our opinion, the combined cystoscopic-abdominal approach is useful in patients with large bladder nodules with limits close to the trigone and ureteral orifice. These large deep bladder nodules seemed paradoxically associated to less nodules on the digestive tract, resulting in an overall comparable total operative time and complication rate.

Robotic surgery for deep-infiltrating endometriosis: is it time to take a step forward?

Endometriosis is a chronic debilitating disease that affects nearly 10% of women of the reproductive age. Although the treatment modalities of endometriosis are numerous, surgical excision of the endometriotic implants and nodules remains the sole cytoreductive approach. Laparoscopic excision of endometriosis was proven to be beneficial in improving the postoperative pain and fertility. Moreover, it was also proved to be safe and efficient in treating the visceral localization of deep endometriosis, such as urinary and colorectal endometriosis. More recently, robotic-assisted surgery gained attention in the field of endometriosis surgery. Although the robotic technology provides a 3D vision of the surgical field and 7-degree of freedom motion, the safety, efficacy, and cost-effectiveness of this approach are yet to be determined. With this paper, we aim to review the available evidence regarding the role of robotic surgery in the management of endometriosis along with the current practices in the field.

Surgical Management of Endometriosis Involving the Bladder and Ureter

BACKGROUND

Endometriosis is a chronic, debilitating condition affecting up to 10% of reproductive-age women. Urinary tract endometriosis is found in 1%-6% of women diagnosed with pelvic endometriosis, with the most common sites being the bladder (70%-85%), ureter (9%-23%), and kidney (4%). Patients typically present with symptoms such as lower abdominal pain, dysuria, and urgency. Unfortunately, urinary tract endometriosis is often asymptomatic, potentially leading to silent obstructive uropathy and kidney failure.

OBJECTIVE

To demonstrate a step-by-step approach for the surgical management of urinary tract endometriosis using conventional laparoscopy for partial cystectomy and robotic-assisted laparoscopy for ureteroneocystostomy.

MATERIAL AND METHOD

Surgical video of 2 cases managed in an academic tertiary referral center for endometriosis. The first case was a 38-year-old Gravida 3, Para 3 with a history of hysterectomy who had an MRI which revealed a T2 hypointense bladder nodule consistent with endometriosis. Patient had significant urinary urgency, dysuria, and suprapubpic pain that improved but did not disappear after starting oral progestin therapy (5 mg of norethindrone). A cystoscopy was first performed to confirm MRI findings of bladder lesion and to delineate borders and depth of invasion. The second case was a 35-year-old nulliparous woman with chronic pelvic pain and primary infertility. The patient had a history of stage IV endometriosis with deep endometriosis into the bowel and extrinsic encasement of the ureters causing subsequent hydronephrosis requiring bilateral ureteral stents. She had continued daily pelvic pain despite of being on oral contraceptives for medical management of endometriosis. She subsequently underwent bilateral percutaneous nephrostomy tube placement to allow for ureteral rest prior to surgery.

RESULTS

In the first case, conventional laparoscopy was utilized to perform bilateral ureterolysis, bladder mobilization, partial cystectomy for complete excision of the lesion, and 2-layered bladder closure. Use of indigo carmine assisted with ureteral orifice identification. In the second case, a cystoscopy was performed with injection of Indocyanine green to assist with ureteral identification. After ureterolysis, distal ureteric obstruction due to extensive disease was confirmed on laparoscopy and ureteroscopy. Bilateral ureteroneocystostomy with placement of Double-J ureteral stents was performed using a robotic-assisted approach. Each patient had an indwelling Foley catheter for bladder decompression during recovery. Pathology in both cases revealed endometriosis. Both patients had an uneventful postoperative course. A postoperative retrograde cystogram confirmed adequate repair prior to removal of each Foley catheter. Patient 2 had uncomplicated office stent removal 6 weeks postoperatively and had a normal renal ultrasound with no hydronephrosis 6 months postoperatively.

CONCLUSION

Endometriosis is an increasingly common condition. It is important for gynecological surgeons to have the proper understanding of anatomy, surgical technique, and multidisciplinary care needed with urology for safe and complete excision of bladder and ureter endometriosis.

Tumefactive Nonneoplastic Proliferative Pseudotumors of the Kidneys and Urinary Tract: CT and MRI Findings with Histopathologic Correlation

A diverse spectrum of pathologically distinct, nonneoplastic, proliferative conditions of the kidneys and urinary tract demonstrate a expansile growth pattern similar to that of neoplasms. The renal pseudotumors include myriad causes of infections as well as rare noninfectious causes such as sarcoidosis, amyloidosis, and immunoglobulin G4-related disease (IgG4-RD). Rare entities such as cystitis cystica, endometriosis, nephrogenic adenoma, and pseudosarcomatous myofibroblastic proliferation and distinct types of prostatitis comprise tumefactive nontumorous disorders that affect specific segments of the urinary tract. The pseudotumors of the kidneys and urinary tract demonstrate characteristic histopathologic and epidemiologic features, as well as protean clinical manifestations, natural history, and imaging findings. Many patients present with genitourinary tract-specific symptoms or systemic disease. Some cases may be incidentally discovered at imaging. Some entities such as perinephric myxoid pseudotumors, IgG4-RD, fibroepithelial polyp, and nephrogenic adenoma display specific anatomic localization and disease distribution. Imaging features of multisystem disorders such as tuberculosis, sarcoidosis, and IgG4-RD provide supportive evidence that may allow precise diagnosis. Fungal pyelonephritis, xanthogranulomatous pyelonephritis, IgG4-RD, actinomycosis, and endometriosis show markedly low signal intensity on T2-weighted MR images. Although some pseudotumors exhibit characteristic imaging findings that permit correct diagnosis, laboratory correlation and histopathologic confirmation are required for definitive characterization in most cases. A high index of suspicion is a prerequisite for diagnosis. Accurate diagnosis is critical for instituting optimal management while preventing use of inappropriate therapies or interventions. Surveillance CT and MRI are frequently used for monitoring the response of pseudotumors to therapy. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Imaging of Urinary Bladder and Ureteral Endometriosis with Emphasis on Diagnosis and Technique

