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Ureteral suspension facilitates surgery for deep pelvic endometriosis
Ureteral suspension facilitates surgery for deep pelvic endometriosis This study describes a technique that facilitates the identification of the ureter during radical excision of endometriosis. After dissection of the ureter, a biocompatible silicone sling is introduced into the pelvis through the trocar; the sling is applied around the ureter and the two ends of the sling are pulled until adequate traction on the ureter is obtained. Ureteral suspension was performed in 126 consecutive women with endometriotic lesions involving the ovarian fossa and/or the uterosacral ligaments. This surgical technique facilitated the identification of the ureter, preventing injuries. (Fertil Steril威 2007;87:1222– 4. ©2007 by American Society for Reproductive Medicine.)
The presence of endometriotic glands and stroma in the ureteral wall (intrinsic ureteral endometriosis) is very rare (1), and it is estimated to occur in about 0.08% to 1% of women with endometriosis (2). More frequently, the ureter itself is not invaded by endometriosis, but it is encircled by constrictive fibrosis caused by the disease of the adjacent uterosacral ligament (3). Typically, endometriotic lesions involving the pelvic sidewall determine a medial displacement of the ureter toward the uterosacral ligament (4) and thicken the peritoneum, making difficult the direct visualization of the ureter; in the presence of these conditions, the ureter is susceptible to surgical injury (5–7). Therefore, retroperitoneal dissection of the ureter is required when excising deep endometriotic lesions of the ovarian fossa, the uterosacral ligaments, and the rectovaginal septum (3, 8). The current study aims to describe a technique of ureteral suspension that may facilitate its identification during excision of deep endometriotic lesions. This study included 126 consecutive women who underwent laparoscopy because of symptomatic endometriosis. Only women with endometriotic lesions involving the ovarian fossa and/or the uterosacral ligaments were included in the study. A four-port laparoscopic technique was used with an umbilical 10-mm port for the scope and three additional 5-mm operating ports (two lateral to the rectus sheath and one in the midline in the suprapubic area). In some cases surgery was started vaginally by circumscribing the lesion with electrosurgery until the soft areolar tissue of the rectovaginal septum was encountered (3). If ovarian endometriotic cysts were present, they were removed before suspending the ovaries to the abdominal wall (9). Before excision of deep endometriotic lesions, ureterolysis was started high on the pelvic sidewall in normal peritoneum overlying the ureter and then continued in the Received April 13, 2006; revised and accepted August 19, 2006. Reprint requests: Simone Ferrero, M.D., Department of Obstetrics and Gynaecology, San Martino Hospital, University of Genoa, Largo R. Benzi 1, 16132 Genoa, Italy. (FAX: 011-39-010-51-1525; E-mail: [email protected]).
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direction of the uterosacral ligament. The ureter was progressively freed up by sharp and blunt dissection combined with small cutting and bipolar coagulation. In some cases it was necessary to sacrifice the uterine artery to completely free the ureter. When the ureter was completely free, a 40-cm biocompatible silicone sling (Medical Biomaterial Products, Neustadt-Glewe, Germany) was introduced in the pelvis through the ipsilateral trocar by using atraumatic forceps. The sling was applied around the ureter. The two ends of the sling were pulled until adequate traction on the ureter was obtained, and the two ends of the sling were brought out of the pelvis via the ipsilateral trocar sleeve (Fig. 1). The sleeve was removed and was replaced in the peritoneal cavity next to the sling. The sling was secured outside the abdomen. The same procedure was repeated on the opposite side if required. The surgery continued with an easy identification of the ureters, which were pushed outward by placing an extracorporeal traction on the slings. At the end of the surgical procedure, the sling was removed. Ureteral suspension was performed monolaterally in 70.6% of the patients (n ⫽ 89; on the left side in 55 cases and on the right side in 34 cases) and bilaterally in 29.4% of the subjects (n ⫽ 37). In 125 (99.2%) cases the fibrotic ring surrounding the ureter was completely removed, leaving the ureter in total safety and without opening the ureteral lumen. In four cases (3.2%) the uterine artery crossing the lowest part of the ureter was coagulated. In one case (0.8%), the muscularis of the ureter was invaded by endometriosis; resection of a portion of the ureter was required and laparoscopic uretero-ureterostomy was performed. This patient underwent intraoperative stent placement, and the catheter was left in place for 3 months. No complication resulting from the ureteral suspension was observed. The technique was easy to perform and normally took ⬍5 minutes to be completed on both sides. In all cases the endometriotic nature of the removed nodules was confirmed at histologic examination. Prevention of ureteric injuries is a primary goal during major laparoscopic pelvic surgery, particularly in the pres-
Fertility and Sterility姞 Vol. 87, No. 5, May 2007 Copyright ©2007 American Society for Reproductive Medicine, Published by Elsevier Inc.
