Laparoscopic management of ureteral endometriosis

Ureteral endometriosis is characterized by the develop- ment of deep infiltrating islets of endometrial tissue affecting the ureter, the optimal management in such cases being still poorly defined. Once the techniques of laparoscopic surgery improved, this minimally in- vasive approach has been proposed with encouraging

in treating such cases. When it comes to the types of surgical procedure which are needed in such cases, they are chosen accordingly to the degree, extent and localization of the endometrial tissue. This is a literature review of the largest studies which were con- ducted on the theme of the laparoscopic management of ureteral endometriosis; the main analyzed param- eters refer to the efficacy and safety of the procedure.

ureteral endometriosis, resection, laparos- copy. MINIREVIEW LAPAROSCOPIC MANAGEMENT OF URETERAL ENDOMETRIOSIS Nicolae BACALBASA1,2 , Irina BALESCU3, Mihaela VILCU1,2, Iulian BREZEAN1,2 1 „Carol Davila“ University of Medicine and Pharmacy, Bucharest, Romania 2 „Ion Cantacuzino“ Clinical Hospital, Bucharest, Romania 3 Ponderas Academic Hospital, Bucharest, Romania Received 26 Aug 2019, Accepted 07 Oct 2019 https:/ /doi.org/10.31688/ABMU.2019.54.4. 17 Address for correspondence: Nicolae BACALBASA „Carol Davila“ University of Medicine and Pharmacy, Bucharest, Romania Email: [email protected], Phone +40 723 540 426 Laparoscopic management of ureteral endometriosis – BACALBASA et al 732 / vol. 54, no. 4

