输尿管子宫内膜异位症临床诊治分析

目的探讨输尿管子宫内膜异位症临床诊治及预后;方法回顾性分析2010年1月至2018年1月解放军总医院第七医学中心诊治的25例输尿管子宫内膜异位症临床资料。结果 21例有严重的痛经;5例突发腰痛,肉眼血尿1例,其余19例无明显泌尿系症状。左肾积水16例、左肾萎缩2例、右肾积水7例,所有患者均为输尿管中下段梗阻(中段4例、下段21例);肾功能重度损伤4例、中度损伤10例,轻度损伤6例,无明显损伤5例。患者均合并子宫腺肌症或卵巢子宫内膜异位囊肿;23例临床确诊后给予术前药物预处理及放置输尿管双J管;腹腔镜手术治疗24例(外在型内异症17例、内在型内异症2例、混合型内异症5例),其中输尿管周围病灶粘连松解术17例、部分输尿管切除+断端吻合术3例、输尿管膀胱植入术4例;1例经腰入路行肾切除手术。术后3个月取出输尿管双J管,随访1例持续存在轻度肾积水,1例肾萎缩、肾脏功能重度损伤,其余肾功能恢复正常。结论输尿管内异症多引起隐匿性尿路梗阻,确诊依赖于病史、影像学检查等,病理为诊断金标准,早期诊治尤为关键,腹腔镜手术治疗可以有效解除梗阻,切除内异症病灶,保护肾功能。     

输尿管子宫内膜异位症5例临床分析

目的:探讨输尿管子宫内膜异位症(输尿管内异症)的临床特点及诊治。方法:回顾性分析我院收治的5例输尿管内异症的临床资料。结果:5例患者均有肾积水及输尿管梗阻;4例有继发痛经;3例术前曾怀疑内异症进行过药物治疗;2例肾血流图检查提示单侧肾功能已很差;5例患者均进行了开腹手术,3例进行了全子宫双附件切除及部分输尿管切除和膀胱输尿管再植术/输尿管端端吻合术,1例部分输尿管切除及输尿管端端吻合术,1例全子宫切除及输尿管松解术;术后随诊时间超过6个月,1例未切除子宫及双附件者,术后1年出现继发痛经,另4例无症状。结论:多数输尿管内异症来自盆腔内异症的直接侵犯,当患者有盆腔内异症,且又出现输尿管梗阻,则高度提示输尿管内异症。应尽早手术治疗,解除梗阻,保护肾脏。除非患者渴望生育,一般最好同时切除全子宫双附件,防止复发。     

腹壁子宫内膜异位症的临床特点及复发相关因素分析

目的　探讨腹壁子宫内膜异位症 (内异症 )的临床特点及复发相关因素。方法　回顾性分析我院 1983～ 2 0 0 2年收治的 5 7例腹壁内异症患者的临床特点、治疗方法及复发情况。结果腹壁内异症占同期内异症的 1 0 4 % (5 7/5 4 78) ,我院剖宫产术后腹壁内异症发生率为 0 0 4 6 %。 5 7例腹壁内异症患者中 ,1例为原发脐部内异症 ,5 6例有下腹部手术史 ,其中 5 5例继发于剖宫产术后。发病潜伏期与发病年龄呈正相关 (P <0 0 0 1)。 5 7例腹壁内异症患者中 ,5 5例接受了手术治疗 ,2例采用药物姑息治疗。术后随诊 1 1～ 2 35个月 ,5例复发 ,其中 1例恶变。复发者的初发病灶往往较大、较深。结论　腹壁内异症根据典型的症状、体征常可正确诊断 ;对无典型症状者 ,超声诊断可辅助排除腹腔内病变。手术是惟一确实有效的治疗方法。对较大、较深的病灶 ,适当扩大切除范围 ,达到切缘干净 ,是防止复发的关键。     

