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Aggiornamento Ureteral Endometriosis

del 26-02-2013

Actas Urol Esp. 2013 Feb 8. pii: S0210-4806(12)00386-5. doi: 10.1016/j.acuro.2012.09.004. [Epub ahead of print]

Ureterectomy in the treatment of urothelial carcinoma of the distal ureter.

[Article in English, Spanish]

García-Segui A, Gómez I, García-Tello A, Cáceres F, Angulo JC, Gascón M.

Source

Servicio de Urología, Hospital General Mateu Orfila, Mahón, España. Electronic address: agarciasegui@gmail.com.

Abstract

INTRODUCTION:

Segmental ureterectomy with preservation of the kidney is a treatment option for the low grade urothelial carcinoma (LG-UC) in distal ureter that is not a candidate for endoscopic resection. Laparoscopic distal ureterectomy (LDU) with ureteral reimplantation is common in benign conditions (stenosis, iatrogenic lesion, endometriosis). However, it has been hardly described in malignant ureteral condition. The literature is reviewed in this regards and the surgical technique described.

MATERIAL AND METHODS:

The experience regarding two cases of LDU due to low grade urothelial carcinoma in distal ureter is presented. In both, previous bladder transurethral resection (RTU) was performed. The urinary cytology was negative and the imaging studies identified urinary obstruction and distal ureter filling defect. One of the patients had a background of T1G3 bladder cancer and suffered renal failure. In both, the ureter was ligated early. Segmental ureterectomy was performed using a combined endoscopic and laparoscopic procedure with ureteral desinsertion in one case. In the other, it was exclusively laparoscopic. Both were done with 4 trocars. Ureteral reimplantation was conducted with continuous hermetic suture and without tension. In one case with background of high grade bladder tumor, pelvic lymphadenectomy was also performed.

RESULTS:

Operating time was 180 and 240min, respectively, with estimated bleeding of 100 and 250ml. Hospitalization time was 6 and 4 days. The only post-operatory complication was paralytic ileum (Clavien I) in the first case. With a 20 and 12 month follow-up, there is no evidence of recurrence or dilatation. In the patient with renal failure, creatinine clearance improved.

CONCLUSIONS:

The LDU with ureteral reimplantation is a complex technique. However, it represents a feasible and effective alternative for the treatment of LG-UC in distal ureter, as long as the oncological and reconstructive principles are respected.

Urologia. 2012 Dec 30;79 Suppl 19:e27-9. doi: 10.5301/RU.2012.9764.

Laparoscopic ureteral reimplantation surgery according to Lich-Gregoir.

Corona A, Serra S, De Lisa A.

Source

Clinica Urologica – Università degli Studi di Cagliari – Italy.

Abstract

Introduction: Terminal ureteral stenosis can occur as a consequence of gynecological diseases or surgical treatment of simple or radical hysterectomy and pelvic endometriosis. Materials and Methods: We evaluated 5 patients aged between 30 and 52 years, who underwent ureterocystoneostomy for ureteral stenosis due to several factors: 2 cases of pelvic endometriosis; 2 cases of surgery treatment of pelvic endometriosis, and 1 case of simple hysterectomy. Patients were placed supine in Trendelemburg position of about 30°. After pneumoperitoneum induction, the following equipment was introduced through four different laparoscopic accesses: the optic tool into the umbilicus access, 5-mm operative accesses on the lesion side, and one of 10-11mm in the contralateral site. Once we incised the peritoneum and isolated the distal ureter until the stenotic tract, we proceeded with the dissection, performing a 2cm serum-muscle incision of the bladder, showing the mucosa after previous distension with 200mL of saline. A little operculum in the mucosa was created by a spatula. After applying a DJ ureteral catheter with the distal end introduced into the bladder, the direct ureteral-vesical anastomosis was made. The application of serum-detrusor sutures next to the ureter created the antireflux barrier. The peritoneum was closed. Results: Surgery was performed by laparoscopy without conversion into open surgery. Average performing time was 205min. Clinical stay was 5 days and DJ ureteral catheter was removed after 3 weeks following cystography and absence of spillage around the bladder. The ultrasound controls performed after three and six months did not show any complication. <p>Conclusions: Laparoscopy is a valid alternative to open surgery, also yielding better esthetic results, particularly in cases where the classical approach is difficult to perform, as for example in obese patients.

Korean J Urol. 2013 Jan;54(1):26-30. doi: 10.4111/kju.2013.54.1.26. Epub 2013 Jan 18.

Laparoscopic ureteroneocystostomy: modification of current techniques.

Ahn JH, Han JY, Nam JK, Park SW, Lee SD, Chung MK.

Source

Department of Urology, Pusan National University Hospital, Busan, Korea.

Abstract

PURPOSE:

To review the feasibility of laparoscopic ureteroneocystostomy with extracorporeal eversion of the ureteral end in various distal ureteral lesions.

MATERIALS AND METHODS:

We conducted a retrospective review of 5 laparoscopic procedures of ureteroneocystostomy with extracorporeal eversion of the ureteral end. Of these, 4 patients (range, 45 to 54 years) had distal ureter stricture or obstruction after gynecological surgeries for endometriosis or a large uterine myoma. One patient (male, 67 years) had low-grade distal ureter cancer. The laparoscopic procedure was combined with cystoscopic insertion of a ureteral stent and extracorporeal eversion of the ureter through the 10-mm port on the affected side.

