Case report and review of the literature: ureteral endometriosis

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.

Ureteral Endometriosis Presenting As Left Ureteral Obstruction: A Case Report

Ureteral endometriosis is a very rare but serious form of infiltrating endometriosis since the risk of urinary tract obstruction and secondary loss of renal function exists. Although not always possible, the clinical and radiologic assessment may help in obtaining a preoperative diagnosis.

We report the case of a 42-year-old woman with left ureteral endometriosis, revealed by left flank pain. Imaging revealed left obstructive uropathy with an endometriotic cyst of the left ovary and a spiculated lesion of the left parametrium. She underwent laparotomy, resection of the diseased ureter with primary re-anastomosis, resection of a left parametrial lesion and an endometriotic left ovarian cystectomy. The pathological assessment confirmed the diagnosis of ureteral endometriosis. Follow-up of the patient showed complete resolution with a stable, normal kidney function.

In conclusion, ureteral endometriosis involvement is infrequent but should be included in the differential diagnosis in a premenopausal woman with ureteral obstruction of unknown cause. An early diagnosis and obstruction relief are critical to a successful outcome.

Deep infiltrating ureteral endometriosis with catamenial hydroureteronephrosis: a case report

BACKGROUND

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

CASE PRESENTATION

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

CONCLUSIONS

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

Surgical Outcomes of Urinary Tract Deep Infiltrating Endometriosis

OBJECTIVE

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

DESIGN

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

SETTING

University tertiary referral center.

PATIENTS

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

INTERVENTION

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSION

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

Endometriosis presenting with right side hydroureteronephrosis only: a case report

Introduction

Endometriosis can be defined as the presence of endometrial glandular and stromal tissue outside the uterus. Affected sites of endometriosis can even be the urinary tract. Here, we present the case of a 30-year-old woman with right ureteral endometriosis. This case was important due to the unusual localization and no signs of the disease except for hydroureteronephrosis.

Case presentation

A 30-year-old Caucasian woman with para 2 was admitted to our department for right side flank pain, dysuria and suprapubic pain. She had no complaints of vaginal discharge, bleeding or painful menstruation. Her menstrual cycles were normal and lasting for three to four days. She did not have a history of any surgical interventions. A physical examination revealed a right side costovertebral angle and suprapubic tenderness. Laboratory test results including a complete blood count, serum biochemical analysis, urine analysis and urine culture were normal. Urinary ultrasonography showed right side hydroureteronephrosis with renal cortical thinning. We suspected a right ureteral stone obstructing the ureter and a computed tomography scan was performed. The computed tomography scan revealed similar right side hydroureteronephrosis with obstruction of the ureter. No signs of stone were observed on the scan. Retrograde pyelography and diagnostic ureterorenoscopy were performed and they showed a focal stricture with a length of approximately 3cm at the distal ureteral part and secondary hydroureteronephrosis. Open partial ureterectomy and ureteroneocystostomy with Boari flap were performed. The pathologic specimen of her ureter demonstrated intrinsic endometriosis of the right ureter with endometrial glandular cells and stromal tissue.

Conclusions

Clinicians should suspect ureteral endometriosis in premenopausal women with unilateral or bilateral distal ureteral obstruction of uncertain cause. The main goals of the treatment should be preservation of renal function, relief of obstruction and prevention of recurrence.

Silent loss of kidney seconary to ureteral endometriosis

Ureteral endometriosis, albeit rare, can be complicated by potential loss of renal function. A laparoscopic approach to treatment is based on the extent of the disease and its localization.

Background:

Ureteral endometriosis is a serious localization of disease burden that can lead to urinary tract obstruction, with subsequent hydroureter, hydronephrosis, and potential kidney loss. Diagnosis is elusive and relies heavily on clinical suspicion as ureteral endometriosis can occur with both minimal and extensive disease. Surgical technique to treatment varies, but the goal is to salvage renal function and decrease disease burden.

Case Descriptions:

We describe 3 cases in which there was documentation of renal atrophy and function loss with subsequent workup and surgical intervention.

Results:

The cases illustrate varying surgical approaches tailored to localization of ureteral endometriosis. All cases were carried out laparoscopically.

Conclusion:

Ureteral endometriosis, albeit rare, can be complicated by potential loss of renal function. Clinical suspicion and preoperative assessment may help with diagnosis and allows for a multidisciplinary preconsultation. Laparoscopic surgical approach is based on extent of disease and localization and can be carried out successfully in the hands of a highly experienced laparoscopic surgeon.

