Endometriosis (EMT) is a puzzling progressive disease with a prevalence of 10-15% in women of childbearing age and accounts for 25% of open gynecologic procedures. Among gynecologic diseases, EMT is second only to uterine fibroids in prevalence. Urinary tract involvement has been reported in 16% of patients who underwent open surgery for EMT, with bladder (endometriosis) being the most common.
endometriosis) is the most common. Although ureteral EMT (ureteral endometriosis) is rare, its onset is insidious and the kidney may be significantly impaired or even non-functional by the time it is diagnosed. Also because of its rarity, it is difficult to conduct randomized controlled prospective studies and there are many controversies regarding its treatment. In recent years, it has attracted the attention of gynecologists and urologists.
EMT of the bladder
Most of the lesions are superficial and invasion of the bladder wall is rare. Goldstein and Brodman studied a case of bladder EMT in which the bladder volume was reduced and the bladder was dysfunctional.
and Brodman performed intravesical pressure monitoring for 4 years in a case of bladder EMT and found that bladder volume reduction and dysfunction caused by superficial bladder EMT was ineffective with conventional antiparasympathetic therapy, and that symptoms disappeared after surgical destruction of the lesion, and when bladder symptoms recurred 2 years later, the bladder dysfunction was relieved again with a course of danazol treatment. Doctors should think of the possibility of EMT if a patient has intractable, unexplained urinary symptoms. When urinary EMT is suspected, intravenous pyelogram, renal ultrasonography and routine blood and urine laboratory tests should be performed, and cystoscopy is recommended for some patients with recurrent hematuria.
For superficial lesions, they can be treated with water separation and vaporization method or resection method. Fluid is first injected below the lesion to separate the fovea between the bladder plasma membrane and the muscular layer under the implantation site, and the lesion is removed in a circular fashion by grasping it with a forceps. Intraoperative flushing with water is repeated to see the depth of vaporization or excision and to ensure that the lesion does not involve the muscular and mucosal layers of the bladder.
If the ectopic lesion invades the whole bladder, excision of the lesion and partial cystectomy is the best treatment. Because the internal structures of the bladder are clearly visible due to carbon dioxide gas filling, laparoscopic surgery seems to expose the operative field more clearly than open surgery, and intraoperative cystoscopy and bilateral ureteral cannulation can be performed simultaneously. This is done by lifting the top of the bladder at the midline with a grasping forceps and removing the lesion starting from 5 mm outside the ectopic node. After excision, the ureteral opening and bladder mucosa are inspected and the entire bladder is closed with 4-0 PDS sutures, interrupted or continuous, and then cystoscopy is performed to check for leakage, and surgical bleeding is usually minimal. A Foley catheter was left in place after surgery. The patient takes antibiotics for 2 weeks and the Foley catheter is removed 7 to 14 days after surgery. The length of stay depends on the size of the lesion, the healing status of the tissue and the cystogram results. Residual or deep lesions can be treated postoperatively with medications.
There were 28 cases of deep invasive urinary EMT, of which 7 cases involved the bladder and underwent partial cystectomy and one-stage repair, all done laparoscopically. 17 cases had partial ureteral obstruction and were operated accordingly. 19 cases of intentional or unintentional bladder lacerations during laparoscopic surgery were repaired laparoscopically with absorbable sutures or (PDS) single interrupted sutures and postoperative catheterization, with only 1 case There was only one case of vesicovaginal fistula complication requiring reoperation. The prognosis of the patients was good at 6-48 months of follow-up.
Ureteral EMT
EMT causing hydronephrosis was first reported by Cullen in 1917, and by 2006 more than 300 cases had been reported in the literature; however, the exact incidence is unknown. The incidence in EMT is estimated to be 0.3%. It has also been suggested that 1-11% of EMTs have ureteral involvement, which may be related to different diagnostic criteria. Ureteral EMT can occur in postmenopausal women and has also been reported to develop after surgical treatment of pelvic EMT. Ureteral EMT is generally superficial, but can invade deeper and even lead to complete ureteral obstruction. It occurs in the lower third of the ureter and only one case has been reported so far in the upper and middle ureter, while renal EMT is rare. In addition, the site of ureteral EMT is consistent with the asymmetry of pelvic EMT, i.e., more on the left than on the right side. 125 cases of ureteral EMT reported by Vercellini et al. occurred on the left side in 47.4%, on the right side in 31.6%, and both sides in 21%. The pathology of ureteral EMT can be divided into extrinsic and intrinsic types, and the ratio of the two types is about 4 to 1. The former is mostly due to direct spreading of pelvic EMT and compression of the ureter.
