微創手術治療輸尿管子宮內膜異位症導致之阻塞性腎水

腫 - 單一醫學中心之報告

徐明蔚、黃志平、張議徽

中國醫藥大學附設醫院 泌尿部

Minimal Invasive Surgery for the Treatment of Ureteral Endometriosis Related Obstructive Uropathy – A Single-Center Experience

Ming-Wei Hsu, Chi-Ping Huang, Yi-Huei, Chang

Department of Urology, China Medical University Hospital, Taichung, Taiwan

Purpose

Endometriosis outside the reproductive tract is not common and ureteral endometriosis is even rare, with reported prevalence less than 1%. Most patients with ureteral endometriosis are asymptomatic but may present with silent hydronephrosis and subsequent loss of renal function.  Patients often underwent hormonal therapy or regular double-J stenting initially.  Surgical intervention is warranted if previous management failed. Here, we provide seven cases successfully treated with minimal invasive surgery in our institution.

Materials and Methods:

From 2016 to 2022, seven female endometriosis patients in CMUH were enrolled, with initial presentation of hydronephrosis and pathology-confirmed as either intrinsic or extrinsic ureteral endometriosis. Five of them underwent ureteroureterostomy and two of them underwent ureteroneocystostomy, respectively.

Results

Among seven patients, five underwent segmental ureteral resection with end-to-end anastomosis and two underwent ureteroneocystostomy. Two of them are robotic surgery. Mean age was 34.8 years old (range 27-46), with mean follow-up time 21.1 months (range 3-62). Three patients initially presented with unilateral flank pain; three patients were asymptomatic and the last one complained of hematuria at first. Imaging modalities disclosed hydronephrosis in all of them and the diagnosis of ureteral endometriosis was supported by MRI or CT imaging. Preoperatively, six patients had normal serum creatinine (range 0.84-1.07mg/dl) and one had impaired renal function with serum creatinine level of 1.26.
All patients underwent ureteroscopy and had treatment by double-J stenting previously, with or without medical treatment.  Lower third ureter was involved in five patients, and middle third ureter was involved in two patients. Double-J stent was placed for all the patients intraoperatively and was removed 4-6 weeks later. The mean operative time was 249.1 min (range, 187–355 min), and the mean postoperative hospital stay was 5.7 days (range, 4–9 days).

Formal pathology reports all revealed endometrial glands over peri-ureter area, which cause obstructive nephropathy.  No complications occurred. Only two patients received hormonal therapy after the operation. Two months after surgery, follow-up sonography all showed resolves of hydronephrosis. 

Conclusion:

Surgery is ultimately needed for ureteral endometriosis patients who show poor response to hormonal therapy and intolerance to the complications of  long-term double-J ureteral stent placement. Our center performed minimal invasive surgery for these patients with low postoperative stays, no complications and no recurrence.