Urology Annals

COMMENTARY
Year
: 2012  |  Volume : 4  |  Issue : 1  |  Page : 12--13

Commentary


Ehab Eltahawy, Sami Heshmat 
 Department of Urology, University of Arkansas for Medical Sciences, AR, USA

Correspondence Address:
Ehab Eltahawy
Department of Urology, University of Arkansas for ­Medical ­Sciences, AR
USA




How to cite this article:
Eltahawy E, Heshmat S. Commentary.Urol Ann 2012;4:12-13


How to cite this URL:
Eltahawy E, Heshmat S. Commentary. Urol Ann [serial online] 2012 [cited 2019 Oct 14 ];4:12-13
Available from: http://www.urologyannals.com/text.asp?2012/4/1/12/91614


Full Text

The authors present their experience with 9 cases of bladder endometriosis managed by transurethral resection and medical treatment, or partial cystectomy, with a success rate of 60% and 100%, respectively. They also had 10 cases of ureteric involvement managed by distal ureterectomy and ureteroneocystostomy, laparoscopic ureterolysis, and stent placement with postoperative medical treatment, or medical treatment alone. The success rate was 100%, 75%, and 67%, respectively.

The diagnosis of urinary involvement in endometriosis is sometimes challenging knowing that it is only present in 1% of women with endometriosis. [1] The two forms, the bladder and ureteral endometriosis, are two distinct clinical diseases. The vesicle form presents with cyclical hematuria, or less obvious aseptic pyuria, while the ureteral form is a more subtle disease that is difficult to diagnose, and is associated with nodules in the Douglas pouch in 11% of ladies. [2] Those patients often have chronic pelvic pain which contributes to the delay in diagnosis. Gradual and silent narrowing of the ureter often leads to the loss of the function of the ipsilateral renal unit in as many as 25-50%. [3] Diagnosis in bladder involvement can be accurately done by urethrocystoscopy, while ureteral involvement requires a high index of suspicion. An initial screening ultrasound can be followed by more accurate localization by intravenous pyelogram, CT with contrast, MRI, retrograde uretropyelogram study, and ureteroscopy.

Although medical treatment is useful in temporary relief of the symptoms associated with endometriosis, these recur once the medicine is withdrawn. Medical treatment is considered contraindicated in patients with ureteral involvement due to the risk of loss of renal function. [4] The surgical management of ureteral involvement requires the surgeon to be experienced in dealing with different alternatives of ureteral stenosis. Uretrolysis is the most common operation for ureteral endometriosis. It has been associated with a higher recurrence rate and complications. It is of little value in high-grade obstruction, and requires stenting for extended periods. The choice of laparoscopic or open surgery depends on the surgeon's experience, and should not compromise the outcome. Ureteral reimplantation with the psoas hitch is possible in most of the patients because the lower third of the ureter is frequently involved.

It is hard to draw solid conclusions from this study based on the small numbers in each group but some observations are clear. Transurethral resection was inferior to partial cystectomy for the management of bladder lesions. Ureteral reimplantation was more successful than ureterolysis and medical treatment. This concurs with other studies. The authors are to be commended for their impressive experience in a not frequently encountered disease, and their further follow-up of this group of patients would add to our knowledge.

References

1Jubanyik KJ, Comite F. Extrapelvic endometriosis. Obstet Gynecol Clin North Am 1997;24:411-40.
2Donnez J, Nisolle M, Squifflet J. Ureteral endometriosis: A complication of rectovaginalendometriotic (adenomyotic) nodules. Fertil Steril 2002;77:32-7.
3Comiter CV. Endometriosis of the urinary tract. Urol Clin North Am 2002;29:625-35.
4Berlanda N, Vercellini P, Carmignani L, Aimi G, Amicarelli F, Fedele L. Ureteral and vesical endometriosis. Two different clinical entities sharing the same pathogenesis. Obstet Gynecol Surv 2009;64:830-42.