ENDOMETRIOSIS. Bladder endometriosis must be considered as bladder adenomyosis MATERIALS AND METHODS

Size: px

Start display at page:

Download "ENDOMETRIOSIS. Bladder endometriosis must be considered as bladder adenomyosis MATERIALS AND METHODS"

Harriet Atkinson
5 years ago
Views:

1 FERTILITY AND STERILITY VOL. 74, NO. 6, DECEMBER 2000 Copyright 2000 American Society for Reproductive Medicine Published by Elsevier Science Inc. Printed on acid-free paper in U.S.A. ENDOMETRIOSIS Bladder endometriosis must be considered as bladder adenomyosis Jacques Donnez, M.D., Ph.D., Francesca Spada, M.D., Jean Squifflet, M.D., and Michelle Nisolle, M.D., Ph.D. Service de Gynécologie, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium Objective: To present data from a series of 17 cases of bladder endometriosis. Design: Clinical study. Setting: A university hospital department of gynecology. Patient(s): Seventeen patients complaining of menstrual urinary symptoms and/or pelvic pain. Intervention(s): Diagnosis and resection of a bladder adenomyotic nodule. Main Outcome Measure(s): Histologic analysis and postsurgical outcome. Result(s): Seventy-six percent of the patients reported menstrual mictalgia and pollakiuria, and 88% reported dysmenorrhea and dyspareunia. Cystoscopy, intravenous pyelography, and magnetic resonance imaging revealed a nodular mass in the anterior fornix adjacent to the uterine wall, developed in the vesical muscularis and involving the vesical mucosa in all cases but one. The bladder nodule was associated with a rectovaginal nodule in six cases (35%). Because recurrence was noted soon after cessation of medical therapy, surgical excision was proposed. The vesical mucosa was found to be intact in almost all cases, so extramucosal laparoscopic excision was the method of choice. Histologic examination proved that 90% of the nodule consisted of smooth muscle hyperplasia. Conclusion(s): So-called bladder endometriosis is actually an adenomyotic nodule of the bladder which, from a histologic point of view, is similar to a rectovaginal adenomyotic nodule and frequently (35%) associated with it. (Fertil Steril 2000;74: by American Society for Reproductive Medicine.) Key Words: Bladder endometriosis, adenomyosis Received February 24, 2000; revised and accepted June 5, Reprint requests: Jacques Donnez, M.D., Ph.D., Service de Gynécologie, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Av. Hippocrate, 10, B-1200 Bruxelles, Belgium (FAX: ; donnez@gyne.ucl.ac.be) /00/$20.00 PII S (00) Although endometriosis is frequently encountered in women of reproductive age (1), bladder endometriosis is relatively rare, representing 1% of all endometriosis cases. One must take particular care, however, to clearly define bladder endometriosis as full-thickness detrusor lesions. Indeed, small implants and small nodules of the vesicouterine fornix cannot be considered as bladder endometriosis. The condition was first described by Judd in 1921 (2), and a review of 200 cases was published in 1980 (3). In the literature, two distinct forms appear to exist: One is found in women without any medical history of uterine surgery (primary), and the other develops after cesarean section (iatrogenic or secondary) (4). This report summarizes a series of 17 cases of bladder endometriosis. We attempt to identify the diagnostic signs, to define the anatomic and pathologic characteristics, and to discuss the pathogenesis of this disease. MATERIALS AND METHODS This study was approved by the Ethical Institutional Board of the Université Catholique de Louvain. Between October 1982 and December 1999, 17 women aged years underwent laparotomy or laparoscopy for bladder endometriosis. During the same period, more than 9,200 patients were treated for endometriosis in our department. The prevalence of bladder endometriosis was thus 0.2%. Only full-thickness detrusor lesions were taken into consideration; small subperitoneal nodules or implants of the anterior cul-de-sac were excluded. Nine patients presented with primary infertility. In seven of them, other endometriotic lesions 1175

