Rate of Recurrent Hydronephrosis After Laparoscopic Ureteroneocystostomy for Ureteral Endometriosis

Rate of Recurrent Hydronephrosis After Laparoscopic Ureteroneocystostomy for Ureteral Endometriosis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Rate of Recurrent Hydronephrosis After Laparoscopic Ureteroneocystostomy for Ureteral Endometriosis Taihei Yamada, Tomonori Hada, Shiori Yanai, Kiyoshi Kanno, Shintaro Sakate, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-732028/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Mar, 2022 Read the published version in Archives of Gynecology and Obstetrics → Version 1 posted 5 You are reading this latest preprint version Abstract Study Objective: To investigate the short-term outcomes of laparoscopic ureteroneocystostomy in patients with ureteral endometriosis (UE). Design: Retrospective cohort study of consecutive patients who underwent surgery for the ureter endometriosis with hydronephrosis. Setting: A private hospital that provide primary, secondary and tertiary care. Patients: 30 consecutive patients with UE who underwent laparoscopic ureteroneocystostomy at our institution between May 2008 and April 2020. Interventions: Laparoscopic ureteroneocystostomy, if necessary, hysterectomy, salpingo-oophorectomy, cystectomy, partial bladder resection, or partial bowel resection were performed. Measurements and Main Results: The most common chief complaint was pelvic pain (40%). Endometriosis affected only the left ureter in 56.7% of patients, only the right ureter in 33.3%, and both ureters in 6.7%. Involvement of the ipsilateral ovary was confirmed in 64.3%. The most frequent location of UE was 1 to 3 cm above the UVJ (46.7%). A psoas hitch was performed in 7 patients (23.3%), and the Boari flap was used in 9 patients (30%). Hysterectomy was performed in 12 patients (40%), and 6 of them had a concomitant bilateral salpingo-oophorectomy (20%). In addition, 3 patients (10%) underwent partial bowel resection, and 2 patients (6.7%) underwent partial bladder resection. After surgery, 24 of 27 patients (80.0%) were free of sever hydronephrosis after surgery. Hydronephrosis recurred in a single patient (3.3%), but the grade of hydronephrosis improved significantly after surgery (P<.001). At 6 months of follow up, 4 patients (13.3%) experienced urinary tract infections and 2 patients (6.7%) reported dysuria. Patients reported a regression of dysmenorrhea symptoms (P<.001). Conclusion: This study shows that ureteroneocystostomy provides good results in terms of relapses and symptoms’ control in patients with ureteral endometriosis. Obstetrics & Gynecology Boari flap endometriosis extravesical psoas hitch ureteroneocystostomy Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Endometriosis, defined as the presence of endometrial glands and stroma outside the uterus [ 1 ], has an estimated prevalence of 5–15% in women of reproductive age [ 2 ]. Urinary tract involvement occurs in 1% of affected women; it involves the ureter in 10% [ 3 ]. Ureteral endometriosis (UE) is typically unilateral, with a predisposition for the left side in 64% of affected women [ 4 ]. Examination of resected ureteral segments reveals 2 types of involvement: 38.5% demonstrate endometriosis inside the muscular layer of the ureter (intrinsic UE), and 61.5% show adventitial infiltration (extrinsic UE) [ 5 ]. Dysmenorrhea is extremely common in patients with UE, reported by 70.6%, while 52.3% report pelvic pain [ 6 ]. The presence of UE is frequently associated with endometriosis of the bladder (47%) and the bowel (43%) [ 7 ]. Hydronephrosis is present in 61% of patients with UE [ 6 ]. Combined Oral contraceptives and progestins are first-line therapies for pain associated with UE [ 8 ], but surgical treatment is necessary to salvage the renal system when UE causes ureteral obstruction [ 9 ]. Both conservative procedures (for example, ureterolysis) and more radical surgery (ureteroneocystostomy) are commonly performed [ 10 ]. Ureteroneocystostomy has a lower recurrence rate but a higher surgical complication rate than ureterolysis [ 11 ]. In recent years, minimally invasive techniques have been used successfully to manage UE [ 12 ]. Laparoscopic ureteroneocystostomy requires either extravesical reimplantation of the ureter, a psoas hitch, or a Boari flap, depending on the length of the proximal residual ureter [ 13 ]. However, the outcomes of laparoscopic ureteroneocystostomy in patients with severe UE is unknown. The purpose of this study is to investigate the short-term outcomes of laparoscopic ureteroneocystostomy. Materials And Methods This retrospective study assessed 30 consecutive patients with UE who underwent laparoscopic ureteroneocystostomy at our institution between May 2008 and April 2020. All patients were referred to our center with a diagnosis of endometriosis and suspected UE. Inclusion criteria for ureteroneocystostomy included moderate to severe hydronephrosis with radiologic evidence of ureteral stricture, and/or symptomatic bladder endometriosis. Exclusion criteria were a history or presence of ovarian cancer related to endometriosis and ureteral stricture with complete loss of renal function. We performed ureteroneocystostomy in patients with hydronephrosis who had radiologic evidence of a ureteral stricture and in patients with endometriotic bladder lesions requiring resection of the ureterovesical junction (UVJ). Patients were evaluated and treated by a multidisciplinary team comprising gynecologists, urologists, gastroenterological surgeons, radiologists, and pathologists. We used the revised American Fertility Society classification of endometriosis, endorsed by the American Society for Reproductive Medicine (ASRM), to define the stages of endometriosis in each patient. The intensity of dysmenorrhea was assessed using a Visual Analogue Scale (VAS) at 1 month before treatment and 6 months after treatment. The grade of hydronephrosis was recorded at 1 month before treatment and 6 months after treatment. It was evaluated by the Society of Fetal Urology grading system. Preoperative evaluation included a physical examination, blood testing, transabdominal and transvaginal pelvic ultrasonography, chest radiography, pelvic computed tomography, and pelvic magnetic resonance imaging. Postoperative evaluation of the hydronephrosis was done by transabdominal ultrasonography. A preoperative double-J catheter was placed when patient complained pelvic pain or hydronephrosis was sever. All patients were informed of the risks and possible complications of surgery. Written informed consent was obtained from all patients prior to surgery. This retrospective study was performed in accordance with the Declaration of Helsinkiwas and approved by the Institutional Review Board of our hospital (IRB number: 877). All patients provided written informed consent for inclusion in this study. All surgical procedures were performed by a single surgeon (MA), experienced in laparoscopic ureteroneocystostomy, with the assistance of the gynecologists on his surgical team. Hysterectomy, salpingo-oophorectomy, cystectomy, partial bladder resection, or segmental bowel resection were also performed when necessary. Ureteroneocystostomy and bowel resection were performed with the support of urologists and gastroenterological surgeons, respectively. Laparoscopic surgery was performed under pneumoperitoneum with intra-abdominal pressure of 8 mm Hg. A 10-mm laparoscope was placed at the umbilical position, with 3 5-mm suprapubic trocars used for instrumentation (Fig. 1 ). Extravesical laparoscopic ureteroneocystostomy was performed in 7 defined steps: The ureter was separated from its surrounding tissue using monopolar or scissors forceps. After locating the margin of the bladder by instilling 200 mL of saline, the medial and lateral paravesical spaces and the retropubic space of Retzius were dissected. The bladder was then mobilized. The length of the proximal residual ureter was assessed, and it was determined whether a psoas hitch or a Boari flap was needed to avoid anastomotic tension. If it was not needed, we proceeded with extravesical reimplantation. The ureter was sutured to the bladder mucosa using 3 − 0 synthetic absorbable suture (Fig. 2 a, b). A double-J catheter was placed into the ureter when half of the anastomotic suturing was completed. The Lich-Gregoir technique was used to close the bladder muscle over the ureter, using 4 − 0 synthetic absorbable