Clinical Characteristics and Surgical Treatment of Ureteral Endometriosis: Our Experience with 40 Cases

Clinical Characteristics and Surgical Treatment of Ureteral Endometriosis: Our Experience with 40 Cases | 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 Clinical Characteristics and Surgical Treatment of Ureteral Endometriosis: Our Experience with 40 Cases Kunlin Yang, Sida Cheng, Yukun Cai, Jiankun Qiao, Yangyang Xu, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-72716/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 May, 2021 Read the published version in BMC Women's Health → Version 1 posted 12 You are reading this latest preprint version Abstract Background: To present the experience of surgical management of ureteral endometriosis (UE) in our single center. Methods: A retrospective analysis of 40 cases of UE who had intraoperative surgical findings of endometriosis involving the ureter and pathology-proven UE. Results: Forty patients (median age, 42.5 years) with histologic evidence of UE were included. Six (15%) patients had history of endometriosis. Twenty-one (52%) patients had urological symptoms and 19 (48%) patients were asymptomatic. All patients had hydronephrosis. The mean glomerular filtration rate of the affected-side kidney was significantly worse than the healthy-side one (23.4 vs 54.9 ml/min; P < 0.001). Twelve (30%) patients were treated with ureteroureterostomy (11 open approaches and 1 robotic approach). Twenty-two (55%) patients underwent ureteroneocystostomy (17 open approaches, 4 laparoscopic approaches and 1 robotic approach). Five patients underwent nephoureterectomy. One patient refused the aggressive surgery and received ureteroscopic biopsy and ureteral stent placement. Thirteen (33%) cases were required gynecological operations. Three (8%) patients in open group suffered from major surgical complications. Nine (24%) patients received postoperative endocrine therapy. Twenty-eight (70%) patients were followed up (median follow-up time, 71 months). The success rate was 25/28 (89%). Conclusions: Although UE is rare, early diagnosis and treatment of UE will help reduce the morbidity of this disease. Most of time, A multidisciplinary team is necessary. For the patients with severe UE, segmentally ureteral resection with UU or ureteroneocystostomy may be a good choice. Health Economics & Outcomes Research Health Policy Ureteral endometriosis Ureteroureterostomy Ureteroneocystostomy Nephroureterectomy Case report Figures Figure 1 Figure 2 Background Endometriosis is a common gynecologic disorder in women of childbearing age, with the prevalence of 10%-20% for general female population. 1 The involvement of the urinary tract by endometriosis is defined as urinary tract endometriosis (UTE). The prevalence of UTE is difficult to be determined because about 50% of women with endometriosis may be asymptomatic. 2 The literature reported the incidence of UTE ranges from 0.3%-12% of all women affected by endometriosis. 3 The ureteral endometriosis (UE) is a relatively rare situation which is the second most common type of UTE followed bladder endometriosis. 4 UE is usually unilateral and the distal ureter is the most commonly affected site. Symptoms related to UE are often nonspecific and clinical presentation is usually asymptomatic. 5 Most of time, UE is diagnosed incidentally at a gynecologic follow-up or annual health examination. However, the late diagnosis and treatment of UE might lead to the silent loss of renal function. The goals of treatment for UE are to relieve ureteral obstruction and protect renal function. The management depends on the site and extend of UE. The aim of this retrospective study is to summary our experience and provide more information on UE. Methods We performed a search of our surgical database and urological pathology database from May 2004 to May 2020 for cases of UE. All patients had pathology-proven ureteral endometriosis and intraoperative surgical findings of endometriosis involving the ureter. We collected the clinical and surgical data of all cases. We followed up the patients who we could contact with. Traditionally, the ureteroneocystostomy and the ureteroureterostomy (UU) were performed by open approach. In recent years, some cases were performed by laparoscopic or robotic approaches in our center. We defined the criteria of success as the relief of the symptoms and hydronephrosis. Any unresolved symptoms about hydronephrosis or deterioration of hydronephrosis would be considered as failure. Statistical analysis was performed with Microsoft® Excel® 2019 for Windows. Two samples were compared using t tests. P value < 0.05 was considered to be statistically significant. Results Forty-two cases were found from surgical database. Two cases without pathological examination were excluded. A total of 40 patients with histologic evidence of UE were finally included. The median age was 42.5 (range, 27–72) years. Six (15%) patients had history of endometriosis. One patient had received hormonal therapy before surgery and one patient had previously surgical history for endometriosis. Of these 40 patients, 4 (10%) had dysmenorrhea, 12 (30%) had flank pain, 1 (3%) had abdominal pain, 3 (8%) had hematuria, 1 (3%) had frequent urination and 19 (48%) had no symptom (Table 1 ). Twenty patients were involved left ureter and 20 patients were involved right ureter. All patients had hydronephrosis. With the data of glomerular filtration rate from 24 (60%) patients who had received renal dynamic scan examination preoperatively. The mean GRF of affected-side kidney was 23.4 ml/min and healthy-side kidney was 54.9 ml/min ( P< 0.001). Table 1 Patients’ characteristics and preoperative findings Total number of patients The median age (years, range) 40 42.5 (27–72) History of endometriosis Previous hormonal therapy Previous surgery for endometriosis No. Pts (%) 6 (15%) 1 (3%) 1 (3%) History of abortion 4 (10%) History of cesarean section 8 (20%) History of ovarian cystectomy 5 (13%) Concomitant myoma of uterus 8 (20%) History of hysterectomy 2 (5%) History of ectopic pregnancy 3 (8%) Presenting symptoms Dysmenorrhea Flank pain Abdominal pain Hematuria Frequent urination Asymptomatic 4 (10%) 12 (30%) 1 (3%) 3 (8%) 1 (3%) 19 (48%) Ureteral involvement Left Right 20 (50%) 20 (50%) Mean GFR under renal dynamic scan (ml/min), No. Pts (%) 24 (60%) Affected-side kidney (range) Healthy-side kidney (range) 23.4 (0–51) 54.9 (39–77) Twelve (30%) patients were treated with UU. Of these 12 patients, 11 received open approach and 1 received robotic approach (Fig. 1 ). Of 22 (55%) patients who underwent ureteroneocystostomy, 17 (43%) received open surgery, 4 (10%) received laparoscopic surgery and 1 (3%) received robotic surgery (Table 2 ). Sometimes, ureteral reimplantation might be performed concomitant with psoas hitch (Fig. 2 ). Among 5 (13%) patients, 2 patients were more likely to be considered