Pelvic endometriosis and ureteral obstruction CHARLES F. LANGMADE, M.D. Pasadena, California Pelvic endometriosis may completely obstruct the ureters and destroy the kidneys with little or no gynecologic symptoms. Five cases are discussed~ all causing u;ete;al obstruction. Two patients suffered the complete loss of a kidney and in each case the remaining kidney was in jeopardy because of partial obstruction due to endometriosis. All these patients were treated by complete removal of all ovarian tissue, dissection of the ureter, and dissection of the scar tissue. In severe cases, retroperitoneal clamping of the infundibular pelvic ligament with clear exposure of the ureter is mandatory to avoid leaving small remnants of ovary in the infundibular ligament clamp. With complete removal of all ovarian tissue, postoperative estrogen therapy will not cause recurrence of the disease.
T o o M u c H emphasis has been placed on the "remaining" ovary in young people with extensive pelvic endometriosis compromising normal renal or gastrointestinal physiology. 1 Small areas of pelvic endometriosis, many times diagnosed at the time of surgery in young patients, surely should be treated differently from endometriosis obstructing the ureters or bowel in any age group. 2 • 3 Pelvic endometriosis as the sole cause of ureteral obstruction has received relatively little consideration in the general study of the disease. 4 • 7 In the reported cases several salient points have been repeatedly stressed by the various authors: ( 1) it is difficult to make the differential diagnosis of extensive pelvic endometriosis vs. extensive pelvic carcinoma; ( 2) incomplete surgery for extensive pelvic endometriosis leads to further difficulties; ( 3) the use of progestational drugs in extensive endometriosis is of little or no value; (4) complete removal of all ovarian tissue and removal by dissection of the ureteral block is the treatment of choice.
and obstruction. Large masses of collagen and fibrocollagenous tissue with rare glands are included in the usual picture. A decidual edematous reaction may be produced in this tissue by the administration of progestins, and in some cases decidual necrosis has been described. 8 The clinical benefits of such treatment in extensive disease are limited and during the administration of these drugs ureteral obstruction may occur. Edema and necrosis of the superficial layers of the larger masses of endometriosis and collagenous fibrous tissue does little if anything to relieve ureteral obstruction. Ciinicai materiai
From 1961 to 1974 inclusive, five cases of ureteral obstruction due to pelvic endometriosis were seen. The vague nature of pelvic endometriosis is emphasized by a comparison of a much larger group of patients seen during the years 1961 to 1970, at the USC/LACGH Medical Center, where no similar cases were encountered by the author. Only two cases of extensive pelvic endometriosis were seen at the Medical Center from 1946 to 1970 and neither case caused ureteral obstruction. Five cases of ureteral obstruction due to histologically proved endometriosis were seen from 1961 to 1974 and all of these patients have been followed closely to the present time. A brief summary of each case is given in Table I. In case 1 there were no pelvic findings of endometriosis, however, the iliocecal endometriosis in this case influenced the management a great deal.
Pathology
The classic picture of endometrial glands surrounded by fibrous tissue is not the pattern seen in long-standing disease leading to periureteral fibrosis From Huntington Memorial Hospital. Presented at the Forty-first Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Near Bend, Oregon, October 6-10, 1974. Reprint requests: Dr. Charles F. Langmade, 65 N. Madison Ave., Pasadena, Caiijornia 9i iOi.
463
464
langmade
June 15, 197S Am. ]. Obstet. Gynecol.
Fig. 3. Postoperative I.V.U. Fig. 1. Endometrial glands over the sacral promontory obstructing the right ureter.
Fig. 2. Preoperative I.V.U.