Endometriosis is a chronic inflammatory gynecological condition affecting 10-15% of women in the reproductive age group. The urinary tract is the second most common extragenital organ system affected by endometriosis, and the urinary bladder and ureter are the two most common sites involved. Involvement of the urinary bladder can cause chronic debilitating symptoms, whereas ureteral involvement may lead to asymptomatic loss of renal function. Both conditions are frequently unsuspected, leading to a delay in diagnosis. Therefore, it is important to recognize this entity early, for which knowledge of imaging appearances and techniques is helpful. In this review article, we describe (a) endometriosis background, pathogenesis, definitions and clinical symptoms, (b) imaging appearance, with emphasis on ultrasound and MRI findings of urinary bladder and ureteric endometriosis, (c) ultrasound technique and MRI sequences useful for making the correct diagnosis, (d) overview of the treatment options and key imaging findings that are important to the surgeon for surgical planning, and (e) a structured reporting template useful for multidisciplinary patient management.

Outcomes of Urinary Tract Endometriosis-Laparoscopic Treatment: A 10-Year Retrospective Study

INTRODUCTION

Urinary tract endometriosis (UTE), a rare manifestation, encompasses bladder and ureteral involvement. Surgical intervention is commonly recommended for UTE, though the optimal surgical approach remains a subject of debate. This study aims to report our centre's experience with UTE.

METHODS

We conducted a retrospective cohort study of 55 patients who underwent surgical treatment for UTE at a single tertiary centre over a 10-year period (2012-2022). Patient data, including demographics, symptoms, intraoperative findings, and complications, were collected from medical records. Data were statistically analysed, and correlations were explored.

RESULTS

The study population had a mean age of 37.11 years, with dysmenorrhea (89.1%) being the most common symptom. Bladder endometriosis was present in 27 cases, ureteral endometriosis in 25, and mixed-location in 3. Laparoscopy was the primary surgical approach, with multidisciplinary teams involving urologists. There were six patients with postoperative complications, and there were six (10.9%) recurrences of endometriosis. A positive correlation was found between age and recurrence, but no significant predictors of recurrence were identified in our analysis.

CONCLUSIONS

Laparoscopic treatment of urinary endometriosis is safe and effective. Multidisciplinary collaboration plays a pivotal role in addressing this challenging condition.

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.

Acute abdominal pain in women of reproductive age: keys to suggest a complication of endometriosis

Although endometriosis is a common gynecological condition in women of reproductive age, a complication of endometriosis is rarely considered as the differential diagnosis of acute abdominal pain in that context. However, acute events in women with endometriosis can represent life-threatening conditions, which require emergent treatment and often surgical management. Mass effect of endometriotic implants can give rise to obstructive complications, specifically occurring in the bowel or in the urinary tract, while inflammatory mediators released by ectopic endometrial tissue can lead to inflammation of the surrounding tissues or to superinfection of the endometriotic implants. Magnetic resonance imaging is the best imaging modality to reach the diagnosis of endometriosis, but an accurate diagnosis is possible on computed tomography, especially in the presence of stellar, mildly enhanced, infiltrative lesions in suggestive areas. The aim of this pictorial review is to provide an image-based overview of key findings for the diagnosis of acute abdominal complications of endometriosis.

The indispensability of macrophage adaptor proteins in chronic inflammatory diseases

Adaptor proteins represent key signalling molecules involved in regulating immune responses. The host's innate immune system recognizes pathogens via various surface and intracellular receptors. Adaptor molecules are centrally involved in different receptor-mediated signalling pathways, acting as bridges between the receptors and other molecules. The presence of adaptors in major signalling pathways involved in the pathogenesis of various chronic inflammatory diseases has drawn attention toward the role of these proteins in such diseases. In this review, we summarize the importance and roles of different adaptor molecules in macrophage-mediated signalling in various chronic disease states. We highlight the mechanistic roles of adaptors and how they are involved in protein-protein interactions (PPI) via different domains to carry out signalling. Hence, we also provide insights into how targeting these adaptor proteins can be a good therapeutic strategy against various chronic inflammatory diseases.

Psychiatric Symptoms in Patients with Cerebral Endometriosis: A Case Report and Literature Review

Endometriosis is a systemic medical condition characterized by endometrial tissue that is abnormally implanted in extrauterine sites, including the central nervous system. In this article, we reported the case of a patient with presumed cerebral endometriosis who was diagnosed with bipolar disorder and panic disorder and systematically reviewed the literature for previously reported neuropsychiatric symptoms in patients with cerebral and cerebellar endometriosis. The PubMed, Scopus, and Web of Science bibliographic databases were searched according to the PRISMA guidelines. Seven previous case reports were found and described. While neurological disturbances dominated the clinical picture in the cases retrieved from the literature, our patient represented the first case to show both neurological and psychiatric manifestations. Atypical features of bipolar disorder including chronic mood instability, mixed episodes, and excitatory interepisodic symptoms were highlighted. During the neuropsychological evaluation, a dysexecutive profile consistent with frontal lobe pathology was evidenced. We hypothesized that the course and features of the illness were largely influenced by the presence of documented brain lesions compatible with endometrial implants, especially in the frontal region. Accordingly, patients with endometriosis who exhibit neurological as well as mental symptoms should be investigated for cerebral lesions.

Symptoms and Surgical Technique of Bladder Endometriosis: A Systematic Review

OBJECTIVE

This systematic review aimed to review all the available evidence regarding bladder endometriosis (BE) surgical techniques, resolution of symptoms, and nodule size.

DATA SOURCES

We conducted systematic searches in PubMed MEDLINE, Embase, Latin American and Caribbean Centre on Health Sciences Information, Cochrane Library, and Web of Science databases from inception to December 2021.

