**8. Urinary tract endometriosis**

Endometriosis expanding and invading the urinary tract is a rare occurrence found in 0.3%- 5% of all endometriotic patients (Chapron *et al.*, 2003; Mereu *et al.*, 2010). The bladder is the most frequently involved organ, followed by the ureters and the kidneys with a proportion of 40:5:1. The endometriosis that comprises the urinary tract cannot be considered to be primary lesions from these organs (Abrao *et al*., 2009).

Abdominopelvic Complications of Endometriosis 75

Transurethral resection is not an optimal treatment because it does not permit complete excision of the disease –the disease originates outside (from the peritoneum) the bladder- (Chapron *et al.,* 2010; Le Tohic *et al.,* 2009), radicality would imply bladder perforation, and the patients have a high recurrence (11.5 %) (Le Tohic *et al.*, 2009). Pang *et al.* (2008) have reported a case treated with combined transurethral and laparoscopic excision followed by

Major complications can occur in 2.7% of patients, such as vesico-uterine or vesico-digestive fistula, intravesical or pelvic hematoma (Chapron *et al.,* 2010; Le Tohic *et al.,* 2009). The painful symptoms improved in 100% of the patients (Chapron *et al.*, 2010). The recurrence rate of clinical-instrumental evidence can range between 0% (Chapron *et al.,* 2010) and 10.9% (Fedele *et al.,* 2005b).The factors influencing rate of recurrence is the extent of surgical excision and the vesical base involvement. When the resection include both the vesical lesion and a 0.5-1 cm deep portion of the adjacent myometrium, recurrence is significantly less frequent compared to the removal of the bladder lesion only (0% vs 26%, respectively)

Ureteral endometriosis is a rare but serious localization of the disease (<0.3%) (Li *et al*., 2008) because it may cause silent loss for renal function (Abrao *et al.,* 2009; Li *et al.*, 2008; Mereu *et al.,* 2010). Disease is predominantly unilateral, with the left ureter affected more commonly than the right, although bilateral disease does occur (Li *et al.,* 2008). The lesions are localized in the lower third of the ureter (Abrao *et al.,* 2009), and associated with endometriosis elsewhere in the pelvis (Li *et al*., 2008; Mereu *et al.,* 2010). There are two major pathologic types of ureteral endometriosis: intrinsic and extrinsic, occurring, respectively with a 1:4 ratio. In the intrinsic disease, ectopic endometrial tissue infiltrates the muscularis mucosa and the uroepithelium. In the extrinsic disease, the endometrial tissue invades only the ureteral adventitia or surrounding connective tissue. These pathologic types can coexist. Indeed, both entities can lead to ureteral obstruction with subsequent hydroureter and dilatation of the renal pelvis that can be also asymptomatic (Li *et al.,* 2008). Generally, bladder is not affected for endometriosis in the patients with ureteral endometriosis. This observations confirms that, although ureter and bladder are both part of the urinary tract, endometriotic lesions affecting these sites have a different

The patients have symptoms predominantly related to pelvic endometriosis (dysmenorrhea, dyspareunia, chronic pelvic pain [75%-100%]) and lower frequency patients have urologic symptoms such as renal colic or urinary frecuency (3.6%-50%). Because of the absence urologic symptoms (56.5%) and the risk for subsequent loss of renal function (20%), checking the integrity of the urinary tract of patients with endometriosis not only before surgery and after surgery but also during medical therapy is recommended (Li *et al.,* 2008; Mereu *et al.,* 2010). Rectal or vaginal infiltration by the posterior DIE is present in 74% of these patients, and extensiveness of adnexal adhesion are factors related to dysmenorrhea severity (Abrao *et al.*, 2009). The presence of retrocervical and rectum-sigmoid involvement in most patients with ureteral endometriosis suggest that the origin of ureteral

endometriosis is extrinsic (Abrao *et al.,* 2009; Mereu *et al.,* 2010).

laparoscopic bladder reconstruction, taking advantage of both approaches.

(Fedele *et al.*, 2005b).

**8.2 Ureteral endometriosis** 

behavior (Abrao *et al.,* 2009).

## **8.1 Bladder endometriosis**

Bladder is the most frequent location in cases of urinary endometriosis. Amongst women suffering from DIE, 11% present lesions that affect the bladder. According to the three major etiopathogenic theories proposed, vesical endometriosis may develop from mulleriam remnants in the vesicouterine septum, or as an extension of an adenomyotic nodule of the anterior uterine wall, or from implantation of regurgitated endometrium (Chapron *et al.*, 2003).

