陳威任¹、黃逸修^{1, 3, 5}、陳怡仁^{2, 4}、林登龍^{1, 3, 5}、陳光國^{1, 3, 5}

¹臺北榮民總醫院泌尿部，²婦女醫學部；³國立陽明大學醫學系泌尿學科，⁴婦產學科；⁵書田泌尿科學研究中心

Wei-Jen Chen¹, Eric Yi-Hsiu Huang ^{1, 3, 5}, Yi-Jen Chen ^{2, 4}, Alex T. L. Lin^{1, 3, 5}, Kuang-Kuo Chen^{1, 3, 5}

Department of Urology¹, Department of Obstetrics and Gynecology², Taipei Veterans General Hospital; Department of Urology³, Department of Obstetrics and Gynecology⁴, School of Medicine, National Yang-Ming University; Shu-Tien Urological Science Research Center⁵

 

Endometriosis occurred in 10-15% of women of childbearing age. Ureteral involvement is a rare manifestation of endometriosis and occurs in only about 0.1% of women. The diagnosis is challenging since up to 50% of patients are asymptomatic and may cause silent kidney or progressive renal function loss. There is no high evidence based treatment protocol available currently. Literature is limited in case series and laparoscopic resection of the endometriosis tissue seems to be the preferred management now. Robotic-assisted management of ureteral endometriosis is a viable option but was scarcely reported. We reported 4 cases of ureteral endometriosis with severe obstructive uropathy successful treated by robotic-assisted segmental resection and ureteroureterostomy or ureteroneocystostomy (RUU or RUC).

From January 2013 to September 2015, 3 women received RUU and 1 woman received RUC due to ureteral endometriosis related obstructive uropathy were reviewed.

Mean age was 36.25 year old (range 29-48), with mean follow-up time 12.5 months (range 3-32). One patient was incidentally found to have hydronephrosis, and 3 patients were initially presented with ipsilateral flank pain. All patients had normal serum creatinine (range 0.62-0.97mg/dl) preoperatively  . Diagnosis was proved by MRI imaging. The mean time of hydronephrosis to definitive treatment was 29.25 months (range 2-75). Left lower third ureter was involved in 3 patients, right lower third ureter was involved in 1 patients. All 4 patients had previous treatment failure by double-J stenting with or without medical treatment. Pre-op ureteroscopy had been performed in all 4 patients, but only 1 patient had endometriosis tissue invasion confirmed by ureteroscopic biopsy. Double-J stenting was performed for all the patients intraoperatively and was removed 4-6 weeks after the operation. The proximal and distal ureter cut ends were examined by frozen section during the operation to ensure free of endometriosis tissue. Permanent pathology reports all confirmed endometrial glands in the ureteral wall. One patient received myomectomy together, and another patient received hysterectomy and left oopherectomy simultaneously. The mean blood loss was 132.5cc (range 30-250). No complication occurred. All patient received diphereline treatment for 6 months after the operation. Follow-up sonography at post-op 3 months all showed resolves of hydronephrosis. Two patients with follow-up of more than one year were free of hydronephrosis.

Our experiences proved the feasibility and efficacy of robotic-assisted approach in this rare situation. The preliminary results seemed promising and prospective patient enrollment is undergoing.