A Review of Urinary Tract Endometriosis.

PURPOSE OF REVIEW: To describe the presenting signs and symptoms of patients with urinary tract endometriosis (UTE), appropriate workup, and to review medical and surgical therapies for symptom palliation and definitive management. RECENT FINDINGS: UTE is a condition that clinicians should maintain a high index of suspicion for, as symptoms can be easily misdiagnosed from other causes. Surgical resection of implants appears to offer safe and durable symptom relief. Urinary tract endometriosis may present with symptoms overlapping with interstitial cystitis, nephrolithiasis, bladder overactivity, or recurrent urinary tract infections, and may or may not be cyclical in nature. Cyclical gross hematuria is considered pathognomonic, though final diagnosis must be made after a pathologic review. Without proper diagnosis and treatment, consequences such as silent renal loss from asymptomatic obstruction may result. After the diagnosis is made, initial therapy can be undertaken with hormonal treatment to palliate symptoms (most commonly in the form of combined oral contraceptives), followed by surgical resection for a definitive treatment option.

Accuracy of transvaginal ultrasound and magnetic resonance imaging for diagnosis of deep endometriosis in bladder and ureter: a meta-analysis.

This meta-analysis aimed to determine the accuracy of transvaginal ultrasound (TVS) and pelvic magnetic resonance imaging (MRI) in diagnosing urinary tract endometriosis (UTE). A comprehensive search of the Pubmed and Embase was conducted between January 1989 and June 2020. Studies that described the accuracy of MRI or TVS for the diagnosis of UTE using surgical data as the reference standard were included. Of the 913 citations identified, 23 studies were analysed. For detection of endometriosis in bladder endometriosis (BE), the overall pooled sensitivities of TVS and MRI were 72% and 68% respectively, and their specificities were 99% and 100% respectively. For detection of endometriosis in the ureteral endometriosis (UE), the overall pooled sensitivities of TVS and MRI were 97% and 87% respectively, and their specificities were both 100%. In conclusion, both TVS and MRI provide good accuracy with specific strong points in diagnosing UTE and seem useful first-line methods from a clinical perspective. Besides, pelvic MRI and TVS are more accurate for predicting UTE localised in the ureter than bladder, especially in terms of sensitivity.IMPACT STATEMENTWhat is already known on this subject? Previous studies have confirmed high diagnostic value of transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) on bladder endometriosis (BE) respectively. However, high heterogeneity was found for both sensitivity and specificity and no meta-analysis has yet been performed to test the diagnostic value of TVS and MRI for ureteral endometriosis (UE).What the results of this study add? In this meta-analysis, we firstly confirmed high diagnostic value of TVS and MRI on UE respectively. For detection of UE, the overall pooled sensitivities of TVS and MRI were 97% and 87% respectively, and their specificities were both 100%.What the implications are of these findings for clinical practice and/or further research? Early preoperative diagnosis and accurate understanding of the widespread distribution of endometriosis are prerequisites for radical surgical in UTE. In the present study, we updated the previous results on the accuracy of TVS and MRI for the diagnosis of BE and firstly confirmed high diagnostic value of TVS and MRI on UE. Both TVS and MRI provide good accuracy with specific strong points in diagnosing UTE and seem useful first-line methods from a clinical perspective.

[Infiltrative endometriosis with ureteral lesion a clinical case of interaction between gynecologist and a urologist in diagnostics, surgical treatment and follow-up].

The article is focused on the problem of diagnosis and surgical treatment of infiltrative forms of endometriosis with lesions of both internal genitalia and urinary tract. A clinical observation of a young woman who underwent a robot-assisted operation on the internal genitals and organs of the urinary system is given. The article emphasizes the need for complete clinical examination in women with suspected endometriosis. The young age of patients, even the absence of bright clinic signs or absence of a long anamnesis of the disease should not exclude the possibility of severe case of endometriosis and the possibility of a combined lesions of pelvic organs. If infiltrative endometriosis is detected, the patients treatment should be carried out in a specialized hospital using modern surgical technologies.