2 (peritoneal and/or ovarian) were present. Four women had never been pregnant and had no desire to conceive. Four (23%) had undergone cesarean section. Symptoms were recorded and a preoperative assessment of the pathology was made by transvaginal echography, cystoscopy, and intravenous pyelography. The last six patients also had magnetic resonance imaging (MRI). In eight patients (47%), surgery was considered as the first choice of therapy, without any previous medical therapy. When many other ovarian lesions were present (cysts 3 cm in size; n 4; 23%), medical therapy was given (3 months of GnRHa therapy, Zoladex; Zeneca, Cambridge, UK) after drainage of the ovarian cyst, as described previously (1, 5). This was followed by surgical treatment, including ovarian cyst wall vaporization and segmental bladder resection, performed by either laparotomy or laparoscopy. In seven patients (41%), a rectovaginal adenomyotic nodule was found to be associated. In these seven women, laparoscopy was performed first to remove the rectovaginal adenomyotic nodule and to vaporize the associated peritoneal and/or ovarian lesions. A second operation was then performed 2 3 months later to resect the bladder lesions. In the first 12 patients, the peritoneal cavity was entered by means of a suprapubic minilaparotomy. The bladder, uterus, ovaries, and peritoneum were checked for endometriotic lesions. If any were found, they were vaporized with the CO 2 laser (Sharplan, Tel Aviv, Israel). After dissecting the bladder from the surrounding tissue, we performed a small resection of the involved bladder wall with scissors. The vesical defect was closed in two layers, with separate submucosal stitches of catgut or a running suture of catgut 2-0 or Vicryl 2-0 (Ethicon, Johnson and Johnson, USA). To ensure the watertightness of the sutures, we injected a solution of dilute methylene blue through the vesical catheter. Bladder drainage was continued for 10 days postoperatively. In the last five patients, prompted by our first anatomic analysis, which revealed an intact vesical mucosa, we performed extramucosal dissection of the bladder nodule by laparoscopy with a CO 2 laser connected to a 12-mm laser laparoscope (Storz, Tuttlingen, Germany) using a coupler system equipped with a swiftlaser (model 757; Sharplan) (6). Deep fibrotic nodular lesions involving the vesical muscularis required excision of the nodular tissue from the anterior uterine wall. Attention was first directed toward achieving complete dissection of the uterine wall throughout its area of attachment or involvement until the loose tissue of the vesical space was reached. The peritoneum covering the bladder was opened. With gentle traction, we exposed the plane of dissection between the fibrotic nodular tissue and the normal vesical muscularis and easily resected the nodule, taking care not to enter the bladder. In the last five patients, extramucosal dissection was successful. At the end of surgery, the vesical muscularis was closed with two or three (0 Vicryl) sutures. If a small hole was made in the mucosa, extramucosal stitches were placed. The resected piece was then sent for histologic analysis. TABLE 1 Clinical characteristics of the patients. Patient Age (y) Parity Urinary symptoms during the menstrual period Other symptoms Size of bladder lesion (cm) (mean) Other endometriotic localization 1 35 G1P1 Mictalgia, pollakiuria Dysmenorrhea, dyspareunia 3 3 (3) None 2 40 G1P1 None Dysmenorrhea, dyspareunia 2 1 (1.5) Appendix, peritoneal endometriosis 3 38 G2P2 Mictalgia, pollakiuria, hematuria Dysmenorrhea, dyspareunia 4 2 (3) Peritoneal endometriosis 4 28 G0P0 Mictalgia, pollakiuria Dysmenorrhea, dyspareunia (2.2) None 5 26 G1P0A1 Mictalgia, pollakiuria Dysmenorrhea, dyspareunia (2.9) None 6 25 G0P0 Mictalgia, pollakiuria Dysmenorrhea, dyspareunia 3 3 (3) Uterosacral ligament, rectovaginal adenomyotic nodule 7 29 G0P0 None None (3.2) Peritoneal, ovarian endometrioma 8 27 G0P0 Mictalgia, pollakiuria None (2) None 9 43 G2P2 Mictalgia, pollakiuria, dysuria Dysmenorrhea 4 4 (4) None G2P2 None Dysmenorrhea, dyspareunia (2.1) Rectovaginal adenomyotic nodule G0P0 Mictalgia, pollakiuria, dysuria Dysmenorrhea, dyspareunia (3.2) Rectovaginal adenomyotic nodule G0P0 Mictalgia, pollakiuria, dysuria Dysmenorrhea, dyspareunia 3 3 (3) Rectovaginal adenomyotic nodule, peritoneal, ovarian endometrioma G0P0 Mictalgia, pollakiuria Dysmenorrhea, dyspareunia (4) Rectovaginal adenomyotic nodule G0P0 None Dysmenorrhea (2.9) Ovarian endometrioma G0P0 Mictalgia, pollakiuria Dysmenorrhea, dyspareunia 2 2 (2) None G0P0 Mictalgia, pollakiuria Dysmenorrhea, dyspareunia 4 4 (4) Rectovaginal adenomyotic nodule G0P0 Mictalgia, pollakiuria Dysmenorrhea, dyspareunia (2.5) Peritoneal, ovarian endometrioma 1176 Donnez et al. Bladder endometriosis or adenomyosis? Vol. 74, No. 6, December 2000

FIGURE 1 Vaginal echography: a regular heterogeneous, hypoechogenic nodule is clearly visible in the vesical muscularis protruding into the bladder cavity.

