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Urogynaecology
these imaging techniques can contribute to halting the local spread of the is often silent (in up to 30% of cases), especially when the prejudice to the
disease and ascertaining the potential involvement of the vesico-uterine upper urinary tract is higher and renal insufficiency or hydronephrotic
septum, which has specific surgical implications.
11
atrophy is diagnosed. Otherwise, symptoms are aspecifically related to the
obstruction of the ureter (renal colic or pyelonephritis; 70% of cases
19
) with
Hormonal treatment is supported by some authors
12
because it leads to no radiological pathognomonic signs, and only in a minority of cases to the
prompt relief of the symptoms, but relapses are common at therapy menstrual cycle. However, a positive medical history for endometriosis
discontinuation. Moreover, it does not permit pregnancy and the side (around 60% of cases
19
) can really help to improve the diagnosis. The
effects of long-term treatment are heavy. Therefore, the removal of the difficulties associated with diagnosing ureteral endometriosis are indirectly
lesion is generally regarded as necessary to cure the disease. Since confirmed by the rate of kidney loss, which is high in historical series
transurethral operative endoscopy cannot be radical due to the (23–47%) and lower but still significant in contemporary ones (10%).
19–21
extramucosal nature of endometriosis,
12–14
the preferred option is surgical Therefore, upper urinary tract evaluation by ultrasonography, CT, NMR or
resection by partial cystectomy. This fully removes the disease, allowing urography is always highly advisable during the diagnosis and follow-up of
durable recovery from the symptoms with acceptable morbidity, especially patients suffering from mild to severe pelvic endometriosis.
when carried out laparoscopically.
8,11
The technical complexity of the
procedure is low for dome locations, which are often isolated and easily Medical treatment has been recommended by some authors,
21
sometimes
identifiable via transperitoneal access. Conversely, as recently reported in a in combination with ureteral stenting, but it is generally considered
large surgical series,
11
the base location can penetrate the vesico-uterine ineffective since fibrosis, which follows the response of endometriosis to
septum and the procedure thus has to be radical, involving partial resection hormone stimulation, contributes significantly to the development of
of the anterior uterine wall. Moreover, such locations are frequently stenosis and consequential loss of responsiveness to hormone stimulation:
associated with severe, diffuse pelvic endometriosis; in these cases medical hormone suppression should therefore be regarded as an adjuvant
laparotomy access can be preferable because a number of additional therapy to surgery or as a preventative therapy for relapses when total
(gynaecological or intestinal) procedures could be necessary.
11,14
hysterectomy with bilateral adnexectomy is not performed. Indeed, the need
Nevertheless, over the last few years the potential of laparoscopy has for new surgery following a relapse falls from 27% of cases treated solely by
certainly increased and its indications are becoming wider, as the data medical therapy to 3% of cases treated by hysterectomy with bilateral
published by referral institutions show.
15
adnexectomy.
22
The young age of the patients, who often wish to have
children, means that this option is not always easy to accept.
Ureteral locations are thought to develop from severe ovarian
endometriosis
16
and are much more frequently associated with other pelvic The degree of recovery of renal function through urinary drainage
foci than with bladder locations.
14
The pelvic ureteral tract is constantly (nephrostomy or ureteral stenting), if necessary, can help to indicate
affected, even though a single case of upper ureteral involvement is reconstructive surgery versus nephrectomy. Elective laparoscopic
reported in the literature;
17
therefore, endometriosis should be included in ureterolysis should be chosen only for minimal, extrinsic and non-
the differential diagnosis of ureteral strictures in young women. The left obstructive ureteral involvement because it is not sufficiently radical in
side is most frequently affected, which may be ascribed to the sigma cases of wider involvement of the ureter or intrinsic endometriosis,
creating favourable local conditions for cell seeding retrogradely from the which is hard to determine without histological examination.
23,24
uterine cavity.
18
However, bilateral involvement is not infrequent and is Conversely, when the urinary flow is obstructed and a dilation of the
reported in 5–23% of cases.
19
Ureteral endometriosis can take either an upper urinary tract is evident, surgical resection represents a more
extrinsic form (70–80% of cases), affecting the external ureteral tunics suitable option because it removes both the disease and the surrounding
through adherence to the surrounding structures or organs, or an intrinsic fibrosis. Urinary tract continuity can be restored by ureteral termino-
form (20–30% of cases), when the endometriosic tissue subverts the terminal anastomosis only when the distal ureteral tract shows no signs
muscular layer or the ureteral mucosa, sometimes with an intraluminal of endometriosis. In our opinion, the safest way to restore urinary
projection. The response of the ectopic endometrial tissue to hormone continuity is by ureteroneocystostomy, which does not use the ureteral
stimulation results in cyclical bleeding of the lesion and its subsequent tract distal to the site of endometriosis – which is marked by a higher risk
desquamation, necrosis and fibrosis, all of which contribute significantly to of recurrence – and warrants tension- and disease-free anastomosis.
the development of ureteral stenosis. Moreover, this is the preferred procedure in cases of relapse of ureteral
endometriosis.
19
Due to the complexity of the operation and the
Intrinsic endometriosis may be associated with lateralised pathognomonic frequent necessity of performing additional gynaecological or intestinal
macrohaematuria synchronised with the menstrual cycle, but such a procedures, laparotomic access may be the best though not the easiest
presentation is rarely found in daily clinical practice. Indeed, the presentation option, even though the feasibility of laparoscopy is known.
25
■
1. Sampson JA, Am J Obstet Gynecol, 1927;14:422–69. 1997;24:410–40. 17. Rosemberg SK, Jacobs H, J Urol, 1979;121:512.
2. Jacobson VC, Arch Surg, 1927;5:281–300. 8. Comiter CV, Urol Clin North Am, 2002;29:625–35. 18. Vercellini P, et al., Br J Obst Gyn, 2000;107:559–61.
3. Boling RO, et al., J Reprod Med, 1988;33:49–52. 9. Koninckx PR, Martin D, Curr Opin Obstet Gynecol, 2004;6: 19. Antonelli A, et al., Int Urogynecol J Pelvic Floor Dysfunct,
4. Pauerstein CJ, Clinical presentation and diagnosis in 231–41. 2004;15:407–12.
endometriosis. In: Schenken RS (ed.), Contemporary concepts in 10. Shook TE, Nyberg LM, Urology, 1988;31:1–6. 20. Stilwell TJ, et al., Urology, 1986;28:81–5.
clinical management, Philadelphia: JB Lippincott, 1989;127–44. 11. Fedele L, et al., Fertil Steril, 2005;83:1729–33. 21. Yohannes P, J Urol, 2003;170:20–25.
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177–200. 13. Vercellini P, et al., J Urol, 1996;155:84–6. 273–6.
6. Van Gorp T, et al., Best Pract Clin Obstet Gynaecol, 2004;18: 14. Antonelli A, et al., Eur Urol, 2006;49:1093–8. 23. Elashry OM, et al., J Urol, 1996;156:1403–10.
349–71. 15. Nezhat CH, et al., Fertil Steril, 2002;78:872–5. 24. Rouzier R, et al., Contracept Fertil Sex, 1998;26:173–8.
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