Description
Endometriosis can affect 10–15% of the women in their reproductive age and it is characterized by the presence of the functional endometrial tissue outside the uterine cavity. Up to 10% of the cases with urinary system endometriosis may involve the ureter. Left distal ureter is the most common site of involvement. The differentiation between intrinsic and extrinsic endometriosis is very substantial for the selection and application of definitive treatment. Medical and surgical treatment alternatives are available for endometriosis management and histopathologic examination is required for definitive diagnosis
Résumé
- The ureter, measuring 20-25 cm, extends from the pelvicalyceal system to the bladder, with a rich blood supply crucial for its integrity. Its structure consists of the adventitia (outermost layer), muscularis, and the lumen, lined by transitional epithelium.
- Urological endometriosis affects 0.3-12% of women, with the ureter involved in 15% of cases, more frequently on the left side. Bilateral involvement occurs in 25% of cases, and 1% require resection. Transvaginal ultrasound has a 42% sensitivity and 100% specificity in detecting endometriosis.
- Within the urological system, the bladder is most commonly affected by endometriosis (80-84%), followed by the ureter (15%), kidney (4%), and urethra (2%). Ureteric endometriosis is categorized as extrinsic (80%), caused by external compression, or intrinsic (20%), involving the ureter's lumen.
- Laparoscopic dissection typically begins at the pelvic brim, identifying the infundibulopelvic (IP) ligament. The ureter lies posterior-medial to the IP ligament. Endometriosis-related fibrosis around the ureter can cause external compression, necessitating ureterolysis.
- Surgical techniques emphasize traction, counter-traction, and opening loose tissue planes around the ureter. Bipolar energy is used in short pulses to minimize thermal damage. The adventitia is preserved during ureterolysis.
- Adnexectomy, when performed, provides better access and visualization of the ureter during hysterectomy. All visible endometriotic nodules should be removed to minimize recurrence. Dissection extends to the ureteric tunnel and into the pararectal space.
- The ureter passes under the uterine artery near the isthmus of the uterus. Complete ureterolysis involves freeing the ureter from fibrotic tissue, restoring normal anatomy, and ensuring maintained vascularity.
- In cases of large endometriomas, ureterolysis is often necessary due to peritonial fibrosis compressing the ureters. Conservative surgeries aim for radical excision while preserving the ureter.
- The presented TLH cases highlight potential anatomical distortions caused by endometriosis, emphasizing the need for careful dissection to avoid ureteral injury. The procedure involves lateralizing the ureter to ensure safe colpotomy.
- Hydronephrosis cases may require parametrectomy and excision of the ureteric opening and trigone due to nodule involvement. Re-implantation of the ureter into the bladder may be necessary, often with a DJ stent placement.
- Severe endometriosis with peritonial fibrosis can bring the ureter in close proximity to structures like the IP ligament. Extensive fibrosis can obscure anatomical planes, requiring meticulous dissection and lateralization of the ureter.
- Relevant anatomy includes the psoas muscle, IP ligament, iliac vessels, ureter's path, and uterine artery crossing over the ureter. Key surgical spaces are the paravesical, pararectal, and Yabuki spaces.
- Risk factors for ureteral involvement include retrocervical nodules and parametrial nodules larger than 17mm. Patients may exhibit ureter-related symptoms, but silent kidney loss is possible. Complete pre-operative evaluation and surgical planning are crucial.
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