Preoperative prediction of ureteral endometriosis without dilatation: instructions for use

There is a major difference between the clinical presentations of endometriosis causing intestinal stenosis and ureteral stenosis. Whereas severe bowel stricture originating from infiltration, by definition, gives rise to subocclusive symptoms, obstructive uropathy because may go unnoticed cause progressive hydroureteronephrosis in absence colicky pain (1Nezhat C. Falik R. McKinney S. King L.P. Pathophysiology management urinary tract endometriosis.Nat Rev Urol. 2017; 14: 359-372Crossref PubMed Scopus (48) Google Scholar, 2Barra F. Scala Biscaldi E. Vellone V.G. Ceccaroni M. Terrone et al.Ureteral endometriosis: systematic review epidemiology, pathogenesis, diagnosis, treatment, risk malignant transformation fertility.Hum Reprod Update. 2018; 24: 710-730Crossref (57) Scholar). Women with diagnosis deep endometriosis, which lesion phenotype most frequently associated involvement, should systematically undergo an ultrasound evaluation rule out dilatation. Reduced or absent kidney function can be detected elusive no previous suggestive although this occurs infrequently With awareness potential condition, ultrasonographic screening active surveillance all women endometriotic lesions limit disease complication. Arena al. (3Arena A. Del Forno Orsini B. Iodice Degli Esposti Aru A.C. hidden enemy: multivariable fractional polynomial approach for pre-operative factors dilatation.Fertil Steril. 2021; 116: 470-479Abstract Full Text PDF (8) Scholar) have tried take further step forward, that is, predict involvement form extrinsic compression distortion caused even secondary Toward aim, they prospectively assessed series posterior compartment who were scheduled excisional surgery. In addition detailed evaluation, including use validated scales measuring severity patients underwent transvaginal transabdominal ultrasonography. According investigators, “the required retroperitoneal isolation examination diameter, course, consistency both ureters pelvis.” During 40-month period, 300 consecutive surgery infiltrating was diagnosed 145 these (48.3%). After exclusion analysis 16 preoperative hydronephrosis, nonobstructive surgery, nodule transverse diameter >1.8 cm, parametrial adenomyosis. Some methodological considerations might help contextualize study findings into everyday practice. The diagnostic standards adopted seem somewhat undefined. Ureteral dilatation fact, whereas hydroureteronephrosis, any criterion not objectively measurable inevitably introduces some degree subjectivity. investigators argue cases, has been histologically demonstrated adjacent ureter removed during ureterolysis. This reassuring, but it still ensure adequate reproducibility what interobserver variability would if same had operated on other surgeons uncertain. Moreover, series, positive negative predictive values test 66% 72%, respectively. Considering high prevalence condition (approximately 50%), probably did markedly change surgical approach. index influences values. If decreases, value tends decrease (for example, approximately 40% case 25%), increase (and vice versa cases higher prevalence). These underline fact result “test” considered cautiously when planning procedures, especially hospitals different rates endometriosis. addition, per se could indicate selection bias, particularly conditions referred self-refer investigators’ renowned highly valued center expertise. Again, true, generalizability observed results limited. Indeed, presence at least three four identified predictors, lesion, fibrotic always raise suspicion possible involvement. For lateral border large rectovaginal very close distal tract. similar anatomic reasons, fibrosis affects parametria. As explain, constitute factor, procedure performed expertise, require technical capabilities safely excised are left behind. result, often centers expertise only repeat eventually necessary. identification adenomyosis as predictor explained its strong association (4Marcellin L. Santulli P. Bourdon Maignien Campin Lafay-Pillet M.C. al.Focal outer myometrium severity.Fertil 2020; 114: 818-827Abstract (17) their important, crucial correct planning, requiring expert surgeon”; “treatment early prevent subsequent potentially loss renal function”; prediction allows “extensive counseling patients.” fundamental partly separate principles merit distinct consideration. When almost one two turns seems sensible plan surgeon sufficient training deal severe, wherever found independently predictors All present single, extremely capable surgeon. such setting, correctly predicting outcome great extent, best available case. less specialized settings, well more relevant but, our opinion, so much try better team, instead refer patient objective optimizing efficacy minimizing complications, variables strictly operator-dependent 5Cunha F.L.D. Arcoverde F.V.L. Andres M.P. Gomes D.C. Bautzer C.R.D. Abrao M.S. al.Laparoscopic treatment review.J Minim Invas Gynecol. 28: 779-787Abstract (10) One essential message provided “routine intraoperative inspection advisable undergoing endometriosis.” useful safety maneuver, identify also inadvertent unrecognized iatrogenic lesions. However, gynecologists trained perform ureterolysis sites characteristics predicted preoperatively (5Cunha It conceivable externally compressing distorting ureter, removed, progressed future. designed define outcome, preventive without remains determined. important determine number needed excision uropathy. morbidity, above procedures surgeons, included overall balance. candidates must receive complete, evidence-based, balanced, quantitative information regarding expected benefits proposed types percentages description short- long-term health consequences, alternatives, diameters type time invaluable ethical, psychological, practical importance. unfortunate concerned about taking operating table pursue radical struggle add minutes consultation empower reach adequately informed decision. conclusion, commended identifying nonobstructing translate increased optimal and, hence, notably, improvement safety. Because factor determining pelvic structures organs, appears availability gynecologists, abdominal urologists specific experience forms (2Barra Scholar), profitable make al.(3Arena tertiary care once predicted. benefit being treated compared general studied measured, magnitude larger than attainable algorithm applied nonspecialized hospitals. dilationFertility SterilityVol. 116Issue 2PreviewTo whether (UE) using mathematical model based findings. Full-Text Open Archive