0015-0282/07/$32.00 doi:10.1016/j.fertnstert.2006.08.116
FIGURE 1 Surgical steps in ureteral suspension. (A) Ureterolysis is started high on the pelvic sidewall in the normal peritoneum overlying the left ureter, and it is then continued in the direction of the uterosacral ligament; the ureter was progressively freed. (B) The silicone sling is introduced into the pelvis through the ipsilateral trocar by using atraumatic forceps. (C) The sling is applied around the ureter. (D) The two ends of the sling are pulled until adequate traction on the ureter is obtained. (E) The same procedure is repeated on the right ureter.
Alessandri. Ureteral suspension in endometriosis. Fertil Steril 2007.
ence of predisposing conditions such as pelvic adhesions secondary to endometriosis or previous pelvic operations, pelvic malignancy, and previous pelvic irradiation. During surgery for deep endometriosis, the risk of ureteral injuries is greater when lesions of the uterosacral ligament are excised. In fact, when the ureter is not identified, there is a relevant risk of inadvertent lacerations or resection. Alternatively, burn injuries and necrosis can occur when bleeding in this area induces the surgeon to use electrical, thermal, or laser energy. Even the use of bipolar electrocoagulation around the ureter may be problematic because many coagulator paddles are too large to apply a small energy footprint (3). Ureteric lesions may cause significant morbidity, including ureteric stenosis or obstruction, uterovaginal fistula, and in some cases hydronephrosis and variable degrees of impaired renal function. Donnez et al. (10) suggested that the placement of ureteral stents just before surgery improves the intraoperative recognition of the ureters in women with endometriosis. When ureteral dissection is judged to be not required, for example during laparoscopyFertility and Sterility姞
assisted vaginal hysterectomy, the chance of ureteral injury may be reduced by creating a window over the anterior and posterior broad ligaments and pushing inferolaterally the areolar tissue (in which the ureter is embedded) on the posterior broad ligament (11). Ureteral suspension with a silicone sling may facilitate the dissection because it allows the surgeon to modulate the traction on the ureter during the procedure. An important property of the silicone sling is its slipperiness; in fact not only it can be easily inserted, but also it slides with minimal friction even when it is placed next to the trocar sleeve. Theoretically, friction during movements of the sling may determine damages to the surrounding tissues (ureter and abdominal wall). The use of a silicone sling in the current study was based on the previous demonstration that silicone-based materials show the greatest ease of movement because of the lower friction (12). In conclusion, we describe a technique of ureteral suspension that not only gave us the opportunity to easily identify the ureter, but also facilitated the excision of 1223
endometriosis through the traction exerted on the ureter by the sling. Franco Alessandri, M.D. Davide Lijoi, M.D. Emanuela Mistrangelo, M.D. Simone Ferrero, M.D. Nicola Ragni, M.D. Valentino Remorgida, M.D. Department of Obstetrics and Gynecology, San Martino Hospital and University of Genoa, Genoa, Italy
REFERENCES 1. Donnez J, Squifflet J, Smets M, Jadoul P. Severe endometriosis involving the urogenital system. In: Sutton C, Jones K, Adamson GD, eds. Modern management of endometriosis. Abington, UK: Taylor and Francis, 2005:205–13. 2. Nezhat C, Nezhat F, Nezhat CH, Nasserbakht F, Rosati M, Seidman DS. Urinary tract endometriosis treated by laparoscopy. Fertil Steril 1996;66:920 – 4. 3. Redwine DB. Endometriosis of the urinary tract. In: Redwine DB, ed. Surgical management of endometriosis. London: Martin Dunitz, Taylor and Francis Group, 2004:191–203.
