Ureteral polypoid endometriosis causing hydroureteronephrosis

Endometriosis is defined as the presence of endometrial tissue outside the uterine cavity.[] Even though reported numbers vary widely depending on the population under each study, the prevalence of endometriosis can be estimated to be around 10% to 15% in premenopausal women, and it is one of the primary causes of hospitalization in female patients between 15 and 44 years of age.[,,,] Recent data suggest that low parity and heavy menstrual cycles are risk factors of endometriosis, supporting the menstrual reflux hypothesis.[] The disease, characterized by local aggressiveness and risk of recurrence, requires both surgical and hormonal (non-surgical) treatments, such as luteinizing hormone-releasing hormone (LHRH) analogues, danazol, and estroprogestins. Therefore, although it is benign, it may be considered as a kind of true neoplastic process.[] The involvement of the urinary tract (the urinary bladder and the pelvic ureter) can be regarded as a rare condition that shares many characteristics with the gynecologic counterpart, but at the same time, has its own peculiar clinical and therapeutic features.[,] From the urological point of view, treatment should achieve the symptom relief and the recovery of the renal function. Herein, a case of ureteral polypoid endometriosis is presented and discussed. CASE REPORT A 44-year-old Japanese woman presented with a left low back pain. She reported a long history of chronic back pain. Abdominal ultrasonography revealed the left hydroureteronephrosis, and then she was referred to Shinko hospital. Her uterus was resected because of endometriosis 3 years before. She had no special family history. Retrograde pyelography showed the defect in the ureter, and on ureteroscopy, a polypoid mass was identified. Biopsy specimen from the ureteral mass showed endometrioid epithelia and edematous stroma, which was positive for progesterone and estrogen receptors and CD 10, a specific marker for endometrial stroma [Figure 1]. The lesion was consistent with endometriosis. The clinical diagnosis was then made as ureteral polypoid endometriosis causing hydroureteronephrosis. For the lesion (endometrioma), partial resection of the ureter and ureteroneocystostomy with Boari flap were adopted. The resected specimen showed a 2-cm polypoid mass, and histologically, the lesion was diagnosed as ureteral endometriosis. Endometrioid epithelial and stromal cells beneath the non-neoplastic urothelium showed no atypia [Figure 2]. The postoperative course was uneventful, the patient showed no evidence of local recurrence after the initial resection, and continues to be under close follow up.

Urinary tract involvement of endometriosis is uncommon (1%-5% of all cases) and mainly involves bladder, ureter and kidney in a 40:5:1 ratio.[,] Endometriosis in the ureter is thought to develop from severe ovarian endometriosis, and in the majority of patients with ureteral endometriosis, diagnosis is more difficult than bladder endometriosis due to the lack of specificity or the absence of symptomatology.[,,,,,] Cystoscopy is recommended in women affected by endometriosis complaining lower urinary tract symptom or hematuria; an ultrasonographic study of the upper urinary tract should be performed in all patients with pelvic endometriosis even if the patient is urologically asymptomatic. Furthermore, besides the neoplasm, endometriosis should be included in the differential diagnosis of ureteral strictures in sexually active young females. Comparing bladder endometriosis with ureteral endometriosis, the latter was generally found to be more severe because other pelvic organs are usually involved and the excretory axis is often impaired or definitely damaged.[] Furthermore, it suggests that the excretory function of a dilated and obstructed system should be verified carefully by urography or computed tomography before the surgery.[] Extensive disease generally requires open surgery with ureterolysis or segmental resection.[] Although the histological diagnosis of urinary tract endometriosis is easy, its treatment is quite controversial because the rarity of this condition makes randomized studies almost unfeasible. Since the symptomatic disease often recurs when therapy is discontinued, close follow up is recommended especially in case of ureteral endometriosis.[,,] Surgical castration is probably the best measure to prevent relapses of endometriosis,[] this procedure cannot be accepted as a preventive measure for the majority of young female patients. When the ureter is obstructed, surgical resection is a more suitable option because it removes the disease and the surrounding fibrosis. The best way to restore urinary continuity is ureteroneocystostomy, which does not utilize the ureteral tract distal to the site, which is at higher risk of recurrence than the proximal part. This patient underwent ureteroneocystostomy and the postoperative course was uneventful. Even when it is applied to a recurrence after ureteroureterostomy, ureteroneocystostomy is available. Radical removal of the affected region can play an important role in curing severe genitourinary endometriosis.[] Endoscopic management in combination with hormone therapy may be a suitable option in patients without significant fibrosis.[] Source of Support: Nil Conflict of Interest: None declared.

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