Urinary tract endometriosis: Enigmas in diagnosis and management J. GEORGE LESTER WILLIAM BARRY
MOORE T.
HIBBARD A.
GROWDON
S. SCHIFRIN
Los Angeles, California The diagnosis and management of endometriisls presents several enigmas. This review, of eight patients with endometriosis involving the urinary tract, from three large clinical services in the City of Los Angeles, highlights some very difffcult probfems. Not only diagnoskc errors but also inappropriate conservatism and inadequate surveiflance have fed to compromised function, resection, and/or destruction of the klneys, ureters, or btadder. The series indicates those findings which are likely to result in urinary tract destruckon and points out those clinical situations in which delays or conservative management ‘must be underdvbken only with pressing indicatiins and then only with continued and careful surveillance.
with significant involvement of the urinary tract is not particularly uncommon. Involvement of the urinary bladder is more common, but associated ureteral obstruction presents a more serious threat to renal function. The magnitude of this threat has become apparent only in recent years. In 1960, a review of the world literature uncovered only 15 reported cases of endometriotic obstruction of the ureter. By 1965, Kerr’s’ review brought the total up to 47 and, in 1974, Durfee, in discussing Langmade’s” report of five cases before this Society, reported 85 such cases in the literature. Reports since thetr-” and the present series bring the total to over 100 patients with ureteral obstruction caused by endometriosis. It is quite probable that there is a far larger number unreported and even unrecognized. In the largest series of endometriosis with ureteral obstruction (11 cases collected over a 40 year period). ENDOMETRIOSIS
From the Departments of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles County-University of Southern Calfornia, and Cedars-Sinai Medical Centers. Presented at the Forty-jiith Annual Coast Obstetrical and Gynecological Beach, Oregon, September 26-30,
Meeting Society,
of the Pactjtr Gleneden
1978.
Reprint requests: Dr. J. George Moore, University qf California, Los Angeles, Medical Center, Department of Obstetrics and Gynecology, Los Angetes, Calgofornia 90024.
162
Stanley and associates’” emphasized that the relative paucity of specific diagnostic symptoms or physical signs augured against an early apprec:iation of a threat to the urinary tract, Catamenia-associated symptoms and even microscopic hematuria represent diagnostic exceptions. Generally excretory urograms taken in the investigation of backache, headache, hypertension, or a pelvic mass bring a suspicion of endometriosis into focus. Occasionally cystoscopy. retrograde ureteropyelograms, and even laparoscopy fail to indicate endometriosis. The present report demonstrates the importance of paying careful attention to the uterosacral ligaments in evaluating ureteral obstruction in women of menstrual age. It is apparent that when the cardinal and the uterosacral ligaments are involved with endometriosis, the ureters and kidneys are at risk and careful surveillance is in order. As indicated by Kerr,’ Meigs emphasized this point four decades ago. Most authors”. 3 indicat.e that prudent management of ureteral obstruction from endometriosis includes relief of obstruction (ureteral lysis, implantation, or diversion), resection of endometriosis, and surgical castration (bilateral oophorectomy and hysterectomy). They emphasize that inordinate delays and what “conscrvationistic” surgery generally Green” terms lead to further problems. Such optimal management presents no great conflict if the patient is multiparous and over 40 years of age. The conflicts arise when the
0002.9378/79/100162+11$01.10/0
@ 1979 The C. V. Mosby
Co.
Volume
134
Number
2
Urinary tract endometriosis
163
Fig. 2. Operative findings in Case No. 1, showing relatively restricted extent of endometriosis involving the left ovary and uterosacral ligament. The proximal ureter, as opposed to that in Case No. 5, is widely dilated.
Fig. notic
1. Retrograde ureteropyelography but bare1.y patent distal left ureter
demonstrating in Case No.
ste1.
patient is in her twenties and strongly desires more children. In the present series an unusually young group of women, highly desirous of maintaining fertility, posed some difficult problems.
Clinical material Patient records of the Cedars-Sinai, Los Angeles County-University of Southern California, and the University of California, Los Angeles, Medical Centers were searched for patients operated upon for endometriosis with ureteral obstruction. Eight such patients, operated upon in the past 8 years, are listed in Table I. Seven were operated upon at the University of California, Los Angeles, Hospital. The record search extending back to 1965 revealed no patients operated upon for this condition at Cedars-Sinai and only one (Case No. 4) al. the Los Angeles County-University of Southern California Hospital. One of the patients operated upon at the University of California, Los Angeles, Hospital (Case No. 5) had previously had a laparoscopic exploration at Cedars-Sinai. Of the eight patients, two (Cases 1 and 7) were over 40 years of age when operated upon and were the only
Fig. 3. Operative findings in Case No. 5. Note that both ovaries and tubes are not involved. The endometrioma, not impressive on the surface, extended deeply retroperitoneal and was confined to the left uterosacral ligament, the cardinal
ligament fully occupying the “web” and the lateral wall of the rectosigmoid colon, and completely obstructing the distal left ureter. Since the kidney was no longer functional the ureter was not distended.
