Bladder psoas hitch in hydronephrosis due to pelvic endometriosis: outcome of urodynamic parameters

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1 ENDOMETRIOSIS Bladder psoas hitch in hydronephrosis due to pelvic endometriosis: outcome of urodynamic parameters Luca Carmignani, M.D., a Antonella Ronchetti, M.D., b Fabio Amicarelli, M.D., b Paolo Vercellini, M.D., b Matteo Spinelli, M.D., c and Luigi Fedele, M.D. b a Urology Unit, IRCCS Policlinico San Donato, University of Milan, Milan, Italy; b Department of Obstetrics and Gynecology, Fondazione Policlinico-Mangiagalli-Regina Elena, University of Milan, Milan, Italy; and c Urology Unit, Fondazione Policlinico-Mangiagalli-Regina Elena, University of Milan, Milan, Italy Objective: To evaluate modifications in bladder sensitivity and function after ureteroneocystostomy with bladder psoas hitch for hydronephrosis due to deep pelvic endometriosis. Design: Prospective study. Setting: Center for the Treatment of Endometriosis of the Department of Obstetrics and Gynecology of the State University of Milan, Italy. Patient(s): Thirteen patients with deep endometriosis and ureteral involvement. Mean age of patients was 36.8 years (range, years). Intervention(s): Ureteroneocystostomy with a psoas hitch. Indications for performing psoas hitch ureteroneocystostomy were severe hydronephrosis, radiologic evidence of ureteral stricture measuring >4 cm, and the impossibility of performing ureterolysis. Main Outcome Measure(s): Impact on urodynamic parameters of bladder psoas hitch ureteroneocystostomy. Result(s): All patients showed normal bladder capacity 3 months after surgery. Two patients presented with stress incontinence immediately after surgery, which almost completely subsided at 3 months follow-up. In 4 patients the bladder was also involved; in these cases a bladder resection was performed, followed by ureteral reimplantation. Follow-up was at 6 months from surgery and then every 6 months thereafter, in which patients underwent urogynecologic examination, completed a questionnaire on urinary symptoms, and underwent renal ultrasound evaluation with no evidence of recurrence of obstructive uropathy. Conclusion(s): On the basis of the results of the present study, bladder psoas hitch along with ureteral resection and ureteroneocystostomy for infiltrating endometriosis do not seem to have a negative impact on urodynamic parameters. (Fertil Steril Ò 2009;92: Ó2009 by American Society for Reproductive Medicine.) Key Words: Endometriosis, bladder psoas hitch, ureteroneocystostomy, hydronephrosis, urodynamic Urinary tract involvement in women with endometriosis was once considered a rare clinical entity but is now increasingly recognized. Although the true incidence has not been precisely determined, recent estimates show a prevalence of urinary tract involvement ranging from 0.3% to 6% in patients with pelvic endometriosis. When endometriosis affects the urinary tract, lesions are located in the bladder in 85% of cases and involve the ureter in approximately 10% of cases, resulting in silent ureteral obstruction; in the remaining 5% of cases, there is renal and urethral involvement (1, 2). Received September 7, 2007; revised April 23, 2008; accepted May 9, 2008; published online August 11, L.C. has nothing to disclose. A.R. has nothing to disclose. F.A. has nothing to disclose. P.V. has nothing to disclose. M.S. has nothing to disclose. L.F. has nothing to disclose. Reprint requests: Luca Carmignani, M.D., Urology Unit, Department of Medicine and Surgery, University of Milan, IRCCS Policlinico San Donato, Via Morandi 30, San Donato Milanese, Milano, Italy (FAX: ; luca.carmignani@unimi.it). In cases of deep endometriosis causing hydronephrosis and loss of renal function, in which resection of a long segment of the ureter is required and in which ureterolysis cannot be performed owing to considerable fibrosis or infiltration with secondary lumen obstruction, the surgical therapy of choice in our center is ureteroneocystostomy with a psoas hitch (3). A similar technique is also used in cases of iatrogenic lesions or infiltrating neoplastic lesions involving the ureter. This technique modifies the shape and anatomic relations within the bladder and could possibly modify bladder sensitivity and voiding. To date there are no studies in the literature evaluating the perioperative modifications in urodynamic parameters in patients undergoing this surgical procedure. The aim of the present study was to assess bladder sensitivity and function after bladder psoas hitch and ureteroneocystostomy in patients with hydronephrosis due to deep pelvic endometriosis /09/$36.00 Fertility and Sterility â Vol. 92, No. 1, July doi: /j.fertnstert Copyright ª2009 American Society for Reproductive Medicine, Published by Elsevier Inc.

