Intrinsic Ureteral Endometriosis Research Articles

Ureteral endometriosis: MR imaging appearance for predicting complex procedures

Rationale and objectivesTo describe MRI characteristics of ureteral endometriosis (UE) in identifying intrinsic involvement of the ureteric wall and predicting complex procedures. MethodsThirty-three UE lesions in 30 patients treated for UE over a 20-year period were reviewed. A systematic analysis of 13 MRI (ureteric wall thickening, circumference, T1 signal, T2 signal, ureterectasis, lateral parametrial endometriosis (LPE), rectal endometriosis, the foregoing three-characteristic diameter, ovarian endometriomas, adenomyosis, paraurethral endometriosis) and 5 clinical (age, BMI, CA125, creatinine and rAFS stage) characteristics was performed. MRI results were compared to histology and surgical procedure performed (simple versus complex ureteral procedures). ResultsTwenty-five extrinsic and 8 intrinsic UE were pathologically identified. Twenty lesions underwent a simple procedure, and 12 underwent a complex procedure, with 1 ureteroscopic biopsy. There were significant differences in the characteristics of ureteric wall thickening, the diameter of dilated ureter and LPE, rectal endometriosis and adenomyosis between extrinsic and intrinsic UE (p < 0.05). UE was associated with LPE (p = 0.033). The criteria of ureteral wall thickening more accurately predicted intrinsic UE than circumference, but the AUC was not significant difference (AUC, 0.806 and 0.639; 95 % CI, [0.594, 0.937] and [0.419, 0.823], respectively; p = 0.350). There were significant differences in creatinine, thickening and adenomyosis between the simple and complex procedures (p < 0.05). In 11 lesions with the absence of ureterectasis, 4 lesions with hydronephrosis and thickening were intrinsic and underwent complex procedures, while 7 lesions extrinsic and simple. ConclusionsUreteric wall thickening as a analytical criterion may accurately predict intrinsic UE and complex ureteric procedures.

Robot-assisted laparoscopic ureteroneocystostomy combined to hysterectomy for intrinsic ureteral and deep pelvic endometriosis: Video presentation

Introduction: We present a case of posterior deep infiltrating endometriosis with intrinsic ureteral involvement in a 43-year-old patient treated by robot-assisted laparoscopic technique. To our knowledge, this is the second case of robot-assisted ureteroneocystostomy with concomitant hysterectomy reported in the literature1–5, yet the first one to be described with a video presentation. Case description: A 43-year-old woman with a past history of endometriosis treated laparoscopically was referred to our clinic for grade II–III left hydronephrosis. Pelvic ultrasound and magnetic resonance imaging demonstrated a 3-cm paracervical endometriotic nodule causing ureteral compression, another 1.6-cm endometriotic nodule at the rectosigmoid junction, an adenomyotic nodule in the anterior uterine wall, and an endometrioma on the right ovary. Given that the patient had an absolute contraindication to hormonal therapy, we opted for robot-assisted laparoscopic complete eradication of endometriosis. The procedure consisted in total hysterectomy with concomitant removal of the rectovaginal nodule, right adnexectomy, left salpingectomy, and left ureteral resection with ureteroneocystostomy. After 8 days, a cystography was accomplished to confirm anastomosis integrity, and the bladder catheter was removed. The patient was discharged on day 8 after a regular postoperative period. One year after the surgery, the patient refers wellbeing. Conclusion: The robotic approach in such a complex procedure as surgical treatment of ureteral and deep infiltrating endometriosis is feasible and safe with acceptable postoperative outcome. Further investigations with larger comparative cohorts that include cost analysis are needed to fully assess the benefits achieved by robotic assistance in patients with ureteral and deep infiltrating endometriosis.