RESULTS:

The laparoscopic ureteral reimplantations with and without a psoas hitch in patients with distal ureteral lesions was successful in all patients. The mean operation time was 137 minutes (range, 104 to 228 minutes). Two patients underwent additional psoas hitch. In all patients, short-term success was confirmed by voiding cystourethrography and intravenous pyelography conducted 3 months after the operation. The mean follow-up of the entire group was 12 months (range, 3 to 30 months). We noted no major or minor complications over the follow-up period.

CONCLUSIONS:

The technique of laparoscopic ureteroneocystostomy for benign or malignant ureteral strictures continues to evolve. Surgeons should be versatile with various options and technical nuances when dealing with these cases. Simple modifications of laparoscopic ureteroneocystostomy with extracorporeal eversion of the ureteral end, nonreflux extravesical anastomosis, and simultaneous cystoscopy will be crucial to the ease of performance and a successful outcome.

Urologia. 2013 Jan 22;0(0):0. doi: 10.5301/RU.2013.10619. [Epub ahead of print]

Management of iatrogenic gynecologic injuries with urologic relevance Causes and prevention of complications: the gynecologist’s opinion.

Jasonni VM, Matonti G.

Source

Toniolo Clinic – Gynepro Medical – Italy.

Abstract

Objective: To detect and prevent urinary tract injuries in gynecological surgery.
Methods: A brief review of the literature about recognition and prevention of ureteral and bladder injuries.
Results: It is well known that factors as intra-operative bleeding, pelvic adhesions and infections, pelvic masses, endometriosis and obesity can make surgery difficult. For these reasons the study of the urinary tract and the use of ureteral catheters may be helpful when alterations of the urinary tract anatomy is suspected. However the surgeon should always operate under direct vision of the ureters with a judicious use of diathermy and taking care when separating bladder from the uterus where the blunt dissection is blind and dangerous. When there are some doubts about the integrity of ureters, the control with i.v. infusion of indigo-carmine or with ureteral catheters should be performed. The same applies for the bladder: the cystoscopy should be in the armamentarium of gynecological surgeons to control the ureteral efflux and the bladder integrity. To fill the bladder with methylene blue at the end of the surgery is also helpful in revealing, under the pressure, even very small lesions as well as partial thickness of the bladder that can cause a delayed
fistula.
Conclusions: Surgeons’ training is the most important factor in avoiding and detecting urinary tract injuries. This is important not only for the technique but also in the selection of patients, and then in planning the more appropriate pre-operative study and in recognizing the presence of injuries during surgery.

JSLS. 2012 Jul-Sep;16(3):451-5. doi: 10.4293/108680812X13462882736213.

Silent loss of kidney seconary to ureteralendometriosis.

Nezhat C, Paka C, Gomaa M, Schipper E.

Source

Center for Special Minimally Invasive Surgery, Stanford University Medical Center, Palo Alto, CA 94304, USA. cnezhat@stanford.edu

Abstract

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.

J Minim Invasive Gynecol. 2013 Jan-Feb;20(1):100-3. doi: 10.1016/j.jmig.2012.09.012.

Retrocervical deep infiltrating endometriotic lesions larger than thirty millimeters are associated with an increased rate of ureteral involvement.

Kondo W, Branco AW, Trippia CH, Ribeiro R, Zomer MT.

Source

Department of Gynecology, Sugisawa Medical Center, Curitiba, Paraná, Brazil. williamkondo@yahoo.com

Abstract

STUDY OBJECTIVE:

To estimate the presence of ureteral involvement in deep infiltrating endometriosis (DIE) affecting the retrocervical area.

DESIGN:

Retrospective study of women undergoing laparoscopic treatment of DIE affecting the retrocervical area. DESIGN CLASSIFICATION: Canadian Task Force classification II-3.

SETTING:

Tertiary referral private hospital.

PATIENTS:

We evaluated 118 women who underwent laparoscopy for the treatment of retrocervical DIE lesions between January 2010 and March 2012.

INTERVENTIONS:

All women underwent laparoscopic surgery for the complete treatment of DIE. After surgery all specimens were sent for pathologic examination to confirm the presence of endometriosis.

MEASUREMENTS:

Patients with pathologically-confirmed retrocervical DIE were divided into 2 groups according to the size of the lesion (group 1: lesions ≥ 30 mm; group 2: lesions < 30 mm) and the rate of ureteral endometriosis was compared between both groups.

MAIN RESULTS:

Ureteral involvement was present in 17.9% (95% confidence interval [CI] 10%-29.9%) of women with retrocervical lesions ≥ 30 mm whereas in only 1.6% (95% CI 0.4%-8.5%) of those with lesions <30 mm (odds ratio = 13.3 [95% CI 1.6-107.3]).

CONCLUSION:

Patients undergoing surgery for retrocervical DIE lesions ≥ 30 mm in diameter have a greater risk of having ureteral involvement (17.9%).

BJU Int. 2013 Jan 10. doi: 10.1111/j.1464-410X.2012.11673.x. [Epub ahead of print]

Robot-assisted reconstructive surgery of the distal ureter: single institution experience in 16 patients.

Musch M, Hohenhorst L, Pailliart A, Loewen H, Davoudi Y, Kroepfl D.

Source

Department of Urology, Pediatric Urology and Urologic Oncology, Kliniken Essen-Mitte, Essen, Germany.

