{"paper_id":"af3c81be-85fe-43cc-b1ba-c801232c1f50","body_text":"Archives of the Balkan Medical Union\nCopyright © 2019 Balkan Medical Union\nvol. 54, no. 4, pp. 731-734\nDecember 2019\nRÉSUMÉ\nApproche laparoscopique de l’endométriose urétérale\nL’endométriose urétérale est caractérisée par le déve-\nloppement d’îlots infiltrants profonds du tissu endo-\nmétrial affectant l’uretère, la gestion optimale dans de \ntels cas étant encore mal définie. Une fois que les tech-\nniques de chirurgie laparoscopique se sont améliorées, \ncette approche peu invasive a été proposée avec des \nrésultats encourageants dans le traitement de tels cas. \nEn ce qui concerne les types d’interventions chirur-\ngicales nécessaires dans de tels cas, ils sont choisis en \nfonction du degré, de l’étendue et de la localisation du \ntissu endométrial. Il s’agit d’une revue de la littérature \ndes plus grandes études menées sur le thème de la ges-\ntion laparoscopique de l’endométriose urétérale ; les \nprincipaux paramètres analysés se réfèrent à l’efficacité \net à la sécurité de la procédure.\nMots-clés: endométriose urétérale, résection, coelios-\ncopie.\nABSTRACT\nUreteral endometriosis is characterized by the develop-\nment of deep infiltrating islets of endometrial tissue \naffecting the ureter, the optimal management in such \ncases being still poorly defined. Once the techniques \nof laparoscopic surgery improved, this minimally in-\nvasive approach has been proposed with encouraging \nresults in treating such cases. When it comes to the \ntypes of surgical procedure which are needed in such \ncases, they are chosen accordingly to the degree, extent \nand localization of the endometrial tissue. This is a \nliterature review of the largest studies which were con-\nducted on the theme of the laparoscopic management \nof ureteral endometriosis; the main analyzed param-\neters refer to the efficacy and safety of the procedure.\nKeywords: ureteral endometriosis, resection, laparos-\ncopy.\nMINIREVIEW\nLAPAROSCOPIC MANAGEMENT OF URETERAL \nENDOMETRIOSIS\n  Nicolae BACALBASA1,2 , Irina BALESCU3, Mihaela VILCU1,2, Iulian BREZEAN1,2\n1 „Carol Davila“ University of Medicine and Pharmacy, Bucharest, Romania\n2 „Ion Cantacuzino“ Clinical Hospital, Bucharest, Romania\n3 Ponderas Academic Hospital, Bucharest, Romania\nReceived 26 Aug 2019, Accepted 07 Oct 2019\nhttps:/ /doi.org/10.31688/ABMU.2019.54.4. 17\n Address for correspondence:   Nicolae BACALBASA\n„Carol Davila“ University of Medicine and Pharmacy, Bucharest, Romania\nEmail: nicolae_bacalbasa@yahoo.ro, Phone +40 723 540 426\n\nLaparoscopic management of ureteral endometriosis – BACALBASA et al\n732 / vol. 54, no. 4\nINTRODUCTION\nDefined by the presence of ectopic islands of en-\ndometrial cells and stroma outside the uterine body, \nendometriosis can be classified according to its depth \nin superficial – invading the peritoneum, and the \novary or deep infiltrating – invading the viscera such \nas rectum, colon, urinary tract or the enteral loops \nby at least 5 mm in depth. According to the depth of \ninvasion, the clinical signs and symptoms may range \nbetween diffuse pelvic pain, constipation, hematuria \nand complete bowel or urinary tract obstruction\n1-3.\nUrinary tract involvement in patients with endo-\nmetriosis\nWhen it comes to the urinary tract involvement, \nthe most commonly affected organs are represented \nby the urinary bladder, followed by ureter and kidney, \naccounting for 0.3-12% of all cases diagnosed with this \npathology\n4,5. Depending on the degree of invasion, ure-\nteral endometriosis can be classified as extrinsic – if \nthe periureteral tissues or the serosa are involved – and \nintrinsic, if the muscularis propria or the mucosa is \ndamaged\n6. In cases presenting extrinsic endometriosis, \nthe lesions originate from the peritoneum, ovaries or \nuterosacral ligaments and produce an extrinsic com-\npression of the ureter, while in intrinsic lesions, inva-\nsion of the muscularis or mucosa occurs. However, it \nseems that extrinsic lesions are up to four times more \nfrequent when compared to intrinsic lesions\n7,8.\nIn order to rule out which are the predictive \npreoperative factors regarding the depth of ureteral \ninvasion, Gennaro et al.  conducted a study on 82 \nwomen in whom ureteral involvement due to endo-\nmetriosis was encountered\n9. Among these cases the \nauthors identified 15 cases in which deep infiltrat-\ning endometriosis was present and in which ureteral \nresections were needed, and 67 cases in which the \nurological procedure was limited to ureterolysis. The \nauthors underlined the fact that the most commonly \nencountered symptom was represented by the ab-\ndominal pain, equally encountered between the two \ngroups, while other signs or symptoms, such as uri-\nnary urgency, hematuria, dysuria or hydronephrosis \nwere significantly more common among patients pre-\nsenting deep infiltrating lesions\n9.