{"paper_id":"941acb3f-4b05-49f0-81b0-e85a7574e4b0","body_text":"116\nCopyright © Journal of Medicine and Life Science\nJournal of Medicine and Life Science Vol. 19, No. 3, 116-120, December 2022\nhttps://doi.org/10.22730/jmls.2022.19.3.116\nSequential treatment with transurethral resection and hormonal \ntherapy for bladder endometriosis of vesicoureteric junction\nAbdulelah AlAdimi\n1\n, Nabil AlOdaini\n1\n, Atef M. M. Darwish\n2\n1\nDepartments of Urology,\n \nAlemadi Hospital, Doha, Qatar \n2\nDepartment of Obstetrics and Gynecology, Alemadi Hospital, Doha, Qatar\nAbstract Objective: T o estimate the efficacy of sequential treatment of \nbladder endometriosis (BE) of the vesicoureteric junction using transurethral \nresection (TUR) and hormonal therapy. Design: Case report. Setting: Private multi-\nspecialty hospital. Patient: A multiparous woman presented with perimenstrual \nlower urinary tract symptoms, cyclic chronic pelvic pain, and left loin pain. \nIntervention[s]: Ultrasonography revealed marked left renal dilatation. Computed \ntomography confirmed the presence of a bladder mass. A diagnostic cystoscopy \nrevealed compression of the left vesicoureteral junction. Complete TUR BE with \nrelease of chocolate material during resection, followed by ureteric double J stent \ninsertion for 3 months, was performed. Histopathology confirmed the diagnosis \nof BE, followed by adjuvant hormonal therapy (dienogest) for 3 months. Follow-\nup for about 2 years revealed complete relief of the symptoms without any \nrecurrence. Main Outcome Measure[s]. Success and recurrence rates of sequential \nTUR and hormonal therapy of BE of the vesicoureteric junction. Result[s]. TUR BE \nfollowed by adjuvant hormonal therapy was very effective in eradicating BE of the \nvesicoureteric junction in a safe manner without recurrence on follow-up for 2 \nyears. Conclusion[s]. BE of the vesicoureteric junction can be properly treated by \nsequential TUR and hormonal therapy without recurrence over a 2-year follow-up.\nKey words:  Urinary bladder, Endometriosis, Resectoscope, Hydronephrosis, \nVesicoureteral junction, Dienogest\nReceived : June 9, 2022\nRevised  : July 14, 2022\nAccepted : August 24, 2022\nCorrespondence to \nAtef M. M. Darwish\nDepartment of Obstetrics and Gynecology, \nAlemadi Hospital, AlHelal, Doha 50000, \nQatar\nTel: 974 30200336\nFax: 974 77741504\nE-mail: atef_darwish@yahoo.com\nCase Report\nINTRODUCTION\nUrinary tract endometriosis is estimated to affect up to 1% \nof women with pelvic endometriosis.\n1\n Bladder endometriosis \n(BE) is a challenging rare condition that is poorly addressed \nin terms of pathogenesis, clinical presentation, and \nmanagement.\n2,3\n In addition to lower urinary tract symptoms \n(LUTS), it may lead to obstructive uropathy and renal \nfailure.\n4\n To achieve the best results, management should \ninvolve collaboration between urologists and gynecologists.\n3\n \nHerein, we describe a rare case of BE localization at the \nvesicoureteric junction. Involvement of or proximity to the \nvesicoureteric junction makes surgical decisions difficult \nbecause if the mass is completely resected, the possibility of \nureteric damage is high, and if it is conservatively resected, \npersistence of the disease is possible. In this case report, \nJournal of Medicine \nand Life Science\neISSN: 2671-4922\n\n\n BE promptly treated by urologists and gynecologists\n117\nhttps://medsci.jejunu.ac.kr/\nAbdulelah AlAdimi, Nabil AlOdaini, Atef M. M. Darwish\na female patient diagnosed with BE was properly treated \nby sequential transurethral resection of BE (TUR BE) and \nureteric double J stent ureteric stenting and a postoperative \ncourse of dienogest for 3 months.\nCASE REPORT\nOn 7th of July 2020, a 34-year-old multiparous (P4+2) \nwoman presented with dull aching and progressive \nsevere left loin pain for 2 weeks. There was no history of \ncesarean section, abdominal myomectomy, or other pelvic \nsurgery. She had a history of LUTS in the form of pelvic \npain, dysuria, and an increased frequency of micturition \ncharacteristically exaggerated just before, during, and \npersisting for a few days after menstruation. There was \nno history of hematuria. Clinically, there was left loin \ntenderness without associated fever. Ultrasonographic \nassessment revealed marked left renal back pressure, \nnormal bladder wall thickness, and absence of gynecologic \nabnormalities, apart from a small posterior wall myoma. \nMultislice Abdominal and pelvic computed tomography \n(CT) plain, post-IV contrast portal venous and delayed \nscans showed grade IV left hydronephrosis with a \nmarkedly dilated and tortuous left ureter and left soft \nFigure 1. Multislice computed tomography scan showing left severe \nhydronephrosis (*, left picture) and a left vesico-ureteral mass (**, \nright picture).