METHODS OF STUDY SELECTION

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the literature search yielded 1279 articles. Two reviewers independently screened abstracts and reviewed full-text articles to meet the eligibility criteria: women diagnosed as having BE, treated surgically to remove the BE nodule, and reported of the nodule size and/or symptoms after the surgery. We included 28 studies, which mainly were case reports and case series.

TABULATION, INTEGRATION, AND RESULTS

The following information was extracted from the included studies: author, country, publication year, study design, number of patients, age, surgery performed, follow-up time, operation time, nodule location, nodule size, and postsurgical symptoms. Patients' ages range from 26 to 44 years and most women were nulliparous. The BE nodule size ranged from 0.7 to 5.5 cm, and the most frequent location (63.57%) was the posterior wall. Dysuria was reported by 27.18% of women and generic lower urinary tract symptoms were reported by 27.95%. After surgery, the recurrence rate of urinary symptoms was 7.34%. Most studies performed a partial cystectomy to remove the nodule, showing that the disease affects the bladder mucosa frequently.

CONCLUSION

Surgical treatment with complete excision of BE lesion was shown to improve complaints of urinary symptoms in patients with BE. Given that most of the studies evaluated were descriptive, additional studies with a large sample population and a better level of evidence for this condition are needed.

Comprehensive surgical treatment for obstructive rectal endometriosis: a case report and review of the literature

Background

Intestinal obstruction caused by endometriosis maybe easily misdiagnosed as a tumor or other occupying disease in emergency condition. How to deal with it depending on the clarity of the preoperative diagnosis and the experience of the surgeon.

Case presentation

A 47-year-old woman, admitted to our emergency service with abdominal pain and distension for 5 days, anal stop exhausting and defecating for 3 days. Based on imaging and laboratory examination, we made a preoperative diagnosis of rectal endometriosis probably. After 7 days of colon decompression with a intestinal obstruction catheter, an operation of laparoscopic partial rectal and sigmoid resection without protective stoma and total hysterectomy was performed successfully. The patient obtained a smooth postoperative course and doing well after 12-weeks follow up.

Conclusions

Obstruction caused by rectal endometriosis is very rare and easily overlooked by surgeon and gynecologist. Appropriate preoperative diagnosis and preoperative management can reduce the trauma and incidence of complications.

MicroRNAs Dysregulation as Potential Biomarkers for Early Diagnosis of Endometriosis

Endometriosis is a benign chronic disease in women that is characterized by the presence of active foci of the endometrium or endometrial tissue occurring outside of the uterus. The disease causes disabling symptoms such as pelvic pain and infertility, which negatively affect a patient's quality of life. In addition, endometriosis imposes an immense financial burden on the healthcare system. At present, laparoscopy is the gold standard for diagnosing the disease because other non-invasive diagnostic tests have less accuracy. In addition, other diagnostic tests have low accuracy. Therefore, there is an urgent need for the development of a highly sensitive, more specific, and non-invasive test for the early diagnosis of endometriosis. Numerous researchers have suggested miRNAs as potential biomarkers for endometriosis diagnosis due to their specificity and stability. However, the greatest prognostic force is the determination of several miRNAs, the expression of which varies in a given disease. Despite the identification of several miRNAs, the studies are investigatory in nature, and there is no consensus on them. In the present review, we first provide an introduction to the dysregulation of miRNAs in patients with endometriosis and the potential use of miRNAs as biomarkers in the detection of endometriosis. Then we will describe the role of the mir-200 family in endometriosis. Several studies have shown that the expression of the mir-200 family changes in endometriosis patients, suggesting that they could be used as a diagnostic biomarker and therapeutic target for endometriosis.

Analysis of Long Non-Coding RNA (lncRNA) UCA1, MALAT1, TC0101441, and H19 Expression in Endometriosis

Endometriosis is a disease of complex etiology. Hormonal, immunological, and environmental factors are involved in its formation. In recent years, special attention has been paid to genetic mechanisms that can have a significant impact on the increased incidence of endometriosis. The study aimed to analyze the expression of four long non-coding RNA (lncRNA) genes, UCA1, MALAT1, TC0101441, and H19, in the context of the risk of developing endometriosis. The material for genetic testing for the expression of lncRNA genes were tissue slices embedded in paraffin blocks from patients with endometriosis (n = 100) and the control group (n = 100). Gene expression was determined by the RT-PCR technique. The expression of the H19 gene in endometriosis patients was statistically significantly lower than in the control group. A statistically significant association was found between H19 gene expression in relation to The Revised American Society for Reproductive Medicine classification of endometriosis (rASRM) in the group of patients with endometriosis. Research suggests that H19 expression plays an important role in the pathogenesis of endometriosis.

Transvaginal ultrasound evaluation of the pelvis and symptoms after laparoscopic partial cystectomy for bladder endometriosis

Objective:

To evaluate transvaginal sonography (TVS) findings after laparoscopic partial cystectomy for bladder endometriosis and to correlate postsurgical ultrasound findings with symptoms.

Material and Methods:

A retrospective study including women who underwent laparoscopic partial cystectomy for bladder endometriosis. Within 12 months after surgery, TVS examination was conducted in all patients to evaluate the bladder morphology, and the presence of any postsurgical sonographic findings of the pelvis. Painful symptoms were assessed using a visual analogue scale.

Results:

A total of 40 women were included. At the follow-up visit, 25 patients were receiving medical treatment while 15 had declined post-surgical therapy and had tried to conceive. The presence of bladder deep-infiltrating endometriosis (DIE) was found in nine (22.5%), fibrotic thickening of the bladder wall was found in 15 (37.5%), and normal bladder morphology was observed in 16 (40%). There was a correlation between anterior adenomyosis and bladder DIE, and fibrotic thickening of the bladder. Patients with TVS signs of bladder DIE and anterior adenomyosis suffered more dysmenorrhea and dysuria than patients with normal bladder.