Abstract

WHAT’S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Open reconstructive surgery of the lower ureteric segment in adults often requires large incisions, as the basic prerequisite for such complex procedures is wide exposure. Published experience on minimally invasive techniques in this challenging surgical field, e.g. conventional laparoscopy or robot-assisted laparoscopy, still remains limited. We report our experience from one of the largest single institution series on robot-assisted reconstructive surgery of the distal ureter in adults, with a special focus on technical aspects of the different surgical procedures.

OBJECTIVE:

To describe the feasibility of and operative techniques used during different daVinci® robot-assisted laparoscopic reconstructive procedures of the distal ureter, and to report the short-term outcome of such procedures.

PATIENTS AND METHODS:

Between June 2009 and October 2011, 16 patients underwent robot-assisted operations of the distal ureter because of various underlying pathological conditions. We present a description of each procedure, the incidence of perioperative complications and the results of follow-up examination. The data were collected retrospectively using the patients’ records and questionnaires sent to the patients and the referring urologists. The follow-up examinations were done at the discretion of the referring urologists.

RESULTS:

The surgical indications and operative techniques were as follows: seven distal ureteric resections [DUR] with psoas hitch procedures (+/- Boari flap; four), extravesical reimplantation (two) or end-to-end anastomosis (one) because of benign distal ureteric stricture; four DUR with psoas hitch procedure (+/- Boari flap) and pelvic lymphadenectomy for urothelial carcinoma of the ureter; one DUR with psoas hitch procedure and Boari flap because of unexpected locally recurrent prostate cancer; one extravesical reimplantation because of vesico-ureteric reflux; one bilateral intravesical reimplantation of ectopic ureters (as part of a radical prostatectomy); one resection of a non-functioning upper kidney pole with associated megaureter and ureterocele and intravesical reimplantation of lower pole ureter; one resection of pelvic endometriosis and ureterolysis with omental wrap. The median operative duration (including docking/undocking of the robot) was 260 min. There were no intraoperative complications but there was one conversion to open surgery. Complications according to the Clavien-Dindo classification occurred in 12 patients (75%) ≤ 90 days of surgery: 10 (62%) minor (grade I-II) and two (12%) major complications (grades IIIb and IVa, respectively). The median hospital stay after surgery was 7.5 days. At a median follow-up of 10.2 months, 15 patients (94%) remained without signs of urinary tract obstruction and 13 (81%) were asymptomatic.

CONCLUSIONS:

Robot-assisted reconstructive surgery of the distal ureter is feasible and can be used without compromising the generally accepted principles of open surgical procedures. The functional outcome was good in short-term follow-up and severe postoperative complications were rare.

Arch Gynecol Obstet. 2012 Dec 2. [Epub ahead of print]

Efficacy of the revised Enzian classification: a retrospective analysis. Does the revised Enzian classification solve the problem of duplicate classification in rASRM and Enzian?

Haas D, Wurm P, Shamiyeh A, Shebl O, Chvatal R, Oppelt P.

Source

Department of Obstetrics and Gynecology, Linz General Hospital, Allgemeines Krankenhaus Linz, Krankenhausstrasse 9, 4021, Linz, Austria.

Abstract

PURPOSE:

The most widely accepted classification for endometriosis is the Revised American Society for Reproductive Medicine (rASRM) system, but this does not take deeply infiltrating endometriosis (DIE) into account. The Enzian classification enables clinicians to classify DIE. Due to complexity and partial overlap with rASRM, it was revised for a second time in February 2011. Using both the systems to classify lesions would be inappropriate, as they refer to different locations. The aim of this study was to analyze whether the revised Enzian classification is easier to use and avoids duplicate classifications.

METHODS:

Retrospective study of 460 women admitted for endometriosis.

RESULTS:

One hundred and eighty-seven of 460 patients (41 %) had histologically confirmed DIE based on the revised Enzian classification. Further classification of these 187 patients using Enzian revealed 270 retroperitoneal lesions, as some patients had several DIE-type lesions simultaneously: 66 in compartment A (rectovaginal septum, vagina), 112 in compartment B (sacrouterine ligaments, pelvic wall), 58 in compartment C (bowel), 15 with adenomyosis uteri, 7 with bladder involvement, 8 with intrinsic involvement of the ureter, and 4 with bowel involvement. All 270 lesions were classified using Enzian alone and not with the rASRM score. There were no duplicate classifications (rASRM and Enzian).

CONCLUSIONS:

The revised Enzian classification is an excellent complement to the rASRM score for morphological description of DIE.

J Minim Invasive Gynecol. 2013 Jan-Feb;20(1):49-55. doi: 10.1016/j.jmig.2012.08.775. Epub 2012 Nov 4.

Partial colpectomy is a risk factor for urologic complications of colorectal resection for endometriosis.

Zilberman S, Ballester M, Touboul C, Chéreau E, Sèbe P, Bazot M, Daraï E.

Source

Service de Gynécologie-Obstétrique, Hôpital Tenon, Paris, France.

Abstract

STUDY OBJECTIVE:

To evaluate urologic complications after colorectal resection for endometriosis.

DESIGN:

Cohort study (Canadian Task Force classification II-2).

SETTING:

Tertiary referral university hospital and expert center in endometriosis.

PATIENTS:

One hundred sixty-six women with colorectal endometriosis proven by transvaginal sonography and magnetic resonance imaging.

INTERVENTION:

Open or laparoscopic colorectal resection for endometriosis.

