4. Clinical and imaging work-up

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 complete loss of renal function in one or both kidneys.

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).

Figure 2. Endometriosis infiltrating the left ureter (green arrow) generating ureterohydronephrosis.

In cases in which impaired renal function is known or suspected, static and dynamic renal scintigraphy should be ordered, and endoscopic investigation (ureteroscopy) contemplated to inform surgical planning.

6.1 Laparoscopic tools and materials used

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

New Paradigms in Endometriosis Surgery of the Distal Ureter

tioning of the catheters.

6.2 Positioning the patient

6.3 Surgical approach: Access

left (Figure 4-B).

Figure 4.

ureter (B).

79

The basic laparoscopic surgical tools required include non-traumatic grasping forceps, Maryland forceps, laparoscopic scissors, laparoscopic needle holders and contra-need holders, as well as an articulating Hook with monopolar cautery. No special clamps are required for this procedure. Bipolar or ultrasonic clamps when available will help with the dissection and hemostasis, reducing surgical time. Contemplating the possibility of a joint intervention – laparoscopy and cystoscopy/ureteroscopy – a cystoscope, ureteroscope, hydrophilic guidewire, and ureteral catheter should be available. If there is more intense manipulation or

segmental resection of the ureter, double J catheter placement will be necessary, in order to ensure a patent ureter and adequate healing. It is worth mentioning that inoperative dynamic C-arm fluoroscopy should be available to verify proper posi-

How the patient is positioned for surgery will depend on the site of ureteral involvement. For the more common case of distal involvement, the patient should be placed in the Lloyd Davies and Trendelenburg position, lying directly on a nonadherent eggcrate foam pad. The legs should be wrapped in pneumatic stockings and secured to boot-like leggings, avoiding continuous compression of the calves.

The first puncture is performed in the umbilical scar where a 10 mm trocar is placed to introduce the optic (Figure 4–black circle) and the patient is kept in dorsal decubitus. After exploration of the cavity, the patient is placed in

Trendelenburg (Lloyd Davies) position and the surgeon inserts two 5 mm trocars (Figure 4–blue circles) and a fourth trocar for the first assistant. The second assistant stands between the patient's legs to manipulate the uterus after placement of the uterine manipulator (Figure 4–second assistant). With the surgical team members in these positions it is possible to perform ureterolysis, uretero-ureteral anastomosis and ureterovesical reimplantations on the right (Figure 4-A) or on the

Trocar sites. Position of surgeons for access to the right distal ureter (A) and for access to the left distal

Preoperative cystoscopy to evaluate bladder endometriosis is necessary especially when a non-invasive imaging method (MRI or ultrasonography) identifies lesions which are suspicious for endometriosis in the compartment anterior to the uterus. In the cases of lesions infiltrating the bladder mucosa, it is important to determine the exact location(s), their size and their distance from the two ureteral ostia, as well as any projection into the ureter intramurally.

Such findings could help determine which surgical approach should be used; options range from simple ureterolysis to ureterectomy with uretero-ureteral anastomosis or a ureterovesical reimplantation. Concomitant cystoscopy with vaginal palpation is important to assess disease or areas of adhesions localized in the vesicouterine septum that may suggest the need for partial cystectomy or suturereinforced bladder shaving (Figure 3).

Figure 3.

Endometriosis infiltrating the bladder trigone and right ureteral ostium as visualized during cystoscopy.