Conclusion:

Post-operative TVS can detect the alteration of pelvis and could explain the causes of the persistence of symptoms.

Long-term conservative management of symptomatic bladder endometriosis: A case series of 17 patients

OBJECTIVES

This study aimed to evaluate the course of long-term conservative management of bladder endometriosis (BE).

MATERIALS AND METHODS

We retrospectively reviewed 17 cases of BE conservatively managed without surgery in our facility. The following factors were analyzed: age, medical history, lesion size, symptoms, hormonal treatment, and follow-up outcomes.

RESULTS

In this study, 15 patients received hormonal therapy and 2 did not. Oral contraceptive (OC), dienogest (DNG), and gonadotropin-releasing hormone agonist (GnRHa) were administered as the first regimen in 7, 5, and 3 patients, respectively. Of the 7 patients, OC administration was effective in alleviating urinary symptoms in all but 2 patients. Of 3 patients who received GnRHa, 2 switched to OC and then DNG, and 1 patient discontinued the treatment because of adverse effects. Of 5 patients who received DNG, all experienced symptom relief. DNG, OC, and GnRHa administration were effective and tolerable in 9 of 10 patients (90.0%), in 5 of 9 patients (55.6%), and in 2 of 3 patients (66.7%), respectively. In particular, 3 patients completed DNG treatment until menopause. The size of the BE lesion significantly decreased after 3 months of DNG administration, and the reduction effect was maintained until 48 months thereafter.

CONCLUSION

This study proposed that hormonal therapy for BE is an effective option for those who are not planning to conceive or to undergo surgery. Specifically, DNG may be suitable for patients refusing surgery, considering the effectiveness and tolerance for long-term use.

Extragenital Endometriosis in the Differential Diagnosis of Non- Gynecological Diseases

BACKGROUND

Endometriosis is a chronic, benign disease that affects approximately 10% of women of childbearing age. Its characteristic clinical features are dysmenorrhea, dyschezia, dysuria, dyspareunia, and infertility. The manifestations of extragenital endometriosis (EE) are a diagnostic challenge, as this disease can mimic other diseases due to its unusual location with infiltration of various organs and corresponding symptoms.

METHODS

This review is based on publications retrieved by a selective search of the literature on the commonest extragenital sites of endometriosis, including the relevant current guideline.

RESULTS

Current evidence on the treatment of extragenital endometriosis consists largely of cohort studies and cross-sectional studies. The treatment is either surgical and/or conservative (e.g., hormonal therapy). Gastrointestinal endometriosis is the most common form of EE, affecting the rectum and sigmoid colon in nearly 90% of cases and typically presenting with dyschezia. Urogenital endometriosis is the second most common form of EE. It affects the bladder in more than 85% of cases and may present with dysuria, hematuria, or irritable bladder syndrome. The diaphragm is the most common site of thoracic endometri - osis, potentially presenting with period-associated shoulder pain or catamenial pneumothorax. Endometriosis affecting a nerve often presents with sciatica. In abdominal wall endometriosis, painful nodules arise in scars from prior abdominal surgery.

CONCLUSION

There is, as yet, no causally directed treatment for chronic endometriosis. The treatment is decided upon individually in discussion with the patient, in consideration of risk factors and after assessment of the benefits and risks. Timely diagnosis is essential.

The current role of robotic surgery in endometriosis management

INTRODUCTION

Endometriosis is a chronic inflammatory disease that affects approximately 10%-15% of women of childbearing age. Laparoscopic surgery is the preferred surgical approach. Recently, robotic surgery has been used for benign gynecologic surgery, but its role in the treatment of endometriosis is still unknown.

AREAS COVERED

We included studies that evaluated the outcomes of robotic surgery for endometriosis. Using the keywords 'endometriosis' and 'robotics', a comprehensive literature search on PubMed, Embase, and the Cochrane Library was performed in July 2021.

EXPERT OPINION

Robotic surgery for endometriosis has similar outcomes as conventional laparoscopy, with no evidence of increased complication rates. Despite the non-inferiority of the surgical route, the associated costs of robotic surgery limit its availability. Rapid development of robot-assisted surgery necessitates long-term prospective randomized controlled trials. However, the limitations of robotic surgery should not be overlooked. If robotic surgery can facilitate the spread of minimally invasive surgery, it will be necessary to evaluate the cost, availability, complexity of the lesions, and most importantly, the results of patient satisfaction and values of value-based medicine.

Laparoscopic Resection of Renal Capsular Endometriosis in a Woman with Menstrual-Related Flank Pain: Case Report

Background

Although involvement of the urinary system is not uncommon, endometriosis in the kidneys is rare. To date, laparoscopic partial nephrectomy has been the preferred approach for managing renal endometriosis. Here, we report for the first time the results of laparoscopic removal of a renal capsular endometriosis in a malrotated kidney in an attempt to save the whole kidney parenchyma, in terms of feasibility and safety.

Case presentation

A 37-year-old female presented with periodic right flank pain associated with her menstrual cycle. On imaging, a malrotated right kidney and a hypodense irregular-shaped lesion measuring 30 * 20 * 15 mm were seen in the superior portion of the right perinephric space. Histologic evaluation of the ultrasound-guided biopsy was consistent with renal capsular endometriosis. The patient underwent laparoscopic surgery to remove the capsular mass while preserving the normal renal parenchyma. Pathological examination of the biopsy obtained during surgery was in favor of renal endometriosis. At 6-month follow-up, the patient’s pain had completely disappeared and no complications had occurred. In addition, imaging did not show any remarkable recurrence.

Conclusion

Renal endometriosis should be strongly considered as a differential diagnosis in female patients with a renal capsular mass and exacerbation of flank pain during menstruation. Based on our experience, with preoperative needle biopsy and clearing the pathology, laparoscopic removal of the mass in spite of renal anatomic abnormality is feasible and safe and thus could be considered as a possible treatment option.