Surgical Management of Urinary Tract Endometriosis: A 1-year Longitudinal Multicenter Pilot Study at 31 French Hospitals (by the FRIENDS Group).

STUDY OBJECTIVE: To describe the surgical management and risks of postoperative complications of patients with urinary tract endometriosis in France in 2017. DESIGN: Multicenter retrospective cohort pilot study. SETTING: Departments of gynecology at 31 expert endometriosis centers. PATIENTS: All women managed surgically for urinary tract endometriosis from January 1, 2017, to December 31, 2017. We distinguished patients with isolated bladder endometriosis or isolated ureteral endometriosis (IUE) from those with endometriosis in both locations (mixed locations [ML]). INTERVENTIONS: Surgeons belonging to the French Colorectal Infiltrating Endometriosis Study (FRIENDS) group enrolled patients who filled a 24-item questionnaire on the day of the inclusion and 3 months later. Data were collected on operative routes, surgical management, and postoperative complications according to the Clavien-Dindo classification in a single anonymized database. MEASUREMENTS AND MAIN RESULTS: A total of 232 patients from 31 centers were included. Isolated bladder endometriosis was found in 82 patients (35.3%), IUE in 126 patients (54.4%), and ML in 24 patients (10.3%). Surgery was performed by laparoscopy, laparotomy, or robot-assisted laparoscopy in 74.1%, 11.2%, and 14.7% of the cases, respectively. Among the 150 ureteral lesions (IUE and ML), 114 were managed with ureterolysis (76%), 28 with ureteral resection (18.7%), 4 with nephrectomy (2.7%), and 23 with cystectomy (15.3%). Concerning bladder endometriosis, a partial cystectomy was performed in 94.3% of the cases. We reported 61 postoperative complications (26.3%): 44 low-grade complications according to the Clavien-Dindo classification (18%), 16 grade III complications (7%), and 1 grade IV complication (peritonitis). CONCLUSION: The surgical management of ureteral and bladder endometriosis is usually feasible and safe through laparoscopic surgery. Ureteral resection, when necessary, is more strongly associated with laparotomy and with more complications than other procedures. Prospective controlled studies are still mandatory to assess the best surgical management for patients.

Ureter Visualization With Transvaginal Ultrasound: A Learning Curve Study.

OBJECTIVES: To evaluate the learning curve of gynecologic surgical fellows (ie, in training) to properly identify the ureters in real time while simultaneously performing and interpreting transvaginal ultrasound (TVUS) examinations. METHODS: We performed a prospective study, which took place at 2 centers in Sydney, Australia, from December 2017 to December 2018. Three fellows (F1-F3), of varying prestudy ultrasound (US) experience, were recruited to participate. One hundred fifty predetermined examinations were planned. A TVUS examination was performed by the study reference standard (an expert in gynecologic US). Subsequently, the fellows performed a focused component to identify bilateral ureters, having been blinded to the patient's clinical history and reference standard findings. Immediate feedback and hands-on teaching were provided after each of the fellow's evaluations were complete. To evaluate the number of scans needed to gain competency, the cumulative summation test for the learning curve was used. RESULTS: A total of 150 examinations were performed on 145 patients. One patient had a single ureter, and 1 patient had US evidence of hydroureter. The cumulative summation test for the learning curve for bilateral ureter identification showed that F1 did not reach competency by 50 TVUS examinations, whereas F2 and F3 required 41 and 31 TVUS examinations to reach competency, respectively. CONCLUSIONS: Contrary to other studies on the topic, this study suggests that although it is feasible for surgical fellows to learn TVUS identification of bilateral ureters, not all fellows can reach competency during a program based on a predefined number of scans. We advocate for an individualized, competency-based medical education model in learning US for identifying the ureters.

Efficacy of Laparoscopic Partial Cystectomy with a Transurethral Resectoscope in Patients with Bladder Endometriosis: See-Through Technique.

