C.Y. Liu, MD

       What                   Causes Endometriosis?

       Symptoms                   of Endometriosis

       Diagnosis                   of Endometriosis

       Current                   Treatment of Endometriosis

Endometriosis is a condition in which the lining of the uterine         cavity (endometrium) grows outside of the uterus. Endometriosis can be         found anywhere in the pelvic cavity, including all the reproductive         organs as well as on the bladder, small bowel, colon, rectum, appendix,         and vagina. However, endometriosis cannot be considered simply as         misplaced endometrium, because it differs in hormonal responses and         visual appearance.

The most common sites of endometriosis in the pelvis are         the uterosacral ligaments, cul-de-sac, pelvic side walls, and ovaries.         In rare occasions, endometriosis has been found on surgical scars such         as from C-section or laparotomy, as well as inside the bladder, lung,         spine, and brain. Although endometriosis differs somewhat from the         normal lining of the uterine cavity, it does respond to a woman's         hormones each month. As a result, the endometrial lesions can be         inflamed and can bleed into the surrounding tissues, causing irritation         of the affected area. They may produce a variety of other symptoms as         well. This cycle of inflammation and bleeding often causes scar tissue         to form. Such scar tissue can be extensive and may become bands of         adhesions that are capable of distorting anatomy and affecting the         normal function of internal organs.         

What is Deep Infiltrating Fibrotic Endometriosis?

About 10 % of endometriosis are found to be more aggressive and tend         to invade deeply into the affected tissues and organs, forming dense         scarring and producing more severe clinical symptoms such as pelvic         pain, menstrual cramps, painful sexual intercourse, and painful         defecation. Deep infiltrating fibrotic endometriosis most often involves         deep pelvic structures such as uterosacral ligaments (the supporting         ligament connecting the sacrum and posterior cervix), cul-de-sac (the         space just above the vagina between the rectosigmoid colon and posterior         wall of cervix), apex of vagina, rectovaginal septum (the tissue between         the rectum and vagina), rectosigmoid colon, pelvic sidewalls, ovaries,         tubes, bladder, and sometimes ureters.

Deep infiltrating fibrotic endometriosis usually does not respond to         hormonal suppressive therapy. Adequate surgical excision of the lesions         provides the best long-term results and symptomatic relief. However,         because of the deep invasive nature of the disease and the frequency of         the disease involving the vital pelvic organs, the gynecologist must be         experienced and competent in performing bowel, bladder, and ureteral         surgery. If not proficient in handling bowel, bladder, and ureteral         defects repair, the gynecologist tends to avoid resecting the         endometriosis adjacent to and/or on those organs, resulting in an         incomplete or inadequate excision of endometriosis and treatment         failure. Laparoscopic surgery, in my opinion, is the best way to excise         endometriosis. With very bright fiberoptic light shining directly onto         the operative field and a sophisticated video camera magnifying the         surgical area onto TV monitors, the surgeon and the entire operating         team can view in precise detail the operative field with imbedded         pathology, enabling them to perform a bloodless dissection and adequate         resection of endometriosis with minimal blood loss. My advice to those         patients suffering from deep infiltrating fibroitc endometriosis is to         find a gynecologist experienced and surgically competent in performing         laparoscopic excision of severe endometriosis. Since our practice is         primarily a referral one, many of our patients are from out of state. We         videotape all our surgeries and provide each of our patients a copy of         the tape of their surgery. Thus each patient can see exactly what she         had before surgery, how the entire surgery was performed, and the         results of the surgery.

In severe cases of endometriosis with dense adhesions, all of the         pelvic organs and the bowels close to the pelvis may fuse together,         causing a condition known as frozen pelvis.

Articles

Endometriosis is a condition in which the lining of the uterine cavity (endometrium) grows outside of the uterus. Endometriosis can be found anywhere in the pelvic cavity, including all the reproductive organs as well as on the bladder, small bowel, colon, rectum, appendix, and vagina. However, endometriosis cannot be considered simply as misplaced endometrium, because it differs in hormonal responses and visual appearance.

What is Endometriosis?

The real cause of endometriosis remains unknown. The following         theories represent current thinking of the etiology of endometriosis,         but none of them can explains all cases of endometriosis. We do know,         however, that endometriosis is not caused by anything that the patient         has done.


               This theory was proposed by Dr. John Sampson of Boston in the               1920’s. His theory that menstrual blood refluxed through the               fallopian tubes and was deposited and grew on the pelvic               peritoneum and pelvic organs remains popular, but the initial               attachment of single or multiple endometrial cells on the               peritoneal surface has not been demonstrated. Additionally, the               time-related geographic spread of endometriosis throughout the               pelvis that would be predicted to occur with repeated seeding of               the peritoneum by refluxed endometrium has not been demonstrated.               

