Management of Endometriosis Involving the Urinary Tract

Endometriosis is a common cause of infertility and disabling pelvic pain in reproductive age women. The most widely accepted theory of its pathogenesis is the retrograde flow of menstrual products, although extra-abdominal and extrapelvic diagnoses have been made. After the pelvic peritoneum and gynecologic structures, the most commonly affected sites are the lower gastrointestinal and urinary tracts. When the urinary tract is involved, the bladder is the predominant site, followed by the ureters. The focus of this seminar will thus be these two anatomic sites. Delayed diagnosis is unfortunately common for endometriosis as a whole, but more so when extrapelvic sites are involved. While the first-line therapy for endometriosis is medical management, urinary tract involvement often represents advanced stage of the disease, thereby requiring surgical intervention. With timely diagnosis and intervention by skilled gynecologic or urologic surgeons, favorable outcomes can be attained. -

- 1 Abeshouse BS, Abeshouse G. Endometriosis of the urinary tract: a review of the literature and a report of four cases of vesical endometriosis. J Int Coll Surg 1960; 34: 43-63 - 2 Antonelli A, Simeone C, Zani D , et al. Clinical aspects and surgical treatment of urinary tract endometriosis: our experience with 31 cases. Eur Urol 2006; 49 (6) 1093-1097 , discussion 1097–1098 - 3 Nezhat C, Nezhat F, Nezhat CH, Nasserbakht F, Rosati M, Seidman DS. Urinary tract endometriosis treated by laparoscopy. Fertil Steril 1996; 66 (6) 920-924 - 4 Shook TE, Nyberg LM. Endometriosis of the urinary tract. Urology 1988; 31 (1) 1-6 - 5 Koninckx PR, Meuleman C, Demeyere S, Lesaffre E, Cornillie FJ. Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil Steril 1991; 55 (4) 759-765 - 6 Abrao MS, Dias Jr JA, Bellelis P, Podgaec S, Bautzer CR, Gromatsky C. Endometriosis of the ureter and bladder are not associated diseases. Fertil Steril 2009; 91 (5) 1662-1667 - 7 Knabben L, Imboden S, Fellmann B, Nirgianakis K, Kuhn A, Mueller MD. Urinary tract endometriosis in patients with deep infiltrating endometriosis: prevalence, symptoms, management, and proposal for a new clinical classification. Fertil Steril 2015; 103 (1) 147-152 - 8 Fauconnier A, Chapron C, Dubuisson JB, Vieira M, Dousset B, Bréart G. Relation between pain symptoms and the anatomic location of deep infiltrating endometriosis. Fertil Steril 2002; 78 (4) 719-726 - 9 Akpınar S, Yılmaz G, Çelebioğlu E. A rare cyclic recurrent hematuria case; bladder endometriosis. Quant Imaging Med Surg 2015; 5 (3) 485-487 - 10 Clement P. Disease of the peritoneum. In: Kurman R, , ed. Blaustein's Pathology of the Female Genital Tract. New York: Springer Verlag; 1994: 647-703 - 11 Yohannes P. Ureteral endometriosis. J Urol 2003; 170 (1) 20-25 - 12 Vercellini P, Pisacreta A, Pesole A, Vicentini S, Stellato G, Crosignani PG. Is ureteral endometriosis an asymmetric disease?. BJOG 2000; 107 (4) 559-561 - 13 Donnez J, Nisolle M, Squifflet J. Ureteral endometriosis: a complication of rectovaginal endometriotic (adenomyotic) nodules. Fertil Steril 2002; 77 (1) 32-37 - 14 Ponticelli C, Graziani G, Montanari E. Ureteral endometriosis: a rare and underdiagnosed cause of kidney dysfunction. Nephron Clin Pract 2010; 114 (2) c89-c93 - 15 Khong SY, Lam A, Coombes G, Ford S. Surgical management of recurrent ureteric endometriosis causing recurrent hypertension in a postmenopausal woman. J Minim Invasive Gynecol 2010; 17 (1) 100-103 - 16 Husby GK, Haugen RS, Moen MH. Diagnostic delay in women with pain and endometriosis. Acta Obstet Gynecol Scand 2003; 82 (7) 649-653 - 17 Hadfield R, Mardon H, Barlow D, Kennedy S. Delay in the diagnosis of endometriosis: a survey of women from the USA and the UK. Hum Reprod 1996; 11 (4) 878-880 - 18 Piketty M, Chopin N, Dousset B , et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod 2009; 24 (3) 602-607 - 19 Benacerraf BR, Groszmann Y. Sonography should be the first imaging examination done to evaluate patients with suspected endometriosis. J Ultrasound Med 2012; 31 (4) 651-653 - 20 Guerriero S, Ajossa S, Minguez JA , et al. Accuracy of transvaginal ultrasound for diagnosis of deep endometriosis in uterosacral ligaments, rectovaginal septum, vagina and bladder: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2015; 46 (5) 534-545 - 21 Fedele L, Bianchi S, Raffaelli R, Portuese A. Pre-operative assessment of bladder endometriosis. Hum Reprod 1997; 12 (11) 2519-2522 - 22 Balleyguier C, Chapron C, Dubuisson JB , et al. Comparison of magnetic resonance imaging and transvaginal ultrasonography in diagnosing bladder endometriosis. J Am Assoc Gynecol Laparosc 2002; 9 (1) 15-23 - 23 Thonnon C, Philip CA, Fassi-Fehri H , et al. Three-dimensional ultrasound in the management of bladder endometriosis. J Minim Invasive Gynecol 2015; 22 (3) 403-409 - 24 Grasso RF, Di Giacomo V, Sedati P , et al. Diagnosis of deep infiltrating endometriosis: accuracy of magnetic resonance imaging and transvaginal 3D ultrasonography. Abdom Imaging 2010; 35 (6) 716-725 - 25 Vercellini P, Meschia M, De Giorgi O, Panazza S, Cortesi I, Crosignani PG. Bladder detrusor endometriosis: clinical and pathogenetic implications. J Urol 1996; 155 (1) 84-86 - 26 Sircus SI, Sant GR, Ucci Jr AA. Bladder detrusor endometriosis mimicking interstitial cystitis. Urology 1988; 32 (4) 339-342 - 27 Nasu K, Narahara H, Hayata T , et al. Ureteral obstruction caused by endometriosis. Gynecol Obstet Invest 1995; 40 (3) 215-216 - 28 Pollack HM, Wills JS. Radiographic features of ureteral endometriosis. AJR Am J Roentgenol 1978; 131 (4) 627-631 - 29 Watanabe Y, Ozawa H, Uematsu K, Kawasaki K, Nishi H, Kobashi Y. Hydronephrosis due to ureteral endometriosis treated by transperitoneal laparoscopic ureterolysis. Int J Urol 2004; 11 (7) 560-562 - 30 Ghezzi F, Cromi A, Bergamini V, Bolis P. Management of ureteral endometriosis: areas of controversy. Curr Opin Obstet Gynecol 2007; 19 (4) 319-324 - 31 Klein RS, Cattolica EV. Ureteral endometriosis. Urology 1979; 13 (5) 477-482 - 32 Lavelle KJ, Melman AW, Cleary RE. Ureteral obstruction owing to endometriosis: reversal with synthetic progestin. J Urol 1976; 116 (5) 665-666 - 33 Gantt PA, Hunt JB, McDonough PG. Progestin reversal of ureteral endometriosis. Obstet Gynecol 1981; 57 (5) 665-667 - 34 Vilos GA, Marks-Adams JL, Vilos AG, Oraif A, Abu-Rafea B, Casper RF. Medical treatment of ureteral obstruction associated with ovarian remnants and/or endometriosis: report of three cases and review of the literature. J Minim Invasive Gynecol 2015; 22 (3) 462-468 - 35 Gardner B, Whitaker RH. The use of danazol for ureteral obstruction caused by endometriosis. J Urol 1981; 125 (1) 117-118 - 36 Matsuura K, Kawasaki N, Oka M, Ii H, Maeyama M. Treatment with danazol of ureteral obstruction caused by endometriosis. Acta Obstet Gynecol Scand 1985; 64 (4) 339-343 - 37 Rivlin ME, Krueger RP, Wiser WL. Danazol in the management of ureteral obstruction secondary to