Antonelli Alessandro, Simeone Claudio, Frego Ezio, Minini Gianfranco, Bianchi Umberto, Cunico Sergio Cosciani
Clinica Urologica, Spedali Civili di Brescia, Piazzale Spedali Civili 1, 25123 Brescia, Italy.
Int Urogynecol J Pelvic Floor Dysfunct. 2004 Nov-Dec;15(6):407-12; discussion 412. doi: 10.1007/s00192-004-1171-7. Epub 2004 Jul 31.
Endometriosis is a biologically benign albeit aggressive pathology marked by high local recurrences. Ureteral involvement accounts for only a minority of cases (0.1-0.4%) with often non-specific symptoms at clinical presentation and difficult preoperative diagnosis. Thirteen cases of severe ureteral endometriosis (i.e. causing significant obstruction to the urinary flow) were observed and surgically treated, out of 17 ureteral units affected (three cases of bilateral involvement, one case of complete pyeloureteral duplicity). The initial symptomatology was acute and related to ureteral obstruction in eight cases, silent and non-specific in the other five; a presumptive diagnosis was made only for the seven patients (53.9%) with a positive medical history for pelvic (and in two cases also ureteral) endometriosis. Preoperative drainage of urine proved necessary for eight patients due to the complete functional exclusion of the excretory axis. One patient (7.7%) underwent nephrectomy due to renal atrophy. Segmental ureteral resection and termino-terminal anastomosis were performed in two patients, while seven patients underwent segmental ureterectomy and ureterocystoneostomy, with bladder psoas hitching in four cases and vesical flap according to Casati-Boari in one case. All three cases of bilateral involvement were treated by bilateral segmental ureterectomy and trans-uretero-uretero-cystoneostomy with bladder psoas hitching. Following histological examination, all patients were diagnosed with active ureteral endometriosis, which was found to be intrinsic in five cases (38.5%) and extrinsic in the other eight. One of the two patients that had undergone ureterectomy and termino-terminal anastomosis had to undergo ureteral resection and ureterocystoneostomy 22 months later due to relapsing endometriosis-induced stenosis. Conversely, no ureteral endometriosis relapses occurred in the remaining 12 patients within the mean follow-up time of 41.1 months (range 6-91). Ureteral endometriosis is marked by non-specific symptoms, making preoperative diagnosis often difficult. Therefore, an ultrasound or urographic examination of the urinary tract in case of pelvic endometriosis is absolutely essential. In our experience, terminal ureterectomy with ureterocystoneostomy has provided long-term favourable results as extended ureteral resection can be performed and continuity of the urinary tract can be restored without resorting to the distal pelvic ureter, which is often affected by the disease besides being more subject to relapses.
子宫内膜异位症是一种生物学上为良性但具有侵袭性的病理状况，其特点是局部复发率高。输尿管受累仅占少数病例（0.1 - 0.4%），临床表现往往是非特异性症状，术前诊断困难。在17个受影响的输尿管单位（3例双侧受累，1例完全肾盂输尿管重复畸形）中，观察到并手术治疗了13例严重输尿管子宫内膜异位症（即导致尿流明显梗阻）。初始症状在8例中为急性且与输尿管梗阻有关，在另外5例中为隐匿性且非特异性；仅7例（53.9%）有盆腔（2例还有输尿管）子宫内膜异位症病史的患者做出了初步诊断。由于排泄轴完全功能丧失，8例患者术前尿液引流被证明是必要的。1例患者（7.7%）因肾萎缩接受了肾切除术。2例患者进行了输尿管节段性切除和端端吻合术，7例患者进行了输尿管节段性切除和输尿管膀胱吻合术，4例采用膀胱腰大肌悬吊术，1例根据卡萨蒂 - 博阿里法采用膀胱瓣术。所有3例双侧受累病例均采用双侧输尿管节段性切除和经输尿管输尿管膀胱吻合术并结合膀胱腰大肌悬吊术治疗。经组织学检查，所有患者均被诊断为活动性输尿管子宫内膜异位症，其中5例（38.5%）为内在性，另外8例为外在性。接受输尿管切除和端端吻合术的2例患者中有1例在22个月后因复发性子宫内膜异位症导致的狭窄不得不再次接受输尿管切除和输尿管膀胱吻合术。相反，在平均41.1个月（范围6 - 91个月）的随访时间内，其余12例患者未发生输尿管子宫内膜异位症复发。输尿管子宫内膜异位症以非特异性症状为特征，术前诊断往往困难。因此，对于盆腔子宫内膜异位症患者，对泌尿系统进行超声或尿路造影检查绝对必要。根据我们的经验，输尿管末端切除并输尿管膀胱吻合术取得了长期良好效果，因为可以进行广泛的输尿管切除，并且无需借助常受该病影响且更易复发的盆腔远端输尿管即可恢复尿路连续性。
