Clinical features and long-term surgical outcomes of ureteral endometriosis with hydroureteronephrosis: a retrospective study

BACKGROUND: Ureteral endometriosis with hydroureteronephrosis can impair renal function, yet few clear guidelines exist for its surgical treatment. This study aimed to compare the clinicopathological features between patients undergoing ureterolysis with nodule excision versus segmental ureterectomy with anastomosis for ureteral endometriosis with hydroureteronephrosis, and to report the postoperative outcomes. METHODS: This retrospective study included 74 patients with ureteral endometriosis and hydroureteronephrosis who underwent surgery at a tertiary hospital between 2004 and 2024. Clinicopathological characteristics were compared between the ureterolysis and segmental ureterectomy groups using Student's t-test or Mann-Whitney U test for continuous variables, and the χ² test or Fisher's exact test for categorical variables. Variables with P < 0.05 on between-group comparisons were entered into a multivariable logistic regression analysis. Surgical outcomes, including recurrence of hydroureteronephrosis and ureteral complications, were reported. RESULTS: Among the 74 patients, 25.7% presented with urinary symptoms. All patients had additional pelvic endometriosis beyond ureteral involvement, including ovarian endometriomas (75.7%) and deep endometriosis at other sites (82.4%). Ureteral endometriosis was classified as extrinsic (82.4%) or intrinsic (17.6%). 54 (73%) patients underwent ureterolysis with nodule excision and 20 (27%) underwent segmental ureterectomy with anastomosis. All 13 intrinsic lesions underwent segmental ureterectomy (P < 0.001). Multivariable analysis revealed that previous endometriosis surgery (OR = 4.413; 95%CI: 1.138-17.108; P = 0.032) and preoperative failed Double-J stenting (OR = 7.833; 95%CI: 1.946-31.522; P = 0.004) were independently associated with the segmental ureterectomy. At a median follow-up of 9 years, the ureterolysis group had 7.4% recurrent hydroureteronephrosis and 1.9% ureteral fistula; the segmental ureterectomy group experienced no recurrent hydroureteronephrosis or ureteral complications. CONCLUSIONS: Ureteral endometriosis complicated by hydroureteronephrosis often lacks urinary symptoms, with only a minority of lesions classified as intrinsic subtypes, and is almost always accompanied by ovarian endometriomas or deep endometriosis at other pelvic sites. After careful patient selection, 73% of subjects underwent ureterolysis with nodule excision and demonstrated acceptable long-term outcomes. Segmental ureterectomy with anastomosis was reserved for refractory cases, such as patients with intrinsic ureteral lesions, a history of prior endometriosis surgery, or failed preoperative Double-J stenting.