endometriosis. Fertil Steril 1985; 44 (2) 274-276 - 38 Donnez J, Spada F, Squifflet J, Nisolle M. Bladder endometriosis must be considered as bladder adenomyosis. Fertil Steril 2000; 74 (6) 1175-1181 - 39 Bohrer J, Chen CC, Falcone T. Persistent bilateral ureteral obstruction secondary to endometriosis despite treatment with an aromatase inhibitor. Fertil Steril 2008; 90 (5) 2004.e7-2004.e9 - 40 Jepsen JM, Hansen KB. Danazol in the treatment of ureteral endometriosis. J Urol 1988; 139 (5) 1045-1046 - 41 Price DT, Maloney KE, Ibrahim GK, Cundiff GW, Leder RA, Anderson EE. Vesical endometriosis: report of two cases and review of the literature. Urology 1996; 48 (4) 639-643 - 42 Efe E, Bakacak M, Serin S, Kolus E, Ercan O, Resim S. Hormonal treatment for severe hydronephrosis caused by bladder endometriosis. Case Rep Urol 2014; 2014: 891295 - 43 Westney OL, Amundsen CL, McGuire EJ. Bladder endometriosis: conservative management. J Urol 2000; 163 (6) 1814-1817 - 44 Camanni M, Bonino L, Delpiano EM , et al. Laparoscopic conservative management of ureteral endometriosis: a survey of eighty patients submitted to ureterolysis. Reprod Biol Endocrinol 2009; 7: 109 - 45 Frenna V, Santos L, Ohana E, Bailey C, Wattiez A. Laparoscopic management of ureteral endometriosis: our experience. J Minim Invasive Gynecol 2007; 14 (2) 169-171 - 46 Soriano D, Schonman R, Nadu A , et al. Multidisciplinary team approach to management of severe endometriosis affecting the ureter: long-term outcome data and treatment algorithm. J Minim Invasive Gynecol 2011; 18 (4) 483-488 - 47 Nezhat CH, Malik S, Nezhat F, Nezhat C. Laparoscopic ureteroneocystostomy and vesicopsoas hitch for infiltrative endometriosis. JSLS 2004; 8 (1) 3-7 - 48 Mereu L, Gagliardi ML, Clarizia R, Mainardi P, Landi S, Minelli L. Laparoscopic management of ureteral endometriosis in case of moderate-severe hydroureteronephrosis. Fertil Steril 2010; 93 (1) 46-51 - 49 Scioscia M, Molon A, Grosso G, Minelli L. Laparoscopic management of ureteral endometriosis. Curr Opin Obstet Gynecol 2009; 21 (4) 325-328 - 50 Nezhat CH, Nezhat FR, Freiha F, Nezhat CR. Laparoscopic vesicopsoas hitch for infiltrative ureteral endometriosis. Fertil Steril 1999; 71 (2) 376-379 - 51 Chapron C, Bourret A, Chopin N , et al. Surgery for bladder endometriosis: long-term results and concomitant management of associated posterior deep lesions. Hum Reprod 2010; 25 (4) 884-889 - 52 Seracchioli R, Mannini D, Colombo FM, Vianello F, Reggiani A, Venturoli S. Cystoscopy-assisted laparoscopic resection of extramucosal bladder endometriosis. J Endourol 2002; 16 (9) 663-666 - 53 Vitagliano G, Villeta M, Castillo O. Laparoscopic partial cystectomy in the management of bladder endometriosis: report of two cases. J Endourol 2006; 20 (12) 1072-1074 - 54 Litta P, Saccardi C, D'Agostino G, Florio P, De Zorzi L, Bianco MD. Combined transurethral approach with Versapoint(®) and laparoscopic treatment in the management of bladder endometriosis: technique and 12 months follow-up. Surg Endosc 2012; 26 (9) 2446-2450 - 55 Nezhat CH, Malik S, Osias J, Nezhat F, Nezhat C. Laparoscopic management of 15 patients with infiltrating endometriosis of the bladder and a case of primary intravesical endometrioid adenosarcoma. Fertil Steril 2002; 78 (4) 872-875 - 56 Seracchioli R, Mabrouk M, Montanari G, Manuzzi L, Concetti S, Venturoli S. Conservative laparoscopic management of urinary tract endometriosis (UTE): surgical outcome and long-term follow-up. Fertil Steril 2010; 94 (3) 856-861