Endoscopic Diagnosis and Management of Ureteral Endometriosis

Deep pelvic endometriosis causing ureteral obstruction

Endometriosis is a chronic disease characterized by the presence and growth of endometrial glands and stroma outside of the uterine cavity. The pathogenesis is unclear, but a common theory attributes the condition to retrograde menstruation into the peritoneal cavity via the fallopian tubes. Hormonal influence causes these ectopic tissues to undergo cyclical bleeding, resulting in subsequent inflammation and scar tissue formation; however, it can affect postmenopausal women. In rare instances, endometriotic lesions can obstruct the ureter and result in hydroureteronephrosis and subsequent loss of renal function. This condition presents with nonspecific symptoms and is known as an often-silent disease, resulting in challenging and delayed preoperative diagnosis. In this article, we report the case of an asymptomatic 65-year old female who was diagnosed with deep pelvic endometriosis, which obstructed the right distal ureter. We focus on optimizing diagnosis and management through the application of radiological imaging modalities, specifically computed tomography (CT) and magnetic resonance imaging (MRI).

Extravertebral low back pain: a scoping review

BACKGROUND

Low back pain (LBP) is one of the most common reasons for consultation in general practice. Currently, LBP is categorised into specific and non-specific causes. However, extravertebral causes, such as abdominal aortic aneurysm or pancreatitis, are not being considered.

METHODS

A systematic literature search was performed across MEDLINE, Embase, and the Cochrane library, complemented by a handsearch. Studies conducted between 1 January 2001 and 31 December 2020, where LBP was the main symptom, were included.

RESULTS

The literature search identified 6040 studies, from which duplicates were removed, leaving 4105 studies for title and abstract screening. Subsequently, 265 publications were selected for inclusion, with an additional 197 publications identified through the handsearch. The majority of the studies were case reports and case series, predominantly originating from specialised care settings. A clear distinction between vertebral or rare causes of LBP was not always possible. A range of diseases were identified as potential extravertebral causes of LBP, encompassing gynaecological, urological, vascular, systemic, and gastrointestinal diseases. Notably, guidelines exhibited inconsistencies in addressing extravertebral causes.

DISCUSSION

Prior to this review, there has been no systematic investigation into extravertebral causes of LBP. Although these causes are rare, the absence of robust and reliable epidemiological data hinders a comprehensive understanding, as well as the lack of standardised protocols, which contributes to a lack of accurate description of indicative symptoms. While there are certain disease-specific characteristics, such as non-mechanical or cyclical LBP, and atypical accompanying symptoms like fever, abdominal pain, or leg swelling, that may suggest extravertebral causes, it is important to recognise that these features are not universally present in every patient.

CONCLUSION

The differential diagnosis of extravertebral LBP is extensive with relatively low prevalence rates dependent on the clinical setting. Clinicians should maintain a high index of suspicion for extravertebral aetiologies, especially in patients presenting with atypical accompanying symptoms.

Chronic Pelvic Puzzle: Navigating Deep Endometriosis with Renal Complications

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

Isolated Intrinsic Ureteral Endometriosis: A Rare Presentation of Ureteral Obstruction

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

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

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

Intrinsic ureteral endometriosis as a cause of unilateral obstructive uropathy

Endometriosis is a common gynecological condition, but involvement of the urinary tract is rare. Ureteral endometriosis can present in a nonspecific fashion, and may mimic ureteral malignancy. This case report describes a 44-year-old woman who initially presented with chronic flank pain and was found to have left-sided renal dysfunction and a distal left ureteric mass. She was eventually diagnosed with ureteral endometriosis after undergoing nephroureterectomy for what was thought to be either a ureteral fibroepithelial polyp or transitional cell carcinoma. Ureteral endometriosis should be considered in the differential diagnosis for a woman presenting with obstructive uropathy in the presence of a ureteric mass.

Urology patients in the nephrology practice

Urologists and nephrologists provide care to many mutual patients. This review addresses the initial management of upper urinary tract issues commonly seen in nephrology practice. Patients with hematuria without clear benign causes should be referred to urologists for workup to rule out urologic malignancies. Asymptomatic microscopic hematuria after negative workup should be followed with annual urinalysis with repeat urologic evaluation if it persists after 5 years. Hydronephrosis is another commonly encountered diagnosis. Functional urinary obstruction should be excluded using a diuretic nuclear renography in the appropriate population. Asymptomatic, stable hydronephrosis can be observed, but those with acute, symptomatic obstruction, or patients with suspected obstruction with signs of infection, should seek urologic care for intervention. Hydronephrosis is common in pregnant women; symptomatic patients merit intervention similar to nonpregnant patients. The management of patients with an acute stone episode is similar to that for those with hydronephrosis. Patients with first stone episodes need evaluation for risk factors for stone formation, whereas patients with identified risk factors or recurrent stones need comprehensive metabolic workup. Patients with incidentally found kidney masses should be referred to urology for possible intervention when they have solid kidney masses or cystic masses that need further evaluation.