suture to prevent vesicoureteral reflux (Fig. 2 c, d). An ureteral catheter was placed into the bladder. For ureteric defects longer than 5 to 7 cm, a length that cannot be bridged using the psoas hitch technique alone, we added a Boari flap to reduce the distance between the ureter and the bladder, thereby reducing anastomotic tension. After completing the first 2 steps of the extravesical ureteroneocystostomy, the Boari flap method was performed as follows: Anastomotic tension was assessed between the ureter and the area of the bladder with maximum mobilization (Fig. 3 a). The bladder wall was incised and a rectangular flap, 3 to 4 cm in width, was created (Fig. 3 b). A submucosal tunnel was created in the flap to allow the ureter to run between the mucosa and the detrusor muscle (Fig. 3 c). The bladder flap was fixed to the psoas muscle using size 0 synthetic absorbable suture (Fig. 3 d). The ureter was pulled through the submucosal tunnel and anastomosis sutured was performed (Fig. 3 e), with a double-J catheter placed when half of the anastomosis was finished. The bladder was closed in 2 layers (mucosa and detrusor), using 3 − 0 synthetic absorbable suture (Fig. 3 f). We removed the ureteral catheter on postoperative day 5 to 7. The double-J catheter was removed 2 to 3 weeks after surgery. Statistical Analysis Statistical analysis was performed using Excel functions (Microsoft Office 2016 for Mac version 16). We used the Wilcoxon matched pairs signed rank test to compare preoperative and postoperative endometriosis-related pain. The Wilcoxon signed rank test was used to compare preoperative and postoperative grade of hydronephrosis. The chi-square test was used to compare the characteristics of patients with intrinsic and extrinsic UE. Statistical significance was defined as a P value less than .05. Results A total of 30 patients with radiologically diagnosed, histologically confirmed UE were included in this retrospective analysis. The median patient age was 38.5 years (range, 25 to 51 years); the vast majority (80%) of patients were in their 30s and 40s. Table 1 lists the patient characteristics. A total of 56.7% of patients were nulliparous, 20% were primiparous, 16.7% had a history of 2 prior deliveries, and 6.7% had undergone 3 deliveries. The most common chief complaint was pelvic pain (40%). An annual health check at workplace brought 5 patients with hydronephrosis and 4 patients with ovarian cysts to our hospital for further examination. An annual health check at workplace includes physical examination, blood testing, transabdominal and transvaginal pelvic ultrasonography. About one-third of patients underwent hormonal therapy with combined oral contraceptives or progestins before surgery. Table 1 The patient characteristics. No. Pts (%) Age 25–29 4 13.3 30–39 13 43.3 40–49 11 36.7 50–51 2 6.7 Parity P0 17 56.7 P1 6 20.0 P2 5 16.7 P3 2 6.7 Chief Complaint Pelvic pain 12 40.0 Hydronephrisis 5 16.7 Ovarian cyst 4 13.3 Abdominal pain 3 10.0 Infertility 2 6.7 Others 4 13.3 Medical treatment Oral contraceptives 3 10.0 Progestins 7 23.3 GnRH agonist 1 3.3 None 19 63.3 Table 2 shows the preoperative findings in our patient cohort. Moderate (Grade 2, 3) to severe (Grade 4) hydronephrosis was present in 26 patients (86%), and a double-J stent was placed in 18 patients (60%) before surgery. The grade of preoperative hydronephrosis was unclear in three patients (10%) since preoperative double-J stent was placed at other hospital. One patient (3.3%) with grade 0 (normal) hydronephrosis underwent ureteroneocystostomy because of bladder endometriosis. Endometriosis affected only the left ureter in 56.7% of patients, only the right ureter in 33.3%, and both ureters in 6.7%. Involvement of the ipsilateral ovary was confirmed in 64.3%. Cancer antigen 125 (CA 125) levels were abnormal in 43.3%. Table 2 The preoperative findings. No. Pts (%) Grades of hydronephrosis Grade4(sever) 7 23.3 Grade3(moderate) 14 46.7 Grade2(moderate) 5 16.7 Grade1(mild) 0 0.0 Grade0(none) 1 3.3 Unknown 3 10.0 Ureteral involvement Rt 10 33.3 Lt 17 56.7 Bilat 2 6.7 None 1 3.3 Ipsilateral ovary involvement 18 64.3 Ureteral stent insertion Preoperative 18 60.0 Intraoperative 12 40.0 CA125 value < 35 8 26.7 36< 13 43.3 Unknown 9 30.0 Table 3 shows the procedures performed and the intraoperative findings. Twelve of the 30 patients (40%) undergoing ureteroneocystostomy underwent concurrent hysterectomy; 6 of these (20%) also underwent bilateral salpingo-oophorectomy (BSO). In addition, 3 patients (10%) underwent partial bowel resection, and 2 patients (6.7%) underwent partial bladder resection. Stage I endometriosis was present in 3.3% of patients, stage II in 10%, stage III in 13.3%, and stage IV was present in 50%. The most frequent location of UE was 1 to 3 cm above the UVJ (46.7%). A psoas hitch was performed in 7 patients (23.3%), and the Boari flap was used in 9 patients (30%). Table 3 The procedures performed and the intraoperative findings. Intraoperative findings No. Pts (%) Surgical treatment Hysterectomy 12 40.0 Bilateral Salpingo-oophorectomy 6 20.0 Salpingo-oophorectomy 6 20.0 Bilateral Cystectomy 6 20.0 Cystectomy 3 10.0 Partial resection of rectum 2 6.7 Low anterior resection 1 3.3 Partial resection of bladder 2 6.7 rASRM Stage I (minimal), 1–5 1 3.3 Stage II (mild), 6–15 3 10.0 Stage III (moderate), 16–40 4 13.3 Stage IV (severe), > 40 15 50.0 Unknown 7 23.3 distance of UE lesion to UVJ 1–3 cm 13 43.3 4–6 cm 11 36.7 more than 7 cm 6 20.0 Ureteroneocystostomy procedure Extravesical 14 46.7 Psoas Hitch 7 23.3 Boari Flap 9 30.0 A comparison of UE lesions with ureteroneocystostomy procedures is listed in Table 4 . Of the 13 patients with UE lesions 1 to 3 cm above the UVJ, extravesical reimplantation alone was performed in 9 patients (69.2%), a psoas hitch was used in 3 (23.1%), and a Boari flap was used in 1 patient (7.7%). The patient who received a Boari flap also underwent partial bladder resection. Of the 11 patients with UE lesions 4 to 6 cm above the UVJ, extravesical reimplantation was performed in 5 patients (45.5%), a psoas hitch was used in 3 (27.3%), and a Boari flap was used in 3 (27.3%). Of the 6 patients with UE lesions more than 7 cm above the UVJ, a psoas hitch was used in 1 patient (16.7%), and a Boari flap was used in 5 (83.3%). Table 4 A comparison of UE lesions with ureteroneocystostomy procedures. 1–3 cm 4–6 cm more than 7 cm Total Extravesical 9 (69.2) 5 (45.5) 0 (0) 14 (46.7) Psoas Hitch 3 (23.1) 3 (27.3) 1 (16.7) 7 (23.3) Boari Flap 1 (7.7) 3 (27.3) 5 (83.3) 9 (30.0) Total 13 (100) 11 (100) 6 (100) 30 (100) Table 5 shows the postoperative findings. 29 of 30 patients (96.6%) were free of sever to mild hydronephrosis (Grade 2–4) after surgery, 27 patients had no hydronephrosis (Grade 0) and 2 patients had mild hydronephrosis (Grade 1). Hydronephrosis recurred in a single patient (3.3%), but the grade of hydronephrosis improved significantly after surgery (P < .001, Fig. 4 ). Patients reported that the intensity of their dysmenorrhea improved significantly 6 months after surgery (P < .001, Fig. 5 ). Histological examination showed that 60% of UE lesions were intrinsic. At 6 months of follow up, 4 patients (13.3%) experienced urinary tract infections and 2 patients (6.7%) reported dysuria. About two-thirds of patients required hormonal therapy with combined oral contraceptives or progestins after surgery to prevent relapses. Of the 18 patients who retained their uterus, 1 had a single subsequent delivery and 2 patients had 2 subsequent deliveries. Table 5 The postoperative findings No. Pts (%) Grades of hydronephrosis Grade4(sever) 0 0.0 Grade3(moderate) 1 3.3 Grade2(moderate) 0 0.0 Grade1(mild) 2 6.7 Grade0(none) 27 90.0 Unknown 0 0.0 Recurrence of hydronephrosis Recurrence 1 3.3 No recurrence 29 96.7 Pathological fidings Intrinsic type 18 60.0 Extrinsic type 7 23.3 Unclear 5 16.7 Postoperative complications Urinary Tract Infections 4 13.3 Dysuria 2 6.7 Pelvic abscess 1 3.3 Intrapelvic hernia 1 3.3 Medical treatment Oral contraceptives 3 10.0 Progestins 18 60.0 None 9 30.0 Postoperative Parity P0 15 83.3 P1 1 5.6 P2 2 11.1 Discussion The presence of dysmenorrhea in women of reproductive age raises the possibility of UE. Up to 80% of patients with UE do not have any urinary symptoms [ 14 ], making the diagnosis difficult. Five of the patients (16.7%) in our study had hydronephrosis detected during annual health check at workplace. Such patients are at risk