Patients may present with variable urinary symptoms (cystalgia 43%-58.3%, dysuria 21%- 25%, urinary frequency 16.6%-71%, macroscopic hematuria 12.5%-19%) (Le Tohic *et al.*, 2009) and/or symptoms related to endometriosis (dysmenorrhea 70.8%, dyspareunia 21%- 50%, chronic pelvic pain 43%-75%); these symptoms may be cyclic (34.6%-100%) (Abrao *et al.*, 2009; Le Tohic *et al.*, 2009). This entity should also be considered in postmenopausal patients receiving hormonal replacement therapy who report voiding symptoms and who are unsuccessfully treated for interstitial cystitis. During pelvic examination an anterior nodule is palpated in 41.7% to 97.5% of the patients. When a bladder nodule is diagnosed, it has to be differentiated from bladder carcinoma, varices, papillomas or angiomas (Chapron *et al.*, 2010; Le Tohic *et al.*, 2009).

The diagnosis of bladder endometriosis is often difficult to make and it is based on ultrasound, MRI, and cystoscopy. Generally, pelvic ultrasound is the first imaging test performed and allows the bladder nodule DIE in the 38%-100% of patients (Le Tohic *et al.,* 2009). Transvaginal ultrasound is capable of diagnosing bladder nodules in 58.3% of patients. Cystoscopy may reveal typical red and/or bluish lesions (30%-38.4%), extrinsic compression (38.4%), or may be normal (Chapron *et al.*, 2010; Le Tohic *et al.,* 2009); and also helps to rule out vesical epithelial malignancy, to ascertain the precise location of bladder DIE nodule (distance with the ureteral meata and the lower endometriotic margin) and to define the ureteral status (Chapron *et al.,* 2010). The presentation of endometriosis varies over the menstrual cycle; the lesions are more obvious and congestive during menstruation (Pang *et al.,* 2008). MRI shows the presence of a nodule in 77.2%-100% of patients. Generally, the bladder DIE nodule is unifocal in the bladder wall (posterior wall 62.5%-74.7%, vesical dome 25.3%-37.5%). The mean size of the bladder nodule at pathological examination is 23.6 mm (range 8-50 mm). Bladder DIE is isolated in 36% of the cases, and 64% of the patients is associated with posterior DIE lesions (intestinal 32%, ureteral 9.3%, unilateral or bilateral ovarian endometriomas 24%, uterosacral ligament 33.3%, vagina 26.7%); therefore, should not be considered as an independent form of the disease (Chapron *et al.,* 2010; Fedele *et al.,* 2005b, Le Tohic *et al.,* 2009).

Treatment of bladder endometriosis can be medical therapy with antiestrogenic agents or surgical excision. Medical therapy often results in temporary improvement of the symptoms, but relapse may occur. Most clinicians agree that surgery is the best option and resection should be complete. This can be carried out by laparotomy or laparoscopy depending on the lesion, skill, and experience of the surgeon (Chapron *et al.*, 2010; Fedele *et al.,* 2005b; Le Tohic *et al.,* 2009). Cystoscopic transillumination was used to better define the edges of the lesion and to maximize sparing of unaffected mucosa (Fedele *et al.,* 2005b). During the surgical procedure complete excision of all associated symptomatic posterior DIE lesions are performed (uterosacral resection, colpectomy, intestinal resection).

Bladder is the most frequent location in cases of urinary endometriosis. Amongst women suffering from DIE, 11% present lesions that affect the bladder. According to the three major etiopathogenic theories proposed, vesical endometriosis may develop from mulleriam remnants in the vesicouterine septum, or as an extension of an adenomyotic nodule of the anterior uterine wall, or from implantation of regurgitated endometrium (Chapron *et al.*,

