Patients with urinary tract endometriosis (UTE) who choose surgery as treatment may have a positive outcome, but they increase the risk of having adverse pregnancies and deliveries, according to a new study.
The study, “Deep Infiltrating Endometriosis Affecting The Urinary Tract—Surgical Treatment And Fertility Outcomes In 2004–2013,” was published in the journal Gynecological Surgery.
UTE is a rare form of deep infiltrating endometriosis (DIE), affecting between 0.3% and 12% of women with endometriosis. About 70% of patients with bladder endometriosis experience symptoms such as urinary frequency, urgency,and dysuria (painful urination); whereas 20-35% of patients present hematuria (blood in urine). Ureter endometriosis, however, has no symptoms, which may lead to a silent loss of kidney function of which the patient is unaware.
Patients who do not respond to medication for severe DIE usually are referred to surgery treatments, such as a complete resection of endometriotic lesions in the bladder, ureters and the bowel. Surgery usually provides sustained pain relief and low rates of disease recurrence, which account for high patient satisfaction.
However, it is not yet clear if this type of surgery could be used to treat infertility in patients with deep infiltrating endometriosis.
So, the objective of this study was to investigate whether surgery in DIE patients could affect their fertility or the course of post-operative pregnancies.
Researchers analyzed the medical records of 400 women with DIE who had been operated on at the Helsinki University Hospital, Finland, between 2004-2013, of which 53 underwent surgery for UTE specifically. Patients were divided into three groups: Group A – patients with isolated bladder endometriosis with no DIE elsewhere (8 patients), Group B – patients with bladder endometriosis associated with other types of endometriosis, but no ureteral lesions (31 patients) and Group C – patients with severe ureteral endometriosis associated with other types of endometriosis (14 patients).
The main outcome measures in the analysis were complications, re-operations, post-operative pregnancies, and deliveries.
Results indicated that diagnosis performed before surgery was accurate in 72% of women with bladder endometriosis and in 93% of women with ureteral disease.
In the group of women who underwent surgery to treat UTE (53), 31 were operated via laparoscopy. Five women had post-operative complications requiring re-intervention and five re-operations were performed in four women who presented endometriosis recurrence, two of whom had UTE recurrence.
The analysis also indicated that 28 patients wished to become mothers, of which 18 succeeded. Indeed, treatment for infertility was necessary in 20 cases. Among the patients who became pregnant, 12 delivered by cesarean section, but 10 experienced delivery complications.
“We found that the UTE operations were usually associated with other DIE lesions, making them demanding; isolated bladder and ureteral endometriosis were rare,” the researchers wrote. “However, the rate of postoperative complications was acceptable and the recurrence rate was low. The women conceived better than expected according to the results of previous studies concerning DIE other than UTE, but needed infertility treatment.”
“On the other hand, the pregnancies and deliveries were complicated, and the high rate of complicated cesarean deliveries was particularly worrying,” they added.
Thus, researchers recommend that care of UTE patients should be provided in referral centers to better follow patients and help them plan their pregnancies and deliveries.