The peritoneal endometriosis and scar were removed as advocated by Ball, 9 but this may have regressed after bilateral salpingo-oophorectomy. The administration of oral estrogens caused no recurrence of symptoms. Fig. 1 demonstrates the glands found over the sacral promontory. Figs. 2 and 3 reveal the preoperative obstruction and the postoperative pyelogram. In case 2 the gross diagnosis of pelvic endometriosis is of the utmost importance. Incomplete surgery at the time of the first operation led to ureteral obstruction and a second hospitalization. Glands were well demonstrated in the tubo-ovarian area of pelvic endometriosis. Fig. 4 demonstrates the preoperative obstruction and Fig. 5 shows the postoperative study after release of the ureteral obstruction. In the premenopausal age group (case 3) with unilateral ureteral obstruction, endometriosis should be considered and complete surgery done to preserve renal function. The glands over the sacral area were demonstrated to be pelvic endometriosis. Fig. 6 illustrates postoperative renal studies. In case 4 no ureteral transplantation was considered because of the questionable viability of the left kidney, massive endometriosis of the bladder,
Volume 122 Number4
Pelvic endometriosis and ureteral obstruction 465
Fig. 4. Preoperative I.V.U. demonstrating obstruction of the right ureter.
and absence of any urinary tract infection. A total hysterectomy could have been done; however, it would have been difficult and the remaining ureter and kidney may have been compromised. Endometriosis invading the bladder is well demonstrated in Fig. 7. In Fig. 8 the dense fibrous tissue involving the ureters containing few glands is shown. In Fig. 9 the preoperative nonfunctioning left kidney is illustrated. In case 5, because of the questionable stricture, the urologic consultant did a retrograde study which revealed a patent ureter (Fig. 10). This study was followed by temperatures of 103° and 104°, pyuria, and E. coli bacteriuria. The patient was acutely ill for 5 days. She responded to antibiotics and was discharged on the sixteenth postoperative day. Comment
The management of ureteral obstruction due to endometriosis requires for the most part a thorough understanding of the kidney function, the degree and duration of the obstruction, and the condition of the involved ureter and bladder. If the patient is young and ureteral obstruction is present, the value of the "remaining" ovary must be placed in its proper perspective. In this series, cases 2, 3, and
Fig. 5. Postoperative I.V.U.
4 all would have avoided ureteral obstruction and further surgery if bilateral salpingo-oophorectomies had been performed at the time of the. initial surgery. The problems of incomplete surgery in this disease have been emphasized many times. Saving an ovary or a part of an ovary leads to uniformly poor results. Ratliff and Cranshaw10 reported a 34-year-old patient with ureteral obstruction because one ovary had been left in at the time of her original surgery. The best results in their series were achieved by total surgical removal of uterus, tubes, and ovaries. Their case treated by x-ray after freeing up a ureter resulted in persistent hydronephrosis. In general, the main symptoms of this condition should be referable to the genitourinary system, but this is not always true. Kerr11 reported that 49 per cent of his cases had flank pain and 13 per cent had hematuria. Patient 4, with the most widespread disease and loss of one kidney, had no pain at any time. One half of Kerr's reported patients had pelvic masses or nodules and 28 per cent had irregular bleeding. He advised culdoscopy for establishing the diagnosis and with this we would disagree because the procedure would be impossible in some cases and ill-advised in others, such as No. 4,
466
langmade
Am.
Fig. 6. Postoperative I.V.U.
J.
June 15, 19/ ;) Gynecol.
Obst~t.
Fig. 7. Endometriosis of bladder.
Table I. Clinical data Case
Age
I Parity I
46
3
49
4
44
5
44
G.U. symptoms
Dysmenorrhea, menor- Right CV A pain rhagia, RLQ pain
39
2
Symptoms
2
2
Previous surgery
Renal status
Good renal function
Appendectomy
T otal abdominal hysterectomy; left salpingo-oophon to my
Pelvic pain
Right hydronephrosis, Left CVA pain, previous right CVA right hydroureter; good renal function pain
Menopausal symptoms
Previous left CVA pain
Good renal function
Previous left hydronephrosi: left salpingo-oophorectomy and left nephrectomy for infection
None
None
Nonfunctioning left kidney, right normal
Cesarean section x2
Lower abdominal pain
None
Left hydroureter and None hydronephrosis; pyelonephritis after retrograde study
Volume 122 Number4
Pelvic endometriosis and ureteral obstruction 467
Fig. 8. Dense fibrous tissue with endometrial glands involving the ureters.
Fig. 9. Preoperative I.V.U. demonstrating nonfunctioning kidney. Postoperative I.V.U. remained the same.