MATERIALS AND METHODS Between January 2005 and January 2007 a prospective study was carried out on 13 patients with deep endometriosis and ureteral involvement undergoing ureteroneocystostomy with a

2 MATERIALS AND METHODS Between January 2005 and January 2007 a prospective study was carried out on 13 patients with deep endometriosis and ureteral involvement undergoing ureteroneocystostomy with a psoas hitch. The study was conducted at a tertiary referral center for the treatment of endometriosis at the Department of Obstetrics and Gynecology of the State University of Milan, Italy. This study received approval from the local institutional review board. FIGURE 1 View of the reimplanted ureter. Intraoperative photograph showing the ureter passing through the bladder wall while maintaining a linear passage. A submucous path three to five times wider than the ureter has been created to avoid postureteroneocystostomy reflux. Indications for performing bladder psoas hitch and ureteroneocystostomy were severe hydronephrosis, radiologic evidence of ureteral stricture measuring >4 cm, and the impossibility of performing ureterolysis due to macroscopic infiltration of endometriosis or secondary atony of the fibrosclerotic segment. Patients were excluded from the study if they had a history of bladder cancer, documented interstitial cystitis, or a history of neurologic bladder or urinary urge. All patients were informed of the aims of the study and signed an informed consent form before participating in the study. Endometriosis was staged according to the revised classification of the American Fertility Society (4). Patients were asked to complete the Patient Global Impression of Severity and Improvement (PGI-S and PGI-I) questionnaires (5) preoperatively and underwent a complete urodynamic examination. This examination was not performed in 4 symptomatic patients who had evident endometriotic lesions in the bladder wall to avoid potential bias, because urinary frequency and urgency are considered pathognomonic symptoms of bladder endometriosis (6). Urodynamic assessment was performed with a Duet Multi-P device (Medtronic, Minneapolis, MN) and included cystometry, uroflowmetry, and urethral pressure profile, the latter of which was performed only in patients with positive stress test results. The following urodynamic parameters were considered to be normal: first desire ml with pressure between 0 and 5 cm H 2 0, strong desire ml with pressure %15 cm H 2 0, cystometric capacity ml with pressure 20 cm H 2 0, postvoid residual volume <50 ml, and a maximum flow peak >15 ml/s (7). All patients underwent standard assessments for deep endometriosis at our center: transvaginal pelvic ultrasound, urinary tract ultrasound, and computed tomography or magnetic resonance imaging. The surgical procedure started with resection of the ureter and mobilization of the bladder from the peritoneum with separation of the contralateral umbilical artery. The bladder was opened transversely and laterally to the bladder dome and fixed to the psoas muscle using three interrupted Vicryl 2/0 sutures (8 10), with particular care taken to avoid the genitofemoral nerve. The ureter was then passed through the bladder wall while maintaining a linear passage, during which a submucous path was created that was three to five times wider than the ureter to avoid post-ureteroneocystostomy reflux (Fig. 1) (10). Ureterovesical anastomosis was Carmignani. Ureteroneocystostomy for endometriosis. Fertil Steril performed using six interrupted sutures in 4/0 Vicryl. The bladder incision was then closed longitudinally with a double suture in 2/0 Vicryl, the first layer of which included the mucosa and muscle and the second of which comprised the muscle and the adventitia. None of the cases required section of the middle bladder pedicles and endopelvic fascia. Finally, a drain was left in the space of Retzius for approximately 2 to 3 days. A double-j stent was left in place for 1 month postoperatively so as to avoid stenosis of the anastomosis. In 8 cases a longitudinal abdominal incision was performed; in the remaining 5 cases the bladder was approached through an extended Pfannenstiel incision, which was the preferred access in the presence of associated intestinal lesions requiring resection (n ¼ 3). When the bowel was involved, intestinal resection was performed during the same urogynecologic surgical session. In 4 cases segmentary bladder resection was required owing to the presence of endometriotic nodules involving the detrusor. Patients underwent a postoperative urodynamic assessment and completed the PGI-I questionnaire (5) 3 months after surgery and subsequently 2 months after removal of the double-j ureteral stents. RESULTS Clinical characteristics of the patients are described in Table Carmignani et al. Ureteroneocystostomy for endometriosis Vol. 92, No. 1, July 2009

