**9.1 Liver endometriosis**

76 Endometriosis - Basic Concepts and Current Research Trends

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

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

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

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

CT and/or MRI (Li *et al.,* 2008).

psoas bladder hitch must be carried out (Mereu *et al.,* 2010).

ureteroureterostomy (33% vs 11.7%) (Mereu *et al.*, 2010).

treated with nephrectomy (Veeraswamy *et al.*, 2010).

**8.3 Renal endometriosis** 

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).

### **9.2 Pancreatic endometriosis**

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).

#### **9.3 Omentum endometriosis**

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

#### **9.4 Nervous system endometriosis**

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

#### **10. Massive ascites and endometriosis**

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

Abdominopelvic Complications of Endometriosis 79

At laparotomy, a substantial amount of hemoperitoneum is found (range: 500 to 4000 mL). The bleeding is not arterial but arise from superficial veins or varicosities on the posterior surface of the uterus or parametria. Treatment of bleeding is variable: thermal coagulation, hemostatic sutures or clips, or hysterectomy after caesarean section (Brossens

Since endometriosis may cause infertility, and assisted reproduction technology is increasingly used to enable patients to conceive, it is likely that there will be more cases with

Malignant transformation is an infrequent complication of endometriosis and has been reported in 0.7-1% of patients and 62%-78.7% of the cases occur in the ovary, whereas extragonadal sites represent 21.3%-38% of tumors. The rectovaginal septum, rectosigmoid colon, vagina, and pelvic peritoneum represented the majority of extragonadal sites. Other locations include: bowel, umbilicus, lymph node, urinary tract, pleura, diaphragm, lung, etc (Slavin *et al.*, 2000; Van Gorp *et al.*, 2004; Yantiss *et al.*, 2001). Two possible explanations for the relation-ship between endometriosis and intraperitoneal cancer have been proposed: (i) endometriotic implants undergo malignant transformation secondary to genetic defects (p53 mutations) (Akahane *et al.*, 2007) that also serve to enable the endometriosis to thrive, or (ii) women with endometriosis have a defect in their immune system that enables the endometriosis to flourish, and this baseline defect leaves them more susceptible to subsequent malignant transformation (Modesitt *et al.*, 2002). It has been seen a direct transition from clearly benign epithelium through atypical endometriosis to carcinoma. This association suggest that atypical endometriosis can act as a precancerous lesion, as seen in

Among malignancies arising from endometriosis of the ovaries, endometrioid adenocarcinoma is the most common histologic type (23%-69.1%), followed by clear-cell carcinomas (13.5%-23%), sarcomas (11.6%), and rare cell types (6%) (Modesitt *et al.*, 2002). Extragonadal lesions are mostly endometrioid tumors (66%) and sarcomas (25%); clear cell histology is seen in only 4.5% of extragonadal malignancies. Tumors arising in endometriosis are predominantly low grade and confined to the site of origin (Slavin *et al.*, 2000; Van Gorp *et al.*, 2004). The histopathological criteria to classify a malignancy as arising from endometriosis include the demonstration of cancer arising in the tissue and not invading it from another source, and the presence of tissue resembling endometrial stroma

The risk factors for malignant transformation in endometriosis are poorly defined. An association has been noted between unopposed estrogen therapy and the development of endometrioid or clear cell epithelial ovarian tumors (Modesitt *et al.*, 2002). Increasing parity, and hormonal contraceptive use for ≥ 5 years, decreases the risks of both subtypes. Breast feeding and tubal ligation are inversely associated, but significantly so only for the endometrioid tumor (Nagle *et al.*, 2008; Van Gorp *et al.*, 2004). Obesity is associated only with clear cell cancers, with a two-fold increased risk. Also a significant trend of decreasing risk with increasing intensity (not duration) of smoking and education beyond high school

unprovoked hemoperitoneum in the near future (Grunewald & Jördens, 2010).

atypical hyperplasia of the endometrium (Van Gorp *et al.*, 2004).

surrounding the epithelial glands (Slavin *et al.*, 2000).

2009).

**12. Malignancy** 

theses cases mimic malignant ovarian neoplasms. In these cases the endometriosis involves mainly the peritoneum, with multiple adhesions and ovarian endometriomas. Ascites is detected in large volumes (4254 mL on average) and is bloody or brown (Sait, 2008).

Ectopic endometrial tissue is influenced by hormonal levels of the uterine cycle, so it flakes off with the drop of the hormonal peak as normal endometrium. This mechanism causes an inflammatory reaction in the site of interest and possible ascites in the case of peritoneal endometriosis. The rapid production of fluid by inflamed tissue and the obstruction of subdiaphragmatic lymph vessels, which impair its reabsorption, may be responsible for the large volumes detected (Zeppa *et al.*, 2004).

Fine-needle cytology has been successfully used to diagnose endometriosis by demonstrating the presence of epithelial and stromal cells in the smears, but usually their cytological features are not specific enough to allow a definite cytological diagnosis of endometriosis, nor to exclude even a neoplastic process (Zeppa *et al.*, 2004). Endometriosisassociated ascites is commonly mistaken for ascites caused by ovarian neoplasms, especially when associated with an elevated CA-125 level (Sait, 2008), and laparoscopy and microscopic examination of tissue are generally required for diagnosis. Nonetheless, the cytological diagnosis of endometriosis in effusions, avoid more invasive diagnostic procedures (Zeppa *et al.*, 2004).

Although there is no established treatment is usually performed conservative surgical resection and suppression of ovulation with a GnRH agonist (Sait, 2008).
