Key Aspects of Ureterolysis in deep endometriosis surgery

Ureters are close neighbors of some vessels and organs and necessitate care during ureterolysis.

Key Points

Importance:

• A safe approach to the ureters is essential during laparoscopic surgery for deep endometriosis.

Highlights:

• Minimal thermal energy exposure and cold instrument usage are critical to preserve ureteral integrity and minimize complications.
• Intraoperative cystoscopy and retrograde pyelography, besides tools like indocyanine green, would help in the identification of ureteral injuries during the operation.

What's done here:

• This chapter, penned by Dr. Chatroux and Dr. Einarsson, includes a brief review of deep endometriosis's epidemiology, and clinical manifestations, and explains how to optimize surgical practice involving the ureters during deep endometriosis surgery.

Basic outlines:

• Ureters that transport urine from the kidneys to the bladder have close proximity to ovaries, uterine vessels, and vaginal apices.
• Through preoperative imaging and medical history, it is important to consider variations in pelvic anatomy and Mullerian anomalies, such as ureteral duplication and renal abnormalities.
• Inspection by a skilled endometriosis radiologist to the sonography or MRI should be done preoperatively to identify ureteropelvic invasion during preoperative planning.
• The reasons that force ureteral surgery during laparoscopy are immobile left ovary, fixed right ovary, right uterosacral ligament endometriosis, left uterosacral endometriosis, and bowel endometriosis.
• Clinical presentation of ureteral endometriosis is asymptomatic in 50% of the patients; 25% have flank pain, 15% have hematuria, and 22% have hydronephrosis.
• Medical treatment to reverse fibrotic tissue is necessary, especially in cases with ureteral obstruction.
• Delayed identification of post-hysterectomy ureteral injuries increases the risk of stricture, obstruction, and fistula formation. Keeping the ureters a quiet distance from the uterus during endometriosis surgery is essential. In the case of reimplantation, adequate bladder compression via a Foley catheter and ureteral stent is crucial for healing.

Lay Summary

Deep endometriosis surgery needs talented surgeons to preserve and protect vital structures during the excision of endometriotic lesions. The technique for ureterolysis is essential to mitigate the risk of ureteral injuries and improve patient outcomes.

Dr. Chatroux and Dr. Einarsson from the Department of Obstetrics and Gynecology of Harvard Medical School, Boston, USA, summarized the ureteral anatomy, identification, and optimal surgical practice of ureterolysis; and clarified the knowledge gaps about endometriosis surgery involving the ureter.

After anatomical description and describing possible genetic anomalies of ureters, the authors pay attention to the preoperative imaging system. Assessing ovarian mobility and an expert inspection of ultrasonography is important for preoperative planning.

Extrinsic involvement of ureters includes the lesions of the peritoneum overlying and compressing ureters, while intrinsic involvement concerns the wall of the ureter, including ureteric muscular and rarely the mucosa. Either extrinsic or intrinsic involvement of ureters can lead to hydronephrosis, hydro-ureters, and even permanent renal damage.

Ureterolysis involves identifying and freeing the ureter from adjacent pathology. It aims to restore normal ureteral anatomy after the surgery for a better outcome. When possible, a nerve-sparing technique can be added to the procedure. 

 The authors concluded that surgeons can safeguard against ureteral injuries by keeping a close eye on ureters throughout the operation. This paper was recently published in Best Practice Research in Clinics of Obstetrics and Gynaecology.

Research Source: https://pubmed.ncbi.nlm.nih.gov/38614884/