Ureteral Endometriosis

Clinical and Radiological Follow-up After Laparoscopic Ureterocystoneostomy

Anna Stepniewska; Gaetano Grosso; Angelo Molon; Giuseppe Caleffi; Elena Perin; Marco Scioscia; Paride Mainardi; Luca Minelli

Disclosures

Hum Reprod. 2011;26(1):112-116. 

In This Article

Abstract and Introduction

Abstract

Background: Ureteral endometriosis is a rare entity that may lead to progressive hydroureteronephrosis and renal loss. When the localization of ureteral stenosis is close to the ureterovesical junction, ureterocystoneostomy may be required. The aim of the present study was to evaluate post-operative complication rates and clinical outcomes at 1- and 6-month follow-up after laparoscopic ureterocystoneostomy.
Method: Twenty patients who underwent ureterocystoneostomy for pelvic endometriosis in our tertiary referral centre for endoscopic surgery during 1 year were studied. A cystography was performed on Day 7 after surgery to verify the integrity of anastomosis and a satisfactory bladder capacity. Follow-up consisted of gynaecological examination and transvaginal ultrasound at 1 and 6 months after surgery. At 6 months, urography and cystography were also performed. Measurements included results of a pre-operative clinical and instrumental assessment, intra- and post-operative complications, post-operative bladder capacity at cystography and improvement of pain, using a visual analogue scale for the main symptoms related to endometriosis and uro-specific pain.
Results: Neither a case of ureteral fistula nor other complications requiring re-intervention were reported. Post-operative transient deficit of bladder voiding occurred in five cases (25%), urinary infection in one and post-operative pyrexia in four (20%) patients. The median time to resuming voiding function was 3 days (range 1–20 days). In six cases, a mild vesico-ureteral reflux at the operated side was observed at 7-day cystography. Post-operative symptomatology was improved significantly (P<0.05) for all symptoms. Urography and cystography performed at 6 months confirmed good post-operative reconstructions in all cases.
Conclusions: The objective of surgical treatment of ureteral endometriosis is to remove the stenotic tract and to preserve renal function. In cases of intrinsic ureteral endometriosis, the procedure of laparoscopic ureterocystoneostomy is feasible and has good outcomes at short- and medium-termfollow-up.

Introduction

Ureteral endometriosis is a rare and worrisome localization as it may lead to progressive hydroureteronephrosis and renal loss. The whole urinary tract is affected in 1–6% of cases (Yohannes, 2003; Antonelli et al., 2006) and the most frequently involved organs are the bladder, ureter and kidney, in a proportion of 40:5:1 cases (Jubanyik and Comite, 1997; Comiter, 2002; Abrao, 2009). Usually, ureteral lesions are extensions of retrocervical endometriosis (Vercellini et al., 2000; Donnez et al., 2002). According to the grade of infiltration of the ureteral wall, two types of ureteral endometriosis are distinguished, the intrinsic form (infiltration of the muscularis mucosa and uroepithelium) and the extrinsic form (endometriosis is found only on the ureteral adventitia and is surrounded by connective tissue) occurring with a 1:4 ratio (Yohannes, 2003). Nevertheless, the two types may co-exist and the most frequent localization is the pelvic tract of the ureter (Yohannes, 2003).

The symptomatology of ureteral endometriosis is not specific. Frequently, the only symptoms are those typically related to endometriosis, such as dysmenorrhoea, dyspareunia or pelvic pain, whereas more indicative symptoms such as renal colic, low back pain (lumbalgia) and haematuria (Gustilo-Ashby and Paraiso, 2006) are rare. Even extremely severe cases with complete ureteral stenosis causing progressive hydronephrosis and subsequent loss of renal function may never present urological symptoms (7). The risk of silent renal loss in these patients is as high as 25–50% (Frego et al., 2002; Yohannes, 2003; Nezhat et al., 2004; Abrao, 2009). Some authors suggested evaluating ureters and kidneys if deep infiltrating endometriosis is suspected, and particularly if nodules of >3 cm involve the rectovaginal septum (Donnez et al., 2002).

Different surgical treatments have been proposed according to extrinsic or intrinsic ureteral endometriosis (Nezhat et al., 1996; Donnez et al., 2002; Ghezzi et al., 2006; Frenna et al., 2007; Scioscia et al., 2009). Nevertheless, in our opinion, in patients with hydronephrosis and the localization of the ureteral stenosis close to the viscoureteral junction, the appropriate procedure is a ureterocystoneostomy (Mereu et al., 2010; Scioscia et al., 2009). The aim of the present study was to evaluate post-operative complications and clinical outcomes at 1- and 6-month follow-up after laparoscopic ureterocystoneostomy.

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