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.     

Combined laparoscopic and vaginal approach for nephrectomy, ureterectomy, and removal of a large rectovaginal endometriotic nodule causing loss of renal function

A late consequence of ureteral endometriosis is the silent loss of renal function caused by progressive "enclosure" of the lower part of the ureter by the endometriosis. In our experience, in cases of severe loss of renal function with cortical atrophy and residual kidney function (evaluated by Tc99 DMSA scintigraphy) of less than 15%, removal of the endometriosis combined with ureterolysis does not allow recovery of renal function. A nonfunctioning kidney associated with hydronephrosis is a risk factor for vascular hypertension, recurrent pyelonephritis, or kidney stones and therefore an indication for nephrectomy. By means of a case report, this paper describes the combination of laparoscopic nephrectomy, ureterectomy, removal of the rectovaginal endometriotic nodule, and extraction of the kidney through the vagina.     

Termino-terminal Ureteral Laparoscopic Anastomosis in a Case of Deep Infiltrating Endometriosis

Study ObjectiveLaparoscopic termino-terminal ureteral anastomosis has all the advantages of a minimally invasive approach in addition to the treatment of the pathologic condition [1]. Ureteral deep endometriosis can lead to severe consequences, such as hydroureteronephrosis and renal failure [2,3]. The main objective of this video is to present our surgical strategy and technique for cases of ureteral deep infiltrating endometriosis, which could help surgeons to understand and perform this surgery in a safe way in patients.DesignVideo demonstration of the technique.SettingFrench university tertiary-care hospital.InterventionsThis video presents a termino-terminal laparoscopic ureteral anastomosis and shows our team's strategy for surgical treatment in a 42-year-old woman with deep infiltrating ureteral left endometriosis, with consequent stenosis and left hydroureteronephrosis. A full resection of the endometriotic ureteral nodule was performed, followed by a termino-terminal anastomosis of the ureter. The use of intravenous indocyanine green to assess the postanastomotic ureteral perfusion and its risk of leakage or fistula are described in the video [2, 3, 4, 5].ConclusionUreteral endometriosis can lead to severe consequences, and the surgical treatment can be difficult and, most times, incomplete. This video gives a detailed example of the strategy our team used to perform a termino-terminal ureteral laparoscopic anastomosis in a structured way.     

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.     

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。     

Can centralised care of complex laparoscopic procedures prevent urinary tract injuries?

Centralised care of complex laparoscopic procedures offers expertise and multidisciplinary care. The objective was to identify if centralised care makes urinary tract injuries less likely or avoidable. This Retrospective Audit was performed at a Tertiary Referral Centre for Advanced Laparoscopic Surgery in North East England. The incidence of injury to bladder/ureter, time of diagnosis, instrument, location, side and mode of repair were evaluated in 105 consecutive complex laparoscopic procedures. Injuries were identified in three (2.8%) cases. There was one bladder injury which was unavoidable. The bladder dome was opened to allow excision of bladder endometriosis. There were two ureter injuries. The first injury involved the ureter being locked in a vaginal vault stitch. The second injury had stage IV endometriosis with peri-ureteric endometriosis where the anatomy was distorted, with medial displacement and kinking of the ureter secondary to fibrosis at the level of the ureter crossing below the uterine artery, with resultant accidental transection of the ureter close to the uterine artery. The first ureter injury was not a laparoscopic injury but due to vaginal vault closure. Arguably, vault closure in any vaginal hysterectomy could carry the same theoretical risk. The only direct laparoscopic injury was the ureteral transection. Such cases present a challenge due to a higher chance of anatomical distortion and predisposition to urinary tract injury. Noteworthy here is the fact that the ureter injury occurred where there was probable distortion of the anatomy, due to endometriosis, of the ureter at the level of the uterine artery. These cases are tackled by experienced laparoscopic surgeons in tertiary centres, yet injuries still occur. Is it possible then that those injuries represent a minimum unavoidable injury rate, and are they injuries or in fact unavoidable consequences of such inherently dangerous and difficult surgery?     

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.     