for decreased renal function if their hydronephrosis remains undetected. The most frequent chief complaint noted by our patients was pelvic pain (reported by 40%). Uccella et al report that 52.3% of patients with UE report pelvic pain [ 6 ]. To avoid missing a potentially serious diagnosis such as UE, abdominal ultrasonography should be performed in all women with pelvic pain. Pharmacologic therapy does nothing to ameliorate the fibrotic, narrowed ureter that results from UE; it can only relieve the pain related to endometriosis [ 15 ]. Surgical treatment is necessary to remove any areas of ureteral stenosis, but the recurrence rate of hydronephrosis after ureterolysis is as high as 12% [ 16 ]. In contrast, the recurrence rate of hydronephrosis after ureteroneocystostomy is 3.1% [ 17 ]. This difference in recurrence may be results from the fact that intrinsic UE occurs hydronephrosis more frequently than extrinsic UE [ 18 ]. However, it is difficult to differentiate intrinsic and extrinsic UE preoperatively. Since intrinsic UE directly involves the muscularis of the ureter, removing the endometriotic lesion surrounding the ureter is inadequate treatment. In our study, 60% of lesions were of the intrinsic type. Patients with intrinsic UE tend to have endometrial lesions of the bladder and rectum (Supplemental table). Sillou et al report that an assessment of the ureteric circumference at the area of the endometriotic lesion can predict whether lesions are intrinsic [ 19 ]. However, this is only speculation. If we cannot rule out intrinsic UE preoperatively, ureteroneocystostomy is a better surgical treatment than ureterolysis in terms of preventing recurrence. We found a recurrence rate of hydronephrosis was 3.3% after ureteroneocystostomy, similar to the rate reported by Ceccaroni et al [ 18 ]. Our experience confirmed that reducing anastomotic tension is a critical part of ureteroneocystostomy [ 20 ]. Our results show that when the distance between the UE lesion and the UVJ is greater than 7 cm, either a psoas hitch or a Boari flap is necessary. Boari flaps are not necessary when the UE lesion is within 3 cm of the UVJ, except when partial bladder resection is performed. Both of these methods can be performed with robotic assistance [ 21 ]. Improving the pain associated with endometriosis is an important factor in patient satisfaction with whatever procedure is performed. We found that the intensity of dysmenorrhea improves significantly after ureteroneocystostomy. Alves et al also report that the intensity of dysmenorrhea, dyspareunia, and chronic pelvic pein improves significantly after surgery [ 22 ]. The grade of hydronephrosis improve significantly after surgery, and it is important for renal function. Huang et al also describe postoperative remission of hydronephrosis [ 23 ]. Our study is limited in that we did not compare outcomes between the laparoscopic approach and laparotomy. Robot-assisted ureteroneocystostomy has better surgical outcomes (less postoperative pain and decreased blood loss) than open surgery [ 24 ]. This indicates the advantage of minimally invasive surgery, including laparoscopic ureteroneocystostomy. In conclusion, our study indicates that laparoscopic ureteroneocystostomy has the benefits for preventing recurrent hydronephrosis for patients with UE. Declarations ACKNOWLEDGEMENTS None declared. DISCLOSURES None declared. Conflict of Interest All authors have no conflict of interest to report. Author Contribution T. Yamada: Protocol/project development, Data collection, Data analysis, Manuscript writing, Statistical analysis, T. Hada: Protocol/project development, Data analysis, Manuscript writing S. Yanai: Protocol/project development, Manuscript writing K. Kanno: Data collection S. Sakate: Data collection M. Sawada: Data collection Y. Yoshino: Data analysis, Statistical analysis M.Andou: Protocol/project development, Responsible surgeon Source of funding None This retrospective study was performed in accordance with the Declaration of Helsinkiwas and approved by the Institutional Review Board of our hospital (IRB number: 877). References Vercellini P, Viganò P, Somigliana E, Fedele L. Endometriosis: pathogenesis and treatment. Nat Rev Endocrinol . 2014;10:261-275. Abrao MS, Dias Jr JA, Bellelis P, Podgaec S, Bautzer CR, Gromatsky C. Endometriosis of the ureter and bladder are not associated diseases. Fertil Steril. 2009;91:1662-1667. Berlanda N, Vercellini P, Carmignani L, Aimi G, Amicarelli F, Fedele L. Ureteral and vesical endometriosis. Two different clinical entities sharing the same pathogenesis. Obstet Gynecol Serv . 2009;64:830-842. Vercellini P, Pisacreta A, Pesole A, Vicentini S, Stellato G, Crosignani PG. Is ureteral endometriosis an asymmetric disease? BJOG . 2000;107:559-561. 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Gennaro KH, Gordetsky J, Rais-Bahrami S, Selph JP. Ureteral endometriosis: preoperative risk factors predicting extensive urologic surgical intervention. Urology. 2017;100:228-233. 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 Updat e. 2018;24:710-730. Lusuardi L, Hager M, Sieberer M, et al. Laparoscopic treatment of intrinsic endometriosis of the urinary tract and proposal of a treatment scheme for ureteral endometriosis. Urology. 2012;80:1033-1038. Stein R, Rubenwolf P, Ziesel C, Kamal MM, Thüroff JW. Psoas hitch and Boari flap ureteroneocystostomy. BJU Int. 2013;112:137-155. 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. 2015;103:147-152. Maccagnano C, Pellucchi F, Rocchini L, et al. Ureteral endometriosis: proposal for a diagnostic and therapeutic algorithm with a review of the literature. Urol Int. 2013;91:1-9. Mereu L, Gagliardi ML, Clarizia R, Mainardi P, Landi S, Minelli L. Laparoscopic management of ureteral endometriosis in case of moderate-severe hydroureteronephrosis. Fertil Steril. 2010;93:46-51. Ceccaroni M, Ceccarello M, Caleffi G, et al. Total laparoscopic ureteroneocystostomy for ureteral endometriosis: a single-center experience of 160 consecutive patients. J Minim Invasive Gynecol. 2019;26:78-86. Seracchioli R, Raimondo D, Di Donato N, et al. Histological evaluation of ureteral involvement in women with deep infiltrating endometriosis: analysis of a large series. Hum Reprod. 2015;30:833-839. Sillou S, Poirée S, Millischer AE, Chapron C, Hélénon O. Urinary endometriosis: MR imaging appearance with surgical and histological correlations. Diagn Interv Imaging. 2015;96:373-381. Azioni G, Bracale U, Scala A, et al. Laparoscopic ureteroneocystostomy and vesicopsoas hitch for infiltrative ureteral endometriosis. Minim Invasive Ther Allied Technol. 2010;19:292-297. Yang C, Jones L, Rivera ME, Verlee GT, Deane LA. Robotic-assisted ureteral reimplantation with Boari flap and psoas hitch: a single-institution experience. J Laparoendosc Adv Surg Tech A. 2011;21:829-833. Alves J, Puga M, Fernandes R, et al. Laparoscopic management of ureteral endometriosis and hydronephrosis associated with endometriosis. J Minim Invasive Gynecol. 2017;24:466-472. Huang JZ, Guo HL, Li JB, Chen SQ. Management of ureteral endometriosis with hydronephrosis: experience from a tertiary medical center. J Obstet Gynaecol Res. 2017;43:1555-1562. Isac W, Kaouk J, Altunrende F, et al. Robot-assisted ureteroneocystostomy: technique and comparative outcomes. J Endourol. 