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Alessandri et al.
Correspondence
4. Nackley AC, Yeko TR. Ureteral displacement associated with pelvic peritoneal defects and endometriosis. J Am Assoc Gynecol Laparosc 2000;7:131–3. 5. Cheng YS. Ureteral injury resulting from laparoscopic fulguration of endometriotic implant. Am J Obstet Gynecol 1976;126:1045– 6. 6. Grainger DA, Soderstrom RM, Schiff SF, Glickman MG, DeCherney AH, Diamond MP. Ureteral injuries at laparoscopy: insights into diagnosis, management, and prevention. Obstet Gynecol 1990;75: 839 – 43. 7. Saidi MH, Sadler RK, Vancaillie TG, Akright BD, Farhart SA, White AJ. Diagnosis and management of serious urinary complications after major operative laparoscopy. Obstet Gynecol 1996;87:272– 6. 8. Chapron C, Dubuisson JB. Laparoscopic treatment of deep endometriosis located on the uterosacral ligaments. Hum Reprod 1996;11: 868 –73. 9. Cutner AS, Lazanakis MS, Saridogan E. Laparoscopic ovarian suspension to facilitate surgery for advanced endometriosis. Fertil Steril 2004;82:702– 4. 10. Donnez J, Suifflet J. Ureteral endometriosis: a complication of rectovaginal adenomyosis. In: Jain N, ed. Atlas of endoscopic surgery in infertility and gynecology. New York: McGraw-Hill, 2004:192–200. 11. Koh LW, Koh PH, Lin LC, Ng WJ, Wong E, Huang MH. A simple procedure for the prevention of ureteral injury in laparoscopic-assisted vaginal hysterectomy. J Am Assoc Gynecol Laparosc 2004;11: 167–9. 12. Jones DS, Garvin CP, Gorman SP. Relationship between biomedical catheter surface properties and lubricity as determined using textural analysis and multiple regression analysis. Biomaterials 2004;25: 1421– 8.
Vol. 87, No. 5, May 2007
The presence of endometriotic glands and stroma in the ureteral wall (intrinsic ureteral endometriosis) is very rare (1), and it is estimated to occur in about 0.08% to 1% of women with endometriosis (2). More frequently, the ureter itself is not invaded by endometriosis, but it is encircled by constrictive fibrosis caused by the disease of the adjacent uterosacral ligament (3). Typically, endometriotic lesions involving the pelvic sidewall determine a medial displacement of the ureter toward the uterosacral ligament (4) and thicken the peritoneum, making difficult the direct visualization of the ureter; in the presence of these conditions, the ureter is susceptible to surgical injury (5–7). Therefore, retroperitoneal dissection of the ureter is required when excising deep endometriotic lesions of the ovarian fossa, the uterosacral ligaments, and the rectovaginal septum (3, 8). The current study aims to describe a technique of ureteral suspension that may facilitate its identification during excision of deep endometriotic lesions. This study included 126 consecutive women who underwent laparoscopy because of symptomatic endometriosis. Only women with endometriotic lesions involving the ovarian fossa and/or the uterosacral ligaments were included in the study. A four-port laparoscopic technique was used with an umbilical 10-mm port for the scope and three additional 5-mm operating ports (two lateral to the rectus sheath and one in the midline in the suprapubic area). In some cases surgery was started vaginally by circumscribing the lesion with electrosurgery until the soft areolar tissue of the rectovaginal septum was encountered (3). If ovarian endometriotic cysts were present, they were removed before suspending the ovaries to the abdominal wall (9). Before excision of deep endometriotic lesions, ureterolysis was started high on the pelvic sidewall in normal peritoneum overlying the ureter and then continued in the Received April 13, 2006; revised and accepted August 19, 2006. Reprint requests: Simone Ferrero, M.D., Department of Obstetrics and Gynaecology, San Martino Hospital, University of Genoa, Largo R. Benzi 1, 16132 Genoa, Italy. (FAX: 011-39-010-51-1525; E-mail: [email protected]).