as ureteral tumor preoperatively and 3 patients were diagnosed with a nonfunctioning affected-side kidney. So, these 5 patients underwent nephoureterectomy. One patient refused to undergo the aggressive surgery and finally received ureteroscopic biopsy and ureteral stent placement. There were 13 (33%) cases who required gynecological operations. The mean operative time was 152.4 min. The mean post-operative hospitalization was 6.7 days. Three (8%) patients in open group separately suffered from major surgical complications (Sigmoid colon injury / Intestinal obstruction / Blood transfusion). Nine (24%) patients received postoperative endocrine therapy (Table 2 ). Table 2 Intraoperative details and follow-up results Surgical procedures Ureteroureterostomy Open Robotic Ureteroneocystostomy Open Laparoscopic Robotic Nephroureterectomy Open Laparoscopic Ureteral stent placement Concomitant gynecologic operation Total hysterectomy + pelvic endometrial nodules resection Total hysterectomy + salpingo-oophorectomy Salpingo-oophorectomy + pelvic endometrial nodules resection Pelvic endometrial nodules resection Salpingo-oophorectomy Myomectomy No. Pts (%) 12 (30%) 11 (28%) 1 (3%) 22 (55%) 17 (43%) 4 (10%) 1 (3%) 5 (13%) 2 (5%) 3 (8%) 1 (3%) 13 (33%) 2 (5%) 3 (8%) 2 (5%) 1 (3%) 3 (8%) 2 (5%) Mean operative time, min (range) 152.4 (19–380) Mean post-operative hospitalization, day (range) 6.7 (2–13) Surgical complications, n Sigmoid colon injury / Intestinal obstruction / Blood transfusion 3 (8%) 1/1/1 Postoperative endocrine therapy, n 9 (23%) Total follow-up patients, n 28 (70%) Median follow-up time, month (range) 71 (11–150) Positive follow-up result, n Flank pain Recurrent urinary tract infection Unresolved hydronephrosis 3 1 1 1 Excluded 2 patients whose follow-up time was still too short and 10 patients who could not be contacted with, 28 (70%) patients were totally followed up. The median follow-up time was 71 months. Among 28 patients, we found 3 (11%) patients still had persistent flank pain, recurrent urinary tract infection or unresolved hydronephrosis, which meant our treatment was failed. Twenty-five patients achieved the criteria for success. The success rate was 25/28 (89%). Discussion In the patients of endometriosis, UE accounts for only 0.01–1.7% according to the reported cases in the literature. 6 Most of the time, UE is very difficult to diagnose due to the absence of special symptoms. About half of the patients are found when accidental health examination. Our data also shows that 48% of patients were asymptomatic. For the symptomatic women of UE, the three most common symptoms are severe dysmenorrhea (75%), dyspareunia (70%) and pelvic pain (60%). 4 In our study, flank pain is the most common symptom. The UE is usually unilateral. Some studies reported that the left UE was more than the right one. 1 , 4 , 7 The distal third of the ureter is most frequently affected by endometriosis. The pathogenesis of UE is still unknown. The hypothesis of retrograde menstruation is the most popular theory. 8 However, this theory can’t completely explain the isolate UE without any other implants of endometriosis. Hydronephrosis is common in endometrial nodules larger than 3 cm. 9 , 10 The UE is found predominantly in women with hydronephrosis and/or in women with lesions larger than 4 cm. 9 The UE lesions are very rarely isolated and are frequently associated with other kinds of endometriosis. 11 , 12 Although physical examination often has no positive findings in UE, the rectovaginal palpation is necessary which may provide a helpful indication of UE. 11 There are two types of UE: extrinsic and intrinsic. The extrinsic compression of the ureteral wall is more common than the intrinsic invasion which may originate from lymphatic or venous metastases. 13 When UE is suspected, all urologic causes of extrinsic and intrinsic ureteral stenosis should be considered, such as stones, primary megaureter, primary or secondary ureteral cancer, infections, retroperitoneal lymphadenopathy and idiopathic retroperitoneal fibrosis. 6 For differentiating these conditions, the imaging techniques are needed. 14 The transvaginal and abdominal ultrasonography are the first-line exam which can detect rectovaginal nodules at the distal third of ureter and evaluate the degree of hydronephrosis and the thickness of the renal parenchyma. 15 The magnetic resonance imaging (MRI) is highly accurate to detect and predict the type of UE. MRI is more sensitive, but less specific than surgery in detecting intrinsic involvement which may overestimate the prevalence of intrinsic lesions. 16 Multislice computed tomography is alternative to MRI, but it has irradiation and can cause discomfort for the eventual enema. 6 Renal scintigraphy should be performed when a decision between kidney preservation and nephrectomy is being considered. When intrinsic UE needs to be distinguished from the malignant ureteral tumor, a ureteroscopic biopsy may also be necessary to help a final choice. However, as it is invasive and it is not able to detect extrinsic lesions, it is now rarely used in clinical practice. 17 The surgical treatment for UE is aim to relieve ureteral obstruction and protect renal function. The main procedures include ureterolysis, ureterectomy with UU, ureteroneocystostomy and excision of all other endometrial lesions. In our hospital, some simple UE cases which may just need ureterolysis were all treated by gynecological doctors. If a more invasive procedure was needed like UU or ureteral reimplantation, the surgery will be mainly performed by urologists. In this study, almost all cases were recommended from gynecological department to urological department. Sometimes, the treatment process needed multidisplinary team. The choice of surgical procedure is determined by the severity and location of lesions. The patients with less extensive endometriosis undergo ureterolysis and excision of all other lesions. Compared with ureteroneocystostomy, UU and uretrolysis have higher restenosis rate (11% and 8% versus 3%). 18 For women with moderate to severe diseases, radical surgery is often required, including segmental resection with UU or ureteral reimplantation. 19 Furthermore, nephrectomy or nephroureterectomy should be performed when renal function is less than 10–15% with symptoms like flank pain, renovascular hypertension and recurrent urinary tract infections. 20 In our study, two patients were considered as ureteral cancer and three patients were diagnosed as nonfunctional kidney who finally underwent nephoureterectomy. In the past ten years, open procedure was the main type of surgery in our center. With the development of laparoscopic and robotic techniques, 21 , 22 we also did some difficult operations under laparoscopy or robot-assisted laparoscopy. Especially for the complex cases, the robotic surgery has special advantages on anastomosis. As the surgery shown in Fig. 1 , it was unlikely to be done by open or laparoscopic approach. In all patients, we noticed that a 72 years old woman who was suspected as malignant ureteral cancer preoperatively was finally diagnosed as UE by the postoperative pathology. As we known, the endometriosis tends to occur in women of childbearing age under 60 years. However, Haydon had reported one of the oldest patients with endometriosis, aged 78. 