multiparous patients in the group. The next oldest patient (Case No. 5) was 33, had one child, was divorced, and hoped for remarriage and more children. The others (Cases 2, 3, 4, 6, and 8) were nulliparous and their ages ranged from 32 down to 21 years. Case No. 1 illustrates very well the diagnostic prob-
Table I. Clinical
data in eight
Year
Case No. 1 (age 43, gravida para 2)
cases of endometriosis
2,
Htitory
1969 1970 197 1 (UCLA)
2 (age 30, gravida
0)
1969 1970 197 1 (UCLA)
3 (age 32, gravida
0)
1967-73 1974 1975 (Indiana U.)
4 (age 25, gravida
0)
5 (age 33, divorced, gravida 4, para 1,3 therapeutic abortions)
1976
(UCLA)
1977
(USC)
1977 (CedarsSinai)
1977
(UCLA)
(UCLA)
6 (age 26, gravida
0)
1978
7 (age 44, gravida para 2)
3,
1962 (Philippines) 1965 1967- 1974 1977
8 (age
2 1, gravida
1976 1978
and
1977
TAH = Total abdominal hysterectomy; left lower quadrant; RLQ = right lower follicle-stimulating hormone. lems.
The
patient
pain
and
was
disease, including dysmenorrhea,
suffered investigated and
for
2 years
thoroughly
myelograms a mass
in
Backache, negative myelogram Dysmenorrhea and postcoital back pain. Endometriosis suspected. Progcstational suppression 3-4 cm mass at base of left broad ligament. Intravenous pyelograms showed left hydronephrosis Dysmenorrhea and infertility, 3 yr. Resection of rt. ovarian endometrioma Progressive dysmenorrhea and dyschezia 8 cm left adnexal mass. Intravenous pyelograms showed obstruction distal to left ureter Oral contraception. Blood pressure 120170 Dysmenorrhea and premenstrual dysuria Intravenous pyelograms showed medial displacement of both ureters. Laparoscopy showed extensive pelvic endometriosis. Renal scans showed hydronephrosis, hydroureter, and delayed excretion. Progestational suppression, followed by resolution of hydronephrosis Dysmenorrhea and recurrence of lo\rer abd. pain oti cessation of menstrual suppression. Blood pressure 130/90 2 yr. history of Hank pain. hematuria, and dysmenorrhea, 2 mo. history of dizzy spells and hypertension. Pelvic examination showed bluish cyst in rights fornix, fixed retroversion (of uterus, uterosacral nodularit!. Blood pressure 17Oi 120, 4+ albuminuria, microscopic hematuria. creatininc 1.3 mgi 100 ml, aldosteronc 24 mcgi24 hr. Aortograms sho\$ed 1 .i mm of right renal cortex with marked bvdronephrosis 5 mo. history of headache and hypertension. Intravenous pyelogram showed delayed left renal function and hydronephrosis. Blood pressure 180/l 10. iMinima uptake of left kidney on renal scan. l.aparoscopy showed no endometricfiis. Arteriogram showed minimal left renal cortex visualized. Blood pressure 1 IO/65 (asymptomatic except for dyschezia and dyspareunia). Pelvic examination showed 4-5 cm tender. fixed, firm mass to left of and posterior to the uterus and cervix
Resection of- left ovarian endometrioma Two term births RLQ pain and intestinal obstruction. Resection bowel resection, appendectomy TAH and IS0 (no menopausal symptoms)
vealed
massive
left
hydronephrosis
confirmed
of endometriosis,
segmental
small
RLQ and RUQ abdominal pain. FSH not elevated. Sonogram showed 9 by 9 cm right pelvic cyst. Intravenous pyelogram showed right hydronephrosis Dysmenorrhea despite oral contraceptives. Pelvic examination showed tender, nodular right uterosacral ligament. Laparoscopic biopsy showed endometriosis 3-4 cm tender mass in area of right uterosacral ligament Angulation, medial displacement, and impaired drainage of right ureter BSO = bilateral salpingo-oophorectomy; quadrant; RSO = right salpingo-oophorectomy;
with for
severe
back
and
ureter
:! to
= left salpingo-oophorectomy; RUQ = right upper quadrant;
4 cm
from
the
vesical
orifice
LLQ FSH
= =
with
retrograde
stenosis of
ted
before the onset the region of the
the marked
the
LSO
marked ureteral dilatation above the stenosis (Fig. 1). At operation a single, solid 4 cm endometrioma involving the left ovary and uterosacrai ligament engulfed the left ureter with a tensely dilated ureter superior to the mass (Fig. 2). At her age and parity management presented no problem. The endometrioma was resec-
discogenic of’ left
uterosacral ligament finally led to the presumptive diagnosis of endometriosis. Intravenous urography repyeloureterography
af@raWal
