{"paper_id":"771fdd79-be17-4b05-b331-8df2c7920abd","body_text":"Abstract\nEndometriosis is a biologically benign albeit aggressive pathology marked by high local recurrences. Ureteral involvement accounts for only a minority of cases (0.1–0.4%) with often non-specific symptoms at clinical presentation and difficult preoperative diagnosis. Thirteen cases of severe ureteral endometriosis (i.e. causing significant obstruction to the urinary flow) were observed and surgically treated, out of 17 ureteral units affected (three cases of bilateral involvement, one case of complete pyeloureteral duplicity). The initial symptomatology was acute and related to ureteral obstruction in eight cases, silent and non-specific in the other five; a presumptive diagnosis was made only for the seven patients (53.9%) with a positive medical history for pelvic (and in two cases also ureteral) endometriosis. Preoperative drainage of urine proved necessary for eight patients due to the complete functional exclusion of the excretory axis. One patient (7.7%) underwent nephrectomy due to renal atrophy. Segmental ureteral resection and termino-terminal anastomosis were performed in two patients, while seven patients underwent segmental ureterectomy and ureterocystoneostomy, with bladder psoas hitching in four cases and vesical flap according to Casati-Boari in one case. All three cases of bilateral involvement were treated by bilateral segmental ureterectomy and trans-uretero-uretero-cystoneostomy with bladder psoas hitching. Following histological examination, all patients were diagnosed with active ureteral endometriosis, which was found to be intrinsic in five cases (38.5%) and extrinsic in the other eight. One of the two patients that had undergone ureterectomy and termino-terminal anastomosis had to undergo ureteral resection and ureterocystoneostomy 22 months later due to relapsing endometriosis-induced stenosis. Conversely, no ureteral endometriosis relapses occurred in the remaining 12 patients within the mean follow-up time of 41.1 months (range 6–91). Ureteral endometriosis is marked by non-specific symptoms, making preoperative diagnosis often difficult. Therefore, an ultrasound or urographic examination of the urinary tract in case of pelvic endometriosis is absolutely essential. In our experience, terminal ureterectomy with ureterocystoneostomy has provided long-term favourable results as extended ureteral resection can be performed and continuity of the urinary tract can be restored without resorting to the distal pelvic ureter, which is often affected by the disease besides being more subject to relapses.\nSimilar content being viewed by others\nReferences\nVessey MP, Villard-Makintosh L, Painter R (1993) Epidemiology of endometriosis in women attending family planning clinics. Br Med J 306:182–184\nJubanyik KJ, Comite F (1997) Extrapelvic endometriosis. Clin Obstet Gynaecol N A 24:420\nRevised American Society for Reproductive Medicine (1997) Classification of endometriosis: 1996. Fertil Steri 67:817–821\nJimenez RE, Tiguert R, Hurley P (2000) Ureteral hydronephrosis resulting from intraluminal obstruction of the ureter by adenosquamous endometrioid carcinoma arising from disseminated endometriosis. Urology 56:331\nRouzier R, Deval B, Muray JM (1998) Endométriose urétérale: un propos de 3 cas. Conduite diagnostique et thérapeutique. Revue de la littérature. Contracept Fertil Sex 26:173–178\nVercellini P, Pisacreta A, Pesole A (2000) Is ureteral endometriosis an asymmetric disease? Br J Obst Gyn 107:559–561\nRosemberg SK, Jacobs H (1979) Endometriosis of the upper ureter. J Urol 121:512\nStilwell TJ, Kramer SA, Lee RA (1986) Endometriosis of ureter. Urology 28:81–85\nYohannes P (2003) Ureteral endometriosis. J Urol 170:20–25\nTakeuchi S, Hiroyuki M, Toyoda N (1997) Intrinsic ureteric involvement by endometriosis: a case report. J Obstet Gynaecol Res 23:273–276\nStebbing JF, Notley RG (1995) Noncalcolous obstruction due to involvement of the ureter in endometriosis. Eur Urol 28:122–125\nComiter CV (2002) Endometriosis of the urinary tract. Urol Clin N A 29:625–635\nNezhat C, Nezhat F, Nezhat CH (1996) Urinary tract endometriosis treated by laparoscopy. Fertil Steril 66:920–924\nDonnez J, Nisolle M, Squifflet J (2002) Ureteral endometriosis: a complication of rectovaginal endometriotic (adenomyotic) nodules. Fertil Steril 77:32–37\nAuthor information\nAuthors and Affiliations\nCorresponding author\nAdditional information\nEditorial Comment: The authors present an appropriate treatment option for a difficult problem. Frequently, endometriosis involving the urothelium, bladder or ureter is not responsive to medical management. This article further emphasizes the need to screen all patients who present with severe endometriosis for ureteral obstruction. A recent article (Yohannes P (2003) J Urol 170:20) discusses attempts at conservative therapy. However, close follow-up is required during attempts at conservative management. Those patients who have failed medical management and/or have extensive scarring with reduction in renal function will require surgery.\nRights and permissions\nAbout this article\nCite this article\nAntonelli, A., Simeone, C., Frego, E. et al. Surgical treatment of ureteral obstruction from endometriosis: our experience with thirteen cases. Int Urogynecol J 15, 407–412 (2004). https://doi.org/10.1007/s00192-004-1171-7\nReceived:\nAccepted:\nPublished:\nIssue date:\nDOI: https://doi.org/10.1007/s00192-004-1171-7","source_license":"CC0","license_restricted":false}