{"paper_id":"39355996-67bc-4aa5-84f3-b63c474e2e04","body_text":"J Urol Ren Dis, an open access journal\nISSN: 2575-7903\n1 V olume 07; Issue 11\nCase Report\nBilateral ureteral Deep infiltrating endometriosis: \na rare case. \nElvin Piriyev1*, Sven Schiermeier2, Thomas Römer³\n1Department of Obstetrics and Gynecology, University Witten-Herdecke, Academic Hospital Cologne Weyertal University of Cologne, \nWeyertal, Germany\n2Department of Obstetrics and Gynecology, University Witten-Herdecke, Marien-Hospital, Witten Marienplatz, 258452, Witten, \nGermany\n³Department of Obstetrics and Gynecology, Academic Hospital Cologne Weyertal University of Cologne, Weyertal, Germany\n*Corresponding author: Elvin Piriyev, Department of Obstetrics and Gynecology, University Witten-Herdecke, Academic \nHospital Cologne Weyertal University of Cologne, Weyertal 76, 50933 Cologne, Germany\nCitation: Piriyev E, Schiermeier S, Römer T (2022) Bilateral ureteral Deep infiltrating endometriosis: a rare case. J Urol Ren Dis \n07: 1295. DOI: 10.29011/2575-7903.001295.\nReceived Date: 15 November, 2022; Accepted Date: 21 November, 2022; Published Date: 23 November 2022\nJournal of Urology and Renal Diseases\nPiriyev E, et al. J Urol Ren Dis 07: 1295.\nwww.doi.org/10.29011/2575-7903.001295\nwww.gavinpublishers.com\nAbstract\nAccording to literature urinary tract is affected in 0.3-12% of women with endometriosis. Ureter endometriosis is a rare \nsituation and occurs in approximately 10% of urinary tract endometriosis and eight time less than bladder endometriosis . \nUreter endometriosis is mostly asymptomatic and can lead to loss of renal function in 11.5%. Laparoscopy is used successfully \nto manage the ureter endometriosis. Ureter endometriosis is typically unilateral and bilateral occurrence is very rare. We \npresent the case of a 41-year-old patient who was admitted to our endometriosis excellence center. She reported very severe \ndysmenorrhea and hypermenorrhea. There was a history of a laparoscopy for deep infiltrating endometriosis with partial \nbladder resection and right nephrectomy because of ureteral affection and subsequent loss of renal function. A re-laparoscopy \nwas carried out. Intraoperatively a large endometriotic nodule appeared on the ureter, which could be removed completely.\nKeywords: Endometriosis; Deep infiltrating endometriosis; \nEndometriom; Ureter; Ureter endometriosis\nIntroduction\nThe prevalence of endometriosis in women in reproductive age \nis 10-20% among the general female population [1]. Endometriosis \nis defined by the ectopic presence of endometrial gland and stroma \noutside the uterus [2]. There are three main types of endometriosis: \nendometrioma, what means ovarian endometriosis, superficial \nperitoneal endometriosis and deep infiltrating endometriosis, \nwhat means infiltrating of peritoneum more than 5mm [3,4]. Deep \ninfiltrating endometriosis is considered as a most assertive form of \nendometriosis [4]. According to literature urinary tract is affected \nin 0.3-12% of women with endometriosis [5]. Ureter endometriosis \nis a rare situation and occurs in approximately 10% of urinary tract \nendometriosis and eight time less than bladder endometriosis [6]. \nThere are two types of ureteral involvement: 38.5% demonstrate \nendometriosis inside the muscular layer (intrinsic) and 61.5% \nshow adventitial infiltration (extrinsic) [7]. Ureter endometriosis \nis mostly asymptomatic and can lead to loss of renal function \nin 11.5% [8-11]. Laparoscopy is used successfully to manage \nthe ureter endometriosis [12]. Ureter endometriosis is typically \nunilateral and bilateral occurrence is very rare [13].