Late results of surgical treatment of the ureteral lesions after gynecologic and obstetric surgery

OBJECTIVES: The increase of the radical oncological operations in gynecology and caesarean section in obstetrics constantly produce urinary tracts injuries. DESIGN: The aim of this paper is retrospective study the results surgical treatment of the ureteral lesions after gynecologic and obstetrics operations. MATERIALS AND METHODS: 65 women in average age 44 years old were undergone to analyze. The follow-up was 1-39 years (mean age 7.6 y.) after ureter injury. Anatomical and functional status of the genitourinary tracts was estimated. RESULTS: Good result was obtained in 75.3%, moderate in 10.8% and bed in 13.8% of the operated women. CONCLUSIONS: The best time for the reconstructive surgery are intraoperations period and the time between 5-14 weeks after ureteral lesions. The multiples urinary tract injures and necessity the extravesical urinary diversion give worse results of the late reconstruction urinary tracts. The percutaneous nephrostomy and employment the Psoas Hitch procedure during ureteral reimplantation, significantly improve the late results in reconstructive surgery of ureter. The late results of reconstruction urinary tracts in last lately 20 years are statistically better than obtained 20 years earlier.     

输尿管子宫内膜异位症33例临床分析

目的探讨输尿管子宫内膜异位症（简称输尿管内异症）的诊断、治疗及预后。方法回顾性分析2000年1月至2013年10月北京大学第一医院诊治的33例输尿管内异症患者的临床资料。结果患者平均年龄（41．3±5．8）岁,占同期总内异症的1．1％（33／3131）。33例患者中,6例无临床症状,27例痛经、腰腹痛及泌尿系统症状。其中输尿管内异症致左侧肾积水14例,右侧19例;输尿管下段梗阻29例,中段4例;内在型内异症9例,外在型24例。17例行肾功能检查,其中轻度损伤2例,中度3例,重度7例,无损伤5例。开腹手术18例,腹腔镜手术15例;盆腔粘连松解、输尿管病灶切除＋膀胱植入、病灶切除＋输尿管端端吻合和肾切除分别为10例、13例、6例和4例。术后随访25例（75．8％）,中位随访时间53．4个月,1例肾积水复发。结论输尿管内异症虽发病率低,但易引起较严重后果,应重视早期诊断。手术治疗为首选,可以有效保护肾功能。     

Retrocervical Deep Infiltrating Endometriotic Lesions Larger than Thirty Millimeters are Associated with an Increased Rate of Ureteral Involvement

Study ObjectiveTo estimate the presence of ureteral involvement in deep infiltrating endometriosis (DIE) affecting the retrocervical area.DesignRetrospective study of women undergoing laparoscopic treatment of DIE affecting the retrocervical area.Design ClassificationCanadian Task Force classification II-3.SettingTertiary referral private hospital.PatientsWe evaluated 118 women who underwent laparoscopy for the treatment of retrocervical DIE lesions between January 2010 and March 2012.InterventionsAll women underwent laparoscopic surgery for the complete treatment of DIE. After surgery all specimens were sent for pathologic examination to confirm the presence of endometriosis.MeasurementsPatients with pathologically-confirmed retrocervical DIE were divided into 2 groups according to the size of the lesion (group 1: lesions ≥ 30 mm; group 2: lesions < 30 mm) and the rate of ureteral endometriosis was compared between both groups.Main ResultsUreteral involvement was present in 17.9% (95% confidence interval [CI] 10%–29.9%) of women with retrocervical lesions ≥30 mm whereas in only 1.6% (95% CI 0.4%–8.5%) of those with lesions <30 mm (odds ratio = 13.3 [95% CI 1.6–107.3]).ConclusionPatients undergoing surgery for retrocervical DIE lesions ≥30 mm in diameter have a greater risk of having ureteral involvement (17.9%).     

Ureteral obstruction: an unfrequent complication of Burch colposuspension. Report of two cases

The injury of the urinary tract in a pelvic surgery is inherent, its real frequency in which it presents, is difficult to establish, due that not all the lesions are published. In this article, two cases of ureteral obstruction posterior to a Burch-procedure, and the way they were resolved is reported. The ureteral obstruction is a very rare complication, but one that has the worst and severe medico-legal consequences, if they are not resolved opportunely. Its frequency in our service was of 0.41%, in 240 Burch-procedures that were realized during April of 1997 and June of 2000.     

