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CASE SNIPPET
Year : 2019  |  Volume : 65  |  Issue : 1  |  Page : 58-59

Isolated intraluminal ureteral endometriosis mimicking tuberculosis


1 Department of Urology, MIOT International, 4/112, Mount Poonamallee Road, Manapakkam, Chennai, Tamil Nadu, India
2 Department of Pathology, MIOT International, 4/112, Mount Poonamallee Road, Manapakkam, Chennai, Tamil Nadu, India

Date of Web Publication28-Jan-2019

Correspondence Address:
Dr. S Rajaian
Department of Urology, MIOT International, 4/112, Mount Poonamallee Road, Manapakkam, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpgm.JPGM_458_18

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How to cite this article:
Rajaian S, Pragatheeswarane M, Krishnamurthy K, Narasimhachar S C. Isolated intraluminal ureteral endometriosis mimicking tuberculosis. J Postgrad Med 2019;65:58-9

How to cite this URL:
Rajaian S, Pragatheeswarane M, Krishnamurthy K, Narasimhachar S C. Isolated intraluminal ureteral endometriosis mimicking tuberculosis. J Postgrad Med [serial online] 2019 [cited 2019 Jun 20];65:58-9. Available from: http://www.jpgmonline.com/text.asp?2019/65/1/58/250959




Endometriosis is defined as presence of endometrial tissue in an ectopic site. Endometriosis affects ovaries,  Fallopian tube More Detailss, skin, lungs, intestines, surgical scars, lymph nodes, and spine.[1],[2] Involvement of ureter is rare and has been reported most often in a non-functioning kidney. Majority of the patients would require nephrectomy.[3] Often the ureteral involvement with endometriosis is silent and involves left distal ureter.[4]

A 26-year-old nulliparous lady presented with a history of intermittent episodes of left lower quadrant abdominal pain for 3 months. Her menstrual cycles were normal. She had no past history of surgical intervention or pelvic infection. About 9 months ago, she had tuberculosis of D3, D5 spine, and successfully completed anti-tuberculous therapy. Her general and pelvic examination was normal. Contrast enhanced computerized tomography (CECT) imaging of the abdomen and pelvis [Figure 1]a and isotope renogram revealed poorly functioning left kidney (split renal function 21%) with hydroureteronephrosis due to left mid-ureteric stricture at S3 vertebra level [Figure 1]b. Tuberculous ureteric stricture was suspected. Left retrograde pyelography (RGP) revealed a passable 1.5 cm stricture in mid-ureter [Figure 2]a. The stricture segment was dilated with a Cook™ ureteroscopic balloon dilator [Figure 2]b followed by ureteroscopy which showed a polypoidal mass of 7 mm in the area of stricture [Figure 2]c. Cold cup biopsy of the lesion was done and a 6 Fr 26 cm silicone DJ stent was placed. Histopathology of the biopsy revealed endometrial glands with rich vascularity [Figure 3]a. Further immunohistochemical studies with special stains revealed estrogen and progesterone receptor positivity in epithelial layer and CD10 positivity in stromal tissue [Figure 3]b, [Figure 3]c, [Figure 3]d. She was started on oral medroxy progesterone and at follow-up of 6 months, she is doing well.
Figure 1: (a) Coronal view of contrast enhanced computerized tomography (CECT) scan of a kidney, ureter, and bladder region showing decreased enhancement of the left kidney with moderate hydroureteronephrosis secondary to mid-ureteric stricture at S3 vertebral level (white hollow arrow). (b) Coronal view of delayed phase of CECT of KUB region showing delayed excretion of contrast from the left kidney with hydroureteronephrosis and stricture at left mid-ureter level (solid white arrow)

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Figure 2: (a) Left retrograde pyelography showing mid-ureteric stricture of approximately 1.5 cm (solid white arrow). (b) Fluoroscopic image showing balloon dilation of the stricture segment (solid white arrow). (c) Ureteroscopic view of intraluminal ureteric polyp at the level of stricture (hollow black arrow)

