Risk Factors for Irreversible Unilateral Loss of Renal Function in Patients With Deep Endometriosis

Risk Factors for Irreversible Unilateral Loss of Renal Function in Patients With Deep 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 Risk Factors for Irreversible Unilateral Loss of Renal Function in Patients With Deep Endometriosis María-Angeles Martínez-Zamora, Eduard Mension, Judith Martínez-Egea, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2787009/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Deep endometriosis (DE) is usually associated with severe pelvic pain, dysmenorrhea and other pain symptoms and can be more aggressive than other types of endometriosis, even leading to irreversible severe complications such as complete unilateral loss of renal function. Previous data showed that up to 30% of patients with urinary tract DE may have reduced kidney function at the time of diagnosis although the real prevalence is unknown. All doctors and health caregivers involved in endometriosis diagnosis and treatment should be aware of this complication and should suspect and avoid this rare, albeit severe, form of the disease. We aimed to describe the clinical and radiologic characteristics of deep endometriosis (DE) patients diagnosed with irreversible unilateral loss of renal function due to unilateral ureteral stenosis and evaluate risk factors for developing this loss. Methods: Retrospective cohort study including 436 patients who underwent laparoscopic DE surgery. We evaluated two groups of patients according to preserved (Non-Renal Loss Group; n=421) or irreversible unilateral damaged renal function (Renal Loss Group; n=15). Preoperative epidemiologic variables, clinical characteristics, radiologic findings and surgical treatments of all patients were collected. Results: The Renal Loss Group had a higher infertility rate and a higher proportion of asymptomatic patients. The following radiological variables showed statistically significant differences between the two groups: mean endometrioma diameter, the presence of intestinal DE and negative sliding sign. Multivariate analysis showed that infertility, being asymptomatic, having intestinal DE or torus uterinus/uterosacral ligament DE and a negative sliding sign significantly increased the risk of loss of renal function. Conclusions: Some clinical and radiological variables may help identify patients with DE at high risk of presenting loss of renal function due to ureteral stenosis. Therefore, among these patients, severe urinary tract obstruction should be specifically ruled out. Endometriosis Laparoscopy Renal loss Ureteral endometriosis Deep endometriosis. Plain English summary Background: Deep endometriosis (DE) is usually associated with severe pelvic pain, dysmenorrhea and other pain symptoms and can be more aggressive than other types of endometriosis, even leading to irreversible severe complications such as irreversible unilateral loss of kidney function. Previous data showed that up to 30% of patients with urinary tract DE may have reduced kidney function at the time of diagnosis although the real prevalence is unknown. All doctors and health caregivers involved in endometriosis diagnosis and treatment should be aware of this complication and should suspect and avoid this rare, albeit severe, form of the disease. We aimed to describe the clinical and radiologic characteristics of deep endometriosis (DE) patients diagnosed with irreversible unilateral loss of renal function due to ureteral stenosis and evaluate risk factors for possibly developing this loss. Methods: Retrospective cohort study including 436 patients who underwent laparoscopic DE surgery. We evaluated two groups of patients according to preserved or irreversible unilateral damaged renal function. Preoperative epidemiologic variables, clinical characteristics, radiologic findings and surgical treatments of all patients were collected. Results: The analysis showed that DE patients who were asymptomatic, infertile or had some specific radiological finding were at high risk of having lost the function of one of the kidneys. Conclusions: Some clinical and radiological variables may help identify patients with DE at high risk of presenting complete unilateral loss of renal function. Therefore, among these patients, severe urinary tract obstruction should be specifically ruled out. Introduction Deep endometriosis (DE) is usually associated with severe pelvic pain, dysmenorrhea and other pain symptoms and can be more aggressive than other types of endometriosis, even leading to irreversible severe complications such as complete unilateral loss of renal function [ 1 , 2 ]. However, severe urinary tract DE is often less symptomatic or even asymptomatic, and may be diagnosed incidentally by hydronephrosis found on abdominal ultrasound or magnetic resonance imaging (MRI) [ 3 ] or during a surgical procedure for other symptomatic DE locations. Furthermore, previous data showed that up to 30% of patients with urinary tract DE may have reduced kidney function at the time of diagnosis [ 4 ] although the real prevalence is unknown. This late diagnosis is the result of the clinically silent form of DE among these patients [ 5 ], being first described not many years ago [ 6 ]. Thus, when there is the suspicion of ureteral obstruction in DE patients, the diagnostic approach should include the performance of renal ultrasound and/or MRI [ 7 ]. Considering the absence of specific urological symptoms, evaluation of the integrity of the urinary tract is recommended before surgery to plan the best surgical approach and for adequate follow-up after surgery. The pre-operative diagnosis of unilateral kidney failure is important to schedule the surgery and inform the patient of the findings. Moreover, patients with known established unilateral loss of renal function must be followed to ensure there is no ureteral involvement of the contralateral side. Furthermore, it is important to note that all doctors and health caregivers involved in endometriosis diagnosis and treatment should be aware of this complication and should suspect and avoid this rare, albeit severe, form of the disease. Therefore, the aim of this study was to describe DE patients diagnosed with an irreversible unilateral loss of renal function due to ureteral stenosis and to identify risk factors for possibly developing this loss. Material/patients And Methods Eligibility criteria The study was approved by the local Ethical Committee, according to prevailing regulations (Reg. HCB/2020/1152). We conducted a retrospective cohort study including 463 patients who underwent laparoscopic DE surgery due to painful symptoms and/or infertility and/or bowel or ureteral stenosis. We selected all patients who had undergone surgery for DE in our tertiary university teaching hospital between March 2015 and March 2020. We evaluated two groups of patients according to preserved (Non-Renal Loss Group) or irreversibly unilateral damaged renal function (Renal Loss Group). The initial evaluation of DE was performed by transvaginal ultrasound in all cases or magnetic resonance imaging (MRI) when transvaginal ultrasound could not adequately be performed due to pain or incomplete endometriosis stratification information. All patients had histological confirmation of DE. We performed renal and urinary tract evaluation among all patients with endometriosis by sonography or MRI before surgery. When ureterohydronephrosis was clinically suspected (loin pain, dysuria and/or hematuria) or detected on transvaginal ultrasound or MRI, it was evaluated by renal ultrasound. Patients with radiological findings suggestive of hydronephrosis or ureteral stenosis with ureteral dilation of the upstream excretory tract, underwent