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.     

Nomogram for Predicting a Complex Ureteral Procedure in Pelvic Endometriosis Surgery

Study ObjectiveTo develop a nomogram for predicting the type of ureteral procedure in pelvic deep endometriosis (DE) surgery (1) and to describe the factors and complications associated with the ureteral procedure (2).DesignRetrospective monocentric study of 920 patients who underwent surgery for pelvic DE between June 2009 and March 2020 in the gynecologic surgery department of the Versailles Hospital Center. The main criterion was evaluation of the ureteral procedure, classified as simple (isolation of the ureter) or complex (dissection of the ureter, segmental ureteral resection, or nephroureterectomy). Postoperative complications, including ureteral stenosis and fistula formation, were tabulated.SettingTertiary referral hospital and expert center in endometriosis.PatientsA total of 920 patients with DE.InterventionsUreteral procedure during surgery for DE.Measurements and Main ResultsIn total, 724 patients (79%) underwent a ureteral procedure, of which 307 (33%) were complex, including 17 (1.8%) segmental ureteral resections. In multivariate analysis, the predictive variables for a complex ureteral procedure were age (p = .036), a previous surgery for endometriosis (p <.01), and ureteral dilatation on magnetic resonance imaging (p <.001). The area under the curve for the model predicting a complex ureteral procedure was 0.68 (95% confidence interval, 0.60–0.71). A complex ureteral procedure was associated with a 3.5% rate of ureteral fistula (n = 15).ConclusionAge, a previous surgery for endometriosis, a rectovaginal nodule size ≥30 mm, endometriotic involvement of the rectum or sigmoid, and ureteral dilatation are significantly associated with a complex ureteral procedure. Our results allowed us to build a nomogram that can be used to better inform patients, anticipate the therapeutic strategy, and optimize the modalities of postoperative surveillance.     

Litigations Involving Ureteral Injury Related to Minimally Invasive Gynecologic Surgery: Lessons Learned from a Legal Literature Review

Ureteral injury is a known complication of minimally invasive gynecologic surgery. Despite being discussed preoperatively and included in consent forms, litigations that involve such injury continue to be prevalent. Our aim was to review all major litigations involving ureteral injuries related to minimally invasive gynecologic surgery to determine the most common allegations from plaintiffs and highlight factors that aided defendants. We used Lexis Nexis, a comprehensive legal database, to search all publicly available federal- and state-level cases on ureteral injury related to gynecologic surgeries. Fifty-nine cases resulted from our search. Of these cases, 19 were deemed pertinent to our question. These 19 cases occurred between 1993 and 2018. The most common allegations included medical negligence, lack of informed consent, and medical battery. Eight of 19 cases (42%) were decided in favor of the defendants, 3 of 19 cases (16%) in favor of the plaintiffs, and the remaining cases proceeded to further trial or are ongoing. The monetary compensation to a plaintiff was as high as $426,079.50. Meticulous documentation, comprehensive consent procedure, timely postoperative evaluation, and the use of immediate postoperative cystoscopy were the critical factors that aided the defendants. Meticulous documentation, a comprehensive consent procedure, timely postoperative evaluation, and the use of immediate postoperative cystoscopy can aid minimally invasive gynecologic surgeons involved in litigations involving ureteral injury.     

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.     

Persisting active and proliferative intrinsic ureteral endometriosis under GNRH agonists therapy: a case with immunohistological study.

We report the case of a 30-year-old patient who underwent a segmental ureteral resection with ureteroureterostomy because of the presence of a left ureterohydronephrosis caused by an intrinsic ureteral endometriotic lesion. Preoperatively, the patient received a 3 months course of GNRH agonists. The serum estradiol level was at 12 pg/ml at the moment of surgery. Histology and immunohistochemistry performed on the resected specimen showed the presence of numerous large haemorrhagic endometriotic foci containing very high levels of alpha-estrogen and progesterone nuclear receptors, a high Ki-67 labeling index and a strong positivity for EGF-receptor. This is the first report of immunohistochemical study performed on ureteral endometriosis preoperatively treated with GNRH agonists. Because hormonal treatments are often prescribed in the treatment of ureteral endometriosis, clinicians should be aware of the possibility of persisting very active and proliferative ureteral endometriotic lesions even under treatment with GNRH agonists and very low levels of circulating estradiol.     

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.     

Is ureteral endometriosis an asymmetric disease?