PURPOSE: Bladder endometriosis (BE) is rare. Deep invasive endometriosis is difficult to control with medications alone; such cases need surgical treatment. Good results of laparoscopic partial cystectomy with a transurethral (TU) resectoscope by the see-through technique for patients with BE are reported. MATERIALS AND METHODS: From January 2008 to February 2016, 12 cases of symptomatic BE were seen in our institution. The chief complaints of 9 cases were micturition pain during menstruation. Preoperative cystoscopy showed a bladder mass with blueberry spots. All surgeries were performed under general anesthesia. Laparoscopic surgery was performed with a fan of 4 ports in the lower abdomen. First, the uterus and bilateral ovaries were checked. Then, the TU resectoscope was inserted. When the affected bladder wall was identified, it was again observed with the laparoscopic light source off, which made it possible to observe the twilight leaking inside from the bladder. This twilight came from the light source of the TU resectoscope via the unaffected bladder wall. In contrast, the thickness of the affected wall prevented the light from inside the bladder from passing through it. We call this the "see-through technique." The tumor was then safely dissected with both laparoscopic and TU resection procedures. Finally, the bladder was sutured by laparoscopic procedures using absorbable sterile surgical suture. The urethral catheter was removed after cystography 7 days after the operation. RESULTS: The surgical margins of all cases were negative. There has been no recurrence of BE so far in any patients. There were no major adverse events perioperatively and the urinary symptoms improved in all cases. CONCLUSIONS: By laparoscopic partial cystectomy assisted with a TU resectoscope and see-through technique, the edge of BE could be easily and precisely identified. These procedures are effective and safe for BE surgical treatment.

Management of ureteral endometriosis with hydronephrosis: Experience from a tertiary medical center.

AIM: We report the clinical characteristics and experience of the surgical management of ureteral endometriosis in our institution. METHODS: We retrospectively reviewed the data of patients with hydronephrosis resulting from ureteral endometriosis. RESULTS: Forty-six patients with different degrees of hydronephrosis were included in the study; 35% had urinary tract symptoms. Concomitant involvement of the ipsilateral ovary occurred in more than two-thirds of the patients. Four patients had nephrectomy, one of which involved ureterolysis because of hydronephrosis recurrence six months later. CONCLUSIONS: Hydronephrosis may be caused by uncommon reasons, such as ureteral endometriosis, which can even cause silent loss of renal function. Routine ultrasound scanning of the upper urinary tract for severe stages of endometriosis is very important in order to detect any potential ureteral lesions. Ureterolysis should be considered as the first surgical step, not only to avoid iatrogenic ureteral injuries but also to better evaluate ureter involvement for further procedures. To warrant tension-free and lesion-free anastomosis, it is wise to perform ureteroneocystostomy for long-term sound results.

Bladder endometriosis: A serious disease.

Urinary tract endometriosis (UTE) is a very rare but serious form of infiltrating endometriosis because of the risk of urinary tract obstruction and loss of renal function. We report the case of A 42-year-old female patient admitted for intense right back pain with lower urinary tract disorders. An abdomino-pelvic ultrasound was done showing right uretero-hydronephrosis. Ureteroscopy showed an inflammatory-like stenosis of the right pelvic ureter. Given the young age of the patient, the poor quality of the right kidney, we opted for a right total nephro ureterectomy. The anatomopathological examination showed a bladder endometriosis .

Outcomes of Urinary Tract Endometriosis-Laparoscopic Treatment: A 10-Year Retrospective Study.

INTRODUCTION: Urinary tract endometriosis (UTE), a rare manifestation, encompasses bladder and ureteral involvement. Surgical intervention is commonly recommended for UTE, though the optimal surgical approach remains a subject of debate. This study aims to report our centre's experience with UTE. METHODS: We conducted a retrospective cohort study of 55 patients who underwent surgical treatment for UTE at a single tertiary centre over a 10-year period (2012-2022). Patient data, including demographics, symptoms, intraoperative findings, and complications, were collected from medical records. Data were statistically analysed, and correlations were explored. RESULTS: The study population had a mean age of 37.11 years, with dysmenorrhea (89.1%) being the most common symptom. Bladder endometriosis was present in 27 cases, ureteral endometriosis in 25, and mixed-location in 3. Laparoscopy was the primary surgical approach, with multidisciplinary teams involving urologists. There were six patients with postoperative complications, and there were six (10.9%) recurrences of endometriosis. A positive correlation was found between age and recurrence, but no significant predictors of recurrence were identified in our analysis. CONCLUSIONS: Laparoscopic treatment of urinary endometriosis is safe and effective. Multidisciplinary collaboration plays a pivotal role in addressing this challenging condition.