Bladder and Urinary Deep Pelvic Endometriosis: A Step-by-Step Standard Approach

Study ObjectiveTo demonstrate how to treat bladder and ureteral deep pelvic endometriosis using a laparoscopic approach with partial cystectomy and resection and end-to-end anastomosis of the ureter.DesignStep-by-step explanation of the surgery using a video approved by the local institutional review board.SettingUniversity Hospital of Strasbourg, France.PatientsA 27-year-old nulliparous woman with severe endometriosis stage IV (revised American Fertility Society classification score >40) of the bladder and left ureter. On pelvic magnetic resonance imaging, we found dilatation of the left ureter and left hydronephrosis induced by a 17-mm endometriosis nodule. A JJ probe was placed on the left ureter before the surgery because of dilatation of the ureter and decreased renal function.InterventionsDuring the exploration, we found an abdominal cavity free of adhesion. There was an endometriosis implant in the bladder in front of the uterus and a large nodule of the left uterosacral ligament that was compressing the ureter. In the first step, we made a section of the round ligament to perform anterior ureterolysis and progressive dissection of the nodule surrounding the ureter. Once the nodule was resected, tight stenosis was observed approximately 1 cm from the bladder. The vesicouterine and vesicovaginal spaces were then dissected to pass under the nodule to the vagina. We opened the dome of the bladder using the thunderbeat (Olympus) and dissected the bladder to remove the transfixing nodule while staying away from the ureters. The closure of the bladder was performed by 2 lateral sutures and a running suture using a braided suture (V-Loc) 2-0, with good tightness as checked by a blue test. Ureteral resection was performed around the JJ probe in place to remove the stenotic zone; thereafter, we performed an end-to-end anastomosis of the ureter using 4 sutures of monofilament (Monocryl) 4-0 with a good anatomic result. Finally, an omentoplasty was fixed around the ureter using a 2-0 monofilament suture (Monocryl).Measurements and Main ResultsThe postoperative course was uneventful. A Foley catheter was left in place for 10 days, and the JJ probe was removed 6 weeks later. The operative time was 140 minutes. The step-by-step explanation technique was simple with minimal operative difficulty and a low rate of morbidity.ConclusionThis video shows how deep urinary endometriosis can be treated laparoscopically. Mastering suturing is essential to avoid complications.     

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.     

The laparoscopic treatment of bladder endometriosis. A retrospective analysis of 21 cases

AIM: Endometriosis is the presence of endometrial tissue, including endometrial glands and stroma, outside the uterine cavity. The incidence of endometriosis in the general population is almost unknown, because it varies between 1% and 50%, depending on the paper considered. In any case, the incidence of bladder endometriosis is generally considered about 1% or less of endometriotic patients. The aim of this study is to evaluate the effectiveness of preoperative exams and the effectiveness of laparoscopic treatment. METHODS: We enrolled 21 patients operated laparoscopically for a severe stage of endometriosis, including at least a bladder localization of 10 mL; in 60% of cases a bowel surgery was associated in the cause of a digestive endometriosis. A complete preoperative and follow-up evaluation was carried out for all patients. RESULTS: The preoperative investigation, especially abdominal sonography, predicted endometriotic bladder invasion in only 38% of cases. Urinary symptomatology was present in only 61.9% of cases. The postoperative follow-up showed the remarkable effectiveness of laparoscopic treatment for the cancellation of pain and to improve the quality of life for patients. CONCLUSIONS: Finally, the treatment of severe endometriosis is possible and effective by laparoscopy even in the cases where there is a bladder localization and when, in the absence of specific symptomatology, it isn't diagnosed preoperatively.     

Surgical treatment of endometriosis

Ovarian endometriotic cysts with adhesions and rectovaginal endometriosis are absolute indications for laparoscopic surgery. Peritoneal minimal endometriosis is considered a relative indications for surgery by many experts. The discussion is ongoing and more randomized studies are necessary. Ureteral and intestinal endometriosis are indicated for surgery in cases of deep infiltration of the ureteral or intestinal wall. In some cases the GnRH analogue (gonadotropin releasing hormone) can be given as neoadjuvant chemotherapy; after it interval endometriotic debulking is possible. In the case of endometriosis we must apply the same strict rules as in oncology especially as regards negative or positive histological findings.     

A rare case of intrinsic ureteral endometriosis causing hydronephrosis in a 40-year-old woman. A case report and literature review

Endometriosis is a multifactorial disease with unclear pathogenesis. Urinary tract endometriosis occurs in about 1% of all endometriotic lesions while isolated ureteral endometriosis is extremely rare. We present a case of intrinsic ureteral endometriosis causing ureteral stenosis in a 40-year's old woman, in combination with intestinal, extensive peritoneal and ovarian endometriosis. The clinicopathological features and investigation methods used, as well as the treatment approach are discussed. An individual therapy plan depending mainly on the patient's age, desire for children and the extent of the endometriotic foci should always be attempted. Collaboration between gynecologists and urologists was essential in our cases.     

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.     

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.     

Pelvic endometriosis and ureteral obstruction.