3 FIGURE 1 Vaginal echography: a regular heterogeneous, hypoechogenic nodule is clearly visible in the vesical muscularis protruding into the bladder cavity. RESULTS Thirteen women (76%) reported menstrual mictalgia and pollakiuria, mostly limited to the menstrual period (Table 1). No microorganisms could be isolated from the urine culture, even after several days. Fifteen patients (88%) experienced dysmenorrhea and dyspareunia. Only one (6%) reported gross hematuria during menstruation, which was confirmed by microscopic analysis. Analysis failed to demonstrate hematuria in all other cases. Among the 17 patients, none presented with uterine adenomyosis, but 6 (35%) had adenomyotic nodules of the rectovaginal septum. The diagnosis of bladder endometriosis can often be made by vaginal examination. In fact, in our series, a tender nodule could be palpated on the anterior fornix of the vagina in all patients. In all cases, transvaginal ultrasonography (US) confirmed the presence of a regular heterogeneous, hypoechogenic nodule of the uterovesical septum (Fig. 1) and showed an association between the endometriotic nodule and the anterior uterine wall. In our series, one patient (6%) had a 1-cm nodule, five (29%) had a 2 3-cm nodule, eight (47%) had a 3-cm ( 0.2 cm) nodule, and three (18%) had a nodule of 4 cm in maximum diameter. Cystoscopy was performed in all patients during the preoperative assessment. In all patients, a protruding mass of the posterior bladder wall was visible at the level of the fundus or the trigone. It consisted of a typical bluish or brownish nodule, but the vesical mucosa was ulcerated in only one case. This was in the patient who experienced menstrual hematuria. Intravenous pyelography demonstrated the typical aspect of an extravesical nodule in all cases, revealed by a filling defect (Fig. 2) in the upper tract of the bladder. Vesical filling defects were more obvious on the profile picture. In two cases, associated with rectovaginal adenomyotic nodules, intravenous pyelography revealed a stricture of the lower portion of the ureter, 2 3 cm long, with resulting moderate hydronephrosis. In these two patients, a JJ stent allowed laparoscopic ureterolysis and was left for 3 months. After the JJ stent was removed, intravenous pyelography demonstrated the absence of any ureteral stricture. MRI was performed on six patients. In these six patients, MRI excluded the presence of associated uterine adenomyosis and clearly revealed a nodular mass in the anterior fornix adjacent to the uterine wall, causing extensive compression of the posterior bladder wall (Fig. 3). In 6 patients (35%) treated from 1987 to 1993, medical FERTILITY & STERILITY 1177

FIGURE 2 Intravenous pyelography demonstrates the typical aspect of an extravesical nodule (arrowheads), revealed by a filling defect. therapy was proposed instead of immediate surgery.

4 FIGURE 2 Intravenous pyelography demonstrates the typical aspect of an extravesical nodule (arrowheads), revealed by a filling defect. therapy was proposed instead of immediate surgery. They received continuous treatment with progestogen drugs, such as Lynestrenol (Organon, Oss, the Netherlands) at 5 mg/d (n 3) or GnRH agonist (Zoladex; Zeneca), consisting of one SC injection per month (n 3). These patients were followed up over a period of 4 months to 1 year. This treatment proved to be effective in relieving recurrent mictalgia and pollakiuria experienced during menstruation. Unfortunately, it was less effective against dyspareunia. In this series of medically treated patients, transvaginal US was performed every 2 months to follow the natural evolution of the vesical nodule during drug therapy. No significant regression in the size of the lesion was noted in any of the six patients. Moreover, 2 3 months after the medical therapy was stopped because of long-term side effects and/or desire to conceive, the irritative urinary symptoms recurred. We decided to use drug therapy only as a presurgical treatment to facilitate the forthcoming operation in some cases (see Materials and Methods). This strategy allowed a smaller vesical wall excision by reducing the size of the lesion and the inflammatory reaction (5) surrounding the nodular lesion. After surgery, the resected lesion was sent to the pathologist. Serial sections were obtained and stained with hematoxylin and eosin or analyzed to evaluate steroid receptor (estrogen receptor [ER] and P receptor [PR]) content according to a previously described method (7). On microscopic examination (Fig. 4), the lesion was characterized by scarce glands with active endometrial-type epithelium and scanty stroma. No secretory changes were observed, even when the patient was taking progestogen therapy or during the luteal phase. More than 90% of the lesion consisted of smooth muscle hyperplasia. The bladder nodule was localized throughout the whole thickness of the bladder wall. The vesical epithelium was intact in all cases but one. By serial section, we were able to demonstrate that endometrial glands were not connected to the peritoneal serosa and were almost in the subperitoneal space. Glands sometimes appeared dilated and lined with flattened cells. But in most of them, the epithelium was represented by a single layer of cylindrical cells with very weak mitotic activity and without any typical P-induced changes. In smooth muscle, ER and PR were systematically present in 40% of the cells. The first 12 patients now have a follow-up ranging from 2 to 18 years. No recurrence has been observed. DISCUSSION Several investigators have recently described two types of bladder endometriosis: The first occurs in women who have not previously undergone any uterine surgery (primary), and the second occurs after cesarean section (iatrogenic or secondary) (8 10). In this study, we report 17 cases of bladder endometriosis. Among the 17 patients, 13 (77%) presented 1178 Donnez et al. Bladder endometriosis or adenomyosis? Vol. 74, No. 6, December 2000