Findings at surgery
Treatment
Endometriosis right pelvic brim obstructing right ureter; endometriosis along right iliac artery
Total abdominal hysterectomy; bilateral salpingo-oophorectomy; postoperative
Hard mass of endometriosis obstructing right ureter; hydroureter, hydronephrosis
Right salpingo-oophorectomy; postoperative estrogens
5 yr., 7 mo.: Symptom-free Normal kidney function Normal IVU Right hydronephrosis and hydroureter subsided
Uterine fibroids, extensive endometriosis surrounding the right ureter and comprising an almost frozen pelvis
Total abdominal hysterectomy; right sal pingo-oophorectomy; postoperative estrogens
6 yr., 6 mo.: Symptom-free Normal renal function Absent left kidney
Endometriosis bladder, vagina, pelvis; obstruction left ureter, cystic nonfunctioning left kidney; small normal right kidney; ureter surrounded by endometriosis
Subtotal obdominal hysterectomy; bi .. lateral salpingo-oophorectomy; postoperative estrogens
Extensive endometriosis; obstruction, left ureter with hydroureter and hydronephrosis
Subtotal abdominal hysterectomy; bilateral salpingo-oophorectorny; postoperative estrogens
estrogens
Follow-up II yr., 6 mo.: Symptom-free ~Jormal kidney function Normal IVU Right hydronephrosis and hydroureter subsided
.d. ........ -.1 J''•J
~
IJ
........... llf.Voo
Symptom-free Non-functioning left kidney Normai renai function, right No return of function, left kidney 7 mo.: Symptom-free Normal renal function Left hydroureter and hydronephrosis subsided
468 longmade
Fig. 10. I.V.U. demonstrating ureteral obstruction, taken immediately after surgery.
with extensive disease. In case 1 the diagnosis would not have been established by such a diagnostic procedure. Reimplantation of an obstructed ureter is possible in almost every case, but may not be the procedure of choice. If the bladder is severely involved, as in case 4, implantation may well lead to fistulas . If the involved kidney is not infected and nonfunctioning, transplantation of the ureter may lead to pyelonephritis in an already nonfunctioning kidney. Case 5 demonstrates the problems of infection even after retrograde studies in the partially obstructed ureter. Case 3 also demonstrates the risks of infection when the ureter is opened or catheters are placed into a nonfunctioning kidney. A subtotal
REFERENCES
I. Gray, L. A.: Clin. Obstet. Gynecol. 3: 472, 1960.
2. Venable, J. H.: AM. ]. 0BSTET. GYNECOL. 113: 1054, 1972. 3. Andrews, W. C., and Larsen, G. D .: AM. J. OssTET. GYNECOL. 118: 643, 1974. 4. Brooks, R. T., Fraser, W. E., and Lucus, W. E.: J. Urol. 102: 184, 1969.
June 15, 197:i
-'-'"· J. Obstet . GynecoL
hysterectomy was done in cases 4 and 5 because of this consideration. In this group of patients, and in our own experience, freeing the ureters and complete pelvic surgery offers the best chance for recovery. Bulkley, Canow, and Esterson 5 emphasized the point that resection is not needed for treatment if complete removal of all ovarian tissue is carried out. In certain cases, however, reimplantation of the ureter into the normal bladder must still remain the procedure of choice.1 2 Gynecologists in general approach bilateral oophorectomy in young patients with great concern, and rightly so. In cases with extensive pelvic endometnosis, however, this concern is not warranted. Kerr 11 in his review of 4 7 cases reported two postoperative deaths. Both of these patients had "refused castration." Surely, how the problems and management of bilateral salpingo-oophorectomy are presented to the patient will govern her course and response to such a procedure. If the physician harbors great concern about such treatment his anxieties will be passed on to the patient. All five of the patients in this series received postoperative estrogen therapy and suffered no recurrence of disease or symptoms of estrogen lack. The question of the postoperative administration of estrogens causing recurrent endometriosis may well be due to incomplete removal of all ovarian tissue. When extensive pelvic endometriosis is present, clamping of the infundibulopelvic ligament without adequate exposure of the ureter may leave small fragments of ovarian tissue in the clamp. With remaining ovarian tissue extensive disease will progress with or without the administration of estrogens. More IVP's should be taken on patients with extensive pelvic endometriosis. Irradiation of pelvic endometriosis with ureteral obstruction has not led to satisfactory results. Incomplete surgery has also failed to alleviate symptoms and ureteral obstruction.
