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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2016  |  Volume : 27  |  Issue : 2  |  Page : 419-422
Recurrent acute kidney injury in a young female: A rare presentation of ureteral endometriosis

1 Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Medical Student, TNMC, Mumbai, India
3 Department of Radiodiagnosis, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

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Date of Web Publication11-Mar-2016

How to cite this article:
Pant P, Prakash S, Dwivedi A N, Prakash J. Recurrent acute kidney injury in a young female: A rare presentation of ureteral endometriosis. Saudi J Kidney Dis Transpl 2016;27:419-22

How to cite this URL:
Pant P, Prakash S, Dwivedi A N, Prakash J. Recurrent acute kidney injury in a young female: A rare presentation of ureteral endometriosis. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2022 Nov 26];27:419-22. Available from: https://www.sjkdt.org/text.asp?2016/27/2/419/178591
To the Editor,

Endometriosis is a common disease with an incidence of 2.5-15% in women of childbearing age group. [1] It can affect the genitourinary tract in about 1% cases. Acute kidney injury (AKI) complicating ureteral endometriosis is rarely reported. We present a patient with recurrent episodes of AKI in association with menstruation in a young female with endometriosis.

A 29-year-old nulliparous female presented with nil urine output, generalized swelling of the body, and vomiting for three days, and these symptoms started with the onset of her present menstrual cycle. History of similar episode was present about one month back during which two sessions of hemodialysis were done. In that episode, renal function improved with increase in urine output, after the cessation of menstruation. Past history revealed severe dysmenorrhea for four years and primary infertility. Ultrasonography (USG) study three years ago showed bicornuate uterus and 3 cm × 3 cm chocolate cyst in the right adnexa. Left kidney was not visualized. Exploratory laparotomy carried out two years ago showed dense adhesions between the right part of uterus, right tube, and ovary. The right adnexal chocolate cyst was drained. The patient remained asymptomatic for two years, after which she again started having dysmenorrhea. Physical examination revealed pulse rate of 80/min and blood pressure of 130/80 mm Hg. Systemic examination was within normal limit. Urinalysis was normal and culture was sterile. Hemoglobin was 10.5 g/dL, total leukocyte count was 8500/mm 3 , platelet count was 180,000/mm 3 , blood urea was 54 mg/dL, serum creatinine was 3.4 mg/dL, serum total protein and albumin were 6.4 and 3 g/dL, respectively, serum calcium was 8.8 mg/dL, serum phosphate was 4.2 mg/dL, and alkaline phosphatase was 180 IU/L.

USG with color Doppler revealed a thickwalled right ovarian cyst with coarse internal echoes. Similar cyst was noted on the left side. There was minimal intralesional vascularity within the cyst wall. The right kidney was enlarged with altered cortico-medullary diffeentiation associated with agenesis of left kidney, suggesting that she had congenital solitary functioning in the right kidney. Sixty-four slice computed tomography (CT) scan revealed enlargement of right kidney (12.3 cm × 8.5 cm × 8.1 cm) with malrotation. It was associated with perinephric fat stranding, thickening of perirenal fascia, and dilatation of right ureter till mid ureteric level [Figure 1]. Right adnexa showed thick wall of complicated cystic lesion (9.1 cm × 5 cm) with iregular adnexa and effacement of periureteric fat plane. Left adnexa showed similar complicated cyst (5 cm × 4 cm). A diagnosis of bilateral endomeriotic cyst with pelvic endometriosis involving right adnexa and periureteric plane associated with left renal agenesis and acute renal failure was made. To confirm the status of obstruction of the right ureter, a retrograde pyelogram was carried out, which showed dilatation of upper two-third of ureter with smooth narrowing of the lower end [Figure 2].
Figure 1: Noncontrast computed tomography scan, coronal section showing enlarged right kidney with dilated pelvicalyceal system. Right adnexa shows complex cystic lesion with contiguous soft tissue stranding.

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Figure 2: Retrograde pyelogram showing dilated upper two-third part of right ureter with a smooth stricture at lower end (arrow).

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D-J stenting of the right ureter was done. Following the procedure, urine output increased with improvement in renal functions. The patient was operated after two weeks of cessation of menstruation. Perioperative findings revealed dense adhesions in the whole pelvis; with adhesion of uterus, fallopian tubes, and ovaries to each other and to bowel loops as well. Bicornuate uterus and bilateral chocolate cyst were also noted. The whole uterus was converted into a fibrotic mass and the possibility of future pregnancy was unlikely; hence, after obtaining the patient's and her husband's consent, hysterectomy with adhesiolysis was done, along with bilateral salpingo-oophorectomy. The patient gradually recovered and was discharged in a stable condition on the 10 th postoperative day. She was asymptomatic with stable serum creatinine of 1.2 mg/dL and normal urinalysis at three months after the AKI episode.