FIGURE 3 MRI shows a nodular mass in the anterior fornix adjacent to the uterine wall (arrowheads), causing extensive compression of the posterior wall.

5 FIGURE 3 MRI shows a nodular mass in the anterior fornix adjacent to the uterine wall (arrowheads), causing extensive compression of the posterior wall. Note the absence of concomitant uterine adenomyosis. with primary bladder lesions and the other 4 (23%) with secondary bladder endometriosis. Koninckx and Martin (11) suggested that extraperitoneal endometriosis derives from endoperitoneal disease. Vercellini et al. (9) later proposed this theory to explain bladder endometriosis. In their opinion, peritoneal lesions are able to penetrate under the peritoneum and develop into deeply infiltrating endometriosis. If this were the case, we would have found peritoneal endometriosis in all cases. In our series, six patients (35%) had no associated endometriotic lesions. Moreover, six cases (35%) were associated with rectovaginal adenomyotic nodules, which we clearly described as a distinct retroperitoneal entity (1, 12). Indeed, the nodule in the rectovaginal septum was described, like the adenomyoma, as a circumscribed nodular aggregate of smooth muscle and endometrial glands surrounded by scanty stroma. As in the uterine adenomyoma (13) and in rectovaginal adenomyotic nodules (1, 12), secretory changes were absent in adenomyotic bladder nodules. Sometimes, there was invasion of the muscle by very active glandular epithelium without stroma, which proved that stroma is not mandatory for invasion in this particular type of pathology. We have previously suggested that the rectovaginal nodule may be due to metaplasia of müllerian remnants. Not surprisingly, the bladder nodule was exactly the same as the rectovaginal nodule from a microscopic point of view. The frequent association and the similar histologic findings observed in our study lead us to propose that bladder endometriosis is actually bladder adenomyosis and also the consequence of metaplasia of müllerian remnants, which can be found in the rectovaginal septum as well as in the vesicovaginal septum (1). Moreover, the invasion of smooth muscle fibers by active glandular epithelium without stroma proves that in the vesical nodule, as well as in the rectovaginal nodule, stroma is not mandatory for invasion; the bladder nodule is thus different from peritoneal endometriosis, in which epithelial glands are surrounded by endometrial-type stroma. These metaplastic changes of müllerian rests into endometriotic glands involving the uterovesical septum are responsible for the striking proliferation of smooth muscle, creating an ad- FERTILITY & STERILITY 1179

FIGURE 4 Vesical adenomyosis; 90% of the lesion (A) consisted of smooth muscle hyperplasia. Scarce glands with active endometrialtype epithelium and scanty stroma were visible (B).