Stepwise approach to the laparoscopic excision of bladder endometriosis

OBJECTIVE

To describe a stepwise approach to the laparoscopic excision of bladder endometriosis.

DESIGN

Narrated surgical video.

SETTING

Academic tertiary care hospital.

PATIENT(S)

Surgical footage was obtained from three patients who underwent surgery for bladder endometriosis. Institutional review board approval was not required in accordance with the Tri-Council Policy Statement of Canada, article 2.5.

INTERVENTION(S)

Laparoscopic excision of bladder endometriotic nodules by partial cystectomy.

MAIN OUTCOME MEASURE(S)

Overview of the relevant anatomy, disease overview, surgical planning and perioperative care, and the approach to the excision of bladder endometriotic nodules.

RESULT(S)

The approach to excision of bladder endometriotic nodules can be standardized in six reproducible steps: cystoscopy with or without ureteral stent placement; abdominal survey and treatment of posterior compartment disease; bladder mobilization; partial bladder cystectomy under cystoscopic guidance; cystotomy closure; and water-leak test.

CONCLUSION(S)

The safe and complete excision of bladder endometriosis relies on the understanding of surgical anatomy, the multidisciplinary aspect of patient care, and the standardization of the surgical approach.

Endometriosis: Epidemiology, Classification, Pathogenesis, Treatment and Genetics (Review of Literature)

Endometriosis is a “mysterious” disease and its exact cause has not yet been established. Among the etiological factors, congenital, environmental, epigenetic, autoimmune and allergic factors are listed. It is believed that the primary mechanism of the formation of endometriosis foci is retrograde menstruation, i.e., the passage of menstrual blood through the fallopian tubes into the peritoneal cavity and implantation of exfoliated endometrial cells. However, since this mechanism is also observed in healthy women, other factors must also be involved in the formation of endometriosis foci. Endometriosis is in many women the cause of infertility, chronic pain and the deterioration of the quality of life. It also represents a significant financial burden on health systems. The article presents a review of the literature on endometriosis—a disease affecting women throughout the world.

Clinical characteristics of urinary tract endometriosis: A one-year national series of 232 patients from 31 endometriosis expert centers (by the FRIENDS group)

OBJECTIVE

To review prospectively the clinical characteristics of patients suffering from urinary tract endometriosis (UTE) in France, in 2017.

STUDY DESIGN

We conducted a prospective observational multicenter study including women managed surgically for UTE in 31 French endometriosis expert centers (FRIENDS group) from January 1, 2017 to December 31, 2017. We distinguished patient with isolated bladder endometriosis ("IBE") or isolated ureteral endometriosis ("IUE") and patients associating both locations (mixed locations "ML"). Surgeons belonging to FRIENDS group enrolled patients by filling a 24 items questionnaire the day of the surgery and 6 weeks later. Data on the locations of UTE, preoperative assessment, urinary symptoms and associated pelvic locations were collected in a single anonymized database.

RESULTS

A total of 232 patients from 31 centers were included. IBE concerned 82 patients (35.3%), IUE 126 patients (54.4%) ML 24 patients (10.3%). 111 patients reported urinary symptoms (47.8%). IUE was more often asymptomatic than the rest of the locations (59.5% versus 43.3%, OR 1,92, p = 0.017). Associated deep infiltrating endometriosis (DIE) lesions were found in 193 patients (83.1%). IUE was significantly associated with other DIE lesions (82.5% versus 66%, OR2.4, p = 0.006), particularly with rectum or sigmoid nodules (57.1% versus 36.8%, OR 2.3, p = 0.002) and retrocervical space nodules (31.7% versus 19.8%, OR 1.9, p = 0.05).

CONCLUSION

Our study reports the second largest series of patients operated from a UTE and shows that ureteral location seems more frequent, less symptomatic and more frequently associated to other DIE locations than bladder endometriosis.

Surgical Management of Urinary Tract Endometriosis: A 1-year Longitudinal Multicenter Pilot Study at 31 French Hospitals (by the FRIENDS Group)

STUDY OBJECTIVE

To describe the surgical management and risks of postoperative complications of patients with urinary tract endometriosis in France in 2017.

DESIGN

Multicenter retrospective cohort pilot study.

SETTING

Departments of gynecology at 31 expert endometriosis centers.

PATIENTS

All women managed surgically for urinary tract endometriosis from January 1, 2017, to December 31, 2017. We distinguished patients with isolated bladder endometriosis or isolated ureteral endometriosis (IUE) from those with endometriosis in both locations (mixed locations [ML]).

INTERVENTIONS

Surgeons belonging to the French Colorectal Infiltrating Endometriosis Study (FRIENDS) group enrolled patients who filled a 24-item questionnaire on the day of the inclusion and 3 months later. Data were collected on operative routes, surgical management, and postoperative complications according to the Clavien-Dindo classification in a single anonymized database.

MEASUREMENTS AND MAIN RESULTS

A total of 232 patients from 31 centers were included. Isolated bladder endometriosis was found in 82 patients (35.3%), IUE in 126 patients (54.4%), and ML in 24 patients (10.3%). Surgery was performed by laparoscopy, laparotomy, or robot-assisted laparoscopy in 74.1%, 11.2%, and 14.7% of the cases, respectively. Among the 150 ureteral lesions (IUE and ML), 114 were managed with ureterolysis (76%), 28 with ureteral resection (18.7%), 4 with nephrectomy (2.7%), and 23 with cystectomy (15.3%). Concerning bladder endometriosis, a partial cystectomy was performed in 94.3% of the cases. We reported 61 postoperative complications (26.3%): 44 low-grade complications according to the Clavien-Dindo classification (18%), 16 grade III complications (7%), and 1 grade IV complication (peritonitis).

