Multidisciplinary team approach to management of severe endometriosis affecting the ureter: long-term outcome data and treatment algorithm

STUDY OBJECTIVE: To examine the efficiency of laparoscopic ureterolysis for ureteral endometriosis and to describe appropriate treatment. DESIGN: Prospective trial (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: Forty-five patients who underwent surgery to treat ureteral endometriosis between 2005 and 2009. INTERVENTION: Laparoscopic ureteral ureterolysis. MEASUREMENTS AND MAIN RESULTS: Long-term follow up of symptoms, urinary tract anatomy and function, and the need for further intervention were performed. Ureteral endometriosis was observed in 14.2% of 315 patients with endometriosis. Of the 45 study patients, 95.5% had dysmenorrhea, 60% had dyspareunia, and 45% were infertile. Half of the patients had previously undergone laparoscopic procedures. Urinary tract symptoms were present in 15.9% of patients. Preoperative hydronephrosis or hydroureter was observed in 10 patients (22.2%), and impaired urinary function in 2 patients (4.4%). Laparoscopy demonstrated left ureteral involvement in 82.2% of patients, and deep infiltrative endometriosis in 80%. Laparoscopic ureterolysis was feasible in 91.1% of patients. In 4 patients, ureterolysis was not feasible, and primary reimplantation of the ureter was performed. Forty-one patients (91.1%) had no symptoms or had marked improvement postoperatively and required no further treatment. Two patients (4.8%) underwent repeat surgery. In 80% of patients with hydroureteronephrosis, the postoperative sonogram was normal. CONCLUSIONS: Ureteral endometriosis can be treated effectively using laparoscopic ureterolysis in almost all patients. Different treatment approaches should be based on the results of preoperative evaluation and operative findings by a multidisciplinary team. Urinary assessment is crucial because most patients demonstrate no urinary tract symptoms and initial renal investigation can prevent irreversible damage.