Patients may present with variable urinary symptoms (cystalgia 43%-58.3%, dysuria 21%- 25%, urinary frequency 16.6%-71%, macroscopic hematuria 12.5%-19%) (Le Tohic *et al.*, 2009) and/or symptoms related to endometriosis (dysmenorrhea 70.8%, dyspareunia 21%- 50%, chronic pelvic pain 43%-75%); these symptoms may be cyclic (34.6%-100%) (Abrao *et al.*, 2009; Le Tohic *et al.*, 2009). This entity should also be considered in postmenopausal patients receiving hormonal replacement therapy who report voiding symptoms and who are unsuccessfully treated for interstitial cystitis. During pelvic examination an anterior nodule is palpated in 41.7% to 97.5% of the patients. When a bladder nodule is diagnosed, it has to be differentiated from bladder carcinoma, varices, papillomas or angiomas (Chapron

The diagnosis of bladder endometriosis is often difficult to make and it is based on ultrasound, MRI, and cystoscopy. Generally, pelvic ultrasound is the first imaging test performed and allows the bladder nodule DIE in the 38%-100% of patients (Le Tohic *et al.,* 2009). Transvaginal ultrasound is capable of diagnosing bladder nodules in 58.3% of patients. Cystoscopy may reveal typical red and/or bluish lesions (30%-38.4%), extrinsic compression (38.4%), or may be normal (Chapron *et al.*, 2010; Le Tohic *et al.,* 2009); and also helps to rule out vesical epithelial malignancy, to ascertain the precise location of bladder DIE nodule (distance with the ureteral meata and the lower endometriotic margin) and to define the ureteral status (Chapron *et al.,* 2010). The presentation of endometriosis varies over the menstrual cycle; the lesions are more obvious and congestive during menstruation (Pang *et al.,* 2008). MRI shows the presence of a nodule in 77.2%-100% of patients. Generally, the bladder DIE nodule is unifocal in the bladder wall (posterior wall 62.5%-74.7%, vesical dome 25.3%-37.5%). The mean size of the bladder nodule at pathological examination is 23.6 mm (range 8-50 mm). Bladder DIE is isolated in 36% of the cases, and 64% of the patients is associated with posterior DIE lesions (intestinal 32%, ureteral 9.3%, unilateral or bilateral ovarian endometriomas 24%, uterosacral ligament 33.3%, vagina 26.7%); therefore, should not be considered as an independent form of the disease (Chapron *et al.,* 2010; Fedele *et al.,*

Treatment of bladder endometriosis can be medical therapy with antiestrogenic agents or surgical excision. Medical therapy often results in temporary improvement of the symptoms, but relapse may occur. Most clinicians agree that surgery is the best option and resection should be complete. This can be carried out by laparotomy or laparoscopy depending on the lesion, skill, and experience of the surgeon (Chapron *et al.*, 2010; Fedele *et al.,* 2005b; Le Tohic *et al.,* 2009). Cystoscopic transillumination was used to better define the edges of the lesion and to maximize sparing of unaffected mucosa (Fedele *et al.,* 2005b). During the surgical procedure complete excision of all associated symptomatic posterior DIE lesions are performed (uterosacral resection, colpectomy, intestinal resection).

**8.1 Bladder endometriosis** 

*et al.*, 2010; Le Tohic *et al.*, 2009).

2005b, Le Tohic *et al.,* 2009).

2003).

Transurethral resection is not an optimal treatment because it does not permit complete excision of the disease –the disease originates outside (from the peritoneum) the bladder- (Chapron *et al.,* 2010; Le Tohic *et al.,* 2009), radicality would imply bladder perforation, and the patients have a high recurrence (11.5 %) (Le Tohic *et al.*, 2009). Pang *et al.* (2008) have reported a case treated with combined transurethral and laparoscopic excision followed by laparoscopic bladder reconstruction, taking advantage of both approaches.

Major complications can occur in 2.7% of patients, such as vesico-uterine or vesico-digestive fistula, intravesical or pelvic hematoma (Chapron *et al.,* 2010; Le Tohic *et al.,* 2009). The painful symptoms improved in 100% of the patients (Chapron *et al.*, 2010). The recurrence rate of clinical-instrumental evidence can range between 0% (Chapron *et al.,* 2010) and 10.9% (Fedele *et al.,* 2005b).The factors influencing rate of recurrence is the extent of surgical excision and the vesical base involvement. When the resection include both the vesical lesion and a 0.5-1 cm deep portion of the adjacent myometrium, recurrence is significantly less frequent compared to the removal of the bladder lesion only (0% vs 26%, respectively) (Fedele *et al.*, 2005b).