23 This reminds us that UE can also occur in the elderly, although it is very rare. Although cases of successful hormone therapy of UE have been reported, 24 , 25 medical treatment is not able to resolve the fibrotic component of the lesion, which is mainly responsible for the ureteral obstruction. 26 Therefore, UE with obvious ureteral obstruction should be treated surgically. For some patients with severe diseases, postoperative adjuvant hormone therapy may be helpful. 27 , 28 Conclusions UE is rare and the diagnosis of UE is difficult with few guidelines on surgical treatment. A multidisciplinary team (at least including gynecologists and urologists) is necessary. For the patients with severe ureteral involvement, segmental resection with UU or ureteral reimplantation may be a good strategy. Abbreviations UTE = urinary tract endometriosis UE = ureteral endometriosis MRI = magnetic resonance imaging UU = ureteroureterostomy Declarations Ethics approval and consent to participate This study was approved by the Peking University First Hospital Ethics Committee, and all of the study procedures met the stipulations of the WMA Declaration of Helsinki. Consent for publication Written informed consent was obtained from all of the patients with respect to publication of this study and any accompanying images. Availability of data and materials The data of the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests Funding Guiyang science and technology plan fund: zhukehe [2018] No. 1-11 Talent innovation and entrepreneurship funding project of Guiyang Municipal Committee: Zhuren ban Contract No. [2019] 33 Science and Technology Fund Project of Guizhou Health Committee: (gzwjkj2019-1-080) These funding belongs to Aobing Mei who is one of corresponding authors and these funding had supported our study. Authors’ contributions XS L and AB M designed the study. XS L, LQ Z and Y Lperformed the operation. KL Y and SD C participated in the operation and drafted the manuscript. YK C and JK Q participated in the analysis and interpretation of the data. YY X, XF L and SW X participated in the operation and clinical follow-up. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Frenna, V., Santos, L., Ohana, E. et al.: Laparoscopic management of ureteral endometriosis: our experience. J Minim Invasive Gynecol, 14: 169, 2007 Seracchioli, R., Mabrouk, M., Montanari, G. et al.: Conservative laparoscopic management of urinary tract endometriosis (UTE): surgical outcome and long-term follow-up. Fertil Steril, 94: 856, 2010 Gennaro, K. H., Gordetsky, J., Rais-Bahrami, S. et al.: Ureteral Endometriosis: Preoperative Risk Factors Predicting Extensive Urologic Surgical Intervention. Urology, 100: 228, 2017 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, 91: 1, 2013 Bosev, D., Nicoll, L. M., Bhagan, L. et al.: Laparoscopic management of ureteral endometriosis: the Stanford University hospital experience with 96 consecutive cases. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-72716","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":3487388,"identity":"95513a27-ec07-448a-87e3-3f952568ee05","order_by":0,"name":"Kunlin Yang","email":"","orcid":"","institution":"Peking University First Hospital Department of Urology","correspondingAuthor":false,"prefix":"","firstName":"Kunlin","middleName":"","lastName":"Yang","suffix":""},{"id":3487389,"identity":"ce97c799-f388-404b-9297-7c22b1766c40","order_by":1,"name":"Sida Cheng","email":"","orcid":"","institution":"Peking University First Hospital Department of Urology","correspondingAuthor":false,"prefix":"","firstName":"Sida","middleName":"","lastName":"Cheng","suffix":""},{"id":3487390,"identity":"9ac966b2-7094-43fd-acc6-ddfe6f7b0c83","order_by":2,"name":"Yukun Cai","email":"","orcid":"","institution":"Peking University First Hospital Department of Urology","correspondingAuthor":false,"prefix":"","firstName":"Yukun","middleName":"","lastName":"Cai","suffix":""},{"id":3487391,"identity":"8d049cb6-f5d7-4042-853a-947f79bbd6a9","order_by":3,"name":"Jiankun Qiao","email":"","orcid":"","institution":"Peking University First Hospital Department of Urology","correspondingAuthor":false,"prefix":"","firstName":"Jiankun","middleName":"","lastName":"Qiao","suffix":""},{"id":3487392,"identity":"4ba7625f-4cce-4cf7-bee3-0d9c239d212c","order_by":4,"name":"Yangyang Xu","email":"","orcid":"","institution":"Peking University First Hospital Department of Urology","correspondingAuthor":false,"prefix":"","firstName":"Yangyang","middleName":"","lastName":"Xu","suffix":""},{"id":3487393,"identity":"2c6eb0b8-6de7-47fd-8b7d-def52de41642","order_by":5,"name":"Xinfei Li","email":"","orcid":"","institution":"Peking University First Hospital Department of Urology","correspondingAuthor":false,"prefix":"","firstName":"Xinfei","middleName":"","lastName":"Li","suffix":""},{"id":3487394,"identity":"9f21a1f8-b651-481e-b707-b88f282f6d35","order_by":6,"name":"Shengwei Xiong","email":"","orcid":"","institution":"Peking University First Hospital Department of Urology","correspondingAuthor":false,"prefix":"","firstName":"Shengwei","middleName":"","lastName":"Xiong","suffix":""},{"id":3487395,"identity":"4321717b-cf0f-4658-99de-13f7a52ccd99","order_by":7,"name":"Ye Lu","email":"","orcid":"","institution":"Peking University First Hospital Department of Obstetrics and Gynecology","correspondingAuthor":false,"prefix":"","firstName":"Ye","middleName":"","lastName":"Lu","suffix":""},{"id":3487396,"identity":"05cdedbd-f5f7-42cb-bb7a-055fd4be24b9","order_by":8,"name":"Aobing Mei","email":"","orcid":"","institution":"The Sencond People's Hospital of Guiyang Department of Urology","correspondingAuthor":false,"prefix":"","firstName":"Aobing","middleName":"","lastName":"Mei","suffix":""},{"id":3487397,"identity":"0284dde0-5fea-44e9-9d77-15525b386485","order_by":9,"name":"Xuesong Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAz0lEQVRIiWNgGAWjYDACZgjF2MfAfIAhgSQtbQxsCURqYYBr4TEgTqk5O+/BxwUVNrJt7D2fPzzcYcfA396N3zLLZr5k4xln0ozbeM5uk0g8k8wgcebsBrxaDA7zmEnzth1ObJPI3caQ2MbMYCCRS1CL+W/ef/8T2+TfPP6Q2FZPlBYzZt6GA0BbeBgkEtsOE9Zi2cxjLM1zLBnolzQzoJbjPAT9Ys5/xvAzT42dbD/74ccff7ZVy/G39xJwGLoAD17lWLWMglEwCkbBKMAAAGaQQd0AJxPrAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-7030-0856","institution":"Peking University First Hospital","correspondingAuthor":true,"prefix":"","firstName":"Xuesong","middleName":"","lastName":"Li","suffix":""},{"id":3487398,"identity":"9d5b06ae-58fb-4828-a8a3-d5d44769b64a","order_by":10,"name":"Liqun Zhou","email":"","orcid":"","institution":"Peking