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Aggiornamento Kidney 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.


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



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.


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.


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.


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.

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

Silent loss of kidney seconary to ureteral endometriosis.

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


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



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.


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


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.

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.


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


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.


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.


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.


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.


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.

Ginecol Obstet Mex. 2012 Oct;80(10):663-7.

Mayer-Rokitansky-Küster-Hauser syndrome. A report of two cases.

[Article in Spanish]

Bautista-Gómez E, Morales-García V, Galván Espinosa H, Flores-Romero AL, Vásquez Santiago E, Pizarro Osorno N.


Hospital General Aurelio Valdivieso, Oaxaca de Juárez, Oax.


The Mayer-Rokitansky-Kuster-Hauser is a rare congenital anomaly characterized by lack of vaginal and uterine development variable and normal ovaries. It results from agenesis or hypoplasia Müller duct system. Cervicovaginal agenesis as part of the complex syndrome, is even rarer. We report two cases: adolescent patient with primary amenorrhea, cervicovaginal agenesis and chronic pelvic pain, and a 28-year-old patient with primary amenorrhea, congenital absence of uterus and vagina.

Acta Med Croatica. 2011 Dec;65(5):435-44.

Acute compartment syndrome as a complication of prolonged surgery in the Lloyd Davies position.

[Article in Croatian]

Mrsić V, Rasić Z, Velnić D, Adam VN, Stojcić EG, Smiljanić A.


University Department of Anesthesiology, Resuscitation and Intensive Care, Sveti Duh University Hospital, Zagreb, Croatia. vivianamrsic0@gmail.com


Acute compartment syndrome of the muscle is condition in which prolonged increase of tissue pressure in closed unyelding fascial compartments reduces capillary perfusion below a level necessary for tissue viability leading to muscle and nerve ischaemia for few hours. There are wide variety different clinical settings associated with compartment syndrome. Acute lower limb compartment syndrome that occur during and after prolonged surgical procedures in Lloyd Davies position is rare but potentially devastating complication that can lead serious local complications and life threatening situations as, rabdomyolysis, kidney failure and death. In this article we summarize pathophysiology, clinical staging and diagnostic procedures of acute compartment syndrome in Lloyd Davies position. We present female patient developed limb compartment sindrome after surgical procedure which lasted 6,5 hours in the Lloyd Davies position for extensive rectovaginal endometriosis. In this article we rewiev different contributing factors that may predispose to compartment syndrome during Lloyd Davies position and undescore importance of recognise the risk factor and prevent the esthablishment of acute compartment syndrome during and after surgery in the Lloyd Davies position.

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.


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



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.


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.


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.


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

J Pediatr Adolesc Gynecol. 2012 Oct;25(5):e111-2. doi: 10.1016/j.jpag.2012.05.013. Epub 2012 Jul 27.

Herlyn-Werner-Wunderlich syndrome–timely diagnosis is important to preserve fertility.

Güdücü N, Gönenç G, Işçi H, Yiğiter AB, Dünder I.


İstanbul Bilim University, Avrupa Hospital, Department of Obstetrics and Gynecology, İstanbul, Turkey. nilgun.kutay@gmail.com



Herlyn-Werner-Wunderlich syndrome is an urogenital malformation with uterus didelphys and obstructed hemivagina with ipsilateral renal agenesis. Most of these patients present after the onset of menstruation. We describe two cases diagnosed too late to prevent the complications.


The first patient presented with acute abdomen one year after the onset of menstruation and had salpingectomy due to pyosalpinx. The blind hemivagina was not recognized and she had severe endometriosis. She underwent hysterectomy 8 years later. The second patient presented with foul smelling vaginal discharge when she was 21 years old. She had a simple vaginal septum resection.


In the presence of uterine cavities in a regularly menstruating girl with dysmenorrhea, the presence of both kidneys should be checked. When unilateral renal agenesis and uterus didelphys coexist the first thing that we should remember is to confirm or refute the presence of a blind vagina.

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

Ureteral stenosis due to endometriosis.

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


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


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.

J Radiol Case Rep. 2012 Mar;6(3):9-15. doi: 10.3941/jrcr.v6i3.877. Epub 2012 Mar 1.

Herlyn-Werner-Wunderlich syndrome: a rare presentation with pyocolpos.

Cox D, Ching BH.


Department of Radiology, Tripler Army Medical Center, Honolulu, HI 96859, USA. devencox@yahoo.com


Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA), also known as Herlyn-Werner-Wunderlich syndrome, is a rare syndrome with only a few hundred reported cases described since 1922. Only a handful of these cases have been associated with pyocolpos. Mullerian duct anomalies have an incidence of 2-3%. While OHVIRA constitutes 0.16-10% of these Mullerian duct anomalies. Symptoms usually present shortly after menarche when hematocolpos develops during menstruation resulting in dysmenorrhea and a pelvic mass. The pelvic mass is the collection of blood products within the obstructed hemivagina. The first study in the diagnostic work-up is usually ultrasonography, which typically demonstrates a pelvic fluid collection which can simulate other disease processes thus confounding the diagnosis. MRI findings of the pelvis reveal a didelphic uterus. Imaging of the abdomen reveals agenesis of the ipsilateral kidney. MRI is beneficial in characterizing the didelphic uterus and vaginal septum for pre-operative planning. Understanding the imaging findings, in conjunction with the clinical presentation, is critical for early diagnosis in attempting to prevent complications such as endometriosis or adhesions from chronic infections with subsequent infertility.

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