{"paper_id":"67c88b4f-cf23-4620-adcf-37b6271d4e34","body_text":"Gynecol Surg (2007) 4: 135 –137\nDOI 10.1007/s10397-006-0229-6\nCASE REPORT\nK. Johnston . A. Shukla . P. Aslan . B. Jones .\nS. Sowter . D. Chou\nLaparoscopic extravesical neoureterocystostomy and vesicopsoas\nhitch for infiltrative ureteric and vesical endometriosis: case\nreport\nReceived: 16 April 2006 / Accepted: 8 June 2006 / Published online: 2 August 2006\n# Springer-V erlag Berlin / Heidelberg 2006\nAbstract We present a multidisciplinary approach to the\nmanagement of a 41-year-old woman who presented with\nan acute on chronic history of pelvic pain and urinary tract\nsymptoms. The underlying pathology was found to be\ninfiltrative ureteric and vesical endometriosis. The extent\nof the disease had caused partial ureteric obstruction. The\npatient subsequently underwent laparoscopic excision of\nthe endometriosis with a laparoscopic extravesical neour-\neterocystostomy and vesicopsoas hitch, performed by an\nadvanced laparoscopic gynaecologist and a urologist.\nKeywords Laparoscopy . Ureteric . V esical.\nEndometriosis . Neoureterocystostomy . V esicopsoas hitch\nCase report\nA 41-year-old multigravid women presented with a 3-\nmonth history of right loin pain, dysuria and haematuria. A\ncomputed tomography (CT) scan reported a 2.4-cm\nthickening of the bladder and the patient subsequently\nunderwent cystoscopy and ureteroscopy in May 2005. This\nshowed a 2- to 3-cm endometriotic nodule involving the\nbladder mucosa near the right ureteric orifice (Fig. 1) with a\n3-cm narrowing of the right ureter. A double-J stent was\npassed through the right ureter and a laparoscopic excision\nof this nodule with ureteric reimplantation planned.\nIn May 2001, a laparoscopic vaginal assisted hysterec-\ntomy (LA VH) was performed for dysmenorrhoea and\nmenorrhagia. Histology of her uterus showed adenomyo-\nsis. Due to persistent pain, a laparoscopy was performed\n1 year later and a nodular deposit of endometriosis was\nseen on the right fundal aspect of the bladder near the\nureteric tunnel. A gonadotrophin-releasing hormone ana-\nlogue was tried but failed to resolve the pain. Cystoscopy\nperformed at the same time demonstrated no endometriotic\nbladder mucosal involvement. In May 2003 the patient\nunderwent a laparoscopic excision of a 3- to 4-cm\nendometriotic bladder nodule and opted to have a bilateral\nsalpingo-oophorectomy at the same time. Cystoscopy up to\nthis stage was normal.\nA four-port laparoscopy was performed with cystoscopy\nto help define the margins of the lesion from an abdominal\nand vesical perspective. Retroperitoneal dissection of the\nureter from the bladder to about 6 cm above the pelvic brim\nwas performed and the endometriotic ureter transected\nabout 3 cm distal to its vesical insertion, exposing the\ndouble-J stent (Figs. 2 and 3). The proximal end of the\nureter was examined and found to be free of endometriosis\nwith a good vascular supply. The vagina was dissected free\nof the bladder to allow for precise resection of the\nendometriotic nodule. This was then excised using high\npower density monopolar diathermy. Despite ureteric\ndissection there was felt to be too much tension to\nreanastomose the ureter to the bladder and a laparoscopic\nvesicopsoas hitch was then performed as described below.\nThe anterior abdominal wall peritoneum was retracted\nvertically down at the level of the median umbilical\nligament and opened to access the cave of Retzius.\nDissection of the cave of Retzius then allowed adequate\nmobilization of the bladder toward the right psoas muscle,\nwhich had been exposed with careful dissection. Two\nsutures (1 –0 Polyglycol Vicryl) were then used to secure\nthe bladder dome to the tendon of the psoas muscle (Fig. 4).\nThe defect in the bladder was closed using interrupted 3 –0\npolydioxanone sutures leaving a small neocystomy\n(Fig. 5). The proximal end of the ureter was spatulated\nand a full thickness tension-free anastomosis to the\nneocystomy with 4 interrupted 3 –0 polydioxanone sutures\nat 3, 6, 9 and 12 o ’clock positions (Fig. 6). The double-J\nstent was left in situ. Indigo carmine was given\nK. Johnston ( *) . A. Shukla . B. Jones . S. Sowter . D. Chou\nSydney Women’s Endosurgery Centre,\nSt George Private Hospital, Ground Level,\n2217 Sydney, Kogarah, New South Wales, Australia\ne-mail: keithmjohnston@bigpond.com\nP . Aslan\nUrology Sydney, St George Private Hospital, Level 1,\n2217 Sydney, Kogarah, New South Wales, Australia\n\nintravenously and this confirmed bilateral ureteral patency.\nA drain was left in the pouch of Douglas for 48 h. An\nintracorporeal suturing technique was used throughout the\noperation.\nThe operation time was 210 min and estimated blood\nloss was less than 50 ml. A single dose of 120 mg of\nGentimycin was given intraoperatively and ceftriaxone 1 g\ndaily given for 48 h intravenously post-operatively. The\npatient had an uncomplicated post-operative period, had an\nindwelling catheter left in situ for 5 days and was\ndischarged home 6 days post-operatively. The pathology\nreport confirmed endometriosis throughout the bladder and\nureter.