1 yr. history of. progressive dysmenorrhea with LLQ abdominal pain despite oral contraceptives. 3-4 mo. of dysuria with menses. Pelvic examination showed tender, nodular uterosacral ligaments with 2 by 6 cm nodule anterior to rectum, 3 by 5 cm irregular. firm mass anterior to uterus. Pelvic ultrasound showed mass impinging on bladder. Intravenous pvelograms showed filling defect in bladderand right hydronephrosis RLQ pain. RSO for endometrioma. Progestational suppression of rnensey
(Feb.) 1978 (Philippines) (Aug.) 1978 (UCLA) 1975 (UCLA)
0)
and diagnostic
and
total
hysterectomy,
bilateral
salpingo-oopho-
Volume Number
Urinary tract endometriosis
134 2
Operative
findings
Operative
procedure
PostOperative
165
course
Endometriosis restricted to left ovary and uterosacral ligament, with massively dilated ureter. Stenosis 2-3 cm above ureterovesical junction
TAH and BSO. Resection of distal third of left ureter. Left ureteroneocystotomy
Normal renal function. Slight urinary reflux. No problems up to 1978
Endometriosis ligament
TAH and LSO. Left ureteral lysis
Normal intravenous pyelogram. Asymptomatic with estrogens up to 1978
Retrograde pyelograms showed medial deviation of right ureter with scarred encasement from 4: to 8 cm from ureterovesical junction. Extensive endometriosis involving both ovaries, uterosacral ligaments, rectosigmoid colon, bilateral periureteral involvement, appendiceal involvement
Bilateral ureteral lysis. TAH and BSO
Uneventful postoperative course. Blood pressure 120/70. Norlutate suppression. Death 4 mo. postoperatively in auto/ train accident
Endometriosis of ovaries and uterosacral ligaments. Obstructed right ureter 2 cm from ureterovesical junction
TAH and BSO. Right ureteroneocystotomy
Uneventful postoperative course. Intravenous pyelogram showed atrophy of right kidney. Blood pressure 120/80
Isolated focus of endometriosis involving base of left broad ligament, left uterosacral ligament, ancl left lateral portion of rectosigmoid colon-largely extraperitoneal with puckering of overlying peritoneum. Frozen section revealed endometriosis obstructing left ureter. Uterus, tubes, and ovaries not involved Cystoscopy showed 2-3 cm mass in right superolateral aspect of bladder wall. Urothelium intact. Large focus of endometriosis involving omentum, wall of transverse colon, wall of Ibladder, and anterior uterine peritoneal surface Extensive endometriosis with endometrioma in right pelvis involving the right ureter, right base of urinary bladder and wall of rectosigmoid colon
Resection of left kidney and ureter. Resection of left parametrium (“the web”) with left uterosacral ligament and wedge resection of left lateral wall of rectosigmoid colon. Left uterine vessels removed but not left ovarian ligament. Left round ligament suspension of uterus. Appendectomy and curettage Open resection of bladder wall, omental resection, segmental resection of transverse colon. Right ureteral lysis. Presacral neurectomy
Uneventful postoperative course. Asymptomatic. Uses diaphragm
of left ovary and uterosacral
3-4 cm endometrioma ligament
of right
uterosacral
Uneventful
postoperative
course
Resection of right ovarian endometrioma, proximal right ureterostomy with placement of ureteral catheter, ureteral lysis, resection of endometriosis of bladder wall and rectosigmoid colon
Uneventful, with removal of ureteral stint on second postoperative day and suprapubic catheter on sixth postoperative day. Discharged with progestational menstrual suppression
Right ureterolysis, resection of endometrioma of uterosacral ligaments
Uneventful
rectomy, appendectomy, and left uteroneocystotomy were performed. In the 8 years of follow-up she has had no problems, intravenous urography is normal and there is very slight left ureteral reflux. In Case 2, after several years of severe dysmenorrhea and infertility, the patient, at the age of 28, underwent right salpingo-oophorectomy for an endometrioma of the right ovary. After two additional years of progressive dysmenorrhea and dyschezia, she developed a cystic left adnexal mass. Intravenous urography showed
postoperative
course
partial obstruction of the distal left ureter. At surgery she was noted to have extensive endometriosis of the left ovary, left uterosacral ligament, and the posterior aspect of the bladder. Because of the disabling symptoms and the extensive distribution of the endometriosis, a right salpingo-oophorectomy, total hysterectomy, and ureteral lysis were performed along with resection of all grossly apparent endometriosis. Case No. 3 had previously been reported” as demonstrating the regression of ureteral obstruction with
Fig. 4. Area of endometriosis nonfunctional.