Ureteral endometriosis with obstructive uropathy

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

Polypoid endometriosis of the ureter mimicking fibroepithelial polyps

We present a case of polypoid endometriosis of the ureter that showed bilateral polypoid intraluminal masses in the lower part of the ureter mimicking ureteral fibroepithelial polyps, arising with a background of pelvic endometriosis and a history of gonadotropin releasing hormone (GnRH) therapy. Magnetic resonance imaging revealed the masses to have high signal intensity on T2-weighted imaging. The location and bilaterality of the polypoid intraluminal masses are considered useful points in the differential diagnosis of fibroepithelial polyps.

Surgical management of bilateral ureteral endometriosis

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

Endometriosis of the urinary tract

Genitourinary endometriosis is a rare manifestation of a common disease. Ectopic endometrial tissue may extrinsically involve or intrinsically invade the bladder or ureter, and, less commonly, the urethra or kidney. Bladder involvement usually presents with irritative symptoms, whereas ureteral disease may present with asymptomatic renal failure. Therefore, a high index of suspicion is necessary, and genitourinary endometriosis should be considered in all symptomatic women with a history of cesarean delivery of other gynecologic surgery. In women beyond reproductive age, definitive surgical treatment is preferred, with removal of the ectopic tissue, relief of obstruction, and castration with or without hysterectomy. In those who desire future fertility, conservative surgery and/or hormonal therapy is often recommended.

Endometriosis: a clinically malignant disease

According to the literature this is the first patient with the primary diagnosis of an endometriosis (EMT) based on the cardinal symptom of an uremia in combination with a colorectal ileus. Operative removal of EMT was possible after hormonal suppression with Dienogest.

Extrapelvic endometriosis

This article reviews extrapelvic endometriosis, emphasizing classic papers as well as recent research. Because of the nature of the existing literature, specifically case reports and retrospective analyses, this article is primarily descriptive in nature. Extrapelvic endometriosis is discussed based on some main areas of occurrence, including gastrointestinal, urinary, and thoracic; other areas are also reviewed. What is known about the epidemiology, pathogenesis, diagnosis, and treatment of extrapelvic endometriosis is highlighted. Areas for future direction of research in the field are also identified.

Intrinsic ureteric involvement by endometriosis: a case report

Endometriosis occasionally involves the urinary tract, and a ureteral obstruction from this order constitutes a rare variant with serious consequences. Intrinsic ureteric involvement by endometriosis is an exceedingly rare event. This case report describes intrinsic ureteric involvement by endometriosis. The case involved 47-year-old woman, gravida 4, para 2, who had a 4-year history of dysmenorrhea and hypermenorrhea. An intravenous pyelogram showed a right hydronephrosis. She underwent a total abdominal hysterectomy and a right ureteroureterostomy. A pathologic examination revealed complete obstruction of the right ureter by intrinsic intramural endometriosis. We conclude that because ureteral endometriosis, especially intrinsic endometriosis, is usually silent and results in a high rate of renal loss before recognition, physicians should have a hightened awareness of this uncommon but serious manifestation of endometriosis.

Ureteral obstruction due to retroperitoneal endometriosis: a conservative approach including surgery and GnRH analogs

Ureteral obstruction due to endometriosis is an infrequent condition which can be asymptomatic for a long time. Irreversible loss of renal function may result in cases with delayed diagnosis. Our report concerns a case of unilateral hydronephrosis and hypertension due to retroperitoneal endometriosis occurring in a 24-year-old woman. The management of patients bearing obstructive uropathy caused by endometriosis is discussed. In the present case, a conservative operation followed by medical treatment, including GnRH analogs, was used to preserve reproductive capacity.

Vesical endometriosis 12 years after a cesarean section

Invasion of the bladder is an unusual manifestation of endometriosis. We report a case of an isolated vesical endometrioma that developed 12 years after an uncomplicated cesarean section. The intraoperative findings were consistent with the possibility that infiltration of the detrusor muscle by endometrial tissues resulted from disruption of the uterine incision.

Salpingoureteral fistula: CT appearance

Laparoscopic laser surgery is becoming increasingly common as treatment for endometriosis. We report a case of computed tomographic (CT) demonstration of salpingoureteral fistula secondary to laparoscopic laser surgery.