AUTHORS' CHRONICLES

 

Ureteral endometriosis

Endometriosis ureteral

 

Viktoria Varvara Palla¹

 

1 Diakonie-Klinikum Schwäbisch Hall gGmbH, Schwäbisch Hall, Alemania

 

Varvara Palla describes for SIIC his article published in Indian Journal of Urology 33(4):276-282, Oct 2017

 

Schwäbisch Hall, Alemania (special for SIIC)

 

Endometriosis is defined as the ectopic presence and growth of functional endometrial tissue, glands, and stroma, outside the uterus with the ovaries, the uterosacral ligaments, the Fallopian tubes, the cervix and the cul-de-sac being most affected. More specifically, ureteral endometriosis is a rare disease with a though increasing incidence.

The present study is a systematic review where the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. One hundred and four articles were finally included in this review: 5 prospective studies and 99 retrospective studies, of which 62 were case reports. A total of 1384 patients (mean age 38.6 years) with ureteral endometriosis were evaluated and data on age, side affected histological type, and management are included.

The pathogenesis of this clinical entity is not definitely clarified but possible theories include the retrograde menstruation,^1,2 the development of endometriosis primarily in the retroperitoneum from the embryonic remains of the Mullerian duct,^1,3 the theory of the benign metastasis, whereas hormonal and molecular pathways, oxidative stress and neuroangiogenetic mechanisms are also involved.⁴

Histopathologically, two major types of endometriosis are recognized according to the grade of infiltration of the ureteral wall: intrinsic and extrinsic.⁵

Concerning the diagnosis of ureteral endometriosis, it may represent a real challenge for clinicians, since the patient may present with the non-specific symptoms of endometriosis. Flank or abdominal pain, renal colic, hematuria associated with flank pain, or cyclic gross hematuria, unexplained hypertension, and silent renal failure may be more specific symptoms. History, vaginal-abdominal ultrasound, MRI/urology MRI, intravenous urography, isotope renography, ureteroscopy, and laparoscopy are included in the diagnostic chain.

Regarding the therapeutic management, conservative and operative treatments are available and should be practiced after an individualized patient approach. In general, the different therapeutic options include the hormonal therapy, the ureteroscopic approach and the operative one, which in turn refers to ureterolysis, ureteral resection with ureteral reconstruction, and nephrectomy in cases of renal insufficiency. The choice depends on the onset and renal function and the issues are: (1) relief of symptoms (2) renal preservation, and (3) prevention of relapse.

Pharmacological treatment includes medroxyprogesterone, estrogen-progestin combination, progestin alone, danazol, GnRH agonists (leuprolide, goserelin), with the last two being the most popular. The above medication functions by suppressing the ovarian function through its antagonising effects on gonadotropin. In cases of pelvic and vesicovaginal septum endometriosis the use of intrauterine levonogestrel device may also be considered since it leads to a high concentration of local progestogens.^6,7 As far as hormonal therapy is concerned, it offers the best option for (a) patients of childbearing age who desire pregnancy, with close follow-up with ultrasound at 6-month intervals to rule out an obstruction,⁵ (b) patients without significant fibrosis in combination with the suitable surgical intervention,^8,9 and (c) postmenopausal women, under close follow-up.¹⁰ The medical management alone is contraindicated in the case of ureteral obstruction and hydronephrosisHormonal therapy appears though with the following disadvantages; not complete response to the therapy, high relapse rate up to 55% after treatment discontinuation and important side effects with low compliance.⁵ Thus, the medical treatment is considered to be used in the palliation for deep infiltrative endometriosis.

The ureteroscopic approach is suitable in case of intraluminal endometriosis and includes the ablation with laser, and balloon dilatation with stent placement.^11-13

Operative management, either per laparoscopy or per laparotomy, includes ureterolysis, ureteral resection with ureteral reconstruction, and nephrectomy in cases of renal insufficiency.

More specifically, ureterolysis should be considered in cases of extrinsic endometriosis with lesions < 3 cm and in the absence of hydroureteronephrosis.^14,15 In cases of extrinsic endometriosis, ureterolysis is contraindicated, since it is associated with high recurrence rates (16%) and ureteral restenosis.

The criteria for the performance of ureteral resection and reconstruction are the presence of intrinsic endometriosis, lesions longer than 3 cm situated below the level of the iliac vessels and hydroureteronephrosis.¹⁶ One technique used when ureteral stenosis is limited to the ovarian fossa and distal ureter can be preserved, is the ureteral-ureteral anastomosis.^17-21 The second technique is the ureteroneocystostomy, which is the operation of choice in cases of extended disease with ureteral stenosis close to the vesicoureteral junction.^18,22-25 The Lich-Gregoire, Leadbetter-Politano or a psoas hitch methods^26-28 or rarely replacement with bowel segments or bladder flaps may be used.^29,30 It is important to perform a tension-free anastomosis in order to reduce the risk of postoperative recurrence of stenosis and hydronephrosis.³¹

When the use of laparoscopic approach comes in question, the recent studies imply that the results are quite satisfying with functional success rate of 10 out of 10.^32,33 On the other laparotomy is a well-established approach.

Nephrectomy is indicated when renal function is deteriorated or when the lesions mimic a urothelial carcinoma.²⁷

To sum up, ureteral endometriosis is a rare disease which presents with atypical symptoms in women of childbearing age. The clinicians should, therefore, present a high index of clinical suspicion and perform the necessary diagnostic assessment of the patient in order to plan, in a multidisciplinary approach, the best matching therapeutic schedule.