Clinical Aspects and Surgical Treatment of Urinary Tract Endometriosis: Our Experience with 31 Cases

doi:10.1016/j.eururo.2006.03.037

European Urology

Volume 49, Issue 6, June 2006, Pages 1093-1098

https://doi.org/10.1016/j.eururo.2006.03.037 Get rights and content

Abstract

Objectives

To present and discuss clinical and surgical management of urologic endometriosis.

Methods

Retrospective review of a database on surgical patients with endometriosis.

Results

Thirty-one patients (incidence, 2.6%; mean age, 33.1 yr) were affected by urologic endometriosis (bladder, 12; ureter, 15; both, 4). Bladder endometriosis was revealed by symptoms related to menses and showed a typical endoscopic picture, whereas ureteral involvement had a nonspecific or silent symptomatology. All patients affected by bladder endometriosis and undergoing transurethral resection (2 cases) developed a bladder recurrence; a ureteral recurrence was observed in two of six patients submitted to laparoscopic ureterolysis and in one of two patients submitted to ureterectomy with ureteroureterostomy. Conversely, no relapses were observed among the 14 patients who had partial cystectomy or the 9 who had ureterectomy and ureterocystoneostomy. Finally, two patients underwent nephrectomy due to end-stage renal atrophy.

Conclusions

Cystoscopy is advisable in women with pelvic endometriosis with lower urinary tract symptoms; the upper urinary tract should be evaluated in all patients with pelvic endometriosis to exclude asymptomatic ureteral involvement. Partial cystectomy gives the best results when used to treat bladder endometriosis. Ureterolysis can be successful only in case of limited ureteral involvement with no urinary obstruction, whereas terminal ureterectomy and ureterocystoneostomy should be preferred in case of obstructive ureteral endometriosis.

Introduction

Endometriosis is defined as the presence of active endometrial tissue outside the uterine cavity. Even though reported figures vary widely depending on the population under study, the prevalence of endometriosis can be estimated to be around 10% in premenopausal women [1], [2], and it is one of the first causes of hospitalization in female patients between 15 and 44 years of age [3]. Recent clinical data suggest that low parity and heavy menstrual cycles are risk factors, supporting the menstrual reflux etiopathogenetic hypothesis [2]. The disease, characterised by high local aggressiveness and risk of recurrence, requires both surgical and hormonal treatments (luteinising hormone-releasing hormone [LHRH] analogues, danazol, or estroprogestins). Therefore, although benign, it may be viewed as a true neoplastic process [4].

The involvement of the urinary tract, concerning the bladder and the pelvic ureter, can be regarded as a rare condition (1–5% of all cases) that shares many aspects with gynaecologic presentations but, at the same time, has its own peculiar clinical and therapeutic features [5], [6].

Treatment should aim at symptom relief and the recovery of the renal function within acceptable morbidity levels.

The data of a single-centre cohort of patients who had surgery were reviewed in this study to provide urologists and gynaecologists with more information about the management of such a rare and complex pathologic condition.

Section snippets

Methods

Since 1995, the clinical, surgical, and follow-up data of patients having surgery because of pelvic endometriosis have been stored in a dedicated database. This study reviews the information concerning the cases of genitourinary endometriosis proved by histology. The cases with negligible adherent involvement that required no specific procedures were excluded.

Two patients with bilateral ureteral endometriosis who had initially been treated in other centres and then in our department due to

Results

Of 1242 patients with surgically proved diagnosis of endometriosis in the decade from 1995 to 2005, the records of 31 patients (2.5%) with urinary tract involvement were selected. The mean age was 33.1 yr (range, 20–48 yr). The bladder was affected in 12 patients, the ureter in 15, and either the bladder or the ureter in 4. Follow-up data were adequate for 30 patients.