\nCase Presentation\nWe present the case of a 41-year-old patient who was \nadmitted to our endometriosis excellence center. She reported \nvery severe dysmenorrhea and hypermenorrhea. There was a \nhistory of a laparoscopy for deep infiltrating endometriosis with \npartial bladder resection and right nephrectomy because of ureteral \naffection and subsequent loss of renal function. Four years after \nnephrectomy a diagnostic laparoscopy was performed, which \nwas unremarkable. Both laparoscopies were performed in other \nhospitals. Drug therapy with various hormone medicaments \n(including dienogest, COC, etc.) has already taken place. During \nthe hormone therapy a severe depression developed, up to suicidal \nthoughts, so the therapy was stopped. The patient did not wish \nany hormone therapy again. A laparoscopic total hysterectomy \nwas discussed with the patient since she had definitively no longer \nfertility desire. Additionally, the result of cervix smear was PAP \n\nCitation: Piriyev E, Schiermeier S, Römer T (2022) Bilateral ureteral Deep infiltrating endometriosis: a rare case. J Urol Ren Dis 07: \n1295. DOI: 10.29011/2575-7903.001295.\n2\nV olume 07; Issue 11\nJ Urol Ren Dis, an open access journal\nISSN: 2575-7903\nIIID. The patient was prepared for the operation and gave the \nconsent. The renal ultrasonography was unremarkable. \nThe laparoscopic total hysterectomy was performed without \nany complications. However, intraoperatively pronounced \nadhesions between the sigmoid and the left pelvic wall were \ndetected. These adhesions were partially dissolved. The peritoneum \nin this area was scarred with suspicion to endometriosis. Since the \npatient was not explicitly informed about extensive ureterolysis \nand because of the high risk of ureteral injury in a patient with \nonly one kidney, it was decided to complete the procedure in \nthis stage. The postoperative course was inconspicuous and the \npatient was discharged. Six months later, the patient presented to \nus again. She had a 6cm endometriom on left ovarian and wanted \na repeat laparoscopy with complete excision of the endometriosis. \nUnilateral endometrioms are associated with deep infiltrating \nendometriosis in 40% [14]. D-J stents is not always required in \nsurgery of deep infiltrating endometriosis [15]. However, in this \ncase because of history of nephrectomy a D-J stent was inserted \nand the patient was prepared for the surgery. There were again \nsevere sigmoid adhesions to the left pelvic wall (Figure 1). \nFigure 1: Adhesion between Sigma and left pelvis wall. \nEndometriom.\nAfter the adhesions were completely dissolved, complete \nureterolysis took place. A large endometriotic nodule appeared \non the ureter (Figure 2). The endometriotic nodule was first \nreduced with cold scissors (Figure 3). The nodule could then be \ncompletely removed (Figures 5). The histologically examination \ncould confirm the endometriosis. The postoperative course was \ninconspicuous and the patient was discharged after three days in \ngood health condition. She came to follow up six months after \nsurgery. No hydronephrosis was detected. She reported significant \nimprovement of complaints. \nFigure 2: Endometiosis nodule on the ureter.\nFigure 3: Reduced endometriosis nodule.\nFigure 4: Complete excision of the nodule.\n\nCitation: Piriyev E, Schiermeier S, Römer T (2022) Bilateral ureteral Deep infiltrating endometriosis: a rare case. J Urol Ren Dis 07: \n1295. DOI: 10.29011/2575-7903.001295.\n3\nV olume 07; Issue 11\nJ Urol Ren Dis, an open access journal\nISSN: 2575-7903\nFigure 5: The ureter at the end of the surgery\nDiscussion\nUrinary tract endometriosis is seldom and ureter \nendometriosis occurs only in 0.01% to 1.7% of endometriosis \ncases reported in the literature [16]. Ureter affection is a dangerous \nform of endometriosis and may impact on renal function in 30% \nof cases, whereby in case of hydronephrosis the ipsilateral kidney \nloses renal function in 30% of cases [8,9]. Typically, the distal \nthird of the ureter is most affected part [17]. Ureter endometriosis \nis usually unilateral and left ureter is more severe than right [18-\n20]. Occurring of endometriosis in both ureter is a way to rare \ncase. Statistic about bilateral ureter affection could not be found in \nPubMed by the authors. In 80% of cases with