\nAs for the preoperative investigations which \nmight predict the presence of ureteral involvement, it \nhas been widely accepted that pelvic MRI, cystoscopy \nand urography might give important information in re-\ngard to the extent of the disease. More recently, a study \nconducted by Lima et al. demonstrated that the pres-\nence of endometrial nodules at the level of the utero-\nsacral ligament represents a strong predictive factor \nfor the association of ureteral involvement. Therefore, \nthey concluded that the presence of uterosacral nod-\nules measuring at least 1.75 cm on the right side and \n1.95 cm on the left side represents a strong predictive \nfactor for the concomitance of ureteral involvement\n10.\nSurgical goals in patients diagnosed with uret-\neral endometriosis\nOnce the diagnosis of ureteral endometriosis is \nestablished, surgery is needed in order to relieve the \nureteral obstruction, to preserve the renal function \nand to prevent the development of any recurrent dis-\nease\n4. In order to achieve these goals certain authors \nproposed initially performing a limited procedure \nsuch as ureterolysis; however, in a significant number \nof cases, recurrent disease might be encountered after \na relatively short period of time; therefore, in such \ncases resection and urinary tract reconstruction is fi-\nnally the option of choice. For example, in Ghezzi’s \nstudy which included 33 patients who were submit-\nted to laparoscopic ureterolysis, the rate of early re-\ncurrence imposing reoperation reached 12% during \nthe first three months postoperatively\n11. In the last \ndecades, once the techniques of minimally invasive \nsurgical approach improved, the number of cases sub-\nmitted to this approach increased as well; therefore, \na higher number of such cases have benefited lately \nfrom the advantages of the laparoscopic approach.\nStudies investigating the role of laparoscopic \nureteral resection for deep infiltrating endome-\ntriosis\nThe utility of the laparoscopic approach in such \ncases has been established in the last decades once \nthe minimally invasive approach started replacing \nthe conventional approach; therefore, it has been \nwidely accepted that the minimally invasive approach \nmight offer certain advantages, such as a magnifica-\ntion of the view and better individualization of the \nstructures. In the study conducted by Chudzinski \net al and published in 2017 the authors included 17 \npatients presenting ureteral involvement in which \nureteral resection and reimplantation were needed\n12. \nAmong these cases, the ureteral involvement was \nknown preoperatively in 82% of cases, in 23% of \nthem bilateral ureteral involvement being reported; \nmoreover 35% of cases also associated renal atrophy, \nwhile renal function impairment was found in 23% \nof cases. When it comes to the preferred approach, \nthe authors underlined the fact that laparotomy was \nthe option of choice in 41% of cases, being followed \nby laparoscopy in 35% of cases and robotics in 23% \nof cases; however, the rate of laparotomies decreased \nfrom 63% before the year of 2010 to 23% after the \nyear of 2010. Among cases submitted to a minimally \ninvasive approach, there were three cases in which \n\nArchives of the Balkan Medical Union\nDecember 2019 / 733\nconversion to open surgery was needed due to the \npresence of bowel injury – in one case and due to \nthe presence of iatrogenic ureteral lesions – in two \ncases\n12. In a similar study conducted by Sconman et \nal in Tel-Aviv, Israel, and which included seven pa-\ntients, the authors reported the necessity to convert \nfrom laparoscopy to laparotomy in two cases, while \nin other four cases laparotomy was the option of \nchoice\n13; interestingly, in all cases a previous history \nof at least one surgical intervention for endometrio-\nsis was reported. In all cases resection with ureteral \nreimplantation by using a psoas hitch technique was \nthe preferred technique. After a mean follow-up pe-\nriod of 42 +/-20 months, a single patient reported no \nimprovement of the symptoms\n13.\nThe benefits of the laparoscopic approach in \npatients with ureteral endometriosis were also dem-\nonstrated by Miranda-Mendoza in 2012\n14. The study \nincluded 13 patients submitted to surgery in a mini-\nmally invasive manner, six cases being submitted to \nureteral resections, while the remaining seven cases \nbeing submitted to ureterolysis. The histopathologi-\ncal studies of the resected specimens demonstrated \nthe presence of ureteral invasion in all cases in \nwhich segmental ureteral resections were performed. \nHowever, at that moment the rates of postoperative \ncomplications remained high, three of the 13 cases \ndeveloping vesical-vaginal leaks. However, after a me-\ndian follow-up period of 24 months all but one cases \nreported a significant improvement of the symptoms, \nas well as the absence of recurrent disease. In the 13\nth \ncase the patient developed an obstructive uropathy \nand an ureteroneocystostomy was performed\n14.