2013;27:318-323. Supplementary Files Supplementaltable.docx Cite Share Download PDF Status: Published Journal Publication published 03 Mar, 2022 Read the published version in Archives of Gynecology and Obstetrics → Version 1 posted Reviews received at journal 02 Dec, 2021 Reviewers invited by journal 08 Nov, 2021 Editor invited by journal 02 Aug, 2021 Editor assigned by journal 20 Jul, 2021 First submitted to journal 19 Jul, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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08:39:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-732028/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-732028/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00404-022-06462-y","type":"published","date":"2022-03-03T10:00:13+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":15446683,"identity":"2c7168ef-b534-4de4-9d71-94ef173ef991","added_by":"auto","created_at":"2021-11-11 16:00:38","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":15920,"visible":true,"origin":"","legend":"Position of umbilical and suprapubic trocars.","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-732028/v1/206b626493e0cbe47a7dccdc.jpg"},{"id":15446331,"identity":"4bc26771-28c8-4211-857f-006b6cdd50ec","added_by":"auto","created_at":"2021-11-11 15:57:38","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":154110,"visible":true,"origin":"","legend":"Procedure of extravesical laparoscopic ureteroneocystostomy","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-732028/v1/d47ecf1bdf4eb57a919cda06.jpg"},{"id":15446334,"identity":"955233d7-357a-4faf-abd1-65cf2a49db1e","added_by":"auto","created_at":"2021-11-11 15:57:39","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":190323,"visible":true,"origin":"","legend":"Procedure of Boari flap method.","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-732028/v1/e68b215ea13fb109d1eb15da.jpg"},{"id":15446333,"identity":"11f466b9-ef28-412c-a4d4-4b1178df6b32","added_by":"auto","created_at":"2021-11-11 15:57:39","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":39947,"visible":true,"origin":"","legend":"A comparison of grades of hydronephrosis before and after surgery.","description":"","filename":"Fig4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-732028/v1/37df9e7a7ae06f214f9e2e8b.jpg"},{"id":15446332,"identity":"136de408-e0d0-45f2-a0cd-d624e7197127","added_by":"auto","created_at":"2021-11-11 15:57:39","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":52248,"visible":true,"origin":"","legend":"A comparison of intensity of dysmenorrhea before and after surgery.","description":"","filename":"Fig5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-732028/v1/5b513ac30f9ad3c6f6797a86.jpg"},{"id":18815343,"identity":"b3c3e613-5456-4485-9d62-d5c7ecf38160","added_by":"auto","created_at":"2022-03-03 10:00:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":536631,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-732028/v1/fe69ae38-b973-4ea5-a6d2-a5d59a230263.pdf"},{"id":15446329,"identity":"f5eb2a15-64dc-47d6-a3ad-2243ea797e8b","added_by":"auto","created_at":"2021-11-11 15:57:38","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":14025,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaltable.docx","url":"https://assets-eu.researchsquare.com/files/rs-732028/v1/cbb4f3cb9836fffb32dada8d.docx"}],"financialInterests":"","formattedTitle":"Rate of Recurrent Hydronephrosis After Laparoscopic Ureteroneocystostomy for Ureteral Endometriosis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEndometriosis, defined as the presence of endometrial glands and stroma outside the uterus [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], has an estimated prevalence of 5\u0026ndash;15% in women of reproductive age [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Urinary tract involvement occurs in 1% of affected women; it involves the ureter in 10% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Ureteral endometriosis (UE) is typically unilateral, with a predisposition for the left side in 64% of affected women [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Examination of resected ureteral segments reveals 2 types of involvement: 38.5% demonstrate endometriosis inside the muscular layer of the ureter (intrinsic UE), and 61.5% show adventitial infiltration (extrinsic UE) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDysmenorrhea is extremely common in patients with UE, reported by 70.6%, while 52.3% report pelvic pain [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The presence of UE is frequently associated with endometriosis of the bladder (47%) and the bowel (43%) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Hydronephrosis is present in 61% of patients with UE [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Combined Oral contraceptives and progestins are first-line therapies for pain associated with UE [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], but surgical treatment is necessary to salvage the renal system when UE causes ureteral obstruction [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Both conservative procedures (for example, ureterolysis) and more radical surgery (ureteroneocystostomy) are commonly performed [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Ureteroneocystostomy has a lower recurrence rate but a higher surgical complication rate than ureterolysis [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn recent years, minimally invasive techniques have been used successfully to manage UE [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Laparoscopic ureteroneocystostomy requires either extravesical reimplantation of the ureter, a psoas hitch, or a Boari flap, depending on the length of the proximal residual ureter [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, the outcomes of laparoscopic ureteroneocystostomy in patients with severe UE is unknown. The purpose of this study is to investigate the short-term outcomes of laparoscopic ureteroneocystostomy.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cp\u003eThis retrospective study assessed 30 consecutive patients with UE who underwent laparoscopic ureteroneocystostomy at our institution between May 2008 and April 2020. All patients were referred to our center with a diagnosis of endometriosis and suspected UE. Inclusion criteria for ureteroneocystostomy included moderate to severe hydronephrosis with radiologic evidence of ureteral stricture, and/or symptomatic bladder endometriosis. Exclusion criteria were a history or presence of ovarian cancer related to endometriosis and ureteral stricture with complete loss of renal function. We performed ureteroneocystostomy in patients with hydronephrosis who had radiologic evidence of a ureteral stricture and in patients with endometriotic bladder lesions requiring resection of the ureterovesical junction (UVJ). Patients were evaluated and treated by a multidisciplinary team comprising gynecologists, urologists, gastroenterological surgeons, radiologists, and pathologists.\u003c/p\u003e\n\u003cp\u003eWe used the revised American Fertility Society classification of endometriosis, endorsed by the American Society for Reproductive Medicine (ASRM), to define the stages of endometriosis in each patient. The intensity of dysmenorrhea was assessed using a Visual Analogue Scale (VAS) at 1 month before treatment and 6 months after treatment. The grade of hydronephrosis was recorded at 1 month before treatment and 6 months after treatment. It was evaluated by the Society of Fetal Urology grading system.\u003c/p\u003e\n\u003cp\u003ePreoperative evaluation included a physical examination, blood testing, transabdominal and transvaginal pelvic ultrasonography, chest radiography, pelvic computed tomography, and pelvic magnetic resonance imaging. Postoperative evaluation of the hydronephrosis was done by transabdominal ultrasonography. A preoperative double-J catheter was placed when patient complained pelvic pain or hydronephrosis was sever. All patients were informed of the risks and possible complications of surgery. Written informed consent was obtained from all patients prior to surgery. This retrospective study was performed in accordance with the Declaration of Helsinkiwas and approved by the Institutional Review Board of our hospital (IRB number: 877). All patients provided written informed consent for inclusion in this study.\u003c/p\u003e\n\u003cp\u003eAll surgical procedures were performed by a single surgeon (MA), experienced in laparoscopic ureteroneocystostomy, with the assistance of the gynecologists on his surgical team. Hysterectomy, salpingo-oophorectomy, cystectomy, partial bladder resection, or segmental bowel resection were also performed when necessary. Ureteroneocystostomy and bowel resection were performed with the support of urologists and gastroenterological surgeons, respectively. Laparoscopic surgery was performed under pneumoperitoneum with intra-abdominal pressure of 8 mm Hg. A 10-mm laparoscope was placed at the umbilical position, with 3 5-mm suprapubic trocars used for instrumentation (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Extravesical laparoscopic ureteroneocystostomy was performed in 7 defined steps:\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003e\n\u003cp\u003eThe ureter was separated from its surrounding tissue using monopolar or scissors forceps.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eAfter locating the margin of the bladder by instilling 200 mL of saline, the medial and lateral paravesical spaces and the retropubic space of Retzius were dissected. The bladder was then mobilized.