University First Hospital Department of Urology","correspondingAuthor":false,"prefix":"","firstName":"Liqun","middleName":"","lastName":"Zhou","suffix":""}],"badges":[],"createdAt":"2020-09-05 10:14:46","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-72716/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-72716/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12905-021-01349-7","type":"published","date":"2021-05-17T21:05:20+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":3021897,"identity":"7b5a1ed7-8a25-4cbe-ae3c-b008764fd155","added_by":"auto","created_at":"2020-10-16 13:16:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":4380108,"visible":true,"origin":"","legend":"Robotic-assisted laparoscopic ureteroureterostomy. (A) Blue area shows the dilated ureter. (B) Cut the suspensory ligament of right ovary and resect the right ovary and endometrial lesion. (C) Dissect the distal ureter with stricture (blue area) which is close to the bladder. (D) Excise the ureteral stricture. (E-I) Perform the ureteroureterostomy. ","description":"","filename":"fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-72716/v1/0eacb3f4c009579e82813889.png"},{"id":3021898,"identity":"3833ba0f-d527-4005-9884-081ffc1c1d7b","added_by":"auto","created_at":"2020-10-16 13:16:20","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3139615,"visible":true,"origin":"","legend":"Laparoscopic ureteroneocystostomy with psoas hitch. (A) Dissect the ureter and the endometrial nodule (red arrow). (B) Blue arrow shows the ureteral stricture and red arrow shows the endometrial nodule. (C) Excise the endometrial lesion and cut the ureter. (D, E) Free the Retzius space. (F) Make a ureteral nipple extracorporeally. (G) Perform psoas hitch of the bladder. (H, I) Perform anastomosis of the ureter and the bladder.","description":"","filename":"fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-72716/v1/bcd07fbd3ed15c4534651d52.png"},{"id":13604017,"identity":"d2364aca-c319-4f62-a618-9d89e2964cdc","added_by":"auto","created_at":"2021-09-17 05:58:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4648636,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-72716/v1/8a7095e6-bc18-4090-ab65-6be2acf63b4c.pdf"},{"id":3021899,"identity":"87de23cd-52bb-45f5-94b8-a3aa0ee65d97","added_by":"auto","created_at":"2020-10-16 13:16:21","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":663173,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklist.pdf","url":"https://assets-eu.researchsquare.com/files/rs-72716/v1/c6fbba41107f535ad38540c2.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eClinical Characteristics and Surgical Treatment of Ureteral Endometriosis: Our Experience with 40 Cases\u003c/p\u003e","fulltext":[{"header":"Background","content":" \u003cp\u003eEndometriosis is a common gynecologic disorder in women of childbearing age, with the prevalence of 10%-20% for general female population.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The involvement of the urinary tract by endometriosis is defined as urinary tract endometriosis (UTE). The prevalence of UTE is difficult to be determined because about 50% of women with endometriosis may be asymptomatic.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e The literature reported the incidence of UTE ranges from 0.3%-12% of all women affected by endometriosis.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe ureteral endometriosis (UE) is a relatively rare situation which is the second most common type of UTE followed bladder endometriosis.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e UE is usually unilateral and the distal ureter is the most commonly affected site. Symptoms related to UE are often nonspecific and clinical presentation is usually asymptomatic.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Most of time, UE is diagnosed incidentally at a gynecologic follow-up or annual health examination. However, the late diagnosis and treatment of UE might lead to the silent loss of renal function.\u003c/p\u003e \u003cp\u003eThe goals of treatment for UE are to relieve ureteral obstruction and protect renal function. The management depends on the site and extend of UE. The aim of this retrospective study is to summary our experience and provide more information on UE.\u003c/p\u003e "},{"header":"Methods","content":" \u003cp\u003eWe performed a search of our surgical database and urological pathology database from May 2004 to May 2020 for cases of UE. All patients had pathology-proven ureteral endometriosis and intraoperative surgical findings of endometriosis involving the ureter. We collected the clinical and surgical data of all cases. We followed up the patients who we could contact with.\u003c/p\u003e \u003cp\u003eTraditionally, the ureteroneocystostomy and the ureteroureterostomy (UU) were performed by open approach. In recent years, some cases were performed by laparoscopic or robotic approaches in our center. We defined the criteria of success as the relief of the symptoms and hydronephrosis. Any unresolved symptoms about hydronephrosis or deterioration of hydronephrosis would be considered as failure. Statistical analysis was performed with Microsoft\u0026reg; Excel\u0026reg; 2019 for Windows. Two samples were compared using t tests. \u003cem\u003eP\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to be statistically significant.\u003c/p\u003e "},{"header":"Results","content":"\u003cp\u003eForty-two cases were found from surgical database. Two cases without pathological examination were excluded. A total of 40 patients with histologic evidence of UE were finally included. The median age was 42.5 (range, 27\u0026ndash;72) years. Six (15%) patients had history of endometriosis. One patient had received hormonal therapy before surgery and one patient had previously surgical history for endometriosis. Of these 40 patients, 4 (10%) had dysmenorrhea, 12 (30%) had flank pain, 1 (3%) had abdominal pain, 3 (8%) had hematuria, 1 (3%) had frequent urination and 19 (48%) had no symptom (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Twenty patients were involved left ureter and 20 patients were involved right ureter. All patients had hydronephrosis. With the data of glomerular filtration rate from 24 (60%) patients who had received renal dynamic scan examination preoperatively. The mean GRF of affected-side kidney was 23.4\u0026nbsp;ml/min and healthy-side kidney was 54.9\u0026nbsp;ml/min (\u003cem\u003eP\u0026lt;\u003c/em\u003e0.001).