a renogram [ 8 ]. Complete unilateral loss of renal function was defined as relative renal function < 30% [ 9 ]. A descriptive analysis of epidemiologic variables, clinical characteristics, ultrasound findings and surgical treatment was performed. Data were extracted from our institutional electronic medical records. Before surgery, patients were asked to quantify dysmenorrhea, dyspareunia, dyschezia, dysuria and chronic pelvic pain according to a 0- to 10-point numerical rating scale (NRS) with “0” indicating no pain and “10” indicating the worst possible pain. In order to use the symptoms as potentially predictive we categorized the results into NRS < 7 and NRS ≥ 7 to distinguish between mild/moderate versus severe pain [ 10 ]. The diagnosis of adenomyosis and endometriosis was achieved using 2D-3D transvaginal sonography (TVS), employing an endovaginal probe (type RIC5-9, Voluson V730 Expert, GE Healthcare, Milwaukee, WI, USA). The procedures were performed by two expert sonographers (C.R and M.R) following the Morphological Uterus Sonographic Assessment consensus statement [ 11 ] and the International Deep Endometriosis Analysis consensus [ 12 ]. To describe the radiologic DE findings we used dichotomic and continuous variables: presence versus absence of DE in different locations (i.e., torus uterinus, uterosacral ligaments, bladder, ureter, ovarian endometriomas, etc.), positive or negative sliding sign, the greatest diameter of DE of each location, and to simplify the total DE burden, the sum of all the largest DE diameters were registered. Bladder DE was considered when patients had endometriosis in the bladder affecting the muscularis. Statistical Analysis Statistical analysis was performed with the Statistical Package for Social Sciences software, release 25.0 for Windows (SPSS, Chicago, Illinois) and the Software for Statistics and Data Science release 15.1 (STATA, College Station, Texas: StataCorp LLC). Continuous variables were compared using the nonparametric Mann-Whitney U test or Kruskal–Wallis test using the post hoc Dunn’s multiple comparison test, when appropriate, and presented as median with interquartile range (25th ; 75th percentiles). Categorical variables were compared using the Chi-square test and presented as total count and relative percentages (%). Statistical significance was defined as a p-value < 0.05. Statistically significant differences among epidemiologic variables, clinical characteristics or radiologic findings were evaluated as independent risk factors using multivariate analysis with logistic regression. Odds ratios (OR) and their 95% confidence intervals (95% CI) were reported. Results A total of 463 DE patients were identified to be included in the study. Twenty-seven patients did not have accurate information in the clinical records and were excluded. Finally, 436 DIE patients were analyzed. Two groups of patients were evaluated: patients presenting complete unilateral loss of renal function due to endometriosis confirmed by renogram (Renal Loss Group; n = 15) and patients with preserved normal renal function (Non-Renal Loss Group; n = 421). All the patients in the Renal Loss Group had been diagnosed or suspected of renal function loss prior to surgery and most had been referred to our tertiary hospital with the diagnosis of loss of renal function or high suspicion of this complication. The baseline clinical and demographic data of the two study groups are shown in Table 1 . There were no differences between the two groups in relation to the mean age, body mass index (BMI), rate of previous surgery (either related or non-related to endometriosis), rate of previous hormone treatment, and rate of different pain symptoms. Comparison of clinical data showed that the Renal Loss Group had a higher infertility rate and a higher proportion of asymptomatic patients, being possible variables of suspicion of high risk of loss of renal function due to ureteral stenosis related to endometriosis. Table 1 Baseline clinical and demographic data of the two study groups. Non-Renal Loss Group (n = 421) Renal Loss Group (n = 15) p-value Age at diagnosis (years) 35.1 (32; 37) 33.8 (28; 38) 0.16 Body mass index (Kg/m 2 ) 22.4 (21.1; 24.3) 22.6 (20.3; 25.6) 0.92 Infertility 173 (41.1) 12 (80.0) 0.003 Previous endometriosis surgery 349 (82.8) 10 (66.7) 0.47 Previous non-endometriosis surgery 232 (55.1) 10 (66.7) 0.40 Previous hormonal treatment 240 (57.0) 8 (53.3) 0.77 Asymptomatic 25 (5.9) 4 (26.7) 0.002 Pain symptoms Dysmenorrhea (NRS ≥ 7) 280 (66.5) 12 (80.0) 0.29 Chronic pelvic pain ( NRS ≥7) 117 (27.8) 3 (20.0) 0.49 Dyspareunia ( NRS ≥7) 109 (25.9) 0 (0.0) 0.06 Dyschezia ( NRS ≥7) 69 (16.4) 0 (0.0) 0.14 Dysuria ( NRS ≥7) 19 (4.3) 0 (0.0) 0.46 Results are expressed as median (25th ; 75th percentiles) or n (%). NRS, numerical rating scale. Radiologic findings are shown in Table 2 . The following variables showed statistically significant differences between the two groups: mean endometrioma diameter, the presence of intestinal DE, negative sliding sign, cumulative DE diameter and bladder DE affecting the muscularis. The presence or absence of adenomyosis or ovarian endometriomas was similar in the two groups. Among the 86 diagnosed ureteral DE, 74 were suspected by imaging before surgery. However, 12 (14%) cases of ureteral DE were diagnosed intraoperatively. The other ultrasound findings were confirmed during the surgical laparoscopic procedure (Table 2 ). Nine (2.1%) patients in the Non-Renal Loss Group and 15 (100%) in the Renal Loss Group were diagnosed with hydronephrosis by sonography before surgery. All these patients underwent renograms. Table 2 Preoperative radiologic data of both study groups. Non-Renal Loss Group (n = 421) Renal Loss Group (n = 15) p-value Adenomyosis 226 (53.7) 4 (26.7) 0.06 Ovarian endometrioma 303 (71.9) 7 (46.7) 0.66 Endometrioma diameter (mm) 32.5 (31.1; 54.3) 68.7 (35.2; 87.9) 0.002 Kissing ovaries 65 (15.4) 2 (13.3) 0.84 Intestinal DE 130 (30.9) 9 (60.0) 0.02 Torus Uterinus/Uterosacral ligament DE 176 (41.8) 11 (73.3) 0.01 Bladder DE 11 (2.6) 2 (13.3) 0.02 Ureteral DE 74 (17.6) 15 (100) < 0.0001 Negative sliding sign 99 (23.5) 10 (66.6) 0.0007 Cumulative DE diameter (mm) 16.6 (12.1; 25.4) 51.1 (21.7; 61.4) < 0.0001 Values are median (25th ; 75th percentiles) or n (%). DE, Deep endometriosis. Table 3 describes the surgical procedures performed in the two groups analyzed. All cases were operated by the same three surgeons (FC, MR and MG). As expected, the surgical procedures in the “Renal Loss Group” were globally more aggressive, including more adnexectomies, bowel resections and ureteral reimplantations. No recurrences of ureteral endometriosis were reported during a minimum follow-up of 24 months. Four patients in the Renal Loss Group had bilateral ureteral involvement but unilateral loss of renal function and underwent ureteral reimplantation on the contralateral side. Table 3 Surgical procedures in both study groups. Non-Renal Loss Group (n = 421) Renal Loss Group (n = 15) p-value Hysterectomy 46 (10.9) 5 (33.3) 0.05 Uni-Bilateral adnexectomy 54 (12.8) 6 (40.0) 0.02 Uni-Bilateral salpingectomy 69 (16.4) 2 (13.3) 0.50 Bowel resection 36 (8.5) 9 (60.0) < 0.0001 Endometrioma resection 161 (38.2) 2 (13.3) 0.008 Ureteral reimplantation 16 (3.8) 4 (26.7) 0.002 Nephrectomy 0 (0.0) 5 (33.3) < 0.0001 Results are expressed as N (%). In the multivariate analysis, infertility, being asymptomatic, presence of intestinal DE, presence of torus uterinus/uterosacral ligament DE and negative sliding sign remained significantly associated with irreversible loss of renal function (Table 4 ). Table 4 Logistic regression analysis of variables associated with complete unilateral loss of renal function in patients with