Ureteral endometriosis: clinicopathological and immunohistochemical study of 7 cases

Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
Human pathology (Impact Factor: 2.77). 07/2008; 39(6):954-9. DOI: 10.1016/j.humpath.2007.11.011
Source: PubMed


Ureteral endometriosis is a rare yet important entity that can lead to renal failure due to silent obstruction of the ureter. Awareness of clinical and morphologic features can help in early detection and treatment. We analyzed the clinical, pathologic, and immunohistochemical findings of 7 cases of ureteral endometriosis. Mean age of patients was 51 years. All patients presented with hydroureter, accompanied in the most cases by hydronephrosis. Superimposed pyelonephritis was experienced by 2 of 7 patients. Most patients (4 of 7) had previously undergone total abdominal hysterectomy with bilateral salpingo-oophorectomy. In 6 of 7 cases, endometriosis involved the left ureter. The distal one third of the ureter was involved in 6 cases, whereas the middle third was involved in 1 case. In 4 cases, endometriosis was located extrinsic to the ureter, whereas in 3 cases, the ureter showed intrinsic involvement by endometriosis. One case showed simple endometrial hyperplasia. Surgical management included nephrectomy in 2 cases, distal ureterectomy with reimplantation in 3 cases, ureteral stent placement followed by ureteroureterostomy in 1 case, and relief of ureteral obstruction by resection of pelvic endometrioma in 1 case. Immunostains for cytokeratin-7 (CK7) and progesterone receptor (PR) were positive in all of the cases, whereas immunostains for estrogen receptor (ER) were positive in 83% of cases and immunostains for CK20 were negative in all cases. CA125 immunostains were positive in 67% of cases. The stromal cells were positive for CD10, ER, and PR immunostaining. Our findings suggest that the diagnosis of ureteral endometriosis is preceded in most cases by hysterectomy and bilateral salpingo-oophorectomy, possibly because of prior symptoms related to adenomyosis or pelvic endometriosis and that ureteral endometriosis has a strong predilection for involvement of the lower third of the left ureter. Ureteral endometriosis should be included in the differential diagnosis of obstructive ureteral lesions in women, particularly those involving the lower third of the left ureter, even in postmenopausal patients. Immunostains for ER, PR, CK7, CA125, and CD10 can be helpful in challenging cases.

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    • "Extrinsic compression occurs due to fibrosis of the overlying tissues and is associated with endometriosis of the peritoneum, pelvic ligaments or ovaries.[34] Less commonly endometriosis is present in the wall of the ureter forming the intrinsic type accounting for 2.5-42.8% of ureteric involvement.[5678] Some authors reported that 85% of the patients with hydronephreosis secondary to endometriosis were successfully managed with ureterolysis as the primary procedure.[6] "
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    ABSTRACT: A 32 year old lady presented with recurrent left flank pain for 4 weeks and chronic lower back pain. CT without contrast showed no stones and mild left hydronephrosis. CT of the spine suggested an inflammatory process at L5-S1 vertebra. The diagnosis was supported by a bone scan. Incidentally, the scan showed nonfunctioning left kidney. Diuretic renography confirmed poor perfusion and no excretion. A retrograde study showed narrowing of the ureter at the pelvic brim. Ureteroscopy showed a papillary mass in the lumen of the ureter from which multiple cold cup biopsies were taken. The pathology however was not conclusive. A robotic nephroureterectomy was carried out. Definitive pathology showed intrinsic endometriosis of the ureter. We conclude that endometriosis should be considered in the differential diagnosis of unexplained ureteric obstruction and ureteric lumen filling defects in young women.
    No preview · Article · Apr 2014 · Urology Annals
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    • "These findings were thought characteristic of a ruptured epidermal inclusion cyst (Fig. 3B). To exclude the presence of endometrial stroma or urothelial tissue,2 the specimen was submitted for CD10 and CK20 staining,3,4 respectively, both of which turned out negative. Postoperatively, the patient had no difficulties from pain, infection, dysuria, or any dyspareunia—in fact, she conceived again at 2 months after the surgery. "
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    ABSTRACT: Objective Acquired clitoromegaly is rare and may result from hormonal and nonhormonal causes, and evaluation of the pregnant patient with clitoromegaly invokes a specific set of differential diagnoses. Methods Case report. Results We describe the case of a young woman with pregnancy-associated clitoral enlargement whose hormonal evaluation proved negative. Further investigation concluded that an epidermoid cyst was the culprit of her pseudoclitoromegaly. The patient underwent successful surgical resection and has had no recurrence at her subsequent pregnancy. Conclusion We review the differential diagnosis of clitoromegaly, including hormonal and nonhormonal causes, with focus on the evaluation of pregnancy-associated clitoromegaly.
    Full-text · Article · May 2013 · AJP Reports
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    • "Histological examination of the three resected ureteric specimens revealed extrinsic endometriosis. This finding is in keeping with the literature, whereby the vast majority of cases have demonstrated extrinsic ureteric endometriosis, and should therefore be suitable for ureterolysis as primary management [3,4,6,14]. "
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    ABSTRACT: Hydronephrosis is a rare but serious manifestation of ureteric endometriosis. One hundred and twenty-six women underwent ureterolysis for ureteric endometriosis betweeen and October 1996 and June 2009. Thirteen of the 126 women were identified as having ureteric obstruction at the time of their procedure and were included in the case series. The median age was 39.5 (30 - 63). Chronic pelvic pain was the most common presenting symptom (53.8%). The point of ureteric obstruction was noted to occur most commonly at a small segment of distal left ureter, where it is crossed by the uterine artery (54%). Seven of the 13 women (53.8%) were successfully managed with ureterolysis only. Three of the 13 women (21.3%) underwent ureterolysis and placement of a double J ureteric stent. Three of the 13 (21.3%) required a segmental ureteric resection. There was one incidence of inadvertent thermal ureteric injury which was managed with a ureteric stent. In all cases the hydronephrosis had resolved at six months follow up. Our findings support the growing body of literature supporting ureterolysis as the optimal treatment for ureteric endometriosis causing moderate to severe ureteric obstruction.
    Full-text · Article · Feb 2010 · BMC Research Notes
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