Laparoscopic Treatment of Ureteral Endometriosis: A Systematic Review

Abstract

Objective: To review the literature for the preoperative clinical characteristics, surgical findings, and outcomes of patients who underwent laparoscopic surgical treatment of ureteral endometriosis (UE). Data Sources: A systematic search was performed in the PubMed and Scopus databases. Methods of Study Selection: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, studies in English language that assessed UE treated surgically by laparoscopy published between 2008 and 2020 were selected. Tabulation, Integration, and Results: In an initial search, 1313 articles were identified, 193 in PubMed and 1120 in Scopus databases. A total of 1291 articles that did not meet eligibility criteria were excluded. The remaining 22 studies were included in the final qualitative analysis, with a total of 1337 patients. Data on preoperative patient's characteristics, preoperative imaging examinations, intraoperative findings, and postoperative complications were abstracted by 1 author. The descriptive nature of included studies prevented the performance of meta-analysis. Preoperative symptoms included dysmenorrhea (76.3%), pelvic pain (59.6%), dyspareunia (46.2%), lower urinary tract symptoms (21.3%), and ureteral obstructive symptoms (9.9%). Intraoperative findings showed that UE lesions were left-sided in 55% of the cases, right-sided in 28.9% of the cases, and bilateral in 8.7% of the cases. Ureterolysis alone or before another technique was performed in 69.1% of the cases, ureteral resection followed by ureteroureteral anastomosis in 6%, ureteroneocystostomy after ureteral resection in 21%, and nephrectomy in 0.45% of the patients. Double-J ureteral stent placement was reported in 33.3% of the cases. Concomitant resection of the bladder owing to endometriosis involvement was performed in 15.5% of the cases. The prevalence of ureteral injury was 3.1%. Postoperative complications included ureteral fistula (2.8%), ureteral stenosis (24.2%), persistence/recurrence of UE (3.8%), and reoperation for fistula and/or stricture treatment (3.9%). Conclusion: UE is associated with common endometriosis pain symptoms and a low rate of lower urinary tract symptoms. The standard surgical technique for UE treatment is not yet a consensus; however, the laparoscopic approach with previous ureterolysis, leaving ureteral resection only for refractory cases, seems to be a safe and effective treatment, with improvement of symptoms and few intraoperative and postoperative complications.

Severe Ureteral Endometriosis Complicated with Hydronephrosis: A Case Report

“…Symptoms in patients with UE are often atypical. Fernando et al concluded that after laparoscopic surgery for patients with UE in the past 10 years, dysmenorrhea (76.3%) and pelvic pain (59.6%) were the most common symptoms, and ureteral obstruction symptoms only accounted for 9.9% [ 4 ]. In a retrospective analysis of this case, the patient had dysmenor-rhea but ignored it because it could be tolerated, reminding clinicians that in cases of dysmenorrhea with hydronephrosis, patients should be alerted to the possibility of urinary tract endometriosis.…”

Uterine artery closure at the origin vs at the uterus level in total laparoscopic hysterectomy: A randomized controlled trial

“…[21][22][23] In these cases, developing the paravesical and pararectal spaces is necessary. [22][23][24] Consequently, the UA occlusion at the origin appears to be a safer and more reproducible maneuver to complete hysterectomy. 21 Moreover, we observed two (2.2%) cases of ureteral duplication in the OR group.…”

“…Notably, the failure to close UAs at the UL was significantly associated with the intraoperative identification of endometriosis and the need for parametrectomy and ureterolysis 21–23 . In these cases, developing the paravesical and pararectal spaces is necessary 22–24 . Consequently, the UA occlusion at the origin appears to be a safer and more reproducible maneuver to complete hysterectomy 21 .…”

Preoperative prediction of ureteral endometriosis without dilatation: instructions for use

“…In such a setting, correctly predicting nonobstructive ureteral involvement may not change the outcome to a great extent, because the women are operated on by the best available surgeon in any case. In less specialized settings, the prediction of ureteral involvement may well be more relevant but, in our opinion, not so much to try to better plan the surgical team, but instead to refer the patient to centers of expertise with the objective of optimizing the efficacy of the procedure and minimizing the risk of complications, two variables that are strictly operator-dependent (1,2,5).…”

“…This is a very useful safety maneuver, not only to identify extrinsic ureteral compression but also to prevent inadvertent and potentially unrecognized intraoperative iatrogenic ureteral lesions. However, not all gynecologists are trained to safely perform ureteral isolation and ureterolysis in women with severe deep endometriosis, even when the lesion sites and characteristics are correctly predicted preoperatively (5).…”