Pelvic endometriosis may completely obstruct the ureters and destroy the kidneys with little or no gynecologic symptoms. Five cases are discussed, all causing ureteral obstruction. Two patients suffered the complete loss of a kidney and in each case the remaining kidney was in jeopardy because of partial obstruction due to endometriosis. All these patients were treated by complete removal of all ovarian tissue, dissection of the ureter, and dissection of the scar tissue. In severe cases, retroperitoneal clamping of the infundibular pelvic ligament with clear exposure of the ureter is mandatory to avoid leaving small remnants of ovary in the infundibular ligament clamp. With complete removal of all ovarian tissue, postoperative estrogen therapy will not cause recurrence of the disease.     

Outcome of laparoscopic repair of ureteral injury: follow-up of twelve cases

Study ObjectiveTo review the feasibility of laparoscopic repair in cases of ureteral injuries occurring during gynecologic laparoscopy.DesignRetrospective study (Canadian Task Force classification II-3).SettingInstitution-specific retrospective review of data from a tertiary referral medical center.PatientsPatients suffering from iatrogenic ureteral injuries diagnosed during or after surgery, and cases with deliberate ureteral resection and repair because of underlying disease.Measurements and Main ResultsWe conducted a retrospective review of all (10 345) laparoscopic gynecologic surgeries performed in our institute between February 2004 and November 2008. Twelve cases (median: 45.5 years, range: 27–63) of ureter transections were diagnosed and repaired laparoscopically by endoscopists. Of these, 10 had previous surgeries, pelvic adhesions, or a large pelvic-abdominal mass. One patient had undergone a segmental resection and laparoscopic ureteroureterostomy for deep infiltrative endometriosis. Of the remaining 11 iatrogenic ureteral transections, 10 were repaired via laparoscopic ureteroureterostomy, whereas 1 had undergone a laparoscopic ureteroneocystostomy. One injury was recognized on the second postoperative day, but intraoperative recognition was attained in 11 cases. The median duration of double J stenting was 73 days. Three patients had development of strictures (between 42 and 79 days after surgery) treated with restenting, but 1 had to undergo an ureteroneocystostomy for ureter disruption when trying to restent. One patient had development of leakage of the anastomotic site but recovered with a change of the double J stent. Only 1 case required another laparotomy for ureteroneocystostomy. Laparoscopic primary repair of ureteral injury was successful for 11 of 12 patients. All the patients were well and symptom free at the conclusion of the study period.ConclusionEarly recognition and treatment of ureteral injuries are important to prevent morbidity. Laparoscopic ureteroureterostomy could be considered in transections of the ureter where technical expertise is available. To the best of our knowledge, this is the largest series, to date, of ureteral repairs via laparoscopy.     

Bladder endometriosis: laparoscopic treatment and follow-up

OBJECTIVES: This study aims to show the treatment outcome in women affected by isolated bladder endometriosis who underwent laparoscopic surgery in our units. Only women with deep nodules located in the bladder were selected, thus excluding women with deep lesions located in other sites. STUDY DESIGN: Between March 2005 and 2007, women with deep vesical endometriosis, referring to the Departments of Obstetrics and Gynaecology of University Hospitals "G. Martino"of Messina, "Paolo Giaccone"of Palermo and "San Paolo"of Milano, were respectively recruited. A preoperative assessment of the pathology was performed. Women who were concomitantly diagnosed deep nodules of the rectovaginal septum and/or endometriotic ovarian cysts were excluded. A medical therapy with oral contraceptive and/or GnRH analogues was first proposed to the patients affected. If medical treatment failed, a laparoscopic treatment was suggested. We performed a segmental resection of the involved wall or an extramucosal dissection of the bladder according to the cases. A clinical and an instrumental evaluation by ultrasound was performed every 6 months after surgery for the first year and subsequently every 12 months. At the time of referral, patients were also questioned about any recurrence of symptoms. RESULTS: Eight women, with a mean age of 33.8 (range 30-37 years; S.D.=2.5) and a mean parity of 1 (range 0-2) were recruited. Medical therapy failed in all cases and the women underwent laparoscopic treatment. Surgery was complete in all cases without a need for ureteral cannulation. No intraoperative complications occurred. The mean estimated blood loss was 98ml (range 40-200ml). All patients underwent at least the first follow-up assessment. In none of the women, recurrence of bladder endometriotic nodules was documented. In contrast, urinary symptoms were reported in three cases. Nevertheless, all the patients reported improvement of symptoms and declared to be satisfied. CONCLUSIONS: We recommend surgical eradication of bladder lesions. Laparoscopic treatment, in the hands of an expert surgeon, is the management of choice. It offers the best approach to the diagnosis allowing good long-term results, with a less invasive approach. Large multicentric studies are however required prior to drawing definite conclusions.