Pathophysiology and management of urinary tract endometriosis (original) (raw)

2017, Nature Reviews Urology

Endometriosis-the presence of endometrial glands and stroma outside of the uterine cavity-predominantly affects the pelvic reproductive organs (FIG. 1a,b). However, endometriosis can also be found outside of the reproductive organs, when it is then termed extra genital endometriosis. The intestine and urinary tract are the most common sites of extragenital endometriosis 1 , which is often deeply infiltrating 2. Laparoscopic management of extensive extra genital endometriosis has been reported since the 1980s 2-8. However, laparoscopic management of urinary tract endometriosis is still not widespread, for multiple reasons including a lack of familiarity with the signs and symptoms. If a woman complains of bladder pain but has a negative urinalysis, the doctor might not think to ask whether her pain is cyclic or to consider bladder endometriosis. Even during surgery, many gynaecologists are unable to accurately visualize the endometriotic lesions because their own teachers were not trained to recognize all forms of endometriosis. During the first few months of our own group's 1-year endometriosis surgery fellow ship, an emphasis is placed on recognition of which spots, blebs, adhesions, and lesions represent endo metriosis and should, therefore, undergo excisional biopsy and pathological evaluation. Furthermore, many surgeons, urologists, and gynaecologists are not trained in the delicate techniques necessary to treat genito urinary endometriosis. With a 4-year obstetrics and gynaecology residency during which trainees must learn the entirety of the broad specialty, the resident training is often unable to focus on the finer aspects of minimally invasive surgeries or on what might be considered to be more esoteric conditions, such as urinary tract endometriosis 9. Medical management of deeply infiltrating lesions of the urinary tract has a high risk of failure and laparotomy for treatment of endometriosis is associated with high morbidity owing to increased blood loss, larger incisions with longer recovery time, and poor magnification of the lesions; however, many patients with urinary tract endometriosis still do not undergo laparoscopic treatment 10-13. This Review will describe and classify the multiple forms of urinary tract endometriosis and discuss our own and other groups' experience of optimal laparoscopic management strategies with and without robotic assistance. Pathophysiology of endometriosis The pathophysiology of endometriosis has yet to be fully determined and remains elusive, despite the existence of a large body of literature and several dominant theories. The most common and also most intuitive theory is that of retrograde menstruation. Early reports suggested that women with genital tract obstructions are more prone to endometriosis than those without, raising the possibility that retrograde flow of menstrual blood might contribute to the pathogenesis of endo metriosis 14,15. However, women without genital tract obstructions seem to have a similar incidence of retrograde menstruation, but not a similar incidence of endometriosis; in fact, 90% of women are found to have retrograde menstruation but only 10% develop