Paraurethral Endometriosis as a Common Pathology in an Uncommon Location: A Case Report and a Review of the Literature.

Paraurethral endometriosis is an extremely rare condition. To the best of our knowledge, only seven cases with details on variable risk factors have been reported in the English literature. Herein, we present the case of a third nulliparous patient described in the literature at the time of diagnosis. A 30-year-old woman presented with mild urinary symptoms. A well-defined 2.3 cm paraurethral cystic lesion was found on clinical examination, and MRI findings were suggestive of hemorrhagic content, with no evidence of pelvic endometriosis. Complete surgical excision was performed, and the patient's symptoms improved. The patient experienced no recurrence for 10 months postoperatively. The histopathological findings were suggestive of endometriosis. These findings might indicate that embryonic remnants are possible causes of the pathogenesis of paraurethral endometriosis.

Renal endometriosis: A benign disease with malignant presentation.

Endometriosis is a common gynecological disorder in which endometrial tissue is located outside the uterine cavity. Urinary tract involvement by endometriosis is uncommon. Renal endometriosis is a rare disorder and is not evident on imaging. It may be misdiagnosed as malignant disease and patients may undergo invasive procedures for it. We report a case of a young lady who presented with symptoms typical for renal mass, and was diagnosed as a tumor on imaging. Patient underwent radical surgery and histology revealed renal endometriosis.

Management of patients with urinary tract endometriosis by gynecologists

Objective: The aim was to report the postoperative outcomes of urinary tract endometriosis (UTE), which is a form of deep, infiltrative endometriosis, and to contribute to the literature by presenting our experience. Material and Methods: In the present study, patients who underwent surgery for endometriosis at our clinic between 2005 and 2019 and had a final pathological diagnosis of UTE were examined in detail. Patient information was retrospectively retrieved from the medical records. Data obtained pre-, peri-, and postoperatively were analyzed. Results: Mean age of the 70 patients included, according to the study criteria, was 32.73±7.09 years. Ureteral involvement alone was observed in 49% (n=34) of the patients, bladder involvement alone was observed in 24% (n=17) of the patients, and both bladder and ureteral involvement were observed in 27% (n=19) of the patients. Microscopic hematuria was detected in 16% (n=11) of the patients, whereas preoperative urinary tract findings, such as recurrent urinary tract infections, were detected in 19% patients (n=13). Of the patients, 56% (n=39) were identified with dyspareunia, 56% (n=39) with dysmenorrhea, and 30% (n=21) with pelvic pain. Visual analog scale score was significantly lower after the procedure (p<0.0001). Conclusion: Although postoperative results were typically considered positive, surgical method performed in deep infiltrative endometriosis should aim to preserve fertility, improve quality of life, and reduce the complication rate to a minimum.

Clinical characteristics of urinary tract endometriosis: A one-year national series of 232 patients from 31 endometriosis expert centers (by the FRIENDS group).

