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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT  
Year : 2011  |  Volume : 22  |  Issue : 1  |  Page : 130-133
Rare case of ureteral endometriosis presenting as hydronephrotic kidney


Department of Surgery, MGM Medical College & MY Hospital, Indore, India

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Date of Web Publication30-Dec-2010
 

   Abstract 

A 29-year-old woman presented with unilateral loin pain because of severely hydro­nephrotic kidney due to deposits of pelvic endometriosis. Double J-stent was placed beyond the obstruction and she was started on hormone therapy. The stent was removed after three months when back pressure changes had resolved. This case is being presented along with a short relevant discussion, due to rarity of ureteral involvement by endometriosis.

How to cite this article:
Gupta SS, Singh O, Shukla S, Mathur RK. Rare case of ureteral endometriosis presenting as hydronephrotic kidney. Saudi J Kidney Dis Transpl 2011;22:130-3

How to cite this URL:
Gupta SS, Singh O, Shukla S, Mathur RK. Rare case of ureteral endometriosis presenting as hydronephrotic kidney. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2019 Nov 20];22:130-3. Available from: http://www.sjkdt.org/text.asp?2011/22/1/130/74386

   Introduction Top


Endometriosis is a common disorder affecting 5-10% of women of reproductive age. [1] It is a benign condition that can sometimes be quite aggressive with a high local recurrence. [2] Pelvic endometriosis can infrequently involve the uri­nary tract.. [3] Involvement of ureter is very rare [4] and accounts for only 0.1-0.4% of cases. [2] Diag­nosis of ureteral endometriosis is often difficult as it presents with non-specific symptomato­logy. [2] Treatment should be given as early as possible to avoid development of obstructive uropathy. [4] We report a case of a 29-year-old female with unilateral extrinsic ureteral involve­ment by pelvic endometriosis, presenting as hy­dronephrotic kidney. Endometriosis was trea­ted conservatively with hormone therapy (levonorgestrel-IUD) and ureteral obstruction was relieved by temporary placement of a double J­stent.


   Case Report Top


A 29-year-old woman presented to our sur­gical clinic because of dull pain over left loin associated with dysuria since the age of 25. She did not have any vaginal discharge or painful menstruation. She had two children and her cycles were normal, regular and lasting for 3-5 days. On examination, her left kidney was found to be enlarged. An ultrasound showed grossly hydronephrotic left kidney with left hydrourete­rosis. Radiograph of KUB region did not reveal any radiopaque shadow. Her serum creatinine and blood urea levels were 1.8 and 48 mg/dL, respectively. A magnetic resonance imaging along with a urogram was got done using ga­dolinium as contrast, which revealed severe obstruction of left distal ureter with proximal hydroureterosis and hydronephrosis, with nor­mal functioning left kidney [Figure 1]A and B.
Figure 1: Magnetic resonance imaging along with a urogram of a 29-year-old woman presenting with
hydronephrotic kidney, showing (A) severe obstruction of left distal ureter with severe hydronephrosis and (B) severe obstruction of left distal ureter with severe hydroureterosis but functioning left kidney.


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Cause of obstruction was shown to be com­pression of distal ureter by deposits of pelvic endometriosis [Figure 2]A and B. This was the first time when she was diagnosed as a case of pelvic endometriosis with compression of the ureter; she had not taken treatment for the same. Ureteroscopy was performed and a double J­stent was passed through the compressed distal left ureter with little difficulty into the left renal pelvis. At the same time, an intrauterine device containing 52 mg of levonorgestrel (Mirena) was placed in the uterus. Patient was followed up every month with ultrasonography (USG) which showed decreasing hydronephrosis and hydro­ureterosis. At three months, when hydronephro­sis resolved, the stent was removed and the pa­tient was followed up clinically as well as ra­diologically with USG and contrast studies for the next eight months. She has not experienced symptom recurrence for the last one year and is still being followed up.
Figure 2: Magnetic resonance imaging along with a urogram of a 29-year-old woman presenting with hydronephrotic kidney, showing (A) deposits of pelvic endometriosis around left ureter, marked by arrow (cross-sectional view) and (B) deposits of pelvic endometriosis around left ureter, marked by single arrow, leading to proximal hydroureterosis, marked by multiple arrows (coronal view).

