6.4 Surgical approach–ureterolysis, ureterectomy and end-to-end anastomosis or ureteral replantation

In endometriosis that involves the ureter, we may encounter ureteral involvement due to fibrosis without extrinsic muscle/muscular infiltration or intrinsic endometriosis infiltrating the muscular layer and/or mucosa. It is only after ureterolysis of the entire affected section of the ureter and segments proximal and distal portions to the disease that the surgical approach can be assessed/determined (Figure 5) and (Figures 10–12). It is always important to perform a ureteroscopy (Figures 6 and 13) to evaluate the internal aspect/lumen of this ureter and if necessary to perform a frozen biopsy to confirm or rule out the possibility of intrinsic endometriosis.

With extrinsic disease – the majority of cases – with careful ureterolysis using "cold" scissors all disease can be removed without the need to resect any segment of the ureter (Figures 7 and 8). After a laborious ureterolysis, it is recommended that the narrowed segment be dilated using a ureteral balloon catheter dilator (Figure 9) endoscopically either by cystoscopy or ureteroscopy, with placement of a double J catheter for 30–60 days.

#### Figure 5.

Ureterolysis with identification of segments proximal and distal to the endometriosis.

#### Figure 6.

Laparoscopic and ureteroscopic views of the ureteral segment with extrinsic endometriosis.

When ureteroscopy reveals intrinsic endometriosis (Figure 13), (typically 3–4 cm from the UVJ) ureterectomy of the involved segment is necessary (Figures 10–16) subject to consideration of the best surgical technique [10]. In those cases where the distal ureter stump (close to the UVJ) is greater than 1 cm, one can elect to perform an end-to-end ureteroureterostomy (Figure 17), another ureteroscopy after the anastomosis (Figure 18), with

Ligature of the uterine artery to access the distal ureter and identification of the uretero-vesical junction (UVJ).

Left parametric endometriosis involving the ureter at the intersection of the uterine artery.

Dilatation of the stented segment using a balloon catheter (laparoscopic view) and posterior placement of the

placement of a double J catheter [11, 12].

Figure 8.

Figure 9.

Figure 10.

Figure 11.

81

double J catheter.

Dissection of the ureter with freeing of the extrinsic endometriosis.

New Paradigms in Endometriosis Surgery of the Distal Ureter

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

#### Figure 7. Dissection of the ureter using scissors (without energy) - initiation of the freeing of the extrinsic endometriosis.

New Paradigms in Endometriosis Surgery of the Distal Ureter DOI: http://dx.doi.org/10.5772/intechopen.81788

#### Figure 8.

6.4 Surgical approach–ureterolysis, ureterectomy and end-to-end anastomosis

In endometriosis that involves the ureter, we may encounter ureteral involvement due to fibrosis without extrinsic muscle/muscular infiltration or intrinsic endometriosis infiltrating the muscular layer and/or mucosa. It is only after ureterolysis of the entire affected section of the ureter and segments proximal and distal portions to the disease that the surgical approach can be assessed/determined (Figure 5) and (Figures 10–12). It is always important to perform a ureteroscopy (Figures 6 and 13) to evaluate the internal aspect/lumen of this ureter and if necessary to perform a frozen biopsy to confirm or rule out the possibility of

With extrinsic disease – the majority of cases – with careful ureterolysis using "cold" scissors all disease can be removed without the need to resect any segment of the ureter (Figures 7 and 8). After a laborious ureterolysis, it is recommended that the narrowed segment be dilated using a ureteral balloon catheter dilator (Figure 9) endoscopically either by cystoscopy or ureteroscopy, with placement of a double J

Ureterolysis with identification of segments proximal and distal to the endometriosis.

Laparoscopic and ureteroscopic views of the ureteral segment with extrinsic endometriosis.

Dissection of the ureter using scissors (without energy) - initiation of the freeing of the extrinsic endometriosis.

or ureteral replantation

Recent Advances in Laparoscopic Surgery

intrinsic endometriosis.

catheter for 30–60 days.

Figure 5.

Figure 6.

Figure 7.

80

Dissection of the ureter with freeing of the extrinsic endometriosis.

#### Figure 9.

Dilatation of the stented segment using a balloon catheter (laparoscopic view) and posterior placement of the double J catheter.

#### Figure 10.

Left parametric endometriosis involving the ureter at the intersection of the uterine artery.

#### Figure 11.

Ligature of the uterine artery to access the distal ureter and identification of the uretero-vesical junction (UVJ).