Defined by the presence of ectopic islands of en- dometrial cells and stroma outside the uterine body, endometriosis can be classified according to its depth in superficial – invading the peritoneum, and the ovary or deep infiltrating – invading the viscera such as rectum, colon, urinary tract or the enteral loops by at least 5 mm in depth. According to the depth of invasion, the clinical signs and symptoms may range between diffuse pelvic pain, constipation, hematuria and complete bowel or urinary tract obstruction 1-3. Urinary tract involvement in patients with endo- metriosis When it comes to the urinary tract involvement, the most commonly affected organs are represented by the urinary bladder, followed by ureter and kidney, accounting for 0.3-12% of all cases diagnosed with this pathology 4,5. Depending on the degree of invasion, ure- teral endometriosis can be classified as extrinsic – if the periureteral tissues or the serosa are involved – and intrinsic, if the muscularis propria or the mucosa is damaged 6. In cases presenting extrinsic endometriosis, the lesions originate from the peritoneum, ovaries or uterosacral ligaments and produce an extrinsic com- pression of the ureter, while in intrinsic lesions, inva- sion of the muscularis or mucosa occurs. However, it seems that extrinsic lesions are up to four times more frequent when compared to intrinsic lesions 7,8. In order to rule out which are the predictive preoperative factors regarding the depth of ureteral invasion, Gennaro et al. conducted a study on 82 women in whom ureteral involvement due to endo- metriosis was encountered 9. Among these cases the authors identified 15 cases in which deep infiltrat- ing endometriosis was present and in which ureteral resections were needed, and 67 cases in which the urological procedure was limited to ureterolysis. The authors underlined the fact that the most commonly encountered symptom was represented by the ab- dominal pain, equally encountered between the two groups, while other signs or symptoms, such as uri- nary urgency, hematuria, dysuria or hydronephrosis were significantly more common among patients pre- senting deep infiltrating lesions 9. As for the preoperative investigations which might predict the presence of ureteral involvement, it has been widely accepted that pelvic MRI, cystoscopy and urography might give important information in re- gard to the extent of the disease. More recently, a study conducted by Lima et al. demonstrated that the pres- ence of endometrial nodules at the level of the utero- sacral ligament represents a strong predictive factor for the association of ureteral involvement. Therefore, they concluded that the presence of uterosacral nod- ules measuring at least 1.75 cm on the right side and 1.95 cm on the left side represents a strong predictive factor for the concomitance of ureteral involvement 10. Surgical goals in patients diagnosed with uret- eral endometriosis Once the diagnosis of ureteral endometriosis is established, surgery is needed in order to relieve the ureteral obstruction, to preserve the renal function and to prevent the development of any recurrent dis- ease 4. In order to achieve these goals certain authors proposed initially performing a limited procedure such as ureterolysis; however, in a significant number of cases, recurrent disease might be encountered after a relatively short period of time; therefore, in such cases resection and urinary tract reconstruction is fi- nally the option of choice. For example, in Ghezzi’s study which included 33 patients who were submit- ted to laparoscopic ureterolysis, the rate of early re- currence imposing reoperation reached 12% during the first three months postoperatively 11. In the last decades, once the techniques of minimally invasive surgical approach improved, the number of cases sub- mitted to this approach increased as well; therefore, a higher number of such cases have benefited lately from the advantages of the laparoscopic approach. Studies investigating the role of laparoscopic ureteral resection for deep infiltrating endome- triosis The utility of the laparoscopic approach in such cases has been established in the last decades once the minimally invasive approach started replacing the conventional approach; therefore, it has been widely accepted that the minimally invasive approach might offer certain advantages, such as a magnifica- tion of the view and better individualization of the structures. In the study conducted by Chudzinski et al and published in 2017 the authors included 17 patients presenting ureteral involvement in which ureteral resection and reimplantation were needed 12. Among these cases, the ureteral involvement was known preoperatively in 82% of cases, in 23% of them bilateral ureteral involvement being reported; moreover 35% of cases also associated renal atrophy, while renal function impairment was found in 23% of cases. When it comes to the preferred approach, the authors underlined the fact that laparotomy was the option of choice in 41% of cases, being followed by laparoscopy in 35% of cases and robotics in 23% of cases; however, the rate of laparotomies decreased from 63% before the year of 2010 to 23% after the year of 2010. Among cases submitted to a minimally invasive approach, there were three cases in which Archives of the Balkan Medical Union December 2019 / 733 conversion to open surgery was needed due to the presence of bowel injury – in one case and due to the presence of iatrogenic ureteral lesions – in two cases 12. In a similar study conducted by Sconman et al in Tel-Aviv, Israel, and which included seven pa- tients, the authors reported the necessity to convert from laparoscopy to laparotomy in two cases, while in other four cases laparotomy was the option of choice 13; interestingly, in all cases a previous history of at least one surgical intervention for endometrio- sis was reported. In all cases resection with ureteral reimplantation by using a psoas hitch technique was the preferred technique. After a mean follow-up pe- riod of 42 +/-20 months, a single patient reported no improvement of the symptoms 13. The benefits of the laparoscopic approach in patients with ureteral endometriosis were also dem- onstrated by Miranda-Mendoza in 2012 14. The study included 13 patients submitted to surgery in a mini- mally invasive manner, six cases being submitted to ureteral resections, while the remaining seven cases being submitted to ureterolysis. The histopathologi- cal studies of the resected specimens demonstrated the presence of ureteral invasion in all cases in which segmental ureteral resections were performed. However, at that moment the rates of postoperative complications remained high, three of the 13 cases developing vesical-vaginal leaks. However, after a me- dian follow-up period of 24 months all but one cases reported a significant improvement of the symptoms, as well as the absence of recurrent disease. In the 13 th case the patient developed an obstructive uropathy and an ureteroneocystostomy was performed 14. One of the largest studies which investigated the feasibility and safety of laparoscopic management of ureteral endometriosis was the one conducted by Cavaco-Gomes et al and published in 2017 2. The study, a review which included 18 articles published since 1997 and 700 patients demonstrated the effi- cacy of the method and underlined the fact that ure- teral endometriosis is a more common finding at the level of the left ureter (being encountered in 53.6%), followed by the right ureter (in 35.8% of cases) and bilateral lesions in only 10.6% of cases). As for the type of surgical procedure which was performed, it consisted of ureterolysis alone in 579 cases and ure- teral resection in the remaining ones; moreover, in two cases nephrectomy was imposed by the secondary renal atrophy, while in other 19.8% of cases concomi- tant urinary bladder resection was also needed. Other common resections were represented by rectovaginal or uterosacral ones. When it comes to the short-term outcomes, the most frequently reported complica- tions were represented by ureteral leaks or stenosis (in 14 cases), hemorrhagic events (in three cases), anastomotic digestive leaks (in two cases), bowel per- foration (in one case), bladder atony (in one case) and vesicovaginal leak (in one case). As for the long-term outcomes, 90.5% of cases reported the resolution or improvement of the symptoms. The authors also un- derlined the recurrent pattern of this pathology as well as the fact that most often this disease is a mul- ticentric one 2. In a recent study conducted by Ceccaromi et al, the authors included 160 patients submitted to total laparoscopic ureteroneocystostomy between January 2009 and December 2016 15; in all cases surgery was successfully ended in a minimally invasive manner, while the histopathological studies confirmed the presence of ureteral invasion in all cases (in 45.6% the urinary tract involvement occurred in an extrin- sic manner while in the remaining 54.4% of cases an extrinsic manner being demonstrated); after resection the authors reported the use of the psoas technique of reconstruction in 58.7%. Moreover, concomitant digestive tract invasion was seen in 75.6% and im- posed performing a bowel resection. When it comes to the short-term outcomes, the authors reported the necessity of reoperation in 4.4% of cases; as for the long-term outcomes, after a follow-up of six months, 15% of cases reported impaired bladder voiding. In the meantime after a mean follow-up period of 20.5 months regression of the symptoms was seen in most patients, only 1.2% of them requiring a ureteroneo- cystostomy on the opposite side 15. When it comes to the modalities of reconstruc- tion after ureteral resections, while certain authors prefer performing an uretero-ureteral anastomosis whenever is possible, other authors consider that a ureteral reimplantation in the urinary bladder through an ureteroneocystostomy should be the op- tion of choice due to a lower risk of complications, such as anastomotic stenosis 14,16,17. Moreover, in cases presenting deep infiltrating lesions, a combined laparoscopic and cystoscopic ap- proach might be tempted, encouraging results being reported so far 18,19. This combined approach seems to have the benefit of removing only the affected segment of the detrusor muscle decreasing in this way the risk of postoperative complications such as dysuria, polaki- uria or bladder denervation. The procedure begins in a laparoscopic manner by identifying and dissecting the endometrial nodule followed by a cystoscopic step which identifies the area of mucosal involvement 20,21.