Six cases of endometriosis obstructing the left ureter were observed among 1054 consecutive patients undergoing surgery in an eight-year period. In addition, 125 women with ureteral endometriosis (left-sided,   n = 66  ; right-sided,   n = 40  ; bilateral,   n = 19  ) were described in 62 articles identified in a systematic review of the English language literature between 1980 and 1998. Considering only the patients with unilateral ureteral endometriosis and combining the published figures with those of our surgical series, the observed proportion of left lesions (72/112, 64%; 95% CI 55% to 73%) was significantly different from the expected proportion of 50% (χ²i, 9.14,   P = 0.002  ). The lateral asymmetry found in the location of ureteral endometriosis is compatible with the menstrual reflux theory and with the anatomical differences of the left and right hemipelvis     

Management of ureteral endometriosis: areas of controversy

PURPOSE OF REVIEW: In this review we critically evaluate what we know and what we still do not know about pathogenesis, diagnosis and treatment of ureteral endometriosis, highlighting areas of controversy. RECENT FINDINGS: Recent studies have produced new insights into diagnostic and management options for ureteral endometriosis. SUMMARY: The diagnosis of ureteral endometriosis entails a high index of suspicion for the disorder. Imaging techniques are of limited value in providing an accurate depiction of extension of ureteral lesions. Preliminary results suggest that magnetic resonance urography is accurate in differentiating between intrinsic and extrinsic forms of ureteral involvement, but further studies are required to define its role in directing better treatment. Current controversies in the treatment of ureteral endometriosis are over whether segmental resection and anastomosis or ureterolysis are indicated, and whether minimal-access procedures are equally effective than their traditional open counterparts. Recent studies suggest that laparoscopic ureterolysis can be an effective treatment option in most patients with ureteral endometriosis but that recurrence rates are not negligible, as suggested in pioneering works. Successful application of laparoscopic surgery, even for procedures that have traditionally necessitated laparotomy, has been reported. Extensive experience with endourological techniques is prerequisite for success.     

Litigation following Ureteral Injuries associated with Gynaecological Surgery

Ureteral injury is one of the complications inherent in any gynaecological pelvic surgery. From the beginning of this century, the range of ureteral injuries during standard gynaecological surgery has been reported to be between 0.04 and 1.46 percent, with a mean of 0.21 percent (234 injuries in 110,351 operations, 1902–1998). The mean ureteral complication rate is essentially the same for the three kinds of hysterectomies performed by most gynaecologists (laparascopic-assisted vaginal hysterectomy [LAVH]-0.42%, total abdominal hysteroctomy [TAH]-0.18%, vaginal hysterectomy [VH]-0.25%). Ureteral injuries occur across the range of pathological conditions, operators and operative techniques which suggest that there is a critical incidence of ureteral injury below which gynaecological surgery has not been able to fall (in the range of 0.1 to 0.5 percent). This may be because the exact position of the ureter is not constant. The course of the ureter as it crosses beneath the uterine artery, as close as one to two cm from the lateral aspect of the uterus, is such that the margin for error is very small.In this report, we summarize the circumstances, allegations and conclusions of 13 Canadian resolved cases of litigated ureteral injuries sustained during gynaecological surgery. By reviewing these cases, surgeons may familiarize themselves with the most frequent allegations brought by plaintiffs, and the questions and principles that judges apply in reaching their conclusions. In all 13 cases, the allegation of informed consent failed as a reasonable person would have agreed to surgery under the conditions, even if the risk of ureteral injury had been disclosed. Furthermore, the risk of ureteral injury does not have to be disclosed because it is a known complication with a frequency of occurrence of less than 0.5 percent and it is not considered a material risk. The use of a pre-operative IVP, ureteral stenting or intra-operative dyes is of little value in preventing ureteral injuries. In nine of the 13 cases (70%) the judge ruled in favour of the defendant.The cardinal rules in the management of ureteral injuries during gynaecological surgery are prevention, identification of the injury intra-operatively and a high index of suspicion postoperatively.     

Ureteral endometriosis: a complication of rectovaginal endometriotic (adenomyotic) nodules.