#### **8.2 Ureteral endometriosis**

Ureteral endometriosis is a rare but serious localization of the disease (<0.3%) (Li *et al*., 2008) because it may cause silent loss for renal function (Abrao *et al.,* 2009; Li *et al.*, 2008; Mereu *et al.,* 2010). Disease is predominantly unilateral, with the left ureter affected more commonly than the right, although bilateral disease does occur (Li *et al.,* 2008). The lesions are localized in the lower third of the ureter (Abrao *et al.,* 2009), and associated with endometriosis elsewhere in the pelvis (Li *et al*., 2008; Mereu *et al.,* 2010). There are two major pathologic types of ureteral endometriosis: intrinsic and extrinsic, occurring, respectively with a 1:4 ratio. In the intrinsic disease, ectopic endometrial tissue infiltrates the muscularis mucosa and the uroepithelium. In the extrinsic disease, the endometrial tissue invades only the ureteral adventitia or surrounding connective tissue. These pathologic types can coexist. Indeed, both entities can lead to ureteral obstruction with subsequent hydroureter and dilatation of the renal pelvis that can be also asymptomatic (Li *et al.,* 2008). Generally, bladder is not affected for endometriosis in the patients with ureteral endometriosis. This observations confirms that, although ureter and bladder are both part of the urinary tract, endometriotic lesions affecting these sites have a different behavior (Abrao *et al.,* 2009).

The patients have symptoms predominantly related to pelvic endometriosis (dysmenorrhea, dyspareunia, chronic pelvic pain [75%-100%]) and lower frequency patients have urologic symptoms such as renal colic or urinary frecuency (3.6%-50%). Because of the absence urologic symptoms (56.5%) and the risk for subsequent loss of renal function (20%), checking the integrity of the urinary tract of patients with endometriosis not only before surgery and after surgery but also during medical therapy is recommended (Li *et al.,* 2008; Mereu *et al.,* 2010). Rectal or vaginal infiltration by the posterior DIE is present in 74% of these patients, and extensiveness of adnexal adhesion are factors related to dysmenorrhea severity (Abrao *et al.*, 2009). The presence of retrocervical and rectum-sigmoid involvement in most patients with ureteral endometriosis suggest that the origin of ureteral endometriosis is extrinsic (Abrao *et al.,* 2009; Mereu *et al.,* 2010).

Abdominopelvic Complications of Endometriosis 77

Hepatic endometriosis is rarely seen. Malignancy must be excluded when endometriosis is discovered in unusual sites like the liver. The majority of patients are symptomatic, generally with epigastric or right upper quadrant abdominal pain. Catamenial epigastric pain is characteristic, although rarely seen. Other possible presentations are malaise, nausea, vomiting, obstructive jaundice, portal vein thrombosis, hepatomegaly (Nezhat *et al.*, 2005; Schuld *et al.*, 2011) and bilioptysis, which is intermittent bile-stained sputum (Schuld *et al.*, 2011). Generally, liver involvement is superficial. The lesion size ranged from 3 to 20 cm. The principal diagnostic method is CT scan or MRI, showing a heterogeneous mass containing septated, thick-walled cystic lesions, implying complex pathophysiology (Veeraswamy *et al.*, 2010). Because of the wide range of possible morphologic features of endometriosis, there are no characteristic imaging findings that can distinguish either pelvic or extrapelvic endometriosis from other processes. Final diagnosis can only be made by pathologic evaluation. The treatment is surgical resection with adequate margins (Nezhat *et al.*, 2005).

Endometriosis involving the pancreas is an extremely rare condition. The patients have pain abdominal in the left upper quadrant and/or abdominal mass. In a woman of childbearing age with intermittent abdominal pain and a cystic lesion in the pancreas on imaging studies, endometriosis must be considered in the differential diagnosis. Partial pancreatectomy and resection of the adjacent viscera affected is the treatment of choice (Tunuguntla *et al.*, 2004).

