**3.2.3 Management**

Treatment has several goals including preservation of renal function, management of the original disease process, maintenance of the patient's fertility, and relief of the patient's symptoms.

Medical treatment does not treat the fibrotic component of endometriotic lesions, which is largely responsible for ureteral obstruction so, medical therapy is usually not effective at relieving ureteral obstruction and treatment of ureteral endometriosis with hydronephrosis is surgical.

Patients with mild or intermittent hydronephrosis can be treated initially with a combination of medical therapy and insertion of a ureteral stent. In such cases, close monitoring of renal function is required.

#### **3.2.3.1 Medical treatment**

While medical therapy is effective for pain relief, symptoms often recur once treatment is completed. If renal function is normal and there is minimal to mild hydronephrosis with no

endometriosis is more symptomatic than extrinsic disease. Notably, a significant portion of patients with ureteral endometriosis do not have genitourinary symptoms and as a

Ureteral endometriosis presents with colicky flank pain in approximately 25 percent of patients and gross hematuria in 15 percent, while up to 50 percent of patients are asymptomatic and is generally discovered at the time of laparotomy or laparoscopy for

Ureteral endometriosis should be included in the differential diagnosis of obstructive ureteral lesions in women, particularly those involving the lower third of the left ureter. Because a large percentage of ureteral endometriosis can result in loss of renal function due to asymptomatic obstruction, all patients with pelvic endometriosis should undergo the upper urinary tract imaging. Initial imaging may be ultrasonography as a noninvasive test to look for hydroureteronephrosis.Although, IVU may be a better test in high suspicious cases. Intrinsic disease appears in IVU as ureteral filling defects, whereas extrinsic disease causes smooth strictures. The exact location and volume of the disease can be defined through retrograde ureteropyelography, CT or MRI , which can be valuable for planning

The diagnosis of ureteral endometriosis requires a high index of suspicion and is aided by clinicians' awareness of the condition. The diagnosis of ureteral endometriosis is suggested by the finding of hydronephrosis in a patient with known or suspected endometriosis, particularly if symptoms consistent with ureteral involvement are present but, definite diagnosis can be reached through direct visualization and biopsy of implants. Histologic

The differential diagnosis of ureteral endometriosis includes any conditions that result in

Treatment has several goals including preservation of renal function, management of the original disease process, maintenance of the patient's fertility, and relief of the patient's

Medical treatment does not treat the fibrotic component of endometriotic lesions, which is largely responsible for ureteral obstruction so, medical therapy is usually not effective at relieving ureteral obstruction and treatment of ureteral endometriosis with hydronephrosis

Patients with mild or intermittent hydronephrosis can be treated initially with a combination of medical therapy and insertion of a ureteral stent. In such cases, close

While medical therapy is effective for pain relief, symptoms often recur once treatment is completed. If renal function is normal and there is minimal to mild hydronephrosis with no

confirmation is the gold standard for diagnosis of endometriosis .

hydronephrosis such as stones and malignancies.

monitoring of renal function is required.

**3.2.3.1 Medical treatment** 

consequence, ureteral endometriosis can lead to silent loss of renal function.

evaluation of pelvic pain or other indications.

**3.2.2 Diagnosis** 

treatment.

**3.2.3 Management** 

symptoms.

is surgical.

functional obstruction as determined by radionuclide renal scanning, hormone therapy may be prescribed.

Ureteral endometriosis is rare, and there are few studies of medical therapy. Ovarian hormonal ablation with gonadotropin-releasing hormone agonists has been utilized with success in some series. Hormonal therapy is not as effective for patients with extensive endometriosis.The aromatase inhibitors such as anastrazole and danazol was unsuccessful in relieving ureteral obstruction in few case reports.

#### **3.2.3.2 Surgeries**

The goals of surgical treatment of ureteral endometriosis are to remove the endometriotic lesion(s) and relieve ureteral stricture or kinking. Surgery is indicated if fertility is a major goal, where symptoms fail to respond to medical therapies, or where ureteric obstruction has been confirmed. Untreated ureteric obstruction may lead to irreversible kidney damage.

Surgical intervention is the treatment of choice for most patients with significant hydroureteronephrosis and periureteral disease. Ureterolysis may correct ureteral obstruction in those with extrinsic disease. If laparoscopic ureterolysis is undertaken, a transperitoneal approach is preferable in that it allows a superior assessment of endometrial implants on the peritoneum.

In the case of intrinsic disease, removal of lesions may be difficult because, endometriotic lesions infiltrate the ureteral wall and there may be no apparent margin of them to be resrcted. So, when intrinsic disease is present or in case of ureterolysis failure, distal ureterectomy with reimplantation is preferred.

As a matter of fact, all lesions adjuscent to the ureters to prevent future stenosis and renal damage, since the progression of endometriosis is unpredictable.Thus any lesion found incidentally during surgery proximal to ureters should be removed.

Ureterolysis is performed by most surgeons laparoscopically. A laparoscopic approach may be offered to patients with ureteral stricture disease. Although, ureteroneocystostomy may require laparotomy.