3 Fertility and Sterility â 37 TABLE 1 Patient profiles. Patient Age at surgery (y) Fertility Ureter Organs involved Bladder detrusor endometriosis Endometriosis stage (1 4) a 1 38 Para III Left Pouch of Douglas, right ovary, No 4 2 left ovary, rectovaginal septum 2 34 Nulliparous Left Right inguinal region, sigmoid colon No Para I 1 miscarriage Left Pouch of Douglas, left ovary, No 3 0 left tube, vagina 4 35 Nulliparous Right þ left Left ovary, rectum, sigmoid colon Yes failed oocyte Right Left ovary, right tube No 4 0 retrievals 6 35 Nulliparous Left Left ovary, left tube Yes VTOP Left Adenomyosis, right ovary, left ovary, No 2 1 right tube, left tube VTOP Left Pouch of Douglas, left ovary, left tube No failed IVF-ET Right Right ovary, vagina No Nulliparous Right Pouch of Douglas, anterior wall of No 2 0 the rectum, sigmoid colon Para I Left Left ovary, left tube, rectum Yes Nulliparous Left Appendix, ileum, left ovary, left Yes 4 0 tube, sigmoid colon Para I Left Pouch of Douglas, broad ligament, left ovary, left tube No 4 0 Note: PGI-S ¼ Patient Global Impression of Severity; VTOP ¼ voluntary termination. a Endometriosis classification: 1 ¼ minimal; 2 ¼ mild; 3 ¼ moderate; 4 ¼ severe. PGI-S score: 0 ¼ absent (no urine leakage); 1 ¼ mild; 2 ¼ moderate; 3 ¼ severe. Carmignani. Ureteroneocystostomy for endometriosis. Fertil Steril PGI-S score a

4 38 Carmignani et al. Ureteroneocystostomy for endometriosis Vol. 92, No. 1, July 2009 TABLE 2 Results of the urodynamic test. Patient First desire Vinf (ml) First desire Pdet (cm/h 2 O) Strong desire Vinf (ml) Strong desire Pdet (cm/h 2 O) Cystometric capacity Vinf (ml) Cystometric capacity Pdet (cm/h 2 O) Urine residual (ml) Peak flow (ml/s) Positive Negative Negative Negative Negative Negative Positive Negative Negative Negative Negative Negative Negative 3 Mean SD Note: Vinf ¼ infusion volume; Pdet ¼ detrusor pressure; PGI-I ¼ Patient Global Impression of Improvement. a PGI-I score: 0 ¼ much improved; 1 ¼ improved; 2 ¼ minimally improved; 3 ¼ no change; 4 ¼ minimally worse; 5 ¼ worse; 6 ¼ much worse. Carmignani. Ureteroneocystostomy for endometriosis. Fertil Steril Stress test result PGI-I score a

5 Mean SD preoperative urodynamic values in 9 of the 13 cases were as follows: volume at first desire to void, ml; pressure at first desire to void, 2 2cmH 2 O; volume at strong desire to void, ml; pressure at strong desire to void, 10 6cmH 2 O; cystometric capacity, ml; pressure at cystometric capacity 13 6cmH 2 O; residual volume, ml; maximum flow, 20 7 ml. All patients showed normal bladder capacity 3 months after surgery. Table 2 shows results of the urodynamic assessment and of the PGI-I questionnaire. Two patients presented with stress incontinence at removal of the urinary Foley catheter, with almost complete remission at 3 months after surgery. In 4 patients the bladder was also involved and presented an endometriotic nodule of 3 to 4 cm; in these cases a bladder resection was performed, followed by ureteral reimplantation. In 8 of 13 patients the left ureter was involved; only 1 patient presented bilateral ureteral involvement, in which left ureteroneocystostomy and right ureterolysis were performed. In all operated patients endometriosis involved more than one organ, and in 3 patients intestinal resection was required concomitantly to the urologic surgical session. Intestinal resection was always performed before ureteral anastomosis because the psoas hitch would impede subsequent intestinal resection. A single case of fever (38.5 C) was observed, lasting 10 days after surgery and which resolved after intravenous antibiotic therapy. In 1 case diarrhea occurred, which lasted from the fourth to the tenth day postsurgically and resolved spontaneously. At 6 months follow-up no ureteral stricture or further conditions in the urinary tract were found, nor was relapse of endometriosis found at clinical, laboratory, and imaging assessments. The 2 patients who complained of second-degree stress incontinence had continence improvement at 6 postoperative months, with only slight leakage persisting. After surgery, patients who were not planning to seek a pregnancy underwent treatment with a low-dose progestin. Patients who desired to conceive were asked to wait at least 6 months after surgery, to permit assessment of ureteral patency. A statistical evaluation of pre- and postoperative urodynamic parameters was carried out using Student s t-test. The comparison between pre- and postoperative levels showed a statistically significant difference only for the first desire. The preoperative mean for the first desire was ml, whereas the postoperative mean was ml; considering a 95% confidence interval, this difference is statistically significant (P¼.0377). The limited number of cases examined, however, does not allow definitive conclusions. All other urodynamic parameters considered showed no statistically significant differences. Subsequent follow-up was at 6 months from surgery and then every 6 months thereafter and consisted of a urogynecologic examination, a questionnaire on urinary symptoms, and renal ultrasound. At present 1 patient has conceived after IVF. DISCUSSION Despite its low frequency, endometriosis of the urinary tract can lead to hydronephrosis and loss of renal function in 25% 50% of cases (11). In patients with infiltrating pelvic endometriosis, renal ultrasound should be routinely performed to avoid late diagnosis of silent renal failure. Ureterolysis should not be the therapy of choice when there are isolated endometriotic implants that are intrinsic in the muscularis and lamina propria, which would inevitably lead to recurrence of stenosis (12). Furthermore, excessive surgical exposition can cause fibrosis and secondary obstruction. The detrusor is often involved in these cases, in which segmentary resection of the bladder is required during reimplantation (12, 13). In the 4 cases in which partial bladder cystectomy (14) was performed during reimplantation in our case series, no urologic conditions arose at follow-up. In cases of intestinal involvement, intestinal resection may be necessary, which increases the risk of dehiscence of the ureteral anastomosis. In our case series the 2 patients with mild preoperative stress incontinence were informed that surgery might cause a slight worsening of the condition, which in fact did not occur. Although a statistically significant difference was present for first desire, postoperative first desire level can be considered to be within acceptable limits. We are aware that in patients who desire to conceive, a delay in pregnancy-seeking of 6 months may be distressing, especially in patients with reduced fertility because of both age and pelvic endometriosis. However, we deem it to be an advisable recommendation because these patients have undergone a critical as well as delicate procedure. Despite being a benign disease, endometriosis heavily affects patient quality of life and fertility. It is thus essential to adequately inform patients regarding possible complications of this type of surgery. Because there were no data in the literature describing such information, we decided to study the possible urodynamic modifications that psoas hitch and ureteral reimplantation might cause. We found no published studies on the urodynamic alterations caused by this surgical technique; the absence of studies on this subject can be explained by the fact that this procedure is usually performed in cancer patients undergoing radiotherapy. The obvious differences in diseases and clinical conditions make it impossible to generalize the results observed to patients with endometriosis. However, on the basis of the results of this study, bladder psoas hitch, ureteral resection, and ureteroneocystostomy for infiltrating endometriosis do not seem to have a negative impact on urodynamic parameters. REFERENCES 1. Comiter CV. Endometriosis of the urinary tract. Urol Clin N Am 2002;29: Gustilo-Ashby A, Paradiso M. Treatment of urinary tract endometriosis. J Minim Invasive Gynecol 2006;13: Fertility and Sterility â 39