deep endometriosis. Variable Adjusted Odds Ratio Lower 95% CI Upper 95% CI p value Infertility 5.66 1.55 20.69 0.003 Asymptomatic patients 5.95 1.63 21.75 0.014 Intestinal DE 3.69 1.26 10.79 0.018 Torus uterinus /Uterosacral ligament DE 9.89 2.16 45.26 < 0.001 Negative sliding sign 6.55 2.13 20.13 < 0.001 CI, Confidence Interval; DE, Deep endometriosis. To identify risk factors for ureteral reimplantation, multivariate analysis was also performed. Patients with torus uterinus/uterosacral ligament DE (odds ratio (OR) 3.7, 95% confidence interval (CI) 1.3–10.1, p 0.009) were more likely to undergo ureteral reimplantation. Discussion This is the largest report of patients from a single center with unilateral complete loss of renal function due to DE-related ureteral stenosis. We provide variables that may be helpful to preoperatively identify DE patients at high risk of presenting irreversible unilateral loss of renal function based on clinical and radiological findings. Suspicion is indicated by the presence of infertility, being asymptomatic, intestinal DE, torus uterinus/uterosacral ligament DE and a negative sliding sign. Urinary tract endometriosis may cause ureteral obstruction and lead to complete unilateral renal loss in up to 11.5% of the patients due to its characteristically silent progression, differing from the usual painful symptoms of pelvic endometriosis [ 3 , 13 – 14 ]. The prevalence of ureteral endometriosis reported in the literature ranges between 0.1-1% among all endometriosis patients [ 15 ]. Few cases of ureteral endometriosis leading to renal function loss have been described [ 16 – 18 ]. Hence, the prevalence of complete unilateral loss of renal function due to ureteral endometriosis obstruction is, in fact, unknown and is probably underestimated. However, the diagnosis of this involvement has probably increased over the last years, probably due to a higher awareness in specialized endometriosis units and improvement of imaging techniques. Previous studies have attempted to identify risk factors for ureteral obstruction by endometriosis to avoid silent losses in renal function [ 19 – 21 ], but none have found a specific risk factor to allow early suspicion or a validated preventive diagnostic and therapeutic strategy. Taking into account that there is a high percentage of asymptomatic ureteral involvement in patients with known pelvic endometriosis, it has been suggested that routine urinary ultrasound may ensure early diagnosis of these patients, although cost/benefits should be carefully evaluated [ 19 ]. In this sense, previous authors have suggested the possibility of using TVS examination as an accurate non-invasive diagnostic tool for the detection of endometriosis ureteral involvement [ 22 ]. Moreover, well-trained gynecologists specialized in endometriosis sonography can perform renal evaluation using transvaginal and/or transabdominal examination to detect/suspect hydronephrosis following well-established recommendations [ 23 ]. Our results are in agreement with the literature regarding the difficulties in diagnosing ureteral endometriosis correctly in the absence of specific symptoms. Conversely, women of reproductive age presenting infertility, pelvic pain and hydronephrosis of unknown cause should be adequately assessed via imaging techniques to achieve high suspicion of ureteral endometriosis [ 2 ]. Previous research [ 13 , 14 , 20 , 24 – 26 ] evaluated endometriosis patients and proposed risk factors for ureteral endometriosis including a lower body mass index [ 25 ], incapacitating dysmenorrhea [ 26 ], parametrial endometriosis [ 25 ], revised American Fertility Society stage IV [ 20 ], rectovaginal DE [ 13 ], retrocervical DE lesions larger than 30 mm [ 24 ], uterosacral ligament endometriosis [ 14 , 21 ] uterosacral ligament DE lesion ≥ 3 cm in diameter [ 21 ], retrocervical endometriosis and rectosigmoid endometriosis [ 26 ], and previous surgery for endometriosis [ 20 ]. Therefore, to sum up and in keeping with previously published results, DE patients mainly with extensive sonographic involvement of the posterior compartment of the pelvis seem to be those at “high risk” and should undergo further renal and ureteral studies. Moreover, it is important to remark that up to 50% of the patients may be asymptomatic [ 2 , 5 ] and/or infertile [ 2 ]. The main strength of our study was that we compared DE patients with or without complete unilateral loss of renal function with a complete study before laparoscopic surgery. We evaluated a large cohort from a tertiary center to which severe patients are referred, thereby allowing the analysis of a large number of patients with this rare DE complication within a short period of time. However, this study has several limitations. First, this study was based on retrospective data from a single tertiary care center to which severe cases are referred. Therefore, the incidence of loss of renal function among our DE patients was most likely higher than in the general endometriosis/DE population. Second, we evaluated only DE patients, and validation including all types of endometriosis patients should be performed. Finally, to identify high risk patients of loss of renal function it is necessary the use of a precise radiological tool, ideally TVS, to assess different DE locations by a well-trained gynecologist/radiologist, and these tools are usually only available in tertiary referral centers although its use is more and more widespread. In conclusion, our study showed that being infertile, being asymptomatic, having intestinal DE or torus uterinus/uterosacral ligament DE and a negative sliding sign may help to identify patients with DE at high risk of presenting irreversible unilateral loss of renal function due to ureteral stenosis. Therefore, among these patients, severe urinary tract obstruction should be specifically ruled out with radiological urinary tract tests. Further studies are needed to confirm our results to identify this rare, albeit severe, DE complication and improve surgical planning and endometriosis follow-up. Declarations Ethics approval and consent to participate: The study was approved by the local Ethical Committee, according to prevailing regulations (Reg. HCB/2020/1152). Consent for publication: Not applicable. Availability of data and materials: All data generated or analysed during this study are included within this published article. Competing interests: The authors have no affiliations or financial involvement with any organization or entity with an interest in or conflict with the subject matter discussed in the manuscript. Funding: This study was supported in part by a donation from the “Asociación de Afectadas de Endometriosis de Cataluña”. Authors contributions: Mension E and Martínez-Zamora MA: Design and filling of the database. Statistical data analysis. Data interpretation. Bibliographic search. Study writing and creation of tables; Martínez-Egea J: Design and filling of the database; Peri L and Franco A: Data interpretation and bibliographic search; Gracia M: Design, data interpretation and study writing; Ros C: Data interpretation and study writing; Rius M: Data interpretation; Carmona F: Study design. Statistical data analysis. Data interpretation. Study writing and creation of tables. Acknowledgements: We thank the “Asociación de Afectadas de Endometriosis de Cataluña” for funding the study. Author´s information (optional): Corresponding author: María-Angeles Martínez-Zamora, MD, PhD. Gynecology Department. Institute Clinic of Gynecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona. Faculty of Medicine, University of Barcelona. Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain. Villarroel St., 170, 08036 Barcelona, Spain. Phone number: 0034 2275534. Fax number: 0034 14 2279325. E-mail: [email protected] References Giudice LC. 