\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\u003ePatients\u0026rsquo; characteristics and preoperative 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\u003eTotal number of patients\u003c/p\u003e\n\u003cp\u003eThe median age (years, range)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e40\u003c/p\u003e\n\u003cp\u003e42.5 (27\u0026ndash;72)\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\u003eHistory of endometriosis\u003c/p\u003e\n\u003cp\u003ePrevious hormonal therapy\u003c/p\u003e\n\u003cp\u003ePrevious surgery for endometriosis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eNo. Pts (%)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e6 (15%)\u003c/p\u003e\n\u003cp\u003e1 (3%)\u003c/p\u003e\n\u003cp\u003e1 (3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHistory of abortion\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (10%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHistory of cesarean section\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 (20%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHistory of ovarian cystectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (13%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eConcomitant myoma of uterus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 (20%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHistory of hysterectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHistory of ectopic pregnancy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePresenting symptoms\u003c/p\u003e\n\u003cp\u003eDysmenorrhea\u003c/p\u003e\n\u003cp\u003eFlank pain\u003c/p\u003e\n\u003cp\u003eAbdominal pain\u003c/p\u003e\n\u003cp\u003eHematuria\u003c/p\u003e\n\u003cp\u003eFrequent urination\u003c/p\u003e\n\u003cp\u003eAsymptomatic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (10%)\u003c/p\u003e\n\u003cp\u003e12 (30%)\u003c/p\u003e\n\u003cp\u003e1 (3%)\u003c/p\u003e\n\u003cp\u003e3 (8%)\u003c/p\u003e\n\u003cp\u003e1 (3%)\u003c/p\u003e\n\u003cp\u003e19 (48%)\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\u003cp\u003eLeft\u003c/p\u003e\n\u003cp\u003eRight\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20 (50%)\u003c/p\u003e\n\u003cp\u003e20 (50%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMean GFR under renal dynamic scan (ml/min), No. Pts (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24 (60%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAffected-side kidney (range)\u003c/p\u003e\n\u003cp\u003eHealthy-side kidney (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.4 (0\u0026ndash;51)\u003c/p\u003e\n\u003cp\u003e54.9 (39\u0026ndash;77)\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\u003eTwelve (30%) patients were treated with UU. Of these 12 patients, 11 received open approach and 1 received robotic approach (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Of 22 (55%) patients who underwent ureteroneocystostomy, 17 (43%) received open surgery, 4 (10%) received laparoscopic surgery and 1 (3%) received robotic surgery (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Sometimes, ureteral reimplantation might be performed concomitant with psoas hitch (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Among 5 (13%) patients, 2 patients were more likely to be considered as ureteral tumor preoperatively and 3 patients were diagnosed with a nonfunctioning affected-side kidney. So, these 5 patients underwent nephoureterectomy. One patient refused to undergo the aggressive surgery and finally received ureteroscopic biopsy and ureteral stent placement. There were 13 (33%) cases who required gynecological operations. The mean operative time was 152.4\u0026nbsp;min. The mean post-operative hospitalization was 6.7 days. Three (8%) patients in open group separately suffered from major surgical complications (Sigmoid colon injury / Intestinal obstruction / Blood transfusion). Nine (24%) patients received postoperative endocrine therapy (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u0026nbsp;\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\u003eIntraoperative details and follow-up results\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSurgical procedures\u003c/p\u003e\n\u003cp\u003eUreteroureterostomy\u003c/p\u003e\n\u003cp\u003eOpen\u003c/p\u003e\n\u003cp\u003eRobotic\u003c/p\u003e\n\u003cp\u003eUreteroneocystostomy\u003c/p\u003e\n\u003cp\u003eOpen\u003c/p\u003e\n\u003cp\u003eLaparoscopic\u003c/p\u003e\n\u003cp\u003eRobotic\u003c/p\u003e\n\u003cp\u003eNephroureterectomy\u003c/p\u003e\n\u003cp\u003eOpen\u003c/p\u003e\n\u003cp\u003eLaparoscopic\u003c/p\u003e\n\u003cp\u003eUreteral stent placement\u003c/p\u003e\n\u003cp\u003eConcomitant gynecologic operation\u003c/p\u003e\n\u003cp\u003eTotal hysterectomy\u0026thinsp;+\u0026thinsp;pelvic endometrial nodules resection\u003c/p\u003e\n\u003cp\u003eTotal hysterectomy\u0026thinsp;+\u0026thinsp;salpingo-oophorectomy\u003c/p\u003e\n\u003cp\u003eSalpingo-oophorectomy\u0026thinsp;+\u0026thinsp;pelvic endometrial nodules resection\u003c/p\u003e\n\u003cp\u003ePelvic endometrial nodules resection\u003c/p\u003e\n\u003cp\u003eSalpingo-oophorectomy\u003c/p\u003e\n\u003cp\u003eMyomectomy\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNo. Pts (%)\u003c/p\u003e\n\u003cp\u003e12 (30%)\u003c/p\u003e\n\u003cp\u003e11 (28%)\u003c/p\u003e\n\u003cp\u003e1 (3%)\u003c/p\u003e\n\u003cp\u003e22 (55%)\u003c/p\u003e\n\u003cp\u003e17 (43%)\u003c/p\u003e\n\u003cp\u003e4 (10%)\u003c/p\u003e\n\u003cp\u003e1 (3%)\u003c/p\u003e\n\u003cp\u003e5 (13%)\u003c/p\u003e\n\u003cp\u003e2 (5%)\u003c/p\u003e\n\u003cp\u003e3 (8%)\u003c/p\u003e\n\u003cp\u003e1 (3%)\u003c/p\u003e\n\u003cp\u003e13 (33%)\u003c/p\u003e\n\u003cp\u003e2 (5%)\u003c/p\u003e\n\u003cp\u003e3 (8%)\u003c/p\u003e\n\u003cp\u003e2 (5%)\u003c/p\u003e\n\u003cp\u003e1 (3%)\u003c/p\u003e\n\u003cp\u003e3 (8%)\u003c/p\u003e\n\u003cp\u003e2 (5%)\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\u003eMean operative time, min (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e152.4 (19\u0026ndash;380)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMean post-operative hospitalization, day (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.7 (2\u0026ndash;13)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSurgical complications, n\u003c/p\u003e\n\u003cp\u003eSigmoid colon injury / Intestinal obstruction / Blood transfusion\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (8%)\u003c/p\u003e\n\u003cp\u003e1/1/1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePostoperative endocrine therapy, n\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (23%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTotal follow-up patients, n\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28 (70%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedian follow-up time, month (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e71 (11\u0026ndash;150)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePositive follow-up result, n\u003c/p\u003e\n\u003cp\u003eFlank pain\u003c/p\u003e\n\u003cp\u003eRecurrent urinary tract infection\u003c/p\u003e\n\u003cp\u003eUnresolved hydronephrosis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003cp\u003e1\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\u003eExcluded 2 patients whose follow-up time was still too short and 10 patients who could not be contacted with, 28 (70%) patients were totally followed up. The median follow-up time was 71 months. Among 28 patients, we found 3 (11%) patients still had persistent flank pain, recurrent urinary tract infection or unresolved hydronephrosis, which meant our treatment was failed. Twenty-five patients achieved the criteria for success. The success rate was 25/28 (89%).