The urinary tract was affected at the time of the first diagnosis of endometriosis in 18 cases (58%); in 13 cases (42%) medical

Discussion

Endometriosis can spread in almost every site, but urinary tract involvement is uncommon (1–5%) and mainly concerns bladder, ureter, and kidney according in a 40:5:1 ratio [7], [8]. Our experience confirms that genitourinary endometriosis should be considered a rare condition. In contrast with literature data, similar incidences of bladder and ureteral endometriosis were noted in our survey, probably because we enrolled only the patients in whom the bladder muscular layer was invaded and

Conclusions

Cystoscopic evaluation is advisable in women affected by pelvic endometriosis with LUTSs, and a study of the upper urinary tract should be performed in all patients with pelvic endometriosis to detect the cases with asymptomatic ureteral involvement. Partial cystectomy offers durable results when used to treat bladder endometriosis. Ureterolysis is indicated for limited and nonobstructive ureteral endometriosis; otherwise ureteral resection is needed. To re-establish urinary continuity,

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Cited by (116)

Symptoms and Surgical Technique of Bladder Endometriosis: A Systematic Review
2022, Journal of Minimally Invasive Gynecology
This systematic review aimed to review all the available evidence regarding bladder endometriosis (BE) surgical techniques, resolution of symptoms, and nodule size.
We conducted systematic searches in PubMed MEDLINE, Embase, Latin American and Caribbean Centre on Health Sciences Information, Cochrane Library, and Web of Science databases from inception to December 2021.
Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the literature search yielded 1279 articles. Two reviewers independently screened abstracts and reviewed full-text articles to meet the eligibility criteria: women diagnosed as having BE, treated surgically to remove the BE nodule, and reported of the nodule size and/or symptoms after the surgery. We included 28 studies, which mainly were case reports and case series.
The following information was extracted from the included studies: author, country, publication year, study design, number of patients, age, surgery performed, follow-up time, operation time, nodule location, nodule size, and postsurgical symptoms. Patients’ ages range from 26 to 44 years and most women were nulliparous. The BE nodule size ranged from 0.7 to 5.5 cm, and the most frequent location (63.57%) was the posterior wall. Dysuria was reported by 27.18% of women and generic lower urinary tract symptoms were reported by 27.95%. After surgery, the recurrence rate of urinary symptoms was 7.34%. Most studies performed a partial cystectomy to remove the nodule, showing that the disease affects the bladder mucosa frequently.
Surgical treatment with complete excision of BE lesion was shown to improve complaints of urinary symptoms in patients with BE. Given that most of the studies evaluated were descriptive, additional studies with a large sample population and a better level of evidence for this condition are needed.
Nomogram for Predicting a Complex Ureteral Procedure in Pelvic Endometriosis Surgery
2022, Journal of Minimally Invasive Gynecology
To develop a nomogram for predicting the type of ureteral procedure in pelvic deep endometriosis (DE) surgery (1) and to describe the factors and complications associated with the ureteral procedure (2).
Retrospective monocentric study of 920 patients who underwent surgery for pelvic DE between June 2009 and March 2020 in the gynecologic surgery department of the Versailles Hospital Center. The main criterion was evaluation of the ureteral procedure, classified as simple (isolation of the ureter) or complex (dissection of the ureter, segmental ureteral resection, or nephroureterectomy). Postoperative complications, including ureteral stenosis and fistula formation, were tabulated.
Tertiary referral hospital and expert center in endometriosis.
A total of 920 patients with DE.
Ureteral procedure during surgery for DE.
In total, 724 patients (79%) underwent a ureteral procedure, of which 307 (33%) were complex, including 17 (1.8%) segmental ureteral resections. In multivariate analysis, the predictive variables for a complex ureteral procedure were age (p = .036), a previous surgery for endometriosis (p <.01), and ureteral dilatation on magnetic resonance imaging (p <.001). The area under the curve for the model predicting a complex ureteral procedure was 0.68 (95% confidence interval, 0.60–0.71). A complex ureteral procedure was associated with a 3.5% rate of ureteral fistula (n = 15).
