{"paper_id":"8cdf2fa2-f508-4847-9709-483e9a567ee0","body_text":"CASE REPORT\nDiagnosis and laparoscopic treatment of an unusual case\nof advanced extragenital endometriosis\nJ. English & K. Baig & T. Liston & G. Hudelist\nReceived: 28 February 2007 / Accepted: 14 June 2007 / Published online: 15 August 2007\n# Springer-V erlag 2007\nAbstract Endometriosis is considered to be a benign gynae-\ncological disorder, although several pathophysiological aspects\nof endometrial lesions resemb le the behaviour of malignant\ntissue: similar to carcinomas, endometriotic cells are able to\ninvade and destroy surrounding anatomical structures. Al-\nthough the medical treatment of endometriotic lesions, includ-\ning the use of GnRH analogues or gestagens, show temporary\neffectiveness and have been reported to cause a regression of\ndisease, they rarely provide long-term relief of symptoms in\nadvanced stages of endometriosis involving extragenital\norgans, such as the rectum or the urinary system. We here\ndescribe the diagnosis and minim ally invasive surgical treat-\nment of an unusually advanced case of endometriosis involving\nthe rectosigmoid, the urinary bladder and the ureter, leading to\nsecondary hydronephrosis and loss of renal function.\nKeywords Endometriosis . Laparoscopy . Surgery\nIntroduction\nEndometriosis is characterised by the presence of endometrial\ntissue outside the uterine cavity and affects about 10% of the\npremenopausal female population [ 1]. The disease, albeit\nconsidered to be a “benign” one, can resemble the biological\nbehaviour of malignant tumours: endometriotic cells attach to\nand invade surrounding tissues, thereby, causing symptoms\nsuch as pelvic pain, dypareunia, dyschezia or infertility. Over\nthe past few decades, a number of treatment strategies have\nbeen evaluated, although none have been proven to be entirely\neffective. V arious medical treatments for endometriosis, such\nas non-steroidal antirheumatics, GnRH analogues or contra-\nceptive pills do not appear to exhibit significant differences in\ntheir effectiveness and only last as long as the patients remain\non their medication [2, 3]. In addition, antihormonal prepara-\ntions such as GnRH analogues and/ or analgetic medications\nshould not be prescribed on a long-term basis due to severe\nside-effects, including hot flushes, decrease of libido and bone\nmineral density, depression or impairment of renal function.\nAlthough radical surgical treatment for endometriosis remains\nan issue of constant debate, a number of studies, including\nrandomised controlled trials, strongly suggest that excisional\nradical surgery is, indeed, highly effective in the treatment for\nendometriosis and warrants long-term curative effects regard-\ning pelvic pain and subfertility [3–9]. However, some patients\nexhibit extensive involvement of extragenital tissues, such as\nthe sigmoid and rectum, ureter and bladder, which confers a\ntechnical challenge for the surgeon, especially in a fertility-\npreserving treatment approach. We here describe the preoper-\native diagnosis and fertility-preserving laparoscopic treatment\nof an unusual case of extraordinary extensive extragenital\nGynecol Surg (2008) 5:45 –47\nDOI 10.1007/s10397-007-0304-7\nJ. English : G. Hudelist ( *)\nDepartment of Obstetrics and Gynaecology,\nWorthing and Southlands Hospital,\nLyndhurst Road,\nWest Sussex BN11 2DH, UK\ne-mail: gernot_hudelist@yahoo.de\nJ. English\ne-mail: james.english@wash.nhs.uk\nK. Baig\nDepartment of Surgery, Worthing and Southlands Hospital,\nWorthing, UK\nT. Liston\nDepartment of Urology, Worthing and Southlands Hospital,\nWorthing, UK\nG. Hudelist\nDepartment of Obstetrics and Gynaecology, LKH Villach,\nVillach, Austria\n\ndisease involving the urinary bladder, the rectum and sigmoid\ncolon and the ureter.