Surgical treatment of ureteral obstruction from endometriosis: our experience with thirteen cases

Alessandro Antonelli, Simeone C, Claudio Simeone, Frego E, E. Frego, Ezio Frego, Gianfranco Minini, Minini G, Bianchi U, Umberto Bianchi, Cunico SC, Sergio Cosciani Cunico
International urogynecology journal and pelvic floor dysfunction · 2004 · vol. 15(6) , pp. 407–412 · doi:10.1007/s00192-004-1171-7 · PMID:15549259 · W1992991159
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⚙ AI-generated summary by claude@2026-06+body, 2026-06-25 ⓘ

This study describes the surgical treatment and outcomes for thirteen cases of severe ureteral endometriosis, finding ureterocystoneostomy effective for long-term results with no relapses in 12 patients.

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This paper reports surgical management experiences in 13 patients with severe ureteral endometriosis causing significant urinary obstruction, drawn from 17 affected ureteral units (including three bilateral cases). The authors describe clinical presentation, preoperative need for urinary drainage in 8 cases, histologic characterization as intrinsic (5) versus extrinsic (8) ureteral disease, and operative approaches including segmental ureterectomy with ureterocystoneostomy (with bladder psoas hitch or Casati–Boari flap) versus resection and termino-terminal anastomosis, with one nephrectomy for renal atrophy. A key finding is that, after surgery, 12 patients had no ureteral endometriosis relapses during a mean follow-up of 41.1 months (range 6–91), aside from one anastomosis case requiring reintervention 22 months later for recurrent stenosis. Limitations include the small case series nature and the reliance on surgical cases, which may limit generalizability to all ureteral endometriosis presentations. This paper is centrally about endometriosis — it specifically studies and reports surgical treatment outcomes for ureteral obstruction due to ureteral endometriosis.

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Abstract

Endometriosis is a biologically benign albeit aggressive pathology marked by high local recurrences. Ureteral involvement accounts for only a minority of cases (0.1-0.4%) with often non-specific symptoms at clinical presentation and difficult preoperative diagnosis. Thirteen cases of severe ureteral endometriosis (i.e. causing significant obstruction to the urinary flow) were observed and surgically treated, out of 17 ureteral units affected (three cases of bilateral involvement, one case of complete pyeloureteral duplicity). The initial symptomatology was acute and related to ureteral obstruction in eight cases, silent and non-specific in the other five; a presumptive diagnosis was made only for the seven patients (53.9%) with a positive medical history for pelvic (and in two cases also ureteral) endometriosis. Preoperative drainage of urine proved necessary for eight patients due to the complete functional exclusion of the excretory axis. One patient (7.7%) underwent nephrectomy due to renal atrophy. Segmental ureteral resection and termino-terminal anastomosis were performed in two patients, while seven patients underwent segmental ureterectomy and ureterocystoneostomy, with bladder psoas hitching in four cases and vesical flap according to Casati-Boari in one case. All three cases of bilateral involvement were treated by bilateral segmental ureterectomy and trans-uretero-uretero-cystoneostomy with bladder psoas hitching. Following histological examination, all patients were diagnosed with active ureteral endometriosis, which was found to be intrinsic in five cases (38.5%) and extrinsic in the other eight. One of the two patients that had undergone ureterectomy and termino-terminal anastomosis had to undergo ureteral resection and ureterocystoneostomy 22 months later due to relapsing endometriosis-induced stenosis. Conversely, no ureteral endometriosis relapses occurred in the remaining 12 patients within the mean follow-up time of 41.1 months (range 6-91). Ureteral endometriosis is marked by non-specific symptoms, making preoperative diagnosis often difficult. Therefore, an ultrasound or urographic examination of the urinary tract in case of pelvic endometriosis is absolutely essential. In our experience, terminal ureterectomy with ureterocystoneostomy has provided long-term favourable results as extended ureteral resection can be performed and continuity of the urinary tract can be restored without resorting to the distal pelvic ureter, which is often affected by the disease besides being more subject to relapses.
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Abstract

