{"paper_id":"82ef5791-8668-4145-97b4-2b1f79896cc1","body_text":"Remedy Publications LLC., | http://clinicsinsurgery.com/\nClinics in Surgery\n2020 | Volume 5 | Article 29621\nA Suprapubic Trocar Port Site Endometriosis Metastatic to \nDeep Bladder and Induced Right Hydroureteronephrosis: \nA Case Report\nOPEN ACCESS\n *Correspondence:\nKok-Min Seow, Department of \nObstetrics and Gynecology, Shin Kong \nWu-Ho-Su Memorial Hospital No. 95, \nWen-Chang Road, Shih-Lin District, \nTaipei, Taiwan, Tel: +886-2-28332211; \nFax: +886-2-28389416;\nE-mail: m002249@ms.skh.org.tw\nReceived Date: 01 Sep 2020\nAccepted Date: 25 Sep 2020\nPublished Date: 28 Sep 2020\nCitation: \nYu C-W, Huang L-W, Tsai Y-L, \nSeow K-M. A Suprapubic Trocar \nPort Site Endometriosis Metastatic \nto Deep Bladder and Induced Right \nHydroureteronephrosis: A Case Report. \nClin Surg. 2020; 5: 2962.\nCopyright © 2020 Kok-Min Seow. This \nis an open access article distributed \nunder the Creative Commons \nAttribution License, which permits \nunrestricted use, distribution, and \nreproduction in any medium, provided \nthe original work is properly cited.\nCase Report\nPublished: 28 Sep, 2020\nAbstract\nEndometriosis located at the urinary tract and/or trocar port site is extremely rare. We present \nthe first case of endometriosis occurs at trocar port site initially, and metastatic to deep bladder \nand induced the complication of right hydroureteronephrosis. A 39 years old female, married, \nwho had been previously operated on for right ovarian endometrioma 2 years ago by laparoscopy, \ncomplaining of a cyclical painful mass at the previous suprapubic trocar site for at least six months. \nShe did not pay much attention to it. Hematuria for ten days during menstrual period was noted \nthree months later. CT-scan demonstrated a suprapubic trocar port site mass, measured 5 cm, \nand suspected endometriosis. The endometriotic mass extended from suprapubic site to bladder \narea. Office cystoscopy revealed some papillary mass at right trigone area. Kidney ultrasonography \nrevealed right hydroureteronephrosis. The mass was excised, and the bladder endometriosis was \nresected with therapeutic, Trans-Ureteral Resection of Bladder Tumor (TURBT). After the excision, \nboth the hematuria and right hydroureteronephrosis were subsided. In conclusion, although bladder \nendometriosis is rare, however, if combined with hematuria and a painful mass in the trocar port \nscar who had a history of pelvic or obstetric surgery, the physician should consider endometriosis.\nKeywords: Endometriosis; Hydroureteronephrosis; Trocar site endometriosis; Bladder \nendometriosis\nCheng-Wei Yu1, Lee-Wen Huang2, Yieh-Loong Tsai2 and Kok-Min Seow3*\n1Department of Obstetrics and Gynecology, Shin-Kong Wu Ho-Su Memorial Hospital, Taiwan\n2Department of Obstetrics and Gynecology, College of Medicine, Fu-Jen Catholin University, Taiwan\n3Department of Obstetrics and Gynecology, National Yang-Ming University, Taiwan\nIntroduction\nEndometriosis is defined as endometrial glands and stroma at extrauterine sites. These ectopic \nendometrial implants can be intrapelvic or extrapelvic. Extrapelvic endometriosis can occur \nthorough the body, but, rarely, at the trocar port site and bladder [1]. The estimated prevalence of \nendometriosis is about 10%. Urinary tract disease or trocar port site is thought to occur in only 1% \nof cases [2]. Both trocar port site and bladder endometriosis can cause severe discomfort, such as \nsevere painful during menstrual cycle in scar endometriosis and hydroureteronephrosis may occur \nin deep infiltrating bladder endometriosis. Both diseases, however, rarely occur simultaneously in \nthe same patient.\nHerein, we present the first case of endometriosis at the suprapubic trocar port site, and \nmetastatic to a deep infiltrating endometriosis on the bladder complicated with hematuria and \nhydroureteronephrosis who had previously undergone laparoscopic resection of a right ovarian \nendometriotic cyst.\nCase Presentation\nA 39-year-old married woman, gravida 0, para 0, presented with hematuria last for ten days \nmenstrual and post-menstrual every month for more than one year prior to diagnosis. She had \na history of laparoscopic right oophoro-cystectomy for endometrioma 2 years ago. She also \ncomplained of cyclical pain during menstrual period and the pain was severe in lower abdomen, and \nhad worsened progressively over the previous six months. On palpation, a hard, firm and irregular \nborder mass, measured 5 cm fixed to the surrounding tissues was detected at the previous 5-mm \nsuprapubic trocar port site. Laboratory test revealed high level of CA-125 of 164 U/ml. Transvaginal \nultrasonography showed no recurrent of endome trioma. However, hematuria was noted three \nmonths after the suprapubic trocar site mass. Office cystoscopy revealed some papillary mass at right \n\nKok-Min Seow, et al., Clinics in Surgery - Gynecological