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Abrao MS, Dias JA Jr, Bellelis P, Podgaec S, Bautzer CR, Gromatsky C. Endometriosis of the ureter and bladder are not associated diseases. Fertil Steril. 2009;91:1662–7. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-2787009","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":190484926,"identity":"b5108a84-573a-4c19-8b9e-a84790f2c58e","order_by":0,"name":"María-Angeles Martínez-Zamora","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAy0lEQVRIiWNgGAWjYDADfgbmhgMMBqRokWxghGlhJlKLwQHGBiiTgBbd9uMPP92ouCdvfPxg4+GCAjsG/vbzB/BqMTuTkCydc6bYcNuZxIbDMwySGSTOJOO3xexAwgHp3LYExm03GBsO8xiAvENIy/mHzb+BWuw3z4Bp4X9MQMuNZDaQLYkbJGBaJAjZcuMZm3UO0EMzQH7hMUjmkbjxGH/smJ1Pf3w7pyLBtr/98OHPPH/s5Pj7Ex/gtwYd8JCmfBSMglEwCkYBVgAAiX5IJp1jGiAAAAAASUVORK5CYII=","orcid":"","institution":"Hospital Clinic of Barcelona, University of Barcelona, Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)","correspondingAuthor":true,"prefix":"","firstName":"María-Angeles","middleName":"","lastName":"Martínez-Zamora","suffix":""},{"id":190484927,"identity":"27b72c5c-efc1-46d3-86c7-69b7cbad98b7","order_by":1,"name":"Eduard Mension","email":"","orcid":"","institution":"Hospital Clinic of Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Eduard","middleName":"","lastName":"Mension","suffix":""},{"id":190484928,"identity":"366b02c4-bf2f-4f5e-88e1-d50c93a4d2d5","order_by":2,"name":"Judith Martínez-Egea","email":"","orcid":"","institution":"Hospital Clinic of Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Judith","middleName":"","lastName":"Martínez-Egea","suffix":""},{"id":190484929,"identity":"f8fa614b-4e94-4d7a-9ab1-f4cb790e239b","order_by":3,"name":"Lluis Peri","email":"","orcid":"","institution":"Hospital Clinic of Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Lluis","middleName":"","lastName":"Peri","suffix":""},{"id":190484931,"identity":"a0c51c10-d11a-4c6a-9846-56beeb879f45","order_by":4,"name":"Agustín Franco","email":"","orcid":"","institution":"Hospital Clinic of Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Agustín","middleName":"","lastName":"Franco","suffix":""},{"id":190484932,"identity":"027e5501-07c1-4d43-9316-4f68397061ba","order_by":5,"name":"Meritxell Gracia","email":"","orcid":"","institution":"Hospital Clinic of Barcelona, University of Barcelona, Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)","correspondingAuthor":false,"prefix":"","firstName":"Meritxell","middleName":"","lastName":"Gracia","suffix":""},{"id":190484933,"identity":"e4efa2d7-61b3-4c10-8707-cc6f1a1848b9","order_by":6,"name":"Cristina Ros","email":"","orcid":"","institution":"Hospital Clinic of Barcelona, University of Barcelona, Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)","correspondingAuthor":false,"prefix":"","firstName":"Cristina","middleName":"","lastName":"Ros","suffix":""},{"id":190484935,"identity":"b65f157a-2ad8-4a8f-8d35-8252195aeca1","order_by":7,"name":"Mariona Rius","email":"","orcid":"","institution":"Hospital Clinic of Barcelona, University of Barcelona, Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)","correspondingAuthor":false,"prefix":"","firstName":"Mariona","middleName":"","lastName":"Rius","suffix":""},{"id":190484936,"identity":"dc40616a-3eeb-4ea3-9c12-2cad3d23005f","order_by":8,"name":"Francisco Carmona","email":"","orcid":"","institution":"Hospital Clinic of Barcelona, University of Barcelona, Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)","correspondingAuthor":false,"prefix":"","firstName":"Francisco","middleName":"","lastName":"Carmona","suffix":""}],"badges":[],"createdAt":"2023-04-06 17:14:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2787009/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2787009/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":35825254,"identity":"fd16d61d-4f39-4ead-b9b0-298cb6ad3db6","added_by":"auto","created_at":"2023-04-16 10:14:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":326235,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2787009/v1/4e846ee7-2d07-4d5b-99f3-0d5a2c5c70ae.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eRisk Factors for Irreversible Unilateral Loss of Renal Function in Patients With Deep Endometriosis\u003c/p\u003e","fulltext":[{"header":"Plain English summary","content":"\u003cp\u003e\u003cstrong\u003eBackground:\u0026nbsp;\u003c/strong\u003eDeep endometriosis (DE) is usually associated with severe pelvic pain, dysmenorrhea and other pain symptoms and can be more aggressive than other types of endometriosis, even leading to irreversible severe complications such as irreversible unilateral loss of kidney function. Previous data showed that up to 30% of patients with urinary tract DE may have reduced kidney function at the time of diagnosis although the real prevalence is unknown. All doctors and health caregivers involved in endometriosis diagnosis and treatment should be aware of this complication and should suspect and avoid this rare, albeit severe, form of the disease. We aimed to describe the clinical and radiologic characteristics of deep endometriosis (DE) patients diagnosed with irreversible unilateral loss of renal function due to ureteral stenosis and evaluate risk factors for possibly developing this loss.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u0026nbsp;\u003c/strong\u003eRetrospective cohort study including 436 patients who underwent laparoscopic DE surgery. We evaluated two groups of patients according to preserved or irreversible unilateral damaged renal function. Preoperative epidemiologic variables, clinical characteristics, radiologic findings and surgical treatments of all patients were collected.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The analysis showed that DE patients who were asymptomatic, infertile or had some specific radiological finding were at high risk of having lost the function of one of the kidneys.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e \u0026nbsp;Some clinical and radiological variables may help identify\u0026nbsp;patients with DE at high risk of presenting complete unilateral loss of renal function. Therefore, among these patients, severe urinary tract obstruction should be specifically ruled out.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eDeep endometriosis (DE) is usually associated with severe pelvic pain, dysmenorrhea and other pain symptoms and can be more aggressive than other types of endometriosis, even leading to irreversible severe complications such as complete unilateral loss of renal function [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, severe urinary tract DE is often less symptomatic or even asymptomatic, and may be diagnosed incidentally by hydronephrosis found on abdominal ultrasound or magnetic resonance imaging (MRI) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] or during a surgical procedure for other symptomatic DE locations. Furthermore, previous data showed that up to 30% of patients with urinary tract DE may have reduced kidney function at the time of diagnosis [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] although the real prevalence is unknown. This late diagnosis is the result of the clinically silent form of DE among these patients [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], being first described not many years ago [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Thus, when there is the suspicion of ureteral obstruction in DE patients, the diagnostic approach should include the performance of renal ultrasound and/or MRI [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Considering the absence of specific urological symptoms, evaluation of the integrity of the urinary tract is recommended before surgery to plan the best surgical approach and for adequate follow-up after surgery. The pre-operative diagnosis of unilateral kidney failure is important to schedule the surgery and inform the patient of the findings. Moreover, patients with known established unilateral loss of renal function must be followed to ensure there is no ureteral involvement of the contralateral side. Furthermore, it is important to note that all doctors and health caregivers involved in endometriosis diagnosis and treatment should be aware of this complication and should suspect and avoid this rare, albeit severe, form of the disease.