MEASUREMENTS AND MAIN RESULTS:

Forty-four patients (26.5%) experienced at least 1 urologic complication, including infection. Eight patients (4.8%) experienced postoperative symptomatic hydronephrosis requiring ureteral stent in 3 cases, a percutaneous nephrostomy in 1 case, and expectant management for the last 4. Urologic fistulas occurred in 5 patients (3%). Postoperative voiding dysfunction requiring self-catheterization was observed in 48 patients (28.9%). With univariate analysis, a relationship was found between voiding dysfunction and partial colpectomy (p = .001) and American Society of Reproductive Medicine total score (p = .02), and between the occurrence of urinary fistula and the use of prophylactic ureteral catheterization (p = .015) and parametrectomy (p = .02). A relationship was found between postoperative symptomatic hydronephrosis and the use of prophylactic ureteral catheterization (p = .003).

CONCLUSION:

Colorectal resection for endometriosis can lead to urologic complications, particularly for patients requiring partial colpectomy, of which patients need to be informed.

Int Surg. 2012 Apr;97(2):135-9. doi: 10.9738/CC124.1.

Laparoscopic trocar port site endometriosis: a case report and brief literature review.

Emre A, Akbulut S, Yilmaz M, Bozdag Z.

Source

1 Department of Surgery, Malatya State Hospital, Malatya, Turkey.

Abstract

Abstract Endometriosis is defined as the presence of ectopic endometrial tissue outside the lining of the uterine cavity. It occurs most commonly in pelvic sites such as ovaries, cul-de-sac, and fallopian tubes but also can be found associated with the lungs, bowel, ureter, brain, and abdominal wall. Abdominal wall endometriosis, also known as scar endometriosis, is extremely rare and mainly occurs at surgical scar sites. Although many cases of scar endometriosis have been reported after a cesarean section, some cases of scar endometriosis have been reported after an episiotomy, hysterectomy, appendectomy, and laparoscopic trocar port tracts. To our knowledge, 14 case reports related to trocar site endometriosis have been published in the English language literature to date. Herein, we present the case of a 20-year-old woman (who had been previously operated on for left ovarian endometrioma 1.5 years ago by laparoscopy) with the complaint of a painful mass at the periumbilical trocar site with cyclic pattern. Consequently, although rare, if a painful mass in the surgical scar, such as the trocar site, is found in women of reproductive age with a history of pelvic or obstetric surgery, the physician should consider endometriosis.

Prog Urol. 2012 Nov;22(15):913-9. doi: 10.1016/j.purol.2012.05.003. Epub 2012 Jun 27.

[Aetiology and management of iatrogenic injury of the ureter: a review].

[Article in French]

Klap J, Phé V, Chartier-Kastler E, Mozer P, Bitker MO, Rouprêt M.

Source

Service d’urologie, université Paris VI, hôpital Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France.

Abstract

OBJECTIVE:

Ureteric injuries (IU) are common complications occurring during abdomino-pelvic surgical procedures. Our aim was to review risk factors, treatment and methods of prevention of these iatrogenic UI.

MATERIAL AND METHODS:

A literature review in English and French by Medline(®) was performed using the keywords: ureter; iatrogenic; injury; ureteroscopy; morbidity and endoscopy.

RESULTS:

The analysis of the epidemiology of IU shows that the first two causes are gynecological and urological surgery. In 80% of cases, the pelvic ureter was concerned. Mechanisms of injury were essentially ligation, section and ischemia by altering the ureteral vasculature. The main risk factors found were pelvic inflammation (endometriosis, radiation…) and the occurrence of bleeding during surgery. In the presence of risk factors, placing a double J stent or a CT may be useful preoperatively. The choice of reparation technique depended on the location of the PU, the circumstances of the occurrence and experience of the surgical team.

CONCLUSION:

Pelvic surgery is a provider of iatrogenic PU. Knowledge of the management of PU once occurred must be mastered before carrying out any risk surgery.

Surg Endosc. 2013 Mar;27(3):946-56. doi: 10.1007/s00464-012-2539-2. Epub 2012 Oct 6.

Causes and prevention of laparoscopic ureter injuries: an analysis of 31 cases during laparoscopic hysterectomy in the Netherlands.

Janssen PF, Brölmann HA, Huirne JA.

Source

Department of Obstetrics and Gynecology, VU University Medical Center, De Boelelaan 1117, 1181 HV, Amsterdam, The Netherlands, pf.janssen@vumc.nl.

Abstract

BACKGROUND:

Ureter injuries are the most dreaded complication in gynecological surgery. Some risk factors for the occurrence of urinary tract injuries are known, but clear guidelines to prevent ureter injuries during laparoscopic hysterectomy (LH) are lacking. The aim of this study was to analyze all known ureter injuries that occurred during LH for a benign indication in the Netherlands, in order to identify patient- and surgeon-related risk factors.

METHODS:

Ninety-five LH-performing gynecologists were asked to recall all cases of known ureter injuries during LH in their hospital. After identification of ureter injuries, a structured interview was performed with a questionnaire that focused on the identification of predisposing factors which could account for the cause of the injury.