beside collapsed ureter (obstructed distally) in Case No. 5. Kidney was
progestational suppression of menses. The following year, with return of symptoms and the development of hydronephrosis on the opposite side, and despite her nulliparity, she underwent bilateral salpingo-oophorectomy, total hysterectomy, appendectomy, resection of endometriomas, and bilateral ureteral lysis. Postoperatively she had normal ureters by intravenous pyelograms with uneventful follow-up to 4 months, when she was killed in an accident. In Case No. 4, the patient was 25 years old and nulliparous, with symptoms and findings suggestive of extensive endometriosis and right renal cortical drstruction. A thorough study of renal function indicated minimal function of the right kidney. Because of extensive endometriosis bilateral salpingo-oophorectomy, total abdominal hysterectomy, resection of endometriomas, and a right ureteroneocystotomy were done. Six weeks postoperatively the blood pressure returned to normal and the renal study showed atrophy of the right kidney with a patent right ureter. In Case No. 5 the patient presented with a 1 year history of left pelvic pain, dyspareunia, and dyschezia
and 5 months of headache and hypertension. Symptoms and findings were those of left renal cortical destruction and the diagnosis of endometriosis could not be made even on laparoscopy. During a period of observation the headache and hyl>ertension disappeared but dyschezia and dyspareuia persisted. A firm mass was noted at the base of the left broad ligament and left uterosacral ligament. At operation a single -1 cm solid retroperitoneal mass engulfed and c-ompletely obstructed the left ureter (Fig. 3). With complete destruction of the left renal cortex the urrtel was no longer dilated proximal to the ohstrut tiotl. She was subjected to a left ureteronephrertom~ including rcsection of the endometrioma (Fig. 4). a segment of the rectocolonic wall, the left uterosacral ligament. the left cardinal ligament, and the left uterine blood vessels. Because of the restricted extent of the endometriosis and her strong desire for maintaining fertility, the ovaries, tubes, and uterus were left intact. Obviously, she is scheduled for careful periodic surveillance. In Case No. 6, the patient was a 26-year-old nulligravid woman with a 6 year history of- dysmenorrhea
Volume Number
134 2
Urinary tract endometriosis
167
Fig. 5. Midline sagittal sonogram in Case No. 6 showing mass anterior to uterus involving wall of bladder. and 3 to 4 months of catemenial dysuria. On examination she was found to have a mass in the region of the right uterosacral ligament and another mass anterior to (Fig. 5), intravenous urogthe uterus. !Sonography raphy (Fig. SKI,and cystoscopy were helpful in delineating the problem. Operative exploration revealed that the tubes and ovaries were not involved (Figs. 7A and 7B) and, in view of her strong desire for children, the endometriosis, though moderately extensive and involving the transverse colon, the bladder, and the uterine wall, was resected with repair of the involved structures and ureteral lysis. This does not represent the safest management of endometriosis of this extent and careful surveillance is mandatory. Case No. ;’ represents a serious urologic problem resulting from inadequate resection of endometriomas in a multiparous woman in her 40’s. Fig. 8, A and B, illustrates the marked ureteral obstruction. Quite obviously residual ovarian tissue was left since a corpus luteum was found in the tissue containing residual endometriosis. On this occasion it was necessary to perform a right ureterostomy’ in order to ensure an adequate ureteral lumen during the ureteral lysis. Although the initial postoperative studies show a normal urinary tract, sufficient time has not elapsed to ensure integrity of the right ureter. Case No. 8 indicates the need for careful continued surveillance of patients with endometriosis of the uterosacral ligament. Two years prior to exploratory surgery, this 21-year-old nulligravid woman had endometriosis confirmed at laparoscopic biopsy of the right uterosacral ligament. The ovaries were not involved and no peritoneal endometriosis could be seen
Fig. 6. Intravenous urography at 10 minutes in Case No. 6, showing involvement of the bladder wall with ureteral dilatation above pelvic brim. outside the-cul-de-sac (Fig. 9). Continued observation disclosed a gradually enlarging 4 cm mass in the right uterosacral ligament, which was confirmed by sonography, and intravenous urography showed medial displacement and angulation of the distal ureter with partially obstructed drainage (Fig. 10, A). At exploration a 3 by 4 cm endometrioma was found in the right uterosacral ligament and, because of the fairly restricted extent of the disease and a strong desire for children, the procedure was restricted to resection of endometriosis, ureteral lysis, and appendectomy. In such cases careful surveillance is mandatory to ensure continued renal integrity. In all, three (or possibly four since in Case No. 6 there was a single but extensive endometrioma) of these eight patients had restricted foci of endometriosis primarily involving the uterosacral ligament and/or cardinal ligaments. In three of these instances, despite the threat of future renal problems, the patient was not castrated and the possibility of childbearing was maintained.
168
Moore et al.
Fig. 7A. adherent
Endometrioma omentum.
in Case
No.
6, showing
massively
Fig.
Fig. 8. Intravenous urography dronephrosis and high obstruction ureter displaced and compressed
at
7B. Case
10 minutes (A) in Case No. of the pelvic ureter and upright by endometrioma.
No.
6 atter
full
opet-a&e
dissection.