5. Buikiey, G. T., Canow, L., and Esterson, R. D.: J. Urol. 93: 139, 1965. 6. Chinn, J., Horton, R . K ., and Rusche, C. : J. Urol. 77: 144, 1957. 7. Kawasaki, D . M .: AM. J. OssTET. GYNECOL. 95: 579, 1965. 8. Kistner, R. W.: Gynecology, Principles and Practice, Chicago, 1969, Year Book Medical Publishers, Inc.
Volume 122 Number 4
Pelvic endometriosis and ureteral obstruction 469
9, Ball, T L' AM J, OBsTET, GvNECOL, 84: 1516, 1962. 10. Ratliff, R. K., and Cranshaw, W. B.: Surg. Gynecol. Obstet. 100: 414, 1955.
1L KPrr_ W, s_, Jr,: C!in, Obstet. GynecoL 9: 331, 1966, 12. Abdel-Shahid, R. B., Beresford, J. M., and Curry, R. H.: Obstet. Gynecol. 43: 113, 1974.
Discussion DR. R. B. DuRFEE, Portland, Oregon. The five cases
resulting in more pain, along with urinary and bowel problems; on the other hand, once these patients have had a total hysterectomy and bilateral salpingo-oophorectomy, they usually may be placed on estrogens, orally or parenterally, without fear of further trouble from endometriosis. My point is that in these latter patients perhaps the endometriosis is no longer active and has "burned out," leaving only the multiple adhesions that must be dealt with surgically. Thus there would be no remaining endometriosis to be reactivated by exogenous estrogen stimulation. DR. LANGMADE (Closing). Dr. Durfee, I appreciate your thorough consideration of this problem and also your experience with ureteral obstruction due to endometriosis. Dr. Kirk, your question of a desmoid type of reaction with the extensive fibrosis found in these cases poses a very interesting problem. The one slide that we used this morning certainly does look very much the same as a desmoid reaction; however, following bilateral salpingooophorectomy, the fibrosis in these patients all cleared up remarkably well. Dr. Rust, your question of retroperitoneal fibrosis again is an interesting thought. I know you have had considerable experience with this condition. The only thing I can say is that none of these patients was on any drugs that have been implicated in the diagnosis of retroperitoneal fibrosis. Dr. Thomas, there is inde€d controversy over the part that estrogens play in the postoperative management of these patients and also questions as to recurrence of endometriosis after the administration of estrogens. It is still my feeling, however, that recurrence of the disease with the administration of estrogens means inadequate removal of all the ovarian tissue. There is something in ovarian secretions that we do not have in the oral preparations that we use and, as you know, research in the medical centers of this country is rather scant in regard to endometriosis. There are no large grants that I am aware of for studying ovarian secretions compared to oral preparations and this would be a very good study for the future.
of endometriosis of the ureter reported by Dr. Langmade are a contribution to knowledge of this disease. These cases represent a large number of an apparently very rare pathologic entity. According to Ochsner, the first case of endometriosis involving the ureter was reported by H. Hauser in 1938, but Kerr stated that T. S. Cullen in 1917 reported a case of massive pelvic endometriosis involving both ureters as well as many other organs. As of the present date there are 85 cases reported in the literature, 25 of which are solitary lesions. Ureteral endometriosis is either extrinsic or intrinsic. There are two forms of the intrinsic disease; in one, there are endometrial cysts with fibrosis and thickening within the wali of the ureter; in the second, there is projection of the endometriosis into the lumen of the ureter-this is designated intraureteral endometrioma. Among others, there are six cases of bilateral ureteral obstruction and 18 cases of an isolated nodule producing unilateral obstruction. Clearly these are not the same disease in the sense that one is massive and the other is not. There have been four cases within the past 10 years in Portland: one was a unilateral lesion with extensive pelvic endometriosis; another was bilateral with endometriosis discovered 5 years ioilowing T AH for myoma and adenomyosis; the other two were unilateral obstruction \vithout specific involvement of the ureteral tissues by endometriosis. The question of stromal endometriosis (endometrial stromal sarcoma) arises in some of the more extensive lesions associated with this disease. Treatment must be aggressive and conservative management is not indicated. DR. JEsSE A. RusT, San Diego, California. In all of your cases was the diagnosis of endometriosis obvious at laparotomy, and was there no question of differential diagnosis between it and retroperitoneal fibrosis? DR. WILLIAM 0. THoMAs, JR., Portland, Oregon. As Dr. Langmade has pointed out that, if any ovarian tissue remains following surgery for extensive pelvic endometriosis, there will often be a ftareup of the endometriosis