\nA post-operative cystogram was done 3 weeks after\ndischarge and showed no filling defects in the bladder and\ncontrast going up the stent. The double-J stent was\nremoved 6 weeks post-operatively and an intravenous\nurethrogram (IVU) was performed and normal. The patient\nremained pain free at the 6-month follow-up.\nDiscussion\nThe urinary tract is affected in approximately 2% of\nwomen with endometriosis [1]. When the ureter is involved\nit appears to affect the extrinsic aspect as opposed to the\nintrinsic aspect at a ratio of about four to one [ 7, 8].\nEndometriosis is often a progressive, infiltrative disease\nFig. 2 Dissected ureter\n Fig. 4 Psoas hitch, to allow a tension-free anastomosis\nFig. 1 Endometric bladder nodule\n Fig. 3 Endometriotic portion of ureter excised\n136\n\nassociated with dense fibrosis of the surrounding tissue.\nFor this reason early diagnosis and treatment may be\nnecessary to avoid loss of renal function if ureteric\nobstruction ensues. In ureteric endometriosis obstruction\nmay be asymptomatic [ 2–5] and silent loss of renal\nfunction has been reported to be as high as 25 –43% [ 6].\nRadiological modalities such as IVU, CT cystogram and\nmagnetic resonance imaging (MRI) although helpful in\ndemonstrating ureteric obstruction, hydronephrosis, lesion\nlocality and renal damage are non-specific in the diagnosis\nof renal tract endometriosis. The gold standard remains\nendoscopy and tissue biopsy.\nThis procedure has only been performed laparoscopi-\ncally in very small numbers. This case offers further\nsupport to the laparoscopic approach of a procedure\ntraditionally performed by laparotomy. It is important\nthat the vesicoureteric anastomosis is tension free and\nwhere this is not the case a psoas hitch or Boari flap may\nhelp achieve this [ 12]. The first case of laparoscopic psoas\nhitch for infiltrative ureteric endometriosis was described\nby Nezhat et al. in 1999 [ 1]. Prior to this the first\nlaparoscopic neoureterocystostomy was performed by\nEhrlich in 1993 [ 9] and the largest series of laparoscopic\nureteric reimplantation is in children performed by\nLakshmanan and Fung.\nLaparoscopy offers a low post-operative morbidity,\nallows a magnified, clear view of the pelvis and ureter\nfacilitating precise, safe anatomical dissection and excision\nof pathology in experienced hands. The development of\nexpertise in excision of endometriosis and other advanced\nlaparoscopic techniques [ 10, 11], particularly where\nlaparoscopic suturing is used such as pelvic floor repair,\nhysterectomy and Burch procedures, means that the\nlaparoscopic approach to neoureterocystostomy, ureteric\nimplantation and psoas hitch is feasible. However, we\nwould stress that it should only be undertaken by\ngynaecologists and urologists with advanced laparoscopic\ntraining and experience. Where endometriosis is the\nunderlying disease process necessitating the operation\nideally the operation should be performed as part of a\nmultidisciplinary approach.\nReferences\n1. Nezhat CH, Nezhat FR, Frieha F, Nezhat CR (1999)\nLaparoscopic vesicopsoas hitch for infiltrative ureteral endo-\nmetriosis. Fertil Steril 71:376 –379\n2. Esen T, Akinci M, Ander H, Tunc M, Tellaloglus S, Narter I\n(1990) Bilateral ureteric obstruction secondary to endometri-\nosis. Br J Urol 66:948 –949\n3. Moore JG, Hibbard LT, Growdon W A, Schifrin BS (1979)\nUrinary tract endometriosis: enigmas in diagnosis and manage-\nment. Am J Obstet Gynecol 134:162 –172\n4. Kerr WS (1966) Endometriosis involving the urinary tract. Clin\nObstet Gynecol 9:331 –357\n5. Koszczuk JC, Fogliette M, Perez J, Dono FV , Tomas RJ (1989)\nUrinary tract endometriosis. J Am Osteopath Assoc 1:83 –89\n6. Stillwell TJ, Kramer SA, Lee RA (1986) Endometriosis of the\nureter. Urology 28:81 –85\n7. Patel A, Thorpe P , Ramsay JW A, Shepard JH, Kirby RS,\nHendry WF (1992) Endometriosis of the ureter. Br J Urol\n69:495–498\n8. Langemeade CF (1976) Pelvic endometriosis and ureteral\nobstruction. Am J Obstet Gynecol 122:463 –469\n9. Ehrlich RM, Gershman A, Fuchs G (1994) Laparoscopic\nvesicoureteroplasty in children: initial case reports. Urology\n43:255–261\n10. Canis M, Bruhat MA, Pouly JL, Cooper MJM, Wattiez A,\nManhes H (1995) Techniques for ablation and excision of\nendometriosis. In: Nezhat CR, Berger GS, Nezhat FR, Buttram\nVC Jr, Nezhat CH (eds) Endometriosis: advanced management\nand surgical techniques. Springer, Berlin Heidelberg New York,\npp 85 –94\n11. Nezhat C, Nezhat F, Luciano AA, Siegler AM, Metzger DA,\nNezhat CH (eds) (1995) Laparoscopic excision of endometri-\nosis. In: Operative gynecologic laparoscopy: principles and\ntechniques. McGraw-Hill, New York, pp 121 –147\n12. Turney-Warick R, Worth PHL (1969) The psoas hitch proce-\ndure for replacement of the lower third of the ureter. Br J Urol\n41:710–714\nFig. 6 Reanastomosis of ureter\nFig. 5 Suturing of neocystotomy\n137","source_license":"CC0","license_restricted":false}