Laparoscopic diagnosis and treatment of urinary tract endometriosis in a referral center

The diagnosis of extra-genital Deep Endometriosis is very frequent in referral centers. The urinary tract represents the second most affected extra-genital site. Bladder Endometriosis is defined as Deep Endometriosis infiltrating the detrusor muscle, partially or fully. Ureteral endometriosis is subdivided into intrinsic and extrinsic form, with an obstruction to the spread of parametric Deep Endometriosis. Patients often come to a referral center after a long period of lack of medical therapy and / or several incomplete surgeries. While patients with Bladder Endometriosis are symptomatic, Ureteral Endometriosis is more often low / asymptomatic, leading to progressive and silent renal failure. Having a systematic model of pre-operative diagnosis, an intra-operative evaluation plan using the cooperation of a multi-disciplinary team in a referral center, represents the solution able to reducing the consequences of late diagnosis and offer precise surgical treatment. A complete ultrasound scan (pelvic and abdominal) performed by an experienced operator could allow the diagnosis; second level exams (Magnetic Resonance Imaging, CT urograhy, scintigraphy) can help to confirm and define it. The treatment of Bladder Endometriosis depends on various factors (symptoms, extent of the disease, age of the patients, childbearing desire). In cases of refractory to medical therapy, laparoscopic surgery is the treatment that leads to more complete cure, long-term relief of symptoms and low relapse rates. Any ureteral stenosis caused by an intrinsic lesion requires a ureteral resection. Ureterolysis is the procedure for removing extrinsic ureteral lesions that do not cause direct stenosis, preventing disease progression. An intraoperative evaluation of the ureters after ureterolysis is mandatory to determine the surgical outcome. The laparoscopic nerve-sparing eradication of Deep Endometriosis of the urinary tract is the way to provide good results in terms of symptoms’ control and relapses, an improvement of quality of life with a low post-operative complications rate. The possibility in a reference center to make use of a multidisciplinary team is essential to be the best surgical strategy before and intraoperatively.

Keywords: deep endometriosis; bladder endometriosis; ureteral endometriosis; partial cystectomy; uretero-neocystostomy.