Ureteral endometriosis: correlation between ultrasonography and laparoscopy

Ultrasound has been shown to be at least as accurate as magnetic resonance imaging for diagnosing deep infiltrating endometriosis, although most efforts have been aimed at evaluating the posterior pelvic compartment1. The lateral pelvic compartment has been less well studied, although endometriosis of the broad ligaments represents the most frequent site at advanced stages2. The importance of identifying endometriosis of the broad ligament is related not only to the resulting adhesions between nodules of the upper part of the broad ligament and the ovary and Fallopian tube, potentially negatively impacting fertility and contributing to chronic pelvic pain, but also to its proximity to the ureter. In fact, the anatomical course of the ureter in the pelvis is highly superficial, lying just beneath the broad ligament3. In some cases, the endometriotic nodule lies on the middle part of the broad ligament and infiltrates the shallow connective tissue up to the ureteral surface, compressing or infiltrating the ureter. This occurrence represents a potentially serious situation due to clinically silent urinary-flow obstruction that may lead to loss of renal function4. An accurate preoperative ultrasound examination can identify dilated ureters and/or hydronephrosis and possibly locate the endometriotic nodule5. The most difficult part of the sonographic evaluation is differentiating between extrinsic compression and ureteral-wall infiltration as they require different surgical approaches4. We present a case of ureteral endometriosis in which ultrasound was useful in evaluating the extent of the disease and planning surgery. A 29-year-old woman presented with severe dysmenorrhea. Transvaginal ultrasonography demonstrated endometriosis with superficial rectal involvement with attachment to the left uterosacral and broad posterior ligaments. The nodule medialized and compressed the left ureter without encroaching its wall (Figure 1a), with asymptomatic Grade-2 hydronephrosis. The ureteral adventitia appeared intact and normal ureteral peristalsis was verified (Videoclip S1 and Figure S1) so laparoscopic ureterolysis was planned. At laparoscopy, the clinical picture was confirmed (Figure 1), with the uterosacral ligament displaced upward and the bowel attached to the endometriotic nodule (Figure 1b). The bowel was detached and the broad posterior ligament was opened at the pelvic brim in order to follow the pelvic ureter course to identify the ureteral stricture (Figure 1c). The proximal part of the ureter was confirmed to be dilated while the distal part appeared normal (Figure 1d). The endometriotic nodule was detached and, during dissection, a clear image of a fibrotic ‘muff’ surrounding the ureter was found at the site of stricture (Figure 1e). Progressive removal of the exposed periureteral fibrotic tissue and the nodule was carried out (Figure 1f). Although the ureteral diameter returned slowly to normal, a protective ureteral stent was inserted. After 3 months, the ureteral stent was removed and a normal ureter was confirmed by retrograde ureterography. Ureteral involvement in deep infiltrating endometriosis is not a frequent occurrence but it requires careful preoperative evaluation to optimize counseling and to plan correctly a multidisciplinary surgical approach4,5. In cases in which the ureteral compression does not involve ureteral wall infiltration, an experienced gynecological surgeon can perform the procedure (ureterolysis) safely while, if the ureter is infiltrated (intrinsic ureteral endometriosis), ureteral surgery (ureteroneocystostomy or ureteroureteral anastomosis) performed by a urological surgeon is mandatory. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.