\nFigure 2. Diagnostic and operative cystoscopy. (A) Diagnostic cystoscopy shows a vesicoureteric mass. (B-D) Transurethral resection of bladder \nendometriosis. (D) Notice chocolate material coming out from the mass on resection (arrow). (E) Complete resection. (F) Insertion of a double J.\nA\nD\nB\nE\nC\nF\n\nVol. 19. No. 3, December 2022\n118\nhttps://medsci.jejunu.ac.kr/\nJournal  of  Medicine  and  Life  Science\ntissue attenuation lesions at the left vesicoureteral junction \nmeasuring 25×15×14 mm, as shown in Figure 1. The patient \nconsented and was prepared for diagnostic/operative \ncystoscopy and possible concomitant surgical interventions \nto save the left kidney after receiving approval of the \nEthical/Institutional Review Board. Diagnostic cystoscopy \nrevealed a congested mass at the left vesicoureteral junction \nobscuring the ureteric orifice (Fig. 2A). Complete TUR \nBE was performed using a bipolar resectoscope (Olympus \nMedical Systems, Hamburg, Germany) until good exposure \nof the ureteric orifice was achieved using a DJ stent, as \nshown in Figure 2B-F. The gynecologist (A.D.) observed \nchocolate material coming from the mass during resection \nand highly suspected an endometriotic lesion before the \nhistopathological report (Fig. 2D). As shown in Figure 3, \ndefinite endometriotic glands and stroma contributed to the \nexcised mass. The postoperative course was uneventful. \nAn immediate postoperative course of 2 mg dienogest \n(Visanne; Bayer, Leverkusen, Germany) daily for 3 months \nwas prescribed. On follow-up visits over a period of 2 years, \nhigh-resolution 2D ultrasonography revealed restoration \nof normal renal appearance without any bladder or pelvic \nmasses. Clinically, the patient noted marked improvement \nof loin pain, attenuated LUTS, and a better quality of life \nbut complained of adverse effects such as headache, breast \ndiscomfort, and depressed mood.\nDISCUSSION\nEndometriosis of the urinary bladder is an uncommon \npathology.\n1,2\n Nevertheless, it should be considered \nin cases of unexplained dysuria or imaging findings \nsuggestive of urinary bladder malignancy.\n5\n In this case, \ntransabdominal ultrasonography missed the diagnosis \nof BE. Even transvaginal ultrasonography may miss \nthe diagnosis of pelvic endometriosis in symptomatic \ncases.\n6\n Since transabdominal ultrasonography revealed \nunilateral hydronephrosis, multislice CT revealed a left \nmarkedly dilated and tortuous ureter and a small mass at \nthe vesicoureteric junction. A dedicated preoperative CT or \nmagnetic resonance imaging work-up would help accurately \nlocalize BE. Some authors recommend adequate bladder \nfilling during examination to estimate the distance between \nendometriosis implants and ureteral orifices to better \npredict the requirement for ureteric stent or resection and \nreimplantation.\n7\nClinicians should consider endometriosis in all cases \nof pelvic pain or perimenstrual LUTS. Clinical suspicion \ncan be confirmed using endoscopy as the ultimate \ndiagnostic tool. In this case, cystoscopy played a central \nrole in confirming the diagnosis, as well as proper surgical \nexcision. The main problem with the surgical treatment of \nBE is the proximity of the nodule to the ureteric orifice. \nSome systematic reviews recommend partial cystectomy \nor combined surgery to guarantee complete removal of \nthe bladder nodule to minimize recurrence; therefore, \ntransurethral surgery alone should be avoided in favor of \nsegmental bladder resection.\n1\n This recommendation was \nnot followed in this case report because invasive procedures \nrequire laparotomy and ureteric reimplantation with short- \nand long-term complications such as recurrent urinary \ntract infections, progressive renal scarring, hypertension, \nand complications during pregnancy.\n8\n In contrast, the \ncystoscopic approach is an ideal minimally invasive \nprocedure with clear and well-settled advantages. It enabled \ncomplete resection of the mass with magnified visual \ndemarcation from the healthy bladder tissue. Leakage of \nFigure 3. (A) prominent endometrial stroma. (B) endometrial glan -\ndular tissues. Histopathologic diagnosis of bladder endometriosis (en-\ndometrial glands along with endometrial stroma in between muscle \nfibers) (Hematoxylin and Eosin stain, ×200).