T o o M u c H emphasis has been placed on the "remaining" ovary in young people with extensive pelvic endometriosis compromising normal renal or gastrointestinal physiology. 1 Small areas of pelvic endometriosis, many times diagnosed at the time of surgery in young patients, surely should be treated differently from endometriosis obstructing the ureters or bowel in any age group. 2 • 3 Pelvic endometriosis as the sole cause of ureteral obstruction has received relatively little consideration in the general study of the disease. 4 • 7 In the reported cases several salient points have been repeatedly stressed by the various authors: ( 1) it is difficult to make the differential diagnosis of extensive pelvic endometriosis vs. extensive pelvic carcinoma; ( 2) incomplete surgery for extensive pelvic endometriosis leads to further difficulties; ( 3) the use of progestational drugs in extensive endometriosis is of little or no value; (4) complete removal of all ovarian tissue and removal by dissection of the ureteral block is the treatment of choice.
and obstruction. Large masses of collagen and fibrocollagenous tissue with rare glands are included in the usual picture. A decidual edematous reaction may be produced in this tissue by the administration of progestins, and in some cases decidual necrosis has been described. 8 The clinical benefits of such treatment in extensive disease are limited and during the administration of these drugs ureteral obstruction may occur. Edema and necrosis of the superficial layers of the larger masses of endometriosis and collagenous fibrous tissue does little if anything to relieve ureteral obstruction. Ciinicai materiai
From 1961 to 1974 inclusive, five cases of ureteral obstruction due to pelvic endometriosis were seen. The vague nature of pelvic endometriosis is emphasized by a comparison of a much larger group of patients seen during the years 1961 to 1970, at the USC/LACGH Medical Center, where no similar cases were encountered by the author. Only two cases of extensive pelvic endometriosis were seen at the Medical Center from 1946 to 1970 and neither case caused ureteral obstruction. Five cases of ureteral obstruction due to histologically proved endometriosis were seen from 1961 to 1974 and all of these patients have been followed closely to the present time. A brief summary of each case is given in Table I. In case 1 there were no pelvic findings of endometriosis, however, the iliocecal endometriosis in this case influenced the management a great deal.
Pathology
The classic picture of endometrial glands surrounded by fibrous tissue is not the pattern seen in long-standing disease leading to periureteral fibrosis From Huntington Memorial Hospital. Presented at the Forty-first Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Near Bend, Oregon, October 6-10, 1974. Reprint requests: Dr. Charles F. Langmade, 65 N. Madison Ave., Pasadena, Caiijornia 9i iOi.
463
464
langmade
June 15, 197S Am. ]. Obstet. Gynecol.
Fig. 3. Postoperative I.V.U. Fig. 1. Endometrial glands over the sacral promontory obstructing the right ureter.
Fig. 2. Preoperative I.V.U.
The peritoneal endometriosis and scar were removed as advocated by Ball, 9 but this may have regressed after bilateral salpingo-oophorectomy. The administration of oral estrogens caused no recurrence of symptoms. Fig. 1 demonstrates the glands found over the sacral promontory. Figs. 2 and 3 reveal the preoperative obstruction and the postoperative pyelogram. In case 2 the gross diagnosis of pelvic endometriosis is of the utmost importance. Incomplete surgery at the time of the first operation led to ureteral obstruction and a second hospitalization. Glands were well demonstrated in the tubo-ovarian area of pelvic endometriosis. Fig. 4 demonstrates the preoperative obstruction and Fig. 5 shows the postoperative study after release of the ureteral obstruction. In the premenopausal age group (case 3) with unilateral ureteral obstruction, endometriosis should be considered and complete surgery done to preserve renal function. The glands over the sacral area were demonstrated to be pelvic endometriosis. Fig. 6 illustrates postoperative renal studies. In case 4 no ureteral transplantation was considered because of the questionable viability of the left kidney, massive endometriosis of the bladder,
Volume 122 Number4
Pelvic endometriosis and ureteral obstruction 465
Fig. 4. Preoperative I.V.U. demonstrating obstruction of the right ureter.