OBJECTIVE: To review prospectively the clinical characteristics of patients suffering from urinary tract endometriosis (UTE) in France, in 2017. STUDY DESIGN: We conducted a prospective observational multicenter study including women managed surgically for UTE in 31 French endometriosis expert centers (FRIENDS group) from January 1, 2017 to December 31, 2017. We distinguished patient with isolated bladder endometriosis ("IBE") or isolated ureteral endometriosis ("IUE") and patients associating both locations (mixed locations "ML"). Surgeons belonging to FRIENDS group enrolled patients by filling a 24 items questionnaire the day of the surgery and 6 weeks later. Data on the locations of UTE, preoperative assessment, urinary symptoms and associated pelvic locations were collected in a single anonymized database. RESULTS: A total of 232 patients from 31 centers were included. IBE concerned 82 patients (35.3%), IUE 126 patients (54.4%) ML 24 patients (10.3%). 111 patients reported urinary symptoms (47.8%). IUE was more often asymptomatic than the rest of the locations (59.5% versus 43.3%, OR 1,92, p = 0.017). Associated deep infiltrating endometriosis (DIE) lesions were found in 193 patients (83.1%). IUE was significantly associated with other DIE lesions (82.5% versus 66%, OR2.4, p = 0.006), particularly with rectum or sigmoid nodules (57.1% versus 36.8%, OR 2.3, p = 0.002) and retrocervical space nodules (31.7% versus 19.8%, OR 1.9, p = 0.05). CONCLUSION: Our study reports the second largest series of patients operated from a UTE and shows that ureteral location seems more frequent, less symptomatic and more frequently associated to other DIE locations than bladder endometriosis.

Surgical management of deep pelvic endometriosis in France: Do we need to be a pelvic surgeon to deal with DPE?

INTRODUCTION: Endometriosis is a common disease in women, which requires a medical and surgical approach. Surgical societies recommend a multidisciplinary management in tertiary referral centers. The objective of our study is to assess the surgical management of endometriosis in France by studying the surgeons' attitude for bowel and urinary endometriosis. METHODS: We sent a survey to french endometriosis surgeons. We did a descriptive analysis and a comparative analysis between surgeons who believe endometriosis surgeons should be considered as "pelvic surgeons", able to treat bowel and urinary involvement. RESULTS: We included 90 answers, from gynaecologic surgeons from all over France. Gynaecologic surgeons perform minor bowel and urinary tract surgery, and more complex procedures are performed with digestive or urological surgeon (bowel resection 85% of cases, ureteric resection-anastomosis 84% of cases, ureteric reimplantation 91% of cases). Surgeons considering that gynaecologists should be able to deal with urinary and bowel endometriosis carry out more bowel and urinary procedures. They have an additional training in surgery and perform more endometriosis surgery every year. However, bowel and urinary endometriosis management by gynaecologic surgeons is contested amongst gynaecologists. CONCLUSION: To this day, there is no dedicated training in France to coach gynaecologist to perform such procedures. Multidisciplinary approach is essential for quality care, in expert centers. The basic education of gynaecologic surgeons does not allow them to perform complex pelvic surgeries, but qualifications can be gained for these interventions with a special training, and perform a greater number of surgeries.

Laparoscopic management of ureteral endometriosis: A systematic review.

The optimal management of ureteral endometriosis (UE) is not yet well defined. The choice on surgical approach and type of procedure has been based both on surgeons' experience and the location and depth of the lesion. The aim of this study was to review evidence about laparoscopic management of ureteral endometriosis, including preoperative evaluation, surgical details and postoperative follow-up. PubMed Central and SCOPUS databases were searched to identify studies reporting cases of laparoscopically managed ureteral endometriosis and including data regarding preoperative findings, surgical interventions and postoperative follow-up. Two sets of MeSH terms were used: 1) "laparoscopy", "endometriosis" and "ureter"; 2) "laparoscopy", "endometriosis" and "urinary tract". Databases were searched for articles published since 1996, in English, French, Spanish and Portuguese, without restrictions regarding study design. Studies reporting surgical approaches other than conventional laparoscopy were excluded, as were case reports and case studies including fewer than 5 cases. From 327 studies obtained through database searching, 18 articles were finally included in this review, including a total of 700 patients with ureteral endometriosis. 57% of patients had at least one previous surgery for endometriosis. Preoperative evidence of significant hydroureter/hydronephrosis was found in 324 of 671 (48.3%) patients. Dysmenorrhea (81.4%), pelvic pain (70.2%) and dyspareunia (66.4%) were the presenting symptoms more commonly reported by the patients. Most patients presented no symptoms specific to the urinary tract. Ureteral endometriosis was more frequent in the left ureter (53.6%) and it was bilateral in 10.6% of cases. Ureterolysis alone was considered a sufficient procedure in 579 of 668 patients (86.7%), and in the remaining 89 patients ureteral resection was necessary. Rectovaginal and uterosacral involvement was present in 58.8% and 47.9% of patients, respectively. Concomitant ureteral and bladder endometriosis was described in 19.8% of patients. Only 6 studies reported cases of accidental ureteral injuries, in 1-24% of patients. Cases of conversion to laparotomy are reported in only 6 studies, in 3-6,7% of patients. Major postoperative complications occurred in 21 out of 682 patients (3.2%). The need for reoperation during follow-up period because of ureteral endometriosis persistence or recurrence was 3.9%. When performed in specialized centers, laparoscopic ureterolysis showed to be a feasible and safe procedure, with a low risk of complications and with satisfactory long-term results. This conservative approach may be used as the initial treatment option in most patients with ureteral endometriosis.

