Üriner semptomlarla ortaya çıkan pelvik endometriyozis: olgu sunumu

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Introduction
The presence of active endometrial tissue outside
the uterine cavity is defined as endometriosis. It is
the second most common pelvic pathology in females with an incidence of approximately 15% (1-3).
Genitourinary tract involvement has been reported
to have an incidence of 1.2%, with the peak age of incidence being between 40 and 44 years. Ureteral involvement accounts for only a small minority of cases (0.1–0.4%), and can be regarded as a rare occurrence. Although ureteral obstruction is a rare complication of endometriosis, early diagnosis and treatment of urinary tract endometriosis is necessary to
avoid loss of renal function (4). We herein present
the diagnosis and treatment of an ureteral endometriosis causing ureterohydronephrosis and deterioration of renal function.
Case Report
A 27-year-old nulligravid female presented to our clinic with left flank pain, fever and weakness. Her physical examination did not reveal any pathology except
for left costovertebral tenderness. Serum urea and creatinin levels were 34 mg/dl and 1.32 mg/dl, respectively. White blood cell (WBC) was 27000/ml and urine analysis revealed pyuria. In kidney ureter bladder
(KUB) X-ray, a 0.5 cm of opacity localized to her left
side of pelvis was noticed. She was hospitalized and
antibiotherapy was started. Her abdominal ultrasound
scan revealed a significant left ureterohydronephrosis
and the left ovary was 4x4x2.5 cm with parenchymal
heterogeneity, hence a gynecological consultation was
requested. Her gynecologic examination was normal.
Carcinoembriogenic antigen CA19-9 and CA15-3 levels were 194.3 U/ml (normal range 0-39 U/ml) and
60.1 U/ml (normal range 0-25 U/ml), respectively. A
thoracoabdominopelvic noncontrast computerized
tomography (CT) was planned due to high levels of serum creatinin. A thorax and abdomino-pelvic CT re-
* Department of Urology, Gülhane Military Medical Faculty Haydarpasa
Training Hospital
** Department of Obstetrics and Gynecology, Gülhane Military Medical Faculty
Haydarpasa Training Hospital
Reprint request: Dr. Ferhat Ateş, Department of Urology, Gulhane Military
Medical Faculty Haydarpasa Training Hospital, Üsküdar-34668, İstanbul
E-mail: drferhatates@yahoo.com
Date submitted: January 14, 2010 • Date accepted: September 02, 2010
SUMMARY
Ureteral obstruction secondary to endometriosis is a relatively rare condition. We present a case of incipient pelvic endometriosis presenting with
urinary symptoms. A 27-year-old, nulligravid female patient admitted to our
clinic with symptoms suggesting pyelonephritis. Radiological studies did
not reveal urolithiasis. However, computerized tomography and magnetic
resonance imaging demonstrated adnexial mass and left ureterohydronephrosis, thus leading to open surgery. During surgical exploration bicornuate
uterus, myoma and a periureteral fibrotic mass were excised and end-toend ureteral anastomosis was performed. Interestingly, the histopathological diagnosis of the periureteral fibrous tissue was endometriosis. Fast recovery was observed in the functions of impaired left kidney during early
postoperative follow-up. During their daily practices urologists should be
aware of ureteral stricture due to endometriosis especially in premenopausal women with dilated collective system. Kidney protective approaches
should be the initial choice while managing ureteral endometriosis in women in child bearing age.
Key words: Endometriosis, surgical treatment, urinary obstruction
ÖZET
Üriner semptomlarla ortaya çıkan pelvik endometriyozis: olgu sunumu
Endometriyozis nedeniyle ortaya çıkan üreter tıkanıklığı nispeten nadir bir
durumdur. Biz üriner semptomlarla ortaya çıkan yanıltıcı bir endometriyozis olgusunu sunuyoruz. Yirmi yedi yaşında hiç doğum yapmamış bir bayan
hasta, kliniğimize piyelonefrit tanısını düşündüren belirtilerle başvurdu. Radyolojik incelemede üriner taşa ait bulguya rastlanmadı. Bununla birlikte bilgisayarlı tomografi ve manyetik rezonans görüntülemede adneksiyal kitle ve
sol üreterohidronefroz saptandı, bu yüzden açık cerrahi uygulanmasına karar verildi. Cerrahi girişimle bikornuat uterus, miyom ve üreter çevresindeki fibrotik kitle çıkarıldı ve uç-uca üreter anastomozu uygulandı. İlginç olarak
üreter çevresindeki fibrotik dokunun histopatolojik tanısı endometriyozisdi.