7, showing marked right hyiilm after voiding (B).
MOORE T.
HIBBARD A.
GROWDON
S. SCHIFRIN
Los Angeles, California The diagnosis and management of endometriisls presents several enigmas. This review, of eight patients with endometriosis involving the urinary tract, from three large clinical services in the City of Los Angeles, highlights some very difffcult probfems. Not only diagnoskc errors but also inappropriate conservatism and inadequate surveiflance have fed to compromised function, resection, and/or destruction of the klneys, ureters, or btadder. The series indicates those findings which are likely to result in urinary tract destruckon and points out those clinical situations in which delays or conservative management ‘must be underdvbken only with pressing indicatiins and then only with continued and careful surveillance.
with significant involvement of the urinary tract is not particularly uncommon. Involvement of the urinary bladder is more common, but associated ureteral obstruction presents a more serious threat to renal function. The magnitude of this threat has become apparent only in recent years. In 1960, a review of the world literature uncovered only 15 reported cases of endometriotic obstruction of the ureter. By 1965, Kerr’s’ review brought the total up to 47 and, in 1974, Durfee, in discussing Langmade’s” report of five cases before this Society, reported 85 such cases in the literature. Reports since thetr-” and the present series bring the total to over 100 patients with ureteral obstruction caused by endometriosis. It is quite probable that there is a far larger number unreported and even unrecognized. In the largest series of endometriosis with ureteral obstruction (11 cases collected over a 40 year period). ENDOMETRIOSIS
From the Departments of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles County-University of Southern Calfornia, and Cedars-Sinai Medical Centers. Presented at the Forty-jiith Annual Coast Obstetrical and Gynecological Beach, Oregon, September 26-30,
Meeting Society,
of the Pactjtr Gleneden
1978.
Reprint requests: Dr. J. George Moore, University qf California, Los Angeles, Medical Center, Department of Obstetrics and Gynecology, Los Angetes, Calgofornia 90024.
162
Stanley and associates’” emphasized that the relative paucity of specific diagnostic symptoms or physical signs augured against an early apprec:iation of a threat to the urinary tract, Catamenia-associated symptoms and even microscopic hematuria represent diagnostic exceptions. Generally excretory urograms taken in the investigation of backache, headache, hypertension, or a pelvic mass bring a suspicion of endometriosis into focus. Occasionally cystoscopy. retrograde ureteropyelograms, and even laparoscopy fail to indicate endometriosis. The present report demonstrates the importance of paying careful attention to the uterosacral ligaments in evaluating ureteral obstruction in women of menstrual age. It is apparent that when the cardinal and the uterosacral ligaments are involved with endometriosis, the ureters and kidneys are at risk and careful surveillance is in order. As indicated by Kerr,’ Meigs emphasized this point four decades ago. Most authors”. 3 indicat.e that prudent management of ureteral obstruction from endometriosis includes relief of obstruction (ureteral lysis, implantation, or diversion), resection of endometriosis, and surgical castration (bilateral oophorectomy and hysterectomy). They emphasize that inordinate delays and what “conscrvationistic” surgery generally Green” terms lead to further problems. Such optimal management presents no great conflict if the patient is multiparous and over 40 years of age. The conflicts arise when the
0002.9378/79/100162+11$01.10/0
@ 1979 The C. V. Mosby
Co.
Volume
134
Number
2
Urinary tract endometriosis
163
Fig. 2. Operative findings in Case No. 1, showing relatively restricted extent of endometriosis involving the left ovary and uterosacral ligament. The proximal ureter, as opposed to that in Case No. 5, is widely dilated.
Fig. notic
1. Retrograde ureteropyelography but bare1.y patent distal left ureter
demonstrating in Case No.
ste1.
patient is in her twenties and strongly desires more children. In the present series an unusually young group of women, highly desirous of maintaining fertility, posed some difficult problems.
Clinical material Patient records of the Cedars-Sinai, Los Angeles County-University of Southern California, and the University of California, Los Angeles, Medical Centers were searched for patients operated upon for endometriosis with ureteral obstruction. Eight such patients, operated upon in the past 8 years, are listed in Table I. Seven were operated upon at the University of California, Los Angeles, Hospital. The record search extending back to 1965 revealed no patients operated upon for this condition at Cedars-Sinai and only one (Case No. 4) al. the Los Angeles County-University of Southern California Hospital. One of the patients operated upon at the University of California, Los Angeles, Hospital (Case No. 5) had previously had a laparoscopic exploration at Cedars-Sinai. Of the eight patients, two (Cases 1 and 7) were over 40 years of age when operated upon and were the only
Fig. 3. Operative findings in Case No. 5. Note that both ovaries and tubes are not involved. The endometrioma, not impressive on the surface, extended deeply retroperitoneal and was confined to the left uterosacral ligament, the cardinal
ligament fully occupying the “web” and the lateral wall of the rectosigmoid colon, and completely obstructing the distal left ureter. Since the kidney was no longer functional the ureter was not distended.
multiparous patients in the group. The next oldest patient (Case No. 5) was 33, had one child, was divorced, and hoped for remarriage and more children. The others (Cases 2, 3, 4, 6, and 8) were nulliparous and their ages ranged from 32 down to 21 years. Case No. 1 illustrates very well the diagnostic prob-
Table I. Clinical
data in eight
Year
Case No. 1 (age 43, gravida para 2)
cases of endometriosis
2,
Htitory
1969 1970 197 1 (UCLA)
2 (age 30, gravida
0)
1969 1970 197 1 (UCLA)
3 (age 32, gravida
0)
1967-73 1974 1975 (Indiana U.)