\u003c/p\u003e \u003cp\u003eTherefore, the aim of this study was to describe DE patients diagnosed with an irreversible unilateral loss of renal function due to ureteral stenosis and to identify risk factors for possibly developing this loss.\u003c/p\u003e"},{"header":"Material/patients And Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEligibility criteria\u003c/h2\u003e \u003cp\u003e The study was approved by the local Ethical Committee, according to prevailing regulations (Reg. HCB/2020/1152). We conducted a retrospective cohort study including 463 patients who underwent laparoscopic DE surgery due to painful symptoms and/or infertility and/or bowel or ureteral stenosis. We selected all patients who had undergone surgery for DE in our tertiary university teaching hospital between March 2015 and March 2020. We evaluated two groups of patients according to preserved (Non-Renal Loss Group) or irreversibly unilateral damaged renal function (Renal Loss Group). The initial evaluation of DE was performed by transvaginal ultrasound in all cases or magnetic resonance imaging (MRI) when transvaginal ultrasound could not adequately be performed due to pain or incomplete endometriosis stratification information. All patients had histological confirmation of DE. We performed renal and urinary tract evaluation among all patients with endometriosis by sonography or MRI before surgery. When ureterohydronephrosis was clinically suspected (loin pain, dysuria and/or hematuria) or detected on transvaginal ultrasound or MRI, it was evaluated by renal ultrasound. Patients with radiological findings suggestive of hydronephrosis or ureteral stenosis with ureteral dilation of the upstream excretory tract, underwent a renogram [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Complete unilateral loss of renal function was defined as relative renal function\u0026thinsp;\u0026lt;\u0026thinsp;30% [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA descriptive analysis of epidemiologic variables, clinical characteristics, ultrasound findings and surgical treatment was performed. Data were extracted from our institutional electronic medical records.\u003c/p\u003e \u003cp\u003eBefore surgery, patients were asked to quantify dysmenorrhea, dyspareunia, dyschezia, dysuria and chronic pelvic pain according to a 0- to 10-point numerical rating scale (NRS) with \u0026ldquo;0\u0026rdquo; indicating no pain and \u0026ldquo;10\u0026rdquo; indicating the worst possible pain. In order to use the symptoms as potentially predictive we categorized the results into NRS\u0026thinsp;\u0026lt;\u0026thinsp;7 and NRS\u0026thinsp;\u0026ge;\u0026thinsp;7 to distinguish between mild/moderate versus severe pain [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe diagnosis of adenomyosis and endometriosis was achieved using 2D-3D transvaginal sonography (TVS), employing an endovaginal probe (type RIC5-9, Voluson V730 Expert, GE Healthcare, Milwaukee, WI, USA). The procedures were performed by two expert sonographers (C.R and M.R) following the Morphological Uterus Sonographic Assessment consensus statement [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and the International Deep Endometriosis Analysis consensus [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo describe the radiologic DE findings we used dichotomic and continuous variables: presence versus absence of DE in different locations (i.e., torus uterinus, uterosacral ligaments, bladder, ureter, ovarian endometriomas, etc.), positive or negative sliding sign, the greatest diameter of DE of each location, and to simplify the total DE burden, the sum of all the largest DE diameters were registered. Bladder DE was considered when patients had endometriosis in the bladder affecting the muscularis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed with the Statistical Package for Social Sciences software, release 25.0 for Windows (SPSS, Chicago, Illinois) and the Software for Statistics and Data Science release 15.1 (STATA, College Station, Texas: StataCorp LLC). Continuous variables were compared using the nonparametric Mann-Whitney U test or Kruskal\u0026ndash;Wallis test using the post hoc Dunn\u0026rsquo;s multiple comparison test, when appropriate, and presented as median with interquartile range (25th ; 75th percentiles). Categorical variables were compared using the Chi-square test and presented as total count and relative percentages (%). Statistical significance was defined as a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Statistically significant differences among epidemiologic variables, clinical characteristics or radiologic findings were evaluated as independent risk factors using multivariate analysis with logistic regression. Odds ratios (OR) and their 95% confidence intervals (95% CI) were reported.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 463 DE patients were identified to be included in the study. Twenty-seven patients did not have accurate information in the clinical records and were excluded. Finally, 436 DIE patients were analyzed. Two groups of patients were evaluated: patients presenting complete unilateral loss of renal function due to endometriosis confirmed by renogram (Renal Loss Group; n\u0026thinsp;=\u0026thinsp;15) and patients with preserved normal renal function (Non-Renal Loss Group; n\u0026thinsp;=\u0026thinsp;421). All the patients in the Renal Loss Group had been diagnosed or suspected of renal function loss prior to surgery and most had been referred to our tertiary hospital with the diagnosis of loss of renal function or high suspicion of this complication. The baseline clinical and demographic data of the two study groups are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. There were no differences between the two groups in relation to the mean age, body mass index (BMI), rate of previous surgery (either related or non-related to endometriosis), rate of previous hormone treatment, and rate of different pain symptoms. Comparison of clinical data showed that the Renal Loss Group had a higher infertility rate and a higher proportion of asymptomatic patients, being possible variables of suspicion of high risk of loss of renal function due to ureteral stenosis related to endometriosis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline clinical and demographic data of the two study groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-Renal Loss Group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;421)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRenal Loss\u003c/p\u003e \u003cp\u003eGroup\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at diagnosis (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35.1 (32; 37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33.8 (28; 38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index (Kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22.4 (21.1; 24.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.6 (20.3; 25.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfertility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e173 (41.