CONCLUSION

The surgical management of ureteral and bladder endometriosis is usually feasible and safe through laparoscopic surgery. Ureteral resection, when necessary, is more strongly associated with laparotomy and with more complications than other procedures. Prospective controlled studies are still mandatory to assess the best surgical management for patients.

A deep insight into pelvic pain and endometriosis: a review of the literature from pathophysiology to clinical expressions

Endometriosis is a chronic inflammatory disease that affects approximately 10% of women of reproductive age. Its clinical manifestations are highly heterogeneous, but pelvic pain is the most frequent, causing functional disability. Cyclic or acyclic chronic pelvic pain (CPP), dysmenorrhea and dyspareunia are frequent symptoms which often compromise all aspects of the women's quality of life (QoL). The pathophysiology of endometriosis-related pain is extremely complex and not always clear. The aim of this literature review is to focus on recent updates on the clinical presentation, the pathophysiology and the most important mechanisms involved in the pathogenesis of pelvic pain in endometriosis. A literature search in the Cochrane library, PubMed, Scopus and web of Science databases has been performed, identifying articles from January 1995 to November 2020. Several processes seem to be involved in the pathogenesis of pain, but many aspects are still unclear. Scientific evidence has shown that a correlation between pain severity and stage of endometriosis rarely occurs, whereas there is a significant correlation between pain and the presence of deep endometriosis. Onset and intensity of pain may be due to a complex process involving central sensitization and peripheral activation of nociceptive pathways as well as dysfunction of the immune system and of the hypothalamic-pituitary-adrenal (HPA) axis. A deeper understanding of these different pathogenetic mechanisms may improve future treatments in women with painful endometriosis.

Alpha-Lipoic Acid Plays a Role in Endometriosis: New Evidence on Inflammasome-Mediated Interleukin Production, Cellular Adhesion and Invasion

Endometriosis is an estrogen-linked gynecological disease defined by the presence of endometrial tissue on extrauterine sites where it forms invasive lesions. Alterations in estrogen-mediated cellular signaling seems to have an essential role in the pathogenesis of endometriosis. Higher estrogen receptor (ER)-β levels and enhanced ER-β activity were detected in endometriotic tissues. It is well known that ER-β interacts with components of the cytoplasmic inflammasome-3 (NALP-3), the NALP-3 activation increases interleukin (IL)-1β and IL-18, enhancing cellular adhesion and proliferation. Otherwise, the inhibition of ER-β activity suppresses the ectopic lesions growth. The present study aims to investigate the potential effect of α-lipoic acid (ALA) on NALP-3 and ER-β expression using a western blot analysis, NALP-3-induced cytokines production by ELISA, migration and invasion of immortalized epithelial (12Z) and stromal endometriotic cells (22B) using a 3D culture invasion assay, and matrix-metalloprotease (MMPs) activity using gelatin zymography. ALA significantly reduces ER-β, NALP-3 protein expression/activity and the secretion of IL-1β and IL-18 in both 12Z and 22B cells. ALA treatment reduces cellular adhesion and invasion via a lower expression of adhesion molecules and MMPs activities. These results provide convincing evidence that ALA might inhibit endometriosis progression.

National survey of bladder endometriosis cases in Japan

AIM

We aimed to describe the clinical presentation, operative or medical management, and postoperative recurrence of bladder endometriosis (BE).

METHODS

We conducted a national survey to investigate BE cases from 2006 to 2016 in Japan. Histologically diagnosed cases were extracted and then investigated for the following factors: age at diagnosis, body mass index, symptoms, imaging modalities, surgical therapy, hormonal therapy, follow-up period, and postoperative recurrence.

RESULTS

Eighty-nine patients with pathologically benign BE were identified. Eighty patients underwent surgery, whereas nine did not. Moreover, 34 and 44 patients underwent transurethral resection (TUR) and partial cystectomy (PC), respectively. Cumulative recurrence rates were significantly higher with TUR than with PC (p < 0.05). The recurrence rate tended to be higher after laparoscopic PC (n = 24) than after open PC (n = 20), but the difference was not statistically significant (p = 0.0879). Of the nine nonsurgical patients, eight received hormonal therapy and one did not. Efficacy rates of dienogest, GnRH agonist, and OC were 85.7%, 66.7%, and 66.7%, respectively. Of five patients with BE extending to the ureter or ureteral orifices, two underwent PC and ureteroneocystostomy and one underwent total nephroureterectomy due to renal function loss.

CONCLUSION

To our knowledge, this is the first study to compare the postoperative recurrence of BE after TUR and PC. We found that cumulative recurrence rate is significantly lower after PC than after TUR. BE extending to the ureter or ureteral orifices is a very challenging condition. Further studies are required for the optimal management of BE.

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.

Endometriosis: A Comprehensive Review

Endometriosis is a relatively common condition in which endometrial tissue is established in locations outside the uterus where, like the eutopic endometrium, it responds to hormonal stimuli and develops internal bleeding, inflammation, and fibrosis. These changes are associated with chronic and often debilitating cyclic pain and infertility. The pathogenesis of endometriosis is multifactorial, and several theories have been proposed to explain it. These include retrograde menstruation, celomic metaplasia, embryologic rests, and lymphovascular spread. Hormones, immunologic status, and genetic factors may also play a role. In most patients, the disease involves pelvic organs, but rarely it may also extend to a large variety of distant locations in the body. Patients with ovarian endometriosis are at higher risk for developing ovarian carcinomas including endometrioid and clear cell carcinomas. Some of these carcinomas may arise in a background of structural and/or nuclear atypia within the endometriotic foci. There is no known cure for endometriosis and treatment mostly consists of managing chronic pain or infertility.

Bladder endometriosis: Preoperative MRI analysis with assessment of extension to ureteral orifices

PURPOSE

The purpose of this study was to retrospectively evaluate the performance of magnetic resonance imaging (MRI) in locating endometriosis implants within the bladder wall with assessment of ureteral orifice extension using surgical findings as standard of reference.

