Ureteral Endometriosis Masquerading As Urothelial Cancer

We present a case of ureteral endometriosis masquerading as urothelial carcinoma of ureter . The patient was diagnosed intraoperatively to have ureteral endometriosis , after excision of the lesion and intraoperative frozen section . Key words : ureteral , endometriosis , urothelial , carcinoma , surgery 1.

Ureteral endometriosis is a rare form of deep endometriosis which often evades diagnosis till the late stages when there is impending or established renal failure . We present a rare case of endometriosis and obstructive uropathy , masquerading as primary urothelial carcinoma of the ureter . 2. Case Report A 42 - year - old woman presented with vague left flank pain since 4 months . There were no episodes of acute exacerbation of the pain and no history of haematuria or any lower urinary tract symptoms . There were no bowel complaints , no abdominal pain or back pain . She also complained of loss of appetite with a weight loss of around 2 kg in 4 months . On enquiry , she gave a history of having undergone total abdominal hysterectomy with preservation of both ovaries at the age of 34 years for complaints of menorrhagia . Prior to this surgery , her menses were painful , but regular . Ultrasonography revealed left severe hydronephrosis secondary to left lower ureteric obstruction and a left haemorrhagic ovarian cyst . Contrast enhanced C T scan ( Figure 1 , 2a &2b ) revealed a 5 .2 x 3 cm left ureteric mass with intraluminal as well as extraluminal extension at the level of S3 vertebra causing severe left hydronephrosis and hydroureter with a 2 .9 x 3 .2 cm left para - aortic and bilateral enlarged iliac lymph nodes . Ureteroscopic evaluation of the left ureter showed narrowed irregular haemorrhagic lower ureteric segment , and it was not possible to negotiate the scope beyond that . It was not possible to take an adequate biopsy from this area . Metastatic work up in the form of CECT chest and isotope bone scan was normal . On DTPA scan , the GFR of the right and left kidneys were 50 ml/min and 16 ml/min . In view of the findings on imaging studies , the patient was advised surgery . In tra - operatively , there was a solid mass lesion of 6 x 3 cm involving the left distal ureter causing gross left hydroureter . The mass was extending laterally to involve the left adnexa . Excision of the left ureteric mass was done and the intraoperative frozen section revealed presence of “endometriosis of the ureter , with no evidence of malignancy” . L eft ureteric re - implantation into bladder [ ureteroneocystostomy ] with psoas hitch was done . The frozen section revealed “ extrinsic endometriosis in the ureter ” . Bilateral oophorectomy was also done . Six months post - operatively , the left sided hydronephrosis has resolved and repeat CT scan showed bilateral well - functioning kidneys . She is presently asymptomatic and free of recurrence of endometriosis clinically and radiologically . 3.

Endometriosis is the presence of functioning endometrial tissue outside the uterine cavity and can be superficial ( peritoneal , ovarian ) or deep and infiltrating ( >5 mm ) [ 1] . The incidence of urinary tract endometriosis is 1 - 1 .5 % with the bladder being involved in 70 - 80% , ureter in 9 - 23% , kidney in 4% and urethra in 2% [ 2 , 3 ] . Patients with ureteric endometriosis are usually associated with more ad vanced stages of endometriosis [ 2 ] . With it s peak incidence in the age group of 30 - 35 year s [ 3 ] , t he diagnosis of ureteral endometriosis is difficult since the disease may be clinically silent in about 30% of patients and non - specific symptoms are present in up to 5 0% of women [ 4 , 5 ] lead ing to an underestimation in its prevalence [ 2 , 5 ] . W hile pelvic pain and dysmenorrhoea are the most common symptoms reported by the patients , o nly about 10 - 15% patients present with urinary symptoms including cyclical haematuria considered highly characteristic of ureteral endometriosis [ 6 ] . Paper ID: SR22212111239 DOI: 10.21275/SR22212111239 694 International Journal of Science and Research (IJSR) ISSN: 2319 - 7064 SJIF (2020): 7.803 Volume 11 Issue 2, February 2022 www.ijsr.net Licensed Under Creative Commons Attribution CC BY Although bilateral lesions occur in 10 - 42% , unilateral lesions are much more common with a pred isposition for the left side [ 7 ] and usually involves the distal 3 - 4 cm of the ureter . The degree of symptoms correlates poorly with the severity of obstruction , which if long - standi ng , could lead to renal failure [ 8 ] . Pateman ( 2015 ) reported a sensitivity of 92% and a specificity of 100% with ultrasonography for diagnosing ureteric endometriosis [ 9 ] . Knabben ( 2015 ) proposed a radiological - clinical classification of ureteric endometriosis – our patient had a Grade 4 ureteric endometriosis in view of the impaired renal clearance [ 2 ] . T he definitive diagnosis of ureteric endometriosis and its extent and severity is often based on surgery and histopathological examination and not on imaging studies . Optimal recommendations regarding diagnostic