输尿管子宫内膜异位症9例临床分析

目的:探讨输尿管子宫内膜异位症患者的临床诊断和治疗方法。方法:回顾性分析9例术后病理检查证实为输尿管子宫内膜异位症患者的临床资料。结果:9例中8例有痛经史。泌尿系统超声检查9例均有中重度肾积水;5例接受了CT检查,均提示患侧输尿管上段扩张伴患侧肾积水。3例腰麻下行输尿管镜检查,1例活检明确为输尿管子宫内膜异位症。4例术前诊断为子宫内膜异位症的患者采用药物治疗,肾积水没有得到明显改善。9例患者因输尿管梗阻、肾积水行手术治疗,2例行输尿管端端吻合术,6例行输尿管膀胱再吻合术,1例行肾切除;3例同期行患侧附件切除。结论:输尿管子宫内膜异位症诊断困难,在临床上对于不明原因输尿管梗阻、肾积水,且有痛经病史的患者应高度怀疑输尿管子宫内膜异位症可能,进一步的影像学检查或输尿管镜检查有助于诊断。药物治疗作用有限,明确中、重度输尿管梗阻者应积极手术治疗。     

盆腔子宫内膜异位症病灶分布特点及其腹腔镜诊断准确性的评价

目的 探讨盆腔子宫内膜异位症（内异症）病灶的分布特点以及腹腔镜用于诊断不同部位、不同类型内异症病灶的准确率及其与病理诊断的符合率。方法 对62例腹腔镜诊断的内异症病灶行切除术,对肉眼正常的腹膜随机进行活检,并均送病理检查。以病理诊断为标准,计算腹腔镜诊断不同类型、不同部位以及不同颜色内异症病灶的阳性预测值、阴性预测值及敏感度、特异度。结果 62例患者中,55例有卵巢子宫内膜异位囊肿。取得219份内异症腹膜病灶组织、54份肉眼正常腹膜组织以及71个卵巢子宫内膜异位囊肿;盆腔后半部腹膜内异症病灶占80．8％（177／219）,左侧（58．0％,127／219）多于右侧（42．0％,92／219）。盆腔腹膜内异症病灶中蓝色病灶最常见,占39．3％（86／219）。腹腔镜诊断腹膜内异症与病理诊断比较,阳性预测值为67．6％,敏感度为93．7％,阴性预测值为81．4％,特异度为38．3％。其中以蓝色病灶和左侧宫骶韧带处病灶的病理诊断阳性率最高,分别为94．2％及84．7％。卵巢子宫内膜异位囊肿中,左侧占43．6％（24／55）,右侧占27．3％（15／55）,双侧占29．1％（16／55）,其中80．3％（57／71）的卵巢子宫内膜异位囊肿被病理诊断证实。肉眼正常腹膜活检54份标本中,10例（18．5％）病理检查阳性。结论 盆腔内异症病灶的分布呈非对称性,盆腔后部多于前部,左侧多于右侧;腹腔镜下所见的蓝色病灶及宫骶韧带病灶的病理诊断阳性率较高。     

会阴子宫内膜异位症的临床分析

目的：探讨会阴子宫内膜异位症（内异位）的诊断和处理。方法：对1院1983－2000年收治的11例会阴内异症病例进行回顾性分析,术后随诊0．5－7．0年。结果：会阴内异症占我院同期内异症的0．37％,我院会阴内异症发生率为0．87／万。根据临床表现及病理检查,11例均诊断正确。除1例外,均有会阴撕裂或侧切史;发病潜伏期,30岁以前多在1年以内,30岁以上多在1年以上,两者差异有显著性（P＜0．05）。会阴内异症病灶完整切除10例,随诊6个月至7年,无复发。结论：根据典型的病史和身体检查,可以对会阴切口内异症做出正确诊断;手术切除为主要治疗方法。     

输尿管子宫内膜异位症手术相关问题

输尿管子宫内膜异位症起病隐匿,临床症状不典型,常合并无症状的肾功能丢失,早期诊断、及时处理至关重要.手术是治疗输尿管子宫内膜异位症的金标准,需要根据输尿管子宫内膜异位症的类型、病灶的大小、部位等决定相应的手术方式.手术方式有输尿管松解术、输尿管节段性切除端端吻合术、输尿管节段性切除输尿管膀胱种植术.手术治疗是安全、有效...     