Ureteroureteral anastomosis for endometriosis involving the ureter: Case series and literature review

Introduction: The purpose of this study was to review operative management of endometriosis involving the ureter. Materials and methods: Retrospective case series of three patients undergoing resection of ureteral endometriosis with ureteroureterostomy for endometriosis involving the ureter by minimally invasive gynecologic surgeons between 2007 and 2018 at a large academic medical center in the Northeastern United States. A literature review was conducted to find cases with a similar approach. Results: Three cases of ureteral endometriosis surgically managed at our institution with ureteroureteral anastomosis were identified. Ureteral endometriosis was identified preoperatively by hydroureteronephrosis on imaging. Intrinsic ureteral endometriosis was confirmed by pathology in two cases; extrinsic endometriosis was grossly visualized in one case. Operative times ranged from 300 to 387 min. Estimated blood loss ranged from 150 to 250 mL. There were no intraoperative complications. A total of 151 cases with a similar approach were described in the literature. Recurrence of obstructive uropathy occurred in 11 cases. Conclusion: Ureteral endometriosis is a rare complication with several management options. Ureterectomy with ureteroureterostomy has been described in the literature and in three cases at our institution with low complication rates and rare stricture formation. This technique can be successful in the management of ureteral endometriosis and warrants further investigation.

Laparoscopic Ureteral End to End Anastomosis for Intrinsic Ureteral Endometriosis

Objective: To present an interesting case of intrinsic ureteral endometriosis causing complete ureteral obstruction and its surgical management with laparoscopic end-to-end ureteral anastomosis.

Laparoscopic Ureteroneocystostomy with a Vesicopsoas Hitch in 10 Steps

Study ObjectiveLaparoscopic ureteroneocystostomy with a vesicopsoas hitch has the advantages of a minimally invasive approach. The standardization and description of the technique are the main objectives of this video. We described this procedure in 10 steps, which could help to understand and perform this procedure. MethodsThis video presents an approach to laparoscopic ureteroneocystostomy with a vesicopsoas hitch, which was clearly divided into 10 steps. The local institutional review board was consulted and ruled that approval was not required for this video article because the video describes a technique and does not report a clinical case. The patient cannot be identified, and she gave informed consent. ResultsThe 10 steps are as follows: step 1, identification of the healthy ureter; step 2, identification of the stenotic part; step 3, section of the ureter; step 4, bladder mobilization; step 5, anterior cystostomy; step 6, psoas hitch; step 7, closure of the anterior cystostomy; step 8, posterior spatulation of the ureter; step 9, cystostomy of the superolateral bladder dome; and step 10, ureteral suture to the bladder. ConclusionLaparoscopic ureteroneocystostomy with a vesicopsoas hitch is an effective technique for intrinsic ureteral endometriosis; it usually needs ureteral resection with end-to-end reanastomosis or reimplantation if the anastomosis is in tension. The 10 steps help to perform each part of surgery in logical sequence, making the procedure faster to adopt and learn. The standardization of laparoscopic techniques could help to reduce the learning curve.

Surgical Outcomes of Urinary Tract Deep Infiltrating Endometriosis

ObjectiveTo report the outcomes of surgical management of urinary tract endometriosis. DesignRetrospective study based on prospectively recorded data (NCT02294825) (Canadian Task Force classification II-3). SettingUniversity tertiary referral center. PatientsEighty-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. InterventionProcedures performed included resection of bladder endometriosis nodules, advanced ureterolysis, ureteral resection followed by end-to-end anastomosis, and ureteroneocystostomy. Measurements and Main ResultsThe 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. ConclusionSurgical 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.

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.

Robotic-assisted ureteroureterostomy/ureteroneocystostomy for the treatment of intrinsic ureteral endometriosis related obstructive uropathy – A preliminary experience of a single academic center

Robotic-assisted ureteroureterostomy/ureteroneocystostomy for the treatment of intrinsic ureteral endometriosis related obstructive uropathy – A preliminary experience of a single academic center

Comparison of the post-operative infection by using different type of prophylactic antibiotics and placebo in healthy adult patients who underwent ureterorenoscopic surgery

Comparison of the post-operative infection by using different type of prophylactic antibiotics and placebo in healthy adult patients who underwent ureterorenoscopic surgery

Histological evaluation of ureteral involvement in women with deep infiltrating endometriosis: analysis of a large series.