In the latter case, the EMT invades the myometrium or even the mucosa of the ureter, causing obstruction of the lumen. Intrinsic ureteral EMT is rare, but almost half of the patients have lost renal function by the time the diagnosis is made. Rarely, ureteral EMT is carcinogenic.
Patients with ureteral EMT often have signs and symptoms of EMT, and the first step in its diagnosis is a high index of suspicion. The possibility of ureteral involvement should be considered for all severe EMT. Ureteral EMT should be considered if there are large ectopic lesions (e.g. >3 cm) in the uterosacral ligament, lateral posterior sulcus and rectovaginal septum, and the diagnosis should be confirmed by renal ultrasound or pelvic MIR and finally by intravenous pyelogram (IVP).
Most believe that ureteral EMT should be treated surgically, but some believe that those with minor ureteral obstruction and good renal function can also be considered to be treated with medication first, but should be followed up closely. In addition, preoperative medication may make surgery less difficult and reduce intraoperative bleeding by lowering estrogen levels. GnRH-a class, danazol, endometrium or high potency progestin may be used for 3-6 months of treatment. Medication may also be used or continued for 3 to 6 months after conservative surgery for ureteral EMT.
In recent years, many scholars have treated ureteral EMT successfully by laparoscopy. Superficial lesions on the ureter can be treated with a variety of water separation techniques. A subperitoneal injection of 20 to 30 ml of lactated Ringer’s fluid in the lateral pelvic wall lifts the peritoneum and creates a water cushion. The fluid will infiltrate around the ureter, pushing the ureter backward, and then the lesion is vaporized or removed with monopolar electrodes or a CO2 laser or any other cutting instrument (20 to 80 W). The peritoneum is lifted with atraumatic forceps and torn off using resection instruments and suction probes. If the ectopic lesion has buried itself in the peritoneum and formed a scar in the subperitoneal connective tissue, water will go underneath the lesion during water separation, often loosening the scar tissue so that the lesion can be safely treated. After water separation of the broad ligament and lateral pelvic wall, about 5% of patients develop external genital edema, presumably caused by the flow of fluid through the inguinal canal into the labia majora, which in most cases resolves spontaneously within 1 to 2 hours without sequelae.
The traditional treatment for ureteral obstruction due to EMT is open excision of the obstructed segment of the ureter. 1990 Nezhat et al. first reported a case of long-term ureteral obstruction due to EMT, which was treated with laparoscopic end-to-end ureteral anastomosis (uretero-ureterostomy). The patient had undergone laparoscopy with a clear diagnosis but refused to undergo open surgery and was treated with pyelostomy placement for drainage for 4 years. Laparoscopic surgery revealed a 3- to 4-cm fibrous nodule in the left ureter approximately 4 cm from the bladder, resulting in a distorted ureteral course consistent with the level of obstruction shown radiographically. Retrograde ureteral cannulation under direct laparoscopic view was unsuccessful; therefore, the decision was made to remove the fibrous nodule. After entering the left retroperitoneal space at the edge of the pelvis and addressing all ectopic lesions, fibrosis and adhesions, the ureter was dissected. A partial ureterectomy was done because the ectopic lesion nodules invaded the entire ureter. A 7-gauge ureteral stent drain was inserted from the ureteral bladder opening under cystoscopic guidance and delivered to the level of the ureter where the lesion was desired to be cut. Intravenous indocyanine was injected to demonstrate proximal ureteral patency. The distal ureter was cut transversely around the catheter to remove the obstructed ureteral segment, then the ureteral catheter was inserted into the proximal ureter up to the renal pelvis, and finally an end-to-end ureteral anastomosis was performed with 4-0 polypropylene sutures with a total of 4 interrupted sutures at 6, 12, 9 and 3 points. The patient was discharged home the next day after the procedure, and the postoperative course was uneventful with no complications. Intravenous pyelogram (IVP) showed a patent ureter with a functioning kidney, and the operative bleeding was estimated to be less than 100 ml with an operative time of 117 minutes. Pathology confirmed ureteral EMT with fibrosis. Since then, the authors have treated more than 12 patients with severe ureteral EMT combined with partial or complete ureteral obstruction, all of whom had a history of EMT and were treated with different medications or surgery. In four cases, the ureteral endometriosis lesions were completely removed without entering the ureteral lumen. In three cases, total ureteral resection was required for ureteral obstruction, including one left and one right ureteral end-to-end anastomosis and one left ureteral bladder reanastomosis (ureterocystoneostomy), in which a ureteral catheter was placed followed by four interrupted stitches with 4-0 PDS sutures at the opposite end of the ureter. In the other 5 cases, the ureter was only partially involved. Severe retroperitoneal and ureteral EMTs could be resected or discreetly vaporized with CO2 laser until ureterotomy. If the ureterotomy incision is minimal and only found after intravenous indocin, the wound does not require suturing and preservation of the ureteral stent is sufficient. Histological examination of the excised specimens was performed with either fibrosis, EMT or both.
