Original Article
Importance of Retroperitoneal Ureteric Evaluation in Cases of Deep Infiltrating Endometriosis

Presented at the 35th Annual Meeting of the American Association of Gynecologic Laparoscopists, Las Vegas, Nevada, November 6–9, 2006.
https://doi.org/10.1016/j.jmig.2008.03.005Get rights and content

Abstract

Study Objective

To discuss our clinical and surgical experience with 30 cases of ureteral endometriosis.

Design

Retrospective analysis (Canadian Task Force classification II-3).

Setting

Tertiary care university hospital.

Patients

Records were assessed for all patients who underwent laparoscopic surgery for deep infiltrating endometriosis (DIE) from June 2002 through June 2006. Thirty patients were laparoscopically given a diagnosis that was histologically confirmed of ureteral involvement by endometriosis.

Interventions

Laparoscopic retroperitoneal examination and management of ureteral endometriosis.

Measurements and Main Results

Variables assessed were: preoperative findings (patient characteristics, clinical symptoms, preoperative workup), operative details (type and site of ureteral involvement, associated endometriotic lesions, type of intervention, intraoperative complications), and postoperative follow-up (short- and long-term outcomes). We recorded details of 30 patients with a median age of 33.33 years and a median body mass index of 21.96. Symptoms reported were: none in 20 (66.7%) of 30 patients, specific in 10 (33.3%) of 30, dysuria (30%), renal angle pain (10%), hematuria (3.3%), and hydroureteronephrosis (33.3%). Ureteral endometriosis was presumptively diagnosed before surgery in 40% of patients. Ureteric involvement was on the left side in 46.7%, on the right side in 26.7%, and bilaterally in 26.7%. It was extrinsic in 86.7% and intrinsic in 13.3%. It was associated with endometriosis of homolateral uterosacral ligament in all (100%) of 30, the bladder in 50%, rectovaginal septum in 80%, ovaries in 53.3%, and bowel in 36.7%. Laparoscopic intervention was: only ureterolysis in 73.3%, segmental ureteral resection and terminoterminal anastomosis in 16.7%, and segmental ureterectomy and ureterocystoneostomy in 10%. Early postoperative complications were: fever greater than 38°C requiring medical therapy for 7 days in 7 patients and 1 patient had transient urinary retention requiring catheterization that resolved without further treatment. During a mean follow-up period of 14.6 months, endometriosis recurred in 3 patients with no evidence of ureteral reinvolvement.

Conclusion

Ureteral involvement is a silent, serious complication that must be suspected in all cases of DIE. Retroperitoneal laparoscopic isolation and inspection of both ureters helps to diagnose silent ureteral involvement. Conservative laparoscopic surgery provides a safe, feasible modality for management of ureteral endometriosis.

Section snippets

Study Population

Between June 2002 and June 2006, a continuous series of 541 patients underwent laparoscopic treatment for pelvic endometriosis in a tertiary referral center for treatment of endometriosis. For all of these patients, medical, gynecologic, and operative records were retrospectively reviewed by 2 authors (R. S., M. M.) and assessed to identify cases with ureteral endometriosis. Diagnosis was done after laparoscopic, retroperitoneal isolation, examination of the diameter and consistency of both

Results

Of the 541 patients eligible for the study, 30 patients with surgical diagnosis and histologic confirmation of ureteral endometriosis were included in the study population. Clinical characteristics of the patients recruited are reported in Table 1.

Discussion

Although ureteral endometriosis is not a frequent disease, it can be considered one of the most serious symptoms of endometriosis that carries high risk of morbidity including loss of renal function [11].

Timely management of ureteral endometriosis is a real challenge not only because of the nonspecific or silent symptoms, but also because of the lack of sensitive diagnostic tools that can detect early involvement. Early suspicion of ureteral endometriosis is fundamental to avoid impairment of

Conclusions

Ureteral endometriosis is a silent, serious disease that carries the risk of renal function loss. Preoperative diagnosis of this condition is really challenging and needs a high index of suspicion. As DIE is a global disease and lesions are multifocal and a large percentage of cases, we strongly recommend that patients with DIE should be referred to specialized centers and the surgical team must have consistent background in laparoscopic management of DIE. We also recommend that all cases of

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The authors have no commercial, proprietary, or financial interest in the products or companies described in this article.

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