In women with deeply infiltrating endometriosis (DIE) what is the prevalence of involvement of endometriotic tissue and fibrosis in ureteral endometriosis (UE), as assessed by histological staining? In women with DIE, ureteral involvement is more often due to endometriotic tissue rather than fibrosis. In the current literature, histological evaluation of ureteral endometriosis is mainly based on the degree of wall infiltration by endometriosis instead of the tissue composition. A few studies reported ill-defined and contradictory histological data on the tissue composition of UE. Retrospective observational study based on clinical records of women affected by DIE, laparoscopically treated for UE at a tertiary referral center, between January 2010 and March 2013. All cases of ureteral nodule excision or ureterectomy with histological examination of the specimens were included. Exclusion criteria were other identified causes of hydroureteronephrosis, medical therapy for a period of at least 3 months before surgery and previous surgery for DIE. A total of 77 patients were included in the study and among them seven (9%) presented with bilateral ureteral involvement, giving a total of 84 cases of UE available for analysis. All patients had stage IV endometriosis. According, respectively, to the presence of endometrial glands and/or stroma cells or of fibrotic tissue only, the endometriotic UE and fibrotic UE groups were compared with regard to hydroureteronephrosis at pre-operative urinary tract computerized tomography scan, type of surgical procedure performed to treat UE (nodule removal or ureterectomy), association with other locations of the disease and post-operative complications (ureteral fistula or stenosis). For the 84 cases of UE, 65 (77%) and 19 (23%), respectively, showed endometriotic tissue and fibrotic tissue only. Presence of hydroureteronephrosis and endometriotic pattern of UE showed a significant association [endometriotic UE 44/65 (68%) versus fibrotic UE 8/19 (42%); P = 0.04]. Fibrotic pattern of UE and presence of concomitant recto-vaginal endometriosis showed a significant association [endometriotic group: 29/65 (45%) versus fibrotic group 18/19 (95%); P < 0.001]. The retrospective and monocentric (tertiary referral center) study design. Besides the distinction between extrinsic and intrinsic UE based on the degree of wall infiltration by endometriosis, a new classification according to the histological pattern of UE could be useful for clinicians, both in the diagnostic and therapeutic fields. None.

Intrinsic Ureteral Endometriosis: Description of a Striking Instance

Intrinsic ureteral endometriosis is a very rare condition. A 41 y. o. woman with right hydroureteronephrosis and other aspecific symptoms came to our attention. The CT scan showed an ureteral obstacle causing the hydroureteronephrosis. She underwent ureterorenoscopy with biopsies of the lesion that did not result to be diriment. Suspecting a ureteral neoplasm, the patient then underwent ureteral resection and ureterocystoneostomy, and the extemporary histological examination resulted as endometriosis. The abdominal exploration showed a parametrial and a peritoneal growth - both compatible with the extemporary histological examination - that were also excised. The post-operative course was uneventful. The definitive hystological examination confirmed the perioperatory diagnosis. Intrinsic ureteral endometriosis is confirmed as a rare pathology with an indefinite clinical presentation; its typical presentation, namely cyclic hematuria, seems to be an anecdotal feature. Therefore the diagnostics of intrinsic ureteral endometriosis is still difficult even despite such a striking presentation.

Endoureterotomy is not a sufficient treatment for intrinsic ureteral endometriosis.

AimTo investigate whether intrinsic ureteral endometriosis could be managed by laser endoureterotomy.Material and methodsWe studied retrospectively 6 patients with intrinsic ureteral endometriosis who underwent laser endoureterotomy and reviewed their clinical data. Pathological sections of them have also been studied by immunohistochemistry for expressional levels of oestrogen (ER) and progesterone (PR) receptors. Ten sections of normal endometrium were included as a control.ResultsFive patients had recurrence of ureteral stricture within 6 months postoperatively despite hormonal therapy for 3 to 6 months. One patient had recurrence 8 months after endoureterotomy. Two patients had secondary surgery for ureteroureterostomy and pathology confirmed recurrence of endometriosis. Immunohistochemistry revealed decreased ER and PR expression compared to the control.ConclusionsEndoureterotomy with hormonal therapy may not be suitable for ureteral endometriosis due to inadequate cutting and expressional change of ER and PR.