RESULTS:

Forty-one injuries were detected in 37 patients (4 bilateral ureter injuries) in a 20-year period. The questionnaire could be completed for 31 cases. Predisposing factors were retrospectively assessed and classified into categories: patient-related (i.e., deep infiltrating endometriosis, intraligamentary fibroids) (n = 18), surgeon-related (insufficient experience and/or technique) (n = 16), or both (insufficient experience and difficult case) (n = 8). According to earlier-mentioned recommendations in a Delphi study among experts, in 48.4 % of these ureter injury cases, more than one of the recommended techniques or predisposing conditions were not applied or available. Only one ureter injury was diagnosed during the LH; the mean time to diagnose the injury was 29 days.

CONCLUSIONS:

Incomplete learning curve, insufficient applied technique such as coagulation of the uterine artery without the use of a uterine manipulator, and/or from the contralateral side and/or without previously performed ureterolysis in case of distorted anatomy may be considered as the main predisposing factors.

Urologia. 2012 Jul;79(3):167-70. doi: 10.5301/RU.2012.9683. Epub 2012 Sep 21.

Urinary tract endometriosis.

Antonelli A.

Source

Department of Urology, University of Brescia, Italy. alxanto@hotmail.com

Abstract

Urinary endometriosis is a rare diagnosis which is becoming much more common at referral centres. The bladder and the pelvic ureter are the sites that can be affected, each posing to the urologist and gynecologist some specific diagnostic and therapeutic difficulties. Bladder endometriosis, indeed, usually causes lower urinary tract symptoms, has a typical appearance at imaging and can be an isolated presentation; ureteral location, at the contrary, often presents with a vague or aspecific symptomatology and is often associated to other pelvic locations, so that a careful evaluation of the urinary tract, preferably with NMR, is mandatory for severe pelvic endometriosis, also in the absence of symptoms. The treatment of bladder presentation is partial cystectomy, preferably via a laparoscopic approach, while ureteral endometriosis can require different surgical solutions, from ureterolysis to ureteral reimplantation, open, laparoscopic or robot-assisted, basing on its extent and on the need of additional procedures for other locations. r.

Urology. 2012 Nov;80(5):1033-8. doi: 10.1016/j.urology.2012.07.036. Epub 2012 Sep 19.

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

Lusuardi L, Hager M, Sieberer M, Schätz T, Kloss B, Hruby S, Jeschke S, Janetschek G.

Source

Department of Urology and Andrology, Paracelsus Medical University Salzburg, Salzburg, Austria. l.Lusuardi@salk.at

Abstract

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.

Fertil Steril. 2012 Sep;98(3):564-71. doi: 10.1016/j.fertnstert.2012.07.1061.

Deep endometriosis: definition, diagnosis, and treatment.

Koninckx PR, Ussia A, Adamyan L, Wattiez A, Donnez J.

Source

KU Leuven, Leuven, Belgium. Pkoninckx@gmail.com

Abstract

Deep endometriosis, defined as adenomyosis externa, mostly presents as a single nodule, larger than 1 cm in diameter, in the vesicouterine fold or close to the lower 20 cm of the bowel. When diagnosed, most nodules are no longer progressive. In >95% of cases, deep endometriosis is associated with very severe pain (in >95%) and is probably a cofactor in infertility. Its prevalence is estimated to be 1% -2%. Deep endometriosis is suspected clinically and can be confirmed by ultrasonography or magnetic resonance imaging. Contrast enema is useful to evaluate the degree of sigmoid occlusion. Surgery requires expertise to identify smaller nodules in the bowel wall, and difficulty increases with the size of the nodules. Excision is feasible in over 90% of cases often requiring suture of the bowel muscularis or full-thickness defects. Segmental bowel resections are rarely needed except for sigmoid nodules. Deep endometriosis often involves the ureter causing hydronephrosis in some 5% of cases. The latter is associated with 18% ureteral lesions. Deep endometriosis surgery is associated with late complications such as late bowel and ureteral perforations, and recto-vaginal and uretero-vaginal fistulas. Although rare, these complications require expertise in follow-up and laparoscopic management. Pain relief after surgery is excellent and some 50% of women will conceive spontaneously, despite often severe adhesions after surgery. Recurrence of deep endometriosis is rare. In conclusion, defined as adenomyosis externa, deep endometriosis is a rarely a progressive and recurrent disease. The treatment of choice is surgical excision, while bowel resection should be avoided, except for the sigmoid.

Clin Exp Obstet Gynecol. 2012;39(2):265-8.

A rare case of intrinsic ureteralendometriosis causing hydronephrosis in a 40-year-old woman. A case report and literature review.

Papakonstantinou E, Orfanos F, Mariolis-Sapsakos T, Vlahodimitropoulos D, Kondi-Pafiti A.

Source

Department of Surgery, Evgenideion Hospital University of Athens, Greece.

Abstract

Endometriosis is a multifactorial disease with unclear pathogenesis. Urinary tract endometriosis occurs in about 1% of all endometriotic lesions while isolated ureteral endometriosis is extremely rare. We present a case of intrinsic ureteral endometriosis causing ureteral stenosis in a 40-year’s old woman, in combination with intestinal, extensive peritoneal and ovarian endometriosis. The clinicopathological features and investigation methods used, as well as the treatment approach are discussed. An individual therapy plan depending mainly on the patient’s age, desire for children and the extent of the endometriotic foci should always be attempted. Collaboration between gynecologists and urologists was essential in our cases.

Int Urogynecol J. 2012 Aug 16. [Epub ahead of print]

Association of bladder pain syndrome/interstitial cystitis with urinary calculus: a nationwide population-based study.