ureter endometriosis \npatients do not have any specific urinary symptoms and 48% \nof patients are asymptomatic [18,21]. Therefore, the diagnose \nof the ureter endometriosis is difficult, the hydronephrosis \nremains undetected and approximately in half of the cases the \nureter endometriosis is diagnosed unexpectedly during routine \nhealth examinations [18,22]. However, there are three common \nsymptoms in patients with ureter endometriosis: dysmenorrhea \n75%, dyspareunia 70%, as well as pelvic pain 60% [19]. For this \nreason, in order to avoid missing a potentially ureter endometriosis \ntarget renal ultrasonography should be performed in all women \nwith these symptoms [22].\nThe standard treatment of ureter endometriosis consists of \ncomplete surgical excision of endometriosis tissue followed by \nconservative hormone therapy. Minimally invasive techniques \nshould be chosen in endometriosis surgery [23-26]. Drug therapy \ncan only relieve the pain related to endometriosis, but is not enough \nfor complete endometriosis treatment, since this does not have \nany impact to ameliorate the fibrotic, narrowed ureter that results \nfrom endometriosis [19]. Especially in case of ureter obstruction \nand/or hydronephrosis medical treatment alone is contraindicated \nbecause of increased risk of recurrence and renal impairment [27]. \nThe surgical therapy depends on the type of ureter endometriosis. \nIn case of intrinsic endometriosis with severe ureter obstruction \nand hydronephrosis ureterectomy with end-to-end anastomosis \nor ureteroneocystostomy are required [28,29]. In patients with \nextrinsic ureter endometriosis without obstruction or with mild \nobstruction without hydronephrosis is ureterolysis suitable [30]. \nIn our case, since the patient had neither hydronephrosis nor sever \nobstruction a ureterolysis with complete excision of endometriosis \nnodule was carried out. In Figure 4 a healthy tissue between ureter \nwall and endometriosis nodule is showed, so we are secure about \ncomplete excision. The ureter wall was not infiltrated. \nConclusion\nIn all patients with dysmenorrhea and pelvic pain an ureter \nendometriosis should be taken into account and examined due \nultrasonography and renal ultrasonography is obligated. Even in \npatients with history of ureter endometriosis surgery in one side an \nendometriosis in contralateral side should be considered, despite \nthis case is rare. The standard surgery method is a laparoscopy. \nThe laparoscopy must be performed by an experienced surgeon. \nDepends on kind of ureter affection (intrinsic or extrinsic) it \nshould be chosen among ureterolysis with complete excision of \nendometriosis, ureterectomy with end-to-end anastomosis and \nureteroneocystostomy.\nReferences\n1. Giudice LC (2010) Clinical practice. “Endometriosis”. N Engl J Med \n362: 2389-2398.\n2. Vercellini P, Viganò P, Somigliana E, Fedele L (2014) “Endometriosis: \npathogenesis and treatment”. Nat Rev Endocrinol 10: 261-275.\n3. Tosti C, Pinzauti S, Santulli P, Chapron C, Petraglia F (2015) \n“Pathogenetic Mechanisms of Deep Infiltrating Endometriosis,” \nReproductive Sciences 22: 1053-1059.\n4. Koninckx PR, Meuleman C, Demeyere S, Lesaffre E, Cornillie FJ \n(1991) “Suggestive evidence that pelvic endometriosis is associated \nwith pelvic pain”. Fertility and Sterility 55: 759-765.\n5. Gennaro KH, Gordetsky J, Rais-Bahrami S (2017) “Ureteral \nendometriosis: preoperative risk factors predicting extensive urologic \nsurgical intervention”. Urology 100: 228.\n6. Berlanda N, Vercellini P, Carmignani L, Aimi G, Amicarelli F, et al. \n(2009) “Ureteral and vesical endometriosis. Two different clinical \nentities sharing the same pathogenesis”. Int J Gynecol Obstet 64: \n615-623.\n7. Antonelli A, Simeone C, Frego E, Minini G, Bianchi U, et al. (2004) \n“Surgical treatment of ureteral obstruction from endometriosis: our \nexperience with thirteen cases”. Int Urogynecol J 15: 407-412.\n8. 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