Endoscopic Diagnosis and Management of Ureteral Endometriosis

Abstract

It is estimated that 1% of patients with endometriosis have involvement of the urinary tract, with the bladder being the most common location. Ureteral endometriosis is a rare entity, and the majority of cases are found at exploratory laparotomy for extensive involvement of the pelvic organs. Obstruction of the ureter may be caused by extrinsic or intrinsic disease, with the extrinsic form occurring four times as often. Progressive ureteral obstruction can be insidious in onset and ultimately lead to renal failure. Hormone therapy has had variable success, and open surgery has been the mainstay of treatment. Only one case of ureteral endometriosis, both intrinsic and extrinsic, diagnosed at ureteroscopy has been reported previously. We present a case of ureteral obstruction secondary to isolated intrinsic endometriosis diagnosed at ureteroscopy and treated endoscopically with holmium laser ablation and leuprolide therapy.

Intrinsic ureteral endometriosis as a cause of unilateral obstructive uropathy

“…7 For more significant disease, medical management with GnRH analogues or oral contraceptives may play a role, although hormone therapy is typically only indicated for early-stage disease. 6,7,9 In approximately 25-43% of cases, ureteral endometriosis can result in ureteral obstructions, which may lead to a loss of kidney function. 9 In such cases, as well as cases in which patients experience intractable symptoms, surgical intervention may be required.…”

“…6,7,9 In approximately 25-43% of cases, ureteral endometriosis can result in ureteral obstructions, which may lead to a loss of kidney function. 9 In such cases, as well as cases in which patients experience intractable symptoms, surgical intervention may be required. 2,3,6,7,9 Up to 47% of patients may require a nephrectomy for either loss of kidney function, or ureteral endometriosis lesions that mimic neoplsms, most notably transitional cell carcinoma.…”

“…9 In such cases, as well as cases in which patients experience intractable symptoms, surgical intervention may be required. 2,3,6,7,9 Up to 47% of patients may require a nephrectomy for either loss of kidney function, or ureteral endometriosis lesions that mimic neoplsms, most notably transitional cell carcinoma. 6 Several treatment strategies have been reported, but the choice between ureterolysis or a major urological procedure (ureterectomy, ureteroneocystotomy, or nephroureterectomy) is an area of uncertainty.…”

“…7 Intrinsic ureteral endometriosis is defined by the presence of endometrial tissue in the lamina propria or tunica muscularis of the ureter, while extrinsic ureteral endometriosis involves the peri-ureteral tissue. 3,6,8,9 Interestingly, it is appears to be an asymmetric disease, with more frequent involvement of the left ureter. 2,3,6,10 Several challenges arise in diagnosing ureteral endometriosis preoperatively.…”

Ureteral Endometriosis: A Rare and Underdiagnosed Cause of Kidney Dysfunction

“…When within the bladder, the lesion is usually situated in the posterior wall or at the dome; more rarely endometrial lesions involve the vesical base being proximal to ureteral hiatus. Ureteral endometriosis is classified as intrinsic and extrinsic with a 1:4 ratio and the ureter is usually involved below the pelvis brim [5,6]. …”