1. Introduction

Endometriosis involving the urinary tract is rare, affecting only 1–2% of women with endometriosis. The vast majority of these cases – 80–85% involve the bladder. Ureteral endometriosis occurs in just 15% of cases. Ureteral involvement usually occurs near its insertion in the bladder, just above the ureterovesical junction (UVJ), near where it crosses the uterine artery [1–6]. We believe that this prevalence is underestimated due to the scarce data in the literature and the lack of standardization of the surgical technique around the world in different countries. Based on our practical experience, we believe that extrinsic ureter involvement is

more prevalent than the data in the literature would suggest, and may exceed 30% of all surgeries for multicompartmental deep endometriosis, especially when there is intestinal (rectal/sigmoid) infiltration and/or parametrical infiltration. Thus, knowledge of ureteral endometriosis and its management are of fundamental importance for surgeons who propose to perform comprehensive treatment of the various presentations of endometriosis.

point, great care must be taken in its identification, as iatrogenic injuries of the

gonadal, aorta and common iliac arteries. More distally in its pelvic segment the ureter is supplied by the internal iliac, superior vesicle, uterine, medial rectal arteries, vaginal, and inferior vesicle arteries (Figure 1). As they approach the ureter, the arterial branches travel along a longitudinal pathway within the adventitia (ureteral sheath), forming anastomotic bundles. In this way the surgical dissection of the ureter should strive to preserve the adventitia in order to avoid ischemia.

Endometriosis can infiltrate the ureter intrinsically or extrinsically. When extrinsic – 80–90% of such cases – the endometriosis infiltrates the adventitia and/ or submucosa. When intrinsic (the remainder of cases), the disease infiltrates the

A thorough history and physical examination are essential in order to recognize or suspect urological impairment secondary to endometriosis. The patient may be asymptomatic or experience cyclical renal colic and hematuria during the menstrual period. In intrinsic cases the endometriosis may progress to obstruct the lumen of the ureter, whereas in extrinsic cases there can be circumferential or annular (extrinsic) compression. Both are capable of insidiously causing partial and even

Assessment using imaging studies is indispensable for surgical planning. Not all anatomical sites are accessible to ultrasound. Magnetic resonance imaging can identify and assess hemorrhagic components of endometriomas throughout the pelvis, and thus is the preferred imaging method to assess ureteral involvement (Figure 2).

mucosa and submucosa and may present as ureteral stenosis [5, 7].

The ureter is irrigated by multiple arteries along its course, starting with the renal,

ureter may occur during pelvic surgeries.

DOI: http://dx.doi.org/10.5772/intechopen.81788

New Paradigms in Endometriosis Surgery of the Distal Ureter

3. Classification: extrinsic versus intrinsic

complete loss of renal function in one or both kidneys.

Endometriosis infiltrating the left ureter (green arrow) generating ureterohydronephrosis.

4. Clinical and imaging work-up

Figure 2.

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