When ureteroscopy reveals intrinsic endometriosis (Figure 13), (typically 3–4 cm from the UVJ) ureterectomy of the involved segment is necessary (Figures 10–16) subject to consideration of the best surgical technique [10]. In those cases where the distal ureter stump (close to the UVJ) is greater than 1 cm, one can elect to perform an end-to-end ureteroureterostomy (Figure 17), another ureteroscopy after the anastomosis (Figure 18), with placement of a double J catheter [11, 12].

#### Figure 12.

Ureterolysis with identification of segments proximal and distal to the endometriosis.

Figure 16.

Figure 17.

Figure 18.

Figure 19.

83

Ureteroscopy of the suture line of the uretero-ureteral anastomosis.

Dissection of the detrusor muscles and confection of the mucosal blister.

Uretero-ureteral anastomosis.

Section and removal of the segment with endometriosis on the ureteral guidewire.

New Paradigms in Endometriosis Surgery of the Distal Ureter

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

#### Figure 13.

Ureteroscopy with identification of the intrinsic lesion and obstruction to the passage of the ureteroscope.

#### Figure 14.

Proximal ureterectomy. Section with spatulation of the ureter proximal to the lesion.

#### Figure 15.

Distal ureterectomy. Section with spreading of the ureter distal to the lesion and separation of the segment with endometriosis.

In cases in which the distal ureteral stump is very small (less than 1 cm) or the endometriotic lesion infiltrates the ureter intramurally and the bladder (via the ureteral ostium), a uretero-vesical reimplantation is required [13, 14] (Figures 19–26).

New Paradigms in Endometriosis Surgery of the Distal Ureter DOI: http://dx.doi.org/10.5772/intechopen.81788

Figure 16. Section and removal of the segment with endometriosis on the ureteral guidewire.

Figure 17. Uretero-ureteral anastomosis.

Figure 18. Ureteroscopy of the suture line of the uretero-ureteral anastomosis.

Figure 19. Dissection of the detrusor muscles and confection of the mucosal blister.

In cases in which the distal ureteral stump is very small (less than 1 cm) or the endometriotic lesion infiltrates the ureter intramurally and the bladder (via the ureteral ostium), a uretero-vesical reimplantation is required [13, 14] (Figures 19–26).

Distal ureterectomy. Section with spreading of the ureter distal to the lesion and separation of the segment with

Proximal ureterectomy. Section with spatulation of the ureter proximal to the lesion.

Ureterolysis with identification of segments proximal and distal to the endometriosis.

Ureteroscopy with identification of the intrinsic lesion and obstruction to the passage of the ureteroscope.

Figure 14.

Figure 12.

Recent Advances in Laparoscopic Surgery

Figure 13.

Figure 15.

82

endometriosis.

Figure 20. Spatulation of the ureter to be implanted.

Figure 21. Starting the anastomosis: Suture in the ureter.

Figure 22. Opening the bladder mucosa.

7. Post-operative care

Figure 24.

Figure 25.

Figure 26.

85

reflux tunnel).

Placement of the double "J" catheter.

New Paradigms in Endometriosis Surgery of the Distal Ureter

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

End of uretero-vesical anastomosis.

after the procedure [15].

As with all transperitoneal surgery, a period of adynamic ileus should be respected after the procedure. The progression of the diet should be individualized, but typically requires less than 8 hours. Early ambulation is essential in this context, and it also helps to minimize thromboembolic events. Early administration of enoxaparin (starting 12 hours after the end of surgery) is indicated unless there are contraindications. Antibiotic prophylaxis should be restricted to the intraoperative period and certainly should not be initiated more than 24 hours

Reinforcement suture of the detrusor muscles on the uretero-vesical anastomosis and on the distal ureter (anti-

Figure 23. First suture of the bladder anastomosis.

New Paradigms in Endometriosis Surgery of the Distal Ureter DOI: http://dx.doi.org/10.5772/intechopen.81788

Figure 24. Placement of the double "J" catheter.

Figure 20.

Figure 21.

Figure 22.

Figure 23.

84

First suture of the bladder anastomosis.

Opening the bladder mucosa.

Spatulation of the ureter to be implanted.

Recent Advances in Laparoscopic Surgery

Starting the anastomosis: Suture in the ureter.

Figure 25. End of uretero-vesical anastomosis.

Figure 26. Reinforcement suture of the detrusor muscles on the uretero-vesical anastomosis and on the distal ureter (antireflux tunnel).
