Deep Infiltrating Endometriosis Leading to Severe Hydro-Uretero-Nephrosis: A Surgical Challenge for Gynecologists and Urologists

INTRODUCTION: A 40-year-old female with known endometriosis presented to the office after 10 days of prolonged bleeding. She had pelvic pain and pressure that could not be managed with ibuprofen. Pelvic MRI showed deep infiltrating endometriosis involving the right adnexa and right pelvic sidewall, extending down towards the ilicoccygeus and obturator internus musculature. She also had severe right-sided hydro-uretero-nephrosis, likely caused by an obstruction of the right ureter from extrinsic compression by an endometriotic plaque. Urology worked with the gynecology department to ensure success. OBJECTIVE: Describe the surgical management of advanced endometriosis causing ureteral obstruction and hydronephrosis. METHODS: The right ovary was then mobilized off the sidewall. The remainder of the right fallopian tube was excised along the length of the mesosalpinx. The right ovary was suspended to the anterior abdominal wall using a 0 prolene stitch as an oophoropexy to provide improved visualization. At this time, an incision was made in the peritoneum along the ovarian fossa. An attempt was made to remove the peritoneum along the right pelvic sidewall, which was difficult due to its degree of friability. Due to the prior peritoneal stripping procedure, there was a deep retraction pocket along the sidewall that had re-peritonealized. The right ureter was significantly dilated from the area of obstruction at the junction with the uterosacral ligament. An incision was then made medial to the ureter along the pararectal space, which was normal. This was carried down parallel and lateral to the rectum, which was not involved with endometriosis. Next, we incised the area of fibrosis along the right pelvic sidewall. We dissected down to the right obturator nerve, which was not involved with endometriosis. The fibrotic tissue coursed medial to the obturator nerve and involved the superior aspect of the obturator internus muscle. This was excised carefully to avoid damage to nearby structures. The fibrosis was removed all the way to the level of the ureter medially and to the bladder superiorly and sent to pathology. At this time, ureterolysis was performed, and the stenotic area was clearly visible. The ureter was then dissected proximally and followed down into the pelvis. The area of scarring and inflammation was encountered, and it was noted that the ureter was encased with fibrosis both extrinsically as well as intrinsically. The ureter was transected at this area with immediate release of urine under pressure signifying proximity to the stricture. The distal stump of ureter appeared to be scarred. A 2-cm opening was made in the bladder, followed by the introduction of a guidewire and backloaded a flexible ureteroscope. The bladder was partially mobilized by transecting the medial umbilical ligament in the lateral attachments of the bladder to the anterior abdominal wall to check the tension on the potential anastomosis. It was determined tension-free, so cystotomy proceeded. With a 3 0 Vicryl suture, we made an interrupted ureteral vesicle anastomosis, creating a posterior plate around the JJ stent. RESULTS: The patient was discharged home on postoperative day 1 after passing a voiding trial. Her postoperative course was uncomplicated, and the ureteral stent was removed 4 weeks after the procedure. Pathology was consistent with deeply infiltrating endometriosis. CONCLUSIONS: We present this case to highlight the complexity of advanced endometriosis. From initial diagnosis to surgical intervention, multidisciplinary coordination is important and necessary to deliver a high level of care.