Elsevier

Urology

Volume 78, Issue 6, December 2011, Pages 1269-1274
Urology

Female Urology
Prevalence and Management of Urinary Tract Endometriosis: A Clinical Case Series

https://doi.org/10.1016/j.urology.2011.07.1403Get rights and content

Objective

To report on the prevalence, surgical management, and outcome of urinary tract endometriosis (UTE) in a cohort of 221 patients undergoing laparoscopic surgery for severe endometriosis. UTE can cause significant morbidity, such as silent kidney or progressive renal function loss. Its frequency is underestimated and data on laparoscopic management are scarce.

Methods

Between 2007 and 2010, 43 patients were eligible for this single-center, retrospective study. The inclusion criterion was the presence of UTE (ie, bladder and/or ureteral endometriosis). All patients were operated laparoscopically.

Results

The prevalence of UTE was 19.5% (43/221). There was no correlation between bladder and ureteral endometriosis (P >.05). Ureteral endometriosis was associated with patient's age (P <.01). Patients with bladder, but not ureteral, involvement complained more frequently about dysuria, hematuria, and urinary tract infections. Intraoperative and magnetic resonance imaging (MRI) findings revealed a moderate to good correlation. UTE was not associated with rectovaginal or bowel endometriosis, but rather with involvement of the uterosacral ligaments (P <.01). Twenty-two patients with bladder endometriosis were treated by mucosal skinning and 11 patients underwent partial cystectomy. Superficial ureteral excision was performed in 4 patients, whereas resection with ureteroureterostomy was done in 9 patients. There was no difference regarding the intra- and postoperative complications in patients with or without UTE.

Conclusion

In severe pelvic endometriosis, involvement of the urinary tract is quite common. Laparoscopic management is feasible and safe. Because of the lack of specific symptoms, the preoperative diagnosis of ureteral endometriosis still remains a challenge. Pelvic MRI represents a useful preoperative diagnostic tool.

Section snippets

Patients

Two-hundred twenty-one consecutive patients who underwent laparoscopic surgery for severe (deep infiltrating) pelvic endometriosis in our referral center between July 2007 and February 2010 were eligible for this retrospective case series. The inclusion criterion was presence of UTE (bladder and/or ureteral endometriosis). The indication for surgery was presence of a symptomatic and severe endometriosis with or without a desire to become pregnant in the future. The diagnosis was made by

Results

The prevalence of UTE was 19.5% in our cohort (n = 43/221). Patients' mean age was 32.3 years (range 24-48). The mean hospital stay was 5.6 days in patients with UTE vs 4.3 days in patients without UTE (P = .001). Patient characteristics are presented in Table 1. In detail, bladder and ureteral endometriosis were found in 30 (13.6%) and 10 (4.5%) patients, respectively. Three patients (1.4%) had both bladder and ureteral involvement. Representative pictures are shown in Figure 1. Our analysis

Comment

The preoperative diagnosis of UTE is difficult and requires great vigilance. It is increasingly recognized the greater the awareness of it. However, on clinical examination and laparoscopic inspection, UTE can be easily missed. Although rare, ureteral endometriosis can cause significant morbidity, such as a silent kidney or progressive renal function loss. Because of delayed diagnosis, the ureteral lumen can progressively narrow, with a consequent worsening of hydronephrosis.

Specific symptoms

Conclusions

In severe pelvic endometriosis, involvement of the urinary tract is quite common. The laparoscopic approach is feasible and appears to be safe. Ureteral endometriosis is often asymptomatic, but should always be kept in mind when the uterosacral ligaments are infiltrated clinically. A preoperative pelvic MRI can be very useful to appreciate the whole extent of the disease.

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