As the first step of the procedure ureterolysis is done. Since the ureter and peritoneum are almost never affected at the level of the pelvic brim, the peritoneum is opened upon the ureter at this site and the ureter is dissected from adjuscent tissues to the level of the cardinal ligament, sharply or bluntly.

If endometriosis invades the ureteral adventitia it may be necessary to cut the adventitial sheath without any manipulation of muscular layer. Any ureteral perforation can be repaired with two interrupted 4-0 polydioxanone sutures.

After ureterolysis is complete, the decision is made regarding whether further intervention is required, based upon visual inspection of the ureter. Then if required, ureteral stent or resection of a diseased segment of ureter must be done to prevent future stenosis and obstruction.

Since most lesions are located in the distal ureter, ureteral resection is usually combined with ureteroneocystostomy. The involved segment of ureter is excised and reimplantation

Urinary Tract Endometriosis 39

Some women with bladder endometriosis are asymptomatic and present with an incidental finding of a bladder nodule on pelvic imaging or as a result of pelvic surgery. Some patients are asymptomatic for the first few years and will only realize that they have the disease

The most common complaint of women that have bladder endometriosis is pain in the abdominal or pelvic area. The degree of pain can be mild to severe or acute to subacute. Usually, this pain will be more intense during monthly period. Many women suffer from endometriosis silently because they feel that the pain is just the normal pain of premenstrual syndrome. However, if the premenstrual pain in a woman hampers her normal activities

Women with bladder endometriosis also experience various urinary problems. It is common to feel a burning sensation during voiding. Since the cause of your urinary problems is endometrium cells in the bladder wall, antibiotics will not cure or alleviate the symptoms.

The gold standard for diagnosis of bladder endometriosis is biopsy and histologic

Symptoms compatible with bladder endometriosis, specially togetherwith known endometriosis at other sites or characteristic symptoms such as pelvic pain, dysmenorrhea, dyspareunia and infertility, and finding of a bladder nodule on ultrasound suggest vesical

The differential diagnosis of bladder endometriosis includes urinary tract infection, interstitial cystitis, and a bladder stone or neoplasm. So, proper tests and examinations must be done based on patient's clinical presentation to rule out these conditions. In more than 70% of cases the presenting symptoms of bladder endometriosis are identical to those of interstitial cystitis. Therefore, endometriosis should always be considered in the patient

Pelvic and renal sonography may show a bladder nodule or hydronephrosis, although, endometriosis is often not visualized on imaging studies. Endometriosis itself and its surgical treatments are capable of VVF formation. Nevertheless, endometriosis of the bladder must be differentiated from VVF because both of them may present with cyclic

In the case of a bladder nodule, cystoscopy and biopsy is performed to rule out malignancy and confirm diagnosis. The distance of the lesion from the ureteral openings is important since, removal of the lesions adjuscent to ureteral orifices may requires ureteral surgery, as well. Magnetic resonance imaging may be useful to detect Lesions that are not visible with cystoscopy. If there is hydronephrosis , radiologic evaluation of the same ureter is required.

Bladder endometriosis, if left unmanaged, may lead to more severe urinary problems in the future such as urinary obstruction or incontinence. However, treatment of vesical endometriosis is indicated only if there is any symptoms or resulted in hydronephrosis. First

when it is already in its serious stage, manifesting more severe symptoms.

confirmation of visualized lesions during cystoscopy or laparoscopy.

referred for frequency, urgency and pain with no documented infection.

she is suspected to has endometriosis.

endometriosis and further evaluation is needed.

**4.2.2 Diagnosis** 

hematuria.

**4.2.3 Management** 

into the bladder is performed. When the endometriotic lesion is in the middle or upper third of the ureter, end ureteroureterostomy should be done after resection of lesions.

Whether to proceed with resection of an endometriotic segment of the ureter or aggressive ureterolysis and stenting is a subjective decision based upon intraoperative visual with no definite criteria to predict normal postoperative ureteral function. In presence of stenosis and significant hydronephrosis, most surgeons have found that the risk of recurrence is lower after ureteral resection and ureteroneocystostomy rather than aggressive ureterolysis and stent insertion. In the case of surface ovarian endometriotic lesions or an endometrioma ipsilateral oophorectomy should be performed as needed. Bilateral oophorectomy is performed in some women to prevent recurrence of endometriosis.

In the cases incidentally discovered at time of laparoscopy or laparotomy, if ureteral adhesions are present, ureterolysis should be performed.

Complications of these surgeries include general complications the same as other abdominal laparoscopy or laparotomy and specific complications to this procedure such as ureteral fistula.

The rates of recurrence for each type of surgical procedures are included in Table.3. Complications are few and most common of them is ureteral fistula. Ureterolysis alone is associated with higher rates of both recurrence and complications compared with ureteroneocystostomy and Ureteroureteral anastomosis


Table 3. The rates of recurrence for each type of surgical procedures for ureteral endometriosis.