Age, a previous surgery for endometriosis, a rectovaginal nodule size ≥30 mm, endometriotic involvement of the rectum or sigmoid, and ureteral dilatation are significantly associated with a complex ureteral procedure. Our results allowed us to build a nomogram that can be used to better inform patients, anticipate the therapeutic strategy, and optimize the modalities of postoperative surveillance.
Renal Pelvis and Ureter
2020, Urologic Surgical Pathology
The renal pelvis and ureter are muscular conduits lined by urothelium that propel urine from the renal calyceal system to the urinary bladder. The ureter and renal pelvis are affected by developmental, reactive, and neoplastic disorders. The developmental disorders are closely related entities that include abnormalities in ureteral number, ureteral location, and both structure and function of collecting system muscularis propria. The mucosa is the site of major reactive and neoplastic disorders.
Successful management of ureteric endometriosis by laparoscopic ureterolysis – A review and report of three further cases
2018, Arab Journal of Urology
To review articles highlighting the effectiveness of conservative laparoscopic ureterolysis as a primary treatment option in patients with ureteric endometriosis and to report on a further three cases.
PubMed, EMBASE, Cochrane database were searched to identify articles reporting cases of laparoscopic management of ureteric endometriosis and, in particular management by ureterolysis. We further described three new cases of ureteric endometriosis managed at our institute.
The present study illustrates the significance of laparoscopic ureterolysis in the management of patients with ureteric endometriosis. In our cases, a systematic surgical approach was followed in order to perform complete but careful excision of the all visible endometriotic implants. During follow-up successful treatment was established by relief of hydroureteronephrosis by ultrasonographic evaluation.
Considering the risk of loss of renal function and due to the nonspecific symptoms, a prompt clinical suspicion and thorough preoperative assessment can potentially help in the diagnosis. We conclude that laparoscopic ureterolysis is a minimally invasive technique with low complication and recurrence rates. It is a suitable option as a primary approach for selected patients with ureteric endometriosis, if done in a systematic step-by-step approach.
Urinary tract involvement by endometriosis. Techniques and outcomes of surgical management: CNGOF-HAS Endometriosis Guidelines
2018, Gynecologie Obstetrique Fertilite et Senologie
L’atteinte endométriosique du tractus urinaire est rare et concerne environ 1 % des patientes endométriosiques (NP3). Elle peut conduire, d’une part, à une symptomatologie pelvienne douloureuse pour les atteintes vésicales et, d’autre part, à une destruction rénale silencieuse pour les atteintes urétérales sténosantes (NP3). La faisabilité de la prise en charge chirurgicale cœlioscopique a été largement démontrée (NP3) et pourrait permettre de réduire la morbidité opératoire et la durée d’hospitalisation (NP4). La chirurgie radicale des atteintes vésicales par cystectomie partielle est efficace à long terme pour un faible taux de complications opératoires graves (NP3). Le traitement médical hormonal semble également efficace à court-terme (NP4). La résection endoscopique transurétrale des lésions d’endométriose vésicale n’est pas recommandée (grade C) en raison du taux élevé de récidive postopératoire (NP4). Compte tenu du risque d’évolution vers la destruction rénale silencieuse, il est recommandé que les patientes présentant une atteinte urétérale endométriosique, notamment en présence de dilatation urétérale ou pyélocalicielle, puissent bénéficier d’une prise en charge diagnostique et thérapeutique multidisciplinaire afin de considérer simultanément la fonction rénale ainsi que les autres localisations endométriosiques potentiellement associées (grade C). Les données de la littérature ne permettent pas de formuler des recommandations sur les indications des différentes techniques : urétérolyse, résection urétérale avec anastomose urétéro-urétérale, et résection urétérale avec réimplantation urétérale, ni sur la place ou la durée d’utilisation des sondes vésicales et urétérales en périopératoire. La chirurgie des localisations endométriosiques vésicales et urétérales ne semble pas avoir d’impact sur la fertilité (NP4). Compte tenu du risque de sténose de l’anastomose urétéro-urétérale ou du site de réimplantation urétérovésicale et du risque d’atrophie rénale progressive pauci-symptomatique, une surveillance postopératoire par imagerie apparaît justifiée (avis d’expert).