[Morbidity and functional long-term follow-up of patients with surgical treatment of urinary tract endometriosis]. / Morbidité et conséquences fonctionnelles de la chirurgie de l'endométriose urinaire.

OBJECTIVE: To assess postoperative complications, improvement of pain symptoms and residual urinary functional symptoms after surgery for deep infiltrative endometriosis affecting ureter or bladder. METHODS: Retrospective study of complications (Clavien-Dindo classification), pain (visual analog scale [VAS]) and urinary functional symptoms (Urinary Symptom Profile questionnaire [USP]) of patients surgically treated between 2007 and 2015 in University Hospitals of Lyon. RESULTS: Among 31 patients with endometriosis involving the bladder, 83.9% had a partial cystectomy and 16.1% an extra-mucosal resection. Among patients (n=20) with ureteral involvement, 85% had ureterectomy with ureterocystoneostomy and 15% had only ureterolysis. Grade III postoperative complications occurred in 6% and 0% of patients with bladder or ureteral surgery, respectively and no grade IV or V complications were reported. Mean bladder VAS dropped from 5.3±4.2 to 0.3±0.9 after a follow-up of 42 months (P<0.0001). In patients with ureteral involvement, mean flank VAS dropped from 3.6 to 0.9 after a follow-up of 33 months (P<0.0005). Mean postoperative USP score for dysuria and detrusor overactivity were 1.35/9 and 2.48/21 in case of bladder involvement, and 1.10/9 and 2.15/21 in case of ureteral involvement. CONCLUSION: Multidisciplinary surgical management of deep infiltrative endometriosis affecting urinary tract was associated to a low risk of severe postoperative complications and to a long-term significant improvement of pain symptoms without significant residual functional urinary symptoms.

Urinary tract endometriosis in patients with deep infiltrating endometriosis: prevalence, symptoms, management, and proposal for a new clinical classification.

OBJECTIVE: To analyze the prevalence of urinary tract endometriosis (UTE) in patients with deep infiltrating endometriosis (DIE) and to define potential criteria for preoperative workup. DESIGN: Retrospective study. SETTING: University hospital. PATIENT(S): Six hundred ninety-seven patients with endometriosis. INTERVENTION(S): Excision of all endometriotic lesions. MAIN OUTCOME MEASURE(S): Correlation of preoperative features and intraoperative findings in patients with UTE. RESULT(S): Out of 213 patients presenting DIE, 52.6% suffered from UTE. In patients with ureteral endometriosis, symptoms were not specific. Among the patients with bladder endometriosis, 68.8% complained of urinary symptoms compared to 7.9% in the group of patients without UTE. In patients with rectovaginal endometriosis, the probability of ureterolysis showed a linear correlation with the size of the nodule. We found that 3 cm in diameter provided a specific cutoff value for the likelihood of ureteric involvement. CONCLUSION(S): The prevalence of UTE has often been underestimated. Preoperative questioning is important in the search for bladder endometriosis. The size of the nodule is one of the few reliable criteria in preoperative assessment that can suggest ureteric involvement. We propose a classification of ureteral endometriosis that will allow the standardization of terminology and help to compare the outcome of different surgical treatment in randomized studies.