**3.2 Ureteral endometriosis**

Endometriosis of the urinary tract is predominantly found in the bladder, accounting for 70% to 80% of the cases. The ureter may be involved in 15% to 20% of the urinary tract cases. Bilateral disease has been reported in up to 23% of cases. The left side is more often affected, which may be because the sigmoid colon prevents the regurgitated endometrial cells to be cleared by the peritoneal fluid on the left side.

Ureteral involvement may be either intrinsic or extrinsic. If endometrial glands and stroma are within the lamina propria, tunica muscularis, or ureteral lumen it is said Intrinsic endometriosis and if they are localized within periureteral tissue extrinsic endometriosis ensues. Eighty percent of ureteral endometriosis is extrinsic and most commonly involves the distal ureter. Differentiation between these two forms of ureteral endometriosis has histologic and pathogenetic importance, but has little impact on clinical management since the precise location of the lesion cannot be determined preoperatively. Moreover, both intrinsic and extrinsic forms of the disease may result in ureteral stenosis.

Silent loss of renal function has been reported in 25% to 43% of patients with ureteral endometriosis, which may result in total loss of function of the affected kidney. Historically, up to one third of kidneys affected by ureteral endometriosis were lost. So, *it has been* recommended to take image of the upper urinary tract in all patients with pelvic endometriosis with ultrasonography or IVU.

Gynecologic laparoscopy for treatment of endometriosis is responsible for a large percentage of ureteral injuries. The reasons for this may be as follows: (1) endometrioma can involve the ureter either extrinsically or intrinsically; (2 adhesions from endometriosis makes ureteral visualization difficult; and (3) the disease can deviate the ureters medially resulting in abnormal anatomy.

In addition, the most commonly affected portions of the ureter are the distal third, followed by the middle third. Involvement of the proximal ureter is rare. Thus, the most frequent sites of ureteral endometriosis are below the level of tubal efflux. The lesions of the distal ureter usually coexist with posterior pouch endometriosis, as the lesions of the middle third of the ureter may be together with involvement of the ovary.

#### **3.2.1 Clinical manifestations**

Classic symptoms and signs of urinary tract endometriosis include cyclical flank pain, dysuria, urgency, urinary tract infection, and hematuria. As a rule, we can say that intrinsic

Urinary Tract Endometriosis 37

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

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

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

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

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

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

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

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

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

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

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

be prescribed.

**3.2.3.2 Surgeries** 

implants on the peritoneum.

require laparotomy.

obstruction.

cardinal ligament, sharply or bluntly.

ureterectomy with reimplantation is preferred.

incidentally during surgery proximal to ureters should be removed.

repaired with two interrupted 4-0 polydioxanone sutures.

damage.

in relieving ureteral obstruction in few case reports.

endometriosis is more symptomatic than extrinsic disease. Notably, a significant portion of patients with ureteral endometriosis do not have genitourinary symptoms and as a consequence, ureteral endometriosis can lead to silent loss of renal function.

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 evaluation of pelvic pain or other indications.