1222
direction of the uterosacral ligament. The ureter was progressively freed up by sharp and blunt dissection combined with small cutting and bipolar coagulation. In some cases it was necessary to sacrifice the uterine artery to completely free the ureter. When the ureter was completely free, a 40-cm biocompatible silicone sling (Medical Biomaterial Products, Neustadt-Glewe, Germany) was introduced in the pelvis through the ipsilateral trocar by using atraumatic forceps. The sling was applied around the ureter. The two ends of the sling were pulled until adequate traction on the ureter was obtained, and the two ends of the sling were brought out of the pelvis via the ipsilateral trocar sleeve (Fig. 1). The sleeve was removed and was replaced in the peritoneal cavity next to the sling. The sling was secured outside the abdomen. The same procedure was repeated on the opposite side if required. The surgery continued with an easy identification of the ureters, which were pushed outward by placing an extracorporeal traction on the slings. At the end of the surgical procedure, the sling was removed. Ureteral suspension was performed monolaterally in 70.6% of the patients (n ⫽ 89; on the left side in 55 cases and on the right side in 34 cases) and bilaterally in 29.4% of the subjects (n ⫽ 37). In 125 (99.2%) cases the fibrotic ring surrounding the ureter was completely removed, leaving the ureter in total safety and without opening the ureteral lumen. In four cases (3.2%) the uterine artery crossing the lowest part of the ureter was coagulated. In one case (0.8%), the muscularis of the ureter was invaded by endometriosis; resection of a portion of the ureter was required and laparoscopic uretero-ureterostomy was performed. This patient underwent intraoperative stent placement, and the catheter was left in place for 3 months. No complication resulting from the ureteral suspension was observed. The technique was easy to perform and normally took ⬍5 minutes to be completed on both sides. In all cases the endometriotic nature of the removed nodules was confirmed at histologic examination. Prevention of ureteric injuries is a primary goal during major laparoscopic pelvic surgery, particularly in the pres-
Fertility and Sterility姞 Vol. 87, No. 5, May 2007 Copyright ©2007 American Society for Reproductive Medicine, Published by Elsevier Inc.
0015-0282/07/$32.00 doi:10.1016/j.fertnstert.2006.08.116
FIGURE 1 Surgical steps in ureteral suspension. (A) Ureterolysis is started high on the pelvic sidewall in the normal peritoneum overlying the left ureter, and it is then continued in the direction of the uterosacral ligament; the ureter was progressively freed. (B) The silicone sling is introduced into the pelvis through the ipsilateral trocar by using atraumatic forceps. (C) The sling is applied around the ureter. (D) The two ends of the sling are pulled until adequate traction on the ureter is obtained. (E) The same procedure is repeated on the right ureter.
Alessandri. Ureteral suspension in endometriosis. Fertil Steril 2007.