\u003c/p\u003e"},{"header":"Discussion","content":" \u003cp\u003eIn the patients of endometriosis, UE accounts for only 0.01\u0026ndash;1.7% according to the reported cases in the literature.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Most of the time, UE is very difficult to diagnose due to the absence of special symptoms. About half of the patients are found when accidental health examination. Our data also shows that 48% of patients were asymptomatic. For the symptomatic women of UE, the three most common symptoms are severe dysmenorrhea (75%), dyspareunia (70%) and pelvic pain (60%).\u003csup\u003e4\u003c/sup\u003e In our study, flank pain is the most common symptom. The UE is usually unilateral. Some studies reported that the left UE was more than the right one.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e The distal third of the ureter is most frequently affected by endometriosis.\u003c/p\u003e \u003cp\u003eThe pathogenesis of UE is still unknown. The hypothesis of retrograde menstruation is the most popular theory.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e However, this theory can\u0026rsquo;t completely explain the isolate UE without any other implants of endometriosis. Hydronephrosis is common in endometrial nodules larger than 3\u0026nbsp;cm.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e The UE is found predominantly in women with hydronephrosis and/or in women with lesions larger than 4\u0026nbsp;cm.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e The UE lesions are very rarely isolated and are frequently associated with other kinds of endometriosis.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAlthough physical examination often has no positive findings in UE, the rectovaginal palpation is necessary which may provide a helpful indication of UE.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e There are two types of UE: extrinsic and intrinsic. The extrinsic compression of the ureteral wall is more common than the intrinsic invasion which may originate from lymphatic or venous metastases.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e When UE is suspected, all urologic causes of extrinsic and intrinsic ureteral stenosis should be considered, such as stones, primary megaureter, primary or secondary ureteral cancer, infections, retroperitoneal lymphadenopathy and idiopathic retroperitoneal fibrosis.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e For differentiating these conditions, the imaging techniques are needed.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e The transvaginal and abdominal ultrasonography are the first-line exam which can detect rectovaginal nodules at the distal third of ureter and evaluate the degree of hydronephrosis and the thickness of the renal parenchyma.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e The magnetic resonance imaging (MRI) is highly accurate to detect and predict the type of UE. MRI is more sensitive, but less specific than surgery in detecting intrinsic involvement which may overestimate the prevalence of intrinsic lesions.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Multislice computed tomography is alternative to MRI, but it has irradiation and can cause discomfort for the eventual enema.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Renal scintigraphy should be performed when a decision between kidney preservation and nephrectomy is being considered.\u003c/p\u003e \u003cp\u003eWhen intrinsic UE needs to be distinguished from the malignant ureteral tumor, a ureteroscopic biopsy may also be necessary to help a final choice. However, as it is invasive and it is not able to detect extrinsic lesions, it is now rarely used in clinical practice.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe surgical treatment for UE is aim to relieve ureteral obstruction and protect renal function. The main procedures include ureterolysis, ureterectomy with UU, ureteroneocystostomy and excision of all other endometrial lesions. In our hospital, some simple UE cases which may just need ureterolysis were all treated by gynecological doctors. If a more invasive procedure was needed like UU or ureteral reimplantation, the surgery will be mainly performed by urologists. In this study, almost all cases were recommended from gynecological department to urological department. Sometimes, the treatment process needed multidisplinary team.\u003c/p\u003e \u003cp\u003eThe choice of surgical procedure is determined by the severity and location of lesions. The patients with less extensive endometriosis undergo ureterolysis and excision of all other lesions. Compared with ureteroneocystostomy, UU and uretrolysis have higher restenosis rate (11% and 8% versus 3%).\u003csup\u003e18\u003c/sup\u003e For women with moderate to severe diseases, radical surgery is often required, including segmental resection with UU or ureteral reimplantation.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Furthermore, nephrectomy or nephroureterectomy should be performed when renal function is less than 10\u0026ndash;15% with symptoms like flank pain, renovascular hypertension and recurrent urinary tract infections.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e In our study, two patients were considered as ureteral cancer and three patients were diagnosed as nonfunctional kidney who finally underwent nephoureterectomy.\u003c/p\u003e \u003cp\u003eIn the past ten years, open procedure was the main type of surgery in our center. With the development of laparoscopic and robotic techniques,\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e we also did some difficult operations under laparoscopy or robot-assisted laparoscopy. Especially for the complex cases, the robotic surgery has special advantages on anastomosis. As the surgery shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, it was unlikely to be done by open or laparoscopic approach.\u003c/p\u003e \u003cp\u003eIn all patients, we noticed that a 72\u0026nbsp;years old woman who was suspected as malignant ureteral cancer preoperatively was finally diagnosed as UE by the postoperative pathology. As we known, the endometriosis tends to occur in women of childbearing age under 60\u0026nbsp;years. However, Haydon had reported one of the oldest patients with endometriosis, aged 78.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e This reminds us that UE can also occur in the elderly, although it is very rare.