and absence of any urinary tract infection. A total hysterectomy could have been done; however, it would have been difficult and the remaining ureter and kidney may have been compromised. Endometriosis invading the bladder is well demonstrated in Fig. 7. In Fig. 8 the dense fibrous tissue involving the ureters containing few glands is shown. In Fig. 9 the preoperative nonfunctioning left kidney is illustrated. In case 5, because of the questionable stricture, the urologic consultant did a retrograde study which revealed a patent ureter (Fig. 10). This study was followed by temperatures of 103° and 104°, pyuria, and E. coli bacteriuria. The patient was acutely ill for 5 days. She responded to antibiotics and was discharged on the sixteenth postoperative day. Comment
The management of ureteral obstruction due to endometriosis requires for the most part a thorough understanding of the kidney function, the degree and duration of the obstruction, and the condition of the involved ureter and bladder. If the patient is young and ureteral obstruction is present, the value of the "remaining" ovary must be placed in its proper perspective. In this series, cases 2, 3, and
Fig. 5. Postoperative I.V.U.
4 all would have avoided ureteral obstruction and further surgery if bilateral salpingo-oophorectomies had been performed at the time of the. initial surgery. The problems of incomplete surgery in this disease have been emphasized many times. Saving an ovary or a part of an ovary leads to uniformly poor results. Ratliff and Cranshaw10 reported a 34-year-old patient with ureteral obstruction because one ovary had been left in at the time of her original surgery. The best results in their series were achieved by total surgical removal of uterus, tubes, and ovaries. Their case treated by x-ray after freeing up a ureter resulted in persistent hydronephrosis. In general, the main symptoms of this condition should be referable to the genitourinary system, but this is not always true. Kerr11 reported that 49 per cent of his cases had flank pain and 13 per cent had hematuria. Patient 4, with the most widespread disease and loss of one kidney, had no pain at any time. One half of Kerr's reported patients had pelvic masses or nodules and 28 per cent had irregular bleeding. He advised culdoscopy for establishing the diagnosis and with this we would disagree because the procedure would be impossible in some cases and ill-advised in others, such as No. 4,
466
langmade
Am.
Fig. 6. Postoperative I.V.U.
J.
June 15, 19/ ;) Gynecol.
Obst~t.
Fig. 7. Endometriosis of bladder.
Table I. Clinical data Case
Age
I Parity I
46
3
49
4
44
5
44
G.U. symptoms
Dysmenorrhea, menor- Right CV A pain rhagia, RLQ pain
39
2
Symptoms
2
2
Previous surgery
Renal status
Good renal function
Appendectomy
T otal abdominal hysterectomy; left salpingo-oophon to my
Pelvic pain
Right hydronephrosis, Left CVA pain, previous right CVA right hydroureter; good renal function pain
Menopausal symptoms
Previous left CVA pain
Good renal function
Previous left hydronephrosi: left salpingo-oophorectomy and left nephrectomy for infection
None
None
Nonfunctioning left kidney, right normal
Cesarean section x2
Lower abdominal pain
None
Left hydroureter and None hydronephrosis; pyelonephritis after retrograde study
Volume 122 Number4
Pelvic endometriosis and ureteral obstruction 467
Fig. 8. Dense fibrous tissue with endometrial glands involving the ureters.
Fig. 9. Preoperative I.V.U. demonstrating nonfunctioning kidney. Postoperative I.V.U. remained the same.