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eThe length of the proximal residual ureter was assessed, and it was determined whether a psoas hitch or a Boari flap was needed to avoid anastomotic tension. If it was not needed, we proceeded with extravesical reimplantation.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eThe ureter was sutured to the bladder mucosa using 3\u0026thinsp;\u0026minus;\u0026thinsp;0 synthetic absorbable suture (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003ea, b).\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eA double-J catheter was placed into the ureter when half of the anastomotic suturing was completed.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eThe Lich-Gregoir technique was used to close the bladder muscle over the ureter, using 4\u0026thinsp;\u0026minus;\u0026thinsp;0 synthetic absorbable suture to prevent vesicoureteral reflux (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003ec, d).\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eAn ureteral catheter was placed into the bladder.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eFor ureteric defects longer than 5 to 7 cm, a length that cannot be bridged using the psoas hitch technique alone, we added a Boari flap to reduce the distance between the ureter and the bladder, thereby reducing anastomotic tension. After completing the first 2 steps of the extravesical ureteroneocystostomy, the Boari flap method was performed as follows:\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003e\n\u003cp\u003eAnastomotic tension was assessed between the ureter and the area of the bladder with maximum mobilization (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003ea).\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eThe bladder wall was incised and a rectangular flap, 3 to 4 cm in width, was created (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eb).\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eA submucosal tunnel was created in the flap to allow the ureter to run between the mucosa and the detrusor muscle (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003ec).\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eThe bladder flap was fixed to the psoas muscle using size 0 synthetic absorbable suture (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003ed).\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eThe ureter was pulled through the submucosal tunnel and anastomosis sutured was performed (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003ee), with a double-J catheter placed when half of the anastomosis was finished.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eThe bladder was closed in 2 layers (mucosa and detrusor), using 3\u0026thinsp;\u0026minus;\u0026thinsp;0 synthetic absorbable suture (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003ef).\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eWe removed the ureteral catheter on postoperative day 5 to 7. The double-J catheter was removed 2 to 3 weeks after surgery.\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n\u003cp\u003eStatistical analysis was performed using Excel functions (Microsoft Office 2016 for Mac version 16). We used the Wilcoxon matched pairs signed rank test to compare preoperative and postoperative endometriosis-related pain. The Wilcoxon signed rank test was used to compare preoperative and postoperative grade of hydronephrosis. The chi-square test was used to compare the characteristics of patients with intrinsic and extrinsic UE. Statistical significance was defined as a \u003cem\u003eP\u003c/em\u003e value less than .05.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 30 patients with radiologically diagnosed, histologically confirmed UE were included in this retrospective analysis. The median patient age was 38.5 years (range, 25 to 51 years); the vast majority (80%) of patients were in their 30s and 40s. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e lists the patient characteristics. A total of 56.7% of patients were nulliparous, 20% were primiparous, 16.7% had a history of 2 prior deliveries, and 6.7% had undergone 3 deliveries. The most common chief complaint was pelvic pain (40%). An annual health check at workplace brought 5 patients with hydronephrosis and 4 patients with ovarian cysts to our hospital for further examination. An annual health check at workplace includes physical examination, blood testing, transabdominal and transvaginal pelvic ultrasonography. About one-third of patients underwent hormonal therapy with combined oral contraceptives or progestins before surgery.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eThe patient characteristics.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNo. Pts\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e(%)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25\u0026ndash;29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e13.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30\u0026ndash;39\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e43.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40\u0026ndash;49\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e36.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50\u0026ndash;51\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eParity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eP0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e56.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eP1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eP2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e16.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eP3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChief Complaint\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePelvic pain\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e40.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHydronephrisis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e16.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOvarian cyst\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e13.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAbdominal pain\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInfertility\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOthers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e13.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedical treatment\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOral contraceptives\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eProgestins\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e23.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGnRH agonist\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e63.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e shows the preoperative findings in our patient cohort. Moderate (Grade 2, 3) to severe (Grade 4) hydronephrosis was present in 26 patients (86%), and a double-J stent was placed in 18 patients (60%) before surgery. The grade of preoperative hydronephrosis was unclear in three patients (10%) since preoperative double-J stent was placed at other hospital. One patient (3.3%) with grade 0 (normal) hydronephrosis underwent ureteroneocystostomy because of bladder endometriosis. Endometriosis affected only the left ureter in 56.7% of patients, only the right ureter in 33.3%, and both ureters in 6.7%. Involvement of the ipsilateral ovary was confirmed in 64.3%. Cancer antigen 125 (CA 125) levels were abnormal in 43.3%.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eThe preoperative findings.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNo. Pts\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e(%)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGrades of hydronephrosis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGrade4(sever)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e23.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGrade3(moderate)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e46.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGrade2(moderate)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e16.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGrade1(mild)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGrade0(none)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnknown\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUreteral involvement\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRt\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e33.