The fact that 90% of women have retrograde flow but only 15 %               of women develop endometriosis further repudiate the validity of               the theory. This theory of origin also implies that older age               groups of patients with endometriosis have more disease than               younger age group and a high and progressively increasing rate of               recurrence after complete surgical resection. The literature,               however, as well as our own experience has shown that the actual               rate of persistent or recurrent disease is surprisingly low after               aggressive conservative surgical excision at laparoscopy or               laparotomy, and the rate of recurrent or persistent disease does               not appear to increase with the passage of time following               excision. Because of these deficits, Sampson’s theory is losing               favor to more modern concepts.

Theory of Embryonically Patterned Metaplasia or Rests


         Metaplasia means a transformation from one type of tissue to another         type of tissue. During the embryonic stage, the primitive cells migrate         and undergo differentiation to form the pelvic organs. This         embryogenesis is controlled and directed by a sophisticated, but still         incompletely understood, fetal system. This fetal developmental control         system may be the fetal analog of the adult immune system.         

If a developmental or heritable defect in this controlling system         exists, then differentiation and migration of cells may be aberrant or         incomplete. Cellular morphology and functionality might be expressed         overabundantly or inadequately. Such cells or tracts of cells are laid         down in the migratory pathway of fetal organogenesis (forming the         organs) across the posterior pelvic floor, although location anywhere         might be possible, depending on the degree of aberrant differentiation         or migration. These cells may be endometrium-like initially, or may         possess the ability to undergo metaplasia into endometriosis after         puberty. Arrest of migration across the posterior pelvis would         conveniently explain the observation that endometriosis is most commonly         and predictably found in the cul-de-sac, uterosacral ligaments, and         medial broad ligaments.

Abnormalities of the fetal development control system may be         preserved into adult life, giving rise to detectable abnormalities of         the adult immune system. The degree of residual abnormality of the adult         immune system may control the aggressiveness of the endometriosis that         develops, with the result that some patients may develop invasive         disease or adhesions, while most do not. The competence of the adult         immune system might be impaired by exposure to environmental toxins         (e.g. Dioxin), with endometriosis emerging as a possible result, as         occurs in experimental laboratory primates, and endometriosis in male         bladder or prostate in later life during estrogen treatment of advanced         prostate cancer.


         This theory has been proposed to explain remote occurrence of the         disease. According to this theory , exfoliated endometrial cells are         swept into the venous drainage of the uterus, with subsequent deposition         possible anywhere in the body. Venous blood draining from the uterus         must pass through the capillary bed to the lungs. Therefore,         hematogenous spread should also result in a high rate of secondary         pulmonary endometriosis unless there exists a high rate of occurrence of         atrial or ventricular septal defects exists, among patients with         extrapelvic endometriosis. Since neither pulmonary endometriosis nor         cardiac atrial or ventricular septal defects have been reported to be         more frequent in patients with endometriosis, hematogenous spread         remains speculative.


         This theory has been supported by the finding of endometriosis in lymph         nodes, although the number of reported cases is quite small compared         with the number of women with endometriosis. Endometriosis in lymph         nodes, however, could plausibly be explained equally by a developmental         process that resulted in embryonic deposition of endometriosis in lymph         nodal tissue.


         Multicenter studies conducted by Stephen Kennedy, M.D. Professor at         Oxford University show that first degree relatives of women with         endometriosis are more likely to develop endometriosis. And when there         is a hereditary link, the disease tends to be worse in the next         generation. Chattanooga Women’s Laser Center is one of the         participating study centers for the genetic predisposition factors in         endometriosis.

The real cause of endometriosis remains unknown. The following theories represent current thinking of the etiology of endometriosis, but none of them can explains all cases of endometriosis. We do know, however, that endometriosis is not caused by anything that the patient has done.

What Causes Endometriosis?

Patients with endometriosis can have symptoms varying from constant         excruciating pelvic pain to no symptoms whatsoever. Paradoxically, the         extent of endometriosis has no correlation to the amount of pain a women         will experience. Some women with severe endometriosis do not have any         symptoms and may not know they have endometriosis until a pelvic mass is         detected on a routine pelvic examination or a problem with infertility         is discovered. The following are the common symptoms of endometriosis,         but remember that women with endometriosis may have all, some, or none         of these symptoms.


         Women with endometriosis most commonly experience increasing pain and         discomfort right before and during their monthly cycles. Painful sexual         intercourse, pressure and bloating in the lower abdomen, and severe,         sometimes incapacitating, cramps during this period are not uncommon.         Some women with endometriosis, however, have constant pelvic pain,         cramps, and painful intercourse which may not be associated with monthly         cycles.


         A women with endometriosis may have some vaginal spotting a few days         before and/or after her period, or she may have abnormally heavy and         long periods.