\u003c/p\u003e \u003cp\u003eAlthough cases of successful hormone therapy of UE have been reported,\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e medical treatment is not able to resolve the fibrotic component of the lesion, which is mainly responsible for the ureteral obstruction.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Therefore, UE with obvious ureteral obstruction should be treated surgically. For some patients with severe diseases, postoperative adjuvant hormone therapy may be helpful.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e "},{"header":"Conclusions","content":" \u003cp\u003eUE is rare and the diagnosis of UE is difficult with few guidelines on surgical treatment. A multidisciplinary team (at least including gynecologists and urologists) is necessary. For the patients with severe ureteral involvement, segmental resection with UU or ureteral reimplantation may be a good strategy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eUTE = urinary tract endometriosis\u003c/p\u003e\n\u003cp\u003eUE = ureteral endometriosis\u003c/p\u003e\n\u003cp\u003eMRI = magnetic resonance imaging\u003c/p\u003e\n\u003cp\u003eUU = ureteroureterostomy\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study was approved by the Peking University First Hospital Ethics Committee, and all of the study procedures met the stipulations of the WMA Declaration of Helsinki.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eWritten informed consent was obtained from all of the patients with respect to publication of this study and any accompanying images.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe data of the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003col\u003e\n\u003cli\u003e\n\u003cp\u003eGuiyang science and technology plan fund: zhukehe [2018] No. 1-11\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eTalent innovation and entrepreneurship funding project of Guiyang Municipal Committee: Zhuren ban Contract No. [2019] 33\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eScience and Technology Fund Project of Guizhou Health Committee: (gzwjkj2019-1-080)\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThese funding belongs to Aobing Mei who is one of corresponding authors and these funding had supported our study.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; contributions\u003c/h2\u003e\n\u003cp\u003eXS L and AB M designed the study. XS L, LQ Z and Y Lperformed the operation. KL Y and SD C participated in the operation and drafted the manuscript. YK C and JK Q participated in the analysis and interpretation of the data. YY X, XF L and SW X participated in the operation and clinical follow-up. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFrenna, V., Santos, L., Ohana, E. et al.: Laparoscopic management of ureteral endometriosis: our experience. J Minim Invasive Gynecol, \u003cstrong\u003e14:\u003c/strong\u003e 169, 2007\u003c/li\u003e\n\u003cli\u003eSeracchioli, R., Mabrouk, M., Montanari, G. et al.: Conservative laparoscopic management of urinary tract endometriosis (UTE): surgical outcome and long-term follow-up. Fertil Steril, \u003cstrong\u003e94:\u003c/strong\u003e 856, 2010\u003c/li\u003e\n\u003cli\u003eGennaro, K. H., Gordetsky, J., Rais-Bahrami, S. et al.: Ureteral Endometriosis: Preoperative Risk Factors Predicting Extensive Urologic Surgical Intervention. Urology, \u003cstrong\u003e100:\u003c/strong\u003e 228, 2017\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. Urol Int, \u003cstrong\u003e91:\u003c/strong\u003e 1, 2013\u003c/li\u003e\n\u003cli\u003eBosev, D., Nicoll, L. M., Bhagan, L. et al.: Laparoscopic management of ureteral endometriosis: the Stanford University hospital experience with 96 consecutive cases. J Urol, \u003cstrong\u003e182:\u003c/strong\u003e 2748, 2009\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. Hum Reprod Update, \u003cstrong\u003e24:\u003c/strong\u003e 710, 2018\u003c/li\u003e\n\u003cli\u003eCavaco-Gomes, J., Martinho, M., Gilabert-Aguilar, J. et al.: Laparoscopic management of ureteral endometriosis: A systematic review. Eur J Obstet Gynecol Reprod Biol, \u003cstrong\u003e210:\u003c/strong\u003e 94, 2017\u003c/li\u003e\n\u003cli\u003eGordts, S., Koninckx, P., Brosens, I.: Pathogenesis of deep endometriosis. Fertil Steril, \u003cstrong\u003e108:\u003c/strong\u003e 872, 2017\u003c/li\u003e\n\u003cli\u003eKoninckx, P. R., Ussia, A., Adamyan, L. et al.: Deep endometriosis: definition, diagnosis, and treatment. Fertil Steril, \u003cstrong\u003e98:\u003c/strong\u003e 564, 2012\u003c/li\u003e\n\u003cli\u003eKondo, W., Branco, A. W., Trippia, C. H. et al.: Retrocervical Deep Infiltrating Endometriotic Lesions Larger than Thirty Millimeters are Associated with an Increased Rate of Ureteral\u0026nbsp;Involvement. J Minim Invas Gyn, \u003cstrong\u003e20:\u003c/strong\u003e 100, 2013\u003c/li\u003e\n\u003cli\u003eKnabben, L., Imboden, S., Fellmann, B. et al.: Urinary tract endometriosis in\u0026nbsp;patients with deep infiltrating endometriosis: prevalence, symptoms, management, and\u0026nbsp;proposal for a new clinical classification. Fertil Steril, \u003cstrong\u003e103:\u003c/strong\u003e 147, 2015\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. Fertil Steril, \u003cstrong\u003e102:\u003c/strong\u003e 160, 2014\u003c/li\u003e\n\u003cli\u003eFujita, K.: Endometriosis of the Ureter. The Journal of Urology, \u003cstrong\u003e116:\u003c/strong\u003e 664, 1976\u003c/li\u003e\n\u003cli\u003eMoosavi, B., Fasih, N., Virmani, V. et al.: Beyond ureterolithiasis: gamut of abnormalities affecting the ureter. Clin Imaging, \u003cstrong\u003e40:\u003c/strong\u003e 678, 2016\u003c/li\u003e\n\u003cli\u003eExacoustos, C., Malzoni, M., Di Giovanni, A. et al.: Ultrasound mapping system for the surgical management of deep infiltrating endometriosis. Fertil Steril, \u003cstrong\u003e102:\u003c/strong\u003e 143, 2014\u003c/li\u003e\n\u003cli\u003eSillou, S., Poiree, S., Millischer, A. E. et al.: Urinary endometriosis: MR imaging appearance with surgical and histological correlations. Diagn Interv Imaging, \u003cstrong\u003e96:\u003c/strong\u003e 373, 2015\u003c/li\u003e\n\u003cli\u003eZanetta, G., Webb, M. J., Segura, J. W.: Ureteral endometriosis diagnosed at ureteroscopy. Obstet Gynecol, \u003cstrong\u003e91:\u003c/strong\u003e 857, 1998\u003c/li\u003e\n\u003cli\u003eBerlanda, N., Vercellini, P., Carmignani, L. et al.: Ureteral and vesical endometriosis. Two different clinical entities sharing the same pathogenesis. Obstet Gynecol Surv, \u003cstrong\u003e64:\u003c/strong\u003e 830, 2009\u003c/li\u003e\n\u003cli\u003eSeracchioli, R., Manuzzi, L., Mabrouk, M. et al.: A multidisciplinary, minimally invasive approach for complicated deep infiltrating endometriosis. Fertil Steril, \u003cstrong\u003e93:\u003c/strong\u003e 1001, 2010\u003c/li\u003e\n\u003cli\u003eDonnez, J., Nisolle, M., Squifflet, J.: Ureteral endometriosis: a complication of rectovaginal endometriotic (adenomyotic) nodules. Fertil Steril, \u003cstrong\u003e77:\u003c/strong\u003e 