泌尿道子宫内膜异位症15例临床诊疗分析

目的:探讨泌尿道子宫内膜异位症(UTE)的诊断方法及治疗效果。方法:回顾分析2000年1月至2019年1月北京大学人民医院收治且经病理证实的15例UTE患者的临床资料。结果:15例患者中有8例诊断为膀胱子宫内膜异位症(BE),7例诊断为输尿管子宫内膜异位症(UE)。12例术前行泌尿系影像学检查(80%),其中泌尿系超声10例(66.67%),泌尿系CT 12例(80%),盆腔MRI 6例(40%);8例行妇科超声检查(53.3%);10例术前行泌尿道内镜检查(66.67%),活检病理诊断UTE率达80%。15例均行手术治疗。8例BE患者中,1例(12.5%)行膀胱镜下膀胱病损切除术、5例(62.5%)行开腹膀胱部分切除术、2例(25%)行腹腔镜下膀胱病损切除术;7例病灶位于膀胱后壁(87.5%),1例病灶位于膀胱顶部正中(12.5%)。7例UE患者中,4例行输尿管部分切除+输尿管膀胱再植术(57.1%),2例行输尿管部分切除+输尿管端端吻合术(28.6%),1例行右肾、右输尿管全长切除术(14.3%);双侧输尿管受累1例,左侧输尿管受累1例,右侧输尿管受累5例。术后病理均诊断膀胱/输尿管子宫内膜异位症。6例术中同时切除卵巢EMs,4例合并子宫腺肌症者同时行全子宫切除术。15例患者均获得随访,平均随访时间7.9年(1～19.4年),5例患者术后联合GnRH-a药物治疗,15例患者术后无UTE复发,仅1例B超提示卵巢EMs复发。结论:UTE诊断依靠临床特点、病史、影像学及膀胱/输尿管镜检查。治疗方法的选择取决于患者年龄、生育要求、病变范围、泌尿系症状严重程度,手术切除为首选治疗方式且临床效果可靠。     

直肠阴道隔子宫内膜异位症的诊断及治疗

目的 探讨直肠阴道隔子宫内膜异位症(内异症)的临床诊断及治疗。方法 回顾分析我院自1992年至2002年收治的10例直肠阴道隔内异症患者的临床资料。结果 临床表现,年龄36—47岁,平均40岁;肛门坠痛6例,性交痛3例,痛经8例,慢性盆腔痛5例;三合诊时均可触及直肠阴道隔结节,平均直径3cm。血清CAl25水平升高者2例。阴道或腹部超声检查均末检出异位病灶。术前4例接受促性腺激素释放激素激动剂3．75mg/28d,共3次的治疗,可短期缓解疼痛,2例病灶体积减小。10例均行手术治疗,其中开腹手术7例、阴式手术1例、腹腔镜联合阴式手术2例。切除病灶经病理检查证实为直肠阴道隔内异症。随诊最长时间5年,完整切除病灶者预后良好,未能完整切除病灶者症状、病灶持续存在。结论 直肠阴道隔内异症以肛门坠痛、性交痛为主要表现,必须进行三合诊检查。B超的辅助诊断意义不大,修订的美国生育协会标准分期不能反映疾病的严重程度。手术是主要的治疗手段。     

腹壁子宫内膜异位症179例诊治分析

目的探讨腹壁子宫内膜异位症(简称内异症)的临床特点及治疗。方法回顾性分析2006年1月至2017年12月北京大学第一医院诊治的179例腹壁子宫内膜异位症患者,分析患者的病史、症状、辅助检查、术中情况、手术疗效、复发率及临床特点之间的相关性。并按发病部位分为皮下型及肌肉型,是否合并盆腔子宫内膜异位症分为单纯组及合并内异症组,比较各组的临床特点。结果腹壁子宫内膜异位症平均发病年龄(33.8±4.4)岁,发病时间在剖宫产术后1个月～12年,中位数2年(1～4年),自出现症状至手术确诊时间为1个月～14年,中位数2年(1～4年)。179例患者中,96%(172/179例)的患者有不同程度的周期性下腹部切口周围疼痛及触痛包块的典型症状;75例患者检测了CA125,平均(30.3±18.0)U/ml,其中22例升高;超声诊断符合率73.2%(131/179)。皮下型和肌肉型分别占61.5%(110/179)和38.5%(69/179),合并内异症组占10.1%(18/179)。合并内异症组和肌肉型患者病灶大、术中需要放置补片的比例高(27.8%,5/18)。179例患者均手术治疗,随访时间10～132个月,33例失访。手术有效率100%(146/146),复发率6.2%(9/146),症状复现中位时间1年(0.75～3.5年)。结论腹壁内异症根据典型的症状、体征常可正确诊断,手术治疗是最佳选择,病灶位于肌层和合并盆腔内异症的患者病灶较大,术中必要时使用补片修补。     