         Gastrointestinal dysfunction ranges from abdominal bloating or nausea to         intestinal cramps, cycles of diarrhea and/or constipation. Rectal         bleeding and painful bowel movements may occur when the rectum and         sigmoid colon are invaded by the endometriosis.


         The most common cause of unexplained female infertility is         endometriosis.


         Frequency, urgency, bladder pain, and occasionally bloody urine may         occur when endometriosis has involved the bladder. Endometriosis can         invade the ureter (tube between the kidney and the bladder), may cause         obstruction of the ureter, and damage the kidney.

Lower back pain which may radiate down the legs

Laboratory and imaging tests (ultrasound and x-rays) are not as         helpful as the history and physical examination in diagnosing         endometriosis. Indeed, in our own experience, the high suspicion and         persistence in seeking the diagnosis of the patient are the two most         important factors in leading to the majority of the diagnoses of         endometriosis. Visualization of endometriosis on the lower genital tract         (vagina and cervix) and tender nodules palpable above the vagina during         routine pelvic examination is considered by many physicians to be         diagnostic of endometriosis. However, laparoscopy (laparo = abdomen,         scopy = inspection, thus, laparoscopy = inspection of abdominal cavity)         to directly inspect the abdominal and pelvic cavity is the only         definitive diagnosis of endometriosis.

Patients with endometriosis can have symptoms varying from constant excruciating pelvic pain to no symptoms whatsoever. Paradoxically, the extent of endometriosis has no correlation to the amount of pain a women will experience. Some women with severe endometriosis do not have any symptoms and may not know they have endometriosis until a pelvic mass is detected on a routine pelvic examination or a problem with infertility is discovered.

Symptoms of Endometriosis

Laparoscopy succeed in overcoming technical difficulties         and poor outcome of traditional open ureteroureteral distal anastomosis.         A technique for laparoscopic repair of injury involving the distal         ureter has been successfully developed.

Injury         to the ureter occurs in 0.1% to 1.5% of pelvic surgeries (Thomson, 1997;         Saidi MH 

 1996). Frequency is increasing as a result of         greater number of complex endoscopic procedures with anatomical         distortions being performed. Although it has to be underlined that         studies reveal that most ureteral injuries occur during simple routine         pelvic surgeries, such as an uncomplicated hysterectomy (Harkki-Siren P,         1998).

It has been recognized that only one third  of ureteral injury are detected during surgery. Instead, intraoperative  recognition of ureteral injury is of paramount importance so that the  damage can be repaired promptly before impairment of the renal function.  Thus is necessary for all pelvic surgeons to be skilled in identifying  and, if necessary, in dissecting out the entire pelvic ureter. The best  way to prevent ureteral injury during laparoscopic surgery is to be  certain of its location at all times during the procedure. In difficult  pelvic surgery, ureteral dissection almost always requires a  retroperitoneal approach.         

When         there is doubt about the possibility of ureteral injury or when pelvic         surgery is difficult, it is recommended to routinely perform cystoscopic         examination. Ureteral obstruction or injury is suspected if no         Indigo-carmine Dye, Methylen Blue Dye or urine effuses from the ureteral         orifice. A 4-5 French sized whistle-tip ureteral catheter can be used to         pass up the ureter in a retrograde fashion. It is crucial that urine is         observed exiting the catheter and that the entire course of the ureter         is observed laparoscopically. If resistance is met or if localization of         the catheter is uncertain, a retrograde pyelogram should be performed by         injecting contrast dye through the catheter. An x-ray is taken to         determine the exact location of the obstruction. It has do be underlined         that thermal injury to the ureter may be difficult to recognize         intraoperatively.

Regardless         of whether the injury is recognized intraoperatively or detected         postoperatively, surgery for ureteral reconstruction should adhere to         the following recommendations:                                  

Adequate             debridement has to be obtained in presence of an otherwise healthy             ureter

Not             too many sutures should be used

Tension             at the anastomotic site has to be avoided

A             complete hemostasis has to be obtained

Indwelling             ureteral catheter has to be inserted as well a retroperitoneal             drainage

There         are essentially three options for ureteral repair

The                 end-to-end reanastomosis is usually recommended if the site of                 ureteral injury is above the midpelvis, and the extent of injury                 is not extensive. Injuries to the distal pelvic ureter are                 usually managed with other techniques given the technical                 difficulty and poor results obtained with open ureteroureteral                 anastomosis (Thompson JD, 1997;Smith AM,1975). In these cases,                 continuity of the urinary tract can best be restored by performing a ureteroneocystostomy. To avoid tension on                 the anastomotic site, the bladder must be mobilized from the                 back of the pubis. An anterior cystotomy is performed and the                 ureter is brought through the wall of the bladder by means of a                 submucosal tunnel. An end-to-side mucosa-to-mucosa anastomosis                 between the end of the ureter and the side wall of the bladder                 is performed. A double-J catheter is inserted and a drain is                 placed retroperitoneally. If                 adequate mobilization of the bladder is difficult, a bladder                 hitch can be done by simply displacing the bladder upward and                 attaching it to the fascia of the iliopsoas muscle.