\nA B\n\n BE promptly treated by urologists and gynecologists\n119\nhttps://medsci.jejunu.ac.kr/\nAbdulelah AlAdimi, Nabil AlOdaini, Atef M. M. Darwish\nchocolate material during resection is an excellent finding, \nassuring that this lesion is mostly endometriotic rather than \nmalignant. An additional advantage was the use of adjuvant \npostoperative dienogest to stop the progression of missed \nendometriotic tissues. This procedure would encourage \ninterested endoscopists to collect similar cases, publish the \nresults, and follow-up for a long time to confirm that there is \nno recurrence or side effects with the current approach.\nCystoscopically guided resection is key to safe and \nsuccessful complete excision, as shown in this case. Since \nthere was no gynecological evidence of endometriosis, we \nomitted the addition of laparoscopy as a diagnostic tool, \nunlike others.\n3\n Some case reports have demonstrated the \nuse of the laparoscopic approach for radical excision of \nBE.\n5\n We believe that cystoscopic access is easier and more \nprecise, particularly if the mass is suspect in the absence of \ngynecologic lesions.\nIn this case report, collaboration between urologists \nand gynecologists was evident, as gynecologists are more \nfamiliar with the diagnosis and management of pelvic \nendometriosis. The AD observed chocolate material \ncoming from the mass during resection and suspected an \nendometriotic lesion before the histopathologic report. The \ngynecologist selected a 2 mg daily dose of dienogest as \nadjuvant therapy to complete the treatment of the lesion, \nas recommended by some studies on BE.\n9\n On follow-up \nvisits performed by urologists, 3-month adjuvant dienogest \nwas considered by the gynecologist to be sufficient to \nensure normal bladder, renal, and ureteric anatomy, unlike \nothers who administered it for 12 months.\n10\n The keys to \nsuccessful BE management in this case were the elimination \nof symptoms, restoration of normal renal and ureteric \nanatomy, and absence of recurrence on follow-up visits for \nup to 2 years. These goals led to the gynecologic decision to \nstop dienogest after only 3 months. The patient complained \nof adverse effects such as dienogest-like headache, breast \ndiscomfort, and depressed mood, as previously reported.\n11\n \nProlonged dienogest therapy is associated with risks and \nside effects.\n12\n Moreover, surgical excision of endometriotic \ntissue is the ideal treatment for all types of extragenital \nendometriosis, while adjunctive treatment might be useful \nin selected cases.\n4\n It is important to follow treatment \nguidelines and tailor care to the woman’s individual \nneeds and desires.\n12,13\n Others have used gonadotrophin \nreleasing hormone (GnRH) agonists to treat extragonadal \nendometriosis.\n12,14\n Nevertheless, dienogest offers advantages \nin terms of safety and tolerability.\n15\n Some studies \nrecommended starting medical treatment before deciding \non surgery, with a success rate of 52.3%.\n16\n In this study, this \napproach was impossible because the patient presented with \nadvanced renal and ureteric affection that urged surgery \nas a first-line therapy, while dienogest was added as an \nadjuvant therapy to ensure the destruction of any remaining \nendometrial lesions.\nThe overall recurrence rate of endometriosis ranges \nfrom 6% to 67%.\n17\n On 2-year follow-up, we detected no \nrecurrence in this case, as the mass was properly resected \nusing a resectoscope followed by adjuvant hormonal \ntreatment. In conclusion, BE of the vesicoureteric junction \ncan be properly treated by sequential transurethral resection \nand hormonal therapy without recurrence over a 2-year \nfollow-up. This rare case report highlights the importance of \nminimally invasive procedures in modern practice and the \nvalue of cooperation between urologists and gynecologists. \nUrogynecology is an attractive collaborative term used to \ndescribe a better management plan for many problems in \nwomen. Establishment of urogynecology units in hospitals \nwould improve the healthcare of women and ensure high-\nquality treatment for patients undergoing urogynecological \nsurgery.\n18\nREFERENCES\n  1. Leonardi M, Espada M, Kho RM, Magrina JF, Millischer AE, \nSavelli L, et al. Endometriosis and the urinary tract: from diagnosis \nto surgical treatment. Diagnostics (Basel) 2020;10:771.\n  2. Leone Roberti Maggiore U, Ferrero S, Candiani M, Somigliana E, \nViganò P, Vercellini P. 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