Keller J, Chen YK, Lin HC.

Source

School of Public Health, Taipei Medical University, Taipei, Taiwan.

Abstract

INTRODUCTION AND HYPOTHESIS:

Although one prior study reported an association between bladder pain syndrome/interstitial cystitis (BPS/IC) and urinary calculi (UC), no population-based study to date has been conducted to explore this relationship. Therefore, using a population-based data set in Taiwan, this study set out to investigate the association between BPS/IC and a prior diagnosis of UC.

METHODS:

This study included 9,269 cases who had received their first-time diagnosis of BPS/IC between 2006 and 2007 and 46,345 randomly selected controls. We used conditional logistic regression analysis to compute the odds ratio (OR) and its corresponding 95 % confidence interval (CI) for having been previously diagnosed with UC between cases and controls.

RESULTS:

There was a significant difference in the prevalence of prior UC between cases and controls (8.1 vs 4.3 %, p < 0.001). Conditional logistic regression analysis revealed that cases were more likely to have been previously diagnosed with UC than controls (OR = 1.70; 95 % CI = 1.56-1.84) after adjusting for chronic pelvic pain, irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, depression, panic disorder, migraine, sicca syndrome, allergy, endometriosis, and asthma. BPS/IC was found to be significantly associated with prior UC regardless of stone location; the adjusted ORs of kidney calculus, ureter calculus, bladder calculus, and unspecified calculus when compared to controls were 1.58 (95 % CI = 1.38-1.81), 1.73 (95 % CI = 1.45-2.05), 3.80 (95 % CI = 2.18-6.62), and 1.83 (95 % CI = 1.59-2.11), respectively.

CONCLUSIONS:

This work generates the hypothesis that UC may be associated with BPS/IC.

Hinyokika Kiyo. 2012 Jul;58(7):329-33.

Mixed type ureteralendometriosis : a case report and a review of the Japanese literature.

[Article in Japanese]

Kurobe M, Kojima T, Uchida M, Miyagawa T, Tsutsumi M, Sugita S.

Source

The Department of Urology, Hitachi General Hospital.

Abstract

Ureteral endometriosis is a rare but important clinical problem that requires early detection and treatment. The urinary tract is affected in approximately 2% of women with endometriosis. Even though the bladder is the most frequent urinary tract organ affected in these patients,the ureter is also affected in 10-40% of the cases, thus requiring immediate clinical attention. The majority of endometrial lesions is typically located in the lower segment of the ureter and is often difficult to differentiate between endometriosis and malignancy. Ureteral endmetriosis should be considered for women with hydronephrosis. In this report we present one clinical case of mixed-type ureteral endometriosis. A 37-year-old woman was referred to our hospital due to left hydronephrosis. Contrast-enhanced CT scan confirmed left hydronephrosis and also showed a solid mass at the left lower ureter. Retrograde pyelography revealed stenosis of the left lower ureter and Renogram revealed severely impaired renal function. Laparoscopic nephroureterectomy was performed. Pathologically, mixed-type endometriosis of the left ureter was diagnosed.

J Surg Res. 2012 Dec;178(2):539-44. doi: 10.1016/j.jss.2012.07.006. Epub 2012 Jul 20.

Real-time infrared thermography for ureter detection during hysterectomy.

Angioli R, Terranova C, Plotti F, Montera R, Damiani P, Scaletta G, Portuesi A, Bonanni A, Tombolini L, Novelli L.

Source

Department of Obstetrics and Gynaecology, Campus Bio Medico, University of Rome, Rome, Italy. r.angioli@unicampus.it

Abstract

BACKGROUND:

Recognition of different anatomic structures might be difficult in the presence of diseases such as neoplasm or endometriosis that can subvert the anatomy. This can be a challenge for young surgeons approaching gynecologic surgery. The aim of the present study was to evaluate the effectiveness of infrared thermocamera to identify the anatomic structures in gynecologic surgery.

MATERIALS AND METHODS:

From February 2010 to May 2011, consecutive patients who required abdominal hysterectomy were considered for eligibility. During a procedure for benign disease, we evaluated the temperature difference between the ureter and infundibulopelvic vessel (experiment A). In patients with gynecologic cancer, the thermal gradient was determined between the iliac vessels and the ureter (experiment B).

RESULTS:

The data from 21 patients were recorded, 12 for experiment A and 9 for experiment B. We found a statistically significant difference between the ureter and vessels in both experiments (31.675°C ± 0.673°C for the ureter and 33.332°C ± 0.828°C for the infundibulopelvic vessel, P < 0.0001; 31.706°C ± 0.751°C for the ureter, 33.787°C ± 0.63°C for the iliac vein, and 33.784°C ± 0.639°C for the iliac artery, P < 0.0001).

CONCLUSIONS:

Infrared imaging allowed us to identify the anatomic structures in laparotomy, providing preliminary data for its application in laparoscopy.

Eur J Obstet Gynecol Reprod Biol. 2012 Dec;165(2):275-9. doi: 10.1016/j.ejogrb.2012.07.002. Epub 2012 Jul 22.

Laparoscopic surgery for severe ureteric endometriosis.

Miranda-Mendoza I, Kovoor E, Nassif J, Ferreira H, Wattiez A.

Source

IRCAD/EITS and Strasbourg University Hospitals, Faculty of Medicine, Strasbourg, France. ignaciomir@med.uchile.cl

Abstract

OBJECTIVES:

To describe the outcomes of laparoscopic surgery for severe ureteric endometriosis.