OBJECTIVE: To present data from 18 cases of ureteral endometriosis. DESIGN: Prospective clinical study. SETTING: Department of gynecology at a university hospital. PATIENT(S): Four hundred and five patients with severe dysmenorrhea or deep dyspareunia due to a rectovaginal endometriotic (adenomyotic) nodule. INTERVENTION(S): Patients were prospectively evaluated using intravenous pyelography. All patients underwent laparoscopic surgery to remove rectovaginal adenomyosis and ureterolysis. MAIN OUTCOME MEASURE(S): Presurgical and postsurgical evaluation and histologic analysis. RESULT(S): Preoperative intravenous pyelography revealed ureteral stenosis with ureterohydronephrosis in 18 patients (4.4%). A significantly higher prevalence (11.2%) was observed in nodules > or = 3 cm in diameter. Five women (20%) had complete ureteral stenosis. Kidney scintigraphy revealed damaged kidney parenchymal function, which ranged from 18% to 42%. Laparoscopic ureterolysis was done in 16 women; 2 women underwent ureteral resection and uretero-ureterostomy. A significant postoperative decrease in ureterohydronephrosis was noted in all patients; however, renal function improved only slightly. CONCLUSION(S): Ureteral endometriosis was found in 4.4% of patients with rectovaginal endometriotic (adenomyotic) nodules. Ureterolysis and removal of associated adenomyotic lesions was sufficient therapy in most patients; two required resection of the ureteral stenotic segment. Intravenous pyelography should be performed in all women with rectovaginal nodules > or = 3 cm to prevent nonreversible loss of renal function.     

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.     

Universal ureteral stent placement at hysterectomy to identify ureteral injury: a decision analysis

Objective  Iatrogenic ureteral injury during gynaecological surgery is associated with increased morbidity when not diagnosed during the initial surgery. Preoperative insertion of ureteral catheters may enhance intraoperative recognition of injury and repair, but it is controversial. We sought to analyse the costs of this approach.
Design/setting/population  A decision-tree analysis of clinical scenarios of using universal ureteral catheterisation compared with no catheterisation was conducted for benign abdominal hysterectomy and radical hysterectomy.
Methods  Diagnostic-Related Groups and Current Procedural Terminology coding and reimbursement information were used as calculated for Medicare patients in the USA.
Main outcome measures  Differences in projections of total hospital-related costs related to clinical scenarios of perioperative care for women undergoing hysterectomy with or without ureteral catheterisation.
Results  Universal ureteral catheterisation is cost saving when the rate of ureteral injury during benign abdominal hysterectomy or radical hysterectomy is greater than 3.2%.
Conclusions  The cost savings of universal ureteral catheterisation at hysterectomy depend on the injury rate but are minimal at common levels of injury.     

Surgical Management of Urinary Tract Endometriosis: A 1-year Longitudinal Multicenter Pilot Study at 31 French Hospitals (by the FRIENDS Group)

Study ObjectiveTo describe the surgical management and risks of postoperative complications of patients with urinary tract endometriosis in France in 2017.DesignMulticenter retrospective cohort pilot study.SettingDepartments of gynecology at 31 expert endometriosis centers.PatientsAll women managed surgically for urinary tract endometriosis from January 1, 2017, to December 31, 2017. We distinguished patients with isolated bladder endometriosis or isolated ureteral endometriosis (IUE) from those with endometriosis in both locations (mixed locations [ML]).InterventionsSurgeons belonging to the French Colorectal Infiltrating Endometriosis Study (FRIENDS) group enrolled patients who filled a 24-item questionnaire on the day of the inclusion and 3 months later. Data were collected on operative routes, surgical management, and postoperative complications according to the Clavien-Dindo classification in a single anonymized database.Measurements and Main ResultsA total of 232 patients from 31 centers were included. Isolated bladder endometriosis was found in 82 patients (35.3%), IUE in 126 patients (54.4%), and ML in 24 patients (10.3%). Surgery was performed by laparoscopy, laparotomy, or robot-assisted laparoscopy in 74.1%, 11.2%, and 14.7% of the cases, respectively. Among the 150 ureteral lesions (IUE and ML), 114 were managed with ureterolysis (76%), 28 with ureteral resection (18.7%), 4 with nephrectomy (2.7%), and 23 with cystectomy (15.3%). Concerning bladder endometriosis, a partial cystectomy was performed in 94.3% of the cases. We reported 61 postoperative complications (26.3%): 44 low-grade complications according to the Clavien-Dindo classification (18%), 16 grade III complications (7%), and 1 grade IV complication (peritonitis).ConclusionThe surgical management of ureteral and bladder endometriosis is usually feasible and safe through laparoscopic surgery. Ureteral resection, when necessary, is more strongly associated with laparotomy and with more complications than other procedures. Prospective controlled studies are still mandatory to assess the best surgical management for patients.     

