Surgical approach to urinary endometriosis: experience on 28 cases.

OBJECTIVES: Endometriosis (e.) involving the urinary tract must be regarded as a rare condition with specific surgical implications. Our experience on the treatment of 28 patients is presented. PATIENTS AND METHODS: Twenty-eight patients with a urological e. (bladder 11 patients, ureter 14, both bladder and ureter 3) were observed and treated between 1995 and 2005. Thirteen patients (46%) had been previously surgically treated for pelvic e. at a mean distance of 22 months before. All the patients with bladder e. presented with typical symptoms related to menses and the urinary location was isolated in 42.8%. Differently, the patients having ureteral involvement complained often a vague or silent symptomatology, but they always showed some extra-urinary pelvic locations. Among the cases with bladder e., 2 patients underwent TUR and hormonal therapy and 12 partial cystectomy. The patients with ureteral e. were submitted to ureterolysis in 5 cases, segmentary ureterectomy and uretero-ureteroanastomosis in 2 and terminal ureterectomy and ureterocystoneostomy in 8. Two more cases with ureteral e. were nephrectomized due to end-stage renal atrophy. RESULTS: At a mean distance of 58 months (9-110 months) from surgery, 22 patients have a unremarkable follow-up. On the other hand, an urological relapse was evidenced in 5 cases previously submitted to TUR (2 cases), ureterolysis (2 cases) or segmentary ureterectomy and termino-terminal ureteral anastomosis (1 case). The relapsing e. was treated by partial cystectomy or terminal ureterectomy with ureterocystoneostomy, with good results over time. CONCLUSION: Urinary tract is rarely involved by e., but this condition has peculiar clinical and surgical implications. Being TUR ineffective, the therapy of choice of bladder e. is partial cystectomy, possibly via a laparoscopic approach. Differently from bladder e., the preoperative diagnosis of ureteral e. is surely hard. So, a high index of suspect should be regarded in each young female patient with a ureteral stricture and a study of the upper urinary tract (US and/or urography) should be performed in all the patients with pelvic e. Ureterolysis can be successful only in a minority of the cases showing a very limited disease not determining any urinary flow obstructions. In all the other cases the procedure of choice is terminal ureterectomy and ureterocystoneostomy without employing the distal ureter.

Clinical aspects and surgical treatment of urinary tract endometriosis: our experience with 31 cases.

OBJECTIVES: To present and discuss clinical and surgical management of urologic endometriosis. METHODS: Retrospective review of a database on surgical patients with endometriosis. RESULTS: Thirty-one patients (incidence, 2.6%; mean age, 33.1 yr) were affected by urologic endometriosis (bladder, 12; ureter, 15; both, 4). Bladder endometriosis was revealed by symptoms related to menses and showed a typical endoscopic picture, whereas ureteral involvement had a nonspecific or silent symptomatology. All patients affected by bladder endometriosis and undergoing transurethral resection (2 cases) developed a bladder recurrence; a ureteral recurrence was observed in two of six patients submitted to laparoscopic ureterolysis and in one of two patients submitted to ureterectomy with ureteroureterostomy. Conversely, no relapses were observed among the 14 patients who had partial cystectomy or the 9 who had ureterectomy and ureterocystoneostomy. Finally, two patients underwent nephrectomy due to end-stage renal atrophy. CONCLUSIONS: Cystoscopy is advisable in women with pelvic endometriosis with lower urinary tract symptoms; the upper urinary tract should be evaluated in all patients with pelvic endometriosis to exclude asymptomatic ureteral involvement. Partial cystectomy gives the best results when used to treat bladder endometriosis. Ureterolysis can be successful only in case of limited ureteral involvement with no urinary obstruction, whereas terminal ureterectomy and ureterocystoneostomy should be preferred in case of obstructive ureteral endometriosis.