Endometriosis is a disorder characterized by the presence of functionally active endometrial cells in areas outside the uterus. Severe disease leads to extensive adhesions and distortion of anatomy, which may lead to pain and infertility. It has an incidence of ~2.5-15% of women of reproductive age group. [1] It is more common in nulliparous women. The pathogenesis of endometriosis is not completely understood. [2] Genitourinary tract endometriosis is rare with an incidence of 0.01-1.2%, with the ratio of bladder to ureteral and to renal involvement being 40:5:1. [2],[3] Left-sided disease is more common, present in ~64% of the cases. Bilateral ureteral involvement is present in 15.2% cases. [4] Ureteral endometriosis can be of extrinsic and intrinsic variety. In the extrinsic form, obstruction is due to external compression by adjacent endometriosis and its attendant inflammation and fibrosis. It is the more common form, occurring in 80% of the cases, and more commonly leading to urinary tract obstruction. The majority of these cases are limited to distal one-third of the ureter. In the intrinsic variety, ectopic endometrial tissue is present in lamina propria and muscular layers of the ureter. [5]

Urethral disease is often silent; symptoms are often due to concomitant genital disease. [6] Cyclical hematuria may be present in intrinsic disease in ~15% of the cases. [7] Because of the insidious nature of the disease, diagnosis is elusive and loss of kidney is reported in 30% of patients. [5],[8] Kerr reported 47 cases of ureteral endometriosis, with varied clinical presentations. [9] Klein and Cattolica reviewed 62 cases of ureteric endometriosis leading to urinary tract obstruction, they concluded that diagnosis is usually late in these cases. [7] Diagnosis requires a high index of suspicion. The symptoms of endometriosis such as pelvic pain, dyspareunia, dysmenorrhea, and menorrhagia are clinical clues to diagnosis. [10]

Ureteric endometriosis causing renal failure is a rare observation. [11] To the best of our knowledge, only three cases of ureteral endometriosis presenting as cyclical renal failure have been described until now in English literature. [12],[13],[14] Akçay et al reported a case of cyclical acute renal failure associated with menstruation in a female with severe bilateral ureteral obstruction due to endometriosis. [12] Kyriakidis and Pappas et al reported a female patient with single kidney presenting with anuria due to ureteral endometriosis. [13] Body et al reported a case of acute renal failure secondary to obstructive bilateral endometriosis, which was diagnosed on laparotomy only. [14] Similar to our case, the patient improved with pelvicalyceal system decompression and hysterectomy, along with bilateral salpingo-oophorectomy.

Treatment is aimed at relief of obstruction and salvage of renal function. Initial therapy with temporary double-J stenting along with danazol or gonadotropin-releasing hormone agonists is usually warranted. Those who fail to respond should be considered for surgery. Patients with extremely fibrotic lesions may be taken for surgery without a trial of hormonal therapy. Surgery includes ureterolysis or partial ureteral resection with hysterectomy and bilateral salpingo-oopherectomy. [8],[15] In our case, the patient had a bicornuate uterus, which is considered to be a risk factor for endometriosis; along with unilateral renal agenesis, which is often associated with gynecological abnormalities. [11]

In summary, to the best of our knowledge, we are reporting the first case of recurrent AKI due to ureteric endometriosis in a patient with congenital solitary functioning kidney from India. Ureteral endometriosis, although rare, should always be considered in a premenopausal female with ureteral obstruction of unknown etiology. Females known to have endometriosis should be followed up with renal functions and radiological surveillance of urinary tract for features of obstruction.

Conflict of interest: None declared.

   References Top

Barbieri RL. Etiology and epidemiology of endometriosis. Am J Obstet Gynecol 1990; 162:565-7.  Back to cited text no. 1
Stillwell TJ, Kramer SA, Lee RA. Endometriosis of ureter. Urology 1986;28:81-5.  Back to cited text no. 2
Jubanyik KJ, Comite F. Extrapelvic endometriosis. Obstet Gynecol Clin North Am 1997; 24:411-40.  Back to cited text no. 3
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
Gehr TW, Sica DA. Case report and review of the literature: ureteral endometriosis. Am J Med Sci 1987;294:346-52.  Back to cited text no. 5
Seracchioli R, Mabrouk M, Manuzzi L, et al. Importance of retroperitoneal ureteric evaluation in cases of deep infiltrating endometriosis. J Minim Invasive Gynecol 2008;15:435-9.  Back to cited text no. 6
Klein RS, Cattolica EV. Ureteral endometriosis. Urology 1979;13:477-82.  Back to cited text no. 7
Rivlin ME, Miller JD, Krueger RP, Patel RB, Bower JD. Leuprolide acetate in the management of ureteral obstruction caused by endometriosis. Obstet Gynecol 1990;75(3 Pt 2):532-6.  Back to cited text no. 8
Kerr WS Jr. Endometriosis involving the urinary tract. Clin Obstet Gynecol 1966;9:331-57.  Back to cited text no. 9
Yohannes P. Ureteral endometriosis. J Urol 2003;170:20-5.  Back to cited text no. 10
Gagnon RF, Arsenault D, Pichette V, Tanguay S. Acute renal failure in a young woman with endometriosis. Nephrol Dial Transplant 2001; 16:1499-502.  Back to cited text no. 11
Akçay A, Altun B, Usalan C, et al. Cyclical acute renal failure due to bilateral ureteral endometriosis. Clin Nephrol 1999;52:179-82.  Back to cited text no. 12
Kyriakidis A, Pappas I. Ureteral endometriosis in a female patient presenting with singlekidney anuria. Eur Urol 1995;28:175-6.  Back to cited text no. 13
Body G, Muteganya D, Descamps P, Janin P, Nivet H, Lansac J. Ureteral endometriosis revealed by an acute renal failure. Eur J Obstet Gynecol Reprod Biol 1996;67:53-7.  Back to cited text no. 14
Brough RJ, O'Flynn K. Recurrent pelvic endometriosis and bilateral ureteric obstruction associated with hormone replacement therapy. BMJ 1996;312:1221-2.  Back to cited text no. 15

Correspondence Address:
Dr. Pragya Pant
Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.178591

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