Ameliyat sonrası takipte erken dönemde bozulmuş sol böbrek fonksiyonlarının hızla düzeldiği gözlendi. Ürologlar günlük pratiklerinde özellikle menapoz öncesi genişlemiş toplayıcı sistemi olan kadınlarda endometriyozise
bağlı gelişmiş olabilecek üreteral darlıklara karşı uyanık bulunmalıdır. Doğurgan yaştaki kadınlarda üreteral endometriyozisin tedavisinde böbrek koruyucu yaklaşımlar ilk seçenek olmalıdır.
Anahtar kelimeler: Endometriyozis, cerrahi tedavi, üriner tıkanıklıkVolume 52 • Issue 4 Endometriosis presenting with urinary symptoms • 291
vealed minimal pleural effusion, an atelectasis in the
basal segments of the lungs and grade 2 ureterohydronephrosis on the left side but no findings of calculus
at left renoureteral unit. A cystic lesion of 6 cm in diameter adjacent to uterus on the right side and a 4 cm
solid mass on the left-anterior side of the uterus were
reported. The relationship of the latter mass with the
main vascular structure could not be clearly explained.
After the antimicrobial therapy, the WBC, pyuria and
creatinin levels returned to normal and a diagnostic
ureteroscopy was performed. During the left ureteroscopy, approximately at the 10th cm of the ureter there was a serious stricture and kinking, obliterating the
upward access with neither an ureteroscope nor with
a double J stent. Her cystoscopic evaluation was normal. A left percutaneous nephrostomy was placed and
the left antegrad ureterography revealed a serious obstruction at the level of the angulation and the solid
mass previously detected with the CT scan. A parenchymal loss and reduced level of activity were reported
in dimercaptosuccinic acid (DMSA) scintigraphy of
the left kidney with a 15% of total renal function. A
magnetic resonance imaging of the pelvic region revealed a myoma in the uterus and multiple hemorrhagic cysts in both ovaries (Figure 1). A reasonable explanation for the elevated CA levels could not be made.
Approximately 1000 cc of daily urine was collected
from left nephrostomy and an exploration was planned together with the Department of Gynecology. In
operation, the distal part of the left ureter was found
to be surrounded with a fibrous mass of 3x3 cm in diameter and tortuosed at the level where it crossed the
iliac artery. When peritoneum was opened in order to
see the distal part of the left ureter, it was observed
that the left ovary and the adnexial structures were not
grown, but a rudimentary horn and a myoma of 5 cm
in diameter on the left side of the uterus were seen.
First of all, horn excision and myomectomy were applied. The solid mass and the related distal part of ureter
were excised completely and ureteroureterostomy was
performed via a double J (DJ) catheter. Nephrostomy
catheter was extracted after the ureterovesical passage
was seen on antegrade ureterography on the 7th postoperative day (Figure 2). One month later there was
no dilation in the left collecting system in sonographic
evaluation and DJ catheter was extracted. Her intravenous urography was normal on the 45th postoperative day with nephrogram and pyelogram phases and
ureterovesical passage. The rudimentary horn revealed a regular myometrium, the excised myoma of uterus was reported as leiomyoma and the fibrotic mass
was an endometriosis externa on the pathologic evaluation. The mercapto acetyl triglycine (MAG-3) scintigraphy on the postoperative 3rd month reported that
the left kidney has a 32% of the total renal function.
Figure 1. Pelvic magnetic resonance imaging of the case revealed
a myoma in uterus (small arrow) and multiple hemorrhagic cysts in
ovaries (big arrow)
Figure 2. An ureterovesical passage was seen on antegrade
ureterography on the 7th postoperative day. The arrow shows that
the contrast material reaches into the bladder through next to the
catheter
Discussion
Endometriosis denotes ectopic localization of endometrial tissue and despite its benign nature it may
spread to almost all pelvic organs reminiscent of an
aggressive tumor. This disorder is not rare and can be 292 • December 2010 • Gulhane Med J Şenkul et al.
seen in 10-20% of all premenopausal women although urinary system involvement is relatively less frequent (1-11%). Incidences of bladder, ureter and renal endometriosis are 40%, 5% and 1%, respectively.
It has been reported that 0.1-0.4% of all cases with
pelvic endometriosis involve ureter (5). Ureteral endometriosis is classified into two main groups as intrinsic and extrinsic. In intrinsic disease, ectopic endometrial tissue directly infiltrates muscle layer, lamina
propria or the lumen and possibly represents lymphatic or venous spread. However, in extrinsic endometriosis, the affected layers are adventitia and periureteral connective tissue (6). According to the pathologic diagnosis, our case was assessed as extrinsic ureteral endometriosis. It is known that the extrinsic disease is more frequent (4:1), and the distal part of ureter is almost always involved (7,8).