Although urinary tract involvement is a com- mon finding in patients diagnosed with endometrio- sis, ureteral invasion is lower when compared to the Laparoscopic management of ureteral endometriosis – BACALBASA et al 734 / vol. 54, no. 4 rates of urinary bladder invasion. Even though, when- ever ureteral involvement is discovered, laparoscopy seems to be a feasible method in order to achieve an adequate alleviation of the symptoms. Depending on the degree of invasion and on the site of invasion multiple therapeutic strategies might be proposed, ranging from ureterolysis to ureteral resection with end to end anastomosis or ureteral resection followed by ureteral reimplantation by ureteroneocystostomy. Although initially the rates of postoperative com- plications were considerable, once more experience has been gained these rates of morbidity decreased. In the meantime, the rates of recurrences seen after a long-term follow-up seem to report a descendent trend during the last decade.

This work was supported by the project enti- tled „Multidisciplinary Consortium for Supporting the Research Skills in Diagnosing, Treating and Identifying Predictive Factors of Malignant Gynecologic Disorders“, project number PN-III-P1- 1.2-PCCDI2017-0833. Compliance with Ethics Requirements: „The authors declare no conflict of interest regarding this article“ “The authors declare that all the procedures and ex- periments of this study respect the ethical standards in the Helsinki Declaration of 1975, as revised in 2008(5), as well as the national law.“

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