and therapeutic management cannot be made in view of the relative rarity of this condition . H ormonal contraceptives and progestogens are the first line for pain relief in deep endometriosis [ 5 ] . Ureteral endometriosis is usually treated with surgery and the mode of treatment varies depending on the level and length of ureteric involvement , the degree of obstruction and the renal function and can range from hormonal therapy alone or with double - J stent insertion to ureterolysis , segmental ureterectomy and end - to - end anastomosis , or segmental ureterectomy and uretro - neocysto stomy , and nephrectomy . DTPA renal scan can be quite useful in deciding between preservation of kidney and nephrectomy . U reteric resection is the

of choice in cases of ureteric obstruction in order to reduce the ri sk of recurrence , as was done in our patient [ 10 ] . The effectiveness of post - operative medical therapy has not yet been proven . Our patient had a long segment lower ureteric involvement and a large mass implicating the ureter and hence she was not suitable for simple ureterolysis or end - to - end ureteric anastomosis after resection of ureteric segment . Hence she underwent ureteroneocystostomy with a psoas hitch to make a tension - free anastomosis . 4.

Ureteral endometriosis is a rare elusive disease which could lead to permanent renal damage . A high index of suspicion is required to aid early detection in order to ensure treatment is less invasive and prognosis is better . Our patient had a pelvic mass masquerading as urothelial cancer and ureteric endometriosis was diagnosed only at laparotomy .

[1] Vercellini P , Viganò P , Somigliana E , Fedele L . Endometriosis : pathogenesis and treatment . Nat Rev Endocrinol .2 014 ; 10 [ 5 ] : 261 - 275 . [2] Knabben L , Imboden S , Fellmann B , Nirgianakis K , Kuhn A , Mueller MD . Urinary tract endometriosis in patients with deep infiltrating endometriosis : prevalence , symptoms , management , and proposal for a new clinical classification . Fertil Steril .2 015 ; 103 [ 1 ] : 147 - 152 . [3] Berlanda N , Vercellini P , Carmignani L , Aimi G , Amicarelli F FL . Ureteral and vesical endometriosis . Two different clinical entities sharing the same pathogenesis . Obs Gynecol Surv .2 009 ; 64 : 830 - 842 . [4] Huang J - Z , Guo H - L , Li J - B , Chen S - Q . Management of ureteral endometriosis with hydronephrosis : Experience from a tertiary medical center . J Obstet Gynaecol Res .2 017 ; 43 [ 10 ] : 1555 - 1562 .1 3 [5] Barra F , Scala C , Biscaldi E , et al . Ureteral endometriosis : a systematic review of epidemiology , pathogenesis , diagnosis , treatment , risk of malignant transformation and fertility . Hum Reprod Update .2 018 ; 24 [ 6 ] : 710 - 730 .1 4 [6] Perez - Utrilla Perez M , Aguilera Bazan A , Alonso Dorrego JM , Hernandez A , de Francisco MG , Martin Hernandez M , de Santiago J , de la Pena Barthel J . Urinary tract endometriosis : clinical , diagnostic , and therapeutic aspects . Urology 2009 ; 73 : 47 – 51 . [7] Alves J , Puga M , Fernandes R , et al . Laparoscopic Management of Ureteral Endometriosis and Hydronephrosis Associated With Endometriosis . J Minim Invasive Gynecol .2 4 [ 3 ] : 466 - 472 .1 7 [8] Vercellini P , Viganò P , Somigliana E , Fedele L . Endometriosis : pathogenesis and treatment . Nat Rev Endocrinol .2 014 ; 10 [ 5 ] : 261 - 275 .2 0 [9] Pateman K , Holland TK , Knez J , Derdelis G , Cutner A , Saridogan E , Jurkovic D . Should a detailed ultrasound examination of the complete urinary tract be rou - tinely performed in women with suspected pelvic endometriosis? Hum Reprod 2015 ; 30 : 2802 – 2807 . [10] Chapron C , Chiodo I , Leconte M , Amsellem - Ouazana D , Chopin N , Borghese B , Dousset B . Severe ureteral endometriosis : the intrinsic type is not so rare after complete surgical exeresis of deep endometriotic lesions . Fertil Steril 2010 ; 93 : 2115 – 2120 . Figure 1 : CT scan showing a left ureteric mass Paper ID: SR22212111239 DOI: 10.21275/SR22212111239 695 International Journal of Science and Research (IJSR) ISSN: 2319 - 7064 SJIF (2020): 7.803 Volume 11 Issue 2, February 2022 www.ijsr.net Licensed Under Creative Commons Attribution CC BY Figure 2A : CT scan showing left hydronephrosis secondary to left ureteric mass Figure 2B : CT IVU showing cut - off at lower end of left ureter with proximal left hydroureter and hydronephrosis Figure 3 : Surgical specimen (cut section) of excised left ureteric mass Paper ID: SR22212111239 DOI: 10.21275/SR22212111239 696