Bilateral ureteral endometriosis-an indolent, aggressive, and dangerous condition.

Objective: To describe an unusual bilateral ureteral reimplantation due to endometriosis and to provide a flowchart of conservative decision making.

Design: Video description of a case, demonstrating a step-by-step explanation of the decision planning and description of the surgical steps in a female patient with bilateral ureteral endometriosis who had previously undergone operation for bowel endometriosis, and who presented with extensive disease in the posterior compartment with no symptoms besides bilateral renal function disruption. The study was reviewed and approved by the Hospital Beneficência Portuguesa de São Paulo Institutional Review Board.

Setting: Tertiary referral center.

Patients: Deep infiltrating endometriosis involving the ureter has an incidence of 0.1% to 1%, normally affecting the lower one-third of its segment, up to 4 cm above the vesicoureteric junction. Bilateral ureteral involvement occurs in 9% of cases. The absence of specific symptoms makes the diagnosis of this condition challenging. Lumbar pain develops when its involvement is complicated by marked obstruction with impaired renal function. Decompressive surgery is mandatory. The necessity of ureteroneocystostomy increases along with the severity of hydronephrosis, accounting for 62% of ureteral decompressive procedures. However, bilateral ureteroneocystostomy is a rare procedure, not exceeding 6% of ureteral reimplantations. This case illustrates a situation in which a patient with a previous bowel segmental resection presented with an advanced bilateral posterior deep infiltrating endometriosis, compromising the lower rectum below the previous anastomosis, vagina, posterior, and lateral parametrium bilaterally and both inferior hypogastric plexi. Hormonal therapy improved endometriosis symptoms but did not control the urinary tract involvement. Along with the patient, considering a high probability of intestinal, urinary, and sexual impairment, a conservative approach was chosen.

Intervention: The procedure started with adesiolysis, accessing the retroperitoneum and identifying both dilated ureters (Figs. 1 and 2). They were dissected as caudally as possible, until endometriosis fibrosis was reached, to have a bigger length of proximal ureter to allow a tension-free ureteroneocystostomy. The Retzius space was developed, and the bladder was freed and mobilized (Fig. 3). After cutting the ureter, the proximal end was spatulated. The bladder dome was approximated to the psoas muscle with an interrupted suture to permit a tension-free ureteroneocystostomy. The detrusor muscle was opened for approximately 2 to 3 cm, exposing the vesical mucosa, which was subsequently opened. The posterior ureterovesical anastomosis was performed with running monofilament absorbable 4-0 sutures. A double-J stent was placed, and the anterior ureterovesical anastomosis was completed. The detrusor muscle was loosely closed over the ureter with interrupted absorbable sutures to avoid urinary reflux. A Maryland clamp was used to ensure sufficient entry of the tunnel. All these steps were repeated in the contralateral side.

Main Outcome Measure(s): Successful performance of a bilateral laparoscopy tension-free ureteroneocystostomy with bilateral psoas hitch.

Results: The postoperative course was uneventful. Renal function was restored. One year after surgery, the patient remained asymptomatic, and endometriotic lesions showed no increase, thus remaining stable.

Conclusion: Ureteral endometriosis can be aggressive and indolent. Decompressive procedures must be performed. The decision-making process must take into consideration the patient's characteristics and expectations. In selected cases, a conservative approach may be required, when future possible functional disfunctions can be worse than the actual symptoms. In those situations, close surveillance is necessary.