4 (age 25, gravida
0)
5 (age 33, divorced, gravida 4, para 1,3 therapeutic abortions)
1976
(UCLA)
1977
(USC)
1977 (CedarsSinai)
1977
(UCLA)
(UCLA)
6 (age 26, gravida
0)
1978
7 (age 44, gravida para 2)
3,
1962 (Philippines) 1965 1967- 1974 1977
8 (age
2 1, gravida
1976 1978
and
1977
TAH = Total abdominal hysterectomy; left lower quadrant; RLQ = right lower follicle-stimulating hormone. lems.
The
patient
pain
and
was
disease, including dysmenorrhea,
suffered investigated and
for
2 years
thoroughly
myelograms a mass
in
Backache, negative myelogram Dysmenorrhea and postcoital back pain. Endometriosis suspected. Progcstational suppression 3-4 cm mass at base of left broad ligament. Intravenous pyelograms showed left hydronephrosis Dysmenorrhea and infertility, 3 yr. Resection of rt. ovarian endometrioma Progressive dysmenorrhea and dyschezia 8 cm left adnexal mass. Intravenous pyelograms showed obstruction distal to left ureter Oral contraception. Blood pressure 120170 Dysmenorrhea and premenstrual dysuria Intravenous pyelograms showed medial displacement of both ureters. Laparoscopy showed extensive pelvic endometriosis. Renal scans showed hydronephrosis, hydroureter, and delayed excretion. Progestational suppression, followed by resolution of hydronephrosis Dysmenorrhea and recurrence of lo\rer abd. pain oti cessation of menstrual suppression. Blood pressure 130/90 2 yr. history of Hank pain. hematuria, and dysmenorrhea, 2 mo. history of dizzy spells and hypertension. Pelvic examination showed bluish cyst in rights fornix, fixed retroversion (of uterus, uterosacral nodularit!. Blood pressure 17Oi 120, 4+ albuminuria, microscopic hematuria. creatininc 1.3 mgi 100 ml, aldosteronc 24 mcgi24 hr. Aortograms sho\$ed 1 .i mm of right renal cortex with marked bvdronephrosis 5 mo. history of headache and hypertension. Intravenous pyelogram showed delayed left renal function and hydronephrosis. Blood pressure 180/l 10. iMinima uptake of left kidney on renal scan. l.aparoscopy showed no endometricfiis. Arteriogram showed minimal left renal cortex visualized. Blood pressure 1 IO/65 (asymptomatic except for dyschezia and dyspareunia). Pelvic examination showed 4-5 cm tender. fixed, firm mass to left of and posterior to the uterus and cervix
Resection of- left ovarian endometrioma Two term births RLQ pain and intestinal obstruction. Resection bowel resection, appendectomy TAH and IS0 (no menopausal symptoms)
vealed
massive
left
hydronephrosis
confirmed
of endometriosis,
segmental
small
RLQ and RUQ abdominal pain. FSH not elevated. Sonogram showed 9 by 9 cm right pelvic cyst. Intravenous pyelogram showed right hydronephrosis Dysmenorrhea despite oral contraceptives. Pelvic examination showed tender, nodular right uterosacral ligament. Laparoscopic biopsy showed endometriosis 3-4 cm tender mass in area of right uterosacral ligament Angulation, medial displacement, and impaired drainage of right ureter BSO = bilateral salpingo-oophorectomy; quadrant; RSO = right salpingo-oophorectomy;
with for
severe
back
and
ureter
:! to
= left salpingo-oophorectomy; RUQ = right upper quadrant;
4 cm
from
the
vesical
orifice
LLQ FSH
= =
with
retrograde
stenosis of
ted
before the onset the region of the
the marked
the
LSO
marked ureteral dilatation above the stenosis (Fig. 1). At operation a single, solid 4 cm endometrioma involving the left ovary and uterosacrai ligament engulfed the left ureter with a tensely dilated ureter superior to the mass (Fig. 2). At her age and parity management presented no problem. The endometrioma was resec-
discogenic of’ left
uterosacral ligament finally led to the presumptive diagnosis of endometriosis. Intravenous urography repyeloureterography
af@raWal
1 yr. history of. progressive dysmenorrhea with LLQ abdominal pain despite oral contraceptives. 3-4 mo. of dysuria with menses. Pelvic examination showed tender, nodular uterosacral ligaments with 2 by 6 cm nodule anterior to rectum, 3 by 5 cm irregular. firm mass anterior to uterus. Pelvic ultrasound showed mass impinging on bladder. Intravenous pvelograms showed filling defect in bladderand right hydronephrosis RLQ pain. RSO for endometrioma. Progestational suppression of rnensey