A review of laparoscopic ureteral injury in pelvic surgery

The objective of this study was to review the body of literature in reference to ureteral injury during laparoscopic surgeries and to determine: 1) the reported rates of ureteral injury; 2) the initial laparoscopic surgeries during which ureteral injury occurred; 3) the time of injury recognition (intra- versus postoperative); 4) the type, 5) the location, and 6) the mode of injury repair; and 7) the surgical laparoscopic instruments involved in ureteral injury.The appropriate medical subject heading (MSH) terms were selected and used in a search of the Medline computerized database and the online American College of Obstetricians and Gynecologists database. World literature published in the English language on ureteral injury during laparoscopic surgery between 1966 and 2003 was reviewed.A total of 70 reported instances of ureteral injury during laparoscopic surgery were identified among 2491 reported cases in which ureteral laparoscopic complications were discussed. Incidences of injury ranged from <1% to 2%. These 2491 cases of laparoscopy were presented as a mixed group, which included case reports, small series of studies, as well as longer, consecutive studies. In 18 of the 70 (25.7%) cases, the initial laparoscopic procedures during which ureteral injury occurred were not described or specified. In cases in which the type of laparoscopic surgery was specified, 14 of the 70 (20.0%) total cases of ureteral injury occurred during laparoscopically assisted vaginal hysterectomy (LAVH). Ureteral injury was identified intraoperatively in 6 of 70 (8.6%) cases, postoperatively in 49 of 70 (70.0%) cases, and, in 15 of 70 (21.4%) cases, the time of diagnosis was not specified. In 36 of the 70 (51.4%) reported injuries, the type of injury was not specified or described. In instances in which the types of injury were described, transection occurred most commonly, accounting for 14 of 70 (20.0%) injuries. The location of ureteral injury was not specified in 46 of the 70 (65.7%) cases. When location was specified, injuries most often occurred at or above the pelvic brim, accounting for 10 of the total 70 (14.3%). Electrocautery was involved in 17 of the 70 (24.3%) cases of ureteral injury, but in 34 of the 70 (48.6%) cases, the surgical laparoscopic instrument involved was not reported. A laparotomy was used to repair the ureteral injury in 43 of 70 (61.4%) cases.Ureteral injuries reported in peer-reviewed journals often lack detailed presentation of the initial laparoscopic surgeries during which ureteral injury occurred, or of the type, the location, and the instrumentation involved in ureteral injury. A high incidence of ureteral injury was found among the laparoscopic procedures analyzed in this review. Laparoscopically-assisted vaginal hysterectomy was the leading procedure in which injury occurred, and instruments involved in electrocoagulation were associated with the most injuries incurred during laparoscopic surgery.     

Deep endometriosis: definition, pathogenesis, and clinical management

"Deep endometriosis" includes rectovaginal lesions as well as infiltrative forms that involve vital structures such as bowel, ureters, and bladder. The available evidence suggests the same pathogenesis for deep infiltrating vesical and rectovaginal endometriosis (i.e., intraperitoneal seeding of regurgitated endometrial cells, which collect and implant in the most dependent portions of the peritoneal cavity and the anterior and posterior cul-de-sac, and trigger an inflammatory process leading to adhesion of contiguous organs with creation of false peritoneal bottoms). According to anatomic, surgical, and pathologic findings, deep endometriotic lesions seem to originate intraperitoneally rather than extraperitoneally. Also the lateral asymmetry in the occurrence of ureteral endometriosis is compatible with the menstrual reflux theory and with the anatomic differences of the left and right hemipelvis. Peritoneal, ovarian, and deep endometriosis may be diverse manifestations of a disease with a single origin (i.e., regurgitated endometrium). Based on different pathogenetic hypotheses, several schemes have been proposed to classify deep endometriosis, but further data are needed to demonstrate their validity and reliability. Drugs induce temporary quiescence of active deep lesions and may be useful in selected circumstances. Progestins should be considered as first-line medical treatment for temporary pain relief. However, in most cases of severely infiltrating disease, surgery is the final solution. Great importance must be given to complete and balanced counseling, as awareness of the real possibilities of different treatments will enhance the patient's collaboration.