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLt\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e56.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBilat\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIpsilateral ovary involvement\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e64.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUreteral stent insertion\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePreoperative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e60.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIntraoperative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e40.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCA125 value\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e26.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e36\u0026lt;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e43.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnknown\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e30.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e shows the procedures performed and the intraoperative findings. Twelve of the 30 patients (40%) undergoing ureteroneocystostomy underwent concurrent hysterectomy; 6 of these (20%) also underwent bilateral salpingo-oophorectomy (BSO). In addition, 3 patients (10%) underwent partial bowel resection, and 2 patients (6.7%) underwent partial bladder resection. Stage I endometriosis was present in 3.3% of patients, stage II in 10%, stage III in 13.3%, and stage IV was present in 50%. The most frequent location of UE was 1 to 3 cm above the UVJ (46.7%). A psoas hitch was performed in 7 patients (23.3%), and the Boari flap was used in 9 patients (30%).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eThe procedures performed and the intraoperative findings.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eIntraoperative findings\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo. Pts\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSurgical treatment\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHysterectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBilateral Salpingo-oophorectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSalpingo-oophorectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBilateral Cystectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCystectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePartial resection of rectum\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLow anterior resection\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePartial resection of bladder\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003erASRM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStage I (minimal), 1\u0026ndash;5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStage II (mild), 6\u0026ndash;15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStage III (moderate), 16\u0026ndash;40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStage IV (severe), \u0026gt;\u0026thinsp;40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnknown\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003edistance of UE lesion to UVJ\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u0026ndash;3 cm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e43.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u0026ndash;6 cm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e36.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003emore than 7 cm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUreteroneocystostomy procedure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eExtravesical\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePsoas Hitch\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBoari Flap\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA comparison of UE lesions with ureteroneocystostomy procedures is listed in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e. Of the 13 patients with UE lesions 1 to 3 cm above the UVJ, extravesical reimplantation alone was performed in 9 patients (69.2%), a psoas hitch was used in 3 (23.1%), and a Boari flap was used in 1 patient (7.7%). The patient who received a Boari flap also underwent partial bladder resection. Of the 11 patients with UE lesions 4 to 6 cm above the UVJ, extravesical reimplantation was performed in 5 patients (45.5%), a psoas hitch was used in 3 (27.3%), and a Boari flap was used in 3 (27.3%). Of the 6 patients with UE lesions more than 7 cm above the UVJ, a psoas hitch was used in 1 patient (16.7%), and a Boari flap was used in 5 (83.3%).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eA comparison of UE lesions with ureteroneocystostomy procedures.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e1\u0026ndash;3 cm\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e4\u0026ndash;6 cm\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003emore than 7 cm\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTotal\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eExtravesical\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (69.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (45.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14 (46.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePsoas Hitch\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (23.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (27.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (16.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (23.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBoari Flap\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (7.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (27.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (83.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (30.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTotal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13 (100)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11 (100)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (100)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30 (100)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e shows the postoperative findings. 29 of 30 patients (96.6%) were free of sever to mild hydronephrosis (Grade 2\u0026ndash;4) after surgery, 27 patients had no hydronephrosis (Grade 0) and 2 patients had mild hydronephrosis (Grade 1). Hydronephrosis recurred in a single patient (3.3%), but the grade of hydronephrosis improved significantly after surgery (P\u0026thinsp;\u0026lt;\u0026thinsp;.001, Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). Patients reported that the intensity of their dysmenorrhea improved significantly 6 months after surgery (P\u0026thinsp;\u0026lt;\u0026thinsp;.001, Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e). Histological examination showed that 60% of UE lesions were intrinsic. At 6 months of follow up, 4 patients (13.3%) experienced urinary tract infections and 2 patients (6.7%) reported dysuria. About two-thirds of patients required hormonal therapy with combined oral contraceptives or progestins after surgery to prevent relapses. Of the 18 patients who retained their uterus, 1 had a single subsequent delivery and 2 patients had 2 subsequent deliveries.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab5\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eThe postoperative findings\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNo. Pts\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e(%)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGrades of hydronephrosis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGrade4(sever)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGrade3(moderate)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGrade2(moderate)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGrade1(mild)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGrade0(none)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e90.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnknown\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRecurrence of hydronephrosis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRecurrence\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo recurrence\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e96.