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious endometriosis surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e349 (82.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious non-endometriosis surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e232 (55.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious hormonal treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e240 (57.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsymptomatic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (26.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDysmenorrhea (NRS\u0026thinsp;\u0026ge;\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e280 (66.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic pelvic pain ( NRS \u0026ge;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e117 (27.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyspareunia ( NRS \u0026ge;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e109 (25.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyschezia ( NRS \u0026ge;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69 (16.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDysuria ( NRS \u0026ge;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eResults are expressed as median (25th ; 75th percentiles) or n (%).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNRS, numerical rating scale.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRadiologic findings are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The following variables showed statistically significant differences between the two groups: mean endometrioma diameter, the presence of intestinal DE, negative sliding sign, cumulative DE diameter and bladder DE affecting the muscularis. The presence or absence of adenomyosis or ovarian endometriomas was similar in the two groups. Among the 86 diagnosed ureteral DE, 74 were suspected by imaging before surgery. However, 12 (14%) cases of ureteral DE were diagnosed intraoperatively. The other ultrasound findings were confirmed during the surgical laparoscopic procedure (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Nine (2.1%) patients in the Non-Renal Loss Group and 15 (100%) in the Renal Loss Group were diagnosed with hydronephrosis by sonography before surgery. All these patients underwent renograms.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreoperative radiologic data of both study groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-Renal Loss Group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;421)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRenal Loss Group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenomyosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e226 (53.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (26.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOvarian endometrioma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e303 (71.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndometrioma diameter (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32.5 (31.1; 54.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68.7 (35.2; 87.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKissing ovaries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e65 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntestinal DE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e130 (30.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTorus Uterinus/Uterosacral ligament DE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e176 (41.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (73.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBladder DE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUreteral DE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e74 (17.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative sliding sign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e99 (23.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (66.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCumulative DE diameter (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16.6 (12.1; 25.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.1 (21.7; 61.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eValues are median (25th ; 75th percentiles) or n (%).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eDE, Deep endometriosis.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e describes the surgical procedures performed in the two groups analyzed. All cases were operated by the same three surgeons (FC, MR and MG). As expected, the surgical procedures in the \u0026ldquo;Renal Loss Group\u0026rdquo; were globally more aggressive, including more adnexectomies, bowel resections and ureteral reimplantations. No recurrences of ureteral endometriosis were reported during a minimum follow-up of 24 months. Four patients in the Renal Loss Group had bilateral ureteral involvement but unilateral loss of renal function and underwent ureteral reimplantation on the contralateral side.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgical procedures in both study groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-Renal Loss Group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;421)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRenal Loss Group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHysterectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46 (10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUni-Bilateral adnexectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54 (12.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUni-Bilateral salpingectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69 (16.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBowel resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36 (8.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndometrioma resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e161 (38.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUreteral reimplantation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (26.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNephrectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eResults are expressed as N (%).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the multivariate analysis, infertility, being asymptomatic, presence of intestinal DE, presence of torus uterinus/uterosacral ligament DE and negative sliding sign remained significantly associated with irreversible loss of renal function (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic regression analysis of variables associated with complete unilateral loss of renal function in patients with deep endometriosis.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAdjusted Odds Ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLower 95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eUpper 95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfertility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e1.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsymptomatic patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e1.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntestinal DE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e1.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTorus uterinus\u003c/p\u003e \u003cp\u003e/Uterosacral ligament DE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e2.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e45.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative sliding sign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e2.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eCI, Confidence Interval; DE, Deep endometriosis.