Urinary tract involvement by endometriosis is reported in 1% of endometriosis patients (NP3). Consequences range from pelvic pain for bladder localizations to silent kidney loss in case of chronic ureteral obstruction (NP3). The feasibility of laparoscopic management was widely proven (NP3) and may reduce hospital stay length (NP4). Radical surgery with partial cystectomy for bladder localizations was shown to significantly and durably reduce pain symptoms with low risk of a severe postoperative complications (NP3). Medical hormonal treatment also shows short-term reduction of pain symptoms (NP4). Transureteral resection of bladder endometriosis nodule is not recommended (grade C) because of a high postoperative recurrence rate (NP4). Given a high risk of silent kidney loss, it is recommended that patients with ureteral involvement by endometriosis are managed by a multidisciplinary team considering urinary and potential extra-urinary localizations of endometriosis (grade C). No recommendation can be made on which technique to prefer between conservative (ureterolysis) or radical surgical techniques or on benefit and length of ureteral stents in case of ureteral involvement. Surgical management of bladder and ureteral localizations of endometriosis do not seem to be associated with altered or improved postoperative fertility (NP4). Since late postoperative ureteral anastomosis stenosis were reported with silent kidney loss, repeated postoperative imaging monitoring is justified (expert opinion).
Laparoscopic Partial Bladder Cystectomy for Bladder Endometriosis: A Combined Cystoscopic and Laparoscopic approach
2020, Journal of Minimally Invasive Gynecology
Urinary tract endometriosis involves the bladder and/or the ureters and is present in approximately 1% of women with endometriosis [1]. Bladder endometriosis is the most frequent type of urinary tract endometriosis, occurring in about 70% to 85% of cases 2, 3. Bladder endometriosis is defined as the presence of endometrial glands and stroma in the detrusor muscle. Surgically, there are 2 ways of excising this disease. The first is by transurethral bladder resection of the tumor, and the second is laparoscopic/robotic/open partial cystectomy of the bladder endometriosis. Because the nodule develops from the outer layer of the bladder wall toward the inner layer, complete excision of the endometriotic lesion is virtually unachievable with transurethral resection surgery. There is also a high risk of bladder perforation 4, 5, 6, 7, 8. Partial cystectomy of the bladder runs a risk of excising normal bladder tissues because it is difficult to ascertain the margins of the bladder nodule. However, we found the best method to deal with bladder endometriosis is a combined approach whereby the margins of the bladder nodule are cut via a cystoscopy and then excision of the bladder nodule is done laparoscopically. This particular technique is presented here with an accompanying video.
Excision of bladder endometriosis by first delineating the tumor via cystoscopy and simultaneously excising the nodule laparoscopically
Mahkota Medical Centre, Melaka, Malaysia.
Here we describe a simultaneous cystoscopic and laparoscopic excision of bladder endometriosis. The patient was first seen in 2005 at age 19 years with an endometrioma. She was single (virgo intacta) at that time. She underwent a laparoscopic cystectomy. Postoperatively, she received 3 doses of monthly gonadotropin-releasing hormone (GnRH) analogue injection. She was last seen in 2006 and was well. She conceived spontaneously after that and delivered 2 babies spontaneously in 2007 and 2010 in another city. She consulted me again in April 2016 complaining of dysuria, dysmenorrhea, and inability to hold her urine. She had consulted a urologist 6 months earlier. Cystoscopy performed by the urologist showed bladder endometriosis. No further surgery was performed, and she was given GnRH analogues for 6 months. However, her symptoms persisted after completion of the GnRH analogue. Examination and ultrasound showed a large bladder nodule measuring 4.17 × 2.80 cm. Intravenous urogram showed stricture in the upper right ureter. She underwent a combined