\nOne of the largest studies which investigated \nthe feasibility and safety of laparoscopic management \nof ureteral endometriosis was the one conducted by \nCavaco-Gomes et al and published in 2017\n2. The \nstudy, a review which included 18 articles published \nsince 1997 and 700 patients demonstrated the effi-\ncacy of the method and underlined the fact that ure-\nteral endometriosis is a more common finding at the \nlevel of the left ureter (being encountered in 53.6%), \nfollowed by the right ureter (in 35.8% of cases) and \nbilateral lesions in only 10.6% of cases). As for the \ntype of surgical procedure which was performed, it \nconsisted of ureterolysis alone in 579 cases and ure-\nteral resection in the remaining ones; moreover, in \ntwo cases nephrectomy was imposed by the secondary \nrenal atrophy, while in other 19.8% of cases concomi-\ntant urinary bladder resection was also needed. Other \ncommon resections were represented by rectovaginal \nor uterosacral ones. When it comes to the short-term \noutcomes, the most frequently reported complica-\ntions were represented by ureteral leaks or stenosis \n(in 14 cases), hemorrhagic events (in three cases), \nanastomotic digestive leaks (in two cases), bowel per-\nforation (in one case), bladder atony (in one case) and \nvesicovaginal leak (in one case). As for the long-term \noutcomes, 90.5% of cases reported the resolution or \nimprovement of the symptoms. The authors also un-\nderlined the recurrent pattern of this pathology as \nwell as the fact that most often this disease is a mul-\nticentric one\n2.\nIn a recent study conducted by Ceccaromi et al, \nthe authors included 160 patients submitted to total \nlaparoscopic ureteroneocystostomy between January \n2009 and December 2016\n15; in all cases surgery was \nsuccessfully ended in a minimally invasive manner, \nwhile the histopathological studies confirmed the \npresence of ureteral invasion in all cases (in 45.6% \nthe urinary tract involvement occurred in an extrin-\nsic manner while in the remaining 54.4% of cases an \nextrinsic manner being demonstrated); after resection \nthe authors reported the use of the psoas technique \nof reconstruction in 58.7%. Moreover, concomitant \ndigestive tract invasion was seen in 75.6% and im-\nposed performing a bowel resection. When it comes \nto the short-term outcomes, the authors reported the \nnecessity of reoperation in 4.4% of cases; as for the \nlong-term outcomes, after a follow-up of six months, \n15% of cases reported impaired bladder voiding. In \nthe meantime after a mean follow-up period of 20.5 \nmonths regression of the symptoms was seen in most \npatients, only 1.2% of them requiring a ureteroneo-\ncystostomy on the opposite side\n15.\nWhen it comes to the modalities of reconstruc-\ntion after ureteral resections, while certain authors \nprefer performing an uretero-ureteral anastomosis \nwhenever is possible, other authors consider that \na ureteral reimplantation in the urinary bladder \nthrough an ureteroneocystostomy should be the op-\ntion of choice due to a lower risk of complications, \nsuch as anastomotic stenosis\n14,16,17.\nMoreover, in cases presenting deep infiltrating \nlesions, a combined laparoscopic and cystoscopic ap-\nproach might be tempted, encouraging results being \nreported so far\n18,19. This combined approach seems to \nhave the benefit of removing only the affected segment \nof the detrusor muscle decreasing in this way the risk \nof postoperative complications such as dysuria, polaki-\nuria or bladder denervation. The procedure begins in \na laparoscopic manner by identifying and dissecting \nthe endometrial nodule followed by a cystoscopic step \nwhich identifies the area of mucosal involvement\n20,21.\nCONCLUSIONS\nAlthough urinary tract involvement is a com-\nmon finding in patients diagnosed with endometrio-\nsis, ureteral invasion is lower when compared to the \n\nLaparoscopic management of ureteral endometriosis – BACALBASA et al\n734 / vol. 54, no. 4\nrates of urinary bladder invasion. Even though, when-\never ureteral involvement is discovered, laparoscopy \nseems to be a feasible method in order to achieve an \nadequate alleviation of the symptoms. Depending on \nthe degree of invasion and on the site of invasion \nmultiple therapeutic strategies might be proposed, \nranging from ureterolysis to ureteral resection with \nend to end anastomosis or ureteral resection followed \nby ureteral reimplantation by ureteroneocystostomy. \nAlthough initially the rates of postoperative com-\nplications were considerable, once more experience \nhas been gained these rates of morbidity decreased. \nIn the meantime, the rates of recurrences seen after \na long-term follow-up seem to report a descendent \ntrend during the last decade.\nAcknowledgements\nThis work was supported by the project enti-\ntled „Multidisciplinary Consortium for Supporting \nthe Research Skills in Diagnosing, Treating \nand Identifying Predictive Factors of Malignant \nGynecologic Disorders“, project number PN-III-P1-\n1.2-PCCDI2017-0833.\nCompliance with Ethics Requirements:\n„The authors declare no conflict of interest regarding \nthis article“\n“The authors declare that all the procedures and ex-\nperiments of this study respect the ethical standards in the \nHelsinki Declaration of 1975, as revised in 2008(5), as \nwell as the national law.“\nREFERENCES\n1. 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