(Feb.) 1978 (Philippines) (Aug.) 1978 (UCLA) 1975 (UCLA)
0)
and diagnostic
and
total
hysterectomy,
bilateral
salpingo-oopho-
Volume Number
Urinary tract endometriosis
134 2
Operative
findings
Operative
procedure
PostOperative
165
course
Endometriosis restricted to left ovary and uterosacral ligament, with massively dilated ureter. Stenosis 2-3 cm above ureterovesical junction
TAH and BSO. Resection of distal third of left ureter. Left ureteroneocystotomy
Normal renal function. Slight urinary reflux. No problems up to 1978
Endometriosis ligament
TAH and LSO. Left ureteral lysis
Normal intravenous pyelogram. Asymptomatic with estrogens up to 1978
Retrograde pyelograms showed medial deviation of right ureter with scarred encasement from 4: to 8 cm from ureterovesical junction. Extensive endometriosis involving both ovaries, uterosacral ligaments, rectosigmoid colon, bilateral periureteral involvement, appendiceal involvement
Bilateral ureteral lysis. TAH and BSO
Uneventful postoperative course. Blood pressure 120/70. Norlutate suppression. Death 4 mo. postoperatively in auto/ train accident
Endometriosis of ovaries and uterosacral ligaments. Obstructed right ureter 2 cm from ureterovesical junction
TAH and BSO. Right ureteroneocystotomy
Uneventful postoperative course. Intravenous pyelogram showed atrophy of right kidney. Blood pressure 120/80
Isolated focus of endometriosis involving base of left broad ligament, left uterosacral ligament, ancl left lateral portion of rectosigmoid colon-largely extraperitoneal with puckering of overlying peritoneum. Frozen section revealed endometriosis obstructing left ureter. Uterus, tubes, and ovaries not involved Cystoscopy showed 2-3 cm mass in right superolateral aspect of bladder wall. Urothelium intact. Large focus of endometriosis involving omentum, wall of transverse colon, wall of Ibladder, and anterior uterine peritoneal surface Extensive endometriosis with endometrioma in right pelvis involving the right ureter, right base of urinary bladder and wall of rectosigmoid colon
Resection of left kidney and ureter. Resection of left parametrium (“the web”) with left uterosacral ligament and wedge resection of left lateral wall of rectosigmoid colon. Left uterine vessels removed but not left ovarian ligament. Left round ligament suspension of uterus. Appendectomy and curettage Open resection of bladder wall, omental resection, segmental resection of transverse colon. Right ureteral lysis. Presacral neurectomy
Uneventful postoperative course. Asymptomatic. Uses diaphragm
of left ovary and uterosacral
3-4 cm endometrioma ligament
of right
uterosacral
Uneventful
postoperative
course
Resection of right ovarian endometrioma, proximal right ureterostomy with placement of ureteral catheter, ureteral lysis, resection of endometriosis of bladder wall and rectosigmoid colon
Uneventful, with removal of ureteral stint on second postoperative day and suprapubic catheter on sixth postoperative day. Discharged with progestational menstrual suppression
Right ureterolysis, resection of endometrioma of uterosacral ligaments
Uneventful
rectomy, appendectomy, and left uteroneocystotomy were performed. In the 8 years of follow-up she has had no problems, intravenous urography is normal and there is very slight left ureteral reflux. In Case 2, after several years of severe dysmenorrhea and infertility, the patient, at the age of 28, underwent right salpingo-oophorectomy for an endometrioma of the right ovary. After two additional years of progressive dysmenorrhea and dyschezia, she developed a cystic left adnexal mass. Intravenous urography showed
postoperative
course
partial obstruction of the distal left ureter. At surgery she was noted to have extensive endometriosis of the left ovary, left uterosacral ligament, and the posterior aspect of the bladder. Because of the disabling symptoms and the extensive distribution of the endometriosis, a right salpingo-oophorectomy, total hysterectomy, and ureteral lysis were performed along with resection of all grossly apparent endometriosis. Case No. 3 had previously been reported” as demonstrating the regression of ureteral obstruction with
Fig. 4. Area of endometriosis nonfunctional.