Findings at surgery
Treatment
Endometriosis right pelvic brim obstructing right ureter; endometriosis along right iliac artery
Total abdominal hysterectomy; bilateral salpingo-oophorectomy; postoperative
Hard mass of endometriosis obstructing right ureter; hydroureter, hydronephrosis
Right salpingo-oophorectomy; postoperative estrogens
5 yr., 7 mo.: Symptom-free Normal kidney function Normal IVU Right hydronephrosis and hydroureter subsided
Uterine fibroids, extensive endometriosis surrounding the right ureter and comprising an almost frozen pelvis
Total abdominal hysterectomy; right sal pingo-oophorectomy; postoperative estrogens
6 yr., 6 mo.: Symptom-free Normal renal function Absent left kidney
Endometriosis bladder, vagina, pelvis; obstruction left ureter, cystic nonfunctioning left kidney; small normal right kidney; ureter surrounded by endometriosis
Subtotal obdominal hysterectomy; bi .. lateral salpingo-oophorectomy; postoperative estrogens
Extensive endometriosis; obstruction, left ureter with hydroureter and hydronephrosis
Subtotal abdominal hysterectomy; bilateral salpingo-oophorectorny; postoperative estrogens
estrogens
Follow-up II yr., 6 mo.: Symptom-free ~Jormal kidney function Normal IVU Right hydronephrosis and hydroureter subsided
.d. ........ -.1 J''•J
~
IJ
........... llf.Voo
Symptom-free Non-functioning left kidney Normai renai function, right No return of function, left kidney 7 mo.: Symptom-free Normal renal function Left hydroureter and hydronephrosis subsided
468 longmade
Fig. 10. I.V.U. demonstrating ureteral obstruction, taken immediately after surgery.
with extensive disease. In case 1 the diagnosis would not have been established by such a diagnostic procedure. Reimplantation of an obstructed ureter is possible in almost every case, but may not be the procedure of choice. If the bladder is severely involved, as in case 4, implantation may well lead to fistulas . If the involved kidney is not infected and nonfunctioning, transplantation of the ureter may lead to pyelonephritis in an already nonfunctioning kidney. Case 5 demonstrates the problems of infection even after retrograde studies in the partially obstructed ureter. Case 3 also demonstrates the risks of infection when the ureter is opened or catheters are placed into a nonfunctioning kidney. A subtotal
REFERENCES
I. Gray, L. A.: Clin. Obstet. Gynecol. 3: 472, 1960.
2. Venable, J. H.: AM. ]. 0BSTET. GYNECOL. 113: 1054, 1972. 3. Andrews, W. C., and Larsen, G. D .: AM. J. OssTET. GYNECOL. 118: 643, 1974. 4. Brooks, R. T., Fraser, W. E., and Lucus, W. E.: J. Urol. 102: 184, 1969.
June 15, 197:i
-'-'"· J. Obstet . GynecoL
hysterectomy was done in cases 4 and 5 because of this consideration. In this group of patients, and in our own experience, freeing the ureters and complete pelvic surgery offers the best chance for recovery. Bulkley, Canow, and Esterson 5 emphasized the point that resection is not needed for treatment if complete removal of all ovarian tissue is carried out. In certain cases, however, reimplantation of the ureter into the normal bladder must still remain the procedure of choice.1 2 Gynecologists in general approach bilateral oophorectomy in young patients with great concern, and rightly so. In cases with extensive pelvic endometnosis, however, this concern is not warranted. Kerr 11 in his review of 4 7 cases reported two postoperative deaths. Both of these patients had "refused castration." Surely, how the problems and management of bilateral salpingo-oophorectomy are presented to the patient will govern her course and response to such a procedure. If the physician harbors great concern about such treatment his anxieties will be passed on to the patient. All five of the patients in this series received postoperative estrogen therapy and suffered no recurrence of disease or symptoms of estrogen lack. The question of the postoperative administration of estrogens causing recurrent endometriosis may well be due to incomplete removal of all ovarian tissue. When extensive pelvic endometriosis is present, clamping of the infundibulopelvic ligament without adequate exposure of the ureter may leave small fragments of ovarian tissue in the clamp. With remaining ovarian tissue extensive disease will progress with or without the administration of estrogens. More IVP's should be taken on patients with extensive pelvic endometriosis. Irradiation of pelvic endometriosis with ureteral obstruction has not led to satisfactory results. Incomplete surgery has also failed to alleviate symptoms and ureteral obstruction.
5. Buikiey, G. T., Canow, L., and Esterson, R. D.: J. Urol. 93: 139, 1965. 6. Chinn, J., Horton, R . K ., and Rusche, C. : J. Urol. 77: 144, 1957. 7. Kawasaki, D . M .: AM. J. OssTET. GYNECOL. 95: 579, 1965. 8. Kistner, R. W.: Gynecology, Principles and Practice, Chicago, 1969, Year Book Medical Publishers, Inc.