ence of predisposing conditions such as pelvic adhesions secondary to endometriosis or previous pelvic operations, pelvic malignancy, and previous pelvic irradiation. During surgery for deep endometriosis, the risk of ureteral injuries is greater when lesions of the uterosacral ligament are excised. In fact, when the ureter is not identified, there is a relevant risk of inadvertent lacerations or resection. Alternatively, burn injuries and necrosis can occur when bleeding in this area induces the surgeon to use electrical, thermal, or laser energy. Even the use of bipolar electrocoagulation around the ureter may be problematic because many coagulator paddles are too large to apply a small energy footprint (3). Ureteric lesions may cause significant morbidity, including ureteric stenosis or obstruction, uterovaginal fistula, and in some cases hydronephrosis and variable degrees of impaired renal function. Donnez et al. (10) suggested that the placement of ureteral stents just before surgery improves the intraoperative recognition of the ureters in women with endometriosis. When ureteral dissection is judged to be not required, for example during laparoscopyFertility and Sterility姞
assisted vaginal hysterectomy, the chance of ureteral injury may be reduced by creating a window over the anterior and posterior broad ligaments and pushing inferolaterally the areolar tissue (in which the ureter is embedded) on the posterior broad ligament (11). Ureteral suspension with a silicone sling may facilitate the dissection because it allows the surgeon to modulate the traction on the ureter during the procedure. An important property of the silicone sling is its slipperiness; in fact not only it can be easily inserted, but also it slides with minimal friction even when it is placed next to the trocar sleeve. Theoretically, friction during movements of the sling may determine damages to the surrounding tissues (ureter and abdominal wall). The use of a silicone sling in the current study was based on the previous demonstration that silicone-based materials show the greatest ease of movement because of the lower friction (12). In conclusion, we describe a technique of ureteral suspension that not only gave us the opportunity to easily identify the ureter, but also facilitated the excision of 1223
endometriosis through the traction exerted on the ureter by the sling. Franco Alessandri, M.D. Davide Lijoi, M.D. Emanuela Mistrangelo, M.D. Simone Ferrero, M.D. Nicola Ragni, M.D. Valentino Remorgida, M.D. Department of Obstetrics and Gynecology, San Martino Hospital and University of Genoa, Genoa, Italy
REFERENCES 1. Donnez J, Squifflet J, Smets M, Jadoul P. Severe endometriosis involving the urogenital system. In: Sutton C, Jones K, Adamson GD, eds. Modern management of endometriosis. Abington, UK: Taylor and Francis, 2005:205–13. 2. Nezhat C, Nezhat F, Nezhat CH, Nasserbakht F, Rosati M, Seidman DS. Urinary tract endometriosis treated by laparoscopy. Fertil Steril 1996;66:920 – 4. 3. Redwine DB. Endometriosis of the urinary tract. In: Redwine DB, ed. Surgical management of endometriosis. London: Martin Dunitz, Taylor and Francis Group, 2004:191–203.
1224
Alessandri et al.
Correspondence
4. Nackley AC, Yeko TR. Ureteral displacement associated with pelvic peritoneal defects and endometriosis. J Am Assoc Gynecol Laparosc 2000;7:131–3. 5. Cheng YS. Ureteral injury resulting from laparoscopic fulguration of endometriotic implant. Am J Obstet Gynecol 1976;126:1045– 6. 6. Grainger DA, Soderstrom RM, Schiff SF, Glickman MG, DeCherney AH, Diamond MP. Ureteral injuries at laparoscopy: insights into diagnosis, management, and prevention. Obstet Gynecol 1990;75: 839 – 43. 7. Saidi MH, Sadler RK, Vancaillie TG, Akright BD, Farhart SA, White AJ. Diagnosis and management of serious urinary complications after major operative laparoscopy. Obstet Gynecol 1996;87:272– 6. 8. Chapron C, Dubuisson JB. Laparoscopic treatment of deep endometriosis located on the uterosacral ligaments. Hum Reprod 1996;11: 868 –73. 9. Cutner AS, Lazanakis MS, Saridogan E. Laparoscopic ovarian suspension to facilitate surgery for advanced endometriosis. Fertil Steril 2004;82:702– 4. 10. Donnez J, Suifflet J. Ureteral endometriosis: a complication of rectovaginal adenomyosis. In: Jain N, ed. Atlas of endoscopic surgery in infertility and gynecology. New York: McGraw-Hill, 2004:192–200. 11. Koh LW, Koh PH, Lin LC, Ng WJ, Wong E, Huang MH. A simple procedure for the prevention of ureteral injury in laparoscopic-assisted vaginal hysterectomy. J Am Assoc Gynecol Laparosc 2004;11: 167–9. 12. Jones DS, Garvin CP, Gorman SP. Relationship between biomedical catheter surface properties and lubricity as determined using textural analysis and multiple regression analysis. Biomaterials 2004;25: 1421– 8.
Vol. 87, No. 5, May 2007