Surgical approach to urinary endometriosis: experience on 28 cases

Endometriosis (e.) involving the urinary tract must be regarded as a rare condition with specific surgical implications. Our experience on the treatment of 28 patients is presented.

Twenty-eight patients with a urological e. (bladder 11 patients, ureter 14, both bladder and ureter 3) were observed and treated between 1995 and 2005. Thirteen patients (46%) had been previously surgically treated for pelvic e. at a mean distance of 22 months before. All the patients with bladder e. presented with typical symptoms related to menses and the urinary location was isolated in 42.8%. Differently, the patients having ureteral involvement complained often a vague or silent symptomatology, but they always showed some extra-urinary pelvic locations. Among the cases with bladder e., 2 patients underwent TUR and hormonal therapy and 12 partial cystectomy. The patients with ureteral e. were submitted to ureterolysis in 5 cases, segmentary ureterectomy and uretero-ureteroanastomosis in 2 and terminal ureterectomy and ureterocystoneostomy in 8. Two more cases with ureteral e. were nephrectomized due to end-stage renal atrophy.

At a mean distance of 58 months (9-110 months) from surgery, 22 patients have a unremarkable follow-up. On the other hand, an urological relapse was evidenced in 5 cases previously submitted to TUR (2 cases), ureterolysis (2 cases) or segmentary ureterectomy and termino-terminal ureteral anastomosis (1 case). The relapsing e. was treated by partial cystectomy or terminal ureterectomy with ureterocystoneostomy, with good results over time.

Urinary tract is rarely involved by e., but this condition has peculiar clinical and surgical implications. Being TUR ineffective, the therapy of choice of bladder e. is partial cystectomy, possibly via a laparoscopic approach. Differently from bladder e., the preoperative diagnosis of ureteral e. is surely hard. So, a high index of suspect should be regarded in each young female patient with a ureteral stricture and a study of the upper urinary tract (US and/or urography) should be performed in all the patients with pelvic e. Ureterolysis can be successful only in a minority of the cases showing a very limited disease not determining any urinary flow obstructions. In all the other cases the procedure of choice is terminal ureterectomy and ureterocystoneostomy without employing the distal ureter.