輸尿管子宮內膜異位追蹤大於十年之案例報告

林育安 康智雄

高雄長庚紀念醫院外科部泌尿外科

Ureteral endometriosis mimicking infiltrating urothelial tumor with follow-up mor than 10 years: A Case Report

Yu-An Lin Zhi-Xiong Kang

Division of Urology, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital

Introduction

Endometriosis is a common, estrogen-dependent gynecological disorder, but its deep infiltrating manifestation in the urinary tract, specifically ureteral endometriosis (UE), is a rare condition. Occurring through either extrinsic compression by surrounding pelvic lesions or direct intrinsic infiltration into the ureteral wall, UE triggers a severe fibrotic response that progressively narrows the ureteral lumen. Patients are frequently asymptomatic or present with non-specific pelvic pain, which frequently leads to a delayed diagnosis. Consequently, this silent progression often results in obstructive uropathy, severe hydronephrosis, and potentially irreversible loss of renal function. This is a case report which described a UE patient followed up for more than 10 years.

Case presentation

This is a 55-year-old female patient with uterine myoma history. She complained intermittent right flank pain for years. She came to our out-patient department in 2010 where abdominal CT showed right hydronephrosis. Right lower ureter showed wall thickening and a mass-like lesion at lower ureter also observed. We performed right ureteroscopy which showed urothelial tumor-like lesion at lower ureter. Tumor biopsy was done for the lesion which showed endometriosis. Double J stent was inserted and hydronephrosis then improved. After that, she came for Double J replacement every 6 months. Her last Double J replacement was performed on 2020/09/21. Menopause was found in that year. Therefore, we removed Double J in 2021 and did not put new one inside. After 5-year-follow-up, no hydronephrosis was found during the period.

Discussion

Ureteral endometriosis (UE) is a silent threat to renal health, affecting roughly 1% of patients with deep infiltrating endometriosis (DIE). Often asymptomatic until irreversible renal atrophy occurs, UE is categorized into extrinsic compression or intrinsic wall infiltration. Because standard exams frequently overlook retroperitoneal involvement and hormonal therapy is ineffective against fibrotic strictures, clinical guidelines advocate for routine renal sonography alongside TVUS and MRI. Furthermore, ureteroscopy (URS) with biopsy plays a vital role in the diagnostic workup, providing histopathological confirmation of endometriotic lesions and allowing for the exclusion of malignancy or other primary ureteral pathologies.

Management strategies prioritize preserving renal function, with the placement of a Double-J (DJ) stent serving as a versatile conservative or temporizing option. In cases where surgery is high-risk, delayed, or when acute hydroureteronephrosis is present, a DJ stent can be used to bypass the obstruction and restore urinary flow. This minimally invasive intervention relieves pressure on the kidney and provides a window of stability before a definitive treatment plan is established, offering a crucial non-surgical path for maintaining renal health in the short term.

When conservative measures are insufficient, definitive surgical intervention becomes necessary. The choice between ureterolysis—the meticulous "shaving" of the ureter from surrounding fibrotic tissue—and segmental resection depends on the depth of infiltration. Ureterolysis is typically the preferred approach for extrinsic disease, while intrinsic involvement often necessitates a more radical resection followed by ureteroureterostomy or ureteroneocystostomy. Modern laparoscopic and robotic-assisted techniques have significantly improved surgical precision, ensuring that the primary goal of preserving long-term renal function is met with reduced postoperative morbidity.