Outcomes of Surgical Management of Deep Infiltrating Endometriosis of the Ureter and Urinary Bladder

To report the outcomes of surgical management of urinary tract endometriosis and discuss the choice between conservative and radical surgery. We reviewed data concerning women managed for ureteral or bladder deep infiltrating endometriosis in 5 surgical departments participating in the CIRENDO prospective database. Preoperative data, surgical procedure data, and postoperative outcomes were analyzed. Data from 30 women pooled in the database showed 15 women presenting with ureteral endometriosis, 14 women with bladder nodules, and 1 with both types of lesions. Ureterolysis was performed in 14 cases; the ureter was satisfactorily freed in 10 of these. In 4 women over 40 years old, who were undergoing definitive amenorrhea, moderate postoperative ureteral stenosis was tolerated and later improved in 3 cases, while the fourth underwent secondary ureteral resection and ureterocystoneostomy. Primary ureterectomy was carried out in 4 women. Two cases of intrinsic ureteral endometriosis were found in 5 ureter specimens. Four complications were related to surgical procedures on ureteral nodules, and 2 complications followed the removal of bladder endometriosis. Delayed postoperative outcomes were favorable with a significant improvement in painful symptoms and an absence of unpleasant urinary complaints, except for one patient with prolonged bladder denervation. Conservative surgery, in association with postoperative amenorrhea, can be proposed in a majority of cases of urinary tract endometriosis. Although the outcomes are generally favorable, the risk of postoperative complications should not be overlooked, as surgery tends to be performed in conjunction with other complex procedures such as colorectal surgery.

Ureteral endometriosis: clinical and radiological follow-up after laparoscopic ureterocystoneostomy

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. 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. 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. 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-term follow-up.

Severe ureteral endometriosis: the intrinsic type is not so rare after complete surgical exeresis of deep endometriotic lesions

To evaluate the rate of intrinsic ureteral endometriosis in patients presenting with severe ureteral endometriosis. Observational study between June 1992 and December 2007. University tertiary referral center. Twenty-nine patients presenting deeply infiltrating endometriosis (DIE) with severe ureteral endometriosis. Severe ureteral endometriosis was defined as DIE lesions causing significant obstruction to the urinary flow with ureteral stenosis. Complete surgical exeresis of DIE lesions. Pre- and peroperative evaluation associated with histologic analysis. Intrinsic ureteral endometriosis was defined as presence of DIE lesions infiltrating the ureteral muscularis. In a series of 627 patients with histologic proved DIE, we observed 29 (4.6%) patients with severe ureteral endometriosis. Ureteral lesions (n = 34) were right sided in 7 (24.1%) patients, left sided in 17 (58.6%) patients, and bilateral in 5 (17.3%) patients. Eleven (37.9%) patients presented intrinsic lesions. Out of the 34 ureteral lesions 13 (38.2%) were intrinsic. In cases of radical ureteral surgery (n = 21 patients; n = 24 ureteral lesions) intrinsic ureteral DIE was observed in 52.4% (11 cases) of the patients and in 54.2% (13 cases) of the ureteral lesions. The prevalence of intrinsic ureteral endometriosis is underestimated. This result must be taken into account when specifying the surgical modalities for patients presenting with severe ureteral endometriosis.

Management of ureteral endometriosis: A report of ten cases

To investigate the clinical features and management of ureteral endometriosis. Patients surgically and histologically diagnosed as ureteral endometriosis from January 2001 to January 2007 in Peking Union Medical College Hospital were retrospectively reviewed. Ten patients were diagnosed as ureteral endometriosis among 7561 cases with surgically and histologically proved diagnosis of endometriosis, with an incidence of 0.132%. Nine out of 10 patients were extrinsic ureteral endometriosis and concomitant with severe pelvic endometriosis, and the other was intrinsic ureteral endometriosis. Hormone therapy failed in 2 patients with urinary tract obstruction. Ureterolysis was performed in 6 patients and ureterectomy was performed in 4 patients. One case of ureteral recurrence was observed in a postmenopausal woman without hormonal replacement therapy who received laparoscopic ureterolysis and hysterectomy with bilateral adnexectomy. No relapse was observed in the other 9 patients. Ureteral endometriosis is a rare entity. The upper urinary tract should be evaluated in patients with severe endometriosis, even in postmenopausal women. The treatment of ureteral endometriosis usually requires surgery, while ureterolysis should not be performed in patients with extensive disease. As a form of adjuvant therapy of surgery, hormonal therapy is an appropriate option.