Laparoscopic management of ureteral endometriosis: our experience

STUDY OBJECTIVE: Ureteral endometriosis is rare, accounting for less than 0.3% of all endometriotic lesions. The aim of our study is to evaluate the prevalence of extrinsic ureteral endometriosis in women undergoing laparoscopic surgery for severe endometriosis and to suggest that laparoscopic ureterolysis represents a mandatory measure in all cases to avoid ureteral injury. METHODS: A retrospective analysis was performed of all cases of patients who underwent laparoscopic surgery for severe endometriosis at the departments of obstetrics and gynecology at CMCO-SIHCUS and Hautepierre Hospital, Strasbourg, from November 2004 through January 2006. MEASUREMENTS AND MAIN RESULTS: We recorded 54 patients with a mean age of 31 years and a mean body mass index of 21.9. Reported symptoms were dysmenorrhea (88%), severe dyspareunia (88%), severe pelvic pain (38.8%), and infertility (74%). Five women presented with dysuria, frequency, recurrent urinary tract infections, and pain in the renal angle, and 2 patients had hydronephrosis. We observed 3 patients (5.6%) with ureteral stenosis, 35 (64.8%) with adenomyotic tissue surrounding the ureter without stenosis, and 16 (29.6%) with adenomyotic tissue adjacent to the ureter. It was on the left side in 47.4% of cases, on the right side in 31.6% cases, and bilaterally in 21% of cases. In 9 patients, ureteral involvement was associated with bladder endometriosis (16.7%). In all patients, ureterolysis was performed. There was 1 case of ureteral injury during the procedure, 2 of transitory urinary retention, and 1 of uretero-vaginal fistula after surgery. During the first year of follow-up, the disease recurred in 4 patients, with no evidence of the disease in the urinary tract. CONCLUSION: Conservative laparoscopic surgery to relieve ureteral obstruction and remove pathologic tissue is the management of choice. Resection of part of the ureter should be performed only in exceptional cases. Ureterolysis should be performed in all patients before endometriotic nodule resection to recognize and prevent any ureteral damage.     

Importance of retroperitoneal ureteric evaluation in cases of deep infiltrating endometriosis

STUDY OBJECTIVE: To discuss our clinical and surgical experience with 30 cases of ureteral endometriosis. DESIGN: Retrospective analysis (Canadian Task Force classification II-3). SETTING: Tertiary care university hospital. PATIENTS: Records were assessed for all patients who underwent laparoscopic surgery for deep infiltrating endometriosis (DIE) from June 2002 through June 2006. Thirty patients were laparoscopically given a diagnosis that was histologically confirmed of ureteral involvement by endometriosis. INTERVENTIONS: Laparoscopic retroperitoneal examination and management of ureteral endometriosis. MEASUREMENTS AND MAIN RESULTS: Variables assessed were: preoperative findings (patient characteristics, clinical symptoms, preoperative workup), operative details (type and site of ureteral involvement, associated endometriotic lesions, type of intervention, intraoperative complications), and postoperative follow-up (short- and long-term outcomes). We recorded details of 30 patients with a median age of 33.33 years and a median body mass index of 21.96. Symptoms reported were: none in 20 (66.7%) of 30 patients, specific in 10 (33.3%) of 30, dysuria (30%), renal angle pain (10%), hematuria (3.3%), and hydroureteronephrosis (33.3%). Ureteral endometriosis was presumptively diagnosed before surgery in 40% of patients. Ureteric involvement was on the left side in 46.7%, on the right side in 26.7%, and bilaterally in 26.7%. It was extrinsic in 86.7% and intrinsic in 13.3%. It was associated with endometriosis of homolateral uterosacral ligament in all (100%) of 30, the bladder in 50%, rectovaginal septum in 80%, ovaries in 53.3%, and bowel in 36.7%. Laparoscopic intervention was: only ureterolysis in 73.3%, segmental ureteral resection and terminoterminal anastomosis in 16.7%, and segmental ureterectomy and ureterocystoneostomy in 10%. Early postoperative complications were: fever greater than 38 degrees C requiring medical therapy for 7 days in 7 patients and 1 patient had transient urinary retention requiring catheterization that resolved without further treatment. During a mean follow-up period of 14.6 months, endometriosis recurred in 3 patients with no evidence of ureteral reinvolvement. CONCLUSION: Ureteral involvement is a silent, serious complication that must be suspected in all cases of DIE. Retroperitoneal laparoscopic isolation and inspection of both ureters helps to diagnose silent ureteral involvement. Conservative laparoscopic surgery provides a safe, feasible modality for management of ureteral endometriosis.     