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTo identify risk factors for ureteral reimplantation, multivariate analysis was also performed. Patients with torus uterinus/uterosacral ligament DE (odds ratio (OR) 3.7, 95% confidence interval (CI) 1.3\u0026ndash;10.1, p\u0026thinsp;\u0026lt;\u0026thinsp;0.04) and a negative sliding sign (OR 5.4, 95% CI 1.5\u0026ndash;19.3, p\u0026thinsp;\u0026gt;\u0026thinsp;0.009) were more likely to undergo ureteral reimplantation.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is the largest report of patients from a single center with unilateral complete loss of renal function due to DE-related ureteral stenosis. We provide variables that may be helpful to preoperatively identify DE patients at high risk of presenting irreversible unilateral loss of renal function based on clinical and radiological findings. Suspicion is indicated by the presence of infertility, being asymptomatic, intestinal DE, torus uterinus/uterosacral ligament DE and a negative sliding sign.\u003c/p\u003e \u003cp\u003eUrinary tract endometriosis may cause ureteral obstruction and lead to complete unilateral renal loss in up to 11.5% of the patients due to its characteristically silent progression, differing from the usual painful symptoms of pelvic endometriosis [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The prevalence of ureteral endometriosis reported in the literature ranges between 0.1-1% among all endometriosis patients [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Few cases of ureteral endometriosis leading to renal function loss have been described [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Hence, the prevalence of complete unilateral loss of renal function due to ureteral endometriosis obstruction is, in fact, unknown and is probably underestimated. However, the diagnosis of this involvement has probably increased over the last years, probably due to a higher awareness in specialized endometriosis units and improvement of imaging techniques.\u003c/p\u003e \u003cp\u003ePrevious studies have attempted to identify risk factors for ureteral obstruction by endometriosis to avoid silent losses in renal function [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], but none have found a specific risk factor to allow early suspicion or a validated preventive diagnostic and therapeutic strategy. Taking into account that there is a high percentage of asymptomatic ureteral involvement in patients with known pelvic endometriosis, it has been suggested that routine urinary ultrasound may ensure early diagnosis of these patients, although cost/benefits should be carefully evaluated [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In this sense, previous authors have suggested the possibility of using TVS examination as an accurate non-invasive diagnostic tool for the detection of endometriosis ureteral involvement [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Moreover, well-trained gynecologists specialized in endometriosis sonography can perform renal evaluation using transvaginal and/or transabdominal examination to detect/suspect hydronephrosis following well-established recommendations [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur results are in agreement with the literature regarding the difficulties in diagnosing ureteral endometriosis correctly in the absence of specific symptoms. Conversely, women of reproductive age presenting infertility, pelvic pain and hydronephrosis of unknown cause should be adequately assessed via imaging techniques to achieve high suspicion of ureteral endometriosis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Previous research [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] evaluated endometriosis patients and proposed risk factors for ureteral endometriosis including a lower body mass index [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], incapacitating dysmenorrhea [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], parametrial endometriosis [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], revised American Fertility Society stage IV [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], rectovaginal DE [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], retrocervical DE lesions larger than 30 mm [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], uterosacral ligament endometriosis [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] uterosacral ligament DE lesion \u0026ge; 3 cm in diameter [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], retrocervical endometriosis and rectosigmoid endometriosis [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], and previous surgery for endometriosis [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Therefore, to sum up and in keeping with previously published results, DE patients mainly with extensive sonographic involvement of the posterior compartment of the pelvis seem to be those at \u0026ldquo;high risk\u0026rdquo; and should undergo further renal and ureteral studies. Moreover, it is important to remark that up to 50% of the patients may be asymptomatic [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and/or infertile [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe main strength of our study was that we compared DE patients with or without complete unilateral loss of renal function with a complete study before laparoscopic surgery. We evaluated a large cohort from a tertiary center to which severe patients are referred, thereby allowing the analysis of a large number of patients with this rare DE complication within a short period of time.\u003c/p\u003e \u003cp\u003eHowever, this study has several limitations. First, this study was based on retrospective data from a single tertiary care center to which severe cases are referred. Therefore, the incidence of loss of renal function among our DE patients was most likely higher than in the general endometriosis/DE population. Second, we evaluated only DE patients, and validation including all types of endometriosis patients should be performed. Finally, to identify high risk patients of loss of renal function it is necessary the use of a precise radiological tool, ideally TVS, to assess different DE locations by a well-trained gynecologist/radiologist, and these tools are usually only available in tertiary referral centers although its use is more and more widespread.\u003c/p\u003e \u003cp\u003eIn conclusion, our study showed that being infertile, being asymptomatic, having intestinal DE or torus uterinus/uterosacral ligament DE and a negative sliding sign may help to identify patients with DE at high risk of presenting irreversible unilateral loss of renal function due to ureteral stenosis. Therefore, among these patients, severe urinary tract obstruction should be specifically ruled out with radiological urinary tract tests. Further studies are needed to confirm our results to identify this rare, albeit severe, DE complication and improve surgical planning and endometriosis follow-up.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThe study was approved by the local Ethical Committee, according to prevailing regulations (Reg. HCB/2020/1152).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eAll data generated or analysed during this study are included within this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors have no affiliations or financial involvement with any organization or entity with an interest in or conflict with the subject matter discussed in the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis study was supported in part by a donation from the \u0026ldquo;Asociaci\u0026oacute;n de Afectadas de Endometriosis de Catalu\u0026ntilde;a\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions:\u0026nbsp;\u003c/strong\u003eMension E and\u0026nbsp;Mart\u0026iacute;nez-Zamora MA: Design and filling of the database. Statistical data analysis. Data interpretation. Bibliographic search. Study writing and creation of tables; Mart\u0026iacute;nez-Egea J: Design and filling of the database; Peri L and Franco A: Data interpretation and bibliographic search; Gracia M: Design, data interpretation and study writing; Ros C: Data interpretation and study writing; Rius M: Data interpretation; Carmona F: Study design. Statistical data analysis. Data interpretation. Study writing and creation of tables.