Different pattern of pelvic ureteral endometriosis. What is the best treatment? Prelimary results of a retrospective analysis.

Introduction and objectives. Endometriosis is an estrogen-dependent disease, characterized by the ectopic presence and growth of functional endometrial tissue, glands and stroma, outside the uterine cavity. The ureter is the second most common site among Urinary Tract Endometriosis (UTE). To date, Ureteral Endometriosis (UE) incidence is progressively increasing in case series, because of improvement in diagnostic procedures as well as greater awareness and skill among clinicians to recognize the disease. In most of cases, the UE is asymptomatic and the diagnosis is often incidental . However, the late diagnosis and treatment of this condition may lead to the silent loss of renal function. We treated both intrinsic (always obstructive) and extrinsic subset of UE, subdividing the latter according to the presence or absence of obstructive pattern . The aim of the current paper is to verify the best surgical procedure for each pattern of UE. Materials and Methods. We performed a retrospective analysis of our data, collected from March 2002 to August 2013. As showed in Table I, we treated 31 patients, 5 with intrinsic and 26 with extrinsic UE. Furthermore, cases of extrinsic UE were divided in in two subsets: with (n=20) and without (n=6) obstructive pattern. In the obstructive subset we performed ureteral stenting, resection and reimplantation (Lich-Gregoire); moreover in 3 of the 20 patients, because of the extension of the mass (>2,5 cm), we had to perform also a Boari flap to obtain a tension-free anastomosis. In the subset with obstructive pattern we performed laparoscopic ureterolysis (shaving). In the intrinsic subset, we performed endoureterotomy with 120-W 2-micron continuous-wave Tm:YAG laser (Revolix 2). As follow-up, we performed ultrasound after one week, URO-TC, blood test and urine test after one month and after six months. Results. As showed in Table II, in the extrinsic subset of UE, we obtained a complete therapeutic success (100 %). Conversely, in the intrinsic subset there was a recurrence of the disease, in fact in 3 patient persisted an hydronephrosis (60%) of first degree and 1 of these had associated hematuria (20%). Conclusions. In the extrinsicUEwithout obstructive pattern, ureterolysis is the gold standard. In the extrinsic UE with obstructive subset, the resection and reimplantation allows excellent results. In the intrinsic subset, the endoureterotomy approach seems to be inadequate (high rate of recurrence of hydronephrosis and symptoms). For these reasons, we suggest to use resection and reimplantation technique also for intrinsic pattern of UE, avoiding the undertreatment of this condition which may cause loss of renal function and high rate of recurrence.