STUDY DESIGN:

Retrospective descriptive study of the clinical and surgical outcomes for patients who underwent laparoscopic surgery for severe ureterohydronephrosis due to endometriosis. The surgery consisted of laparoscopic ureterolysis, ureteric end-to-end anastomosis and ureteral stenting at the Department of Obstetrics and Gynecology, Strasbourg Hospitals, between June 2004 and June 2009. Data were collected from patients’ notes and also included telephone interview. Normally distributed data are presented as mean ± SD, and skewed data as median (range). Categoric variables are reported as absolute values and percentages. Continuous variables are compared using the paired samples t-test. Statistical significance was set at P<0.05.

RESULTS:

Thirteen patients had severe disease. Two patients had non-functioning kidneys. Left sided lesions were more common (76.9%). All patients had associated deep infiltrative endometriosis (DIE) elsewhere in the pelvis. Laparoscopic treatment was feasible in all cases without the need to convert. Ureterolysis was performed in seven patients (53.8%) and segmental resection with end-to-end anastomosis in six (46.2%) patients. Ureteric wall endometriotic infiltration was present in four cases (30.8%). Median follow up duration was 24 months. All patients had improvement of their pain symptoms. There were no intraoperative complications. Major postoperative complications were seen in three patients (23%).

CONCLUSIONS:

Ureteric involvement is usually asymptomatic, and therefore in patients with evidence of deep endometriosis it must be excluded by ultrasound or magnetic resonance imaging. Laparoscopic treatment of ureteric endometriosis is feasible. Intrinsic ureteric endometriosis is quite frequent in severe ureterohydronephrosis. Complete excision of the disease is essential to improve pain symptomatology and to prevent recurrence of disease. Long term follow up is required to exclude any stenosis.

Rev Bras Ginecol Obstet. 2012 Jun;34(6):278-84.

Deep infiltrating endometriosis: anatomical distribution and surgical treatment.

[Article in Portuguese]

Kondo W, Ribeiro R, Trippia C, Zomer MT.

Source

Hospital Vita Batel e Centro Médico-Hospitalar Sugisawa – Curitiba (PR), Brasil.

Abstract

PURPOSE:

To evaluate the anatomical distribution of deep infiltrating endometriosis (DIE) lesions in a sample of women from the South of Brazil.

METHODS:

A prospective study was conducted on women undergoing surgical treatment for DIE from January 2010 to January 2012. The lesions were classified according to eight main locations, from least serious to worst: round ligament, anterior uterine serosa/vesicouterine peitoneal reflection, utero-sacral ligament, retrocervical area, vagina, bladder, intestine, ureter. The number and location of the DIE lesions were studied for each patient according to the above-mentioned criteria and also according to uni- or multifocality. The statistical analysis was performed using Statistica version 8.0. The values p<0.05 were considered statistically significant.

RESULTS:

During the study period, a total of 143 women presented 577 DIE lesions: uterosacral ligament (n=239; 41.4%), retrocervical (n=91; 15.7%), vagina (n=50; 8.7%), round ligament (n=50; 8,7%), vesico-uterine septum (n=41; 7.1%), bladder (n=12; 2.1%), and intestine (n=83; 14.4%), ureter (n=11; 1.9%). Multifocal disease was observed in the majority of patients (p<0.0001), and the mean number of DIE lesions per patient was 4. Ovarian endometrioma was present in 57 women (39.9%). Sixty-five patients (45.4%) presented intestinal infiltration on histological examination. A total of 83 DIE intestinal lesions were distributed as follows: appendix (n=7), cecum (n=1) and rectosigmoid (n=75). The mean number of intestinal lesions per patient was 1.3.

CONCLUSIONS:

DIE has a multifocal pattern of distribution, a fact of fundamental importance for the definition of the complete surgical treatment of the disease.

Rom J Morphol Embryol. 2012;53(2):433-7.

Ureteral stenosis due to endometriosis.

Traşcă ET, Traşcă E, Tiţu A, Riza ML, Busuioc I.

Source

Department of Surgery, University of Medicine and Pharmacy of Craiova, Craiova, Romania. etrasca@yahoo.com

Abstract

Endometriosis is characterized by the presence of endometrial tissue outside the uterine cavity, with potential to undergo malignant transformation. We report the case of a 36-year-old patient with a clinical and imagistic diagnosis of left vaginal pouch and left parametrium tumor. The patient presented lumbar and pelvic pain, dysuria and polakyuria. Ultrasound revealed changes in the left kidney confirmed by the CT scan, which also revealed the presence of a tumor in the left parametrium infiltrating the bladder, juxtavesical ureter, uterus and cervix. Laboratory tests were within normal limits. Surgery consisted of interadnexal hysterectomy, proximal colpectomy, left distal ureterectomy with ureterocystoneostomy. Pathological examination established the final diagnosis of infiltrative deep endometriosis involving the urinary tract. In the case of a young fertile patient with gynecological symptoms and morphofunctional changes of the urinary system, urinary tract endometriosis should always be a diagnostic option.

Hum Reprod. 2012 Aug;27(8):2352-8. doi: 10.1093/humrep/des211. Epub 2012 Jun 12.

The value of MRI in assessing parametrial involvement in endometriosis.

Bazot M, Jarboui L, Ballester M, Touboul C, Thomassin-Naggara I, Daraï E.