6 3. Nezhat CH, Malik S, Nezhat F, Nezhat C. Laparoscopic ureteroneocystostomy and vesicopsoas hitch for infiltrative endometriosis. JSLS 2004;8: American Fertility Society. Revised American Fertility Society classification of endometriosis. Fertil Steril 1997;67: Yallin I, Bump RC. Validation of two global impression questionnaires for incontinence. Am J Obstet Gynecol 2003;189: Fedele L, Bianchi S, Carmignani L, Berlanda N, Fontana E, Frontino G. Evaluation of a new questionnaire for the presurgical diagnosis of bladder endometriosis. Hum Reprod 2007;22: Sand P, Dmochowski R. Analysis of the standardisation of terminology of lower urinary tract dysfunction: report from the standardisation subcommittee of the international continence society. Neurourol Urodynam 2002;21: Riedmiller H, Becht E, Hertle L, Jacobi G, Hohenfellner R. Psoas-hitch ureteroneocystostomy: experience with 181 cases. Eur Urol 1984;10: Zugor V, Krot D, Rosch WH, Schrott KM, Schott GE. Endometriosis of the ureter and urinary bladder. Urologe A 2007;46: Ahn M, Loughlin KR. Psoas hitch ureteral reimplantation in adults analysis of a modified technique and timing of repair. Urology 2001;58: Warwick RT, Worth PH. The psoas bladder-hitch procedure for the replacement of the lower third of the ureter. Br J Urol 1969;41: Marcelli F, Collinet P, Vinatier D, Robert Y, Triboulet JP, Biserte J, et al. Ureteric and bladder involvement of deep pelvic endometriosis. Value of multidisciplinary surgical management. Prog Urol 2006;16: Fedele L, Bianchi S, Zanconato G, Bergamini V, Berlanda N, Carmignani L. Long-term follow-up after conservative surgery for bladder endometriosis. Fertil Steril 2005;83: Vercellini P, Frontino G, Pisacreta A, DeGiorgi O, Cattaneo M, Crosignani PG. The pathogenesis of bladder detrusor endometriosis. Am J Obstet Gynecol 2002;187: Carmignani et al. Ureteroneocystostomy for endometriosis Vol. 92, No. 1, July 2009

ENDOMETRIOSIS When and how to implement treatment

ENDOMETRIOSIS When and how to implement treatment Francisco Carmona Hospital Clínic ENDOMETRIOSIS TREATMENT It depends on the severity of symptoms the patient's desire for pregnancy the extent of disease