Preoperative diagnosis of ureteral medial deviations secondary to deep endometriosis using transvaginal ultrasound examinations: Can we predict the need for ureterolysis during laparoscopic surgery?

OBJECTIVE: To evaluate ureteral involvement using transvaginal sonography (TVS) regarding the distortion of the course of the ureters caused by deep endometriosis (DE), which can facilitate predicting the need for ureterolysis during surgery, even in the absence of ureteral stenosis or dilatation. METHODS: This is a single-center, observational, retrospective pilot study of 88 consecutive patients who later underwent surgery for DE that used ultrasound preoperative diagnosis of ureteral medial deviation of one or both ureters between January 2019 and January 2022. At TVS, the course of the ureter was considered medialized if, in longitudinal and transversal section, any distance was detectable between the ureter and the cervix at the point where the ureter crosses the uterine artery. The primary end point was to determine sensitivity, specificity, and positive and negative predictive values of "ureteral medial deviation" diagnosed using TVS, in order to predict the need for ureterolysis. RESULTS: Our series included 88 women with a median age of 39 (interquartile range 33-43) years. Ureteral medialization showed a relatively low false-positive rate (10.9%), with a specificity of 89.1% (95% confidence interval [CI] 81.4%-96.7%) and a sensitivity of 86.6% (95% CI 80.3%-92.9%), along with a high positive predictive value of 93.3% (95% CI 88.4%-98.1%), and a lower negative predictive value of 79.1% (95% CI 69.8%-88.5%), respectively. CONCLUSIONS: This study introduced a new ultrasound sign with a high degree of accuracy to predict ureterolysis and this may have positive implications in the management and surgical planning of patients with ureteral endometriosis.

Vascular- and nerve-sparing bowel resection for deep endometriosis: A retrospective single-center study.

OBJECTIVE: Surgical management of bowel endometriosis is still controversial. Recently, many authors have pointed out the potential benefits of preserving the superior rectal artery, thus ensuring better perfusion of the anastomosis. The aim of this study was to evaluate the complication rate and functional outcomes of a bowel resection technique for deep endometriosis (DE) involving a nerve- and vascular-sparing approach. METHODS: A single-center retrospective study was conducted by enrolling patients who underwent segmental resection of the rectus sigmoid for DE in our department between September 2019 and April 2022. Intraoperative and postoperative complications were recorded for each woman, and functional outcomes relating to the pelvic organs were assessed using validated questionnaires (Knowles-Eccersley-Scott-Symptom [KESS] questionnaire and Gastro-Intestinal Quality of Life Index [GIQLI] for bowel function, Bristol Female Lower Urinary Tract Symptoms [BFLUTS] for urinary function, and Female Sexual Function Index [FSFI] for sexual function). These were evaluated preoperatively and postoperatively after 6 months from surgery. RESULTS: Sixty-one patients were enrolled. No patients had Clavien-Dindo grade 3 or 4 complications, there were no rectovaginal fistulas or ureteral lesions, and in no cases was it necessary to reoperate. Temporary bladder voiding deficits were reported in 8.2% of patients, which were treated with self-catheterizations, always resolving within 45 days of surgery. Gastrointestinal function evaluated by KESS and GIQLI improved significantly after surgery, whereas sexual function appeared to worsen, although without reaching the level of statistically significant validity. CONCLUSION: Our vascular- and nerve-sparing segmental bowel resection technique for DE had a low intraoperative and postoperative complication rate and produced an improvement in gastrointestinal function after surgery.

Are ureterolysis for deep endometriosis really all the same? An anatomical classification proposal for ureterolysis: A single-center experience.

OBJECTIVE: Ureteral endometriosis has an incidence of 0.1% to 1%. The type of surgery required is either conservative (ureterolysis) or radical treatment, depending on the degree of ureter infiltration. The incidence of intraoperative and postoperative complications is heterogeneous. Thus, the aim of the current study was to propose a classification of ureterolysis based on the anatomical structure of the ureter and differing complication rates with procedures. METHODS: A total of 139 ureterolysis procedures were included in the study. Patients were divided into three groups according to the depth of ureterolysis required. Differences were recorded across the three types of ureterolysis in terms of intraoperative and postoperative complications. RESULTS: The incidence of ureteral fistula was reported in 0.7% of cases, with postoperative ureteral stenosis in 2% of type 2 ureterolysis. In the case of type 3 ureterolysis, after conservative procedures, 52.9% of patients required an ureteroneocystostomy to solve the ureteral stenosis. CONCLUSION: The risk of ureteral injury and ureteroneocystostomy after conservative procedures appears to be associated with type 3 ureterolysis, probably due to excessive devascularization, secondary to the incision of adventitia. Obviously, these data should be confirmed through a prospective study of a larger number, but our proposed classification can provide the basis for making data from future studies more comparable.