Rectosigmoid deep infiltrating endometriosis and ureteral involvement with loss of renal function

Endometriosis is a complex disease with unclear pathogenesis, defined as the presence of endometrial tissue (glands and stroma) outside its usual location in the uterine cavity. Ureteral involvement is rare, with an estimated frequency of 10-14% in cases of deep endometriosis with nodules of 3 cm or larger. An important complication of ureteral involvement is asymptomatic loss of renal function. In a patient with asymptomatic renal failure the relevance of extrinsic ureteral involvement by deep endometriosis has been taken to account. CASE REPORT: A 32-year-old nulliparous woman presented with chronic pelvic pain associated with severe dysmenorrhea, dyspareunia and digestive problems including diarrhea, occasional constipation and rectal bleeding. She reported no urological symptoms. Magnetic resonance imaging (MRI) identified a 4 cm nodule in the recto-vaginal septum, compressing and infiltrating the rectal wall, and chronic left hydronephrosis. Isotope renogram revealed 91% function in the right kidney and 9% in the left kidney. A multidisciplinary surgical team including consultants from the departments of digestive surgery and urology assessed the patient. The treatment recommended was a joint approach of laparoscopic surgery to perform adhesiolysis, ureterolysis, freeing of the uterus and appendages, resection of the rectovaginal septum nodule, and left nephrectomy. COMMENT: Diagnosis and treatment of deep endometriosis should be performed in specialized centers and in the context of multidisciplinary collaboration. We must be aware of the potential risk of ureteral involvement and the asymptomatic loss of renal function in any patient with endometriosis nodules of 3 cm or larger.     

输尿管子宫内膜异位症的治疗进展

输尿管子宫内膜异位症临床少见,症状隐匿,易漏诊而导致肾功能损害。治疗原则为切除病灶,解除梗阻,保护肾功能,防止复发。手术治疗是首选治疗方法,并配合以围手术期药物治疗。目前对于适宜的输尿管术式尚无定论,腹腔镜手术是今后输尿管子宫内膜异位症手术治疗的趋势。     

Surgical management of endometriosis

Both laparoscopic techniques (excision and ablation) for the treatment of superficial peritoneal endometriosis are equally effective (EL2). For the treatment of ovarian endometriomas larger than 3 cm, laparoscopic cystectomy is superior to drainage and coagulation (EL1). Excision of deep rectovaginal endometriosis with or without rectal invasion significantly reduces endometriosis-associated pain (EL4). Laparoscopic partial bladder cystectomy is easier for dome endometriosis than vesical base lesions (EL4). Hysterectomy with ovarian conservation is associated with a high risk of pain recurrence (EL4). Despite bilateral oophorectomy, pain recurrence can occur with hormonal treatment (EL2). Rates of major (ureteral, vesical, intestinal or vascular) complications of endometriosis surgery range from 0.1 to 15% of patients. Higher rates are more common with deep endometriosis surgery (EL2). Patients should be aware of these specific major complications. It is advisable to explain that pain improves, either partially or completely, in about 80% of patients.     

