The Surgical Management of Endometriosis of the Ureter and Bladder

Ureterolysis presents a good risk-benefit rate and should be considered in the first line for the management of ureteral endometriosis, the study suggests.

Key Points

Highlights: 

• Laparoscopic surgery is feasible and safe to treat ureteral and bladder endometriosis.
• Ureteral resection is associated with more complications compared to other techniques.
• Ureterolysis should be considered in the first line for the management of ureteral endometriosis.

Importance:

• The findings of this study could guide decision-making about surgeons for the choice of the best surgical approach to treat ureteral and bladder endometriosis.

What's done here:

• Researchers conducted a multicentric retrospective cohort pilot study in 232 women who underwent surgery to treat their endometriosis.

Key results:

• Following surgery, 44 low-grade complications, 16 grade III complications, and one grade IV complication occurred.
• Ureteral resection was associated with more complications compared to other techniques and was more strongly associated with laparotomy.

Limitations:

• The study does not contain any follow-up data about the efficacy of the surgical approaches.
• The study was not randomized in terms of surgical management and could be influenced by patient characteristics.

Lay Summary

Laparoscopic surgery is feasible and safe to manage endometriosis of the ureter and bladder, according to a new study published in the Journal of Minimally Invasive Gynecology. According to the authors of the study, ureteral resection is more strongly associated with laparotomy and more complications compared to other procedures and should be reserved for cases where ureterolysis is not feasible or in case of recurrence.

The best surgical management of patients with endometriosis of the ureter and bladder remains controversial. 

In order to assess the surgical management and risk of postoperative complications in patients with urinary tract endometriosis, a team of researchers led by Prof. Gil Dubernard, an obstetrics and gynecology specialist at Hôpital Universitaire de la Croix Rousse in Lyon, France, conducted a multicentric retrospective cohort pilot study.

They analyzed a total of 232 patients from 31 centers who were surgically treated for urinary tract endometriosis between January 1 and December 31, 2017. 

Of these women, 82 (35.3%) had isolated bladder endometriosis, 126 (54.4%) had isolated ureteral endometriosis, and 24 (10.3%) had endometriosis in both locations. 

Three types of surgeries were performed. These included laparoscopy performed in 74.1% of cases, laparotomy performed in 11.2% of cases, and robot-assisted laparoscopy performed in14.7% of cases. 

The patients had a total of 150 ureteral lesions. Of these, 114 (76%) were managed with ureterolysis, 28 (18.7%) with ureteral resections, four (2.7%) with nephrectomies, and 23 (15.3%) with cystectomies.

In 94.3% of bladder endometriosis cases, a partial cystectomy was performed. 

Following the operations, there were 61 complications. This corresponded to 26.3% of all operations. They included 44 low-grade complications, 16 grade III complications, and one grade IV complication.

The researchers found that ureteral resection was associated with more complications compared to other techniques and more strongly associated with laparotomy. They concluded that ureterolysis should be considered in the first line in the management of ureteral endometriosis as it presents a good risk-benefit rate and that ureteral resection should be reserved for cases where ureterolysis is not feasible or in case of recurrence.

Urinary tract endometriosis is relatively rare affecting between 1.2% and 6% of endometriosis patients. Bladder endometriosis is more frequent than ureteral endometriosis with an eight to one ratio. 

Research Source: https://pubmed.ncbi.nlm.nih.gov/33964459/