Volume 122 Number 4
Pelvic endometriosis and ureteral obstruction 469
9, Ball, T L' AM J, OBsTET, GvNECOL, 84: 1516, 1962. 10. Ratliff, R. K., and Cranshaw, W. B.: Surg. Gynecol. Obstet. 100: 414, 1955.
1L KPrr_ W, s_, Jr,: C!in, Obstet. GynecoL 9: 331, 1966, 12. Abdel-Shahid, R. B., Beresford, J. M., and Curry, R. H.: Obstet. Gynecol. 43: 113, 1974.
Discussion DR. R. B. DuRFEE, Portland, Oregon. The five cases
resulting in more pain, along with urinary and bowel problems; on the other hand, once these patients have had a total hysterectomy and bilateral salpingo-oophorectomy, they usually may be placed on estrogens, orally or parenterally, without fear of further trouble from endometriosis. My point is that in these latter patients perhaps the endometriosis is no longer active and has "burned out," leaving only the multiple adhesions that must be dealt with surgically. Thus there would be no remaining endometriosis to be reactivated by exogenous estrogen stimulation. DR. LANGMADE (Closing). Dr. Durfee, I appreciate your thorough consideration of this problem and also your experience with ureteral obstruction due to endometriosis. Dr. Kirk, your question of a desmoid type of reaction with the extensive fibrosis found in these cases poses a very interesting problem. The one slide that we used this morning certainly does look very much the same as a desmoid reaction; however, following bilateral salpingooophorectomy, the fibrosis in these patients all cleared up remarkably well. Dr. Rust, your question of retroperitoneal fibrosis again is an interesting thought. I know you have had considerable experience with this condition. The only thing I can say is that none of these patients was on any drugs that have been implicated in the diagnosis of retroperitoneal fibrosis. Dr. Thomas, there is inde€d controversy over the part that estrogens play in the postoperative management of these patients and also questions as to recurrence of endometriosis after the administration of estrogens. It is still my feeling, however, that recurrence of the disease with the administration of estrogens means inadequate removal of all the ovarian tissue. There is something in ovarian secretions that we do not have in the oral preparations that we use and, as you know, research in the medical centers of this country is rather scant in regard to endometriosis. There are no large grants that I am aware of for studying ovarian secretions compared to oral preparations and this would be a very good study for the future.
of endometriosis of the ureter reported by Dr. Langmade are a contribution to knowledge of this disease. These cases represent a large number of an apparently very rare pathologic entity. According to Ochsner, the first case of endometriosis involving the ureter was reported by H. Hauser in 1938, but Kerr stated that T. S. Cullen in 1917 reported a case of massive pelvic endometriosis involving both ureters as well as many other organs. As of the present date there are 85 cases reported in the literature, 25 of which are solitary lesions. Ureteral endometriosis is either extrinsic or intrinsic. There are two forms of the intrinsic disease; in one, there are endometrial cysts with fibrosis and thickening within the wali of the ureter; in the second, there is projection of the endometriosis into the lumen of the ureter-this is designated intraureteral endometrioma. Among others, there are six cases of bilateral ureteral obstruction and 18 cases of an isolated nodule producing unilateral obstruction. Clearly these are not the same disease in the sense that one is massive and the other is not. There have been four cases within the past 10 years in Portland: one was a unilateral lesion with extensive pelvic endometriosis; another was bilateral with endometriosis discovered 5 years ioilowing T AH for myoma and adenomyosis; the other two were unilateral obstruction \vithout specific involvement of the ureteral tissues by endometriosis. The question of stromal endometriosis (endometrial stromal sarcoma) arises in some of the more extensive lesions associated with this disease. Treatment must be aggressive and conservative management is not indicated. DR. JEsSE A. RusT, San Diego, California. In all of your cases was the diagnosis of endometriosis obvious at laparotomy, and was there no question of differential diagnosis between it and retroperitoneal fibrosis? DR. WILLIAM 0. THoMAs, JR., Portland, Oregon. As Dr. Langmade has pointed out that, if any ovarian tissue remains following surgery for extensive pelvic endometriosis, there will often be a ftareup of the endometriosis