Surgery\nRemedy Publications LLC., | http://clinicsinsurgery.com/\n 2020 | Volume 5 | Article 29622\ntrigone area (Figure 1) and incisional biopsy was performed, and the \nspecimen was sent for routine histopathological examination and was \nreported endometriosis. Kidney ultrasonography was performed and \nshowed right sided hydroureteronephrosis. We advised a contrast \nenhanced computed tomography scan of the abdomen and pelvis, \nand demonstrated a heterogeneously enhancing mass associated \nwith lobulated border, measuring 5 cm located at anterior pelvic wall \nrectus abdomens muscle area, suspected endometriosis. In addition, \nthe endometriotic mass growth extended to the deep bladder with a \nheterogeneously enhancing mass, measuring 5.1 cm located at right \nposterior aspect of the bladder, associated with obstructive hydroureter \nand hydronephrosis. Following detailed multi-disciplinary discussion \nand informed consent, she underwent excision of the abdominal \nwall lesion with flap reconstruction. Cystoscopy demonstrated the \nbladder tumor growth into the right ureter and the ureteral orifice \nwas 90% obstructed. The bladder mass was resected with therapeutic, \nTrans-Ureteral Resection of Bladder Tumor (TURBT) and right \nDouble-J placement. Kidney ultrasonography three days after the \nsurgery revealed complete relieved of the hydroureteronephrosis. The \npatient was discharged on the 4th postoperative day in a satisfactory \ncondition. The pathohistological specimen demonstrated both \nthe excised bladder nodule and the anterior pelvic wall mass were \nendometriosis. Two weeks the surgery, the level of CA-125 was \ndeclined to 25 U/ml. As postoperative medical treatment, the patient \nwas prescribed visanne 2 mg a day for 6 to 12 months.\nDiscussion\nTrocar site endometriosis and bladder endometriosis after \nlaparoscopic surgery are a rare extrapelvic endometriosis, and \nrarely happen in the same patient. Herein, we report the first case \nof laparoscopic trocar site endometriosis and bladder endometriosis \nhappened simultaneously in the same patient.\nPatients with surgical scar endometriosis are always suspected \nas abdominal wall hematoma, suture granuloma or inguinal hernia \ninitially. The diagnosis of scar endometriosis is always make if the \npatients have the symptoms of palpable mass in the abdominal wall, \ncyclic pain, and a previous gynecologic procedure or patient with \nhistory of treated pelvic endometriosis. The symptoms of bladder \nendometriosis include dysuria, urinary frequency or urgency, \nand suprapubic pain; rarely, patients might mention hematuria \ncoinciding with menses and hydroureteronephrosis [1]. Our \npatient has both the symptoms of abdominal mass with cyclic pain \ninitially, and hematuria during menstruation thereafter. According \nto these symptoms, we therefore could make an accurate diagnosis \nof extrapelvic endometriosis in this patient and metastatic from \nsuprapubic trocar site to deep bladder area.\nThe treatment for trocar site endometriosis is a wide local \nexcision of the lesion with at least 5 mm to 10 mm of healthy tissue \nas surgical margin, even for recurrent disease and great attention \nmust be paid not to break the mass during excision to prevent the \nre-implantation of microscopic endometrial cells [4]. Treatment of \nbladder endometriosis is aimed at resolving symptoms. The aim of \nsurgical treatment of bladder endometriosis is complete excision of \nsymptomatic endometriotic lesion to prevent recurrence.\nIn summary, trocar port site and bladder endometriosis is rare, \nand extremely rare if both the disease occur simultaneously in the \nsame patient. The disease should be considered as an important \ndifferential diagnosis in females with a positive history of prior \nlaparoscopic surgery, presented with mass at the site of the surgery \nand catamenial hematuria.\nReferences\n1. Tetsushi T, Tetsuya H, Ikumi A, Matsumoto Y, Oda K, Fujii T, et al. Mixed \nendometrioid and clear cell carcinoma arising from laparoscopic trocar \nsite endometriosis. J Obstet Gynaecol. 2019;45:1613-8.\n2. Kumar S, Tiwari P, Sharma P, Goel A, Singh JP, Vijay MK, et al. Urinary \ntract endometriosis: Review of 19 cases. Urol ANN. 2012;4(1):6-12.\n3. Alsinan TA, Aldahleh LA, Alreefi HAA, Albiabi SA, Alsouss YO, \nAlshayeh FA, et al. Endometriosis of the urinary bladder causing a right \nhydronephrosis: A case report. Am J Case Rep. 2019;20:1360-3.\n4. Mauro C, Stefania M, Corioni S, Moncini D, Mattei A. Abdominal wall \nendometriosis on the right port site after laparoscopy: Case report and \nliterature review. Ochsner J. 2015;15(3):251-55.\n5. Coeman V, Sciot R, Van Breuseghem I. Case report. Rectus abdominis \nendometriosis: A report of two cases. Br J Radiol. 2005;78(925):68-71.\nFigure 1: Office cystoscopy revealed some papillary mass at right trigone \narea (arrow).","source_license":"CC0","license_restricted":false}