Hematoureter due to endometriosis

Original Video Article

Hematoureter due to endometriosis

Nisha Lakhi, M.D., Erica C. Dun, M.D., Ceana H. Nezhat, M.D.
Atlanta Center for Minimally Invasive Surgery & Reproductive Medicine, Atlanta, Georgia

This video illustrates the intra-operative identification and laparoscopic management of ureteral endometriosis in a 17-year-old female with uterine didelphys, history of left nephrectomy, and partial ureter resection.

Objective: To report the laparoscopic management of a rare case of hematoureter due to endometriosis in a young female with multiple genitourinary anomalies.
Design: Video demonstration of a surgical technique and review of genitourinary endometriosis.
Setting: Hospital.
Patient(s): A 17-year-old nulliparous female with multiple genitourinary anomalies presented with pelvic pain and unilateral retroperitoneal mass. The patient had uterine didelphys, history of left nephrectomy and partial ureter resection as an infant. She had a partial resection of a left transverse vaginal septum due to hematocolpos at age 12. A preoperative MRI revealed a left retroperitoneal mass with extension to the paravesical region, reaccumulation of the hematocolpos behind the partially resected left transverse vaginal septum, and a dilated left uterine horn with hematometria.
Intervention(s): Laparoscopic management of hematoureter due to intrinsic endometriosis.
Main Outcome Measure(s): Intraoperative findings showed uterus didelphus with dilated left horn, normal right horn and normal right and left fallopian tubes and ovaries. The left transverse vaginal septum was resected vaginally and the hemoatocolpos and hematometria drained. The left uterine horn and cervix were laparoscopically resected. The left sided serpiginous retroperitoneal mass was dissected from the pelvic sidewall, ligated, and transected with spillage of thick, brown liquid. The pathology of the mass wall was smooth muscle and transitional epithelium consistent with ureter in addition to hemorrhage and glandular structures consistent with endometriosis. Endometriosis was also present in the serosa of the left uterine horn. Thus, the left retroperitoneal mass was the left ureter remnant which acquired endometriosis and collected menstrual debris, resulting in hematoureter.
Conclusions: Two major pathological types of ureteral endometriosis have been described: intrinsic, as had occurred in this patient, and extrinsic. Women with Müllerian anomalies, vaginal obstruction, or imperforate hymen are at higher risk of endometriosis. Prior urogenital surgery can further complicate and distort the anatomy. Thus, a preoperative understanding of the patient’s urogenital anomalies is important in order to consider the differential diagnoses and anticipate surgical needs.

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