Deep endometriosis: definition, diagnosis, and treatment

Deep endometriosis, defined as adenomyosis externa, mostly presents as a single nodule, larger than 1 cm in diameter, in the vesicouterine fold or close to the lower 20 cm of the bowel. When diagnosed, most nodules are no longer progressive. In >95% of cases, deep endometriosis is associated with very severe pain (in >95%) and is probably a cofactor in infertility. Its prevalence is estimated to be 1%?-2%. Deep endometriosis is suspected clinically and can be confirmed by ultrasonography or magnetic resonance imaging. Contrast enema is useful to evaluate the degree of sigmoid occlusion. Surgery requires expertise to identify smaller nodules in the bowel wall, and difficulty increases with the size of the nodules. Excision is feasible in over 90% of cases often requiring suture of the bowel muscularis or full-thickness defects. Segmental bowel resections are rarely needed except for sigmoid nodules. Deep endometriosis often involves the ureter causing hydronephrosis in some 5% of cases. The latter is associated with 18% ureteral lesions. Deep endometriosis surgery is associated with late complications such as late bowel and ureteral perforations, and recto-vaginal and uretero-vaginal fistulas. Although rare, these complications require expertise in follow-up and laparoscopic management. Pain relief after surgery is excellent and some 50% of women will conceive spontaneously, despite often severe adhesions after surgery. Recurrence of deep endometriosis is rare. In conclusion, defined as adenomyosis externa, deep endometriosis is a rarely a progressive and recurrent disease. The treatment of choice is surgical excision, while bowel resection should be avoided, except for the sigmoid.     

输尿管子宫内膜异位症的诊治——附3例分析

目的:探讨输尿管子宫内膜异位症诊断和治疗中应注意的问题。方法:总结3例输尿管子宫内膜异位症临床资料和随访结果,复习国内外文献报道,进行分析讨论。结果:1例为混合型输尿管子宫内膜异位症,因梗阻严重行病灶切除输尿管端端吻合术,术后配合内分泌治疗。2例为腔外型,内分泌治疗效可,其中1例配合输尿管支架管置入术。结论:争取早期发现输尿管子宫内膜异位症,在保护肾功能的前提下制订适宜的治疗方案。     

Gonadotropin-releasing hormone agonist treatment for endometriosis of the rectovaginal septum

OBJECTIVE: This study was undertaken to evaluate the effectiveness of a 6-month course of gonadotropin-releasing hormone agonist treatment for patients with symptomatic endometriosis of the rectovaginal septum. STUDY DESIGN: Fifteen patients with rectovaginal endometriosis and moderate to severe pain symptoms were the subjects of the study. None of these patients had either clinical or objective evidence of ovarian endometriosis, nor was there evidence of any obstructive lesions of the intestine or ureters. All patients were given leuprolide acetate depot at 3.75 mg, 1 ampule intramuscularly every 28 days, and treatment had a planned duration of 6 months. Follow-up evaluations were set every 2 months during the treatment phase and every 3 months thereafter until the completion of 1 year after discontinuation of medical therapy. At each follow-up visit pain symptoms were recorded, and clinical exploration, transvaginal ultrasonography, and transrectal ultrasonography were performed. RESULTS: Two patients stopped the treatment early after the second and fourth leuprolide doses; in both cases the reason was persistence of pain, and both requested a surgical solution. The other 13 patients showed a marked improvement with respect to pain during the 6-month treatment course but had early pain recurrence after drug suspension; 11 of them required further treatment within the first year of follow-up. The failure rate of gonadotropin-releasing hormone agonist therapy to produce 1-year pain relief after treatment discontinuation was 87% (13/15) on an intent-to-treat basis. The endometriotic lesions showed a slight but significant reduction in size during therapy but had returned to the original volume within 6 months after cessation of the gonadotropin-releasing hormone analog treatment. CONCLUSION: Our results suggest that gonadotropin-releasing hormone analogs should not be considered a real therapeutic alternative to surgical treatment for patients with symptomatic endometriosis of the rectovaginal septum, except possibly in a limited and unpredictable number of cases.