Obviously,                 the upper segment of the ureter can be further mobilized to                 reduce the tension on the anastomotic site.

An         advantage of laparoscopic ureteral surgery is that an end-to-end         ureteral re-anastomosis can be performed, even in cases of injury of the         distal ureter between the ureteric canal and the base of the bladder. A         technique of laparoscopic ureteroureteral anastomosis in the distal         ureter has been developed  with         good long term results.

Laparoscopic         ports are placed using a five-puncture method. One 10- to 12-m trocar is         placed at the umbilicus. Two 5 mm trocars are positioned approximately 8         cm above the pubic bone and lateral to deep epigastric vessels on each         side of the abdomen. Two additional 5 mm trocars are placed higher, at         the level of the umbilicus, lateral to the rectus muscle and         approximately 7 to 8 cm lateral to midline on each side of the abdomen.

 The                 site of the injury or stricture has to be identified


and the ureter dissected out further to free the                         proximal and distant ends of the anastomosis site with                         thorough debridement of both ends. Adequate dissection is                         mandatory to guarantee a tension-free anastomosis. The                         ureter is usually dissected proximally to beyond the level of the pelvic                         brim.                                          


                 The proximal and distal ends are prepared by excising                         the damaged area or the                  lesion                         with sharp laparoscopic scissors (5 mm curved dissector                         with monopolar coagulation; Ethicon Endosurgery,                                                  Cinncinnati                         ,                          OH                                                  ). The excision should be done 45 degrees to the length of the                 ureter.

A                 5F whistle-tip ureteral catheter (bard Hospital Division, Murry                 Hill,                 N.J

)                 is introduced through the bladder during cystoscopy.                                           


The                 catheter is placed in retrograde fashion across the injured                 area.                                           

                 The ends of the ureter arere approximated over the ureteral                 catheter with six simple interrupted sutures placed through the                 full thickness of the ureteral wall at 6, 12, 2, 4, 8, and                  10                 o’clock                                  positions.                                           

Polydioxanone 6-0 sutures are placed using laparoscopic                         needle holders and tied with intracorporeal knots. 				

                 Complete hemostasis is achieved at the site of the anastomosis                 with microbipolar electrosurgery at 20 W. A Penrose drain is                 left in place at the anastomosis site. The ureter is                 reperitonealized with 3-0 polyglactin in a continuous running                 fashion.                  

                 The                 whistle-tip catheter is replaced with a double-J ureteral stent                 (Circon Surgitek, Racine,                 WI                                  ).                 The Penrose drain is removed in 24 hours or later, when minimal                 or no drainage is noted.                                   

The                 double-J stent is maintained in place for 6 weeks, and an                 intravenous pyelogram (IVP) is performed to document patency                 after it has been removed Testo Riga

Between June 1993 and May 1998 four laparoscopic         end-to-end reanastomosis were performed. Indications were ureteral         injury resulting from other laparoscopic procedures or ureteral         stricture secondary to endometriosis. All four cases of ureteral         anastomosis were carried out with no complications. The postoperative         course was uneventful and all the patients were discharged in 1 or 2         days. The long term follow-up shows good results.

Nowadays,         laparoscopic repair of ureteral injury is a reality (Nezhat C and Nezhat         F, 1992). The level of injury or level of resection of the ureter was         important in the past and usually prescribed the type of surgical repair         to be performed. Injury farther down than the pelvic brim and especially         in lower 4 to 5 cm made traditional open reanastomosis difficult and         usually resulted in poor results ( Walsh PC, 1998; Thompson JD, 1997;         Smith AM,1975). Technical difficulties preclude end-to-end reanastomosis         in the distal ureter, but they have been overcome with laparoscopy. The         laparoscope allows magnification of the of the injured site with better         visualization of the anastomotic area. Moreover, the laparoscopic         instruments allow an easier access to area in the deep pelvis that         traditional instruments would have difficulties to reach.

It         is mandatory that the damaged injured is extensively mobilized to         guarantee tension-free anastomosis. To increase the anastomotic area, we         prepare the ends in a 45-degree angle. This ensure an easier         approximation of the cut edges and provides adequate anastomotic area to         minimize problems with stenosis at the site. In fact, no stenosis has         been detected in our patients.

A good teaming with a colleague urologist is essential.

Laparoscopy succeed in overcoming technical difficulties and poor outcome of traditional open ureteroureteral distal anastomosis. A technique for laparoscopic repair of injury involving the distal ureter has been successfully developed.

C.Y. Liu, MD

Articles

What is Endometriosis?

What Causes Endometriosis?

Symptoms of Endometriosis

Laparoscopic End-to-End Reanastomosis on the Distal Ureter