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Figure 3: (a) Ureteral epithelium (solid black arrow) and endometrial glands (hollow black arrow) are intermixed (H and E, ×10). (b) Estrogen receptor positivity shown in the endometrial glands (hollow black arrow) (IHC, ×40). (c) Progesterone receptor positivity shown in the endometrial glands (hollow black arrow) and negativity in the stroma (asterisk) (IHC, ×40). (d) Stromal tissue showing CD10 positivity (solid black arrow) (IHC, ×40)

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Endometriosis affecting the ureter is usually extrinsic and unilateral (80%).[5] Theories proposed for pathogenesis are:

  1. Menstrual reflux theory – Refluxing endometrial cells are poorly cleared by the peritoneal scavenging system[6]
  2. Embryonal theory – Ureter and endometrium shares the same embryological development from the Müllerian duct remnants, hence the endometrial rests can develop in the ureter[6]
  3. Loaded sigmoid colon creating hidden microenvironment resulting in asymmetric involvement of left distal ureter[6]
  4. Hematogenous and retrograde lymphatic seeding theory.[6]


Differential diagnosis of isolated ureteral endometriosis will include amyloidosis, fibroepithelial polyp, sloughed papilla, and transitional cell carcinoma. Tuberculous strictures involving the ureter are generally multifocal and diffuse, and rarely present as an isolated short segment stricture. CECT urography may be required to rule out extrinsic compression of ureter, while magnetic resonance imaging (MRI) may be beneficial in ruling out pelvic endometriosis. Diagnostic laparoscopy is still the gold standard in pelvic endometriosis.[7] As the conventional imaging is less beneficial in poorly functioning kidney, ureteroscopy with biopsy will be of more value as in our case.[8] Management of ureteric endometriosis includes double J stenting, ureterolysis, ureteric resection, and anastomosis or ureteric reimplantation. Despite all the surgical ureteric intervention, progressive renal dysfunction occurs in 40%.[6] Endometriosis especially in women of childbearing age group should be considered as differential diagnosis in ureteric obstruction as the renal unit can be salvaged by endoscopic intervention at the earlier stage of the disease course.

Declaration of patient consent

The authors certify that appropriate patient consent was obtained.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 :: References Top

1.
Ludwig M, Bauer O, Wiedemann GJ, Diedrich K. Ureteric and pulmonary endometriosis. Arch Gynecol Obstet 2001;265:158-61.  Back to cited text no. 1
    
2.
Dongxu Z, Fei Y, Xing X, Bo-Yin Z, Qingsan Z. Low back pain tied to spinal endometriosis. Eur Spine J 2014;23(Suppl 2):214-7.  Back to cited text no. 2
    
3.
Klein RS, Cattolica EV. Ureteral endometriosis. Urology 1979;13:477-82.  Back to cited text no. 3
    
4.
Vercellini P, Pisacreta A, Pesole A, Vicentini S, Stellato G. Crosignani PG. Is ureteral endometriosis an asymmetric disease? BJOG 2000;107:559-61.  Back to cited text no. 4
    
5.
Takeuchi S, Minoura H, Toyoda N, Ichio T, Hirano H, Sugiyama Y. Intrinsic ureteric involvement by endometriosis: A case report. J Obstet Gynaecol Res 1997;23:273-6.  Back to cited text no. 5
    
6.
Maccagnano C, Pellucchi F, Rocchini L, Ghezzi M, Scattoni V, Montorsi F, et al. Ureteral endometriosis: Proposal for a diagnostic and therapeutic algorithm with a review of the literature. Urol Int 2013;91:1-9.  Back to cited text no. 6
    
7.
Nisenblat V, Prentice L, Bossuyt PM, Farquhar C, Hull ML, Johnson N. Combination of the non-invasive tests for the diagnosis of endometriosis. Cochrane Database Syst Rev 2016;7:CD012281.  Back to cited text no. 7
    
8.
Pollack HM, Wills JS. Radiographic features of ureteral endometriosis. AJR Am J Roentgenol 1978;13:627-31.  Back to cited text no. 8
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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