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   Discussion Top


Endometriosis is a common disorder affecting 5-10% of women of reproductive age. [1] It is a biologically benign, albeit aggressive, pathology with high local recurrences, [2] which can exceptionally involve the urinary tract and the ureter in particular. [3] Involvement of the urinary tract by endometriosis occurs in about 1% of women with pelvic endometriosis, and it mainly affects the bladder. [1],[5],[6] Ureteral involvement occurs rarely and accounts for only 0.1-0.4% of cases. [4] Moreover, ureteral involvement followed by development of obstructive uropathy can occur unilaterally or bilaterally. [7]

Ureteral endometriosis leads to variable deg­ree of ureteral obstruction which may be caused by extrinsic or intrinsic disease; the extrinsic form occurs four times more often than intrin­sic. [8] Extrinsic involvement of ureter occurs as a result external compression by adjacent endo­metriosis, and inflammation and fibrosis caused by it. Although the majority of cases due to extrinsic involvement are nearly always limited to the distal third of the ureter, as in the present case, rare cases of proximal ureteral involve­ment have also been described. [7] Rarely, ureteric involvement can also be intrinsic due to im­plantation of endometrial tissue in the wall of the ureter. [7]

The clinical characteristics of involvement of the ureters by endometriosis are not so clear. Ureteral endometriosis is typically marked by non-specific symptoms. [2],[7] Moreover, recognition of this condition with resultant obstructive uro­pathy usually depends on alteration in renal functions, with a significant rise in serum crea­tinine, a fact which along with non-specific pre­sentation, makes the preoperative diagnosis often difficult and delayed. This results in progressive deterioration of renal function due to the obstruction. [2],[3],[7],[8],[9] About 25% patients develop irreversible renal damage because of the delay in diagnosis. [4] Thus, it is suggested that imaging of the urinary tract, with either intravenous uro­graphy or preferably isotope renography, should be used routinely to assess any patient with endometriosis, [10],[11] and thereby, to prevent the fibrotic complications and permanent renal da­mage that can occur with this disease. [12] But the condition should be suspected in a pre-meno­pausal woman with unilateral or bilateral distal ureteral obstruction of uncertain cause. [9]

The management of obstructive uropathy caused by endometriosis has, in the past, relied essen­tially on surgical approaches including uretero­lysis, distal ureterectomy and ureteral reimplan­tation or interposition of an ileal segment bet­ween the ureter and bladder. [13] Surgery to resect the involved segment of ureter along with en­dometriotic tissue and re-implant the ureters (uretero-cystoneostomy) has shown long-term favorable results. [2] More recently, the benefit of the use of hormonal treatment of endometriosis, in general, has been applied to endometriosis in­volving the urinary tract, with variable success. [13] Reversal of ureteral endometriosis has also been reported on treatment with progestin, [14] gonado­tropin-releasing hormone (GnRH) agonists [3] and danazol. [15] However, once fibrosis has occurred, danazol does not seem to alter the course of ureteric obstruction. [16] Generally, about 80-90% of women gain relief with any particular hor­mone therapy. [17] Frachet et al regarded the sur­gical treatment associated or not with GnRH agonist to be the best treatment. [3] But it should be highlighted that monitoring of renal functions for obstructive uropathy at regular intervals is needed for all patients with endometriosis. [18]

In conclusion, involvement of ureters by pel­vic endometriosis is uncommon but should be suspected in a pre-menopausal woman with unilateral or bilateral distal ureteral obstruction of uncertain cause. Key to the successful out­come is an early diagnosis and relief of obs­truction. Long-term hormonal management can cure the disease entity.