MATERIALS AND METHODS

MRI examinations of 39 consecutive women (mean age: 31.2±5.5 [SD] years; age range: 22-42years) operated in 3 university hospitals for bladder endometriosis over a 6-year period were reviewed by 2 independent readers. Interobserver agreement was assessed using Kappa tests. Results of consensus reading were used to calculate sensitivity, specificity and accuracy of MRI for the diagnosis, location and extent of endometriosis implants using surgical findings as the standard of reference.

RESULTS

Mean bladder repletion volume was 134±110 [SD] mL (range: 21-479mL). The mean largest endometriosis implant diameter was 30±7 [SD] mm (range: 19-41mm). On MR images, 34/39 (87%) endometriosis implants were present in the two anterior thirds of the dome (k=0.45), 31/39 (79%) extended or were present in the posterior third pouch (k=0.92) and 25/39 (64%) extended into the bladder base (k=0.84) with sensitivities of 100% (31/31; 95% confidence interval [CI]: 89-100%), 100% (30/30; 95% CI: 88-100%) and 90% (19/21; 95% CI: 69-98%), respectively, specificities of 83% (5/6, 95% CI: 36-100), 88% (7/8, 95% CI: 47-100%), 87% (13/15; 95% CI: 52-96), respectively and accuracies of 97% (36/37, 95% CI: 86-100%), 97% (37/38; 95% CI: 86-100%), and 89% (32/36; 95% CI: 74-97%), respectively. In 9 (9/25; 36%) patients with bladder base involvement, a zero distance was reported between endometriosis implants and ureteral orifices, all but one presenting with low-to-moderate bladder volumes. In the two patients who needed ureteral resection-reimplantation, ureteral dilation was associated with a zero distance. External adenomyosis was reported in 26/39 (66%) patients (k=0.94).

CONCLUSION

A dedicated preoperative MRI work-up for bladder endometriosis helps accurately depict and locate endometriosis implants. Adequate bladder filling is needed to improve appropriate estimate of the distance between endometriosis implants and ureteral orifices to better predict requirement of ureteral resection-reimplantation.

The Genetic Background of Endometriosis: Can ESR2 and CYP19A1 Genes Be a Potential Risk Factor for Its Development?

Endometriosis is defined as the presence of endometrial foci, localized beyond their primary site, i.e., the uterine cavity. The etiology of this disease is rather complex. Its development is supported by hormonal, immunological, and environmental factors. During recent years, particular attention has been focused on the genetic mechanisms that may be of particular significance for the increased incidence rates of endometriosis. According to most recent studies, ESR2 and CYP19A1 genes may account for the potential risk factors of infertility associated with endometriosis. The paper presents a thorough review of the latest reports and data concerning the genetic background of the risk for endometriosis development.

BCL-6 Overexpression as a Predictor for Endometriosis in Patients Undergoing In Vitro Fertilization

OBJECTIVE

To evaluate the positive predictive value (PPV) of endometrial BCL-6 overexpression as a noninvasive screening test endometriosis in patients undergoing in vitro fertilization (IVF).

METHODS

Retrospective cohort study at a university-affiliated private practice. Inclusion criteria were reproductive age females currently undergoing IVF with a diagnosis of unexplained infertility or unexplained recurrent pregnancy loss. Those with endometrial BCL-6 overexpression underwent laparoscopic surgery with an indication for treatment of suspected endometriosis. The primary outcome was the PPV of endometrial BCL-6 testing to surgically diagnose endometriosis. Statistical analysis was performed using SPSS v.25.0.

RESULTS

Seventy-five patients met inclusion criteria for our study. The PPV of BCL-6 testing for endometriosis was 96%. Of those patients without endometriosis, 100% had other inflammatory pelvic pathologies, which were diagnosed and treated at the time of laparoscopy.

CONCLUSIONS

Endometrial BCL-6 overexpression has a high PPV for diagnosing endometriosis and can help identify a patient population that may require surgical treatment before embryo transfer.

Nerve-Sparing Modified Radical Hysterectomy for Severe Endometriosis and Complex Pelvic Pathology

Background Laparoscopic nerve-sparing modified radical hysterectomy with or without robotic assistance is known for its benefits as a definitive treatment for severe endometriosis. Undiagnosed endometriosis is common in patients with symptomatic fibroids or chronic pelvic pain. There are minimal studies that outline the safety and feasibility of nerve-sparing modified radical hysterectomy for other complex pelvic pathology in addition to endometriosis. Objectives The aim of this study is to evaluate the incidence of hospital readmission, intraoperative and postoperative complications, and long-term pain relief after laparoscopic nerve-sparing modified radical hysterectomy for severe endometriosis and complex benign pelvic pathology. Study design We performed a retrospective observational study of patients who underwent laparoscopic nerve-sparing modified radical hysterectomy with and without robotic-assistance with a high-volume minimally invasive endoscopic surgeon between November 2017 and December 2019. Results A total of 112 patients met the inclusion criteria. There were no cases of vaginal cuff dehiscence, venous thromboembolism, genitourinary system injury, gastrointestinal tract injury, vessel injury, nerve injury, sepsis, or death. Three patients required postoperative hospital admission for the management of umbilical cellulitis, acute blood loss anemia, and possible Addison's crisis. Other postoperative complications included allergic reaction to adhesives (1.8%) and urinary retention (0.9%). All patients reported significant pain relief at the time of their postoperative visits. Three patients reported return of pain symptoms within the first seven months after surgery, with one requiring an additional surgery for persistent pain. Conclusions Laparoscopic nerve-sparing modified radical hysterectomy with or without robotic assistance is a safe and feasible alternative that provides long-term symptom relief in patients undergoing hysterectomy for a variety of indications.

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.