\nCase report\nA 26-year old (gravida 0 para 0) female of Caucasian origin\npresented with a long-standing history of dysmenorrhea,\npelvic pain, dyspareunia, severe dyschezia and primary\nsubfertility at our department. In addition, haematuria and\ndysuria with intermittent episodes of frequency had\ndeveloped within the past 3 months. Her medical history\ndid not reveal any abnormalities and she was treated for\ncommon menstrual pain with non-steroidal antirheumatics\nand opioids over the recent few years. At presentation in\nSeptember 2006, urinalysis revealed microhaematuria and\nmoderate leukocyturia, lacking the significant growth of\norganisms on urine culture. However, an ultrasound scan of\nher kidneys exhibited signs of hydronephrosis of her left\nkidney that was reconfirmed as complete hydronephrotic\nfailure by a Mercapto Acetyl Tri Glycine (MAG3) scan\nexhibiting 11% residual renal function. On clinical exam-\nination, a fixed and retroverted uterus and a hard nodular\nmass of about 1.5 cm in diameter originating from the\nupper third of the rectovaginal space (RVS) with queried\ninfiltration of the anterior rectal wall were palpated.\nA transvaginal ultrasound scan of her pelvis finally\nrevealed a 3.7×4×3 cm hyperechogenic, round-shaped\nmass originating from the posterior wall of the urinary\nbladder, protruding into the bladder cavity (Fig. 1). In\naddition, a 3×1.3×2 cm hypoechogenic mass with a\nhyperechogenic halo was located in the upper third of the\nRVS, distorting the hypo- and hyperechogenic layer of the\nFig. 1 Transvaginal ultrasound (transverse section) of the urinary\nbladder, showing a round-shaped hypoechogenic mass involving the\nposterior wall of the bladder, protruding into the bladder cavity.\nU=uterus; B=bladder; E=endometriotic nodule\nFig. 2 Transvaginal ultrasound of the rectovaginal space, showing a\nhypoechogenic structure with a hyperechogenic halo distorting the\nhypo- and hyperechogenic layer of the anterior rectal wall, thereby,\nsuggesting infiltration of the rectal muscularis\nFig. 3 Laparoscopic incision of the urinary bladder, revealing a\nnodular, livid structure infiltrating the posterior wall of the bladder\nFig. 4 Rectum with luminal obstruction caused by endometriotic\ninfiltration of the anterior rectal wall\n46 Gynecol Surg (2008) 5:45 –47\n\nanterior rectal wall, suggesting infiltration of the rectal\nmuscularis (Fig. 2). A similar structure of size 1.2×1×\n1.3 cm was identified at the level of the uterine fundus,\nagain suggesting infiltration of the rectosigmoid. Further-\nmore, a 2×1.5×3 cm round-shaped isoechogenic mass was\nidentified on the right ovary, suggesting endometrioma of\nthe ovary. Flexible cystoscopy for further evaluation of her\nhaematuria revealed a nodular, livid structure infiltrating the\nposterior wall of the bladder. Finally, a diagnostic laparos-\ncopy performed 3 months prior to the surgical procedure\nrevealed a “frozen pelvis, ” strongly suggestive of endome-\ntriosis of the bowel. Based on these findings, the patient\nwas admitted for laparoscopic radical resection of endome-\ntriosis and the left nephrectomy.\nAt operation, incision of the bladder showed macro-\nscopic features of an endometriotic tumour originating from\nthe posterior bladder wall (Fig. 3). In addition, dissection\nof the pouch of Douglas revealed extensive endometriosis of\nthe RVS and anterior rectal wall. An isolated endometriotic\nnodule of the rectal wall was identified 6 cm cranial to the\nlower infiltration site. Following salpingo-ovariolysis, an\nendometrioma of the right ovary was drained and excised.\nThe patient finally underwent anterior segmental resection\nof the rectal wall with end-to-end anastomosis (31 cm\nEndogia® device) (Fig. 4). Partial cystectomy involving\nresection of the posterior wall of the urinary bladder and\nsuturing of the resection margins, as well as the left\nlaparoscopic nephrectomy, was carried out. Histological\nanalysis of paraffin-embedded tissue confirmed endo-\nmetriosis of the right ovary, rectal muscularis (muscularis\npropria and submucosal layer) and the urinary bladder.\nPatho-histological analysis of the left kidney revealed a 6×\n4×3.5-cm specimen and a 25-cm-long ureter. Histological\nanalysis demonstrated generalised renal atrophy due to\nhydronephrosis, as well as extrinsic and intrinsic endome-\ntriosis of the ureter. Her postoperative course was uncom-\nplicated and the urinary catheter was removed on day\n8 after the operation without complication. The patient was\nfinally discharged following a control cystogram to exclude\nleakage. At follow-up four weeks postoperatively, the\npatient was complaining of moderate symptoms of urge\nincontinence but was otherwise doing well. A bladder scan\nshowed minimal residual volume.