beside collapsed ureter (obstructed distally) in Case No. 5. Kidney was
progestational suppression of menses. The following year, with return of symptoms and the development of hydronephrosis on the opposite side, and despite her nulliparity, she underwent bilateral salpingo-oophorectomy, total hysterectomy, appendectomy, resection of endometriomas, and bilateral ureteral lysis. Postoperatively she had normal ureters by intravenous pyelograms with uneventful follow-up to 4 months, when she was killed in an accident. In Case No. 4, the patient was 25 years old and nulliparous, with symptoms and findings suggestive of extensive endometriosis and right renal cortical drstruction. A thorough study of renal function indicated minimal function of the right kidney. Because of extensive endometriosis bilateral salpingo-oophorectomy, total abdominal hysterectomy, resection of endometriomas, and a right ureteroneocystotomy were done. Six weeks postoperatively the blood pressure returned to normal and the renal study showed atrophy of the right kidney with a patent right ureter. In Case No. 5 the patient presented with a 1 year history of left pelvic pain, dyspareunia, and dyschezia
and 5 months of headache and hypertension. Symptoms and findings were those of left renal cortical destruction and the diagnosis of endometriosis could not be made even on laparoscopy. During a period of observation the headache and hyl>ertension disappeared but dyschezia and dyspareuia persisted. A firm mass was noted at the base of the left broad ligament and left uterosacral ligament. At operation a single -1 cm solid retroperitoneal mass engulfed and c-ompletely obstructed the left ureter (Fig. 3). With complete destruction of the left renal cortex the urrtel was no longer dilated proximal to the ohstrut tiotl. She was subjected to a left ureteronephrertom~ including rcsection of the endometrioma (Fig. 4). a segment of the rectocolonic wall, the left uterosacral ligament. the left cardinal ligament, and the left uterine blood vessels. Because of the restricted extent of the endometriosis and her strong desire for maintaining fertility, the ovaries, tubes, and uterus were left intact. Obviously, she is scheduled for careful periodic surveillance. In Case No. 6, the patient was a 26-year-old nulligravid woman with a 6 year history of- dysmenorrhea
Volume Number
134 2
Urinary tract endometriosis
167
Fig. 5. Midline sagittal sonogram in Case No. 6 showing mass anterior to uterus involving wall of bladder. and 3 to 4 months of catemenial dysuria. On examination she was found to have a mass in the region of the right uterosacral ligament and another mass anterior to (Fig. 5), intravenous urogthe uterus. !Sonography raphy (Fig. SKI,and cystoscopy were helpful in delineating the problem. Operative exploration revealed that the tubes and ovaries were not involved (Figs. 7A and 7B) and, in view of her strong desire for children, the endometriosis, though moderately extensive and involving the transverse colon, the bladder, and the uterine wall, was resected with repair of the involved structures and ureteral lysis. This does not represent the safest management of endometriosis of this extent and careful surveillance is mandatory. Case No. ;’ represents a serious urologic problem resulting from inadequate resection of endometriomas in a multiparous woman in her 40’s. Fig. 8, A and B, illustrates the marked ureteral obstruction. Quite obviously residual ovarian tissue was left since a corpus luteum was found in the tissue containing residual endometriosis. On this occasion it was necessary to perform a right ureterostomy’ in order to ensure an adequate ureteral lumen during the ureteral lysis. Although the initial postoperative studies show a normal urinary tract, sufficient time has not elapsed to ensure integrity of the right ureter. Case No. 8 indicates the need for careful continued surveillance of patients with endometriosis of the uterosacral ligament. Two years prior to exploratory surgery, this 21-year-old nulligravid woman had endometriosis confirmed at laparoscopic biopsy of the right uterosacral ligament. The ovaries were not involved and no peritoneal endometriosis could be seen
Fig. 6. Intravenous urography at 10 minutes in Case No. 6, showing involvement of the bladder wall with ureteral dilatation above pelvic brim. outside the-cul-de-sac (Fig. 9). Continued observation disclosed a gradually enlarging 4 cm mass in the right uterosacral ligament, which was confirmed by sonography, and intravenous urography showed medial displacement and angulation of the distal ureter with partially obstructed drainage (Fig. 10, A). At exploration a 3 by 4 cm endometrioma was found in the right uterosacral ligament and, because of the fairly restricted extent of the disease and a strong desire for children, the procedure was restricted to resection of endometriosis, ureteral lysis, and appendectomy. In such cases careful surveillance is mandatory to ensure continued renal integrity. In all, three (or possibly four since in Case No. 6 there was a single but extensive endometrioma) of these eight patients had restricted foci of endometriosis primarily involving the uterosacral ligament and/or cardinal ligaments. In three of these instances, despite the threat of future renal problems, the patient was not castrated and the possibility of childbearing was maintained.
168
Moore et al.
Fig. 7A. adherent
Endometrioma omentum.
in Case
No.
6, showing
massively
Fig.
Fig. 8. Intravenous urography dronephrosis and high obstruction ureter displaced and compressed
at
7B. Case
10 minutes (A) in Case No. of the pelvic ureter and upright by endometrioma.
No.
6 atter
full
opet-a&e
dissection.
7, showing marked right hyiilm after voiding (B).