Conservative management of bladder endometriosis with acute renal failure

Endometriosis involving the bladder is rare, but generally has a severe presentation with prominent lower urinary tract symptoms and can progress to renal failure. As endometriosis has a significant effect on quality of life and fertility, treatment plans must be centered on the patient's symptoms, expectations, and priorities. We present a case of a 37-year-old African American female with advanced bladder endometriosis and consequent renal failure, who desired to avoid extensive surgery and maintain her fertility. This case highlights the importance of shared decision making in balancing disease management with patient autonomy.

Protective effect of cabergoline on mitochondrial oxidative stress-induced apoptosis is mediated by modulations of TRPM2 in neutrophils of patients with endometriosis

Calcium ion (Ca²⁺) signaling in endometriosis (ENDO) is associated with increased neutrophil activation and oxidative stress. A Ca²⁺ signaling modulator and antioxidant actions of cabergoline (CBG) in some cells were recently reported. TRPM2 cation channel is activated by reactive oxygen species (ROS). Antioxidant action of CGB via inhibition of ROS may modulate the channel. We aimed to investigate the effect of CBG on TRPM2 inhibition in serum and neutrophils of patients with ENDO. The serum and neutrophil samples were grouped into healthy samples (no treatment), ENDO and ENDO + CBG treated groups (n = 10 in each). In some experiments, the neutrophils were also incubated with TRPM2 (ACA) and PARP-1 (PJ34) blockers. The values of intracellular ROS, Ca²⁺ concentration, mitochondrial membrane depolarization, lipid peroxidation, apoptosis, and caspase - 3, caspase - 9, PARP-1 and TRPM2 expressions were high in the neutrophils of patients with ENDO, although antioxidant levels (reduced glutathione, glutathione peroxidase, vitamin A, and vitamin E) were low in the neutrophils and serum from these patients. However, markers for apoptosis, oxidative stress, and mitochondrial dysfunction were reduced with CBG, ACA and PJ34 treatments, although the antioxidant levels were increased in the serum and neutrophils following treatment with CBG. Taken together, our current results suggest that CBG are useful antagonists against apoptosis and mitochondrial oxidative stress via inhibition of TRPM2 in neutrophils of patients with ENDO.

Optimal Management of Endometriosis and Pain

The pathophysiology of endometriosis-associated pain involves inflammatory and hormonal alterations and changes in brain signaling pathways. Although medical treatment can provide temporary relief, most patients can achieve long-term sustained pain relief when it is combined with surgical intervention. Owing to its complexity, there is an ongoing debate about how to optimally manage endometriosis-associated pain. We believe optimal management for this condition requires: 1) possible egg preservation in affected young patients with and without endometriomas; 2) preoperative medical suppression to inhibit ovulation and to avoid removal of functional cysts that might look like endometriomas; and 3) postoperative hormonal suppression to decrease recurrence, but this treatment should be modified according to disease severity, symptoms, and fertility goals.

Multidisciplinary laparoscopic management of deep infiltrating endometriosis from 2010 to 2017: A retrospective cohort study

Background

Laparoscopy has become the standard of care in the surgical management of deep infiltrating endometriosis (DIE). However, it is a challenging procedure with a high complication rate. Despite the benefits of the minimally invasive approach, DIE resection is often performed by surgeons without adequate training, especially in developing countries like Chile.

Objective

To asses our experience in the diagnosis and laparoscopic management of DIE during seven years.

Methods

A retrospective cohort study of data including 137 patients with pathology-proven DIE. Surgical and fertility outcomes were evaluated.

Results

All procedures were performed laparoscopically without conversion. Dysmenorrhea and dyspareunia were the most common symptoms in 85.4% and 56.9%, respectively. Uterosacral ligaments were the most common DIE location. Endometrioma was present in 48.9% of cases. Median operative time was 140 minutes; however, it was longer in cases requiring bowel surgery (p < 0.0001). The complication rate was 10.9%. Median follow-up was 24.5 months. The pregnancy rate was 58.1% and 90% of patients reported significant symptom relief after surgery.

Conclusion

Laparoscopic surgical management of DIE is effective and safe but it must be performed in tertiary centers with the availability of multidisciplinary teams.

Thoracic Endometriosis Syndrome: A Review of Diagnosis and Management

Background:

Endometriosis is characterized by the presence of endometrial-like glands and stroma outside the uterine cavity and is believed to affect 6%–10% of reproductive-age women. Endometriosis within the lung parenchyma or on the diaphragm and pleural surfaces produces a range of clinical and radiological manifestations. This includes catamenial pneumothorax, hemothorax, hemoptysis, and pulmonary nodules, resulting in an entity known as thoracic endometriosis syndrome (TES).

Database:

Computerized searches of MEDLINE and PubMed were conducted using the key words “thoracic endometriosis,” “catamenial pneumothorax,” “catamenial hemothorax,” and “catamenial hemoptysis.” References from identified sources were manually searched to allow for a thorough review.

Conclusion:

TES can produce incapacitating symptoms for some patients. Symptoms of TES are nonspecific, so a high degree of clinical suspicion is warranted. Medical management represents the first-line treatment approach. When this fails or is contraindicated, definitive surgical treatment for cases of suspected TES uses a combined video laparoscopy performed by a gynecologic surgeon and video-assisted thoracoscopic surgery performed by a thoracic surgeon. Postoperative hormonal suppression may further reduce disease recurrence.

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.

Case report and video presentation: Trans-urethral resection of bladder endometriosis

Urinary endometriosis is a rare condition accounting for 1-5.5% of the extragenital endometriosis locations. The diagnosis takes long time during which patient misdiagnosed as urinary tract infection or interstitial cystitis. A 25-year-old married woman presented with cyclical pain last for ten days every month for six months prior to diagnosis. There was no history of hematuria. Had three times caesarian section. Endometrial mass on posterior wall of bladder about 3 × 2 cm treated by transurethral resection. Chocolate appearance of blood during transurethral resection is highly suggestive of diagnosis of bladder endometriosis.

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.