The diagnosis of ureteral endometriosis should
be considered in a patient presenting with chronic
backache even in the absence of hematuria or pelvic symptoms (9). Intravenous urography and more
recently, spiral computed tomography still remain
important diagnostic tools for ureteral endometriosis, as they may localized the level, degree and laterality of ureteral involvement. However, urography is
unable to identify the cause of an extrinsic obstruction. In the case of intrinsic endometriosis, urography
may show a filling defect within the lumen of the
ureter, but this finding is not specific as it can be caused by stones or transitional cell cancer (10). In women with chronic pelvic non-cyclic pain, the occurrence of endometriosis should be taken into account.
In the differential diagnosis, the postoperative adhesions, pelvic varices, interstitial cystitis and irritable
bowel syndrome should be considered (11).
The disease itself has a considerably silent clinical
course. Antonelli stated that 38% of the patients had
slight complaints and 8 out of the 13 cases were diagnosed with urinary symptoms (12). The fact that
“the diagnosis of ureteral endometriosis is rather difficult” has been confirmed with the high ratio (23-
47%) of renal function loss associated with this disease (13). However, the wide availability of ultrasonography and laparoscopic procedures has reduced the
ratio of nephrectomy to 7% (12). While the left kidney functions of our case were negligible at the time
of presentation it showed a perfect recovery soon after the urinary diversion. This significantly emphasizes that nephrectomy should be deferred particularly
in young patients. In accordance with this observation, Antonelli et al. reported excellent results (improvement in renal functions in 90% of cases) following
urinary diversion which was done preoperatively in
patients with ureteral endometriosis associated with
serious ureterohydronephrosis (14). Interestingly, the
diagnosis could be made in less than half (46%) of
the cases preoperatively due to the variant presentation of the disease (12).
Vercellini and Antonelli reported that the unilateral cases were mainly at the left side. They explained
this situation with the following hypothesis: the sigmoid colon is acting as a natural path allowing retrograde cell implantation from uterine cavity (15).
In addition to this explanation, a congenital uterine
anomaly might contribute as well. It is possible that
the Mullerian duct remnants are pivotal in initializing the pathological process. In fact, the embryonic
theory is still valid for the pathophysiology of endometriosis (6).
Ectopic endometrial tissue bleeds periodically, and
desquamation, necrosis and fibrosis follow the hemorrhage. This process leads to ureteral stricture (12).
GnRH analog therapy can also cause ureteral stricture
due to the fibrosis. However, medical therapy following surgery should be considered as a prophylactic
intervention in patients who did not undergo total
hysterectomy and bilateral oopherectomy. Formerly,
ureteral catheterization and ureterolysis were done
for these patients (16,17), but no successful outcome
has been reported (12).
Surgical treatment may consist of ureteroneocystostomy, laparoscopic ureterolysis, with later ureteral resection and end-to-end anastomosis, or even autotransplantation in case of ureteral relapses. Traditionally,
laparotomy has been the method of choice for ureteral injuries even when the injury is identified during
a laparoscopic procedure. Today, however, some urologists feel that laparotomy should be avoided as it
shows a higher rate of infection and incisional hernias, longer hospital stay, and slower recovery compared with laparoscopy. It is still debated whether segmental resection and anastomosis or ureterolysis or
minimal-access procedures are preferable. Recent studies suggest that laparoscopic ureterolysis can be an effective treatment option in most patients with ureteral endometriosis but that recurrence rates are not negligible. Successful application of laparoscopic surgery,
even for procedures that have traditionally necessitated laparotomy, has been reported. Extensive experience with endourological techniques is prerequisite
for success. The frequency of associated lesions (urinary, gynecological gastrointestinal) justifies a multidisciplinary surgical approach (10).Volume 52 • Issue 4 Endometriosis presenting with urinary symptoms • 293
Segmental ureterectomy provides the removal of
both endometriotic and fibrotic tissues. If there is no
sign of endometriotic tissue in the distal ureter, an
uretero-ureteral anastomosis can be done safely. In
the case of diffuse ureteral involvement, ureteroneocystostomy would be more appropriate. Our case
was treated with segmental ureterectomy and ureteroureteral anastomosis since the ureteral endometriosis
was present in a limited area. One might also consider that an underlying congenital anomaly could
have contributed the clinical setting. Hence, medical treatment in the case of recurrence and a close
follow-up will be appropriate for this young woman.
In conclusion, urologists should be aware of ureteral stricture due to endometriosis especially in premenopausal women with dilated collective system during their daily practices. It should be kept in mind
that this pathology may accompany uterine anomalies. As highlighted in this case report, kidney protective approaches should be the initial choice while managing ureteral endometriosis in women in child bearing ag