Urinary tract endometriosis A challenging disease

Errico Zupi, M.D., Gabriele Centini, M.D., Lucia Lazzeri, M.D.

Volume 103, Issue 1, Pages 41-43


Reflections on “Urinary tract endometriosis in patients with deep infiltrating endometriosis: prevalence, symptoms, management and proposal for a new clinical classification” by Knabben et al.

  • L. Knabben

    Prof. Zupi

    Thank you very much for your distinguished comment
    concerning urinary tract endometriosis and its preoperative diagnosis.

    We consider the Endometriosis Surgical-Ultrasonographic System a very useful and
    detailed tool for preoperative mapping of endometriosis (1). Whereas this
    mapping system involves ultrasound and surgical findings, our classification
    aims at involving functional renal aspects as well and cannot be seen as a
    substitution of the mapping system by Exacoustos et al but more as an additional
    classification system. The main difference is the assessment of functional

    We fully
    agree that a prospective and multicentric approach in order to validate the
    systems should be performed.

    differences in the origin of the extrinsic endometriosis involving the ureter
    may be caused by different patient populations; in our study, the majority of
    patients suffered from large endometriosis nodules as we are a tertiary
    referral centre for this disease.

    (2) detected a reduced depth of the pouch of Douglas in women with DIE
    suggesting that such lesions cause a shrinkage of the space behind the cervix. As
    this space is laterally delimited by the uterosacral ligaments, these
    structures will consequently be involved in the nodule as the ureters will be.
    If the DIE is located more on one side than the other, the ipsilateral
    uterosacral ligament will be incorporated in the nodule more rapidly.

    Chapron (3)
    determined the uterosacral ligaments as major location of DIE as in his series
    more than half of 426 patients with DIE had an involvement of the uterosacral
    ligaments. We totally agree with Prof. Zupi that the uterosacral ligaments play
    a crucial role in the development of urogenital endometriosis, but we think
    that they might actually be two different ways to involve these structures.

    We appreciate
    your comment and will validate both classifications in future studies.


    Laura Knabben
    on behalf of the authors

    Exacoustos C
    Malzoni M Di Giovanni A Lazzeri L Tosti C Petraglia F Zupi E Ultrasound mapping
    system for the surgical management of deep infiltrating endometriosis; Fertil
    Steril 2014; 102: 143-50

    Vercellini P
    Aimi G Panazza S Vicentini S Pisacreta A Crosignani PG Deep endometriosis
    conundrum: evidence in favor of peritoneal origin Fertil Steril 2000; 73:

    Chapron C Chopin
    N Borghese B Foulot H Dousset B Vacher Lavenu MC Viera M Hasan W Bricou A
    Deeply infiltrating endometriosis: pathogenetic implications of the anatomical
    distribution Hum Reprod 2006; 1839-45

    • Errico Zupi

      Dear Laura,

      thank you for your reply. We believe that the good idea you had in proposing your classification has to be validate through a prospective study that we can conduct, if you want, together.
      At that time we will better understand how and if is useful to determine by the new classification, the ureteral involvement.
      At the same time we strongly appreciate your paper that underlined the importance of a preliminary detection of the ureteral/renal involvement in case of DIE

      Looking forward to possible future collaboration

      Best regards
      Errico Zupi

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