Involvement of the omentum by endometriosis is not rare. Probably occur by transmission through peritoneal fluid or lymphatics. The commonest clinical features are abdominal distension, dymenorrhoea and brown or bloody ascites. Laparoscopy and biopsy may still be necessary to exclude malignancy. Treatment is by excision of endometriotic nodule

The most common site of endometriosis involving the nervous system has been within nerves in or near the pelvis. Sciatic nerve endometriosis presents as sciatic pain, muscle weakness, sensory deficits, and pelvic pain. Cyclic sciatica related to menses should be considered suggestive of endometriosis. Similarly, endometriosis involving obturator nerve, produces pain and proximal muscle weakness. Theses patients are treated by excision of endometriosis and associated fibrosis surrounding the nerve. Although the direct spread of pelvic endometriosis to and along nerves coursing through the pelvis seems logical, not all

The association of endometriosis with massive bloody ascites is extremely rare and represent a diagnostic dilemma for gynecologists, owing to their rarity and to the fact that

patients have been found to have pelvic disease (Veeraswamy *et al.*, 2010).

**9. Other sites of intra-abdominal endometriosis** 

**9.1 Liver endometriosis** 

**9.2 Pancreatic endometriosis** 

**9.3 Omentum endometriosis** 

**9.4 Nervous system endometriosis** 

**10. Massive ascites and endometriosis** 

and/or ovarian suppression (Naraynsingh *et al.*, 1985).

The diagnostic exams include ureteroscopy with intraluminal ultrasound, computerized tomography, abdominal ultrasound, intravenous pyelography and laparoscopy. Ultrasound as a screening tool to rule out urinary tract obstruction in patients with pelvic endometriosis is routinely used, whereas intravenous pyelography and cystoscopy are used only for patients with urologic symptoms or positive ultrasound for ureteral or bladder involvement. When ureteral involvement and cortical atrophy are revealed, renal function should be checked by kidney scintigraphy (Camanni *et al.,* 2010). Patients with renal compromise may benefit from percutaneous nephrostomy for urinary diversion before definitive surgery. The pelvic spread of the disease and its involvement of the other pelvic organs are evaluated by CT and/or MRI (Li *et al.,* 2008).

The treatment of ureteral endometriosis should be tailored to relieve urinary tract obstruction, eliminate symptoms, preserve renal function, and to avoid disease recurrence and any morbidity associated with radical surgery (Li *et al.,* 2008). Hormonal therapy has been proposed by some authors for the treatment, but others have noted that drugs are unlikely to relieve ureteral obstruction once dense fibrosis has occurred. Hormonal therapy is an appropriate option for patients with normal renal function or minimal obstructions. Surgical treatment remains the gold standard in severe forms of endometriosis: ureterolysis, segmental resection and anastomosis, or ureteroneocystostomy; taking into account that ureteral endometriosis and pelvic disease should be treated at the same time when they coexist (Li *et al.,* 2008). Minimally access procedures are equally effective as the open techniques (Camanni *et al.,* 2010; Mereu *et al.,* 2010). Ureterolysis could be used as the initial surgical step for patients if the extension of ureteral involvement is limited in length and there is no residual ureteral damage or dilatation (Camanni *et al.,* 2010; Mereu *et al.,* 2010). Preoperative endoscopic ureteral double pig-tail stenting may help to prevent delayed ureteral ischemic necrosis related to extensive ureterolysis. In cases of intrinsic ureteral endometriosis, it is necessary to perform a ureteral dissection. When the localization of the stricture is far from the bladder, an uretero-ureterostomy has to be considered. When the ureteral stenosis is reasonably close to the vesicoureteral junction the best choice is the ureteroneocystostomy. In some cases, when the localization of the stricture is halfway or in which resection of a long segment of the ureter is required, ureteroneocystostomy with a psoas bladder hitch must be carried out (Mereu *et al.,* 2010).

Ureterolysis has demonstrated to be effective as the first-line surgical approach in patients with deep endometriosis despite the rate of recurrence reported (0-15.8%) (Camanni *et al.*, 2010; Li *et al.*, 2008; Mereu *et al.*, 2010). Reintervention during hospitalization and follow-up is more frequent in patients undergoing ureterolysis than in those treated with ureteroureterostomy (33% vs 11.7%) (Mereu *et al.*, 2010).

#### **8.3 Renal endometriosis**

Renal endometriosis is a rare condition. Presenting symptoms and signs include flank or back pain, hematuria, hydronephrosis, or a renal mass (Dirim *et al.*, 2009). Additional studies are necessary to help determine its etiology (intravenous pyelography, computerized tomography scan or MRI). Unfortunately, in the absence of a biopsy there is no accurate preoperative method to exclude malignancy, so a majority of patients are treated with nephrectomy (Veeraswamy *et al.*, 2010).