6 FIGURE 4 Vesical adenomyosis; 90% of the lesion (A) consisted of smooth muscle hyperplasia. Scarce glands with active endometrialtype epithelium and scanty stroma were visible (B). enomyomatous appearance similar to that of uterine adenomyosis and the rectovaginal adenomyotic nodule. One of the hypotheses forwarded by Fedele et al. (4), that detrusor endometriosis could result from the extension of adenomyotic lesions from the anterior uterine wall to the bladder, is not supported by our study. Indeed, although the adenomyotic vesical nodule was systematically found to be adherent to the uterine wall, no adenomyotic nodules of the anterior uterine wall were found. These data, observed at surgery, were corroborated by the absence of uterine adenomyosis at vaginal echography and MRI, when available. Moreover, on histologic examination, we noted that there was no continuity between the endometrial glands and the mesothelium, proving that the bladder nodule is a retroperitoneal disease. A further finding to support this view is the intact vesical mucosa observed in 94% of the patients. Although medical therapy has proved effective in relieving symptoms, the quick recurrence of irritative urinary symptoms after cessation of therapy indicates that surgery is required. In the literature so far, partial cystectomy (or segmental bladder resection) has been considered as the treatment of choice (8, 9, 14, 15). As a result of our histologic findings, extramucosal resection of bladder adenomyosis must be seriously considered. Indeed, the vesical mucosa was intact, as proved by serial histologic sections, and did not need to be resected. This is why we proposed extramucosal bladder resection of the adenomyotic nodule in the last five patients. In conclusion, so-called primary bladder endometriosis must be considered as a retroperitoneal adenomyotic nodule, which is the consequence of metaplasia of müllerian rests and which can be resected by an extramucosal laparoscopic approach Donnez et al. Bladder endometriosis or adenomyosis? Vol. 74, No. 6, December 2000

7 References 1. Nisolle M, Donnez J. Peritoneal endometriosis, ovarian endometriosis and adenomyotic nodules of the rectovaginal septum are three different entities. Fertil Steril 1997;68: Judd ES. Adenomyomata presenting as a tumor of the bladder. Surg Clin North Am 1921;1: Fianu S, Ingelman-Sundberg A, Nasiell K, Rosenc J, Vaclavinkova V. Surgical treatment of post abortum endometriosis of the bladder and postoperative bladder function. Scand J Urol Nephrol 1980;14: Fedele L, Piazzola E, Raffaeli R, Bianchi S. Bladder endometriosis: deep infiltrating endometriosis or adenomyosis? Fertil Steril 1998;69: Donnez J, Nisolle M, Gillerot S, Anaf V, Casanas-Roux F, Clerckx F. Ovarian endometrial cysts: the role of gonadotropin-releasing hormone agonist and/or drainage. Fertil Steril 1994;62: Donnez J, Nisolle M, Anaf V, Smets M, Bassil S, Casanas-Roux F. Endoscopic management of peritoneal and ovarian endometriosis. In: Donnez J, Nisolle M, editors. An atlas of laser operative laparoscopy and hysteroscopy. Carnforth: Parthenon Publishers, 1994: Nisolle M, Casanas-Rous F, Wyns Ch, de Menten Y, Mathieu PE, Donnez J. Immunohistochemical analysis of estrogen and progesterone receptors in endometrium and peritoneal endometriosis: a new quantitative method. Fertil Steril 1994;62: Nezhat CR, Nezhat Fr. Laparoscopic segmental bladder resection of endometriosis: a report of two cases. Obstet Gynecol 1993;81: Vercellini P, Meschia M, De Giorgi O, Panazza S, Cortesi I, Crosignani PG. Bladder detrusor endometriosis: clinical and pathogenetic implication. J Urol 1996;155: Brosens IA, Puttemans P, Deprest J, Rombauts L. The endometriosis cycle and its derailments. Hum Reprod 1994;9: Koninckx PR, Martin D. Deep endometriosis: a consequence of infiltration or retraction or possible adenomyosis externa. Fertil Steril 1992;85: Donnez J, Nisolle M, Smoes P, Gillet N, Beguin S, Casanas-Roux F. Peritoneal endometriosis and endometriotic nodules of the rectovaginal septum are two different entities. Fertil Steril 1996;66: Dubuisson JB, Chapron C, Aubriot FX, Osman M, Zerbib M. Pregnancy after laparoscopic partial cystectomy for bladder endometriosis. Hum Reprod 1994;9: Zaloudek C, Norris HJ. Mesenchymal tumors of the uterus. In: Kurman R, editor. Blaustein s pathology of the female genital tract. New York: Springer-Verlag, 1987: Nezhat C, Nehzat F. Laparoscopic segmental bladder resection for endometriosis: a report of two cases. Obstet Gynecol 1993;81: FERTILITY & STERILITY 1181

Peritoneal endometriosis and "endometriotic" nodules of the rectovaginal septum are two different entities*

Peritoneal endometriosis and endometriotic nodules of the rectovaginal septum are two different entities* FERTILITY AND STERILITY Vol. 66, No.3, September 1996 Copyright 1996 American Society for Reproductive Medicine Printed on acid-free paper in U. S. A. Peritoneal endometriosis and "endometriotic" nodules