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Pathophysiology and management of urinary tract endometriosis

Key Points

  • Estimates of incidence of endometriosis vary from <10 to >20% of women

  • Although considered rare, endometriosis of the urinary tract might be more common than previously thought, owing to changing definitions and a lack of recognition by surgeons

  • Endometriosis of the ureter can result in silent kidney loss if not effectively managed

  • Treatment options differ depending on whether the endometriosis is superficial or deep infiltrating, and also on the site of the lesions

  • Laparoscopy with or without robotic assistance is feasible and advisable to treat urinary tract endometriosis

Abstract

Endometriosis predominantly affects the pelvic reproductive organs but can also affect the urinary tract. A number of theories for the pathogenesis of endometriosis have been suggested, but the exact mechanisms remain elusive. Endometriotic lesions can be found on both the ureter and bladder, and the optimal therapeutic approach depends on the extent, depth, and location of these lesions. Medical approaches, including hormonal therapies such as GnRH agonists and oral contraceptives, tend to be a temporary measure, but can be useful in a preoperative setting or if the patient is unsuitable for surgery, and are also useful as a postoperative treatment. If surgical resection is deemed appropriate, laparoscopic management with or without robotic assistance of urological endometriosis is feasible and advisable. Newer techniques, such as nerve-sparing surgery, might help to decrease the risk of urinary complications following resection of deeply infiltrating endometriosis.

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Figure 1: Anatomy and innervation of the pelvic organs.
Figure 2: Left ureteral endometriosis before excision, as seen on laparoscopy.
Figure 3: Extrinsic endometriosis of the ureter, as seen on laparoscopy.
Figure 4: Intrinsic endometriosis of the ureter.
Figure 5: Bladder endometriosis on MRI in a 34-year-old woman with frequency, urgency, and a bladder mass.
Figure 6: Schematic and ultrasonographic image of an endometriotic nodule at the bladder base.
Figure 7: Endometriosis of the bladder serosa, as seen on laparoscopy.
Figure 8: Cystoscopic view of deep infiltrative endometriosis of the bladder.
Figure 9: Deep infiltrating endometriosis on ultrasonography.

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Acknowledgements

We would like to thank Sahar Houshdaran of the University of California at San Francisco for her contributions to the genetics portion of this paper. For their review of the manuscript, we would also like to thank Ceana Nezhat of the Atlanta Center for Minimally Invasive Surgery and Reproductive Medicine, and Farr Nezhat of Nezhat Surgery for Gynecology/Oncology in New York. We also thank Gity Meshkat Razavi for her help with drawing up the original figures in this article.

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All four authors researched data for the article and wrote the manuscript. C.N., R.F., and L.K. took part in discussions of content. C.N. and R.F. reviewed and edited the manuscript before submission.

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Correspondence to Camran Nezhat.

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The authors declare no competing financial interests.

Supplementary information

DIE at the bladder base.

The sonographer evaluates the size, location, and extent of a deeply infiltrative endometriosis lesion at the bladder base. This type of assessment can aid a physician in understanding endometriosis as the cause of a patient's UTI-like symptoms and help them counsel the patient on operative planning. Preoperative knowledge of a bladder endometrioma informs the surgeon of whom to gather for an interdisciplinary surgical team, often including a laparoscopically trained urologist and/or minimally invasively trained gynaecology expert. Permission obtained from ISUOG; published by John Wiley and Sons Ltd. © Guerriero, S. et al. Ultrasound Obstet. Gynecol. 48, 318–332 (2016). (MP4 6757 kb)

Laparoscopic treatment of endometriosis of the ureter with and without robotic assistance.

In this video, multiple forms of urinary tract endometriosis are classified and laparoscopic management strategies described. First, ureterolysis of extrinsic (superficial) disease of the ureter is shown, using robotic assistance. Next, release of a choked ureter constricted by endometriosis is demonstrated and then ureteroureterostomy for intrinsic (deeply invasive) endometriosis necessitating excision of a segment of ureter is shown. Next, ureterolysis and peritoneal stripping with robotic assistance is described. Use of the CO2 laser for excision and vaporization of endometriotic lesions as well as the role of hydrodissection in protecting the ureter and other vital structures from harm is shown in all cases. Finally, two cases of laparoscopic segmental bladder resection of deeply infiltrating endometriosis are shown, one performed with robotic assistance and one without. In both cases, cystoscopy is routinely performed to guide operative cystotomy. Complete excision of the deeply infiltrating endometriosis is required, with a 5 mm margin. Following the excision, bilateral stents are placed in the ureters, and the bladder is closed with 4–0 through-and-through. With or without robot assistance, the operative surgeon must be comfortable and adept at laparoscopic suturing of the bladder. (MP4 107967 kb)

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Nezhat, C., Falik, R., McKinney, S. et al. Pathophysiology and management of urinary tract endometriosis. Nat Rev Urol 14, 359–372 (2017). https://doi.org/10.1038/nrurol.2017.58

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