Ureteral endometriosis has intrinsic and extrinsic pathological types . The intrinsic type is characterized by invasion of endometriotic glands and stroma in the ureteral wall, and it is less common than extrinsic ureteral endometriosis, which is caused by external compression by surrounding DIE. According to Stanley et al. , endometriosis of the ureter usually arises by extension from pelvic endometriosis. The distal segment of the left ureter is more frequently involved because of the adjacent reproductive organs .
Symptoms of endometriosis, depending on the location and extent of lesions and severity of disease, can lead to pain, cyclic hematuria, and infertility caused by extensive adhesions and distortion of anatomy. Among these, cyclic hematuria is pathognomonic for urinary tract involvement by endometriosis and presents in 20% of cases with bladder endometriosis . Symptoms are especially aggravated during menstruation because blood is increased within the involved organs and can distend the surrounding tissue or peritoneum . If a reproductive age woman presents with these symptoms and no documented infection, endometriosis should be suspected.
The symptoms of urinary tract endometriosis are nonspecific and can be confusing. Ureteral endometriosis is asymptomatic in as many as 50% of patients . Because of nonspecific symptoms, insufficient preoperative evaluation, misinterpretation of imaging findings, or nonspecific imaging findings, ureteral endometriosis is suspected before surgery in only 40% of patients . Incorrect diagnosis of ureteral endometriosis can lead to obstructive uropathy and permanent renal failure.
Our patient’s case of right distal ureteral endometriosis caused extrinsic compression with fibrous adhesion formation by DIE of the right uterosacral ligament. The only symptom was right flank pain aggravated during the menstrual period with no symptoms suggesting endometriosis, such as dysmenorrhea, dyspareunia, or cyclic urinary pain. Pelvic and vaginal examination findings were also nonspecific. The only clue to endometriosis was the periodic right flank pain and hydronephrosis on radiological examination. Given the history and concern about the possibility of endometriosis, transvaginal US was performed and revealed a suspicious nodular lesion at the right uterosacral ligament, which correlated with a heterogeneous mass on MRI. Right ureteral wall thickness with delayed enhancement was confirmed during surgery as fibrotic change associated with endometriosis.
Surgery is necessary in patients with ureteral endometriosis who have persistent symptoms and/or hydroureteronephrosis. The main goals of surgery are preservation of renal function, relief of obstruction, and prevention of recurrence. The surgical modalities include ureterolysis, ureterostomy, distal ureterectomy, and ureteral reimplantation, according to the extent, severity, and type of disease. Ureterolysis using a laparoscopic or open approach is indicated in patients with extrinsic ureteral endometriosis if there is an extrinsic lesion < 3 cm and/or nonobstructive ureteral involvement . Laparoscopic ureterolysis, DIE resection, and double-J ureteral stent insertion were performed in our patient because she had extrinsic distal ureteral endometriosis without complete obstruction. An individualized therapy plan, including hormone or surgical therapy, should be considered according to patient age, type of ureteral endometriosis, extent of disease, degree of hydronephrosis, and renal function.
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