Outcome of laparoscopic ureterolysis for ureteral endometriosis

To evaluate the adequacy of laparoscopic ureterolysis as a primary treatment option for ureteral endometriosis. Prospective collaborative cohort study. Gynecologic departments of three university hospitals. Women with ureteral endometriosis exhibiting moderate-to-severe hydronephrosis on preoperative intravenous pyelography. Laparoscopic ureterolysis. Cure rate, disesase recurrence. Thirty-three patients underwent laparoscopic ureterolysis during the study period. Bilateral involvement of ureters was found in 4 (12.1%) cases. In women with unilateral lesions the left ureter was more frequently affected (24/29 vs. 5/29). Ureteral involvement was associated with uterosacral ligaments endometriosis in 65.5% (22/34) of cases. No inadvertent ureteral injuries occurred during ureterolysis. A partial wall resection of the ureter was necessary in one case and a segmental ureteral resection with vescicopsoas hitch was required in a women with intrinsic ureteral endometriosis. The median (range) follow-up time was 16 months (range: 3-53 months). Thirty-two patients (96.7%) had a patent ureter on the 3-month postoperative intravenous pyelography. The recurrence rate of ureteral lesions was 12.1% (4/33). Our findings suggest that a conservative laparoscopic approach is an effective treatment option in most patients with ureteral endometriosis exhibiting moderate-to-severe hydronephrosis.

Endometriosis ureteral: A propósito de un caso

Ureteral endometriosis is a rare entity which may produce urinary tract obstruction with subsequent loss of renal function if treatment is not undertaken early due to its asymptomatic but locally aggressive course. We report one case of intrinsic ureteral endometriosis with unilateral renal failure (renal atrophy) and unresectable periureteral fibroinflammatory thickening involving vascular or visceral structures. We emphasize the diagnostic and therapeutic importance of a high degree of clinical suspicion about this entity, mainly in patients with history of genital endometriosis.

Persisting active and proliferative intrinsic ureteral endometriosis under GNRH agonists therapy: a case with immunohistological study

We report the case of a 30-year-old patient who underwent a segmental ureteral resection with ureteroureterostomy because of the presence of a left ureterohydronephrosis caused by an intrinsic ureteral endometriotic lesion. Preoperatively, the patient received a 3 months course of GNRH agonists. The serum estradiol level was at 12 pg/ml at the moment of surgery. Histology and immunohistochemistry performed on the resected specimen showed the presence of numerous large haemorragic endometriotic foci containing very high levels of α-estrogen and progesterone nuclear receptors, a high Ki-67 labeling index and a strong positivity for EGF-receptor. This is the first report of immunohistochemical study performed on ureteral endometriosis preoperatively treated with GNRH agonists. Because hormonal treatments are often prescribed in the treatment of ureteral endometriosis, clinicians should be aware of the possibility of persisting very active and proliferative ureteral endometriotic lesions even under treatment with GNRH agonists and very low levels of circulating estradiol.

Three Cases of Urinary-Tract Endometriosis with Different Clinical Findings

Endometriosis is the presence of endometrium-like tissue outside the uterus. Ureteral involvement is rare and may result in a high rate of renal loss before it is recognized. Different treatment modalities are reported in the literature, including medical therapy and radical surgery. The authors report three cases of ureteral endometriosis with different clinical features. In one patient, bilateral distal ureterectomy and ureteroneocystostomy was performed, and the histopathologic diagnosis was consistent with intrinsic ureteral endometriosis. In the other two patients, surgical treatment consisted of endometrioma cyst excision, ureterectomy, and ureteroneocystostomy.