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eWe thank the\u0026nbsp;\u0026ldquo;Asociaci\u0026oacute;n de Afectadas de Endometriosis de Catalu\u0026ntilde;a\u0026rdquo; for funding the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026acute;s information (optional): Corresponding author:\u0026nbsp;\u003c/strong\u003eMar\u0026iacute;a-Angeles Mart\u0026iacute;nez-Zamora, MD, PhD. Gynecology Department. Institute Clinic of Gynecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona. Faculty of Medicine, University of Barcelona. Institut d\u0026acute;Investigacions Biom\u0026egrave;diques August Pi i Sunyer (IDIBAPS), Spain. Villarroel St., 170, 08036 Barcelona, Spain. Phone number: 0034 2275534. Fax number: 0034 14 2279325. E-mail:\u0026nbsp;\u003ca href=\"mailto:[email protected]\"\[email protected]\u003c/a\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGiudice LC. Clinical practice. Endometriosis. N Engl J Med. 2010;362(25):2389\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang P, Wang XP, Li YY, Jin BY, Xia D, Wang S, Pan H. Hydronephrosis due to ureteral endometriosis in women of reproductive age. Int J Clin Exp Med. 2015;8:1059\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWatanabe Y, Ozawa H, Uematsu K, Kawasaki K, Nishi H, Kobashi Y. 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Complete loss of unilateral renal function secondary to endometriosis: a report of three cases. Eur J Obstet Gynecol Reprod Biol. 2013;171:132\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNezhat C, Paka C, Gomaa M, Schipper E. Silent loss of kidney seconary to ureteral endometriosis. JSLS. 2012;16:451\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLangebrekke A, Qvigstad E. Ureteral endometriosis and loss of renal function: mechanisms and interpretations. Acta Obstet Gynecol Scand. 2011;90:1164\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarmignani L, Vercellini P, Spinelli M, Fontana E, Frontino G, Fedele L. Pelvic endometriosis and hydroureteronephrosis. Fertil Steril. 2010;6:1741\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHu Z, Li P, Liu Q, Zhu H, Sun Y, Zhao X, Xie L, Liu K. Ureteral endometriosis in patients with deep infiltrating endometriosis: characteristics and management from a single-center retrospective study. Arch Gynecol Obstet. 2019;300:967\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLima R, Abdalla-Ribeiro H, Nicola AL, Eras A, Lobao A, Ayroza Ribeiro P. Endometriosis on the uterosacral ligament: a marker or ureteral involvement. Fertil Steril. 2017;107:1348\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarfagna P, De Cicco Nardone C, De Cicco Nardone A, Testa AC, Scambia G, Marana R, De Cicco Nardone F. Role of transvaginal ultrasound in evaluation of ureteral involvement in deep infiltrating endometriosis. Ultrasound Obstet Gynecol. 2018;51:550\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuerriero S, Condous G, Van Den Blosch T, Valentin L, Leone FPG, Van Schoubroeck D, Exacoustos C, et al. Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the International Deep Endometriosis Analysis (IDEA) group. Ultrasound Obstet Gynecol. 2016;48:318\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKondo W, Branco AW, Trippia CH, Ribeiro R, Zomer MT. Retrocervical deep infiltrating endometriotic lesions larger than thirty millimeters are associated with an increased rate of ureteral involvement. J Minin Invasive Gynecol. 2013;20:100\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRaimondo D, Mabrouk M, Zannoni L, Arena A, Zanello M, Benfenati A, Moro E, Paradisi R, Seracchioli R. Severe ureteral endometriosis: frequency and risk factors. J Obstet Gynaecol. 2018;38:257\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbrao MS, Dias JA Jr, Bellelis P, Podgaec S, Bautzer CR, Gromatsky C. Endometriosis of the ureter and bladder are not associated diseases. Fertil Steril. 2009;91:1662\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Endometriosis, Laparoscopy, Renal loss, Ureteral endometriosis, Deep endometriosis.","lastPublishedDoi":"10.21203/rs.3.rs-2787009/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2787009/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eDeep endometriosis (DE) is usually associated with severe pelvic pain, dysmenorrhea and other pain symptoms and can be more aggressive than other types of endometriosis, even leading to irreversible severe complications such as complete unilateral loss of renal function. Previous data showed that up to 30% of patients with urinary tract DE may have reduced kidney function at the time of diagnosis although the real prevalence is unknown. All doctors and health caregivers involved in endometriosis diagnosis and treatment should be aware of this complication and should suspect and avoid this rare, albeit severe, form of the disease. We aimed to describe the clinical and radiologic characteristics of deep endometriosis (DE) patients diagnosed with irreversible unilateral loss of renal function due to unilateral ureteral stenosis and evaluate risk factors for developing this loss.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u0026nbsp;\u003c/strong\u003eRetrospective cohort study including 436 patients who underwent laparoscopic DE surgery. We evaluated two groups of patients according to preserved (Non-Renal Loss Group; n=421) or irreversible unilateral damaged renal function (Renal Loss Group; n=15).\u003c/p\u003e\n\u003cp\u003ePreoperative epidemiologic variables, clinical characteristics, radiologic findings and surgical treatments of all patients were collected.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The Renal Loss Group had a higher infertility rate and a higher proportion of asymptomatic patients. The following radiological variables showed statistically significant differences between the two groups: mean endometrioma diameter, the presence of intestinal DE and negative sliding sign. Multivariate analysis showed that infertility, being asymptomatic, having intestinal DE or torus uterinus/uterosacral ligament DE and a negative sliding sign significantly increased the risk of loss of renal function.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Some clinical and radiological variables may help identify patients with DE at high risk of presenting loss of renal function due to ureteral stenosis. Therefore, among these patients, severe urinary tract obstruction should be specifically ruled out.\u003c/p\u003e","manuscriptTitle":"Risk Factors for Irreversible Unilateral Loss of Renal Function in Patients With Deep Endometriosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-04-12 07:08:30","doi":"10.21203/rs.3.rs-2787009/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b1e25dc2-dea0-48cc-8ca6-c998c4abbd43","owner":[],"postedDate":"April 12th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-04-26T06:59:23+00:00","versionOfRecord":[],"versionCreatedAt":"2023-04-12 07:08:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2787009","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2787009","identity":"rs-2787009","version":["v1"]},"buildId":"0U-iFTyB6qxOgVj8rjrZV","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}