 
   References Top

1.Olive DL, Schwartz LB. Endometriosis. N Engl J Med 1993;328:1759-69.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Antonelli A, Simeone C, Frego E, Minini G, Bianchi U, Cunico SC. Surgical treatment of ureteral obstruction from endometriosis: our experience with thirteen cases. Int Uro J Pelvic Floor Dysfunct 2004;15:407-12.  Back to cited text no. 2
    
3.Frachet O, Mallick S, Comoz F, Rousselot P, Bensadoun H. Ureteral obstruction from endo­metriosis: a case report and review of the lite­rature. J Gynecol Obstet Biol Repord (Paris) 2006;35:500-3.  Back to cited text no. 3
    
4.Moore JG, Hibbard LT, Growdon WA, Schifrin BS. Urinary tract endometriosis: Enigmas in diag­nosis and management. Am J Obstet Gynecol 1979;134:162-72.  Back to cited text no. 4
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5.Jenkins S, Olive DL, Haney AF. Endometriosis: Pathogenetic implications of the anatomic dis­tribution. Obstet Gynecol 1986;67:335-8.  Back to cited text no. 5
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6.McGuire EJ, Gudziak M, O'Connell H, Ali V. Gynecological aspects of urology. In: Gillen­water JY, Grayhack JT, Howard SS, Duckett JW, eds. Adult and Pediatric Urology. Mosby, St Louis 1996:1853-78.  Back to cited text no. 6
    
7.Gagnon RF, Arsenault D, Pichette V, Tanguay S. Acute renal failure in a young woman with endometriosis. Nephrol Dial Transplant 2001; 16:1499-502.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Generao SE, Keene KD, Das S. Endoscopic diagnosis and management of ureteral endo­metriosis. J Endourol 2005;19:1177-9.  Back to cited text no. 8
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9.Klein RS, Cattolica EV. Ureteral endometriosis. Urology 1979;13:477-82.  Back to cited text no. 9
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10.Langmade CF. Pelvic endometriosis and ure­teral obstruction. Am J Obstet Gynecol 1975; 122:463-9.  Back to cited text no. 10
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11.Manyonda IT, Neale EJ, Flynn JT, Osborn DE. Obstructive uropathy from endometriosis after hysterectomy and oophrectomy; two case re­ports. Eur J Obstet Gynecol Reprod Biol 1989; 31:195-8.  Back to cited text no. 11
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12.Brough RJ, O'Flynn K. Recurrent pelvic endo­metriosis and bilateral ureteric obstruction asso­ciated with hormone replacement therapy. BMJ 1996;312:1221-2.  Back to cited text no. 12
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13.Metzger DA, Luciano AA. Hormonal therapy of endometriosis. Obstet Gynecol Clin North Am 1989;16:105-22.  Back to cited text no. 13
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14.Gantt PA, Hunt JB, McDonough PG. Progestin reversal of ureteral endometriosis. Obstet Gynecol 1981;57:665-7.  Back to cited text no. 14
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15.Jepsen JM, Hansen KB. Danazol in the treat­ment of ureteral endometriosis. J Urol 1988; 139:1045-6.  Back to cited text no. 15
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16.Rivlin ME, Krueger RP, Wiser WL. Danazol in the management of ureteral obstruction secon­dary to endometriosis. Fertil Steril 1985;44:274-6.  Back to cited text no. 16
[PUBMED]    
17.Speroff L, Fritz MA. Endometriosis. In Clinical Gynecologic Endocrinology and Infertility, 7th ed. Philadelphia: Lippincott Williams and Wilkins; 2005;1103-3.  Back to cited text no. 17
    
18.Yohannes P. Ureteral endometriosis. J Urol 2003; 170:20-5.  Back to cited text no. 18
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Correspondence Address:
Shilpi Singh Gupta
Department of Surgery, MGM Medical College & MY Hospital, Indore 452001
India
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PMID: 21196629

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    Abstract
    Introduction
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    References
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