2133 Bilateral Ureteral Endometriosis - an Indolent, Aggressive and Dangerous Condition

Abstract

Video Objective Describe an unusual bilateral ureteral reimplantation due to endometriosis and a flowchart of a conservative decision making. Setting Deep infiltrating endometriosis (DIE) involving the ureter has an incidence of 0.1 – 1%, normally affecting the lower third of its segment, up to 4 cm above the vesicoureteric junction. Bilateral ureteral involvement happens in 9% of the cases. The absence of specific symptoms makes its diagnostic challenging. Lumbar pain takes place when its involvement is complicated by a marked obstruction, with an impaired renal function. Decompressive surgery is mandatory. The necessity of ureteroneocystostomy increases along with the severity of hydronephrosis, accounting for 62% of the ureteral decompressive procedures. Even though, bilateral ureteroneocystostomy is a rare procedure, not trespassing 6% of ureteral reimplantations. Interventions This case illustrates a situation where a patient with a history of a bowel segmental resection presents with an advanced bilateral posterior DIE, compromising lower rectum below the previous anastomosis, vagina, parametrium (posterior and lateral) bilaterally and both inferior hypogastric plexus. Hormonal therapy improved endometriosis symptoms, but did not control the urinary tract involvement. Along with the patient, considering a probability of intestinal, urinary and sexual impairment, a conservative approach was decided and a laparoscopy bilateral ureteroneocystostomy was performed with a post-operative close clinical and imaging surveillance. Conclusion Ureteral endometriosis can be aggressive and indolent. Decompressive procedures must be performed. The decision making process must take in consideration patient's characteristics and expectations.