Müllerianosis: four developmental (embryonic) mullerian diseases

The theory of müllerianosis predicts that embryonic müllerian tissue, misplaced during organogenesis, results in the formation of 4 benign müllerian diseases-developmental adenomyosis, endometriosis, endosalpingiosis, and endocervicosis-(developmental müllerian diseases) that will be identified in human female fetuses, infants, children, adolescents, and adults. Direct evidence is presented to support the existence of developmental adenomyosis, developmental endometriosis, and developmental endocervicosis in human female fetuses along with strong circumstantial evidence supporting the existence of all 4 developmental müllerian diseases in human female infants, children, adolescents, and adults. This evidence throws light upon the pathogenesis of rare müllerian lesions whose pathogenesis remains inexplicable by classical and modern theories. Furthermore, this research has scientific and clinical relevance: scientific relevance because it opens up a new field of comparative research-the 4 developmental müllerian diseases complement the 4 acquired müllerian diseases; clinical relevance because it identifies rare müllerian diseases curable by complete surgical excision.

Laparoscopic treatment of intrinsic endometriosis of the urinary tract and proposal of a treatment scheme for ureteral endometriosis

OBJECTIVE

To discuss the contemporary management of urinary tract endometriosis and report our experience concerning laparoscopic treatment of intrinsic urinary tract endometriosis.

METHODS

We performed a retrospective, multicenter study of data collected from March 2006 to March 2011. Ten women were referred from gynecology, seven with ureteral involvement and hydronephrosis and three with bladder involvement, for urologic management. Of the 7 women with hydronephrosis, 5 were symptomatic, with recurrent urinary tract infections or pain. All 3 women with bladder endometriosis had hematuria. All patients had previously undergone unsuccessful hormonal therapy. Ureteral endometriosis was extensively investigated and treated by laparoscopic excision of endometriotic plaques and excision of intrinsic endometriosis of the ureter. Bladder endometriosis was treated by partial cystectomy. Some patients also had endometriosis in other organs and underwent, for example, wedge resection of sigmoid colon and oophorectomy.

RESULTS

The median age of the patients was 30 years (range 25-44). Seven patients with intrinsic endometriosis of the ureter all had hydronephrosis and proximal hydroureter and underwent laparoscopic ureteral segment excision and either end-to-end, spatulated uretroureterostomy or ureteral reimplatation with psoas hitch. Three patients had hematuria, and cystoscopic biopsy of the bladder lesions confirmed intrinsic endometriosis. They were treated with laparoscopic partial cystectomy. One patient with bowel symptoms also underwent laparoscopic wedge resection of the sigmoid colon and another underwent oophorectomy for a chocolate cyst. Most patients also had peritoneal endometriotic plaques excised. We did not perform simple ureterolysis. No complications were encountered. The median follow-up was 26.5 months (range 4-53), with no return of symptoms or recurrence. The annual follow-up examinations included urinalysis and ultrasonography of the urinary tract.

CONCLUSION

Intrinsic endometriosis can be successfully managed with minimally invasive techniques to provide relief of symptoms, protect renal function, and prevent recurrence. We describe a classification of ureteral endometriosis determined from staging investigations.

Ressonância magnética na endometriose do trato urinário baixo: ensaio iconográfico

Endometriose é definida como a presença de tecido endometrial funcionante fora da cavidade endometrial e do miométrio. É uma doença comum, de causas multifatoriais, porém o envolvimento do trato urinário baixo é raro. A ressonância magnética tem elevada sensibilidade, especificidade e acurácia no diagnóstico da endometriose do trato geniturinário baixo, principalmente por permitir a identificação das lesões de permeio a aderências e a avaliação da extensão das lesões subperitoneais. Neste estudo são ilustrados, sob a forma de ensaio iconográfico, os principais achados à ressonância magnética do envolvimento por endometriose do trato urinário baixo.

Treatment of urinary tract endometriosis

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