Source

Department of Radiology, University Hospitals, Est Parisien, Tenon Hospital, 4 rue de la Chine, Paris 75020, France. marc.bazot@tnn.aphp.fr

Abstract

STUDY QUESTION:

What is the accuracy of magnetic resonance imaging (MRI) in the diagnosis of parametrial endometriosis in comparison with surgicopathological findings? SUMMARY ANSWER: MRI displayed an accuracy of 96.4% in the preoperative diagnosis of parametrial involvement by deep infiltrating endometriosis (DIE). WHAT IS KNOWN AND WHAT THIS PAPER ADDS: MRI is the best technique for preoperative mapping of DIE. This preliminary paper shows that T2-weighted MRI is a valuable tool for the preoperative evaluation of parametrial involvement by endometriosis.

DESIGN:

A retrospective study of an MRI database was used to identify examinations performed in women, who had a clinical suspicion of pelvic endometriosis (n=666), between 2005 and 2009 in a university medical centre in France.

PARTICIPANTS AND SETTING:

Exclusion criteria were previous surgery for DIE, incomplete surgical evaluation, repeat MRI examinations and incomplete MR protocol. Only symptomatic patients who underwent surgery with a pathological correlation were included (n=83). An experienced radiologist, blind to the surgical and histological findings, evaluated sagittal, axial and thin-section oblique axial MR images obtained from the 83 patients. DATA ANALYSIS METHOD: Descriptive statistics and Fisher exact test were used.

MAIN FINDINGS:

The prevalence of DIE and parametrial endometriosis was 76/83 (91.6%) and 12/83 (14.5%), respectively. The sensitivity, specificity, positive and negative predictive values, accuracy and positive and negative likelihood ratios for the diagnosis of parametrial endometriosis of low signal intensity on T2-weighted MRI, pelvic wall involvement and ureteral dilatation, were 83.3%, 98.6%, 90.9%, 97.2%, 96.4%, 59.2 and 0.17, 58.3%, 98.6%, 87.5%, 93.3%, 92.8%, 41.4 and 0.42 and 16.7%, 100%, 100%, 87.7%, 88%, infinity and 0.83, respectively, with the patient as the unit of analysis. BIAS AND LIMITATIONS: The study design was retrospective, and thus prone to bias. Only one experienced reader performed the analysis, so no data are available on intra- or interobserver variability. GENERALISABILITY: At present, no consensus exists on the optimal MR protocol to be used for the evaluation of DIE, thus limiting the wider implications of this study. STUDY FUNDING AND COMPETING INTERESTS: No funding was obtained for this study. The authors have no conflict of interest.

JSLS. 2011 Oct-Dec;15(4):439-47. doi: 10.4293/108680811X13176785203798.

Outcomes of surgical management of deep infiltrating endometriosis of the ureter and urinary bladder.

Rozsnyai F, Roman H, Resch B, Dugardin F, Berrocal J, Descargues G, Schmied R, Boukerrou M, Marpeau L; CIRENDO Study Group.

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Source

Department of Gynecology and Obstetrics, University Hospital, TârguMure, Romania.

Abstract

OBJECTIVES:

To report the outcomes of surgical management of urinary tract endometriosis and discuss the choice between conservative and radical surgery.

MATERIALS AND METHODS:

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.

RESULTS:

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.

CONCLUSION:

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.

Eur J Obstet Gynecol Reprod Biol. 2012 Jun;162(2):121-4. doi: 10.1016/j.ejogrb.2012.02.030. Epub 2012 Apr 24.

Rectosigmoid deep infiltrating endometriosis and ureteral involvement with loss of renal function.

Muñoz JL, Jiménez JS, Tejerizo A, Lopez G, Duarte J, Sánchez Bustos F.

Source

Endometriosis Unit, Gynecology Service, Hospital 12 de Octubre, Madrid, Spain.

Abstract

Endometriosis is a complex disease with unclear pathogenesis, defined as the presence of endometrial tissue (glands and stroma) outside its usual location in the uterine cavity. Ureteral involvement is rare, with an estimated frequency of 10-14% in cases of deep endometriosis with nodules of 3 cm or larger. An important complication of ureteral involvement is asymptomatic loss of renal function. In a patient with asymptomatic renal failure the relevance of extrinsic ureteral involvement by deep endometriosis has been taken to account. CASE REPORT: A 32-year-old nulliparous woman presented with chronic pelvic pain associated with severe dysmenorrhea, dyspareunia and digestive problems including diarrhea, occasional constipation and rectal bleeding. She reported no urological symptoms. Magnetic resonance imaging (MRI) identified a 4 cm nodule in the recto-vaginal septum, compressing and infiltrating the rectal wall, and chronic left hydronephrosis. Isotope renogram revealed 91% function in the right kidney and 9% in the left kidney. A multidisciplinary surgical team including consultants from the departments of digestive surgery and urology assessed the patient. The treatment recommended was a joint approach of laparoscopic surgery to perform adhesiolysis, ureterolysis, freeing of the uterus and appendages, resection of the rectovaginal septum nodule, and left nephrectomy. COMMENT: Diagnosis and treatment of deep endometriosis should be performed in specialized centers and in the context of multidisciplinary collaboration. We must be aware of the potential risk of ureteral involvement and the asymptomatic loss of renal function in any patient with endometriosis nodules of 3 cm or larger.

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