Endometriosis is a biologically benign albeit aggressive pathology marked by high local recurrences. Ureteral involvement accounts for only a minority of cases (0.1–0.4%) with often non-specific symptoms at clinical presentation and difficult preoperative diagnosis. Thirteen cases of severe ureteral endometriosis (i.e. causing significant obstruction to the urinary flow) were observed and surgically treated, out of 17 ureteral units affected (three cases of bilateral involvement, one case of complete pyeloureteral duplicity). The initial symptomatology was acute and related to ureteral obstruction in eight cases, silent and non-specific in the other five; a presumptive diagnosis was made only for the seven patients (53.9%) with a positive medical history for pelvic (and in two cases also ureteral) endometriosis. Preoperative drainage of urine proved necessary for eight patients due to the complete functional exclusion of the excretory axis. One patient (7.7%) underwent nephrectomy due to renal atrophy. Segmental ureteral resection and termino-terminal anastomosis were performed in two patients, while seven patients underwent segmental ureterectomy and ureterocystoneostomy, with bladder psoas hitching in four cases and vesical flap according to Casati-Boari in one case. All three cases of bilateral involvement were treated by bilateral segmental ureterectomy and trans-uretero-uretero-cystoneostomy with bladder psoas hitching. Following histological examination, all patients were diagnosed with active ureteral endometriosis, which was found to be intrinsic in five cases (38.5%) and extrinsic in the other eight. One of the two patients that had undergone ureterectomy and termino-terminal anastomosis had to undergo ureteral resection and ureterocystoneostomy 22 months later due to relapsing endometriosis-induced stenosis. Conversely, no ureteral endometriosis relapses occurred in the remaining 12 patients within the mean follow-up time of 41.1 months (range 6–91). Ureteral endometriosis is marked by non-specific symptoms, making preoperative diagnosis often difficult. Therefore, an ultrasound or urographic examination of the urinary tract in case of pelvic endometriosis is absolutely essential. In our experience, terminal ureterectomy with ureterocystoneostomy has provided long-term favourable results as extended ureteral resection can be performed and continuity of the urinary tract can be restored without resorting to the distal pelvic ureter, which is often affected by the disease besides being more subject to relapses. Similar content being viewed by others

References

Vessey MP, Villard-Makintosh L, Painter R (1993) Epidemiology of endometriosis in women attending family planning clinics. Br Med J 306:182–184 Jubanyik KJ, Comite F (1997) Extrapelvic endometriosis. Clin Obstet Gynaecol N A 24:420 Revised American Society for Reproductive Medicine (1997) Classification of endometriosis: 1996. Fertil Steri 67:817–821 Jimenez RE, Tiguert R, Hurley P (2000) Ureteral hydronephrosis resulting from intraluminal obstruction of the ureter by adenosquamous endometrioid carcinoma arising from disseminated endometriosis. Urology 56:331 Rouzier R, Deval B, Muray JM (1998) Endométriose urétérale: un propos de 3 cas. Conduite diagnostique et thérapeutique. Revue de la littérature. Contracept Fertil Sex 26:173–178 Vercellini P, Pisacreta A, Pesole A (2000) Is ureteral endometriosis an asymmetric disease? Br J Obst Gyn 107:559–561 Rosemberg SK, Jacobs H (1979) Endometriosis of the upper ureter. J Urol 121:512 Stilwell TJ, Kramer SA, Lee RA (1986) Endometriosis of ureter. Urology 28:81–85 Yohannes P (2003) Ureteral endometriosis. J Urol 170:20–25 Takeuchi S, Hiroyuki M, Toyoda N (1997) Intrinsic ureteric involvement by endometriosis: a case report. J Obstet Gynaecol Res 23:273–276 Stebbing JF, Notley RG (1995) Noncalcolous obstruction due to involvement of the ureter in endometriosis. Eur Urol 28:122–125 Comiter CV (2002) Endometriosis of the urinary tract. Urol Clin N A 29:625–635 Nezhat C, Nezhat F, Nezhat CH (1996) Urinary tract endometriosis treated by laparoscopy. Fertil Steril 66:920–924 Donnez J, Nisolle M, Squifflet J (2002) Ureteral endometriosis: a complication of rectovaginal endometriotic (adenomyotic) nodules. Fertil Steril 77:32–37 Author information Authors and Affiliations Corresponding author Additional information Editorial Comment: The authors present an appropriate treatment option for a difficult problem. Frequently, endometriosis involving the urothelium, bladder or ureter is not responsive to medical management. This article further emphasizes the need to screen all patients who present with severe endometriosis for ureteral obstruction. A recent article (Yohannes P (2003) J Urol 170:20) discusses attempts at conservative therapy. However, close follow-up is required during attempts at conservative management. Those patients who have failed medical management and/or have extensive scarring with reduction in renal function will require surgery. Rights and permissions About this article Cite this article Antonelli, A., Simeone, C., Frego, E. et al. Surgical treatment of ureteral obstruction from endometriosis: our experience with thirteen cases. Int Urogynecol J 15, 407–412 (2004). https://doi.org/10.1007/s00192-004-1171-7 Received: Accepted: Published: Issue date: DOI: https://doi.org/10.1007/s00192-004-1171-7

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endometriosis

MeSH descriptors

Endometriosis Ureteral Obstruction Urologic Surgical Procedures Adult Endometriosis Endometriosis Endometriosis Female Follow-Up Studies Humans Retrospective Studies Treatment Outcome Ultrasonography Ureter Ureter Ureter Ureteral Obstruction Ureteral Obstruction Ureteral Obstruction Urography

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