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePathological fidings\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIntrinsic type\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e60.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eExtrinsic type\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e23.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnclear\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e16.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePostoperative complications\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUrinary Tract Infections\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e13.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDysuria\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePelvic abscess\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIntrapelvic hernia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedical treatment\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOral contraceptives\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eProgestins\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e60.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e30.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePostoperative Parity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eP0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e83.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eP1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eP2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e11.1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe presence of dysmenorrhea in women of reproductive age raises the possibility of UE. Up to 80% of patients with UE do not have any urinary symptoms [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], making the diagnosis difficult. Five of the patients (16.7%) in our study had hydronephrosis detected during annual health check at workplace. Such patients are at risk for decreased renal function if their hydronephrosis remains undetected. The most frequent chief complaint noted by our patients was pelvic pain (reported by 40%). \u003cem\u003eUccella\u003c/em\u003e et al report that 52.3% of patients with UE report pelvic pain [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. To avoid missing a potentially serious diagnosis such as UE, abdominal ultrasonography should be performed in all women with pelvic pain.\u003c/p\u003e \u003cp\u003ePharmacologic therapy does nothing to ameliorate the fibrotic, narrowed ureter that results from UE; it can only relieve the pain related to endometriosis [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Surgical treatment is necessary to remove any areas of ureteral stenosis, but the recurrence rate of hydronephrosis after ureterolysis is as high as 12% [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In contrast, the recurrence rate of hydronephrosis after ureteroneocystostomy is 3.1% [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This difference in recurrence may be results from the fact that intrinsic UE occurs hydronephrosis more frequently than extrinsic UE [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, it is difficult to differentiate intrinsic and extrinsic UE preoperatively.\u003c/p\u003e \u003cp\u003eSince intrinsic UE directly involves the muscularis of the ureter, removing the endometriotic lesion surrounding the ureter is inadequate treatment. In our study, 60% of lesions were of the intrinsic type. Patients with intrinsic UE tend to have endometrial lesions of the bladder and rectum (Supplemental table). Sillou et al report that an assessment of the ureteric circumference at the area of the endometriotic lesion can predict whether lesions are intrinsic [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, this is only speculation. If we cannot rule out intrinsic UE preoperatively, ureteroneocystostomy is a better surgical treatment than ureterolysis in terms of preventing recurrence. We found a recurrence rate of hydronephrosis was 3.3% after ureteroneocystostomy, similar to the rate reported by Ceccaroni et al [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Our experience confirmed that reducing anastomotic tension is a critical part of ureteroneocystostomy [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Our results show that when the distance between the UE lesion and the UVJ is greater than 7 cm, either a psoas hitch or a Boari flap is necessary. Boari flaps are not necessary when the UE lesion is within 3 cm of the UVJ, except when partial bladder resection is performed. Both of these methods can be performed with robotic assistance [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eImproving the pain associated with endometriosis is an important factor in patient satisfaction with whatever procedure is performed. We found that the intensity of dysmenorrhea improves significantly after ureteroneocystostomy. Alves et al also report that the intensity of dysmenorrhea, dyspareunia, and chronic pelvic pein improves significantly after surgery [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The grade of hydronephrosis improve significantly after surgery, and it is important for renal function. Huang et al also describe postoperative remission of hydronephrosis [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study is limited in that we did not compare outcomes between the laparoscopic approach and laparotomy. Robot-assisted ureteroneocystostomy has better surgical outcomes (less postoperative pain and decreased blood loss) than open surgery [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This indicates the advantage of minimally invasive surgery, including laparoscopic ureteroneocystostomy.\u003c/p\u003e \u003cp\u003eIn conclusion, our study indicates that laparoscopic ureteroneocystostomy has the benefits for preventing recurrent hydronephrosis for patients with UE.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eACKNOWLEDGEMENTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDISCLOSURES\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have no conflict of interest to report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eT. Yamada: Protocol/project development, Data collection, Data analysis, Manuscript writing, Statistical analysis,\u003c/p\u003e\n\u003cp\u003eT. Hada: Protocol/project development, Data analysis, Manuscript writing\u003c/p\u003e\n\u003cp\u003eS. Yanai: Protocol/project development, Manuscript writing\u003c/p\u003e\n\u003cp\u003eK. Kanno: Data collection\u003c/p\u003e\n\u003cp\u003eS. Sakate: Data collection\u003c/p\u003e\n\u003cp\u003eM. Sawada: Data collection\u003c/p\u003e\n\u003cp\u003eY. Yoshino: Data analysis, Statistical analysis\u003c/p\u003e\n\u003cp\u003eM.Andou: Protocol/project development, Responsible surgeon\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource of funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003eThis retrospective study was performed in accordance with the Declaration of Helsinkiwas and approved by the Institutional Review Board of our hospital (IRB number: 877).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eVercellini P, Vigan\u0026ograve; P, Somigliana E, Fedele L. Endometriosis: pathogenesis and treatment. \u003cem\u003eNat Rev Endocrinol\u003c/em\u003e. 2014;10:261-275.\u003c/li\u003e\n \u003cli\u003eAbrao MS, Dias Jr JA, Bellelis P, Podgaec S, Bautzer CR, Gromatsky C. Endometriosis of the ureter and bladder are not associated diseases. \u003cem\u003eFertil Steril.\u003c/em\u003e 2009;91:1662-1667.\u003c/li\u003e\n \u003cli\u003eBerlanda N, Vercellini P, Carmignani L, Aimi G, Amicarelli F, Fedele L. Ureteral and vesical endometriosis. Two different clinical entities sharing the same pathogenesis. \u003cem\u003eObstet Gynecol Serv\u003c/em\u003e. 2009;64:830-842.\u003c/li\u003e\n \u003cli\u003eVercellini P, Pisacreta A, Pesole A, Vicentini S, Stellato G, Crosignani PG. Is ureteral endometriosis an asymmetric disease? \u003cem\u003eBJOG\u003c/em\u003e. 2000;107:559-561.\u003c/li\u003e\n \u003cli\u003eAntonelli A, Simeone C, Frego E, Minini G, Bianchi U, Cunico SC. Surgical treatment of ureteral obstruction from endometriosis: our experience with thirteen cases. \u003cem\u003eInt Urogynecol J Pelvic Floor Dysfunct\u003c/em\u003e. 2004;15:407-412.