ureteral endometriosis with severe hydronephrosis
Description
DISCUSSION SUMMARY
◉ Site and Epidemiology:
• The distal third of the ureter, or the upper 3–4 cm above the bladder junction, is primarily affected by UE.
◉ Pathogenesis:
• Implantation theory: endometrial tissue is implanted as a result of surgical seeding or retrograde menstrual flow.
• Urinary involvement can be explained by distant dissemination through vascular or lymphatic pathways.
◉ Diagnosis:
• The most prestigious is histopathology.
• Imaging:
• TVS (specificity 100%, sensitivity 97%).
• MRI (specificity 100%, sensitivity 87%).
• To assess hydronephrosis, CTU, IVP, renal scan, and ultrasound are required.
• For patients unable to have TVS or to distinguish between cancer and other conditions, MRI is helpful.
◉ Grouping:
• Intrinsic UE (≈20%): invasion of the lumen, submucosa, or ureteral wall.
• External compression from the surrounding endometriotic tissue is known as extrinsic UE (≈80%).
◉ Medical Care:
• Only pain is alleviated by hormonal therapy (OCPs, progestogens).
• Ineffective for fibrosis or ureteral strictures.
◉ Options for Surgical Management:
• Ureterolysis: for minor lesions (less than 3 cm) with extrinsic UE.
• For severe or intrinsic situations, end-to-end anastomosis along with segmental resection is used.
• For lower ureteral involvement, ureterocystostomy is used.
• The recurrence rate of laser incision is significant (around 60%).
• Temporary, high recurrence balloon dilatation/stenting (as demonstrated in this example).
◉ Outcomes from Studies:
• In approximately 86.7% of 668 cases, simple ureterolysis was successful.
◉ When hydronephrosis recurs:
• 12% following ureterolysis.
• 3.1% following ureterovesical anastomosis.
• Recurrence rate for ureterocystostomy: 3.3%; 80% success rate.
◉ Advances in Surgery:
• By evaluating blood perfusion intraoperatively, indocyanine green (ICG) can increase safety.
◉ Significance of the Case:
• represents intrinsic UE that responds poorly to stenting and balloon dilatation.
• Segmental resection combined with end-to-end anastomosis produced a definitive cure.
◉ Details about the Patient:
• Age/Sex: female, age 51
• History:
• Unintentional discovery of right-sided hydronephrosis (3-week history).
• No signs of pain or urination.
• Eight years ago, I had hysteroscopic surgery to remove endometrial polyps.
• no endometriosis history.
• 22 years old, married, and had a vaginal birth.
◉ Clinical Outcomes
• Physical Examination:
• Renal regions are not complete.
• slight soreness at the right upper ureteral point and minor percussion pain in the right renal area.
• Lab:
• Level of creatinine: 80 µmol/L
• eGFR: 69.88 milliliters per minute
• Imaging Results:
• KUB, IVP, and CTU:
• The upper-middle right ureter has 1.5 cm of stenosis.
• severe hydronephrosis on the right side.
• Right kidney cortical thinning (A).
• narrowing that is marked and has a small contrast passage (B).
• 3D reconstruction: limited visualization of the right kidney (C).
Protocol
◉ Course of Treatment:
• The first step is:
• balloon dilatation and stent implantation in the right ureter.
• On ureteroscopy, there is narrowing.
• After two months, the stent was removed.
• A week later, the hydronephrosis returned.
• The second step is:
• Repeat the stent placement and dilation.
• same recurrence following the removal of the stent.
◉ Definitive surgery:
• Under general anesthesia, ureterolysis, ureteral stenectomy, and end-to-end anastomosis are performed.
• Four months later, the double J stent was removed.
• Post-operative pathology:
• right ureter endometriosis verified by:
• Endometrial foci are visible in the HE stain (D).
• Endometrial glandular cells that are ER-positive (E).
• Stromal cells that are CD10-positive (F).
• he patient's issues include right-sided severe hydronephrosis, which is a kidney swelling brought on by an accumulation of urine and is brought on by ureteral stenosis (narrowing).
• delayed diagnosis due to a subtle and asymptomatic appearance.
• hydronephrosis and symptom recurrence following initial therapy.
• risk of renal function loss in the absence of treatment.
• lumbar pain and stiffness in the right side.
• medicine failure because it was unable to relieve the ureteral blockage.
◉ Interventions in Management Surgery:
• Stent insertion and retrograde ureteral balloon dilatation were among the first methods used to treat the stricture.
• Repeat balloon dilation and stenting were performed due to recurrent symptoms and prolonged hydronephrosis, however the results were not good in the long run.
• Ureteterolysis (removing adhesions from the ureter), ureteral stenectomy (removing the constricted segment), and ureteral end-to-end anastomosis were the final surgical procedures.
• monitoring following surgery and managing stents till they recover.
◉ Nursing Interventions:
• Observation and Evaluation
• regular evaluation of the degree and location of lumbar discomfort.
• To identify renal impairment, track renal function tests (eGFR, serum creatinine).
• keeping an eye out for symptoms of infection, urinary blockage, or recurrence.
• careful observation of the properties and production of urine.
• Prior to surgery:
• Patient education regarding surgical techniques, postoperative expectations, and the nature of the disease.
• getting ready for diagnostic and imaging procedures.
• emotional support as a result of kidney function and surgery-related anxiety.
• After Surgery:
• keeping ureteral stents intact and guarding against infection or dislodgement.
• pain control based on the patient's requirements.
• keeping an eye out for indications of problems like infection, leaking, or persistent blockage.
• promoting early mobilization in accordance with the surgeon's recommendations in order to aid in healing.
• Long-Term Monitoring:
• routine renal ultrasonography tests to identify the recurrence of hydronephrosis early.
• counseling for patients with symptoms that call for immediate medical care.
• Encourage commitment to diagnostic monitoring and follow-up appointments.
Notes
FOR MORE DETAILS VISIT: https://pmc.ncbi.nlm.nih.gov/articles/PMC11350447/?utm_source=chatgpt.com