urology and gynecology surgery to excise the bladder nodule. Informed consent was obtained from the patient, and the local institutional board provided the approval. The surgery was performed with the patient in the dorsosacral position. A Verres needle was inserted into the abdomen at the umbilicus, and carbon dioxide insufflation was performed. A 10-mm trocar was inserted in the umbilicus, and a 3-dimensional laparoscope (Aesculup–BBraun Einstein Vision; BBraun, Melsungen AG, Germany) was inserted to view the pelvis. Three 5-mm trocars were inserted, 1 on the right side and 2 on the left side of the abdomen. A RUMI (CooperSurgical, Trumbull, CT) uterine manipulator was placed into the uterine cavity. Laparoscopy showed no adhesions in the upper and mid-abdomen. The appendix and the intestines looked normal. Both the ovaries and fallopian tubes were normal. Uterine insufflation with methylene blue showed that both tubes were patent. There was dense endometriosis between the bladder and fundus of the uterus. The omentum was also adherent to the site of the endometriosis. There were endometriotic nodules on the left uterosacral ligaments and the peritoneum in the wall in the pouch of Douglas. The omentum was released, and laparoscopic adhesiolysis was performed. Both the paravesical spaces lateral to the nodule were dissected out. The bladder was released from the uterus with some difficulty. The peritoneal endometriosis in the Pouch of Douglas and the nodules in the left uterosacral ligament were excised. Cystoscopy was performed and stents were first placed in both ureters. The nodule was found to be in the central position, and the margins were about 2 cm from both the ureteral orifices. The nodule was seen protruding into the bladder containing bluish lesions. Demarcation of the bladder endometriosis was done using a resectoscope. Using a needle electrode, a deep circular incision was made around the bladder nodule and into the detrusor muscle. Cystoscopic perforation of the bladder was done and was seen laparoscopically. The bladder endometriotic nodule was completely excised laparoscopically after the demarcation line created via the cystoscopy. Stay sutures were first placed at the superior and inferior edges of the defect. The bladder was repaired continuously in 1 layer using polyglactin 3-0 sutures. The nodule was placed in a bag cut into smaller pieces and removed through the umbilical incision. At the end of the surgery a cystoscopy was perform to check the integrity of the suture. The pelvis was then washed. A bladder catheter was placed. The trocars were then removed under vision, and the rectus sheath was closed using polyglactin 1 suture. The skin incisions were closed. The operation time was 2 hours. The patient received antibiotics for 10 days. She was discharged with a catheter in place on day 3. She underwent a cystogram on day 10 of the surgery, and the bladder was found to be intact. The catheter was then removed. She was seen 6 weeks after the surgery and was well without any symptoms. The ureteric catheters were removed. Histopathology confirmed bladder endometriosis. Five months later she conceived spontaneously and delivered her third child naturally in June 2017. She was seen after her delivery and was advised to take oral contraceptive pills continuously or an intrauterine contraceptive device to prevent recurrence of the endometriosis. She took the oral contraceptive pills for 3 months and then refused any further treatment. She was last seen in February 2019 and was well without any symptoms.
In bladder endometriosis a combined approach with the urologist can assist in safely excising deep bladder endometriosis without removal of normal bladder tissue. Stents placed in the ureter assist in avoiding injury to the ureters. Demarcating the endometriotic nodule by the urologist through the bladder and excising the bladder nodule laparoscopically is both safe and effective.

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Female Urology – IncontinenceClinical Aspects and Surgical Treatment of Urinary Tract Endometriosis: Our Experience with 31 Cases

Abstract

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conclusions

Best Pract Res Clin Obstet Gynaecol

Best Pract Clin Obstet Gynaecol

Fertil Steril

Am J Obstet Gynecol

Urol Clin North Am

Urology

J Urol

J Urol

J Urol

Fertil Steril

Fertil Steril

Female Urology – Incontinence
Clinical Aspects and Surgical Treatment of Urinary Tract Endometriosis: Our Experience with 31 Cases