Introduction

The prevalence of endometriosis in women in reproductive age is 10-20% among the general female population [1]. Endometriosis is defined by the ectopic presence of endometrial gland and stroma outside the uterus [2]. There are three main types of endometriosis: endometrioma, what means ovarian endometriosis, superficial peritoneal endometriosis and deep infiltrating endometriosis, what means infiltrating of peritoneum more than 5mm [3,4]. Deep infiltrating endometriosis is considered as a most assertive form of endometriosis [4]. According to literature urinary tract is affected in 0.3-12% of women with endometriosis [5]. Ureter endometriosis is a rare situation and occurs in approximately 10% of urinary tract endometriosis and eight time less than bladder endometriosis [6]. There are two types of ureteral involvement: 38.5% demonstrate endometriosis inside the muscular layer (intrinsic) and 61.5% show adventitial infiltration (extrinsic) [7]. Ureter endometriosis is mostly asymptomatic and can lead to loss of renal function in 11.5% [8-11]. Laparoscopy is used successfully to manage the ureter endometriosis [12]. Ureter endometriosis is typically unilateral and bilateral occurrence is very rare [13].

Case Presentation

We present the case of a 41-year-old patient who was admitted to our endometriosis excellence center. She reported very severe dysmenorrhea and hypermenorrhea. There was a history of a laparoscopy for deep infiltrating endometriosis with partial bladder resection and right nephrectomy because of ureteral affection and subsequent loss of renal function. Four years after nephrectomy a diagnostic laparoscopy was performed, which was unremarkable. Both laparoscopies were performed in other hospitals. Drug therapy with various hormone medicaments (including dienogest, COC, etc.) has already taken place. During the hormone therapy a severe depression developed, up to suicidal thoughts, so the therapy was stopped. The patient did not wish any hormone therapy again. A laparoscopic total hysterectomy was discussed with the patient since she had definitively no longer fertility desire. Additionally, the result of cervix smear was PAP IIID. The patient was prepared for the operation and gave the consent. The renal ultrasonography was unremarkable.

The laparoscopic total hysterectomy was performed without any complications. However, intraoperatively pronounced adhesions between the sigmoid and the left pelvic wall were detected. These adhesions were partially dissolved. The peritoneum in this area was scarred with suspicion to endometriosis. Since the patient was not explicitly informed about extensive ureterolysis and because of the high risk of ureteral injury in a patient with only one kidney, it was decided to complete the procedure in this stage. The postoperative course was inconspicuous and the patient was discharged. Six months later, the patient presented to us again. She had a 6cm endometriom on left ovarian and wanted a repeat laparoscopy with complete excision of the endometriosis. Unilateral endometrioms are associated with deep infiltrating endometriosis in 40% [14]. D-J stents is not always required in surgery of deep infiltrating endometriosis [15]. However, in this case because of history of nephrectomy a D-J stent was inserted and the patient was prepared for the surgery. There were again severe sigmoid adhesions to the left pelvic wall (Figure 1).

Figure 1: Adhesion between Sigma and left pelvis wall. Endometriom.

After the adhesions were completely dissolved, complete ureterolysis took place. A large endometriotic nodule appeared on the ureter (Figure 2). The endometriotic nodule was first reduced with cold scissors (Figure 3). The nodule could then be completely removed (Figures 5). The histologically examination could confirm the endometriosis. The postoperative course was inconspicuous and the patient was discharged after three days in good health condition. She came to follow up six months after surgery. No hydronephrosis was detected. She reported significant improvement of complaints.

Figure 2: Endometiosis nodule on the ureter.