32, 2002\u003c/li\u003e\n\u003cli\u003eCollinet, P., Leguevaque, P., Neme, R. M. et al.: Robot-assisted laparoscopy for deep infiltrating endometriosis: international multicentric retrospective study. Surg Endosc, \u003cstrong\u003e28:\u003c/strong\u003e 2474, 2014\u003c/li\u003e\n\u003cli\u003eHung, Z. C., Hsu, T. H., Jiang, L. Y. et al.: Robot-assisted laparoscopic ureteral reconstruction for ureter endometriosis: Case series and literature review. J Chin Med Assoc, \u003cstrong\u003e83:\u003c/strong\u003e 288, 2020\u003c/li\u003e\n\u003cli\u003eHaydon, G. B.: A study of 569 cases of endometriosis. Am J Obstet Gynecol, \u003cstrong\u003e43:\u003c/strong\u003e 704, 1942\u003c/li\u003e\n\u003cli\u003eRivlin, M. E., Krueger, R. P., Wiser, W. L.: Danazol in the management of ureteral obstruction secondary to endometriosis. Fertil Steril, \u003cstrong\u003e44:\u003c/strong\u003e 274, 1985\u003c/li\u003e\n\u003cli\u003eRivlin, M. E., Miller, J. D., Krueger, R. P. et al.: Leuprolide acetate in the management of ureteral obstruction caused by endometriosis. Obstet Gynecol, \u003cstrong\u003e75:\u003c/strong\u003e 532, 1990\u003c/li\u003e\n\u003cli\u003eVercellini, P., Crosignani, P. G., Somigliana, E. et al.: Medical treatment for rectovaginal endometriosis: what is the evidence? Hum Reprod, \u003cstrong\u003e24:\u003c/strong\u003e 2504, 2009\u003c/li\u003e\n\u003cli\u003eSomigliana, E., Busnelli, A., Benaglia, L. et al.: Postoperative hormonal therapy after surgical excision of deep endometriosis. Eur J Obstet Gynecol Reprod Biol, \u003cstrong\u003e209:\u003c/strong\u003e 77, 2017\u003c/li\u003e\n\u003cli\u003eYap, C., Furness, S., Farquhar, C.: Pre and post operative medical therapy for endometriosis surgery. Cochrane Database Syst Rev\u003cstrong\u003e:\u003c/strong\u003e D3678, 2004\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":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ureteral endometriosis, Ureteroureterostomy, Ureteroneocystostomy, Nephroureterectomy, Case report","lastPublishedDoi":"10.21203/rs.3.rs-72716/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-72716/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eTo present the experience of surgical management of ureteral endometriosis (UE) in our single center.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA retrospective analysis of 40 cases of UE who had intraoperative surgical findings of endometriosis involving the ureter and pathology-proven UE.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eForty patients (median age, 42.5 years) with histologic evidence of UE were included. Six (15%) patients had history of endometriosis. Twenty-one (52%) patients had urological symptoms and 19 (48%) patients were asymptomatic. All patients had hydronephrosis. The mean glomerular filtration rate of the affected-side kidney was significantly worse than the healthy-side one (23.4 vs 54.9 ml/min; \u003cem\u003eP \u003c/em\u003e\u0026lt; 0.001). Twelve (30%) patients were treated with ureteroureterostomy (11 open approaches and 1 robotic approach). Twenty-two (55%) patients underwent ureteroneocystostomy (17 open approaches, 4 laparoscopic approaches and 1 robotic approach). Five patients underwent nephoureterectomy. One patient refused the aggressive surgery and received ureteroscopic biopsy and ureteral stent placement. Thirteen (33%) cases were required gynecological operations. Three (8%) patients in open group suffered from major surgical complications. Nine (24%) patients received postoperative endocrine therapy. Twenty-eight (70%) patients were followed up (median follow-up time, 71 months). The success rate was 25/28 (89%).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eAlthough UE is rare, early diagnosis and treatment of UE will help reduce the morbidity of this disease. Most of time, A multidisciplinary team is necessary. For the patients with severe UE, segmentally ureteral resection with UU or ureteroneocystostomy may be a good choice.\u003c/p\u003e","manuscriptTitle":"Clinical Characteristics and Surgical Treatment of Ureteral Endometriosis: Our Experience with 40 Cases","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-10-16 13:16:10","doi":"10.21203/rs.3.rs-72716/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-11-03T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-10-28T00:00:00+00:00","index":4,"fulltext":"Recommendation: Reviewer's comments unavailable pending editorial decision\n"},{"type":"editorInvitedReview","content":"","date":"2020-10-28T00:00:00+00:00","index":2,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\n\n\nThis article needs major revision:\nIn the entire article the concepts need to be expressed more clearly to make the study more understandable.\nIt could be specified the reason why you have excluded the patients whit mild endometriosis (patients who underwent to ureterolysis and or minor surgery).\nIt should be declare:\n- the classification criteria of ureteral lesions that determined the surgical strategy. it\n- the inclusion and exclusion criterias\nIf the aim of the study is to identify the effective surgical strategies to treat cases of UTE, it might be better to consider only the patient that you have followed up (28/40 pz)\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **No**\n* Are the methods sufficiently described to allow the study to be repeated?: **No**\n* Is the use of statistics and treatment of uncertainties appropriate?: **No**\n* Is the presentation of the work clear?: **No**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **No**\n"},{"type":"reviewerAgreed","content":"","date":"2020-10-15T12:00:00+00:00","index":4,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-10-14T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-10-14T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-10-14T12:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-10-14T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nThank you for giving me the opportunity to review this interesting study \"Clinical characteristics and surgical treatment of ureteral endometriosis: our experience with 40 cases\".\nHowever, I have some comments and recommendations:\nComments:\nTitle:\n- Is appropriate for the content of the article.\nAbstract:\n- Represents a suitable summary of the work.\nArticle content:\n- The methods and analysis of the results from the study have been explained and are appropriate for the study.\nConclusions:\n- Are justified on the basis of the study.\nRecommendations:\nIntroduction:\n- Emphasize the knowledge about ureteral endometriosis.\nMethods:\n- Mention details of data collection.\nResults:\n- The text should complement the tables and figures.\nDiscussion:\n- Mention the limitations of the study.\nReferences:\n- Update some references.\nGeneral:\n- Revise language, grammar and syntax.\n* Publons Reviewer Recognition. 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