\nDiscussion\nThe most frequent localisations of endometriotic lesions are\nthe uterosacral ligaments, the pelvic peritoneum and the\novaries [10]. In a subgroup of patients, endometriotic growth\nis deeply infiltrating, i.e. the presence of endometriotic tissue\nmore than 5 mm under the peritoneum [ 11]. Deep infiltrating\nendometriosis, which is commonly involving the RVS and\nthe rectum, can be diagnosed in up to 10% of all patients\nwith endometriosis [ 11]. However, endometriotic involve-\nment of the urinary system is rather rare and has been\nreported to occur in only 1 –2% of all cases of pelvic\nendometriosis [ 12]. Urinary endometriosis commonly\ninvolves the urinary bladder and/or the ureter. However,\ndue to its rarity and asymptomatic course in the early stages\nof the disease, final diagnosis can be delayed [13]. In the case\npresented, endometriotic tissue not only involved the\nrectosigmoid but also caused considerable distortion of the\nurinary bladder due to extensive involvement of the posterior\nwall. In addition, ureteral obstruction finally led to hydro-\nnephrosis with a subsequent long-standing impairment and,\nfinally, a loss of renal function. Although there is evidence of\ntemporary regression of endometriosis under hormonal\ntreatment, such as GnRH analogues or gestagens, we suggest\nthat, in cases of extensive involvement of extragenital tissues,\nsuch as the bowel or the urinary tract, surgical therapy is\nmandatory and should especially be considered in patients\nwith subfertility.\nReferences\n1. Gao X, Outley J, Botteman M, Spalding J, Simon JA, Pashos CL\n(2006) Economic burden of endometriosis. Fertil Steril 86\n(6):1561–1572\n2. Jones KD, Sutton C (2002) Endometriosis. Emphasis on medical\ntreatment is misleading. BMJ 324:115\n3. Olive DL, Pritts EA (2002) The treatment of endometriosis: a\nreview of the evidence. Ann N Y Acad Sci 955:360 –372\n4. Ferrero S, Abbamonte LH, Giordano M, Ragni N, Remorgida V .\n(2006) Deep dyspareunia and sex life after laparoscopic excision\nof endometriosis. Hum Reprod 22:1142 –1148\n5. Lyons SD, Chew SS, Thomson AJ, Lenart M, Camaris C, V ancaillie\nTG, Abbott JA (2006) Clinical and quality-of-life outcomes after\nfertility-sparing laparoscopic surgery with bowel resection for severe\nendometriosis. J Minim Invasive Gynecol 13(5):436–441\n6. Garry R, Clayton R, Hawe J (2000). The effect of endometriosis\nand its radical laparoscopic excision on quality of life indicators.\nBJOG 107(1):44 –54\n7. Redwine DB, Wright JT (2001) Laparoscopic treatment of complete\nobliteration of the cul-de-sac associated with endometriosis: long-\nterm follow-up of en bloc resection. Fertil Steril 76(2):358–365\n8. Ford J, English J, Miles W A, Giannopoulos T (2004) Pain, quality\nof life and complications following the radical resection of\nrectovaginal endometriosis. BJOG 111(4):353 –356\n9. Keckstein J, Ulrich U, Kandolf O, Wiesinger H, Wustlich M (2003)\nLaparoscopic therapy of intestinal endometriosis and the ranking of\ndrug treatment (in German). Zentralbl Gynakol 125(7–8):259–266\n10. V ercellini P , Trespidi L, De Giorgi O, Cortesi I, Parazzini F,\nCrosignani PG (1996) Endometriosis and pelvic pain: relation to\ndisease stage and localization. Fertil Steril 65(2):299 –304\n11. Cornillie FJ, Oosterlynck D, Lauweryns JM, Koninckx PR (1990)\nDeeply infiltrating pelvic endometriosis: histology and clinical\nsignificance. Fertil Steril 53:978 –983\n12. Gustilo-Ashby AM, Paraiso MF (2006) Treatment of urinary tract\nendometriosis. J Minim Invasive Gynecol 13(6):559 –565\n13. Schneider A, Touloupidis S, Papatsoris AG, Triantafyllidis A,\nKollias A, Schweppe KW (2006) Endometriosis of the urinary\ntract in women of reproductive age. Int J Urol 13(7):902 –904\nGynecol Surg (2008) 5:45 –47 47","source_license":"CC0","license_restricted":false}