\u003c/li\u003e\n \u003cli\u003eUccella S, Cromi A, Casarin J, et al. Laparoscopy for ureteral endometriosis: surgical details, long-term follow-up, and fertility outcomes. \u003cem\u003eFertil Steril\u003c/em\u003e. 2014;102:160-166.e2. doi: 10.1016/j.fertnstert.2014.03.055\u003c/li\u003e\n \u003cli\u003eBosev D, Nicoll LM, Bhagan L, et al. Laparoscopic management of ureteral endometriosis: the Stanford University hospital experience with 96 consecutive cases. \u003cem\u003eJ Urol.\u003c/em\u003e 2009;182:2748-2752.\u003c/li\u003e\n \u003cli\u003eBarra F, Scala C, Ferrero S. Current understanding on pharmacokinetics, clinical efficacy and safety of progestins for treating pain associated to endometriosis. \u003cem\u003eExpert Opin Drug Metab Toxicol.\u003c/em\u003e 2018;14:399-415.\u003c/li\u003e\n \u003cli\u003eNezhat C, Paka C, Gomaa M, Schipper E. Silent loss of kidney seconary to ureteral endometriosis. \u003cem\u003eJSLS.\u0026nbsp;\u003c/em\u003e2012;16:451-455.\u003c/li\u003e\n \u003cli\u003eGennaro KH, Gordetsky J, Rais-Bahrami S, Selph JP. Ureteral endometriosis: preoperative risk factors predicting extensive urologic surgical intervention. \u003cem\u003eUrology.\u0026nbsp;\u003c/em\u003e2017;100:228-233.\u003c/li\u003e\n \u003cli\u003eBarra F, Scala C, Biscaldi E, et al. Ureteral endometriosis: a systematic review of epidemiology, pathogenesis, diagnosis, treatment, risk of malignant transformation and fertility. \u003cem\u003eHum Reprod Updat\u003c/em\u003ee. 2018;24:710-730.\u003c/li\u003e\n \u003cli\u003eLusuardi L, Hager M, Sieberer M, et al. Laparoscopic treatment of intrinsic endometriosis of the urinary tract and proposal of a treatment scheme for ureteral endometriosis. \u003cem\u003eUrology.\u003c/em\u003e 2012;80:1033-1038.\u003c/li\u003e\n \u003cli\u003eStein R, Rubenwolf P, Ziesel C, Kamal MM, Th\u0026uuml;roff JW. Psoas hitch and Boari flap ureteroneocystostomy. \u003cem\u003eBJU Int.\u0026nbsp;\u003c/em\u003e2013;112:137-155.\u003c/li\u003e\n \u003cli\u003eKnabben 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. \u003cem\u003eFertil Steril.\u003c/em\u003e 2015;103:147-152.\u003c/li\u003e\n \u003cli\u003eMaccagnano C, Pellucchi F, Rocchini L, et al. Ureteral endometriosis: proposal for a diagnostic and therapeutic algorithm with a review of the literature. \u003cem\u003eUrol Int.\u0026nbsp;\u003c/em\u003e2013;91:1-9.\u003c/li\u003e\n \u003cli\u003eMereu L, Gagliardi ML, Clarizia R, Mainardi P, Landi S, Minelli L. Laparoscopic management of ureteral endometriosis in case of moderate-severe hydroureteronephrosis. \u003cem\u003eFertil Steril.\u003c/em\u003e 2010;93:46-51.\u003c/li\u003e\n \u003cli\u003eCeccaroni M, Ceccarello M, Caleffi G, et al. Total laparoscopic ureteroneocystostomy for ureteral endometriosis: a single-center experience of 160 consecutive patients. \u003cem\u003eJ Minim Invasive Gynecol.\u003c/em\u003e 2019;26:78-86.\u003c/li\u003e\n \u003cli\u003eSeracchioli R, Raimondo D, Di Donato N, et al. Histological evaluation of ureteral involvement in women with deep infiltrating endometriosis: analysis of a large series. \u003cem\u003eHum Reprod.\u003c/em\u003e 2015;30:833-839.\u003c/li\u003e\n \u003cli\u003eSillou S, Poir\u0026eacute;e S, Millischer AE, Chapron C, H\u0026eacute;l\u0026eacute;non O. Urinary endometriosis: MR imaging appearance with surgical and histological correlations. \u003cem\u003eDiagn Interv Imaging.\u0026nbsp;\u003c/em\u003e2015;96:373-381.\u003c/li\u003e\n \u003cli\u003eAzioni G, Bracale U, Scala A, et al. Laparoscopic ureteroneocystostomy and vesicopsoas hitch for infiltrative ureteral endometriosis. \u003cem\u003eMinim Invasive Ther Allied Technol.\u003c/em\u003e 2010;19:292-297.\u003c/li\u003e\n \u003cli\u003eYang C, Jones L, Rivera ME, Verlee GT, Deane LA. Robotic-assisted ureteral reimplantation with Boari flap and psoas hitch: a single-institution experience. \u003cem\u003eJ Laparoendosc Adv Surg Tech A.\u003c/em\u003e 2011;21:829-833.\u003c/li\u003e\n \u003cli\u003eAlves J, Puga M, Fernandes R, et al. Laparoscopic management of ureteral endometriosis and hydronephrosis associated with endometriosis. \u003cem\u003eJ Minim Invasive Gynecol.\u003c/em\u003e 2017;24:466-472.\u003c/li\u003e\n \u003cli\u003eHuang JZ, Guo HL, Li JB, Chen SQ. Management of ureteral endometriosis with hydronephrosis: experience from a tertiary medical center. \u003cem\u003eJ Obstet Gynaecol Res.\u0026nbsp;\u003c/em\u003e2017;43:1555-1562.\u003c/li\u003e\n \u003cli\u003eIsac W, Kaouk J, Altunrende F, et al. Robot-assisted ureteroneocystostomy: technique and comparative outcomes.\u003cem\u003e\u0026nbsp;J Endourol.\u003c/em\u003e 2013;27:318-323.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Boari flap, endometriosis, extravesical, psoas hitch, ureteroneocystostomy","lastPublishedDoi":"10.21203/rs.3.rs-732028/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-732028/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eStudy Objective: To investigate the short-term outcomes of laparoscopic ureteroneocystostomy in patients with ureteral endometriosis (UE).\u003c/p\u003e\u003cp\u003eDesign: Retrospective cohort study of consecutive patients who underwent surgery for the ureter endometriosis with hydronephrosis.\u003c/p\u003e\u003cp\u003eSetting: A private hospital that provide primary, secondary and tertiary care.\u003c/p\u003e\u003cp\u003ePatients: 30 consecutive patients with UE who underwent laparoscopic ureteroneocystostomy at our institution between May 2008 and April 2020. \u003c/p\u003e\u003cp\u003eInterventions: Laparoscopic ureteroneocystostomy, if necessary, hysterectomy, salpingo-oophorectomy, cystectomy, partial bladder resection, or partial bowel resection were performed.\u003c/p\u003e\u003cp\u003eMeasurements and Main Results: The most common chief complaint was pelvic pain (40%). Endometriosis affected only the left ureter in 56.7% of patients, only the right ureter in 33.3%, and both ureters in 6.7%. Involvement of the ipsilateral ovary was confirmed in 64.3%. The most frequent location of UE was 1 to 3 cm above the UVJ (46.7%). A psoas hitch was performed in 7 patients (23.3%), and the Boari flap was used in 9 patients (30%). Hysterectomy was performed in 12 patients (40%), and 6 of them had a concomitant bilateral salpingo-oophorectomy (20%). In addition, 3 patients (10%) underwent partial bowel resection, and 2 patients (6.7%) underwent partial bladder resection. After surgery, 24 of 27 patients (80.0%) were free of sever hydronephrosis after surgery. Hydronephrosis recurred in a single patient (3.3%), but the grade of hydronephrosis improved significantly after surgery (P\u0026lt;.001). At 6 months of follow up, 4 patients (13.3%) experienced urinary tract infections and 2 patients (6.7%) reported dysuria. Patients reported a regression of dysmenorrhea symptoms (P\u0026lt;.001). \u003c/p\u003e\u003cp\u003eConclusion: This study shows that ureteroneocystostomy provides good results in terms of relapses and symptoms’ control in patients with ureteral endometriosis.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Rate of Recurrent Hydronephrosis After Laparoscopic Ureteroneocystostomy for Ureteral Endometriosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-11-11 15:57:37","doi":"10.21203/rs.3.rs-732028/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2021-12-02T16:50:28+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-11-08T22:40:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Archives of Gynecology and Obstetrics","date":"2021-08-02T14:10:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-07-20T08:49:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Gynecology and Obstetrics","date":"2021-07-19T04:38:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"e2d892f4-6f0c-40d8-a3b0-9c39afd56632","owner":[],"postedDate":"November 11th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":8441689,"name":"Obstetrics \u0026 Gynecology"}],"tags":[],"updatedAt":"2022-03-03T10:00:13+00:00","versionOfRecord":{"articleIdentity":"rs-732028","link":"https://doi.org/10.1007/s00404-022-06462-y","journal":{"identity":"archives-of-gynecology-and-obstetrics","isVorOnly":false,"title":"Archives of Gynecology and Obstetrics"},"publishedOn":"2022-03-03 10:00:13","publishedOnDateReadable":"March 3rd, 2022"},"versionCreatedAt":"2021-11-11 15:57:37","video":"","vorDoi":"10.1007/s00404-022-06462-y","vorDoiUrl":"https://doi.org/10.1007/s00404-022-06462-y","workflowStages":[]},"version":"v1","identity":"rs-732028","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-732028","identity":"rs-732028","version":["v1"]},"buildId":"zG6E5Sm6oA1kbPE6fP8qF","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}