Nezhat later summarized 28 cases of urologic EMT with deep infiltration, with lesions involving the ureter in 21 cases. 17 cases of partial ureteral obstruction were treated with periureteral adhesion release and ectopic lesion excision in 10 cases and partial ureteral wall resection in 7 cases. 4 cases of complete ureteral obstruction were treated with partial ureteral resection and end-to-end ureteral anastomosis in 3 cases and ureterocystic anastomosis in 1 case. The patients had a good prognosis at 6-48 months of follow-up. Another case was reported of a patient, 24 years old, who had been diagnosed with pelvic EMT several months ago and underwent laparoscopic palliative surgery and postoperative treatment with GnRH-a. At the second laparoscopy, the patient was found to have severe EMT in the left uterosacral ligament, pelvic wall, and ureter, resulting in complete ureteral obstruction. After excision of the diseased segment of the ureter, an end-to-end ureteral anastomosis was performed. After intraoperative intravenous injection of indocin, no fluid flow from the ureter was seen, and it was considered that the kidney might have been non-functional. Postoperative follow-up imaging proved that the function of the affected kidney was 10% to 20% of normal, but the ureter was patent. In such patients, ureteral stent drainage tubes should be placed and kept until 2 months postoperatively, and IVP, ultrasonography and renal secretory function should be done at the follow-up visit.
Ghezzi et al. reported satisfactory results in 33 patients with ureteral EMT combined with moderate to severe hydronephrosis who underwent laparoscopic ureteral adhesions (laparoscopic ureterolysis), although 12.1% (4/33) had recurrence at follow-up. Frenna et al. reported good results with this procedure in 54 cases of extrinsic ureteral EMT, with only one case of intraoperative ureteral injury. At 1 year follow-up, there was no recurrence of urinary EMT. Although laparoscopic treatment of ureteral EMT has achieved some efficacy, some recurrence rates seem to be slightly higher. Failure to perform laparoscopic separation of periureteral adhesions and reoperation has also been reported. Therefore, the surgical modality should be developed by the surgeon according to his skill level.
We have admitted 4 cases of ureteral EMT in recent years, all patients had mild to moderate hydronephrosis, 3 of them had lower ureteral stenosis with affected sacral ligament EMT, 2 had rectovaginal septum EMT. 1 case had middle ureteral EMT resulting in luminal stenosis and only ovarian EMT in the pelvis. preoperative ureteral placement (Duoble-J) was performed by a urologist under cystoscopy on the affected ureter, followed by Three cases of lower ureteral stenosis were treated with pelvic EMT along with resection of the periureteral lesion, separation of its surrounding adhesions, and freeing of the ureter. One patient with mid-ureteral stenosis was 47 years old, and due to the difficulty of lesion excision, partial excision of the lesion was performed along with hysterectomy and bilateral adnexal resection. In three cases, the Duoble-J was removed 3-6 months after surgery, and IVP showed ureteral patency. In patients with failed cystoscopic placement of Duoble-J suggesting severe ureteral obstruction and possibly intrinsic ureteral EMT, we recommend surgery by a urologist. End-to-end ureteral anastomosis after resection of the diseased ureter should be considered in these patients, and ureteral bladder implantation anastomosis is more effective in those with severe lesions.
References
1. Translated by Zhou Yingfang and edited by Weng Liju. Laparoscopic surgical treatment of EMT. In: Gynecologic laparoscopic surgery: treatment principles and techniques (2nd ed.). Translated by Cui H, Wang Qiusheng. People’s Health Press 2002 P135
2. Ghezzi 3, Asimakopoulos G. Ureteral endometriosis: diagnosis and management. Rev Med Chir Soc Med Nat Iasi. 2006;110(3):575-81. 4, Frenna 5. Ghezzi F, Cromi A, Bergamini V, et al. Outcome of laparoscopic ureterolysis for ureteral endometriosis. Fertil Steril. 2006: 86(2):418-22. 6, Vercellini P, Pisacreta A, Pesole A, et al. Is ureteral endometriosis an asymmetric disease? BJOG. 2000;107(4):559-61. 7, Nezhat C, Nezhat F, Nezhat CH, et al. Urinary tract endometriosis treated by laparoscopy. Fertil Steril. 1996;66(6):920-4.